Violence

 

 

Violence can be a feature of mental illness and every year in England and Wales, on average, 55 people are killed by persons who are judged to be mentally ill at the time of the homicide. It is a devastating tragedy for that individual and his/her family when a life is prematurely cut short, and government, the media and the public should be concerned to minimise the number of such tragedies. However, every year 3500 people are killed on the roads and although there is some concern, the response is feeble compared to the size of the problem.

 

There is much to be learnt from trying to understand this discrepancy. Most of us do not think that we will be killed in an aeroplane crash, struck by lightning, poisoned by a badly fitted gas appliance or drown while swimming for pleasure, even though all these activities have a risk greater than that of being killed by a stranger with mental illness. If the government ordered an expensive public inquiry into all these events, and if the media gave them great prominence, then we would no longer be able to keep the possibilities out of mind and would become more fearful of them.

 

 

Although the number of homicides has risen steeply in recent years, the number committed by the mentally ill has remained steady at about 50-55, so that as a proportion of the total it has steeply declined. By contrast, the number of people killed in accidents with police cars, has risen and amounted to 50 in 2001.

 

Homicide is most usually committed against a family member or acquaintance and this is even more pronounced where the assailant is suffering from a mental illness.

Of the 55 people killed in a year by persons who were mentally ill, only five were strangers.

Of the 315 other assailants who were found not to be mentally ill at the time, 70 killed strangers.
A further 150 assailants had not been psychiatrically examined, presumably because it was obvious that mental illness was not present.

 

Drink and drugs featured more prominently in those who were not mentally ill. It has been concluded in the National Confidential Inquiry into Suicide and Homicide that 'the public fear the mentally ill but they are more at risk from heavy drinkers'.

 

 

A reason why homicide by the mentally ill looms larger than it should is that as well as having a mental illness, the person commonly has a drug and/or alcohol problem, dissocial personality disorder and usually lives in socially deprived circumstances. All these other factors are independently linked to the greater likelihood of homicide and it is simplistic to focus on mental illness and to assert that it is 'the cause' of the homicide, pre-eminent over the other factors. In most of the inner London boroughs the incidence of homicide is more than ten times that found in the outer suburbs and is highly correlated with indices of social deprivation.

 

Although drug and alcohol problems are handicaps, which can be helped by psychiatrists, the great majority of those who misuse these substances are not interested in seeking help. The current Mental Health Act respects the right of the individual to use these substances. Although they are often associated with homicide, there are, nonetheless, very few homicides but a very great number of persons, probably a quarter million people, with problems in their lives related to their use of drugs and alcohol. There must be a roughly equal number of people with substantial mental illness. Disorders of personality are also very common and can contribute to violent acts although by themselves would rarely be accepted as a defence in a case of homicide.

 

 

In the case of violence that does not lead to death it is difficult to get reliable statistics. Violence is very common. In some inner London boroughs, 1.3% of the entire population is recorded as suffering 'violence against the person' every year and this is certainly less than the actual level of violence. As with homicide, there is a considerable difference in incidence between the inner city and the outer suburbs of London by a factor of 6. Violence is also highly correlated with social deprivation.

 

A restricted comparison has been made between lesser forms of violence in patients with schizophrenia and in the general population, which has concluded that violence is four times more frequent among the patients with schizophrenia. However, those patients who also misused drugs and alcohol were much more likely to be violent, so that the incidence of violence in the remainder of the patients was not that much greater than in the general population. It would make more sense to see this violence as related to the current epidemic of drug and alcohol use, rather than as specific to schizophrenia. It requires a political rather than a psychiatric solution.

 

 

Given that the risks to a member of the public of being killed by a stranger with mental disorder are scarcely greater than being struck by lightning, why does it feature so large in the national consciousness compared to road traffic accidents where the risk is vastly greater?

 

We can only speculate.
There is more moral outrage against someone who kills intentionally rather than by accident. It is perverse to put the mentally disordered into this category, as the killing is in the context of delusions or hallucinations that constitute the 'reality' of the sick person, for example, a belief that he is to be killed by the person whom he then attacks in ' self defence'. On the other hand, what appears to be an 'accident' on the road is often due to driving recklessly, commonly under the influence of drugs and alcohol, despite knowing that this is likely to cause harm to others.

 

In the public imagination, the manner of death by the attack of a mentally disordered person is more horrifying. Phrases like ' mad axe-man' have crept into the language but do not represent reality. Having an object weighing a half-ton hurtle into you must be in the same league of horror as being attacked with a knife. In addition, for every one person killed in a road accident, there are ten or more with very serious injuries and often, lifelong disability.

 

We are surrounded by hazards, but provided they are small and not harped upon, we can put them out of our minds. However, government and media, against the evidence, seem intent on stressing the danger of violence from people who have a mental illness. It is likely that our fellow human beings who are mentally ill have been targeted because of the common prejudice against them, at all levels of Society. Thus a vicious circle has been created in which the public have become more disturbed and fearful than they need be, with an increase in the social exclusion and stigma heaped on people already suffering greatly from their mental illness.

 

 

Education, education and education together with extending respect to all fellow human beings as we are learning to do towards women, black people, the physically disabled, members of minority cultures and other religions.

 

 

This paper has been produced by the Royal College of Psychiatrists as part of their anti-stigma campaign, "Changing Minds: Every Family in the Land".
April 2003

 

"The stigma of dangerousness"
article by Professor John Gunn, in Every Family in the Land:
Understanding prejudice and discrimination against people with mental illness.