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 ^{Reference Summerfield1} and a more thoughtful piece by Bhui. ^{Reference Bhui2} 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’. ^{Reference Gani and Slawson4} 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’. ^{Reference Anderson5}

Bhui and Summerfield ^{Reference Summerfield1,Reference Bhui2} made emotive suggestions that Prevent required mental health professionals to carry ‘a high index of suspicion’ of terrorism that some might interpret ‘with zeal’. ^{Reference Bhui2} There was a call for ‘doing away with policies without evidence’, ^{Reference Bhui2} 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. ^{Reference Summerfield1} 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 a patient may pose to others 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’. ^{Reference Bhui2} 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 literature on terrorism studies. ^{Reference Borum8} 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. ^{Reference Capellan9–Reference McCauley, Moskalenko and Van Son11} 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 people with mental illness, 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. ^{Reference Corner and Gill12} 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 individuals with mental illness 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 ^{Reference Spaaij13,Reference Gill14} and that it is lone actors embracing far-right ideologies that pose a greater threat in Europe than Islamist ones, causing 48% of terrorism-related fatalities. ^{Reference Ellis, Pantucci, van Zuijdewijn, Bakker, Gomis and Palombi15} 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, ^{Reference Summerfield1} 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.