Understanding the Connection Between Mental Illness and Violence
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.
References (118)
The effect of co-occurring disorders on criminal careersInteraction of antisocial personality, alcohol, and drug disorders
International Journal of Law and Psychiatry
(1989)- et al.
The prevalence of major mental disorders among homicide offenders
International Journal of Law and Psychiatry
(1992) - et al.
A comparison of criminal recidivism among schizophrenic and nonschizophrenic offenders
International Journal of Law and Psychiatry
(1992) - et al.
Psychopathy, schizophrenia, alcohol abuse and violent recidivism
International Journal of Law and Psychiatry
(1995) - et al.
Toward hospitalization criteria for violent patients
Comprehensive Psychiatry
(1980) The problem of co-occurring disorders among jail detaineesAntisocial disorder, alcoholism, drug abuse, and depression
Law and Human Behavior
(1990)- et al.
Co-occurring disorders among mentally ill jail detaineesImplications for public policy
American Psychologist
(1991) Diagnostic and statistical manual of mental disorders
(1994)- Avison, W. R. (1993). Families in poverty: A stress process analysis of the psychosocial consequences. Paper presented...
- Barker, P. R., Manderscheid, R. W., Hendershot, G. E., Jack, S. S., Schoenborn, C. A., & Goldstrom, I. (1992). Serious...
Exclusion criteria of DSM-IIIA study of co-occurrence of Hierarchy-free syndromes
Archives of General Psychiatry
Poverty and psychiatric statusLongitudinal evidence from the New Haven epidemiologic catchment area study
Archives of General Psychiatry
Childhood sexual and physical abuse as factors in adult psychiatric illness
American Journal of Psychiatry
Effects of alcohol on human aggressionAn integrative research review
Psychological Bulletin
Structural brain abnormalities as indicators of vulnerability to schizophrenia
Schizophrenia Bulletin
Neuropsychological functioning in siblings discordant for schizophrenia and healthy volunteers
Archives of General Psychiatry
Victims of violence and psychiatric illness
American Journal of Psychiatry
The health effects of economic insecurityAn analytic review
American Journal of Public Health
Using ECA survey data to examine the effect of job layoffs on violent behavior
Hospital and Community Psychiatry
Poverty and the course of schizophreniaImplications for research and policy
Hospital and Community Psychiatry
Acute and chronic effects of alcohol use on violence
Journal of Studies on Alcohol
Co-occurring mental disorders among criminal offenders
Bulletin of the American Academy of Psychiatry and Law
Are there neurochemical indicators of risk for schizophrenia?
Schizophrenia Bulletin
A longitudinal study of substance use and community violence in schizophrenia
Journal of Nervous and Mental Disease
Mechanisms in the cycle of violence
Science
Socioeconomic status and psychiatric disordersAre the issues still compelling?
Social Psychiatry and Psychiatric Epidemiology
Socioeconomic status and psychiatric disordersThe causation-selection issue
Science
Diagnosis of alcohol use disorders in schizophrenia
Schizophrenia Bulletin
Violence in psychiatric facilities in Europe and the United States
Reason to hopeA psychosocial perspective on violence and youth
The influence of social networks and social support on violence by persons with serious mental illness
Hospital and Community Psychiatry
Violence between spouses and intimatesPhysical aggression between women and men in intimate relationships. In A. J. Reiss & J. A. Roth (Eds.)
Understanding and preventing violence
Mental disorders in urban areas
Resilience in children’s adaptation to negative life events and stressed environments
Pediatric Annals
Health and medicine on television
New England Journal of Medicine
The literature on personality disorders, 1985–88Trends, issues, and controversies
Hospital and Community Psychiatry
Psychotic homicides in Copenhagen from 1959 to 1988
Acta Psychiatrica Scandinavica
Minor physical anomalies in schizophrenic patients, bipolar patients and their siblings
Schizophrenia Bulletin
State psychiatric hospital patients with past arrests for violent crimes
Psychiatric Services
Crimes of violence by mentally abnormal offenders (H. Marshall, Trans.)
Psychopathy, mental disorder and crime
The clinical significance of command hallucinations
American Journal of Psychiatry
Mental disorder, intellectual deficiency, and crimeEvidence from a birth cohort
Archives of General Psychiatry
Mental disorder and crime
The increased risk for specific psychiatric disorders among persons of low socioeconomic status
American Journal of Social Psychiatry
Evaluating changes in symptoms and functioning of dually diagnosed clients in specialized treatment
Psychiatric Services
The prevalence of psychiatric disorder among incarcerated womenII. Convicted women felons entering prison
Archives of General Psychiatry
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