No Easy Answers: Mental Illness and Violence

The tendency to associate mental illness with criminal behavior is very natural, especially in the case of violent offenses. ‘You’d have to be crazy,’ we think, ‘to beat or rape or kill another human being.’ In high profile cases, such as the Aurora Theater shootings in 2012 or the Virginia Tech shootings in 2007, the media often fixates on the perpetrator’s history of mental illness. Prime-time television is rife with crime dramas that exploit mental illness as a plot device. The idea of committing a violent crime is so anathema to most people that we automatically assume the behavior must be the result of mental illness. In reality, a large portion of the prison population does suffer from some type of mental illness. Many sociologists argue that as governments have defunded mental health programs, prisons have come to replace insane asylums. However, the mentally ill are far more likely to be victims of crime than perpetrators. The public fear of the mentally ill is largely unfounded. Mental illness is one in a constellation of factors that contributes to criminal behavior, including poverty, education, and race. As a nation, we are doing a dismal job of caring for our mentally ill. When the mentally ill do not receive the care and services they need, they are more likely to descend into poverty and drug abuse. These circumstances can often lead to increased incarceration rates. Making significant efforts to address the needs of the mentally ill could reduce crime rates, decrease the burden on prisons, and allow mentally ill people to live fuller, happier lives.

The concept of mental health is largely a product of the 20th century. For much of human history, mental illness was viewed as some sort of demonic possession or religious failing. Even after mental illness was recognized as a physiological condition, the mentally ill often went untreated and lived in abysmal circumstances. In the early part of the century, the mentally ill were often confined to large institutions, but these facilities suffered from a lack of staff and funding. By the 1950s, a movement began to decentralize mental health facilities and move toward a community-based approach that would allow the mentally to integrate into the larger community. Although this movement has improved the lives of many, it has left some members of the mentally ill community underserved. When their illness goes untreated, it often manifests itself in ways that result in criminal behavior. One study concluded that, upon incarceration, 14.5% of male inmates suffer from mental illness, and 31% of female inmates are afflicted (Steadman). Unfortunately, prisons are not adequately equipped to address the influx of mentally ill prisoners. Prison is not conducive to mental health “because of overcrowding, violence, lack of privacy, lack of meaningful activities, isolation from family and friends, uncertainty about life after prison, and inadequate health services. The impact of these problems is worse for prisoners whose thinking and emotional responses are impaired by schizophrenia, bipolar disease, major depression, and other serious mental illnesses” (Fellner, 2006). The prison model does nothing to help the mentally ill.

The definition of mental illness has expanded over the last century. The National Alliance on Mental Illness (NAMI, 2014) defines mental illness as “a medical condition that disrupts a person's thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life.” This is a broad definition that reflects the slippery nature of mental illness. In the United States, “severe mental illness is estimated to affect one in 17 persons, or 6% of adults” (Choe). Considering the stigma around mental illness, it is possible that this estimate is conservative and the actual figure is much higher. Many people experience mental illness at some point in their lives. In recent years, Post-Traumatic Stress Disorder (PTSD) has received significant attention because of the mental health issues surrounding veterans of the wars in Iraq and Afghanistan. In 2008, the New York Times reported 121 cases where veterans were charged with a killing after their return from active duty (Sontag, 2008). Mental illness alone does not make people violent, but when mental illness goes untreated it can lead to dangerous emotional and physical conditions that can lead to violence.

There is a significant stigma around mental health issues. This stigma can be crippling, “spurring family silence, outright discrimination, a lack of parity for mental health care coverage, and social isolation. The pain of mental illness is searing enough, but the added layer of stigma affects personal well-being, economic productivity, and public health, fueling a vicious cycle of lowered expectations, deep shame, and hopelessness” (Hinshaw, 2007, p. 329). Mental illness is different from other types of illness in that it is not immediately visible or easily addressed. Mental illness cannot be removed like a cancerous tumor. It cannot be cured with a transplant or dialysis treatment. People with mental illnesses are often criticized as being unwilling to participate in normal society, instead of unable. Due to this stigma, many people hesitate to get proper treatment for fear that it will damage their reputations. In this country, mental illness is variously associated with violent behavior and weakness of character.

Mental illness does not create violence. The vast majority of people with mental illnesses never commit violent crimes. The association of mental illness with violence comes from two sources. First, the media portrays mental illness and violence as inextricably linked. Many programs exploit mental health issues to create drama and titillate the viewer. This link contributes to the stigma around mental illness, as it creates the perception that people with mental illnesses are socially deviant. Study after study has shown that “people with mental and substance use disorders are not major contributors to police-identified criminal violence. Public perceptions of mentally ill persons as criminally dangerous appear to be greatly exaggerated” (Stuart). In fact, the majority of people with mental illness who end up in prison committed crimes “that would not be cause for arrest if they did not occur in public” such as “loitering, disorderly conduct and disturbing the peace” (Hiday, 2013). These type of crimes are better served by addressing their mental health needs, instead of simply locking them up.

The other reason that violence is associated with mental illness is that the sociological community has been drawing conclusions about mental illness and violence based on a population that largely been institutionalized, either in a prison or a mental hospital. Even though “fewer than 17% of persons with severe mental illness in the United States are hospitalized…nearly half of the studies that investigate violence among persons with severe mental illness examined only inpatients” (Choe). Statistics claiming that a quarter of the prison population suffer from mental illness generate the perception that mental illness makes people behave violently. The statistics do not address the rates of mental illness in the general population, or distinguish between those incarcerated for violent crimes and those who were charged with crimes related to drug use and homelessness. We cannot focus our dialogue on mental health on extreme cases only: we must recognize that “any effective system of mental health services must take into account the multiple influences that are involved as individuals or others around them recognize a mental health problem, initiate care, and sometimes take very different pathways into the mental health system” (Pescosolido, 2013, p. 505). Statistics make for good sound bites, but they don’t show the whole picture of mental health.

Mental illness is often considered to be no more than a weakness of character or constitution. People who suffer from mental illness are perceived to be weak. Everyone encounters periods of stress or emotional upheaval, but not everyone suffers from PTSD or major depression. The family and friends of people who suffer from mental illness struggle with the suspicion that the mentally ill person is somehow malingering or “faking it” to gain sympathy. Men, especially, hesitate to get treatment for mental illness. Culturally, men are not typically encouraged to discuss their feelings or express their emotions. One veteran who feared that a diagnosis of mental illness would hurt his military career chose to not get treatment for his PTSD because “The marine way was to suck it up” (Sontag, 2008). Without an avenue to receive treatment for mental illness many people self-medicate with drugs or alcohol, exacerbating the problem. Violent behavior can occur as the sufferer becomes increasingly isolated and delusional. As long as mental illness is perceived to be a fault of character rather than a legitimate ailment, treatment will always lag behind need.

The stigma associated with mental illness keeps many people from openly discussing the issue. Given proper treatment, people with mental illnesses can lead normal lives. Unfortunately, treatment for mental illnesses is not easy. There is no cure-all for mental illness. As NAMI puts it, “there are several definitions of recovery; some grounded in medical and clinical values, some grounded in context of community and some in successful living. One of the most important principles is this: recovery is a process, not an event.” (2013). Recovery is a slow, evolving activity that does not lend itself to the sort of impressive numbers that a politician might use to further his campaign. Mental illness treatment has been chronically underfunded by state and national governments, even though improving mental illness treatment would likely lower crime rates (Fazel). Reducing the stigma around mental illness would help those who suffer from mental illness as well as the communities that support them.

Society may envision the mentally ill as violent predators, but in reality the mentally ill are far more likely to be the victims of crime than the perpetrators. A 2005 study found that more than 25% of mentally ill persons had been the victim of violent crime in the past year, 4 times higher than the rate experienced by the rest of the population. The study also found that “depending on the type of violent crime (rape/sexual assault, robbery, assault, and their subcategories), prevalence was 6 to 23 times greater among persons with (severe mental illness) than among the general population” (Teplin). The mentally ill are vulnerable to victimization both in institutionalized settings and in the world as a whole. Predators target the mentally ill, using the social stigma associated with mental illness to their advantage. When a mentally ill person reports a crime, doubt automatically settles over their claims. Mentally ill persons often live in poverty or self-medicate with illegal substances, and both of these circumstances increases the likelihood of victimization. Being the victim of a violent crime can spark depression or PTSD, or exacerbate a pre-existing condition. In 2013 paper, Peggy A. Thoits demonstrates the stress of denying or hiding a mental ailment can drastically increase the severity of the ailment (2013, p. 357). Far from being guilty of committing violent crimes, mentally ill people are actually far more likely to be the target of violent crimes.

From perspective of functionalism, the best way to deal with mental health issues is with a top-down government program that attempts to improve treatment and access all over the country. In 2009, NAMI issued a state-by-state ‘report card’ that measured mental health treatment all over the nation. No state received an ‘A’ for their programs, and only six states received a ‘B.’ The overall national grade was a ‘D.’ In a nation that purports to care for their citizenry, this score is unacceptable. Mental health issues often manifest in other health issues, and “people living with mental illnesses often die prematurely from largely preventable cardiovascular diseases and accidents, or by suicide” (2013). Mental health services vary wildly throughout the country. In periods of economic strife, states often look to balance their budgets by slashing health and wellness services. This may seem like a reasonable strategy in the short term, but in the long term reducing access to mental health services is frequently quite costly. When mentally ill persons do not receive treatment, they often turn to drugs or alcohol to self-medicate. People who do not receive the treatment they need often end up costing the state money through the legal or medical systems.

Sociologists and mental health professionals are eager to see how Obamacare will affect the quality of mental health care all over the nation. The Affordable Care Act has special provisions for mental health, and will “expand mental health and substance use disorder benefits and federal parity protections for behavioral health to 62 million Americans.” Moreover, “health plans must now cover preventive services like depression screening for adults and behavioral assessments for children at no cost. And starting in 2014, most plans won’t be able to deny you coverage or charge you more due to pre-existing health conditions, including mental illnesses” (mentalhealth.gov). By making mental health part of the Obamacare package, the government is attempting to address the stigma associated with mental health treatment. Prescreening for mental illnesses is a key part of improving health care in this country. Mental health issues are often diagnosed only after a person has committed a crime.If we make a concerted effort to address mental health issues before they become criminal matters, we can reduce the crime rate and improve society as a whole.

The theory of symbolic interaction postulates that interpersonal relationships are more important than governmental institutions in creating society. For the mentally ill, it is critically important to have a supportive community. A network of professionals, family and friends can help a mentally ill person to recognize disordered behaviors and maintain vigilance about fighting the battle against mental illness. One simple way we can improve interpersonal relationships for the mentally ill is to consciously treat sufferers with respect. The 2009 NAMI study found that when the mentally ill “feel scorned or badly treated, they may avoid the services they need.” The Substance Abuse and Mental Health Administration argues that “respect ensures the inclusion and full participation of (the mentally ill) in all aspects of their own lives” (2013). Just like the rest of the population, the mentally ill benefit from feeling as if they have allies and agency in their own existence. One innovative program at Connecticut’s largest state psychiatric hospital has all new employees taking an orientation class taught by people who are currently hospitalized there. Changing the dynamic from doctor-patient or jailer-inmate to that of two co-workers is a fundamental shift in the level of respect shown to the mentally ill that could potentially have significant benefits.

Another way that symbolic interaction theory applies to improving the lives of the mentally ill is consciously improving the portrayals of the mentally ill in the media. When most movies or television shows portray a person with mental illness, it is either to incite fear or elicit laughter. We need better, more realistic portrayals of mental illness in order to de-stigmatize the disease. In New Zealand, a program designed to use community education and mass media advertising to change the perception of mental health successfully did just that. The study found that “advertising involving the stories of well-known and famous people who have experienced mental illness has created significant interest, awareness and improved attitudes among the general public” (Vaughan, 2004). Bringing mental health issues out of the shadows will allow more people to consider early treatment. Media portrayals of mental illness must be improved to decrease the stigma surrounding mental health issues. If we work to reduce the stigma around mental illness, it is more likely that sufferers will receive the care they need.

Through the lens of conflict theory, the high rate of inmates with mental illness is not a side effect, but an intentional result of the privatization of prisons. Conflict theory is a sociological approach that postulates that competition for resources encourages the wealthy and powerful to actively exploit the weak and powerless. Sociologists call it “stigma power,” arguing that the powerful deliberately encourage the stigma around mental illness because “stigma is a source of power that helps the stigmatizer control the stigmatized and thereby keep them down, in or away” (Link, 2013, p. 525). A letter from Ray Jasper, a death row inmate in Texas, recently went viral. Jasper claims that “all prisoners in America are considered slaves” under the 13th Amendment to the Constitution, which allows for prisons to force convicts to work. Jasper rails against “those in the corporate world making money off prisoners, so the longer they're in prison, the more money is being made. It's not about crime & punishment, it's about crime & profit” (Nolan). Under conflict theory, there is discernible benefit to imprisoning the mentally ill. They can be used as a source of cheap labor. Furthermore, if a mentally ill person acts out, they can be isolated in solitary confinement, which will only exacerbate their condition. In modern prisons, Jasper argues, “you have thousands of people with a lot of prison time that have no choice but to make money for the government or live in isolation. The affects of prison isolation literally drive people crazy. Who can be isolated from human contact and not lose their mind?” (Nolan) The prison system exploits the mentally ill, and is ill-equipped to deal with mental health issues. The need for comprehensive prison reform in America is now becoming critical. If we continue to accept the abysmal conditions in prisons, we run the risk of disenfranchising a whole generation and causing irreparable damage to our culture.

Conflict theory would also support the notion that the spike in PTSD and veteran-related crime is a product of intentional government neglect. The military is concerned with its soldier’s physical health and readiness for duty; focusing on the trauma caused by conflict impedes their primary mission. Soldiers are not encouraged to talk about painful battlefield experiences because it would undermine morale, but if they internalize traumatic incidents they can end up bringing the war back home. One veteran tells his story:

“In my mind at the time, he had this I.E.D. hidden out there during the day and he was going to set it in place…We radioed it in. They said, ‘Whatever, use your discretion.’ So, I popped him…I reported the kill to the battalion…They said, you know: ‘Good shot. It’s legal. Whatever. Don’t worry about it.’ After that, it was never mentioned. But, you know, I had some issues with it later…I’m trying not to be [upset]…I mean, how can you not be? If you’re human. What if I had waited?...Maybe I was too eager…Maybe I wanted to be the first one to get a kill, you know? Maybe, maybe, maybe. And that will never go away…Get over it. You shot somebody. Everybody else shot somebody, too.” (Sontag, 2008)

This veteran never received counseling for his role in this incident. At home on leave, he drunkenly killed a stranger after being called “a paid killer” (Sontag, 2008). Although the military does offer mental health care, many people fail to make use of it for fear that it will affect their standing as a soldier. The military desperately needs to address the high incidence of PTSD in veterans of the Iraq and Afghanistan Wars. We must improve our performance in this area to adequately honor the sacrifice made by our troops.

It is not possible to draw a clear line from mental illness, to violence, to crime. The relationship is convoluted, and ever-changing; poverty, education, and economics also play a role. However, it is clear that the mentally ill experience violence and crime more often than the rest of the population. We do not have a singular national mechanism that addresses mental health issues. We do not have a culture that supports recovery from mental illness. Instead, we have two faulty institutions, prisons and the military, that end up dealing with a significant number of mentally ill persons. It serves no benefit to our culture to continue to stigmatize mental illness. It does not create violence; it does not signify weakness. Everyone suffers bouts of anxiety and depression; everyone is capable of violence in extreme circumstances. In some ways, the stigma surrounding mental illness is a way to comfort ourselves about our own sanity. So what if we have strange fixations, or high stress, or violent urges; we are still more normal than the gibbering maniacs we envision when we contemplate the mentally ill. And thus we validate not addressing mental health issues. It is much harder to acknowledge the notion that mental illness is part of a continuum of health that will fluctuate throughout our lives. We owe it to the mentally ill to reduce the ways in which violence affects their outcomes. In doing so, we improve our society as a whole.

References

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