(Editors Note: Four articles. They use the term 'stigma', but many are now recognizing there is no stigma to having a mental illness. It is a no-fault illness. What the author's and others call 'stigma' is more accurately described as 'discrimination'.)
Stigma and Violence: Isn’t It Time to Connect the Dots?
E. Fuller Torrey*
Schizophrenia Bulletin published June 7, 2011
Reprinted by permission of Author
Stigma against mentally ill persons is a major problem and has increased in incidence. Multiple studies have suggested that the perception of violent behavior by seriously men- tally ill individuals is an important cause of stigma. It is also known that treating seriously mentally ill people decreases violent behavior. Therefore, the most effective way to decrease stigma is to make sure that patients receive adequate treatment.
Stigma against individuals with mental illnesses is condemned by everybody. Efforts to combat it have in- cluded a National Mental Health Awareness Campaign, a National Anti-Stigma Campaign, an Elimination of Barriers Initiative, a National Stigma Clearinghouse, Na- tional Alliance on Mental Illness Campaign to End Dis- crimination and StigmaBusters, and efforts by individuals, such as Glenn Close’s recent BringChange2- Mind campaign. Everybody wants to fight stigma, and for good reason—it is probably the heaviest burden borne by mentally ill persons. It affects opportunities for housing, employment, and socialization and becomes for many a scarlet letter.
Despite efforts to combat stigma, there has been a reluc- tance by the mental health community to objectively assess its causes. It is as if putting up enough posters saying ‘‘mentally ill persons make good neighbors’’ will make stigma go away. As professionals who are theoretically trained to be aware of denial and other mental mecha- nisms for avoiding the truth, our profession has an unenvi- able record in our response to the problem of stigma. I will argue that solutions to this problem are obvious and can be achieved by connecting 6 dots.
Dot 1: Stigma Against Individuals With Mental Illnesses has Increased Over the Past Half Century
Using comparable national surveys, Phelan et al1 com- pared public attitudes toward mentally ill persons in
1950 and 1996. They reported that, despite an increased understanding of the causes of mental illness in 1996, stigma had increased. This finding was also reflected in the 1999 Surgeon General’s report on mental health: ‘‘Stigma in some ways intensified over the past 40 years even though understanding improved.’’2
More recently, using comparable 2006 data, the same research group compared the 2006 findings with those from 1996.3 They again assumed that ‘‘neuroscience offers the most effective tool to reduce prejudice and dis- crimination’’ and theorized that the 1990s ‘‘Decade of the Brain’’ would have increased public understanding and thereby decreased stigma. Instead, they found that stigma has continued to be a major problem: ‘‘Our most striking finding is that stigma among the American public appears to be surprisingly fixed, even in the face of antic- ipated advances in public knowledge.’’
Dot 2: Violent Acts Committed by Mentally Ill Person Have Increased Over the Past Half Century
This is suggested by studies carried out between 1900 and 1950, in which the percentage of homicides committed by ‘‘insane’’ or ‘‘psychotic’’ persons ranged from 1.7% to 3.6%. A review of these studies concluded that the pro- portion of homicides committed by seriously mentally ill individuals ‘‘is usually 2% or less.’’4–7 By contrast, in more recent years, a New York study by Grunberg et al8,9 reported that 8/48 (17%) of individuals who com- mitted homicide had schizophrenia and a California study reported that 7/71 (10%) of individuals who com- mitted homicide had paranoid schizophrenia.10 Most re- cently, in a study of convicted murderers in Indiana, Matejkowski et al11 reported that 95 of 518 on which there were sufficient records available had a ‘‘severe mental illness.’’ That would be 17%. Such findings are consistent with 14 studies of homicides in other coun- tries; the percentage of seriously mentally ill individuals ranged from 5.3% to 17.9% (average 9.3%) in these studies.12
Dot 3: The Perception of Violent Behavior by Mentally Ill Persons is an Important Cause of Stigma
It is clearly established that viewing mentally ill persons as dangerous leads to stigmatization. As summarized by Link et al13 more than 2 decades ago: ‘‘When a measure of perceived dangerousness of mental patients is intro- duced, strong labeling effects emerge. . The interaction between labeling and perceived dangerousness is highly significant.’’ The studies that reported an increase in stigma against mentally ill persons also reported that the public perception of their dangerousness had also in- creased. Studies of public attitudes in the 1950s reported that stigma against mentally ill persons was rather non- specific and based primarily on a lack of knowledge, eg, there was a widespread belief that it was God’s punish- ment for sin. At that time, violent behavior did not ap- pear to be a prominent cause of stigma.14 In contrast, between 1950 and 1996 ‘‘perceptions that such people (people with psychosis) are dangerous increased nearly two and a half times since 1950 to a point that, in 1996, nearly one-third of respondents spontaneously vol- unteered the idea that psychotic persons may be vio- lent.’’1 As the 1999 Surgeon General’s report on mental health summarized the issue: ‘‘Why is stigma so strong despite better public understanding of mental ill- ness? The answer appears to be fear of violence: people with mental illness, especially those with psychosis, are perceived to be more violent than in the past.’’2
Several studies have also demonstrated a direct link between violent behavior by mentally ill persons and stigma. Thornton and Wahl15 showed that ‘‘reading a newspaper article reporting a violent crime committed by a mental patient’’ produced ‘‘negative attitudes to- ward people with mental illnesses.’’ In Germany, follow- ing ‘‘2 attempts on the lives of prominent politicians committed by mentally ill persons during 1990, there oc- curred a marked increase in social distance toward the mentally ill among the German public.’’16 Given such studies, it seems likely that media coverage of the recent shooting of Congresswoman Gabrielle Giffords by Jared Loughner probably reversed the effects of all anti-stigma campaigns for the last decade.
Dot 4: Most Episodes of Violence Committed by Mentally Ill Persons are Associated With a Failure to Treat Them
This has been demonstrated in many studies. For exam- ple, 2 meta-analyses of individuals with serious mental illness who commit acts of violence, including homicides, reported that a disproportionate number of these acts oc- cur during the person’s initial psychotic episode, before they have been treated.17,18 A study of 60 seriously men- tally ill men charged with violent crimes reported that medication noncompliance played a significant causal role.19 A study of 1011 seriously mentally ill outpatients reported that ‘‘community violence was inversely related to treatment adherence.’’20 A study of 802 adults with se- rious mental illnesses found that those who were violent were 1.7 times more likely to have been noncompliant with medication.21 Multiple older studies have also dem- onstrated this association, including one that reported an inverse correlation between blood level of antipsychotic medication and propensity to violence among inpa- tients.22 As Dr Thomas Insel, the director of the National Institute of Mental Health, recently summarized it: ‘‘The data support the proposition that people with schizo- phrenia are more likely to be involved in violence either toward others or toward themselves unless they’re treated.’’23
Dot 5: Treating People With Serious Mental Illnesses Significantly Decreases Episodes of Violence
Multiple studies have demonstrated that the treatment of individuals with serious mental illnesses with antip- sychotic medication, especially clozapine, is effective in reducing arrests rates and violent behavior.24,25 Re- searchers in Germany measured aggressive behavior (‘‘threats, physical aggression against persons and objects, self-directed aggression’’ in individuals with schizophrenia before and after beginning antipsychotic medication. They reported: ‘‘The day-to-day decline of aggressive incidents after the start of neuroleptic (anti- psychotic) medication was highly significant. . The results support the assumption that the increased figures for violence by schizophrenics are, at least in part, due to the lack of adequate treatment.’’26 Similarly, an assess- ment of violent behavior among patients in the Clinical Antipsychotic Trials of Intervention Effectiveness study reported that ‘‘medication adherence across all treat- ment groups was significantly associated with reduced violence, except in patients with a history of childhood antisocial conduct.’’27 The latter group would be as- sumed to have an antisocial personality disorder that would be the cause of their violent behavior; thus, an- tipsychotic medication would not have been expected to be as effective.
Finally, 2 studies have directly assessed the effect of assisted outpatient treatment (AOT) on violent behavior. Patients referred for AOT are a special group, usually having a history of medication noncompliance often ac- companied by violent behavior. AOT is a means of en- suring that such individuals take their medication. In North Carolina, subjects with a history of serious vio- lence had a reduction in violence from 42% to 27% when the AOT was continued for at least 6 months.28 In New York, AOT reduced the proportion of individu- als who ‘‘physically harmed others’’ from 15% to 8% and the proportion who ‘‘threatened physical harm’’ from 28% to 16%.29 Thus, as Dr Insel summarized the situa- tion: ‘‘Treatment may be the key to reducing the risk if violence, whether that violence is self-directed or di- rected at others.’’30
Dot 6: Reducing Violent Behavior Among Individuals With Mental Illnesses Will Reduce Stigma
This is the corollary of Dot 3. If violent behavior by men- tally ill persons is an important cause of stigma, then re- ducing violent behavior should logically reduce the stigma. As far as I know, nobody has ever attempted to assess this. It could theoretically be done by measuring stigma before and after the implementation of an effec- tive treatment program, allowing for a sufficient number of years for public opinion to change. Or it could be done by comparing the level of stigma in 2 countries with sig- nificantly different levels of violence by individuals with serious mental illnesses.
Connecting the dots would seem, at first glance, to be both logical and easy to do. Since stigma is a major prob- lem, increasing in incidence, and caused in part by violent behavior by mentally ill persons who are not being trea- ted, and since we know that treating people with serious mental illnesses reduces violent behavior, all we have to do is make sure patients receive treatment. Stigma would then decrease, and everyone would be happier. Why doesn’t this happen?
There are 2 major reasons why the dots do not get con- nected. The first is a reluctance to go to Dot 3 because it acknowledges that violent behavior among individuals with serious mental illnesses is a problem. That is polit- ically incorrect. The mental health community reports like a mantra, ‘‘mentally ill persons are not more violent than the general population,’’ despite overwhelming data to the contrary.
Variants of this mantra include the following: ‘‘most acts of violence are not committed by mentally ill individ- uals’’; ‘‘mentally ill individuals are the victims of violence much more often than they are the perpetrators of vio- lence’’; ‘‘people with alcoholism and drug addiction are more violent than people with serious mental ill- nesses’’; and ‘‘most mentally ill people are not violent.’’ All 4 statements are true, but they neither contradict nor negate the fact that a small number of seriously mentally ill individuals do become violent when they are not trea- ted, and these episodes of violence are an important cause of stigma against all mentally ill persons. The public understands these differences. In the 1996 public survey referred to above, they were asked to rate the likelihood of violence by people with cocaine addiction, alcohol dependence, schizophrenia, major depressive disorder, and a ‘‘troubled person’’ (‘‘worrying, sadness, nervous- ness, and sleep problems’’). The public rated the likeli-
hood of violence as 87%, 71%, 61%, 33%, and 17%, respectively.31
The reluctance of mental health professionals to link violent behavior and mental illness should not be underestimated. It is reflected in a 1992 statement by Dr John Monahan:
The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disor- dered or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social and demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior. . Denying that men- tal disorder and violence may be in any way associated is disingenuous and ultimately counterproductive.32
When professionals are asked why they are reluctant to link violence with mental illness, they often respond that doing so will increase stigma. But if the stigma is being caused by the violence, then failing to address this link will guarantee that the problem will never improve.
The second reason why the dots do not get connected is because they lead to a politically incorrect end point. It is known that approximately half of individuals with schizophrenia and bipolar disorder have impairments of brain function that make it difficult or impossible for them to perceive their need for treatment. This is not mere denial, but a biologically based deficit related to the disease process and similar to the unawareness of illness seen in Alzheimer’s disease. Neurologically, it is referred to as anosognosia. Since this is true, in order to ensure that seriously mentally ill individuals are receiv- ing treatment so that they will not become violent, a sub- set of them will have to be treated involuntarily. Such treatment is regarded as an infringement on the person’s civil liberties and, as such, is politically incorrect.
Historically, then, we have come a long way but in doing so have gone nowhere. In 1950, there was stigma against people with mental illness because people did not understand what mental illnesses were and regarded such illnesses as God’s punishment. There was a relatively weak association between violence and mental illness among the public at that time. In the intervening 60 years, the public has become edu- cated so they now understand that mental illnesses are brain diseases. But during those same years, we have also emptied the hospitals and allowed approxi- mately half of individuals with serious mental illnesses to remain untreated at any given time. A small number of these people commit violent acts, often widely pub- licized, and such acts have increased stigma. Thus, over the past 60 years, we have traded stigma associated with God’s punishment for stigma associated with vi- olent acts; such stigma is now greater than it was 60 years ago and is still increasing. This hardly qualifies as progress.
The people who are hurt most by our failure to connect the dots are people with mental illnesses. Following the shooting of Congresswomen Giffords and others in Tuc- son, a woman with schizophrenia wrote to President Obama: ‘‘I am very concerned about the problem in this country of the UNTREATED severely mentally ill population. When violent, they give the rest of us a bad name. I take that personally. . Please see that this tragedy does not happen again.’’33
At a practical level, what this means is that we can con- tinue to try to educate the public about mental illnesses, but it will have no effect on stigma. A lack of knowledge is not an important cause of stigma, but violent episodes by men- tally ill individuals are. In 1981, Henry Steadman noted that ‘‘recent research on contemporary populations of ex-mental patients support these public fears (of danger- ousness) to an extent rarely acknowledged by mental health professionals.’’34 Thirty years later, professional attitudes are little changed. It is as if we are experiencing a flood, but we professionals are fooling ourselves and averting our eyes from the source of the water. The public knows better. En route to work, they glance at the poster proclaiming that mentally ill people make good neighbors. Then they see the news about the latest violent act by an untreated person with mental illness. The public knows which one to believe.
The Authors have declared that there are no conflicts of interest in relation to the subject of this study.
1. Phelan JC, Link BG, Stueve A, Pescosolido BA. Public concep- tions of mental illness in 1950 and 1996: what is mental illness and is it to be feared? J Health Soc Behav. 2000;41:188–207.
2. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, Na- tional Institute of Mental Health; 1999.
3. Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. ‘‘A disease like any other’’? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. Am J Psychiatry. 2010;167:1321–1330.
4. Phelps HA. Rhode Island’s threat against murder. J Crim Law Criminol. 1925;15:552–567.
5. Dublin LI, Bunzel B. Thou shalt not kill: a study of homicide in the United States. Surv Graph. 1935;24:127–139.
6. Cassity JH. Personality study of 200 murderers. J Crim Psy- chopathol. 1941;2:296–304.
7. Wolfgang ME. Patterns in Criminal Homicide. New York, NY: John Wiley; 1966. 314 (originally published in 1958).
8. Grunberg F, Klinger BI, Grumet B. Homicide and deinstitu- tionalization of the mentally ill. Am J Psychiatry. 1977;134:685–687.
9. Grunberg F, Klinger BI, Grumet BR. Homicide and commu- nity-based psychiatry. J Nerv Ment Dis. 1978;166:868–874.
10. Wilcox DE. The relationship of mental illness to homicide. Am J Forensic Psychiatry. 1985;6:3–15.
11. Matejkowski JC, Cullen SW, Solomon PL. Characteristics of persons with severe mental illness who have been incarcerated for murder. J Am Acad Psychiatry Law. 2008;36:74–86.
12. Torrey EF. The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens. New York, NY: W.W. Norton; 2008. 145,213–218.
13. Link BG, Cullen FT, Frank J, Wozniak JF. The social rejec- tion of former mental patients: understanding why labels mat- ter. Am J Sociol. 1987;92:1461–1500.
14. Rabkin J. Public attitudes toward mental illness: a review of the literature. Schizophr Bull. 1974;10:9–33.
15. Thornton JA, Wahl OF. Impact of a newspaper article on attitudes toward mental illness. J Community Psychol. 1996;24:17–24.
16. Angermeyer MC, Matschinger H. Violent attacks on public figures by persons suffering from psychiatric disorders: their effect on the social distance towards the mentally ill. Eur Arch Psychiatry Clin Neurosci. 1995;245:159–164.
17. Large MM, Nielssen O. Violence in first-episode psychosis: a systematic review and meta-analysis. Schizophr Res. 2010;125:208–220.
18. Nielsson O, Large M. Rates of homicide during the first epi- sode of psychosis and after treatment: a systematic review and meta-analysis. Schizophr Bull. 2010;36:702–712.
19. Alia-Klein N, O’Rourke TM, Goldstein RZ, Malaspina D. Insight into illness and adherence to psychotropic medica- tions are separately associated with violence severity in a fo- rensic sample. Aggress Behav. 2007;33:86–96.
20. Elbogen EB, Van Dorn RA, Swanson JW, Swartz MS, Monahan J. Treatment engagement and violence risk in mental disorders. Br J Psychiatry. 2006;189:354–360.
21. Swanson JW, Swartz MS, Essock SM, et al. The social- environmental context of violent behavior in persons treated for severe mental illness. Am J Public Health. 2002;92: 1523–1531.
22. Yesavage JA. Inpatient violence and the schizophrenic pa- tient: an inverse correlation between danger-related events and neuroleptic levels. Biol Psychiatry. 1982;17:1331–1337.
23. Insel T. Interview of Thomas Insel on the Schizophrenia Re- search Forum (Posted August 9, 2007). http://www. schizophreniaforum.org/for/int/Insel/insel.asp. Accessed May 17, 2011.
24. Frankle WG, Shera D, Berger-Hershkowitz H, et al. Cloza- pine-associated reduction in arrest rates of psychotic patients with criminal histories. Am J Psychiatry. 2001;158:270–274.
25. Krakowski MI, Czobor P, Citrome L, Bark N, Cooper TB. Atypical antipsychotic agents in the treatment of violent patients with schizophrenia and schizoaffective disorder. Arch Gen Psychiatry. 2006;63:622–629.
26. Steinert T, Sippach T, Gebhardt RP. How common is vio- lence in schizophrenia despite neuroleptic treatment? Pharma- copsychiatry. 2000;33:98–102.
27. Swanson JW, Swartz MS, Van Dorn RA, et al. Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia. Br J Psychiatry. 2008;193:37–43.
28. Swanson JW, Swartz MS, Borum R, Hiday VA, Wagner HR, Burns BJ. Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. Br J Psychiatry. 2000;176:324–331.
29. Governor and Commissioner of the Office of Mental Health.
Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment. New York: New York State Office of Mental Health; 2005.
30. Insel T. Understanding Severe Mental Illness. National Inst Mental Illness. Director’s Blog, January 11, 2011. http:// www.nimh.nih.gov/about/director/2011/understanding- severe-mental-illness.shtml. Accessed May 17, 2011.
31. Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA. Public conceptions of mental illness: labels, causes, dan- gerousness, and social distance. Am J Public Health. 1999;89:1328–1333.
32. Monahan J. Mental disorder and violent behavior: percep- tions and evidence. Am Psychol. 1992;42:511–521.
33. Wakefield M. Jared Loughner and the Problem of Untreated Severe Mental Illness in the U.S. Schizophrenia and Related Disorders Alliance of America blog, January 16, 2011. http://www.sardaa.org/blog/?p=1221. Accessed May 17, 2011.
34. Steadman HJ. Critically reassessing the accuracy of public perceptions of the dangerousness of the mentally ill. J Health Soc Behav. 1981;22:310–316.
The Stanley Medical Research Institute, 8401 Connecticut Avenue, Suite 200, Chevy Chase, MD 20815 *
# # #
Taking Issue – Combating stigma by providing treatment
By H. Richard Lamb, M.D.
Professor of Psychiatry, University of Southern California School of Medicine, Los Angeles
Psychiatric ServicesJune 1999, Vol. 50, No. 6. Reprinted with permission. Copyright 1999 Psychiatric Services. All rights reserved.
No problem has been of greater concern to mental health professionals, families, and people with mental illness than the stigma of mental illness in our society. Much effort has been expended in demonstrating that mental illnesses are comparable to physical illnesses, in showing that mentally ill persons can take their place in society like any other citizens, and in trying to influence the media to portray mentally ill persons sympathetically rather than as dangerous, frightening persons who can strike with irrational and unpredictable violence. All these efforts are important and need to be pursued.
However, there is another area where we might accomplish still more. Probably nothing contributes more to the stigmatization of mental illness than the commission of violent crimes by persons who are clearly severely mentally ill. Such events evoke an extremely strong reaction from the public. Unfortunately, mental health professionals often respond by blaming the media who report the violence and by explaining that it is mentally ill patients who are untreated or are substance abusers or both who commit these crimes. Besides, they say, this violence constitutes only a small proportion of the violence in our very violent society. They blame society for not providing enough funding for community treatment. All those explanations are true, but they do little to lessen the public's fears and reduce the resulting stigmatization.
Most severely mentally ill persons who refuse treatment, especially medications, are known to us. Why do we not act to place them in some form of mandatory outpatient treatment, such as outpatient commitment? Many of them have also demonstrated what any good clinician recognizes as a need for 24-hour, highly structured inpatient care, perhaps for a brief period of stabilization, perhaps for an intermediate or long-term period. Increasingly, mentally ill persons are receiving mandatory outpatient treatment and 24-hour structured care through the criminal justice system. But they should not have to commit a crime to receive the care they need. To be labeled both mentally ill and criminal is to be doubly stigmatized.
I have been told that many people, especially those without clinical responsibilities for severely mentally ill persons, so highly value liberty for mentally ill persons, and so strongly oppose involuntary treatment, that they would sacrifice their lives to maintain these liberties. As I see it, they might be sacrificing not their own lives, but ours instead.
We can reduce stigma by doing what needs to be done to ensure that persons with severe mental illness who resist treatment receive the treatment they so clearly need.
STIGMA, DISCRIMINATION AND VIOLENCE
by Dr. E. Fuller Torrey
Stigma/Discrimination is one of the most important problems encountered by individuals with severe psychiatric disorders. It lowers their self-esteem, contributes to disrupted family relationships, and adversely affects their ability to socialize, obtain housing, and become employed (Wahl, 1999). In December 1999, the Surgeon General's Report on Mental Health called stigma "powerful and pervasive," and then-Secretary of Health and Human Services Donna Shalala added: "Fear and stigma persist, resulting in lost opportunities for individuals to seek treatment and improve or recover."
In recent years, the origins of stigma and discrimination against individuals with severe psychiatric disorders and the solution to the problem have become clearer.
The public's association of mental illness with violence is a major cause, probably the major cause, of stigma/discrimination against mentally ill individuals.
Recent studies have demonstrated that stigma against people with mental illnesses has increased over the past half century and is still increasing. Multiple studies have also shown that the major cause of this stigma is the perception that some individuals with mental illnesses are dangerous. Given this fact, it seems self-evident that stigma will not be decreased until we decrease violent behavior committed by mentally ill persons, and this can only be done by ensuring that they receive treatment.
Thus, campaigns to decrease stigma by simply trying to educate people will not work. The current situation finds an average commuter riding a bus to work, facing an anti-stigma poster proclaiming that "mentally ill persons make good neighbors," and simultaneously reading a newspaper detailing the most recent violent act committed by a mentally ill person.
This was demonstrated by Link et al., who, after reviewing several studies, concluded that "when a measure of perceived dangerousness of mental patients is introduced, strong labeling [stigma] effects emerge…. the interaction between labeling and perceived dangerousness is highly significant…. Such individuals find former patients threatening and prefer to maintain a safe distance from them" (Link et al., 1987). One example of such studies is Penn et al.'s study of 329 university students in which it was reported that "those individuals who had no previous contact perceived the mentally ill as dangerous and chose to maintain a greater social distance from them" (Penn et al., 1994).
The cause-and-effect relationship between perceived dangerousness and stigma against mentally ill individuals has also been demonstrated by naturalistic studies. A study in Germany reported that, following two attempts on the lives of prominent politicians by mentally ill individuals in 1990, "there occurred a marked increase in social distance towards the mentally ill among the German public." Although this social distance slowly decreased over the following two years, "it had not yet completely returned to its initial level by the end of 1992" (Angermeyer and Matschinger, 1995). An American study of university students similarly reported that reading a newspaper article reporting a violent crime committed by a mental patient led to increased "negative attitudes toward people with mental illness" (Thornton and Wahl, 1996).
Most directly relevant is the fact that the causal relationship of violence and stigma is experienced by individuals with mental illness themselves each time a violent incident occurs. In 1999, a man with schizophrenia killed two people in a library in Salt Lake City. According to a newspaper account, within hours Valley Mental Health began getting calls from frightened clients. "Clients were just sobbing," says Connie Hines, public relations director for Valley Mental Health. They were afraid, she says, that the public would want to retaliate against them.… whatever progress had been made in the de-stigmatization of mental health "has been set back years" by the shooting (Jarvik, 1999).
In 2010, Pescosolido et al. assessed stigma against mentally ill persons using a 2006 survey that had been done similarly to a survey in 1996. They reported that stigma had increased during that 11-year period and that "significantly more respondents in the 2006 survey than the 1996 survey reported an unwillingness to have someone with schizophrenia as a neighbor. . . . Our most striking finding is that stigma among the American public appears to be surprisingly fixed, even in the face of anticipated advances in public knowledge."
Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. "A disease like any other"? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry 2010;167:1321–1330.
2. The association of mental illness with violence is very strong and has increased in recent years.
A 1984 survey in California reported that the majority of adults believed that individuals with schizophrenia were more likely than other people to commit violent crimes (The Field Institute, 1984).
A 1987 study reported that 43 percent of students and 47 percent of police officers associated individuals with schizophrenia with "aggression, hostility, violence" (Wahl, 1987).
A 1993 survey reported that more than half of people agreed with the statement that "those with mental disorders are more likely to commit acts of violence" (Clements, 1993).
A 1994 survey of Utah residents reported that 38 percent agreed that "people with mental illness are more dangerous than the rest of society" (Fraser, 1994).
A 1996 survey reported that 61 percent of adults believed that an individual with schizophrenia was "very likely" (13 percent) or "somewhat likely" (48 percent) to do "something violent to others" (Pescosolido et al., 1999).
3. This association of mental illness with violence is apparently increasing.
One of the most remarkable findings to emerge from the 1999 Surgeon General's Report on Mental Health was the fact that "the perception of people with psychosis as being dangerous is stronger today than in the past…. People with mental illness, especially those with psychosis, are perceived to be more violent than in the past" (Report, p. 7). This finding was based on a study that compared public opinion concerning mental illness and violence in 1950 and 1996 using the same survey instrument. This study found that "the proportion [of respondents] who described a mentally ill person as being violent increased by nearly 2-1/2 times between 1950 and 1996" (Phelan et al., 2000); the increase was from 13 to 31 percent.
The authors of the Surgeon General's report noted that they had expected to find a significant decrease in stigma. During the 46-year period, there had been a marked increase in knowledge of mental illness among the general public, an increased number of people who themselves utilized mental health professionals, and self-revelations of many public figures, such as William Styron and Mike Wallace, about their own mental illness. However, the Surgeon General's report concluded that "Stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred: stigma in some ways intensified over the past 40 years even though understanding improved" (Report, p. 8).
4. The most likely reason for this increasing stigma and discrimination is an increasing number of violent crimes committed by individuals with severe psychiatric disorders.
Multiple studies have demonstrated that individuals with severe psychiatric disorders who are being inadequately treated, or not treated at all, are more likely to be violent than the general population (Yesavage, 1982; Taylor, 1985; Smith, 1989; Bartels et al., 1991; Link et al., 1992; Modestin and Ammann, 1996; Kasper et al., 1997; Swanson et al., 1997; Swartz et al., 1998; Taylor et al., 1998; Arango et al., 1999). Individuals with severe psychiatric disorders who are being treated are not more likely to be violent than the general population. Studies by NIMH have reported that approximately 40 percent of individuals with severe psychiatric disorders are not receiving treatment in any given year (Regier et al., 1993).
It is therefore not surprising that violent crimes committed by individuals with severe psychiatric disorders are increasing in frequency. This increase has been noted anecdotally (Torrey, 1997) as well as by recent studies. A study in New York, for example, assessed all psychiatric admissions to a university hospital over an 18-month period in 1991-1992, regarding whether they had "physically attacked another person in the month before admission"; these results were compared with an identical survey done at this hospital in 1981-1982 (Tardiff et al., 1997). The frequency of such assaults had increased over the decade among male patients from 10 percent to 14 percent and among female patients from 6 percent to 15 percent. In both studies, all admissions were voluntary and the diagnoses of the patients were similar. The authors attributed the increasing violence to an increased availability of cocaine and other illegal drugs.
Furthermore, on April 9-12, 2000, the New York Times published the results of a study of 100 "rampage killings," defined as "multiple-victim killings that were not primarily domestic or connected to a robbery or gang," committed during the preceding five decades. As part of their research, the Times staff examined "nearly 25 years of homicide data from the Federal Bureau of Investigation" and concluded that "the incidence of these rampage killings appears to have increased." Most of the increase was noted to have taken place in the late 1980s and 1990s (personal communication, Ford Fessenden, April 26, 2000). Among the 100 killers examined by the Times, "more than half had histories of serious mental health problems" and 48 of them had "some kind of formal diagnosis, often schizophrenia." Although the Times attempted to identify cases across 50 years, 90 of the 100 "rampage killings" they examined occurred during the 1980s and 1990s, which was said to be due at least partially to the availability of more recent information on electronic databases.
5. A reduction in stigma and discrimination against mentally ill individuals is unlikely to take place until there has been a reduction in violent crimes committed by them.
It has been clearly demonstrated that assisted treatment for individuals with severe psychiatric disorders both improves treatment compliance and reduces episodes of violence committed by them. One form of assisted treatment is conditional release, whereby a patient's discharge from a psychiatric hospital is conditional on compliance with treatment, including the taking of medication when prescribed. In New Hampshire a study of conditional release reported that it increased treatment compliance by more than three-fold and reduced episodes of violence to less than one-third the rate prior to using conditional release (O'Keefe et al., 1997). Other studies of conditional release have found it to be similarly effective (Bloom et al., 1986 and 1991).
Another form of assisted treatment is outpatient commitment, in which patients are court-ordered to comply with their treatment plans. This has been shown to increase treatment compliance in studies in North Carolina (Hiday and Scheid-Cook, 1987), Arizona (Van Putten et al., 1988), Ohio (Munetz et al., 1996), and Iowa (Rohland, 1998). Outpatient commitment has also been shown to "lower odds of violence in the community" (Swartz et al., 1998). In a recent study, 262 severely mentally ill patients were randomly assigned to outpatient commitment or to customary community psychiatric care. For those who remained on outpatient commitment for more than six months and who also made regular clinic visits, the "probability of any violent behavior was cut in half from 47% to 24%, attributable to extended OPC [outpatient commitment] and regular outpatient services provision" (Swanson et al., 2000).
6. Promoting assisted treatment is thus the most effective type of anti-stigma campaign to reduce stigma against mentally ill individuals.
The public's association of mental illness with violence is probably the major cause of stigma against mentally ill individuals. This association is very strong and has apparently increased in recent years. The most likely reason for this increasing stigma is an increasing incidence of violent crimes committed by seriously mentally ill individuals who are not receiving treatment for their psychiatric disorders. Therefore, the most effective way to decrease stigma is to reduce the incidence of such violent crimes; this can be done by utilizing various forms of assisted treatment. As summarized by Link et al. in a recent discussion of this issue: "If the dangerousness stereotype is to be addressed, we need to confront it directly" (Link et al., 1999).
There are currently several ongoing campaigns to reduce stigma against mentally ill persons, including NAMI's Anti-Stigma Campaign and the White House's National Mental Health Awareness Campaign. These campaigns rely primarily on educating the public about psychiatric disorders, an approach that has been shown to be largely ineffective in reducing stigma (Corrigan et al., 2000). To date, these campaigns have been silent regarding the issue of violence and have strongly encouraged the media to report violent incidents less prominently. Some of the advocates have even blamed the media for causing the stigma; blaming newscasters for reporting episodes of violence by individuals with severe mental illnesses is like blaming weather reporters for causing bad weather. This slay-the-messenger approach is doomed to failure, as was noted by Dr. Henry Steadman as early as 1981:
Recent research data on contemporary populations of ex-mental patients supports these public fears [of dangerousness] to an extent rarely acknowledged by mental health professionals…. It is [therefore] futile and inappropriate to badger the news and entertainment media with appeals to help destigmatize the mentally ill (Steadman, 1981).
This was also observed by Dr. John Monahan:
The data suggest that public education programs by advocates for the mentally disordered along the lines of 'people with mental illness are no more violent than the rest of us' may be doomed to failure…. And they should: the claim, it turns out, may well be untrue (Monahan, 1992).
The current situation, then, finds the average commuter riding a bus to work, facing an anti-stigma poster proclaiming that "mentally ill persons make good neighbors" and simultaneously reading a newspaper detailing the most recent violent act committed by a mentally ill person. Until the issue of violence is addressed and greater use is made of assisted treatment, anti-stigma campaigns will fail and mentally ill persons will continue to be among the most stigmatized groups in our society.
- Angermeyer MC, Matschinger H. Violent attacks on public figures by persons suffering from psychiatric disorders: their effect on the social distance towards the mentally ill. European Archives of Psychiatry and Clinical Neuroscience 245 (1995): 159-164.
- Arango C, Barba AC, González-Salvador T et al. Violence in inpatients with schizophrenia: a prospective study. Schizophrenia Bulletin 25 (1999): 493-503.
- Bartels J, Drake RE, Wallach MA et al. Characteristic hostility in schizophrenic outpatients. Schizophrenia Bulletin 17 (1991): 163-171.
- Bloom JD, Williams MH, Rogers JL et al. Evaluation and treatment of insanity acquittees in the community. Bulletin of the American Academy of Psychiatry and Law 14 (1986): 231-244.
- Bloom JD, Williams MH, Bigelow DA. Monitored conditional release of persons found not guilty by reason of insanity. American Journal of Psychiatry 148 (1991): 444-448.
- Clements M. "What We Say About Mental Illness." Parade Magazine, October 31, 1993, pp. 3-6.
- Corrigan PW, River LP, Lundin RK et al. Stigmatizing attributions about mental illness. Journal of Community Psychology 28 (2000): 91-102.
- Fessenden F. "They Threaten, Seethe and Unhinge, Then Kill in Quantity." The New York Times, April 9, 2000, p. A1.
- Fessenden F. Personal communication, April 26, 2000.
- The Field Institute. In Pursuit of Wellness, Vol. 4: A Survey of California Adults Regarding Their Health Practices and Interest in Health Promotion Programs. California Department of Mental Health, Mental Health Promotion Branch, 1984.
- Fraser ME. Educating the public about mental illness: what will it take to get the job done? Innovations and Research 3 (1994): 29-31.
- Hiday VA and Scheid-Cook TL. The North Carolina experience with outpatient commitment: a critical appraisal. International Journal of Law and Psychiatry 10 (1987): 215-232.
- Jarvik E. "Mental Health Clients Fear Growing Stigma." The Deseret News [Salt Lake City, Utah], April 24, 1999, p. A1.
- Kasper JA, Hoge SK, Feucht-Haviar T et al. Prospective study of patients' refusal of antipsychotic medication under a physician discretion review procedure. American Journal of Psychiatry 154 (1997): 483-489.
- Link BG, Cullen FT, Frank J et al. The social rejection of former mental patients: understanding why labels matter. American Journal of Sociology 92 (1987): 1461-1500.
- Link BG, Andrews H, Cullen FT. The violent and illegal behavior of mental patients reconsidered. American Sociological Review 57 (1992): 275-92.
- Link BG, Phelan JC, Bresnahan M et al. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89 (1999): 1328-1333.
- Modestin J, Ammann R. Mental disorder and criminality: male schizophrenia. Schizophrenia Bulletin 22 (1996): 69-82.
- Monahan J. Mental disorder and violent behavior. American Psychologist 47 (1992): 511-521.
- Munetz MR, Grande T, Kleist J et al. The effectiveness of outpatient civil commitment. Psychiatric Services 47 (1996): 1251-1253.
- O'Keefe C, Potenza DP, Mueser KT. Treatment outcomes for severely mentally ill patients on conditional discharge to community-based treatment. Journal of Nervous and Mental Disease 185 (1997): 409-411.
- Penn DL, Guynan K, Daily T et al. Dispelling the stigma of schizophrenia: what sort of information is best? Schizophrenia Bulletin 20 (1994): 567-577.
- Phelan JC, Link BG, Stueve A et al. Public conceptions of mental illness in 1950 and 1996: what is mental illness and is it to be feared? Journal of Health and Social Behavior 41 (2000).
- Pescosolido BA, Monahan J, Link BG et al. The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health 89 (1999): 1339-1345.
- Regier DA, Narrow WE, Rae DS et al. The de facto US mental and addictive disorders service system. Archives of General Psychiatry 50 (1993): 85-94.
- Rohland BM. The role of outpatient commitment in the management of persons with schizophrenia. Iowa Consortium for Mental Health, Services, Training, and Research, May 1998.
- Smith LD. Medication refusal and the rehospitalized mentally ill inmate. Hospital and Community Psychiatry 40 (1989): 491-496.
- Steadman, HJ. Critically reassessing the accuracy of public perceptions of the dangerousness of the mentally ill. Journal of Health and Social Behavior 22 (1981): 310-316.
- Swanson J, Estroff S, Swartz M et al. Violence and severe mental disorder in clinical and community populations: the effects of psychotic symptoms, comorbidity, and lack of treatment. Psychiatry 60 (1997): 1-22.
- Swanson JW, Swartz MS, Borum R et al. Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. British Journal of Psychiatry 176 (2000): 224-231.
- Swartz MS, Swanson JW, Hiday VA, et al. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. American Journal of Psychiatry 155 (1998): 226-231.
- Tardiff K, Marzuk PM, Leon AC et al. Violence by patients admitted to a private psychiatric hospital. American Journal of Psychiatry 154 (1997): 88-93.
- Taylor P. Motives for offending amongst violent and psychotic men. British Journal of Psychiatry 147 (1985): 491-498.
- Taylor PJ, Leese M, Williams D et al. Mental disorder and violence. British Journal of Psychiatry 172 (1998): 218-226.
- Thornton JA, Wahl OF. Impact of a newspaper article on attitudes toward mental illness. Journal of Community Psychology 24 (1996): 17-24.
- Torrey EF. Out of the Shadows: Confronting America's Mental Illness Crisis. New York: John Wiley and Sons, 1997. Paperback edition 1998.
- U. S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
- Van Putten RA, Santiago JM, Berren MR. Involuntary outpatient commitment in Arizona: a retrospective study. Hospital and Community Psychiatry 39 (1988): 953-958.
- Wahl OF. Public vs. professional conceptions of schizophrenia. Journal of Community Psychology 15 (1987): 285-291.
- Wahl OF. Mental health consumers' experience of stigma. Schizophrenia Bulletin 25 (1999): 467-478.
- Yesavage, JA. Inpatient violence and the schizophrenic patient: an inverse correlation between danger-related events and neuroleptic levels. Biological Psychiatry 17 (1982): 1331-1337.
Stigma and public education about mental illness
55: 833-834, July 2004
To the Editor:
Dr. Corrigan and his colleagues reported that an antistigma educational presentation lowered several measurements of stigmatizing beliefs and attitudes among participants, whereas a presentation that focused on the greater propensity for violence among people with mental illnesses had the opposite affect. But what if the goals of groups that address violence among people with mental illnesses are different from the goals of groups that fashion antistigma campaigns? Then the comparison is between the impact on the unilateral objective of one project and the ancillary effects on that objective on another—the approach is akin to comparing the rain-stopping abilities of an umbrella and a T-shirt.
The only entity described by Dr. Corrigan and his colleagues as a proponent of violence education is the Treatment Advocacy Center. Yes, our center does address the heightened propensity for violence to help foment reforms that will, among other objectives, prevent future violence. Although such endeavors may to a small extent heighten stigma by increasing awareness of the problem, the magnitude of the effect should be gauged in a real-world context.
To help readers gain perspective: a search of a database of leading newspapers that used both "Treatment Advocacy Center" and "violence" yielded a total of 71 articles, editorials, op-ed commentaries, columns, and other media pieces for the past five years, whereas a search of the same database that used both "mental illness" and "violence" yielded 536 media items from the past month.
The issue of violence emerges in conjunction with campaigns to establish programs such as assisted outpatient treatment, assertive community treatment, crisis intervention teams, and mental health courts that are designed for people who are most acutely and chronically afflicted with severe psychiatric disorders—the small subset of people with mental illnesses most prone to homelessness, hospitalization, incarceration, self-harm, and violence.
For example, the effort to bring assisted outpatient treatment to New York in 1999 was spurred by a succession of tragedies caused by individuals with untreated psychotic disorders. Inevitably, legislators, media, and the public focused on the incidents and on violence prevention, which may have resulted in increased stigma analogous to Dr. Corrigan's results. New York's legislature adopted assisted outpatient treatment swiftly and overwhelmingly, which may reflect Dr. Corrigan's additional finding that better knowledge of the causes of violence engenders support for treatment interventions. Furthermore, although the Corrigan study found that recognition of a connection between violence and mental illness had no affect on participants' support for increased resources, not only did New York mandate new funding for Kendra's Law but Governor Pataki also dedicated an unanticipated $125 million to community services three months after signing the legislation.
Since 1999 more than 5,600 people have either been placed in assisted outpatient treatment or received intensive service enhancements pursuant to Kendra's Law. For a group of 1,407 individuals who completed initial six-month assisted outpatient treatment orders, 63 percent fewer were hospitalized than in the six-month period before the orders (31 percent compared with 84 percent) (personal communication, New York State Office of Mental Health, 2003). Similarly, 55 percent fewer became homeless while in assisted outpatient treatment (5 percent compared with 11 percent). In addition, 75 percent fewer were arrested (6 percent compared with 24 percent) and 69 percent fewer had been incarcerated (4 percent compared with 13 percent). Among the first 2,433 individuals who were placed in assisted outpatient treatment, moreover, the rate of self-harm declined by 45 percent and the rate of harm to others fell by 44 percent (1).
By improving the quality of life of people with mental illnesses, Kendra's Law combats direct sources of stigma. These outcomes equate to fewer stigmatizing beliefs and attitudes among the other citizens of New York—people can't see what doesn't happen and newspapers can't print it.
Jonathan Stanley, J.D.
Mr. Stanley is assistant director of the Treatment Advocacy Center in Arlington, Virginia.
1. New York State Office of Mental Health, Kendra's Law: An Interim Report on the Status of Assisted Outpatient Treatment, Jan 2003. Available at www.omh.state.ny.us/omhweb/Kendra_web/interimreport.