The Occasional Tragedy of Mental Health


A Problem of Understanding
I used to work with people who had committed the most serious and often disturbing of crimes. All in all I spent twelve years in very close proximity to patients in secure psychiatric units. I played cards with killers, badminton with rapists and darts with men you had last seen played by an actor on Crimewatch.

I’ve been shopping with people who hadn’t seen a town centre for twenty years. I’ve handed out tissues to those still haunted by what they had done, and locked up patients in small secure rooms as the voices commanded them to kill anyone within range of a pool cue.

I’ve had the sort of conversations you could and should never forget with fellow human beings who have done unimaginable things. But one thing I have never done is to understand.

Not for want of trying or because I wasn’t clever enough. I ‘got’ the psychopathology of the psychopath. I ‘got’ the biochemistry of psychosis. I ‘got’ the medical model and the social model. But faced with someone who had tortured a child, blown off a neighbours head with a shotgun, or knocked nails into someone’s skull, I simply failed to truly understand.

Thirteen-year old Casey Kearney was walking through a park on her way to a friend’s. She was stabbed by a woman walking in the opposite direction. It wasn’t a frenzied attack, just one brief blow with a one of two kitchen knives purchased earlier that day by a woman called Hannah Bonser, who simply continued on her way before turning up at a local mental health resource to confess to what she called “a silly thing” and hand over her knives.

This was an appallingly random act of extreme violence. Bonser would have expended more time and energy stopping to ask her victim for the time. For any parent to imagine the deliberate killing of a child is not only incomprehensible, but entirely unimaginable for any more than the most fleeting of dark moments. But Casey Kearney’s family have had to deal with this reality since February 14 this year, and have no doubt tried and failed to make sense of the senseless.

Making Sense of the Senseless
Hannah Bonser was yesterday convicted of murder and sentenced to life imprisonment. She will serve an absolute minimum of twenty-two years before being able to seek parole. Those not involved with the case might have been surprised that Bonser did not receive a Mental Health Act hospital order and a conviction for Manslaughter rather than Murder.

After all, this was a bizarre and random killing committed by someone well-known to mental health services for some time before the event. Her legal defence argued she was suffering from Paranoid Schizophrenia at the time of the offence, and that her responsibility for the crime was therefore ‘diminished.’ The jury did not accept this argument.

But as with all homicides involving mental health service users, an independent inquiry will now take place in the aftermath of the trial. Like the dozens that have preceded it since the mid-1990s (when such inquiries became mandatory) the report will provide a public and detailed account of Bonser’s relationship with mental health services in the months and years prior to February 14th 2012.

As both a practitioner and trainer who has read with depressing regularity how tragedy has resulted from the failure of various services involved in mental health care over the years, I very much hope we will not be hearing from the usual suspects. Failures of communication, lack of information sharing, poorly motivated professionals, bureaucracy. All these and more have become depressingly familiar to readers of such reports, but seldom appear to change the way we work with potentially dangerous people.

What’s in a Diagnosis?
For some months prior to the killing, a close friend of Hannah Bonser had noted how her behaviour had become increasingly unusual. She claimed that her flat was possessed by demons. Her self-care deteriorated and she travelled down to London, where she slept rough and searched for a character called ‘Simon of Lambeth’. She was detained under the Mental Health Act before being transferred back to a Doncaster hospital, but was discharged shortly afterwards. Life appears to have become increasingly disjointed and chaotic. Shortly before Casey’s death, her killer had presented to mental health staff stating she was hearing voices commanding her to harm others.

Her legal defence was that her actions were driven by severe mental illness. It’s well beyond the scope of a short blog post to attempt to describe what we mean by this, but on current evidence we could state the following. That at the time of the offence her brain was showing signs of abnormal structural and biochemical functioning and was interacting with an environment which to Hannah Bonser would be a very, very different place to how most of you reading this would experience that environment. It may have been quite a terrifying place. Perhaps terrifying enough to randomly stab a complete stranger.

The prosecution argued that Bonser was not psychotic but suffered from a Personality Disorder. We know even less about the inner workings of PD than Schizophrenia, and argue about it a great deal more. This diagnosis would imply that the person is fully aware of one’s actions and knows exactly what they are doing, even when what they are doing is indescribably unpleasant.

The Sadness of Madness v Badness
The difference between severe mental illness and personality disorder is characterised by some as the ‘mad versus bad’ dichotomy. This is a very false dichotomy. In fact, it’s not a dichotomy at all.  The opposite of ‘mad’ is ‘sane’ and the opposite of bad is of course ‘good’. It’s an old and rather stale argument often used by lazy mental health professionals to characterise the difference between behaviours which are driven by ‘genuine’ and ‘proper’ mental illness on the one hand, and behaviours which are apparently ‘manipulative’ or ‘attention seeking’ on the other.

Being ‘Mad’ is beyond both the conscious control of the sufferer, and the moral judgement of others. It warrants our intervention, diagnosis and treatment, particularly with pharmacological means which offer a quick and relatively simple solution to ‘Mad.’

But ‘Bad’ is just, well, bad. If it isn’t ‘Mad’, isn’t a psychiatric problem, we needn’t offer an intervention. Personality Disorder is ‘Bad’ and this is what Hannah Bonser is now judged to be. She’ll go to prison not hospital.

The jury at Doncaster Crown Court accepted medical evidence suggesting Bonser suffered from a Personality Disorder. Essentially, she knew what she was doing.

The conception from both the public and aggrieved families is often that a ‘proper’ sentence is infinitely more acceptable than the apparently soft option of a psychiatric bed. Part of the argument around this case was that the stabbing of Casey Kearney was a calculated and manipulative act designed to achieve Bonser’s demands for hospital admission. To have received a Mental Health Act section might have been seen as a triumph for Bonser’s manipulation, and one could understand how that might be seen as unacceptable by many.

To Inquire or Not Inquire?
Nonetheless, an inquiry will now take place and the report will tell us something of how a family have lost a 13-year old girl who just happened to be in the wrong place at the wrong time. The court has already delivered it’s verdict on Hannah Bonser, but the inquiry will hopefully reveal a highly complex interaction between a twenty-six year old woman, her troubled background, her environment, her mental state, the services she turned to for help and the killing of Casey Kearney.

There are some who now call for the end of mandatory inquiries into each and every mental health related homicide. I wouldn’t disagree. It’s a hugely expensive procedure which, as we’ve already seen, throws up very similar conclusions time after time without seemingly making much difference.

But perhaps we should continue to study events such as these which, incredibly rare as they are, remain sufficiently horrific to merit the deepest scrutiny and may help us to at least try to prevent the preventable in future.

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3 thoughts on “The Occasional Tragedy of Mental Health”

  1. An interesting blog again, highlighting the tragedy for everyone involved. I fully believe that with these inquiries, when we do hear the same results over and over again, it might be an idea that we either follow the results of that inquiry or admit that it's not possible to stop every person slipping through the cracks in the services. Although with the benefit of hindsight we can see all the failings in Hannah Bonser's care, how many others in similar situations fail to receive the same care, but don't commit unspeakable crimes. The complexity of the human mind never ceases to amaze and not always in a good way.

  2. Thanks Timian. A couple of interesting points here. None of us can pre-judge the inquiry report and I wasn't assuming there were any 'cracks' as such, but what will be fascinating is what is made of how her diagnosis affected her overall care.You're absolutely right that we should all be following the findings of all these zillion-plus reports, but I really think it's time someone such as the National Confidential Inquiry http://www.medicine.manchester.ac.uk/cmhr/centreforsuicideprevention/nci/ started to take over the functions of these various scattered bodies and really did something with the findings rather than have them filed away on yet another dusty shelf until the next fatality occurs.

  3. The Bonser case seems rotten. As I think imply, her diagnosis of a so-called personality disorder seems to have worked against her (rather than indicating a more enduring complex need) – both in terms of being denied an alternative or additional diagnosis of a psychotic disorder like schizophrenia and therefore denied inpatient care, and then to give the jury an excuse to convict her. Also absurd that her attempt – utterly correctly and responsibly – to seek inpatient care while feeling at risk of harming others due to uncontrollable delusions/hallucinations – was then used against her at court as a supposed motive and reason to again not let her receive hospital care! Would that be a sane or an insane motive then, jury? PD does not equal bad or evil – in fact the judge said she was of previous ood character – so?Incidentally I've worked at Rethink mental illness community services and their risk monitoring procedures were pretty slack, I raised concerns about it several times, and I am extremely far from surprised that they either discharged her the day before or have lied about that to distance themselves, though the NHS must carry responsibility for the overall situation.

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