The Dangerously Mentally Ill

You know what I’m referring to here, don’t you?  Just that term, “the dangerously mentally ill” tells you all you need to know about the group of people I’m referring to.  It’s such a self-justifying, explanatory term that it doesn’t really need any further explanation or clarification – you’re delivered straight to a vision of those in our society that are caught by this classification, right?  Surely, as a policeman, I meet people from this strata of our society all the time and they’re easy to recognise – maybe it’s those who would do harm to strangers or their close family and friends?

But what do you think I mean by ‘dangerous’? … and what do I mean by ‘ill’ or ‘mentally ill’?!

If you haven’t already realised: these words take us almost nowhere at all – let me briefly explain why and let me tell you the reasons behind labouring the point —

Have you ever listened to a psychiatrist and a lawyer discussing terminology and definitions, especially legal ones?  It’s worth buying popcorn and setting aside time because those discussion can go on and on and they’re highly entertaining – lawyers are from Mars and psychiatrists from Venus.  You see, the concept of ‘dangerousness’ was so problematic when the Mental Health Bill 2004 was making its way through Parliament that the whole thing fell and we were deprived of a new Mental Health Act.  The previous government had hoped to create new laws for dangerous and severe personality disorder, allowing pre-emptive detention of individuals like Michael STONE who was convicted of murdering Lin and Megan RUSSELL in Kent in 1996.  But once discussion began about the ethics, the labelling and the role of psychiatrists in our society, it became clear that it would be very difficult indeed to work out who was ‘out’ and who was ‘in’.

So the whole Bill collapsed and we lost potentially decent reform of other legislative problems like the inadequacy of sections 135 and 136 of the 1983 Act, again being reviewed by the Government ten years down the line.

PROBLEMS OF DEFINITIONS

There are some of us in society who live with mental distress every day and in some circumstances we know that violent or dangerous things have occured.  It’s not merely semantics to ask that we try to define what we mean by ‘dangerously mentally ill’, if we are going to use the appropriateness of that term to determine responses to complex situations.  We know that the interface between policing, mental health and criminal justice is about creating pathways and diversions for those we decide are covered by the terms and language, whilst leaving others to the exclusive majesty of the police, courts and prisons.  So if special procedures need to exist, we have to know how to identify those of us who are ‘in’ and ‘out’.

All becomes rather difficult, if we can’t get very far with that!

So what do we mean by mentally ill? … and by ‘dangerous’?!  — well the Michael STONE case highlighted this issue too – he was diagnosed with a personality disorder.  In terms of mental health law, it means he’s ‘mentally ill within the meaning of the Mental Health Act’.  So he’s ‘in’, right?!  Not necessarily.  A feature of inquiries in recent years has been that people who in hindsight appear to have been very likely to do dangerous or violent things, were not detained under the Act and when those risks and threats became realised, there was outcry that ‘nothing’ had been done.  This is far from a British problem.  The book Neither Mad nor Bad, by Deirdre GRIEG is devoted to the discussion of one man in the context of how psychiatry interfaces with the law.

Garry DAVID from Melbourne, Australia was a convicted criminal with a serious personality disorder who spent time in prison making very serious threats to inflict incredible harms upon the public when he was released.  These threats, along with the seriously mutilating self-harm that he used to undertake, prompted much debate about how to ensure the public remained protected from his potential given that he was “obviously mentally ill”.  But for some years, the Victorian state authorities could find no psychiatrist in the land who would put their professional reputation to a diagnosis of mental illness.  In the end, the Parliament of Victoria introduced legislation specifically for him: the Community Protection Act 1990.  It allowed for his detention after the expiration of his sentence on the grounds of his dangerousness.  A quite remarkable case and a book worth reading.

Another book for your reading list that I would highly recommend is Mental Health and Crime by Professor Jill PEAY.  This book, perhaps more than any other, drives home the problems of attempting to doubly classify people and their conduct under the term ‘mentally disordered offender’.  Even harder to extrapolate further and label people as ‘the dangerously mentally ill’.  These words seem to defy easy explanation because science is still struggling with objective classification of what the medical textbooks call ‘mental disorder’ and almost everywhere, that leads to legal definitions that seem to suit no-one.  It is probably for that reason that our modern mental health law is still derived from the 19th century definitions we saw of vagrancy and insanity – we know it’s not great, but can’t seem to agree on anything better.

POLICE ONE

This post was motivated by an article I came across online: from the US e-magazine Police One.  Entitled, “The Dangerously Mentally Ill: spotting the signs to prevent tragedy” I admit I struggled to get beyond the first four words in the headline but forced myself to try.  I wrote last year about the many differences in the US compared to the rest of the world and I was reminded of them all whilst reading this article.

The United States typically sees mental distress through a far more medical lens than elsewhere, has particular challenges around its healthcare system and has a culture around law enforcement and criminal justice that is sufficiently different to matter.  So put that all together and you are not comparing apples with apples when you discuss the comparative issues that arise.  We see in this article references to Kendra’s Law (New York) and Laura’s Law (California) which alludes to the legal frameworks which allow preventative detention of individuals on the basis of their propensity for future types of behaviour – this would include dangerousness and violent behaviours.  These are the kinds of laws to which UK psychiatrists objected in the lead up to the collapse of the 2004 Mental Health Bill.

I’ve long since thought that police jargon is not suited to the kind of discourse we need to see about mental ill-health and distress.  The legal tendency to label in all kinds of different ways; the very fact that legal processes have to determine who is ‘in’ and who is ‘out’ of consideration for the application of those processes – these things has a propensity to reinforce stigma, especially in terms as awful as ‘mentally disordered offender’.  Given these problems of labels and discrimination also arise from lived experience of significant mental distress, it’s a real doubly whammy when access to mental health systems comes via the criminal justice system and people find themselves labelled as ‘the dangerously mentally ill’.

Most police officers have seen plenty of danger in crisis situations, but by far the most severe of it has been the danger that some people pose to themselves, not to others.  In the most serious crisis related events of my career, I have been worried mainly about whether someone would cause themselves significant harm – not whether they pose a risk to others or the public at large.  Indeed, some of those incidents that will stay with me forever are those where people have done exactly that.  So whatever it is that we mean by ‘dangerously mentally ill’, we need to see that the use of such a term, in itself, creates and perpetuates the stigma that attends mental health disorders by implying most often, that danger is outward facing.  We know that does happen, but we know that the reverse is often true.  So the term is not necessarily a helpful one and it emphatically does not inherently indicate a cogent group of people to whom it will apply.

We need to do better than this otherwise police attempts to argue that we have improved attitudes towards this most sensitive of subjects will never really be taken seriously.

In case you’re wondering about the Anthony HOPKINS picture, above – it’s from one of his more famous films in which you’ll remember he played a psychiatrist.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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12 thoughts on “The Dangerously Mentally Ill

  1. As a former psychiatric social worker in an emergency room, I could not agree more with your concluding statements. I have been a victim of patient assault and also a witness to a really severe one. This is in contrast with the hundreds of people who I evaluated who did not hurt anyone and were fighting themselves more internally. These don’t make the news. Unfortunately, It is usually the individuals with mental illness who go outward who we hear more about.

    1. I agree that you only ever get to hear the very worst about MH patients in terms of violence etc and the press is biased but there is a lot more to this which I as a mother have looked into having had 2 daughters affected.

      GPs and Psychiatrists – many of them have no knowledge of pharmacokinetics and pharmacodynamics and do not consult with the pharmacologists who do know about them. When so called professionals such as these are prescribing concomitant drugs and know nothing about how they work then it is like taking control of a Jumbo Jet having had gliding lessons, except that drug accidents kill far more people than air crashes. Drug companies dominate psychiatry and do nothing to check on such dangerous situations and those who do speak out are subject to bullying and ridicule. Sometimes my daughter has been on several drugs at the same time which have caused mixed reactions with her – when you draw to the attention of a psychiatrist these terrible side effects they do not wish to listen. Right now the entire team is choosing to ignore an independent doctor’s report with a completely different diagnosis of PTSD and that of course is more convenient than changing someone’s treatment in line with NICE Guidelines which the team have chosen to ignore as well. I believe there should be metabolite testing into routine medical practice which would save huge money on drugs and draw attention to faulty and ridiculous diagnoses such as “treatment resistant schizophrenia” ie a patient’s inability to metabolise the drug which is totally ignored. This is the sort of thing that should be in the news as no one stops to think behind the behaviour of a so called violent patient what drugs is that person on, how many and has that patient been tested and monitored properly for drug interactions? What about the damage to a patient’s physical health as well in the long term. All of this should be put before the anti-stigma campaigns as how many have a physical health condition underneath it all that is not properly checked out such as Endocrinal Disorders. As for PTSD this is often mistaken for Schizophrenia and is a reactive psychosis – the drugs are of limited use in treating this condition. So with all this as you can see patients are not getting the right treatment such as my daughter and medical professionals are hopelessly out of touch with modern pharmaceutical science and something needs to be done about this. This is what needs to be documented in the news and I have had to look beyond a GP and Psychiatrist for the correct information and advice. Doctors who do not know about the drugs are the ones who are dangerous.

      1. There are many stories that NEED to be told. I certainly don’t disagree with some of your points. I encourage you to read my blog as I am in 100% agreement thinking critically about many issues including differential diagnosis,informed consent, and exploring therapies that can supplement/eliminate the need for medication. It does not seem like you are in dispute with the original post.

  2. I read that article awhile ago and I cringed at the “Dangerous Mentally Ill” just as you do.

    Thank you for your compassion for individuals with mental illness. You show a great understanding of their behavior. My sister has schizophrenia. When people hear that diagnosis they are scared b/c the media has made people with that diagnosis crazy psycho killers. In reality, as you wrote, they are far more often victims than victimizers and are more scared of you than you need to be scared of them. Violence is possible obviously, but in my experience it’s due to added substances and/or voices that are telling them to do something. Schizophrenia is 1 out of 100 people — if all people with schizophrenia were dangerous to others we’d be seeing tragedy every single day. As it is, we only hear about the circumstances that end badly.

    Kendra’s Law (Assisted Outpatient Treatment) is in many states, but few people know about it or use it. If we had known about it my very bright and talented sister would have had a completely different life.

    Again, thank you for all you do.

  3. I was immediately offended by the picture you chose – from a movie that has done more to push backward any progress than perhaps any other movie in recent times. I also disagree with many premises presented here that are muddying the waters and nothing more – all I had to do to disagree, was read the very detailed and very clearly written investigation into the Virginia Tech shooting, and 9/10 mass shootings of recent times have had the same horrific background, not just considering the crime at the end, but also the horrific suffering of the untreated individual for many years leading up to the final act- the suffering of a person who is too ill to seek out help. Signs of SEVERE mental illness with MULTIPLE opportunities for treatment and CONTINUOUS deterioration and worsening over YEARS while nothing is done despite ample opportunity and the begging of the doctor who fully realizes what is going on and is ignored. And for one reason and one reason alone: money. This dilemma is the ‘expensive child of a frugal era’ when it comes to mental illness treatment. Most of these people discharged by hospital administrators AGAINST the begging and pleading of their psychiatrists and family, and insistence that these people were in severe danger. The mentally ill extremely violent offender is a very special case, yet no progress is made because too many pundits insist this is an ethereal and far flung issue with all sorts of totally tangential arguments that have nothing to do with the issue. There is nothing difficult to understand or act upon, that is going on here. The mentally ill extremely violent offender is nearly always someone who has deteriorated very obviously over a very long time, with multiple warnings and very clear misery, a person who has even begged for help initially, but is now too irrational to seek help out on his own. He is a miniscule minority in the population of the mentally ill as a whole, but he requires a very different approach and a very different intervention. Otherwise he does incredible damage to himself and others and he does incredible damage to the community of the mentally ill as a whole. The mentally ill extremely violent offender is, in fact, the most vulnerable in the entire community, and the neglect of these people takes a horrible toll on everyone, not the least, the individual himself. When it was announced the Aurora Theatre was shot up by a person named James Holmes, a friend told me, he sighed a sigh of relief. I asked why, and he said, ‘because that was not my brother. But there is always tomorrow’. The suffering of his family from attempting to get their beloved son into assisted outpatient treatment for the last THIRTY years has been incredible. Every day they wake up to the fear that today may be the day that it is he who shoots up the theatre, instead of someone else. These families have been abandoned by a system that treats all mentally ill the same, despite a small minority needing a very, very different kind of help. If I have mild depression I can choose medicine, yoga, going for a walk in the park, or positive self talk. If I am one of the few who have severe psychosis and am teetering on the edge of violence, a positive pep talk isn’t the answer for my troubles.

  4. I have worked many years with those diagnosed and hospitalized with mental illness, some of which had been committed as “mentally ill and dangerous” People would ask me if I was afraid and I would quickly state that I had little to no fear of those residents, but rather those (with any diagnosis) that were actively using chemicals.
    I also think a part (small maybe)is that people want to pill for a quick fix (and push for that) rather than long term therapy (think DBT for Borderline personality disorder) for personlity disorders which medications often are rarely effective.

  5. Language is reflective of meaning and value. Words are powerful in their intent and impact. And, yes, I agree the legal system does a confusing job of turning those words into categories that are not so clear cut. I also don’t think the recent edit of the DSM that came out helps much either.
    As a psychologist in the U.S,, I have been more and more relieved to see the term “Severe Emotional Disturbance” used to qualify level of psychiatric severity and chronicity.
    What the public does not understand is that a psychiatric illness occurs on a continuum with functioning and ability varying by individual and by impact from environment. The labeling of “Dangerous” is more likely to occur for danger to self; those with danger to others are either on a severe psychiatric break during which the symptoms have escalated over a period of time where a safe intervention could have been critical.
    Or, the character pathology is primary and either impulse is poor or premeditation was clear.
    I also have to say, here in NY, while I have seen all sorts of interactions happen with the police and the mentally ill; I have also seen an enormous amount of compassion and patience in situations that I’m not sure how I would have handled alone.
    Thank you for the original post and the thoughtfulness it reflects.
    Dr. M

  6. The treatment of mental health issues in the US is to leave such folks alone until they commit a mass murder or murder all their children or relatives. One would think someone who has just killed 20 people and is sitting pulling the petals off a flower unaware of others around them would be in for a significant mental evaluation. Not so. First we have to take them to jail and get all the criminal charges and so forth done then there’s the investigation and the trial for capital murder. Finally, during the trial, they may get around to discussions of mental stability. What is bothersome at that point is the prosecutor will continue to cast the defendant in terms of faking mental instability, actually knowing what they where doing and deserving only of a death sentence.

    The effort to prosecute continues unabated until the judge takes some action or the jury returns a verdict of guilty but mentally ill or some such thing. We end up with far too many folks who are developmentally mental midgets, low IQs, or who are just not in contact with this world. Still of great concern are those with diagnosed mental illnesses that will often times seem normal, but have incidences of loss of contact with reality, commit crimes because of irrational anger and then return to acting fairly normal.Both bi-polar and schizophrenics can act that way. Living with one who is bi-polar, I’ve seen them fly into an uncontrollable rage over some issue and attack the object or person of their ire. I know and understand what happens. Bi-polar folks are most danger to others in a mania state because when they get to that point it’s like they are so up or high or however you choose to describe it, they feel like they are on top of the world and the world is their oyster and they are perfect as is their world. However as soon as something happens that upsets their perfect world, they will become irrationally angry and strike. If you’ve never seen a 100 lb. woman streak across a yard and attack a 180 lb 35 year old man and beat the crap out of him before he can get his hands up to defend himself, then you’ve never seen a very manic person in action.

    The usual definition in the US of mental illness in an insanity defense is the person was not aware of what they were doing and/are not aware of the consequences. Talk to a bi-polar person after the anger subsides and you often find out they knew mostly what they were doing but simply could not stop themselves. That will likely get a conviction and death sentence.

  7. I’m bipolar. I didn’t get diagnosed and medicated until I was 57. I suffered my whole life wrestling with suicide and dramatic mood swings. Now I’m so medicated I have no desire to be the accomplished artist I used to be or a pile of other things. I stay away from other people because they overstimulate me by THEIR moods and so on. When I go down into the pit of suicidal thoughts it lasts for months some times. Yet I will never hurt anyone and never have.
    I’ve done a lot of outrageous things that could have and nearly killed me however. Now that I’m medicated I just get into self neglect and deep depression. Even given all of that, I hate the stigma that goes with being bipolar. We suffer enough without the sick jokes and the taunting and avoiding.

    The dangerously mentally ill are a possible danger to others or themselves. That is the criteria they use when it comes to having to go to the nut house here. Of course once you get in there it’s the Cuckoo’s nest all over again.

    I got attacked in the street last September in daylight hours, fistfuls of my hair got pulled out and my wallet got stolen. It was obvious the woman who was at least 20 years younger than I was off her nut completely. The cops found her but she had already given my wallet to her boyfriend at the shelter. They took her in because of several warrants out on her. They told me she was well known to them and instead of being in jail she needed to be in a hospital. But there she was, floating around the streets. They also told me repeatedly not to press charges because it would be her word against mine. Mugged and robbed not a block away from my apartment and told not to press charges because I’d put myself through punishment which would not amount to any satisfaction. People watched the whole thing but none would stand up for me. Nice world we live in.

    I used to work for 911 and have a deep affection for the cops. I don’t like that we need them but I love that we have them. Thanks for your thoughts on mental illness. Your concern is very much appreciated.

    ——–Karen

  8. In the early 1970’s a woman named Joan Little- who was a prisoner in a Southern state at the time- was acquitted of Murder charges after she shot and killed her jailer, who was intent on raping her. That set a very important legal precedent which believe applies here.
    I propose that Forcible Administration of Neuroleptic drugs be added to the short list of crimes a citizen may use Deadly Force to protect herself against.

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