"There are people who commit violent crimes because they are literally crazy...but there aren't that many and virtually none is a serial killer or rapist. The true crazies are not difficult to catch". John Douglas - former FBI expert on criminal profiling. (Douglas and Olshaker, 1998).

"It is...important to realise that people who are mentally ill are only rarely violent". Dr David Canter (1994) - profiling expert and author of 'Criminal Shadows'.

"Only a tiny and unchanging percentage of murders can be understood as a result of actual madness. Truly 'insane' murders are relatively rare everywhere, in terms either of hallucinatory derangement and dissociation from the conventional world or of legal or psychiatric technicalities". Prof. Elliot Leyton (Leyton, 1995; p.38)

"Images of axe-wielding maniacs are based on highly visible and intuitively attractive evidence, but are not statistically replicable". Dr Jill Peay (1997).

"Public anxiety over the dangers of care in the community is fuelled by a false assumption that killings by mentally ill people are on the increase". (Brindle, 1999).

"The risk of a serious crime being committed by someone with a major mental illness is small and does not justify...increased institutional containment or greater coercion". Serious Criminal Offending and Mental Disorder Case Linkage Study. (Wallace, et al. 1998).

WIDESPREAD FEARS

The widespread fear about the danger supposedly represented by psychiatric patients probably has several sources. These include primitive prejudice and folkloric fantasies; deliberate media manipulation by opponents of community care; encounters with difficult or disturbing people mis-identified as mentally ill and sensationalised, saturation reporting of untypical incidents by the popular press.

MARAUDING MENTAL PATIENTS

The image of the marauding mental patient is so well-entrenched in modern culture that most people hearing of violent or apparently motiveless assaults, intuitively think these must be acts of madness. Yet the perpetrators often turn out not to be mentally ill at all (Muijen 1996). This mis-attribution of mental illness to the unknown - and therefore undiagnosable - perpetrators of rapes, robberies, stalkings and sexual assaults is typified by tabloid newspapers which routinely describe unidentified assailants as "madmen", "maniacs" etc. For example, knife-attackers are almost invariably described as "crazed"; sex-attackers are "maniacs"; stalkers are "unhinged" -even dangerous drivers are "demented" (Howitt, 1998; Philo, 1996).

The constant commingling of terminology related to mental illness and violence percolates away in public consciousness and combines with cinematographic images from films typified by Alfred Hitchocks 'Psycho' together with television series such as 'Cracker' -with most perpetrators depicted as mentally ill (Philo, 1996). In a poll taken for Total Film magazine, a list of 'the most evil murderers' was headed by characters who were all implicitly or explicitly mentally ill (Rankin, 2002). It is unsurprising if even (otherwise) well-informed people are often convinced of the failure of community care.

An examination of the major authoritative studies into mental illness and violence (Brindle, 1999; Cooper, 1998; Hall, 1999; Monahan, 1992; Muijen, 1999; Peay, 1997; Prins 1990; Taylor and Gunn, 1999; White, 1999, et al.) shows the image of the axe-weilding lunatic-at-large to be mostly a media-manufactured myth; however, the displaying of Anthony Hopkins (Silence of the Lambs) posters by protesters objecting to the opening of a mental health facility (Sayce, 1995) neatly illustrates how public perceptions are coloured by popular culture (Howitt, 1998).

Yet psychiatric patients are not the people of whom we should be most afraid: the latest and best research indicates that if you are attacked (in England or Wales) your assailant is most likely to be young, sane, male, uneducated or immature -and possibly intoxicated by street-drugs or alcohol. As researcher Dr Jill Peay commented: "Images of axe-wielding maniacs are based on highly visible and intuitively attractive evidence, but are not statistically replicable" (Peay, 1997).

Naturally, a small percentage of murderers do turn out to be mentally ill -and these sustain the myth; yet it would be remarkable if the mentally ill never committed homicide. In recent years, doctors and nurses; policemen and solicitors; bus drivers and labourers -among others- have committed murder (and most have been found to be compos mentis). It would be extraordinary if psychiatric patients - as a discrete social category - uniquely abstained from homicide.

MASS MURDER AND MADNESS

Following the September 11th, 2001, terrorist attack on the World Trade Centre and the Pentagon, it was predictable that the presumed instigator - Osama bin Laden - would be deemed by the psychiatrically un-educated to be mentally ill. Notwithstanding the obviously pre-planned and well co-ordinated nature of these attacks, several serious commentators claimed that bin Laden must be "insane", while popular tabloids mentioned "mad mullah's". A few weeks' later, a British Sunday newspaper (noted for its opposition to community care), contained an alleged interview with an unidentified doctor claiming to have treated one of bin Laden's closest associates for mental instability. On November 6th, the British Foreign Secretary, Jack Straw, reportedly denounced bin Laden as "psychotic and paranoid". This automatic - but uninformed - linkage of extreme violence and mental illness has considerable intuitive appeal and seems stubbornly resistant to evidence.

This is illustrated by the persistence of the prejudices generated by the shocking 1996 massacre at Dunblane when Thomas Hamilton killed 16 children and a teacher. The subsequent enquiry, chaired by one of Scotland's most respected legal figures, the Rt. Hon. Lord Cullen - after accessing the best forensic psychiatric opinions available - concluded that "Thomas Hamilton was not mentally ill" and that his "violence...would not have been predictable." (Cullen, 1996).

Hamilton, was in fact, a typical paedophile: sane, cunning and capable of considerable pre-planning. Yet, apparently many people still think that his murder-spree was somehow connected with community care. Despite the (admittedly under-reported) Cullen Enquiry verdict, several subsequent radio phone-ins - focusing on community care - had numerous callers repeating: "We don't want another Dunblane".

The media's potential for promoting misleading perceptions was shown again when Tasmanian gunman Martin Bryant ran amok killing 35 people and wounding 22 others - in one of the worst peacetime massacres perpetrated by a single gunman. Shortly afterwards, one British tabloid newspaper claimed that "Bryant was a paranoid schizophrenic" citing this event as further evidence of the folly of community care. Yet when Australian psychiatric experts gave their verdict on Bryant - that he was not mentally ill - this surprised no-one familiar with the confusion, disorganisation and lack of efficiency which usually accompanies serious mental illness. As Barbara Hocking of Schizophrenia Australia remarked: "The degree of organisation that he has shown is really quite atypical for people with schizophrenia" (Guardian, 1996).

On a bad day, severe mental illness sufferers can hardly get out of bed or fasten their shoe laces; they cannot carry out carefully pre-planned acts of violence such as serial killings, genocide and other mass murders; nor can they organise coordinated terrorist attacks or construct vast networks of extermination camps or gulags. Furthermore, most mental illness sufferers share mainstream social values and are as horrified by murder and violence as anyone else.

DISORDERED OFFENDERS

John Douglas, an expert on criminal profiling who worked for 25 years at the FBI's world-famous Psychological Profiling Unit at Quantico, has commented that not only are the worst offenders rarely mentally ill but "the true crazies are not difficult to catch" (Douglas and Olshaker, 1998, p41). Furthermore, researchers have consistently found that most violent offenders are usually not mentally ill (but are often unintelligent or immature: see Wilson and Herrnstein, 1985). For example, the criminologist Dr. Jill Peay found that psychiatrically 'normal' (non-mentally ill) criminals were slightly more likely to have been convicted of violence that those deemed to be psychiatrically 'disordered'.

She writes: "...offence categories amongst 'disordered offenders' mirror those of 'normal' populations with the only differences being that the disordered populations are slightly less likely to be convicted of offences of violence and slightly more likely to have commited property offences (Peay, 1997).

As C.R. Bartol noted in Criminal Behavior, severely mentally disordered individuals are no more likely to commit serious crimes against others than are members of the general population (Bartol, 1995).

Summarising the evidence, Professor Herschel Prins (1990) concluded that the link between mental illness and criminal behavior is uncertain: and even when an offender has some sort of psychiatric problem, this may not be relevant to his offending behavior. For instance, as Ken McLaughlin (2001) points out: "Somebody may have had a psychiatric history and may have committed a violent act, but this does not necessarily mean that the former led to the latter. Somebody may suffer from psychosis and may commit an act of violence, but if the psychosis played no part in the act that is not the same as an actively psychotic person attacking somebody. Such causal explanations are too simplistic...In relative terms, a diagnosis of major mental illness is less a predictor of violence than being young, male, substance-abusing or substance-dependent" (McLaughlin, 2001).

SUBSTANCE ABUSE, MENTAL ILLNESS AND VIOLENCE

The community care controversy was revived following New Year's Eve, 1992, when a young man climbed into the lions' den at London Zoo and was later convicted of knife-attacks on policemen. He had used street-drugs for years and was widely reported to have been 'failed' by community care. More recently, the stabbing of ex-Beatle George Harrison by a long-term user of heroin and cannabis created further concerns about care in the community.

The whole issue of the relationship between drug abuse and mental illness is complicated by difficulties surrounding psychiatric diagnosis. (See Mind in Manchester's QUDOS site for more on this issue) But there is no doubt that spectacular high-profile incidents involving substance-abusers have made a major contribution to the mythology linking mental illness and violence.Yet several studies show that drug and alcohol-abuse are far more reliable predictors of violence than having a mental illness; also, when the mentally ill do offend, alcohol and drug-abuse may be much more significant than their psychiatric status. (Brindle, 1999; Cooper, 1998; Hall, 1999; Soyka, 2000; Steadman, 1998; Taylor and Gunn, 1999; Wallace, 1998; White,1999).

Naturally, if violent or anti-social people engage in drug-abuse, it is unlikely to make them more amicable or pleasant: as Dr John Henry, consultant physician at Guy's Hospital Toxicology Unit has pointed out: "Cannabis...is associated with psychosis and paranoia...a six-fold increase in paranoia..." (Guardian, 1996). As Consultant psychiatrist Robin Murray remarked: "Society has to balance the enjoyment that the majority get from cannabis with the harm it causes to a vulnerable few" (Murray, 2002).

Dr. Henry J. Steadman (1998) found that "People discharged from psychiatric hospitals who do not abuse alcohol or drugs are no more likely to commit violent acts than their neighbours who do not abuse alcohol or drugs".

Possibly, the most significant characteristic of violent offenders is simply their propensity to use violence, independently of any accompanying psychiatric symptoms or drug use. For instance, New Zealand researchers found that the high level of violence among cannabis-dependent people may stem mainly from their long personal histories of violent and anti-social behavior, rather than from the drug itself. Dr. Richie Poulton of the Dunedin's Multidisciplinary Health and Development Unit found that the violent, drug-dependent people in his study - who were nearly four-times as likely to be violent than their peers - had histories of violent behavior stretching back until they were three years old. "They were... beating up other kids in the sandpit" (New Zealand Herald, 2001).

Given that most mental-illness sufferers are not normally violent and that many sane substance-abusers and alcoholics are, it is likely that that substance and alcohol abuse are far more relevant to any offending by psychiatric patients than their illness. (A German study showed that 35% of people diagnosed as having schizophrenia "reported symptoms in the month they first took cannabis" Haefner, 2002). It is more likely still, that many supposedly 'disturbed' violent offenders were violent individuals who developed psychiatric-type symptoms through drug-abuse (Illicit drug-usage being extremely common in criminal culture).

This possibility was indicated by the major study looking at the link between mental illness and offending, cited in the British Journal of Psychiatry (Wallace, 1998) It was found that drug-addicts and alcoholics were twice as likely to commit a violent crime than someone suffering from schizophrenia and even when people diagnosed as having a psychiatric illness did offend, "the incident was more likely to be associated with drugs and alcohol abuse than with their condition". (Cooper, 1998).

As forensic psychiatrist Professor John Gunn has commented, to make a major impact on the homicide statistics [rather than persecuting psychiatric patients] it would probably be more productive to do something about alcohol and drug-abuse. He said: "A lot of data shows that the greatest thing that contributes to an increase in violence is substance abuse...It's a big social problem and in my view if you really want to get the big numbers down in the homicide column, that's the area you have to tackle". (Hall, 1999).

While not wishing to enter the debate about street-drug legislation, we feel we must register the anger and distress caused to mental-illness sufferers whenever substance-abusers (whose psychiatric status is often uncertain) perpetrate murderous assaults or other violence and are subsequently deemed to be 'mentally ill'. Most of the headline-grabbing killings and other incidents cited by opponents of community care involved people with extensive, preexisting backgrounds of drug-abuse and violence. In nearly all such cases, their criminality and violence long preceded the appearance of any psychiatric symptoms: i.e. it seems they were, essentially, violent people who took drugs and subsequently developed schizophreniform symptoms.

As the Serious Criminal Offending and Mental Disorder Case Linkage Study concluded, any offending found amongst schizophrenia or affective illness sufferers may be linked to their "...co-existing substance misuse. The risk of serious crime being committed by someone with a major mental illness is small and does not justify subjecting them, as a group, to either increased institutional containment or greater coercion" (Wallace, et.al. 1998).

YOBBERY AND VIOLENCE

It is tempting to assume that any difficult, disruptive or dangerous people we encounter are psychiatric patients receiving (or not receiving) community care. This potential for misidentification was neatly illustrated by an incident in Manchester's Arndale Centre: a loud, threatening (non-mentally ill individual -known to one of our directors) was seen shouting and waving his arms about, in unconscious caricature of a lunatic-at-large. As alarmed shoppers fled the scene, one was heard to remark to her companion: "I think he's a schizophrenic!" In fact this person (who has been clinically-assessed) is simply an immature, antisocial individual: a persistent petty criminal and prodigious consumer of street-drugs and alcohol.

It cannot be reiterated too often that sufferers of mental illness usually practise social withdrawal and do not wish to interact with others; and mental illness - even the most serious kinds, like schizophrenia - do not usually change one's basic character or values. Most mentally ill people subscribe to mainstream social values and are no more likely to commit acts of violence than anyone else. Referring to even the most severely mentally ill (sufferers from schizophrenic psychosis) consultant psychiatrist Dr. John Cutting wrote: "Most people who have schizophrenia are never violent at any stage of their illness. A minority are violent while they are acutely psychotic. In between the acute phases of the illness people with schizophrenia are, if anything, less aggressive than normal people". (Cutting and Charlish, 1995, p.192)

Arguably, the loutish, violent, hooligans who stalk the streets indicate a failure of the criminal justice system - not community care. The violence and disruption displayed by these sane (but frequently intoxicated or immature) individuals should not be allowed to discredit the largely successful policy of care in the community.

INFORMED CHOICES

Mind in Manchester has no corporate opinion on the controversies surrounding street-drug legalisation. Our position is that people taking any type of drugs - prescribed or proscribed - should be making informed choices: e.g. know about potential side-effects or dangers. (For information on the dangers of prescribed drugs, e.g. anti-depressives and anti-psychotics see Bazire, 2000; Breggin, 1993; Breggin and Cohen, 2000; Lacey, 1996; Marensson, 1999; For hazards associated with street-drugs see Ahuja, 2000; Boettcher, 1982; Guardian, 1996; Hall, Solowji and Lemon, 1994; Hall and Solowij, 1997; Henry, 2000; Murray, 2002; Robson, 1999) If you can recommend additional sources, please let us know.

STALKING

Another misleading myth of modern times is that of the deranged stalker. Stalking appears to be on the increase and high-profile incidents involving various celebrities in the past two decades - together with films such as Fatal Attraction - have given the problem wide publicity. Although stalkers often turn out to be bizarre or pathetic people with no prior involvement with mental health services, the increase in the media representation of stalking undoubtedly fuels fears about the supposed failure of community care.Yet Home Office researchers found that (in non-celebrity stalking) only about 8 per-cent of stalkers were total strangers.

Yet in two, recent, major British television documentaries stalkers were mostly depicted as being mentally ill, with prominence being given to sufferers of the highly unusual de Clerambault's Syndrome - a rare psychotic condition thought to have been diagnosed only a handful of times in the whole of Europe. Perhaps program makers considered the banal reality to be too uninteresting, i.e. most stalkers are pathetic, boring, harmless and sane. No doubt many stalkers are 'odd', 'strange' or - more usually - emotionally immature; but that does not necessarily mean that they are mentally ill as such and although some stalkers are extremely dangerous, these appear to be un-typical.

Forensic psychiatrist Dr. David James who looked specifically at stalkers who were violent found that these (violent stalkers) were rarely mentally ill. He concluded that "The vast majority (of violent stalkers) are inadequate people who do not know how to conduct human relations". (Murray, 2000) This study also found that "stalkers who assault their victims are far more likely to be former lovers than crazed strangers." These findings revealed that of the relatively few stalkers in their sample of 50 who were violent, only 3 of the 14 (subgroup of violent) stalkers had a psychotic illness. These were all former lovers. Only 12 of the stalkers were total strangers. (Farnham, et al. 2000).

CHILD ABDUCTION AND STRANGER DANGER

One of the most damaging mis-conceptions relating to dangerousness and mental illness is that of the psychotic child-abductor. In fact, child-molesters (paedophiles) are almost never mentally ill and the mentally ill are almost never paedophiles. These cunning, clear-thinking predators know precisely what they are doing and understand that it is wrong. (Confusion is caused by controversial sections of the 1983 Mental Health Act which allow courts to send sex-offenders, arsonists, and similarly scary - but sane - social misfits to psychiatric hospitals. The confusion is compounded by psychologists' use of a medical model for the 'treatment' of these offenders).

Home Office research has shown that: "The vast majority of child sex offenders know their victims..." (Campbell, 1999). In fact, contrary to expectation, an NSPCC study found that "most child abuse is carried out by siblings" (Arlidge, 2000; Fisher, 2000).

The public's - understandable - fears surrounding child killing are largely un-founded: Dr Colin Pritchard, Professor of Psychiatric Social Work at Southampton University who made a specialist study of child murders, found that these homicides have been falling steadily over several years. "From 1973 when nearly 200 children were killed each year in Britain, the figure had dropped by 1995 to 46 ...seven of those were killed by strangers". Professor Pritchard commented: "The chance of your child dying at the hands of a stranger is less than one in a million..." (Rayner, 1999).

In fact, despite widespread public fears of 'stranger danger', researchers have found that the vast majority of children are killed by relatives, not strangers. Olivia Bell, an NCH (formerly National Childrens Homes) official, said: "There are 12 million children in the UK. Of those killed every year...five are killed by strangers". (Kelso, 2002).

Reassuringly, a UNICEF report released in February, 2001, found that Britain is one of the world's safest countries (second only to Sweden) for children to live in: we have one of the lowest rates of child deaths from physical attacks or such accidents as drowning (Judge, 2001).

FEAR AND DISTRUST

The harm done to mental illness sufferers by the quasi-psychiatric status wrongly attributed to paedophiles was shown by events in South London: a supported housing scheme for people with mental health difficulties - like anxiety and depression - has been repeatedly attacked by local residents responding to rumours that it may house paedophiles (Petit-Zeman, 2001).

As well as creating a more fearful and distrustful society, the cumulative effect of the constant media mythologising and demonisation of mental patients is likely to further depress and demoralise them and deter them from accessing services - as well as unfairly undermining the largely successful policy of community care. Furthermore, it may also persuade politicians to introduce ill-informed and unnecessary legislation. As approved social worker Paul Jewitt pointed out: "Fear appears to be the impetus behind...the drive for compulsory treatment law..." (Jewitt, 2001).

This comment echoes the concerns expressed by the leading forensic psychiatrist Professor John Gunn of the Institute of Psychiatry. After finding that killings by the mentally ill had actually declined in recent years, he commented that: "...there is no evidence that it is anything but stigmatising to claim that [having psychiatric patients] living in the community is a dangerous experiment which should be reversed". (Taylor and Gunn, 1999).

COMMUNITY CARE DOES WORK

The Serious Criminal Offending and Mental Disorder Case Linkage Study concluded: "The risk of a serious crime being committed by someone with a major mental illness is small and does not justify...increased institutional containment or greater coercion" (Wallace, et al. 1998).

Yet, Professor of Social and Cultural Psychiatry, Dr Julian Leff, has warned that unless the successful nature of the policy of community care is better publicised: "we are likely to face increasingly restrictive mental health legislation enacted by governments pandering to public misperceptions" (Leff, 2001).

As Jan Wallcraft, a researcher with the Mental Health Foundation, commented: "Additional powers of compulsion would reduce the incentive to make services more acceptable. A culture of compliance would force doctors to practise defensive medicine and apply the new law, when in doubt, to avoid blame. Relationships between key workers and existing clients would be damaged, while others would be discouraged from seeking help. This could increase the levels of violence and suicide and raise costs, without improving services" (Wallcraft, 1999).

Like Jan Wallcraft, we believe that "community care can work for most people if we invest in child care, education, jobs, housing, transport, the environment and community development, and bring together all the relevant stakeholders to design 'safe, sound and supportive' mental health services".

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