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Untreated Psychosis and Violence: It's Not a Stigma if it's True

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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.