The conflation between mental illness and violent behavior is a common public perception. According to the understanding of the general public, almost all violent offenders are mentally ill. That is, mental illness and violence in the face of the general public remain inextricably intertwined. Media, on the other hand, plays a major role in fueling the tendency to conflate mental illness with the expectation of an individual to be dangerous. The reason for why media has perpetuated the notion that mental illness is a predictor of violence is because media not only sensationalize violent crimes that have been committed by individuals with mental illness but also ignores much of the other violent crimes committed by those without mental illness. In fact, the media usually focuses on the mental illness part of reports on violent crimes so as to emphasize the relationship between mental illness and violence. However, the general perception is not borne out of available literature on mental illness and violent behaviors. Instead, the available studies show that mental illness make up a very small proportion of violent offenders generally. The conflation of mental illness with violent offenders, which in turn makes it look as if all violence offenders have a mental illness is largely a myth.
Definition of Violence
Perhaps the best way to begin examining the relationship between violence and mental illness to define violence. The definition of violence has been conceptualized in many ways. There remains no consensus as to which definition is the most appropriate. However, World Health Organization (WHO) provides a definition that is all-encompassing and would definitely suffice as a reference in this discussion. According to WHO, violence refers to "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation (as quoted by Varshney et al., 2016:223). Looking at the definition of violence by WHO, it is apparent that it does not include violence as social or cultural construction. WHO defines restricts the definition of violence to its health outcomes and impact on the well-being of the offender and victims. Apart from the self-harm or suicidal behavior captured by WHO, the definition also such terms as threats, intimidation, neglect, and abuse, the latter which can be physical, sexual or psychological or a combination of these. Therefore, it is immediately clear from the definition that mental illness is not the single predictor of all forms of violence.
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Prevalence of Violence among Psychiatric Patients
The definition of violence abovementioned does not suffice as an implicit relationship between violence and mental illness. There are quite a number of studies that have been conducted to examine the relationship between violence and mental illness. Studies that have been conducted to determine the prevalence of violence among psychiatric patients, in particular, provides more interesting insights as to whether or not mental illness predicts violent behavior. Generally, studies show that violence varies widely among psychiatric patients depending on the treatment setting. Those patients in the outpatient setting show the lowest rate of violence (Varshney et al., 2016). However, the rate of violence among psychiatric patients is highest for patients who have been involuntarily committed to a mental health institution or among patients in the acute care settings.
In what may suggest that mental illness contributes to the risk of violence, Varshney, and colleagues (2016) observe that 10% of schizophrenic patients are likely to be violent offenders. When compared with 2% of the general public, it would be easy to make a conclusion that public perception is proven. However, it is important to note that the study which was referred to by Varsheny et al. (2016) had shown that a 1-year population-attributable risk (PAR) of violence predetermined by mental illness was only 4%. Therefore, if the risk of violence attributed to psychiatric patients was to be reduced to the level of violent offenders without mental illness, then 96% of all violent crimes would still continue to occur. Moreover, it is clear from research that mental illness is more of a predictor of violence among those with severe mental disorders such as schizophrenia. In short, the prevalence of violence among psychiatric patients, although can be used to predict violent behavior, does not suffice as an explanation for the conflation of mental illness with violent crimes. It is quite evident that a very small proportion of violence in society results from those who have a mental illness. Additionally, there is also the dynamic interaction between social and contextual factors within the care settings for psychiatric patients that also play a role in determining violent behavior.
Predictors of Violent Behavior
Both recent and past studies show that more than initially imagined, there is a very complex relationship between mental illness and violence. For example, after reanalyzing data from National Epidemiologic Survey on Alcohol and Related Conditions(NESARC), researchers have come to the conclusion that the primary association between mental illness and violence is a subject of the accumulation of risk factors of all kinds (Van Dorn, Volavka, & Johnson, 2012; Varshney et al., 2016; and Webermann & Brand, 2017), including risk factors associated with the context(such as divorce, victimization among others), history(such as physical abuse, juvenile detention,), and disposition(sex, age, among others). It is why similar studies of the mentally ill who do not have a history of substance abuse, according to Elbogen and Johnson (2009), show the modest relationship between mental illness and violence. This further helps to explain why individuals with schizophrenia and bipolar disorder are seen as more violent. From a number of longitudinal studies with psychiatric patients, patients with schizophrenia or bipolar disorder are shown to have diagnosable alcohol and substance use, which then explains the critical role of substance use as a determinant of violent behavior among mentally ill people (Webermann & Brand, 2017). Beyond substance abuse comorbidity and care settings examined earlier, other risk factors associated with violent behavior among mentally ill people include age (younger patients tend to be more violent), gender (males are more violent), history of psychiatric illness(a history of psychiatric illness is a predictor of violent behavior), and victimization(which increases propensity to violence among mentally ill patients) (Varshney et al., 2016). Speaking of victimization, Varsheny et al. (2016) observe that mentally ill people are well aware of their situation and know that it often results in their victimization. For example, some of the mentally ill face aggression or even physical abuse as well as an involuntary commitment to psychiatric settings. Such victimization is likely to increase the likelihood of a mentally ill person to react violently. On the other hand, substance abuse which is shown to play a key role in determining violent behavior among psychiatric patients is yet another cause of victimization (Varshney et al., 2016).
Apart from the findings of research regarding predictors of violent behavior among mentally ill people, there are limitations on both past and present research on the relationship between mental illness and violence. For example, one major concern for researchers is the fact that Varshney et al. (2016) observe that "identified risk indicators of violent behavior have poor predictive validity" (p.224) in both short- and long-term. Studies on violence among psychiatric patients have also been limited to specific demographics, results of which may not be used to predict violence across all other quotas. Additionally, some of the assessment tools and research methodologies are not suitable enough for some of the studies and may give misleading outcomes. For instance, Webermann and Brand(2017) note that studies conducted decades ago to examine violent behavior among patients with dissociative identity disorder(DID) were conducted with small sample groups rather than a large one, were based on clinician reports rather than on self-reports, and instead of using specific time frames, "utilized adult lifetime reporting times" (p.6). Such inconsistencies also play a very huge role in misrepresenting results.
Conclusion
From the preceding discussion, violent offenders face harmful and inaccurate stereotypes associating all of them with mental illness. None of the studies reviewed substantially proves the general public perception of the association between violent offenders and mental illness. Instead, the studies show that there are a wide variety of risk factors that determine violent behavior among those are mentally ill. Such risk predictors do not necessarily prove that mentally I'll people are inherently violent. Instead, it is the victimization by the general public that increases the probability of violence among those with mental illness. That said, it remains clear that the attempt to conflate violence offenders with mental illness is in most part a myth that is not borne out of available research.
References
Elbogen, E. B. & Johnson, S. C. (2009). The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry , 66 , 152–61.
Van Dorn, R., Volavka, J., & Johnson, N. (2012). Mental disorder and violence: is there a relationship beyond substance use? Social Psychiatry and Psychiatric Epidemiology, 47, 487–503.
Varshney, M., Mahapatra, A., Krishnan, V., Gupta, R, & Deb, K. S. (2016). Violence and mental illness: what is the true story? Journal of Epidemiology and Community Health, 70 (3), 223-225.
Webermann, A. R. & Brand, B. L. (2017). Mental illness and violent behavior: the role
of dissociation. Borderline Personality Disorder and Emotion Dysregulation, 4 (2), 1-13.
