Are the Mentally Ill Really Violent?

In November 1999, on the corner of Madison Avenue and 42nd Street in midtownManhattanan a man walked up to a pedestrian and, without warning, smashed her skull with a six-and-one-half pound paving stone. In March of the same year, in metropolitan Pittsburgh, another man walked through a fast food restaurant and methodically shot and killed three people and wounded two others. Both communities, and the nation as a whole, were horrified by these instances of random violence, both perpetrated by men who were mentally ill. The horror deepened when both cities experienced strikingly similar incidents within months of the earlier atrocities: In July of this year, less than fifteen blocks from the first incident in Manhattan, a man known to be mentally ill dropped a chunk of concrete on the head of a young woman passing by. In April, a man who was not clinically ill but was clearly disturbed--went on a shooting spree in suburban Pittsburgh, injuring six people and killing five.

These terrifying acts of violence were merely the latest on a growing list that has included the shootings at a brokerage office in Atlanta and the shoving of a commuter in front of a Manhattan subway train. They have prompted researchers and policymakers to take renewed interest in old questions: Are the mentally ill more violent than the rest of the population? And how can these tragedies can be prevented?

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Thanks to the recent headlines highlighting shocking crimes committed by the mentally ill, the common public perception is that random violence is on the rise and that people with mental disorders are especially violence-prone. But most experts agree that such incidents are a statistical rarity. Many also believe that these infractions are not easily predicted or prevented; their relative infrequency makes it difficult to create a profile of individuals prone to such behavior. Individuals diagnosed with mental illness often engage in disturbing behavior without ever coning violent acts. While there may, in many cases, have been "warning signs" before actual violence erupted, they are often clearer in hindsight.

Even when someone suspects that a family member, employee or student may be violent, the mental health system often does not vide sufficient and affordable avenues of treatment and monitoring that might reduce the likelihood of violence. Few approaches target violence reduction specifically; most operate on the assumption that treating the obvious symptoms of mental illness will reduce the risk of violence. In addition, because of concerns over the infringement of individual liberty, the law requires substantial evidence that a person is violence-prone before they can be required to submit to treatment.

In the wake of recent rampage killings and other acts of violence, the public has demanded that mental health professionals and the judicial system do more to protect them. A few recent court decisions have reflected this sentiment, ruling that mental health professionals have a duty to warn potential victims of the risk of harm from psychiatric patients. Certain advocates also hope to relax legal roles that limit the ability of clinicians and courts to require and monitor the treatment of those suspected to have violent tendencies.

Fortunately, there is now a considerable body of research that explores the relationship between mental illness and violence. The results of this research can and should--provide real answers al)out the link between violence and the mentally ill.

The Truth About Mental Illness and Violence

For many years, conventional wisdom in the mental health field held that the mentally ill were no more prone to violence than those without mental illness. It was also widely accepted that clinicians had no way of identifying individuals likely to engage in violence. More recent), however. researchers (including the co-author, Ed Mulvey) have concluded that there is a statistically significant association between mental illness and violence: Overall, the mentally ill are more likely to act out violently than the general public. However, this association is nor very strong. The overwhelming majority of people with diagnosed mental disorders do not engage in violence. Also, the manner in which mental illness contributes to violence, when it does, varies considerably and is often far from clear.

Certain factors that appear to be associated with an increased likelihood of violence are in line with common sense. Not surprisingly, a prior history of violence has been found to be a significant risk factor for the occurrence of future violence. So has the presence of substance abuse. Location, too, is important: The kind of neighborhood in which a mentally ill person lives appears to have a strong relationship to violence--or its absence. Moreover, violence is most likely to take place when an individual is experiencing active symptoms of a mental disorder--the low of a depressive jag, the panic of an anxiety attack--than it is while the disorder is lying dormant.

Recent studies, particularly a 1998 study published in the General Archives of Psychiatry by the MacArthur Risk Assessment Project; show that the circumstances in which mental patients most commonly commit violence do not differ markedly from those surrounding crimes committed by people who are not mentally ill. In both groups, violence most often arises from everyday stress, such as conflicts with spouses, family members and co-workers. Just as important, the risk of violence does not appear to remain stable over time. Again, as one might expect, the risk seems to change as circumstances in an individual's life change: It may surge during periods of marital turmoil and wane as an individual settles into a new job.

Other findings, however, are far more surprising. New research, for example, suggests that individuals who have less serious forms of mental illness but who engage in substance abuse have the highest risk for violence among the mentally ill. People with more severe mental disorders but no substance abuse problems, however, are no more likely to be violent than their "normal" neighbors. A newer analysis of the MacArthur Risk Assessment Project, published this year in the American Journal of Psychiatry, found that individuals with violent delusions were no more likely to be violent than other individuals with mental illness. Other studies, notably those by Charles Lidz and the co-author and those by the MacArthur group, have also found that, contrary to popular belief, schizophrenics are less likely to engage in violence than those with other mental disorders.

This is not to say that serious psychological problems are completely unrelated to violence. It's just that the types of psychological problems associated with a higher risk of violence may not be the problems that people most commonly think of as "mental disorders." Indeed, it seems from these studies and others (for example, studies by Mamie Rice, Ph.D., and Grant Harris, Ph.D.), that one of the strongest predictors of violence might be psychopathy--a personality characteristic marked by self-centeredness, lack of remorse, and limited ability to control antisocial impulses.

In the past several years, researchers have also tracked the mentally ill after their discharge from hospitals to see how accurate clinicians were at predicting their risk of furore violence. Contrary to prior findings, clinician. were surprisingly successful, though far from infallible, in identifying people with an enhanced risk of violence.

There has been progress in identifying the risk of violence among the mentally ill. Nonetheless, the public's demand for greater protection from violence has led to broad initiatives directed at the mentally ill population as a whole, rather than at those few who might actually have a heightened risk for committing violence.

Silencing the Violence

A growing, fearful chorus of critics has proposed that mentally ill persons who refuse treatment should be threatened with coercion--namely, financial penalties or the loss of freedom--if they don't take their medication, regardless of whether there is a perceptible threat of violence.

Civil commitment--that is, involuntary confinement to a psychiatric hospital has traditionally been used to assure that "dangerous" persons receive necessary treatment. Many advocates argue that it should be easier to comfit the mentally ill against their will. Not only does relaxing commitment standards impinge upon patients' civil rights, however, but it is simply not feasible became the mental health system currently lack the necessary facilities.

As a result, other less restrictive (and, theoretically, less expensive) means to mandate treatment have been proposed. E. Fuller Torrey, Ph.D., of the National Alliance of the Mentally Ill (NAMI), has been a strong proponent of community-based outpatient treatment, most notably the "Program of Assertive Community Treatment," which attempts to provide a round-the-clock setting outside the hospital where patients with severe mental illness can receive care. Involvement in these programs is often mandatory. Statutes in many states, such as New York's well-publicized "Kendra's Law," named for a young woman pushed in front of a Manhattan subway train by a man with a long history of untreated mental illness, empower authorities to order outpatient treatment for those who refuse to seek help.

Other tools for mandating treatment for mentally ill persons include making their receipt of governmental benefits contingent on the acceptance of treatment. Finally, a number of states have passed laws authorizing "psychiatric advance directives." Under these laws, persons with a mental disorder, while competent, can make treatment decisions for themselves that may be legally enforced in the event that they become incapacitated by their disorder.

Of course, mandated treatment based simply on a refusal to accept professional help is a crude tool for preventing violence; it targets both the relatively small percentage of the mentally ill who might engage in violence, as well as those with psychological disorders whose only sin is to refuse treatment. Civil libertarians and consumer groups--advocates for the mentally ill, often themselves mental health patients--believe that the supposed link between violence and mental illness is at best exaggerated, and that such linkage stigmatizes the mentally ill and threatens them with an unwarranted loss of freedom. Some experts are concerned that a relaxation of involuntary commitment standards or other forms of coercion may result in appropriate treatment, particularly in less striking cases of mental disturbance. Mandated treatment and its frequent emphasis on medication discourage society from putting more resources into treatments that rely less on pills but may be more effective in the long run.

A Fairer Approach

Rather than allowing states to intervene in the lives of the mentally ill or expanding the rights of mentally ill persons to reject intervention, a middle ground might provide a more effective solution. In light of recent research, public policy may best be served if clinicians focus more intently on those most likely to be violent, instead of wasting their efforts on more harmless individuals.

We still need to sharpen our understanding of violent behavior and its relationship to mental illness. But what the public needs to realize is that not all mentally ill people are prone to acting out, shooting strangers or stalking family members. And the ones who are prone to violence may not be the people we might think. Recent studies have been valuable in reminding us that the cause and prevention of violence is not a simple issue. They question misconceptions that may push mental patients farther away from community life when what they often need is better integration with it.

Researchers may not be able to allay the public's fear that tragedy can randomly strike on a city street, subway platform or office elevator. Our hope, however, is that the developing body of knowledge will contribute to reducing outbreaks of violence, making the general public feel safer. In the process, the long-held stigma against the mentally ill may finally dissolve, allowing them to participate more fully in mainstream society.


Force Under Pressure, Lawrence Blum (Lantern, 2000)

Almost A. Revolution: Mental Health Law and the Limits of Charge, Paul S. Applebaum (Oxford, 1994)

Adapted by Ph.D. and J.D.

Edward P. Mulvey, Ph.D., is director of the law and psychiatry program at the Western Psychiatric Institute and Clinic of the University of Pittsburgh School of Medicine. Jess Fardella, J.D., is a lawyer in New York.

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