Mental Health Homicide And Society: Understanding Health Care Governance

Author: David P. Horton
Publisher: Oxford, UK: Hart/Bloomsbury, 2019. 256p.
Reviewer: Peter Morrall | September 2020

This book examines the most important issue in the management of people who have been or are in the care of any mental health service. As with all killings, each homicide carried out by people who are diagnosed as mentally disordered creates two or more primary victims (the perpetrator and the person or persons killed), and a multitude of secondary victims (family members and friends of primary victims). Although far more difficult to observe and measure than the first two, there is a third form of victimhood. Tertiary victimhood can have both tacit and prolonged term detrimental effects on the communities of primary and secondary victims. Furthermore, fatal violence by people diagnosed with a mental disorder, when perceived by the public to be uncontrolled and either amplified or reported inaccurately by the media, can then lead to adverse effects that can spread through larger sections of society. This is what happened in, for example, the United Kingdom, Australasia, and North America during the 1990s (Morrall, 2000; Laurence, 2003). Death, serious psychological distress, and social disruption are the personal and societal side-effects from homicides of any hue. However, the aftermath of homicides committed by people receiving mental health care may propagate a morass of ‘communications’ concerning accountability. The public, journalists, politicians, health service managers, secondary victims, clinicians, and lawyers all may (some are required to legally) contribute to these communications. This is the scenario (specifically in England) to which David Horton applies his ideas and evidence.

The author adopts a variant of ‘systems theory’ to examine what he labels ‘patient homicides’ and the consequential inquiries. Systems theory, put simply, is a holistic approach to understanding the interconnectedness of society and human performance (the thoughts, emotions, and thinking of individuals). Patient homicides are defined by Horton as killings committed by people who were in receipt of care from formal mental health services at the time of the incident, or had been receiving such care within the previous six months. In England an inquiry is mandatory if the homicide occurs during this six-month period.

The specific ‘theoretical lens’ through which Horton looks at patient homicide incidents, their consequential inquiries, and society overall, is extracted from the philosophy of German sociologist Niklas Luhmann. Luhmann’s written work, admits Horton, is not easy to decipher, and may seem ‘alien’ and ‘eccentric’ to the uninitiated. A key element of Luhmann’s alien and eccentric philosophising is his separation of biological, ‘psychic’ (that is, consciousness: thinking; and emotions), and social spheres, claiming that these are autonomous aspects of human functioning. There is no interdependence between these spheres, and therefore there can be no conflation of one with any other. Moreover, for Luhmann the social sphere is wholly made up of communication systems. Put starkly, the mind does not mingle with the body, and there is complete distancing of the social from both. Thoughts and organic life exist outside of society. This is hardly holism.

The individual is either absent or radically re-evaluated as disconnected from society in Luhmann’s theory. ‘Meanings’ are not generated by individuals but by social systems of communication. Humans are therefore socially constructed ‘semantic artefacts’ and, teleologically, their semantic activities construct society. Humans are neither aware nor in control of the communications that make-up society.

According to Horton’s deciphering, Luhmann does seem to be promoting a position held by many social scientists that both individuals and society are complex, that communication is central to the activities of both, and that what appears ‘real’ is in fact (pun intended) fabricated. From this position, Horton postulates that societal situations such as investigations into patient homicides are much more convoluted, and their content more camouflaged, than would seem apparent to either observers or participants. The most important contextual influences comprise the construction of communication patterns, pictograms, and parameters which arise from the associated occupational disciplines and lay inputs from, for example, the family of the deceased. These ‘communication systems’ contribute to the substance and shaping of what appear to be authoritative understandings (or more pertinently from Horton’s viewpoint, non-understandings) of homicide incidents.

Horton’s theory-driven empirical research consists of interviews and documentary analysis. He interviewed fourteen inquiry investigators with the collective experience of hundreds of cases, and the head of the charity ‘Hundred Families,’ and a television producer whose father had been the victim of a patient homicide. He reviewed legal papers, inquiry reports, government missives and policies, and academic publications.

The author claims by using Luhmann with the evidence of his interviews and analysis of documents that he is introducing a perspective to the investigatory processes and is delivering what he calls a ‘creative tapestry’ regarding patient governance. Horton’s alleged original insight is that every patient homicide investigation is not only socially constructed by systems of communication, but that these systems do not coalesce. For him every one of these communication systems has a self-justifying and self-reproducing internal logic, and each system is communicatively closed off from all the others. That is, medical practitioners, lawyers, health care workers, managers and policy makers amongst other occupational disciplines, have what the French philosopher Michel Foucault describes (but Horton noticeably does not) as their own ‘discourse’. These discourses, according to Horton, are produced, internalised and utilised by internal operatives, but not used or comprehended by anyone else with whom they are, according to inquiry mandates, intended to have synergy. Those operating within these unique, fixed, and incompatible discourses become competitors rather than collaborators in the supposed search for certainty regarding patient homicides. For Luhmann, and Horton, ‘cause and effect’ reasoning about human performance and societal situations does not reveal reality but is itself a social construction. Attempting to find hard-and-fast linkage between, for example, schizophrenia or practitioner incompetence and a fatality, is an atavistic and flawed mode of thinking. ‘Facts’ about the histories, situations, practices, motivations, psychiatric diagnoses and treatment, are collected about patient homicide cases and presented in official reports, but should not be, reasons Horton, accepted as reality other than what functions as being real within each closed communication sphere.

These are remarkable assertions.

Can it be that that the individuals partaking in homicide investigations exist in their own bubble of meanings, wholly indoctrinated by a specific discourse which means they are unable to comprehend the meanings expressed by colleagues in other occupations? Can it be, by extrapolation, that none of those linked to the care of people with a diagnosed mental disorder (medical practitioners, nurses, psychologists, social workers, psychotherapists, legal representatives, and patients or their advocates) really know the significance of verbal and non-verbal messaging conveyed by their colleagues from alternative occupations or those in their care? Can it be that Luhmann and Horton are the only ones to see through these mystified realties, and the only ones not to be mystified by their own discourse (the supplications of which emanate from intellectualism, empiricism, and more generally the rules of sociology)? Can it be that they are the only humans not to be ‘semantic artefacts’?

Notwithstanding these dubiously dramatic declarations about communicative disconnectedness, Horton’s book is still a valuable contribution to the field. Its value is twofold. First, it is scholarly work in terms of presentation of a high standard. I’m assuming, due to the presentational style, that much of this content has been presented as a thesis for the award of a higher degree. The style is credibly academic and the material admirably scholarly. As such it demands from the reader assiduous attention. There is regular ‘topping and tailing’ of the core messages of the book as a whole, and of the specific issues addressed in each of the eight chapters (including the Introduction and Conclusion). Again, this stylistic tactic is indicative of the content’s previous life as a thesis. If this is the case, then Horton, in my view, certainly deserves the accolade of a PhD award. Second, it serves as an unambiguous one-dimensional take on interdisciplinary scenarios which extend beyond investigations into patient homicides. The author communicates an extreme position (and does so meaningfully), and therefore is the work to cite when arguing for a more complex reasoning about inquiries into patient homicides or any societal scenario in which individuals are endeavouring to communicate with each other.

I do have a few relatively minor niggles about the book. I am struck by the illogicality in the book’s title. To link mental ‘health’ to homicide is an understandable miscommunication about the thesis of the book. The fervent pressure on academics, practitioners, media, and the public to destigmatise and de-medicalise psychological troubles leads to a mystification of language, when what Horton is really writing about is mental ‘disorder’ (which he so does within the first sentence of the blurb on the inside cover). Also, the use of the ‘third person’ rather than ‘first person’ when referring to himself as author is unusual in contemporary social scientific writing. It has gone out of favour for good reasons. It can detract from the coherence of the text.

There are two related major failures of the book — one of which is Horton’s, and the other is that of Luhmann’s theory. Luhmann fails to recognise the dynamic and reflexive relationship between individuals and society. More explicably, considering how much neuroscience has developed since Luhmann was writing, he fails to appreciate biological, psychological (or in his parlance ‘psychic’), and societal interconnectivity. Contemporary sociological writing about mental disorder eschews these failings (see for example: Morrall, 2017; Rose, 2019). Horton’s failure is to not offer practical recommendations for those connected to patient homicides. It may be interesting for the psychiatrists, managers, politicians, lawyers, and secondary victims to note that they do not in any meaningful way understand each other, but Horton does not then tell them what they can do to make their meanings understandable.


Laurance J (2003) Pure Madness: How Fear Drives the Mental Health System. London: Routledge.

Morrall P (2017) Madness: Ideas About Insanity. London: Routledge.

Rose N (2019) Our Psychiatric Future, Cambridge, UK: Polity.

Dr Peter Morrall, Visiting Associate Professor in Health Sociology, University of Leeds, UK. Tutor, Centre for Lifelong Learning , University of York, UK. 

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