Schizophrenia and violence: the problem is reality, not violence.

Nobody wants to own it. It’s senseless, gory, unpredictable, and always gut-wrenchingly sad. I wouldn’t want to own it, either, but I do. It’s the violence of insanity. How should we think about it? Does mental illness cause violence, or doesn’t it?

Lots of harm comes from thinking that all people with a mental illness are dangerous. Currently, advocates at NAMI and other organizations point out this harm, noting that almost nobody wants to be considered dangerous, so this danger stigma makes it harder for someone with a mental illness to admit it. But lots of harm also comes from thinking that there’s no link between the illness and the violence. As a mother, I object strongly to one of the implications of delinking them. If there’s no link, then my son must have committed a violent act out of some other motive, and since he killed a family member, wow he must be really evil. Nope. He just isn’t; that’s the wrong answer.

So how do we handle this linkage? Does mental illness cause violence? Does it cause patients to be victims of violence? Statistics can be used to support either one, depending on who’s included in the study group and what’s studied. I’m not going to argue with numbers. Let’s just look, instead, at what thought disorders actually do.

There are three kinds of mental disorders: anxiety, mood, and thought. Anxiety disorders could make someone dangerous; men, especially, may attack when they’re panicking. Mood disorders usually make someone dangerous to self, when the mind is seized with darkness caused by a brain malfunction. But thought disorders are a horse of a different color.

There may be thought disorders other than schizophrenia; right now, we tend to call them all “schizophrenia,” as an umbrella term. Thought disorder means the brain’s ability to process real sensory data is being disrupted. It’s so weird to realize this, but the brain can actually generate its own images, sounds, and memories without any reference to what the eyes and ears are collecting. Sometimes, a temporary state like fever or seizure can create this effect.

In a thought disorder like schizophrenia, the disruption becomes common enough that the person can’t tell which sounds and images came in through eyes and ears, and which ones were created in the brain. Worse, there’s a deeper malfunction in that the fake images may be more tinged with emotion: they seem more real. More important. More relevant. More urgent.

We trust our eyes and ears to give us accurate information about where we’re standing in traffic, whether we’re in the deep end of a swimming pool, or whether that guy just punched us or not. We count on this information being accurate so that we can decide whether to step forward or backward. Imagine how much danger you’d be in if you were in the middle of jaywalking through heavy traffic and suddenly got an attack of vertigo. You might walk straight into an oncoming car’s fender.

Thought disorders cause people to live in a chronic state of uncertainty, or worse, false certainty. Most of the time, they can trust their eyes and ears, otherwise they could not even walk down stairs. But some of the time, they shouldn’t. They never quite know when those times are happening.

It isn’t hard to see that the real problem here is reality-testing, not violence. If you see things that don’t correspond to actual bodies and buildings, if you hear things that didn’t come to your ears via sound waves, if you remember things that never happened, you might well either become a victim of violence or commit violence. You’re lost, like the jaywalker with vertigo.

The only thing that can save that poor jaywalker is if someone can grab his shoulders and steer him, stumbling, to the sidewalk to sit down until the fit passes. And that’s what people with thought disorders need, too. There’s a huge problem, though: in order to steer them to safety, we need to correct their brain disorder, and that process is always invasive and often difficult. Treatment laws try to protect us from mistaken or unnecessary interventions, but they usually have a fundamental fallacy.

Right now, most states have treatment laws that presume the patient himself can tell real reality from fake reality. Knowing he’s seeing fake reality, he asks for treatment. Well sometimes this happens, sometimes it doesn’t. Now what? Most state treatment laws do not permit an outsider to decide that treatment must happen unless there is “clear and present danger.” That’s like saying you can only steer a stumbling, dizzy person if he’s in the middle of jaywalking through New Jersey rush hour. Stumbling down the sidewalk? Hands off. Stumbling down Main Street of a one-stoplight town? Leave ’em alone. Stumbling around his house? None of your business. Danger has to be clear and imminent.

When the laws were written, there may not have been a clear understanding of what thought disorders really were. Many people simply do not believe that thought disorders are possible. They’ve been around liars and manipulators so much that it seems patently obvious to them that anyone who claims to see, hear, or remember a false thing is just lying.

When states permit families or doctors to force treatment only when there’s clear and present danger, they are essentially saying either that thought disorders don’t exist, or that we can’t ever know when they exist or not. We have to presume that someone’s brain is working well, no matter what they say or do. We have to presume this right up until the moment when, like a person with vertigo, they step in front of a truck.

False reality tells the schizophrenic patient that it would really make sense to run away, to strike out, to hide, or to refuse to eat. They’re only doing what makes sense, and that’s what anyone would do. Don’t expect me to take a step forward if I believe there’s a cliff in front of my feet, or to eat a cookie that people have warned me is poisoned. The problem isn’t what they are choosing. The problem is that they’re working from a false reality.

Our mental illness laws will start to make sense when, first, we have a scientific way to tell who’s seeing false reality, who’s actually just lying, and who’s just being imaginative. Until we have a scientific method to know, we’ll have to use human judgment. Second, our laws will start to make sense when we permit those with special training or those who know the person well to say “okay yeah this is false reality, not lying or pretending.”

It’s not as hard as you might think; since thought disorders are caused by disease processes, there are other signs. Facial muscles grow more rigid, neurological reactions may slow down. Eye contact is disturbed: their eyes just don’t look right. And they do things that no liar or pretender would do, things that have no point or put them in danger.

We’ll get a handle on violence, and victimization from violence, when we start actually believing that thought disorders are real enough to be identified. Then we can shift from waiting for “clear and present danger” to freeing someone from the dangers of false reality.