Violence and schizophrenia: let us take a deep breath and gain a meta-perspective

Despite increased openness concerning mental health problems, severe mental illness is still subject to stigmatising attitudes. Thus, attributing a heightened risk of violence to already vulnerable individuals inevitably raises important questions. Although most people with schizophrenia will never act violently, well-replicated epidemiological research shows robust associations between violence and schizophrenia after accounting for known confounding factors such as substance use and social adversity,¹ and qualitative research has identified psychological processes leading to violence in schizophrenia.² However, concerns have been voiced regarding the strength of this association owing to putative flaws in interpretations of existing evidence that allegedly contribute to perpetuation of social biases.³ Could it be that by reporting an association between schizophrenia and violence, researchers inadvertently perpetuate stigma and the perception of all individuals with schizophrenia as dangerous? We believe that an open discussion about research on this complex and context-dependent issue is essential. Such a discussion should include transparency about the limits of knowledge acquired through research, the potential for subjective interpretation of results, and how these are communicated and received by the public.

Keeping this in mind, two strikingly different perspectives on violence and schizophrenia appear to circulate in the research community. How can such contrasting narratives coexist? We propose three reflections to gain a better understanding of what we are really talking about when we talk about violence and schizophrenia.

All humans are immersed in their historical and cultural contexts, a concept Martin Heidegger described as ‘thrownness’ into the world.⁴ With this broader perspective, significant cross-cultural differences in attitudes towards psychiatric treatment appear, shaped by core values and social norms. These can be epitomised by an urge for individual autonomy and freedom of choice (prevalent in the USA) or by perceiving top-quality free-of-charge psychiatric treatment as a fundamental human right (present in Scandinavia). In cultures prioritising individual freedom, providing hospital admission in mental health facilities to homeless individuals with schizophrenia may be met with strong criticism owing to infringement of autonomy.⁵ Labelling someone as ‘dangerous’ and ‘mentally ill’ can lead to social exclusion, especially in societies lacking a safety net to prevent a complete fall. This can translate to researchers’ approach towards forensic psychiatry. In societies where mental healthcare is a fundamental right, openness to psychiatric treatment may be more widespread, yet it is important to acknowledge heterogeneity of perspectives. Scandinavia's socioeconomic equality and high societal trust foster public recognition of the need for intervention as a collective responsibility. This sociocultural setting with its publicly available healthcare has enabled the establishment of population-based registries, which in turn has facilitated investigations of important health issues such as the association between violence and schizophrenia.⁶ Registry-based knowledge has the potential to support autonomy and enhance public safety by, for example, reducing coercive restraints for those at low risk based on the development of accurately calibrated prediction tools.

Moreover, a researcher's intellectual and professional milieu may also influence their stance. A discourse on violence and psychiatry in the Western world warrants mention of Franco Basaglia, a pivotal figure in deinstitutionalisation of psychiatric care, and Michel Foucault, a postmodern philosopher, who challenged the conceptualisation of mental illness across historical contexts. Here, the traditional psychiatric system is intertwined with power dynamics, thus contributing to stigma and oppression. Even if unacknowledged, this intellectual ‘zeitgeist’ may subtly influence researchers’ perceptions of the link between violence and mental disorders.

Further, through the lens of the is-ought fallacy, a logical principle introduced by the philosopher David Hume,⁷ we cannot derive what should be (‘ought’) from what is (‘fact’). Thus, observing that a phenomenon exists does not necessarily mean it should. ‘Saying that we advocate something just because we report it is like saying oncologists advocate cancer’, to quote the neurobiologist Robert Sapolsky.⁸ Reporting an association between schizophrenia and violence does not imply subjective support for this link, nor does it mean the researcher is pleased with identifying it. Conversely, by flipping this principle to an ought-is fallacy, one interprets what should be as what is. Whereas a researcher might wish individuals with schizophrenia did not face additional burdens or the risk of being a perpetrator of violence, her desires do not translate into facts. Yet, it may be tempting to contest this reality for fairness and seek alternative explanations for these associations. This is analogous to denying the harmful human impact on the environment because it should not occur and thus concluding that it does not happen.

Finally, let us delve into a fundamental aspect of the discourse on severe mental disorders and violence: stigma. Originally, the Greek word ‘stigma’ referred to a mark branded on criminals or slaves to denote inferiority. Sociologist Erving Goffman popularised the term, identifying various types, including blemishes of individual character such as mental illness or criminal record.⁹ Such characteristics become stigmatised as they deviate from cultural norms regarding ethical behaviour. A challenge then arises: how can we alleviate the stigma against individuals with schizophrenia and a history of violence? Let us first examine this statement: ‘Reporting an association between schizophrenia and violence perpetuates the stigma linked to this disorder’. And now applying reductio ad absurdum, a philosophical technique meaning ‘reduction to absurdity’, we assume the inverse: ‘not reporting an association between violence and schizophrenia would mitigate the stigma’. Is this latter statement true? Or could it be that not reporting the potential link would remove the topic from the public and scientific focus, leading to it slowly becoming a taboo? If so, the public would lack comprehensive and nuanced information, potentially intensifying fear and reliance on unreliable sources of information, and eventually fuelling stigmatisation. Perhaps the best approach to dispel the stigma is an in-depth understanding of the association between violence and schizophrenia while acknowledging the limitations of scientific inquiry. This endeavour requires an ongoing, balanced discourse supported by rigorous longitudinal quantitative and qualitative research that confronts rather than shies away from the complexities of these issues. This may help identify causes of violence and the steps needed to mitigate it, including refinement of prediction tools. Ultimately, this could lead to identification of subgroups at risk, thereby destigmatising schizophrenia as a whole.