‘Mental health’ is a term that frequently arises in the headlines and front-page spreads shortly after a violent act of terrorism. In a previous article relating to media reactivity after the mass shooting in Plymouth last year, we briefly addressed the possibly tenuous links between mental health, mental-ill health and radicalisation.

Speaking to Jillian Peterson, one of the heads of the US Violence Project, the country’s largest mass shooter database, she told us:

“Mental illness is often a part of the pathway to violence for these perpetrators, but it doesn't fully explain their crime.”

Shortly before we published that article, The Guardian had published an article titled ‘Up to 70% of people referred to Prevent may have mental health issues’. The language is very careful here, ‘may have’.

When discussing radicalisation and those who have been radicalised to the point of violence, it's easy to fall into generalisations. But what is the truth to the association between mental health and radicalisation? And what might this mean for the professionals treating those who might be vulnerable to radicalisation and, those who might act on that radicalisation?

Prevent, the focus on mental health in radicalised individuals and perceived vulnerability

A major study by the charity, Medact, found in May of 2021 that ‘vulnerability support hubs’, which had been set up by Prevent (the national anti-terrorism effort) to assess possibly radicalised individuals, were at risk of compromising medical ethics owing to having police present for assessments.

At the time the study was published, Medact voiced concerns that police were causing escalations of patient risk, in order to “secure admission and prevent discharge”. Medact also raised the issue of possible racist profiling, as those identifying as Muslim were 23 times more likely to be referred to a hub for assessment, than a white British individual displaying far-right, nationalist extremist behaviour.

In conclusion, Medact found that the ‘vulnerability support hubs’ were not fit for purpose, from inadvertently forcing mental health professionals into compromising their professional ethics and duty of care, to possible racial profiling, the study certainly brought into question how mental health might be inappropriately used in the fight against terrorism and radicalisation.

However, there is a question here worth asking. If we acknowledge that mental health or mental-ill health is not a direct cause of radicalisation and/or acts of terrorism, might it make some people more vulnerable to possible radicalisation?

The current UK government definition of radicalisation is missing from documentation, however there is a definition of extremism that our government, and Prevent refer to:

“Extremism is vocal or active opposition to fundamental British values, including democracy, the rule of law, individual liberty and mutual respect and tolerance of different faiths and beliefs. We also include in our definition of extremism calls for the death of members of our armed forces, whether in this country or overseas.”

Though restrictive, this definition is however clear on this idea of extremism and acts of terrorism as being rooted in ‘otherness’, as something outside our ‘fundamental British values’.

Experiences of being othered are common among those who are marginalised for a wide range of reasons. From poverty, race, religion, disability, sex and gender to mental health; marginalised people and communities are frequently seen as other by our society that is based on white, classist, ableist and patriarchal values.

Two leading psychiatrists in the field of studying radicalised individuals, Professor Edgar Jones and Professor Kamaldeep Bhui from Kings College London and University of Oxford, conducted a 2019 study with Elizabth-Rose Ahearn on Muslim men and women in Bradford and East London.

In the study, a ‘significant association’ was found between anxiety and terrorism sympathy. The study also found that the links between anxiety, depression and terrorism sympathy were likely ‘driven by underlying biological and cognitive causes of these common mental disorders’.

Last year, the government published it’s ‘Commission on Race and Ethnic Disparities’, more colloquially referred to as the Sewell Race Report. In it they briefly mention research by Synergi Collaborative Centre which found ‘a growing and convincing body of evidence that psychosis and depression, are more likely in those exposed to racism’.

However, the study by Jones, Bui and Ahearn found that discrimination, social capital and a sense of belonging did not increase risk of being radicalised or terrorism sympathy. Nor has Bhui and Jones’s wider research on radicalisation among white British, Pakistani and Bangladeshi people in the UK found any correlation between religion, whether or not someone attends a mosque and extremism or radicalisation.

Clearly there is something other than being marginalised and/or mentally unwell that is driving some people to radicalisation, but what?

To help us understand the complex relationship between mental health and radicalisation we spoke to Professor Edgar jones, to start he said:

“The relationship between radicalisation and mental health is a complex one, rather than simple cause and effect. We have shown in our research that mental illness can increase the risk of being susceptible to radical appeals. However, it remains the case that only a small minority of people with psychological illnesses are radicalised and then act on their beliefs. Further, many terrorists show no evidence of mental illness either at the time they commit violent acts or beforehand. Each case needs careful assessment.”

Following on from this, we briefly discussed what can be done in reporting to handle cases, such as that of Khairi Saadallah who was diagnosed with post-traumatic stress disorder at the time of his attack, with responsibility.

“When a violent attack takes place, it is important that the media observe caution in judgements about individuals and their motivation… The full picture often emerges only at trial when the court calls for specialist medical opinion.”

Speaking to The Guardian in 2020, Prof. Jones said, “We don’t say that mental illness causes terrorism. We say that if you suffer from mental illness, it may increase your risk of being radicalised.”

He then Elaborated this point by saying, “We think that if you suffer from depression, PTSD or anxiety, it increases your risk of wanting bonding capital”.

In our discussion with Jones, we asked him about what public health or criminal justice system interventions might help to address this group of people, who might be more at risk of radicalisation through their need for community. He said:

“It is unlikely that public health interventions will eradicate violent offending, but they can plausibly reduce the number. We found that those vulnerable to radicalisation have often invested socially in their communities but may identify with a narrowly defined group."

"Recruiters seek to restrict contacts with all but the extreme to motivate violent action. Interventions designed to broaden social capital, bridging between diverse groups, could produce a more inclusive society where people feel a greater sense of belonging. This in turn would erode much of the appeal offered by extreme ideologies.”

In 2016, The Royal College of Psychiatrists (RcPsych) published a position statement on the impact of counter-terrorism and psychiatry. In it they stated, ‘there is no link between mental disorders and group-based terrorism’, however they did point out that those who commit lone acts of terrorism are ‘statistically more likely to have a background that includes mental illness’.

They also acknowledged groups of people loosely described as ‘alienated’ or ‘troubled’, particularly young people, who would benefit from better ‘access to existing services, in particular child and adolescent mental health services.’

When preventing radicalisation and terrorism meets with practice, ethics and confidentiality

The RcPsych position statement also raises another interesting element to the mental health/radicalisation debate. The moment we begin addressing risk of radicalisation through mental health services we inevitably run into issues with how this could potentially impact practice, especially through client/patient confidentiality.

On this, RcPsych said: ‘The Royal College of Psychiatrists supports and encourages psychiatrists to fulfil their safeguarding responsibilities, but has some concerns about the implementation of Prevent. These focus in particular on the variable quality of the evidence underpinning the strategy, and potential conflicts with the duties of a doctor as defined by the GMC [General Medical Council]. There is also a risk that Prevent could reduce the willingness of people to access mental health treatment.’

Here, RcPsych refers to the fact that the GMC sets out the circumstances in which doctors and psychiatrists are obliged to report concerns about patients in order to prevent harm to themselves or others.

In many ways, pre-empting what Medact found in their 2021 study, RcPsych also voiced concerns over the fact that there should not be a ‘system that overly identifies’ those fleeing war-torn countries, who frequently flee terrorism, with that the very same thing they are fleeing. RcPsych added that this could ‘add’ to already existing trauma and psychological distress.

On the psychiatric practice that might aid in the prevention of terrorism – which in itself RcPsych cited as raising ‘ethical, clinical, professional-boundary and confidentiality issues’ – RcPsych said:

‘In this context, approaches to safeguarding people from harm should be explicit that doctors are not acting in a surveillance capacity, but rather focus on doctors working in partnership with patients, discouraging stigma and assisting individuals to access the care they need.’

In conclusion of their position statement, RcPsych laid out a list of 12 actions. The ninth in this list addressed the possible ethical quandries at the heart of this discussion, quite plainly:

‘When they [psychiatrists] are practising in this area, psychiatrists’ primary duty is to their patient, and their clinical judgement and expertise should be valued and respected. As always, they should work within the GMC’s and Royal College of Psychiatrists’ legal and ethical frameworks that put patients at the centre of their work, appropriately recognising when patient confidentiality needs to be breached for the purposes of crime prevention or to safeguard patients and/or others. There should be no compulsion for psychiatrists to act in ways that go against their evidenced best judgement.’

How might practice, treatment and support from within mental health services address a very modern radicalised movement: incels?

To end our questions for Professor Edgar Jones we asked him about the rising concerns over young people, particularly young men being radicalised online into far-right communities such as the incel community. Short for ‘involuntary celibate’, the community, found on various online forums, is based on misogynist ideas about men, women and sex.

In our question we brought up the mass shooting in Plymouth last year and the issue of encouraging young men, who might be vulnerable to radicalisation but unlikely to access services, into mental health support, Prof. Jones said:

“By reducing daily human contact, successive lockdowns may have provided new opportunities for on-line recruiters. Isolated or vulnerable individuals whose grievances have been reinforced by far-right groups are unlikely to seek mental health support because of stigma. Pro-active programmes to engage and build trust are needed. Yet this is a significant challenge because interaction through online forums is thought to make incels feel valued and provide them with a sense of identity. To contact those vulnerable to incel narratives, a holistic approach has been proposed, including spaces where they meet, such as video games and chat forums.”

Reflecting on Professor Jones’s observations on what might be affective in preventing radicalisation as we move forward, it seems as though the answer is, as he said, in a holistic approach. Radicalisation in of itself, is not a mental disorder, instead it is a process in which a person is influenced or sometimes groomed into changing their mindset, behaviours and worldview to an extreme level.

The solution to radicalisation, if there is any, must take into consideration the complex and nuanced spectrum of factors that lead to this, which of course does include mental health, whilst being careful to not ‘autopilot’ into using mental health as a catch-all solution.