Understanding the Connection Between Mental Illness and Violence

International Journal of Law and Psychiatry, Vol. 20, No. 4, pp. 399–417, 1997Copyright © 1997 Elsevier Science LtdPrinted in the USA. All rights reserved

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Understanding the Connection Between Mental Illness and Violence

Virginia Aldigé Hiday*

Introduction

Recently, sophisticated epidemiological studies have found an association be-tween severe mental illness and violence that cannot be explained away by in-adequate sampling or measurement, or with demographic and ecological con-trols (Link et al., 1992; Link & Stueve, 1994; Swanson et al., 1990; Swanson, 1993,1994). These studies reinforce findings from restricted samples of hospitalizedand incarcerated persons showing that mental patients have relatively high ratesof violence (Lagos et al., 1977; McNiel & Binder, 1986, 1994; Monahan, 1992)and that jail detainees and prison inmates have high rates of mental illness(Collins & Schlenger, 1983; Coté & Hodgins, 1990, 1992; Jordan et al., 1996;Teplin, 1990; Teplin, Abram, & McClelland, 1996). The epidemiological re-searchers have emphasized three important qualifications of their findings: (1)the association between mental disorder and violence is modest; (2) mentallyill persons account for only a small proportion of the total violence in society; and(3) not all mentally ill persons have higher rates of violence but only those with amajor mental illness and active psychotic symptoms (Link & Stueve, 1995).

To understand how mental illness and violence are associated, this paperpresents a series of models based on empirical research that illuminate the sta-tistical association between the two phenomena. It begins with the most sim-ple model showing a direct sequence of severe mental illness producing vio-lence, then moves to build more complexity in the relationship with multiplepaths involving socializing conditions and intervening experiences that con-nect active, major mental illness to violence. It concludes with a model sug-gesting that both violence and manifestations of mental illness largely grow from

*Professor, North Carolina State University, Raleigh, NC 27695-8107.

The author wishes to thank B. Link, P. L. McCall, J. Monahan, H. J. Steadman, J. Swanson, M. Swartz,L. Teplin, and H. Wales for their helpful comments on an earlier version of the manuscript.

Work on this article was partially supported by Grant RO1-MH48103 from the National Institute ofMental Health.

Address correspondence and reprint requests to Virginia A. Hiday, Department of Sociology, NorthCarolina State University, Raleigh, NC 27695-8107.

400 VIRGINIA ALDIGÉ HIDAY

the structural arrangements in which individuals are embedded, and that thepaths between mental illness and violence are mainly indirect and contingent.

Two Direct Models

The most simple relationship between mental illness and violence is a modelin which mental illness directly causes violence (Severe Mental Illness

→

Vio-lence). This model represents the age-old belief kept current in news stories andfiction that it is mental illness which overrides self-control to produce violentbehavior (Gerbner et al., 1981; Link et al., 1987; Monahan, 1992). A first addi-tion to this simple model adds psychotic symptoms as a crucial interveningvariable through which severe mental illness operates to bring about violentbehavior. But it is not psychotic symptoms in general such as odd delusions,hallucinations, or disorganization that lead to violence (Estroff & Zimmer,1994; Taylor et al., 1994), or even command hallucinations since the majorityof dangerous commands are not followed (Hellerstein, Frosch, & Koenigs-berg, 1987; Junginger, 1995; McNiel, 1994). Rather, this model adopts Linkand Stueve’s proposition (1994) that violence in mentally ill persons is causedby those symptoms that produce feelings of personal threat or involve intru-sion of thoughts that can override self-control (Severe Mental Illness

→

Threat/Control–Override Symptoms

→

Violence). They hypothesized that be-havior constraints are more likely to be overridden and violence is more likelywhen a disordered person believes he or she is gravely threatened by otherswho intend harm and believes that others are dominating his or her mind.Link and Stueve (1994) tested this hypothesis with New York City communitydata and found threat/control–override symptoms to be significant predictors ofrecent violence when other psychotic symptoms and individual sociodemo-graphic and community context variables were held constant. Four subsequentstudies (Link & Stueve, 1996; Mulvey et al., 1996; Swanson et al., 1996, 1997)also found support for this hypothesis with analyses of a psychiatric emergency-service clientele, a severely mentally ill treatment sample, and two large com-munity samples, one from the United States and one from Israel.

Two Indirect Paths

Link and Stueve’s hypothesis of threat/control–override symptoms inducingfear and disrupting internal controls to produce violence describes an internalprocess of intrapsychic forces propelling the violence. A more social and inter-personal process could also be operating, that is, threat/control–override symp-toms could result in violence through another, more interactive path. Thesesymptoms could create tense situations between a mentally ill person andothers as nerves fray (from hearing about the delusions or seeing the psychoticperson acting delusional), as others mock or rebut the delusions, or as otherstry to persuade the mentally ill person to desist in the annoying behavior orcomply with treatment. The tense situation can escalate to accusations, angerand eventually pushing, hitting, and fighting (Edwards & Reid, 1983; Sheridanet al., 1990; Straznickas et al., 1993), especially in environments where physical

CONNECTION BETWEEN MENTAL ILLNESS AND VIOLENCE 401

aggression is commonly used in disputes (Steadman, 1982; Tedeschi & Felson1994; Yesavage et al., 1983) (see Fig. 3).

Similarly, severe mental illness can lead to violence through other psychoticsymptoms; bizarre or other annoying behavior can produce tension in others.Or years of deviant behavior may make a mentally ill person an object of bul-lying, which provokes him or her to engage in defensive violent acts. A historyof such bullying can make the victim more reactive, especially toward old per-petrators. Mentally disordered individuals can be expected to react in thesame manner and for the same reasons as nonmentally disordered persons insituations of unfairness, which definition bullying meets. Thus, one can predictthat those with major mental disorder who suffer a history of being bullied willanticipate mistreatment, appraise situations antagonistically, and become an-gry more frequently than others not so provoked (Dodge et al., 1990; Estroff &Zimmer, 1994; Estroff et al., 1994; Novaco, 1994). Anger is neither necessarynor sufficient for physical aggression, but it is significantly related to violenceamong both mental patients and nonpatients (Dodge et al., 1990; Kay et al.,1988; Novaco, 1994; Segal et al., 1988; Tedeschi & Felson, 1994). As Figure 1depicts, when symptoms lead to tense situations that break out in physical ag-gression, major mental illness and its symptomatology are an indirect cause,rather than a direct cause, of violence (Link et al., 1992, and Monahan, 1992,also make this point). (Figure 1 also incorporates the direct model of severemental illness leading to violence through the psychotic symptoms of threat/control–override.)

Tense situations include other “provocation categories” to use Novaco’sterm (1994); that is, conflictive situations in which recurrent problems emerge:when chronically scarce resources must be divided such as food, space, and

FIGURE 1. Two Indirect Paths to Violence.


spending money among members of a chaotic and congested household; orwhen goal-directed behavior is blocked and the blocking is seen to be incon-siderate, arbitrary, and unfair. The latter provocation categories include afamily’s attempts to thwart an alcoholic from meeting his drinking buddies;group members demeaning, manipulating, or falsely accusing one of their own;or other people reacting with fear or coercive measures to the words andactions of a mentally disordered person. These tense situations are more likelyto become violent in social environments where physical attack is a commonalternative in conflicts (National Research Council, 1993; Rosenberg & Fenley,1991; Tedeschi & Felson, 1994).

The Social Structure

Tense or conflictive situations that lead to violence can be produced by stressfulnegative events such as losing a job, divorce, or death of a family’s breadwinner(Catalano et al., 1993; Levinson & Ramsey, 1979; National Research Council, 1993;Steadman & Ribner, 1982). These situations along with stressful events are morelikely to occur in conditions of social disorganization and poverty. (see Fig. 2).

Social disorganization is found in impoverished communities where individ-uals experience extremely low income for a large percentage of their lives. Intoday’s society, at least in the United States, that means living with constantdeprivation, lacking hope of having anything better, and believing in an inex-plicable world where external forces arbitrarily determine what outcomes oc-cur, outcomes that are too often negative and painful. More importantly, so-cial disorganization involves the breakdown of family and other microinstitutions that give meaning and sustain the individual. Socially disorganizedcommunities are unable to exert social control over a large proportion of theirmembers or offer opportunities beyond menial or illegal jobs; and today thesecommunities are drug plagued. Individuals living in these conditions often losetheir moorings, live in a state of anomie, and have increasingly less chance ofovercoming their current poverty and deprivation, especially by legal means.These individuals have little sense of control or constructive ways of express-ing anger and fear. Their families tend to be fatherless, offer little shelter froma hostile world and little guidance to overcome environmental deprivations.Figure 2, thus, depicts social disorganization and poverty as an indirect causeof violence through stressful events.

Figure 3 indicates that social disorganization and poverty lead to victimization/violence, which affects later violence. Both official records and survey datafind violence higher in lower socioeconomic groups and in poverty areas(Barker et al., 1992; Dodge et al., 1990; Eron et al., 1994; Land et al., 1990;Link et al., 1992; National Research Council, 1993; Patterson, 1991; Rosen-berg & Fenley, 1991; Sampson & Lauritsen, 1993; Seltzer & Kalmuss, 1988;Swanson et al., 1990; Widom, 1989). The violence occurs inside the family withchild, spouse, and elder abuse; and outside the family from acquaintances andstrangers, and between others the individual observes. Evidence from ECA(Epidemiological Catchment Area) data also points to recent economic hard-ship in the form of job loss, causing violence and being more predictive of vio-lence than psychiatric disorder (Catalano et al., 1993). Similarly, victimization,


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which incorporates not only violence but also other types of harm and exploi-tation, is more likely to occur among those living in poverty areas (Eron et al.,1994; Mirowsky, 1985; Mirowsky & Ross, 1983; National Research Council,1993; Rosenberg & Fenley, 1991).

Social disorganization and the accompanying poverty lead to later violencethrough victimization/violence in three ways (see Fig. 3). The first, throughtense situations, is a straightforward path that does not involve mental illness.In an atmosphere of violence, tension and conflict are ever-present, ready toerupt into new violence (Fagan & Brown, 1993). The other two paths from so-cial disorganization/poverty to later violence go through both victimizationand the new variable of suspicion/mistrust. Violence victims become fearful,distrusting, and suspicious of others (Fagan & Brown, 1993; Mirowsky & Ross,1983). This can lead to tense and conflictual situations and to later violence inpersons without mental disorder; but the severely mentally ill with thoughtproblems or delusions and hallucinations are particularly vulnerable. Mirowsky(1985) has shown that members of the lower class are more likely to be suspi-cious and distrustful, and that the mistrust of lower-class persons with thoughtproblems or delusions and hallucinations is likely to turn into paranoid beliefs.The prevalence of violence in the environment at the bottom of the stratifica-tion system makes it more likely that lower-class individuals with paranoid be-liefs will choose violence as a solution to their perceived threats. Severe men-tal illness, thus, produces the delusions and hallucinations, but location in thestratification system produces the distrust, suspicion, and socialization to phys-ical aggression. The interaction between mental illness and underclass life (in-cluding the violence therein) results later in higher rates of violence amongthose with severe mental disorder.

Comorbidity

Social disorganization and poverty also produce substance abuse/depen-dence, which leads to violence. Ever since the early days of social-science re-search, empirical studies have found substance abuse/dependence and otherforms of deviance to be more frequent among conditions of poverty and socialdisorganization (American Psychiatric Association [APA], 1994; Catalano,1991; Tedeschi & Felson, 1994). Also, much research has implicated substanceabuse, especially long-term abuse, in violent behavior (Bushman & Cooper,1990; Collins & Schlenger, 1988; Miczek et al., 1993; Pihl & Peterson, 1993). Fig-ure 4 links substance abuse/dependence to violence both directly and indirectlythrough stressful events (as an alcoholic wrecks his car, loses his job, or alien-ates his family and friends) and through tense situations (as the alcoholic makesunreasonable demands, or others try to thwart his finding more liquor or drugs).

Figure 4 also indicates a two-way path between substance abuse/dependenceand severe mental illness. Each could be a predisposing, precipitating, or per-petuating factor in the other. What is important for our purposes is that sub-stance abuse has been associated with violence among the mentally ill in mul-tiple studies (Cuffel et al., 1994; Drake et al., 1990; Grossman et al., 1995;Hodgins, 1992; Lindqvist & Allebeck, 1989;

Psychiatric News

, 1995; Rice &Harris, 1992, 1995). Swanson and colleagues (1990, 1993, 1994, 1997) have


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shown that substance abuse/dependence increases the risk of violence amongpersons with major mental illness by a fourfold factor. Studies of jail andprison inmates, which have reported higher prevalence rates of major mentaldisorders than in the general population (Coté & Hodgins, 1990; Teplin,1990), have found on closer inspection that the mentally disordered inmatestend to be substance abusers (Abram, 1989, 1990; Abram & Teplin, 1991; Coté& Hodgins, 1990) and were likely to have been using drugs or alcohol at thetime of their arrests (Abram & Teplin, 1991; Gottlieb et al., 1987). Thus, wesee another path between severe mental illness and violence: Persons with ma-jor mental disorders who abuse alcohol or drugs are likely to become violentbecause of their abuse.

Figure 5 adds antisocial personality (ASP)/psychopathy

1

to the model,showing that social disorganization/poverty produces persons with ASP orpsychopathy, which, in turn, leads directly to violence. The criteria for makingan ASP diagnosis include violent behavior itself and other behaviors such asirritability, aggressiveness, and impulsivity, which are likely to lead to violence(APA, 1994; Robins et al., 1991). ASP/psychopathy also leads indirectly toviolence through stressful events and tense situations because of the results ofsymptomatic behaviors. For instance, persons with ASP are more likely toblame others, be promiscuous, not honor financial obligations, and the like(Robins et al., 1991; Rodgers et al., 1994).

There are two two-way paths joining ASP with both severe mental illnessand substance abuse/dependence. As in the relationship between substanceabuse and severe mental illness, each could be influencing the other by predis-position, precipitation, or perpetuation (Gorton & Akhtar, 1990). ASP/psy-chopathy frequently co-occurs with severe mental disorder among mentally illpersons who are criminal and violent (Abram & Teplin, 1991; Robins, 1993);and some evidence indicates that ASP/psychopathy rather than major mentalillness propels the assaultive behavior. Rice and Harris (1992) found psychop-athy to predict violent recidivism among schizophrenic patients who wereevaluated in a forensic psychiatric hospital. Hafner and Boker (1982) foundindividuals with major mental illness who committed violent crimes to be basi-cally different from nonoffending mentally disordered individuals in that theyhad a history of antisocial traits preceding the onset of their psychosis. Thissample of mentally ill offenders tended to have delusions and fears, suggestingthat it is a certain type of psychotic individual who also is ASP who becomes

1

Antisocial personality disorder (ASP) is a recognized Axis II diagnosis of the American Psychiatric As-sociation, characterized by violation of social norms across many areas, including irresponsibility and ag-gressiveness toward others beginning in childhood and continuing into adulthood (Robins et al., 1991). Aswith other personality disorders, there is much comorbidity with Axis I disorders (Gorton & Akhtar, 1990).The diagnosis is faulted for being no more than a medicalization of bad behavior, and for validity and reli-ability shortcomings (Hart et al., 1994). Attempts to link ASP with violence and crime can become tautolog-ical: Being violent or an offender leads to an ASP diagnosis; whereupon ASP is said to predict violence andcrime. Hare, Hart, and their colleagues (1993, 1994) have shown an association between psychopathy (theirpreferred term) and violence while avoiding the tautology. They measure two stable factors underlying psy-chopathy, only one of which includes violent and/or criminal behavior—the social deviance factor (impul-sive, antisocial, and unstable lifestyle). They have found that the second factor of interpersonal and affectivecharacteristics (superficiality, grandiosity, manipulativeness, irresponsibility, and lack of remorse and empa-thy) is just as predictive of violence as is the social-deviance factor (Hart et al., 1994).


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violent. Robins (1993) reported that the association between all crime (notjust violent crime) and major mental illness completely disappeared when con-trols were placed for ASP adult symptoms, childhood conduct disorder symp-toms (generally considered integral to ASP diagnosis), and substance abuse.Robins concluded there is no direct association between major mental illnessand crime (including violent crime), but rather the connection occurs whensevere mental disorder is secondary to ASP and substance abuse.

It is not unlikely that both ASP and substance abuse are involved in the vio-lent behavior of the severely mentally ill given that ASP and substance abuseare very closely associated (Boyd et al., 1984; Gorton & Akhtar, 1990; Robinset al., 1991) and given that almost 90% of active psychotic episodes occuramong individuals with three or more lifetime disorders (Kessler et al., 1994).

Neurobiological Pathology

Figure 6 introduces to the model neurobiological pathology, involving ab-normalities in both brain function and structure, showing it as a causal influ-ence in severe mental illness and in substance abuse/dependence. Behavioralgenetics and epidemiological research support these causal links, with family,twin, and adoption studies providing strong evidence that genetic factors areoperative in schizophrenia, affective disorders, and alcoholism (Cannon et al.,1994; Kelty et al., 1994; Kendler & Silverman, 1991; Moldin, 1994); and withlarge community samples linking prenatal infections and specific insults suchas anoxia with the development of schizophrenia (Green et al., 1994; Mednicket al., 1988, 1994; Torrey et al., 1994). However, the exact mechanisms produc-ing the disorders have been difficult to characterize. Indirect pharmacologicevidence suggests neurochemical explanations; but even there, research hasbeen unable to identify the specific defects responsible for behavioral manifes-tations of psychoses (Csernansky & Newcomer, 1994; Martin et al., 1987). Anewer line of research is pursuing theories that structural brain abnormalitiesplay a part in vulnerability to schizophrenia (Cannon & Marco 1994; Csernan-sky & Newcomer, 1994). Although the available evidence shows that neurobi-ological pathology is causative, it also indicates that neurobiological pathologyalone cannot account for the disorders.

We add to our model in Figure 6 an arrow indicating that social disorganiza-tion, along with neurobiological pathology, is a causative agent in severe men-tal illness. affecting its development and course

2

(Cohen, 1993; Dohrenwendet al., 1992). Much research has shown that the prevalence of mental illness aswell as other forms of deviance is higher among conditions of poverty and so-cial disorganization (Barker et al., 1992; Faris & Dunham, 1939; Holzer et al.,1986; Leighton et al., 1963; Srole et al., 1962). Socioeconomic deprivation andthe cultural norms arising in such conditions have been offered as major expla-

2

Severe mental illness, especially schizophrenia, can cause an individual to lose social status and becomepoor as that individual fails to achieve higher education, maintain a high status job or even remain in thework force (Dohrenwend et al., 1992). But severe mental illness or schizophrenia among a few cannot causea community to fall into poverty and social disorganization. Because the social disorganization/poverty vari-able in the model is a community variable, no reciprocal arrow runs from severe mental illness to social dis-organization/poverty.


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nations of this relationship (see Kohn, 1972, and Wheaton, 1980, for links tomental illness through distrust, fatalism, coping ability, and effort). Stress the-orists have pointed to the chronic strain of social disorganization/poverty ascausal in producing stress; and they have shown how long-term economic andsocial deprivation may lead directly and indirectly through stress to greatersymptomatology and psychotic episodes in adults (Bruce et al., 1991; Catalano,1991; Cohen, 1993; Dohrenwend, 1990; Dohrenwend et al., 1992; Kessler, 1982;Pearlin, 1989; Pearlin et al., 1981). Recently, researchers have posited that bothcurrent and persistent poverty affect children as well as adults, demonstratingthe impact of poverty on children’s manifestations of mental-disorder sympto-matology (depression, anxiety, dependence, and antisocial behavior) throughthe detrimental effect of poverty on parental behavior (Avison, 1993; McLeod &Shanahan, 1993). Such childhood symptoms, though not indicative of majormental disorder and not set for life (Garmezy, 1991), place these children at adisadvantage as they go through life in coping with adverse conditions, includingthe likely continuing strain of social disorganization/poverty and any major neuro-biological pathology that may become active (Cohen, 1993).

Discussion and Summary

The dominant medical model’s focus on the individual in etiology, progno-sis, and treatment has influenced the description of the violence associatedwith mentally ill persons in both medical records and research reports suchthat it appears separate from the social context in which it occurs, separatefrom social and interpersonal interactions, and separate from the interper-sonal history of those involved. Although psychiatrists recognize that violentbehavior derives from causes other than mental illness (McNiel et al., 1992;Nedopil, 1994; Skodol & Karasu, 1980), the medical model’s individual focushas resulted too often in physically aggressive behavior being incorrectlyattributed to the mentally ill person, and resulted in the mentally ill person’slegitimate fears being incorrectly attributed to psychotic symptoms. Estroffand her colleagues (Estroff & Zimmer, 1994; Estroff et al., 1994) attempted tocorrect this state of affairs by using in-depth interviews of severely ill mentalpatients and their significant others. They found that mentally ill persons wereoften victims of violence by members of their close social networks and thatpatients’ high scores on a common paranoia measure were often based in real,violent, and threatening relations. Their findings are reinforced by studies re-porting high rates of victimization experienced by mentally ill persons, espe-cially abuse as children and from spouses as adults (Bryer et al., 1987; Carmenet al., 1984; Kessler & Magee, 1994; Rose et al., 1991; Winfield et al., 1990).

The final model presented in this paper links not only the immediate socialcontext but also the larger social environment with both major mental illnessand violence through the structured types of strains, events, situations, andpersons an individual experiences as an integral part of life. It posits that thesocial context is largely responsible for violence committed by individuals withsevere mental illness in shaping both their nonpsychotic behavior and theirmanifestations of active psychosis. For severe mental illness or even activepsychosis to lead to violence, social factors must intervene. Neurobiological


pathology may be the origin of severe mental illness; but social factors affectits course, manifestations, and connections to violence.

The final model does show severe mental illness propelling violence. It hasits effects through the active psychotic symptoms of threat/control overridethat develop in conjunction with suspicion/mistrust arising out of earlier vio-lence and victimization. But many more paths, all social and interactive, con-nect severe mental illness to violence, suggesting that severe mental illness iscoincidental to or indirectly associated with violence rather than being a directcause. Violence by severely mentally ill persons is often produced by the co-morbidity of substance abuse/dependence and/or ASP/psychopathy, which arethemselves caused by social factors. In other cases, violence arises out of tensesocial situations. The symptomatology of a mentally disordered person mayinduce the tense situation; but the violence occurs because one or more partieslearned from earlier experiences that physical aggression is an acceptablemethod of settling disputes and failed to learn alternative methods of resolu-tion. Tense situations turn to violent interactions because of the environmentof violence/victimization in which they occur, an environment more likely tooccur among conditions of social disorganization and poverty.

In concentrating on explicating violence-inducing social forces, the modelneglects moderating factors that should be considered in the production of vi-olence. Most notably absent are the demographic variables of age and gender,which have well-established relationships to violence (Grossman et al., 1995).Also missing are empirically verified mediators such as appropriate medication,psychosocial therapy, and supportive instrumental and emotional relationshipsthat can reduce psychotic symptoms, stressful events, and tense situations(Jerrell & Ridgely, 1995; Swanson et al., 1996b). Although these mediators areobviously affected by a community’s economic and social organization, theycan intervene to reduce the effects of social disorganization and poverty on anindividual with severe mental illness. Clinicians rely on these mediators intreating mentally ill persons; but the model suggests other interventions—bothclinical and extraclinical—for breaking the link between mental illness and vio-lence. Clinicians need to look for and treat substance abuse/dependenceamong individuals with major mental disorders. Clinicians would also do wellto work with patients and their families on coping strategies, particularly onconflict resolution and avoidance of tense situations. But the model points tothe need for preventive measures that reach beyond the clinic. Programsteaching prosocial skills and conflict coping for at-risk children and their par-ents hold potential for preventing violence. Finally, the model points to theneed for even more basic interventions such as family strengthening and com-munity building, which are required to overcome the social disorganization atthe root of the multiple links between severe mental illness and violence.

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Understanding the Connection Between Mental Illness and Violence