People with untreated psychotic disorders have a higher rate of violence than do the general population. The word "untreated" can't be overemphasized. People whose severe mental illnesses are treated do not commit more violent acts than do other people.
Acknowledging this reality is not politically correct and I can already anticipate the furious accusations of promoting stigma that this column will produce.
Current anti-stigma campaigns emphasize that most people with mental illnesses aren't violent. This is very true. They also point out that people with mental illnesses are much more likely to be the victims of violence rather than the perpetrators. Also true. But if we want the public to understand all aspects of mental illness, we need to start with the facts and the research is clear that people with untreated psychosis are a greater danger to themselves and others than people who aren't psychotic.
The Mental Health Commission of Canada's recent anti-stigma conference was missing a key notion that needs to enter the discussion; we won't get rid of stigma as long as we have the public constantly experiencing the negative impact of untreated psychotic illnesses. A comprehensive examination of stigma can be found in Dr. E. Fuller Torrey's article "Stigma and Violence: Isn't It Time to Connect the Dots?". Torrey points out that lack of appropriate treatment has led to an increased rate of violence and a corresponding increase in stigma.
Recent high profile mass murder cases have heightened the link in public consciousness between violence and mental illness. The resulting increase in stigma hurts the vast majority of people with mental illnesses who lead peaceful lives. At the same time, most news articles are not reporting basic information about psychotic illnesses, information that could lead to greater public empathy and more helpful responses.
Accused mass murderer James Holmes, a doctoral student in neuroscience, knew enough about mental illness and still had enough awareness at some point to get himself to the University of Colorado's mental health services. And psychiatrist Lynne Fenton heard enough to go to both the police and the university's threat assessment team for help. The public may cry for blood (or at least want someone to lose their job or get sued), but what we are seeing is not one university's glitch. We are witnessing a systemic problem.
There are many factors that could have contributed to the lack of appropriate action. We have become overly concerned about violating the rights of extremely mentally ill people; many argue that people must always be allowed to choose or refuse treatment despite the well-documented lack of insight that usually accompanies psychosis.
Individuals and hospitals can be sued for admitting people involuntarily. Holmes might have challenged his admission; the U.S. government's Substance Abuse and Mental Health Services Administration, which has become dominated by the perspectives of the psychiatric survivor movement, now provides federal funds to lawyers to assist patients challenging their involuntary admission.
As well, in the past decades there has been a dangerous reduction in acute psychiatric beds across North America. Colorado, for instance, lost a third of its beds in recent years.
In British Columbia, Kathy Tomlinson's CBC Go Public series last year examined the dismal state of facilities at Vancouver General Hospital and the ease with which patients walk away. The director of mental health services for Vancouver Coastal Health acknowledged that 100 beds are needed, not the current 74.
A problematic interpretation of human rights is leading to more very ill people being left untreated. Canadians need to watch carefully as the Mental Health Commission of Canada's Mental Health and the Law Advisory Committee releases an upcoming report on its Human Rights Evaluation Project and its suggestions for changes to provincial mental health acts.
This committee has been examining B.C., Manitoba and Nova Scotia to investigate possible human rights abuses in legislation and policies. We need to understand the beliefs of the well-meaning members of this committee if we want to construct the best mental health policies. Committee member Archibald Kaiser provides a good opportunity to learn about the competing belief systems that are vying to inform mental health policies. In his presentation to the Canadian Mental Health Association (pages 14 -15), Kaiser presents his position. He objects to the "medical model" where people with what Kaiser calls "mental health problems" are portrayed as having primarily "a biomedical need."
Mr. Kaiser prefers the "Social or Disability Model" which sees disability as socially constructed, not coming from some kind of individual pathology, and as being situated in society's failure to embrace diversity. This understanding of "mental health problems" leads to very different ideas about the best policies for responding to severe mental illnesses. I wonder if most Canadians believe that society should adjust better to the behaviour of people experiencing psychosis and that the people themselves should be encouraged to embrace their diversity.
The Human Rights Evaluation Project has met with many people in B.C., Manitoba and Nova Scotia about human rights abuses in mental health policies. It will be important in reading their report to see if these meetings included people like the many families I know with undertreated mentally ill people who have killed themselves. Also, we'll need to see if the report contains the underrepresented perspectives of many people like Erin Hawkes who recognize that involuntary treatment gave them back their lives. Hawkes argues in her article "Forced Medication Saved My Life" that people with psychotic disorders have a right to be protected from the illnesses that are destroying them.
The potential for antipsychotic medications to restore people to sanity has been demonstrated in other high profile cases. Following the involuntary administration of antipsychotic medication over the past year, Tucson mass murderer Jared Loughner has become legally capable of understanding the charges against him and has pleaded guilty.
Similarly, in Canada, Vince Li who beheaded and cannibalized a fellow passenger on a Greyhound bus, has responded well to treatment. His psychiatrist reports that he no longer has delusional beliefs, recognizes that he has schizophrenia, and understands that he needs medication.
If we believe, as contemporary psychiatry and neuroscience inform us, that psychosis is a treatable brain disorder, we need to ensure that people have timely access to the treatments they need. Vince Li, Jared Loughner and James Holmes' bio-medical needs have been recognized too late.
Statistically speaking, humans are MUCH more likely to be abused or assaulted by a family member or an intimate partner. So, how is our sensationalized fear of people with a brain disorder 'true' to any known evidence on the statistical prevalence of violence?
Motor vehicle accidents cause approximately half of ALL serious injury in North America. Yet, we do not cross the street when we see a parked car or feel shame when we admit we drive a vehicle. This failure to see every day (statistically valid) threats as 'threatening' and to continue to fear people with brain disorders is the result of hundreds of years of Western ideas such as that of Descartes, prime-time entertainment like Criminal Minds and media sensationalism.
The relationship of our fear of people with brain disorders to the actual threat of violence is NOT true, logical or reasonable. I fear that Susan Inman is pulling a Margaret Wente move in journalism; to be intentionally politically incorrect to generate more attention to her article. Poor writing, poor research, mis-guided. Very disappointing.
On the subject of psychiatric drugs, many of them have been shown to actually INCREASE the risk of violent behavior - so much so that some of them carry a black box warning stating that risk. Where is the wisdom in forcing an already troubled person to take a psychotropic drug which may or may not help him and might actually make him violent, or even more violent.
1. You say that Holmes was receiving psychiatric treatment. My own daughter who has schizophrenia received treatment at the emergency room of the local hospital for more than a year while her illness deteriorated to the point where she lost her apartment and ended up living on the streets (not just homeless, actually sleeping on the streets because she was so ill the local shelter refused to take her). Her "treatment" consisted of a nurse and a doctor assessing her condition and then releasing her from the hospital without any medication. That may have been "treatment" but it was utterly ineffective to prevent the relentless toll the disease took on her brain.
2. Psychiatric drugs increase the risk of violent behavior?? I suspect you may have actually made that up. Do you realize that the type of severe mental illness we are speaking about here utterly devastates people;s lives? My daughter lost every due to her schizophrenia - apartment, schooling, jobs, friends, family members, and most of her life opportunities. The anti-psychotic medication she takes today gives her a quality of life and enables her to function.
3. It is well established scientifically that early treatment of severe mental illness (schizophrenia, bi-polar and schizoaffective disorder) actually reduces the terrible effects of the disease and gives the person a much better outcome in recovery.
In 2004 the FDA mandated that all antidepressants carry a black box warning for increased risk (in children and adolescents) of suicidal thinking and behavior. Do you consider suicide a violent behavior? I do.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2004/ucm108363.htm
And here is a list of top ten prescription drugs linked to violence. Surprisingly, (or not) there are quite a few SSRIs on the list. http://www.chicagonow.com/fighting-autism-and-winning/2011/02/big-pharmas-top-ten-legal-drugs-linked-to-violent-behavior/
Neuroleptics (a.k.a. antipsychotics) are well known for causing movement disorders, including akathisia, (restlessness/agitation), http://www.tardivedyskinesia.com/causes/neuroleptics.php
and agitation has been linked to aggression and violence.
http://www.madinamerica.com/2012/08/neuroleptic-drugs-and-violence/
A couple Google searches will turn up lots of information about how unsafe these drugs can be. Or how safe - you can find studies/articles to back up just about any hypothesis or statement. It’s hard to know who to trust for reliable information, isn’t it?
You claim that psych drugs help your daughter. That's great. But that doesn't mean they're for everyone.
MY RESPONSE: PART 2 OF 2
I didn't write part 1 of my response because I am opposed to medication or treatment. I live with schizophrenia and I take medication. But I have also been able to experiment with going off medication and it is through that experimentation that I have learned about my limitations and the need for medication. I value my right to take risks and learn from that risk taking. I value my right to try going off of medication (although I do it with a safety net around me). There was even a point in my life where the ability to go off of medication prevented a suicide attempt. It was when I was being treated by force and the side effects were worse than the illness itself. The knowledge that the forced treatment was temporary and I would be able to get off the medication prevented the suicide attempt.
Happily, the medication I take now has no noticable side effects beyond the risk of metabolic syndrome.
But in the past I spent years struggling with mostly untreated psychosis - WITHOUT violence.
My concern in reading the article is that it can contribute to stigma by generating fear that if people do not take medication they will be violent. I am an example of a person with schizophrenia who has gone off of medication multiple times and experienced psychosis as a result - &
Six months later my daughter was once again admitted to the psych ward involuntarily.
She is now back on the original dose and doing well again.
I do believe that once people are established in treatment, they should have the opportunity to make their own decisions in partnership with their doctors. If that decision includes going off meds or reducing meds, that is fine, as long as the support system around the person is aware of what is happening.
MY RESPONSE: PART 1 OF 2
It is important to note that most people who go off of medication for psychotic disorders such as schizophrenia are never violent. Also, most violent crimes are not committed by people who have psychotic illnesses. One study found that only a small proportion of violence in society is attributable to mental illness (up to 10%). See http://www.responseability.org/site/index.cfm?display=134897
It’s also significant to remember that adherence with treatment is not the ONLY risk factor for violence. For example, substance abuse is another: “In the May 20 JAMA, Seena Fazel of the University of Oxford, Warneford Hospital in Oxford, England, and colleagues offer evidence that substance abuse spikes the risk of violence in people with schizophrenia. Indeed, they conclude that, in the absence of substance abuse, schizophrenia raises the risk of violence only a little.” See http://www.schizophreniaforum.org/new/detail.asp?id=1525
Similarly, an article in The British Journal of Psychiatry lists other predictors of violence as: childhood conduct problems, substance use, victimization, economic deprivation and living situation. It also notes that negative psychotic symptoms predict lower violence. See http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2801826/
Others note that violence is more closely correlated with the sex of the offender (i.e. male) and drug or alcohol use than with mental disorders.” See http://www.responseability.org/site/index.cfm?display=134897
It is a pet peeve of mine when people use the term "mental illness" in far too broad a sense. Lets be clear. I have experienced moderate depression myself and involuntary treatment was not needed for me because I continued to function to some degree and I also had full insight about my own illness (I knew I was sick and I sought out treatment)
People who have never experienced the severity of what it is like to be around someone who is going through severe psychosis often have a very hard time understanding it.
Due to her untreated schizophrenia, my daughter lost everything - friends, schooling, job, apartment. At one point she was literally sleeping on the street because she was so psychotic that the emergency shelters refused to give her a bed. How can someone put the abstract notion of "rights" above the very real human suffering that results when a person in a psychotic crisis is refused or denied medical treatment due to the fact that they lack insight into their own illness?
I believe much of this problem is due to a grave misunderstanding of the differences between mild mental illness and severe mental illness. People with mild - moderate mental illness should never be forced into involuntary treatment. But for those who have severe mental illness with untreated psychosis, involuntary psychiatric treatment literally saves lives.
Identifying and treating mental illness saves lives - including the people who have been diagnosed. My son, Ben, age 30, who does receive treatment for schizophrenia (ok, we the family have pushed for it, advocated for him, gone through chaos and despair to hope and help and still keep our fingers crossed...) - is a Dean's list college student now (after having dropped out of high school as his illness developed) and has now held a job for almost 18 months. A miracle? Yes, in a way. But also possible - with treatment, services, and an educated, supportive family.
Without treatment? I shudder to think. Ben is not violent by nature, thank goodness, but still could be in jail, homeless, or a victim of violence. Susan Inman has written an excellent piece. Let's hope those who create and uphold laws - in Canada, the United States, and elsewhere - will listen and act.
Randye Kaye, author Ben Behind His Voices: One Family's Journey from the Chaos of Schizophrenia to Hope.
I know we both want to keep encouraging families to hang in; in our cases, it took years for our children to rebuild lives that are stable and satisfying.
Randye, can you please supply the link to your very helpful blog?
Susan
In Canada, that's about 60,000 people, Unfortunately, it usually takes a psychotic episode to make a diagnosis.
The medications used to treat psychosis have severe and unpleasant side effects which make compliance to the medication regime problematic especially combined with the inability of psychotic people to recognize the severity of their illness.
However repeated psychotic episodes are really detrimental to people's ability to function in society.
One of the reasons these horrible situations keep happening in the US is that the number of ill people is closer to 6,000,000 and they have easy access to guns.
And healthcare for the mentally ill is dismal in both countries. I can't see that this commission will help things at all.
Citizens must insist our governments fix this non-system--before we lose more other innocents to its dysfunction.
which should not be given the undeserved description of being a System . It is no system, when appropriate and timely treatment are denied to the most severely ill.
It seems to be a bag of tricks, where any professional is free to grab the trick that appeals to them individually. The system" has no stated principles to guide it aside from the usual wordy recommended
This is advocacy for a return to the 50's, where America's state hospitals were filled with thousands of "mentally ill" people, often incarcerated for life without trial or committing a crime. It is "Big Nurse" asking you to ignore all the research that shows that traditional psychiatry is nonsense, that the drugs like Thorazine that were, and the newer drugs that are given today, just fry the brain.
If you care, go to http://www.madinamerica.com, or read Bob Whitaker's book, Mad in America, and see the truth for yourself.
The VA had a problem after the Vietnam War, many veterans of that war were returning and were having problems. Instead of calling them "mentally ill", the VA called it ptsd, post traumatic stress disorder, and created Vet Centers to help the traumatized war veterans. And things got better.
I am someone who was forcibly locked up in a state hospital, injected with Thorazine, and had my life made horribly harder by what this writer is advocating.
Then I learned what trauma does to people. What the writer is expressing, in opposing the views of the psychiatric survivor movement and human rights, is exactly what Big Nurse would write.
Please, educate yourself and don't condemn more thousands to the insanity of traditional psychiatry, who invent undiagnosable diseases and then use that excuse to destroy the lives of so many.
Hugh Massengill
After the person has been stabilized with anti-psychotic medication, ideally a sensible plan of recovery and rehabilitation in the community can be put in place so the person can go about living their life. This is called "recovery" and it is a far cry from what you describe.
Thank you for explaining this so well.
Susan
But I am done trying to communicate with those who cheerfully destroy the lives of the traumatized and lost. it must be nice living in a world with such a trust in psychiatry. Nuts but nice.
Hugh massengill, Eugene Oregon
And I deeply resent those who call my beautiful, talented and loving daughter "lobotomized" because she has lives with schizophrenia which is managed by medication. The disease she lives with is bad enough but the cruel and unnecessary stigmatization of those who live with schizophrenia makes it so much worse.