Mentally disturbed people 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 to the perpetrator too. But typically the verdict is diminished rather than total loss of responsibility. As Theodore Dalrymple reminds us in his 2017 book The Knife Went In: Real Life Murderers and Our Culture, 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 has been 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. Lessons, though, are not learned and avoidable tragedies continue. Ordinarily, this would be a national scandal. However, the well-intended campaign to destigmatise mental illness and the much misunderstood policy of care in the community have mutated into an ideologically motivated suppression of inconvenient truths.
Changing Attitudes towards Mental Health
In recent years, celebrity-led campaigns have challenged unsympathetic perceptions of mental illness. The well publicised Heads Together project, launched in 2016 by the Duke and Duchess of Cambridge and Prince Harry, encouraged people to open up about issues such as anxiety and depression.
A more humane understanding of the struggles faced by people with mental health problems has advanced by a process of normalisation, eschewing harsh language and hurtful stereotypes. Mental illness has been replaced by mental health and wellbeing. The conceptualisation of mental illness implied an objectively diagnosable dysfunction, but without pathological evidence. In principle and in practice, this was both demeaning and unhelpful.
Few 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 anti-social personality disorder. Here, the rhetoric of non-judgmentalism and empathy can be misguided because it obscures accurate diagnosis of psychiatric disorders and glosses over the potential threats to public safety.
Care in the Community
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 admissions. Forbidding Victorian asylums were regarded as an anachronism, and Enoch Powell, as Minister of Health, announced their demise in his Water Tower speech in 1961. Mental health campaigners increasingly presented the needs of psychiatric service users as a rights-claim of freedom, dignity and citizenship.
Care in the community was, though, greeted with scepticism when it was first introduced in the 1990s. Persistent criticism in the media tended to portray the policy as a penny-pinching exercise that evicted patients onto the streets. Most people were unaware of the plethora of community-based services (including locality teams and supervised residential accommodation). By comparison, large mental hospitals were, in fact, cheaper to run.
Cynicism was reinforced by scandals of discharged patients slipping through the net. One case that drew widespread media coverage was the killing by Christopher Clunis, who stabbed Jonathan Zito in the face at Finsbury Park Underground station in December 1992. Clunis had paranoid schizophrenia. After the incident, police found unopened letters from social workers and a large unused supply of anti-psychotic medication in his home. Clunis was sent to Rampton high-security hospital. Shortly after this case, in January 1993, another psychiatric patient, Ben Silcock, was mauled to death after climbing into the lions’ enclosure at London Zoo.
Despite the bad press in the early years, 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. 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. 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 National Health Service (NHS) to funding constraints, the problem of killings by mentally unwell people is an unintended but inevitable consequence of ideology seeping into mental healthcare provision. 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.
Struck by Lightning? Miscounting Homicides
The problem is that it is not always possible to care safely for acutely disturbed patients in their own homes. The well-meaning attempt to quell prejudice has led to a censorial tendency against any criticism of mental health policy. A front-page report in 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 ends 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 conditions, despite the factual reporting (the precise number of deaths was 1,226).
Television producer Julian Hendy founded the charity Hundred Families after the killing of his father by a psychiatric patient in Bristol in 2007. The charity supports families of victims and demands safer mental health care. Hendy exposed gaping holes in the system, and showed that official reports underestimate the incidence of homicide by mentally ill people.
Mental health professionals and advocates often argue that people with mental illness are more likely to be victims than perpetrators 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 occur in the UK annually, compared to 34 killings by schizophrenic patients (according to the National Confidential Inquiry). In 2016, on the ITV documentary series Tonight, Hendy interviewed Professor Simon Wessely of the Royal College of Psychiatrists, who stated that the number of such incidents is declining. Data collated by Hendry suggests the exact opposite.
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. 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 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 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. 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 health 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 facilities 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 usually parroted by NHS trusts after a homicide involving one of their patients, but, on examining details of 1,274 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 having been discharged or having moved 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 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 state and heavy cannabis use, 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. Opened 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. Local residents expressed concerns about dangerous patients in their midst, and 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 (ironically) 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 south-eastern fringe of London. A 1999 study by Baxter and colleagues 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 by Hendy under freedom of information provisions showed that Oxleas patients were responsible for 18 murders over a fifteen-year period.
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 in 2018, Robin Murray and fellow researchers at King’s College London 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 and Minority Ethnic (BAME) 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, has 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.”
Writing in the British Medical Journal in 2006, psychiatrists Swaran Singh and Tom Burns 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 a 2010 article in Prospect Magazine, Singh argued that portraying mental health services as racist is counterproductive: “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 2005 action plan, Delivering Race Equality in Mental Health Care, which aimed to reduce disproportionate admissions of black patients to psychiatric wards. He 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? 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: they are higher than average among the black population, and lower among south Asians. As Roland Littlewood and Maurice Lipsedge explain in their 1982 book Aliens and Alienists: Ethnic Minorities and Psychiatry, there is no straightforward explanation for these differences. Simplistic notions of racist diagnosis or racial or cultural susceptibility are unhelpful. A 1994 study by P. A. Sugarman and D. Craufurd showed that, compared to their parents, second-generation black people have higher rates of psychiatric disorder. Research in 1997 by Dinesh Bhugra and colleagues revealed a disproportionately high incidence of paranoid schizophrenia among 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 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 and arrested on failing to prove his identity.
As a 2013 study by researchers Kitty Farooq, Greg Lydall and Dinesh Bhugra has shown, psychiatry is a branch of medicine with a high proportion of black and Asian practitioners. This may enhance cultural sensitivity, but not necessarily. The umbrella term BAME suggests homogeneity amongst 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 this may also be true of, for example, 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, however, not divert attention from the priority of protecting patients and the public from harm.
The Exception that Proves the Rule: Islamist Homicide
An intriguing departure from the contemporary reluctance to ascribe mental illness to individuals is the enthusiastic willingness to attribute mental dysfunction to incidents with apparent Islamist motives. A number of violent attacks in recent years illustrate this trend.
In 2016, Zakaria Bulhan, a Norwegian national of Somali descent, went on a stabbing spree in Russell Square in London, killing one American tourist and wounding five others. The police declared that the attack was “triggered by mental illness.” Prior to the incident, Bulhan had been 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 entitled Fortress of the Muslim. According to the report of the trial proceedings in the Guardian on 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 officer 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 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, and jihadist literature was found in his home, notably recordings of extremist preacher Anwar al-Awlaki. Deemed fit to stand trial, he pleaded guilty to three counts of attempted murder, and was sentenced to life in a high-security psychiatric hospital.
In 2019, a Libyan asylum-seeker stabbed five people at the Arndale Shopping Centre in Manchester. Police stated that a 40-year-old man had been 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.
We can note the obvious dissonance in the reporting of these events in comparison to the current emphasis on normalising mental health issues in public discourse and the unwillingness to attach labels of mental illness. By contrast, when it comes to Islamist violence, the emphasis is in the opposite direction: to talk up the role of mental dysfunction and discount political-religious motivations. For example, Simon Wessely has argued that “lone actors are more likely to have psychotic disorders such as schizophrenia than the general population, and more likely to have autistic spectrum disorders.” The credentialization of the lone actors as mentally ill thesis encourages unverified diagnostic generalisations by unqualified writers. Writing in the Times in July 2016, Alice Thomson asserts that most terrorists “have a history of mental illness,” while Raffaello Pantucci of the Royal United Services Institute claims in the Daily Telegraph in November 2016 that terrorists “may simply be using the method of a terrorist attack—under whatever ideology—to excise personal demons.”
While a link between lone wolf acts of political violence and the existence of psychiatric disorders (and drug misuse) cannot be disregarded, recourse to the explanation of terrorism as madness in public commentary reflects the profound difficulty that the secular rationalist mindset of the commentariat has in acknowledging the role of religiously illiberal belief systems as the principal motive for violent political activism. We can speculate that this arises, in part, from a wish to avoid drawing attention to the problems that the policy of multiculturalism has caused in the UK. Nevertheless, at minimum, the inconsistent application of the label of mental illness to particular phenomena indicates that diagnosis is instrumental and capable of shifting according to political and ideological expediency.
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 people who endanger others may be detained until their symptoms are ameliorated. The policy of care in the community has resulted in a drastic reduction in hospital beds and only the most serious cases are now admitted to psychiatric wards. In 2013, psychiatrist Peter Tyrer observed that, unlike in the past when patients were excluded from society, they are now excluded from hospital.
“Community” is no panacea for mental disorder, practitioners are carrying a heavy burden of responsibility, and we may be approaching a situation of peak community care: an example of counterproductive 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, has spoken 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 people from the streets for racial motives. Practitioners are trying to save lives—both of their patients and of other members of the public.
Paradoxically, while mental health professionals, the NHS and campaigning bodies have challenged associations between mental disorder and violence, there is a tendency to attribute some heinous crimes to mental health problems, seemingly for political convenience. Incidents of Islamist violence are rapidly redefined in media reports as the deeds of madmen, rather than as planned attacks on non-believers. Misuse of psychiatric diagnostics and language in this manner can only increase public scepticism. While progressive ideology is being stretched too far, political expedience is hastening regression to past prejudice.