Commentary
On July 27, 2015, Lai Hang shot and killed her son, George, at the Valley Hotel in Rosemead, Calif. Ms. Hang had been diagnosed with terminal cancer a few months prior and was concerned about the future of her son. George was almost 18 and diagnosed with schizophrenia.
In thinking about why Ms. Hang chose this act, I can’t help but wonder about our role in perpetuating the myth that mental illness and violence go hand in hand.
Loss and tough adjustment
George had been born to Lai and Peter Hang, who moved to the United States in 1992 from the southeast Asian country of Laos to open a printing shop and pursue the “American dream.” In 2012, Peter Hang was diagnosed with metastatic cancer and died, a development that was a severe stressor for George.
Over a period of months, George reportedly started withdrawing from friends and acting differently. He destroyed things around the house, including a garden he had planted with a family friend. His grades slipped in school; he was getting report cards full of Fs. He subsequently was diagnosed with schizophrenia. Ms. Hang grew increasingly concerned about him in the context of the multiple highly publicized mass shootings attributed to patients with mental illness.
When George became more interested in Adolf Hitler after a school project on World War II, Ms. Hang’s fear intensified. Her concerns grew even more in the wake of reports of killings by James Holmes in Aurora, Colo.; Adam Lanza in Newtown, Conn.; and Elliot Rodger in the Santa Barbara County, Calif., town of Isla Vista. After the Charleston, S.C., church shootings of June 2015, George Hang reportedly became fixated on Dylann Roof. With increasing distress over her son, Ms. Hang wondered whether anything could have been done to stop those shooters.1
Politicians long have perpetrated the belief that patients with mental illness cause violence. Former President Barack Obama often linked mental illness to gun violence. For example, in a 2016 statement, he said: “While individuals with mental illness are more likely to be victims of violence than perpetrators, incidents of violence continue to highlight a crisis in America’s mental health system.”2
The recent election also was a prime example, with quotes such as: “This isn’t a gun problem; it’s a mental health problem ... these are sick people,” by now-President Donald Trump, and “We are not making sure that someone who is mentally ill can’t get access to a gun”3 by Ohio Gov. John Kasich.
The media also have promoted this view with headlines such as “Get the violent crazies off our streets,” and “They threaten, seethe and unhinge, then kill in quantity.” In one article, the writer contended: “In our newfound complacency, we had forgotten a particular kind of violence to which we are still prey … violence of the mentally ill.”4
How the evidence stacks up
Nonetheless, the scientific evidence contradicts those views. Most reviews on the topic come to conclusions similar to those of Debra A. Pinals, MD, and Lisa Anacker, MD, who recently wrote: “Despite media accounts to the contrary, persons with mental illness account for only a small percentage of persons who commit acts of violence ...”5
Jeffrey W. Swanson, PhD, who has spent his career examining these issues, studied more than 10,000 people with and without mental illness over 1 year, and found that serious mental illness was found in only 4% of the cases of violence. He found three factors that do predict the occurrence of violence: whether the perpetrator was male, poor, or abusing drugs.6 “That study debunked two myths,” Dr. Swanson, professor in the department of psychiatry and behavioral sciences at Duke University, Durham, N.C., reportedly 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.”7
Despite the consistent research on this topic, the voice of psychiatry has been muddled. Many have promoted this intuitive yet wrong narrative. In particular, this approach has been embraced by the Treatment Advocacy Center (TAC), a large nonprofit organization “dedicated to eliminating barriers to the timely and effective treatment of severe mental illness.”
In 2013, E. Fuller Torrey, MD, the executive director of TAC, contended in an interview “about half of … mass killings are being done by people with severe mental illness.” His solution is explicit: “The U.S. would have fewer mass killings if individuals with severe mental illnesses received proper treatment.”8 In a fact that implies tacit approval of Dr. Torrey’s problematic positions, three past presidents of the American Psychiatric Association currently serve on TAC’s board: Jeffrey A. Lieberman, MD; Steven S. Sharfstein, MD; and John A. Talbott, MD.
It is worrying that some psychiatrists have started sounding false alarms again when advocating for laws that support assisted outpatient treatment (AOT). In AOT, an individual meeting specified criteria for mental illness and potentially asserted to have a risk for violence is compelled by court order to comply with outpatient psychiatric treatment as a condition of remaining in the community.9 Some psychiatrists contend that “the relationship between deinstitutionalization and the increasing episodes of violent behavior by individuals with serious mental illness who are not being treated has been firmly established. Until we address the treatment issue and use proven remedies, such as assisted outpatient treatment … we should expect these episodes of violent behavior to continue,” they conclude.10
Dr. Nicolas Badre
I am concerned about this issue, not only because of the stigma faced by our patients. I want to prevent our patients from realizing that behind their backs, outside of the office, we speak of them as dangerous and in need of involuntary confinement. I am concerned that patients will no longer trust psychiatrists if we describe them in such scary fashions without even the backing of science. If nonmaleficence is at the cornerstone of medical ethics, maybe as psychiatrists we could start by not falsely accusing our patients of being dangerous.
As Irvin D. Yalom, MD, famously said: “It’s the relationship that heals.” I cannot think of anything more important to my practice than cultivating genuine and meaningful relationships. I work as a psychiatrist with patients who have severe mental illness. They are dehumanized by the system, disenfranchised from society, and feared by the media. My role is to create a relationship that helps them overcome those obstacles.
References
1 Los Angeles Times. May 22, 2017
2 Obama White House Archives, Jan. 4, 2016
5 Psychiatr Clin N Am. 2016;39:611-21
6 Ann Epidemiol. 2015 May;25(5):366-76
7 The New Yorker. Nov. 19, 2014
9 Psychiatr Serv. 2016 Jul 1;67(7):784-6
10 CNS Spectr. 2015 Jun;20(3):207-14
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego; and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre also mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.