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Does receiving a clinical diagnosis of a mental illness represent being given a dangerous label.

Writer's picture: DSRM-1DSRM-1

Updated: Jan 27



I wrote this paper in 2012 - today it seems more relevant...


Seeking Relevance?


Here I look at the stigma of dangerousness attached to those with mental illness. I recognise there are a wide range of mental illnesses, all of which are beyond the parameters of this document which has a slight emphasis on schizophrenia. The discussion will introduce a number of serious crimes and show how those committed by mentally ill offenders’ have been sensationalised and how one mentally ill offender’s case dealt with by a senior judge was disposed of very differently from another which was left to twelve members of the public, a jury.

 

I will show that there exists a stigma of dangerousness attached to the mentally ill which arguably is unjustified as it is based more on a lack of understanding of mental illness which creates fear. It is suggested that demonstrating understanding and sympathy could alleviate that fear but in contrast it could lead to more acts of unpredictable violence, thus we should tread with care if we are to attempt to alter current perceptions of mentally ill people.


On 12th December 2012 I made a number of Internet name searches using the then popular portal Yahoo! in order to ascertain how many search hits each name would return. The first name searched was that of Andre Radjpaul (123 hits) followed by Bukky Osoteku (175 hits). Third was Hannah Bonser (72,200 hits); then Martin Davies (210,000 hits). Each of these individuals had been arrested for serious stabbing incidents and only the victim of Andre Radjpaul survived, however she was just seven months old. Each assailant attacked with a knife, or as in the case of Osoteku, was part of a gang which attacked with knives. They are all in a similar age range, 26, 18, 26 and 23 years, and each incident was widely reported in the mainstream British media.

 

What is interesting from these searches is the difference in the number of return results for Radjpaul and Osoteku compared with Bonser and Davies. Perhaps the reason for this is that Bonser and Davies were both mentally ill at the time of their offences, whereas Radjpaul and Osoteku were apparently both mentally healthy, highlighting the sensationalism that seems to attach to violent crimes involving mentally ill offenders and hence the stigma.

 

Prior to the commission of Bonser’s crime she was being treated for mental illness in the community where she was also using cannabis (Cantrill P. 2012: p.4). On 10th January 2012 Bonser reported that she wished to be detained because she feared she might hurt someone. She also described symptoms she had been experiencing for 10 to 12 years which suggested she had been suffering from hallucinations as she claimed there were seven people inside her, some of whom didn’t like children (Cantrill P. 2012: p.113). On 14th February 2012 Bonser stabbed a child, randomly selected in a park, who would later die of her injuries.

 

Davies was also receiving care in the community for mental illness having been released from a psychiatric unit four months prior to the commission of his crime. He had also requested that he be detained again to seek more intensive care. He was taking anti-psychotic medication yet on the day of the offence had also consumed vodka. His offence was to take a bread knife and stab a pensioner; a stranger, four times resulting in her death.

 

Bonser is a schizophrenic who was suffering from command hallucinations. It is worth noting that she was convicted of murder and not manslaughter or any other offence which recognised she had a diminished responsibility. She had never denied the killing but had asked the jury to return a verdict of manslaughter due to diminished responsibility, yet they rejected this and convicted her of murder denying her the opportunity to use her mental illness as mitigation. She was given a 22 year prison sentence as oppose to being detained in a mental institution.

 

Davies is also a schizophrenic and was also suffering from command hallucinations which on the day of the murder were telling him to kill. He was told by the presiding judge at Cardiff Crown Court:

 

“This was a terrible crime, a senseless killing. You knew it was wrong to kill someone, but it was the voices that told you to do so.”

(Justice Griffith Williams cited by Savill R. 2010)

 

He was allowed to plead guilty to manslaughter on the grounds of diminished responsibility and has been detained indefinitely in a high security mental hospital where presumably he will be treated.

 

Both Bonser and Davies are schizophrenic; suffering from hallucinations; had requested readmission to hospital which was denied; had committed very similar crimes, and yet were dealt with very differently by the courts.

 

The interesting contrast in these two cases is that when the matter was left to the skill and understanding of the judge, Davies’s mental illness was clearly taken into consideration. However, when it was left to the jury, twelve members of the general public, they did not accept that Bonser’s mental illness could be used as mitigation. Did the jury apply the dangerous stigma to Bonser and see to it that she was punished? We may never know, but in their defence the prosecution had argued that Bonser was only suffering from depression and everything else was exaggerated to cover for her crime.

 

It is quite possible the hallucinations experienced by Bonser and Davies caused them to act in the way they did. Hallucinations are one symptom of schizophrenia and can be described as voices perceived by the patient as coming from outside the head. There may be one or multiple voices and they can be insulting (Andraeson N. et al 1980: p.182). Command hallucinations take the symptom further in that they give instructions to the patient and these can be violent actions either for self harming or against others (Andraeson N. et al 1980: p.183).

 

Not all commands are violent, nor are they all obeyed, but Kasper et al did discover that 48% (n=12) of their test pool heard commands to be violent towards hospital staff, and of those 91.7% (n=11) obeyed the command (Kasper E., Rogers R., Adams P., 1996: p222). Perhaps a weakness of Kasper’s research is the relatively small test pool of 25 patients as approximately 1% of the American population will suffer from schizophrenia (Spearing M.K. 1999: p1), and in the United Kingdom one in 100 people will suffer from it (Mental Health Foundation 2012).

 

Hallucinations could be explained by the fact that when we think to ourselves we are able to hear our own voices. A person suffering from hallucinations may well be hearing his own voice but is unable to recognize it. However, in cases where the commands are given by a familiar voice the patient is more likely to comply (Junginger J. 1995; in Kasper et al 1996: p.220).

 

Fazel et al suggest there exists a body of evidence which links psychoses and violent behavior (Fazel S., Gulati G., Linsell L., Geddes J.R., Grann M., 2009: p12), however Peay states that in first offence categories offences by the mentally ill are the same as those committed by the mentally healthy, although a distinctive difference is that the mentally ill are less likely to be convicted of an offence of violence and more likely to commit a property offence (Peay J. 2002: p.772), while Prins claims “the relationship between mental illness and criminality is an uncertain one” (Prins H. 1990, in Peay J. 2002: p.772).

 

Those who assume, and thus stigmatise, the mentally ill to be dangerous may not be aware of the fact that mental illness covers a range of challenges which are quite dissimilar. However if investigated properly a fear of unpredictable behaviour is likely to be revealed, but above all it would expose a lack of understanding of mental illness.

 

Categorising mental illness would start with either neurosis or psychosis. Neurosis covers illnesses such as anxiety and depression whereas psychosis would include illnesses such as personality disorders, bi-polar disorder and schizophrenia. Although these are common clinical terms most people might struggle to understand the symptoms and or the causes of such ailments.

 

Indeed “psycho” and “schizo” have become derogatory slang words despite psychopathy and schizophrenia being very serious conditions. In 2001 the BBC reported on an unnamed government study reflecting the number of youths abusing the mentally ill. Out of 500 16 to 24 year olds questioned 60% would use derogatory terms such as “schizo, psycho, nutter and or loony” to describe someone with a mental illness (BBC 2001), with only 33% believing that terms such as “schizo and psycho” were unacceptable.

 

Compare that with the sympathy a cancer sufferer would naturally receive; and compare again cancer with AIDS. The patient with AIDS would probably be less forthcoming about his illness for fear of being shunned. That rejection would stem from the fear of this dangerous and incurable disease. That same stigma is thus applied in the same way to the mentally ill; 36% of the public believe mentally ill people are prone to violence i.e. dangerous (National Mental Health Development Unit: ND), and only 43% of respondents in a Northern Ireland study believed the majority of people with mental health problems can be cured (Health Promotion Agency: 2006: p.15); and this is due in large part to the uncertainties surrounding mental illness, reinforced by sensationalist media coverage, as in Bonser and Davies, focusing on the dangerousness label attached to the individuals and not their illnesses. But this may not be an entirely bad thing and we shall return to this point later.

 

Parsons puts forward Social Role Theory as an example of positive labelling. Social role theory accepts behaviours by those who act out what are socially accepted roles, which in this case would be that of a patient who is naturally afforded a degree of sympathy as oppose to suspicion in the case of a criminal. Such patients are less likely to be viewed responsible for their actions (Parsons T. cited by Angermeyer M. & Matschinger H. 2003: p.304). Thus it is the consequence of Social Reaction (labelling) Theory which tends to stress the negative effects of mental illness.

 

A study of German adults to assess the impact of labelling on public attitudes towards people with schizophrenia and major depression concluded that mentally ill people are at a high risk of being stigmatised due in large part to the stereotype of being dangerous (Angermeyer M. & Matschinger H. 2003: p.308). However, where depression was offered as the mental illness it had no impact on public attitudes.

 

This view is supported by Applebaum (2001 in Wood J. & Francis B. 2007: p.6) who claimed that public concerns over the mentally ill, as they pertain to dangerousness were disproportionate. However Pescolsolido et al (1996) quoted in the same Wood and Francis paper (p.6) reported in their US study that more than 33% of respondents believed that persons with a major depressive illness were likely to commit a violent act, and if they were suffering from schizophrenia then the opinion was shared by 60% of respondents.

 

Appleby reports that one person each week is killed by an offender with a mental illness (Appleby et al 2006 in Wood J. & Francis B. 2007: p.6). On its own that statistic might appear quite shocking; however in the 2005/2006 crime year there were 766 homicides in England and Wales and in the 2006/2007 crime year there were 755 (Nicholas S., Kershaw C., Walker A., 2006/7: p56). Thus the average for the 2006 year of the Appleby report would be 760 homicides which equates to 14.6 homicides per week. Therefore if Appleby is correct then those killed by the mentally ill is just 0.146%.

 

When the issue of comorbidity with substance abuse is introduced the risk of violent behaviour which is generally increased by two and half times for a mentally healthy individual, increases by seven times for the mentally ill (Weaver C. 2005 p.1). Boles & Johnson support this assertion claiming that substance abuse increases the risk of violence in schizophrenics (Boles S.M., & Johnson P.B. 2001 in National Addiction Centre 2003:p.68), although the violence is mostly directed at family members and friends (Spearing M.K., 1999:p.5).

 

Another study found that patients discharged from hospital who do not abuse substances are no more likely to commit an act of violence than healthy members of the community who likewise are not involved in substance abuse (Steadman H. et al 1998: p.393). However, of the patients that did report substance abuse the prevalence of violence was significantly higher than the substance abusers from the healthy community members (Steadman H. et al 1998: p.400). But it is also argued that the risk of substance abuse in patients suffering from psychoses is similar to those substance abusers who would otherwise be healthy (Fazel S. et al 2009:p1).

 

Comorbidity is not restricted to drug abuse and would also include alcohol; and the reader will recall that while Bonser was a cannabis user, Davies had consumed vodka on the day of his crime.

 

68 young adults studying criminology at university were asked if they perceived offenders with a mental illness more dangerous than other offenders (Wood J. & Francis B. 2007: p.8). The presence of schizophrenia increased the odds of being dangerous (p.19) although previous convictions and lifestyles were considered higher risk factors. This was an interesting observation as the most efficient way of predicting future violence is to look at an individual’s previous history of violent behavior.


Criminology students are expected to have an understanding of these issues with access to expert literature and opinions. However the wider public are more likely to form their opinions based on wider media publications and television. In a study of fourteen prime time television dramas on New Zealand free-to-air channels during 1995 and 1996 a total of twenty mentally ill characters were part of the scripts. Of those twenty, fifteen were depicted as physically violent (Wilson C., Nairn R., Coverdale J., Panapa A. 1999: p.234). Of those fourteen dramas, 10 originated in Britain.

 

In a British study of mentally ill characters on peak-time BBC1, BBC2, ITV1, Channels 4 and Five television over a 3 month period a total of 74 programmes involved storylines with mental health issues (Philo G., Henderson L., McCracken K. 2010: p.5). Of these 74 there were 33 instances of violence towards others, 48 instances of other types of harm, 53 instances of self harm, and 33 instances of a sympathetic portrayal (Philo G. et al 2010:p.5).

 

In discussing a scene of the popular British drama EastEnders the BBC controller John Yorke accepted how a suicide scene in 1986 could have had the potential for copycat suicides (Philo G. et al 2010: p.11). If dramas can have this effect then surely it is possible to create scenes with the opposite impact and this is one area where the media can start to alter perceptions of the mentally ill to a more positive light.

 

From a government policy perspective changes have already commenced with a review of the 1983 Mental Health Act being amended by the 2007 Mental Health Act. Section 1 of the Mental Health Act 1983 defines Mental Disorder and divides it into four types; (1) Mental Illness, (2) Psychopathic Disorder, (3) Mental Impairment, and (4) Severe Mental Impairment. The definitions applied to Psychopathic Disorder and Severe Mental Impairment were not helpful in reducing the stigma of dangerousness:

 

(2) Psychopathic Disorder

… a persistent disorder or disability of mind …which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned

Section 1 (2) Mental Health Act 1983

 

(4) Severe Mental Impairment…a state of arrested or incomplete development of …with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned

Section 1 (4) Mental Health Act 1983

 

By including aggression within the definition the negative perceptions given above are suddenly well founded. However, under the 2007 Mental Health Act the definition of Mental Disorder has been amended to:

 

… any disorder or disability of the mind.

Section 1 Mental Health Act 2007

 

But if we now enter a period of perception alteration are we at the same time moving into what could be unchartered territory? What we know is that those suffering from mental illness and in particular schizophrenia and hearing hallucinations are more likely to become quiet and recluse. It is thus very important to consider what is happening during this reclusion. Could it be that the individual who is also ignored and at greater risk of being a victim of crime is in need of attention or relevance? Perhaps it’s the need for relevance that causes them to create a major incident, such as a violent crime. Suddenly they are in the news, getting ample attention, and very relevant.

 

If in order to become relevant mentally ill persons commit a violent act, as did Bonser and Davies, who had essentially been unheard of, how should it be reported? Currently the sensationalist media focuses on the dangerousness of the unpredictable mentally ill individual. However, if as Parsons suggests, sympathy is shown then the mentally ill violent attacker may not feel he has done anything very bad and is rewarded with a great deal of attention and relevance. Would this send a message to others that if they were to commit such a violent act they too would be sympathised with and would become relevant? This may inadvertently lead to further attacks as oppose to the current culture which could be keeping others at bay.

 

To conclude we have shown that there is a culture of concern surrounding the mentally ill which tends to label them as dangerous. News reports on crime involving the mentally ill are far more widely reported on than other similar crimes committed by the mentally healthy. In two comparable cases involving mentally ill offenders, one who was dealt with by a jury, members of the public, was sent to prison whereas the one who was dealt with by a legal expert was sent to hospital for treatment.


I have explained the potential consequences of hallucinations and command hallucinations and how they can be obeyed although this is not a common occurrence.

 

Despite the labelling concerns surrounding the mentally ill the same cannot be said for those suffering from cancer; yet I introduced AIDS as a way of emphasising the fear surrounding the unknown and incurable.

 

This allowed us to better explain that education and understanding of mental illnesses would lead to a reduction in the fear which was demonstrated as mostly unwarranted. We looked at Social Role Theory to emphasise that where a mentally ill individual is looked upon as a patient then it is likely he will be afforded more sympathy and considered less responsible for his crimes.

 

We have shown that public opinions of the mentally ill are likely derived from sensationalist news reporting and negative portrayals in TV dramas although where an effort is made the mentally ill can be shown in a positive light and the negative perceptions can be altered thus a wider programme of public awareness is needed. This perception alteration has already commenced with amendments made to the Mental Health Act 1983.

 

However I have cautioned that such a perception alteration could lead to an increase in violent attacks unless it can be ascertained that the patient is not seeking ‘relevance’ because if they know they will be met with sympathy after committing a violent action then they could be encouraged to act knowing the consequences will not be harsh and this is an area of research that should be conducted.



References 

Andraeson N., Clayton P., Endicott J., Lipinski J., Mavroidis M., Pope H., Spitzer R., Williams J., Woodruff R., Wynne L. 1980

Schizophrenic Disorders in 

DSM III (Diagnostic and Statistical Manual of Mental Disorders) (Third Edition) 1980

Washington: The American Psychiatry Association

Angermeyer M., Matschinger H. 2003

The stigma of mental illness: effects of labeling on public attitudes towards people with mental disorder

Acta Psychiatr Scand 2003: 108: 304-309;

Leipzig: Blackwell Munksgaard

BBC 2001

Mentally ill abused by the young. Retrieved from

http://news.bbc.co.uk/2/hi/health/1211814.stm 

Cantrill P. 2012

Independent Multi-agency Review Report – In respect of Miss G

(Report of official enquiry into handling of Miss G) Doncaster: NHS Doncaster

Fazel S., Gulati G., Linsell L., Geddes J.R., Grann M., 2009

Schizophrenia and Violence: Systematic Review and Meta-AnalysisPlos Medicine, Volume 6, Issue 8, August 2009 

Oxford: Department of Psychiatry, University of Oxford

 

HPA (Health Promotion Agency) 2006

Public attitudes, perceptions and understanding of mental health in Northern Ireland

Belfast: Health Promotion Agency for Northern Ireland

 

Kasper E., Rogers R., Adams P. 1996

Dangerousness and Command Hallucinations: An Investigation of Psychotic Inpatients in Bull Am Acad Psychiatry Law, Vol.24, No.2, 1996

Retrieved from:http://www.ncbi.nlm.nih.gov/pubmed/8807161

MHF – (Mental Health Foundation)Bi-Polar Disorder

Retrieved from: http://www.mentalhealth.org.uk/help-information/mental-health-a-z/B/bi-polar/  

 


NAC – National Addiction Centre 2003

Dangerousness of Drugs – A Guide To The Risks And Harms Associated With Substance Misuse

Department of HealthRetrieved from:

http://www.nta.nhs.uk/uploads/dangerousnessofdrugsdh_4086293.pdf

 

NFWI – National Federation of Women’s Institutes 2010

Care Not Custody (joint report with the Prison Reform Trust)

London: NFWI & Prison Reform Trust

 

Nicholas S., Kershaw C., Walker A., 2006/7

Crime in England and Wales 2006/7

Home Office Statistical Bulletin

London: Home Office

NMH (National Mental Health Development Unit) ND

Stigma and discrimination in mental health – Fact file 6

London: The National Mental Health Development Unit

Peay J. 2002

Mentally Disordered Offenders in

The Oxford Handbook of Criminology: Third Edition

Oxford: Oxford University Press

Philo G., Henderson L., McCracken K. 2010

Making Drama out of a Crisis: Authentic Portrayals of Mental Illness in TV Drama

Glasgow: The Glasgow Media Group, Glasgow University for SHIFT, Department of Health

Spearing M.K. 1999

An Overview of Schizophrenia – Information from the National Institute of Mental Health

National Institute of Mental Health, NIH Publication No. 02-3517

Retrieved from:

http://www.schizophrenia.com/pdfs/szoverview.pdf

Steadman H., Mulvey E., Monahan J., Robbins P., Appelbaum P., Grisso T., Roth L., Silver E.

Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods

Arch Gen Psychiatry / Vol 55, May 1998

Chicago, IL.: American Medical Association

 

Weaver C. 2005

Violence and Mental Illness: Unpacking the Myths

Canadian Mental Health Association – BC Division

Retrieved from:

http://cmha.bc.ca/files/3-violence_myths.pdf

Wilson C., Nairn R., Coverdale J., Panapa A., 1999

Psychiatry and the media – Mental illness depictions in prime-time drama: identifying the discursive resources in

Australian and New Zealand Journal of Psychiatry 1999: 33:232-239

Retrieved from:

http://www.brown.uk.com/stigma/wilson.pdf 

 

Savill R. (04 May 2010) Schizophrenic killed grandmother while under health care supervisionThe Daily Telegraph Newspaperhttp://www.telegraph.co.uk

 

Wood J., Francis B. 2007Public Perceptions of Offender Dangerousness – Views of Young Adults in the UK

Lancaster: Centre for Applied Statistics, Lancaster University

 

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