Violence & Mental Illness

Violence & Mental Illness

This piece was prompted by MHANYS' Joe Glazer. At a time when tragic murders on Long Island apparently by a man with a diagnosis of major mental illness have raised the ugly specter of stigma and discrimination, it is useful to look at the research on violence and mental illnesses. Following are several pieces from 1998 and 2000..the first summarizing a study indicating that people with 'severe mental illness' are 2 1/2 times more likely to be victims, not perpetrators of violence...and the second an early executive summary of the findings of the landmark MacArthur study that found that people discharged from psychiatric hospitals were found to be no more violent than the general public except when, as is true of the general public, substance abuse is involved.

Mentally Ill Attacked at Higher Rate

By Claudine Chamberlain Associated Press 2000

When a schizophrenic man pushes a complete stranger into the path of an oncoming subway train and kills her, it's easy to assume that all people with severe mental illness are violent or somehow dangerous. But sensational cases like that of Andrew Goldstein, now under arrest in New York City for the Jan. 3 subway killing, are very rare. The truth, experts say, is that most people who are mentally ill are no more violent than anyone else. And in fact, they're more likely than others to be the victims of violent crime.

A new study by researchers at North Carolina State University and Duke University has found that people with severe mental illness - schizophrenia, bipolar disorder or psychosis - are 2½ times more likely to be attacked, raped or mugged than the general population. For people like Sam Guardino, those statistics aren't surprising at all. He's an outreach worker for Threshold, a Chicago social services agency that helps the mentally ill live independently. Having an obvious mental illness, he says, can make people easy targets.

Who's Really the Perp?

Just this past summer, for example, a manic-depressive man Guardino works with was attacked by a man and woman in the stairwell of his apartment building. As he tried to get away, they stabbed his hand. To make things worse, the police who responded to the scene thought Guardino's client was the attacker, because he was the one with the apparent mental illness. Hiday's study found that people with severe mental illness were much more likely to be victims of violence. (ABCNEWS.com)

"He couldn't articulate himself very well. He couldn't present his
case," Guardino says. "So he was mugged, stabbed - and then arrested."

Thankfully, the case against him was later dropped.

Sociologist Virginia Hiday, who led the North Carolina study, studied 331 severely mentally ill patients who had been discharged from psychiatric inpatient treatment. Interviews revealed that 8.2 percent of them had been the victims of violent crime in the four months before they entered the hospital. For the general population, that figure would have been only 3.1 percent.

Among mentally ill women who live on the streets, according to another recent study, rape is so common that it's seen as normal. "Just about every woman I've ever known who's living on the streets has been raped, sometimes more than once," Guardino says. "And they get into dependent, abusive relationships. They're very commonly targeted." Doing Unto Others Hiday says there are a few key factors that increase a mentally ill person's risk for becoming a crime victim - residing in a city, using alcohol or drugs and having transient living conditions. Those are the same things that would put anyone at higher risk for violence, she says, but the mentally ill are especially vulnerable. Their illness might make it more difficult to hold down a job and maintain a stable home. In fact, roughly one-third of all homeless people are mentally ill.

And people with severe mental illness, according to a 1998 study, are twice as likely as the general population to be alcoholics or use drugs. For many, it becomes a way to self-medicate. Not only does it increase a person's chances of becoming a victim, substance abuse also makes it more likely that they themselves will turn violent. A MacArthur Foundation study found that mentally ill people who use alcohol or drugs are five times as likely to be violent.

Hiday was interested in studying victimization of the mentally ill because she wanted to see if their victim status might prompt them to behave violently towards others. "One of my theories is that people act out because people pick on them," she says. "They're victims."

It may be hard to think of violent criminals like Andrew Goldstein, Unabomber Ted Kaczynski or Capitol Hill gunman Russell Weston - all of whom reportedly suffer from schizophrenia - as victims. But those cases are the sensational exceptions, not the rule...

Source:
http://abcnews.go.com/sections/living/InYourHead/allinyourhead_25.html

THE MacARTHUR VIOLENCE RISK ASSESSMENT STUDY(1)

Executive Summary Revised: 14 May, 1998

The risk that a person with mental disorder may physically harm others is a critical concern of both civil and criminal mental health law in the United States and in many other countries. On the civil side, involuntary mental hospitalization -- and, increasingly, involuntary treatment and intensive supervision in the community -- is often predicated on a clinical judgment of "dangerousness to others." In criminal law, involuntary treatment in a forensic hospital -- and, also increasingly, involuntary community treatment and monitoring -- for mentally disordered offenders turns on an assessment of undue risk of violence. Tort liability for clinicians who negligently assess risk, or who fail to take professionally appropriate actions to prevent assessed risk from being realized, has been the law in some American jurisdictions for 20 years.

Despite legal mandates that violence risk assessments be routinely performed, a great deal of research conducted over the past 20 years suggests that the validity of such assessments is -- at best -- only modestly greater than chance. Nor does that research identify ways in which the accuracy of clinical risk assessments could be readily improved. When it reviewed this body of research, however, the Research Network on Mental Health and the Law of the John D. and Catherine T. MacArthur Foundation isolated four problems that severely limit the ability of existing studies to provide information about risk assessment useful to either clinicians or to policy makers:

	The range of predictor variables studied has been very narrow, often no more than chart diagnosis or simle demographic information.
	The measures of the criterion variable -- violence in the community -- have been very weak, typically arrest or rehospitalization for a new violent crime.
	The patient samples analyzed have been highly restricted, usually to males with a prior history of violence.
	Past research efforts have been fragmented and have lacked coordination.

To surmount these problems to the greatest extent possible, the Network set about planning the MacArthur Violence Risk Assessment Study.

The MacArthur Violence Risk Assessment Study

The MacArthur Violence Risk Assessment Study was designed with three purposes in mind: to improve the validity of clinical risk assessment, to enhance the effectiveness of clinical risk management, and to provide information on mental disorder and violence useful in reforming mental health law and policy.

The problem of poor quality predictor variables was addressed by identifying a richer and more coherent array of risk factors for violence by persons with mental disorder. The risk factors were culled from available "mid-range" theories of violence and of mental disorder, from our own clinical experience, and from those robust findings that have emerged from existing research by ourselves and others. These risk factors -- some stable and some dynamic -- were subsumed in four "domains": dispositional or personal factors, historical or developmental factors, contextual or situational factors, and clinical or symptom factors. Some instruments for measuring the risk factors were designed to be administered by a clinician and some by a highly-trained community interviewer.

The problem of weak violence markers was addressed by using multiple measures to estimate the occurrence of violence to others in the community. The measures were patient's self-report, the report of a "collateral" (usually a family member)(2), arrest records, and mental hospital records. The patient and collateral interviews took place five times over the course of the first year after the patient's hospital release (i.e., approximately every 10 weeks). We counted as "violent" a variety of aggressive acts that resulted in physical injury or sexual assault, or that involved weapon use or a threat that was made while the patient had a weapon in his or her hand.

The problem of studying a narrowly selected group of patients was confronted by studying a sample broadly representative of acute psychiatric admissions, including: both males and females; with and without prior violence; admitted on a voluntary or an involuntary legal basis; of all diagnoses (except mental retardation); and of white, African American, or Hispanic ethnicity. Subjects were between 18 and 40 years of age, and all spoke English.

The problem of uncoordinated research projects was met by synchronizing research methods and instruments over three acute inpatient sites: the Western Psychiatric Institute and Clinic in Pittsburgh, Pennsylvania (a University-based facility), the Worcester State Hospital and the University of Massachusetts Medical Center, in Worcester, Massachusetts (a state hospital and a University-based facility), and the Western Missouri Mental Health Center, in Kansas City, Missouri (a public-sector mental health facility). The average patient length-of-stay in these facilities was approximately 2 weeks. For reasons of statistical power, a total sample size of approximately 1,000 patients was set. Results of this research should be available in late 1998.

The MacArthur Community Violence Risk Study

The Network realized that while the MacArthur Risk Violence Assessment Study might provide much new information about the risk of violence among released mental patients, as designed it would not be able to address another question of great relevance to mental health law and policy: How does the rate of violence by former mental patients compare with the rate of violence by other members of the community? To address this question, the Network designed the MacArthur Community Violence Risk Study as a supplement to its ongoing work.

In this research, approximately 500 adults from one of the three sites of the Violence Risk Assessment Study (Pittsburgh) were recruited as subjects. A stratified random sample of persons -- between the ages of 18 and 40, and of either white or African American ethnicity -- living in the same neighborhoods in which the former patients resided was obtained. Persons in the Community Violence Risk Study were interviewed once. The principal assessment instruments given to the patients were also administered to this general population sample, and the same questions about violence in the past 10 weeks asked of the patients were also asked here. Interviews with collaterals, usually family members, were obtained, and police record checks were made.

Among the early conclusions from this study are the following:

	People with a major mental disorder diagnosis and without a substance abuse diagnosis are involved in significantly less community violence than people with a co-occurring substance abuse diagnosis.
	The prevalence of violence among people who have been discharged from a hospital and who do not have symptoms of substance abuse is about the same as the prevalence of violence among other people living in their communities who do not have symptoms of substance abuse.
	The prevalence of violence is higher among people -- discharged psychiatric patients or non-patients -- who have symptoms of substance abuse.

This "Mental Health E-News" posting is a service of the New York Ass'n of Psychiatric Rehabilitation Services, a statewide coalition of people who use and/or provide community mental health services dedicated to improving services and social conditions for people with psychiatric disabilities by promoting their recovery, rehabilitation and rights.

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