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The Myth of the Violent Mentally Ill, Part One

When a mass act of violence occurs, mental illness often becomes top of mind.

It happens all too frequently. Whenever a mass shooting or violent act occurs, the first question asked is whether the perpetrator was mentally ill. In some cases the answer is yes, but the vast majority of people with mental illness are no more violent than anyone else.

People with mental illness are not inherently violent. They can become violent if they are not receiving treatment for their symptoms or if they are abusing substances that inflame symptoms.

There are many myths about violence and mental illness, which is why I recently interviewed for the Healthy Minds public television series, two world renowned experts Lloyd Sederer, M.D., Medical Director, NY State Office of Mental Health, and Jeffrey Lieberman, M.D., Professor and Chairman, Department of Psychiatry, Columbia University, to explore the relationship between mental illness and violence, and how science and public perception differ.

According to Dr. Sederer, people who are mentally ill are far more likely to take their own lives than kill someone else. In fact, 90 percent of people who take their own lives have a mental illness.

Dr. Sederer explains there are four different profiles for people at risk of committing violent acts:

  • Psychopaths don’t care about other people. They consider other people purely a means to an end. They don’t care about consequences, and have no guilt or remorse;
  • Angry people who are aggrieved and out to settle a score often have a specific target;
  • People with psychotic illness, particularly those who are under the influence of paranoid delusions, are often afraid someone will hurt them. They sometimes commit “altruistic” violence in the delusional belief that by hurting someone else, including a loved one or a child, they are saving them from something worse; and
  • People with mental illness who are under the influence of drugs, alcohol or both are at higher risk for violence when they are under the influence. Alcohol and many drugs can in increase psychotic symptoms or reduce inhibitions.

Often friends and family members see changes in behavior that can indicate a problem. These changes can be subtle, at first, and occur over time. It may take time for people to realize what is happening; sometimes they lack confidence in what they are seeing or don’t understand what it means.

We suggest that family members begin writing down their observations: the person has not left their room in several days; they have stopped showering; the person wears multiple layers of clothing or no clothing at all; they seem to be thinking or speaking strangely. Then, compare notes with a friend or family member to validate what you have seen.

Mental illness is extremely common, affecting one in five people. Most people know someone who suffers from depression or anxiety, but In the face of a persistent problem, many people don’t know where to turn.

A family doctor is often a good place to start. Another is the National Alliance on Mental Illness (NAMI), which serves over 300,000 family members with a chapter in every state offering free referrals, and support groups.

However, convincing someone who is mentally ill to get help is often difficult, especially if that person is experiencing delusions. Mentally ill people with firm, fixed beliefs can often be difficult to budge, and efforts to help can lead to fights, especially when family members are frightened and concerned about safety issues. Sometimes people who are mentally ill categorically reject the idea of getting help.

When reason fails, it often helps to try listening to the person to try to find out why they are saying or doing something. This can involve asking questions: Why aren’t you going to work? Why aren’t you eating? Why don’t you leave your room?

Then, it is sometimes possible to use leverage to convince the person to seek help. This is especially true when the person with mental illness is younger or is someone you’re supporting. Being part of a family requires giving as well as taking. Responsibility requires taking care of oneself. For someone who is mentally ill, that means taking medication and seeing a doctor.

When a mixture of listening and leverage works, there can be progress as long as the person is in treatment. Treatment, which can include therapy and medication, requires time, hard work, and there are often setbacks. Reward what is working and never give up.

In Part Two of this blog post, I will discuss my conversation with Dr. Jeffrey Lieberman, who looks at circumstances that lead people with mental illness to commit violent acts and discuss what steps need to be taken to address this public health crisis.

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