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Mental illness, crime, and violence: Risk, context, and social control

Fred E. Markowitz

Department of Sociology, Northern Illinois University, DeKalb, IL 60115, United States

a b s t r a c ta r t i c l e i n f o

Article history:

Received 18 October 2010

Received in revised form 23 October 2010

Accepted 25 October 2010

Available online 2 November 2010

Keywords:

Mental illness

Crime

Violence

Psychiatric hospital

Jail

Prison

In this article, I review theory and research on the relationship between mental illness, crime, and violence.

I begin by discussing the larger backdrop of deinstitutionalization of mental illness and its consequences for

the criminal justice system in both individual and macro-level terms. I then compare public perceptions of

dangerousness associated with mental illness with individual-level studies that assess the risk of violence and

criminal behavior among those with mental illness. I review key findings as to the role of certain psychotic

symptoms, social demographic characteristics, and the context in which violence unfolds. Finally, I discuss

recent efforts at managing persons with mental illness who violate the law, focusing on the limitations of

diversionary programs.

© 2010 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2. Deinstitutionalization, mental illness, and the criminal justice system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.1. Deinstitutionalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.2. Mental illness and the criminal justice system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.3. The role of homelessness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

3. Public perceptions of dangerousness associated with mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

3.1. The changing nature of public understanding of mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

3.2. Perceptions of dangerousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

3.3. Causal attributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

4. Individual-level research on mental illness and the likelihood of violence and crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

4.1. Treatment sample studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

4.2. Community sample studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

4.3. Symptoms associated with violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

4.4. Demographic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

5. Community context: The role of socially disorganized neighborhoods in violence among persons with mental illness . . . . . . . . . . . . . . . . . . . 40

5.1. Social disorganization and mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

5.2. Police encounters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

6. Situational dynamics: The role of stress and conflicted relationships in violence among persons with mental illness . . . . . . . . . . . . . . . . . . 41

6.1. Stress and conflicted relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

7. Public policy responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

7.1. Community treatment alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

7.2. Outpatient civil commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Aggression and Violent Behavior 16 (2011) 36–44

E-mail address: fredm@niu.edu.

1359-1789/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.

doi:10.1016/j.avb.2010.10.003

Contents lists available at ScienceDirect

Aggression and Violent Behavior

1. Introduction

High-profile shootings at schools, universities, and government

buildings bring public attention to the problem of mental illness and

violence. Visible homeless persons with mental illness and substance

abuse problems are commonplace in urban areas. In this article, I

provide an overview of the perceptions, realities, and processes

surrounding these issues by organizing and reviewing research

related to the study of mental illness violence, and crime. Specifically,

I address the following questions: How has the nature of mental

health care changed in such a way that has led to more people with

mental illness in jails and prisons than in hospitals? What are the

pathways by which persons withmental illness end up there?What is

the public perception of violence among the mentally ill compared to

objective assessments of the risk? Finally, how effective are recent

efforts at addressing the problem of mental illness in the criminal

justice system?

In an effort to integrate our understanding of these issues, I begin

by discussing major developments in legal and treatment systems

that manage persons with severe mental illness. I then examine

recent research on public perceptions of dangerousness among

persons with mental illness. Next, I review research on the

relationship between mental illness, crime, and violence, focusing

on individual, macro, and situational processes. Finally, I discuss

recent legal and social policy initiatives related to mental illness and

violence.

2. Deinstitutionalization, mental illness, and the criminal

justice system

2.1. Deinstitutionalization

Until the 1960s, substantial numbers of persons with mental

illness were treated in large, publicly funded hospitals. Based on the

National Institute of Mental Health (NIMH) estimates, in 1960, about

563 000 beds were available in U.S. state and county psychiatric

hospitals (314 beds per 100 000 persons), with about 535 400

resident patients. By 1990, the number of beds declined to about

98 800 (40 per 100 000) and the number of residents to 92 059

(National Institute of Mental Health, 1990). By 2005, there were only

17 public psychiatric beds available per 100 000 persons, despite

increases in the population and estimates that about 50 beds per

100 000 are needed for minimal treatment capacity (Torrey, Kennard,

Eslinger, Lamb, & Pavle, 2010). Several factors contributed to the drop

in inpatient capacity. First, medications were developed, which

controlled the symptoms of the most debilitating mental disorders

(e.g., schizophrenia). Second, an ideological shift, advocating a more

liberal position on confinement, led to states adopting stricter legal

standards for involuntary commitment (dangerousness to self or

others) that are not frequently used. Third, and perhaps most

important, fiscal policy changed, including the shifting of costs for

mental health care from states to the federal government (Medicare,

Medicaid, Social Security Disability Income), followed by budget cuts

and substantial underfunding of community mental health services

(Gronfein, 1985; Issac & Armat, 1990; Kiesler & Sibulkin, 1987;

Mechanic & Rochefort, 1990; Redick, Witkin, Atay, & Manderscheid,

1992; Weinstein, 1990). These trends and associated policies are

generally referred to as the deinstitutionalization of the mentally ill.

The sharp decline in public psychiatric hospital capacity has been

offset to some extent by inpatient units in private psychiatric and

general hospitals, as well as by moving patients to nursing homes. An

important component to the changing nature of psychiatric hospital-

ization is the increased role of general hospitals. Emergency rooms

and psychiatric units in general hospitals provide acute treatment for

those with mental illness and can bill Medicaid for doing so

(Mechanic, McAlpine, & Olfson, 1998). Although these hospitals

contribute to treatment capacity, they still do not provide the longer

term care that public psychiatric hospitals did. Moreover, recent

studies show changes in how psychiatric hospitalization is accessed,

with many disadvantaged patients not admitted to private hospitals

because of an inability to pay for their care (Lincoln, 2006).

Paradoxically, federal rules prohibit patients aged 21–64 with

Medicaid from receiving care in specialized psychiatric hospitals.

Therefore, capacity for maintaining and treating America's mentally

ill, especially the most severely impaired and economically disadvan-

taged patients, has been substantially diminished (Ehrenkranz, 2001;

Lamb & Bachrach, 2001; Torrey, 1995, 1997).

As hospitals closed and the number of beds reduced,many patients

were discharged from state hospitals into the community. Others, as a

result of stricter standards for involuntary commitment, were not

even admitted—an “opening of the back doors” and “closing of the

front doors.” Moreover, in the early 1960s the average length of stay

was about 6 months, but by the early 1990s it had declined to about

15 days (National Institute of Mental Health, 1990). By 2007, it was

less than 10 days. Meanwhile, the rate of admissions from the early to

mid 2000s has increased slightly (Manderscheid, Atay, & Crider,

2009). This indicates that patients are often stabilized (i.e., given

medication) and released, without adequate follow-up treatment and

support (Weinstein, 1990). Not surprisingly, substantial numbers of

these patients end up being readmitted. This has been referred to as

the “revolving door” phenomenon (Kiesler & Sibulkin, 1987).

Historically, psychiatric hospitals have functioned as a source of

control of persons who are unable to care for themselves and whose

behavior may be threatening to the social order (Grob, 1994; Horwitz,

1982). In the early 1990s, the public mental health care system

crossed a threshold where the majority of expenditures previously

directed toward state hospital inpatient care were now directed

toward community-based services (Lutterman & Hogan, 2000). An

important consequence of reduced hospital capacity is that a large

portion of persons with severe mental illness now live in urban areas

with less supervision and support. Although some do well, many lack

“insight” into their disorders, go untreated, or have difficulty

complying with medication regimens, and are unable to support

themselves (Mechanic, 2008). This presents considerable difficulties

for families and others who are often unable or unwilling to deal with

persons whose behavior may at times be unmanageable or threaten-

ing (Avison, 1999; Karp, 2001).

2.2. Mental illness and the criminal justice system

Very early research demonstrated the interdependence of the

mental health and criminal justice systems (Penrose, 1939). More

recently, in the aftermath of deinstitutionalization, prisons and jails

have supplanted public psychiatric hospitals as institutions of social

control of the mentally ill (Liska, Markowitz, Bridges-Whaley, &

Bellair, 1999). Studies have examined frequency of arrest, jail, and

imprisonment among people admitted into psychiatric hospitals

before and during deinstitutionalization (Adler, 1986; Arvanites,

1988; Belcher, 1988; Cocozza, Melick, & Steadman, 1978; Steadman,

Monohan, Duffee, Hartstone, & Robbins, 1984; Steadman, Fabiasak,

Dvoskin, & Holohean, 1987; Steadman, McCarty, & Morrisey, 1989).

Studies from the 1970s and 1980s found that the percentage of

patients with prior arrests increased (Arvanites, 1988; Melick,

Steadman, & J.J. Cocozza, 1979a; Melick, Steadman, & J.C. Cocozza,

1979b). Studies of imprisonment reported an overall increase in the

percentage of prison inmates with prior mental hospitalization

(Steadman et al., 1984, 1978). Many researchers thus concluded

that the mentally ill are being overarrested and warehoused in city

and county jails (Adler, 1986; Lamb & Grant, 1982; Palermo, Smith, &

Liska, 1991; Pogrebin & Regoli, 1985; Teplin, 1984, 1990).

More recent nationally representative surveys of state and federal

prisoners, jail inmates, and probationers are consistent with earlier

37F.E. Markowitz / Aggression and Violent Behavior 16 (2011) 36–44

research, indicating that persons who report “currently” or “ever

having a mental or emotional condition” are overrepresented in all

those groups (Ditton, 1999). One study estimates that up to 16% of

persons in prisons and jails may have a mental illness, many of whom

have committed serious offenses (Ditton, 1999). That is over 300 000

persons, a rate (for men) which is about 4 times higher than the

general population. Thus, it is estimated that there are nowmore than

three times as many persons with mental illness in jails and prisons

than in psychiatric hospitals (Torrey et al., 2010). The most recent

study puts the estimate of the percentage of inmates with a history of

mental health problems in jails at 64% and at 56% for state prison

inmates, with 50–60% reporting current symptoms (James & Glaze,

2006). In terms of types of offenses, Silver, Felson, & VanEseltine

(2008) found that, among prison inmates, those with serious mental

illness were somewhat overrepresented among those incarcerated for

assaultive violence and sexual crimes, but not property, and other

types of crime.

Because of a lack of appropriately trained staff and screening

procedures, many persons are retained in jails and prisons without

adequate treatment. These inmates are less likely than others to be

released on bail, more likely to experience abuse from guards and other

inmates, and are at an increased risk of suicide (Torrey, 1995). Thus,

corrections facilities serve, in part, as rather dysfunctional alternatives to

psychiatric hospitals. Although many jails and prisons provide mental

health services, and several communities have programs to divert

mentally ill offenders from jail to treatment (discussed below), the

availability of these services and programs is limited relative to the need

for them (Fisher, 2003; Goldstrom, Henderson, Male, & Manderscheid,

1998; Morris, Steadman, & Veysey, 1997; Steadman, Morris, & Dennis,

1995).

2.3. The role of homelessness

Homelessness is an important pathway to incarceration among the

mentally ill. Studies estimate that approximately one-third of

homeless persons meet diagnostic criteria for a major mental illness

(Jencks, 1994; Lamb, 1992; Shlay & Rossi, 1992). Including substance-

related disorders, the figure is closer to 75%. Consequently, surveys of

jail and prison inmates find that mentally ill offenders are more likely

than other inmates to have been homeless at the time of arrest and in

the year before arrest (DeLisi, 2000; James & Glaze, 2006; McCarthy &

Hagan, 1991). Because of a lack of community treatment programs

and limited staffing (critical for monitoring medication compliance),

personal resources, and social supports, many mentally ill homeless

persons are at increased risk of police encounters and arrest for not

only “public order” types of offenses, such as vagrancy, intoxication, or

disorderly conduct, but also for more serious types of crimes, such as

assault (Dennis & Steadman, 1991; Estroff, Zimmer, Lachotte, &

Benoit, 1994; Fisher, Silver, & Wolff, 2006; Fisher et al., 2006; Hiday,

1995; Hiday, Swanson, Swartz, Borum, & Wagner, 2001; Lamb &

Weinberger, 2001; McGuire & Rosenbeck, 2004; Mechanic &

Rochefort, 1990; Silver et al., 2008; Teplin, 1994).

The presence of homeless persons and associated public order

offenses may be a source of neighborhood disorder, generating fear

and reducing social cohesion among neighborhood residents, thus

facilitating more serious crime, such as robbery (see Markowitz,

Bellair, Liska, & Liu, 2001; Sampson, Raudenbush, & Earls, 1997;

Skogan, 1990). High levels of urban disorder, including the visibility of

homeless mentally ill persons, has led many cities to take aggressive

policing approaches that, at times, may contribute to the overrepre-

sentation of mentally ill persons in jails and prisons.

The vulnerability of homeless mentally ill persons also increases

their risk of being the victims of crime, well beyond the rates generally

found by the National Crime Victimization Surveys (Choe, Jeanne,

Teplin, & Abram, 2008; Dennis & Steadman, 1991; Teplin, McClelland,

Abram, &Weiner, 2005). They are easier targets for offenders. Insights

from routine activities theory suggest that homeless persons have

reduced levels of “capable guardianship” necessary to protect

themselves from crime (Felson, 2002; Hagan & McCarthy, 1998).

Moreover, the likelihood of victimization among homelessmentally ill

persons is increased because of the risks of victimization associated

with alcohol use more generally (Felson & Burchfield, 2004).

Altogether, mental illness and homelessness creates “criminogenic”

situations.

A macro-level study by Markowitz (2006) showed that, across U.S.

cities, higher public inpatient psychiatric capacity was associated with

fewer homeless persons and lower crime and arrest rates. Moreover,

pooled analyses of states from 1980s to the late 1990s showed that

increases in the proportion of private, for-profit psychiatric hospital

beds was associated with an increase in the size of jail populations as

well as suicide rates (Yoon, 2011; Yoon and Bruckner, 2009). The

exact effect of reduced public hospital capacity on homelessness,

crime, and arrest rates may be difficult to predict however, since this

effect likely depends on the availability and quality of a variety of

fragmented community-based treatment and housing services, of

which data are not systematically compiled in the same way that

hospital data is. In these studies, per capita spending on community

mental health services shows no effect on crime and arrest rates and is

associated with an increase in the size of jail populations, but it offsets

the effect of loss of public inpatient capacity on suicide rates.

Unfortunately, macro-level data do not allow estimates of the

proportion of jail and prison inmates with mental illness. One study,

comparing two jails in different catchment areas, one with higher

levels of community-basedmental health services found no difference

in the prevalence of mental illness across the two jails (Fisher, Packer,

Simon, & Smith, 2000). Together, although limited in scope, the

findings from these studies suggest that provision of greater

community-based mental health services alone may not be sufficient

to reduce the number of persons with mental illness in jail.

3. Public perceptionsof dangerousness associatedwithmental illness

3.1. The changing nature of public understanding of mental illness

There is both ‘good news’ and ‘bad news’ when it comes to public

understanding of mental illness generally. Early research in the 1950s,

based on a nationally representative survey, asked respondents the

open-ended question: When you hear someone say that a person is

‘mentally ill,’ what does that mean to you? Results showed that

Americans had a somewhat narrow view of mental illness, with the

majority associating mental illness with psychosis. For example,

respondents indicated that mental illness means that “persons are not

in touch with reality” or “live in their own world.” Respondents also

used colloquial terms such as “nuts,” “deranged,” or “out of one's

mind” to describe mental illness (Starr, 1955). In 1996, the same

question was asked again in a nationally representative survey. This

time, fewer persons gave answers reflecting psychosis (35%) and

more persons gave responses reflecting other disorders such as

anxiety/depression (34%), personality disorders, substance abuse, or

cognitive impairment, suggesting that the public's conceptions of

mental illness has broadened beyond stereotypical conceptions

associated with psychotic disorders and is seen as something less

alien and extreme (Phelan, Link, Steuve, & Pescosolido, 2000).

Other recent research used vignettes that described persons who

fit the criteria for one of several mental illnesses (schizophrenia,

major depression, and substance dependence) and asked respondents

whether they thought “the person was likely to have mental illness?”

About 88% said “yes”when a presented with a description of a person

with schizophrenia, and about 69% said “yes” when a person with

major depression was described. When asked specifically whether

they thought the person was “likely to have depression,” 95% said

“yes” (Link, Monahan, Steuve, & Cullen, 1999; Link, Phelan, Bresnahan,

38 F.E. Markowitz / Aggression and Violent Behavior 16 (2011) 36–44

Stueve, & Pescosolido, 1999). Also, Americans are more likely to

attribute the causes of disorders such as schizophrenia and depression

to chemical imbalances, genetic factors, and stressful life circum-

stances, rather than to “bad character,” “the way the person was

raised,” or “God's will” (Martin, Pescosolido, & Tuch, 2000). Together,

these findings suggest that public understanding of the causes of

mental illness has become somewhat more sophisticated and

consistent with professionals' views.

3.2. Perceptions of dangerousness

However, the ‘bad news,’ concurrent with these favorable

developments, is that there has been an increase in the proportion

of persons who associate mental illness with dangerousness, violence,

and unpredictability. In 1950, when askedwhat ‘mental illness’means

to them, about 7% of respondentsmentioned violentmanifestations or

symptoms, compared to 12% in 1996. Also, those who think of mental

illness in terms of psychosis are more likely to associate mentally ill

persons with dangerousness and are less willing to live near them,

socialize with them, work with them, have a group home for the

mentally ill nearby, or have someone with mental illness marry into

their family, i.e., they want to have greater ‘social distance.’Moreover,

perceptions of dangerousness increase support for coercive measures

to treat persons with mental illness, such as involuntary commitment

(Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999).

Paradoxically, public understanding of mental illness has appar-

ently increased, yet perceptions of persons with psychotic disorders

as dangerous have increased as well. A likely possible explanation is

that media images and high publicity surrounding certain violent

events have created misunderstanding of the actual risk of violence.

While there has been a good deal of research on howmental illness is

presented in the mass media, in terms of inaccurate depictions and

overemphasis on violence (Corrigan, 2005; Wahl, 1995), the link

betweenmedia portrayals and attitudes towardmental illness has not

been fully examined. However, one study found that highly publicized

college campus shootings may lead to increases in fear among college

students of being a victim of violent crime on campus (Kaminski,

Koons-Witt, Thompson, & Weiss, 2010).

3.3. Causal attributions

Recent research has examined the effects of beliefs about the

causes of mental illness and perceptions of dangerousness on

attitudes toward persons with mental illness. Survey studies using

experimental vignettes examined the impact of causal attributions

and perceptions of dangerousness on responses toward persons with

mental illness (Corrigan, Markowitz, Watson, Rowan, & Kubiak,

2003). This research has shown that when the onset of mental illness

is viewed as being under one's control (e.g., as a result of drug use),

persons are more likely to avoid, withhold help, and endorse coercive

treatment. Also, when persons are seen as responsible for causing

their condition, this leads to decreased feelings of pity and increased

feelings of anger and fear. Anger, fear, and lack of pity, in turn, lead to

rejecting responses, such as social avoidance and increased support

for the use of coercive control. The findings also show that

information about dangerousness increases the likelihood of discrim-

inatory responses. However, findings from this study also suggested

that those who are more familiar with mental illness are more likely

to offer interpersonal help and less likely to avoid people with

psychiatric disorders (Corrigan et al., 2003). Taken together, this

research suggests that certain beliefs about mental illness may

increase discrimination toward persons with mental illness, resulting

in social exclusion, and further limiting employment and housing

opportunities, all of whichmay thenworsen psychiatric condition and

may thus exacerbate the likelihood of aggressive behavior.

In an innovative study among police officers in a major

metropolitan area, Watson, Corrigan, and Ottati (2004) showed that

when suspects are described as having schizophrenia, they are viewed

not only as less responsible for their condition and more in need of

help but also as potentially more dangerous. This highlights the

paradoxes inherent in attitudes toward persons with mental illness—

on one hand, increased understanding of mental illness and its causes,

yet increased fear and stigma on the other. A limitation of the study

was that it did not indicate the type of behavior the suspect was

exhibiting. Also, given the lack of real-life context in these types of

studies, it may be difficult to evaluate to what extent educating police

officers and others on mental illness and diagnostic labels would help

them manage situations in such a way that minimizes escalation of

conflict, leading to violence.

4. Individual-level research on mental illness and the likelihood of

violence and crime

4.1. Treatment sample studies

Given public perceptions and conflicting interests among advocacy

groups, the risk of violence among persons with mental illness has

been a somewhat ideologically charged issue, with some emphasizing

increased risk as a way of highlighting the need for better and more

compulsory treatment, and others downplaying the risk of violence as

a way of reducing stigma and discrimination that may worsen a

person's psychiatric condition (Monahan, 1992; Torrey, Stanley,

Monahan, & Steadman, 2008). Much research has examined the

direct relationship between mental disorder and the likelihood of

violent and criminal behavior. One major study—The MacArthur

Violence Risk Assessment Study—compared the frequency of violence

among patients discharged from inpatient treatment units with that

of a “matched” sample of persons living in the same (often

disadvantaged) neighborhoods (Monahan et al., 2001). The study

found a higher risk of violence among persons withmental illness that

had co-occurring substance abuse disorders. This suggested that

mental illness affects violence indirectly by increasing the likelihood

of substance abuse. The most recent and comprehensive study,

including over 1400 adult patients with schizophrenia sampled from

57 clinical sites in 24 states showed that about 19% reported violent

behavior in the last 6 months, a rate much greater than would be

expected in the general population (Swanson et al., 2006).

One of the limitations of studying persons who are in treatment is

that they may be ‘selected’ into treatment because they are inclined

toward disruptive behavior, thus producing somewhat of an upward

bias in the prevalence of violence among persons with, for example,

conditions such as schizophrenia or bipolar disorder. However,

persons with these types of disorders are the most likely among

those with mental illness to receive specialty treatment at some point

in the lifetimes (Wang, Demler, & Kessler, 2002). On the other hand,

as in the MacArthur study, persons with schizophrenia with low

insight and paranoid symptoms are significantly less likely to take

part in studies, and may thus contribute to an underestimate of the

risk of violence (Torrey et al., 2008). It is not clear exactly to what

extent these types of countervailing biases affect estimates of the

likelihood of violence among persons with mental illness.

4.2. Community sample studies

One influential study that used data from the New York

metropolitan area included those in treatment and a community

sample and asked about self-reported violent behavior and arrests.

This study also included data on respondents' official arrest records

(Link, Andrews, & Cullen, 1992). It showed that thosewhowere either

new, ongoing, or former patients, including many with schizophrenia,

bipolar disorder, and major depression are at an increased risk of

39F.E. Markowitz / Aggression and Violent Behavior 16 (2011) 36–44

violence and arrest compared to those with no treatment history

(Link et al., 1992). In this case, while estimates of arrests are more

objective, there is still the problem of the validity of self-reported

aggressive behavior. However, in general, studies have shown that

self-reports are valid, but that there may be a tendency for racial

minorities to underreport violent behavior (Hindelang, Hirschi, &

Weis, 1981). In an effort to overcome this, Link et al. (1992) employed

controls for social desirability bias to correct for underreporting,

along with controls for demographic variables, including race. An

important limitation to this study is that a significant portion of

those with mental illness go untreated; therefore, treatment history

itself is an imperfect indicator of mental health status (Kessler et al.,

2005).

The best, larger scale studies use diagnostic criteria to establish the

prevalence of mental illness, irrespective of treatment history and also

include self-reportedmeasures of violence. They yield similar findings

to the studies above. Using data from the Epidemiological Catchment

Area (ECA) study, Swanson, Holzer, Ganju, & Jono (1990) found that

violent behavior, including hitting, throwing things, and use of

weapons in the last year was found among 25% of those who met

the DSM criteria for a mental disorder, compared to only 2% of those

with no mental disorder. Studies using data from Israel and Finland

with comparable measures, yielded similar results (Link, Monahan,

et al., 1999; Link, Phelan, et al., 1999; Tiihonen, Isohanni, Rasanen,

Koiranen, & Moring, 2007).

It is important to note, however, that persons with mental illness

are not only more likely to engage in violent behavior, but, controlling

for their own violent behavior, are also more likely to be the victims of

violence (Choe et al., 2008; Silver, Arseneault, Langley, Caspi, &

Moffitt, 2005; Teplin et al., 2005). This is understandable, given that

violent encounters are most often a two-way street—one person

initiates violence while the other engages in violence as a means of

responding to threats or in retaliation for perceived harm (Tedeschi &

Felson, 1994). Furthermore, people with severe mental illnesses such

as schizophrenia, bipolar disorder, or major depression are at

increased risk of death by not only suicide but also homicide (Hiroeh,

Appleby, Mortensen, & Dunn, 2001).

4.3. Symptoms associated with violence

Both the treatment sample and general population studies show

that, in many cases, those experiencing certain “positive” psychotic or

“threat control/override” symptoms (e.g., delusional thinking and

hallucinations) are at an increased risk of violence (Elbogen &

Johnson, 2009; Swanson, 1994; Link, Monahan, et al., 1999;

Link, Phelan, et al., 1999; Swanson et al., 1996; Swanson et al.,

2006; Teasdale, 2009). Consistent with symbolic interactionist theory,

persons experiencing these symptoms may accept irrational thoughts

as real, misperceiving the actions of others (including familymembers

or police officers) as threatening and respond aggressively (Link,

Monahan, et al., 1999; Link, Phelan, et al., 1999). In contrast, patients

with “negative” symptoms (e.g., social withdrawal) are at a lower risk

of violence. Moreover, one study finds the effect of threat-control

override symptoms is limited to men (Teasdale, Silver, & Monahan,

2006). These studies also show that the risk of violence is increased

among those with multiple disorders, those with co-occurring

substance use/dependence disorders, and noncompliance with med-

ication regimens that reduce troublesome symptoms (Swartz et al.,

1998).

Despite emphasis on symptoms, other problems associated with

mental illness must be taken into account. Matejkowsi, Solomon, &

Cullen (2008) found that, among 95 persons with severe mental

illness who were convicted of murder in Indiana between 1990 and

2002, most were raised in households with significant family

dysfunction, had extensive histories of substance abuse and crimi-

nality, and had received little treatment for their mental and

substance use disorders. Furthermore, some nonviolent criminal

behavior among homeless persons with mental illness may be

considered “survival” crimes, such as shoplifting and trespassing.

Also, some crime may result from “antisocial” personalities that are a

part of some mental illnesses (Hiday, 1997).

4.4. Demographic factors

Very importantly, in the community studies discussed above, the

association betweenmental disorder and violence or arrest holds after

controlling for demographic factors. In fact, the risk of violence among

those with mental illness is at par with or exceeded by the risk

associated with simply being male, younger, or a disadvantaged racial

minority. In terms of public perceptions, demographic variables, while

perhaps contributing to fear of crime (Quillian & Pager, 2001), are

likely seen as unchangeable, while mental illness may be regarded, to

a certain extent, as something the person “brought on themselves,”

thus outweighing demographic variables that compound perceived

risk. Therefore, persons may be more likely to discriminate based on

the knowledge that someone has mental illness, for fear of disturbing

behavior, than based on demographic characteristics, that, when

taken together, determine the risk of violence to a greater extent. The

interaction among demographic variables and mental illness in their

impact on risk and perceptions of dangerousness remains to be fully

examined.

5. Community context: The role of socially disorganizedneighborhoods

in violence among persons with mental illness

5.1. Social disorganization and mental illness

Theories that explain crime generally can be applied to understand

crime and violence among persons with mental illness. Key to this

approach is understanding howmental illness enhances the effects of

crime-causing variables. One important explanation is that seriously

mentally ill persons have long been more likely to reside in

disadvantaged urban areas, as a result of the downward drift in

socioeconomic status that mental illness often leads to (Faris &

Dunham, 1939). Currently, as a result of deinstitutionalization, lack of

long-term care facilities, and selection processes that limit job and

residential opportunities, many mentally ill and homeless persons

reside in group homes, shelters, or single-room occupancy hotels, or

in subsidized housing, all of which are more likely to be located in

“socially disorganized” neighborhoods. These are neighborhoods

where there are more economically disadvantaged persons, there is

greater racial diversity, and there aremore fragmented families. Social

disorganization theory predicts that neighborhood disorganization

leads to weakened social cohesion, thereby lessening the ability of

communities to exert both formal and informal control over the

behavior of their residents, resulting in increased crime (Bursik &

Grasmick, 1993; Markowitz et al., 2001; Sampson & Groves, 1989;

Sampson et al., 1997). Moreover, in these types of neighborhoods,

cultural norms regarding violent retaliation in disputes are prevalent

(Anderson, 2000). Following from this line of thinking, studies show

that, for persons with mental illness, living in such neighborhoods

increases the risk of criminal offending beyond individual demo-

graphic characteristics, highlighting the role of criminogenic contexts

in facilitating violence (Silver, 2000a,b; Silver, Mulvey, & Monahan,

1999).

5.2. Police encounters

In the face of limited treatment options, disturbing behavior that

might have been dealt withmedically prior to deinstitutionalization is

nowmore likely to be treated as criminal behavior. For example, even

though police may recognize some disruptive behavior as resulting

40 F.E. Markowitz / Aggression and Violent Behavior 16 (2011) 36–44

from mental illness, they often have little choice but to use “mercy

bookings” as a way to get persons intomental health treatment. Police

officers are among those most likely to deal with persons with mental

illness in crisis situations and are now one of the main sources of

referral of persons into mental health treatment (Engel & Silver, 2001;

Lamb,Weinberger, & DeCuir, 2002). Also, police, who see troublesome

situations through the lens of their role as “law enforcers” are

motivated to maintain their authority in conflict situations, often

invoking the power of arrest to do so (Watson & Angell, 2007).

In the wake of deinstitutionalization, these processes have led

some to argue that mental illness has been “criminalized” (Lamb &

Weinberger, 1998; Lamb et al., 2002; Steury, 1991; Teplin, 1990). The

evidence in support of the criminalization hypothesis comes primarily

from the systematic observation of police–citizen encounters that

show mentally ill suspects are more likely to be arrested than their

nonmentally ill counterparts (Teplin, 1984). However, a more recent

study of police–citizen encounters in 24 police departments in three

metropolitan areas elaborates on those findings (Engel & Silver,

2001). That study showed that other factors, not considered in

previous research, such as whether suspects are under the influence

of drugs, are noncompliant, fight with officers or others, as well as the

seriousness of their offense predicts the likelihood of arrest among

mentally ill suspects. Consistent with that research, Kaminski (2007),

using pooled time series data of the 50 states for the period 1972 to

1996 found that the number of mentally ill persons released each year

from state and county mental hospitals was related to rates of lethal

violence against the police. An important implication of these studies

is that if mentally ill persons are overrepresented in criminal justice

settings, it is not solely attributable to discriminatory treatment on the

part of police, but due, in part, to a greater likelihood of arrest-

generating behavior. Many cities have attempted to mitigate the

potential for conflict in police encounters with mentally ill citizens by

implementing crisis-intervention training (CIT) programs. However,

it is difficult to fully assess their effectiveness. Some studies indicate

that while CIT improves police understanding of mental illness, it may

not reduce, for example, the use of force and the likelihood of arrest

(Compton, Bahora, Watson, & Oliva, 2008). Factors, such as the

availability of nonjail treatment, may offset effects of CIT.

6. Situational dynamics: The role of stress and conflicted relationships

in violence among persons with mental illness

6.1. Stress and conflicted relationships

Research on the role of stress and mental illness has been brought

to bear on understanding part of the reason that persons with mental

illness are at an increased risk of violent behavior and victimization.

This research is guided by the logic of the stress process model, the

dominant approach to understanding the social patterns of psycho-

logical distress—more common, sub-clinical symptoms of anxiety and

depression (Mirowsky & Ross, 2003). The theory holds that stress (or

life strains) places persons at risk of psychiatric illness and that stress

is socially distributed, principally according to socioeconomic status,

gender, age, and marital status. Moreover, social support and other

coping resources (e.g., self-efficacy) mitigate the effects of stress on

well-being. Hiday (1995) was among the first to develop a model that

applies these insights to violence and serious mental illness. In her

model, economic disadvantage not only places persons at risk for

developing symptoms of mental illness, but also because of the

disadvantage that mental illness creates, persons with mental illness

experience greater levels of stress and conflict. Aggressive behavior

becomes both an externalized expression of symptoms and a way of

coping with conflict, fear, and goal-blockage—especially in socially

disorganized neighborhoods where violence is more common.

The findings of several studies are consistent with the stress model.

Using ECA data, Silver and Teasdale (2005) find that, controlling for

social demographic variables, stressful life events (e.g., disruptions or

changes in employment, relationships, and living situations) in the past

year and impaired social support explained a significant portion of the

association between mental/substance disorders and violence. Al-

though untested, it is likely that disputes with intimates surrounding

involuntary treatment, efforts to control disruptive behavior, and

financial disagreements may facilitate violent behavior (Estroff et al.,

1994). In fact, similar to violence committed by nonmentally ill persons,

family members are highly likely to be the targets of violence involving

persons with mental illness (Estroff et al., 1994).

Similarly, DeCoster andHeimer (2001)find that violent behavior is a

response to stressful life events and an externalized expression of

depressive symptomsamongyoungadults. Since stressful life events are

structured by social background factors, notably social class, these types

of studies link criminological and mental health research by suggesting

an important pathway by which disadvantaged persons become

involved in serious violence. Moreover, depressive symptoms weaken

family attachments, which, in turn, can lead to further depression and

aggressive behavior (DeCoster & Heimer, 2001). This is consistent with

research that shows that not only are social relationships important for

reducing symptoms, but that, unfortunately, symptoms may erode the

quality of social relationships (Markowitz, 2001). Oneway this operates

is through aggressive behavior.

7. Public policy responses

7.1. Community treatment alternatives

In recognition of the risk of violence and criminalization of mental

illness, there have been increased efforts to provide services within

correctional settings and support for community treatment alter-

natives, such as intensive case management, jail diversion programs,

including mental health courts, and legally mandated assisted

outpatient treatment (Compton et al., 2008; Dvoskin, 1994; Morris

et al., 1997; Morris et al., 1997; Steadman et al., 1995, 1999; Watson,

Hanrahan, Luchins, & Lurigio, 2001). These types of programs take a

variety of forms: some with mental health professionals involved at

the scene of a disturbance and diversion taking place prior to arrest,

others with diversion taking place after arrest (involving special

mental health courts), or crisis intervention training for police to

manage persons in crisis situations and help them get into treatment

facilities, rather than into jail (Reuland & Cheney, 2005). Such

programs require effective coordination between law enforcement,

judges, prosecutors, and mental health professionals. However, the

cultural orientations of these groups can be at odds—public order,

authority maintenance, and punishment versus treatment. The

evidence regarding the effectiveness of these often uncoordinated

programs is somewhat limited in terms of symptom improvement,

quality of life, and likelihood of re-offending, according to the findings

of a large (n=2000), national, randomized, multi-site study (Broner,

Lattimore, Cowell, & Schlenger, 2004; Fisher, 2003; Mechanic, 2008).

However, one recent study using random assignment of subjects to a

post-booking jail diversion program found that those in the program

experienced reduced contact with the criminal justice system over a

12-month evaluative period (Case, Steadman, Dupuis, & Morris,

2009). Reductions were greatest among those with a criminal history.

However, no improvements were shown regarding symptoms,

suggesting that these types of programs may have more a public

safety, rather than public health benefit.

7.2. Outpatient civil commitment

The majority of states' laws allow for mandatory assisted

outpatient treatment (outpatient civil commitment, or AOT) for

those who lack the capacity to care for themselves, many of whom are

at risk of homelessness and criminal behavior (Appelbaum, 2005).

41F.E. Markowitz / Aggression and Violent Behavior 16 (2011) 36–44

However, relatively few states implement the law or have a

comprehensive system of treatment programs to accompany it.

There have been some attempts to gauge the effectiveness of AOT.

One study of 78 patients in New York City did not show any

differences in outcomes between those who received court-ordered

mental health services and those who received non-court-ordered

services (Steadman, 2001). However, that study excluded persons

with a history of violence. Another study of several thousand patients

throughout New York State that had been considered for court-

ordered treatment as a result of troublesome behavior reported

significant improvements in service use and community living among

those under an AOT order compared to those not under such an order

(Van Dorn et al., 2010). However, patients were not randomly

assigned to AOT. Moreover, one implication of these studies is that it

may simply be the availability of services, rather than the court-order

per se that led to improved outcomes.

Unless implemented on a significant scale, these types of programs

may be insufficient to take the place of public institutions focusing

specifically on the inpatient care of persons with serious mental

illness and substance abuse disorders. Moreover, these types of

programs are likely to be most effective when they address a wide set

of issues that are required to facilitate recovery from mental illness

more generally, including illness management, employment, housing,

substance abuse, and trauma intervention (Osher & Steadman, 2007;

Watson et al., 2001). This has led Fisher, Roy-Bujnowski, et al. (2006)

and Fisher, Silver, and Wolff (2006) to argue there has been an

overemphasis on “need for services” in reducing violence among

mentally ill persons rather than on the more general factors that lead

to criminal behavior, such as the failure to make normative life course

transitions, economic disadvantage, and criminogenic lifestyles that

can accompany mental illness.

8. Conclusion

In sum, public psychiatric hospital capacity is an important source

of control of those whose behavior or public presence may at times

threaten the social order. This capacity has been reduced dramatically

over the last several decades. In the absence of this capacity, many

persons with mental illness have fallen through the cracks of

community based services, which can be effective, but are often

fragmented and require active engagement on the part of persons

who require them, yet may not recognize the need to do so.

Unfortunately, this leads to an increased risk of homelessness and

involvement in the criminal justice system, as well as victimization.

The problem is especially pronounced among those who are

economically disadvantaged, who are more likely to reside in

‘disorganized’ neighborhoods, where stress and cultural differences

in dispute resolution enhance the risk of crime.

Concurrently, public perception of violence among persons with

mental illness has increased over the last several decades. Despite an

apparent improvement in understanding the nature and causes of

mental illness, there is the tendency to associate mental disorders,

especially psychosis, with an increased likelihood of violence. As such,

the general public's perceptions are not entirely out of line with

objective assessments of risk. Unfortunately, perceptions of violence

are a significant component to the stigma associated with mental

illness which likely adds to the devaluation and discrimination that

many persons who are diagnosed—yet are not violent—experience.

Stigma and social rejection, in turn, limits social opportunities, such as

jobs, housing, and social networks for persons with mental illness,

which, to some extent, serve as protective factors in reducing stress,

and thereby reducing the risk of violence.

The proportion of persons with mental illness who are at risk of

violence or other criminal behavior is modest. In the aggregate, the

risk translates into appreciable increases in the rates of violent and

other types of crime, resulting in substantially greater numbers of

persons with mental illness who find their way into the criminal

justice system—a system that was not intended for therapeutic

purposes, but has been forced to adapt by becoming the nations

largest residential facility for the mentally ill. High quality, well-

coordinated community mental health services that focus on both

symptom reduction and social-economic well-being (e.g., housing

and employment)may reduce the number of mentally ill personswho

end up in jails and prisons. In response to this significant social

problem, congress has enacted the Mentally Ill Offender Treatment

and Crime Reduction Reauthorization and Improvement Act of 2008,

intended to provide more funding for local programs that will help

divert persons from the criminal justice system into mental health

treatment. Such efforts require tremendous initiative on the part of

policy makers and local agencies, and are likely to be limited in their

development and effectiveness relative to the scale of the problem. An

important next step for research is to compile systematic data at the

community level on such services in order to assess their aggregate

impact. Also, national jail survey data needs to make offenders' city-

level identifiers available to researchers so that aggregate estimates of

the proportion of personswithmental illness in jails in a given city can

be computed and linked with data on mental health services and

examined across a number of cities.

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