On Mental Illness and Crime
Fighting stigma while acknowledging reality
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This week, another horrific New York nightmare took the life of a young woman. Christina Yuna Lee was followed into her Chinatown apartment by a 25-year-old man who stabbed her to death. Lee’s death comes on the heels of the murder of Michelle Go, who was pushed into the subway last month, and after a spate of attacks against Asian people in New York, San Francisco, Los Angeles, DC, and in other cities across the country. According to FBI data, anti-Asian hate crimes increased by more than 300 percent last year. Many of the perpetrators, including the men who killed Lee and Go, were homeless and mentally ill.
There’s an understandable resistance on the left to talking about the connection between mental illness, homelessness, and crime. Mental illness is already stigmatized, and associating it with criminality imposes potential costs on the overwhelming majority of people living with mental illness who do not commit crimes, and are in fact more likely to be victims than perpetrators. Homelessness has long been treated as a personal failing rather than a policy one; tying homelessness to mental illness, and homelessness to crime, risks justifying the further neglect of people who are unhoused entirely because of government failures.
And yet we do collectively understand that there’s a problem here, and there is a connection between these awful crimes and mental health — which is why you hear so many progressives make vague nods to the need for “better mental healthcare” in the wake of these events.
While that’s true — we do need better mental health services in the US — it doesn’t help progressive causes, or vulnerable people, to remain intentionally vague. And it undermines our credibility and our goals when we stake out positions that may feel emotionally satisfying or in line with progressive orthodoxy but are factually untrue — arguing, for example, that there’s no connection between crime and mental illness, or mental illness and homelessness, or homelessness and crime.
The research is pretty clear: “mental illness” and “mental disorders” are categories so broad that it’s silly to make sweeping generalizations about them, but there are specific mental illnesses and personality disorders that are tied to elevated rates of criminality and to homicidal violence in particular, and the relationship becomes even stronger if there are substance abuse issues at play. Schizophrenia, antisocial personality disorder, and drug or alcohol abuse are the categories of disorders that make a person many times more likely than average to engage in homicidal violence. People who struggle, untreated, with these three disorders are radically overrepresented among people who commit homicidal violence, and are also overrepresented among the unhoused. According to one review of the evidence:
Mental disorder increases the risk of homicidal violence by two-fold in men and six-fold in women. Schizophrenia increases the risk of violence by six to 10-fold in men and eight to 10-fold in women. Schizophrenia without alcoholism increased the odds ratio more than seven-fold; schizophrenia with coexisting alcoholism more than 17-fold in men. We wish to emphasize that all patients with schizophrenia should not be considered to be violent, although there are minor subgroups of schizophrenic patients in whom the risk of violence may be remarkably high. According to studies, we estimated that this increase in risk could be associated with a paranoid form of schizophrenia and coexisting substance abuse. The prevalence of schizophrenia in the homicide offenders is around 6%. Despite this, the prevalence of personality disorder or of alcohol abuse/dependence is higher: 10% to 38% respectively. The disorders with the most substantially higher odds ratios were alcohol abuse/dependence and antisocial personality disorder. Antisocial personality disorder increases the risk over 10-fold in men and over 50-fold in women. Affective disorders, anxiety disorders, dysthymia and mental retardation do not elevate the risk. Hence, according to the DMS-IV, 30 to 70% of murderers have a mental disorder of grade I or a personality disorder of grade II.
It would be wrong to read these numbers and conclude “people with schizophrenia are dangerous.” Overwhelmingly they are not, the same way that the overwhelming majority of people who struggle with addiction are not violent or dangerous to others. But it would also be a mistake to decide that these figures showing disproportionate acts of violence are potentially stigmatizing and therefore simply too hot to discuss.
It’s important to understand that people struggling with mental illness are more likely to be crime victims than crime perpetrators. But here again it’s useful to address the complexities at play: people with untreated major mental health issues are more likely to also have substance abuse disorders (self-medication is common and understandable), and are less likely to be able to hold down a job, navigate complex government bureaucracies, and so on, which is why people with major mental health issues are overrepresented among people who are chronically homeless, and particularly struggle with housing and support if they’re living with the double whammy of major mental illness and substance abuse. According to an estimate from the Substance Abuse and Mental Health Services administration, 30 percent of the chronically homeless live with a mental health condition, and 50 percent with a substance abuse disorder.
Many people with major mental illnesses are victimized by those charged with caring for them, including family members, health workers, and police officers. Many are victimized by people who commit hateful attacks on people who they believe to be mentally ill, unhoused, or both. And many people with major untreated mental illnesses and substance abuse disorders are victimized by other struggling people with whom they are sharing public and communal space. Homeless shelters are notoriously chaotic and unsafe. The encampments into which we have relegated a great many vulnerable people are often astoundingly violent and dangerous places — the public just looks the other way, because the victims are people we have thrown away.
This was the case in New York City last year, when a series of attacks left several homeless people dead. The perpetrator was a man who was also unhoused, and struggling with an untreated mental illness and a drug abuse disorder. A similar incident happened in Chinatown in 2019, when four unhoused men were killed by another unhoused man who was struggling with an untreated mental illness and a drug abuse disorder.
The vast majority of crimes are committed by people who are not mentally ill. And that’s why you get tweets, like this viral one from Noah Smith, about how it’s irresponsible to tie mental illness to crime. His critique was also that in doing so, we excuse or hand-wave away violent crimes, including homicide — as if people who point to mental health needs are suggesting that all a murderer needs is some Zoloft and a few conversations about their childhood. “I don't claim to know what the solution to murder is,” Smith wrote. “But I AM very sure that labeling it a mental health issue is not going to help, and is going to stigmatize a lot of harmless folks who are already suffering.”
It’s true that murder isn’t a mental health issue. But no one is actually “labeling [murder] a mental health issue.” People are instead trying to understand the broad universe of why some people commit violent crimes, because understanding the reasons why people commit crimes beyond “some people are just bad” can help us to prevent crimes before they happens. After all, if criminality were somehow inborn and simply a fact of good versus evil, we’d see similar crime rates across nations and consist crime rates year over year, but we don’t. Instead we know that policy shapes crime rates — and not just policing and incarceration policies, but policies related to health, housing, and even consumer safety.
It is unhelpful and dishonest to tie crime to mental illness writ large. It is potentially helpful, and more honest, to look at how a small number of specific mental illnesses and personality disorders are tied to the perpetration of some violent crimes, as well as to crime victimization, and how the risk of crime radically increases when people are not able to get the healthcare they need. It’s helpful to explore all of the ways in which our healthcare system isn’t working, and in which even the gold standard of mental health care remains woefully insufficient — that we need more research, better drugs, better treatments. It’s helpful to understand all of this not so that we can write off violent crimes as excusable, and not so that we can write off entire categories of people as dangerous, but rather so that we can understand how our collective social failures create widespread suffering.
No society has totally solved the problem of violent crime, nor of providing vulnerable citizens all of the help they need. But many have gotten much closer than we have — by highly regulating gun ownership, for one, and by providing generous resources for people who struggle with mental illness, poverty, and substance abuse disorders, instead of tossing them into the revolving door or jail / street / hospital / shelter.
There is much more we can do. But solutions have to be based in reality, and narrowly targeted to need. Avoiding the reality of ties between some crimes and some disorders, and the ties between some disorders and crime victimization, by either arguing against making the observation at all because of stigma or by relying on overly broad and vague statements about “mental health,” cedes important ground. It cultivates broad public distrust: If progressives can’t be trusted to be honest about these complex problems, how we can be trusted to come up with reliable solutions?
These are difficult questions involving some of the most neglected people in society. And that’s why those among us who care about everyone’s wellbeing, and who don’t want to toss vulnerable people into the jail / hospital / street / shelter revolving door, are obligated to address them.
xx Jill