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.

Keeping children safe

As a community tries to understand the shocking deaths of three children at the hands of their own mother, today’s Deseret Morning News reports on the link between severe mental illness and filicide:

In the medical community, the practice of parents killing their children is known as filicide. A study printed in a 2005 Journal of the American Academy of Psychiatry and the Law article found about 2 percent of homicides are filicides.

Another study found about 40 percent of filicidal parents previously had been treated for psychosis, but about 75 percent likely were suffering from symptoms of mental illness.

While people who are being treated for their severe mental illness are no more violent than the general population, those who are not properly treated for their symptoms do pose a greater risk to themselves, others and, sadly, even their own children.

NIMH's Insel:"Our failure to talk about the risk [of violence] has lead to a loss of credibility..."

Tom Insel (TI), director of the National Institutes of Mental Health, interviewed on Schizophrenia Research Forum (SRF), on violence and stigma …

SRF: I just noticed a new paper from the CATIE study showing that violence in schizophrenia has roots in pre-disease conduct problems (Swanson et al., 2007). It seemed like a fitting bookend, if you will, for a year that saw the death of Wayne Fenton and the killings at Virginia Tech, and so I wonder if we should be cautiously optimistic that a study like this could have some positive impact on efforts to combat stigma and perhaps focus research on root causes of violence and things like that. Any thoughts about that?

TI: Yes, it's a really interesting question; I like the way you posed it. In the past, my own sense of the community is that there's been an avoidance of talking about violence in schizophrenia because of a concern that it would increase the stigma. In fact, 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. So there's every reason to treat people with this illness to reduce violence. But we also shouldn't avoid discussing the risk of violence in those who are not treated. Our failure to talk about the risk has led to loss of credibility in some of our attempts to reduce stigma. People with this illness, or with bipolar illness during the manic phase, are more likely to be violent than the general population by several-fold. Some people estimate that 50 percent of manic episodes involve violence, sometimes self-directed but other times not. What's interesting about this new study is that it breaks down the problem here; at least it clarifies that we may be talking about two quite different things. On the one hand, people who have a history of conduct disorder and who are at a greater risk for violence towards others, and for whom schizophrenia in some ways disinhibits them, exacerbates violent tendencies that they've had in the past. And that appears very different from people who are schizophrenic and are acting out a delusional fantasy.

As to the Wayne Fenton murder, in recent newspaper coverage of that, this young man said that he had a particular delusion about Dr. Fenton and he was trying to liberate Dr. Fenton's soul as a way of cleansing it. That's not sociopathy.

Increased risk for family members

Family members are the primary caregivers for people with severe mental illnesses who live in the community. If their loved one has an untreated severe mental illness, they face a very real risk of violence. A 1997 study focusing on the prevalence of abuse faced by families of individuals with a mental illness found that 32 percent of relatives had been struck on at least one or two occasions. Verbal abuse, threats, and temper outbursts were reported by more than 50 percent of the relatives. The American Psychiatric Association notes that

"Family members are most at risk of a violent act committed by a mentally ill person … [Another study] found that among those who had attacked people prior to their admission [to a psychiatric hospital], 65 percent ... had attacked a family member."

Two stories that made the news this week emphasize the danger families can face if a loved one with untreated mental illness becomes violent:

In Palo Alto, California this week a middle-aged man with paranoid schizophrenia stabbed his brother to death in their mother’s home where both men were living. The middle aged man had a long history of mental illness and criminal activity.

In Indiana, a younger sibling is alleged to have shot his older brother in self-defense after the older brother, who had bipolar disorder attacked his younger sibling.

Of course, individuals with severe psychiatric disorders are no more dangerous than the general population - IF they are being treated. Click here for tips on what to do if someone with severe mental illness does become assaultive.

More insight into the link between violence & schizophrenia

The more we understand about the link between violence and schizophrenia, the better chance there is to prevent violent episodes from happening. A recent report from the CATIE studies informs us that:

there may be two pathways in which adults with schizophrenia may become violent — one in which pre-existing conditions like that of antisocial conduct in childhood, regardless of the presence of psychotic symptoms, may link to violence, and one in which psychotic symptoms of schizophrenia themselves may link to violence.

Violence, mental illness and stigma: A misleading combination

A recent letter to the editor in the Frederick Free Lance-Star takes the politically correct stance that people with mental illnesses are no more violent than the general public. This myth is further asserted by claims that recognizing and trying to address the correlation between violence and untreated mental illness creates stigma which in turn is the greatest barrier to treatment. This is mental health sophistry.

Certainly, when people with a severe mental illness are receiving appropriate treatment, they are no more violent than the general population; however, a number of studies show that a portion of people with mental illnesses ARE more dangerous when not receiving treatment.

As TAC president, Dr. E. Fuller noted in his recent op-ed in the Wall Street Journal:

Since 1994, nine U.S. studies have illustrated this [link to violence and untreated mental illness]. The best known, the Violence Risk Assessment Study, funded by the MacArthur Foundation, followed 961 seriously mentally ill individuals for one year after hospital discharge. During that time, these individuals committed 608 acts of serious violence (physical injury, threat of or actual assault with a weapon, or sexual assault), including six homicides. The most important finding: Those who regularly attended treatment sessions had less than one-quarter the rate of violence compared to those who did not.

As for stigma as the greatest barrier to treatment? Hardly. Surely stigma exists and keeps some people from seeking treatment, but as we’ve witnessed with the recent Virginia Tech shootings, the greatest barriers to treatment are misinformation, lack of education amongst mental health professionals, and poor treatment laws.

Undying love and the search for treatment

Without appropriate treatment options, parents of a grown child with severe mental illness are often the ones left to provide care. As care providers, families face a very real risk of violence. In fact, the most common victims of violence and homicides are family members, especially mothers. Despite this risk, families continue providing care and fighting for treatment.

“The first thing I thought of is … I can’t help him if I’m dead.”
- One mother’s reaction to her son’s attempt to harm her.

The danger of dangerousness

Regular readers of this blog already know that Australia has been publishing very interesting work on mental health and treatment. And now, a Sydney psychiatrist is making a powerful argument that dangerousness standards delay necessary treatment by as much as six months.

Dr Olav Nielssen, a psychiatrist at Sydney's St Vincent's Hospital, found that the length of untreated psychosis was 25 weeks longer on average in countries that utilize dangerousness standards rather than “need for treatment” based standards for admission to mental health care. “That is staggering,” he said, “and not surprising really because you can't get treatment until you're dangerous, which means you've hurt or killed someone or at least threaten to. This 'dangerousness' criteria means delayed treatment and that need to be changed to save lives.”

Virginia AG calls for better mental illness tx law

Virginia Attorney General Bob McDonnell explained to WDBJ 7 Roanoke that he will ask the Virginia legislature to pass Kendra’s Law when they return in January. As regular readers of this blog will remember, legislation to update Virginia’s outpatient commitment standard was passed over by the Virginia Courts of Justice committee in January.

Their reasoning? They wanted to wait for the Supreme Court Commission’s report, due in 2008 and since bumped to 2009.

Recent events at Virginia Tech may finally convince legislators that compelling treatment for a small number of the sickest people is not only humane, but cannot wait 2 more years – people across the state are suffering every day. Just because their stories don’t make international headlines doesn’t mean they aren’t horrible and worthy of attention. For instance, in the same week of the Virginia Tech shooting, a man in Roanoke was killed by police responding to a call that he was suicidal – he had bipolar disorder and was not taking medication.

TAC commends the attorney general for recognizing the many benefits that improved outpatient commitment standards can bring to the Virginia mental health system.

A classic case of shooting the messenger

Thanks to United States Psychiatric Rehabilitation Association (USPRA) for demonstrating so aptly why they shouldn’t be taken seriously. USPRA’s response to the Va Tech tragedies “urges all media networks to avoid over generalizations about the link between mental illness and violence.” That’s right! God forbid the media educate the public about the risks of untreated mental illness so that tragedies can be prevented. Instead follow USPRA’s lead and deceive the public:

USPRA: “Violence is no more prevalent among individuals with mental illness than the general public”
Fact: The CATIE violence study found that patients with schizophrenia were 10 times more likely to engage in violent behavior than the general public (19.1% vs. 2% in the general population).

USPRA: “Public perceptions that violence is strongly associated with mental illness are fueled by graphic media reports of violent crimes.”
Fact: The media does not commit the violent acts. Public perceptions are formed by violent crimes spawned from the dangerous untreated symptoms of mental illness and USPRA should stop trying to intimidate the media into silence.

USPRA: “it is incredibly rare for someone with a mental illness to commit gross acts of violence, especially on such a scale as the Virginia Tech shootings”
Fact: Yes, the scale of the scale of the Va Tech shooting is rare because sadly, this was a record. But, half of all “rampage shootings” such as the one in Blacksburg are committed by mentally ill shooters.

USPRA should be ashamed!

Media recognize flaws in treatment laws

More media on the Virginia Tech shooting is focusing on the need to improve state mental illness treatment laws.

An oped by Dr. Torrey in today’s New York Post notes:

The students and faculty at Virginia Tech correctly identified Cho as being very disturbed and potentially dangerous but that only resulted in a virtually universal refrain: "There was nothing we could do."

Newsday’s Jamie Talan writes:

The mental health system has long battled the vexing question about what to do with the small number of psychotic patients who are violent but who have yet to act on their thoughts. Mental health experts say only 5 percent of mentally ill patients with a history of psychosis are violent. That said, according to Dr. E. Fuller Torrey, president of the Treatment Advocacy Center in Arlington, Va., there are about 4 million people in the United States at any given time suffering from psychosis. The majority, 95 percent, of these patients are not dangerous to themselves or others …

"Legally, in these cases, everyone's hands are tied," said Mary Zdanowicz, executive director of the Treatment Advocacy Center. The organization was formed in 1998 to attempt to help states rewrite their mental health laws. "There is a lot that needs to be changed. We know too much now about the risks of these illnesses when patients are not treated."

This indepth piece in the Richmond Times Dispatch captures the horror of the state not providing needed treatment:

"It's outrageous that a young man showing such symptoms to this dedicated teacher somehow never got the treatment that he so clearly needed," said Mary Zdanowicz, executive director of the Arlington-based Treatment Advocacy Center, a national advocacy group for the mentally ill.

And the San Francisco Chronicle covers the Virginia Tech shooting in terms of California’s AOT law, Laura’s Law, which California counties have access to but have not implemented.

"Being completely and absolutely overcome with illness -- walking around and thinking you're on Mars and that everyone is a Venusian -- is not enough to get someone into treatment. They have to be in physical danger at the time," said Jonathan Stanley, assistant director of the Treatment Advocacy Center, a national group based in Arlington, Va., that supports forced treatment.

Media reacts to Cho

Behind some of the plaints of Virginia Tech staff that nothing could be done about Cho, you can hear the undercurrent: Who were we to judge? Of course, if he had occasionally uttered racial slurs rather than frightening those around him with bizarre behavior, the full apparatus of administrative power at Virginia Tech would have been brought down on him.

But Virginia Tech also had to cope with an extremely strict state law that requires that someone represent an "imminent danger" to himself or others before he can be compelled to seek treatment. ...

There is, of course, a balance to be struck between civil liberties and treating the mentally ill. But that balance is now badly off-kilter. Cho Seung-Hui was basically abandoned to his private mental hell at Virginia Tech. While he hatched his lunatic and hateful plot, everyone tried to ignore the scary guy in class behind the sunglasses.

- Rich Lowry, editor of National Review

Cho became by any person's reckoning a danger not only to himself but to others, although his future behavior was hard to predict. Because of that unpredictability, the law in California and elsewhere should allow involuntary detention based on current actions and past history of mental illness.
No one wants anyone held involuntarily without reason. No one wants anyone housed in Dickensian facilities. There can be, however, times when one person's continued liberty collides with the public's safety. This week's shooting spree was such a time.
- San Diego Union Tribune

But when you face a decision about a human life that is crumbling before your eyes, and the law reduces the complexities of a malfunctioning mind -- or, if you prefer, a lost soul -- to a printed checklist ("Alternatives to involuntary hospitalization and treatment . . . were deemed suitable," says choice "A" on Virginia's Form DMH 1006), it's time to treat the law as it treats people in pain: dismissively.
- Marc Fisher, Washington Post

Common sense and human decency also would have dictated some mandated treatment for the tormented Mr. Cho. But the law put that out of reach, as well. And here we are.
This situation is an understandable overreaction to abuses of the past, when the mentally ill were confined too often and too long. But it's time for the pendulum to swing back to a more sensible middle.
That's slowly happening.

- Steve Blow, Dallas Morning News

Hiding from warnings at VA Tech

Still in denial, major mental health organizations are rushing in the wake of the Virginia Tech shootings to deny the increased risk of violence that can accompany the symptoms of untreated mental illness. If caregivers, law enforcement and university officials do not recognize - or are unwilling to acknowledge - the risks, how can we hold them accountable when tragedy strikes? Mental health advocates and officials who engage in this concerted effort to hide the truth about violence are actually contributing to the violence.

A more responsible and credible approach is to acknowledge the risks of violence. A recently published study offers an eerie prediction that might have helped prevent this and future tragedies had the mental health community sounded the alarm rather than hide their heads in the sand:

We found that the greatest risk of homicide being committed by people during psychotic illness was during the early phase of the illness, particularly the first episode. Many subjects had had contact with mental health services in the weeks before the offence, and many of the deaths might have been prevented if the dangerous symptoms had been identified and there had been assertive intervention. In addition to the devastating effect on the families of the victims, who were often also relatives of the perpetrators, the deaths resulted in great cost to the community in legal proceedings and secure hospitalisation.
Homicide during psychotic illness in New South Wales between 1993 and 2002

Warning signs from VA Tech shooter

Lucinda Roy, Virginia Tech English Department, told Neal Conan on Talk of the Nation that the Virginia Tech shooter was a disturbed young man ... and that she had tried to get him some help to no avail.

"I just felt that he was a very depressed youth and seemed to be angry about some things and so I felt that there was some things I needed to do ... because that's what you're meant to do as a teacher ..."

"I contacted the police, contacted counseling, student affairs, the college to try to sound the alarm, and they felt that their hands were tied legally for various reasons ... as you probably know until someone actually threatens to do something, it can be incredibly difficult to make something happen ..."

We’ve heard this all too many times before - one Virginia mother asked “what do I have to do, have him kill someone to get him treatment?” shortly before her son killed her. We’ve been sounding the alarm that Virginia’s law, which is one of the most restrictive in the nation, needs to be reformed. Perhaps someone will now listen.

Questions in Virginia

As details become known from Virginia, questions will grow more specific.

Did the gunman have a history that included any sign of mental instability? Was he treated? Did the school know of his condition and monitor his progress? Did anyone report problems or potential problems? It is worth considering these questions in tandem.

All too frequently, it is easier for a disturbed person, even a psychopath, to get a firearm than to get sound treatment for mental illness.

- excerpt from Boston Globe Editorial, April 17, 2007

It's important to ask

Psychiatric patients are rarely screened for firearm possession.

Researchers found nearly a 10 fold increase in reported access to or possession of firearms when psychiatric inpatients were specifically asked whether they owned or had access to a gun. Researchers suggest involving families or friends in weapons management. However, they also point out that it is more common in the mental health field not to inquire about weapons unless a person has a history of suicidal or violent behavior. This is increasingly becoming a problem for families and friends who are not warned of the risks associated with the untreated symptoms of mental illnesses. It is not uncommon, after the fact to hear responses like this:

McGrath didn't know there were guns in the house, but even if he had, he never dreamed Michael would become violent. …I don't think he ever hit her or threatened to hit her or anything like that.

Base Rates of Firearm Possession by Hospitalized Psychiatric Patients
Dale E. McNiel, Ph.D., Christopher M. Weaver, Ph.D. and Stephen E. Hall, M.D. Psychiatr Serv
58:551-553, April 2007

Treatment reform in Illinois

The Chicago Tribune recently reported on SB 234 in Illinois; a bill that would update the strict treatment standard to provide treatment options for Illinois’ most seriously mentally ill before they are an imminent danger to themselves or others. The Treatment Advocacy Center’s executive director, Mary Zdanowicz was quoted in the article:

We have an obligation to those who are hurting to not withhold treatment.

Studies suggest that, when properly medicated, these folks are no more dangerous than the general population.

New York state data showed significant decreases in homelessness, incarceration and psychiatric hospitalization among people who were ordered into involuntary treatment under Kendra's Law. There were fewer suicide attempts and fewer cases of physically harming others or damaging property.

It's not mental illness that makes them violent, Zdanowicz said. It's untreated symptoms.

Long road to treatment for Vitali Davydov

At least Vitali A. Davydov won’t be going to prison.

Davydov, 20, pled guilty this week to murdering Dr. Wayne Fenton, a psychiatrist who, as we’ve said before, was the exception in a mental health system that is geared almost exclusively to patients who are able to seek treatment voluntarily. Dr. Fenton embraced the most difficult cases and never turned people away who were really suffering, including Davydov.

"The average psychiatrist in the Washington area is on Connecticut Avenue and he's seeing . . . some executive who got passed over for a promotion and is having a midlife crisis," said Fuller Torrey, a local psychiatrist who often referred severe cases to Fenton. "Wayne was one of the few out here seeing the severely mentally ill. He was strongly committed to providing care and promoting research for the sickest people."

Davydov will be committed to a Maryland psychiatric facility until he is no longer considered dangerous. Hopefully, that means he will finally receive the treatment Dr. Fenton was trying to get him the day he was murdered.

Who is left to do the right thing?

William Demegall got 25 to life for the stabbing, bludgeoning and burning of 56-year-old George Mancini. His severe mental illness, though acknowleged by the court, was not seen as a factor in sentencing.

Despite pleas by members of the local NAMI, the judge gave Demegall the maximum sentence possible.

Once again, we turn to the prison system as the last hope for treatment. As the editors of the local paper noted in an editorial today:

"It is now up to the New York State Department of Corrections to be the institution, at last, to do the right thing in this case and assign Mr. Demagall to a facility that can properly treat mental illness." [Berkshire Eagle, March 23, 2007]

The right to choose?

James DiCioccio, a 43-year-old man who has been described as schizophrenic, is sitting in jail for punching and choking a man to death because he was “tired of the man bothering him.”

DiCioccio had a history of violence, and, on multiple occasions, police had been called to the group home where he lived because of DiCioccio’s violent outbursts.

According to Detective Sgt. John Kelty who is investigating:

“James R. DiCioccio, known as Dusty, had not been taking medications that would have allowed him to function. Caregivers at the facility for mentally ill men are not permitted to force residents to take their medications.”

A city health department nurse who inspects group homes said:

“Residents have a right to refuse medication. It's not desirable because most of the medicines are psychotropics that help with psychological disorders.”

Maybe now that DiCioccio is in jail on a murder charge, he will get the treatment he wasn’t able to ask for, but obviously needed.