Which statement concerning the stigma associated with serious mental illnesses is accurate

Misperceptions about the relationship between mental health, mental illnesses and violence contribute significantly to stigma, discrimination and social exclusion. Studies indicate that people living with mental health conditions are no more likely to engage in violent behaviour than the general population (September, 2011)

People living with mental health conditions may experience stigma, discrimination and social exclusion that significantly impacts on their lives. Misperceptions about the relationship between mental health, mental illnesses and violence contribute significantly to these experiences. Studies have shown that people living with mental health conditions are no more likely to engage in violent behaviour than the general population. However, public perceptions, often influenced by the media, are contributing to attitudes that have a significant impact on the lives of people with mental illnesses.

What We Know

• Estimating the rate of violent behaviour by people with mental illnesses is complex, and a definitive causal relationship between violence and mental illnesses has not been established. There are challenges due to definitions, data gaps and technical issues related to the reliability, consistency and generalizability of available data.
• People with mental health conditions experience stigma, discrimination and social exclusion that significantly impacts on their lives, including fears that they may be violent.
• People with serious mental illnesses are more likely to be victims of violence themselves, than the general population.
• Freedom from violence and discrimination promotes positive mental health and well-being.
  Media reporting and portrayals contribute to public misperceptions about the relationship between violence and people with mental illnesses.

Considering language

The fear that people with mental health conditions may be dangerous or violent is at the core of the stigma, discrimination and social exclusion experienced by individuals with mental health conditions. 1, 2, 3  Research on public perceptions and attitudes about mental health have identified stereotypes that people with a mental illness pose a threat to public safety.4,5  Indeed, a 2008 study found that one in four Canadians admitted they would be fearful to be around someone with a serious mental illness.6 As detailed below, existing research indicates that these fears are misplaced. So what is behind these fears?

Language plays a key role in how we think, talk and respond to this complex issue and can contribute to misperceptions about violence and mental health. There are many forms of violence, including physical acts, such as physical or sexual abuse, and non-physical acts, such as emotional abuse, harassment or intimidation. Violence can be directed against others or against oneself.

The term “mental illness” is misleading because it suggests that all mental health conditions or illnesses are the same, or have similar characteristics. In reality, there is no single mental illness, but a range of mental health conditions with different symptoms and experiences. Oversimplifying discussions about mental illnesses can incorrectly infer that all individuals who are living with mental health conditions are impacted in the same way, or that all individuals share the same behaviours. In many cases, symptoms of acute mental illnesses are episodic, surrounded by periods of recovery or wellness.7 Thus, a person can experience mental well-being in spite of a diagnosis of a mental illness.

Media influence on public attitudes

Many studies have found that media and the entertainment industry play a key role in shaping public opinions about mental health and illness. People with mental health conditions are often depicted as dangerous, violent and unpredictable.8,9 News stories that sensationalize violent acts by a person with a mental illness are typically featured as headline news; the comparatively small number of articles that feature stories of recovery or positive news about individuals with a mental illness are often opinion pieces or are framed in the lifestyle or health section.10,11 Films and television shows often portray individuals with mental illnesses as hypersexual, dangerous and/or violent.12 As Dr. Heather Stuart, a leading Canadian researcher in the area of mental health and stigma, notes, the violent depictions are simply more memorable for the viewing public.13

Entertainment frequently features negative images and stereotypes about mental illnesses, and these portrayals have been strongly linked to the development of public fears concerning individuals with mental health conditions.14,15 Television portrayals do little to convince the public that individuals with mental illnesses do recover; and are active and productive members of our society.16 A recent study analyzed references to mental health in three months of television programming in the UK.17 The results revealed that 63 percent of the references to mental health in the program dialogue were pejorative, flippant or unsympathetic; terms included “crackpot,” “a sad little psycho,” “basket case,” and “looney tunes.” Forty-five percent of programs featuring mental illness-related storylines portrayed people with mental health conditions as dangerous, while 45 percent had sympathetic representations of individuals with mental illnesses. Key themes in the characterisation of people with mental health conditions included representations as being dangerous outsiders and tragic victims deserving of sympathy.

Impact of negative public attitudes

There are significant consequences to the public misperceptions and fears. Individuals are more likely to support or condone forced legal action and coerced treatment for individuals living with mental health conditions if violence is perceived to be at issue.18 The association of violence with mental illness has been used to justify bullying, as high rates of victimization have been recorded for this group.

A UK study found that psychiatrists who associated mental illnesses with violence were more likely to give a diagnosis of schizophrenia, if a history of violence was included in the case history.19 This finding has important implications, not only because of the stigma often experienced with a diagnosis of schizophrenia, but also because it is essential to ensure that individuals receive appropriate diagnosis and treatment.

Violence and discrimination are often linked. Discrimination refers to actions taken to exclude or treat others differently because of their identity, including race, ethnicity, gender, sexual orientation, disability and/or other factors, and violence is often the vehicle through which discrimination is acted out.20 Experiences of discrimination and violence can result in psychological distress and feelings of low self-esteem, as well as anxiety and depression.21 Such experiences can impede recovery, and create multiple barriers to accessing the social determinants of health, including housing, employment and education. Being a victim of violence is also strongly associated with substance abuse and mental health conditions.

Stigma and discrimination also impact other issues in one’s life, such as employment, housing, interpersonal relationships and encounters.22 Research has shown that the general public is more likely to reject a relationship with someone with a mental illness and less likely to recommend them for a job. 23,24 As a result of these type of situations, individuals with mental illnesses often are hesitant to disclose matters pertaining to their mental health.25

Stigma and discrimination are daily realities for people with a mental illness, and they report that both the fear and reality of how others judge them is one of their greatest barriers to a complete and satisfying life. Stigma and discrimination against people with a mental illness can impede recovery and diminish quality of life.

A look at the research on violence and mental health

Research regarding violence and mental health includes federal, provincial and municipal crime statistics, medical research, and investigative reports by the media. However, there is minimal critical social science research conducted on this topic, and even fewer studies that incorporate the perspectives of people living with a mental illness or their families. Furthermore, there is a lack of Canadian and Ontario-specific research on violence and mental health, which also raises the question whether studies conducted in the United States, in Europe or Australia can be generalized to the Canadian population.

Challenges in understanding the data

The existing research on violence and mental health raises more questions than answers. A majority of the known research studies focus on estimates of the rates of violent incidents, defined as prevalence. However, violence itself may be defined in different ways, and regardless of the definition, it is difficult to measure. While some studies rely solely on official documentation, other data is based on uncorroborated self-reports.26These types of limitations are well known sources of research bias. Furthermore, common sources of data, such as the use of police databases or hospital-based studies of involuntarily committed inpatients, do not represent the overall population of people living with mental illnesses.27Therefore, prevalence rates will differ depending on the source of information.

Information Gaps

• A definitive causal relationship between mental illnesses and violence has not been established.
• There are no population-based Canadian studies looking at violence or victimization among people with serious mental illnesses.
• Some studies do not distinguish between mental illnesses, substance abuse/dependence or co-occurring mental illnesses and addictions.

There are also inconsistencies in how mental illnesses are defined by research studies. Different studies include different disorders under the definition of “mental illness.” Schizophrenia, substance use, personality disorders, and psychopathy are often examined in relation to violent behaviour. As a result, different statistics can emerge depending on which disorders are included or excluded in a particular study. For example, research shows violent behaviours are significantly elevated when a mental illness co-occurs with substance use.28,29 However, rates of violence among mentally ill individuals without concurrent substance disorders are similar to the rates of violence within the public. As a result, inconsistent definitions often create difficulties with the generalizability of the research findings.

Research studies may utilize risk assessments to estimate an individual’s propensity for violent behaviour. However, different methods and types of risk calculation can generate different “conclusions” regarding the risk of violent behaviour among people living with mental illnesses. For example,absolute risk identifies the likelihood that an individual with a mental illness might be violent, whereas relative risk calculates the odds that an individual with a mental illness might be violent, compared to people without a mental illness. A third type of calculation looks at the risk of violence at the population level. Presenting each of these risk assessments in isolation can lead to different perceptions of the risk of violence by people with a mental illness.

For example, a random sample of individuals entering a provincial detention centre in Alberta found that while 19 percent of persons charged with committing a violent crime had a mental disorder, only 3 percent of total charges related to violence could be attributed to the mental illness itself.30 Similarly, a study in Sweden found that people with schizophrenia were 3.8 times more likely to have been convicted of committing a violent crime than those without a mental illness, yet the crimes attributed to mental illness represented approximately 5 percent of all violent crimes in Sweden.31 Regardless of the higher odds that a person with a mental illness would be convicted for a violent crime, 19 out of every 20 violent crime convictions in Sweden were committed by someone who did not have a mental illness.

Given these methodological challenges, estimating the rate of violent behaviour by people with mental illnesses is complex, and a definitive causal relationship between mental illnesses and violence has not been established.

Factors that contribute to violence

Much of the existing research has focused on the prevalence of violence among people with mental illnesses; yet, little attention has been paid to other causal factors of violence. The predominant determinants of violence are demographic and socio-economic factors, such as being young, male and of lower socio-economic status.32 A history of experiencing or witnessing violence, or previous involvement with the criminal justice system are also contributing factors.

Violent behaviours are often associated with life stressors, which are the events in a person’s life that bring about significant anxiety and stress. Stress is often related to major and everyday life events, such as life transitions, loss and grief, experiences of trauma or victimization, loss of a job or career changes, or changes to family structure or among friends. Diminished access to the social determinants of health, including income insecurity, unemployment, inadequate housing and food insecurity, can also cause life stress. People with a serious mental illness are oftentimes highly vulnerable to these difficult life circumstances. For example, people with serious mental illnesses are 3.7 times more likely to have experienced physical abuse by their parents and 2.5 times more likely to be unemployed, recently victimized, or to have grown up witnessing physical fighting between their parents, compared to people without a mental illness.33 People with a serious mental illness also tend to be more economically disadvantaged and live in neighbourhoods with higher crime rates.34 Yet, living in poverty and poor social conditions, and experiencing social exclusion are all risk factors for violence in any population, not just among people with mental illnesses.35

Furthermore, it is important to note that violence is a learned behaviour. For example, having witnessed parents fighting is a common factor among people who are violent.36 This relationship appears also to hold true among people with mental illnesses. Links have been found between people with schizophrenia who have been charged with a violent crime and a similar history of violent crime convictions among their parents and/or siblings.37,38 This learned violent behaviour is a problem that can be understood and changed.39

Violent and aggressive acts are not always directed against others, but can also be committed against oneself. The risk of committing or threatening self-harm is elevated among people who experience mental illnesses.40 Risk factors for committing self-harm include being young and male, in the early stages of a mental illness, having concurrent drug and/or alcohol abuse, and having inadequate access to treatment.41,42

The multiple contributing factors of violence are outlined in the Government of Ontario report, theReview of the Roots of Youth Violence (2008).43 This report focuses on the effects, rather than the existence, of the root causes of violence, and highlights the major conditions in which the immediate risk factors for violence flourish within our society. Several root causes are identified, including: poverty, racism, community design, education, family issues, health, lack of economic opportunities, and involvement with the justice system.

The roots of violence are therefore multi-faceted and include lack of access to the social determinants of health. Increasing access to the social determinants of health is an important strategy for addressing violence and promoting mental health.

Victimization of people with mental illnesses

There is minimal research on the victimization of individuals with mental illnesses. One in four individuals with a mental illness are likely to be a victim of violence in a given year.44,45 People with mental illnesses often face socio-economic deprivation, such as unemployment, poverty, lack of social supports and inadequate housing and/or homelessness. These factors increase vulnerability to victimization.46 The stress and trauma of being victimized can heighten an individual’s sense of vulnerability and anxiety, which can exacerbate symptoms of the mental illness, increase the likelihood of homelessness, and diminish quality of life.47

Victimization also occurs during incarceration. Threats and assaults against inmates can occur in prison environments, due in part to often over-crowded, enclosed spaces and the material deprivation that characterizes correctional facilities.48,49,50 Up to 60 percent of Canadian inmates have reported some level of victimization in prison, and people with mental illnesses are often at increased risk for victimization.51,52 Recent American research has found that both male and female inmates with a mental illness were more likely than other inmates to report having been physically victimized by other inmates or correctional staff.53 Furthermore, the Office of the Correctional Investigator of Canada has reported that self-harm behaviours of federal inmates are increasing. In the six-month period between April and September 2008, there were 184 self-harm incidents reported, more than double the number recorded over the same period in 2006.54

People with mental illnesses who have been in conflict with the law, tend to have higher rates of substance abuse, homelessness, challenges in adhering to treatment, and experiences of victimization, as well as lower rates of social support, when compared to other adults with a mental illness.55Many of these characteristics are common to other Canadians who have been in conflict with the law. Incarcerated women in Canada typically have a history of childhood sexual abuse and physical abuse, as well as social and economic marginalization.56 Experiences with homelessness are linked to both poor mental health and incarceration.57 All of these characteristics increase the likelihood of further victimization in communities and correctional facilities.

Recent victimization is a risk factor for violent behaviour within the general population, as well as among people with mental illnesses.58,59 In a vicious circle, victimization, past history of crime and acute psychiatric symptoms in turn increase the risk of further victimization.60 Thus, when examining the research on the prevalence of violence among individuals with mental illnesses, it is also important to consider the rates of victimization faced by such a vulnerable group.

A look at solutions for addressing violence and mental health

The majority of individuals with mental illnesses are not involved in violence. However, given the complex associations and the consequence of negative public perceptions, a multi-faceted approach is needed to address violence and mental health.

Addressing Root Causes

The recent Roots of Youth Violence report (2008) affirms many of the root causes of violence in society and its impact on Ontarians. These root causes include poverty, racism, community design, access to education, family structure, lack of economic opportunities and involvement in the justice system.61 Providing safe housing, meaningful employment and promoting social inclusion through supportive and safe neighbourhoods are key strategies for improving the lives of people with mental illnesses.

People with mental illnesses are at greater risk for victimization in correctional facilities. This level of risk for victimization continues upon release from custody due to lack of adequate and accessible housing. In Ontario, mental health courts and court diversion programs are beginning to redirect individuals with mental illnesses who are in conflict with the law into community support, supervision and/or treatment programs as an alternative to incarceration. Various community mental health agencies across the province are now providing community-based discharge planning to individuals with mental illnesses transitioning out of the correctional system. These programs link individuals with a mental illness to essential housing, income supports, and mental health services and supports.

In addition, violence has a recognized causal relationship with increasing the risk of poor mental health.62 That is why freedom from violence and discrimination has been identified as a key factor in promoting positive mental health.63

Reducing Stigma and Discrimination

Public fears of dangerousness can exclude people with mental illnesses from safe and healthy environments and in turn, expose them to victimization.”Not in my backyard” thinking, often referred to as NIMBYism, can lead to neighbourhood residents exercising power to keep people with serious mental illnesses isolated from the communities in which they live. Precarious, inadequate or unavailable housing options for people with mental illnesses can restrict individuals to neighbourhoods that lack amenities such as community centres, public transportation, health and social service agencies, recreational areas. Living in marginalized communities can create feelings of isolation and insecurity, and can contribute to poor or worsening mental and physical health.

Misconceptions about the risk of dangerousness can also generate stigma among service providers and their response to persons with a mental illness.64 The judgments, attitudes and behaviours of providers toward people with mental illnesses can be a disincentive for individuals who might otherwise seek care.

Increasing Availability and Access to Mental Health Services

It is essential that individuals with mental health conditions have timely access to mental health services to support their recovery and promote well-being. While new investments are occurring, Ontario still lacks capacity to provide a comprehensive core basket of services and supports in all areas across the province.

A More Sensitive Approach by the Media

A reduction in negative media portrayals of mental illnesses is a critical strategy for altering sensationalized beliefs about the dangerousness of people with mental illnesses. The media can challenge negative attitudes by presenting stories that challenge myths and misinformation. The media also has great potential to transform public misperceptions by including positive portrayals of individuals with mental illnesses to help reduce the stigma and discrimination associated with mental illnesses. Recent examples of positive media response include series in the Globe and Mail and the Toronto Star that reported on the state of mental health programs in Canada, and provided balanced stories of people living with mental illnesses.

Moving forward

Understanding Data

1. When reporting statistics on violence and mental health it is important to understand the source of information, the type of analysis done and its limitations, and assess the credibility of the data interpretation. Canadian Mental Health Association, Ontario has developed a guide for critically reviewing research and media articles (Appendix A) with the purpose of promoting greater understanding and discussion about the complex issues related to mental health and violence.

Responsible Media

1. As the media plays an important role in shaping and influencing public opinion, a balanced approach is essential to reporting on mental health. Media should refer to guidelines on responsible media coverage, such as the guidelines developed by the Canadian Psychiatric Association (2008) and the Centre for Addiction and Mental Health (2009). When reporting on this topic, the media should ensure that all perspectives are represented, including that of consumer/survivors, family members, and care providers.

Additional Research

1. Support research that engages relevant stakeholders, especially consumers and family members, in asking critical questions about representations of mental health and illness, and the impacts of these representations on people living with mental health conditions.

Reduce Stigma and Discrimination

1. Public attitudes need to be challenged that incorrectly link violence with mental illnesses. This should be part of a comprehensive, multi-faceted strategy to address stigma and discrimination. Ontario’s Select Committee on Mental Health and Addictions (2010) and the Minister’s Advisory Group (2010) have both recommended that Ontario address stigma. In 2009, the Mental Health Commission of Canada initiated support for local anti-stigma initiatives, and the Ontario Human Rights Commission has begun development of a human rights and mental health strategy for the province.

Promote Positive Mental Health and Well-Being

1. Positive mental health for all requires access to economic resources, freedom from violence and discrimination, and ensuring social inclusion. Interventions need to be targeted at the individual and community level, as well as strategies for healthy public policy. This will require intersectoral and whole-of-government approaches.

Appendix A:

Guide for Critically Reviewing Research and Media Articles on Violence and Mental Health

Discussions about violence and mental health require a balanced approach as they have the potential to reinforce stigma and social exclusion of people living with mental health conditions. Therefore, Canadian Mental Health Association Ontario recommends the use of a screening tool or guide to ensure that information and reporting on violence and mental health is balanced.

CMHA Ontario proposes that the following questions be used as a guideline when reviewing research and media articles, including research studies, journal articles, newscasts and other media resources, with the purpose of promoting greater understanding and discussion of the complexities of the issues related to mental health and violence.

1. What type of document is it? Academic, journalistic, or an editorial? (The type of document will indicate how rigorous the research is).
2. Who is conducting the research? Who is funding the research?
3. When was the research conducted?
4. Whose voices are included in the research? Whose voices are excluded?
5. How is “mental illness” defined? How is “violence” defined?
6. What type of approach is taken to understand mental health?

Canadian Mental Health Association, Ontario would like to express our appreciation to the following individuals and organizations for contributing their time to reviewing and providing feedback on earlier versions of this discussion paper. Please note that this is not an endorsement by the organizations listed.

Dr. Greg Brown, Nipissing University
Lisa Cameron, Crown Attorney, Halliburton/Kawartha Lakes/Pine Ridge Region
Jennifer Chambers, Empowerment Council
Dr. Dorothy Cotton, Mental Health Commission of Canada
Ryan Fritsch, Psychiatric Patient Advocate Office
Vani Jain, Schizophrenia Society of Ontario
Dr. Heather Stuart, Queen’s University
Allan Strong, Provincial Consumer/Survivor LHIN Leads Network

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What is the stigma associated with mental illness?

How has the stigma of mental health changed?

What are the 3 types of stigma?

Where does stigma of mental illness come from?