The Point of No Return
Events and reports from recent weeks have caused me to delve a little deeper into the concept of “violence” during a mental health crisis.
At the end of this I am now more convinced than ever of the unfairness (to both the patient and the officers) of expecting the police to deal with such situations.
I have only scratched the surface and my research could best be described as “unacademic” but it was a paragraph in Lord Adebowale’s report which got me thinking.
It can be found on Page 19 and it says this:
The police deal with situations involving violence, both on the street and in custody, as a regular part of their work and understandably violence is something they expect. However this can then be used to describe any form of resistance to them. This then turns into an unconscious bias that automatically links mental health and violence and indeed then reflects a prejudice that is still common among members of the public. The language used to describe the situation (from CCC onwards) is that of danger and violence when in fact there was, at the time, no indication that violence, (rather than resistance or agitation when the police approached) was involved. In several cases there was significant force used (including blows to the head, gunshot wounds and tasers) but the evidence is not clear as to whether alternative techniques would have produced less traumatic results
Even for someone with as much of an interest in mental health as I have this came as a surprise. Surely violence is violence – right?
No – what I have learned from even the most cursory of glances is that violence is not violence and we are dealing with two very different things.
Lord Adebowale’s report makes the distinction between “aggression” and “violence” and says that police officers don’t differentiate between the two well enough.
In fact, I have since read a report which goes one step further and says that there is a continuum which runs from anxiety to high anxiety to agitation and into aggression. Presumably, from there, the next step is violence.
I have also learned that the violence in a mental health crisis is coming from a very different place than violence for violence sake.
Although police officers use the National Decision Model (as used to be “The Force Continuum”) to constantly and dynamically assess risk and respond to it appropriately there seems to be a big gap in the tactics police officers have been trained in when it comes to dealing with violence in a mental health crisis.
We have been taught that verbal communication is a vital and important step in “conflict resolution” but have never been given any specific training in types of verbal communication.
There is comprehensive training in unarmed defence tactics, hand-cuffing, ASP, CS and physical restraint but, as Lord Adebowale’s report states, they all rely on the same principle – pain compliance.
This is where the distinction in types of violence becomes critically important.
If someone is being violent because they want to hurt police officers and they are unaffected by substances then it is likely that pain compliance will work. Eventually it will subdue someone , they will be “over-powered” and will submit.
This, of course, changes if someone is affected by drugs or alcohol and this is a known factor when dealing with such instances.
However, I have learned that pain compliance is not likely to work when someone is suffering an acute behaviour disturbance or mental health crisis.
The “fight” in someone in this state is almost primeval. It comes from deep within. It is true “flight or fight.”
For someone experiencing delusional psychosis then, in their minds, it is very likely to be a life or death fight. Their desperation to escape, driven by the psychotic beliefs they are experiencing, means that they aren’t going to give up.
Add to this the increased risk of cardiac arrest from certain anti-psychotic drugs and also the increased likelihood of excited delirium it is no wonder then that prolonged restraint in a mental health crisis is classified as an acute medical emergency.
There is a wealth of evidence which suggests that non-coercive “rapid de-escalation techniques” are the first and preferable option when someone starts moving through the anxiety continuum.
I have read that these techniques can be effective even in the majority of “aggression” situations if given long enough (roughly ten-fifteen minutes) to work. The effort required by someone employing the technique is Herculean. It requires the practitioner to put their own “fight or flight” instincts aside and stick to a very repetitive message which aims to bring the patient “under control” in a guided manner.
No physical force is applied during this technique and this, in itself, carries risks but it appears to work.
The guidance I have read does recognise that there will be cases where it doesn’t work or simply isn’t appropriate because of the immediate risk presented by the patient to themselves or others. In these cases the guidance says that restraint is likely to be required.
It is here that we run into the major problem facing the police in dealing with such a situation.
There are very strict guidelines and advice given to medical practitioners for such occurrences. As previously stated, this is defined as a medical emergency and, as such, there must be immediate access to a defibrillator, all staff must be trained to at least intermediate life support first aid and a doctor must be readily accessible to administer the ultimate resolution if necessary – chemical restraint.
This rapid tranquillisation is only to be used in extremis but it prevents the need for prolonged restraint and all the inherent risks it carries.
Another option is to restrain briefly and, if in a mental hospital, take the person to a specially equipped seclusion room where they can do no harm to themselves or others and can be monitored safely. These seclusion rooms are suitably designed for purpose.
Whichever option is necessary or achievable, the physical restraint is not about pain compliance and only lasts as long as is necessary to chemically restrain or seclude the patient in a safe environment.
Specifically, it has also been decided that, in the UK, the use of mechanical restraints is neither clinically nor socially acceptable in a medical setting. The use of “straight jackets” or other forms of restriction are simply not used any more.
We can therefore, reasonably assume, that medical staff have a far better ability to recognise what is happening, they have techniques and tactics available to them to try and resolve the situation verbally and, if restraint does become necessary, they have the medical facilities, suitable rooms and medical training to be able to resolve the situation rapidly or be able to deal with any medical complications which arise.
To put it bluntly and abruptly – the police don’t have any of these things.
From everything I have read and seen recently I believe that police officers are not trained to differentiate between aggression and violence (particularly not violence with a mental health cause) and are likely to resort to physical restraint far too early.
When they do take that option they only have “pain compliance” in the tool box and it is likely that mechanical restraint (cuffs, limb restraints) will be used.
Neither of these options is advocated in any medical guidance and police are dealing with a medical emergency.
If it were just these issues then they could be rectified through training in the presentation of mental health conditions, rapid de-escalation techniques and different forms of restraint.
The problem, however, goes further.
One problem is cultural and the other is strategic.
Changing the way officers react to aggression – and in particular mental health related aggression – is going to take a massive cultural change.
Police officers “DO” and often “DO QUICKLY”.
The path of least resistance when dealing with an aggressive or violent mental health detainee is to gain physical control, apply restraints, convey rapidly to a police station and secure in a cell. This is a recipe for disaster as has been shown many times and is well documented in the Adebowale report as well as a number of IPCC reports.
Changing the mindset of officers to recognise that this is absolutely the last thing they need to be doing is going to be hard.
The main difficulty facing officers, however, is the lack of options available to them.
Once officers decide that restraint is necessary (and it often is) they have reached a point of no return.
If this happens at the roadside there is a problem with conveying the detainee to a place of safety.
If the person is that violent then there is always the possibility that the hospital place of safety will refuse to accept them. (We know that they refuse patients who aren’t even remotely violent – just resistant – and that these Exclusion Criteria are in direct contravention of the Royal College of Psychiatrists guidelines.)
At present the officers then have no option other than to restrain and convey the detainee in a police van.
This in itself is an area of major focus in the Adebowale report – which states that the practice should end forthwith and ambulances be used instead.
Police van or ambulance – the officers are then faced with the situation where the only place they can take the detainee is to a police custody unit.
Police custody units do not have suitable seclusion rooms.
Police custody units do not have the emergency medical facilities to deal with this medical emergency and police officers cannot administer drugs to chemically restrain a patient (nor should they EVER be allowed to.)
Whether a mental health crisis involving the use of restraint takes place at the roadside, in a house, in a police station or in a mental health hospital there is only one place which is adequately prepared and equipped to deal with it.
In whichever of these settings it may take place the SITUATION is exactly the same – it remains an acute medical emergency no matter where it is happening.
The guidelines for dealing with it in a medical setting are very clear – there are no guidelines for dealing with it anywhere else. If there were – they would need to be exactly the same.
How can it possibly be right or fair to the detainee that if one agency deals with it it is dealt with appropriately and with all the right training and equipment and yet, if it is dealt with by another, then none of this is in place?
How can it possibly be right or fair to expect police officers to deal with a clinical emergency when all they have available is brute force, mechanical restraints, no appropriate training and without having been taught the best way to “talk down” a patient in crisis.
Once officers move to restraint they are trapped with nowhere to go. They have passed the point of no return and the risks to everyone concerned suddenly go through the roof.
There will always be a need for police to become involved in medical situations especially ones involving potential or real violence but these are life threatening situations, they are happening daily and it simply isn’t fair on anyone involved.
A medical emergency should be dealt with in one place and one place alone – a hospital.
If it happens away from a hospital then the person needs to be taken to a hospital rapidly and by medics (with police assistance if necessary.)
Once there – the handover to medical staff should be immediate.
A police station is not a suitable place of safety and police officers involvement should be temporary at most.
We do not expect psychiatrists to investigate crime or deal with public order situations.
Why, therefore, is it deemed acceptable for police officers to be left to their own devices and be expected to deal with mental health crises and the resultant medical emergencies?