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."
years, the origins of stigma against individuals with severe
psychiatric disorders and the solution to the problem have
1. The public’s
association of mental illness with violence is a major cause,
probably the major cause, of stigma against mentally ill
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
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).
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.
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
study reported that 43 percent of students and 47 percent of
police officers associated individuals with schizophrenia
with "aggression, hostility, violence" (Wahl, 1987).
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).
survey of Utah residents reported that 38 percent agreed
that "people with mental illness are more dangerous than the
rest of society" (Fraser, 1994).
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).
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.
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
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).
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.
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).
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).
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.
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
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).
also observed by Dr. John Monahan:
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).
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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