"There is no such thing as absolute safety" Forensic expert warns against snap judgments after knife attack in Winterthur

Following the violent crime in Winterthur, there is a debate as to whether such crimes can be prevented. In an interview with blue News, forensic psychiatrist Elmar Habermeyer explains why absolute security remains an illusion and which people fall through the net particularly often.

The deadly act of violence in Winterthur has raised questions throughout Switzerland: Could the crime have been prevented? How well can dangerous developments be identified? And where does the psychiatric care system reach its limits?

For Elmar Habermeyer, Director of the Clinic for Forensic Psychiatry at the Psychiatric University Hospital Zurich, the debate often falls short of the mark. In an interview with blue News, he explains why acts of violence cannot be predicted, why severe mental illness often coincides with addiction problems and why he is particularly concerned about a small group of severely troubled people who are often difficult to reach in today's system.

Many people ask themselves after such cases whether such an act could have been prevented. What do you say to this?

Of course we should try to prevent violent crime. There are different approaches to this: Prevention programs, police measures and the treatment of mental illness, which can increase the risk of violent acts. In the penal system, there is also the explicit task of preparing for resocialization and preventing recidivism.

However, the absolute security that is often demanded does not exist. If we wanted absolute security, we would have to massively restrict civil liberties. For example, young men between the ages of 18 and 24 are at the greatest risk of committing violent acts.

If all of them were locked up, there would be significantly less violence. But the question is whether this would make sense and what social costs and restrictions on freedom would be associated with it.

We cannot predict acts of violence, but we can assess risks. We cannot say that a certain person will commit a violent crime tomorrow. We can only determine probabilities.

How do you assess the risk of someone becoming violent?

In everyday life, we are often surprisingly good at identifying risks at very short notice. If someone approaches you aggressively on the street, shouting and gesticulating, you don't need an expert to recognize that caution is called for.

Forensic psychiatry is about a more systematic assessment. We take into account factors such as previous acts of violence, age, gender or substance use. If someone has already been violent, is young, male and also consumes alcohol or drugs, the risk increases.

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This gives us an overall picture that we can use to determine probabilities. We can say that someone within a certain group has an increased risk. We can therefore make a reliable statement about the risk, but we cannot predict exactly whether a person will actually commit a serious offense.

What are the limits of such an assessment?

One important limit is the information available. The more information and sources we have at our disposal, the more precise the assessment becomes.

The second major limit is of a statistical nature. Serious acts of violence and in particular homicides are rare. Therefore, although we can use statistical methods to recognize that someone is at increased risk, we cannot reliably determine whether this person will actually commit a homicide.

This requires an individual prognosis: if there are additional concrete indications, such as an acute psychological crisis, threats against a specific person, planning acts or being armed, then this is of course also included in the risk assessment.

How often are people with an increased potential for violence treated in your clinic?

In forensic psychiatry, we treat around 140 to 150 inpatients every year. They come to us precisely because they are at increased risk.

In general psychiatry, on the other hand, we treat several thousand people a year. The potential for violence is not usually the main focus there. Acute risk situations primarily affect certain groups, such as people who are placed in care, as this can be due to a disorder-related acute danger to others.

Are psychiatric clinics and forensic facilities reaching their capacity limits?

Acute wards in general psychiatry are practically always at full capacity, especially in urban regions such as Zurich.

In forensic psychiatry, there is currently a considerable shortage of inpatient treatment places.

Is that why there are waiting lists?

Yes, the forensic clinics in Switzerland work with waiting lists. Priority is given to particularly serious illnesses, pronounced propensity to violence or cases in which someone is not fit for prison or their state of health would deteriorate as a result of imprisonment.

Has the number of people suffering from severe mental illness, addiction problems and violence increased?

The number of seriously mentally ill people has not changed significantly overall. The prevalence is relatively stable.

What has changed, however, is the combination of severe mental illness and addiction. This combination is now almost the rule rather than the exception. As a result, several risk factors come together at the same time.

We are also experiencing social developments that put a strain on many people. People with mental illness often react even more sensitively to such stress. When society becomes more irritable or tolerance towards those affected decreases, this creates additional pressure.

What happens if someone is considered potentially dangerous but cannot use outpatient services and no suitable place is available?

This is one of the biggest challenges. There is also a fundamental social question behind this: how much freedom and how much protection do we want to allow?

In the past, many people with severe mental illnesses spent a large part of their lives in hospitals. Today, psychiatry deliberately takes a different approach and focuses on outpatient support and a life in society that is as self-determined as possible. For well over 95 percent of those affected, this is a great benefit.

However, there is a small group of severely affected people with complex biographical burdens, multiple mental illnesses and often a lack of insight into their illness. Voluntary outpatient services often do not work for these people. They sometimes fall through the net.

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If these people later commit an offense and are admitted to a forensic psychiatric clinic, we have significantly more time for treatment. Inpatient treatment can last several years. This allows us not only to treat the illness, but also to create sustainable social conditions in the long term.

We have enough time to sustainably improve the symptoms and prepare together with those affected which facility they can live in in the future or which steps towards an independent life make sense.

In the current debate, some people are now calling for treating physicians to have more comprehensive access to information. What is your view on this?

As much information as possible is generally helpful for a risk assessment. But the question is what exactly we want and what price we are prepared to pay for it.

Do we really want doctors to have automatic access to police files? They may also contain accusations that later turn out to be unfounded.

We always have to weigh up security interests and civil liberties. I warn against questioning fundamental civil liberties after individual incidents.

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I also think that register solutions that record who is placed in psychiatric clinics on the basis of a preventive placement are problematic. If you create lists of thousands of potentially dangerous people, the question arises as to what you actually want to do with this information.

In forensic psychiatry, however, there are other possibilities than in general care. There, those affected are already undergoing criminal proceedings. Accordingly, information is gathered from different sources.

In such cases, there are also fewer data protection hurdles. For example, cell phones or computers can be analyzed. However, these are exceptional cases and the exchange of data takes place when there is an urgent suspicion of a crime to clarify specific dangers.

Have particularly complex cases increased in recent years?

The proportion of mentally ill people in prisons is increasing. At the same time, acute psychiatric wards are working at full capacity and the capacities in forensics are no longer sufficient in many places, despite the expansion of places.

This indicates that more mentally ill people are ending up in the justice system. At the same time, however, the way society deals with them has also changed. Behavior that may have been ignored in the past is now reported more frequently and prosecuted more consistently.

However, this development does not only have disadvantages. If someone is assessed for an offense or conspicuous behaviour in the first place and receives appropriate treatment as a result, this can also be an opportunity. Some people receive appropriate psychiatric care for the first time in this way.

How does cooperation between psychiatry, the police and the judiciary work?

In Zurich, the PUK's Forensic Psychiatry and Psychotherapy department has a specialist unit that provides low-threshold advice to the police and public prosecutors in high-risk situations.

We are called in when authorities require a specialist assessment. We advise on case management, risk assessment and what support could be useful.

For example, the police conduct risk interviews and seek direct contact with people with increased risk potential. The aim is to mitigate risks at an early stage, offer assistance and determine whether a risk situation is worsening.

We provide support with specialist advice on risk management. If those affected are willing to accept help, we can also arrange suitable treatment or counseling services. There is already very close and constructive cooperation in this area.

What misunderstanding do you encounter most often when it comes to mentally ill offenders?

The biggest misunderstanding is the idea that every person with a serious mental illness is potentially violent.

It is true that there are certain illnesses that are statistically associated with an increased risk. But even then, the individual risk remains low.

One example: In the general population, the rate of serious violent acts is approximately one in 10,000 to 12,000 people. In people with schizophrenia, it is around one in 2000. The risk is therefore statistically five to six times higher, but despite this, 1999 out of 2000 people with schizophrenia never become violent.

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If we place mentally ill people under general suspicion, we reinforce prejudices and stigmatization. This can lead to those affected being less open about their illness and less likely to seek help.

At the same time, as psychiatrists we must recognize that certain illnesses can be associated with increased risks. However, naming these risks does not mean placing all sufferers under general suspicion.

What challenges do you see in the psychiatric and forensic psychiatric care system in Switzerland?

Basically, I think the Swiss care system is very good. Individual cases should not lead us to question it completely.

However, I am concerned about a certain group of seriously mentally ill people: People who have little insight into their illness, do not make use of voluntary services and are often unable to stand up for their own interests.

I have the impression that some of the treatment resources are increasingly being concentrated on people who are able to name their problems and actively seek help. That is legitimate. At the same time, there is a danger that the most severe cases will receive too little attention.

Do gender differences play a role in this?

Yes, women often accept psychotherapeutic offers more easily. Young men, on the other hand, often find it more difficult to reflect on their feelings or seek help. There are also clear differences in the services available for certain problems.

Today, there are numerous specialized treatment services for people with self-harming behaviour. There are far fewer for young men with aggressive behavior towards others. This is also due to the fact that this group often does not actively seek psychiatric help.

Young men with aggressive behavior often find it difficult to reflect on their feelings or their own behavior. They are more action-oriented and are less likely to attend appointments regularly. This is why they often fall between a rock and a hard place in the outpatient care system.

At the same time, men exhibit more risky behavior overall. This can be seen in traffic accidents, swimming accidents or even violent crimes. This is precisely why young men with aggressive behavior belong to a group that would require special care services.

Can this change in the long term?

I think so. Social developments happen slowly. When I compare my own school days with those of my children, I see big differences. Violence in the schoolyard used to be much more normal than it is today.

Today, we are much more concerned with bullying, prevention and conflict resolution. However, such changes are gradual and do not happen overnight.

Where do you see the greatest need for political action?

I would like to see the expansion of so-called prevention outpatient clinics. In other words, services for particularly difficult patient groups with intensive outreach care and an interdisciplinary approach.

This is not just about medicine. It is also about social contacts, leisure activities, support in everyday life and maintaining long-term contact with challenging people.

However, such services quickly become the subject of a funding debate. The question then arises as to why, for example, social activities or leisure activities should be paid for by health insurance. This discussion is understandable, but it does not make prevention work any easier.

Many of these prevention measures ultimately save costs because they can prevent crime. A violent crime causes enormous human suffering, but also high costs for the healthcare system, the justice system and society.

In my view, we are not talking about hundreds of victims here. In the canton of Zurich, we are probably talking about a relatively small group of perhaps 20 to 30 people for whom targeted solutions would have to be developed.