Is the public’s association of mental illness with dangerousness justified?
An enduring link exists in the public mind between dangerousness and mental disorder (Link et al 1999a: 316). ‘Mental disorder’ is defined in the Mental Health Act 1983 (amended by the Mental Health Act 2007) (Jones 2009:307) under section 1 as “any disorder or any disability of the mind”. ‘Mental illness’ encompasses diagnoses of ‘psychoses, anxiety states, affective disorders and hysteria’ (Jones (2009:308). Danger and dangerousness are ‘fuzzy’ concepts (Dallaire et al. (2000:681), difficult to define or assess (Slovic and Monahan (1995:50). Cocozza and Steadman (1976:1087) define ‘dangerous’ behaviour as ‘violent assaultative behaviour’ against others, stating that perceiving dangerousness involves estimating that a person will exhibit such behaviour. Allen and Nairn (1997: 379) highlight different forms of perceived dangerousness, including violence to persons and property, threats, destroying the peace of mind or family lives of ‘normal’ people, and of course, danger to the mentally disordered individual themselves.
PUBLIC FEAR OF MENTAL DISORDER
A fundamental aspect of the human condition stigmatises the ‘different’ (Gilbert (2000). On a psychosocial level, concerns of ‘dangerousness’ are closely related to unpredictability. We rely daily on a set of normative ‘expectancies’ – where these are not met – as often occurs with the mentally disordered, we perceive a threat to these norms – and to ourselves (Dallaire (2000:681-2). A connection between mental disorder and dangerousness was highlighted by nineteenth century psychiatrists to account for serious crimes, which were committed without ‘logical reason’ (Foucault 1978, Jones 2009:316). Studies from the 1950s document highlight fear felt by the public when faced with mental disorder (Nunnally (1961). This connection is ‘enduring’ (Crisp et al. (2000:4) – from references in Greek and Roman literature, through the Middle Ages, the Renaissance and into the modern era, the perceived link between mental disorder and violent behaviour is as ‘old as recorded history’ (Ion and Beer (2003:238).
Thanks to ‘disproportionate and often flamboyant’ media coverage, images of the ‘violent mental patient’ remain deeply ingrained in public consciousness (Harris and Lurigio 2007:543, Porter 2003, Meyer and Barry 1992:77). Coverage of the Virginia Tech massacre in 2007 was centred on the perpetrator’s previous psychiatric care (Elbogen and Johnson (2009:152). Although the complex relationships between media portrayal and public attitude have yet to be fully researched, Kaminski et al. (2010) found that highly publicised shootings on college campuses led to increased fear among students. Link and Stueve (1995:172) state that the results of a 1990 nationwide telephone survey showed that 80% of the American public linked mental illness to public fear and violent activity. In 1994, the Glasgow Media Group found that 75% of media coverage linked mental illness to violence (Allen and Nairn 1997:375, Philo et al. 1994). Similar results emerged from studies of daytime television (Fruth and Padderud 1985:387), primetime television dramas (Signorelli 1989:330) and movies (Hyler et al. 1991:1047). Historically perpetuated through word-of-mouth, contemporaneous fear of the mentally disordered is heavily influenced by relentless media portrayal of the ‘violent’ mentally disordered individual (Monahan (1992:513).
However, this perception is by no means unique to the media-saturated Western world; public association between mental disorder and violence has been found in Israel (Link 1999a), Laos Westermeyer and Kroll 1978, Australia Jones and Horne 1973) and Central Africa (Murphy 1976). It has also been found to endure across socio-demographic divides (Nunnally 1961, Pescosolido 1999:1345), remaining a ‘cornerstone’ of public apprehension and fear about the mentally disordered (Stuart and Arboleda-Flórez 2001:659).
Szmukler (2010) and Dallaire (2000:692-3) believe mental health legislation in ‘most’ jurisdictions carries an underlying assumption that the mentally ill are ‘dangerous to others’, allowing a form of preventative detention based on ‘risk’. Peay (2003,2009:490) and Pescosolido et al. (1999:1339) support this, stating that legislating for compulsory treatment regardless of the consent of the mentally disordered patient (in contrast to the physically troubled patient, whose consent is obligatory) serves to reinforce the conclusion that the mentally ill are ‘more dangerous and more deserving of intervention’.
The concepts of ‘mental illness’ and ‘dangerousness’ have, in effect, ‘merged’ (Dallaire et al. 2000:691, Szasz 2003:227). Causality in the public mind runs seamlessly from mental disorder to danger – social construction is such that actions are more likely to be seen as dangerous if the actor is, or has been mentally ill (Dallaire et al. 2000:684), Cohen et al. 1998). The effects of this social stigma are tantamount to public rejection. Martin et al (2000:210) cite a plethora of studies from the 1970s onwards that document continued public ‘desire for social distance’ from mental illness (Aviram and Segal 1973, Rabkin 1972, Armstrong 1976, Olmstead and Smith 1980, Roman and Floyd 1981), and these findings are corroborated by Corrigan et al. (2001:953). Such avoidance may aggravate a mental disorder, potentially increasing the likelihood of future violence (Markowitz 2011:39). Misconceptions and unfounded fears often determine the responses of the general public and the criminal justice system to the mentally ill, affecting social policy, legal practice and treatment of the mentally disordered (Martin et al. (2000:210).
IS THIS BELIEF EMPIRICALLY JUSTIFIED?
The controversial relationship between mental disorder and violent behaviour has been the subject of scientific study for more than 20 years (Elbogen and Johnson 2009:152).
The early 1980s saw a rare consensus emerge among both mental health professionals and researchers (Mullen 1997:3, Monahan and Steadman 1983:164), concluding that there was no empirical relationship between mental disorder and dangerous behaviour (Monahan 1992:513, Bonta et al. 1998:123). Despite this, public calls increased for
professionals to ‘predict’ the dangerousness of the mentally disordered, causing a ‘dangerousness criteria’ to be introduced into civil commitment procedure in America, the United Kingdom and Australasia (Mullen (1997:4).
Academic consensus has a notoriously short life strong. Thus, few eyebrows were raised when new research in the 1990s resulted in an academic ‘about-face’. Mulvey (1994:667) found that “contrary to the findings of earlier research, an association does appear to exist between mental illness and the likelihood of being involved in violent incidents.” The new studies established a “consistent, albeit modest, relationship between mental disorder and violent behaviour” (Monahan 1992:514).
Three categories of research strategy are used to investigate this relationship (Mullen 1997:4, Eronen 1998:S13-S14). The first studies the prevalence of violence amongst the mentally disordered who have received treatment within the psychiatric system. The second studies the prevalence of mental disorders in those committing violent acts, and who are therefore within the criminal justice system. Finally, community-based epidemiological studies are carried out to examine separately the presence of mental disorder, and the levels of violent behaviour. The association between these results is then examined.
Former psychiatric patients
Studies of former psychiatric patients have shown, in general, a higher risk of those suffering from severe mental disorders committing violent acts in comparison with the general population (Eronen et al. 1997:S14). Hodgins et al. (2007) found that 39% of female and 49% of male psychiatric patients reported committing assaults in the preceding six months.
The prevalence of mental illness amongst prison populations
The results of prison population studies, although varied, do demonstrate that mental disorder is prevalent within prison inmates (Jones 2009:308). The most recent American study estimated that 64% of prison populations have a history of mental illness (James and Glaze 2006). Markowitz 2011:42) believes that the criminal justice system is, in fact, the ‘largest mental health facility’ in the country – Torrey et al. (2010) reported more than three time as many mentally ill individuals are within the criminal justice system as in mental health facilities. Silver et al. (2008:417) found that offenders with mental health problems were overrepresented in those imprisoned for more deviant types of criminal acts, such as assaultative violence and sexual crimes. A study into those convicted of homicide in England and Wales between 1996 and 1999 found that 10% had experienced symptoms of mental disorder at the time of offending (Shaw et al. 2006). Jones (2009:316) cites the Criminal Statistics, stating that one-fifth of those convicted of unlawful killing successfully plead diminished responsibility. However, he highlights that findings of diminished responsibility may having underlying motives, such as plea-bargaining – and are thus an unreliable indicator of mental disorder.
The relationship between mental disorder and community violence was recently explored by Elbogen and Johnson (2009), using the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). They found that severe mental illness was not an independent factor in predicting future violence. However, it was also found that those with mental illness reported violence more often, primarily due to other factors associated with violence, such as co-morbidity, environmental stressors or violent histories (Elbogen and Johnson 2009:156). These findings were critiqued by Van Dorn et al. (2011), who used the same NESARC data, and found a far stronger statistical relationship between severe mental illness and violence
Whilst there is a general perception that all mental disorders have links to violence – to others or to the self (Link et al. 1999b:1332), Pescosolido et al. 1999:1341), Pescosolido 1999:1341-1343) found that the public, in fact, distinguishes between different types of mental disorder as having differing degrees of ‘dangerousness’. Two types of mental disorder that are affected by particularly strong stigma are schizophrenia and psychopathy (Marie and Miles (2008:131).
Eronen et al. (1998: S14) confirm that levels of violence differ between diagnostic groups, reporting a consistently elevated risk of violence from schizophrenics when compared to the general population. Several studies support this conclusion – Lindqvist and Allebeck’s (1990) Swedish longitudinal study found that the rate of (minor) violent re-offending was four times higher for schizophrenics than for the general population. Tiihonen et al (1997) reported that schizophrenics were seven times more likely than those without mental illness to be convicted of violent crime. In 1986, Taylor found a high prevalence of schizophrenia in those serving life sentences in London – but maintains (1993) that in the aggregate, schizophrenics are in fact unlikely to commit serious violence. This finding was supported by Appleby et al. (1999), who found that schizophrenia accounted for only 4% of homicides between 1996 and 1997.
Angermeyer et al. (1998:S2) reports a significantly stronger association between violence and this severe personality disorder. However, the circular definition of psychopathy (largely based on tendencies to violent outbursts) affects the reliability of empirical research (Jones 2009:316). Black and Spinks (1985) revealed that, following release, psychopaths are likely to commit more violent crime than other mental diagnoses. However, this association was significantly reduced when previous offending was taken into account. Hare et al. (1988) found re-offending rates generally were higher for psychopaths versus non-psychopaths. Jamieson and Taylor (2004) found that two-thirds of discharged patients classified as ‘psychopathic’ reoffended within two years.
Although links have been found between violence and positive symptoms of mental disorder (Elbogen and Johnson 2009, Teasdale 2009), Skeem and Monahan 2011:40) take a different perspective, finding that only 10% of violence committed by the seriously mentally disordered is caused by symptoms. They believe that, minus active symptoms, most of the mentally disordered have the same risk factors for violence as their non-disordered counterparts. Harris and Lurigio (2007:549) believe predicators of mental illness and violence are very similar to those of violence in the general criminal population. This is supported by Stuart and Arboleda-Florez (2001:658), who believe that less than 3% of violent crime can be attributed solely to mental disorders.
Despite a recent report (Department of Health 2009) suggesting that far fewer people now associate mental illness with dangerousness (O’Hara 2009), the perception that mental disorder is inextricably linked to violence persists (Martin 2000:219-220). Phelan et al. (2000:203) concluded that between 1950 and 1996, despite large-scale public education efforts, perception of the seriously mentally ill as ‘violent’ or ‘frightening’ actually substantially increased (Link 1999b:1332). Penn and Martin 1998:239-40, Monahan 1992:519-520 and Link et al. 1992:277) agree that whilst this perception is to some extent justifiable based on a broad view of the empirical evidence, the level of fear is ‘excessive’ when considered in relation to other factors also affecting violent behaviour, which include age, gender, socio-economic status and education. Researchers maintain that the number of mentally disordered individuals who pose a risk to the public is modest (Stuart and Arboleda-Florez 2001:654), Markowitz 2011:42). The public at large are in fact at lower risk of violence from someone suffering from severe mental disorder than from someone who is mentally healthy (Bradford (2008:635) – Steadman et al. (1998:7) held that mentally disordered patients were 11% less likely to be violent towards strangers – 86% of violence occurs within a patient’s network of family and friends (Eronen et al. 1998:S22). Although the mentally disordered may be slightly more likely to engage in violent behaviour, they are far more likely to be victims than perpetrators (Peay 2009:491, Amos et al. 2006:9).
METHODOLOGICAL PROBLEMS WITH ESTABLISHING A LINK
Elbogen and Johnson (2009:153) suggest several reasons why the empirical evidence remains inconclusive. First, current cross-sectional epidemiological studies analyse correlations between past violence and current psychiatric diagnoses – but in order to establish a causal connection, diagnosis of mental disorder must precede the violent behaviour. Secondly, longitudinal studies primarily focus on individuals already within clinical or institutional systems, rather than using representative samples of the general population – limiting their utility in analysing mental illness as an independent risk factor for violent behaviour. Finally, the common practice of combining all violent behaviour to make a single composite variable leaves the question of whether mental disorder is causally related to specific types of violence over others unanswered. Furthermore, the relationship between mental disorder and violent behaviour is ’ideologically charged’ – many believe emphasising an increased risk posed by the mentally ill highlights the need for better mental health services (Markowitz 2011:39), whilst others believe that downplaying any link will reduce stigma and discrimination (Torrey et al 2008).
Further problems include the possibility that any connection between violent behaviour and mental illness is ‘spurious’. Thornicroft (2006:139) sums up additional factors that must be taken into account:
“…the type of diagnosis, the nature and severity of the symptoms present, whether the person is receiving treatment and care, if there is a past history of violence by the individual, the co-occurrence of anti-social personality disorder and substance misuse and the social, economic and cultural context in which an individual lives.”
Link et al. (1999a:320) state that co-morbidity with anti-social personality disorders and substance abuse complicates already convoluted research in this area. Dallaire et al. (2000:682) concludes that among those with substance abuse symptoms, there is no difference between violent acts caused by the mentally ill and the non-mentally ill, believing that almost all associations between violent behaviour and mental illness are affected by substance abuse.
The relationship between mental disorders and violent, or ‘dangerous’ behaviour is intricate and highly complex. There is still a need for ‘significant’ further research before conclusions can be made or causal links drawn (Bradford 2008:635). Mental disorders make ‘at best a trivial contribution to the overall level of violence in society’ (Monahan (2007:144). Szmukler (2010) believes less than 5% of serious violence in our society is perpetrated by the seriously mentally disordered. Yet there is no denying that statistically significant, but modest links can be drawn between mental disorder and violent behaviour. To this extent alone, the public are justified in some associations between the two. However, level of stigma attached to mental disorder has clearly reached a level that is not justified by the empirical evidence. The public need to realise that violence committed by the mentally disordered may be a reflection of failure to treat or to support (Mullen 1997:9), and accept that this can only be remedied through improvements to both social and professional support systems.
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