Amid rising cases in America, psychosis patients suffer in the darkness. One thing that often goes unnoticed is how psychosis experiencers, who are usually assumed to be the ones inciting violence, are often the ones who experience the violence themselves.

Rates for those at risk for psychotic experiences increased from 73% at risk in 2019 to 80% in 2023, Mental Health America reported in May of 2024. The growing prevalence is not just confined to data, but shows up in frontline clinical settings.

“There's a prison sort of dynamic where sometimes some guys will want a distraction,” said Je Ko, the head psychiatrist at Westwood Psychiatry. He used to work with incarcerated individuals and described one instance he remembers experiencing.

“And then they'll kind of tell [the person who experiences psychosis], suggest that he jump off the rail.”

The man, who Ko described as using drugs at the time, jumped off a tall railing at the prison. In the next few days, he was treated and made a full recovery, but the image still haunts Ko. He described the person as suggestible and vulnerable, their psychosis being a catalyst for harm at the hands of people who were using him for a laugh.

Harmful situations befall psychosis experiencers in public spaces, like on the street or the subway. They happen in the “safety” of the home. And they also happen in intimate relationships.

Sanders started to experience symptoms of psychosis in elementary school. At the time, she was hearing voices that were religious-themed. Growing up in the Bible Belt, however, these experiences were often validated rather than questioned.

Alyssa Sanders. (Photo courtesy of Alyssa Sanders)

“It's not that uncommon for somebody to say, ‘Oh, it felt like God told me to do this,’” Sanders explained.

In college, she entered a romantic relationship with a boy at her school. In the beginning, Sanders noticed a couple of red flags. Her boyfriend consistently ignored her boundaries and used guilt, emotional withdrawal, or threats to get his way, especially when it came to sexual expectations. Despite Sanders’ medical condition that makes certain acts painful, he would continue to press her until he got his way.

Sanders recalls one particularly traumatic experience as a turning point in the relationship during which she realized something might be wrong. During an instance of penetrative sex, she was in intense physical pain, crying and dissociating throughout the act—yet her partner failed to notice or stop. She said it was the worst physical pain she had ever experienced. When he finally realized something was wrong, his first words were not of concern or apology, but simply, “Why didn't you stop me?”

“With the stigma of schizophrenic people being violent, I think that tends to push a lot of us into forcing ourselves to be very passive and gentle, to not play into the stereotype. And especially for women, nobody wants to be seen as the crazy girlfriend,” said Sanders.

Sanders experienced sexual and emotional abuse at the hands of her then-boyfriend throughout the beginning of her college career. She believes that her experience with psychosis played a role in becoming stuck in the relationship, unable to recognize the abuse while it was happening.

(Photo courtesy of Alyssa Sanders)

Sanders finds escape at a local pond.

According to a 2014 study, patients with severe mental illnesses are at a substantially increased risk of domestic and sexual violence.

Multiple peer-reviewed studies point out the heightened vulnerability of people with severe mental illness to domestic and community violence. One 2013 article from The British Journal of Psychiatry found a high prevalence of domestic violence among psychiatric patients. Similarly, a 2014 study published in Psychological Medicine concluded that patients with SMI—primarily those with affective or non-affective psychosis—face a substantially increased risk of domestic and sexual violence and significant health consequences. Supporting this, a 2005 study in General Psychiatry reported that over 25% of individuals with SMI were victims of violent crime within a year, a rate over 11 times higher than that of the general population. Additionally, research published in 2014 by the American Journal of Public Health found that adults with mental illnesses experienced high rates of violent outcomes, being more frequently victims than perpetrators of community violence.

“It’s absolutely true that people with schizophrenia or other forms of psychosis are much more likely to be victimized and victims of violence than they are to be perpetrators of violence,” said James Kirkbride, a Professor of Psychiatric and Social Epidemiology and joint Head of the Research Department of Epidemiology and Applied Clinical Research in the Division of Psychiatry at the University College London.

He added that people with psychosis are more likely to come into care through coercion, be that through the prison or court systems or being forcibly hospitalized, sometimes against their will.

Dr. Andrew Graham is the assistant clinical director at Exis Recovery, an evidence-based dual diagnosis treatment center that treats substance abuse and mental health disorders. He explained how a lack of empathy and understanding from onlookers can lead to misinterpretations and aggressive reactions towards individuals with psychosis. When asked what one of the biggest misconceptions was for people with psychosis, he pointed to the hostile stereotype.

In December of 2023, Hailey Anderson, a Cloud Engineer in Providence, Rhode Island, was admitted to a psychiatric hospital after experiencing delusions and going days without sleeping.

“I witnessed the fight between two people inside. I think one of them was hearing things. He was very on edge,” Anderson said in an interview over a phone call.

Even in spaces where care is meant to be administered, violence still befalls those who experience psychosis. Certain symptoms, like paranoia or agitation, can sometimes lead to situations where individuals become involved in violent incidents. But violence also happens outside of care facilities.

A high-profile case of a person with psychosis enduring violence, and in this case death, is Jordan Neely. In New York City on May 1, 2023, Neely, a 30-year-old homeless man riding the subway, was killed after being put in a chokehold by Daniel Penny, a 24-year-old United States Marine Corps veteran. He was shouting that he was hungry at the time of the incident. Neely had a history of schizophrenia. Penny was acquitted of negligent homicide, a verdict that caused an uproar among activist groups.

One such group that spoke out in Neely’s defense was the National Coalition for the Homeless. Donald Whitehead, the executive director, believes the interaction should’ve gone differently. He has worked in homeless shelters for 40 years and has even been attacked before. In a particularly dicey situation, Whitehead said that he was able to hold the person for a while before releasing and talking to them.

“It's not the intervention that's the issue. It's the murder that's the issue,” said Whitehead of the Neely case.

Others disagree.

“No, I don't think he was a victim,” said Eric Wexler, a medical director and co-owner of California OnTrack, referring to Neely. He went on to say that if in the same situation as Penny, he would’ve been afraid for his life.

Neely’s death sparked debates about homelessness and mental health care and also about the perception of violence among people with psychotic disorders. It becomes clear how the belief that people with psychosis are inherently violent influences public reactions and legal outcomes.

Some viewed him as a victim of excessive force, while others saw Penny’s actions as justified out of fear. However, research consistently shows that individuals with psychosis are more likely to be victims of violence than perpetrators.

“A lot of people, because they can't be fully open with others, they become more reserved, and that also puts you in a more vulnerable position to abuse,” said Sanders.

Sanders reflected on her childhood, explaining how she was pretty shy and hid a lot of her symptoms. She still hasn’t completely opened up to her friends about her experiences with psychosis, only recently providing details on her abuse.

Carlos Paul Duarte is a therapist in Los Angeles. He worked for one year with the SB 82 mobile triage team, an LA County Department of Mental Health program that was designed specifically to reach out to homeless individuals who were experiencing mental health issues. He would go out once a week to do a welfare check on a person and try to get them to accept mental health care and treatment. He can recount numerous occasions where the people he would talk to would tell him about the violence they had experienced, where people would attack them in the middle of the night as they were alone, sleeping on the street. He recounts one individual who was experiencing psychosis and was attacked multiple times by multiple people on the same night.

“This person was not just a victim of violence but really wasn't getting the support that they could have received from law enforcement,” Duarte added.

He clarified that the LAPD was “not very interested” in helping the man.

When looking at how people with psychotic disorders end up on the street, Ko said that it can be due to a kind of spiral effect.

There are also ideas that violence in adolescence may lead to the development of schizophrenia later in life. Stephen Marder is a distinguished professor of psychiatry at the Semel Institute for Neuroscience at UCLA. He spoke on a phone call about how violence during adolescence can lead to the disorder.

“There's an interaction between this kind of environmental event and genetic risk factors for schizophrenia,” said Marder.

It is known in the medical community and studies show that exposure to early stress in the form of abuse and neglect in childhood can increase the risk of developing schizophrenia.

Sometimes, what makes one more vulnerable is the state that they are in. Some aspects of psychosis can alter how one sees and interacts with the world around them.

“It's like getting extremely high and not being able to control it, when I had psychosis, I could be laying in bed and my body would feel like it's shaking,” said Grace Davis, a certified trainer/speaker at Johnny’s ambassadors–a nonprofit that seeks to educate teens, parents, and communities about the dangers of high-THC marijuana on adolescent brain development, mental illness, and suicide.

Davis, like many people who experience psychosis, felt like people were after her. She was fearful that people were about to harm her, socially, emotionally and physically, all of which created extreme stress.

Ko expanded on this idea. He described how, even in situations where people have support systems, the delusions that come with psychosis can create tension and conflict. These things can wear down the emotional reliance of those who offer support, eventually causing interactions to become more hostile. This, in turn, reinforces the individual’s delusions and leads to further isolation.

“With psychotic illness, even if you have a support system, sometimes you will not even feel that you will reject them. So, you might have a faster, more accelerated path to a lower and lower, less protected environment,” said Ko.

The downward spiral can be caused by several factors, but many point to cannabis.

In the last couple of years, Carlos Paul Duarte, a therapist in Los Angeles, has been witnessing a change.

“The weed that people are smoking today versus the weed that was being smoked even 10 years ago or 15 years ago it's just more potent,” Duarte said.

Between 1995 and 2022 the THC potency in illegal cannabis products seized by law enforcement quadrupled from 3.96% to 16.14%, according to the National Institute on Drug Abuse. Today, dispensaries can carry cannabis that has THC concentrations of more than 40%.

With stronger cannabis, psychiatrists are seeing more psychosis patients.

“A lot of the new patients that I've been working with had been hospitalized because of cannabis-induced psychosis, resulting in them actually having schizophrenia,” Duarte added.

Consuming cannabis during critical stages of brain development (like adolescence) can cause a disturbance of the endocannabinoid system and cause an inappropriate hardwiring of the brain. Cannabis can play a role in the complex interactions involving dopamine, glutamate transmission, gamma-aminobutyric acid, or other factors that cause psychotic disorders, according to a case report published in Psychiatry (Edgmont) in 2009.

(Photo courtesy of Alyssa Sanders)

Sanders uses painting as a way to relax.

Institutional Violence

In its “Use of Force Year-End Review,” the LAPD reported 34 shootings by officers in 2023. Twenty-nine of these were people who were hit, five were people who were not hit. Seventeen of them died.

2023 was one of the highest numbers of shootings by officers in recent years.

(Source: LAPD)

Twelve or about a third of the 34 people shot in 2023 were perceived to suffer from a mental illness and/or a mental health crisis.

Two of the 12 were perceived as threatening and armed with a gun or gun-like weapon and could be considered “justified,” given California state law about how law enforcement can use deadly force only when necessary. That is, they can only use deadly force when the officer has a reasonable belief that the person they are using force on poses an imminent danger of death or serious physical injury to the officer or to another person, according to California Penal Code 835a.

Five of the 12 had a knife or other cutting instrument, and three had a blunt object. Two used vehicles in the altercation.

Of those 12 people who were experiencing a mental health crisis, or had a history of mental health illness, and were shot by police, five of them died. One of them was Takar Smith.

On Jan. 2, 2023, Shameka Smith walked a couple of blocks away to her local police station to ask for help when her husband, Takar Smith, was talking to himself in the midst of a schizophrenic episode.

In the 911 call that Shameka made when she got back to her house after coming back from the station, she expressed that Takar had “a mental illness.” She said that she had a restraining order against him and that he wouldn’t leave her house. The officers knocked on the door, and Takar opened. They asked him to step outside, but he stayed in the apartment. He moved around the space, picked up a chair, and one of the officers threatened to fire a rubber bullet at him.

He eventually moved into the kitchen and picked up a bike. Police responded by firing a Taser stun gun at him. Takar then picked up a knife from the kitchen counter, The police continued to use the Taser stun gun on him as he fell to the floor, knife in hand. Takar raised the knife to his head, and an officer fired seven bullets into his chest and head. The officers handcuffed his lifeless body.

Duarte recalls a conversation he had with an LAPD officer he was paired with, who expressed their goal as simply getting the criminals off the streets.

“When we're talking about somebody that's experiencing a psychotic episode on a street corner, the solution to that is not ‘putting a bad guy in jail.’ The solution is to approach the person, to try to create a safe space for the individual, to try to provide some kind of support to help them get whatever treatment they need,” said Duarte.

Solutions

One thing that may be able to help this population is the destigmatization of so-called “positive” symptoms of psychosis. These are experiences that add to or distort a person's normal functioning. They include hallucinations, disorganized speech or behavior, and delusions. “Negative” symptoms are things that are “taken away” or reduced from the person experiencing psychosis. These include reduced motivation, lack of interest in other people, or reduced intensity of emotion.

“Positive” psychotic symptoms do not necessarily prevent a person from living a fulfilling and successful life, according to Wexler.

“Marjorie Taylor Greene thinks that Jewish space lasers are setting fires to the forest in California, and she got reelected to Congress. So it's not that you hear voices, it's not that you have bizarre beliefs–it's how you handle them in context,” said Wexler.

One woman he has worked with believes she is an opossum. He worked with her on how she could not disclose that information when talking to employers. With his counseling, she now has a job working in a library.

“Is it brain surgery? No, does it give purpose to her day. Absolutely,” said Wexler.

In order to destigmatize the disorder, one must first understand it.

It is also about treating people who have psychosis with more humility. By learning from others’ experiences and building relationships with them, one can deepen their understanding of psychosis experiencer’s views and feelings on mental health and wellness.

“If people approached it with compassion, understanding, and listened to the people who experience it, they would come to understand that we're just regular people too, that we're not violent or crazy,” Sanders said.

Graham said that people also must start changing the language they use around mental health.

One resource that people can use when they are in a mental health crisis is the 988 number. This mental health hotline is similar to "911" for emergency situations. It is a 24-hour line that connects individuals to the Suicide and Crisis Lifeline and provides access to trained crisis counselors for anyone experiencing suicidal thoughts, mental health distress, or substance use crisis.

“With my experiences with 988 it's just going to be more of a conversation and less of a ‘hey, I'm with this the police department, we're coming to get you,’” Davis said.

One of the most important things when one is dealing with psychosis is to have a stable support system. Through the intervention of others, the person experiencing psychosis can have a better chance of getting the help they need. Speaking to those who are struggling, Sanders wanted to assure them that they are not alone.

“There are people who will take you seriously and who want to help you move to a safer place.”