By Sally Satel and D J Jaffe
A MacArthur Foundation study found that the mentally ill are no more violent thananyone else. Can it possibly be true?
Last May, Raymond Cook went on trial for first-degree murder in the death four yearsago of Thomas J. Guinta, a police officer in Fall River, Massachusetts. The same day thatCook shot Guinta, he spared the life of a longtime neighbor because he mistook her for amovie star who had played opposite James Cagney.
The day before Easter, 26-year-old Keith Powell of Red Oak, North Carolina, showed upwith a shotgun at his aunt Louise’s birthday party and killed his grandfather and twouncles. Months earlier when he walked away from his group home, his mother knew that hehad quit taking his medication, and she feared that the voices in his head would soonreturn. After the shootings, Powell committed suicide.
In the most spectacular recent case, Michael B. Laudor of Hastings-on-Hudson, New York,a brilliant Yale Law School graduate who seemed to have beaten back his mental illness (hewas working on a screenplay based on his successful fight) allegedly stabbed hisgirlfriend to death. He too had stopped taking his medication, and his mother had becomeso alarmed that she asked police to check on him shortly before his girlfriend’s body wasfound.
Cook, Powell, and Laudor all suffered from schizophrenia. Lacking adequate treatment,they became deranged and violent. Homicide, to be sure, is rare even among schizophrenics,and yet untreated psychosis is so intimately linked to aggression that mental hospitalsroutinely rely on locked wards and often use physical restraints to control patients untilantipsychotic medications take effect.
The connection between certain types of severe mental illness and violence would seemto be a matter of common sense. But until the 1960s, when deinstitutionalization began inearnest, most of the severest cases were out of sight, helping people forget how volatilethe psychotic can be. And in the 1970s a movement focused on reducing the stigma of mentalillness, and hence downplaying the risk of violence, became better organized and moreinfluential. Thus, the old common-sense view became increasingly controversial.
Now a new study from the MacArthur Foundation says the notion that people with seriousmental illnesses may be particularly prone to violence is little more than a stigmatizingmyth. The study got wide play in the media-including front-page coverage in the New YorkTimes and some sensational headlines-from the AP, “Mentally Ill Not EspeciallyViolent” and from the Washington Post, “Are Former Mental Patients more Violent?If they Don’t Abuse Drugs and Alcohol the Answer is Generally No, Study Finds.” Itcould have a major impact on the running debate over involuntary-treatment laws byproviding ammunition to civil libertarians and advocates for the mentally ill who believethat ill people should be left to wallow in their psychosis, haunting the streets of ourcities.
The MacArthur findings were published in the May issue of the prestigious Archives ofGeneral Psychiatry, under the title “Violence by People Discharged from AcutePsvchiatric Inpatient Facilities and by Others in the Same Neighborhoods.” The studydoes admit that drugs and alcohol increase violence in people with mental illness morethan they do in the general population, but it concludes that, otherwise, these people areno more violent than anyone else.
This contradicts the findings of numerous studies over the last thirty years. Forexample, a study of three hundred patients discharged from California’s Napa StateHospital between 1972 and 1975 showed they had an arrest rate for violent crimes ten timeshigher than the general population. A 1994 British study of schizophrenics in Camberwellfound that they were four to five times more likely than their neighbors to be convictedon charges involving serious violence. How did the authors of the MacArthur Violence RiskAssessment Study, all prominent researchers, come to such a radically differentconclusion?
First, they excluded many potentially violent people by the way they constructed theirsample, such as persons who were currently in or recently released from a prison, jail,forensic hospital, or long- term psychiatric hospital. “We always teach medicalstudents that past violence is the best predictor of future violence,” sayspsychiatrist and schizophrenia researcher E. Fuller Torrey. “While purporting tostudy violence, the first thing the authors did was omit violent people from thestudy.”
The researchers limited the study to patients in acute-care hospitals. Only one in tenpatients stayed longer than thirty days with half of all patients successfully treated andreleased in under nine days. This largely eliminated anyone too sick to be stabilizedacutely, again reducing the chance of including non-psychotic individuals. Among thoseasked to participate, 29 per cent refused; a disproportionate number were suffering fromschizophrenia, the very disorder which, if untreated, is most likely to result inviolence.
Second, by choosing a narrow, high-end definition of violence, the study left out manydangerous people. For example, the authors counted as violence only those acts thatproduced bodily harm. As the father of a woman with schizophrenia and a mean left hooksummed it up, “If you’re a good ducker, your relative is not consideredviolent.” While most of us would consider setting fires and trashing rooms to beviolent acts, the authors of the study did not.
Conversely, the authors chose to study the broad category of mental illness rather thanthe narrow category of psychosis. Since people suffering from depression rarely commitviolence against others, including them in the pool studied skews the results. In fact, 40per cent of the sample suffered from depression.
Third, the researchers selected a violence-prone control group, residents of poor,chaotic, drug-ridden sections of Pittsburgh (one of the three cities from which the studydrew patients) that had higher crime rates than the city as a whole. Since many of thepatients were discharged to this same neighborhood, the authors assumed that a higherlevel of patient violence, if discerned, would be due to their mental illness. But thislikely minimized the violence differential between the patients and the control group.That’s because many people with psychiatric illnesses-illnesses that can impede economicadvancement-end up living in marginal areas with hotheaded neighbors.
Despite all these stratagems, the authors still found that over half of the patientsstudied engaged in some form of threatening behavior within one year after discharge fromthe hospital. Specifically, 18 per cent of the patients without a drug or alcohol problemcommitted at least one act of violence (e.g., throwing objects, kicking, hitting, using aweapon) and an additional 33 per cent engaged in at least one act of aggression (same asabove except that no harm resulted). Violence was nearly double (31 per cent) amongmentally ill people who also abused drugs and alcohol.
So, in reality, the MacArthur study proves only that nonviolent people tend to benon-violent. But the fact remains that seriously mentally ill people are more prone toviolence than the rest of the population. Indeed, one of the MacArthur study authorsacknowledges as much.
In a 1992 issue of The American Psychologist, John Monahan of the University ofVirginia wrote: “The data that have recently become available, fairly read, suggestthe one conclusion I did not want to reach: whether the sample is people who are selectedfor treatment as inmates or patients in institutions or people randomly chosen from theopen community, and no matter how many social or demographic factors are statisticallytaken into account, there appears to be a relationship between mental disorder and violentbehavior.”
Advocates will seize upon the MacArthur study as “proof” that all the otherresearch is wrong-and that involuntary-treatment laws are unnecessary. In fact, those lawsneed to be strengthened, not repealed. Many states still rely solely on the standard ofwhether a person is “imminently and provably” dangerous to himself or others.What about those who are not yet dangerous but, already prisoners of their delusions, arelikely to deteriorate further if not treated soon? A number of states allow theauthorities to hospitalize such people against their will, but judges are notoriouslyreluctant to do so.
And many states do not allow judges to consider past violence when deciding whethersomeone should be committed. Even a court order for hospitalization does not guaranteemedication, since in some states judges may not mandate that a hospitalized psychoticpatient take an antipsychotic drug merely because he is dangerous: he must also be judgedincompetent to refuse the medication. While over half the states permit judges to order apatient to continue to take his medication once he is discharged from the hospital (if hehas a known habit of stopping the medication and becoming dangerous), such laws areactually applied only infrequently.
Obviously, treatment is of profound importance. It can keep people with serious mentaldisorders out of jails and shelters. It can prevent suicide and help the afflicted rejoinsociety. And certainty that the mentally ill will be treated might make communities lessresistant to supervised housing and other desperately needed community-based programs.Yet, political correctness-an unwillingness to offend or “stigmatize”-promptsefforts to conceal the risk of violence from people suffering from unmedicated psychosis.
After years of denying the association between untreated mental illness and aggression,the National Alliance for the Mentally Ill, the largest and most influential grass-rootsorganization of family members of mentally ill people, has come full circle. Carla Jacobs,a NAMI board member from California, became an activist for involuntary commitment afterher mother-in-law was fatally stabbed and shot by a mentally ill relative.
“We used to think it was stigmatizing to acknowledge violence,” she says.”Now we recognize that violence by the minority tars the majority, and makescommunities less likely to welcome the community- based housing that can facilitatetreatment and reduce violence.” Besides, she adds, “too many of our relativesare hurting others, and winding up in jail. The first step to helping them is admittingthere’s a problem.”
Unfortunately, the MacArthur study will make it harder even to take that first, basicstep.
Dr. Satel is a practicing psychiatrist in Washington, D.C., and a lecturer at theYale University School of Medicine. Mr. Jaffe is cofounder of the NAMI Treatment AdvocacyCenter in Arlington, VA (Update: Now with Mental Illness Policy Org.)
For more information about the McArthur Foundation study referenced in this article,visit the following website: http://ness.sys.virginia.edu/macarthur
NATIONAL REVIEW July 20, 1998, pp. 36-37
Reprinted with permission. Copyright 1998 by National Review, Inc., 215 Lexington Avenue, New York, NY 10016. All rights reserved.