Does Not Compute

The whole issue of “suicide intervention” really isn’t lying down for me at the moment.

The response from that commentator on The Other Way Around continues to bother me. (I am a ‘reflector’ – I can’t help it.)

I have been thinking about the number of suicide interventions I have been involved in, the training I (haven’t) had, the legislative dilemmas, the responsibility and the responses from other agencies. None of it is sitting well with me.

Part of the problem stems from identifying what a call from a suicidal person actually means.

In my experience, if someone calls the Crisis Team and expresses suicidal thoughts it is rare for the Crisis Team to do very much with the caller. Sometimes they even simply suggest calling the police.

Compare that to the police who will inevitably send a unit to the location.

This is a huge difference in approach and I cannot understand it.

I have had arguments with Crisis Team staff on many occasions. This doesn’t exactly please me but it has always been down to differences of approach. In a recent example, the person I spoke to on the telephone was quite comfortable to assume that the person in question was drunk because they had spoken to them on the telephone. As a result of this they were quite comfortable in refusing to engage in any way and refuse to do anything to assist in resolving the issue. Leaving officers with an apparently suicidal person and no powers to do anything.

In another example I have heard of a situation where the Crisis Team have called the police because they were now “concerned” for the welfare of an individual who had been to see them and now could not be found.

This led to six hours of frantic police activity before the person concerned was located. By this time it was too late.

It transpired that the person had attempted suicide two or three times in the preceding week, had been to their GP, been referred to the Crisis Team who sent them home with medication.

12 hours later they had taken their own life.

The authors comment as well mocks me for not being medically trained. It’s not a medical issue – “In reality it’s just a difficult person you don’t know what to do with?”

That *I* don’t know what to do with?
Why is it a police issue?

From experience, these and many other examples and the comments I can only therefore assume that simply being suicidal is not enough to fully engage the services of a mental health team.

And whereas the police will treat all suicidal people as “immediate priority” or “high risk” that this risk assessment is not shared by those operating within the mental health services.

This is something I am finding very difficult to reconcile.

Who is right and who is wrong?
Can you accurately grade the level of risk in someone who is suicidal? Can you do it over the phone?

There is an old wives tale which suggests that the people who call the police saying that they are going to commit suicide are not really going to go through with it.

The myth suggests that those who are intent on ending their own lives with just go off and do it without telling anyone.

I wouldn’t like to suggest that this is accurate but in my experience it can go either way. Usually – and I base this purely on empirical evidence – the cases where someone else reports concerns for someone who is suicidal tens to be the ones which don’t end so happily. I have no idea if it is statistically true – I don’t actually think it is.

However, in just about every single one of these cases where someone has suddenly disappeared when you start asking questions it is quite clear that there is a history leading up to this point. It usually comes from friends or family members who will talk about how the person was depressed (clinically diagnosed or not) or may have had a significant negative life event or who had tried or talked about suicide in the recent past.

When my friend took his own life four years ago it was a complete shock to me. But that is only because I didn’t know the history. When his wife frantically banged on my door to say that he had gone missing I flicked into “work mode” and started asking the usual questions. At this point I learned that he had been very down for ages, had been to his GP, had been thinking or dreaming about suicide and had been prescribed anti-depressants.

I thought he had seemed “down” but he had hidden it well from me. He had been more honest with his partner.

None of us had assessed just how bad his depression was. Not even the doctor.

What strikes me is that whilst this is all building up – whether someone seeks help or not – the response never seems to be what you would classify as an emergency response.

I would like to be corrected on this but it seems that most people are sent away to continue to self manage the issue.

The author of the comment on the previous blog criticises me for thinking that by being suicidal it automatically makes someone “ill.”

I don’t think I have ever said this exactly and I have learned that this does not seem to be the case.

Trying to loosely categorise suicidal people has led me devise this, very unscientific, list:

1: truly suicidal
2: potentially suicidal
3: depressed
4: cry for help
5: attention seeking
6: drunk and 1-5

How do you determine between them? How can Crisis Teams take such a different risk assessment on the same facts than the police will take.

How do you determine the difference between 1 and 5 or 6 if both are hanging over the edge of a bridge?

Ultimately the police (and ambulance / fire) are most likely to be the services dealing with such a situation.

Which takes us back to training. With the exception of trained negotiators, police officers have had no suicide intervention training and there is nothing within the police service which provides any form of after care for a suicidal person. There is no “suicide intervention” department. We crisis manage and then refer back to the health service.

There are charities and voluntary services out there who can help but I don’t think we have really and properly tapped into their resources.

Another stark difference can be found when you look at what happens if someone calls the police and says they are suicidal and if someone calls The Samaritans and says the same thing.

The Samaritans are a charity and are not beholden to Article 2 of the Human Rights Act of course but their staff are probably a damn site more effectively trained to deal with a suicidal caller than a police call taker.

Police response is to send a unit. The Samaritans don’t do that.

The upshot of all this, it would seem, is that the only organisation who routinely and consistently treat a “suicidal” caller as presenting an immediate high risk are – the police.

Why is this? Have the police become so risk averse that they daren’t do anything else? Is the health service not taking risk assessment seriously?

Is it because the police have been so heavily and scrutinised and criticised where things have not ended well?
Has this level of scrutiny and criticism ever been equally applied to mental health teams?

Is there as effective and intrusive a body as the IPCC looking into possible shortfalls in the Health Service?

If there isn’t – shouldn’t there be?

It all comes back to the question I posed in “Whose Line is it Anyway?” – if it isn’t a medical issue and the police have no powers or training to deal with it then who should take primacy in dealing with suicide intervention?

Put it it another way – why do we expect an agency with no powers or training or support services in suicide intervention to deal with suicide intervention?

This really isn’t computing with me and the more I think about it the more confused I get.

How can one agency say “this person is drunk and we aren’t helping” whilst another is left standing there thinking “What do we do now? We can’t just leave.”

Should police “just leave” after making a number of sensible calls for advice and assistance.

I am pretty sure that the subject of suicide intervention is probably worthy of a national summit. A national summit involving all interested agencies and charities.

Would anyone in a position of authority like to organise one because this needs thrashing out?

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9 responses to “Does Not Compute”

  1. anonymous says :

    It’s true that previous threats of suicide should be taken seriously & are included by most MH professionals when undertaking risk assessments. Also previous attempts whether presumed as ‘a cry for help’ or not are risk indicators. Ask carers what they are told to do if immediately worried out of hours or if emergency MH appt not available (which is the norm) & carers will tell you they are told by the MH team to call the police. MH services need to think about the message they are giving to suicidal patients- if they aren’t bothered enough to provide crisis care, refuse to admit ppl after 136 sections etc how is that suicidal person going to feel? Bit of a low blow to someone who already feels their life isn’t worth living. The reality is that 90% of the time it is carers, friends & emergency services who are on call for suicidal ppl & most of them are not equipped to deal with this & advise the patient to speak to his/her MH worker. Who isn’t available or particularly interested. And so the cycle of attempts & threats followed by inadequate care continues. No wonder that it ends all too often in a completed suicide.
    Keep on pushing for change NC!

  2. Paul Alker says :

    A valid blog that shows how the Police are used by other professional bodies, probably due to the perceived risks involved, lack of resources and under-funding.
    How it came to this, simply passing the “problem” to the Police, where I would suggest most front-line officers have no training in mental health nor suicide prevention? Mission creep, senior professionals realising budget constraints, lack of resources, or just plain “the police do 24/7 response constructs?
    Lives lost?
    I do hope the wishes of the Inspector come to fruition and a summit and meetings come to fruition. Time for change, time for others to consider their responsibilities? New pathways need to be considered. I would assist in ensuring change; those in need deserve better. It is basically unfair to put it all on the Police.

  3. Mike D says :

    I can’t help but defend the Crisis teams again, simply because i used to work for one and i still keep in touch with ex-colleagues who work in an extremely busy team. You comment that ‘In your experience it is rare for the Crisis team to do much with the caller’. However the vast majority of calls crisis teams receive from suicidal people the police will never hear of. They are dealt with professionally, sensitively and successfully without involving the police. Sure sometimes things go wrong, i know from experience that not all staff are confident in dealing with high risk situations and are quick to off load difficult situations onto other agencies but that doesn’t mean the police are the automatic default alternative.
    I do think that the sheer number of calls a Crisis team or A & E Liaison team takes from people expressing suicidal thoughts can lead to complacency and it is up to the professionals to guard against this but most do. However what it also teaches the mental health professionals is that the vast majority of people who ring saying they are suicidal are not, certainly not at that precise moment. This may explain the difference in the risk assessments made by Police and Crisis teams.

  4. anonymous says :

    I think this is the problem. It becomes more about chance than risk. We know that expressing suicidal intent is a big risk factor but some staff take the chance that person X won’t do it because they’ve threatened it before, or because person Y made the same threats & didn’t do it. In my eyes that’s not patient centred care.
    In considering parity in MH care- would a known cardiac patient be refused full assessment if he complained of chest pains even though he had done this several times before & not had a heart attack yet? I doubt many community cardiac nurses would be confident in ever documenting that they’d left it to the police to ascertain that the person was safe & well. (I may be wrong as I’m not a community cardiac nurse so feel free to correct me!)
    The crisis is there already when someone is desperate enough to be in touch with emergency services, whether or not it leads to them completing suicide they are surely at a desperate point? I would’ve hoped that repeated emergency services contacts indicate that the person is lacking input in other areas and maybe other MH teams (Early intervention , CAMHS etc) should be providing more input for their clients should the person be recurrently presenting as in crisis.
    I do appreciate the immense pressures on MH staff. I think the underlying issues are that the beds aren’t there anymore, acute care isn’t always great, there’s a lack of suitable community care & the carers are not supported. Hence why people keep ending up back in crisis.

    • Myrtle says :

      “The crisis is there already when someone is desperate enough to be in touch with emergency services … I would’ve hoped that repeated emergency services contacts indicate that the person is lacking input in other areas”
      Spot on.
      A related issue is that psych services tend to distinguish between a ‘mental’ issue (the voices are telling me to kill myself) and a supposedly ‘social’ one (life isn’t worth living since my partner left/I want to die because I am homeless and frightened/etc). There’s a sort of twisted logic that says if there is good reason to be distressed/terrified, it somehow doesn’t attract support.
      Those diagnosed with so-called ‘personality disorder’ are in an even worse position – despite it’s high co-morbidity with other recognised disorders such as depression. Even if their distress is purely down to their disorder they will be dismissed by services BECAUSE of this, ie. “they’re alwyas like that”. Nvermind the long-term damage being done to somebody who lurches from one crisis to another without any support to help them cope, having their low self-worth compounded by being treated as if their pain doesn’t matter.

      I call the whole issue around suicide and attempting to get psychiatric help “the Suicidal Paradox”. (Own blog post coming soon..!)
      Basically, if one is suicidal and asks for help, doesn’t get it, and remains alive… then apparently it’s attention-seeking/they weren’t serious/in real danger. If you’re dead, they then know you were serious.
      Obviously this is not much use to anybody!
      It seems then, that the only chance of getting help is the very first time someone is suicidal – after that they’re either dead or dismissed as not serious.

  5. Me says :

    “Samaritans don’t do that”
    No, but it’s not because they don’t believe someone that the risk is real when they say they’re suicidal. They just understand that the cast-iron guarantee of confidentiality and non-intervention is crucial in helping people feel it’s safe to talk, and having somewhere to do that saves lives. Probably many more lives than intervening… that ‘saves them’ the first time, but once that trust is destroyed and there would be nowhere else safe to talk left the second time, what then? I for one probably wouldn’t be here.

    Not a stance the police can take, or arguably ever should. But I agree that there’s a pool of skills and experience there – all the things the Samaritans do instead of intervening – which sounds like it could be a useful addition to your toolkit.

  6. Myrtle says :

    A few months ago a friend of mine was taken to hospital by police under a section 136 for an assessment by the crisis team. He was then put on a hospital section, but they couldn’t find him a bed, so quietly ‘un-sectioned’ him (pretty sure this isn’t legal!)
    The cop who took him back home actually stayed there for several hours, just chatting with him and drinking tea, as he was so concerned for my friend’s safety.
    Funny how those whose job it is to care for mentally ill people are often the least useful or compassionate… and the real care and help comes by chance from someone going the extra mile.

  7. Myrtle says :

    “Usually – and I base this purely on empirical evidence – the cases where someone else reports concerns for someone who is suicidal tends to be the ones which don’t end so happily.”
    You have quite rightly been cautious in saying this, but it appears to be a view commonly held by mental health services. The more skeptical amongst us would say this is because family/friends calling with concerns means family/friends who will seek justice if the person commits suicide for want of treatment! It seems to be a general feature of the MH system that it is easier to get appropriate treatment if the individual has some kind of advocate.
    On the other hand, those with friends or relatives who care about them enough to enter the maze of trying to get MH treatment are also easier to fob off onto said friends/relatives as an alternative to actually doing something.

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