I hate random acts of violence. I hate the fact that human beings have the ability and potential to commit horrible acts of violence. I hate the fact that these things actually happen. I am amazed at how well most of us are able to function knowing that, at any minute, our lives can be ended or permanently changed through an act of violence. I guess that speaks to the resiliency of the human mind.
Human beings are born with a “drive” toward violent or aggressive behavior but that is generally thought to serve an evolutionary, protective need. At the same time it is difficult to comprehend how human beings are capable of random violence. The brain is wired to have a certain level of anxiety, which translates into guilt or empathy, around hurting other people. This leads to ethics and morality and is what keeps most of us from harming others. For these reasons, random acts of violence, especially those severe enough to garner national attention, usually elicit an initial thought of “Why?!?”
I suppose most of you have seen the mug shot of the Tucson shooter, Jared Loughner. There is ferocity in his eyes along with a smug grin that is absolutely chilling. He looks, for lack of a better word, crazy. It would be fair to assume that he is crazy. The clinical psychiatric term for “crazy” is “insane”. Insanity is basically a break from reality and is generally caused by severe mental illness.
The public tends to exaggerate the actual risk of violence that a severely mentally ill person poses. Some of this is grounded in research. Studies have shown that a person with severe mental illness (Schizophrenia, Bipolar mood disorder and Major Depressive Disorder) is 2-3 times more likely to commit an act of violence. These studies, however, are flawed. They tend to include a biased population of incarcerated people with severe mental illness, not factoring in those in general public. People who are incarcerated have a higher risk of engaging in violent acts. The studies also tend to overlook important variables such as the relational or environmental issues that led to the violence.
The question, therefore, of whether or not those with severe mental illness are more likely than others to engage in violent behavior does not have a clear answer. A direct association may never be established as there are too many variables in each case of violence. Additionally, violence is difficult to predict and basically can only be studied retrospectively. Retrospective studies are never as powerful as prospective studies, which offer the ability to control most variables.
One of the better assessments of the risk of violence in severely mentally ill patients comes from the Epidemiologic Catchment Area (ECA) survey. It is administered by the National Institute of Mental Health every few years. One finding reported is that those with severe mental illness have a higher lifetime prevalence of committing a violent act. This finding is a bit deceiving. In the survey, people with severe mental illness who engaged in violent behavior tended to have risk factors including substance abuse, not being in treatment, being homeless, having been victims of violence, and having poor medical health. The violence risk decreases as the amount of risk factors decrease. “The one year rate of violent behavior for subjects with none or only one of these risk factors was 2%, which is close to the ECA study’s estimate for the general population.” Perhaps most striking, those with no mental health problem but who abused alcohol or drugs reported violent behavior almost seven times more than the general public.
The general public tends to fear and shun people with severe mental illness. This fear contributes to the stigma against people with mental illness, as they are considered insane. Regarding insanity and criminal acts, the American Psychiatric Association’s position statement reads that, “…the insanity defense has always been grounded in the belief that there are defendants whose mental conditions are so impaired at the time of the crime that it would be unfair to punish them for their acts.” In other words, these people suffer from a medical condition of severe mental illness. That condition can “substantially impair an individual’s capacity to reason rationally and to inhibit behavior that violates the law.” These people need help, not to be feared and pushed away or incarcerated.
Jared Loughner may or may not suffer from severe mental illness. Allegedly, he has abused drugs and alcohol at times in his life. Maybe he knew exactly what he was doing and should be punished to the full extent of the law. We may never know why he did what he did. I am concerned that he will become a symbol of what mental illness is and that the public will misconstrue severe mental illness and therefore further stigmatize those who suffer from it. Ironically, this stigma can decrease the amount of support available to people suffering from severe mental illness or substance abuse and can cause those suffering to turn away from medical help when it is needed. This ultimately increases their risk of violence.
The onus is on providers in the field of mental health to work on better ways to educate patients and the public and to provide treatment to those in need. The onus is additionally on all of us to decrease the stigma of mental illness; to work towards better understanding and ways to support people who suffer from severe mental illness and substance abuse.
Go Representative Giffords. We are all pulling for you in your amazing recovery!
1. “Violence and Mental Illness — How Strong is the Link?” Richard A. Friedman, M.D. N Engl J Med 2006; 355:2064-2066November 16, 2006