Radicalisation and mental health

Dr Philip McGarry is a psychiatrist from Belfast. He is an old friend, a little younger than me. He is former Chair of the non-sectarian Alliance Party of Northern Ireland. He knows a lot more than most people about political violence and its relationship with mental disorder. Philip sent me an email on Sunday, concerned about media accounts originating from the police saying that potential terrorist recruits are likely to be mentally unwell. He felt that this was stigmatising and that it is seriously unhelpful in trying to understand terrorism.

Simon Cole, Chief Constable of Leicestershire and police lead for Prevent, was quoted as saying that data from the Channel Process shows that about 50% of people referred to this anti-radicalisation programme are “likely to have vulnerabilities with regard to mental health or psychological difficulties”. Chief Constable Cole went on to explain: “There is a thing about vulnerable individuals who need some help and support to make the right decisions because they are not very well”. He did say that there are other causes of terrorism. If reported accurately, his main suggestion was that targeting people with mental health problems might help to stem the flow of British recruits into jihadism and other forms of political violence.

This is reflective of a school of thought that has developed amongst terrorism researchers. It is argued that modern terrorists are different from their predecessors. In the twentieth century, it was generally accepted that terrorists were recruited person-to-person and showed no characteristic antecedent profile of psychological abnormality. Martha Crenshaw summarised: “the outstanding common characteristic of terrorists is their normality”. Since 2001, according to the argument, the face of terrorism has changed through sophisticated use of online propaganda and social media, so that isolated, troubled individuals are drawn into groups that they could never have encountered in person. You can read a clear exposition of this argument in a paper by Anton Weenink, who is a Senior Researcher in the Central Unit of the National Police of the Netherlands. The stated research question is “to what extent do jihadists have a history of problem behaviour or mental disorder?”

Of course, there should be caveats about such research findings and the conclusions drawn from them. Active jihadis and terrorists do not willingly submit to rigorous psychiatric or psychological evaluation in properly sampled cohorts. Conclusions are based on imperfect intelligence information. Suspicions that individuals are drifting towards jihad may be provoked by changes in behaviour due to mental illness, creating a false association based on circular reasoning.

Limitations such as these are always likely to be a problem in conducting research on terrorists when the risk of atrocity is at its height and the need for knowledge is greatest. Nonetheless, scientific researchers should set out their findings in the context of uncertainties. Weenink appears to feel that the answer to his research question is settled, but the paper would be given a hard time in the average journal club. For example, there are no normative data other than uncorrected general population prevalences, and the presence of three people in the sample with a diagnosis of schizophrenia is taken to represent an excess without the application of a statistical test.

The Royal College of Psychiatrists is preparing a response to the psychiatric aspects of Prevent and other anti-terrorism initiatives. The College is looking at the full evidence and considering the ethical issues. This may seem like a ponderous way of proceeding, but the whole point of Royal Colleges is that they make considered and authoritative statements. Their value lies in their ability to be credible, not in their ability to respond instantly. In the meantime, Philip McGarry and I agree that Simon Cole’s statement, as reported, is seriously flawed. Neither of us is involved in forming the Royal College response to Prevent.

In the background, there is the refrain, endlessly repeated for decades, that terrorists are “nothing but mindless, blood-thirsty psychopaths”. This uses a psychiatric diagnosis as an insult. It implies that there is no need to try to understand what causes political violence other than a personal abnormality. A modern variation is that Islamic State is “nothing but a death cult”. I am not sure what that means, but it seems to lack explanatory power. What, I wonder, has suddenly made a death cult so alluring that people are joining it without duress and of their own volition?

To be fair, Simon Cole does not seem to have suggested that mental disorder is a sufficient cause of terrorism, but that ‘not being very well’ makes people vulnerable to recruitment. Personally I doubt if any extremist group would deliberately recruit psychologically vulnerable people to participate in organised and carefully planned violence. If 50% of potential jihadis have psychological problems, then it is reasonable to guess that people from the other 50% will be selected for active service.

The signs of psychological maladjustment that are associated with radicalisation (according to these studies) are non-specific. As can be seen in the Weenink paper, they are very widely defined, for example, trouble at school, quarrels and lack of self-control. A very small number of people make suicide attacks. A very large number show the behaviours described in the paper. Is it plausible that it would ever be possible to intervene successfully with enough people to prevent one suicide attack? It is a pity that neither Chief Constable Cole nor Anton Weenink appears to have made a Number Needed To Treat calculation.

Of course, the above only applies to membership of organised terror cells and militia. What about lone wolf attacker, recruited to political violence and taking action without face-to-face contact or specific directions from an organised group? Surely it is plausible that they have psychological problems and could be targeted by impersonal on-line recruitment techniques? People like Anders Breivik, Theodore Kaczynski (the Unabomber) and David Copeland (the London nail bomber). Plus Thomas Hamilton (Dunblane), Ralph Moat and an increasing number of US high school shooters. The trouble is that the first set seems to have acted in reaction to political groups’ failure to organise acts of violence. The second set appears to have had no political motive at all. There is more to lone wolf attacks than clever use of on-line propaganda by third parties.

Nearly all media reports about these isolated violent men suggest that they have profound psychological problems, but I doubt if they would they look any different to countless harmless loners if you did not know about their violence. Is it plausible that you could identify these angry, isolated men and change them sufficiently to avoid their descent into atrocity?

People with a mental illness diagnosis are directly affected by the idea that they are potential terrorists. There is an association between psychosis and violence, but it is a weak one. It is uncertain whether the association is due to the features of psychosis itself or whether it is due to other factors such substance misuse, which are common amongst people with mental illness and independently associated with violence. A gross exaggeration of the link between mental illness and violence is a recurrent media theme, and it hurts people who are trying to lead an ordinary life. Confirmation of a link between terrorism and mental illness by people in authority should only be given if there is reasonable evidence that the link is real. I am far from convinced.

I am quite sure that Simon Cole is sincere in his desire to promote positive intervention with unhappy people in order to prevent terrorism. I think he should bear in mind a few points. Firstly, having psychological vulnerabilities is different to being mental unwell, and conflating the two confuses everything. Secondly, trying to prevent very uncommon behaviours by intervening with large numbers of people is intrinsically problematic unless you have extremely potent and cheap interventions available to you. Thirdly, vulnerable young men sometimes join the Army, but this does not explain British foreign policy, so why would putative vulnerability in recruits explain terrorism? Finally, genuinely well-intentioned interventions can cause harm. That is why we need evidence.

The last word goes to Philip McGarry: “IS are vicious, sectarian, bigoted killers, but they have a rationale and a clear political agenda which is not remotely connected to mental illness. The suggestion that counselling or better psychiatric care might stop people gravitating to them is offensive”.