Unsafe? Yes, but Only if Untreated: Violence and SMI
I woke up searching frantically for my glasses on the nightstand — knocking over a glass of water before touching the wire rims. Pulling them on, I saw it was 4 a.m. I was in a cold sweat and my heart was pounding. My brother, Henry, was pacing in the hallway, shouting at the voices only he could hear. The thought of talking with him never entered my mind — I had been up late trying to convince him he needed to go back on the medicine, but all I had accomplished was to further agitate him. Listening to his side of a heated argument, I imagined him bursting through the door with a knife in his hand. I swung my legs over the bed and walked to the door with my head hung low in shame and weariness and locked it.
My research and my book, “I am Not Sick, I Don’t Need Help!,” are frequently cited by advocates who promote assisted outpatient treatment (AOT) and by advocates who oppose involuntary treatments on the grounds they would not be needed if adequate outpatient treatments were available. I can see the wisdom in both sides of the debate.
That said, until suicide, gross self-neglect, other forms of self-harm and violence stemming from psychotic states can be reliably controlled, involuntary treatments will always be needed. To turn our heads and look the other way would be immoral and criminal — which brings me to the focus of this blog.
Are people with schizophrenia more apt to commit violent crimes and acts compared to “the chronically normal,” as my good friend Dr. Fred Freese (a consumer and psychologist with schizophrenia) used to say? On a more personal note: should I have been afraid of my brother, who, before he became ill, had never before been violent and who I had trusted more than anyone?
Research on violence and schizophrenia
When giving seminars, I often say, “Individuals with schizophrenia and related psychotic disorders are no more violent than the general population,” and then go on to cite the research that backs me up. For nearly two decades, this statement has been a mantra for many of us who are advocates for better treatments, services, and laws for persons with schizophrenia. But more recent, well-replicated research indicates the story is not so simple.
For example, in a recent national study of violent behavior in persons with schizophrenia, the authors found that symptoms of losing contact with reality, such as delusions and hallucinations, increased the odds of serious violence by nearly three times the normal rate. Results of the study, which was conducted with patients in real-world community settings as part of the NIMH-funded Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), are consistent with previous independent studies. Most studies show that when hallucinations and delusions are worsened, the potential for violence increases dramatically.
As a forensic expert who has worked on more than 90 death-penalty cases involving persons with schizophrenia and related disorders who have committed homicides, I can say unequivocally that the anecdotal evidence is overwhelming. The story was the same in nearly every case I worked on. When hallucinations, thought disorder, and delusions worsened, the defendants became frightened and angry, and, in some cases, coolly planned how they would commit murder.
Anosognosia causes medication non-adherence which increases the risk of violence
Most persons with schizophrenia and other psychotic disorders, including bipolar disorder, benefit from treatment with antipsychotic medication. When we look at the majority — those who do respond to treatment — we find that the most common cause of medication refusal and partial non-adherence is anosognosia (poor insight into having an illness). Consequently, if we want to decrease the rate of violence in the population of persons with schizophrenia and other psychotic disorders, we have to break the cycle caused by anosognosia: Believing “I am not sick” leads to the conclusion “I don’t need medicine,” which, in turn, leads to a worsening of those symptoms that cause otherwise peace-loving people with no history of aggression or violence to become violent.
How do we break that cycle? Part of the answer lies in the same nationwide study that recently emphasized the well-replicated link between a worsening in psychotic symptoms and violence. The CATIE study found that participants living with families “they felt listened to them ‘most of the time’ had half the rate of violence compared to those living with families that did not listen to them.”
If they had measured it, I believe the CATIE investigators would have found the same result — less violence in persons working with therapists who listened “most of the time” instead of offering unsolicited advice and debating whether their clients were ill. The reason I believe this is that research shows that communication strategies that emphasize active listening skills — whether used by therapists, friends, or family — create trusting relationships that lead people to accept treatment even when they do not believe they are ill.
Forty years ago, when I was woken from sleep by my brother’s ranting at his hallucinations, should I have locked the door? In light of the recent research and the professional experiences I have had since that night, I have to say the answer is yes. Although he was never violent, he was nevertheless exhibiting some of the warning signs of potential violence (increased hallucinations, agitation, and paranoid delusions).
Today, when asked, “Are people with schizophrenia more violent?” I now answer, “No, not when they are in treatment and the symptoms are well-controlled.”
*Portions of this blog appeared previously in my book, I am Not Sick, I Don’t Need Help! (Vida Press, New York, 2020)
