Psychosocial Symptoms and Poor Insight as Predictors of Homicidality Among Clients With Psychosis: Implications for Counseling Practice and Research

Psychosis is found in almost every culture (World Health Organization, 1995); in the United States, the lifetime prevalence rate for psychotic disorders is approximately 2% of the general population (American Psychiatric Association [APA], 2000). The most common types of psychosis (e.g., schizophrenia, schizoaffective disorder, delusional disorder) are usually long-term, pervasive, and costly to society (APA, 1997). Psychotic symptoms (e.g., hallucinations, delusions, cognitive impairments) are among the most confusing and distressing of those experienced by persons with mental disorders. These disorganizing and frightening symptoms can lead to heightened anxiety and suspiciousness in clients, often resulting in changes to the individual's social life (e.g., social withdrawal) and physical health (e.g., reduced self-care skills; Schwartz, 2001). In many respects, the primary psychological conflicts in clients with psychosis are literally existential (i.e., existence vs. psychological obliteration, safety vs. terror; Laing, 1965). Psychosocial difficulties usually lead to the development of ideas of reference (i.e., attributing personal and unusual meaning to external events that may not have a direct connection with one's self), paranoia, and distrust of others (APA, 2000). In addition, psychotic experiences often evolve into considerable distress, feelings of vulnerability, and anger toward others for "causing" or "inflicting" pain on oneself. In this respect, it has been reported that one of the most common psychological defenses used by clients with psychosis is projection (McWilliams, 1994). That is, because many clients with psychosis lack a firm boundary between themselves and the external world, they misunderstand internal experiences and attribute them to or project them onto others. In its extreme form, especially when coupled with paranoia, anger, and resentment, this scenario can lead to homicidality. For decades the popular media have shown a fascination with homicidality and its correlation with mental illness. Individuals with psychotic disorders are often portrayed as "insane" and unpredictable, and research has demonstrated that laypersons who lack accurate information about psychosis tend to misunderstand these clients and overemphasize their risk of dangerousness (Penn, Kommana, Mansfield, & Link, 1999). In fact, early researchers attempted to dispel many of the stereotypes about psychosis by reporting that persons with schizophrenia are infrequently involved in violent crimes (Guze, Woodruff, & Clayton, 1974). For example, in one research study, Monahan and Steadman (1983) reported that when demographic factors (e.g., age, sex, socioeconomic status) were controlled, the association between violence and psychosis largely disappeared. In similar studies, several other researchers have asserted that psychosis is not predictive of violence toward others (Soliman & Reza, 2001); that much of the debate about crime and mental illness is highly influenced by a few well-publicized homicides (Wessely & Castle, 1998); and, contrary to media stereotypes, that clients with schizophrenia are more apt to be victims than perpetrators of crimes. For example, the National Institute of Mental Health (2006) stated that "most individuals with schizophrenia are not violent; more typically, they are withdrawn and prefer to be left alone" (p. 9). However, assertions such as those just described have resulted in a great deal of debate during the past decade about the link between aggression and psychosis. Junginger (1996) explained that there is ample empirical evidence linking homicidality with psychosis. He stated that recently accumulated research in this area "has caused even influential skeptics such as Monahan (1992) to re-evaluate their position that mental illness is unrelated to violence" (Junginger, 1996, p. 92). Although contradictory evidence does exist, the majority of contemporary research now demonstrates that clients with more severe psychopathology (Nolan, Volavka, Mohr, & Czobor, 1999), and especially those with active psychosis (Hodgins, 1993; Link, Callen, & Andrews, 1992; Monahan, 1992), are at greater risk to become aggressive and violent than the general population. …