3 weeks, 6 days ago
I’ve previously cataloged mental health professionals and their reaction to the notion that their patients perpetrate violence more frequently than others.
Clinicians treating patients hear their fears, anger, sadness, fantasies and hopes, in a protected space of privacy and confidentiality, which is guaranteed by federal and state laws. Mental health professionals are legally obligated to break this confidentiality when a patient “threatens violence to self or others.” But clinicians rarely report unless the threat is immediate, clear and overt.
Mental health professionals understand that, despite our intimate knowledge of the thoughts of our patients, we are not very good at predicting what people will do. Our knowledge is always incomplete and conditional, and we do not have the methods to objectively predict future behavior. Tendencies, yes; specific actions, no. To think that we can read a person’s brain the way a scanner in airport security is used to detect weapons is a gross misunderstanding of psychological science, and very far from the nuanced but uncertain grasp clinicians have on patients’ state of mind.
What about diagnoses?
If mental health professionals were required to report severe mental illness (such as paranoid schizophrenia) to state authorities, it would have an immediate chilling effect on the willingness of people to disclose sensitive information, and would discourage many people from seeking treatment. What about depression, bipolar disorder, substance abuse or post-traumatic stress disorder, along with other types of mental illness that have some link to self-harm and impulsive action? The scope of disclosure that the government could legally compel might end up very wide, without any real gain in predictive accuracy.
Diagnosis is an inexact and constantly evolving effort, and it is contentious within the profession. To use a diagnosis as the basis of reporting the possibility of violence to the authorities would make the effort of accurate evaluation much more fraught. And what of the families and friends of the mentally ill? Should their weapons purchases be restricted as well? A little reflection shows how unworkable in practice any screening by diagnosis would be.
“We’re not likely to catch very many potentially violent people” with laws like the one in New York, says Barry Rosenfeld, a professor of psychology at Fordham University in The Bronx….
A study of experienced psychiatrists at a major urban psychiatric facility found that they were wrong about which patients would become violent about 30 percent of the time.
That’s a much higher error rate than with most medical tests, says Alan Teo, a psychiatrist at the University of Michigan and an author of the study.
One reason even experienced psychiatrists are often wrong is that there are only a few clear signs that a person with a mental illness is likely to act violently, says Steven Hoge, a professor of psychiatry at Columbia University. These include a history of violence and a current threat to commit violence ….
Perhaps most important, although people with serious mental illness have committed a large percentage of high-profile crimes, the mentally ill represent a very small percentage of the perpetrators of violent crime overall. Researchers estimate that if mental illness could be eliminated as a factor in violent crime, the overall rate would be reduced by only 4 percent. That means 96 percent of violent crimes—defined by the FBI as murders, robberies, rapes, and aggravated assaults—are committed by people without any mental-health problems at all. Solutions that focus on reducing crimes by the mentally ill will make only a small dent in the nation’s rate of gun-related murders, ranging from mass killings to shootings that claim a single victim. It’s not just that the mentally ill represent a minority of the country’s population; it’s also that the overlap between mental illness and violent behavior is poor.
Jeffrey W. Swanson, a professor of psychiatry and behavioral sciences at the Duke University School of Medicine and lead author of the article in Annals of Epidemiology was quoted in the UCLA Newsroom saying ”but even if schizophrenia, bipolar disorder and depression were cured, our society’s problem of violence would diminish by only about 4 percent.” That is not very much. When people with mental illness do act violently it is typically for the same reasons that people without mental illness act violently.
And yet … the raison d’être, we are told, for background checks is to prevent the mentally ill from obtaining guns. Enter Huffington Post (yet again) claiming that gun violence is a medical condition due to “recurrent violent injury.”
An article has just been published that is a must-read for everyone concerned about violence and guns because it places violent behavior in its proper context — namely, as a disease that, in order to see it decline, needs to be handled like other chronic medical conditions. The researchers followed two groups of young men and women, ages 14 to 24, who were patients at the ER in Flint, Michigan, between 2008 and 2010. One group consisted of patients who were admitted for the first time suffering from a serious injury due to an assault. The other group were first admitted for some other medical issue.
Except for their histories in the ER, both groups were basically the same. They were mostly African-American, mostly from families on public assistance, they had the same degree of drug use and the same number who had either been convicted of some crime and/or were on parole. Finally, a majority of the members of both groups reported family incomes below the poverty line. In other words, both groups of patients shared the same social culture that breeds violence, but one group never came to the ER as victims of violent assaults, the other group not only came at least once, but many came multiple times.
The researchers characterized this latter group as suffering from what they call “recurrent violent injury,” which is estimated to cost the medical system somewhere between $600 million and $1 billion per year.
Welcome to the condition of recurrent violent injury. I’m willing to bet that you’ve never heard of that before. And yes, the author linked an abstract rather than a paper. As if on queue, a more studied author tells us something different. I have to quote at length for you to get the full force of the argument.
When mass shooters strike, speculations about their mental health—sometimes borne out, sometimes not—are never far behind. It seems intuitive that someone who could do something terrible must be, in some sense, insane. But is that actually true? Are gun violence and mental illness really so tightly intertwined?
Jeffrey Swanson, a medical sociologist and professor of psychiatry at Duke University, first became interested in the perceived intersection of violence and mental illness while working at the University of Texas Medical Branch at Galveston in the mid-eighties. It was his first job out of graduate school, and he had been asked to estimate how many people in Texas met the criteria for needing mental-health services. As he pored over different data sets, he sensed that there could be some connection between mental health and violence. But he also realized that there was no good statewide data on the connection. “Nobody knew anything about the real connection between violent behavior and psychiatric disorders,” he told me. And so he decided to spend his career in pursuit of that link.
In general, we seem to believe that violent behavior is connected to mental illness. And if the behavior is sensationally violent—as in mass shootings—the perpetrator must certainly have been sick. As recently as 2013, almost forty-six per cent of respondents to a national survey said that people with mental illness were more dangerous than other people. According to two recent Gallup polls, from 2011 and 2013, more people believe that mass shootings result from a failure of the mental-health system than from easy access to guns. Eighty per cent of the population believes that mental illness is at least partially to blame for such incidents.
That belief has shaped our politics. The 1968 Gun Control Act prohibited anyone who had ever been committed to a mental hospital or had been “adjudicated as a mental defective” from purchasing firearms. That prohibition was reaffirmed, in 1993, by the Brady Handgun Violence Prevention Act. It has only become more strictly enforced in the intervening years, with the passing of the National Instant Criminal Background Check System Improvement Act, in 2008, as well as by statewide initiatives. In 2013, New York passed the Safe Act, which mandated that mental-health professionals file reports on patients “likely to engage in conduct that would result in harm to self or others”; those patients, who now number more than thirty-four thousand, have had their guns seized and have been prevented from buying new ones.
Are those policies based on sound science? To understand that question, one has to start with the complexities of the term “mental illness.” The technical definition includes any condition that appears in the Diagnostic and Statistical Manual of Mental Disorders, but the D.S.M. has changed with the culture; until the nineteen-eighties, homosexuality was listed in some form in the manual. Diagnostic criteria, too, may vary from state to state, hospital to hospital, and doctor to doctor. A diagnosis may change over time, too. Someone can be ill and then, later, be given a clean bill of health: mental illness is, in many cases, not a lifelong diagnosis, especially if it is being medicated. Conversely, someone may be ill but never diagnosed. What happens if the act of violence is the first diagnosable act? Any policy based on mental illness would have failed to prevent it.
When Swanson first analyzed the ostensible connection between violence and mental illness, looking at more than ten thousand individuals (both mentally ill and healthy) during the course of one year, he found that serious mental illness alone was a risk factor for violence—from minor incidents, like shoving, to armed assault—in only four per cent of cases. That is, if you took all of the incidents of violence reported among the people in the survey, mental illness alone could explain only four per cent of the incidents. When Swanson broke the samples down by demographics, he found that the occurrence of violence was more closely associated with whether someone was male, poor, and abusing either alcohol or drugs—and that those three factors alone could predict violent behavior with or without any sign of mental illness. If someone fit all three of those categories, the likelihood of them committing a violent act was high, even if they weren’t also mentally ill. If someone fit none, then mental illness was highly unlikely to be predictive of violence. “That study debunked two myths,” Swanson said. “One: people with mental illness are all dangerous. Well, the vast majority are not. And the other myth: that there’s no connection at all. There is one. It’s quite small, but it’s not completely nonexistent.
In 2002, Swanson repeated his study over the course of the year, tracking eight hundred people in four states who were being treated for either psychosis or a major mood disorder (the most severe forms of mental illness). The number who committed a violent act that year, he found, was thirteen per cent. But the likelihood was dependent on whether they were unemployed, poor, living in disadvantaged communities, using drugs or alcohol, and had suffered from “violent victimization” during a part of their lives. The association was a cumulative one: take away all of these factors and the risk fell to two per cent, which is the same risk as found in the general population. Add one, and the risk remained low. Add two, and the risk doubled, at the least. Add three, and the risk of violence rose to thirty per cent.
Other people have since taken up Swanson’s work. A subsequent study of over a thousand discharged psychiatric inpatients, known as the MacArthur Violence Risk Assessment Study, found that, a year after their release, patients were only more likely than the average person to be violent if they were also abusing alcohol or drugs. Absent substance abuse, they were no more likely to act violently than were a set of randomly selected neighbors. Two years ago, an analysis of the National Epidemiologic Survey on Alcohol and Related Conditions (which contained data on more than thirty-two thousand individuals) found that just under three per cent of people suffering from severe mental illness had acted violently in the last year, as compared to just under one per cent of the general population. Those who also abused alcohol or drugs were at an elevated, ten-per-cent risk.
Psychiatrists also have a very hard time predicting which of their patients will go on to commit a violent act. In one study, the University of Pittsburgh psychiatrist Charles Lidz and his colleagues had doctors at a psychiatric emergency department evaluate admitted patients and predict whether or not they would commit violence against others. They found that, over the next six months, fifty-three per cent of those patients who doctors predicted would commit a violent act actually did. Thirty-six per cent of the patients thought not to be violent in fact went on to commit a violent act. For female patients, the prediction rates were no better than chance. A 2012 meta-analysis of data from close to twenty-five thousand participants, from thirteen countries, led by the Oxford University psychiatrist Seena Fazel, found that the nine assessment tools most commonly used to predict violence—from actuarial ones like the Psychopathy Checklist to clinical judgment tools like the Structured Assessment of Violence Risk in Youth—had only “low to moderate” predictive value.
Mental health does not bear on propensity to violence any more than any other condition, or said another way, some mentally ill people are intent on evil just like mentally healthy people. Not, by the way, that I think that one can logically define “mentally ill.” Definitions of mentally ill fall prey to a formal logical fallacy. The definition requires a listing of conditions that doctors consider mentally ill, and thus presence on the list crafts the definition itself. It’s circular reasoning.
But gun controllers don’t care about that, or the mentally ill either. It’s another tool to effect their designs on your freedom. And in conclusion, I would remind you of reader menckenlite on psychiatry.
Control freaks love psychiatry, a means of social control with no Due Process protections. It is a system of personal opinion masquerading as science. See, e.g., Boston University Psychology Professor Margaret Hagan’s book, Whores of the Court, to see how arbitrary psychiatric illnesses are. Peter Breggin, Fred Baughman and Thomas Szasz wrote extensively about abuses of psychiatry. Liberals blame guns for violence. Conservatives blame mental illness. Neither have any causal connection to violence.
Despite this, expect the calls for universal background checks to continue, and the “mentally ill” – whatever that means – to endure discrimination. Soldiers and Marines with PTSD – are you listening?