Diminished responsibility. The recent Valdo Calocane case has driven the term into our consciousness.

Calocane, a 32-year-old male, fatally stabbed Barnaby Webber and Grace O’Malley-Kumar, both aged 19, and Ian Coates, a school caretaker, in Nottingham, England, on June 13, 2023. He also drove a stolen van at three pedestrians. Calocane was charged with murder and three counts of attempted murder. He was a dual Guinea-Bissau/Portuguese national with settled status in the UK and an engineering graduate from the University of Nottingham.

Over the next several months, it emerged that Calocane had been known to mental health services since 2020 and had been prescribed treatment. Police also pursued but did not arrest him for allegedly attacking two people weeks before the stabbings.

While in custody awaiting trial, Calocane was transferred to a “secure hospital setting” and assessed by forensic psychiatrists. Forensic psychiatrists have expertise in both psychiatry and the legal system. Their work involves conducting evaluations to assess issues like competency to stand trial, criminal responsibility and other mental health-related aspects of legal cases.

The forensic psychiatrists’ conclusions were presented to the judge. He declared himself “satisfied” that Calocane was suffering from paranoid schizophrenia and converted the charge to manslaughter on the grounds of diminished responsibility.

“Malign forces”

Paranoid schizophrenia is a subtype of schizophrenia, a severe and chronic mental disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, better known as the DSM-4, defined it by “preoccupation with one or more delusions or frequent auditory hallucinations.” (The Fifth Edition, however, no longer recognizes “paranoid schizophrenia” or other subtypes.)

Calocane experienced paranoid delusions in which he believed he was being targeted by “malign forces” and agencies such as MI5 (Britain’s domestic counterintelligence agency) which were controlling his thoughts and behavior. The symptoms apparently began in 2019.

Auditory hallucinations (i.e., hearing voices) reinforced his beliefs. Calocane’s thinking seemed muddled, and it’s possible that his inability to distinguish between reality and delusions impacted his judgment. He may not have lacked the ability to distinguish between right and wrong, but his condition could have affected his ability to assess situations accurately. If this sounds unclear, that’s because it is. This is why the legal system accepted diminished responsibility and committed Calocane to a medical facility where he would presumably receive psychiatric treatment. But it was a controversial decision.

Had the forensic psychiatrists not persuaded the judge, he would almost certainly have imposed a lengthy prison sentence, probably life. Instead, the judge accepted Calocane’s guilty plea of manslaughter and handed him a restricted hospital order. In the UK, if judges determine that an offender poses a danger to the public, they can invoke section 41 of the Mental Health Act and commit the offender to an indefinite period in a special hospital where physical security arrangements are the equivalent of a prison’s. (There are nearly 8,000 people currently living under such conditions in the UK. Historically, the Moors murderer Ian Brady, Peter Sutcliffe aka the Yorkshire Ripper, and infamous gangster Ronnie Kray, all spent periods of their sentences in high-security hospitals.)

The parents of Webber and O’Malley-Kumar were understandably enraged by what they regard as leniency shown to their children’s killer. As far as they were concerned, it was murder, and Calocane should have been charged accordingly. Webber’s mother Emma declared that “true justice has not been served” and accused the police chief of having blood on his hands.

“This man [Calocane] made a mockery of the system and he has got away with murder,” added Coates’s son.

The medical model of mental illness

The case forces us to think about mental health, but not in the almost-comfortable way we ordinarily turn it over in our minds. Rock stars, athletes and other celebrities habitually solicit public sympathy by professing their so-called mental health issues, typically undiagnosed and self-treated.

According to the World Health Organization (WHO) 301 million people worldwide suffer from anxiety disorders and over 280 million people have depression. The WHO estimates that 1 in 8 people worldwide suffers from some mental disorder. Most of these people are functional in the sense that they hold down jobs and get through their days, perhaps with the help of selective serotonin reuptake inhibitors (SSRIs) like Prozac or monoamine oxidase Inhibitors like Elavil.

Graver forms of mental illness such as schizophrenia have typically been treated with antipsychotic drugs since the early 1950s. The first known antipsychotic medication was chlorpromazine. Care providers also employ non-pharmacological methods such as cognitive behavioral therapy and group therapy, but medication adherence is crucial for managing symptoms. It seems Calocane had refrained from taking medication, presumably antipsychotic drugs.

In the 1970s, psychiatry underwent a revolution. Mental illness came to be considered distinct and separate from physical health. Practitioners rejected the “medical model” which assumed that mental illness always had a physical basis. They considered it a crude, reductive simplification that was easy on the intellect, but of limited value in understanding. Unlike physical ailments that may have visible symptoms, mental health issues were more elusive, making diagnosis and treatment challenging. The subjective nature of the mental added another layer of complexity.

I learned from lodestars of the movement like Thomas Szasz (1920–2012), R.D. Laing (1927–1989) and Thomas Scheff (b.1929) during my own undergraduate studies. Each of them offered ways of analyzing mental illness as the result of experiences in social contexts, whether the family or large-scale institutions. All emphasized the importance of response, reaction and cultural labeling in affecting our understanding and treatment of people considered, rightly or wrongly, to be mentally ill. These and other sociologically inclined scholars were critical of the medical model’s indifference to social influences.

Yet treating mental illness as a disease, even metaphorically, has proven both intellectually appealing and practically favorable. The catalytic effect of Prozac (fluoxetine) in boosting the popularity of the medical model shouldn’t be underestimated. The US Food and Drug Administration (FDA) first approved it for prescription in 1987. Since then, Prozac has been widely prescribed for the treatment of depression, obsessive-compulsive disorder, panic disorder and several other mood disorders. This popularity led to the proliferation of other SSRIs.

Despite the simplification involved, approaching mental illness as analogous to physical sickness has yielded colossal benefits. As well as removing much, if not all, of the stigma traditionally associated with mental illness, it has facilitated more open discourse and, by implication, enhanced inclusiveness. No one today feels embarrassed by declaring themselves to be experiencing mental health issues — “issues” now having replaced “problems,” “difficulties” or “troubles.”

Also, by considering mental health in the broader framework of illness, society is compelled to recognize the interconnectedness of mental and physical well-being. This approach promotes a more holistic understanding of health. But, the medical model, though serviceable, should be approached with caution. Mental illness is analogous to, not the same as, physical illness. We need to respect the unique features of mental health conditions, especially when it comes to a case like Calocane’s.

Liquid society

Unlike medical practitioners, sociologists like me tend not to see the world in terms of types or categories; rather, we see it as sequences of moments in perpetual flux. Sociologist Zygmunt Bauman’s concept of liquid modernity emphasized the fluid and uncertain nature of relationships, institutions and other social phenomena.

While Bauman didn’t study mental illness, his approach would probably emphasize constantly changing patterns rather than identifiable, diagnosable types. Recently, mental health professionals visualize mental health as lying on a spectrum. Yet even this seems overly reductionist. One may be at one end of a spectrum or the other, but the spectrum itself does not change. Instead, imagine mental illness as a kaleidoscope — a mix of changing elements, confused, chaotic and unpredictable.

The mental illness may be permanent, temporary or sporadic. Its causes or antecedents may lie in physical injury or decay, or they may be congenital (present from birth). A neurobiological model of mental illness would posit that mental disorders are primarily caused by physiological factors, such as neurotransmitter imbalances in the brain. According to this perspective, conditions like depression, anxiety, schizophrenia and others would result from disturbances in the functioning of neurotransmitters.

On the other hand, the causes may lie outside the individual in social experiences such as poverty, geographical dislocation or cultural disengagement. Interpersonal relations convulsed by, for example, unemployment, bereavement, the departure of a loved one or any radical change in circumstances can give rise to trauma.

Given the scope, scale and complexity of the phenomena we group together as “mental illness,” the treatment options we have available seem limited. In the early to mid-20th century, the practice of treating mental illness with physical surgery, known as psychosurgery, gained prominence. This was the period of lobotomy, which involved severing or damaging the connections between the prefrontal cortices (which govern higher-order cognitive functions) and the rest of the brain.

While lobotomy is no longer practiced, some surgical interventions, like deep brain stimulation (DBS), are still used for conditions like treatment-resistant depression or OCD. (DBS involves implanting electrodes into certain brain regions and is considered a last resort when other treatment options have failed.) But the trend has been away from invasive methods and toward medication and psychotherapy.

So, how much confidence should we have in British Prime Minister Rishi Sunak when he promises Calocane’s victims’ families that “we will get the answers”? Do we even know the questions? The Calocane case challenges us to square circles when we don’t know whether a circle means a figure consisting of points equidistant from a center, or a curved upper tier of seats in a theater. In other words, when you and I talk about “mental illness,” we don’t even know whether we are thinking about the same thing. How could we begin to talk about the diminished responsibility “mental illness” supposedly implies?

If Calocane resisted taking prescribed medication, was he exercising freely willed choice? Or was he behaving in accordance with delusions or auditory hallucinations? Can he thus be held responsible? At the moment, the answer is “no,” or at least, “not completely.” This may change when Attorney General Victoria Prentis completes her review of the case.

Still, she will discover that the case poses problems incapable of an indisputable solution. No matter how many sides to the argument Prentis considers, her conclusion will be controversial. Mental health resists pat answers; it just offers tougher questions.

[Ellis Cashmore’s most recent book is The Destruction and Creation of Michael Jackson.]

[Anton Schauble edited this piece.]

The views expressed in this article are the author’s own and do not necessarily reflect Fair Observer’s editorial policy.