Mad or Bad

Does mental illness make you a danger to others? 

In the wake of a number of terrorist atrocities and mass shootings we can find ourselves asking the question: 'Why would someone commit such a terrible crime and cause so much misery and suffering?' - In fact this has became a major focus of media coverage.

A range of public opinions are often expressed in the media and it is surprising how many of them associate with mental illness. Following the Las Vegas shooting their opinions on the shooter’s behaviour was variously described as “deranged”,  “disturbed”, “insane”, “demented”, “sick” and “pure evil”.  While these responses were emotive and ‘off-the-cuff’ I believe the language used highlights a broader public perception and negative stereotype: that there is a strong link between violence and mental illness and that people who suffer with mental illness are likely to be dangerous.
 
Progress has been made in reducing the negative perception of individuals with mental illness. Unfortunately, the public response to events such as the Las Vegas shooting highlight the persistence these negative attitudes. The assumption of dangerousness in those with mental disorder is a real part of this problem. Not only does this represent another source of shame for those already stigmatized by mental disorder it also creates social distance - based on fear - from those who are alienated and isolated.

Fact or Fiction

In my clinical practice individuals who experience mental health difficulties are far more likely to report symptoms of psychological distress or emotional numbing rather than anger, hostility or violent urges. These clients tend to internalize, i.e. blame themselves, rather than externalize the problems in their life. Similarly I have found that it is extremely rare for someone to report both suicidal and homicidal ideation, i.e. a desire to harm or kill or others.
 
But what does the evidence tell us about the relationship between violence and mental illness? Over the last 25 years several epidemiological and population based studies have examined this question. The findings of these studies are complex but broadly consistent.  Overall, there does appear to be a very small association between violence and mental disorder. For example, a recent epidemiologic survey that looked at 32,653 people in the United States found that 2.9% of persons with serious mental illness committed violent acts in a year, compared with 0.8% of people with no mental disorders.

97% Will never Be Violent to Others

This 2.1% disparity has to be put into perspective! It means that the vast majority (over 97%) of people with mental disorders will not engage in any violence against others. Furthermore, this slightly increased risk of violence in those with mental disorder seems to have little to do with mental disorder itself. Rather, it appears to have more to do with the fact that people with mental illness in the community are often socially disadvantaged. For example, another recent study that looked at the association between violence and mental illness found that those with mental disorder were vastly more likely to be unemployed, to be economically deprived, to be exposed to neighborhood violence, to misuse drugs and alcohol, and to report high levels of trauma and victimization over their life. Many of these characteristics and experiences were found to have highly significant associations with violence. This study found that those who simply had a diagnosis of mental disorder (without these other experiences) had annual rates of violence similar to that of the general population. 
 
The key point to take from this is that the assumption of dangerousness is inaccurate and unhelpful, as the vast majority of people with mental illness will never act violently towards others. 
 
How can we avoid perpetuating this misconception? Firstly, we should be careful in our use of language when acts of serious violence occur in society. This does not mean we should not condemn an act as morally abhorrent but rather that we abstain from using mental health labels to describe the offender. When we do this we infer - perhaps inadvertently - that mental disorder is the primary causative factor and that those who are “insane” are also “evil”. It may be that in some incidents of serious violence mental illness is a contributing factor but this is likely to be embedded in a complex range of contextual and background factors. Usually the multi-factorial nature of these violent events emerges months or years later after extensive investigation and does not receive the same level of attention in the media.

Changing the Narrative

More generally we must begin to change the narrative around mental disorder by challenging the assumption that “people with mental illness are dangerous”. This will begin reducing the fear of those with serious mental disorder and increase the likelihood that they will find belonging and acceptance in our places of worship, work and our homes. This need is fundamental to our wellbeing and it is something that sadly eludes many with serious mental health issues. Finally, as we change this narrative we also eliminate a source of stigma for those with mental illness. This is of great importance as stigma has been referred to as “the most formidable obstacle to future progress in the arena of mental health and mental illness”.
 
A far greater problem for those suffering mental illness (and in society generally) is that of violence towards the self. This is supported by a large number of studies that demonstrate a strong association between mental illness and suicide. This is a problem that warrants more attention from the media, government and church.  
 

Jared Watson is a Clinical Psychologist in NHS practice at the Birmingham and Solihull Mental Health NHS Foundation Trust.