After Aurora, Questions About Mass Murder and Mental Illness

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RJ SANGOSTI / AFP / Getty Images

James Holmes appears in court at the Arapahoe County Justice Center in Centennial, Colo., on July 23, 2012

With the recent revelations that alleged movie-theater shooter James Holmes had been seeing a psychiatrist prior to carrying out the July 20 massacre in Aurora, Colo., questions about the link between violence and mental illness have risen once again: What are the root causes of seemingly random violence? Does mental illness provoke it or predispose people to harm others?

Advocates for the mentally ill are faced with a deep dilemma each time extreme and deadly crimes are perpetrated by those with a mental illness. Obviously, such acts are not sane or normal; it beggars common sense to suggest that a person who is thinking straight would choose to kill or wound dozens of strangers. And yet most mentally ill people — even those with conditions that have been linked to violence, such as addictions and schizophrenia — are no threat to anyone other than themselves.

So how can we understand who is at risk for becoming violent without increasing the stigma associated with mental illness, especially when that stigma may account for a large part of the association between the two? Some data may help: people with schizophrenia — a disorder being studied by the psychiatrist who was treating Holmes — are roughly twice as likely to be violent as those who do not have the disorder, according to a 2009 review of research. People who have schizophrenia and a substance-use disorder are at even greater risk: they have a nine times higher risk of violence than people with neither disorder. The association is especially marked for homicide: those with schizophrenia are nearly 20 times as likely to kill another person as people unaffected by the disease.

However, the majority of people with schizophrenia (about 1% of the population) never commit acts of violence. A 2011 review of data on people who had suffered a first episode of psychosis — which is often a sign of schizophrenia (though psychosis is also associated with severe depression and amphetamine or marijuana misuse) — found that 35% had committed some type of violent act. That means that nearly two-thirds were nonviolent. Further, of those who did become violent, fewer than 1% had committed violence severe enough to result in hospitalization or permanent injury.

(MORE: Viewpoint: The Overwhelming Maleness of Mass Homicide)

When looking at the rates of violent crime overall — homicide, for instance — the best estimate is that 5% to 10% of murders are committed by people with mental illness. But a far larger proportion of mass homicides, including the brutal July 2011 attacks in Norway, the Tucson, Ariz., shooting that wounded Congresswoman Gabby Giffords and the Virginia Tech massacre in 2007, involve perpetrators with mental illness. The proportion far outstrips the rates of mental illness in the population.

So what leads one person to violence but not another? In some cases, it may be the stigma of mental illness that provokes it, by exacerbating existing symptoms of delusion, disconnection from reality, social withdrawal and lack of emotion. A rare insight into the mind of a patient with schizophrenia comes from a former academic who wrote anonymously about her experience with social stigma from her disease (via writer David Dobbs at Wired). “N” writes:

I was diagnosed with schizophrenia just a month after Steven Kazmierczak (quickly identified as “schizoaffective”) shot six people to death on the campus of [Northern Illinois University] … Undoubtedly primed by this shooting, wary, uncertain, without enough time to think, my doctoral adviser suspended my graduate assistantship, banned me from the university, and alerted all faculty, graduate students and staff to forward all emails [from me] to her and, under no circumstances, respond.

N writes that her adviser had been operating under the wrongheaded assumption that she was planning to plant a bomb on campus. Although the decision to suspend N’s position was reversed within a week, it triggered a downward spiral that ultimately resulted in her expulsion. She writes:

Friends — my doctoral cohort, as is often the case, were a close and tight-knit group — abandoned me overnight. Students and faculty passed me in the halls, staring ahead blankly as if I were an undergraduate they had never seen and would never see again. Parties were announced, talked about, and I was never invited. Never again.

The social rejection worsened her disease and she became afraid to interact with people, eventually ceasing to attend classes and campus functions:

For a while I struggled through classes, overwhelmed, perhaps in equal measure, by delusions and this new and unprecedented isolation. Voices took the places of both professors and friends. Following a hospitalization (and consequent withdrawal from a semester’s worth of classes), I descended into a state of the most stunning dysfunction, unable (or simply unmotivated) even to walk from my bed to the bathroom.

(MORE: James Holmes Might Be Crazy but Not Legally Insane)

After a review by an academic committee, during which her formerly trusted professors said they saw no chance that she would ever succeed, N was dismissed from her program. She broke down:

Me: Everything I have ever been told was a lie. My one way out — of poverty, desperation, madness — was never more than an illusion. And then disbelief. And then, how will I ever explain this to anyone, to family, to old mentors? And then betrayal. No language this time, no thoughts; crying, crying for hours. Alcohol, unconsciousness, unbidden dreams.  Even there: repeating their words, over and over and over again. Isolation so intense, there is no way I will ever bridge it. I am lost. Days go by, weeks.

Eventually:

I fixated on a single vision, me, sometimes hanging, sometimes with gun in hand and a pool of blood on the floor, outside [her former adviser’s] office. Suicide, yes, obviously, but also something more: revenge.

Although N did not plan a mass killing, she writes that she understands how someone in Holmes’ situation — a former academic superstar and Ph.D. student in neuroscience, who had withdrawn from his program in June after a reportedly dismal performance on an oral exam — might have become so unhinged.

(PHOTOS: The Movie-Theater Shooting in Aurora, Colo.)

Dobbs points out in Wired that outcomes for people with schizophrenia may depend heavily on the patient’s cultural milieu: research conducted in the 1970s by the World Health Organization found that while 40% of people with schizophrenia in industrialized countries had severe impairments, less than a quarter of those in the developing world did and that over time, the disease followed a less devastating course in countries without advanced medical treatment.

The difference appears to rest on whether the larger culture views the disorder as a permanent affliction that destroys the person or, by contrast, as a brief possession by bad spirits. In the latter case, families and friends tend to accept affected people, letting them marry and work. (Of course, people with schizophrenia who live in cultures that stigmatize and reject those afflicted by bad spirits may get the worst of both worlds.)

Later studies have shown that medical treatment does improve outcomes in people with schizophrenia — indeed, appropriate medical treatment in the West has been shown to essentially eliminate patients’ risk of violence — but it’s clear that social support and the cultural environment clearly matter, not only when it comes to violence perpetrated by the mentally ill but also to violent crime in general.

As Eric Michael Johnson writes for Scientific American, the biggest contributor to homicide in the U.S. is not mental illness, addictions or even the accessibility of guns. It’s economic disparity: the wider the gap between the rich and poor, the more violence a population breeds. Describing an analysis of homicide rates in 50 states conducted by Harvard’s Ichiro Kawachi, Johnson writes:

The results were unambiguous: when income inequality was higher, so was the rate of homicide. Income inequality alone explained 74% of the variance in murder rates and half of the aggravated assaults. However, social capital had an even stronger association and, by itself, accounted for 82% of homicides and 61% of assaults. Other factors such as unemployment, poverty, or number of high school graduates were only weakly associated and alcohol consumption had no connection to violent crime at all. A World Bank sponsored study subsequently confirmed these results on income inequality concluding that, worldwide, homicide and the unequal distribution of resources are inextricably tied.

In other words, the connections we have to one another — our social capital, our ability to seek and receive support from others — is the most important weapon we have against violence. These connections are put at risk when economic inequality rises. Studies show that social cohesion and trust drop when disparities between the rich and poor rise. Since markets rely on trust to function smoothly — and since distrust can provoke political paralysis and polarization — a vicious cycle can ensue.

(MORE: How Economic Inequality Is Literally Making Us Sick)

For the mentally ill, who might be seen as canaries in this coal mine, stigma serves to wall them off from the social support and medical care that are necessary to spur recovery and prevent illness from leading to tragedy. As a society, we need to understand that risk does not equal destiny — and that believing it does is a self-fulfilling prophecy. It’s not wrong to see schizophrenia as a disease or even to appreciate its association with violence, but to view people with schizophrenia as hopeless can in some cases worsen their course unnecessarily.

Indeed, the greatest individual risk factor for violence is not mental illness but gender — another characteristic over which people have no control. Schizophrenia doubles your odds of becoming violent, but being a man multiplies your risk by a factor of nine. Yet we don’t stigmatize or reject men for this risk factor; similarly, we shouldn’t treat the mentally ill that way. To prevent future catastrophes, we need to understand the range of cultural, social and medical factors that affect us all.

Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland’s Facebook page and on Twitter at @TIMEHealthland.

64 comments
trimeldamcdaniels
trimeldamcdaniels

People have been poor for centuries. In the USA the majority of people in America were very poor for many years. They also had guns for hunting and defense. Yet there were no spontaneous break downs of people into homicidal violence. If poverty was the cause of violence where people shot folks and then shot themselves, then why haven't we seen this before now?


I grew up in a ghetto. I never saw anyone run through the "hood" shooting people spontaneously. That STILL doesn't happen. How many spontaneous shootings happen? None. Lots of guns. Lots pf poverty. No school shooters. Why not, if poverty and guns are the cause of these shootings?


Don't think so.

tinker6
tinker6

People seem to make many names for disorders, but I believe most fall under "the special ones", that don't need to respect and learn in life what others have had to do as being human, as well as pass on the knowledge to their off spring, instead let strangers deal with them and whatever despair is brought forth. 

Then you have laws that are irresponsible, lawyers that want to collect more than money from the innocent, believe that is a good start for the 2 billion human reduction.

Majority of the old attitudes expected sometimes more from another, or was it the whines of the other that created the gaping hole in humanity, try saying bless you these days with non attitude, people will swear your killing them and most likely call on their gang or lawyer, be open minded and your rendered as one that creates the problems of the world, seriously though how many ways is there to wipe an ass, "Oh"  I'm not interested, even though you think it's my place to serve the problem, so I must have become non empathetic now.

An easy answer to the 2 billion problem, for the whole of humanity not the hole.

Depending on the religion, it could be the egomaniac of no resolve. )o( not for everything.


MarcShakter
MarcShakter

Mental health care is in it's infancy and it's foundation of "scientists" is a bunch of egomaniacs and drug addicts... What do you really expect to happen when the inmates run the asylum?

Paulpot
Paulpot

End the drug war and there will be a significant decrease in gun violence across the America's.

michaelkad
michaelkad

Income inequality, Mental Health Care and the lack of an adequate social saftety net are in that order, the primary causes of gun violence in the United States. Access to weapons and the size of a magazine is farther down the list of causes. We need to address the root causes of gun violence, starting with  the most important causes first. But the media and the politicians don't even discuss the larger problems first. They focus on one of  the least contributing factors, gun control. This means that they are not serious about solving the problem. Sad.

EN66
EN66

I love how the perfectly detectable but largely untreatable condition of clinical psychopathy is not discussed here and instead people with schizophrenia –that can be managed with a variety of treatments and is rarely violent– are blamed. Nice job propagating the stigma!

Jeff Nasser
Jeff Nasser

HE IS A MURDERER!! HE KILLED  14  OF OUR PRECIOUS BROTHERS AND SISTERS. IN DEATH THEY ARE TOO WEAK TO DEFEND THEMSELVES. I HOPE HE GETS THE DEATH PENALTY---BUT I AM NOT THE DECIDER OF THAT GOD WILL.

RMG2446
RMG2446

It's time for us to figure out how society can ensure that those who are on medication for a psychosis actually are taking the medication.  The recent mass murders involving mental illness appear to have something in common - the killer wasn't properly taking his medication so the psychosis wasn't being treated.  

Kathe Skinner
Kathe Skinner

Is the alleged schizophrenic,  diagnosable as personality disordered - Schizotypal or Schizoid, or both? It would seem that defense activities are already in gear to present an insanity defense although I don't know that I'd buy that.  Other mass murderers haven't been deemed "insane", even after eating their victims.  What we would term "insane" does not necessarily meet the criteria set by the law or mental health definitions as set forth by the DSM-IV TR.  The writer ought to be very careful with the term "sane" when talking about mental health issues and stigma.  Stigmatizing those who are truly insane has nothing at all to do with Aurora.

USMC76
USMC76

OUR SOCIETY HAS A WAY TO PUSH OTHERS OVER THE ***EDGE ***AND ASK WHY ?  THE WAY PEOPLE ARE TREATED BY THE WELL TO DO >>CAN YOU BLAME THEM >>WHEN THEY HAVE NO WHERE TO DEFENDE THEMSELVES  FROM  BULL SHIT

Do Dock
Do Dock

In fact the 2009 review cited in the article states ""The data on medication adherence has reported associations with violence in naturalistic studies [68], but a recent analysis of the Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) trial data for violent outcomes found no overall association with violence [69]."

Do Dock
Do Dock

"Later studies have shown that medical treatment does improve outcomes in

people with schizophrenia — indeed, appropriate medical treatment in

the West has been shown to essentially eliminate patients’ risk of

violence —    "

I find this paragraph strange. Unlike the rest of the article no sources are cited for this extraordinary claim. And it's not true because studies, even with big pharma behind them, have failed to show that antipsychotics necessarily prevent violence in those with a risk.

Harold Maio
Harold Maio

"The" mentally ill?

Is your intention the same as earlier  "the" Jews? "The" Blacks?

---Advocates for "the mentally ill" ---are faced with a deep dilemma each time extreme and deadly crimes are perpetrated by those with a mental illness.

I cannot say I am an advocate of  --"the" mentally ill --, the form disinforms, is wholly non-specific.  I do not recommend to journalists, to any professional.

As to the deep dilemma: I feel no such dilemma. I am fully aware that the person committing the crime does not represent any demographic to which he might belong. Nor any to which I do.

stigma_stomper
stigma_stomper

I Think There Would Be A Lot Less Stigma And Ignorance If The Media Would Give Equal Space With Recovery Models As They Do With The Doom And Gloom. 

Oh Thats Right,  Positive Solutions And Resources Don't Sell Or They Are Overshadowed By Negativity. Besides, How Often Do We Hear About Mental Illness? It's Only When Tragedy Strikes That It Is Brought To Our Attention. We Don't Have To Wait For A Tragic Event To Talk Freely And Open About Recovery

jimlawrie
jimlawrie

This is an excerpt from a letter I wrote to a friend concerning a David Brooks' editorial.

I believe we are missing a far larger point here.Most Americans have become rootless, not tethered to the neighbors or to the “’hood.”  

It is simply a fact of life in modern American society.   

Obviously it happens in other Western societies, but not nearly to the extent as here in America.  

I used to joke that in Latin America people kill for political reasons whereas here in America we just kill for the shear hell of it.   Joking aside, I think, as I grow older there is more truth in that observation then I suspected.  The irony here is that even some of the most heinous crimes in Latin America usually involved a "group effort". 

It surprises me that Brooks would bring in psychology into the picture but yet leave out sociology, (ahem… his forte.) Schizophrenia is nothing new.  Tragic as it may be, it is a component of the human condition.     I don’t believe that we can address this problem.  It is the price we pay for our mobility, our freedom and for each our own individuality.  

It’s time to say, “Get over it America!”  And in some ways, however horrific as it may be, I think we are getting over it.

Bob Bennett
Bob Bennett

"...the way that mental disorders are defined in the present diagnostic system does not incorporate current information from integrative neuroscience research, and thus is not optimal for making scientific gains through neuroscience approaches."  [National Institute of Mental Health Strategic Plan 2008 (pg. 8)]  The DSM-IV was designed in 1952, and its basic structure has not changed, nor is there any hope of having structural implemented.  "From 5–40% of psychiatric patients are found to

have medical ailments that would adequately explain their symptoms" ( Allen MH, Fauman MA, Morin SF. Emergency psychiatric evaluation of “organic”

mental disorders. New Dir Mental Health Serv 1995;67:45-55. ) {Other studies have shown this to be as high as 75%.} Lorrin Koran, MD, of Stanford University was

tasked with leading the development of a corrective procedure. The results of

his team’s work were reported to the California Department of Mental Health and

local mental health programs in 1991 as the Medical Evaluation Field Manual (available at http://goo.gl/kXIuS).  While passed into law in California, but it seems as if it was promptly ignored. Then there is the question of Trauma which had not been adequately researched at that time.  Research - see Healing Trauma by Peter Levine, Ph.D. shows symptoms of trauma could explain the large majority of the various mental illness.  Yet the DSM-IV (and likely the forthcoming DSM-IV maintains "“Inclusion of a disorder in the Classification (as in medicine generally) does not require that there be knowledge about its etiology.."  (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition DSM-IV , Introduction, pg. xxiii).  The mental health system and other professionals - as shown in your article promotes fear and possibly even hatred- and needs immediate reform.

More on this is included in Re-Establishing Justice amp; Creating A First Rate Mental Health System :  http://occupyreno.org/upload/R...

jenniflower05
jenniflower05

This article has the wrong diagnosis. I believe this with everything in me. This guy is looking more like a Bipolar rather than a schizophenic. My son is Bipolar. He is 12 yo and has carried this Dx since he was 3yo. He has been on medication for it since he was 4 yo. I have also worked 11 years in Psych hospitals and Mental Health unit in hopitals. The manic phase of this diorder is extremely intense and can have a phychosis component to it. The deregulation of mood and perceptions can happen over a period of time, resulting in a "psychotic break" and then a "Crash" , Mental fatigue and dopiness. Why do I say this so strongly because I have seen this with my own child. I also know that as long as I do everything in my power to educated him, support him and medicate him lessen the risk of this happening to him in his life. I also know  that after he moves out of my house, I have no control over how he handles his illness. I realize that just because he has this illness doesn't keep him from being resposible for his choices in life but it is an explaination for how things work for him and what potential traps he could fall into.

As for the grogginess it is very much apart of the "crash" of a Bipolar brain. My son would crest into a "red rage" and afterwards he would almost pass out for a few hours and sometimes take days to recover. When he was younger it would take a longer time for him to come back to us. When he did recover, you would never had known he had crash. Alot of the times he wouldn't even have any memory of his "red rage" after it was all done.

This is very real and my family has run the gauntlet with this isuue in our lives. Bipolar is tough for the simple fact that if well maintained and handle you wouldn't even know a person has it.

This is just my 2 cents on the subject.

Patrice Marie
Patrice Marie

I find it interesting that an article about the stigma of mental illness also includes a link to another article with the headline "James Holmes Might Be Crazy but Not Legally Insane."  I have a mental illness and, though I am perfectly stable with medication treatment and therapy, the word "crazy" has been used to describe me.  It feels demeaning when people have called me such things and these words do, in fact, feed the stigma surrounding mental illness.

JeanClellandMorin
JeanClellandMorin

Society has a tiny box of accepted comportment. If you dare step out, you are punished. Those who are "different" are feared. How we treat them can be a major factor in how they will be able to cope and find a productive niche. I think of the film, A Beautiful Mind. I am sure it was romanticized, but it illustrated what a "different" person could achieve. It also showed us the unnecessary hell that is caused by those who fear what they don't understand. // Jean Clelland-Morin

HPM3
HPM3

I think that the conversation should be more about mental health -(the long list of what we can do to aid and support people... rather than waiting until after they have suffered in their own private hell, or harmed themselves or others).

In the 1950s, scientists thought they would be able to mass produce robots (able to function like humans) within a 10 year period. This is because their knowledge about the human body was ridiculously simplistic. For example, in the 50s EVERYTHING that was known about vision, in any medical journal, could FIT ON ONE page. Scientists also didn't realize that lack of movement and experiential learning can lead to immaturity of the vestibular and limbic systems (which can have long lasting and detrimental effects on cognition, learning, memory, and so on). They hadn't imagined the way that our muscles "remember" their activities; that there are sequenced stages and activities in which the individual must engage during critical windows of development -in order to develop the neurons that are required to perceive stimulus with acuity. 

The developing human organism needs innumerable trial and error opportunities under multiple conditions to inhibit primitive reflexes, and to develop statistical mechanisms that can reflect probability with any level of accuracy. Lack of real world interactions and opportunities to explore/experiment can mean a lack of implicit and procedural knowledge (i.e. "common sense", understanding cause and effect or if/then relationships, ability to correctly predict outcomes, effective management of resources and time, and so on). We also require interdisciplinary experiences to connect the applicability of information to solving holistic problems. Effectiveness in communication requires practice and interactions with others of varying attributes (age, ability, backgrounds) and so on. 

Many of our social institutions and responses (school, welfare, and so on) have failed because we did not understand cognition, and underestimated the complexity of human development, relationships, and culture. We did not understand the role we played in causing many of the phenomenon that we witnessed, and observable outcomes only served to reinforce errors in thinking. In other words, we inhibited potential, then observed the deviated result --and supposed this outcome was either an inherent trait or an immutable reality. We did not understand the malleability of the brain during development (which can even effect genetic expression and lifelong physical health outcomes). 

If the mental health of our citizens ever became a true priority (respecting and supporting the creative potential and dignity of each person-- aka the "inalienable rights endowed by our Creator," as the Declaration of Independence states)- our country could be a very different place.

Jessica_Leigh
Jessica_Leigh

When the author states that being a man multiplies your risk of committing a violent crime by a factor of nine, does she mean men with schizophrenia? Or just being male, period?

swift2010
swift2010

if someone is sick but can gain access to an assault rifle 3 glock handguns 6000 rounds of ammo /explosives to wire an apartment

then there is more chance of that person causing harm to others 

if they have difficulty getting hold of all this stuff 

Then there is more chance of people who are sick getting help and recovering to live a full life 

Fastgirl
Fastgirl

This is where the discussion should be in this country, on mental illness and what part it plays in these tradgesdies not gun control. The experts say that before these tragedies there are signs and that professionals, friends and family do nothing because they don't want to be invovled. We need to change the laws so it is easier to get individuals who are a threat to others into treatment so they can get they help they need. 

Boxingwithangels
Boxingwithangels

Is it naive to say there should be some kind of safety net - notification of family to keep close ties/prevent social isolation, or some kind of mentor system if there is no family, whether it be triggered by mental care professionals or the schools?  I just think so many of these cases could be prevented from snowballing if someone would just speak the *f* up and also prevent the total isolation.  Families seem to either be in denial or have no idea, and friends are often the first to see what's going on, but never raise a  red flag to family.

Guest
Guest

All nonsense. This guy isn't sick, he's playin the system.

TuSA23
TuSA23

I was just talking about this with someone the other day. Tragedies like this have less to do with gun laws and more to do with access to mental health services in this country. It's easier to buy a gun than it is to get appropriate mental health treatment! 

Harold Maio
Harold Maio

When you use the term "stigma" what do you mean?