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Position Statement 72: Violence: Community Mental Health Response
Despite the fact that most people with serious mental illnesses are never violent, and 95-97% of gun violence is not caused by a mental illness, the involvement of people with acute mental illnesses in recent incidents of mass gun violence has become a significant issue in American society, and a considered response is needed. Gallup polling data from January, 2013 showed that 48% of adult Americans blame the mental health system “a great deal” for mass shootings in the United States. When there is an incident of mass gun violence, as has become tragically common in America, mental illness is routinely discussed as a likely cause, and the rights and liberties of the up to 25% of Americans with mental health conditions are placed in jeopardy. We are particularly concerned by efforts to increase involuntary treatment and to create a national data base of persons with mental health conditions.
Although people with mental health conditions are only slightly more likely than anyone else to commit violence, readily available, community-based, integrated, high-quality, evidence-based, culturally and linguistically competent preventive and therapeutic services and supports for mental and substance use conditions offer the greatest promise of preventing violent behavior of anyone experiencing a mental health crisis. Mental Health America (MHA) is committed to the development of public policies and allocation of public resources to foster access to preventive as well as therapeutic services that can both prevent violence and reduce the fear of violence. Public policy must also work to prevent the violent victimization of persons with mental health and substance use conditions, particularly those who are homeless or incarcerated in jails and prisons.
MHA has decided not to take a position on gun control because it is not part of MHA’s core mission and is an issue on which MHA affiliates and advocates may not agree. But the fact that so many people now identify serious gun violence as proof of mental illness, without any further justification, and the media’s over-reporting of every possible link, has made the public and media reaction to gun violence the most significant current source of stigma against people with mental illness.
Many MHA affiliates will prefer to remain neutral on gun control issues, and MHA will remain neutral in deference to them and to the need to welcome people of different views to the mental health movement. But in areas where the politics permit it, some MHA affiliates, weighing the pros and cons, are deciding to speak out, and MHA supports diverse efforts to assist in reining in the scourge of suicide and gun violence that threatens all Americans. Gun violence and the reaction to it threaten our national health and well-being, stigmatize all Americans recovering from mental illnesses, and re-traumatize individuals, families, and communities that have been victims of gun violence. Additionally, guns play a disproportionately large role in suicides, an issue of great concern to MHA and its affiliates.
It is essential to remind the public and policy makers as each event of mass violence galvanizes their attention that mental health conditions are largely unrelated to increased risk of violent behavior. MHA’s efforts to reduce stigma must include a more sophisticated response to incidents of mass violence because those incidents are a threat to rational recovery-oriented treatment policies and at the same time provide an opportunity to plead for needed treatment resources. As aptly stated by the current leading experts on violence and mental illness, Jeffrey Swanson and Beth McGinty, both of whom consulted in the development of this position statement (but bear no responsibility for its content), “… stakeholders … face the difficult prospect of debunking the public perception that ‘the mentally ill are dangerous,’ while attempting to leverage that very perception to build support for (much-needed) public funding to improve the mental health care system in the United States—and to achieve this goal without also spawning crisis-driven laws that might overreach in restricting the rights and invading the privacy of people with mental illnesses.” This dilemma requires a nuanced communications strategy.
We live in a violent society. Rates of homicide and other violent death in the United States dramatically exceed those of other industrialized, high-income nations. Our toxic environment of racial and ethnic discrimination and conflict, abuse of women, children, elders, and the weaker members of our society, and the decline of community and family connections, are among the root causes of violence in the United States. Diagnosable mental health conditions are not.
Unfortunately, public attitudes often associate mental health conditions with increased risk of violence. These attitudes are ill-informed and ignore several important distinctions.
- Considering mental health conditions as a singular phenomenon makes no more sense than collapsing distinctions between general health conditions. [example omitted] We must be more precise in our language when discussing mental health conditions.
- While untreated or undertreated mental health conditions, when accompanied by untreated or undertreated substance use conditions, may be associated with an increased risk of violence, this does not justify discrimination against people with mental health conditions as a class. Our growing understanding of mental illnesses and our dedication to humanitarian principles have led our society to reject confinement as the means of addressing mental health conditions, and to embrace community-based treatment. We must not abandon these values in response to isolated incidents linking mental illness and violent acts.
- People today have a greater understanding of mental health and substance use conditions than did earlier generations, including an increased awareness of the role of stress and brain chemistry as causative factors in some conditions. Nevertheless, evidence suggests that public attitudes toward people with mental health conditions reflect enormous fear and prejudice. 1996 and 2006 nationally representative surveys indicated that over 60% of respondents felt that a person with schizophrenia was likely to be violent.
- A 2013 national public opinion survey conducted after the Newtown tragedy found that 46% of Americans believed that persons with a serious mental illness were “far more dangerous than the general population”
- The Surgeon General's Report on Mental Health concluded that the contribution of mental health conditions to violence in our society is very small. The greatest risk of violence is from individuals who have an untreated or undertreated substance use disorder either solely or in combination with a mental health condition. Successful treatment ameliorates the risk of violence. Engaging persons in evidence-based care so that they fully participate and implement a meaningful treatment plan is the key to successful treatment.
- Most people with serious mental illness are never violent, and 95-97% of gun violence is NOT caused by a mental illness.
- Persons with severe mental illnesses are much more likely to be victims rather than perpetrators of violence. The word "violence" has its roots in the Latin violare, which means "to violate;" and people with mental health conditions are often violated, but are rarely violent themselves. Continuing public perceptions linking violence and mental illness frustrates access to care and undergirds an “us versus them” attitude that further marginalizes persons labeled with mental illnesses. 
RESEARCH EVIDENCE: MHA believes that the public must be reminded, as each sensationalized incident of violence is thrust into public view, that the vast majority of people with mental health conditions are not violent, and most violence is caused by other factors, not by psychopathology. A landmark 2009 study by Elbogen et al. published in the Archives of General Psychiatry found that mental illness alone is not an adequate basis for a prediction of dangerousness. As stated in the abstract, “bivariate analyses showed that the incidence of violence was higher for people with severe mental illness, but only significantly so for those with co-occurring substance abuse and/or dependence. Multivariate analyses revealed that severe mental illness alone did not predict future violence; it was associated instead with historical (past violence, juvenile detention, physical abuse, parental arrest record), clinical (substance abuse, perceived threats), dispositional (age, sex, income), and contextual (recent divorce, unemployment, victimization) factors.”
However, a 2012 study used a more rigorous methodological approach in challenging Elbogen’s analysis. Consistent with prior studies, Van Dorn and colleagues found that serious mental illness was associated with a small but statistically significant heightened risk of violence: “Those with serious mental illness, irrespective of substance abuse status, were significantly more likely to be violent than those with no mental or substance use disorders. This finding held in both bivariate and multivariable models. Those with comorbid mental and substance use disorders had the highest risk of violence. Historical and current conditions were also associated with violence, including childhood abuse and neglect, household antisocial behavior, binge drinking and stressful life events.” The study concluded that: “there is a statistically significant, yet modest relationship between serious mental illness … and violence, and a stronger relationship between serious mental illness with substance use disorder and violence.”
MHA believes that risk of violence is in fact slightly higher among persons with mental illness than among persons without mental illness. Among small subgroups of persons with serious mental illness, such as those experiencing first-episode psychosis or during the period surrounding inpatient psychiatric hospitalization, rates of violence toward others are elevated compared to rates in the overall U.S. population. And mental illness is a significant cause of suicide.
Of course, whatever the statistics may show, some people with serious mental illnesses are violent, but so are many more people with a record of past violence, juvenile detention, physical abuse as a child, or with a parental arrest record. Similarly, substance abuse, young age, male sex, low income, a recent divorce, unemployment, and victimization predispose people to violence. With the exception of past violence, which the criminal justice system addresses to some extent, no one advocates state intervention against any of these other groups. Why then single out people with mental illness or a civil commitment in their background?
STIGMA: Nevertheless, there is a widespread, profoundly troubling misconception that people with mental health conditions are inherently violent and this perception may be getting more rather than less prevalent. Ironically, there is little understanding of the extent to which many people with mental health conditions are victims of violence and experience repeated trauma.
The ridicule, bullying, shunning, and other demeaning behaviors to which people with mental and substance use conditions are subjected are a form of violence and violate human dignity.
Society's passive acquiescence in the ignorance and discrimination surrounding mental and substance use conditions is fundamentally at odds with deep-rooted values that would foster every individual's opportunity to fully realize his or her potential. Such behavior, when directed at children and youth, can have a devastating and profound impact with tragic consequences.
People with severe mental illnesses can be easy prey to violence. Some live a marginalized existence as a result of mental illness and subsequent loss of income and assets, and may become targets of opportunity for theft, mugging, and rape. Incarceration of large numbers of people with mental and substance use conditions in county jails and state penitentiaries subjects them to violent victimization. And the plight of thousands of individuals in every major U.S. city who are both homeless and have a mental health and/or substance use condition is exacerbated by a high incidence of violent acts against them.
MHA encourages people with mental and substance use conditions to enter and remain in treatment as often as necessary to sustain their recovery. MHA supports the development of accessible and acceptable treatment strategies that engage people in care, using science-based approaches that provide effective and ongoing treatment for persons in need. MHA advocates confidentiality as the prerequisite for all effective mental health treatment. MHA opposes the use of intimidation, sanctions and compulsion that can deter full participation in treatment for mental health conditions.
DUTY TO WARN: MHA recognizes that the evolution of tort law in the Unites States since Tarasoff v. Regents has made it clear that treating mental health professionals have a duty to take reasonable steps to protect potential victims of violence when they have knowledge of a credible and imminent threat of violence toward a particular victim. MHA supports state laws that codify this duty, recognizing that the duty to protect potential victims supersedes even the duty to guard patient confidentiality when necessary to prevent an imminent act of violence. However, care must be taken that these laws do not deter candor or promote overprediction of dangerousness.
PUBLIC POLICY HAS BEEN MISGUIDED: Media sensationalization of violence, and especially graphic coverage of isolated instances of mass gun violence that involve persons with mental health conditions, tend to rekindle deep-seated fears and stereotypes. In such an inflammatory environment, the contagion of fear can infect policymakers and lead to ill-considered public policy.
For example, in response to highly publicized tragic incidents, Congress in 2007 passed legislation aimed at including in a national criminal database names and identifying information on persons who had been involuntarily treated for mental health conditions, as a means of enforcing a ban on their purchasing firearms. While well intended, these statutes confuse a temporary state of dangerousness with a persistent trait of dangerousness. They focus on a tiny proportion of individuals who are involuntarily treated, ignoring persons with similar circumstances who enter treatment voluntarily. They have no effect on people who are treated voluntarily or who remain untreated. And they devote considerable public resources that could be much more effectively allocated to expanding well-proven treatment programs. In fact, many states have ignored the mandate to submit names to the list, and lax procedures have made removal of names from the list very easy.
Likewise, making it easier to commit people for involuntary mental health treatment will do little or nothing to prevent violent acts. It will only scare people from seeking help voluntarily and fail to increase the number who are committed. The premise that we can predict or prevent violent acts is unsupported. Even in the case of severe mental illnesses, mental health professionals possess no special knowledge or ability to predict future dangerous behavior.
Paradoxically, making it easier to commit people to treatment will not lead to more commitments or more people getting care. A chronically underfunded mental health system, which has experienced $4.6 billion in state budget cuts since 2009, does not have the capacity to meet those needs. When Illinois lowered its standard to allow the commitment of virtually every person with schizophrenia and bipolar disorder, commitments decreased because of the continued reduction in public and private inpatient beds. Similarly, in Washington, a study of the state's lowered commitment standard revealed fewer voluntary admissions and a rapid increase in the revolving door of discharges and re-admissions. In fact, the number of people who meet existing commitment standards in every state already exceeds the beds available for them.
It is highly unlikely we will increase the number of psychiatric beds. Nor should we. In fact, according to a recent analysis by the Bazelon Center for Mental Health Law, “there is a strikingly low (and not statistically significant) correlation between the number of psychiatric beds and the firearms murder rates in the 47 states for which reliable statistics were found. Low per capita numbers of public psychiatric hospital beds in states were not associated with higher rates of murder by firearms, and states with relatively greater numbers of beds were not associated with lower firearm murder rates. Furthermore, the 2007 data reflecting both public and private psychiatric beds show essentially zero correlation with firearm murders that year (Pearson’s r (47)=-0.004, p=.489).”
Rather than forcing more people into treatment, we should dedicate adequate resources toward prevention and early identification of emotional disturbances in children and fund cost-effective community-based interventions that work.
Given that only a tiny fraction of violent acts are perpetrated by persons with mental health conditions, efforts to bar such individuals from purchasing firearms or to increase preventive detention can have no meaningful impact on public safety. Such legislation wastes public resources, violates the civil liberties of the vast majority of people with mental illness who are not dangerous, powerfully reinforces the myth that links mental health conditions with violence, and further cements stigma in the public mind. Incapacitated people may need to be treated against their will, but the circumstances are appropriately limited and should not be expanded in response to the public’s reaction to the horrific gun violence of Columbine, Tucson, Aurora, Newtown, and all of their predecessors and sequels. See MHA Position Statement 22 Involuntary Mental Health Treatment.
Preventive services have been shown to increase resiliency (an individual's ability to deal with stress and conflict) and to increase protective factors which significantly reduce the likelihood of engagement in high risk behaviors. When an individual with mental illness experiences decompensation, crisis interventions like mental health first aid and crisis intervention teams can help an individual in crisis connect with appropriate professional, peer, social, and self-help care. Episodes of decompensation include a temporary worsening of symptoms, a loss of the ability to adapt to normal changes and stress, and difficulty with the normal activities of life. Trauma frequently causes mental health consequences, including decompensation. Social policies that minimize trauma and promote community connection and inclusion are essential, both for people in mental health crises and for the general population. The broader goal is to foster mental wellness in everyone. This policy focus is more likely to reduce violence than policies that discriminate against people with mental health conditions by singling them out as supposed causes of violence.
Call to Action
MHA calls for a national dialogue on violence and mental and substance use conditions, with an eye to dispelling myth, combating stigma, and laying a foundation for sound public policymaking to reduce the overall level of violence in the United States. We staunchly support public policy changes to dramatically improve access to readily available, comprehensive and integrated, high-quality, evidence-based, culturally and linguistically competent mental and substance use services and supports. These services and supports should include a preventive focus, to foster mental wellness and recovery from mental health conditions that may otherwise lead to violence or victimization. We further support the implementation of evidence based prevention programs to reduce the overall levels of violence and trauma. We oppose coercive and punitive measures against people with mental health and substance use conditions.
MHA calls on policymakers to support efforts (such as public education campaigns) to unravel myths associating persons with mental and substance use conditions and violence and to ensure effective treatment and supports for people with mental health and substance use conditions as well as the safety of these vulnerable individuals. Policymaking aimed at deterring violence should not single out people with mental and substance use conditions. The most reliable predictor of violence is a history of violence or threats. MHA vigorously opposes efforts - in the name of public safety - to deny people rights or privileges, or otherwise discriminate against people on the basis of a mental health condition. Such efforts should be rejected as dangerously stigmatizing, making effective treatment more difficult, and as a violation of the civil liberties and human rights of people with mental health conditions.
The Mental Health America Board of Directors adopted this policy on September 13, 2014. It will remain in effect for a period of five (5) years and is reviewed as required by the Mental Health America Public Policy Committee.
Expiration: December 31, 2019
 A 1990 NIMH study showed that even if the elevated risk of violence in people with mental illness were reduced to the average risk in those without mental illness, an estimated 96% of the violence that currently occurs in the general population would continue to occur. Swanson, J.W., Holzer, C.E., Ganju, V.K., and Jono, R.T., “Violence and Psychiatric Disorder in the Community: Evidence from the Epidemiologic Catchment Area Surveys. Hosp Community Psychiatry 41:761–770 (1990).
 SAMHSA’s published 1-year prevalence estimate from the combined 2011 and 2012 National Surveys on Drug Use and Health (NSDUHs) is that 18.2 percent of the adult population of the US had any diagnosable “mental, behavioral, or emotional disorder” in a year.
3A recent example is the 2011 Tucson tragedy involving Jared Lee Loughner, the accused attempted assassin of Rep. Gabrielle Giffords. There is no question that Mr. Loughner needed mental health counseling and that he did not get it. However, the only evidence at the time of the shootings was that Mr. Loughner had acted out bizarrely, but not violently, in class. So far as we know, he never made a threat of violence against anyone, even though threats against public officials are unfortunately common in contemporary American society. Although he made people nervous, Mr. Loughner was never deemed dangerous by anyone prior to the attempted assassination and was apparently never referred to the Pima County mental health system or the courts. As urged by this policy, assertive intervention by the mental health system could have stemmed the violence. But Pima County underwent a dramatic 45% reduction in public mental health treatment in 2010-2011, as local and state human services funding collapsed. This is an extreme case of a phenomenon experienced nationwide. Thus, the first lesson of the Tucson tragedy has to be to understand the impact on public safety of the inability of the underfunded community mental health system to follow up in cases like this. Defunding of human services has serious consequences for society, as well as for the people who lose essential supports. Although Mr. Loughner might have refused counseling even if it were offered, there is no evidence that sensitive outreach would have been ineffective, because it was never tried. There were inadequate resources to do so.
 Miles, et al., “Suicide Mortality in the United States: The Importance of Attending to Method in Understanding Population Level Disparities in the Burden of Suicide,” Annual Review of Public Health 33:393-408 (2012).
 Swanson, J.W., McGinty, E.E., Fazel, S. and Mays, V.M., “,Mental Illness and Reduction of Gun Violence and Suicide: Bringing Epidemiologic Research to Policy, Annals of Epidemiology (in press) (2014). http://www.annalsofepidemiology.org/article/S1047-2797%2814%2900147-1/fulltext#sec10
 Krug E.G., Powell, K.E. & Dahlberg, L.L.. “Firearm Related Deaths in the United States and 35 Other High and Upper Middle Income Countries,” International Journal of Epidemiology, 27(2), 214-221(1998); Milton, T., “Violence in a Violent Society,” Journal of Public Health Policy 19(3):289-302 (1998). WHO, World Report on Violence and Health (Geneva 2002). http://www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf.
 Link, B.G., Phelan, J.C., Bresnahan, M., Stueve, A & Pescosolido, B.A., “Public Conceptions of Mental Illness in 1950 and 1996: What is Mental Illness and is it to be Feared?” Journal of Health and Social Behavior, 41(2):188-207 (2000).
 Pescosolido, B.A., Martin, J.K., Long, J.S., Medina, T.R., Phelan, J.C., and Link, B.G., “A Disease Like any Other”? A Decade of Change In Public Reactions To Schizophrenia, Depression, and Alcohol Dependence,” Am J Psychiatry 167:1321–1330 (2010).
 Barry, C.L., McGinty, E.E., Vernick, J.S., and Webster, D.W. “After Newtown–Public opinion on gun policy and mental illness,” N Engl J Med. 368: 1077–1081 (2013).
 Mental Health: A Report of the Surgeon General. http://mentalhealth.samhsa.gov/cmhs/surgeongeneral/surgeongeneralrpt.asp.
 Steadman, H.J., Mulvey, E.P., Monahan, J., Robbins, P.C., Appelbaum, P.S., Grissom, T., Roth, L.H., & Silver, E. (1998). “Violence by People Discharged from Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods,” Archives of General Psychiatry 55(5):393-401 (1998). Swanson, J.W., Swartz, M.S., Essock, S.M., Osher, F.C., Wagner, H.R., Goodman, L.A., Rosenberg, S.D. & Meador, K.G. The Social-Environmental Context of Violent Behavior in Persons Treated for Severe Mental Illness, .American Journal Of Public Health 92(9):1523-1531 (2002).
 Swanson, J.W., McGinty, E.E., et al., op. cit.
 Easton, C.J., “The Role of Substance Abuse in Intimate Partner Violence,” Psychiatric times, 25(1), 1-2 (2006). http://www.psychiatrictimes.com/showArticle.jhtml;jsessionid=ZFMPWLFYYHP3MQSNDLOSKH0CJUNN2JVN?articleID=177101044&pgno=2.
Elbogen, E.B. & Johnson, S.C., “The Intricate Link Between Violence and Mental Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions,” Arch. Gen. Psychiatry. 66(2):152-161 (2009),. doi:10.1001/archgenpsychiatry.2008.537. http://archpsyc.amaassn.org/cgi/content/full/66/2/152?maxtoshow=&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
 Van Dorn, R., Volavka, J & Johnson, N, “ Mental Disorder and Violence: Is There a Relationship Beyond Substance Use?” Soc Psychiatry Psychiatr Epidemiol 47:487–503(2012).
 Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14 (Cal. 1976), was a case in which the Supreme Court of California held that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient. The original 1974 decision mandated warning the threatened individual, but a 1976 rehearing of the case by the California Supreme Court called for a "duty to protect" the intended victim. The professional may discharge the duty in several ways, including notifying police, warning the intended victim, and/or taking other reasonable steps to protect the threatened individual. It has been followed in many American jurisdictions.
 “Some With Histories of Mental Illness Petition to Get Their Gun Rights Back” By MICHAEL LUO New York Times July 2, 2011 http://www.nytimes.com/2011/07/03/us/03guns.html) Thus, the law serves as another trap for the uninformed and unwary.
 Swanson, J.W., McGinty, E.E., et al., op. cit.
“Illinois Statistics” Illinois Department of Humans Services, Office of Mental Health and Developmental Disabilities Fiscal Years 2008, 2009 and 2010: In re Torski, 395 Ill. App. 3d 1010, 918 N.E.2nd 1218 (2009).
 Durham & LaFond, “the Empirical Consequences and Policy Implications of Boradening the Statutory Criteria for Civil Commitment” 3 Yale Law & Policy Review 395(1985)
 Judge David L. Bazelon Center for Mental Health Law, The Relationship between the Availability of Psychiatric Hospital Beds, Murders Involving Firearms, and Incarceration Rates, Issued January 15, 2013. http://www.bazelon.org/portals/0/Archives/Statements%20&%20Releases/Relationship%20Between%20Psychiatric%20Hospital%20Beds%20and%20Firearm%20Murder1.15.13.pdf?utm_source=1.15.13+new+analysis+PR&utm_campaign=1.15.13new+analysis+PR&utm_medium=email
 MHA particularly opposes legislative efforts to respond to isolated incidents of violence by making involuntary treatment easier. That is because the overwhelming cause of violence among the small number of persons with mental health conditions who do become violent is our failure, due to lack of resources, to either offer these persons appropriate treatment or implement existing involuntary treatment laws. Such incidents of violence cannot be attributed to any supposed legal roadblocks to involuntary treatment.