Does Stranger Mean Danger?

The main reason given for depriving a person of his or her liberty by imposing involuntary hospitalizations and/or forced medication is that “the patient poses a danger to self or others.”  The assessment that danger exists is then used to justify taking measures to alleviate the threat of harm.  And if the danger is frightening enough, then risky measures can be taken that are themselves known to have a fairly high probability of causing significant harm.  Danger must be minimized.

The lost art of deliberate clinical inertia:  Don’t just do something; stand there!

Now, of course, when people are suffering, we should just stand there only when there isn’t anything more helpful we can do.  Then, just standing by them as they suffer—keeping company with them and keeping them from feeling alone or abandoned in their anguish—may actually be doing something.  It may be doing something despite how ineffectual and awful it feels not to feel like you’re doing something.

That awful feeling is actually another kind of danger when a person’s strange behavior appears to threaten violence.  This is the danger to the clinician’s identity.  When faced with a distressing situation, those who have studied and trained to make their meaning in life lie in their identity as healers often feel compelled to do something.  If they don’t do something then they have failed at their chosen assignment in life.  If the action then taken provides no benefit—and even if it makes the situation worse—at least it reaffirms the clinician’s identity as an expert who doesn’t just stand by passively when faced with human suffering.

In their struggle with these dangers, some leading psychiatrists have even justified the prescription of drugs that are known to increase suicidal thoughts and feelings to treat suicidal thoughts and feelings!  And they can do that despite the fact that those drugs (the antidepressants) have been shown to be no more effective than a placebo for the vast majority of patients for whom they are prescribed.

Whether or not the evidence supports the belief, in order for good folks to force treatment on others, they do have to believe that the measures they employ are effective, meaning that they will do more good than harm.  However, when that belief is applied to the use of “antipsychotics”—I put the word in quotes because in and of itself it implies effectiveness—we see that the research (even that produced by advocates of medication) does not support the conviction.  Thus, the actors must deceive themselves in order to (forcefully) sell dubious, dangerous treatment.  This is an example of the evolutionary principle of self-deception in the service of deception.

Indeed, assessing danger and treatment effectiveness involves judgments that reveal as much, if not more, about the one doing the assessment than the one labeled as being at risk.  The research shows that the only folks who consistently benefit from the coercive use of antipsychotics and involuntary hospitalization are the ones selling the drugs, running the hospitals, and doing the prescribing.  While the cautious, limited use of hospitals and medications appears to benefit some patients some of the time, reliable benefits accrue to the doctors, hospitals, and pharmaceutical companies.  Objective measures suggest that, despite the benefit that some may receive (and for whom judicious use of the treatment could be justified), on average, such standard treatment makes life worse for the majority of patients, especially those on whom the treatment is forced.

Stranger danger

In an earlier article, I suggested that there is one thing folks who receive a label of psychosis have in common:  The social surround finds something strange about their behavior or statements.  They don’t conform to expectations.  Therefore, they are “strange.”  And I suggested that we have been designed (via evolution through natural selection) to feel that strangeness indicates possible danger.

If that is so—and especially if the standard treatment is more often than not detrimental—we need to be sure we are not over-assessing danger (1) because of a natural tendency to find strangeness somewhat anxiety provoking and (2) because of the assessors’ natural, self-interested bias.  Regarding the latter, we must always be wary of the danger of Maslow’s Hammer:  “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”  And psychopharmacology is psychiatry’s hammer.

With this concern, in that earlier article, “A Phenomenological View of Madness and Medicine,” I looked at the interaction between stranger=danger and self-interested bias when it comes to mental health treatment.  But first I felt compelled to acknowledge that there is, in fact, a higher rate of violence committed by folks who are labelled psychotic.

The association of “mental illness” with violence and the correlation-causation fallacy

You see, John Monahan, a prominent psychologist whose work was often cited in legal opinions exploring the validity of expert predictions of dangerousness, had long championed the notion that serious mental illness was not associated with increased violence.  More recently, however, he felt forced by the data to change his opinion:

The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social and demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior.

The question remained, however, as to why there is a higher rate of violence committed by those diagnosed with major mental illness.  I noted that there was also research that suggested that violence was not associated with mental illness directly, but rather with substance abuse.  If those diagnosed as psychotic had a higher rate of substance abuse, then indirectly there would be an association between diagnosis and violence, with the latter being due to substance abuse, not psychosis.

This is an example of the correlation-causation fallacy:  Mental illness apparently is correlated with increased violence.  But the problematic factor is not the “illness” per se; rather the problem may be the attempt to escape from the pain of psychotic experience using drugs.  In fact, other research showed that those diagnosed as psychotic who also have a history of substance abuse are not more likely to be violent than those involved with substance abuse without a psychosis diagnosis.

Who started it?

Furthermore, when medication is forced upon a person, physical struggles against the aggressors occur.  Indeed, if force is used, then the existence of such struggles is tautological.  And when such struggles cause injury or other serious problems, they are then considered examples of dangerous behavior on the part of the patient.  This alone would lead to a correlation of psychosis and violence.

If you think that’s farfetched and medication and other forced treatment struggles couldn’t be common enough to account for the association between a major mental illness diagnosis and violence, then you haven’t been involved in the mental health system.  To illustrate the problem, I described a patient whose “treatment [was] focused exclusively on ‘medication compliance.’ It, and nothing else of substance, was on every page of Henry’s hospital, treatment record.”  At first, folks may feel a person is acting strangely.  When they then try to control that person’s behavior with force, is it not possible that they are causing the violence that ensues?

Let’s leave that possibility aside and return to the research findings that show associations between diagnosis, substance abuse, and violence.  As noted, the earlier empirical evidence suggested that the direct problem associated with violence was substance abuse.

A new study

Now, a new study supports the conclusion that it is substance abuse that accounts for the increases in violence and not mental illness. Using recidivism (the rearrest rate) of releasees as the target measure, the authors reviewed the data from 10,000 New Jersey state inmates released in 2013.

What they found was that those releasees who had been identified as having a mental illness but who lacked a history of substance abuse had the lowest rate of recidivism, even lower than those who had no history of substance abuse and no diagnosis of a mental illness.

Rearrest by Diagnosis (from Zgoba, et al., 2020)

Comparing the rearrest rate of those with a “mental illness” and no substance abuse history (.92) with those with a mental illness diagnosis and a substance abuse history (1.47), we see a 160% greater rate when both elements are present. The difference is statistically significant (two-tailed p=0.0016). The driving factor does appear to be substance abuse, not mental illness.

What about antipsychotic meds?

A claim could be made that antipsychotic medication accounts for the low rate of recidivism among those releasees with a mental illness diagnosis and without a history of substance abuse. However, only a fifth of those diagnosed as mentally ill had a prescription for antipsychotic meds upon release. In the CATIE Study (Clinical Antipsychotic Trials of Intervention Effectiveness), close to 75 percent of the patients discontinued their medications during the 18 months of the study, confirming that antipsychotic compliance was the exception, not the norm.  Thus we can be fairly sure that relatively few releasees—most likely well under 5%—with a mental health diagnosis took antipsychotic medication regularly during the three years (36 months) of this study.

Furthermore, from the data presented in the research report I was able to calculate the average number of rearrests per releasee with a mental health diagnosis with and without prescriptions for antipsychotic medication. When this is done, we find that the average number of rearrests was almost exactly the same (1.4) for both those prescribed antipsychotic medication as well as the unmedicated group. Antipsychotic medication—with its known risks and dangerous, long-term side effects—had no effect on the rearrest rate.

One policy conclusion that could be drawn from this study is that the attempt to use drugs to make mental patients less dangerous is the exact opposite of what is needed. What we need are effective programs that reduce the use of all unnecessary, harmful drugs, including the antipsychotics.