"WHAT DO WE KNOW ABOUT MENTAL DISORDER AND VIOLENCE" is the title of a new brochure supported by the Center for Mental Health Services through its Memorandum of Understanding with the National Institute of Justice and produced by Policy Research Associates (December 1994). Production and distribution of this brochure has been limited to less than 20,000 copies and arrangments for future production/dissemination have not yet been made with the CMHS. Therefore, the complete text follows. Information on how to order copies is located at the end. WHAT DO WE KNOW ABOUT MENTAL DISORDER AND VIOLENCE? Source Of This Information In January 1993, the National Institute of Mental Health convened a conference of leading researchers, consumers, family members, and mental health administrators, titled "Treatment of Violent Mentally Ill persons in the Community: Issues of Policy, Services and Research." This brochure is drawn from the information presented there, some subsequent publications, and the critiques of conference participants on prior drafts of this document. The content here is not a consensus of that group, but is intended to reflect their main points of agreement. ----------- PUBLIC PERCEPTIONS * The belief in a strong link between violence and mental illness is firmly rooted in the minds of many U.S. citizens. Television, movies and newspapers regularly foster this view by selective and sensationalized reporting (Steadman and Cocozza, 1978). * In a recent survey, members of the National Alliance for the Mentally Ill (NAMI), when asked about their experiences, consistently cited media sources (film and news stories about mentally ill criminals, in particular) as primary contributors to mental illness stigma (Wahl and Harman, 1989; Wahl, 1992). ------------ DOES RESEARCH SUPPORT THE PUBLIC'S PERCEPTION? * In a word, NO. There is no empirical support for the strong connection the public assumes between mental disorder and violence. In fact, prior history of violence and current alcohol and drug abuse are much more accurate indications of the risk of violence. * 1970s: Research in the 1970s began to indicate some relationship between mental illness and violence, but not for the direct, strong link presumed by the public. * 1980s: Studies continued to show higher arrest rates for patients released from inpatient mental hospitals than for the general public. These studies, however, were inconsistent in finding any relationships between certain psychiatric diagnoses and violence, except for substance abuse and antisocial personality disorder. * 1990s: The recent NIMH Epidemiological Catchment Area Study estimated that about 90 percent of persons with current mental illnesses are not violent within one year (Swanson, et al., 1990). This fact alone refutes the dominant media representation of most persons with mental illnesses. In fact, violent behavior of persons with mental illnesses represents only a minor contribution to all violent crimes. * Link and colleagues (1992) state, "If a patient is not having a psychotic episode, or if psychiatric problems do not involve psychotic symptoms, then he or she is nor more likely than the average person to be involved in violent/illegal behavior." * However, certain types of symptoms, especially disorders in which people perceive threats against themselves, may increase the probability of risk of violence in persons with mental illnesses." It may be that inappropriate reactions by others to psychotic symptoms are involved in producing the violent/illegal behavior" (Link, 1992). * Nevertheless, compared with the risk associated with alcoholism and other drug abuse, the risk associated with major mental disorders, such as schizophrenia and affective disorder, is small. Compared with the risk associated with the combination of male gender, young age, and lower socioeconomic status, the risk of violence presented by mental disorder is modest. * The bottom line from recent research is that "the studies to date have shown an increased risk for violence among (certain) individuals with mental illness compared to the general population; mental illness increases the likelihood of having a violent incident." But, "the absolute risk posed by mental illness is small, and only a small proportion of the violence in our society can be attributed to the mentally ill" (Mulvey, 1994). * "Clearly, mental health status makes at best a trivial contribution to the overall level of violence in society" (Monahan, 1992). ------------ WHAT ARE THE IMPLICATIONS? * Substance abuse presents much greater risks for violence than does mental disorder. * The type and level of symptoms and disabilities are more important than diagnoses for understanding, treating, and preventing violent behavior in persons with mental illnesses. * Violence among persons with mental illnesses may be caused by many of the same factors producing violence in the general public (e.g., people become violent when they feel threatened and when they use alcohol and drugs excessively). * In efforts to predict and treat violence, it is important to recognize that risk fluctuates over time. Risk is not a static personality trait; violent behavior is a product of the interactions between an individual and his or her environment. The level of risk depends on many factors other than mental disorder that vary, thus increasing or decreasing risk of violence by persons with mental illnesses (Campbell, Stefan, and Loder, 1994). * Appropriate legal protections for persons receiving various forms of community supervision are necessary so that individuals' rights are properly balanced with the community's right to protection (e.g., legal representation at hearings to change the conditions of community supervision). * It is possible to identify families at risk, but the nature of effective interventions is unclear. Furthermore, we really have not asked, and therefore don't know, what preventive intervention(s) families and consumers might prefer. It may be useful to think about "risky environments" rather than "risky persons" when framing research questions. * To the degree that support services are available, are used, and are effective, persons with mental illnesses pose no greater threat to the community than other individuals. If these elements are not in place, some persons with mental illnesses may commit violent acts that will lead to their arrest (Dvoskin and Steadman, 1994). * Future research should not only study relevant experiences, but also examine how these experiences are interpreted by consumers and families. * Inadequate attention has been paid by researchers to violence against people with mental illnesses. * Intensive Case Management programs have shown considerable promise for helping the small group of persons with mental disorders who are violent (Dvoskin and Steadman, 1994), and brief inpatient treatment or crisis stabilization services may also be warranted (Task Force on Homelessness and Severe Mental Illness, 1992). * Future research should focus more closely on wellness models, i.e., consumers whose violent behavior decreased after certain interventions occurred. ---------- STATEMENT ON VIOLENCE BY PERSONS WITH MENTAL DISORDERS This statement was drafted by the John D. and Catherine T. MacArthur Foundation Research Network on Mental Health and the Law, under the direction of John Monahan, Ph.D., in collaboration with the National Stigma Clearinghouse. "Mental disorder" and violence are closely linked in the public mind. A combination of factors promotes this perception: sensationalized reporting by the media whenever a violent act is committed by "a former mental patient," popular misuse of psychiatric terms (such as "psychotic" and "psychopathic"), and exploitation of stock formulas and narrow stereotypes by the entertainment industry. The public justifies its fear and rejection of people labeled "mentally ill," and justifies its fear and rejection of people labeled "mentally ill," and attempts to segregate them in the community, by this assumption of dangerousness." The experience of people with psychiatric conditions and of their family members paints a picture dramatically different from the stereotype. The results of several, recent large-scale research projects conclude that only a weak association between mental disorder and violence exists in the community. Serious violence by people with major mental disorders appears concentrated in a small fraction of the total number, and especially those who use alcohol and other drugs. Mental disorders -- in sharp contrast to alcohol and drug abuse -- account for a minuscule portion of the violence that afflicts American society. The conclusions of those who use mental health services and of their family members, and the observations of researchers, suggest that the way to reduce whatever modest relationship exists between violence and mental disorder is to make accessible a range of quality treatments including peer-based programs, and to eliminate the stigma and discrimination that discourage, sometimes provoke, and penalize those who seek and receive help for disabling conditions. -------- REFERENCES Campbell, J., Stefan S., and Loder, A. (1994). Putting Violence in Context. Hospital and Community Psychiatry, 45, 633. Dvoskin, Joel A. and Steadman, Henry J. (1994). Using Intensive Case Management to Reduce Violence by Mentally Ill Persons in the Community. Hospital and Community Psychiatry, 45 (7), 679-684. Lidz, C.W., Mulvey, E.P. and Gardner, W. (1993). The Accuracy of Predictions of Violence to Others. Journal of the American Medical Association, 269, 1007-1011. Link, B.G., Andrews, H. and Cullen, F.T. (1992). The Violent and Illegal Behavior of Mental Patients Reconsidered. American Sociological Review, 57, 275-292. Monahan, John (1992). Mental Disorder and Violent Behavior: Perceptions and Evidence, American Psychologist, 47 (4), 511-521. Monahan, John and Steadman, Henry J., Eds., (1994). Violence and Mental Disorder: Developments in Risk Assessment. Chicago, IL: The University of Chicago Press. Mulvey, Edward P. (1994). Assessing the Evidence of a Link Between Mental Illness and Violence. Hospital and Community Psychiatry, 45, 663-668. Steadman, Henry J. and Cocozza, Joseph J. (1978). Selective Reporting and the Public's Misconceptions of the Criminally Insane. Public Opinion Quarterly, 41 (4), 523-533. Steadman, Henry J. (1981). Critically Assessing the Accuracy of Public Perceptions of the Dangerousness of the Mentally Ill. Journal of Health and Social Behavior, 22, 310-316. Swanson, J.W., Holzer, C.E., Ganju,V.K., and Jono, R.T. (1990). Violence and Psychiatric Disorder in the Community: Evidence from the Epidemiological Catchment Area Surveys. Hospital and Community Psychiatry, 41, 761-770. Task Force on Homelessness and Severe Mental Illness (1992). Outcasts on Main Street: Report of the Federal Task Force on Homelessness and Severe Mental Illnesses. Washington, DC: Interagency Council on the Homeless. Wahl, O.F. and Harman, C.R. (1989). Family Views of Stigma. Schizophrenia Bulletin, 15, 131-139. Wahl, Otto F. (1992). Mass Media Images of Mental Illness: A Review of the Literature. Journal of Community Psychology, 20, 343-352. ----------- CONFERENCE PARTICIPANTS Joseph Bevilacqua, M.D., Commissioner South Carolina Department of Mental Health Jean Campbell, Ph.D. Maine Department of Mental Health and Mental Retardation Joel Dvoskin, Ph.D. New York State Office of Mental Health Sue E. Estroff, Ph.D. University of North Carolina Jeffrey L. Geller, M.D., M.P.H. University of Massachusetts John Lion, M.D. Baltimore, MD Ann Loder Fort Lauderdale, FL Edward P. Mulvey, Ph.D. University of Pittsburgh Barbara Rankin Prospect, KY Chris Slobogin, J.D., LL.M. University of Florida Holland Law Center Henry J. Steadman, Ph.D Policy Research Associates Susan Stefan, J.D. University of Miami School of Law Jeffrey Swanson, Ph.D. Duke University Melvin Wilson, Ph.D. University of Virginia Ecford S. Voit, Jr., Ph.D. National Institute of Mental Health