Part 2 in a series
In the media, we frequently hear reports of violent crime on the rise, the rampant use of excessive police force — particularly in minority communities — and, in general, overall an inaction to adequately protect marginalized people. All of this is further compounded by a severe global mental health crisis as the effects of the COVID-19 pandemic loom over us. In Part 2 of our blog series on the intersection of the mental health and criminal justice systems, we discuss violence and its relation to mental health stigma, treatment efficacy, and the ethics of involuntary treatment.
Starting with Stigma
Violence attributable to mental illness represents a very small proportion of overall societal violence. For example, in most studies the percentage of overall societal violence directly attributable to mental illness is less than 3 to 5%; this means that 95% of violence is due to non-mental-health-related factors.(1) Despite this, the media continues to bombard us with a biased and often sensationalized sample of those extremely rare cases where mental illness leads to extreme violence. This further increases mental health stigma, fear, and shame which, in turn, leads to further marginalization and victimization of the mentally ill.
Research shows that the stigma of mental illness is an insidious burden on those who suffer, their families and loved ones, and ultimately, on all of society. And we know that this burden is disproportionately greater for those in marginalized communities. In fact, mental health sufferers and their loved ones identify mental health stigma as the #1 barrier to accessing and adhering to mental health treatment. The fear and shame surrounding mental illness keep people from even talking about it, never mind taking action to do anything about it. And thus, a vicious and tragic downward spiral is perpetuated.
Compounding the issue of stigma is the reluctance by many well-meaning mental health professionals, ethics advocates, and “defund the police” movement proponents to actually acknowledge cases of increased violence by those suffering from untreated mental health and addiction. It is thought to be politically incorrect or further stigmatizing. But denial of this actual risk of violence despite overwhelming evidence to the contrary only prevents us from arriving at effective solutions. Simply put, if an important cause of mental health stigma is violence by the mentally ill, then failing to address actual violence only perpetuates the stigma.
How are competing ethical principles at play?
We discussed the history and political thrust of deinstitutionalization in our recent Open Mind Health blog, Part 1: The Policing of the Mentally Ill. Deinstitutionalization was a long overdue and necessary movement based on the fundamental principles of respect for individual autonomy and justice. The human rights violations within the walls of many mental health institutions were absolutely horrendous and wrought with horrible violence and atrocities. Unfortunately, abrupt deinstitutionalization as it was enacted did not effectively rectify the injustice or provide access to effective treatment for many suffering from mental illness. Critically, the investment of adequate resources did not follow them to the community and the streets where, more than ever, the mentally ill continue to be at risk of victimization and need protection — a fundamental right that ought to accompany a just society. We have fallen terribly short in providing vulnerable people with housing, food security, social supports, and motivational/treatment interventions to assist those struggling to adhere to treatment voluntarily. Instead, many have conveniently shifted the blame for violence perpetrated by the mentally ill on the mentally ill themselves.
Unfortunately, closing institutions and advances in medications have not adequately improved critical issues like a person’s insight into having a mental health condition and the need for ongoing treatment. There hasn’t been the much-needed fundamental cultural shift to accept responsibility and accountability for our society’s most vulnerable and marginalized, nor have any alternative solutions been created or enacted. Their problems are our problems.
Treatment + Support + Protection = Reduced Violence.
Treatment Effectiveness
Treatment is shown to be effective in reducing violent incidents among those suffering from mental illness and addiction. But access to effective treatment and support for treatment adherence is multifaceted. For example, medications like antipsychotics and mood stabilizers are effective at reducing violent incidents. Access to these medications, along with support for basic needs such as housing, food security, and social supports is also critical. Psychotherapeutic approaches can increase insight and treatment motivation. Unfortunately, not all people gain the requisite insight and adhere to treatment, often resulting in disastrous consequences. This is where interventions including legal leverage and assisted outpatient treatment (AOT) ought to come into play in order to ensure compliance and optimize outcomes. This is precisely when society’s responsibility and accountability ought to be greater, not less. Society is neglectful, possibly from ignorance but, quite frankly, it is callous to allow the most vulnerable and marginalized people to suffer and languish in undignified and inhumane circumstances — especially when they are not capable of acting in their best interests or worse are at risk of significant harm to themselves or others.
Treatment is an essential component to reducing violence, yet stigma is a barrier to accessing treatment.
Not all violence is the same
How do the police differentiate mental health-related violence from the vast majority of other violence? How do they address their own bias related to mental health stigma? How does the Blue Wall of Silence in police culture contribute to the lack of police reporting or intervention in response to marginalized people who are the highest proportion of victims of police violence? All good questions that require further understanding and solutions.
Police report a majority of their time is spent responding to calls related to mental health. Fortunately, we are seeing a trend toward integrating mental health professionals into police departments. But are these fundamental philosophies and principles of “protect and serve” really aligned with, or in contradiction to “law enforcement“ in North America?
Are we expecting too much for our police to make a judgment call in response to crises involving violent behavior? How do they differ in hostile situations with a quick assessment between the 3 to 5% of mental health-related violence and the 95 to 97% of that requiring a justice system response? In various situations “decision paralysis” can occur where they either over or under respond given their social context, bias, training, risk comfort, and fear. Police may vacillate between a “social work” response leaving the burden on health care and social systems to respond where a more appropriate justice response to serve and protect from harm (both victims and offenders) was more appropriate or the best intervention involves firm limit setting, boundaries, consequences, and even force. Understandably, there is an even higher degree of scrutiny on police and they may cite fear of actual or perceived violence as justification for their use of force and violence.
The solutions demand breaking down these silos, balancing broader access to and acceptance of treatment, and support and education for those suffering, their loved ones, and those tasked with “protecting” us all. A culture fed by the fear of violence only perpetuates instead of prevents violence. We also know that marginalized communities are disproportionately represented in the criminal justice system, especially as victims of serious police violence. The triad of having a mental illness and being marginalized and economically challenged all converge to further escalate tensions on multiple levels.
The solutions aren't straightforward but are achievable if we start actually addressing, understanding, and correcting the root causes of violence related to mental illness. A recent CDC report recommended the following four overarching principles in effectively addressing this critical topic:
Validate, normalize, and educate police.
Create a culture of dignity and accountability versus shame, fear, and avoidance.
Develop true individualized and active treatment interventions.
Address and reform the broken criminal justice, mental health, social services systems.
Co-authors:
(1) This does not include substance use, which significantly increases violence risk, alone and in combination with other mental illness.