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Position Statement 72: Violence: Community Mental Health Response

Policy

Readily available, high-quality, evidence-based, culturally and linguistically competent preventive and therapeutic services and supports for mental and substance use conditions offer the greatest promise of preventing violent behavior.(1) Mental Health America (MHA) is committed to the development of public policies and allocation of public resources to foster access to preventive as well as therapeutic services that can both prevent violence and reduce the fear of violence. Public policy must also work to prevent the violent victimization of persons with mental and substance use conditions, particularly those who are homeless or incarcerated in jails and prisons.

Preventive services have been shown to increase resiliency, an individual's ability to deal with stress and conflict. More broadly, social policies are needed that promote community connection and inclusion, both for people in mental health crisis and for the general population. The broader goal is to foster mental wellness in everyone. This policy focus is more likely to reduce violence than policies that discriminate against people with mental health conditions by singling them out as supposed causes of violence. It is important for the public and policy makers to recognize that mental health conditions are not associated with an increased risk of violent behavior.

Background

We live in a violent society. Rates of homicide and other violent death in the United States dramatically exceed those of other industrialized, high-income nations.(2) Our toxic environment of racial and ethnic discrimination and conflict, abuse of women, children, elders, and the weaker members of our society, and the decline of community and family connections, are among the root causes of violence in the United States.(3) Diagnosable mental health conditions are not.

In fact, trauma that results from violence is a significant precursor to the development of mental and substance use conditions.(4) Solutions to the root causes of violence in the United States are required to reduce overall rates of mental and substance use conditions and improve social well-being.

Unfortunately, public attitudes often associate mental health conditions with increased risk of violence.(5) These attitudes are ill-informed and ignore several important distinctions. First, considering mental health conditions as a singular phenomenon makes no more sense than collapsing distinctions between general health conditions. Grouping phobia with schizophrenia is like equating cancer with a cold. We must be more precise in our language when discussing mental health conditions.

Second, while untreated or undertreated mental health conditions, when accompanied by untreated or undertreated substance use conditions, may be associated with an increased risk of violence, this does not justify discrimination against people with mental health conditions as a class. Our growing understanding of mental illnesses and our dedication to humanitarian principles have led our society to reject confinement as the means of addressing mental health conditions, and to embrace community-based treatment. We must not abandon these values in response to isolated incidents linking mental illness and violent acts.

Third, persons with severe mental illnesses are much more likely to be victims rather than perpetrators of violence. The word "violence" has its roots in the Latin violare, which means "to violate;" and people with mental health conditions are often violated, but are rarely violent themselves.(6) Continuing public perceptions linking violence and mental illness frustrates access to care and undergirds an ‘us versus them' attitude that further marginalizes persons labeled with mental illnesses.(7)

MHA believes that the public must be reminded, as each sensationalized incident of violence is thrust into public view, that people with mental health conditions are no more likely to be violent than other people. A 2009 study published in the Archives of General Psychiatry(8) found that mental illness alone is not an adequate basis for a prediction of dangerousness. As stated in the abstract, "bivariate analyses showed that the incidence of violence was higher for people with severe mental illness, but only significantly so for those with co-occurring substance abuse and/or dependence. Multivariate analyses revealed that severe mental illness alone did not predict future violence; it was associated instead with historical (past violence, juvenile detention, physical abuse, parental arrest record), clinical (substance abuse, perceived threats), dispositional (age, sex, income), and contextual (recent divorce, unemployment, victimization) factors."

Of course, some people with serious mental illnesses are violent, but so are many more people with a record of past violence, juvenile detention, physical abuse as a child, or with a parental arrest record. Similarly, substance abuse, young age, male sex, low income, a recent divorce, unemployment, and victimization predispose people to violence. With the exception of past violence, which the criminal justice system addresses to some extent, no one advocates state intervention against any of these other groups. Why then single out people with mental illness or a civil commitment in their background?

Nevertheless, there is a widespread, profoundly troubling misconception that people with mental health conditions are inherently violent and this perception may be getting more rather than less prevalent.(9) Ironically, there is little understanding of the extent to which many people with mental health conditions are victims of violence and experience repeated trauma.

The ridicule, bullying, shunning, and other demeaning behaviors to which people with mental and substance use conditions are subjected are a form of violence and violate human dignity.

Society's passive acquiescence in the ignorance and discrimination surrounding mental and substance use conditions is fundamentally at odds with deep-rooted values that would foster every individual's opportunity to fully realize his or her potential. Such behavior, when directed at children and youth, can have a devastating and profound impact with tragic consequences.

People with severe mental illnesses can be easy prey to violence. Some live a marginalized existence as a result of mental illness and subsequent loss of income and assets, and may become targets of opportunity for theft, mugging, and rape. Incarceration of large numbers of people with mental and substance use conditions in county jails and state penitentiaries. subjects them to violent victimization. And the plight of thousands of individuals in every major U.S. city who are both homeless and have a mental health and/or substance use condition is exacerbated by a high incidence of violent acts against them.

MHA advocates encourage people with mental and substance use conditions to enter and remain in treatment as often as necessary to sustain their recovery. MHA supports the development of accessible and acceptable treatment strategies that engage people in care, using science-based approaches that provide effective and ongoing treatment for persons in need. MHA advocates confidentiality as the prerequisite for all effective mental health treatment. MHA opposes the use of intimidation, sanctions and compulsion that can deter full participation in treatment for mental health conditions.

People today have a greater understanding of mental health and substance use conditions than did earlier generations, including an increased awareness of the role of stress and brain chemistry as causative factors in some conditions. Nevertheless, evidence suggests that public attitudes toward people with mental health conditions reflect fear and prejudice. A 1996 nationally representative survey indicated that over 60% of respondents felt that a person with schizophrenia was likely to be violent while over 70% felt that this characterized persons with alcohol addiction and nearly 90% felt that this characterized persons with cocaine addiction.

The Surgeon General's Report on Mental Health(10) concluded that the contribution of mental health conditions to violence in our society is very small. The greatest risk of violence is from individuals who have an untreated or undertreated substance use disorder either solely or in combination with a mental health condition.(11) Successful treatment ameliorates the risk of violence. Engaging persons in evidence-based care so that they fully participate and implement a meaningful treatment plan is the key to successful treatment.

Echoing trends in criminal statistics, violent acts are most likely to be committed against family members or other acquaintances. This underlines the importance of involving family and friends in the recovery process and promoting education and mental wellness for all.

Media sensationalization of violence, and especially graphic coverage of isolated instances of violence that involve persons with mental health conditions, tend to rekindle deep-seated fears and stereotypes. In such an inflammatory environment, the contagion of fear can infect policymakers and lead to ill-considered public policy. For example, in response to highly publicized tragic incidents, Congress in 2007 passed legislation aimed at including in a national criminal database names and identifying information on persons who had been involuntarily treated for mental health conditions, as a means of enforcing a ban on their purchasing firearms. While well intended, these statutes confuse a temporary state of dangerousness with a persistent trait of dangerousness. They focus on a tiny proportion of individuals who are involuntarily treated, ignoring persons with similar circumstances who enter treatment voluntarily. And they devote considerable public resources that could be much more effectively allocated to expanding well-proven treatment programs.

In fact, many states have ignored the mandate to submit names to the list, and lax procedures have made removal of names from the list very easy.(12) Firearms legislation is controversial and beyond the scope of this policy. But people with mental health conditions should be treated the same as other Americans. Current policy, despite its popular appeal, fails to do that.

Given that only a tiny fraction of violent acts are perpetrated by persons with mental health conditions, efforts to bar such individuals from purchasing firearms or to increase preventive detention can have no meaningful impact on public safety. Such legislation wastes public resources, violates civil liberties, powerfully reinforces the myth that links mental health conditions with violence, and further cements stigma in the public mind. Incapacitated people may need to be treated against their will, but the circumstances are appropriately limited and should not be expanded in response to the public's blind reaction to Tucson and all of its predecessors and sequels. See MHA Position Statement 22 Involuntary Mental Health Treatment.(13)

Call to Action

MHA calls for a national dialogue on violence and mental and substance use conditions, with an eye to dispelling myth, combating stigma, and laying a foundation for sound public policymaking to reduce the overall level of violence in the United States. We staunchly support public policy changes to dramatically improve access to readily available, comprehensive and integrated, high-quality, evidence-based, culturally and linguistically competent mental and substance use services and supports. These services and supports should include a preventive focus, to foster mental wellness and recovery from mental health conditions that may otherwise lead to violence or victimization. We further support the implementation of evidence based prevention programs to reduce the overall levels of violence and trauma. We oppose coercive and punitive measures against people with mental health and substance use conditions.

MHA calls on policymakers to support efforts (such as public education campaigns) to unravel myths associating persons with mental and substance use conditions and violence and to ensure effective treatment and supports for people with mental health and substance use conditions as well as the safety of these vulnerable individuals. Policymaking aimed at deterring violence should not single out people with mental and substance use conditions.(14) MHA vigorously opposes efforts - in the name of public safety - to deny people rights or privileges, or otherwise discriminate against people on the basis of a mental health condition. Such efforts should be rejected as dangerously stigmatizing, making effective treatment more difficult, and as a violation of the civil liberties and human rights of people with mental health conditions.

Effective Period

The Mental Health America Board of Directors adopted this policy on September 17, 2011. It is reviewed as required by the Mental Health America Public Policy Committee.

Expiration: December 31, 2016

  1. A recent example is the 2011 Tucson tragedy involving Jared Lee Loughner, the accused attempted assassin of Rep. Gabrielle Giffords. There is no question that Mr. Loughner needed mental health counseling and that he did not get it. However, the only evidence at the time of the shootings was that Mr. Loughner had acted out bizarrely, but not violently, in class. So far as we know, he never made a threat of violence against anyone, even though threats against public officials are unfortunately common in contemporary American society. Although he made people nervous, Mr. Loughner was never deemed dangerous by anyone prior to the attempted assassination and was apparently never referred to the Pima County mental health system or the courts.As urged by this policy, assertive intervention by the mental health system could have stemmed the violence. But Pima County underwent a dramatic 45% reduction in public mental health treatment in 2010-2011, as local and state human services funding collapsed. This is an extreme case of a phenomenon being experienced nationwide. Thus, the first lesson of the Tucson tragedy has to be to understand the impact on public safety of the inability of the underfunded community mental health system to follow up in cases like this. Defunding of human services has serious consequences for society, as well as for the people who lose essential supports. Although Mr. Loughner might have refused counseling even if it were offered, there is no evidence that sensitive outreach would have been ineffective, because it was never tried. There were inadequate resources to do so.
  2. Krug E.G., Powell, K.E. & Dahlberg, L.L.. "Firearm Related Deaths in the United States and 35 Other High and Upper Middle Income Countries," International Journal of Epidemiology 27(2):214-221(1998); Milton, T., "Violence in a Violent Society," Journal of Public Health Policy 19(3):289-302 (1998). WHO, World Report on Violence and Health (Geneva 2002). From http://www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf.
  3. Adverse Childhood Experiences Study: Bridging the Gap Between Childhood Trauma and Negative Consequences Later in Life. http://www.acestudy.org/.
  4. Link, B.G., Phelan, J.C., Bresnahan, M., Stueve, A. & Pescosolido, B.A., "Public Conceptions of Mental Illness: Labels, Causes, Dangerousness and Social Distances." American Journal of Public Health, 89(9):1328-133 (1999).
  5. Link, B.G., Phelan, J.C., Bresnahan, M., Stueve, A & Pescosolido, B.A., "Public Conceptions of Mental Illness in 1950 and 1996: What is Mental Illness and is it to be Feared?" Journal of Health and Social Behavior, 41(2):188-207 (2000).
  6. Id.
  7. Easton, C.J., "The Role of Substance Abuse in Intimate Partner Violence," Psychiatric Times, 25(1), 1-2 (2006). http://www.psychiatrictimes.com/showArticle.jhtml;jsessionid=ZFMPWLFYYHP.... (requires free registration)
  8. Elbogen, E. & Johnson, S.C., "The Intricate Link Between Violence and Mental Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions" Arch Gen Psychiatry 66(2):152-161 (2009).
    http://archpsyc.amaassn.org/cgi/content/full/66/2/152?maxtoshow=&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
  9. National Institute on Alcohol Abuse and Alcoholism, Alcohol and Violence. NIH Publication 38 (1997).http://pubs.niaaa.nih.gov/publications/aa38.htm
  10. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General-Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. http://www.surgeongeneral.gov/library/mentalhealth/home.html.
  11. Steadman, H.J., Mulvey, E.P., Monahan, J., Robbins, P.C., Appelbaum, P.S., Grissom, T., Roth, L.H., & Silver, E. (1998). "Violence by People Discharged from Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods," Archives of General Psychiatry 55(5):393-401 (1998). Swanson, J.W., Swartz, M.S., Essock, S.M., Osher, F.C., Wagner, H.R., Goodman, L.A., Rosenberg, S.D. & Meador, K.G. The Social-Environmental Context of Violent Behavior in Persons Treated for Severe Mental Illness, American Journal Of Public Health 92(9):1523-1531 (2002).
  12. "Some With Histories of Mental Illness Petition to Get Their Gun Rights Back" By MICHAEL LUO New York Times July 2, 2011 http://www.nytimes.com/2011/07/03/us/03guns.html) Thus, the law serves as another trap for the uninformed and unwary.
  13. http://www.nmha.org/go/position-statements/22
  14. MHA particularly opposes legislative efforts to respond to isolated incidents of violence by making involuntary treatment easier. That is because the overwhelming cause of violence among the small number of persons with mental health conditions who do become violent is our failure, due to lack of resources, to either offer these persons appropriate treatment or utilize existing involuntary treatment laws. Such incidents of violence cannot be attributed to any supposed legal roadblocks to involuntary treatment.

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