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Recovery Model: Mental Health Recovery Model Applied to Severely Mentally Ill; JH Rick Massimino MD

Violence and Psychosis

Are psychotic individuals dangerous? 

Each time a tragedy (often death and mayhem) becomes public involving a seriously mentally ill person, well intended advocates promote the mantra that mentally ill people are no more dangerous than any other community citizen. The public and selected professionals know this to be preposterous. Psychotic and untreated patients are very dangerous! An old axiom of medicine is that one cannot correct a problem that is not acknowledged. Until we accept the truth that untreated psychosis is dangerous, we will never create the proper treatment environment.

We must start with an understanding of what is meant by psychosis. There are different symptoms which characterize psychosis. Some of these symptoms, thought disabling and serious may not necessarily be or result in danger. Examples of these less dangerous or negative symptoms are social withdrawal, personality changes, apathy and indifference. The so called positive symptoms of psychosis such as hallucinations and delusions are potentially very dangerous. Especially dangerous are command hallucinations which are voices telling a person to commit an act. Equally dangerous are delusions (false thoughts which cannot be changed by reason or logic) when the thoughts create fear, panic, paranoia, and other emotions causing aggression. Often, both hallucinations and delusions are present in the same person and generally these individuals are diagnosed with chronic paranoid schizophrenia. Again, untreated hallucinations and delusions create an extremely dangerous situation which worsens over time.


If untreated hallucinations and delusions are dangerous, are effectively treated individuals also dangerous? NO, almost never and this group are truly no more dangerous than the average citizen. In fact, this group may be less dangerous than your average citizen because they work continuously to maintain symptom control and appropriate behavior. These effectively treated patients are not the perpetrators of random violence. Never treated, partially treated or refusing treatment patients are the perpetrators of random violence.

Why are some citizens who experience hallucinations and delusions only partially treated or never treated or allowed to stop taking their medication? The answer can be found in several places on this website. The so called right to refuse treatment is a contributor. Another contributor is the current system of evaluation which allows most of the clinical decisions on the street to be made my police. These well intended officers use a definition of imminent danger which is incorrect and counter therapeutic (for an analysis of imminent vs immediate danger see Recovery Model Analysis). Police also lack the clinical training to correctly identify the presence of psychosis and its significance. Unfortunately when mental health professionals accompany officers on the streets, the same errors occur. The incorrect assessment of imminent danger and the right to refuse treatment paralyze the assessment teams and nothing is done. If commonsense and moral judgment were used instead, most assessments on the streets would result in hospitalizations. Instead, these assessors wait until a crime, assault, or worse occur before they contain the psychotic person.