STIGMA AND VIOLENCE

Stigma 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 against individuals with severe psychiatric disorders and the solution to the problem have become clearer.

1. The public’s association of mental illness with violence is a major cause, probably the major cause, of stigma against mentally ill individuals.

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).

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).

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.

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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).

3. The most likely reason for this increasing stigma 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.

4. A reduction in stigma 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).

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Summary

In summary, 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). Promoting assisted treatment is thus the most effective type of anti-stigma campaign to reduce stigma against mentally ill individuals.

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.

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