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Flash, the emperor and policies without evidence: counter-terrorism measures destined for failure and societally divisive

  • Kamaldeep Bhui (a1)

Governments around the world are uniting in trying to defeat terrorist movements. In this context, recent counter terrorism laws in the UK place public duties on all citizens to help prevent terrorism. Yet, the science of predicting rare events such as terrorist offending yields consistently poor results. There are ethical, clinical and scientific dilemmas facing the professions if we are to investigate social, religious and political belief systems in routine assessment in order to inform judgements about terrorist offending risk. A balanced and evidence-based approach is necessary.

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This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Correspondence to Kamaldeep Bhui (
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Declaration of interest

K.B. is Editor of the British Journal of Psychiatry and College Editor, but played no part in the decision to publish this paper.

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1 Home Affairs Committee. The Roots of Violent Radicalisation. House of Commons, 2012.
2 McCauley, C, Moskalenko, M. Friction: How Radicalization Happens to Them and Us. Oxford University Press, 2011.
3 Arena, MP, Arrigo, BA. Social psychology, terrorism, and identity: a preliminary re-examination of theory, culture, self, and society. Behav Sci Law 2005; 23: 485506.
4 Crone, MHM. Homegrown terrorism in the West, 1989–2008. Terr Polit Violence 2010; 23: 15.
5 Neuman, PRB. Recruitment and Mobilisation for Islamist Militant Movements in Europe. European Commission, 2008.
6 Aggarwal, NK. Mental Health in the War on Terror: Culture, Science, and Statecraft. Columbia University Press, 2015.
7 Dein, S, Cook, CCH, Powell, A, Eagger, S. Religion, spirituality and mental health. Psychiatrist 2010; 34: 63–4.
8 Bartocci, G. Cultural psychiatry and the study of the bio-psycho-cultural roots of the supernatural: clinical application. World Cult Psychiatry Res Rev 2014; June: 9.
9 Bhui, K. Radicalisation: a political or public health problem? Political Insight; 12 March 2015. Available at (accessed 14 January 2016).
10 Alfaro-Gonzales, L, Barthelmes, RJ, Bartol, C, Boyden, M, Calderwood, T, Doyle, D, et al. Report: Lone Wolf Terrorism. Georgetown University, 2015.
11 Summerfield, D. Mandating doctors to attend counter-terrorism workshops is medically unethical. BJPsych Bull 2016; 40: doi: 10.1192/pb.bp.115.053173.
12 Bhui, K, Everitt, B, Jones, E. Might depression, psychosocial adversity, and limited social assets explain vulnerability to and resistance against violent radicalisation? PloS One 2014; 9: e105918.
13 Bhui, K, Warfa, N, Jones, E. Is violent radicalisation associated with poverty, migration, poor self-reported health and common mental disorders? PloS One 2014; 9: e90718.
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Flash, the emperor and policies without evidence: counter-terrorism measures destined for failure and societally divisive

  • Kamaldeep Bhui (a1)
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21st century truism

David V. James, consultant forensic psychiatrist, Theseus LLP, London, UK
Jonathan M. Hurlow, consultant forensic psychiatrist, Birmingham & Solihull Mental Health NHS Foundation Trust
04 August 2016

Phillip McGarry previously highlighted benefits of maintaining medical impartiality in an era of political dissent (1), but this strive for neutrality seems vulnerable to coming unstuck when it comes to analysis of putative relationships between mental illness and terrorism. In his response to the piece by Hurlow et al (2) he sets up and then demolishes a straw man.

Of course, he is entirely correct that those who are members of terrorists groups are generally psychologically stable. This is a consistent finding in the literature. After all, as observed by Lord Alderdice in his analysis of the 30-year campaign of terrorism in Northen Ireland, 'individuals with psychosis....are excluded by terrorist organizations since they create a high risk' and those with 'personality disorder...often become impossible for their organizations to handle' (3). But the same is not the case with lone actors, where a high prevalence of mental illness is found. And, within the UK, this has been the finding of those whose research background is the civil strife in Northern Ireland, to which McGarry wishes us to turn our attention (4).

One might question whether any lone actor can truly be called a terrorist, as most exhibit a mixture of mental disorder and social grievance, wrapped in a political flag. Indeed, the overlap between so-called lone actor terrorists, lone actor school/university killers, lone actor workplace shootings, lone actor assassins and lone actor spree killings is sufficiently large to suggest that they all be considered as parts of one phenomenon, that of grievance-fuelled violence.

The role of mental illness in lone actor political assassinations, a companion phenomenon to that of lone actor terrorism, has been understood for centuries, if not millennia (5). And it has also been subject to systematic study since the 19th century with the work of Laschi and Lombroso (6) and, in particular, the eighty case study by Régis (7). In this second decade of this millennium it is beginning to seem reasonable to ask if the trend of repeating the truism that most mentally ill people are not violent is tipping the balance towards a culture within psychiatry that does not assist in the task of preventing violence from occurring where we can, both for the sake of the patient and their potential victims.

1) McGarry, P. (2015) The fortunes of the legal and medical professions during the “Troubles” - Presentation to The Northern Ireland Medicolegal Society - October 14 2014
 Ulster Medical Journal, 84(2):119-123.

2) Hurlow J, Wilson S, James D.  Protesting loudly about Prevent is popular but is it informed and sensible? BJ Psych Bull 2016; 40: 162–3

3) Alderdice J., The individual, the group and the psychology of terrorism. International Review of Psychiatry, 19 (3): 20-209

4) Gill P. Lone-Actor Terrorists: A Behavioural Analysis. Routledge, 2015.

5) James, D.V. (2015) Another Helping of “Intellectual Hash”: Commentary on “Assassins of Rulers” (MacDonald, 1912). Journal of Threat Assessment and Management, 1, 228– 240.

6) Laschi, M., & Lombroso, C. (1886). Le délit politique. In: Actes du Premier Congrès International d’Anthropologie Criminelle, Rome 1885 (pp. 379–389). Turin, Florence & Rome, Italy: Bocca Frères

7) Régis, E. (1890). Les régicides dans l’histoire et dans le présent. Paris, France: Maloine.
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Conflict of interest: None Declared

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Terrorism: it’s not mental illness - it’s politics

Philip J McGarry, Consultant Psychiatrist, Belfast Health and Social Care Trust, Belfast, UK
04 July 2016

Hurlow et al (1) appear to argue that psychiatrists have a major role in preventing terrorism. This might lead one to think that there has been a massive wave of attacks by people who are  mentally ill. In fact, Britain is fortunate to have had only one terrorism-related murder since 2005!

By contrast, Northern Ireland saw almost 1000 terrorist killings by unionists/loyalists and 2000 by nationalists/republicans – Dr Hurlow's home city Birmingham had 21 people killed in the 1974 IRA bombings. The contribution of mental illness to the 3000 killings was, in essence, totally negligible. Indeed Lyons et al (2) noted that terrorists were mentally healthier than ' ordinary' killers. This has face validity: it is doubtful that a person or persons with psychosis could plan and execute the sort of sophisticated attacks we have witnessed in Birmingham, Brighton, Enniskillen, Madrid and London. Did police contact psychiatric services in the wake of the Paris attacks in November 2015? Of course not! Terrorism is, by definition, politically motivated.

Politicians, the media and others all too often respond to terrorism by lazily and superficially claiming it to be ‘psychotic’, ‘crazy’, ‘insane’, ‘psychopathic’ or (most mindlessly of all)  ‘mindless’. Islamic State are disgustingly murderous, but Abu Bakr al Bhagdadi and his activists are not driven by mental illness. It is very worrisome if psychiatrists contribute to this unscientific discourse.

There will always be a tiny number of mentally disturbed people who respond to the current zeitgeist and act out violent fantasies. Psychiatrists must always take account of the risk to other people from such individuals and act appropriately. However, to extrapolate from this a new obligation to routinely monitor our patients and work in close contact with anti-terrorism policing is both stigmatising to people with a mental illness, and damaging to our independence and professional reputation. Crucially, it is also useless in preventing serious terrorism. If colleagues are in any doubt about this I would suggest that they speak to the real experts in terrorism: senior police officers in Northern Ireland. 


1 Hurlow J, Wilson S, James D.  Protesting loudly about Prevent is popular but is it informed and sensible? BJ Psych Bull 2016; 40: 162–3

2 Lyons H, Harbinson H. A comparison of political and non-political murderers in Northern Ireland, 1974-1984. Med Sci Law 1986; 26: 193–7

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Protesting loudly about Prevent is popular but is it informed and sensible?

Jonathan Hurlow, Consultant Forensic Psychiatrist, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
Simon Wilson, Consultant and Honorary Senior Lecturer in Forensic Psychiatry, Barnet, Enfield and Haringey Mental Health NHS Trust and UCL Department of Security and Crime Science, London, UK
David V James, Consultant Forensic Psychiatrist, Theseus LLP, London, UK.
17 March 2016

BJPsych Bulletin has recently published several articles that were critical of the Prevent limb of the government’s current counter-terrorism strategy, including a polemical article by Summerfield (1) and a more thoughtful piece by Bhui (2). Criticisms of the strategy are not confined to the professions; the Home Affairs Select Committee enjoyed media attention recently by staging a similar critique, with a special session held in Bradford (3). However, objections to Prevent have included knee-jerk criticisms that have not stood up to closer scrutiny. When the BBC published an article suggesting that a child was referred for misspelling ‘terraced’ house, the Lancashire Constabulary’s Police and Crime Commissioner, Clive Grunshaw, revealed that ‘the police visit took place because of other worrying issues in the boy’s school work, not just the ‘terrorist house’ line’ (4). The Independent Terrorism Legislation Reviewer, David Anderson QC, has recommended that the strategy ‘should be the subject of review by an independent panel’, but he also advised that such a review should be open to the possibility ‘that the problems have been exaggerated or misrepresented (as may have been the case in the “terrorist house” incident), either inadvertently or in pursuance of a political agenda (5).’

Within the articles by Bhui and Summerfield (1,2) were emotive suggestions that Prevent required mental health professionals to carry ‘a high index of suspicion’ of terrorism that some might interpret ‘with zeal’ (2). There was a call for ‘doing away with policies without evidence’ (2), the most extreme suggestions being that the ideas underlying Prevent are ‘of a piece with the era of McCarthyism in the USA of the 1950s’ and that they are so harmful that attending Prevent training would be unethical (1). A more measured and balanced approach is needed.

The most substantive of these authors’ ethical concerns relates to the contention that making disclosures to third parties - in this instance, Channel (6) - would be to breach the confidentiality inherent in the fiduciary doctor-patient relationship. However, there is no absolute duty of medical confidentiality and there are already circumstances in which it can ethically be breached, including ‘when a disclosure would be likely to assist in the prevention, detection or prosecution of serious crime’ (7). The Prevent duty brings with it no legal change to our existing duties as doctors and it seems no different to the responsibility we might have in any other case where we believed a patient might be at risk of becoming involved in serious crime.

We too would object to a requirement that we monitor and report all unacceptable thoughts, but of course this is not what we are being asked to do. We are being asked to be more informed and better educated about a particular sort of criminal activity and to consider breaching confidentiality when appropriate, just as we would do in any other case where we believed this was necessary to prevent serious crime.

There is nothing within the Prevent strategy that would interfere with clinical judgement. Perhaps the greater risk is from those who boycott Prevent training and then find themselves making rash decisions, after failing to make use of opportunities to rehearse some of the dilemmas that this strategy could create. Indeed, we would suggest that such cases would be very similar to others where one becomes concerned about risks to others in a patient and which would normally be managed by thoughtful discussion within the clinical team and with one’s peers, before one made a clinical decision that might include making a disclosure to a third party.

Running throughout the articles in the Bulletin were concerns that British Muslims risk alienation through the Prevent process, and that psychiatrists are currently ill-equipped ‘to separate beliefs that are benignly religious from those that include political motivations and incite violence, but are disguised through religious rhetoric’ (2). There was also the erroneous contention that severe mental illness is of little importance overall in the area of terrorism. Islamophobic hate crime and misrepresentation of Muslims as terrorists deserve censure and, in some cases, criminal sanctions. But the problems in understanding what Prevent is about – evident here – may lie not with the Prevent strategy itself but the ‘radicalisation’ model. This is itself more hypothesis than empiricism and has been criticised within the terrorism studies literature (8). Our reading of the literature is that such models are probably unhelpful in the psychiatric context and that a case-by-case analysis is preferable.

If a model is required, then a better one is that of grievance-fuelled targeted violence, a category that includes lone-actor terrorists, public figure assassins, school shooters and workplace attackers, groups which share important characteristics and risk factors (9-11). It is with such lone actors that psychiatrists are most likely to have contact, reflecting the evidence that, here, severe mental illness is of central importance. Other psychiatrists, in common with us, will have encountered cases where counter-terrorism police have been monitoring people whose ‘radicalisation’ proved to signal the onset of a psychotic illness, with delusional beliefs involving religiose and paranoid themes drawn – as is typical – from the surrounding cultural milieu.

Psychiatrists should be concerned with the well-being of the mentally ill, rather than the dictates of political correctness. Recent research has shown that 43% of so-called lone-actor terrorists have a history of mental illness – no doubt an underestimate given the limited access that the researchers had to any form of medical record (12). Psychiatrists deal with the mentally ill; they do not concern themselves with the mentally well. Cases where vulnerable patients are drawn towards violence or cloak their paranoid and delusional grievances in the flag of a terrorist cause are ones where multiagency working, including through the Prevent strategy, is to the benefit of all.

Whether we like it or not, the role of the psychiatrist involves the protection of society from violence resulting from mental illness, as well as preventing the mentally ill from ruining their lives by becoming involved in serious criminal acts. A reticence to do so where Islam is concerned is illogical and indefensible. It also seems to betray an ignorance of the fact that studies of terrorism have consistently found that a greater number of lone-actor incidents in Europe and the USA are perpetrated by right wing extremists or white supremacists (13,14) and that it is lone actors embracing far right ideologies that pose a greater threat in Europe than Islamist ones, causing 48% of fatalities (15). It is unclear to us whether opponents of the Prevent strategy in healthcare would have similar qualms about using Prevent mechanisms with, for instance, a future potential Breivik. We can all deplore, with Summerfield (1), the way that poor – and possibly illegal – British and US foreign policy decisions in Afghanistan and Iraq have had unintended consequences; but we cannot put the clock back. We may not like the way societal changes impinge on our professional duties, but this does not mean we are entitled to turn our back on them.


1. Summerfield D. Mandating doctors to attend counter-terrorism workshops is medically unethical. BJPsych Bull 2016. Published online ahead of print 11 February 2016.

2. Bhui, K. Flash, the emperor and policies without evidence: counter-terrorism measures destined for failure and societally divisive. Published online ahead of print 11 February 2016.

3. BBC News UK. Extremism discussion event held in Bradford by committee. 2016; 28 Jan ( (accessed 8 March 2016)

4. Gani A, Slawson N.  Lancashire police criticise BBC over 'terrorist house' story. Guardian 2016; 21 Jan ( (accessed 8 March 2016)

5. Anderson D. Supplementary written evidence submitted by David Anderson Q.C. (Independent Reviewer of Terrorism Legislation) to Home Affairs Committee Countering Extremism Inquiry. 2016; 29 Jan ( ) (accessed 8 March 2016)

6. HM Government. Revised Prevent Duty Guidance: for England and Wales. Crown Copyright, London. 2015; 16 Jul ( ) (Accessed 8 March 2016)

7. General Medical Council. Confidentiality. GMC, 2009 (

8. Borum, R. Informing Lone-Offender Investigations. Criminology & Public Policy 2013; 12: 103–112.

9. Capellan, J.A. Lone Wolf Terrorist or Deranged Shooter? A Study of Ideological Active Shooter Events in the United States, 1970-2014. Studies in Conflict & Terrorism 2015; 38: 395–413.

10. Gruenewald J, Chermak S, Freilich JD.  Distinguishing “Loner” Attacks from Other Domestic Extremist Violence: A Comparison of Far-Right Homicide Incident and Offender Characteristics. Criminology & Public Policy 2013; 12: 65–91.

11. McCauley C, Moskalenko S, Van Son B. Characteristics of Lone-Wolf Violent Offenders: a Comparison of Assassins and School Attackers. Perspectives on Terrorism 2013; 7: 4–24.

12. Corner E, Gill P. A False Dichotomy? Mental Illness and Lone-Actor Terrorism. Law and Human Behavior 2015. 39: 23–34.

13. Spaaij R. Understanding lone wolf terrorism: global patterns, motivations and prevention. Dordrecht: Springer, 2012.

14. Gill P. Lone-actor terrorists: a behavioural analysis. Routledge, 2015.

15. Ellis C, Pantucci R, van Zuijdewijn J, Bakker E, Gomis B, Palombi S, Smith M. Lone Actor Terrorism: Analysis Paper. Countering Lone-Actor Terrorism Series No. 4. Royal United Services Institute, 2016. 

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