Discourse / Letters / March 9, 2011

A public service announcement from the members of Psychology 277

We noticed that the TKS printed an opinion from political psychology on the recent Arizona shootings and the 22 year-old charged with the criminal acts. This 1/19/2011 TKS article addressed the possible connection (or the lack of one) between mental illness and violence. We, the Clinical and Abnormal Psychology class (PSYC 277), agree that this is an important issue and would like to offer an opinion from clinical psychology [the branch of psychology which deals with the diagnosis and treatment of mental illnesses.]

What is Mental Illness?

The term mentally ill might be vague to some – perhaps a particular profile comes to mind. In fact, mental illness has many faces. The Diagnostic and Statistical Manual (DSM-IV-TR) outlines over 100 different mental illnesses, including disorders of adjustment (e.g., feeling somewhat depressed after moving away to college for the first time), intellectual functioning (e.g., mental retardation), anxiety (e.g., constant worrying, flashbacks of traumatic experiences), attention (e.g., AD/HD), substance abuse (e.g., cannibis dependence), thought (e.g., thinking patterns which are cut off from reality), and personality (e.g., stable, persistent dysfunction in relationships). Given the vast array of mental disorders, 25% of adults in this country meet criteria for a mental disorder in any given year – that’s 1 in 4 of us (National Institute of Mental Health, 2011)!

Is There a Connection Between Mental Illness and Violent Crime?

Evidently, 25% of people in the U.S. are violent criminals. Of those who are violent, only a small proportion have a mental illness. To clarify, there is much more violence from people without a mental illness than people with a mental illness (see Nordstrom, Kullgren, & Dahlgren, 2006). And further, there is a very small percentage of people diagnosed with a mental illness who are violent. Yet some people still believe that if a horrible violent act committed, the person must have been mentally ill. This type of blame and jumping to conclusions could be due to false information and misconceptions. The reason that the public has this illusion that people with mental illnesses are dangerous is partially due to the media, and these messages begin in childhood. For example, a recent research investigation of children’s films found that among those containing mentally ill characters, ⅔ of those characters had violent behaviors, and approximately ⅔ of the non-mentally ill characters in those same films reacted to the mentally ill characters with fear (Wahl et al., 2003a). In addition, the stories that make the news tend to involve more drama to attract viewers. Research examining the portrayal of mentally ill individuals in newspapers also shows that ‘dangerousness’ is the most prominent thread in the stories (Wahl, 2003b). Perhaps in the public’s eye, a story about a shooting with a perpetrator who has a mental illness is more interesting than someone who just has anger problems.

Despite the fact that most violent crimes are not committed by individuals who are mentally ill, there are occasions in which certain individuals who are mentally ill carry out violent acts. Research suggests that specific risk factors include being a young male, being in the early stage of a mental illness, having concurrent substance abuse disorders, personality disorders or psychotic symptoms such as paranoid delusions (e.g., individuals with schizophrenia appear to have 4-6 times higher risk of committing a violent crime, according to Nordstrom, Kullgren & Dahlgren, 2006 – see next paragraph for description). Surprisingly, targets of these violent acts are primarily immediate family, then friends. Acquaintances and strangers are very rarely targets.

There are two particular mental disorders worth mentioning here ¬– the first because of common misconceptions about it, and the second because of general ignorance about it. 1) Schizophrenia which affects 1% of the US population, is a disorder that contains delusions, hallucinations, disorganized thinking and paranoia. Patients who suffer from this illness cannot determine reality from imagination. The delusions (ideas that are not real) create irrational behavior and thoughts. For example, believing all doctors are part of a huge conspiracy to experiment on people and then never going to a doctor. The hallucinations (e.g., seeing and hearing things that are not real) can play into the delusions; for example, hearing a disembodied voice telling you the government is evil. Disorganized thinking (mixed up thoughts, that do not have a logical order) leads to confusion and a general lack of understanding of the world. For example, a patient may not understand a conversation as simple as discussing what to cook for dinner. Paranoia (illogical panic that someone will hurt you) can bring fear into a normal situation. For example, becoming convinced that your professor wants to kill you and being frozen with fear in class. These symptoms make it very hard for a person to carry out everyday life. Such as, the person could become convinced that imaginary people only they can see (hallucinations) are trying to hurt them (paranoia) and they might never want to leave the house. Combined with the disorganized thinking that makes it hard to learn or work makes it hard for patients to live independently. Such a person may have difficulty carrying out a violent plan.

A mental illness more likely to lead to violence is Antisocial Personality Disorder (ASPD). People suffering from an extreme form of this disorder are commonly called psychopaths. ASPD affects 4% of Americans but 75% of all prisoners meet the standards for diagnosis (not all prisoners are diagnosed; Reid, 2000). They suffer from an extreme lack of empathy – this leads them to not care about harming other people. They can commit horrible crimes such as murder and sexual assault and not feel any regret. Researchers in New Mexico have discovered that people suffering from ASPD do not feel any emotion deeply and cannot recognize the emotions of others. They also have a problem stopping a behavior after they have started. Another key symptom is disregarding the rights of others (Kiehl). Together this can lead to a person with ASPD continuing to kill people and ignoring the victims begging him to stop. These researchers believe that in the future, treatments can be devised that can help deepen the emotions of psychopaths and make it easier for them, but for now, they are the most likely mentally ill people to commit crimes.

According to Loughner’s close friends, he felt offended when congresswoman Giffords did not answer a delusional non-sensical question he asked at an event years prior to the shooting (Huffington Post, 2011). This perceived personal slight seems to have festered into a deep bitterness on Loughner’s part. Years later, in what appears to be increasing psychosis, he then executed a plan to assassinate her and others around at the moment whom he may have perceived in his delusional thinking to share her belief system. 4) say which disorder profile above (Sch or ASPD) seems to fit him best.

Can We Predict Violent Acts?

Unfortunately, simply knowing the risk factors for violence stated above is not enough. Predicting the occurrence of specific violent acts or their timing can be extremely difficult (Freedman et al., 2007). The best predictor is a clearly stated intent and plan to harm another person by a person who has the means – this is very rare. In the absence of stated intent, one thing to look for is a history of violence. As the saying goes, history repeats itself, thus past aggression and violence can be a good predictor of the future. Another red flag and a better predictor is a statement of a plan and a victim. Even with that information, there is still uncertainty as to whether the plan will come to fruition. It is common for people to daydream or mention off-hand how they would like to harm someone who they are angry at or someone they do not like. But this does not mean they will go through with it. Therapists and researchers have noticed that plans of violence stay in the mind of the individual for a long time, then in a moment of high arousal and impulsively, it is acted out (Freedman et al., 2007). If a patient is talking to a therapist and specifically states a plan with a victim, it is the therapist’s duty to protect that intended victim with necessary measures. This could involve the police or informing and relocating the potential victim.

Despite the difficulty predicting specific violent acts or their timing, active psychotic symptoms of the nature we discussed (i.e., increasing paranoia) are not difficult for a clinical psychologist or other mental health professionals to diagnose, nor are they very difficult to treat with anti-psychotic medications. For example…1) insert info on Jared’s likely psychotic symptoms see Huffington post website for this and even quote some of his writings in his videos (see TKS article or Loughers videos – link below). A thorough clinical interview can also easily uncover a history of aggression. 2) Insert text on Jared’s history of aggression (see TKS article or Lougher’s videos – link below)

An important part of the problem with the small proportion of violence perpetrated by individuals who are mentally ill is the inadequacy of care the state offers them. If a person is ill and does not receive the care s/he needs, the condition will worsen – this is true for physical and mental illness. Over the course of history, many different approaches have been taken to provide adequate care for those with mental illnesses. One of the more recent and currently influential movements of this nature is that of “deinstitutionalization,” which began in the 1960s. At that time, many people came forward to advocate for the rights of mentally ill people in hopes of affording them more freedom and community-based support. These demands came about as a reaction to the housing of thousands of mentally ill people in psychiatric wards where they may not have been receiving adequate care and were actually worsening over time. As a direct result of this movement, many/most psychiatric hospitals were closed and patients were released back into their homes and communities, and the U.S. government provided funding for the creation of community mental health centers across the nation, where individuals with varying levels of psychopathology could come for outpatient treatment within their own neighborhood. Large numbers of previously institutionalized individuals were rehabilitated into regular community living, and were only readmitted to psychiatric wards when they had acute episodes. Unfortunately, a number of problems ensued, many of which occurred because of a lack of adequate funding for community mental health centers from the start and a continuous decline in the funds provided annually. Currently, large numbers of people with severe mental illnesses do not receive any professional treatment within a given year, and many more receive substandard care by understaffed facilities. There has also been a large increase since the 1960s in the number of mentally ill people being housed in nursing homes or living on the streets. Particularly in the cases of some mental disorders which are associated with violence and aggression, some of these formerly institutionalized mentally ill people have committed crimes and ended up in jail. (all information on deinstitutionalization is from Nolen-Hoeksema, 2010).

What Can We Do as a Society and as Individuals?

1) Give recommendation on how to improve MH care in general…including for physicians/GPs/pediatricians.

2) Discuss avoiding stigma and labels? Empathy – remember most of us have had a friend or family member who has experienced a mental disorder or episode, or have ourselves experienced one. Praise TKS prior articles for this (read the portions where students were quoted).

3) Realize how social support and acceptance by family and friends can help individuals with SMI have less severe symptoms and prevent relapse

4) Strongly encourage family/friends to seek help when you suspect it may be needed (e.g., increasingly distressed, increasingly illogical, or increasingly strange behaviors, etc.). Sometimes it help to offer to accompany them to the appointment.

5) If you feel distressed psychologically (i.e., in terms of hard-to-handle emotions or disorganized thoughts) call the Knox counseling center for an appointment (X7492)

This document is a collaborative effort by Gail Ferguson, Asia Bey, Lauren Smith, Tara Jarvie, Jessica Joyce, and Katie Wrenn. On behalf of Psych 277

References and resources for further reading

American Psychological Association (2011). Managing your distress in the aftermath of a shooting. Retrieved from http://www.apa.org/helpcenter/mass-shooting.aspx

Freedman, R., Ross, R., Michels, R., Appelbaum, P., Siever, L., Binder, R., Carpenter, W., Hatters Friedman, S., Resnick, P., & Rosenbaum, J. (2007). Psychiatrists, mental illness, and violence. American Journal of Psychiatry, 169:3, 1315-1317.

Huffington Post (2011). Jared Lee Loughner Identified As Gabrielle Giffords Shooter. Retrieved from

http://www.huffingtonpost.com/2011/01/08/jared-lee-loughner-gabrielle-giffords- shooter_n_806243.html

Meier, A. (2011). From politics to psychiatry: laying blame in Arizona. Determining the causes of the Arizona shooting. Retrieved from http://www.theknoxstudent.com/newsroom/article/from- politics-to-psychiatry-laying-blame-in-arizon/

National Insitutes of Mental Health (2011). The Number Count: Mental Disorders in America. Retrieved from http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-

america/index.shtml

Nolen-Hoeksema, S. (2010). Abnormal Psychology. New York: McGraw Hill.

Nordstrom, A., Kullgren, G., & Dahlgren, L (2006). Schizophrenia and violent crime: The experience of parents. International Jurnal of Law and Psychiatry, 29, 57-67.

Reid, W. (2000). Treatment of antisocial personality, psychopathy, and other characterological antisocial syndromes. Behavioral Sciences and the Law, 18, 647-662.

Kiehl, Kent; Buckholtz, Joshua, (2010). Inside the mind of a Psychopath. Scientific American Mind, 22-29.

Wahl, O., Wood., A., Zaveri, P., Drapalski, A., & Mann, B., (2003a). Journal of Community Psychology, 31(6), 553-560.

Wahl, O. (2003b). News media portrayal of metal illness: implications for public policy. American Behavioral Scientist, 46, 1594-1600.

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