by Emalee Gillis, NAMI Spokane Blog Editor.

On January 18, as part of the NAMI Ask the Expert series, Dr. Eric Elbogen, Professor of Psychiatry at Duke University, presented a webinar that looked at evidence related to mental illness and violence.  Dr. Eric Elbogen is a Professor of Psychiatry and Behavioral Sciences at the Duke University School of Medicine and a psychologist at the U.S. Department of Veterans Affairs (VA). He has done clinical work in mental health facilities for over thirty years and has conducted research at the intersection of law and mental health and authored over 200 scientific articles

During this webinar, Dr. Elbogen discussed the social stigma and cognitive bias that fuels exaggerated beliefs about the link between violence and mental illness, provided research highlighting numerous other risk factors that are predictors of violence, and explored promising approaches and interventions for preventing violence and enhancing public safety.

To begin the discussion, Dr. Elbogen defined mental illness as it will be used in his presentation. He used the definition by The Substance Abuse and Mental Health Services Administration (SAMHSA) that calls psychotic disorders, bipolar disorders, and major depressive disorders “serious mental illnesses.”

Dr. Elbogen explained that mental illness is not necessary for violence to occur. Only a fraction of violence (about 5%) perpetrated is attributable to psychotic, bipolar, or major depressive disorders.  In other words, the vast majority of violence is not connected to mental illness.

“Mental illness is not sufficient for violence to occur,” he said. “”Lacking empathy,” “criminal thinking,” and “hatred” are not symptoms of schizophrenia, bipolar disorder, or major depression. Every study on the subject shows that most people with mental illness are not violent. Indeed, people with these mental illnesses are more likely to be victims of violence than those without.”

Dr. Elbagen continued, “Yet, when a violent incident worthy of national media coverage occurs, news outlets, politicians, pundits, and others often blame mental illness for the violence, often within 24 to 48 hours. Such discussion typically continues for a day or two. Sometimes mental illness is present in the offender, and sometimes it is not. But mentioning mental illness at that early point is speculative nine times out of ten. Most facts are still unknown, and a mental health expert has not yet evaluated the offender. When (and if) the media reports other information, it is often days later, and their audience has likely moved on to other stories. The public largely remains in the dark about the other factors contributing to the violence. The media and public are caught in this cycle when violence occurs that has been deemed newsworthy.

“The current pattern of reacting to violence is like a person starting a jigsaw puzzle, picking up a single “mental illness” piece, and announcing that the puzzle has been solved,” he said. That makes no sense, yet reflects the mindset of many people when tragedy strikes; they want a simple answer to soothe panic, even if it’s wrong. After high-profile violence, it’s natural for people to want clear and immediate answers. But violence is multifactorial, there is no single cause. Each act is made up of multiple puzzle pieces. Instead of reflexively jumping to conclusions, society needs to recognize that many risk factors contribute to each violent act.”

Dr. Elbagen presented study after study that looked at the perceived link between mental illness and violence. He said, “The research showed that the link between mental illness and violence is intricate and impacted by non-mental illness factors. People with mental illness are vulnerable to risk factors such as childhood abuse, social stressors, financial strain, or being victimized. Mental illness without substance abuse is less strongly related to violence. Mental illness doesn’t exist in a vacuum; one cannot artificially isolate it from the rest of a person and say it is the single and only cause of a violent act. Even in the case of a person with a psychotic disorder, it was shown psychotic symptoms immediately preceded only 12% of violent incidents. Mental illness alone as a diagnosis is less consistently related to violence. Symptoms such as hostility and suspiciousness are more relevant than diagnosis. For these reasons, it is simplistic to say mental illness is “the” cause of a violent act as this exists within a web of multiple risk factors.”

Dr. Elbagen said, “There is no pattern of mental illness showing a strong effect size for any violence type. Rather, for most types of violence, mental illness or mental health problems showed a small effect size, if listed at all. Evidence shows that the public’s view of mental illness as a top cause of violence is mistaken.”

He continued, “Instead of fixating on mental illness as the sole cause, a broader exploration of risk factors is essential to understanding and preventing violent acts. While mental illness might play a role in some violent acts, it is virtually never a sole or primary cause. Many factors contribute to violence, such as criminal behavior, substance abuse, anger, and psychopathic traits. Simplifying violence as solely linked to mental illness neglects other important risk factors that can contribute to violent behavior.”

“By overly emphasizing mental illness as the cause of violence, society overlooks other crucial risk factors that contribute to violent acts, such as hate, poverty, substance abuse, and access to weapons,” he explained.  “Effective violence prevention strategies must consider a comprehensive range of risk factors and not solely focus on mental health. To better understand and prevent violence, it’s essential to consider a broader spectrum of risk factors, including external factors (like social support and financial strain), internal factors (like anger management), and violence-defining risk factors (such as gun access and antisocial traits).”

Dr. Elbagen identified numerous evidence-based interventions that address this broader spectrum of risk factors.

Dr. Elbagen said, “Shifting the narrative from blaming mental illness to exploring a more comprehensive understanding of violence risk factors can lead to more effective interventions and policies to promote public safety.” He added that, “Media, politicians, and the public must move beyond knee-jerk reactions blaming mental illness for violence. Recognizing multiple risk factors is crucial to avoid perpetuating bias, stigma, and neglecting more significant contributors.” He concluded, “Failure to prioritize addressing stronger risk factors and reducing the viability and acceptability of violence hampers our ability to prevent future violent tragedies, making us all less safe.”

Dr. Eric Elbogen is a Professor of Psychiatry and Behavioral Sciences at the Duke University School of Medicine and a psychologist at the U.S. Department of Veterans Affairs (VA). He has done clinical work in mental health facilities for over thirty years and has conducted research at the intersection of law and mental health and authored over 200 scientific articles.

Emalee Gillis is a writer and blog editor. She is the author of the memoir Adventures on the Path to Living Well with a Mental Illness and has a related TEDx Talk.