Homicide and Severe Mental Disorder
Michael Farrell’s book is a welcome, if abridged, contribution to understanding the connection between homicide and mental disorder. After describing the content of the book in detail, I will return to the issue of ‘abridgement’.
The purpose of the book is presented in the first sentence of its Preface:[The book] provides a complete picture of how severe mental disorder can be assessed in cases of homicide, and how improved understandings can impact risk reduction and prevention.
This unambiguous aim is ambitious. To be fair, it seems to have been written by the publisher and not Farrell. But Farrell’s own description of the book’s intention is no less unequivocal and aspirational. Farrell states that his book lays the ‘foundation of understanding’ and provides ‘opportunities to prevent’ homicide by people [diagnosed] with severe mental disorder (pp.4/5). Understanding and prevention can be achieved, argues Farrell, through the application of a specific criminological perspective developed by Ron Clarke, a research officer at a boarding school for ‘delinquent’ boys in Bristol, England during the 1980s. This perspective, which has become known as Situational Crime Prevention, focuses not on the motivations and malefactions of people committing criminal acts or on grand theorising about the causes of and cures for criminality, but on the specific settings in which crime occurs. Situational crime prevention seeks to reduce crime by analyzing the circumstances that engender particular types of crime. Recognizing that there are identifiable, physical, and interpersonal factors that provide opportunities to commit offenses or prompt offending, modifications are sought to both the physical environment and to the management of potential and actual locations of criminality. These locations include family homes, both crowded and isolated zones of areas of cities, venues where alcohol is consumed, and large sports and music events.
After an introductory chapter titled ‘Prospect,’ the book’s content is split into two parts. Part one titled ‘Understanding’ contains three chapters. The first chapter in Part 1 presents Farrell’s ‘understanding’ of severe mental disorder, homicide, and prevention. In the next chapter, the theoretical basis and practical policies of Situational Crime Prevention are provided. The third chapter of Part 1 reviews the legal processes and demographic features of cases of killings conducted by people with a diagnosis of severe mental disorder. These cover the period 2000 to 2020 that predominately occurred in the USA and United Kingdom (although Farrell does make effective use of data from other countries in Europe, Australasia, and Singapore). Details of twenty-five of these cases comprise the book’s Glossary.
Part 2 titled ‘Prevention’ has five chapters, the last of which serves as the conclusion to the book by summarizing the main points. The first three chapters of Part 2 are concerned with research connecting severe mental disorder with violence, more on the background to Situational Crime Prevention, and the relevance to that perspective of means, opportunity, location, and motive. The penultimate chapter reviews the organizational constraints affecting the effectiveness of preventative strategies, especially problems that sit within systems of communication between various professional disciplines. There are oddities in the structuring of the book’s content. For example, the book’s introductory or set-up chapter is prior to Part 1, but the summarising chapter is within Part 2, and there are discussions about ‘understanding’ and ‘prevention’ in both parts of the book.
Psychotic symptoms, for Farrell, are most associated with definitions of severe mental disorder and, thereby, chooses to focus on homicides committed by those diagnosed with psychosis. He concentrates on the diagnostic categories of schizophrenia, psychosis induced by substance abuse, depression, and ‘manic episodes.’ Another relevant category, that of personality disorders (including psychopathy), is not covered. Relying heavily on the descriptions of mental disorder contained in the fifth version of the American Psychiatric Association’s ‘Diagnostic and Statistical Manual of Mental Disorder, published in 2013, Farrell records delusions, hallucinations, disorganised speech, catatonic behavior, and ‘negativity,’ including reduced emotional expression in non-verbal and verbal communications as the main indicators of psychosis. There is mention by Farrell that defining such psychiatric conditions is contestable. But he does not expand on these debates and avoids in-depth appraisal of the historical processes and epistemological assumptions that have furnished conceptions and perceptions of deviances in human performance.
To repeat, the purpose of applying the Situational Crime Prevention approach to the arena of homicide and severe mental disorder is to reduce opportunities for offending. Farrell refers to five broad ‘strategies’ (although they are framed as more as goals) that, he argues, can reduce offending opportunities. These strategies are to: increase the effort it would take to kill; increase the risk of discovery either before or after violence is committed; reduce the rewards; reduce provocations; and remove excuses. Farrell also refers to immediate, long-term, hard, and soft prevention ‘tactics’ for homicide, some of which relate to severe mental disorder. These include: interpersonal intervention to disarm an attacker or protecting would-be targets; skilled medical attention for when a victim is wounded but whose life may be saved; substantial controls over lethal weapons; increasing the presence of law enforcement personnel in criminal ‘hot spots’; and adequate security for potential victims and surveillance of potential perpetrators; alleviate emotional arousal that otherwise could lead to conflict; and clear messaging of what actions are illegal. Furthermore, Farrell argues for predicting the triggers of psychotic episodes, such as not taking prescribed medication, substance abuse, and not keeping appointments with mental health professionals, in order to prevent homicide committed by people diagnosed with mental disorder. Farrell adds to the mix of situational factors and triggers wider contextual influences, most notably that of poverty.
The key to Situational Crime Prevention must be effective risk assessment. However, after decades of apparent developments in risk assessment the lack of progress is documented by Farrell, “predicting violence from a specific individual with SMD is challenging” (p.89). This book remains absent in detail regarding risk assessment. Crucially, what is not covered are specifics of validity, reliability, and efficacy in preventing homicides by those diagnosed with severe mental disorder. The absence of this detail undermines extravagant facet of the book’s stated rationale, although not the worthiness of its content as a step towards comprehension and deterrence.
Just as disappointing as the persisting nascent state of risk assessment, as Farrell realizes, are the continuing organizational flaws, including poor communication and confusion over roles and responsibilities within and between the agencies involved with people diagnosed with mental disorder (severe or not). Furthermore, the concerns of family members, carers, and associates of people diagnosed with mental disorder, are still undervalued, or ignored by professionals. This is inexcusable given that, in most of homicide committed by people diagnosed with mental disorder, there is or has been a relationship between perpetrator and victim.
As with so much of the literature about homicide in general, in this book there is an imbalance between the attention given to perpetrators and that of their victims. Collectively, primary, secondary, and tertiary victimhood can involve thousands of people. Family and friends, associates, and communities can suffer in varying degrees. There is reference in the book to ‘A Hundred Families,’ a British charity that supports secondary victims. Also, Farrell does recognize the wider impact when killings do occur and points out that people diagnosed with mental disorder are far more likely to be victims of violence (including self-harm) than perpetrators. But Farrell’s recognition of this impact is mollified because of his qualifications that it ‘can be’ wide and ‘especially when the killing is dramatically violent.’ There are much available data, from sources such as ‘A Hundred Families,’ that the impact is habitually horrendous, especially for partners and relatives. What is cited frequently by secondary victims in court impact statements and personal accounts gathered by organisations, such as A Hundred Families, is how their lives have become ‘devastated.’
Clearly, Farrell makes an important contribution to understanding and prevention, and this alone is a laudable achievement for any criminological project. Farrell’s coverage, although concise, is intelligent and intelligible. However, its conciseness means that core complexities concerning homicide and mental disorder are omitted and, therefore, Farrell’s clear intention to provide a ‘complete picture’ and ‘foundation’ is not achieved.
Foremost amongst the absent complexities is the disputatiousness of ‘mental disorder’ as a concept. There are amongst scholars, clinicians, politicians, media, and the public copious contentions regarding the overall idea of mental disorder, and about what if any elements of human performance (behaviors, thoughts, and emotions) can be construed as normal or abnormal. Moreover, acting, thinking, and feeling different to what are perceived by various professionals and the politically powerful as norms of human performance may attract therapeutic and regulatory imposition, both of which may be administered involuntary. Rarely does a physical disorder incite incarceration and inhumaneness at a level experienced by those regarded as mentally disordered. Exceptions are when public health is threatened such as in times of widespread lethal contagions and measures are installed to control the movement or populations and punish infringements by individuals. Past and present management of mental disorder, however, is replete with examples of people considered by professionals and the politically powerful to be a danger to themselves, to others, or the status quo, being locked-up for long periods, if not for life, and handled brutally. Moreover, notwithstanding a degree of improvement in public and press opinions about mental disorder, those so described continue to encounter misunderstanding, social disapprobation, stigma, and fear.
It is not just a problem of (mis)perception. There are fundamental epistemological differences. Deviations, and divisions abound about the nature of the elements of human performance deemed ‘disordered’. Rivalry amongst ‘experts’ over what counts as legitimate knowledge and concomitant praxes complicate the conundrum of trying to define and deal with mental disorder to such an extent that there is not even agreement over nomenclature. Most psychiatrists, by virtue of their medical training, approach psychological suffering through the narrow explanatory prism of organic malfunctioning, seeking signs and symptoms of biological faults. Consequently (although not necessarily logically) remedies are recommended that are intended to correct defects in an individual’s brain or biochemistry, and these can include certain psychotherapies especially if they seem to correlate with biological rectification. However, some psychiatrists take an ‘anti’ or ‘critical’ view of standard professional tenets and have more in common with the radical clinical psychologists who denounce inserting psychological suffering into the diagnostic and ameliorative straitjacket of the main psychiatric taxonomies composed by the American Psychiatric Association and the World Health Organisation.
Psychotherapy is also fractured by competing explanations for psychological solidity and suffering. Psychoanalysts, cognitive therapists, and humanistic therapists, differ from each other, and they have differing subdivisions. Additionally, psychotherapeutic eclecticists ‘pick-and-mix’ from the primary perspectives on the assumption that so doing is more effective or practicable than sticking to one approach. The worthiness of psychotherapy is given negligible consideration by Farrell although he does offer understated approval for its usefulness when he states, “Psychotherapy may be used” (p.23). for major forms of depression.
Not to be left out, sociologists have a sundry of possible ideological paths to follow which can lead to very different endpoints or dead ends in terms of comprehending both accepted and unaccepted human performance. Constructivist and labelling theorists, symbolic interactionists, feminists, critical-realists, Marxists, and functionalists, offer idiosyncratic insights into how ‘madness’ is manufactured and managed (and into the connections between society and homicide). Most of sociological endeavor, however, is aimed at illuminating otherwise concealed influences such as power and control, rather than the usually patent minutiae of situations.
People who have experienced a mental health service (which are actually ‘mental illness/disorder’ services) as patients may be grateful for the care they received. However, there are those who maintain that their experience was more callous than compassionate. Various groups of ‘psychiatric survivors’ are characteristically in confrontation with the professionals and the State. Some of those who have used and perhaps been abused by formal psychiatric systems have formed support and pressure groups aimed at improving or removing those systems. Moreover, while some people rail against the prejudice they encounter once they are portrayed as mentally disordered, others highlight the positives of their state of mind. A subgroup of the latter campaign under the banner of ‘mad pride.’
These contrasting standpoints confound severely not only the delineation of normality from abnormality, but that of ‘minor’ mental disorder from ‘severe’ mental disorder. Attempting to separate mental orderliness from mental disorderliness depends on defining the former and, thereby, defining the latter as not the former. Defining minor mental disorder, as opposed to severe mental disorder, requires a similar demarcation. For example, is ‘everyday misery’ in the Freudian synonymous with ‘clinical depression,’ does the separation of schizophrenia from that of experiencing of ‘divine visitations’ depend merely on context rather than biological or psychological errors, or is human performance always moving about on a spectrum with normality at one end and abnormality at the other? Patently, the muddled mix of meanings and tensions of knowing what is abnormality and, thereby, knowing what is abnormality means that the medicalization of psychological suffering should not be taken as a given. However, this book’s content overall underscores the medical model with minimal attention proffered for alternative perspectives, such as social causation and societal cures. The connection between violent acts and a culture of violence is not given enough attention.
Terminology considered ‘correct’ highlights another part of the complexity. Whilst not necessarily incorrect, abbreviations can be confusing to those readers (and I am one of them) who have forgotten what was the original phrase. Worse, is the unintentional depersonalization of using the abbreviation ‘people with SMD’, as well as the implication that this medical categorisation is beyond contestation. Furthermore, to refer to people ‘with’ severe mental disorder rather than ‘diagnosed with’ underscores uncritically medicalised attribution. There is, however, a wider debate about correctness. The vogue expression of ‘mental health problem’ is either deliberately or fortuitously de-stigmatising and de-medicalising. But it is also oxymoronic (‘mental health’ is presumably not a ‘problem’). Many social scientists, notably social historians and sociologists, adopt the term ‘madness’ rather ‘mental disorder’ (or ‘mental illness’) because they do not accept unequivocally that medicalizing some elements of human performance is progressive and sacrosanct. However, public (and media) use of the idiom madness and similar expressions can indicate ignorance, intolerance, or uneasiness. That latter is much more likely when dangerousness is implicated.
Dangerousness leads to the difficulty faced within judicial processes when decisions must be made about whether the perpetrator of non-fatal or fatal violence is ‘bad’ or ‘mad.’ Expert opinion on which side of this divide an offender should fall is notoriously inconsistent. Diagnostic doubt is made worse by a lack of agreement amongst legal and psychiatric professionals and academics about the perimeters and pertinence of psychiatric categories, such as psychopathy, borderline personality disorder, and psychosis. There is considerable arbitrariness affecting decisions on degrees of responsibility for a crime, what type of crime has been committed, whether the convicted should be punished or provided with treatment, and if to be confined should this be in prison or hospital. To be clear, homicide refers to the killing of one human by another, whereas ‘murder’ and manslaughter are legal terms denoting proscribed killings. In the judicial system covering England and Wales, the defence adopted for cases of killings carried-out by people diagnosed with a mental disorder (severe or not) can be that of ‘diminished responsibility’ or ‘not guilty by reason of insanity.’ As assessment of diminished responsibility still relies on components of the 19th century McNaughton Rule. In essence, a judgement is made on whether the perpetrator knew what he/she was doing, and, if aware, then was he/she aware it was wrong. Apart from the judgement of who has carried out a killing, judging whether that person is mentally disordered and, if so, then what is the disorder and to what degree did that disorder affect that person’s judgement, are delicate and debatable discernments.
All the above complexities mean that Farrell’s conceptual rubric of ‘homicide and severe mental disorder’ is fragile, and that ‘situation’ is only part of the answer to understanding and prevention. The issues of violence and madness are not as simple as may be assumed by reading only Farrell’s book. However, Farrell’s book is an excellent starting point.
Dr Peter Morrall is a Visiting Associate Professor in Health Sociology at the University of Leeds, UK.