Mental illness and terrorism
BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4869 (Published 13 September 2016) Cite this as: BMJ 2016;354:i4869All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I fully support Derek Summerfield's statement in his rapid response
Dr Peter J Gordon
Competing interests: No competing interests
I fully support Derek Summerfield's statement in his rapid response. Psychiatrists should refuse to collude with the State's Prevent strategy - the reasons for doing so have been well aired already. As a retired psychiatrist I well recall the ethical stance of the Royal College of Psychiatrists in opposing the collusion of Russian psychiatrists in the so-called 'abuse of psychiatry' in the 1960s. I feel ashamed that the College appears to have dropped its ethical standards and note that other medical bodies in UK so far remained silent on the ethics of asking doctors to collude in Prevent.
Suman Fernando
Honorary Professor in Faculty of Social Sciences at London Metropolitan University; formerly Consultant Psychiatrist at Chase Farm Hospital, Enfield Middlesex.
Competing interests: No competing interests
Earlier this year I noted that the GMC, BMA, Royal Colleges, and medical journals had all been remarkably silent about Prevent training as a mandatory duty for clinicians. (1) Discussion ensued with the President of the Royal College of Psychiatrists (RCPsych), who is one of the 3 authors of the BMJ editorial, and in due course a RCPsych working group was set up with his encouragement. I have been a member of the group, which has produced a position paper on which the editorial is largely based (the other 2 editorial authors were also members of the working group).
The editorial acknowledges that there has been unease amongst some psychiatrists, is open about the slipperiness of “terrorism” and any putative relationship with mental disorder, the difficulty of predicting rare events, and the lack of reliable tools. This is all true, but in so saying it is deploying instrumental reasoning about problems viewed as merely technical and value-neutral. This is to side-step any a priori question of principle, which here is the question of whether doctors are being expected to behave unethically if compelled to attend a training intended to prime them for the referral of clinical cases to a counter-terrorism programme set up by MI5, a spy agency. It is about spying on their patients, a corruption of the doctor-patient relationship, and this cannot be ducked. I canvassed doctors in psychiatric training in my NHS Trust and picked up considerable unease and bewilderment on this account.
I was asking the working group to recommend that the RCPsych state publicly that it could not endorse Prevent on medical ethical grounds, but they have not and thus I dissent from the conclusions of the position paper. As far as the editorial is concerned, it rather reads as a call to raise the standard of the way Prevent is applied. The last sentence talks about the need to “create more trust and support for Prevent.” This is sadly collusive.
Furthermore, the argument about principle is not just about medical ethics per se, but about the deteriorating climate of civil liberties in this country, not least in relation to population surveillance. The Prevent programme is consistent with actions taken during the era of McCarthyism in 1950s USA. When that ignominious era finally waned, many ordinary, decent people who had been drawn into co-operation with it by, say, reporting a colleague, came to feel embarrassed and bemused at having done so.
The ethical basis for doctors to refuse to co-operate with Prevent, including the training, stands, and I recommend that doctors say no as I and others continue to do.
1. Summerfield D. Mandating doctors to attend counter-terrorism workshops is medically unethical. BJPsych Bull 2016;40:87-doi:10.1192/pb.bp.115.053173 pmid:27087993
Competing interests: No competing interests
A welcome balanced editorial that neither minimises nor exaggerates lone actor terrorism offences by people with mental illness & other conditions.
Two citations peaked my interest. The description without a value judgement of the Summerfield polemic call to boycott PREVENT gives the impression of an endorsement of his stance by the authors. Was this indirect support of the boycott intended?
The reference to college guidance suggests a position on the PREVENT limb of CONTEST, but isn't the cited guidance about post event trauma management part of the PREPARE limb of the CONTEST counter terrorism strategy?
Competing interests: No competing interests
As highlighted it seems appropriate to group acts of terror in with other violent potential conclusions of mental health, notably suicide/self harm and homicide. And as Bhui et al suggest the extent to which MH professionals should and need to act in all these situations follow standard safeguarding protocol, including police involvement when appropriate. There is nothing new in this.
In my mind what this piece flags up concerns the vulnerability to radicalisation of those with MH diagnoses. Speculatively, akin to the apparent increase in radicalisation occurring in UK prisons, resulting in a new, as ever nebulously named 'directorate of Security, Order and Counter-terrorism'[1], vulnerable individuals whether with or without SMI may, perhaps, similarly be predisposed to being swayed by others who do not have their best interests at heart. Just as a social and medical service we might act to advise patients away from certain individuals in their community involved in drugs or criminal activity, recognising our service users as vulnerable people we take the necessary precautions to forewarn and protect from those who may have nefarious political intentions. Vulnerable adults for whatever reason deserve social support.
By highlighting this vulnerability I do not mean to propagate the very real public zeitgeist popularly generated, among others, by Christopher Nolan's "Batman: The Dark Knight, in which The Joker coerces 'Gotham asylum' patients into committing his acts of terror. Pragmatically our authors point out that this is very likely not the case.
People with diagnosed mental illnesses are not incapacitated of being as viciously motivated to act for change against political, social, cultural, legal, in their eyes, injustices, as those without mental ill health. Any intention of committing acts of terror may, for one, develop without the contribution of their mental health condition, and secondly, without the input of a radicalising other. (In fact to some degree we may even want to encourage independent political engagement in this group as a tool to promote social engagement on a broad scale. I wonder what voting turnout/political party membership rates are in SMI patient groups?)
While this piece is genuinely fascinating and initially seems to be introducing a new facet, on examination any solutions we might want to find probably only reopen the already appreciated ever lasting debates in psychiatry: capacity, over valued vs. delusional ideas, patient confidentiality, safeguarding and the so many others.
[1] https://www.gov.uk/government/news/government-sets-out-new-measures-to-t...
Competing interests: No competing interests
Nowadays media reports about terrorist activities and incidents of terrorism are of great concern. Over-reporting and over-coverage may result in adverse effects and further incidences.
This type of media attitude may interfere with ongoing investigations and may help the terrorists to escape.
So definitely certain guidelines are important for the media in covering, reporting and telecasting incidences of terrorism.
All the media all over the world should always adhere to these guidlines for safe, fearless day to day living.
Moreover terrorism is not a mental illness and there is no excuse or reconsideration for any terrorist activities based on this.
Competing interests: No competing interests
Dear Dr. Saripanidis:
Thanks for your reply. With all due respect, I beg to differ. The mere fact that there are no studies or statistics linking terrorism with malnutrition, dehydration, and addiction proves nothing except that our leaders lack common sense and have overlooked the obvious. Here are some examples:
1) "Biden Promises Foreign Policy Shifts" - NPR Morning Edition - U.S. General David Petraeus states, "First and foremost, our forces and those of our Afghan partners have to strive to secure and serve the population. We have to recognize that the Afghan people are the decisive terrain. A nuanced appreciation of local situations is essential. This requires listening and being respectful of local elders and mullahs. And it also requires, of course, many cups of tea."
http://www.npr.org/templates/story/story.php?storyId=100405742
2) "Iraq's Best And Brightest Are Among The First Targeted By A Growing Resistance" - Newsweek - "I liked [Faris Assam] the moment I met him. He was a technocrat, not a politician, an engineer whose confidence and competence helped him rise quickly under the occupation administration to be deputy mayor of the Iraqi capital...On Sunday evening, just hours after Assam got back home, he went to a crowded cafe to drink tea, play dominos and smoke a water-pipe with his friends."
http://www.newsweek.com/shadowland-hit-list-139105
3) "Honey, I Love You" - Faik Nasser - "To the ancient people, honey was seen as a symbol of wealth and happiness. It was associated with strength, beauty and longevity. Even the Biblical Promised Land was described as the Land flowing with Milk and Honey."
http://www.islamicmedicines.com/forum/threads/honey-i-love-you.207/
4) "The Merits of Honey" - Verity, An Islamic Resource - "God Almighty has informed us that there is a special ability in honey to heal and cure diseases."
http://www.ummah.com/forum/archive/index.php/t-47506.html
5) "Middle East Sweet on U.S. Honey" - AgExporter - "In 2000, the United States exported 1,861 tons of honey to the Middle East, a slight increase over the 1,724 tons in sold 1999. That volume accounts for 36 percent of the total U.S. honey sold overseas. Honey is an important staple in Yemen; a survey conducted by the Honey Board found that 30 percent of the respondents eat honey every day. Moreover, 37 percent ate honey two to three times a week. In 2000, Yemen imported 488 tons of the amber fluid from the United States."
https://www.highbeam.com/doc/1G1-79088029.html
6) "Little Iraq" - The New Yorker - "We...drank warm, thick coffee in a fast-food restaurant full of Jordanian families eating fried chicken and drinking Pepsi...I sat with a group of Iraqis who were smoking and drinking sweet tea...I left, my hands full of sweets pressed on me by the Imam."
http://www.newyorker.com/magazine/2003/04/07/little-iraq
7) "Coffee Legends" - National Geographic - "Coffee as we know it kicked off in Arabia, where roasted beans were first brewed around A.D. 1000. By the 13th century Muslims were drinking coffee religiously."
http://www.nationalgeographic.com/coffee/ax/frame.html
8) "Arabian Coffee (Coffee with Grind Cardamom)" - Shalam.org - "If you think Coke is the taste of life, then you certainly haven't tried Arabian Coffee. This kind of coffee is widely spread in the Middle East and more specifically amongst Palestinians. Back home, it is the drink of every occasion..."
9) "Mecca Cola Challenges U.S. Rival" - BBC News - "Mr. Mathlouthi says that two million bottles, each holding 1.5 litres, have already been sold and the demand for advance orders has been phenomenal."
http://news.bbc.co.uk/2/hi/middle_east/2640259.stm
10) "Cola" - The Journal of the American Botanical Council - "[Cola] has been traded [from West Africa] to other countries since at least the fourteenth century and it is used particularly by Islamic people..."
11) "Water-pipe tobacco smoking in Israel" - Harefuah Journal - "Tobacco smoking via a water-pipe (Nargile) is a new phenomena among school children in Israel in recent years."
http://www.ncbi.nlm.nih.gov/pubmed/14631902?dopt=Abstract
12) "The Editor's Desk" - Newsweek - "In 1987, Arafat was living in Iraq, in one of Saddam Hussein's villas, and received Chris over a breakfast of cornflakes covered with tea and honey."
http://www.newsweek.com/editors-desk-124365
13) "The Agent" The New Yorker - "[Abu Jandal] seemed to enjoy drinking tea and lecturing the Americans on the radical Islamist view of history..."
http://www.newyorker.com/magazine/2006/07/10/the-agent
14) "Forcefeeding Peace To The Middle East" - The Toronto Sun - "Most Arab leaders live on a lethal diet of syrup-sweet coffee, cigarettes, fatty food, candy, fear and adrenalin."
http://www.twf.org/News/Y1998/19981025-WyeAgreement.html
15) "Water for Israel tops former ambassador's agenda" - The Jewish News Weekly of North California - "The former Israeli ambassador to England and Australia believes water is the key to self-reliance, peace and stability in the Middle East."
http://www.jweekly.com/article/full/13198/water-for-israel-tops-former-a...
16) "The Agent" - The New Yorker - Soufan walked directly toward [the Yemeni soldiers], carrying a bottle of water as the guns followed him. It was a hundred and ten degrees outside.
“You look thirsty,” Soufan said, in Arabic, to the officer with the walkie-talkie. He handed him the bottle.
“Is it American water?” the officer asked.
Soufan assured him that it was, adding that he had American water for the other soldiers as well. The Yemenis considered the water such a precious commodity that some would not drink it. With this simple act of friendship, the soldiers lowered their weapons.
http://www.newyorker.com/magazine/2006/07/10/the-agent
Competing interests: No competing interests
I concur wholeheartedly with the importance of destigmatising the oft media reports of lone actor violence as terrorist acts by mentally ill persons. Aside from the contagion effect of such reports that can create a 'heroic-martyr' figure, there is the inappropriate and ineffective politically driven consequence of such labelling. We already saw this with the DSPD debacle, must we revisit such unfounded and harmful nonsense in a misguided and ineffectual attempt to allay our fears?
Competing interests: No competing interests
Using medical conditions as an excuse has many forms. This example is one of many and disgusting . Before and still religion was a popular excuse for atrocities.
Competing interests: No competing interests
Some dissent is an endorsement
I was reassured to find the PS04/2016 the Royal College of Psychiatry position statement on Counter Terrorism & Psychiatry, and to read Derek Summerfield's response to this editorial. Perhaps this type of open, transparent and lively debate, alongside rule of law, guards the UK against drift towards Soviet style political abuse of Psychiatry. I think Summerfield is right to raise the potential harm that CHANNEL referrals could cause, but unless he is privy to security service activity he is speculating about MI5 independently governing PREVENT and the inevitability of harms that CHANNEL could cause. This why we must stand with the editorial call for sharing data and empirical scrutiny of any healthcare referrals and any interventions. It would also be good if the governance structure of PREVENT was even more transparent so that we were not left with fears that it is about spying on patients without any safeguards and rights to appeal.
Competing interests: No competing interests