Recovery to Practice Special Feature: One Response to One Reaction to the Newtown Tragedy

While the country argues over stricter gun control legislation proposed by the president, mental health providers, along with persons with mental health conditions and their loved ones, continue to be in the position of having to respond to how some people in broader society have reacted to the tragedy in Newtown, Connecticut. Although much of the country has been compassionate and thoughtful, there have also been media reports, talk shows, op-eds, blogs, and other media outlets replete with highly offensive and stigmatizing references to persons with mental illnesses-in which the mass shootings that unfortunately seem to be becoming a not-so-rare part of American culture are blamed (inexplicably) on “the mentally ill.” The use of terms such as “monsters,” “mental defects,” and “madmen” is not only based on grave misunderstanding of mental illness and extremely hurtful to tens of millions of Americans who are working hard at their recovery; it also does nothing to explain the loss of 28 lives in Newtown on December 14. More important, perhaps, it does nothing to prevent such horrors from occurring again in the future.

Many of us would like to simply dismiss such false and destructive myths and sever the erroneous connections made between mental illness and violence completely. But for those practitioners, persons in recovery, and family members who feel they are in a position of having to respond to these damaging attitudes and beliefs, we offer the following facts and considerations.

Let’s start with the facts. According to the Institute of Medicine (IOM), “Although studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small, and further, the magnitude of the relationship is greatly exaggerated in the minds of the general population” (IOM, 2006). In fact, according to the MacArthur Study of Mental Disorder and Violence-the most rigorous scientific study conducted to date by the country’s leading experts on mental illness and violence-the contribution to violence made by persons with mental illness is no larger than the contribution made by persons who do not have a mental illness (Monahan et al., 2001), with other demographic and socioeconomic factors contributing much more than mental illness. The subgroup most at risk for committing violent acts is actually young and single working-class white males. Within behavioral health, broadly, active substance use does contribute to violence. But within mental health, schizophrenia (the condition most alluded to by people who characterize “the mentally ill” as violent) contributes least to violence among the major illnesses. As summarized by Stuart (2003):

“The prevalence of violence among those with a major mental disorder who did not abuse substances was indistinguishable from their non-substance abusing neighborhood controls … those with schizophrenia had the lowest occurrence of violence over the course of the year (14.8 percent), compared to those with a bipolar disorder (22.0 percent) or major depression (28.5 percent).”

Not only does mental illness contribute little to violence (estimated to be around 4 percent); persons with mental illnesses are generally much more at risk for being victims of violence than being perpetrators (Appleby, Mortensen, Dunn, & Hiroeh, 2001). Here the data are quite striking. Studies have consistently found that “people with severe mental illnesses… are 2 ½ times more likely to be attacked, raped, or mugged than the general population” (Hiday, 1999). In addition, “individuals with schizophrenia living in the community are at least 14 times more likely to be victims of a violent crime than to be arrested for one” (Brekke, Prindle, Bae, & Long, 2001). Despite the highly consistent findings that persons with mental illnesses are much likelier to be victimized by others than to hurt them, there have been 13 times as many articles on the violence presumably perpetrated by persons with mental illnesses as there have been on crime victimization among persons with mental illnesses.

In the face of the atrocity committed in Newtown, these facts unfortunately do little to persuade many people that mental illness is not the culprit. They want somebody and something to blame, and have a hard time believing a person could act in such a heinous way without being out of touch with reality. Confronted with so many deaths, especially of children, appealing to science may be seen as cold and heartless. What, then, should we do? Below are a few considerations-some based on research, others on experience-that may be useful in moving the discussion in a more constructive direction.

• Point out that mental illnesses are much more common than stereotypes suggest, with one in five Americans experiencing a mental health disorder during his or her lifetime. Were Congress to pass new laws that affect persons with mental illnesses, these would apply to one fifth of the American population, or roughly 60,000,000 Americans. These laws would affect at least one in two American families.
• Personalize the issue by disclosing you have a mental illness (if you do) or know and care about people who have mental illnesses-whether they are loved ones, friends, coworkers, or the people you serve. Point out visible examples of people who have, or have had, mental illnesses who have made important contributions to our society-from Abraham Lincoln to Beethoven and Mozart to Paul Wellstone, William Styron, Kate Jamison, Robin Williams, Billy Joel, and Alma Powell, to more recent figures such as teen idol Demi Lovato, rapper DMX, and soccer legend David Beckham. Although most people with mental illnesses will not become such public figures, they are more likely to succeed in politics, write stirring music or fluid prose, or become an accomplished actor or athlete than they are to hurt anyone.
• Educate people about the “real problem” associated with mental illness today-that so few people can or choose to access effective care for their condition, leading to unnecessary suffering on the part of the person and his or her loved ones (rarely on the part of the community) as well as lost productivity. Because mental health care has yet to be adequately funded in this country (the money never followed patients out of state hospitals, and our society has not viewed mental illnesses as illnesses for which effective treatments exist), very few people can access care. This travesty will hopefully be redressed through the combination of parity legislation passed in 2008 and provisions of the Affordable Care Act passed in 2010 (i.e., by mandating states include adequate coverage for behavioral health conditions in all benefits packages). At the present time, high-quality, effective mental health care remains difficult to access in most parts of the country, and impossible to access in some.

  Additionally, even when care is available, many people choose not to access that care, precisely because of the pervasive societal attitudes and beliefs about mental illness we criticized above. Many people choose not to access mental health care or follow through with outpatient care once discharged from a hospital because they do not see themselves as “mental defects” or “madmen”-nor do they want to. Rather than being a justified approach based on accurate information, societal responses that view persons with mental illnesses as dangerous and unpredictable accomplish exactly the opposite of what they intend. They drive people in need away from the care that would be effective in addressing their concerns.

  No one would willingly choose to adopt the label and identity of a “mental patient” or “crazy person.” This is why it requires considerable courage for people to seek mental health care in the first place. One recent consequence of these attitudes is the startling statistic mentioned in our Jan. 10 RTP Highlight: more American soldiers died from suicide in the previous year than from combat in Afghanistan. Painting misguided and offensive pictures of mental illness only fortifies the barriers that already exist and keep people from getting the care that is available. If we want to decrease the actual burden that mental illnesses impose on our country, we should disseminate accurate information to the public and offer fact-based education to our youths on as broad a scale as possible. We should make role models of recovery as visible and accessible to as many people as possible, infusing the mental health workforce-and general workforce-with persons who embody the reality of recovery. And we should invite, rather than coerce, people into care that is respectful and responsive to their needs, so they need not suffer in silence and alone, and so using mental health care need no longer be something to be ashamed of.

A final consideration has to do with the issue of “insight.” We addressed this issue at length in the Feb. 6 Special Feature. In the context of current debates about mental health policy, we would like to point out that there are many reasons why some people with mental illnesses choose not to participate in care or take psychiatric medications. The stigma and stereotypes that surround mental health care are at least as prominent a reason for not accessing care or taking medications as the reason for lacking “insight” into having such an illness. No one is born knowing what mental illnesses are or how to know or recognize when one begins to experience symptoms associated with having one. How, then, can a person develop such “insight”? If the only things people are taught about mental illnesses are the negative and insulting stereotypes described above, we can assume many people will continue not to have “insight” when they begin to experience the symptoms of a mental illness. From their perspective, they are not “crazy” or “insane”… they are not “mental defects” or “madmen”-so they could not possibly have a mental illness. They are, after all, just like you and me (because they are, after all, you and me).

If we truly want people to recognize and gain insight into having a mental illness when they begin to experience the symptoms of one, we need to dispel these fallacious and off-putting myths. We need to educate the public and youths in particular about what mental illnesses are, including how common they are (e.g., one in five Americans will have one), that effective treatments are available, and, importantly, how possible it is to recover. Then we can turn our attention to the isolation, rejection, alienation, silent suffering, and culture of violence that truly underlie such atrocities.

Dr. Davidson is the RTP Project Director.

References

Appleby, L., Mortensen, P.B., Dunn, G., & Hiroeh, U. (2001). Death by homicide, suicide, and other unnatural causes in people with mental illness: A population-based study. The Lancet, 358, 2110–12.

Brekke, J.S., Prindle, C., Bae, S.W., & Long, J.D. (2001). Risks for individuals with schizophrenia who are living in the community. Psychiatric Services, 52, 1358–66.

Hiday, V.A. (2006). Putting community risk in perspective: A look at correlations, causes and controls. International Journal of Law and Psychiatry, 29, 316–31.

Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use conditions. Washington, D.C.: Institute of Medicine.

Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P., Mulvey, E., Roth, L., Grisso, T., & Banks, S. (2001). Risk assessment: The MacArthur Study of Mental Disorder and Violence. Oxford: Oxford University Press.

Stuart, H. (2003). Violence and mental illness: An overview. World Psychiatry, 2(2), 121–24.