Dispelling the Myth of Violence and Mental Illness

John M. Grohol, Psy.D.
June 1998; Reviewed: February 2004

Historically, society (this means you!) has perceived people with mental disorders as being more violent and dangerous than normal folks. People have this image of someone who is "crazy" as being more inclined to acting on those thoughts and causing mayhem and destruction. This has always been a part of the stigma associated with the mentally ill, and one which has been especially difficult to successfully deal with. It is difficult because when it comes to a person's own feelings of safety and security (mixed in with our innate fear response), we tend to be very conservative. "If I ignore that crazy person, then they won't harm me!" Luckily, the proof that people with mental disorders -- such as depression, schizophrenia, and anxiety -- has finally been published.

A study published in May, 1998 in the Archives of General Psychiatry found that:

[...] patients discharged from psychiatric facilities who did not abuse alcohol and illegal drugs had a rate of violence no different than that of their neighbors in the community. Substance abuse raised the rate of violence both among discharged psychiatric patients and among non-patients. However, a higher portion of discharged patients than of others in their neighborhoods reported having symptoms of substance abuse, and -- at least when they first got out of the hospital --substance abuse was more likely to lead to violence among discharged patients than among non-patients.

Significantly, this contradicts one of central perceptions of mental illness within society today. Unless drugs or alcohol are involved, people with mental disorders do not pose any more threat to the community than anyone else. This finding cannot be emphasized enough.

In the commentary accompanying the study, Bruce Link, Ph.D. and Ann Stueve, Ph.D. note

[...] Steadman et al asked about the targets of violence and found that the vast majority (86%) of violent acts committed by former patients occurred within the context of family and friendship networks. Indeed, members of the Pittsburgh public who were violent were slightly (but not significantly) more likely to target strangers (22%) than were Pittsburgh patients (11%)! Public fears that patients with mental illness will attack them are sharply contradicted by such findings.

This is something to note, but not to blow out of proportion. The violence that does occur in those individuals who have a co-existing substance abuse problem is focused on family members and others known to the individual. This doesn't mean you need to be paranoid that someone with a mental illness who is your friend or family member is going to hurt you. It does mean, however, that you need to be wary of someone you know who has a substance abuse problem and a mental disorder. Statistically, they are more prone to violence. Taking reasonable precautions to reduce that violent potential may be prudent if you find yourself in such a situation. A good predictor of future behavior is past behavior. If the person has acted violently toward you in the past, they are likely to do so again in the future, regardless of their mental health status.

In an interesting development coinciding with the study's release, one organization has put its own unique spin on the findings (as first reported by MadNation). The National Alliance for the Mentally Ill took the study's results and suggested it "[...] conclusively demonstrates what many people have long suspected: treating individuals with major psychiatric disorders markedly reduces episodes of violent behavior." Yet, importantly, this study did not measure the effectiveness of treatment versus no treatment on violence rate (e.g., no control group was used specifically examining the effects of treatment on violence rate). The authors themselves warn of drawing conclusions from the data in this manner:

Our most unexpected finding is the decline in the proportion of subjects engaging in violence over time. Substantive hypotheses to account for this decline are legion. Patients may become more engaged in treatment over time or social support from family members may increase. Rates of violence may peak around the time of hospital admission, when patients are in acute crisis, and remain high for a period of time after discharge because many patients still have active mental disorders after they leave the hospital.

Caution should be exercised before using the rates reported here as summary statistics to characterize violence by discharged patients. We found that the rate of patient violence varied during the course of the 1-year follow-up for the 2 groups with co-occurring substance abuse diagnoses. The effects of hospitalization and treatment on these rates are unknown. In addition, for all 3 patient diagnostic groups, the highest rate of reported violence did not occur during the follow-up year at all, but rather during the 10 weeks prior to the hospitalization during which the patients were enrolled in the study. The prehospitalization rates are likely to be artificially high due to ascertainment bias (ie, violence may have precipitated hospitalization). In addition, an inevitable limitation of research in this area is that patient refusal or attrition can compromise the representativeness of the sample studied.

Significantly, NAMI used some creative statistical methods to obtain its claims that violence is reduced by half by treatment. As Table 4. Prevalence of Violence and Other Aggressive Acts clearly shows, violence is reduced significantly over time. When patients first come out of treatment, note that violence is still significantly higher than by Follow-Up 5. Also note that the pre-hospital admission violence rate is self-reported only. The authors warn about drawing conclusions based upon only one source of data, "Our data suggest that it is crucial for [...] studies to use multiple measures of violence rather than the single measures that have characterized most prior research." Relying on a patient's self-report of violence is not a very reliable or accurate means in which to draw conclusions from.

Modified** Table 4. Prevalence of Violence and Other Aggressive Acts


Major Mental Disorder,
No Substance Abuse

Major Mental Disorder,
Substance Abuse


ViolenceOther
Aggressive
Acts Only
% Change
in
Violence
ViolenceOther
Aggressive
Acts Only
% Change
in
Violence

Prehospital admission 8.921.2  22.628.4 
Follow-up 16.722.4-25% 17.924.7-21%
Follow-up 25.818.6-35% 10.227.5-55%
Follow-up 34.014.3-55% 8.419.4-63%
Follow-up 46.414.0-28% 8.719.8-62%
Follow-up 54.410.4-51% 6.118.3-73%
1-Year aggregate17.9 32.7 31.133.7

 Other Mental Disorder,
Substance Abuse

Total Patient
Sample


ViolenceOther
Aggressive
Acts Only
% Change
in
Violence
ViolenceOther
Aggressive
Acts Only
% Change
in
Violence

Prehospital admission  24.931.4  17.425.8 
Follow-up 1 22.334.7-10% 13.525.2-22%
Follow-up 2 22.122.1-11% 10.322.7-41%
Follow-up 3 11.130.3-55% 6.918.8-60%
Follow-up 4 9.224.5-63% 7.618.0-56%
Follow-up 5 11.912.9-52% 6.314.2-64%
1-Year aggregate43.0 32.4 27.533.0 

* All data are given as percentage unless otherwise indicated.
Includes 21 subjects with a personality disorder and no major mental or substance abuse disorder.
Self-report only.
** In order to make the table more readable for our purposes, we left out the "Number" column and added the "% Change in Violence" column. You can view the original table here.

Analysis of Table 4's Violence Data:

 Major Mental Disorder, No Substance Abuse
Major Mental Disorder, Substance Abuse
Other Mental Disorder, Substance Abuse
Total Patient Sample

Change immediately after treatment 25% 21% 10% 22%
Change which occurred with passage of time* 26% 52% 42% 42%

* % Change at Followup 1 - % Change at Followup 5

Our own analysis of Table 4's data clearly shows that time alone could easily account for more than one-half of the improvement in violence ratings, and in some cases could account for more than 80% of the improvement. This is a far cry from NAMI's claim that "the effect of treatment in reducing violence [... is] 54 percent." The fact of the matter is, though, that we don't know what really accounted for these reductions, as the authors conclude. NAMI ignored the author's own conclusions and instead created their own.

There is another finding entirely ignored by NAMI, which should raise some additional questions and concerns about NAMI's conclusions. Look closely at Table 4 above. When you look at the columns labeled "Other Aggressive Acts Only," treatment in some cases appears to actually cause these rates to rise in comparison to pre-hospitalization rates. The authors defined these acts as "other aggressive acts (battery that did not result in physical injury)" and "acts that were coded as other aggressive acts were primarily 'throw objects/push/grab/shove/slap.'" Potentially serious aggressive behaviors such as these should not be ignored.

NAMI twisted the study's findings in this manner apparently in order to promote its political agenda. In late 1997, the NAMI-Treatment Advocacy Center was formed to promote the implementation of laws and practices that increase access to treatment for persons with mental disorders. A major focus of that effort involves issues concerning involuntary commitment. In this light, NAMI appears to be suggesting that, if need be, laws should be created or reinforced which encourage the greater use of involuntary commitment for those with mental disorders. This research study, from NAMI's point of view, shows how violence can be reduced through treatment, voluntary or not.

This study has nothing to do with involuntary commitment and showed nothing related to that issue. Don't be confused by this attempt by NAMI to cloud the study's findings -- the mentally ill are no more violent that those who carry no diagnosis.

It's time that, as a society, we begin to knock down stereotypes and start breaking down the stigma associated with mental disorders. The first stereotype to go down -- permanently, we hope -- is that people who suffer from depression, anxiety, schizophrenia, an eating disorder, or any other type of mental disorder, are somehow more violent than others. This simply isn't true, unless they are involved in substance abuse. Use and abuse of substances such as drugs or alcohol is often correlated with an increase in violence anyway (e.g., due to impaired judgment).

Violence is most often a criminal activity which has little correlation with a person's mental health. Most people who suffer from a mental disorder are not violent -- there is no need to fear them. Embrace them for who they are -- normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support.

Reference
Grohol, J.M. (Jun 1998). Dispelling the violence myth. [Online].

Last reviewed: By John M. Grohol, Psy.D. on 7 Dec 2008
    Published on PsychCentral.com. All rights reserved.

 

 

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