“A murderous psychosis”: mental health and dangerousness

Photo credit Sean Jones QC @seanjones11kbw

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You know the stereotype: the “mad axe-murderer” or “deranged maniac” who appear in the media in the extremely rare and therefore newsworthy instances where someone with serious mental illness commits a violent crime. I wrote recently about how the “unpredictable and potentially dangerous” stereotype is so accepted that it goes unnoticed, assumed to be a natural fact; how it is therefore repeated, and reinforces negative assumptions about those of us managing mental health problems in our daily lives. Almost goes unnoticed, that is, because I for one do challenge outrageously stigmatising and inaccurate stereotypes about mental ill-health when I see them. I say this sort of thing:

1. People with mental health problems are far more likely to be victims of crime than perpetrators; and are far more likely to be victims of crime than the general population.
2. People with serious mental illness are far more likely to take their own life than that of someone else; and the vast majority of people with serious mental illness are never violent towards others.
3. The risk factors for violence – such as being male, having a past history of violence, or of alcohol or drug abuse – are the same as for the general population as they are for people with serious mental health problems; therefore, measures to reduce violence will be more effective if targeted at the general population, not specifically at mental health patients.
4. Violent acts during psychosis are so extremely rare that it is not possible or practical to predict let alone prevent them – other than by measures aimed at the general population.
5. Psychosis is causal in violent crime in a tiny minority of cases; where someone with a mental health diagnosis commits a violent crime, the mental illness causes the crime to be committed in only a tiny minority of cases. In other words, almost always, mental illness is simply another of a person’s characteristics, in the same way as diabetes or red hair.
6. People with mental health problems are, well, people.

Yesterday, I was asked by Sean Jones QC to put my money where my mouth was and come up with research links to dispel his “murderous psychosis” stereotype that I’d just challenged. How did I know that these statements, which all contradict the stereotypical media portrayal of people with mental health problems, are true? How could I prove these points to someone who wants to know – or at least give them sufficient information so that they can go away, do their own checking and make an informed judgment for themselves?

When someone asks me what my proof is that the “murderous psychosis” stereotype is untrue, I usually refer them to organisations like Time to Change, Mind and Rethink Mental Illness. In other words, experts; organisations that make it their full-time business to know what’s what in the field of mental health.

• Here’s the Time to Change guidance on mental health and violence. There are no links to research papers, however.
• Here’s mental health charity Mind‘s 5-page factsheet on violence and mental health (there used to be a more comprehensive guide to mental health & dangerousness on the website, which included guidance on how to interpret research reports and statistics, which is perhaps being updated) and some facts and statistics about mental health.

Both are a good starting point. However, they may not satisfy someone who wants to drill down into the details themselves. Of course they could contact those organisations direct themselves, but what can I do to help? What else is there, if you want to dig a little further? Here are some more links I send to people:

• My page of media guidance, which includes lots of links to stuff that’s useful to everyone.
• My page on important reports & documents (such as At Risk, Yet Dismissed – The criminal victimisation of people with mental health problems – I was one of the people interviewed for this research).
• The Mental Elf website, has links to research summaries which do contain links to the research reports discussed, and these do occasionally cover the topics of violence and homicide. For example:
  • Are you really at risk of attack by someone with schizophrenia? (June 2013)
  • New review confirms strong association between criminal history & violence risk in psychosis (February 2013)
  • Preventing serious adverse outcomes in schizophrenia (July 2014)
• The National Confidential Inquiry into Suicide and Homicide in People with Mental Illness, which reports annually on suicides, homicides and unexpected deaths in people with mental health problems.

Here’s more about psychosis and on still being human whilst having serious mental health problems:

• Sometimes (I Have Schizophrenia)/All Of The Time (I’m Just Human) (3 mins). There are many more videos in Jonny Just Human, Jonny Benjamin’s YouTube channel on his experiences of schizoaffective disorder and other stuff on being human. In the words of Jonny Benjamin, “We’re not all dangerous or violent, as some papers would have you believe.”
• Finding Mike – Short film (45 mins) including Jonny Benjamin talking about his experiences of psychosis (here’s the 50 second promo trailer).
• Facts about psychosis from mental health charity Mind – “Psychosis (also called a psychotic experience or episode) is when you perceive or interpret events differently from people around you. This could include experiencing hallucinations, delusions or flight of ideas.”
• A personal experience of psychosis from mental health blogger Charlotte Walker (April 2014)
• Simon says: Psychosis! – Short film in which (amongst others) people with lived experience of psychosis talk about their experiences of psychosis in the context of receiving treatment from a particular Early Intervention in Psychosis service (June 2014)

These are all good places to start. But where else might I point people to? I’m good in 140 characters – but that’s about it. I’ve retweeted interesting studies when I’ve randomly stumbled across them, and that’s how I’ve formed my views. I’m not a mental health researcher. I’m not even organised. I don’t have access to scientific reviews behind pay walls. I haven’t been collating a database of relevant research – unless you count my list of favourites on twitter (currently running to over 2,000).

New research is published all the time but the general public (including me) will mostly only have access to press reports on the research, which typically highlight some juicy aspect to ‘sell’ the story to potential readers. I’ve also noticed that not all research is particularly good quality: sometimes research seems to ask the wrong questions; some studies look at just criminals or just people with psychosis, rather than looking at the whole population. Mostly it seems research conflates cause and correlation, simply counting violent crimes by people with mental health problems when the fact of having a mental health diagnosis (either at the time a violent act was committed or at a later assessment) does not prove that the mental health problem was the cause of the violence.  There was a US study I came across that said, in convicted violent criminals with serious mental illness, the mental illness was the cause of the offence in under 7% of cases. It was interesting because it highlighted the difference between having a mental health problem at the time of a crime and that mental health problem having been the cause of the crime. But then I lost the link to the study and haven’t been able to find it since. Like I say, I’m good in 140 characters.

Like plane crashes, “murderous psychosis” makes the headlines because it’s rare. It’s alarmist, inaccurate and causes suffering to people managing mental health problems in our daily lives. There’s ignorance about psychosis & violence, with the media stereotype we’re fed. But, when challenged, some people do want to know more.

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Related links:

• My original twitter conversation with Sean Jones QC which prompted this post
• My tweets earlier where I mused on the topic

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Update (pieces written or added since publication of this piece):

• The myth of mental illness and violence – BBC, Claudia Hammond (July 2015)
• Gun violence and mass shootings — myths, facts and solutions – Washington Post, Deweg G Cornell (June 2014)
• Reporting & media portrayal of violence and mental health – let’s look at the bigger picture – Georgia Belam (August 2015)

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Background links

• Violence and schizophrenia: examining the evidence – British Journal of Psychiatry (2002)
• Homicide and schizophrenia: maybe treatment does have a preventive effect – Criminal behaviour and mental health (2006)

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“Safety” in mental health care

 

Safety Dance – Men Without Hats

When you think “safety”, what comes to mind? Seeing someone on top of a rickety ladder reaching out to wash a window perhaps. Or putting a guard rail along a high pathway or using an oven mitt to pull out a hot grill pan. Protections from physical harm. But what does “safety” mean in the context of mental health care?

Caring for people with mental health problems should naturally – since the pain and suffering is mental – involve alleviating mental distress. So often, however, the terms in which mental health is spoken and the means by which people are assessed and treated in psychiatric care appear to be almost entirely physical: assessing someone from their demeanor; treating them with drugs; locking them on a psychiatric ward. I’ve speculated about that before (here). Sadly, I haven’t heard any contradiction to that suggestion yet.

Today, it was announced by psychiatrist Professor Louis Appleby that this year’s annual “safety in mental health care” report was being launched. There would also be a tweet chat, on the hashtag #ncish14. What could the report be about and would it deal purely in physical aspects of mental health care?

The report, it turned out, was about death: suicide, homicide and sudden deaths in mental health patients. It was a serious and sobering report about tragic deaths which also dispelled myths about “dangerous mental patients” (a tiny proportion of homicides are by people with mental health problems; but a far higher proportion of suicides) and offered concrete recommendations to reduce the rates of all three. Mental health charities Rethink Mental Illness and Mind released a statement about the report.

What struck me in addition, however, were two things: first that, in mental health, the word “safety” seemed to be a euphemism for “preventing deaths” rather than, say, patients feeling safe and cared for in their distress or alleviating distress; and that the only thing measured and reported nationally on an annual basis in relation to mental health was a physical outcome, namely death.

I joined in the tweet chat and exchanged some tweets with the NCISH (National Confidential Inquiry into Suicide and Homicide by People with Mental Illness in the Centre for Mental Health and Risk at the University of Manchester) and with Professor Appleby. I’m still pondering this and may add to this blog post later. But, in the meantime, I’m left with the impression that – hundreds of years since practices such as mechanical restraint, confinement in madhouses and cold baths began to be condemned – mental health care is still viewed, treated and measured in largely physical terms.

 

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Related links

 

 

The report and related documents:

• Press release about the report
• The report – National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: Annual Report 2014 – England, Northern Ireland, Scotland and Wales (pdf) (by the National Confidential Inquiry, based at the Centre for Mental Health and Risk at the University of Manchester)
• Comment by mental health charities Rethink Mental Illness and Mind about the report

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On twitter:

• My tweets
• Tweets on the hashtag #ncish14
• Tweets during the tweet chat on hashtag ncish14

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Additionally:

• My earlier post – Mental health? Physical treatment (May 2014)
• Madness to Mental Illness – A History of the Royal College of Psychiatrists (sample chapter) – A snippet of psychiatric history, full of references to”the insane” and “the mentally ill”, despite being only 6 years old.
• Men Without Hats – The Safety Dance (Music Video) (1982)

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Compulsory treatment and benefit sanctions: stoking fear and prejudice for political ends

Benefits Street arrived on the iPads of Telegraph readers on Saturday night. A story about scroungers refusing help to get back on their feet and the Conservative party’s proposed “tough love” solution provoked strong reactions. And that’s no surprise.

People with mental health problems who are unable to work and dependent on state support were led to believe that payments would be docked if they refused treatment. This would effectively make state-sanctioned treatment compulsory on pain of losing your only source of income. Telegraph readers were fed the line that people with common mental health problems were willfully refusing to engage with treatments almost guaranteed to succeed just so that they could lounge about at taxpayers’ expense; but reassured that the Tories had proposed a simple and cost-effective solution (sanctions and compulsory treatment) to get people back to work.

Although at first glance the story might follow a coherent line, at second glance it became clear there was more to it. None of the reasons for publishing the story (see below) had anything to do with the advice of mental health professionals nor with helping people with mental health problems back into paid work: people with mental health problems are being used as pawns in a game of politics.

The story could prove a useful example for journalism, behavioural science and politics tutors. But does that mean it is baseless and can be dismissed entirely? No. Even though, a few minutes ago, the Department of Health tweeted me a disclaimer – there were “no plans to make mental health treatment compulsory for people receiving Employment Support Allowance” – there is a real story behind the vile propaganda, namely the current and proposed pilots of new ways to provide back-to-work support (see below).

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Why was the story published? Kite flying, dog whistles, nudging and click bait

Political parties thinking about whether to make a potentially controversial policy official will occasionally send up a little kite: they’ll brief a journalist anonymously, typically for one of the Sunday papers, to see how the idea flies. If it is ridiculed or condemned by the public, the idea can simply be dropped. If it proves hugely popular, it can be embraced. In any case, there’ll be new information. Another reason for kite flying is to put an idea out there which could never be put into effect for good practical reasons but will nonetheless get enough coverage to plant an idea in the minds of relevant voters. Some call this dog whistle politics.

The proposed policy has all the hallmarks of a ludicrous back-of-the-envelope idea dreamed up by people with no experience of mental health or clinical practice (see below). In other words, it is utter tosh. Yet the idea has been planted, without it ever having to become a practical reality, that the government is tough on skivers and tough on the causes of skiving.

The government’s Behavioural Insights Team (or, as it is known colloquially, the Nudge Unit) looks at ways to subtly alter behaviour by “nudging” or encouraging us in the right direction. Here we can see the hallmarks of a “nudge” to people with mental health problems that it really would be in our very best interests to buck up and get back into work, because we will not get an easy ride on benefits. The proposed policy is a signal that, if we must insist on being dependent on social security in future, we should prepare ourselves to jump through further hoops. Though, for practical and ethical reasons (see below), it may not be this particular hoop, there will be new hoops nonetheless.

We can also see a “nudge” in the direction of “hard working families”: the public is being softened up for the introduction of further welfare benefits cuts to disabled people. Because, as the story makes clear, there are the deserving poor and the undeserving poor – the skivers – and what they need is “tough love”.

Newspapers aren’t impartial public information services: they’re there to sell advertising and papers. Facts and context don’t sell papers: controversy, fear and outrage are the sorts of things that do. We haven’t seen the original briefing note so it’s hard to tell where the line lies between what the “government source” said and how the journalist interpreted it. But, whatever the case, the story contains a potent cocktail of inflammatory statements which appear to seek to stoke up outrage at “lazy scroungers” lounging on benefits refusing treatment that is almost guaranteed to cure them. And that’s just perfect for selling newspapers and driving traffic to  your website and up its desirability to advertisers. In other words, a controversial story is “click bait”.

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How true, complete and accurate is the story?

There are numerous problems with the story as reported, including:

• The news coverage (initially in the Telegraph and subsequently in other news outlets) lacks analysis or context. For the main part, it repeats the same line, namely making a case for people with mental health problems to be sanctioned for refusing to engage with treatment. The news reports the proposed Tory policy, rather than the actual DWP/DoH pilot schemes (see below).
• No acknowledgment that people in receipt of Employment Support Allowance already have to “prove they are depressed” (or whatever the reason for incapacity is) through the Work Capability Assessment. It’s not simply a case of saying “I’m unwell, give me money”.
• There is a conflation of treatments for unwell people with JobCentre schemes currently on offer to people judged fit to work. That’s like conflating treatment received from doctors and nurses at the chemotherapy outpatient clinic and workshops at the JobCentre to help a cancer patient in remission to build confidence and return to the workforce. They are different things, but the news coverage blurs the lines.
• There is no acknowledgment that diagnoses of depression and anxiety, which may be helpful descriptions or guidelines, are not uniform conditions to which uniform fixes can be applied. There is no acknowledgement that CBT is not appropriate nor effective for everyone. As Professor Louis Appleby says, even bacterial infections need treatment with different antibiotics.
• No context is provided about benefits payments. Instead, people with mental health problems are presented as a drain on the economy when in fact we receive a minority of the welfare budget.
• Misleading statements – frank factual inaccuracies – are being peddled about the treatability of depression and anxiety and about success rates for CBT. If CBT for depression and anxiety had a 90% success rate, that would be a wonderful thing. But it doesn’t. Even the government’s own IAPT services claim a success rate below half.
• There is no acknowledgement that, with IAPT aiming to only treat 15% of need in England (and different circumstances applying elsewhere in the UK), it is pure fabrication to say that people are turning down treatment. Mental health services face devastating and ongoing cutbacks.
• There is no discussion of the ethics for doctors or therapists of engaging in compulsory talking therapy.
• There is no acknowledgement that talking therapy can be hard work for people. It is not nothing. It is not an easy option. It can be traumatic and upsetting. It can make people worse before it makes them better.
• Incredibly, today the story took a further turn when it was reported that the government had refused to rule out compulsory drug treatment. It’s one thing compulsorily treating people who lack mental capacity (under the Mental Capacity Act) or people who are sectioned (under the Mental Health Act). (I have been compulsorily treated when sectioned and I can tell you I am not in favour.) But to compulsorily treat people – people who are not sectioned and who have capacity – for common mental health problems? Ridiculous. Does anyone really believe that people’s benefits will be docked if their weekly blood test at the JobCentre shows they haven’t taken their state-mandated pills? No. It’s utter tosh.

The proposals reported could never come into action: they are unethical and impractical. As the Department of Heath statement said this afternoon:

“There are no plans to make mental health treatment compulsory for people receiving Employment Support Allowance. Experiencing a mental health problem can be distressing and we want people to be able to seek treatment at the right time. We also want to help people to stay in work or return to work as part of their recovery, which is why we’re looking at options to offer more support.”

And it’s in the phrase, “we’re looking at options to offer more support” that the factual element to the story lies.

Reports say there are four trials either proposed or ongoing. The paper produced jointly for the Department for Work and Pensions and Department of Health by Rand Europe earlier in the year, Psychological Wellbeing and Work – Improving Service Provision and Outcomes, proposed trials of the following four policy options (see Part 5):

• Policy option 1: Embed vocational support based on the principles of IPS in local IAPT or psychological therapy services
• Policy option 2: Introduce group work approaches based on JOBS II in Jobcentre Plus
• Policy option 3: Improving access to online assessments and interventions for common mental health problems
• Policy option 4: Commission third-party organisations to provide a combination of psychological and employment related support to claimants

Each policy option is discussed in detail in the report and costed. They make for fascinating reading. It may well be that these are the pilots referred to by the government source. If so, they do have real implications for people with mental health problems, whether in receipt of welfare benefits or not.

This is a real story. .

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What is the fallout from the story and what may happen next?

The Telegraph story and those that followed that parroted it without analysis has stoked prejudice against people with mental health problems and facilitated and encouraged discrimination. The tone of the piece is around benefits scroungers, presenting mental health issues as something other than genuine illness, as something people can get over with the right motivation – in this case, financial penalties for people with no other source of income.

It is no wonder people on twitter have expressed such fear and despair. When ill-health forces you to rely on social security payments to keep a roof over your head, when you desperately need treatment but are unable to get it due to cutbacks and waiting lists, then being blamed for your inability to work, being told your sole source of income will be docked and that you could be forced into treatment is supremely unwelcome. People with mental health problems are a vulnerable and discriminated-against minority. Being used cynically for political purposes in this way is sickening.

We will start to learn more about the pilots in due course. And there will be implications for people with mental health problems, whether or not they are in receipt of welfare benefits.

 

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Related links

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Mainstream media

Saturday 12th

• Tories discuss stripping benefits claimants who refuse treatment for depression – Senior ministers now believe the rules should be reviewed in order to reduce the “huge” numbers of people who are declared unfit for work due to mental health problems – Telegraph newspaper, by Tom Ross (political correspondent)

Sunday 13th

• Benefit claimants who refuse treatment for depression face having handouts axed – Sunday Express newspaper, by Daniel Macadam

• Mental health and benefits: ministers get the wrong end of the stick – Spectator blog, by Isabel Hardman – Recommended for an excellent summary of what’s wrong with the scare story

• Mental health job support scheme piloted – BBC news

• See shrink if you want Government handouts – Plan for mentally ill – “Benefit claimants with anxiety and depression like TV’s White Dee may be forced to get counselling or lose handouts.” – Sun newspaper

• Stripping benefits claimants if they refuse depression treatment is ‘unethical’ – Telegraph, by Steven Swinford
• Tories Plan to Make Mental Health ESA Claimants Prove They Are Really Depressed – Huffington Post, by Jessica Elgot (UK assistant news editor)
• Tory MP blasts Iain Duncan Smith plan to grab mentally ill’s cash as ‘brainless’ – “Dr Sarah Wollaston the chair of the Health Select Committee, described the proposals as “unethical, unworkable nonsense” and “complete tosh” – Daily Mirror newspaper

Monday 14th

• Benefit claimants may be ‘forced’ to undergo mental health treatment – “Government officials are piloting ways to force benefit claimants to undergo mental health treatment or risk losing their benefits, reports suggest.” – Inside Housing
• Government considers plans to make benefit claimants prove they are depressed – or be stripped of payments – Independent newspaper
  
• Totnes MP Sarah Wollaston blasts new Government benefit strategy for anxiety and depression patients – “Totnes Tory MP Sarah Wollaston is among critics who have expressed horror at Conservative plans to make benefit claimants prove they suffer from anxiety or depression, or risk having their payments cut.” – Torquay Herald Express

Tuesday 15th

• Mental health benefit claims denied  – “Norman Lamb also told MPs there are no plans to force people to access therapy, adding pilot projects would seek to develop ways to ensure unemployed people with mental health problems receive help.” – Press Association

 

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Mental health charities

• Proposal to force people to undergo treatment is unacceptable – “We are deeply concerned by the rumoured Government proposals to strip people of social security if they don’t undergo treatment for mental illness. We doubt that the Government would consider doing the same to people with diabetes if they didn’t take insulin, so why should people with mental illness be treated this way?” – Rethink Mental Illness (Monday 14th July)

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Department of Health

• Government statement on support for people with mental health problems who receive ESA (Monday 14th July)

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Blogosphere and commentators

Sunday 13th

• A lie gets halfway around the world before the truth has a chance to get its pants on. Winston Churchill. – Walk A Mile In My Shoes blog (@walkamileuk)

• Another Government ‘Fag packet’ proposal for Benefit Sanctions & Cuts ? – Jane Linney blog

• Forced treatment for depression is beyond satire – Left Eye, Right Eye blog by Louise McCudden

• Recover or else? – Delusions of Candour blog

• Take our ‘treatment’ or we’ll stop your benefits, Tories threaten mentally ill – Open Democracy website, by freelance journalist Louise McCudden

• “Tories discuss stripping benefits from claimants who refuse treatment for depression” – Comprehensive collation of tweets by Mark Brown (@MarkOneinFour)

Monday 14th

• Authoritarianism, work and therapy – LibCom blog by psychiatric nurse Sometimes Explode (@DroneModule) – Well worth a read

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Background reading

• Psychological Wellbeing and Work – Improving Service Provision and Outcomes – Department for Work & Pensions, Department for Health (January 2014)
• The problem with nudge policies is that they threaten our freedom to choose to act well – London School of Economics blog, by Paula Zoido-Oses (PhD candidate) – On the ethics of nudge policies and the Behavioural Insights Team (9th July 2014)
• Ingeus recruiting “Health Advisors” for DWP forced “bio-psychosocial health assessments” and Sick people to be forced to talk to the DWP’s own “healthcare professionals” – A Latent Existence blog spot (November 2013)
• Psychobabble – A4e and NLP – Watching A4e blogspot (June 2012)
• Talking therapies: a 4 year plan of action – Department of Health (February 2011) – This plan outlines how the government will achieve its commitment to increase access to psychological therapies in the 4 years from April 2011.

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Twitter comments and conversations

• My tweets – Saturday, Sunday and Monday
• Criticisms of the policy proposal for the benefits sanctions and compulsory treatment
• Norman Lamb – LibDem MP and minster for care and support
• Dr Sarah Wollaston – Tory MP and chair of the Commons Health Select Committee
• Robin Brant – BBC journalist who announced the DWP pilots
• Luciana Berger – Labour MP responsible for mental health
• Isabel Hardman – Journalist
• Dr Sarah Knowles – Mental health researcher
• Shaun Lintern – Award-winning HSJ health journalist with a special interest in mental health
• Prof Louis Appleby – Psychiatrist and government adviser
• Mark Brown – Editor of One in Four magazine who was fired up by this story!

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