Stigma, violence and severe mental illness

A message about violence and severe mental illnesses from the Treatment Advocacy Center’s executive director –

As someone who has been treated for bipolar disorder for 12 years and who has no history of violence, I understand it would be highly unfair and completely inaccurate for any organization to argue or imply that all people with severe mental illnesses are dangerous. That has never been our position.

The Treatment Advocacy Center has repeatedly pointed out that people with severe mental illnesses who receive proper treatment are no more likely to commit violent acts than people without severe mental illnesses. However, we simply cannot ignore the evidence that shows that people with severe mental illnesses who go untreated are more likely to commit violent acts.

We are very sensitive to the need not to stigmatize people with mental illnesses. Again, as a person who has struggled with bipolar disorder, my attitude toward others who struggle with mental illnesses is one of compassion and empathy. Our overriding desire is to help people who may not be able to help themselves – not to cast a negative light on them.

The Treatment Advocacy Center publicizes stories about people with mental illnesses who commit harm to themselves or others to highlight the need for better treatment laws and practices. We are not the source of stigma. Rather, the stigma arises because of the tragic number of incidents in which people neglected by a broken system end up committing harm to themselves or others. Our mission is to bring about more effective and timely treatment for people with severe mental illnesses. When we succeed in fulfilling this mission, violent acts and resulting stigma are reduced.

Guest Blog: Justice and Discrimination

Guest Blog
Written by Angela Vickers, author of Brain Bondage- The Delay in Mental Illness Recovery

When I first faced injustice due to my mental illness diagnosis, I thought that all I needed was a good lawyer who understood bipolar recovery. I assumed there was justice, even for those with a mental illness diagnosis. The more I asked for legal help, the more I learned about prejudice and how little lawyers knew about mental illnesses. I understood the problem, as I knew nothing about psychiatric illness when I experienced my manic episode at age 36. Like me, I learned that few people knew even the most basic facts about bipolar and the other mental illnesses.

Discrimination was and is pervasive.

As with other national battles for civil rights, a victory for those with mental illness will require an educated media, an informed legal community, the support of the faith community, and educators willing to teach new truths to the generations to follow.

Angela D. Vickers’ book Brain Bondage is available through her website:www.angelavickers.net

The opinions expressed by guest bloggers are their own and not necessarily that of the Treatment Advocacy Center.Want to be a guest blogger? Tell us why at info@treatmentadvocacycenter.org.

Good Judge-ment

A powerful letter to the editor by Judge Tom Rickhoff, a probate judge from Bexar County, Texas, highlights many of the unfortunate realities of our nation’s mental health system. Judge Rickhoff rightly points out the important role lack of treatment must play in any discussion of stigma, explaining that “we must recognize and treat the dangerously mentally ill, not just fight the stigma.”

We couldn’t agree more.

England: Many say new law needed now

Letters to the editor in reaction to Tim Salmon's oped about his son have been fierce. A few examples ...

In all The Observer coverage last week of the new Mental Health Bill, the insightful portrayal by Tim Salmon of his son's schizophrenia best explained why we must reform the law to help patients and their carers ensure that the small number of who need it receive the treatment and protection they need. The proposals in the Mental Health Bill are essential to reflect how care is now delivered. Eight years of consultation have shown how difficult it is to find a consensus, but there is broad agreement that we must update the 1983 Act, and it is urgent that we make these changes.

- Rosie Winterton Minister of State for Health, London SW1

As doctors, we, too, have noted the linguistic shifts where people are called 'service users' when they may only be 'using' the services after legally being forced to do so. The aim, apparently, is to empower patients. In fact, health providers use this language to withdraw care. To talk of 'choices' makes it easy to present them as no longer in need. One of us has suffered a mental illness for the past 25 years. The 'care' was perfunctory and punitive. It is almost now non-existent. We were told to 'take responsibility', often by people unable to do so themselves.

- Sally Baker and BJ Brown Llanrug, Caernarfon

England: "They're getting away with murder"

There has been much public outcry in the aftermath of the headline-grabbing tragedy of John Barrett, a man with schizophrenia who killed a stranger in England.

A distraight father, Tim Salmon, talks poignantly in the Observer about stigma and the system and the impossibility of getting real help for his son in a cuture that values language and empowerment above all else - including medical intervenation. He writes that one mental health worker noted his son was "having issues" - a euphamism for his schizophrenia, and then discuses:

... the intractable and messy nature of an illness whose distinguishing feature is loss of reason. Not that you are allowed to say that, because it runs counter to the 'ethos of optimistic realism', probably promotes stigma and generally interferes with our modern desire to pretend that there are no inequalities or other unpalatable differences between people.

This extreme aversion on the part of the caring professions to calling things by their proper names is one of the most vexatious 'issues' I have encountered. The sick are no longer patients, but clients or service users and, by implication, considered capable of evaluating their own needs, entering into contractual relations with doctors and other agencies whose function is to deliver the chosen service or care package. If this seems a surprising way of approaching people who, when ill, are almost by definition 'not in their right minds', what are we to make of the recent 'best value' review of mental health services by Camden council in north London in which it proposes to give patients/clients direct payments from social services with which 'to organise and buy the services you need for yourself'? And this, when one of the most notorious symptoms of schizophrenia is an inability to understand your own situation.

Camilla Cavendish in today's Times is also up in arms about the culture of what we way seeming to matter more than the importance of what we actually do to help people.

[The] determination [of the mental health lobby] to stamp out stigma can lead them to rewrite reality. Illness has become health. Patients have become clients. Savage attacks on other people have become "untoward incidents".

Now last week’s devastating inquiry into the death of 50-year-old Denis Finnegan, murdered while cycling through Richmond Park by a paranoid schizophrenic, John Barrett, is being twisted by powerful groups who put patient "rights" above public protection.

A respected consultant psychiatrist neatly summed up his profession’s hostility to inquiries. "Being retrospective," he said, "they foster a simplistic notion of the preventability of homicides". Really? What last week’s inquiry showed was that Finnegan’s death was wholly preventable, caused by gross incompetence and arrogance — from the tribunal that discharged Barrett in the absence of his doctor, to the psychiatrist who gave him an hour's leave from hospital, to the nurses who
failed to warn the right people that he had not returned ....

The whole reaction has been surreal. On Friday the Royal College of Psychiatrists insisted that "all the professionals involved in this inquiry [must] be supported" and
announced that it is planning — a seminar. Shouldn’t someone be sacked? ...

The Mental Health Alliance, a group of 80 charities, is concerned only to emphasise that Finnegan’s death was "extremely rare". This is a familiar refrain from those who fear the public will shun schizophrenics. But it borders on falsehood. When I called the Department of Health this week, I discovered that between 55 and 63 people are killed every year by people who have recently been in contact with mental health services. At about 10 per cent of the total murder count, dare I say this is quite a lot? The charity SANE believes that at least one in three of those murders is preventable. Its analysis of 69 such inquiries finds that in half the cases, professionals had ignored warnings from family and friends. Some psychiatric patients refuse treatment. What is less well known is how many others are denied it, even when they or their relatives are crying out for it ....

There was a preference for "engaging" with patients, over "intervening". There is an understandable reluctance to act in loco parentis for adults who may at times be perfectly capable. But the jargon of "empowerment" creates nonsenses. It means a manic depressive choosing not to "engage" with social services, which then walk away. It means a schizophrenic choosing whether or not to take medication, even if he has a violent history. It means setting Barrett free to buy a packet of knives
and take a taxi to Richmond Park. In most cases, treating people who have lost
their reason as though they were rational beings leads to misery and neglect. In
a few cases it leads to death.

Ending stigma ...

The vice president of the Heritage Foundation wants to end the stigma of mental illness - through, among other things, parity and outpatient commitment. "America has abandoned those who suffer with brain disorders for far too long," she says. "We can, and must, do better."

Normalizing, glorifying, stigmatizing …

Big Pharma’s latest campaign will probably send everyone in New York City running to their doctor to see if they have bipolar disorder.

Their goal is to sell more pills. But the result is just as bad as that of well-meaning advocates who use the normalizing approach to try to reduce stigma. Their advocacy leave the general public wondering “if people with severe mental illnesses are just like everyone else, why can’t they work to support themselves? Why should we use tax dollars to pay for their treatment programs?” These are severe and debilitating illnesses – trivializing their impact on people is not helpful.

Nor is it always useful to illuminate the accomplishments of historical figures who suffered severe mental illnesses. Public figures like Patrick Kennedy, who entered a treatment program after crashing his car through a gate at the Capitol, can draw needed attention to the symptoms of these illnesses can be and how critical it is to get treatment. But sometimes that lends a false impression – that symptoms are desirable, like with Van Gogh, or quickly overcome.

Normalizing and glorifying severe mental illnesses don’t eliminate stigma – it just confuses the issue for everyone. Stigma is a huge problem for people with severe mental illnesses – one that can be fixed with straight talk, not feel-good platitudes.

Fighting generalizations with science and truth

There is a big difference between someone who has schizophrenia, is in treatment, and is doing well vs. someone like William Bruce.

For too long, it seems the only choice in public discourse about the role of violence in schizophrenia has been to demonize EVERYONE with schizophrenia as being potentially violent, or to preach that NOBODY with schizophrenia has a greater risk of violence than anyone else. Neither is reasonable or logical.

Implying that all people are violent is simply not true and is hurtful to the majority of people with schizophrenia who are taking medication and not violent. Failing to acknowledge that under some circumstances some people with schizophrenia have an increased risk of violence is not only misleading, it can lead to dangerous situations when caregivers, police, or the mentally ill do not recognize the warning signs such as paranoid delusions.

We are grateful that the editors at the Kennebec Journal and Morning Sentinel chose a third option – clarifying who of that larger group really needs humane intervention and helping them. Educating the general public to not paint everyone with either the broad brush of violence or the broad brush of nonviolence is the best way to not only remove stigma from the majority of people with mental illnesses, but also to avert tragedies.

TAC’s stance on talking about violent episodes

Yesterday's post on violence coincided with a thoughtful email we received from someone questioning why the Treatment Advocacy Center talks about violent episodes. We removed only the emailer's name and identifying information.

The email:

I totally support the Treatment Advocacy Center's desire to obtain legislation in all 50 states requiring "assisted treatment" for the mentally ill but I am getting disgusted at the misrepresentation of violence and mental illness. The statistics are that the seriously mentally ill constitute 5-6% of the United States population and they commit 4-5% of violent crimes (I use homicide as the basis).

SOME ELEMENTS of the Treatment Advocacy Center use "1000 homicides a year" as a sensationalist approach to getting assisted treatment legislation without putting the figure in the total perspective of the percentage of the general population. I am bitter because I feel that this does the same disservice [to] the mentally ill that Alfred Hitchcock's movie "Psycho" did for the mentally ill.

The basic predictors for violence among the mentally ill appear to be the same as in the general population: alcohol or drug abuse and a previous history of violent behavior. My support for assisted treatment is simply humanitarian reasons - to ensure that people who cannot take care of themselves and who lack the basic cognitive skills to understand this fact get into appropriate settings and on appropriate medications, for the same reason we treat a well established biological brain disease, Alzheimer's disease, this way.

TAC’s response:

Thank you for thoughtfully expressing your concern about the violence issue. This is a very difficult issue, but it is not one we can afford to ignore.

TAC is very concerned about the consequences of non-treatment. It is well documented that one of the consequences of non-treatment is harmful behavior. We would not be credible if we discussed other consequences of non-treatment (such as homelessness, hospitalization, victimization or suicide) and ignored violence.

In fact, I believe we would do a disservice to people with mental illnesses, their families and others if we did not discuss this issue intelligently. Stories about random acts of violence involving people with severe mental illnesses appear in papers literally every day.

TAC attempts to educate media, the public and policymakers that it is not all people with mental illness, but rather those who are not getting the treatment that they need, who are most often the perpetrators of such violence. That approach does more to reduce stigma that ignoring the problem.

Similarly, it is a disservice to families -- I know of too many cases in which mental health professionals dismissed families' concerns about a loved one becoming violent, so that those families were not prepared when their loved one did hurt themselves or someone else.

Assisted outpatient treatment has been shown to reduce violent behavior. Researchers in North Carolina found that people who had long-term court orders (at least 6 months) combined with regular mental health services (3 or more service contacts per month) were 50% less likely to be violent. Similarly in New York, Kendra’s Law resulted in dramatic reductions in the incidence of harmful behaviors for AOT recipients at six months in AOT as compared to a similar period of time prior to the court order. Among individuals participating in AOT: 55 percent fewer recipients engaged in suicide attempts or physical harm to self; 47 percent fewer physically harmed others; 46 percent fewer damaged or destroyed property; and 43 percent fewer threatened physical harm to others. Overall, the average decrease in harmful behaviors was 44 percent. This is information that must be shared.

I applaud your support for assisted treatment for "humanitarian reasons." We share your goals and take your concerns seriously. It is our intention to educate the public, media and policymakers about all of the consequences of non-treatment so that people with SMI can get the support and treatment they need and deserve.

Thank you again for sharing your thoughts and for your advocacy.

Mary Zdanowicz, Executive Director