Briefing - Severe mental illness and violence

“There has been no assessment of the effectiveness of community treatment orders on reducing the number of homicides because this is not the intended purpose of the orders as proposed in the draft Mental Health Bill.”
Health minister Jacqui Smith November 7 2002

There is a perception amongst the general public that mental ill-health, particularly in its most severe forms such as schizophrenia, is linked to violence. That “perception” is being used by politicians to press for new mental health laws that would make it easier to detain people. Rethink is a member of the Mental Health Alliance, which brings together over 50 organisations. They believe that, while a new modern Mental Health Act is needed, it should not be founded on a false understanding of mental health and violence.

Death is obviously the most serious outcome of a violent act. So are people with mental health problems the big “killers” in society? Each year:

• 5,000 people die from NHS acquired infections
• Over 3,000 people die on the roads
• Around 300 of these people are killed by drunk or dangerous driving
  300 people are killed at work
• Around 100 women and 100 children will be killed during domestic violence
  Between 600 and 700 people are murdered – the result of “homicide” to use the legal term
• Around 400 will involve someone abusing alcohol
• Around 40 homicides will involve someone with a mental disorder
• Around half of these 40 homicides – 20 each year – will involve someone with a mental disorder who was in touch with mental health services at the time.

The simple truth is that most violent, avoidable or preventable deaths have nothing at all to do with the 630,000 people who are today in contact with mental health services.

That is why the government’s draconian proposals for reforming the Mental Health Act to “make sure … that the public are properly protected from people who may be mentally ill” are unfounded and, as a result, will add to the stigma faced by people with mental health problems.

What will protect the public – and the up to 1,000 people a year with mental ill-health who kill themselves - are quality mental health services, open accessible and free from the stigma that now surrounds them.

Fact one
Under the present (1983) Mental Health Act anyone deemed to have a mental disorder can already be detained against their will if “it is necessary for the health or safety of the patient or for the protection of other persons.”

Fact two
Detention can continue so long as the authorities believe that the mental disorder can be alleviated or prevented from getting worse.

Fact three
The government is already committed to changing the criminal law to allow courts to impose sentences of indefinite length on people convicted of serious crimes who may be a danger for a very long period of time. People convicted in this way will not be released until the authorities are satisfied that they are no longer a danger to the public.

Fact four
The main predictor of a person’s future violent and dangerous behaviour is their previous actions. However, it is impossible to predict with any certainty who might be dangerous in the future, even if they have been dangerous in the past. The experts themselves have not been able to come up with a method of predicting future violence which they can all agree on as being satisfactory, whether that method is based on statistics or clinical judgement.

Fact five
Official inquiries into a small number of horrific cases over the last two decades have shown that a number of deaths could have been avoided. These high-profile cases led to a climate in some political quarters demanding changes to the law. But the failings identified in the official inquiries were in the way services were delivered, warning signs were ignored and agencies failed to communicate with each other. They did not result in calls for legal changes to lock up people who have committed no crime.

Fact six
Government plans to change the law do not conform with the Human Rights Act. The definition of mental disorder and the conditions for detaining people are too wide and there are insufficient safeguards for people affected by the Bill.

Fact seven
There “has been such pressure to change the law” but it has come from the more than 600,000 people in contact every day with specialist mental health services, their families and many of the 52 organisations including the Law Society, Royal College of Psychiatrists and voluntary organisations that make up the Mental Health Alliance. They want a new Mental Health Act fit for the 21st century that recognises people’s rights to quality care as the best protection for the whole of society.

Fact eight
Legislation to underpin “safe, sound and supportive” mental health services and to protect people using these services and the public is a priority for the government and Rethink.

We and the Mental Health Alliance believe that safe, sound and supportive services are best promoted by:

• Raising the quality of services on offer
• Minimising the amount of compulsion involved
• Encouraging people to use services, not drive them away by increasing the threat of compulsion
• Making sure people can get the services they need, when they need them as a right
• Reducing the stigma and misunderstanding of mental ill health
• Promoting the social inclusion of people with mental health problems.

Backing up the facts with hard evidence
Fact One – Section 2 and 3 of the Mental Health Act
Fact Two - Section 20 of the Mental Health Act
Fact Three – Criminal Justice Bill
Fact Four – Link, Cullens and Andrews (1992)
Fact Five – Key issues from homicide inquiries, Mind, May 1999
Fact Six – the Joint Committee on Human Rights response to the draft Mental Health Bill.
Fact Seven – Care Before Compulsion, Mental Health Alliance, 2001. Better Act Now, Rethink March 1999.
Fact Eight – Modernising Mental Health Services: Safe, Sound and Supportive, Department of Health 1998. Common Concerns, Mental Health Alliance 1998.

The Royal College of Psychiatrists (British Journal of Psychiatry 1999, 174, 9-14) noted: “the public and politicians believe, or are being encouraged to believe through the mass media, that unless people with a mental disorder are once more segregated, the streets will not be safe.” It analysed homicide figures for England and Wales between 1957 and 1995 and concluded that there was “little fluctuation in numbers of people with a mental illness committing criminal homicide over the 38 years studied, and a 3 per cent annual decline in their contribution to the official statistics.”

The Audit Commission reported in 1997 that, over the last 20 years, the number of homicides committed by people with mental illness had not increased, while the number committed by others has more than doubled.

The Confidential Inquiry into Suicide and Homicide by People with a Mental Illness (May 1999) noted: “The majority of homicides in the general population were committed by young men who were unmarried and/or unemployed. Alcohol and drug misuse were common.” It found that 14 per cent of people convicted of homicide (for whom psychiatric reports were available) had symptoms of mental illness at the time of the offence. Six per cent of people convicted of homicide had a history of schizophrenia. People with a mental illness were most likely to kill a family member or spouse; the proportion of victims who were strangers was lower than in those killings carried out by a person without mental illness.

The Zito Trust (October 1997) estimates that there have been 285 homicides involving people with a severe mental illness since January 1990. Those killed include: 75 strangers, 39 acquaintances, five health professionals, 22 co-residents and 60 family.

Only at times of acute crisis do levels of violence among people with schizophrenia outstrip those of the general public. At other times, unless alcohol or drugs abuse is present, rates of violence among people with schizophrenia are no higher than for the general population.

Levels of violence among people abusing alcohol or drugs are higher than levels of violence involving people with a severe mental illness such as schizophrenia. Some 62 per cent of violent crime is committed by people under the influence of alcohol. People dependent on street drugs are three times as likely to be violent as people with schizophrenia who are not.

Rates of violence among the general public are closely related to gender, age and social class. Violence is seven times as prevalent among the young as the old, twice as prevalent among men as women and three times as prevalent among the lowest social class as the highest social class.

The government’s proposals to reform the Mental Health Act are erroneously based on an objective to increase public safety. A new Act should instead be based on the need to help people get well and stay well.