Violence and Mental Illness: An Uncomfortable Subject But A Grim Reality For Some Families

Public fears of violence on the street by discharged (mental) patients who are strangers to them is misdirected. The people at the highest risk are family members and friends who are in their homes or in the patient’s home.

(6-23-16) In a study released this week, the Treatment Advocacy Center investigates a subject few like to discuss: family violence, specifically homicides committed by persons with mental illnesses. 

Because of stigma, we always begin every conversation about violence by explaining that individuals with mental illnesses are no more violent than the general public and, in fact, are more likely to become victims than perpetuators.

And that is exactly how the authors of RAISING CAIN: The Role of Serious Mental Illness In Homicide begin their 48 page study.

But they quickly explain their rational in writing about murders committed by persons with mental disorders:

It is…politically incorrect to study the relationship of family homicides to serious mental illness, especially in the United States, where the concept of “recovery” is the dominant theme in writing about individuals with mental illness. (But) …it is not discourse about family violence and homicides that is a major cause of stigma against all people with mental illness; rather, it is the family violence and homicides themselves. Until we confront the causes of family violence and homicides directly,  the stigmatization of persons with serious mental illness will continue to be an enormous problem. Yet, to ignore that a small percentage of persons with mental illness can be violent seems disingenuous.

This reasoning should not surprise anyone who is familiar with TAC, which is one of a few advocacy groups that speaks openly about violence. What did the authors of the report find:

To summarize it briefly:

• This is the first study of the role of serious mental illness in all family homicides.  There are approximately 4,000 family homicides in the United States each year.  Individuals with serious mental illness are responsible for 29% of these, or approximately 1,150 homicides.  This is 7% of all homicides in the U.S.
• The role of serious mental illness varies depending on the family relationships.  Approximately 67% of children who kill their parents are seriously mentally ill. Only 10% of spouses who kill their spouses are mentally ill.
• Although total homicides have decreased markedly in the U.S. in recent years, there has been no decrease in the number of children killing parents or parents killing children, the two types of family homicides most closely associated with serious mental illness.
• Women are responsible for 11% of all homicides in the US but 26% of family homicides.
• Elderly family members, especially women, are disproportionately victimized.  Among all homicides in the U.S. only 2.2% of victims are ages 75 and older.  In a media sample of 2015 family homicides, 9.2% of the victims were age 75 and older.
• Guns are used as the weapon in less than half of family homicides.
• The failure of individuals with serious mental illness to take their medication and their abuse of alcohol and drugs are risk factors for family homicides.
• The majority of family homicides are preceded by warnings and threats that are often ignored. The adequate treatment of individuals with serious mental illness would prevent the majority of family homicides associated with serious mental illness.  

In addition to its own statistical extrapolation, the TAC report cites at least four other studies of violence and families including a one funded by the MacArthur Foundation where researchers followed 1,136 psychiatric patients for one year after their discharge from a hospital. (Quote at beginning of this blog post is from that study) Also, a 1991 survey by the National Alliance of Mental Illness that found 11% percent of the families reported a mentally ill family member had physically harmed a family member or another person in the past year; another 12% of their loved ones had threatened to do so.

In addition, the TAC report quoted from an online survey carried out in 2014–2015  based on 573 completed questionnaires from families with an adult relative with a psychiatric disorder. In 84% of cases, the diagnosis of the relative was schizophrenia, bipolar disorder or major depression. In 22% of the cases, respondents had been the victim of violent acts by their mentally ill family members within the previous six months. In 14% of cases, the violent act was categorized as minor (e.g., battery without the use of a weapon, not resulting in injury); in 8% of cases, the violent act was categorized as serious (e.g., battery resulting in injury or involving a weapon). In viewing the results of their own as well as previous studies, the TAC authors concluded:

The results of this study, in combination with sparse research previously conducted, suggest that 20% to 35% of persons with high levels of contact with a relative with psychiatric disorders have been the victim of violence committed by their relation with psychiatric disorders in the past six to 12 months.

Because the Raising Cain report was undertaken and issued by TAC and its primary author is Dr. E. Fuller Torrey, those who oppose Assistant Outpatient Treatment will quickly dismiss the study. And, not surprisingly, TAC uses the study to buttress its call for more use of AOT to reduce violence.

But violence within families and violence toward mental health providers and caregivers is an issue that needs to be addressed, not hidden, and TAC deserves credit for raising it. The question is how to best reduce the threat of violence, especially since the TAC report and previous ones conclude that there are ample warning signs before violence happens.

I found the citations in the TAC report from other studies useful. Such as a Canadian study that found 85% of the mothers and 62% of the fathers had a “psychiatric motive” for their crimes when they murdered their own children.  TAC’s report adds examples — beyond Andrea Yates-–  that happened in 15 states. All are horrific and sad.

Florida: John Jonchuck, 25, diagnosed with schizophrenia, was charged with killing his 5-year-old daughter by throwing her off a bridge. He believed that there was a conspiracy against him and was found to be not competent to stand trial..

When it comes to children killing their parents, TAC recites the well-known story of Robert D. Joe Bruce whose son, Will, murdered his mother after being coached by an advocate on what to say to be discharged prematurely from a state mental hospital in Maine.

Based on the existing studies, it seems reasonable to estimate that at in least two thirds of homicides in the United States in which a child kills a parent, the offender had a serious mental illness.

The report cites examples from 17 states of children murdering their parents before turning attention to the next depressing category: spouses killing their spouses, followed by siblings murdering siblings.

Finally, TAC discusses non-fatal attacks:

The killing of persons by mentally ill members of their own family is an ongoing tragedy. The true tragedy runs even deeper than that, however, because these homicides are merely the visible tip of the iceberg; the other nine-tenths of the consequences of family violence lies below the surface. Nonfatal injuries caused by mentally ill family members are relatively common.

Dr. Torrey adds a personal touch by describing how his sister, Rhoda, who had been diagnosed with schizophrenia, attempted to kill their mother. (The other authors of the report include: Robert Joe Bruce, Dr. H. Richard Lamb,  Carla Jacobs, D.J. Jaffe, and TAC Executive Director John Snook.)

TAC’s report ends with six recommendations:

1. provide adequate psychiatric treatment.
2. ensure that prescribed antipsychotic medication is actually taken.
3. use assisted outpatient treatment.
4. reform the federal HIPAA regulations.
5. focus on the individuals with the most risk factors.
6. improve data collection and research.

Reading the report was a grim reminder of how families are most in danger when someone is psychotic and turns violent. The report also reminded me of how foolish we are in our country to not get people meaningful help before they become so sick that violence happens. Remember, in nearly all cases, there are warning signs. I would be curious how large of a factor our legal standard of requiring an individual to become a danger to himself/herself or someone else before intervening plays in these tragedies.

How many individuals with mental disorders and their families have found our current mental health system completely unresponsive until someone becomes dangerous only then to discover that it is the police and criminal justice system that responds to what should have been dealt with much earlier as a medical crisis?