Lone actor grievance fuelled violence and the role of the psychiatrist

Summary

There exists a correlation between mental health conditions and people who commit serious acts of violence. While psychiatrists have a role to play in the treatment and assessment of these individuals, they cannot predict who will go on to commit acts of violence.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this position statement to articulate the RANZCP’s position on the link between mental illness, lone actor grievance fuelled violence (LAGFV) and the psychiatrist’s role in the identification and assessment of individuals who are at risk of committing LAGFV. 

Key messages

• Psychiatry plays a key role in caring for patients and their families/whānau and preventing patients from being violent to themselves and others. 
• Psychiatrists play a key role in assessing individuals to minimise any risk to the person themselves and the wider public. 
• There is a complex relationship between LAGFV and mental illness. Mental illness is one of a range of cumulative risk factors that contribute towards the likelihood of an individual committing LAGFV. More research on the relationships between these cumulative risk factors and LAGFV is required.
• Assessment tools can help identify groups that are vulnerable and in need of intervention but cannot predict which specific individuals will perpetrate LAGFV.
• Patient confidentiality should not be compromised in counterterrorism legislation unless a patient demonstrates a serious risk to public safety. A risk does not need to be assessed as imminent to be deemed a serious risk.
• Grievance is an important concept that avoids the definitional controversies of terrorism and allows for appropriate focus on individuals and the harm they cause, rather than a distracting preoccupation with ideology.

Lone actor grievance fuelled violence 

The concept of LAGFV was developed after research showed that lone-actor terrorists and mass murderers/spree killers may be better conceptualised as a single offender type rather than two separate types. Studies such as those by Paul Gill et al., which compared the profiles and behaviours of 71 lone-actor terrorists and 115 public mass murderers, found over 80% of the 180+ variables showed no significant difference between offender types.[1] While lone-actor terrorists often attribute their acts of violence to political or ideological motivations and goals, many also list personal grievances as being strong motivators for their actions.[1] Mass murderers often target those with which they have personal grievances, but also often hold ideologies that justify those beliefs and may refer to them in manifestos or other justifying statements.[1] In understanding these two groups, it is more useful to focus on the phenomena of grievance and fixation. These phenomena are often harmful to the individual harbouring them and are stronger drivers of behaviour and escalation for these groups rather than ideology or mental health conditions.[2] Treating these offenders as two distinct groups rather than one may hinder efforts by psychiatrists and authorities to identify and understand potential offenders and intervene before violence occurs.[1] 

Responsibilities for public safety

LAGFV is a public and community safety issue. All areas of society share a degree of responsibility for the prevention of violence and early identification of and intervention with at-risk individuals.[3, 4] While psychiatrists have the responsibility for specialist assessments and monitoring of those in their care or brought to their attention, law enforcement has the responsibility for decision-making around these individuals and responding appropriately when individuals present unacceptable levels of risk or commit acts of violence. The wider community has the responsibility to support and maintain connections with one another where safe to do so. Community members can play a significant role by challenging dangerous beliefs or behaviours early, preventing individuals from becoming isolated, encouraging help-seeking and bringing people of concern to the attention of police and security agencies.[4] Effective action at all levels of society ensures acts of LAFGV are extremely rare if they occur at all.

The links between LAGFV and mental health conditions

While having a diagnosed mental health condition only presents a modest increase in a person’s risk of violence, a significant proportion of perpetrators of LAGFV had a current mental health condition (including undiagnosed conditions).[5-7] These mental health conditions rarely absolve individuals of the responsibility for their actions but do help explain their behaviour. Mental health conditions can have significant impacts on a person’s judgement and behaviours and enable disinhibition.[2] However, these levels of correlation should not be taken to indicate a causal relationship. The vast majority of individuals with serious mental health conditions do not act violently and those that do so, very rarely commit violence to the level of lone-actor terrorism or mass murder.[8] There are also significant numbers of perpetrators of LAGFV who experience no mental health conditions.[9] Further research is needed to understand the relationship between mental health and LAGFV and what other factors may drive LAGFV. These individuals also experience high rates of social isolation.[1] The lack of a restraining peer group can result in a disconnection from social values, and a loss of judgement.[2] 

While the prevalence of stressors, grievances and ideologies that contribute to violence are difficult for government and health authorities to reduce, mental health conditions are a factor that governments and health authorise can effectively respond to. The significant prevalence of mental health conditions amongst perpetrators of LAGFV makes treatment of these mental health conditions a possible means of violence prevention. Assessment tools can help identify groups that are vulnerable and in need of intervention but cannot predict which specific individuals will perpetrate LAGFV.[7] However, identifying individuals in those groups which are at risk of committing acts of LAGFV and referring them for treatment is a population-level strategy that has been shown to significantly decrease rates of LAGFV where implemented.[2] Treating mental health conditions avoids criminalising individuals which can be significantly costly to governments and harmful to these individuals. This is the strategy that underpins fixated threat assessment centres currently operating in several countries including Australia and New Zealand.[2]

Patient confidentiality

In most circumstances, psychiatrists should seriously consider maintaining strict confidentiality of discussions with their patients and any carers, family and whānau where consulted. This is outlined in principle 4.1 of the RANZCP Code of Ethics (‘Psychiatrists shall instil confidence in patients that whatever information they reveal will not be used improperly or shared’).[10] However, it is recognised that at times it is in the public good to breach this confidentiality and share relevant and appropriate information when the immediate safety of others is in jeopardy with someone who can take action on it with the aim of lessening or prevent the harm from occurring. These disclosures are permitted under principle 4.4 of the RANZCP Code of Ethics (‘A breach of confidentiality may be justified where there are public-interest considerations, to protect the safety of the patient or other people).[10]

Psychiatrists should be aware that a disclosure of this kind is likely to affect the clinical relationship.[11] Psychiatrists need to consider these consequences against the possible consequences if a disclosure is not made. While reporting may be required where an individual presents an immediate and identified risk to another person or a serious risk to the public, defining terms such as ‘serious’ or ‘immediate’ is not always clear. If psychiatrists are unsure of the level of risk an individual poses, it is recommended they discuss this person with a more experienced colleague. If the psychiatrist decides not to make a report about the individual, they should ensure their reasoning for not disclosing is documented. Such documentation may be necessary for legal proceedings if the person does go on to commit an act of violence. 

The role of the psychiatrist

Psychiatrists play a role in assessing a person’s risk of LAGFV, assessing the accused to provide advice to courts in legal processes, and in the treatment of individuals who have committed or are at risk of committing acts of LAGFV.

During their practice, psychiatrists may encounter individuals who pose risks of committing serious acts of violence. While a psychiatrist’s primary duty is to the care and treatment of their patient, psychiatrists also recognise that their treatment may not always change a patient’s behaviour quickly or reliably enough to provide sufficient risk reduction.[4, 12] If a psychiatrist believes a patient or other individual brought to their attention, poses serious risks of violence to the public or specific individuals, they have a responsibility (and possible legal obligation) to notify police or agencies such as fixated threat assessment centres.[13] Once these agencies have been contacted, psychiatrists should then work with these agencies to conduct appropriate interventions (if any) in a way that appropriately balances an individual’s rights with the need for public safety.

For individuals who are not at such high risk that they warrant notification of police and security agencies, psychiatrists are vital to the treatment and risk management of these individuals.[13] Though they may not be at immediate risk of violence, their behaviour may still be emotionally and psychologically harmful to those around the individual.[14] Appropriate intervention and support is important to ensure the individual preserves relationships with those around them and does not become further isolated.[14] 

While individuals who are prosecuted for acts of LAGFV are likely to receive significant prison sentences, it is likely these individuals will eventually be released back into the general population. It is important these individuals have any mental health conditions appropriately treated and are rehabilitated while incarcerated to reduce their risk to other prisoners and the public if/when they are released.[15] Providing psychiatric care and assisting in rehabilitation in no way endorses a perpetrator’s actions or lessens the punishment they receive for their offence. A psychiatrist providing care to such individuals does so as a professional obligation, in the interests of public and prison safety. Their goal is to enable these individuals to better understand the harm their actions have caused and attempt to make amends for what they have done.[16, 17]

LAGFV risk assessments

Assessing the risk of LAGFV presents challenges not often found in other areas of risk assessment. Those managing and anticipating the risk of LAGFV must be vigilant for a wide variety of attack methods against a variety of possible targets. The grievances and fixations on those targets may be escalated through a variety of means. Managing and anticipating the risk of violent individuals is the business of many agencies (police, correctional services, security, and intelligence agencies) and health and welfare professionals (psychiatrists, psychologists, social workers, and community support workers). These agencies and professionals each operate with different codes of practice, skill sets, expectations, limitations and legal frameworks.[18] An effective response to people at risk of committing acts of LAFGV requires a multidisciplinary, multi-agency and at times transnational response. This scale of cooperation and coordination between organisations with different frameworks, values and priorities is an exceptional challenge. 

To assist psychiatrists, the field of violence risk assessment has evolved significantly since its inception in the 1990s.[18] Psychiatrists have at their availability a number of tools based on both discretionary and non-discretionary approaches. Discretionary approaches (also referred to as structured professional judgement approaches) allow health professionals to use their judgement to fill in gaps in the current knowledge base. Non-discretionary approaches adhere more rigidly to the existing evidence base and only allow for decision-making based on strict criteria which are evidence-based. Due to the multidisciplinary and multi-agency environment LAGFV risk assessment operates in, best practice calls for psychiatrists and health professionals to utilize discretionary approaches (such as the HCR-20 assessment tool) while assessors without significant expertise should use non-discretionary approaches.[18] 

It is recognised that the literature and best practice in this area is dynamic and rapidly evolving. Ensuring consistent best practices is difficult as intelligence agencies use their own methods for risk assessments but to maintain operational effectiveness these methods are not publicly disclosed. Therefore, it is more useful to discuss the principles that should inform future risk assessment approaches rather than identify a specific method. The Framework for Risk Assessment and Management Evaluation (FRAME) published by the Scottish Risk Management Authority sets out a number of principles some of which are listed below and provide an ideal starting point for further expansion.[20]

Key principles for an approach to risk assessment of LAGFV include:

• An approach that is human rights based.
• An approach that explicitly acknowledges and seeks to address that risk is uncertain and can never be eliminated but can and should be understood. 
• An approach that manages the expectations of others through shared awareness of the limitations of risk assessment.
• An approach that is transparent, accountable, and defensible in its decision-making.
• An approach that is evidence-based
• An approach that is sensitive to the clinical organisational, legal, and political contexts
• An approach that is tailored to the needs of the individual being evaluated
• An approach that is dynamic, iterative, and responsive to change to facilitate continual improvement.
• An approach that ensures its findings and management strategies are understood by those they seek to inform and guide.

Psychiatrists, law enforcement and security agencies

As part of their role in threat assessment and responding to incidents of violence, law enforcement and security agencies may engage psychiatrists to provide guidance and assessment of the mental state of individuals. While this work is in line with the skills of forensic specialist psychiatrists and some non-specialist psychiatrists, agencies working with psychiatrists must understand the limitations of psychiatric advice. Despite significant progress in threat assessment, no tool or method currently exists for psychiatrists to provide a risk assessment with any predictive validity.[7] Psychiatry training also does not enable a psychiatrist to know the inner thoughts of another person, especially where they do not have direct access and limited time or information. People with serious mental health conditions can experience emotional instability, irrationality, and delusions, and have difficulty controlling emotions and impulses.[2] Psychiatric assessments or advice should never be taken as a prediction of behaviour or a definitive statement of what a person is thinking.

While agencies are encouraged to seriously consider the advice and assessments of psychiatrists, responsibility for decision-making and responding to this advice sits with the agencies themselves.[4] Responding to risks of violence requires judgements on what are acceptable and unacceptable levels of risk, appropriate allocation of resources, balancing the rights of an individual and the rights of the public, the likelihood of a successful intervention and at times appropriate use of force (including lethal force) to intervene.[21] These are areas outside a psychiatrist's training and responsibilities.[19] Making decisions to respond to the risk of violence can be exceptionally difficult with significant implications, short timeframes and limited options. Decisions to respond to a risk of violence should only be made by appropriately authorised individuals from agencies with the responsibility of responding to these risks.

Agencies working with psychiatrists and any courts or commissions reviewing responses to acts of LAGFV should also understand the limits of psychiatric advice and the role psychiatrists play in risk assessment.[7] Being called upon to assess a person’s risk of LAGFV is a challenging task even for forensic specialists.[19] Where they are called upon to provide this risk assessment with short notice, limited information or in a live and dynamic environment, they are inherently limited in the accuracy and rigour of their advice.[19] Those who are responsible for reviewing a psychiatrist’s advice after an act of violence has occurred should be cognisant of the need for future psychiatrists to feel comfortable providing frank and fearless advice in future scenarios. If psychiatrists have reason to be concerned their advice may be taken out of context or inappropriacy attributed to the action or inaction of others, they may be over-cautious in their advice. This would inhibit the need for police and intelligence to have access to high-quality psychiatric advice quickly when it is needed most.

Family, friends, whānau and LAGFV

Families of individuals at risk of committing acts of LAGFV can play an important role in mitigating the risks their loved ones pose, but the experience can be difficult and at times dangerous. Maintaining these relationships can also be physically dangerous. It is not unusual for those who commit LAGFV to have a history of family or sexual violence towards others.[22] Partners of at-risk individuals who have concerns for their safety or who are experiencing domestic and family violence are encouraged to contact family and domestic violence support services to discuss their situation and seek assistance.

A correlation exists between social isolation and acts of LAGFV, a person’s family or friends may be the last social contact having a regulatory effect on their behaviour and play a pivotal role in preventing their behaviour and thoughts from escalating.[2] Where it is safe to maintain a relationship, families friends and whānau can push back on harmful beliefs or ideologies an individual may hold, encourage help-seeking and in the worst cases, alert authorities before violence occurs. The experience of maintaining a relationship with someone experiencing delusions, adhering to violent ideologies or holding fixations or grievances can be emotionally exhausting and at times traumatic.[14] Those maintaining a relationship with an at-risk individual are encouraged to seek support for their own mental health and discuss their circumstances with others who can assist. 

Recommendations

• Agencies working with psychiatrists in the area of LAGFV threat assessment should ensure they appropriately understand the scope of advice and guidance psychiatrists are able to provide.
• Australian and New Zealand governments should continue to support the use of Fixated Threat Assessment Centres to identify and prioritise individuals in need of treatment.
• Australian and New Zealand governments should utilise population-level approaches to reduce rates of LAGFV.
• Australian and New Zealand governments should target social isolation and treatment of mental health conditions, particularly psychosis, as a method of reducing rates of LAGFV.
• Australian and New Zealand governments should develop educational materials for the general public for family, friends and whānau of an at-risk individual to explain what may be occurring with the individual, what they should do to assist them, where they can seek help and how to remain safe.
• Australian and New Zealand media entities should ensure their coverage of psychiatric advice does not critique the inability of psychiatrists to predict LAFGV or otherwise comment on areas outside their expertise. 
• Australian and New Zealand media entities should be careful in their coverage of links between mental health conditions and LAGFV. Coverage attributing causal links runs the risk of demonising and stigmatising people with mental health conditions and discourages help-seeking. 

Additional resources

• Communications Threat Assessment Protocol
• American Psychological Association. Gun Violence: Prediction, Prevention and Policy

References

1.         Gill P, Silver J, Horgan J, Corner E, Bouhana N. Similar crimes, similar behaviors? Comparing lone‐actor terrorists and public mass murderers. Journal of forensic sciences. 2021s.2021 13/6/2021 [cited 21/10/2022];66(5)1797-804. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/1556-4029.14793.

2.         Barry-Walsh J, James DV, Mullen PE. Fixated Threat Assessment Centers: preventing harm and facilitating care in public figure threat cases and those thought to be at risk of lone-actor grievance-fueled violence. CNS spectrums. 2020s.2020 07/04/2022 [cited 21/10/2022];25(5)630-7. Available from: https://www.cambridge.org/core/journals/cns-spectrums/article/abs/fixated-threat-assessment-centers-preventing-harm-and-facilitating-care-in-public-figure-threat-cases-and-those-thought-to-be-at-risk-of-loneactor-grievancefueled-violence/0D21CEF790DE78E8522D70B5583BB16D.

3.         United Nations Office of Counter Terrorism. Plan of Action to Prevent Violent Extremeism. New York: United Nations; 2016 15/01/20168. 

4.         American Psychological Association (US). Gun Violence Prevention and Policy. Washington DC: American Psychological Association; 2013 201352. 

5.         Hirschtritt ME, Binder RL. A Reassessment of Blaming Mass Shootings on Mental Illness. JAMA Psychiatry. 2018s.2018 April 2018 [cited 10/17/2022];75(4)311-2. Available from: https://doi.org/10.1001/jamapsychiatry.2018.0010.

6.         Gøtzsche‐Astrup O, Lindekilde L. Either or? Reconciling Findings on Mental Health and Extremism using a Dimensional Rather than Categorical Paradigm. Journal of forensic sciences. 2019s.2019 29/01/2019 [cited 21/10/2022];64(4)982-8. Available from: https://pure.au.dk/ws/files/210864065/Either_or_Accepted_manuscript_2019.pdf.

7.         Policy and Public Affairs Committee and Council (UK). Counter Terrorism and Psychiatry Position Statement London: Royal College of psychiatrists; 2016 16/09/20228. Report No.: PS04/16 

8.         Swanson JWP, McGinty EEPMS, Fazel SMMDF, Mays VMPM. Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Annals of epidemiology. 2015s.2015 25/05/2022 [cited 21/10/2022];25(5)366-76. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4211925/.

9.         Silver J, Fisher W, Horgan J. Public Mass Murderers and Federal Mental Health Background Checks. Law & policy. 2018s.2018 07/03/2018 [cited 21/10/2022];40(2)133-47. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/lapo.12102.

10.       Code of Ethics RANZCP, (2018).

11.       Grace Lee MD, Debra A. Pinals, M.D., Louis Kraus, M.D., Jeffrey Metzner, M.D., Tina Thomas, M.D., Carl E. Fisher, M.D., Michael Champion, M.D., Bhinna Park, M.D., Lisa Harding, M.D., Reena Kapoor, M.D., Christopher Hoffman, M.D., Elissa Benedek, M.D., Abhishek Jain, M.D., Allison Brandt, M.D., Pratik Bahekar, M.D., Richard Bonnie, L.L.B. Resource Document on Mental Health Issues Pertaining to Restoring Access to Firearms. American Psychiatric Association; 2020 02/20228. 

12.       Code of Ethics RANZCP, (2018).

13.       Abikoff H, Klein RG. Attention-Deficit Hyperactivity and Conduct Disorder: Comorbidity and Implications for Treatment. Journal of consulting and clinical psychology. 1992s.1992  [cited 21/10/2022];60(6)881-92. Available from: https://pubmed.ncbi.nlm.nih.gov/1360990/.

14.       Prats M, Raymond S, Gasman I. Religious Radicalization and Lone‐Actor Terrorism: A Matter for Psychiatry? Journal of forensic sciences. 2019s.2019 26/12/2018 [cited 21/10/2022];64(4)1253-8. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/1556-4029.13992.

15.       Polaschek DLL, Collie RM. Rehabilitating serious violent adult offenders: an empirical and theoretical stocktake. Psychology, crime & law. 2006s.2006 22/08/2006 [cited 21/10/2022];10(3)321-34. Available from: https://www.researchgate.net/publication/247500369_Rehabilitating_serious_violent_adult_offenders_An_empirical_and_theoretical_stocktake.

16.       Rich LE, Ashby MA. Crime and Punishment, Rehabilitation or Revenge: Bioethics for Prisoners? Journal of bioethical inquiry. 2014s.2014 26/07/2022 [cited 21/10/2022];11(3)269-74. Available from: https://link.springer.com/article/10.1007/s11673-014-9569-5.

17.       Konrad N, Völlm B, Weisstub DN. Ethical Issues in Prison Psychiatry. 1st ed. 2013. ed. Dordrecht: Springer Netherlands; 2013.

18.       Logan C, Lloyd M. Violent extremism: A comparison of approaches to assessing and managing risk. Legal and criminological psychology. 2019s.2019 29/08/2022 [cited 21/10/2022];24(1)141-61. Available from: https://bpspsychub.onlinelibrary.wiley.com/doi/abs/10.1111/lcrp.12140.

19.       Augustin D, Fagan TJ. Roles for mental health professionals in critical law enforcement incidents: An overview. Psychological services. 2011s.2011 2011 [cited 21/10/2022];8(3)166-77. Available from: https://psycnet.apa.org/record/2011-11837-001.

20.       Risk Management Authority (UK). Framework for Risk Assessment Management and Evaluation (FRAME) for Local Authorities and partners Scottish Government; 2014 November 201449. 

21.       Police Executive Research Forum (US). Critical Response Toolkit for First-Line Supervisors. United States Department of Justice; 2018 37. 

22.       Geller LB, Booty M, Crifasi CK. The role of domestic violence in fatal mass shootings in the United States, 2014–2019. Injury Epidemiology. 2021s.2021 2021/05/31 [cited 21/10/2022];8(1)38. Available from: https://doi.org/10.1186/s40621-021-00330-0.

This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.