A Country Mile

My esteemed colleague Michael Brown OBE, recently posted this blog called missing the point as a response to the comments of Sir Thomas Winsor, Her Majesty’s Chief Inspector of Constabulary, in relation to police managing mental health crises.

My blog Ever Decreasing Vicious Circles was posted very soon after the report was published and covers a lot of the same territory.

Both of us have attempted, in our own ways, to consider the issue of whether we actually want the police dealing with such incidents and how we have ended up in this position. Not just looking at the how we do it or the where we do it – but asking the more fundamental question of how it got to a position where the police are a first resort response to mental health issues?

I don’t wish to keep going on about my own research into this area but I have been looking at specifically this issue during the early stages. I think I have a good idea though it may not be the full picture.

This morning, Michael posted this tweet and invited us to *think* about the comments made in response to his post.


I did so and replied to Michael with a simple tweet.


There are a great many issues arising from the replies and they absolutely lay bare the distance we have to travel before the various agencies can be said to be on the same page.

First, I would invite you to note the difference in approach coming from the medical respondents. There is a very consistent theme that people should be prosecuted rather than taken to hospital. Regular reference to “inappropriate” use of Section 136 and even the phrase “wasting police time.”

My initial research identified something of a cliff-edge when it comes to provision of care. Whilst personality disorders are recognised as mental disorders in both of the main clinical classification books (DSM5 – ICD10) there appears to be some debate about how best to treat them. There is a large school of thought which asserts that hospitalisation is not the best form of treatment and yet there is another which advocates this very approach at the point of crisis.

Professor Louis Appleby, as identified in Michael’s blog, was one of the most vocal critics of Sir Thomas’s comments describing it as a “simplistic analysis of complex problem, lack of data & no recognition of positive collaboration in many areas.”

It was actually Professor Appleby’s research in the late 80’s which identified that psychiatrists do not like dealing with patients with personality disorders. (Lewis and Appleby 1988)

The questions were asked again more recently by Dimitrios et al (2016) who replicated the original 1988 work to see if attitudes had changed. They had. They were considerably worse.

There appears to be a major problem in how people with personality disorders are being cared for or managed.

Several of the respondents to Michael’s blog commented on the inappropriate use of Section 136 but Michael was able to quote stats which showed that in one area at least 75% of people coming into contact with the police due to mental health incidents were open to mental health services.

Which begs the question “why are so many people in crisis so frequently?”

Secondly, and linked, is the issue of how then to deal with these incidents as they arise. Police are duty bound – legally obliged in fact – to take action to protect life (Article 2 Human Rights Act) and they only have a few tools to do it. When it comes to mental health matters – in order to deal with a non-compliant person they only have one power available to them – Section 136 of the Mental Health Act 1983. This ensures that the person is taken to a place of safety for assessment.

The responses on Michael’s blog criticise the police for taking this approach. Several of the respondents clearly state that the police should be taking legal action and prosecuting people. We come back to the issue of “inappropriate use of Section 136” and what is “inappropriate”? The phrase usually used to cover this is the “conversion rate” – how many people are subsequently sectioned after a 136 assessment. Figures suggest that the number of people hospitalised is less than the number detained under Section 136 and this leads to the accusation of those who are not being inappropriately detained.

Cummins and Edmonson deal with this argument quite succinctly – their argument is that if these detentions are inappropriate then so is every single assessment undertaken voluntarily by mental health services where the person is not subsequently sectioned. In their own words “This does not stand any critical scrutiny” (Cummins & Edmonson 2016)

This fixation with conversion rates belies a complete and utter misunderstanding of what Section 136 is used for. Section 136 is used by police very frequently as a suicide prevention tool (Menkes and Bendelow 2014)

It is used because there isn’t another tool in the box.

I have been recently giving talks at work to staff on the police role in dealing with mental health and in the last one I said that the problem wasn’t necessarily down to officers or mental health staff but a lot of it came down to “crap law.”

How can you sensibly have a situation where police are the first agency to be called to deal with a suicidal person – they are compelled by law to protect life – they detain the person to ensure this happens – they take them to a medical Place of Safety – because that is the only thing the law allows them to do – and then they get criticised for it.

Which leads to the third point. What is clear is that the law, the policies, the language, the risk assessments and the guidance in relation to dealing with mental health matters are different between the agencies involved and often completely contradictory.

At the most strategic level there has been utter outcry over the criminalisation of the mentally ill, criticism that prisons are full of sick people and the whole discussion about “stigma” which even comes down to not transporting people in police cars. The government rhetoric on this is quite clear and yet the responses to the blog from medical staff (and even the entire direction of NHS Protect) was do exactly the opposite.

One argument says “stop criminalising an illness” and the other says “stop medicalising anti-social behaviour.”

Update: Michael has since blogged on this specific issue

These are utterly diametrically opposed to one another. It’s the whole irresistible force / immovable object debate. How do you resolve such contradictory stances?

My favourite quote in the responses is from the person who says “triage is a sticking plaster over a gaping bullet wound”. I am not going to criticise triage here but I am going to concentrate on the latter half of that comment.

The issues at stake here are not going to be dealt with something as simple as triage. Largely because triage cannot actually deal with the issues at stake.

They are bigger than police officers and nurses working together.

They are fundamental differences in aim, objective, strategy, language, understanding and direction. They cannot be resolved locally no matter how well everyone gets along.

These are significant national issues which will prevent us ever getting to grips with the problems identified here.

If we want the police to deal with mental health issues – if that is to be their mandate – then it needs to be properly recognised and then they need to the tools to do it.

If we don’t want the police to deal with mental health issues then we need someone else to do it. All day – every day.

Local initiatives can be a very positive thing – but this is deeper – so much deeper. We may be getting closer to some of our local colleagues in certain places but the distance between many of us – and particularly on some of the key existential issues – can be measured by a country mile.

References:

Cummins I.D, Edmonson D (2016) – “Policing and Street Triage” The Journal of Adult Protection Vol 18 No 1 pp 40-52

Dimitrios C, Michalis K, Dracass S, Tennyson L, Kamaldeep B (2016) – “Personality Disorder – still the patients psychiatrists dislike?” BJPsych Bulletin, 1-6,

Lewis G & Appleby L (1988) – “Personality Disorder: the patients psychiatrists dislike” The British Journal of Psychiatry, July 1988, Vol 153 pp 44-49

Menkes D.B, Bendelow G.A. (2014) – “Diagnosing vulnerability and dangerousness: police use of Section 136 in England and Wales” Journal of Public Mental Health, Vol 13, No 2 pp 70-82

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3 responses to “A Country Mile”

  1. jo says :

    Yes tricky area where it would be easy to make the situation worse. Ultimately unless acutely unwell we have to proceed on the basis that ppl are responsible for their own actions and attempts , even subtlety, to give the impression that services can treat/make better (magic words /give magic tablets ) tend to lead to disempowering ppl and making repeat presentations and increased risk very likely. Hence “known to services ” being used as a sign of failure . However of course ppl are individuals and an assessment can Help to support the person to begin to change ( if indeed change is what they want). Expectation management ,with a healthy dose of realism , for all concerned is important

    • J says :

      It is this sort of response as above from mh services that can tip someone with that label personality disorder over the edge. I will take a deep breath right now – perhaps more comments later.
      There is in Gloucestershire a Suicide Crisis centre who treat even those with PD with kindness, compassion and gentleness. No one in their care yet has died. Police too often have a kinder attitude than mh services who fob off, dismiss and dump on the police these ‘difficult’ service users

      • judyb says :

        I totally agree with you. Second hand experience, but being told ‘you have to take responsibility’, ‘you have to learn to manage your emotions’, really not helpful, especially when there is no-one to help you do so. More second hand experience, 20 s136s in 2.5 years, then finally treated for depression, now basically well. Why don’t community services focus on diagnosing and treating, rather than deciding on a diagnosis in a half an hour session and then not treating…….Personality disorders can also be treated, but too often people are just left to get on with it.

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