Stigma and Violence: Isn’t It Time to Connect the Dots?

Abstract

Stigma against mentally ill persons is a major problem and has increased in incidence. Multiple studies have suggested that the perception of violent behavior by seriously mentally ill individuals is an important cause of stigma. It is also known that treating seriously mentally ill people decreases violent behavior. Therefore, the most effective way to decrease stigma is to make sure that patients receive adequate treatment.

Stigma against individuals with mental illnesses is condemned by everybody. Efforts to combat it have included a National Mental Health Awareness Campaign, a National Anti-Stigma Campaign, an Elimination of Barriers Initiative, a National Stigma Clearinghouse, National Alliance on Mental Illness Campaign to End Discrimination and StigmaBusters, and efforts by individuals, such as Glenn Close’s recent BringChange2Mind campaign. Everybody wants to fight stigma, and for good reason—it is probably the heaviest burden borne by mentally ill persons. It affects opportunities for housing, employment, and socialization and becomes for many a scarlet letter.

Despite efforts to combat stigma, there has been a reluctance by the mental health community to objectively assess its causes. It is as if putting up enough posters saying “mentally ill persons make good neighbors” will make stigma go away. As professionals who are theoretically trained to be aware of denial and other mental mechanisms for avoiding the truth, our profession has an unenviable record in our response to the problem of stigma. I will argue that solutions to this problem are obvious and can be achieved by connecting 6 dots.

Dot 1: Stigma Against Individuals With Mental Illnesses has Increased Over the Past Half Century

Using comparable national surveys, Phelan et al¹ compared public attitudes toward mentally ill persons in 1950 and 1996. They reported that, despite an increased understanding of the causes of mental illness in 1996, stigma had increased. This finding was also reflected in the 1999 Surgeon General’s report on mental health: “Stigma in some ways intensified over the past 40 years even though understanding improved.”²

More recently, using comparable 2006 data, the same research group compared the 2006 findings with those from 1996.³ They again assumed that “neuroscience offers the most effective tool to reduce prejudice and discrimination” and theorized that the 1990s “Decade of the Brain” would have increased public understanding and thereby decreased stigma. Instead, they found that stigma has continued to be a major problem: “Our most striking finding is that stigma among the American public appears to be surprisingly fixed, even in the face of anticipated advances in public knowledge.”

Dot 2: Violent Acts Committed by Mentally Ill Person Have Increased Over the Past Half Century

This is suggested by studies carried out between 1900 and 1950, in which the percentage of homicides committed by “insane” or “psychotic” persons ranged from 1.7% to 3.6%. A review of these studies concluded that the proportion of homicides committed by seriously mentally ill individuals “is usually 2% or less.”^4–7 By contrast, in more recent years, a New York study by Grunberg et al^8,9 reported that 8/48 (17%) of individuals who committed homicide had schizophrenia and a California study reported that 7/71 (10%) of individuals who committed homicide had paranoid schizophrenia.¹⁰ Most recently, in a study of convicted murderers in Indiana, Matejkowski et al¹¹ reported that 95 of 518 on which there were sufficient records available had a “severe mental illness.” That would be 17%. Such findings are consistent with 14 studies of homicides in other countries; the percentage of seriously mentally ill individuals ranged from 5.3% to 17.9% (average 9.3%) in these studies.¹²

Dot 3: The Perception of Violent Behavior by Mentally Ill Persons is an Important Cause of Stigma

It is clearly established that viewing mentally ill persons as dangerous leads to stigmatization. As summarized by Link et al¹³ more than 2 decades ago: “When a measure of perceived dangerousness of mental patients is introduced, strong labeling effects emerge… . The interaction between labeling and perceived dangerousness is highly significant.” The studies that reported an increase in stigma against mentally ill persons also reported that the public perception of their dangerousness had also increased. Studies of public attitudes in the 1950s reported that stigma against mentally ill persons was rather nonspecific and based primarily on a lack of knowledge, eg, there was a widespread belief that it was God’s punishment for sin. At that time, violent behavior did not appear to be a prominent cause of stigma.¹⁴ In contrast, between 1950 and 1996 “perceptions that such people (people with psychosis) are dangerous increased nearly two and a half times since 1950 to a point that, in 1996, nearly one-third of respondents spontaneously volunteered the idea that psychotic persons may be violent.”¹ As the 1999 Surgeon General’s report on mental health summarized the issue: “Why is stigma so strong despite better public understanding of mental illness? The answer appears to be fear of violence: people with mental illness, especially those with psychosis, are perceived to be more violent than in the past.”²

Several studies have also demonstrated a direct link between violent behavior by mentally ill persons and stigma. Thornton and Wahl¹⁵ showed that “reading a newspaper article reporting a violent crime committed by a mental patient” produced “negative attitudes toward people with mental illnesses.” In Germany, following “2 attempts on the lives of prominent politicians committed by mentally ill persons during 1990, there occurred a marked increase in social distance toward the mentally ill among the German public.”¹⁶ Given such studies, it seems likely that media coverage of the recent shooting of Congresswoman Gabrielle Giffords by Jared Loughner probably reversed the effects of all anti-stigma campaigns for the last decade.

Dot 4: Most Episodes of Violence Committed by Mentally Ill Persons are Associated With a Failure to Treat Them

This has been demonstrated in many studies. For example, 2 meta-analyses of individuals with serious mental illness who commit acts of violence, including homicides, reported that a disproportionate number of these acts occur during the person’s initial psychotic episode, before they have been treated.^17,18 A study of 60 seriously mentally ill men charged with violent crimes reported that medication noncompliance played a significant causal role.¹⁹ A study of 1011 seriously mentally ill outpatients reported that “community violence was inversely related to treatment adherence.”²⁰ A study of 802 adults with serious mental illnesses found that those who were violent were 1.7 times more likely to have been noncompliant with medication.²¹ Multiple older studies have also demonstrated this association, including one that reported an inverse correlation between blood level of antipsychotic medication and propensity to violence among inpatients.²² As Dr Thomas Insel, the director of the National Institute of Mental Health, recently summarized it: “The data support the proposition that people with schizophrenia are more likely to be involved in violence either toward others or toward themselves unless they’re treated.”²³

Dot 5: Treating People With Serious Mental Illnesses Significantly Decreases Episodes of Violence

Multiple studies have demonstrated that the treatment of individuals with serious mental illnesses with antipsychotic medication, especially clozapine, is effective in reducing arrests rates and violent behavior.^24,25 Researchers in Germany measured aggressive behavior (“threats, physical aggression against persons and objects, self-directed aggression” in individuals with schizophrenia before and after beginning antipsychotic medication. They reported: “The day-to-day decline of aggressive incidents after the start of neuroleptic (antipsychotic) medication was highly significant… . The results support the assumption that the increased figures for violence by schizophrenics are, at least in part, due to the lack of adequate treatment.”²⁶ Similarly, an assessment of violent behavior among patients in the Clinical Antipsychotic Trials of Intervention Effectiveness study reported that “medication adherence across all treatment groups was significantly associated with reduced violence, except in patients with a history of childhood antisocial conduct.”²⁷ The latter group would be assumed to have an antisocial personality disorder that would be the cause of their violent behavior; thus, antipsychotic medication would not have been expected to be as effective.

Finally, 2 studies have directly assessed the effect of assisted outpatient treatment (AOT) on violent behavior. Patients referred for AOT are a special group, usually having a history of medication noncompliance often accompanied by violent behavior. AOT is a means of ensuring that such individuals take their medication. In North Carolina, subjects with a history of serious violence had a reduction in violence from 42% to 27% when the AOT was continued for at least 6 months.²⁸ In New York, AOT reduced the proportion of individuals who “physically harmed others” from 15% to 8% and the proportion who “threatened physical harm” from 28% to 16%.²⁹ Thus, as Dr Insel summarized the situation: “Treatment may be the key to reducing the risk of violence, whether that violence is self-directed or directed at others.”³⁰

Dot 6: Reducing Violent Behavior Among Individuals With Mental Illnesses Will Reduce Stigma

This is the corollary of Dot 3. If violent behavior by mentally ill persons is an important cause of stigma, then reducing violent behavior should logically reduce the stigma. As far as I know, nobody has ever attempted to assess this. It could theoretically be done by measuring stigma before and after the implementation of an effective treatment program, allowing for a sufficient number of years for public opinion to change. Or it could be done by comparing the level of stigma in 2 countries with significantly different levels of violence by individuals with serious mental illnesses.

Discussion

Connecting the dots would seem, at first glance, to be both logical and easy to do. Since stigma is a major problem, increasing in incidence, and caused in part by violent behavior by mentally ill persons who are not being treated, and since we know that treating people with serious mental illnesses reduces violent behavior, all we have to do is make sure patients receive treatment. Stigma would then decrease, and everyone would be happier. Why doesn’t this happen?

There are 2 major reasons why the dots do not get connected. The first is a reluctance to go to Dot 3 because it acknowledges that violent behavior among individuals with serious mental illnesses is a problem. That is politically incorrect. The mental health community reports like a mantra, “mentally ill persons are not more violent than the general population,” despite overwhelming data to the contrary.

Variants of this mantra include the following: “most acts of violence are not committed by mentally ill individuals”; “mentally ill individuals are the victims of violence much more often than they are the perpetrators of violence”; “people with alcoholism and drug addiction are more violent than people with serious mental illnesses”; and “most mentally ill people are not violent.” All 4 statements are true, but they neither contradict nor negate the fact that a small number of seriously mentally ill individuals do become violent when they are not treated, and these episodes of violence are an important cause of stigma against all mentally ill persons. The public understands these differences. In the 1996 public survey referred to above, they were asked to rate the likelihood of violence by people with cocaine addiction, alcohol dependence, schizophrenia, major depressive disorder, and a “troubled person” (“worrying, sadness, nervousness, and sleep problems”). The public rated the likelihood of violence as 87%, 71%, 61%, 33%, and 17%, respectively.³¹

The reluctance of mental health professionals to link violent behavior and mental illness should not be underestimated. It is reflected in a 1992 statement by Dr John Monahan:

The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social and demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior… . Denying that mental disorder and violence may be in any way associated is disingenuous and ultimately counterproductive.³²

When professionals are asked why they are reluctant to link violence with mental illness, they often respond that doing so will increase stigma. But if the stigma is being caused by the violence, then failing to address this link will guarantee that the problem will never improve.

The second reason why the dots do not get connected is because they lead to a politically incorrect end point. It is known that approximately half of individuals with schizophrenia and bipolar disorder have impairments of brain function that make it difficult or impossible for them to perceive their need for treatment. This is not mere denial, but a biologically based deficit related to the disease process and similar to the unawareness of illness seen in Alzheimer’s disease. Neurologically, it is referred to as anosognosia. Since this is true, in order to ensure that seriously mentally ill individuals are receiving treatment so that they will not become violent, a subset of them will have to be treated involuntarily. Such treatment is regarded as an infringement on the person’s civil liberties and, as such, is politically incorrect.

Historically, then, we have come a long way but in doing so have gone nowhere. In 1950, there was stigma against people with mental illness because people did not understand what mental illnesses were and regarded such illnesses as God’s punishment. There was a relatively weak association between violence and mental illness among the public at that time. In the intervening 60 years, the public has become educated so they now understand that mental illnesses are brain diseases. But during those same years, we have also emptied the hospitals and allowed approximately half of individuals with serious mental illnesses to remain untreated at any given time. A small number of these people commit violent acts, often widely publicized, and such acts have increased stigma. Thus, over the past 60 years, we have traded stigma associated with God’s punishment for stigma associated with violent acts; such stigma is now greater than it was 60 years ago and is still increasing. This hardly qualifies as progress.

The people who are hurt most by our failure to connect the dots are people with mental illnesses. Following the shooting of Congresswomen Giffords and others in Tucson, a woman with schizophrenia wrote to President Obama: “I am very concerned about the problem in this country of the UNTREATED severely mentally ill population. When violent, they give the rest of us a bad name. I take that personally… . Please see that this tragedy does not happen again.”³³

At a practical level, what this means is that we can continue to try to educate the public about mental illnesses, but it will have no effect on stigma. A lack of knowledge is not an important cause of stigma, but violent episodes by mentally ill individuals are. In 1981, Henry Steadman noted that “recent research on contemporary populations of ex-mental patients support these public fears (of dangerousness) to an extent rarely acknowledged by mental health professionals.”³⁴ Thirty years later, professional attitudes are little changed. It is as if we are experiencing a flood, but we professionals are fooling ourselves and averting our eyes from the source of the water. The public knows better. En route to work, they glance at the poster proclaiming that mentally ill people make good neighbors. Then they see the news about the latest violent act by an untreated person with mental illness. The public knows which one to believe.