Debate on mental illness and violence was oversimplified

BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7375.1300/a (Published 30 November 2002) Cite this as: BMJ 2002;325:1300
  1. Tom Clark, clinical research fellow in forensic psychiatry (thomas.clark{at}sbmht.wmids.nhs.uk)
  1. University of Birmingham, Reaside Clinic, Rubery, Birmingham B45 9BE

    EDITOR—The central message of Walsh and Fahy's editorial—that the contribution to societal violence of mentally disordered persons is too small to justify the apparent preoccupation of politicians and the print and broadcast media—is correct, although it is becoming hackneyed after endless repetition.1 Despite this, an established association exists between mental disorder and violence that cannot be explained by cofactors.2 Even if there were no statistical association psychiatry would still have a role when they do coexist.

    The failure of forensic psychiatry to show simple associations between specific symptoms (of psychosis) and violence has been followed in recent years by repeated assertions that the relation between mental illness and violence is minor. At the same time, medium secure psychiatric facilities continue to proliferate and forensic psychiatry continues to expand and superspecialise. Some might say that “less than 10% of serious violence” is an appreciable proportion to be attributable to psychosis—the most severe and least common form of mental illness.

    Unsurprisingly, the public, politicians, and the media are confused. What is left is a perpetual conflict between, on the one hand, the public's understandable insistence that psychiatry engages in public protection and, on the other hand, psychiatry's endless repetitions of the same tired statistics, which pointedly fail to address the public's concerns.

    Psychiatry cannot expect the public to understand the vicissitudes of psychiatric diagnosis so long as it continues to insist that there is one group of patients with “real mental illness” (usually psychosis or schizophrenia) who pose little risk, and another group of people with “pseudo-mental illness” (personality disorder and substance misuse) who cause all the problems. Everyone knows that this is overly simplistic and irrelevant to the real world, where personality disorder, substance misuse, severe mental illness, and less severe mental illness commonly coexist. Attempts to divine exactly what proportion of violence may be attributable specifically to psychosis or to other psychiatric syndromes is futile.

    The public deserves a more sophisticated debate than this. Rather than avoiding responsibility on the basis of what will appear to be spurious diagnostic conveniences, psychiatry must accept its occasional role in public protection and the importance of risk of violence assessment in clinical practice, while openly and clearly explaining the limits and difficulties of clinical risk assessment and debating the appropriate boundaries of psychiatric care.


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