A violent stigma for mentally ill
Psychiatric nurses argue that more staff are needed to manage violent patients – but are patients with mental illness any more violent than the rest of the community?
WHEN THE union representing psychiatric nurses launched a campaign for extra staff earlier this month, it painted a disturbing and violent portrait of life on the wards of our mental hospitals.
Due largely to hundreds of staff vacancies, the union argued, there has been a sharp increase in assaults on members of staff. It said 1,314 assaults on staff were recorded last year, up from 966 in 2007 and 1,104 in 2008.
On one occasion eight gardaí in riot gear had to come to the assistance of nurses trying to manage a highly aggressive patient at St Brendan’s Hospital in Dublin. In Ennis, it says, a single patient was being managed 24 hours a day by security staff due to a shortage of nurses and secure facilities.
The result, the Psychiatric Nurses Association said, was that patients suffering from depression, anxiety and bipolar disorder were having their recovery threatened by this “frightening and threatening hospital environment”.
The picture depicted by the union, however, has been criticised by some mental health campaigners. John McCarthy, founder of the Mad Pride movement, says the behaviour of a small minority of patients has been used to further nurses’ demands for higher staffing levels and better working conditions.
The collateral damage, he says, is that efforts to reduce stigma against people with mental health problems are being undermined.
“There are vastly more assaults on staff in A&E units on any Friday or Saturday night than in all our mental health facilities,” he says. “This kind of language just undermines the effort, good work of those of us living and battling with stigma on a daily basis.”
The episode has opened a debate about violence and mental health problems. Do psychiatric patients pose a greater risk to the public than the rest of the community? In recent years the public has become increasingly concerned about the risk of violence from patients with severe mental illness, particularly those who have been discharged into the community.
A few incidents have received considerable attention and left a strong impression of the potential danger posed by psychotic patients.
In addition, the media has been criticised for its portrayal of the mentally ill as violent and dangerous. In the UK, studies have found that as many as 40 per cent of tabloid articles about mental health used stigmatising words such as “nutter” and “loony”. Similar findings have been uncovered in Ireland by Headline – a HSE-funded group that monitors media coverage of mental health issues.
Last year researchers at the University of North Carolina set out to find some definitive answers about the links between mental illness and violence. They interviewed some 35,000 people, one of the largest ever studies of its kind, and came up with a surprising conclusion: people with mental illness alone are no more likely than anyone else to commit acts of violence.
“We found that several other factors – such as a history of violence or substance abuse, or a recent divorce or loss of one’s job – are much more predictive of future violence than mental illness alone,” said Prof Eric Elbogen, lead author of the study and assistant professor at the university’s forensic psychiatry programme.
These findings, he said, challenge the perception often reflected in the media: that mental illness alone makes someone more dangerous. “Our study shows that this perception is just not correct,” added Prof Sally Johnson, the report’s co-author.
When they dug deeper into the data, they found that when mental illness was combined with substance abuse, the risk for future violence was statistically significant. However, even mental illness combined with substance abuse ranked only ninth on the study’s list of the top 10 predictors for future violence. (Details such as age, sex, history of violence or abuse were more important factors.) The study concluded that it was “simplistic as well as inaccurate” to say the cause of violence among mentally ill individuals was the mental illness itself.
That’s not to say that there isn’t a problem with violence in psychiatric facilities. Clearly the number of incidents is significant. For one, there are patients with a dual diagnosis of mental illness and substance abuse. This subgroup is more likely to be involved in a violent act, according to research.
In addition, there is the issue of the physical environment and treatment options available in what is still a largely antiquated mental health system.
Research by the Royal College of Psychiatrists indicates that the built environment plays a crucial determining role in patient behaviour: access to privacy, open spaces, fresh air and making the environment more homely all contributed to lower levels of violence. These findings are especially relevant given the state of many of our Victorian-era mental hospitals.
For campaigners such as John McCarthy, giving patients a greater say in their treatment and more access to alternatives is important. Just as urgent, he says, is the need to tackle the ongoing stigma surrounding mental illness by increasing awareness and understanding of the condition.
“We host Mad Pride family fun days to engage the community through fun and laughter, and thereby break down stigma and increase awareness and understanding of the normality of madness,” he says. “We’ve had thousands of people enjoy these outings in Cork, Portlaoise, Killarney – and even in Uganda.”