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?

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6 responses to “The Point of No Return”

  1. Mal says :

    Insightful as always, thank you, totally agree.

  2. northmead01 says :

    This should be national practice. I can’t understand why it isn’t. How many more deaths and near deaths will have to happen before it is? Then the officers that have been trying to ” do the right thing” are investigated by the ipcc? I have been, doing it as per mha codes is virtually impossible in my area. This is due to ignorance and operational inertia from all the agencies involved. SMT in all areas must make it right. Its a scandal.

  3. Victor says :

    This is an excellent article and makes the point we made in the report with eloquence and a deep knowledge of policing and an admirable respect for the public. I would hope that senior leaders across policing take note of the pressure from the grass roots for the tools and training to be able to deal confidently with these incidents. But the key point and one made in my report is that the NHS needs to step up to the plate the Police should not be dealing with MH incidents alone and should expect and receive expert medical support in sec136 suites, in hospitals and in the community. Voa

    Lord Victor O Adebowale

    • nathanconstable says :

      I am truly humbled by you taking the time to read and comment on my article.
      Thank you so much and thank you for the report you have written – I believe it will be a game changer.

      NC

  4. jezabella07 says :

    As always sensible suggestions having to deal with this every other day I don’t believe that anyone whose mental health has declined in such a way that we find it necessary to arrest them and take them into police custody it saddens me that this is the only solution in the 21st century we have to help these people . Police custody is no place for such a person they need professional medical care a police station should not be deemed as a place of safety it’s not a permanent solution at all it’s a solution to enable them to receive the medical help they should of received in the first place . But then you know I have strong views not from my job but my personal experience with family members . Well written your wasted just writing blogs

  5. Rachel Rogers (@DorsetRachel) says :

    You have written that physical restraint is the point of no return and that, when that point is reached, there is currently no exit strategy. It seems to me that this lack of exit strategy is key here. In prisons, restraint takes place on a regular basis, including the restraint of prisoners who are experiencing mental health difficulties. However, physical/mechanical restraint in prisons is primarily a holding action, used until the area can be made safe and the prisoner can be moved to a more appropriate location. This doesn’t normally take long. Five minutes. Ten max except in exceptional circumstances. And a good supervisor will be hawk-eyed to ensure that the restraint lasts no longer than necessary, that there is no unnecessary (and therefore illegal) use of force. And so there is an exit strategy, which is the resolution of the incident which caused the restraint to be used and, if necessary, the successful relocation of the prisoner to a place of greater safety. It seems that in a police station, the relocation aspect of this strategy is mysteriously absent but that this could be resolved fairly easily by redesigning custody suites to ensure the presence of a safe environment and by building new custody suites to include such a facility. Clearly this would have staffing implications but so too does prolonged restraint and it would pose less risk to the health and well-being of both staff and detainee.

    However, from reading this and other blogs, it appears that there is also a need for increased training in de-escalation techniques. De-escalation techniques are prison officers’ bread and butter. Good officers are those who are rarely assaulted, who know how to defuse a situation, who know that your voice is your best weapon. De-escalating potentially violent situations makes sense in terms of reducing demand on staff, reducing injury to staff and reducing wastage of staff time through sick leave. It also improves both morale and relationships with the public – especially with those young people who may be quick to anger.

    There is plenty of information online about de-escalation techniques. I have chosen these two examples for their relevance to the point in hand.

    Police Chief Magazine claims to be the official publication of the International Association of Chiefs of Police. This article, from the May 2004 edition, deals specifically with de-escalating juvenile aggression and I would recommend it wholeheartedly.

    http://www.policechiefmagazine.org/magazine/index.cfm?fuseaction=display_arch&article_id=288&issue_id=52004

    The author explains that “juveniles are unlike adults physically, psychologically, and socially, and the aggression they display toward authority figures is significantly different from the aggression displayed by adults” and adds that, as a consequence, “effective techniques used to de-escalate juvenile aggression are different from those used to de-escalate adults”

    CPI (www.crisisprevention.com) is an international training organization committed to best practices and safe behaviour management methods that focus on prevention. CPI stresses the importance of listening with empathy.

    This article, which was originally published in Law and Order magazine, focusses mainly on empathic listening:

    “Like other skills, empathic listening can be learned. The five keys are: give the person undivided attention; be non-judgmental; focus on the person’s feelings, not just the facts; allow silence; and use restatement to clarify messages”

    http://www.crisisprevention.com/Resources/Knowledge-Base/General/De-escalation-Tips

    For me, these skills are a pre-requisite for working with the soft machine, with the people who come within our sphere of influence. It is our job to keep them safe, to keep others safe and to keep ourselves safe. The best way to do this is by reducing both legitimate use of force and outbreaks of violence to a minimum. However, these are not necessarily skills which come naturally. Talking is a great way to resolve a potentially violent situation but if you choose the wrong words, the wrong tone of voice, the wrong body language, you may well exacerbate rather than de-escalate the situation. These are skill which require face-to-face training, workplace reinforcement and regular practice until they become an automatic weapon in our conflict management armoury.

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