In the 1980s, around the time of the massive deinstitutionalization of the mentally ill, I was working toward my degree in clinical psychology by training at a psychiatric hospital in Washington, D.C. One sweet, diminutive, elderly patient sometimes wandered the halls. She had been committed to the hospital after she stabbed someone in a supermarket. She was what is sometimes referred to as a revolving-door patient: She was schizophrenic and heard frightening voices in her head, and when she became psychotic enough, she would be hospitalized, stabilized on medication, and then released back to the community. There she would soon go off her medication, become psychotic, be rehospitalized, stabilized again on medication, released, etc.
At her commitment hearing, she testified that she had become extremely upset in the grocery store before repeatedly stabbing the man in front of her in the checkout line. The hearing officer, aware of her history and sympathetic to this woman with such a sweet demeanor, asked helpfully if she had been hearing voices at the time. Yes, she replied, she had. “And what were the voices telling you?” the officer inquired supportively. She explained that the voices were telling her not to hurt the man, but he had gotten in the express checkout lane with more than 10 items, and that made her so mad that she couldn’t stop herself.
In addition to being a valuable cautionary tale about grocery etiquette, the story illustrates an important truth about violence and mental health: Violence is not a product of mental illness; violence is a product of anger. When we cannot modulate anger, it will control our behavior.
In the wake of a string of horrific mass shootings by people who in many cases had emotional problems, it has become fashionable to blame mental illness for violent crimes. It has even been suggested that these crimes justify not only banning people with a history of mental illness from buying weapons but also arming those without such diagnoses so that they may protect themselves from the dangerous mentally ill. This fundamentally misrepresents where the danger lies.
Violence is not a product of mental illness. Nor is violence generally the action of ordinary, stable individuals who suddenly “break” and commit crimes of passion. Violent crimes are committed by violent people, those who do not have the skills to manage their anger. Most homicides are committed by people with a history of violence. Murderers are rarely ordinary, law-abiding citizens, and they are also rarely mentally ill. Violence is a product of compromised anger management skills.
In a summary of studies on murder and prior record of violence, Don Kates and Gary Mauser found that 80 to 90 percent of murderers had prior police records, in contrast to 15 percent of American adults overall. In a study of domestic murderers, 46 percent of the perpetrators had had a restraining order against them at some time. Family murders are preceded by prior domestic violence more than 90 percent of the time. Violent crimes are committed by people who lack the skills to modulate anger, express it constructively, and move beyond it.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the reference book used by mental health professionals to assign diagnoses of mental illness, does very little to address anger. The one relevant diagnosis is intermittent explosive disorder, a disorder of anger management. People with IED tend to come from backgrounds in which they have been exposed to patterns of IED behavior, often from parents whose own anger is out of control. But the DSM does not provide a diagnostic category helpful for explaining how someone can, with careful advance planning, come to enter an elementary school, nursing home, theater, or government facility and indiscriminately begin to kill.
Violent crimes committed by people with severe mental illnesses get a lot of attention, but such attacks are relatively rare. Paolo del Vecchio of the federal Substance Abuse and Mental Health Services Administration has said, “Violence by those with mental illness is so small that even if you could somehow cure it all, 95 percent of violent crime would still exist.” A 2009 study by Seena Fazel found a slightly higher rate of violent crime in schizophrenics—but it was almost entirely accounted for by alcohol and drug abuse. Likewise, the MacArthur Violence Risk Assessment Study found that mentally ill people who did not have a substance abuse problem were no more violent than other people in their neighborhoods.
With no clear explanation of the causes of violent crime from the mental health field, and with significant encouragement from the gun lobby, the public has begun to seize on the wrong explanation for tragic, violent events. They focus not on the IED-diagnosed patients but on those with other diagnoses, schizophrenia in particular, ignoring the fact that what the perpetrators have in common in every single one of these cases is a loss of control of their anger.