Glasgow Caledonian University Programme : MSc Psychology & Mental Health Module : Clinical Governance and social context

MMM208486-12-A Student : Petrovan Florentina Arianna

Violence, Stigma and Severe Mental Disorder

Introduction As we witness a new era in the evolution of technology, access to information and means of communication becomes a more and more significant and indispensable aspect of our daily lives. The channels of media are one of our main sources of information so the content of this stream can have a great impact on the way we understand and perceive the world. Reports on extremely violent incidents that are attributed to mental illness and more specifically, to schizophrenia, films that portray merciless serial killers as people that have a psychotic illness, labeling a person with socially unacceptable behavior as mad, crazy, psycho, all of these issues are now a common sight on all sources of media. Linking violent behavior, fear, dangerousness and unpredictability with psychotic illnesses is a regular practice that has a high impact on the general populations response and attitudes towards mental disorder. The purpose of this research is to critically examine the evidence for the association between aggressive behavior and severe mental disorder (schizophrenia) and the impact of this association on society.

Stigma and Schizophrenia According to Zelst (2009), the process of stigmatization represents a negative interaction with the environment that most of the people with schizophrenia face on a regular basis. Stigmatization of this syndrome embodies a set of negative attitudes, stereotypes, fear and incorrect beliefs that greatly influence how this diagnosis is understood and perceived by others. It is rooted in problems of knowledge (that are mainly the result of ignorance), attitudes (prejudice) and behavior (causing discrimination) and may be highly influenced by scientifically inaccurate descriptions of the biogenetic model of mental illnesses by both professionals and the media. Not only does stigma cause harmful effects at a personal level, by changing the individual`s own perceived self-value as he internalizes the negative attitudes and emotions reflected by others (Ritsher et al, 2004), but it actively contributes to the evolution of the illness as a active negative environmental stressor. This influence can be reflected in all stages of development of the disorder, from potential risk factors to onset, and course of illness. Structural discrimination can be viewed as a component of social adversity which can result in social defeat and lead to negative beliefs about the self and others (Collip et al, 2008). By examining the perceived discrimination regarding gender, age, ethnicity, appearance, skin color, disability and sexual orientation, Janssen et al (2003) concluded that stigma predicted incident delusional ideation. What we could conclude from this finding is that in populations who suffer from structural discrimination, the proportion of individuals who actually develop psychotic illnesses is higher than in non-stigmatized populations (Zelst, 2009). This hypothesis can be supported by examining the recent findings that demonstrate a strong link between ethnic minority groups (as they are more likely to experience the effects of structural discrimination) and schizophrenia. In terms of course and outcome of the illness, negative discrimination can have a direct impact in access to care, social functioning, poor health services, delay in seeking treatment and help caused by shame and diminished self-esteem under the burden of the schizophrenic label.

Mental Illness and the Media As Thornicroft (2006) argues, our perception of mental illness is mainly influenced by three things: our previous experience and knowledge on what the diagnoses mean, our own attitudes on what type of emotional reactions towards mentally ill people are socially accepted and the types of behavior that are socially allowed. Our main source of information that shapes and places certain boundaries within the social context is the media (Philo, 1996), so the importance of the contents of this stream of information (regarding attitudes, behavior and knowledge) is crucial. As evidence suggests (Thornicroft, 2006), the misleading depiction of mental illness is a very common practice in all forms of mass media. Glasgow Media Group in Scotland analyzed the content of one month`s output regarding mental disorders in press and magazines, national and local television. From a total of 570 items, the authors found that 85% were non-fictional and 66% of these stories were focused on reported harm to others, followed by treatment (18%), harm to self (12%), comic images (2%) or criticism of accepted definitions of mental illness (2%). The fictional items also presented a tendency to focus on violence and harm to others (60%) (Philo et al, 1996). According to Flynn (et al, 2001), it is the media, more than scientists or even the truth itself, that will finally determine whether a stigma impact will exist in a particular situation. Newspapers Results of an Australian study (Williams et al, 1995) that analyzed the content of the stories about mental illness in national newspapers showed that more than half of these items classified the mentally ill person as being dangerous, a threat to others (61%), unpredictable, linked to criminality or danger to self. Authors concluded that print media portrayals are negative, exaggerated and do not reflect the reality of most people with mental illness (Coverdale et al, 2001; Coverdale et al, 2002).

Almost half of the newspaper coverage related to mental illness from newspapers in UK included derogatory terms such as nutter or looney (Ward, 1997) and 64% of the psychiatric stories were negative compared to 46% of general medical pieces (Lawrie, 2000). Research of over 3000 newspaper stories about mental illness in USA 2002 found that front page stories were mostly focused on violence and dangerousness (39%) and rarely on treatment (14%) or recovery (4%) (Corrigan et al, 2005). The way in which front page news of violent crimes is attributed to people with mental illness, with no clear evidence of illness or specific diagnosis, has a major influence on public attitudes. In the reporting of the recent tragic events of the Sandy Hook Elementary School shooting (2012), all channels of media automatically attributed several mental illness diagnoses, with no evidence to support any of these assumptions, to the shooter, Adam Lanza. Even though it was later found that Adam Lanza was suffering from Asperger syndrome, which is a brain-related developmental problem and not a mental illness, this report had a dramatic effect on the association between violent behavior and psychosis. As an aftermath consequence, the New York State government passed a new law that has provisions to ban weapons from mentally ill individuals. A German national survey analyzed the impact of such stories on the public`s perception regarding mental illness and concluded that over a two year period since initial reports of violent incidents, there was a significant deterioration in social distance towards schizophrenics, which affected all aspects of their life (employment, social relationships, housing) (Angermeyer, 1996).

Films and Television The illustration of mental illness on screen follows a similar pattern to the printed media standards and reinforces stereotypes based on misleading, exaggerated and inaccurate information. People in mental distress are commonly depicted as vicious serial killers, stalkers or placed in situations that would make them look awkward and ridiculous,

stripped of any traces of human dignity. In films, although the main focus is on violence, other themes also enter the frame. Amongst the most popular stereotypes that can be found in films regarding mental illness we can distinguish: homicidal maniac, rebellious free spirit, narcissistic parasite, zoo specimen, seductress (Hyler et al, 1991). There is now clear evidence to support the idea that films which promote the stereotype of the violent schizophrenic have enormous impact on public`s attitudes (Baumann et al, 2003), reinforcing negative stereotypes and increasing social distance (Wahl et al, 1995). People who watch more television, have a lower level of education and less contact with people with mental illnesses tend to be more influenced by the media and show greater social distance towards people with mental illness (Angermeyer et al, 1998). It would be inconsiderate to suggest that only media is to blame for promoting the negative portrayals associated with mental illness. Academic clinicians or even mental health staff can play a significant part in reinforcing social stigma. Maden (2007) concluded in his book Treating Violence that there is a highly significant link between mental illness and violence, comparable to the magnitude of the link between smoking and lung cancer. This is a very unfortunate association, as smoking is an established cause of lung cancer which kills thousands of people every year. There is no evidence of a causal association between severe mental disorder and violence, and the magnitude of their rates cannot be compared. Yet such statements, coming from respected academics or mental health professionals, have a major impact on shaping the notion of mental disorder in the mind of the general population.

Aggressive behavior and severe mental illness Despite enormous efforts, after more than half century of research, the association between violence and sever mental illness still remains a controversial theme. Although many researchers have tried over the past decades to demonstrate the existence of a positive link between violence and mental illness, the role of other factors such as comorbidity with substance abuse (Wallace et al, 1998; Elbogen and Johnson, 2009), social

conditions of the mentally ill (Swanson et al, 2002) or the contribution of psychotic symptoms leave the results open to dispute. As Elbogen et al (2009) argue, the association between mental illness and aggressive behavior has a major influence on mental health practice (Freidman, 2006) and policy (Appelbaum, 2006), and it is the foundation for imposing compulsory treatment to protect public safety at the expense of the patients` autonomy and liberty. Maybe it is the existence of such legislation that reinforces the common fears of the general population that mentally ill people are dangerous and should be treated with caution. Another aspect that could contribute to this issue is the legal special arrangement for people with severe mental illness in the case of homicide, as diminished responsibility for one`s actions. Even though such situations do exist, they are rare compared to the number of killings committed every year by people with no mental disorder or people that kill as an impulsive response to a stressor (Peay, 2009). As Walsh (2002) suggests, it is inappropriate that mental health policy and legislation should be focused on the risk of violence rather than on delivering effective treatments in the community. Statistics have demonstrated that over the past quarter of century, the number of homicides committed by people with severe mental illness has declined whilst those committed by people with no mental disorder has increased (Large et al, 2008). The reconviction rates of people with mental illness that were involved in serious crime have fallen over the past 20 years (Buchanan, 1998). As the main focus of research is targeting the risk of violence posed by the people with severe mental illnesses, little attention has been paid to the risk posed to this vulnerable group of people (Wehring et al, 2011), evidence suggesting that people with schizophrenia are in fact 14 times more likely to be victims of crime rather than criminals (Brekke et al, 2001). Choe et al (2008) argued that out of all the research that assessed violence in severe mental illness since 1990, 31 studies focused on the risk of violence posed by people with severe mental illness and only 10 studies regarded this group of people as victims of violence.

Comorbidity with substance use Although the overall contribution of mental illness to serious violence falls below 10 per cent (Walsh et al, 2002), recent evidence has demonstrated the enormous influence of other risk factors on the final outcome that ties violence and schizophrenia. Fazel et al (2009) conducted a systematic review of studies that reported an association between violence and schizophrenia or other psychotic illnesses. The meta-analysis included bibliographic databases and reference lists dating from 1970 to February 2009. The authors identified 20 studies that reported data on 18,423 individuals with schizophrenia or other psychoses. Results have shown that the risk estimates of violence in individuals with substance abuse but no psychotic illness was similar to the risk posed by those with psychotic illnesses and comorbidity with substance use. These risk estimates were overall higher than in studies that targeted individuals with psychosis irrespective of comorbidity. Men with schizophrenia or other psychosis were found to be four to five times as likely as men from the general population to commit a violent act. For women with schizophrenia, the risk was eight times greater than women in general population and this result was thought to be explained by the lower prevalence of alcohol in the general female population. The authors concluded that, although schizophrenia and other psychotic illnesses are associated with violent behavior and offending, most of the excess risk appears to be mediated by substance use comorbidity. As this risk is similar to that of substance abuse without psychosis, they advise that public health strategies for reducing violence should focus mainly on prevention of substance abuse, as substance use disorders are three to four times more common than psychoses. The findings of this research support Walsh`s argument (2002) which states that the contribution of mental illness alone to violence is low and individuals with psychotic illnesses alone have a modest increase in risk for violent behavior. The American Epidemiologic Catchment Area study (Swanson et al, 1990) measured self reported violence in a community sample of 10,059 individuals over the course of one year. Prevalence for violence in people with a psychiatric disorder was 8%, highest risk being presented by people with alcohol or drug misuse (24%) or dependence disorders (34%).

Findings of a Danish study of birth cohort followed by age 44 illustrated that only 7% of lifetime arrests in the male population were attributable to psychotic illness, of which 5 % were marked by comorbidity with substance use (Brennan et al, 2000). As a result, only 2% of the total were attributable to mental illness alone and this might include other coexisting risk variables which were not named. This evidence supports the idea that the contribution of mental illness to violence is modest. Another important study was the US National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a 2-wave face-to-face survey conducted by the US National Institute on Alcohol Abuse and Alcoholism. The study included a total of 34,653 subjects, from the civilian population residing in the United States. Wave 1 data on severe mental illness and risk factors were used to predict wave 2 data on aggressive behavior. The main goal of this study was to analyze what risk factors predict violent behavior, whether severe mental illnesses predict future aggressive behavior and how risk factors predict certain types of violence (Elbogen et al, 2009). Results of the NESARC indicated that incidence of violence was higher for people with severe mental illness but significant only for those with comorbidity with substance abuse and dependence. Schizophrenia alone did not predict violence. Socio - demographic factors and violence risk Findings of the NESARC also suggested that mental illness alone did not predict future violence but a combination of historical, clinical, dispositional and contextual factors which occurred more often in the case of individuals with severe mental illness (Elbogen et al, 2009). Consequently, as mental illness did not independently predict future violent behavior, the authors advised that in order to understand the association between mental disorder and violent incidents other variables, such as substance abuse, history of violence, environmental stressors should be taken under consideration. Therefore, this finding suggests that an individual`s risk of future violence may vary according environmental stressors he experiences. Data analysis also revealed that, contrary to public fears, individuals with severe mental illness were not at risk of committing violent

crimes (use of deadly weapons, extreme forms of physical aggression). The highlighted risk factors that were found to be predictors of serious violence were mainly attributed to social differences such as: lower social status, younger age, lower level of education, male gender, history of violence and being divorced or separated in the past year. Psychotic symptoms such as perception of hidden threats from others were also attributed to serious violence risk factors. Psychotic symptoms and violence risk In examining the contribution of psychotic symptoms to the risk of future violence, early studies found that persecutory delusions can be associated with an increased risk of aggression (Wessely et al, 1993). The content of these delusions can include the belief that the mind is dominated by external forces beyond the one`s control, that other people represent a threat and conspire to harm the person, that the individual is being stalked or that thoughts are being put into the person`s head (Scott et al, 2005). These assumptions have been dismissed by more recent research (Appelbaum et al, 2000; Monahan et al, 2001) that found no evidence between predicting future violent behavior and delusions. Hallucinations were also found not to be related to violent acts in individuals with schizophrenia, but certain types of hallucinations might increase the risk of violence (Zisook et al, 1995) if they generate negative emotions (Cheung et al, 1997). The MacArthur study (2001) results suggested there was a significant link between command hallucinations to commit violent acts and violence.

Crime victimization amongst people with severe mental illness Deinstitutionalization and the beginning of community care marked a significant change not only in the approach and understanding of mental health treatment but also in the lives of the people with severe mental illness. The consequences of this change were measured in terms of risk and damage to the general population, very few taking into consideration the impact on the exposed targeted group. Similar to other vulnerable

populations (homeless people, people with developmental disabilities), individuals with severe mental illnesses are a high-risk group (Teplin et al, 2005). A significant amount of factors that correlate with victimization can be found in this group: low social status, homelessness, conflicting social relationships and substance abuse (Hiday et al, 1999; Silver, 2002). An epidemiologic study conducted by Teplin et al (2005) analyzed the prevalence and incidence of crime victimization among people with severe mental illness by age, gender and ethnicity and compared rates with the general population data. Findings demonstrated that more than a quarter of persons with severe mental illness had been victims of a violent crime over the course of one year, a rate 11.8 times higher than the general population rates. Depending on the type of violent crime, prevalence was 6 to 23 times higher among people with severe mental illness than among the general population (Teplin et al, 2005). Significantly more women than men were victims of violent acts and sexual assault and more men were victims of robbery. This demonstrates the disproportion between public fears of dangerousness and stereotyped negative attitudes towards individuals with severe mental disorder and the reality of the mental illness as the result of the impact of these generally spread beliefs . Walsh et al (2003) conducted a study on the prevalence of violent victimization in severe mental illness. The study involved 708 participants that met the criteria for inclusion with a diagnosis of psychosis, recent hospital admissions and exclusion of coexisting substance use disorder or brain damage. Findings suggested that 40% of the subjects were dissatisfied with their personal safety, victims of violence reporting higher rates in perceived threat to personal safety (58%). In terms of socio-demographic factors, victims were significantly more likely to be male, under 40 years, have low socio-economic status (cases of homelessness included) and were less likely to engage in daily contact with their peers and family. Results on clinical characteristics of the victims evidenced that this group displayed significantly more clinical symptoms than the non-victim participants. Authors conclude that it is becoming more and more evident that the focus

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on community risk posed by individuals with mental disorders should be turned to risk posed by the members of society to these vulnerable people. Conclusion As it has been illustrated above, review of scientific literature does not establish any causal relationship between severe mental illness and violent conduct. Emphasizing more on what is newsworthy rather than worthy and on entertainment rather than education (Thornicroft, 2006), the common portrayals of this association promoted by the media have no scientific background and are grossly exaggerated. Although the current evidence does not refute this association completely, it is argued that the contribution of mental illness alone to violence in the community is very modest and that other factors should be taken into consideration when assessing the risk of future violent behavior. Socio-demographic factors such as male gender, young age, low socio-economic status or low level of education, as well as history of violent offending are considered to be far better predictors of future aggressive conduct. The effect of media`s misleading depictions can have a crushing impact on mental health service users, as it promotes negative attitudes and beliefs which ultimately result in social stigma and structural discrimination. As demonstrated by studies that analyzed the prevalence and incidence of crime victimization among people with severe mental illness, the general population is more likely to be the source rather than the target of aggressive behavior for individuals with mental disorders.

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