Reports reveal an increase in the number of individuals with serious mental illness in jails, prisons and forensic hospitals. Despite the wide-ranging and devastating consequences of this 'criminalization' of mental illness, there remains a lack of information on the subject as well as on the provision of care for these patients. This important new book fills a gap in the literature by examining topics such as: the history and policy factors related to criminalization; original research on forensic populations; pharmacological and psychological treatment strategies; and principles and guidelines for diversion out of the criminal justice system. Contributions from leading experts in the field further our understanding of this important subject, offering advice on how to provide humane care for patients. A must have for all mental health clinicians including psychiatrists, psychologists, social workers, rehabilitation therapists, and mental health nurses. A useful tool for mental health administrators and policy makers.
Chapter 33 Fixated Threat Assessment Centres: Preventing Harm and Facilitating Care in Public Figure Threat Cases and Those Thought to Be at Risk of Lone-Actor Grievance-Fuelled Violence
Justin Barry-Walsh , David V. James , and Paul E. Mullen
Developments in threat assessment, particularly in the area of concerning communications and approaches to public figures, have led to the setting-up in a number of countries of a new style of service for assessing and managing risk to the prominent from the actions of lone individuals. Known as fixated threat assessment centres (FTACs), their central characteristic is that they are jointly staffed by police officers and by psychiatric staff from health services. They are based on the realization that the interests of the prominent in terms of protection overlap with those of the people harassing them in terms of medical care. Research over the last decade has re-established that the majority of those threatening, harassing, or attacking public figures have unmet mental health needs, and that attention to these is often the most effective way of reducing risk, whilst at the same time improving their lot and focusing on treatment, rather than criminalization. The approach has recently been expanded to encompass assessment and intervention in individuals suspected of being radicalized into extreme ideologies and at risk of proceeding to commit terrorist acts.
The presence of psychiatrists in FTACs allows the understanding of motive and mental state which is essential to accurate risk assessment. It also allows health-based interventions to lower or manage risk. The psychiatric involvement here has little to do with the application in courts of the Victorian psychiatric defence of insanity, a legal rather than a medical concept. Nor is it to do with issues of responsibility for an individual’s actions which are prominent in some jurisdictions and completely absent in others. Rather, it deals with the reality that mental illness affects people’s judgment and behavior, not simply through prominent symptomatology, but through the disinhibition associated with illness, the loss of judgment which comes with social isolation and the absence of a restraining peer group, and the disconnection with social values that often accompanies social decline. Effective interventions will involve compulsory psychiatric treatment in some cases, but in others simple interventions such as connecting the individual with treating services. Networking with statutory agencies such as social work or housing may be highly effective, as may family contact. It is important to note at the outset that the focus of these interventions is prevention of harm. The exercise is not solely concerned with violence, but also with other forms of risk. Concerning communications and approaches may give rise to psychological distress, to fear as to what might happen next, to public embarrassment, to disruption of the ability to perform a public role, and to the use of expensive police resources, some of which prove unnecessary when comprehensive risk assessment is applied.
A key concept in this field is that of fixation. Fixation has been described by Mullen et al. as “an intense preoccupation with an individual, activity, or idea,” “an obsessive preoccupation…pursued to an abnormally intense degree.”1 In the public figure context, fixation may be the result of grievances, real or otherwise, of idiosyncratic quests for “justice,” of perceived rejection, bizarre amorous attachments or misguided quests for help. Fixation may arise out of mental illness, although this is not always the case. People who engage in stalking behavior and those who become vexatious litigants or querulants commonly are fixated. A striking feature of pathological fixation is the level of psychosocial harm done to the fixated individual as well as the potential for harm both to those closest to the individual and to those who are the object of their fixation. The work of FTACs and similar units in consequence limits harm, not only to prominent people, but to the families and communities from which the fixated individuals come.
In 2003, the British government funded a research project designed to increase the efficiency and effectiveness of the royal and parliamentary protection services.2 The aim was to improve their ability to evaluate and manage the threat presented by stalkers, threateners, and those who attempted to force their way into the presence of royalty or members of parliament, whether it be with ill or benign intent. For efficiency, read decrease the escalating costs, both of monitoring increasing numbers of potentially problematic people and of providing close protection to an ever-wider circle of royalty and parliamentarians. For effectiveness, read improve methods of recognizing and managing those at high risk of acting to disrupt, or even endanger, the lives of protectees. To give some idea of the magnitude of the problem, the Queen alone, at that time, was the target of the activities of over 2,000 active, problematic individuals.
The commissioning of the research reflected the realization that, in terms of threat towards public figures, although the motivation and modus operandi of terrorist and criminal groups was understood and well-established systems were in place to assess and manage them, there was little understanding of risks posed by disturbed members of the general public who exhibited a pattern of harassment and stalking towards public figures and made repeated attempts to communicate with them or enter their presence. Such individuals did not fit into standard policing methods for assessing and managing threat. Whilst it was recognized terrorist organizations tended to engage in random attacks on mass population targets rather than prominent individuals, isolated loners remained an unknown quantity.
At the outset of the research phase, those of us involved in what was termed the Fixated Research Group believed we would face the classic problem of identifying and prioritizing multiple factors correlated with moving from stalking and threatening to acting in a manner which placed the principals at risk. In the end, we hoped to generate some kind of predictive algorithm. The researchers were given extraordinary access to the records of the police, protection services, and mental health services. In addition, vast quantities of material generated by the stalkers and threateners were made available. Our initial assumptions about multiple factors and the need for complex algorithms proved mistaken.
As the data accumulated, it became increasingly clear that one factor above all determined both the continuing persistence and intensity of the problem behaviors themselves and the probability of progression to actions which were even more disruptive and on occasion violent. That factor was the presence of untreated mental illness. Most of the persistent stalkers and threateners had serious mental disorders, and virtually all of those attempting to break through the barriers protecting the principals, or making attempted or actual attacks, were psychotic at the time.3 Severe mental illness was the key both to understanding an individual’s motivation and to assessing different forms of risk – the probability of persistence, intensity, and progression to violence. Of course, this is not the same as saying that one has to be mad to target a public figure or that psychotic illness, which is relatively common, could be used as a marker for potential attack. Rather, it affords an avenue for better understanding and assessment of public figure threat cases, as well as opening possibilities for prevention. The treatment of mental illness was revealed as the management method most likely to reduce risk. A predominately criminal justice and security problem became a predominately mental health problem.
The findings of the Fixated Research Group, published in a series of 13 papers in peer-reviewed journals, led to the establishment of the Fixated Threat Assessment Centre (FTAC) in the United Kingdom in 2006 – a model subsequently adopted elsewhere. The unit is located within the Specialist Operations section of the Metropolitan Police, based in London but with a national remit. Its key feature is that it is staffed both by medical personnel from the National Health Service and by police officers, being jointly funded by the Office of Security and Counter-Terrorism at the Home Office and by the Department of Health.
The aims of the approach are twofold: to improve the outcomes for the individuals referred and at the same time to reduce the risk they may pose to the individual they are focused on, or indeed others close to them. The service does not attempt the futile task of attempting to predict who might go on to act in dangerous ways. Rather, it has adopted a population model. It is possible, through looking at the associations of progressing to commit destructive behaviors, to tell which individuals lie in the minority of cases from which problems are likely to come. By intervening in all such cases, it is possible to prevent individuals going on to engage in dangerous actions without knowing which particular individuals would, without intervention, have gone on to do so. An analogy is attention to risk factors in cardiac disease: by identifying those with high cholesterol, obesity, smoking, and so on, it is possible to intervene in a population to reduce the risk of adverse outcomes without knowing exactly which cases, without intervention, would have gone on to suffer them.
A pilot scheme established for 18 months demonstrated the effectiveness of the approach,4 and led to the unit becoming permanent. The presence of psychiatrists allowed the diagnosis of mental illness and an analysis of its influence on motivation, risk and potential management options. UK FTAC considered referrals of those who made inappropriate approaches or communications to the royal family, senior politicians, and “iconic sites.” These referrals led to a process of information gathering by police and mental health professionals and an assessment of the problems each individual might produce. A level of concern was used in describing these,5 not a level of risk, given that concern levels involve decisions made on limited information in real-time operational situations, as opposed to risk assessment which involves considering large amounts of information at relative leisure. Ways of mitigating or removing concerns were then considered, and a management plan established.6 This generally involved catalyzing action from statutory services around the country, including police, health services, social services, and even housing. Where mental illness was evident, there was usually liaison with the psychiatric services responsible for the individual’s domicile. The role of FTAC was not direct involvement in treatment; rather the emphasis was on the appropriate sharing of information, and the communication of this information in a targeted way to relevant agencies in the part of the country in which the individual lived, with the aim of initiating interventions from other services locally, sometimes on a multiagency basis. In many cases, FTAC arranges a networked community response, which will involve both the monitoring of cases and practical interventions, with the provision of a support worker. Such practical interventions can be remarkably effective. This reflects the fact that the importance of mental illness to assessing and managing risk concerns not only psychotic symptomatology, but also difficulties in the correct interpretation of events, poor judgment, disinhibition, and social isolation which removes the moderating influence of personal relationships and peer groups.
The range of possible interventions also means that the model can be used in jurisdictions with very different health care arrangements and mental health laws. The UK has advantages in terms of ease of compulsory hospitalization, given the low legal threshold and the existence of the National Health Service. The UK also differs in that responsibility in the mentally ill is only relevant in homicide cases, and hospitalization is routinely used as a final disposal in sentencing at court, with the criteria being the person’s health, rather than meeting any insanity criteria. Yet, the model has proved equally useful in countries with quite different systems and in jurisdictions such as Australian states which have a system not dissimilar to the competency/insanity limitations in the USA.
The efficacy of UK FTAC’s operations was demonstrated in part by the proportion of referrals in which mental illness was identified. In a study of 100 individuals assessed as being of high or moderate concern by FTAC, 86% were found to be suffering from psychotic illness. Compulsory admission was the outcome in 53% of cases and voluntary admission in 4%, whilst 26.5% were taken on for management by community mental health teams or assertive outreach services.4 With intervention, 80% of cases had been managed down to a low level of concern by the end of the study period. A more sophisticated assessment of FTAC outcomes used a mirrored design in which individuals were in effect their own controls.7 The study looked at one- and two-year periods before and after FTAC intervention. It identified highly significant reductions both in the number of individuals engaging in communications and problematic approaches and in the total numbers of incidents of concern.7 It also saw a reduction in police call-outs, raising the possibility that the exercise might prove cost-neutral.
The establishment of the UK FTAC, and the research upon which it was based, can be considered something of a watershed moment in that it brought a focus on mental illness back into threat assessment practice, and it illustrated the overlap between public figure threat assessment and the field of stalking, so enabling insights in terms of motivation, classification, and formalized means of assessing threat to be brought across from stalking research.8 Threat assessment and management as a construct and a paradigm had seen a resurgence in interest from the 1980s onwards after a century of neglect.9 This included the development of a threat assessment service in 1986 for Congress in the United States,10 (which over time increasingly came to resemble the approach taken in the UK FTAC) and the establishment of the LAPD threat management unit in 1990 following the killing of Rebecca Schaeffer by an obsessive fan Robert Bardo in 199011,12 and the subsequent introduction of antistalking legislation in California. However, research in the US into harassment, threats, and violence towards public figures had either failed to report findings about mental illness or had failed to interpret them. Dietz and Martell considered threatening and otherwise inappropriate communications to Congress in a lengthy report to the Department of Justice in 1989,13,14 but did not include their mental illness findings in their subsequent published account.11 The Exceptional Case Study Project in 1997 conducted for the United States Secret Service further expanded the knowledge base in the United States in this area,15 but there was a delay in recognizing the significance of mental illness in this population.16 Its authors looked at 83 cases, of which 45% were assassinations and 54% “near lethal approaches.” They found that 61% of the individuals concerned had a history of psychiatric problems, 43% of delusional ideas, and 10% of violent command hallucinations. Nevertheless, the conclusion of the authors was that mental illness was not of particular importance. This is despite the fact that, if one takes the figure for delusional ideas as representing the prevalence of psychosis in the sample and compares it with the point prevalence of psychosis in the general population of around 0.4%,17 the study cases were 110 times more likely to have a psychotic disorder. Suggestions as to why the mental illness factor was played down are various:18 it may be that mental illness was thought to be a politically unacceptable form of exculpation, that there was confusion between the (medically meaningless) concept of legal insanity and the presence of psychotic illness, or simply that the constellation of psychiatric services in the USA was not such that psychiatric care seemed a relevant management option. As regards the legal test of insanity in many Anglo-Saxon jurisdictions, it is relevant to note that its roots lie in criteria set out by the UK’s Law Lords in 1843, in the wake of the case of Daniel McNaughton, their specific aim being to demedicalize and recriminalize attacks on public figures by psychotic individuals.
Dietz and Martell,19 in reconsidering their 1989 findings 21 years later, contended that their omission of their mental illness findings in their published paper was for national security reasons. They then put forward the contention that: “Every instance of an attack on a public figure in the United States for which adequate information has been made publicly available has been the work of a mentally disorder person who issued one or more pre-attack signals in the form of inappropriate letters, visits or statements” (p. 344). This is along the lines of the conclusions of the Fixated Research Group’s study of attacks on European politicians20 which found that death and serious injury were significantly associated with psychosis, the presence of delusions, loner status, and the absence of a political motive. Similar results were obtained in a subsequent and partially overlapping study of violence towards German politicians21 and also in the Fixated Research Group’s study of historical attacks upon the British royal family.22 However, such conclusions are not new, and it appears characteristic of research in this field that insufficient attention is paid to publications from previous centuries or to those not in the English language. None of the recent US researchers had gone back to the ground-breaking work of Laschi23 or the 1890 “exceptional case series” by Régis24 which had described and classified public figure attacks and identified the central role of mental illness.18 The problem of fixated individuals, it is evident, is common across recent centuries and across different countries within the Western world.
Interest in the FTAC model led to the formation of the European Network of Public Figure Threat Assessment Agencies, which brought together police and security services from countries within the European Union, as well as further afield, and which functioned as a forum for discussing new developments. An FTAC was then set up in the Netherlands where a study of inappropriate communications and approaches to the Dutch royal family found that 75% were psychotic and a further 11% suffering from mood disorders.25 Surveys were also conducted of the extent of the problem of harassment and stalking for politicians. In Sweden, a study of members of parliament from the years 1998–2005 found that 74% had been subject to harassment, threats, or violence, and 68% of perpetrators were thought probably to be mentally ill.26 A survey of regional politicians in Canada found that 30% had suffered harassment, with 87% believing their harassers to be mentally ill.27
Next, a survey in the UK of members of the Westminster Parliament found that 81% of respondents were subject to at least one of the intrusive/aggressive behaviors studied.28 This survey was repeated for the Queensland (Australia) State Parliament in 2011.29 A similarly high rate (93%) of harassment was identified. The survey was also conducted in Norway30,31 and in New Zealand.32 The New Zealand survey benefited from an unusually high response rate (84%) and consistent with the other surveys found that one form of harassment or another was the norm (87% of respondents reporting such behavior) with a distinct increase in the contribution from electronic media compared with the UK (60% reported inappropriate social media contact), likely due to the later date at which the survey was conducted. The effects of such behavior are not trivial, as has been illustrated by James et al.33 with significant proportions of MPs suffering psychological ill effects. These surveys and the experience of established FTACs also highlighted that it is not the MPs alone who bear the brunt of this behavior, but also their staff, including those in often isolated and vulnerable constituency-based offices.
The Queensland survey led to the establishment of an FTAC in Queensland in 2013 operating under a similar model to the United Kingdom – one with an emphasis on joint work between police and mental health, and a high rate of mental health interventions in those referred.34 Similarly, in New Zealand, a small pilot service was established in September 2017, with a permanent service following in July 2019. In both these services, referrals are drawn from those who communicate to or intrude upon members of parliament, with a finding of high rate of mental illness amongst the communicators and threateners, again providing an opportunity for intervention and treatment in these individuals.
Within Australia, interest in this approach was accelerated by several high-profile incidents. The inquest into the Lindt cafe siege in New South Wales recommended the establishment of a fixated threat service in that state.35 The individual at the center of this siege had made abnormal communications to the Queen on several occasions, and the UK FTAC had notified Australian Federal Police of their concerns. In Victoria, the tragic events of January 2017 on Bourke Street in Melbourne where a car was used to attack pedestrians, resulting in the death of six and over 30 wounded, provided further impetus for the establishment of a service in that state. In Australia, FTACs have now been established in New South Wales (2017), Victoria (2018), and Western Australia (2018). In 2016, the Australian Federal Police (AFP) established an FTAC in the Australian capital, Canberra.36 FTAC capabilities are also evolving in smaller jurisdictions (South Australia, the Australian Capital Territory, Tasmania, and the Northern Territory).
An important finding from the new FTACs is that the cases that they deal with are virtually indistinguishable, regardless of country. This is presumably a reflection of the fact that mental disorders occur with similar frequency across different populations. A consistent finding has been the significant proportion of cases with delusional disorder, a form of psychosis which rarely presents to general mental health services, given that the personality is preserved and it does not lead to disturbance of day-to-day functions in the manner typical of the schizophrenias. Given the association of delusional disorder with querulousness and persistent litigation as well as paranoid and grandiose presentations, this finding is perhaps not surprising. The other group which appears to be consistently over-represented in FTAC samples is autism.