Breaking the Cycle of Violence in Patients With Mental Illness

Jeffrey A. Lieberman, MD


March 05, 2018


Hello. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today for Medscape.

The title of my commentary could be called "Breaking the Cycle of Mental Illness–Fueled Violence," and it's prompted by the Parkland, Florida, mass killing that was perpetrated by a 19-year-old named Nikolas Cruz [on February 14, 2018].

This title really gets at the heart of what has been roiling America for the past several years: the social pathology of violence, particularly mass violence, when one individual kills numerous people—oftentimes random strangers with whom the killer has no relationship—for no particular reason.

This [latest mass shooting] is, in many ways, déjà vu all over again, something akin to the movie Groundhog Day, where Bill Murray plays a weatherman who relives the same events and day—Groundhog Day—over and over again.

Likewise, we as a nation find ourselves reliving and repeating the same things over and over again when one of these [mass shooting] incidents occurs. When some unspeakable act is perpetrated, the nation reacts with collective horror and shock at the obscene and wanton violence that has been perpetrated. People say, "This is terrible; this cannot happen again; we have to do something; this has got to stop now." The politicians weigh in, echoing their outrage and calling for action, and the media trumpets all of this across the airwaves and the Internet.

Then people default to their standard ideological positions with respect to gun control, mental illness as the problem, the need for more security in buildings, the need for more prisons—some quick fix that addresses some aspect of the problem but misses the root cause.

The root cause is not just violence but, more broadly, the way in which our country treats mental illness—our mental health care policies and services. In this sense, [the violence caused by people with mental illness] represents what I call the tips of the iceberg of our deficient, negligent mental health care policy.

Addressing Our Social Pathologies

Violence caused by people with mental illness is a social pathology that is similar to, but receives much more attention than, other social pathologies that accrue from a failed mental health care policy, such as the increased number of incarcerated individuals who have a mental illness, those who have addiction disorders, who are suicidal, or who have committed acts of domestic violence. These are the things that get people's attention but are the downstream complications or consequences of not addressing mental health care in the same way that we address primary public healthcare.

Nikolas Cruz is a 19-year-old kid who had a troubled past environmentally in that he was not raised by his biological parents and was transferred from foster home to foster home after his adoptive mother died. He had some constitutional and developmental limitations, but he also had manifest behavioral problems that were variably diagnosed. He had occasioned physical altercations and interactions with the police, and he underwent evaluations by different types of mental health care professionals.

It is not like [this shooting] happened out of the blue, yet nothing was done in any definitive way that really helped Nikolas Cruz substantially to prevent his [mental] issues from progressing until they welled up into this explosion of violence.

Obviously something is really wrong with our system. A lot of problems exist in our country and the world that are complicated and difficult, for which there may not be answers; however, this is not one of them.

Mental illness is a condition that is understandable, tractable, and solvable. It is not climate change; it is not terrorism; it is not distribution of wealth and poverty—all of which are very complicated, multifaceted problems that require a lot of analysis, thought, and further discovery of knowledge before they can be effectively solved. This can be solved. It is simply a matter of deploying resources to provide mental health care in an available and accessible way, and ensuring that they are competent, reasonably comprehensive, and affordable. I will come back in a moment to what exactly these might be.

The Relationship Between Mental Health and Violence

Violence, as a whole, is not something that we want to traditionally associate with mental illness. In fact, the standard refrain from advocates, mental health professionals, and consumers is that the mentally ill are more victims of violence than perpetrators of violence. If you look at all violent crimes in the United States, approximately 4% are due to individuals with mental illness.[1,2] Most crime has to do with robberies, greed, passion, feuds, gangs—lawlessness of various sorts.

If we restrict the type of violence to mass violence (which is very specifically defined) or intrafamily violence, we find that people with mental illness are overly represented in these forms of violence. In terms of mass violence, we have two main groups of perpetrators. We have people with mental illness who are largely untreated, presumably impelled by their illness. We have terrorism, which is ideologically driven, and there is some overlap in terms of how these things may exist. Then you also have instances where acts of violence are perpetrated, for example, by disaffected individuals or disgruntled employees. The first two are really the main groups. The number of untreated individuals with mental illness has been growing and accounts for probably the largest proportion of mass violence at this point.

It is very rare for [an incident of mass violence] to occur and for somebody who is mentally ill to engage in such actions, but when it occurs, it is shocking and unacceptable, and we all act surprised. Why should it be a surprise? It is a downstream complication of not having addressed this much earlier in a person's life and on a broader public scale.

A problem is not so much that we cannot do anything to prevent mass acts of violence but that we refuse to develop an enlightened consensus about what to do about it. Gun control clearly is something that would help and would be desirable, but we cannot deceive ourselves that this kind of thing does not occur in every country. People with mental illness who are not treated [do] become violent; however, without access to an automatic weapon, they use other implements - a knife, hammer, or some instrument that hurts one person as opposed to 20, 30, or 40 people.

Culture has something to do with the issue. Our permissive culture, which prioritizes individual freedom and the right of self-determination, does not easily allow medical professionals or law enforcement authorities to proscribe an individual’s behavior by requiring that he or she accept treatment, even if the person is acting in a manifestly [alarming] way, unless he or she poses an imminent danger to self or to others.

There is also the issue of where to treat these individuals and how to get them to treatment. These are implementation issues that need to be addressed, but contrary to what may have existed centuries ago, mental health care is effective and there are treatment options. The symptoms of mental illness can be alleviated. People can lead normal lives, or at least less disabled and disturbed lives, resulting in a lower frequency of the complications associated with mental illness, such as addiction, suicide, homelessness, or violence.

Addressing This Pervasive Problem

What are the solutions? I cannot give you a comprehensive plan, and even if I did, the likelihood of it being enacted would be very limited. I will mention some of the things that I think should be considered in trying to address the problem.

One is that there has to be a willingness to understand what mental illness is and a comfort level of the American people to recognize and to try and address it. What does this mean? We now have a policy of "see something, say something," which applies to terrorism as much as it does to [potentially dangerous behaviors of] mental illness. Another way of looking at this is that we are our brother's keeper, and if you see someone in distress, whether it is a family member, friend, or coworker, you should not feel shy, constrained, or that it is not your place to say something.

If somebody were choking, fainting, or sweating and flushing, you would ask if he or she is okay or if anything is wrong. If somebody is clearly in distress, is making no sense in what he or she says, or is intoxicated too often, you can ask if anything is wrong. What is the worst that can happen? The person might tell you to mind your own business or say that he or she is perfectly fine. You might be able to probe the individual in a way that helps to understand if there is in fact something happening that reflects mental illness, and then recommend that he or she see somebody, even if it is just his or her own primary care physician.

In addition, there need to be available and accessible mental health services. The first thing is to evaluate and diagnose possible mental illness, but there has to be a place where this can be done. Then there needs to be a way for people to be treated. This gets at the lack of available mental health care services and the fact that they are not always affordable. Also, some people are reluctant to seek services due to uncertainties or skepticism about psychiatry and the effectiveness of treatment, or because they do not want to be labeled and stigmatized.

In addition, [many] people have less understanding about mental illness than they do about physical illnesses, or, even if they do, they often do not know where to go for help. Those with mental illness might not be able to afford treatment, as their insurance is not always accepted. There needs to be a way to overcome these limitations. This includes creating outreach programs and being proactive in trying to make people aware of mental health care services and how to access them.

How can this be done? Apart from just trying to educate the public, it can be done by having mental health professional services available in settings that people normally frequent, such as schools. Youth is the "sweet spot" for many types of mental illness. There could be mental health professionals performing screening evaluations for individuals who appear to have problems. Also, primary care settings could be sites where one is examined not just from the neck down but from the neck up as well.

In addition, mental health care services could be sited at workplaces—employment settings. For many underrepresented, underserved minorities who have historical suspicions or aversion to traditional healthcare settings, we could meet them in the community—churches, religious institutions, community centers. This outreach is to try to engage people and provide at least an initial screening evaluation, with the possibility of referring them to a mental health care center where more extensive services are available.

There needs to be a policy, a plan for the types of services, and models for service delivery. There also needs to be funding for these services. In the aggregate, to do this, there must be a willingness to overcome stigma, skepticism of what psychiatry is and can do, and the value and effectiveness of mental health care treatments and services. To do this, we need to overcome this lack of awareness at best and this stigma and suspicion at worst.

This is the root cause of these violent, mass tragic incidents, and we should not deceive ourselves or allow people to purvey explanations such as that gun control or more security and background checks will eliminate this problem. These measures will help, but they are not the source of the problem.

By addressing the source of the problem, we will not just eliminate these heinous acts from occurring, but we will help a substantial portion of our population to have a better quality of life and less suffering, and to be more productive members of society. In the long run, that will be enormously valuable.

Thank you for listening. This is Dr Jeffrey Lieberman, Columbia University, speaking to you today for Medscape.


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