Criminal Behaviour and Mental Health 24: 1–4 (2014) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/cbm.1895
Fear of the (almost) unknown
MATTHEW LARGE1,2, ANDREI GOLENKOV3 AND OLAV NIELSSEN2,4 1 Prince of Wales Hospital, Sydney, Australia; 2University of New South Wales, Sydney, Australia; 3Psychiatry and Medical Psychology, Chuvash State University, Cheboksary, Russia; 4Clinical Research Unit for Anxiety and Depression, St Vincent’s Hospital, Sydney, Australia ‘The psychiatrist is the friend of the patient but the servant of society’ (Russian aphorism of uncertain origin) In this issue of the journal, Sturup and Lindqvist help fill the void of data on the factors associated with serious recidivism, with their report on violent recidivism in a cohort of 174 people convicted of homicide in Sweden during the decade 1971–1980 (Sturup and Lindqvist, 2014). Twenty-two (13%) of these offenders had a psychotic illness and five (3%) had committed a previous homicide. One hundred and fifty-three were followed after the index homicide for an average of over 21 years, during which time 15 committed further serious offences, including five homicides. Only one of the recidivist homicide offenders had a diagnosed psychotic illness; the remaining nine members of the cohort who had committed earlier or later homicides had been diagnosed with personality disorder. However, five of the 15 serious recidivists suffered from psychosis, which was the only clinical factor that was significantly associated with repeat offending. In a previous issue of the journal we reported a 30-year retrospective study of homicide offenders with schizophrenia from the Chuvash Republic of the Russian Federation between 1981 and 2010 (Golenkov et al., 2013). We found that 16 (11%) of the 149 homicide offenders with schizophrenia had committed a previous homicide. We found some possible risk factors – living in a rural area and dissocial personality traits – but a limitation of the study was that we were not able to examine whether homicide offenders with schizophrenia were more likely to commit a second homicide than other homicide offenders. It is widely believed that schizophrenia is a risk factor for homicide recidivism. Although this may well be true, the assumption is largely on the basis of the findings of a single study from Finland with a small number of cases. The Finnish study found that four of the 93 (4%) homicide offenders with a diagnosis of
Copyright © 2013 John Wiley & Sons, Ltd.
24: 1–4 (2014) DOI: 10.1002/cbm
2
LARGE et al.
schizophrenia had committed a previous homicide, compared with the 32 of the 1491 (2%) other homicide offenders (Eronen et al., 1996a; Eronen et al., 1996b). The authors of this study concluded that schizophrenia was a risk factor for homicide recidivism, despite the small number of cases on which this conclusion was based. In fact, other studies of offenders with psychosis report very low levels of homicide recidivism. In New South Wales, Australia, only one of the 134 homicide offenders with psychosis committed a second homicide in a 17-year period (Nielssen et al., 2007; Nielssen et al., 2011a, 2011b). The authors of population-based studies of homicide in New Zealand conducted over 30 years (Simpson et al., 2004) and Austria over 25 years (Schanda et al., 2004) reported no recidivists with psychosis. None of the other authors of studies included in a systematic review of homicide in schizophrenia (Large et al., 2009) who we could contact by email knew of any recidivist offenders among those included in their studies. Hence, the total number of homicide recidivists with schizophrenia in population-based studies might be as low as 22, 16 from Chuvashia, four from Finland and one each from Sweden and Australia. Most jurisdictions have systems to determine when homicide offenders who are found not guilty by reason of insanity can be released to the community (Pasewark et al., 1979; Lamb et al., 1988; Griffin et al., 1991; Parker 2004; Nielssen et al., 2011a, 2011b). These systems have the task of balancing the rights of the general public for protection with the needs of the people who committed their offences during an episode of mental illness from which they have recovered. The main consideration in any release decision must be whether the offender will commit another offence, especially a second homicide. Any release decision, however, involves a degree of uncertainty and an often unstated conclusion that the risk of recidivism is acceptable, rather than non-existent. That uncertainly is partly a result of the very limited data on both the probability of a future homicide and the characteristics of individuals who are more likely to commit a further homicide offence. Uncertainty, though, creates cognitive biases that affect our judgments of the risks associated with the release of mentally ill offenders. The cognitive biases associated with rare but catastrophic events were described by the authors of the 17th century best seller, Logic and the Art of Thinking (Arnauld and Nicole, 1662, reissued in English in 1964). In the chapter ‘belief in future contingent events’, the authors use the example of fear of lightning strikes to warn that Fear of an evil ought to be proportionate not only to the magnitude of the evil but also to the probability of occurrence (Arnauld and Nicole, 1662).
There is a similar tendency to over-value rare but beneficial outcomes, such as subscribing to lotteries, in what is known in horse racing as the ‘long-shot bias’.
Copyright © 2013 John Wiley & Sons, Ltd.
24: 1–4 (2014) DOI: 10.1002/cbm
Recidivist homicide
The tendency to overvalue the benefits and losses associated with rare events is best described in the Nobel Prize winning work known as ‘prospect theory’ (Kahneman and Tversky, 1979). The irrational fear of very rare events is also apparent in the fear of homicide of strangers. The enquiry that followed a single homicide of a stranger by Christopher Clunis in the UK and the homicide of the popular sports commentator Brian Smith by a psychiatric patient in Ontario, both resulted in significant changes to psychiatric practice. Homicides of strangers by people with schizophrenia are, however, perhaps the least predictable of adverse events in mental health care, as they occur at a rate of about one in 14 million of the general population per annum, and two-thirds are committed by people who are unknown to mental health services at the time of the homicide (Nielssen et al., 2011a, 2011b). Research that provides better estimates of the rates and factors associated with these rare and catastrophic events could reduce the cognitive bias arising from the over-estimation of their probability. Researching rare events is difficult because of the small number of cases, even in large jurisdictions. Prospective studies of homicide recidivism have to be conducted over decades because of the long periods of detention and the observation that second homicides can occur many years after the release of the first offence. Moreover, any findings might become less relevant over time because of the changes in release policies and in the sociological conditions in the community that determine overall homicide rates, rates of homicide by the mentally ill and presumably the rates of homicide recidivism (Large et al., 2009). The only way of conducting a prospective study with a large enough sample of cases would be an international multicentre study, including countries with large populations. Although we can be reassured by the low rate of serious recidivism in countries with low rates of homicide and comprehensive mental health services, decisions about the release of individual mentally ill offenders are based on ethical and political considerations as much as scientific data. With this in mind, we have to ask ourselves, how do we balance the harms of prolonged secure detention to the patient and the overcrowding of forensic hospitals, against the risk posed by the release of mentally ill offenders? And how long should we detain recovered forensic patients who committed their offences during the acute phase of mental illness, in order to prevent the rare outcome of a second homicide?
References Arnauld A, Nicole P (1662) The art of thinking: Port-royal logic. Translated by J Dickoff & P James. New York: Bobbs-Merrill, 1964: 354–357. Eronen M, Hakola P, Tiihonen J (1996a) Factors associated with homicide recidivism in a 13-year sample of homicide offenders in Finland. Psychiatric Services 47: 403–406. Eronen M, Tiihonen J, Hakola P (1996b) Schizophrenia and homicidal behavior. Schizophrenia Bulletin 22: 83–89.
Copyright © 2013 John Wiley & Sons, Ltd.
24: 1–4 (2014) DOI: 10.1002/cbm
3
4
LARGE et al.
Golenkov A, Large MM, Nielssen O (2013) A 30-year study of homicide recidivism and schizophrenia. Criminal Behavior and Mental Health Aug 5. DOI: 10.1002/cbm.1876. [Epub ahead of print] Griffin PA, Steadman HJ, Heilbrun K (1991) Designing conditional release systems for insanity acquittees. Journal of Mental Health Administration 18: 231–241. Kahneman D, Tversky A (1979) Prospect theory: An analysis of decision under risk. Econometrica 47: 263–291. Lamb HR, Weinberger LE, Gross BH (1988) Court-mandated community outpatient treatment for persons found not guilty by reason of insanity: A five-year follow-up. The American Journal of Psychiatry 145: 450–456. Large M, Smith G, Nielssen O (2009) The relationship between the rate of homicide by those with schizophrenia and the overall homicide rate: A systematic review and meta-analysis. Schizophrenia Research 112: 123–129. Nielssen O, Bourget D, Laajasalo T, Liem M, Labelle A, Hakkanen-Nyholm H, Koenraadt F, Large MM (2011a) Homicide of strangers by people with a psychotic illness. Schizophrenia Bulletin 37: 572–579. Nielssen OB, Westmore BD, Large MM, Hayes RA (2007) Homicide during psychotic illness in New South Wales between 1993 and 2002. The Medical Journal of Australia 186: 301–304. Nielssen OB, Yee NL, Millard MM, Large MM (2011b) Comparison of first-episode and previously treated persons with psychosis found NGMI for a violent offense. Psychiatric Services 62: 759–764. Parker GF (2004) Outcomes of assertive community treatment in an NGRI conditional release program. The Journal of the American Academy of Psychiatry and the Law 32: 291–303. Pasewark RA, Pantle ML, Steadman HJ (1979) Characteristics and disposition of persons found not guilty by reason of insanity in New York State, 1971–1976. The American Journal of Psychiatry 136: 655–660. Schanda H, Knecht G, Schreinzer D, Stompe T, Ortwein-Swoboda G, Waldhoer T (2004) Homicide and major mental disorders: A 25-year study. Acta Psychiatrica Scandinavica 110: 98–107. Simpson AI, McKenna B, Moskowitz A, Skipworth J, Barry-Walsh J (2004) Homicide and mental illness in New Zealand, 1970–2000. The British Journal of Psychiatry 185: 394–398. Sturup J, Lindqvist P (2014) Homicide offenders 32 years later - A swedish population based study on recidivism. Criminal Behavior and Mental Health.
Address correspondence to: Dr Matthew Large, The Kiloh Centre, Prince of Wales Hospital, Barker Street, Randwick, Sydney, NSW, 2031, Australia. Email: [email protected]
Copyright © 2013 John Wiley & Sons, Ltd.
24: 1–4 (2014) DOI: 10.1002/cbm
Fear of the (almost) unknown
MATTHEW LARGE1,2, ANDREI GOLENKOV3 AND OLAV NIELSSEN2,4 1 Prince of Wales Hospital, Sydney, Australia; 2University of New South Wales, Sydney, Australia; 3Psychiatry and Medical Psychology, Chuvash State University, Cheboksary, Russia; 4Clinical Research Unit for Anxiety and Depression, St Vincent’s Hospital, Sydney, Australia ‘The psychiatrist is the friend of the patient but the servant of society’ (Russian aphorism of uncertain origin) In this issue of the journal, Sturup and Lindqvist help fill the void of data on the factors associated with serious recidivism, with their report on violent recidivism in a cohort of 174 people convicted of homicide in Sweden during the decade 1971–1980 (Sturup and Lindqvist, 2014). Twenty-two (13%) of these offenders had a psychotic illness and five (3%) had committed a previous homicide. One hundred and fifty-three were followed after the index homicide for an average of over 21 years, during which time 15 committed further serious offences, including five homicides. Only one of the recidivist homicide offenders had a diagnosed psychotic illness; the remaining nine members of the cohort who had committed earlier or later homicides had been diagnosed with personality disorder. However, five of the 15 serious recidivists suffered from psychosis, which was the only clinical factor that was significantly associated with repeat offending. In a previous issue of the journal we reported a 30-year retrospective study of homicide offenders with schizophrenia from the Chuvash Republic of the Russian Federation between 1981 and 2010 (Golenkov et al., 2013). We found that 16 (11%) of the 149 homicide offenders with schizophrenia had committed a previous homicide. We found some possible risk factors – living in a rural area and dissocial personality traits – but a limitation of the study was that we were not able to examine whether homicide offenders with schizophrenia were more likely to commit a second homicide than other homicide offenders. It is widely believed that schizophrenia is a risk factor for homicide recidivism. Although this may well be true, the assumption is largely on the basis of the findings of a single study from Finland with a small number of cases. The Finnish study found that four of the 93 (4%) homicide offenders with a diagnosis of
Copyright © 2013 John Wiley & Sons, Ltd.
24: 1–4 (2014) DOI: 10.1002/cbm
2
LARGE et al.
schizophrenia had committed a previous homicide, compared with the 32 of the 1491 (2%) other homicide offenders (Eronen et al., 1996a; Eronen et al., 1996b). The authors of this study concluded that schizophrenia was a risk factor for homicide recidivism, despite the small number of cases on which this conclusion was based. In fact, other studies of offenders with psychosis report very low levels of homicide recidivism. In New South Wales, Australia, only one of the 134 homicide offenders with psychosis committed a second homicide in a 17-year period (Nielssen et al., 2007; Nielssen et al., 2011a, 2011b). The authors of population-based studies of homicide in New Zealand conducted over 30 years (Simpson et al., 2004) and Austria over 25 years (Schanda et al., 2004) reported no recidivists with psychosis. None of the other authors of studies included in a systematic review of homicide in schizophrenia (Large et al., 2009) who we could contact by email knew of any recidivist offenders among those included in their studies. Hence, the total number of homicide recidivists with schizophrenia in population-based studies might be as low as 22, 16 from Chuvashia, four from Finland and one each from Sweden and Australia. Most jurisdictions have systems to determine when homicide offenders who are found not guilty by reason of insanity can be released to the community (Pasewark et al., 1979; Lamb et al., 1988; Griffin et al., 1991; Parker 2004; Nielssen et al., 2011a, 2011b). These systems have the task of balancing the rights of the general public for protection with the needs of the people who committed their offences during an episode of mental illness from which they have recovered. The main consideration in any release decision must be whether the offender will commit another offence, especially a second homicide. Any release decision, however, involves a degree of uncertainty and an often unstated conclusion that the risk of recidivism is acceptable, rather than non-existent. That uncertainly is partly a result of the very limited data on both the probability of a future homicide and the characteristics of individuals who are more likely to commit a further homicide offence. Uncertainty, though, creates cognitive biases that affect our judgments of the risks associated with the release of mentally ill offenders. The cognitive biases associated with rare but catastrophic events were described by the authors of the 17th century best seller, Logic and the Art of Thinking (Arnauld and Nicole, 1662, reissued in English in 1964). In the chapter ‘belief in future contingent events’, the authors use the example of fear of lightning strikes to warn that Fear of an evil ought to be proportionate not only to the magnitude of the evil but also to the probability of occurrence (Arnauld and Nicole, 1662).
There is a similar tendency to over-value rare but beneficial outcomes, such as subscribing to lotteries, in what is known in horse racing as the ‘long-shot bias’.
Copyright © 2013 John Wiley & Sons, Ltd.
24: 1–4 (2014) DOI: 10.1002/cbm
Recidivist homicide
The tendency to overvalue the benefits and losses associated with rare events is best described in the Nobel Prize winning work known as ‘prospect theory’ (Kahneman and Tversky, 1979). The irrational fear of very rare events is also apparent in the fear of homicide of strangers. The enquiry that followed a single homicide of a stranger by Christopher Clunis in the UK and the homicide of the popular sports commentator Brian Smith by a psychiatric patient in Ontario, both resulted in significant changes to psychiatric practice. Homicides of strangers by people with schizophrenia are, however, perhaps the least predictable of adverse events in mental health care, as they occur at a rate of about one in 14 million of the general population per annum, and two-thirds are committed by people who are unknown to mental health services at the time of the homicide (Nielssen et al., 2011a, 2011b). Research that provides better estimates of the rates and factors associated with these rare and catastrophic events could reduce the cognitive bias arising from the over-estimation of their probability. Researching rare events is difficult because of the small number of cases, even in large jurisdictions. Prospective studies of homicide recidivism have to be conducted over decades because of the long periods of detention and the observation that second homicides can occur many years after the release of the first offence. Moreover, any findings might become less relevant over time because of the changes in release policies and in the sociological conditions in the community that determine overall homicide rates, rates of homicide by the mentally ill and presumably the rates of homicide recidivism (Large et al., 2009). The only way of conducting a prospective study with a large enough sample of cases would be an international multicentre study, including countries with large populations. Although we can be reassured by the low rate of serious recidivism in countries with low rates of homicide and comprehensive mental health services, decisions about the release of individual mentally ill offenders are based on ethical and political considerations as much as scientific data. With this in mind, we have to ask ourselves, how do we balance the harms of prolonged secure detention to the patient and the overcrowding of forensic hospitals, against the risk posed by the release of mentally ill offenders? And how long should we detain recovered forensic patients who committed their offences during the acute phase of mental illness, in order to prevent the rare outcome of a second homicide?
References Arnauld A, Nicole P (1662) The art of thinking: Port-royal logic. Translated by J Dickoff & P James. New York: Bobbs-Merrill, 1964: 354–357. Eronen M, Hakola P, Tiihonen J (1996a) Factors associated with homicide recidivism in a 13-year sample of homicide offenders in Finland. Psychiatric Services 47: 403–406. Eronen M, Tiihonen J, Hakola P (1996b) Schizophrenia and homicidal behavior. Schizophrenia Bulletin 22: 83–89.
Copyright © 2013 John Wiley & Sons, Ltd.
24: 1–4 (2014) DOI: 10.1002/cbm
3
4
LARGE et al.
Golenkov A, Large MM, Nielssen O (2013) A 30-year study of homicide recidivism and schizophrenia. Criminal Behavior and Mental Health Aug 5. DOI: 10.1002/cbm.1876. [Epub ahead of print] Griffin PA, Steadman HJ, Heilbrun K (1991) Designing conditional release systems for insanity acquittees. Journal of Mental Health Administration 18: 231–241. Kahneman D, Tversky A (1979) Prospect theory: An analysis of decision under risk. Econometrica 47: 263–291. Lamb HR, Weinberger LE, Gross BH (1988) Court-mandated community outpatient treatment for persons found not guilty by reason of insanity: A five-year follow-up. The American Journal of Psychiatry 145: 450–456. Large M, Smith G, Nielssen O (2009) The relationship between the rate of homicide by those with schizophrenia and the overall homicide rate: A systematic review and meta-analysis. Schizophrenia Research 112: 123–129. Nielssen O, Bourget D, Laajasalo T, Liem M, Labelle A, Hakkanen-Nyholm H, Koenraadt F, Large MM (2011a) Homicide of strangers by people with a psychotic illness. Schizophrenia Bulletin 37: 572–579. Nielssen OB, Westmore BD, Large MM, Hayes RA (2007) Homicide during psychotic illness in New South Wales between 1993 and 2002. The Medical Journal of Australia 186: 301–304. Nielssen OB, Yee NL, Millard MM, Large MM (2011b) Comparison of first-episode and previously treated persons with psychosis found NGMI for a violent offense. Psychiatric Services 62: 759–764. Parker GF (2004) Outcomes of assertive community treatment in an NGRI conditional release program. The Journal of the American Academy of Psychiatry and the Law 32: 291–303. Pasewark RA, Pantle ML, Steadman HJ (1979) Characteristics and disposition of persons found not guilty by reason of insanity in New York State, 1971–1976. The American Journal of Psychiatry 136: 655–660. Schanda H, Knecht G, Schreinzer D, Stompe T, Ortwein-Swoboda G, Waldhoer T (2004) Homicide and major mental disorders: A 25-year study. Acta Psychiatrica Scandinavica 110: 98–107. Simpson AI, McKenna B, Moskowitz A, Skipworth J, Barry-Walsh J (2004) Homicide and mental illness in New Zealand, 1970–2000. The British Journal of Psychiatry 185: 394–398. Sturup J, Lindqvist P (2014) Homicide offenders 32 years later - A swedish population based study on recidivism. Criminal Behavior and Mental Health.
Address correspondence to: Dr Matthew Large, The Kiloh Centre, Prince of Wales Hospital, Barker Street, Randwick, Sydney, NSW, 2031, Australia. Email: [email protected]
Copyright © 2013 John Wiley & Sons, Ltd.
24: 1–4 (2014) DOI: 10.1002/cbm
