Mental health and homicide: progressive ideology meets political expedience
By Niall McCrae & MLR Smith, this was first published in 2020 but no less relevant today – because lessons do not seem to be learned
NIALL MCCRAE
Who kills and why? Mentally disturbed persons commit over a hundred homicides every year in Britain. In simplified reasoning, the motives for such killings are beyond comprehension – to a court of justice and perhaps the perpetrator too. But typically the verdict is diminished rather than total loss of responsibility. As Theodore Dalrymple reminds us in The Knife Went In: Real Life Murderers and Our Culture (2017), the blade has no agency. Often targets appear to be randomly chosen, but just as the act of killing requires volition, victims are to some extent selected. Understanding who is at risk, as well as who is likely to attack, is crucial to patient care and public safety.
Mental disturbance has always been associated with violence, although much of this thinking was based on fear and ignorance. Clearly some patients, some of the time, present a danger to others. Inquiries into such killings often find failings in care, indicating that deaths were preventable. However, lessons do not seem to be learned by an often defensive NHS, and the toll of tragic deaths continues to rise.
Ordinarily this would be a national scandal. As this essay will show, however, the well-intended campaign to destigmatise mental illness and the much misunderstood policy of care in the community have progressed into an ideologically motivated suppression of inconvenient truths. However, safer mental health care is inhibited by the imperative to cast a positive light on mental health, compounded by cultural sensitivities.
Changing attitudes to mental health
In recent years celebrity-led campaigns have challenged unsympathetic and fearful connotations of mental illness. The well-publicised Heads Together project launched in 2016 by the Duke and Duchess of Cambridge and Prince Harry encouraged people (particularly the young) to open up about anxiety and depression, which are believed to affect one in four of the UK population (although such figures are not derived from clinical diagnosis). ’We have seen time and time again’, the Royals declared, ‘that shattering the stigma on mental health starts with simple conversations’.
A more humane understanding of the struggles faced by people with mental health problems has advanced by a process of normalisation. Discourse on mental health is normalised by eschewing harsh language and hurtful stereotypes. ‘Mental illness’ is replaced by ‘mental health’ and ‘wellbeing’. The conceptualisation of ‘illness’ implied an objectively diagnosable corporeal dysfunction, but without pathological evidence. Many people found the medical model, in principle and in practice, demeaning and unhelpful.
Few in society would wish to return to an era of sweeping generalisations about mental illness, stigmatising labels and remote asylums. Nonetheless, a positive view of mental health does not eliminate the existence of people suffering from severe psychiatric conditions such as paranoid delusions, manic impulsivity and dangerously antisocial personality disorder. The rhetoric of non-judgmentalism and empathy may be naive if expressed in public discourse, but such thinking is hazardous if it leads to practitioners and services maintaining a liberal approach when it is necessary to act illiberally.
Care in the community
Myths around mental health care persist. The impetus for the policy of care in the community sprang from a conscious attempt to remove the stigma around mental illness and to enable people to receive care and treatment without unnecessary hospital admission. The forbidding Victorian asylums were regarded as an anachronism, and Enoch Powell, as Minister of Health, declared their demise in his famous ‘Water Tower’ speech in 1961. From a liberal (or perhaps libertarian) stance, mental health campaigners claimed rights, freedom, dignity and citizenship for psychiatric ‘service-users’. Deinstitutionalisation was promoted as progress of equality and civil rights.
Care in the community was, though, hardly welcomed when it was fully implemented in the 1990s. With persistent criticism in the media, the policy tended to be perceived by the public as a penny-pinching exercise that evicted patients on to the streets. Most people were unaware of the plethora of community-based services (including locality teams and supervised residential accommodation). The large mental hospitals were, in fact, comparatively cheaper to run.
Cynicism was reinforced by scandals of discharged patients ‘slipping through the net’. One case that drew widespread media coverage was an apparently random killing by Christopher Clunis, who stabbed Jonathan Zito in the face at Finsbury Park Underground station in December 1992. Clunis had paranoid schizophrenia, and after the incident police found unopened letters from social workers and a large unused supply of antipsychotic medication in his home. Clunis was sent to Rampton high-security hospital. In January 1993, soon after the mass media coverage of Clunis, another psychiatric patient, Ben Silcock, was mauled to death after climbing into the lions’ enclosure at London Zoo.
Community care policy, therefore, had a bad press in its early years. Partly to assuage public concerns, the legal framework, structures and processes were bolstered. Meanwhile campaigning bodies were successful in nurturing a more sympathetic and supportive attitude to mental health. Sensationalist or stigmatising newspaper reports were condemned, and homicides involving psychiatric patients began to be reported with no more prominence than any other killings. The societal shift from fear to acceptance allowed mental health services to continue on their journey from institutional segregation to community immersion. Indeed, the pattern of psychiatric ward closures has continued long after the last of the traditional mental hospitals closed two decades ago. The number of psychiatric beds in England, around 150,000 in the 1950s, fell to 26,000 in 2009, and now stands at 18,000 beds. Acute psychiatric units in general hospitals have been trimmed or closed, as resources have moved into the community.
Contrary to the popular attribution of anything that goes wrong in the health service to funding constraints, the problems of killings by mentally unwell people is an unintended but inevitable consequence of ideological absolutism. The policy of care in the community, previously doubted by the mental health professions and politicians, is now regarded as an incontrovertible cause of social justice. Yet it is not always possible to safely care for acutely disturbed patients in their own homes.
Struck by lightning
The well-meaning attempt to quell prejudice has led to a censorial tendency against criticism (however informed) of mental health policy. To illustrate, a front page of the Sun newspaper in 2013 declared: ‘1200 killed by mental patients’. This figure was taken from the National Confidential Inquiry into Suicide and Homicide, which has collated data on incidents involving people with mental illness since 1999. Campaigners were enraged by the headline, and a critical commentary in the Guardian ended with the question: ‘how would you want to see us reporting on mental health?’ Hundreds of readers’ comments condemned the Sun for stigmatising those with mental health problems, despite the factual reporting (the precise number of deaths was 1226).
Television producer Julian Hendy founded the charity Hundred Families after the unprovoked killing of his father by a psychiatric patient in Bristol in 2007. The charity supports families of victims and demands safer mental health care. Through freedom of information requests to mental health service providers, Hendy has exposed gaping holes in the system, and showed that official reports underestimate the incidence of homicide by mentally ill people.
Mental health professions and advocates often argue that people with mental illness are more likely to be a victim than a perpetrator of violence. Paul Jenkins, chief executive of the mental health charity Rethink, argued in 2010: –
The media often exaggerates the likelihood of homicide by a person with schizophrenia, when it is in fact very rare… You’re more likely to be struck by lightning than killed by someone with schizophrenia.
Regrettably, this is untrue. According to the Royal Society for the Prevention of Accidents approximately three cases of death by lightning are recorded in the UK annually, compared to 34 killings by schizophrenic patients (according to the National Confidential Inquiry). On the ITV documentary series Tonight (2016), Hendy interviewed Professor Simon Wessely of the Royal College of Psychiatrists, who stated that the number of such incidents is declining. However, data collated by Hendry suggest that the message is managed better than the hazard.
In 2016 Hendy sent freedom of information requests to all 57 NHS trusts with mental health services in England, seeking data on confirmed and suspected homicides involving psychiatric patients. In this extensive survey, all but three organisations supplied data. The results showed a considerably higher number than the National Confidential Inquiry, which is limited to court convictions of patients in mental health care, and which counts incidents with multiple victims as one. The 12 victims of a shooting spree by Derrick Bird in Cumbria in 2010 were not included, despite psychiatric evidence at the inquest showing that Bird was mentally ill at the time. Hendy concluded that the National Confidential Inquiry had missed around 200 deaths over the last 10 years.
In August 2020 the Mail on Sunday obtained an NHS report marked ‘official – sensitive’, which revealed an increase in suspected or confirmed killings by psychiatric patients in England and Wales from 93 in 2016-2017 to 121 in 2017-2018. In 2018-2019 the toll was 111. Around 11 per cent of homicides are by mentally ill assailants. There is no sign of this carnage abating. Even a single incident in 2019 was enough to correct the lightning strike comparison: Alexander Lewis-Ranwell, who suffered from paranoid schizophrenia, bludgeoned three elderly men to death in Exeter.
Lessons not learned
Before delivering their verdict in the Lewis-Ranwell case the jury expressed their concern at the failings of the psychiatric system in a note to the judge. The confidential report exposed by the Mail on Sunday, likewise, affirmed that the NHS was providing inadequate access to psychiatric beds and in many cases of homicide had ignored warnings by the killer’s family. The editorial column observed:
A worrying number of violent crimes are committed by people who are gravely mentally ill. Attempts to point this out are discouraged by politically correct fears that even a discussion of this issue will stigmatise mental illness.
The mantra ‘lessons will be learned’ is parroted by NHS trusts after a homicide involving one of their patients, but examining details of 1274 killings by people with mental illness, Hendy found the same failings repeated again and again. Often the killer is someone who has been in contact with mental health services but inadequately monitored, in some cases discharged or moving to another area. Days before Lewis-Ranwell’s triple homicide, he had been arrested after attacking a farmer with a saw, but was released from police custody despite grave concerns over his mental state expressed by his mother.
Another illustrative case was the killing of Jeroen Ensink, a lecturer at the London School of Hygiene and Tropical Medicine, in December 2015. Leaving his house to deliver cards to neighbours announcing the birth of his daughter, Ensink was fatally stabbed to death by Femi Nandap. In May 2015 Nandap had assaulted a police officer and was found to be carrying a knife. He was bailed, and before the court appearance in August he visited the family home in Nigeria, where a doctor wrote a letter stating that he was suffering from psychosis. Nandap returned to Britain but although his sister had warned the authorities of his mental disturbance and heavy cannabis use, mental health services did not engage with him. On conviction of manslaughter with diminished responsibility he was sent to a high-security hospital.
Secure mental hospitals
There is limited public knowledge about the secure mental hospital system, which houses some of the most dangerous offenders. For decades the government has been planning a gradual closure of Broadmoor Hospital. Opening in 1863 as the first state institution for the criminally insane in Britain, Broadmoor was followed in the twentieth century by Rampton in Nottinghamshire, Moss Side near Liverpool, and Carstairs in Scotland. In 1989 Moss Side merged with the adjacent Park Lane (a Broadmoor overspill opened in 1974) to become Ashworth Hospital.
In the 1970s medium-secure units, each serving a regional health authority, were built in the grounds of ordinary mental hospitals. As well as local residents’ concerns about dangerous patients in their midst, the trade unions put up obstacles. After much controversy, the first unit opened at Prestwich near Manchester in 1976. At Bethlem Royal Hospital near Croydon the health authority ‘reassured’ the public by holding an opening ceremony featuring television personality Jimmy Saville.
Public concerns about the security of forensic psychiatric services have frequently been justified by events. For example, the Bracton Centre is located at the former Bexley Hospital on the southeastern fringe of London. A study by Baxter and colleagues (1999) showed that two-thirds of schizophrenic patients at the Bracton Centre reoffended violently within ten years of discharge. Oxleas, the mental health trust running this unit, has had an unusually high number of homicides by psychiatric patients under its care. Data obtained under freedom of information provisions by Hendy showed that 18 Oxleas patients killed over a period of fifteen years.
The skunk effect: race, racism and homicide
A high proportion of forensic psychiatric patients have used illicit psychoactive drugs. Cannabis sold on the streets today is much stronger than that used by ‘hippies’ in the 1960s. ‘Skunk’ has a high concentration of tetrahydrocannabinol, which has hallucinogenic effects. Analysing 995 samples from police seizures, Robin Murray and fellow researchers at King’s College London (2018) found that 94 per cent of marijuana was of high potency, compared with 51 per cent in 2005. Murray’s team produced compelling evidence of a causal relationship between heavy cannabis use and psychosis. Compared with those who use weaker cannabis resin (hash), skunk users have a higher risk of paranoid delusions
Murray’s research was conducted in socio-economically deprived areas of south London, where there is a high black population and pervasive use of skunk. This is a sensitive topic, particularly as mental health services have been accused of racial prejudice. Lee Jasper, deputy mayor of London during Ken Livingstone’s mayoralty and chairman of African and Caribbean Mental Health, stated:
I have visited mental health hospitals across London and I was astounded to see the huge over representation of black people in the most secure wards. It is horrendous to see rows and rows of black people locked up in these places where we know they get treated badly because the services are institutionally racist.
When the annual Count Me In census for England and Wales reported higher rates of psychiatric hospital admission and use of Mental Health Act detention for black patients, Jasper asserted:
This census confirms once and for all that mental health services are institutionally racist and overwhelmingly discriminatory. They are more about criminalising our community than caring for it.
Psychiatrists Swaran Singh and Tom Burns, writing in the British Medical Journal in 2006, refuted Jasper’s claim. They observed that Jasper had ignored the advice of the Count Me In report, which cautioned against generalisations on differences between minority ethnic groups, finding no conclusive evidence of any race-specific service failure. In Prospect Magazine (2010) Singh argued that portraying service as racist is counter-productive:
Erroneous allegations drive a wedge of mistrust between ethnic minority patients and mental health services, creating a self-fulfilling prophecy whereby patients seek help only in a crisis, disengage from services prematurely and have repeated admissions with poor outcomes.
Singh was concerned about the government’s action plan, ‘Delivering Race Equality in Mental Health Care’ (2005), which aimed to reduce disproportionate admissions of black patients to psychiatric wards. Singh argued that ‘following this logic, an ill young black male could be denied admission if a ward required elderly white females to restore ethnic balance’. As Singh further explained, social adversity is a strong factor in mental illness, but this is not necessarily due to racism.
Could societal messages about racism provoke some cases of homicide? Several incidents have involved a black male perpetrator and a white victim. Perhaps in a state of paranoid ideation, a theme of racist oppression has come to the fore? A person who perceives society as racist is perhaps more likely to think this when mentally disturbed, as strange behaviour draws disapproving or fearful glances and refusal of inappropriate requests.
Cultural sensitivity in diagnosis
Reported rates of severe mental illness differ between ethnic groups: higher than average in the black population, and lower among south Asians. As Roland Littlewood and Maurice Lipsedge explained in Aliens and Alienists: Ethnic Minorities and Psychiatry (1982), there is no straightforward explanation for these differences. Simplistic notions of racist diagnosis or racial/cultural susceptibility are unhelpful. An earlier study by Sugarman and Crawford (1994) showed that compared to their parents, second-generation black people have higher rates of psychiatric disorder. Research by Dinesh Bhugra and colleagues (1997) revealed a disproportionately high incidence of paranoid schizophrenia in the black population in Britain.
A possible reason for the higher rate of schizophrenia is cultural insensitivity in diagnosis. To test this hypothesis, in the late 1990s a Jamaican psychiatrist, Fred Hickling, was invited to evaluate the diagnoses of several white psychiatrists. Overall, the frequency of schizophrenia diagnosed by Hickling was similar to that of the London doctors, indicating that diagnosis was not influenced by racial prejudice. As an interesting footnote to this study, Hickling was stopped by police in his hired car on his way from his hotel to the psychiatric hospital; he was arrested on failing to prove his identity.
Psychiatry is a branch of medicine with a high proportion of black and Asian practitioners (Farook, Lydall & Bhugra, 2013). This may enhance cultural sensitivity, but not necessarily. The umbrella term ‘BAME’ suggests homogeneity between all ethnicities other than white, but this is a fallacy. Relating to black patients may be as challenging for Asian psychiatrists as it is for those of white British background (and similarly for a Nigerian doctor assessing a Vietnamese patient).
Fear of being accused of discrimination (particularly following the ascent of the Black Lives Matter movement) could lead to practitioners erring on the side of risk rather than caution. Risk assessment and subsequent intervention should not be diverted from the priority of protecting patients and the public from harm.
The exception that proves the rule: Islamist homicide
The general reluctance to attribute violence to mental illness appears to be dropped in response to homicides of apparent Islamist motive. Several recent incidents illustrate this trend.
In 2016 Zukaria Bulhan, a young Norwegian national of Somali descent, went on as stabbing spree in Russell Square in London, killing one American tourist and wounding five others. The police announced that the attack was ‘triggered by mental illness’. Prior to the incident Bulhan was receiving treatment for low mood and anxiety, and allegedly exhibiting aggressive behaviours. At his trial the arresting police officer stated that Bulhan was mumbling ‘Allah, Allah, Allah’, and among his possessions at the time of arrest was a pamphlet Fortress of the Muslim. According to the report of the trial proceedings in the Guardian (7 February 2017): ‘The judge was told that these two details were not considered relevant to the attack’. Bulhan was found guilty of manslaughter on the grounds of diminished responsibility.
In 2018 Mahdi Mohamud, a 26-year-old man of Somali background, stabbed three people including a police office at Victoria Station, Manchester. He shouted ‘this is for Allah’ and ‘keep bombing Muslim countries, we’ll see what happens’. Mohamud was detained under the Mental Health Act, and in court a year later it was revealed that he had a history of several psychiatric hospital admissions. Although diagnosed with paranoid schizophrenia he was not under mental health care at the time of the incident. The attack was carefully planned, with jihadist literature found in his home, notably recordings of extremist preacher Anwar al-Alwaki. Deemed fit to stand trial, he pleaded guilty to three counts of attempted murder, and was sentenced to life (actually a minimum of 11 years) in a high-security psychiatric hospital.
In 2019 a Libyan asylum-seeker stabbed five people indiscriminately at the Arndale Shopping Centre in Manchester. Police stated that a 40-year-old man was detained under the Mental Health Act. The attacker had shouted the familiar ‘Allahu Akbar’ and ‘long live the Caliphate’, although this was omitted in most media reports of the incident. The outcome of this case is not known, and the attacker remains anonymous. In the summer of 2020 three gay men were stabbed to death in a park in Reading. The killer was 25-year-old Libyan asylum-seeker Khairi Saadallah. The police stated that mental health was being considered as a factor. Saadallah was known to the security services and was alleged to have shouted ‘Allahu Akbar’ during the attack.
Another incident occurred in June 2020 in Glasgow, outside a city-centre hotel used as temporary accommodation for asylum-seekers during the coronavirus pandemic. Sudanese man Badreddin Abadlla Adam stabbed six people including a policeman, before he was shot dead by police. The charity Positive Action in Housing blamed the incident on ‘dire conditions’ in the hotel, causing mental distress.
There is obvious dissonance in the reporting of these events: in several cases, the Islamst perpetrator had little or no prior use of mental health services. For Islamist violence, the emphasis is in the opposite direction from the normalising of mental health. Dreadful deeds are blamed on mental dysfunction, to discredit or deny political-religious motivation. Psychiatry appears willing to exercise this role for the state. Simon Wessley argued that ‘lone actors are more likely to have psychotic disorders such as schizophrenia than the general population’. .
The credentialisation of the ‘lone actors as mentally ill’ thesis encourages unverified diagnostic generalisations by unqualified writers. Writing in the Times Alice Thomson (July 2016) asserted that most terrorists ‘have a history of mental illness’, while Raffaelo Pantucci of the Royal United Services Institute claimed in the Daily Telegraph (November 2016) that ‘terrorists ‘may simply be using the method of a terrorist attack – under whatever ideology – to excise personal demons’.
While ‘lone wolves’ may be disproportionately likely to have psychological problems and to use illicit drugs, the explanation of ‘terrorism as madness’ in public commentary seems to be an avoidance strategy of the secular, relativist, rationalist establishment and its media lackeys. Religiously illiberal belief systems are thus excused as the principal motive for violent political activism. Defending multiculturalism, apparently, is more important than the positive mental health campaign. The inconsistent application of mental illness to particular phenomena indicates that diagnosis is instrumental and malleable to political expediency.
Conclusion: from radical ideology to Soviet-style containment
Mental health services are essential to a civilised society. Normally care and treatment are provided on a voluntary basis, as they are in any other type of health service, but the mental health system also has an important role in public safety. Severely disturbed persons who endanger others may be detained until their symptoms are ameliorated. However, with a drastic reduction in hospital beds, the threshold is now so high that only the most serious cases are admitted to psychiatric wards. Turnover is so rapid that inevitably many patients are discharged before they are well enough. Prominent psychiatrist Peter Tyrer (2013) observed that unlike the past when patients were excluded from society, they are now excluded from hospital.
‘Community’ is no panacea for mental disorder, and practitioners are carrying a heavy burden of responsibility. McCrae and Hendy (2016) argued that the system is approaching ‘peak community care’: a condition that could become another example of counter-productive liberalism where the ultimate outcome is the opposite of that intended. If fighting stigma is prioritised over safety, a backlash is likely to arise. It would be better for policy-makers to turn the corner now, before they are forced to act by a resurgence of public hostility. Larry Gostin, who was instrumental in the reform of mental health legislation in Britain, spoke of his journey from ‘civil libertarian to sanitarian’. Tragic incidents cannot always be predicted, but a safer system is needed.
Attention has been drawn to the disproportionate use of the Mental Health Act on black patients. Allegations of institutional racism are based on the higher frequency of ‘sectioning’, forced tranquillisation and seclusion. There may be some truth in the perceived cultural insensitivity in diagnosis and risk assessment, but it is difficult to believe that psychiatrists in an extremely stretched service are conspiring to remove sane persons from the streets for racial motives.
Paradoxically, while mental health professions, the NHS and campaigning bodies have challenged (and arguably censored) any association between mental disorder and violence, there is a tendency to attribute some heinous crimes to mental health problems. Incidents of Islamist violence are rapidly redefined in media reports as the deeds of a madman rather than a planned attack on infidels. Inevitably this will shape public perceptions of mental illness. While progressive ideology is being stretched too far, political expedience is hastening regression to past prejudice.
This article (Mental health and homicide: progressive ideology meets political expedience) was created and published by Niall McCrae and is republished here under “Fair Use”
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