Coverage of the Germanwings crash has focused primarily on two things: Mr. Lubitz's psychiatric history and how the system failed to identify him as a danger. This framing of the event reflects shifting cultural conceptions of the mentally ill and those who treat them. Any attempts to prevent such tragedies in the future would profit from an examination of unwitting distortions that pervade beliefs about both of these populations.
The notion that individuals who suffer from mental illness represent a danger to the public has a long history. Despite advances in neuroscience and public awareness of the causes of mental illness, the prevalence of this stigma has increased over the past half century. Between 1950 and 1996, those Americans who associate mental illness with violence nearly doubled.
So let's look at what the data tells us.
The MacArthur Violence Risk Assessment Study provides a recent and rigorous attempt to address the flawed and conflicting research findings on this issue. It found that the prevalence of violence among those with a major mental disorder who did not abuse substances was indistinguishable from the non-substance-abusing neighborhood controls. Contrary to popular opinion, something that carries remarkable influence, delusions were not found to be associated with violence.
For those with a major mental disorder, the attributable risk, a measure of the extent to which they contribute to the prevalence of community violence, was found to be 4.3 percent. The attributable risk for individuals with a substance disorder was 34 percent.
Despite inconsistencies in the research literature, some observations appear repeatedly. The violence occurs most frequently in the home with family members or close acquaintance.
The most striking difference between the mentally ill and the rest of the population with regard to violence concerns victimization. The mentally ill are much more likely to be the victim than the perpetrator. A large and well-conducted 2005 study found that those with severe mental illness were victims of violent crime 11 times more frequently than the general population.
These findings suggest that mental illness is neither a sufficient nor necessary cause of violence. Rather, like the rest of the population, a nexus of variables must be considered when attempting to predict something as complex as human behavior.
However misguided, the association of mental illness and violence has shaped both mental health laws and ideas about the role of mental health professionals. Starting in the late 1960s the rationale for psychiatric commitment shifted from paternalistic care for those in need to protecting the public from potential harm.
The landmark 1976 Tarasoff case formally established this new paradigm. It stated:
When a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger.
The decision elaborated upon the obligation to protect stating that the therapist might have to "warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps are reasonably necessary under the circumstances."
This may not seem earth-shattering. The directive is predicated on the assumption that a core competency of mental health workers is the capacity to predict violent behavior.
So how good are they in the violence prediction business?
Not so good.
The history of psychiatry and violence prediction can be broken into two periods. In the first period, 1970-1980s, clinical research indicated that psychiatrists and psychologists were accurate in no more than one out of three predictions of violent behavior over a several-year period among institutionalized populations that had both committed violence in the past and who were diagnosed as mentally ill. The American Psychiatric Association (APA) acknowledged that "the unreliability of psychiatric predictions of long-term future dangerousness is by now an established fact within the profession." The APA estimated that two out of three predictions of long-term future violence made by psychiatrists were wrong.
Starting in the late 1980s the accuracy of these predictions began to improve. This advance was accomplished in large part by changing the question. Rather than the binary, "Will they or won't they be violent?" the question was reframed as "What is the probability of violent behavior?"
In addition the method of answering the question (in research settings) changed from clinical (based on a doctor's evaluation) to actuarial (based on statistics of similar people in similar situations). The time frame of the answer was also dramatically shortened from a year or more to several days. A distinguished researcher in this arena stated that these improvements allowed clinicians to distinguish violent from nonviolent patients with "a modest, better-than-chance level of accuracy."
Most people would agree that this level of competence does not seem appropriate for determining whether or not to commit an individual to a psychiatric facility, especially if that individual is you.
So how do false assumptions (the danger of the mentally ill and the capacity of psychiatrists to identify who will be violent) bear on the Germanwings incident?
In perpetuating the stigma of the mentally ill as dangerous, the logical approach to preventing another disaster is to screen for mental illness and identify those who present a threat to the public.
This is exactly wrong.
While mental health professionals may not perform well in predicting violent behavior, they can do a great deal to ease the suffering of individuals who live with mental illness. The continued stigmatization of this population makes it less likely that they will risk revealing themselves by seeking treatment. The only chance we have at preventing that small minority of the mentally ill who might harm others from such acts is by facilitating access to treatment.
The Germanwings tragedy provides an opportunity to rethink the manner in which negative stereotypes of the mentally ill compromises their care and thereby the welfare of all.
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