Understanding the Connection Between Mental Illness and Violence

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Introduction

Recently, sophisticated epidemiological studies have found an association between severe mental illness and violence that cannot be explained away by inadequate sampling or measurement, or with demographic and ecological controls (Link et al. 1992; Link & Stueve 1994; Swanson et al. 1990; Swanson 1993Swanson 1994). These studies reinforce findings from restricted samples of hospitalized and incarcerated persons showing that mental patients have relatively high rates of violence (Lagos et al. 1977; McNiel & Binder 1986McNiel & Binder 1994; Monahan 1992) and that jail detainees and prison inmates have high rates of mental illness (Collins & Schlenger 1983; Coté & Hodgins 1990Coté & Hodgins 1992; Jordan et al. 1996; Teplin 1990; Teplin, Abram, & McClelland 1996). The epidemiological researchers have emphasized three important qualifications of their findings: (1) the association between mental disorder and violence is modest; (2) mentally ill persons account for only a small proportion of the total violence in society; and (3) not all mentally ill persons have higher rates of violence but only those with a major mental illness and active psychotic symptoms (Link & Stueve 1995).

To understand how mental illness and violence are associated, this paper presents a series of models based on empirical research that illuminate the statistical association between the two phenomena. It begins with the most simple model showing a direct sequence of severe mental illness producing violence, then moves to build more complexity in the relationship with multiple paths involving socializing conditions and intervening experiences that connect active, major mental illness to violence. It concludes with a model suggesting that both violence and manifestations of mental illness largely grow from the structural arrangements in which individuals are embedded, and that the paths between mental illness and violence are mainly indirect and contingent.

Section snippets

Two Direct Models

The most simple relationship between mental illness and violence is a model in which mental illness directly causes violence (Severe Mental Illness → Violence). This model represents the age-old belief kept current in news stories and fiction that it is mental illness which overrides self-control to produce violent behavior (Gerbner et al. 1981; Link et al. 1987; Monahan 1992). A first addition to this simple model adds psychotic symptoms as a crucial intervening variable through which severe

Two Indirect Paths

Link and Stueve’s hypothesis of threat/control–override symptoms inducing fear and disrupting internal controls to produce violence describes an internal process of intrapsychic forces propelling the violence. A more social and interpersonal process could also be operating, that is, threat/control–override symptoms could result in violence through another, more interactive path. These symptoms could create tense situations between a mentally ill person and others as nerves fray (from hearing

The Social Structure

Tense or conflictive situations that lead to violence can be produced by stressful negative events such as losing a job, divorce, or death of a family’s breadwinner (Catalano et al. 1993; Levinson & Ramsey 1979; National Research Council 1993; Steadman & Ribner 1982). These situations along with stressful events are more likely to occur in conditions of social disorganization and poverty. (see Fig. 2).

Social disorganization is found in impoverished communities where individuals experience

Comorbidity

Social disorganization and poverty also produce substance abuse/dependence, which leads to violence. Ever since the early days of social-science research, empirical studies have found substance abuse/dependence and other forms of deviance to be more frequent among conditions of poverty and social disorganization (American Psychiatric Association [APA], 1994; Catalano 1991; Tedeschi & Felson 1994). Also, much research has implicated substance abuse, especially long-term abuse, in violent

Neurobiological Pathology

Fig. 6 introduces to the model neurobiological pathology, involving abnormalities in both brain function and structure, showing it as a causal influence in severe mental illness and in substance abuse/dependence. Behavioral genetics and epidemiological research support these causal links, with family, twin, and adoption studies providing strong evidence that genetic factors are operative in schizophrenia, affective disorders, and alcoholism (Cannon et al. 1994; Kelty et al. 1994; Kendler &

Discussion and Summary

The dominant medical model’s focus on the individual in etiology, prognosis, and treatment has influenced the description of the violence associated with mentally ill persons in both medical records and research reports such that it appears separate from the social context in which it occurs, separate from social and interpersonal interactions, and separate from the interpersonal history of those involved. Although psychiatrists recognize that violent behavior derives from causes other than

Acknowledgements

The author wishes to thank B. Link, P. L. McCall, J. Monahan, H. J. Steadman, J. Swanson, M. Swartz, L. Teplin, and H. Wales for their helpful comments on an earlier version of the manuscript.

Work on this article was partially supported by Grant RO1-MH48103 from the National Institute of Mental Health.

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