Mass violence, radicalization and terrorism: A role for psychiatric profession?

Autism Spectrum Disorder, Extremism, and the Role of Developmental-Behavioral Pediatric Clinicians

ABSTRACT

Extremism is a global phenomenon, with an increasing domestic and international presence. Extremists recruit persons to their causes through online forums that spread hate-filled narratives and promote violence. Individuals with autism spectrum disorder may be vulnerable to recruitment through these online forums, and clinicians who work with autistic adolescents, young adults, and their families should familiarize themselves with the risk and identify strategies based on a multidisciplinary approach in the early identification, holistic prevention, and care-based intervention strategies of at-risk adolescents. This special article, representing an international collaboration between developmental-behavioral pediatrics, law enforcement, and psychology, hopes to shed light on the issue for clinicians.

Psychopathology of Young Terrorist Offenders, and the Interaction With Ideology and Grievances

Psychopathology might be a risk factor for terrorist offending as it is for violent offending. Therefore, we examined the prevalence of psychopathology in young and adult Jihadist terrorist offenders on the basis of primary source judicial information and forensic mental health reports with the European Database of convicted Terrorist offenders (EDT). We hypothesised that psychopathology might be associated with ideological risk factors, and that these associations might be different for young and adult terrorist offenders. Therefore, we examined whether and to what extent psychopathology is related to a violent ideology, to grievances and anger about perceived injustice. We investigated whether this differs among 120 adult and 46 juvenile terrorist offenders. We found that most adult and young Jihadist terrorist offenders with a forensic mental health report had psychopathological problems. Most frequently found were symptoms and traits of intellectual disability disorders, depressive disorders, psychotic/schizophrenic disorders, substance use disorders, and personality disorders. Most frequently found clinically relevant personality traits were problems with relationships, poor regulation of aggression, feelings of anger, and paranoid feelings. We found some first indications for a positive association between psychopathology and grievances and anger about perceived injustice. In the young terrorist offenders with depressive symptoms, grievances about perceived injustice were more often present than in young terrorist offenders without these symptoms. In adult terrorist offenders it was found that grievances about perceived injustice and the anger were related to cluster B personality traits. In addition, in both young and adult terrorist offenders expressed grievances about perceived injustice were related to problems with relationships. Further research into psychopathology in terrorist offenders seems necessary with larger groups of adolescents and adults in relation to ideological, personal and contextual risk factors and how these factors relate to different terrorist acts. This may lead to more knowledge about engagement into terrorism and possible disengagement from terrorism. It may also lead to the inclusion of psychopathology into violent extremism risk assessment tools.

Not in Their Right Mind? Right-Wing Extremism Is Not a Mental Illness, but Still a Challenge for Psychiatry

Most research in psychiatry on extremism focuses on the question whether there is a connection between extremism and psychiatric diagnoses. In addition, practitioners are increasingly asked to take part in programs aimed at preventing and countering violent extremism by assessing risk for radicalization. However, an issue that remains largely unaddressed is that the rise of the far right in many countries during the last years poses a challenge for psychiatric services as working with right-wing patients can be a source of conflict for practitioners and patients alike. In this article, we assert that the narrow conceptual scope on psychological vulnerabilities and the practical focus on risk assessment contribute to processes of psychiatrization and limit the scope of research on right-wing extremism in psychiatry. By giving a brief overview of social research into right-wing extremism, the article argues that right wing beliefs should not be conceptualized as an expression of psychological vulnerabilities but rather as attempts to deal with conflict-laden social reality. Thus, a shift of perspective in psychiatric research on extremism is needed. On a conceptional level, the scope needs to be broadened to grasp the interplay of individual and social factors in radicalization with sufficient complexity. On a practical level, it is necessary to further investigate challenges for practitioners and institutions working with right-wing extremist patients.

Einstellung der Allgemeinbevölkerung zur Schweigepflicht von Ärzt:innen und Psychotherapeut:innen bei Patient:innen mit extremistischer Einstellung

Hintergrund

Um extremistische Gewalttaten zu verhindern, wurde in der Vergangenheit immer wieder diskutiert, inwieweit eine allgemeine Aufhebung der ärztlichen Schweigepflicht und der Verschwiegenheitspflichten bei psychologischen Psychotherapeut:innen und Ärzt:innen im Zusammenhang mit extremistischen Einstellungen bei Patient:innen ein sinnvolles Mittel zur Gefahrenabwehr sei. Bislang gibt es keine Untersuchung darüber, ob dies im politischen Diskurs ein mehrheitsfähiges Argument ist, da es keine Befragung zur Einstellung der Allgemeinbevölkerung im Zusammenhang mit religiösem oder politischem Extremismus und Verschwiegenheitspflichten gibt.

Material und Methoden

Anhand einer bevölkerungsrepräsentativen Befragung (n = 2503) wurde die Einstellung der Allgemeinbevölkerung untersucht.

Ergebnisse

Es zeigt sich, dass über die Hälfte der Befragten (58 %) den Schutz vor möglicher Gefährdung durch extremistische Gewalt als wichtiger ansehen als die Einhaltung der Schweigepflicht bei Psychiater:innen und Psychotherapeut:innen. Über die Hälfte (54 %) stimmen dem zu, dass die Möglichkeit zum Bruch der Schweigepflicht grundsätzlich bestehen sollte, wenn Psychotherapeut:innen oder Psychiater:innen von extremistischen Einstellungen bei Patient:innen erfahren. Die Zustimmung war insbesondere dann höher, wenn die Befragten Terrorismus grundsätzlich in einen Zusammenhang mit psychischen Erkrankungen brachten.

Schlussfolgerung

Die Ergebnisse zeigen einerseits die Notwendigkeit, über die Bedeutung der Schweigepflicht als zentrale Grundlage einer Heilbehandlung stärker aufzuklären, andererseits aber auch sehr kritisch Stellung zu beziehen, welche Rolle psychische Erkrankungen tatsächlich bei der Entstehung von extremistischer Gewalt spielen, um eine Stigmatisierung von Betroffenen zu vermeiden.

Between Psychopathology and Ideology: Challenges and Practices in Interpreting Young Extremists Experiencing Mental Illness in the Netherlands

How violent extremism is interpreted among adolescents and young adults who experience a form of psychopathology can have far-reaching consequences for these youth and for society. A fundamental consideration here is the role that ideology and psychopathology play in radicalization and possibly related extremist violence. Risk management is challenged at various levels. This article seeks to contribute to academic and policy discussions on psychopathology and extremism by combining relevant insights from practices in the Netherlands. In this perspective article our aim is to stimulate awareness and research, on the basis of operational knowledge of the Dutch case, that helps professionals across the various domains of risk management with more expertise and the ability to better integrate and interact the concepts of psychopathology and ideology. We end with formulating hypotheses for further research.

Global Adversities, the Media, and Mental Health

Global communities are currently confronted with a number of complex problems and threats, the reality of which is amplified by the media. These environmental and socio-political stressors have been accompanied by the spread of problematic psychological and behavioural tendencies, such as the growing polarisation of opinions and values, online radicalisation and extremism, deepening xenophobia and nationalism, the proliferation of irrational beliefs and conspiracy theories, and resistance to rational public policy measures. Here we argue that although they fall outside the scope of psychopathology, they nevertheless currently constitute a major challenge for psychiatry as a research domain and a clinical practise. To substantiate this claim, we outline the mechanisms by which media-transmitted stressors impact mental well-being and possibly psychopathology. The common denominator of these global problems and the media's construction of reality is the increase in uncertainty, unpredictability, and uncontrollability, which prompts defensive responding and, in predisposed individuals, functions as a potent source of chronic stress. These contribute to cognitive inflexibility, a strong predisposing factor for the development of rigid beliefs and attitudes, which to varying degrees underlie the adverse psychological and behavioural tendencies mentioned above. We suggest that the tightening of beliefs and ideas that is the result of cognitive rigidity may correspond to the clinical characteristics of induced delusional disorder. This can be seen as a (ultimately maladaptive) defensive strategy for coping with a high degree of uncertainty and unpredictability. We conclude by briefly outlining the possible ways in which psychiatry can face this challenge.

Haben radikalisierte Personen Zugang zu psychotherapeutischer Unterstützung?

Hintergrund

Im Zusammenhang mit extremistischer Gewalt wird häufig die Rolle von Psychotherapeuten in der Prävention und Früherkennung von Radikalisierung diskutiert, insbesondere um ungünstige Entwicklungsverläufe bei jungen Menschen zu verhindern. Bislang fehlen Studien, die radikalisierte Personen nach ihren Kontakten mit Psychotherapeuten befragen. Fragestellung der Studie war daher, ob radikalisierte Personen Zugang zu psychotherapeutischer Unterstützung oder zu anderen Hilfesystemen haben, und ob es dafür in ihrem Leben Anknüpfungspunkte gegeben hat bzw. hätte.

Material und Methode

Zur Beantwortung der Frage wurden mit 7 jungen Erwachsenen, die von Fachkräften als „radikalisiert“ eingeschätzt wurden, leitfadengestützte Interviews durchgeführt. Diese wurden im Anschluss inhaltsanalytisch ausgewertet.

Ergebnisse

Es zeigt sich, dass die Befragten bislang kaum bis gar keinen Kontakt mit Psychotherapeuten hatten. Gleichzeitig fanden sich bei den Probanden hohe Belastungen durch ungünstige und größtenteils traumatische Kindheitserlebnisse, bei denen eine therapeutische Intervention wahrscheinlich hilfreich gewesen wäre. Aufseiten der Probanden wird der eigene Hilfebedarf erkannt. Es besteht allerdings große Skepsis gegenüber therapeutischen Hilfen.

Schlussfolgerung

Es wird diskutiert, wie radikalisierte Personen einen besseren Zugang zu psychotherapeutischen Hilfen erhalten könnten, beispielsweise durch eine bessere Vernetzung und Zuweisungspraxis der verschiedenen Hilfesysteme. Zudem wird diskutiert, wie Betroffene mehr Vertrauen in das Hilfesystem gewinnen können. Die Ergebnisse dieser Pilotstudie basieren auf einer kleinen Stichprobe, weshalb weitere Arbeiten zum Thema sich trotz des erheblich limitierten Zugangs zu entsprechenden Probanden anschließen sollten.

Uncertainties in practice: terrorism and mental illness

Ho et al (2018) tackle a controversial and sensitive issue on which clinicians and the public have strong, often irreconcilable views, fuelled by their own experiences and political positions about the causes, consequences and necessary responses to political violence. This commentary explores some of the assumptions and uncertainties they present, as well as the framing of their position.

DECLARATION OF INTEREST

None.

What should global mental health do about violent extremism?

To prevent radicalization to violence and to rehabilitate returned foreign terrorist fighters, new programs which go by the name of 'preventing and countering violent extremism' are being implemented globally, including in low- and middle-income countries. In some of these countries, global mental health strategies are also being implemented so as to deliver mental health care or psychosocial support to individuals and populations in need. This commentary addresses what global mental health should considering doing about violent extremism. Global mental health should be open to addressing the challenges of violent extremism but should do so based upon existing mental health and public health values, practices, and evidence. Global mental health could help by critically appraising preventing and countering violent extremism practices and by working with multidisciplinary stakeholders to develop new evidence-based and best practice models that are rooted in civil society ownership, community collaboration, broader prevention programing, and non-securitized approaches.

Religious Radicalization and Lone-Actor Terrorism: A Matter for Psychiatry?

This article discusses the place of the psychiatric field in the ongoing phenomenon of religious radicalization. First, the article provides an overview of the existing literature on lone-actor terrorists and the link with mental illness. Current research is focusing increasingly on lone-actor terrorists. This is the most recent and rising development on the global terrorism scene. The literature is currently developing a more precise and informed definition of lone-actor terrorism. The article then describes and discusses the case study of a mentally ill patient arrested following his assault on a military serviceman on the grounds of religious radicalization. The patient, diagnosed with schizophrenia, is taken as an example of the specific case of religious radicalization in patients with schizophrenia. Finally, the article discusses the curative and preventive roles that can be played by psychiatrists and other professionals who are in contact with these types of patients.

Conference proceedings of the 4th Masterclass Psychiatry: Transcultural Psychiatry - Diagnostics and Treatment, Luleå, Sweden, 22-23 February 2018 (Region Norrbotten in collaboration with the Maudsley Hospital and Tavistock Clinic London)

BACKGROUND

According to estimates from the European Commission, Europe has experienced the greatest mass movement of people since the Second World War. More than one million refugees and migrants have arrived in the European Union in the past few years. Mental health and primary care professionals are more likely than ever to meet patients from different cultures and backgrounds.

AIMS

To equip mental health and primary care professionals with transcultural skills to deal with patients from unfamiliar backgrounds.

METHOD

Lectures and case discussions to explore the latest advances in the diagnosis and treatment of serious mental health problems in a transcultural context.

RESULTS

Lectures covered transcultural aspects of mental health problems, treatment in different cultural and ethnic contexts, and assessment of risk factors for self-harm and harm in migrant populations.

CONCLUSIONS

Clinicians require a sound grounding in transcultural skills to confidently and empathically deal with patients from unfamiliar backgrounds.

Clinical challenges in cultural psychiatry - searching for meaning, searching for methods†

BACKGROUND

Mental health services in Sweden are confronted with globalization and refugee migration from conflict- and war-torn countries.

AIM

To discuss how clinicians in Sweden can deal with a series of challenges in a changing globalized society, ranging from difficulties of overcoming barriers to help seeking to difficulties of identifying trauma and finding culturally adapted clinical tools.

METHOD

Case vignettes are presented to exemplify challenges. Different approaches developed to support clinicians are presented.

RESULTS

The concepts of patient centered care and shared decision-making as well as the cultural formulation interview, are recommended to explore the significance of culture and context in psychiatric assessments. Acknowledging relational aspects of care and of paying attention to the patients' social worlds in clinical work is also essential.

CONCLUSIONS

The article includes recommendations for training as well as an appeal for the involvement of the wider society in the work to guarantee equitable and high-quality mental health services for some of the most vulnerable patient groups in society.