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 themselvesfrom 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.
The attribution of violent crime to people diagnosed with mental illness is increasing stigmatization of the mentally ill while virtually no effort is being made to address the much broader cultural problem of anger management. This broader problem encompasses not just mass murders but violence toward children and spouses, rape, road rage, assault, and violent robberies. We are a culture awash in anger.
Anger disorders are a product of long-term anger mismanagement. They are a pathological misdirection of normal aggressive feelings. Anger is, at its essence, a part of the basic biological reaction to danger, the fight or flight response. The physiological shift makes us stop thinking and mobilize for immediate action, as though our life depends on it. It is a primitive response, and very powerful. Anger prepares us to stand our ground and fight. It helped our ancestors survive, but in today's complex technological world, it is often more hindrance than help. The angrier you feel, the less clearly you can think, and therefore the less able you are to negotiate, take a new perspective, or effectively handle a provocation.
The violence that is a part of anger disorders is fueled by chronic repressed rage that has found no socially acceptable outlet. It is fostered by families in which adults behave in violent, intimidating ways or in which anger is tightly repressed. In either situation there is no appropriate model for the safe or constructive expression of anger.
One of the allegations that have recently been made is that the mental health community is failing society in dealing with violent crime. I would agree with this assessment. We have failed to provide an appropriate diagnosis for out-of-control anger or a framework to assist people in understanding the senseless violence around them, and worse, we have done nothing to prevent it.
The truth is, anger management skills are simple techniques that can and should be taught to children and adolescents. We should not wait to teach these skills until verbally or physically violent behavior has become habitual and, often, life-threatening.
The skills involve balancing the initial fight-or-flight response, governed by the sympathetic nervous system, with its opposite, the parasympathetic nervous system, which permits reasoning to take over again. It's simple, but it requires a significant amount of practice. There are many techniques that can be taught to achieve this end: deliberate shifting from emotional to more objective thinking, deep breathing and other relaxation techniques, communication and listening skills, and identifying warning cues before anger boils over.
Mindfulness training is a technique that shows great promise as a tool for the development of healthy and constructive management of negative emotions. Mindfulness can reduce anxiety, depression, and stress. It has been used with success in populations as diverse as cardiac patients, prison inmates, police officers, and children. It incorporates deep breathing, heightened attention to one's internal state, and the acceptance of internal discomfort. One can observe one's own thoughts without identifying with them and acting on them.
Dialectical behavior therapy, a kind of cognitive therapy developed by the psychologist Marsha Linehan, was designed to meet the needs of extremely emotional, volatile individuals and has been used successfully over the past 25 years. It incorporates mindfulness skills and also teaches distress tolerance, emotional regulation, and interpersonal effectiveness.
Uncontrolled anger has become our No. 1 mental health issue. Though we have the understanding and the skills to treat the anger epidemic in this country, as a culture, we have been unwilling to accept the violence problem as one that belongs to each and every one of us. We have sought scapegoats in minority cultures, racial groups, and now the mentally ill. When we are ready to accept that the demon is within us all, we can begin to treat the cycle of anger and suffering.