Discourse / Letters / March 9, 2011

Letters to the Editor: Violence and mental illness

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 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 “mental illness” might be vague to some but it is important to understand the vast array of forms it takes. 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., ADHD), substance abuse (e.g., cannabis dependence), thought (e.g., thinking patterns which are cut off from reality), and personality (e.g., persistent dysfunction in relationships). Given the vast array of mental disorders, 25 percent 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?

Whereas 25 percent of the population will qualify for a mental disorder this year, 25 percent of the population will not commit a violent crime. In fact, only a small proportion of violent criminals have a mental illness; most violent crimes are committed by people without a mental illness (Nordstrom, Kullgren, & Dahlgren, 2006). Though there are few incidents where mental illness is to blame for a violent act, there is still an expectation that violence and mental illness often coincide with one another. This incorrect association is due in part to media misinformation and sensationalization. Research examining the portrayal of mentally ill individuals in newspapers shows that “dangerousness” is the most prominent thread in these stories (Wahl, 2003a). This is also true in children’s media: a recent research investigation of children’s films found that among those containing mentally ill characters, two-thirds of those characters had violent behaviors, and approximately two-thirds of the non-mentally ill characters in those same films reacted to the mentally ill characters with fear (Wahl et al., 2003b). These stories aim to provide entertainment, but their inaccuracies misguide the public and fuel harmful stigmatization of the mentally ill.

Research suggests that specific risk factors are involved in the minority of instances in which certain individuals who are mentally ill carry out violent acts. These risk factors include including being a young male, being in the early stage of a mental illness, having a concurrent substance abuse disorder, a comorbid personality disorders, or the presence of psychotic symptoms such as paranoid delusions.

In any discussion of mental illness and violence there are two particular mental disorders worth mentioning—the first because of common misconceptions about it, and the second because of general ignorance about it. Schizophrenia, which affects one percent of the U.S. population, is a disorder characterized by delusions, hallucinations, and disorganized thinking, and one of its subtypes includes severe paranoia. Patients who suffer from this illness cannot determine reality from imagination. The delusions (ideas that are not real) create irrational thinking and behavior such as believing all doctors are part of a huge federal conspiracy to experiment on people. Hallucinations (e.g., seeing and hearing things that are not real) can be completely separate or 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 misunderstandings of the world. Paranoia (illogical expectation that someone will hurt you) can induce irrational fear in a perfectly safe situation. These symptoms make it very hard for a person to carry out everyday activities such as, work, school, and the development of interpersonal relationships. The inability to perform daily tasks and formulate organized plans makes living independently extremely difficult and stressful for these individuals. Individuals with schizophrenia appear to have four to six times higher risk of committing a violent crime compared to the general population, due mostly to paranoid psychotic episodes (Nordstrom, Kullgren & Dahlgren, 2006).

A mental illness more likely to involve violent crimes is Antisocial Personality Disorder (ASPD). People suffering from an extreme form of this disorder are commonly called psychopaths. ASPD affects four percent of Americans but 75 percent of all prisoners meet the standards for diagnosis (not all prisoners are diagnosed; Reid, 2000). They suffer from an extreme lack of empathy, which leads them not to care about harming other people. They can commit horrible crimes and not feel any regret. Researchers in New Mexico have discovered that they do not feel any emotion deeply and cannot recognize the emotions of others. Because they feel less fear and regret, they also do not learn from punishment, including jail time, in the same way that others do (Nolen-Hoeksema, 2011). Researchers believe that in the future treatments can be devised that can help deepen the emotions of psychopaths; but for now, they are the most likely mentally ill people to commit violent crimes.

Lastly, it is important to understand who is likely to be a target of the minority of violent acts committed by individuals with mental illness. Research suggests that family, friends and acquaintances are the most common targets (in that order); strangers are rarely targets. The violent acts are also not random; they are planned out over a long period of time and only executed under very stressful conditions. Therefore, the general public should not fear attacks from the mentally ill.

According to Loughner’s close friends, he felt offended when congresswoman Giffords did not answer a delusional nonsensical question he asked at an event years prior to the shooting (Huffington Post, 2011). This perceived personal slight seems to have festered into deep bitterness on Loughner’s part. Years later, in what appears to be a state of increasing paranoid psychosis, he then executed a plan to assassinate her and those at her talk, whom he may have perceived to share her belief system. Thus, Loughner’s behavior was most consistent with schizophrenia.

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 statement of intent to harm a specified victim along with a plan and means to carry out the plan. 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 for the future. Even with that information, there is still uncertainty as to whether a plan with come to fruition. It is common for people to daydream or mention off-handedly a desire to harm someone with whom they are angry without actually going through with it. Therapists and researchers have noticed that plans of violence stay in the mind of the individual for a long time before being acted out impulsively in a moment of high arousal (Freedman et al., 2007). If a patient is talking to a therapist and specifically states a plan to harm an intended victim, it is the therapist’s duty to protect that intended victim by informing the authorities and 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. A thorough clinical interview can also easily uncover a history of aggression. (See the Huffington Post online for a list of Loughner’s past paranoid and aggressive behaviors, on account of which he was dismissed from his community college pending a clear psychological evaluation).

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 occurred in the 1960s following the advent of effective antipsychotic drugs. 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. 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 (Nolen-Hoeksema, 2010).

What Can We Do as a Society and as Individuals?

Our society needs to lend a supportive hand to those with and/or affected by mental illness. This can be done through better health coverage for visits to mental health professionals and by opening more community health centers staffed by qualified clinicians. This will provide better access to care for these individuals.

As a society we can also work to improve the relationships between general medical practitioners and mental health specialists. It is important that mental health is promoted with the same vigor that physical health is. Another way to accomplish this goal might be to add a mental health unit to school curricula in order to educate children and adolescents on how to be mentally healthy.

Family and friends who show empathy and do not stigmatize these individuals can also help by acting as support systems. Family and friends can also help when they notice a psychological change in a loved one (e.g., increasingly distressed, increasingly illogical, or increasingly strange behaviors, etc.). If an individual is reluctant to receive care, you can remind them of the prevalence information cited in this article (i.e., 25 percent of U.S. population will qualify for a diagnosis each year). Reassure him/her that having difficulties is not as uncommon as they think, and that treatment can really help.

In addition, monitor yourself. If you feel distressed psychologically (i.e., hard-to-handle emotions or disorganized thoughts) call the Knox counseling center for an appointment (X7492). It is very common for students to reach out to these services; in fact in a recent visit to student senate, counseling staff member Dan Larson stated 18 to 20 percent of the student body utilizes the counseling center throughout the year.

This document is a collaborative effort by Asia Bey, Tara Jarvie, Jessica Joyce, Lauren Smith, Katie Wrenn and Gail Ferguson 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

Larson, D., personal communication, March 3, 2011.

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. (2011). 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. (2003a). News media portrayal of mental illness: implications for public policy. American Behavioral Scientist, 46, 1594-1600.

Wahl, O., Wood, A., Zaveri, P., Drapalski, A., & Mann, B., (2003b). Mental illness depictions in children’s films. Journal of Community Psychology, 31(6), 553-560.

Gail Ferguson

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