Are the Mentally Ill Really Violent?

Presents information on the association of mental illness and violence. Symptoms of mental disorder; Factors to consider in assessing whether a mentally ill person has propensity for violence; Tools in mandating treatment for mentally ill persons.

By Edward P. Mulvey, Jess Fardella, published on November 1, 2000 - last reviewed on January 23, 2015

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?

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.

READ MORE ABOUT IT

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.