During a discussion this week about police responses to particular types of individuals who come to police attention a question was put about acute anti-social personality disorder. It revolved around a man who had been in contact with the police on at least one occasion in every year since 1999 and situations typically revolved around hostage situations, barricading himself in his flat and severe slashing and self-harm. The police were spending and inordinate amount of time responding to these situations, one of which had involved a female police officer being held by this man for a few hours against her will. More often however, the situation did not involve him committing offences, but did involve what any police officer or lay person would call mental health problems. Hence most police responses involved attempts to access medical services, often through the use of s136 of the Mental Health Act and removal to a place of safety.
The story had a frustrating end for the police officers however. Although occasionally the man was sectioned under s2, he was often released within a few days or a week. Acute anti-social personality disorder. So he has got a mental disorder? He has a mental disorder he’s engaging in severely destructive behaviours, occasionally involving risk to other people and sometimes involving him using weapons to hurt himself? So why can’t he be kept in hospital and treated?!! Especially – why can’t he be kept in hospital for treatment when there is now a litany of evidence that if not detained, he will continue to engage in further behaviour that bring him back to police attention in sub-criminal, barely criminal or obviously criminal circumstances?
As I got interested in this area, I kept hearing people talking about ‘the medical model’ of mental illness. I also kept hearing people talk about the psychological model and the psycho-social model of mental illness. I’ll be frank: this confused the life out of me. Illness is illness isn’t it? … and that means doctors and nurses, right?!
Well – it turns out that it’s not. I learned of various ‘approaches’ to mental health and I would be grateful for any feedback on what I’m about to write, without ripping me to shreds for the simplicity of this explanation for the benefit of police officers! – to describe me as ‘out of my depth’ here, is somewhat of an under-statement! If you want to read more by someone who knows what they are on about, I recommend Stuart Sorenson’s blog on the subject of ‘models’ of mental illness.
THE MEDICAL MODEL
The approach to mental ill-health, as illness or disease. A considerable amount of time and effort over the last 175 years has been spent attempting to uncover what have been assumed to be underlying causes of ‘brain disease’. History has seen psychiatrists from Emile Kräpelin onwards working to understand causation in mental illness and to classify it into discrete disease entities, identifiable through symptom clusters. The medical model, with psychiatry as a specialist sub-discipline of the broader medical profession, sought to use the two traditional approaches of medicine to cure disease entities: pharmacy and surgery. The use of drugs to treat mental illness really took off in the 1950s with the discovery of the anti-psychotic chlorpromazine and pharmaceutical developments continue to the present day. More infamously, a more ‘surgical’ approach mental illness – psychosurgery - included leuchotomies (or lobotomies) as well as Electro-Convulsive Therapy. ECT is still in use today, although the law now means in cannot be forced upon people.
Psychiatry became controversial for some during the 20th century because of its history and its more infamous techniques. It also became associated in some regimes to state supression. Some of that history is reflected in current practices: for example, psychiatrists in Germany need the legal system to independently authorise and oversee its practice of compulsory admission following various problems involving psychiatrists during World War Two.
Of course modern professional psychiatry is inter-disciplinary in nature and legal frameworks around compulsory admission or treatment focus ever more on personal autonomy, consent and the right of appeal against state enforce treatment in the context of universal human rights.
THE PSYCHOLOGICAL MODEL
Of course, psychological approaches to mental health issues have become more widely known about in recent years. Clinical Psychologists (and forensic psychologists) are more frequently found in multi-disciplinary teams now than they were even thirty years ago but medical recommendations to ‘section’ can still only be taken by psychiatrists. The law is still drafted with the medical model in mind, although AMHPs take the civil liberties decision to detain.
Looking at mental illness from a psychological point of view, or attempting to address mental health problems using psychological techniques (often via ‘talking’ therapies such as Cognitive Behavioural Therapy) is often claimed as successful with conditions like personality disorders and Post Traumatic Stress Disorder. It’s about examining how to relieve symptoms of mental ill-health by addressing how people think about their experiences in order to contextualise them or find coping mechanisms for historic events or for the onset of anxieties, depression and crisis. Good books to read on this include “Doctoring the Mind” and “Madness Explained” by Richard BENTALL.
THE SOCIOLOGICAL MODEL
Looking and mental illness from a sociological point of view, entails looking at social structures and the pressures they bring to bear on societies and social groups as well as upon individuals and their particular circumstances. Necessarily, this involves poverty and debt; family life and education; and employment and equality. Far too simply: is it reasonable to predict that someone who suffers a difficult childhood, poor education and struggles into adulthood with little or no employment prospects in a life maintained amidst poverty, drug and alcohol abuse may suffer from mental ‘health’ problems; is it it possible to look at an individual struggling to cope in any kind of abusive relationship without wondering about whether their consequential symptomatology would be relieved if that abuser were removed from the equation one way or another? Of course it is. A good book on this, is Allan HORWITZ’s “Creating Mental Illness”.
A NATURAL VENN DIAGRAM
Of course, in reality, suffering mental illness is a balance of all of these things: notwithstanding ongoing debates about causation we know from research that genetics and biology do have an impact upon propensities in mental disorder. The extent of their influence may be debated, but no-one doubts that influence is there. Can we remove the relevance of social structures and circumstances as well as individual psychology from experiences of mental illness? Again, no.
I am going to stop there before my attempts to explain further embarrass me and people who know me! – so where does this leave us with the acute anti-social personality guy at the start?!
There are three ways in which society can respond to individuals like this, regardless of their diagnosis or specific condition:
- coercively – and detain under Mental Health Law for compulsory assessment or treatment
- coercively – by prosecution under criminal law with a view to disincentivise or incarcerate
- non-coercively – and by seeking to ‘engage’ individuals in relevant recovery / treatment programmes
Of course, the law allows a ‘blend’ of these approaches: after prosecution, it is possible for Magistrates to impose a ‘Mental Health Treatment Requirement’ as part of a community sentence, although this is not often done. It obliges individuals to engage with health services amidst a threat of sanctions if they do not. There are other versions of how these things can blend.
You will notice that mental health law kicks in when risks are posed: not when health is at risk. <<< This is the heart of it all, for me.
It was only recently when the Mental Health Act 2007 was enacted to amend the 1983 Act that the definition of mental disorder and ‘treatability’ requirement for personality disorder was expanded. When I first joined the police, it was almost always the case that upon discovery of personality disorder, mental health professionals would decline to admit someone to hospital or bring their detention to an end, even where they posed a risk to others. In particular, such individuals were often thought more suitable for criminal prosecution where offences had been alleged. That’s where it can start to get fractious: he’s suffering from mental disorder (PD) and posing a risk to himself or others, but can’t be detained?! OK, but when we tell the CPS he’s got a mental disorder, prosecution considerations start to turn to ‘diversion‘ (whatever that means).
So the police service have two broad options when faced with repeat callers like this who often absorb a phenomenal amount of resource:
- Where there is no criminal offence: keep referring the matter incident by incident to the NHS and where repeat callers and becoming high consumption callers;
- Where there is a criminal offence, consider using it as tactic to achieve a ‘blended’ approach through the justice system: assuming of course that ‘diversion’ has been tried and failed.
A whole book was once written to an individual who, on a much more serious scale, represented this dilemma for health and justice professionals: Garry David, from Melbourne, Australia. Deidre GRIEG’s book “Mad or Bad” is a brilliant exposition of how the State of Victoria wrestled with the debate about how to manage a high-demand individual who posed a significant risk to the public, who had a diagnosis of mental disorder, but who it was repeatedly argued could not be detained under normal mental health law. Eventually, the State enacted the Community Protection Act 1991 – a law specifically designed for Garry David and no-one else. An extraordinary case which brings this whole debate in to a sharp focus.