Schizophrenia and violence When is someone a danger to himself or others?

The news from Tucson is painful for all of us, but in a particular way for anyone related to someone with mental illness.   For parents of the mentally ill, headlines about a person who is almost certainly psychotic cause anxiety and pain.  But psychosis isn't the same thing as rage, even though it may involve it; in fact, it is often a state of intense fear.  People with schizophrenia, as well as those with bipolar psychosis, seem to want to protect themselves, first and foremost; sometimes they want to right some enormous wrong and save the world; sometimes they want to stop the hurt and end it all.   A world where nothing looks real and no perception can be trusted -where the TV is sending cryptic messages and the faces of loved ones are distorted masks-is at best unsafe; at worst, intolerable.

 Because aggression is a natural response to fear, violence (or the potential for violence) is part of the landscape for patients and parents alike.   Even if parents would rather not acknowledge the danger of violence, getting appropriate treatment forces them to confront the issue.  The legal requirement in order to keep someone on an inpatient ward involuntarily is that the person has to be "a danger to self or others."

But it's very hard to get treatment, the way things are set up.  For one thing, parents hesitate to try to "prove" that they themselves are in danger.  They can't believe their child is so changed that he would do something unthinkable, and they don't want to say anything damaging about their child.  Almost a decade after the events, I'm still troubled over how things went in the first year my son was sick.  He was hospitalized ten times, often for "three-days," the length of stay before a judge had to rule on the "danger" issue in order to keep someone in the hospital against his will.   The typical three-day admission involved a once-over by the psychiatrist, a prescription for a new antipsychotic medication, and a discharge to home-where the meds would be dumped and things would go back to square one.  My son did do things that might qualify as dangerous.  I imagine a lot of parents with an ill child are familiar with items like knives under the bed, smashed crockery, empty pill bottles, baseball bats, shards of glass.  Ultimately my husband and I made a formal statement about his "dangerousness" in a court of law in order to get a Roger's guardianship that allowed us to enforce the taking of antipsychotic medication.  The guardianship, plus a refusal to allow our son to be discharged to home-a very difficult step for us--ultimately led to the long-term treatment that he needed.

Even so, the mention of danger still rankles both my son and me.  In the legal system, where these things usually go, "danger" doesn't feel like the description of a symptom, but more like an accusation.   It's a painful way to help someone get help.  Families find it hard to "tell" on their child, and hard to face up to the fact that something tragic and irreversible could occur.  When I worried that I'd overstated my son's potential for violence in order to get the hospital to keep him longer, a social worker told me, "Isn't it better that you got him help and stopped him from something worse?"  Still, I'm haunted by questions: How dangerous was he?  Should we have tried to keep him at home and off the locked ward?  Is it worse for him that he fell into "the system" and formally became a "schizophrenic"?  Is it worse for him that we became his guardians?

There is no way of knowing for sure when someone assaulted by delusions or hallucinations will go off the grid and commit violence.  (Against "self" more often than "others":  people suffering from psychosis are much more likely to commit suicide-10% of young males with schizophrenia kill themselves-- than homicide.)  Given the uncertainty, it does seem it would be better to allow for vigorous and effective treatment without forcing parents to prove the danger.   Because so much of the burden falls on families, with so little help from the mental health system, it's no wonder that some kids just "fall through the cracks."

Published on January 15, 2011 by Betsy Seifter, Ph.D. in Schizophrenia Diary