Saturday, December 15, 2007

Violence and Schizophrenia – Part Two

As previously discussed, and as confirmed by the comments received, Schizophrenia sufferers are often the victims of violent intrusive thoughts. But are people with Schizophrenia violent?

If your opinions are easily swayed by headline news then you would probably conclude that they are. I am aware that within the town I live in, stabbings and murder are far more common than I would like, but rarely – if ever – does it reach national news. The only type of killings that do reach national headlines are the ones that are particularly shocking in some way – a child perhaps; a whole family; or a murder committed by someone with mental health problems. Now there’s a headline.

With so much media coverage every time a person with mental health problems commits a murder, it’s no wonder that people think they are all mad, axe wielding murderers. In fact, as few as 50 murders a year in the UK are recorded as being committed by someone with mental health problems, compared to 1,300 suicides – when it is said that people with Schizophrenia are more likely to hurt themselves, it’s true.

95% of murders are committed by “sane” people. My guess is that of those 5% of murders which are recorded as being committed by people with mental health problems, many of them could have been prevented, and many of them would have been committed whether the person suffered from mental illness or not. Why do I say that?

It is a myth that people with Schizophrenia will suddenly “snap” and become violent. Uninformed (and even misinformed) individuals still believe that people with Schizophrenia have a split personality and will switch without warning between the two. Often people believe that whilst one of their personalities may appear “normal” the other is often psychopathic. The truth is that people with Schizophrenia only have a “split mind” in the sense that they are split from reality, with principle symptoms of Schizophrenia being delusions and hallucinations. If suffering from Schizophrenia was really the cause of a person committing murder it would be because of these delusions and hallucinations. The person would probably have a strong belief that he or she was acting in self defence, as many delusions include feelings of persecution.

It is thought that maybe only 1% of the 1% of people who suffer from Schizophrenia commit violent crime.

"True Figures" by Philippa King

Of course, with adequate mental health care this situation should be rare. Although symptoms can progress quickly in a person with Schizophrenia, we are talking about a matter of days or weeks rather than minutes or hours. Before a person ever deteriorates to the point of acting on their belief that they have to kill in order to protect themselves or their family, the deterioration should have been recognised and intervention should already have taken place.

But as I said earlier, many of those murders which are committed by people with mental health problems may have occurred anyway. A diagnosis of Schizophrenia, or any mental illness, does not define a person or their personality. Like any other illness, Schizophrenia is indiscriminate and can affect people from all walks of life, different upbringings, and different personalities. It stands to reason then, that with as many as 1 in every 100 people suffering from Schizophrenia, at least some of them will have a criminal mind. Add to the equation the fact that illegal drug usage can induce Schizophrenia, and it’s easy to see that many of those murderers could already have been on a criminal path even before the onset of their illness.

Obviously, the job of their solicitor, if the crime is undeniable, would be to negotiate the shortest prison sentence possible, and if that means playing on a persons mental health – whether relevant or not – they will do so.

So taking these things into account, I wonder what the true figure should be of those who commit murder because of their mental health. And how many more could be prevented? Also, are we really in more danger of being murdered by a person suffering from Schizophrenia – whose condition should be closely monitored by a Community Mental Health Team – rather than your average bad tempered driver, a group of drunken youths, or even that friendly and polite neighbour of yours who hides bodies under the floor boards?

Related Posts: Violence and Schizophrenia - Part One, Violence and Schizophrenia - Comments from Readers


Anonymous said...

Schizophrenics are more afraid of hurting people then regular people are.

Mr Mans Wife said...

Hi Doc, welcome to my blog and thank you for the link.

You make an interesting point and no doubt you speak from your own experience. Regarding the violent intrusive thoughts, Mr Man said that although he feels awful for having such thoughts he doesn't fear that he may act on them.

I'd be interested to know how other readers feel about this.

Thanks for your comment Doc.

Slurry said...

I never think I would act on them, but they cause great distress, and I wonder why my head does this to me? I dont like swatting wasps, let alone harming a person, its just not me at all.

Angela said...

I keep trying to write a comment and deleting it again because I don't think I'm making any sense.

A really interesting couple of posts that have got me thinking. Despite what the media might like us to think I have never considered that someone with schizophrenia would be more incliend to violence than someone without.

It's also got me wondering about whether people without schizophrenia, or other mental illness, also have intrusive thoughts. Thoughts like you have described aren't something someone would want to admit to. Also, at what point do they change from being violent, unwanted thoughts outside of a person's character to intrusive thoughts. Is there a distinction?

I know I'm rambling a bit here but it comes from this: I have had violent thoughts, thoughts of commiting violent acts, that are entirely out of character, and that I would never act upon. That are disturbing, unwanted and seem to "pop" into my mind from apparently no where. I would not say that I am mentally ill at present (though have been unwell in the past) but they sound similar to the intrusive thoughts that you describe. I have never admitted to or described these thoughts to people for fear of sounding "mad" or dangerous. But your post has got me wondering if perhaps intrusive thoughts affect people without mental illness, perhaps to a lesser degree or with a lesser degree of anxiety or fear? Or perhaps not a lesser degree at all.

Rambleramble. At this point I'm quite glad no one who knows me in my real life will read these comments. Particularly in my line of work, it's not the sort of thing I feel I should be admitting to.

Mr Mans Wife said...

Thank you for your comments Angela; they are very interesting.

You ask: at what point do they change from being violent, unwanted thoughts outside of a person's character to intrusive thoughts?

I think everyone experiences thoughts from time to time that would normally be out of character for them, and it’s normal to experience a measure of guilt or to feel disturbed by our own ability to think in such ways.

I’m no expert, but I think the key point is that many people who experience intrusive thoughts describe them as being inserted into their brain as if from an outside source - so foreign are the thoughts to them. It's really this description that makes me wonder if they are connected to hallucinations in some way, and of course in some cases they are accompanied by hallucinations.

Also, there seems to be an inability to “switch it off” and think about something else. Perhaps it is this that causes the heightened anxiety and fear as there is no escape from these thoughts.

It would be interesting to read other reader’s comments on this, and of course Doc’s point raised earlier.

Thanks again Angela. Please, ramble as much as you like :)

Mr Ian said...

Since 1992 violence and mental health has received a more inquisitive mind-set of the MH services.
A brief look at the Zito trust website can explain more

However, this extract from Behind Closed Doors (available on that site) surmises much of the current issue:
"The problem of course is that those who pose a danger to society represent only a tiny fraction of people with mental illness, while many others may find themselves the victims of a system that is ‘taking no chances.’ "

I agree with the understanding that 'intrusive thoughts' are an issue that lead to further distress that the person needs to offload (to prevent further distress or repetitive thinking).
Unfortunately, the reality is, that "once bitten, twice shy" (or more politically correct: risk assessment/risk management) has long been the battle-cry of the MH services since Jonathon Zito was killed by a 'service user' who was poorly monitored/supported.
MH services have fallen further into a litigious and parentally defensive mode that does not allow MH staff to disregard or minimise (or even rationalise) any statement of intent or thought of harm without providing a "risk management strategy". Such a strategy is usually based on restrictive monitoring/access/leave/etc and can do more harm to the person's feeling of trustworthiness and 'safety' than actual good. It's the care vs custody dichotomy really.
As a MH nurse I have been faced with this dilemma many times, even before the Zito Trust came into being. As example of 'risk' (rather than intrusive thoughts) I proffer this scenario; a self-harming woman disclosed that she brought a carpet blade into the unit with intention to 'top herself' while away from family. She'd been thinking about it all weekend. I was able to accept her telling me her story, hand in the blade and support her to let the feeling/thought pass; but I got stuck at the part where she told me she'd rather I didn't tell the other staff because they'd stop her leave or would do some other restrictive measure. What pressure that put on me was, especially as a student nurse, as stressful as some of the issues some people end up in hospital for!
It is a hugely dichotomous area for all concerned; the 'patient' who has the intrusive violent thought needs to talk it out, but without fear of being vilified for the thoughts. The practitioner needs to preserve the integrity of any therapeutic relationship, provide supportive solutions yet also needs to 'protect' the interests of anyone identified (imagining that the person has stated the thoughts involve harm to a particular person - any inquiry would severely question why action was not taken to prevent the notified potential harm of taking place if it subsequently did); and the rights of the individual to whom potential threats have been made, when such disclosures may breach confidential trust.
It is not possible to 'judge' the realistic probability of something happening or not. And when it comes down to balancing potential harm; the patient does tend to come second if that harm may indicate something fatal or severe.
There certainly needs to be more understanding of the nature of intrusive thoughts, and especially on the predictability of that thought becoming an action. Currently there is only anecdotal evidence, sweeping generalised 'risk assessment' tools and a pressing management policy that prevention is better than any other option.

In regard the myth of the "snap" theory, I agree. It never comes unannounced. It frequently goes unnoticed or unattended tho. I have worked with violent mentally disordered offenders for several years now. What you say is true and accurate from my perspective also; that the true cause of the violent act being purely in psychotic reasoning is pretty rare. Often it is increased in probability by prior personality, intellectual or environmental influences; or is more to do with those predisposing/predictive factors and not psychoses at all. Most people with psychoses harm themselves before other people as they still maintain their moral reasoning that it is wrong to hurt others. Those that do harm others, only do so because they feel they are severely threatened, regard it as the best/only option for their dilemma, or they have a delusional belief that such behaviour is 'ok' (once nursed a guy who stabbed a horse guardsman in the leg because it was an act of mutual bonding and honour that the guardsman would have understood. The guardsman concerned disagreed in the form of a 3 foot sabre sword at the time).

As for an answer to the dilemma... I see little alternative to the present situation other than more open and honest disclosure between all parties. That is, if, in the instance of violent intrusive thoughts, the person is more afraid of the thoughts and the content because s/he knows it is not him and wants to deal with them - collaborating to some form of 'risk management' with the team and other supportive members and open regular feedback would be more beneficial than merely restricting movements or behaviours. If the person feels that they still have some form of control or authority in their care/treatment they are more likely to feel it as beneficial.
However, feeling they have to keep them pushed down can lead to more stress and further problems.
My emphasis is always on support first, agreed controls (collaborative risk management - which need not be 'restrictive' but may include increased monitiring/discussions) second and, as final resort, restrictive measures. However, I always (have to) err on the side of caution depending on the severity of potential harm to another person.

Mr Mans Wife said...

Hi Mr Ian, thank you for your comments.

I really appreciate having some input from someone who has worked in Mental Health for so long.

I found your comments about risk assessment interesting. I fully appreciate that not enough is understood about intrusive thoughts, and therefore precautions need to be taken to prevent possible risk to others, even if this simply means additional monitoring. I agree that the emphasis should be on support first.

Where were you when Mr Man was in hospital?! He received no support, and no collaborative risk management - he was just simply told he wouldn't "get away with it"!! He was regularly sent home for home leave, no matter what his state of mind was - whether he was suffering from intrusive thoughts or command hallucinations, and even when he had self harmed and made a serious suicide attempt.

If only all MH nurses were blessed with your common sense.

mental health said...

Interesting article , this article make some interesting points.

Mental Health web

Mr Mans Wife said...

Thank you Mental Health.

The website you link to looks very useful for those who live in the US. Thanks for leaving the link.

Anonymous said...

I have been reading your journal with interest and after some time have decided to post a reply to this thread.

On the topic of intrusive thoughts my guess is that we all have these and from time to time they can be elaborate explicit and violent but a filter or whatever prevents us from taking these fantasies and enacting them in the real world. If this were not close to the mark I fail to understand the attraction that violent films and latterly computer games have for a large proportion of the population. In fact, children may reenact what they have seen but as play rather than through real aggression.

I am reluctant to continue this post as I believe it will be unpopular with the non sufferers of schizophrenia and those with the illness who read this blog. However my opinion is as valid as anyone elses and deserves to be considered.

A small percentage of people with serious mental illness are capable of the most appalling violence. I know of no way to differenciate those who will go on to kill and those who will not. I believe that by claiming that there are far worse dangers out there you are bordering on denial. There are many dangers out there, far more people are killed by the sane than the mentally ill but a percentage of schizophrenics will go on to kill.

Even a small percentage is significant, I personally know of no one who has been killed by a seriously mentally ill person. I have however been stabbed over a prolonged period by one and am lucky not to be one of the statistics I feel some would rather ignore.

Mr Mans Wife said...

Anonymous, thank you for your comments. As you so rightly point out, your views are as worthy of consideration as anyone else's, and as your views are likely to be shared by others I have decided to reply in the form of a blog post.

Thank you for taking the time to comment.

GJD86 said...

I am currently studying in my final year at University and have undertaken an optional dissertation with the working title of “Is there a link between schizophrenia and serious crime?” I was just wondering if anyone had any good sources from where I can look at studies and facts around this topic area. Any help would be greatly appreciated. Thank you.

Mr Mans Wife said...

Hi GJD86, I recommend that you visit the Mental Nurse blog and ask for help there, as I believe some of the contributors actually teach, and some of the others seem to be very keen on reading studies. They may be able to point you in the right direction.

Thanks for visiting. I wish you well with your dissertation.

Anonymous said...

I wish I could say I agree with the statement that it's a myth for ALL schizophrenics to be violent. My soon to be ex-husband beat the crap out of me one night because he was convinced that I gave his thoughts to Bill Cosby! Or how about the time when he thought that my unborn child was a 'bad seed' and trapped me in a tub full of water because he just knew that I had been hunting him down for YEARS to trap him. Or the time he destroyed our marraige license....

the list goes on. You got lucky. But your blanket statement doesn't apply to all.

Mr Mans Wife said...

Thank you for your comment Anonymous. I appreciate you sharing your experiences.

I'm sorry that you have had such an awful experience, but I stand by what I said that it is a myth that all people with Schizophrenia are violent. However, it's not a myth that some people with Schizophrenia are violent. But it is wrong to presume that someone could be violent based solely on their diagnosis of Schizophrenia.

Whilst it's true that some people with Schizophrenia commit violent acts due to the level of their psychosis, I also feel that some people use the illness as an excuse. This gives people the wrong impression that violence in Schizophrenia is more common than it is. Even so, the statistics speak for themselves, and the number of those with Schizophrenia committing violent acts is relatively low.

I hope your bad experience doesn't affect the way you feel about all those suffering from mental illness.

Thanks again for your comment.

Anonymous said...

I feel we need to remember that this is on an individual basis. I too have lived with a schizophrenic husband. His hallucinations included God "telling" him to slay the wicked, among other things. This was not constant and pervasive, mind you. But even at the infrequent intervals that this did occur, it was still very serious. It took all the powers of persuasion I could muster to get him to check himself into the psych ward until he was stabilized.

We also need to remember that schizophrenics, in general, do not deal well with caring for a family as it increases their stress levels. When they are stable they can care for themselves, mostly, and perhaps one other person. You push beyond that two person limit and you will see the effects of daily life begin to wear them down. Their "odd" social behaviors become intensified and more frequent. I do not feel that extensive family life is in their best interest.

I have done much research myself for years on end hoping to help him. This was to no avail. I finally decided that it was not his fault he had schizophrenia. But it wasn't my fault either. And I ended it. I respect other people's decisions as we need to do what we feel is best.

As I said: Keep their stress to a minimum as when stress is present their medication will not bond to the receptor no matter how much they take and will just free float doing nothing. You can do a temporary add in med to help stabilize this until the brain chemistry is able to use the medication as it was intended.

Perhaps it is best that most schizophrenics tend to shy away from extensive social connections as this will definitely add to their stress. I believe that if you look at the percentages of schizophrenics whose families push them to function "normally" there is approximately a 26-30% violence rate. Hence why they are better off living alone or perhaps with one other person. I think this number speaks for itself and correctly corresponds to my past daily experience as well as the all of the information I have extrapolated.