The use of physical force, by anyone, has only two outcomes: it either moves / hurts / kills people; or it moves / damages / destroys things. Whether any broader, secondary purpose is achieved by that use of force – whether the force has ‘utility’ – is quite another matter again. This is why the use of force by Armed Forces, Police Services and others is controversial and needs to be better understood.
These are NOT my thoughts – although I sincerely wish they were! The book I took on my honeymoon was “The Utility of Force” by General Sir Rupert Smith and as soon as I finished reading it, I started reading it all over again. It is a fascinating rummage through the last two hundred years of military history which was my main interest, but it is interspersed with such a clarity of thought about how one achieves a ‘utility’ in the use of force used as to render the book one of the most important things I’ve ever read.
Since then (over 7yrs ago!), I’ve continued to think of the utility of the police service’s use of force in the terms how SMITH explained his own approach. I would imagine some reading this are thinking about how appropriate it is for a police officer to be taking things from someone with a military background and considering them as being of any relevance to mental health issues? Well, reading the book – I encourage you – would reveal that SMITH’s main argument about why conflicts in the last fifty years have been often failed or been perceived to fail – Vietnam, Iraq, Bosnia, etc.. – is because it was believed force in and of itself could bring about political solutions. He rightly argued that it was a political and strategic failure to link the use of force to the expectations of the populations in those countries, that often meant that force was not perceived as legitimate. And as soon as we use the word ‘legitimate’, one will think about controversy in the UK around the use of force in public order situations – G20, student protests, Summer Riots – to see the parallels. I’ll let you decide for yourself where there was a wider view of the ‘utility’ of the force used.
THE LEGITIMACY OF FORCE
We have also had high-profile uses of force with regard to mental health related crises, too, where the question of legitimacy has been raised in connection with the chosen tactics. So what does all of this mean for us?
Well, utility is judged not only in terms of whether the force achieved the pure objective it was intended to bring about. For example: was that person safely moved from here to there, utilising techniques that may have (temporarily) hurt or discomforted them, in order to do so, but whilst maintaining legitimacy because of reasonableness, proportionality and dignity in the meanwhile. In other words, did officers managed to secure an arm-lock, in order to allow handcuffing, thereby achieving greater control over a resistant subject and thereby force them into a vehicle for transport somewhere else? It is judged in terms of legitimacy.
Read back the above paragraph whilst imagining an illegal arrest for which there was no justification at all. You will immediately recognise that this force lacks ‘utility’ and legitimacy. It is illegal, it is unjustified, it would not command public support. Read it in the context of officers who, without resort to any greater force than that which was described, managed a threat posed by a knife-wielding offender intent on street robbery and there is immediate ‘utility’. Lawful, necessary and almost heroic given the risks to them and the fact that they could have ‘justified’ in legal terms, a high-level intervention. Of course, a lot of situations are not as clear-cut as this.
We know that police officers occasionally are called to exceptionally violent situations involving highly resistant people. Occasionally – thankfully, rarely – these situations involve mental health patients in crisis, sometimes suffering from delusions and paranoia that officers may be intent on causing them harm. Restraint situations in cases like this are always challenging and let’s be frank: there have been some extremely high-profile disasters involving deaths in police custody or following contact. The Metropolitan Police has established an independent commission to look at such cases and the wider issues and I’m sure that restraint will be a feature. The techniques involved, the training given, the alternative options that may, or may not, have existed, etc..
I have heard it suggested that where possible the police service should look to CONtain rather than REstrain patients presenting with disturbed behaviour. Maybe there will be something in that for some situations and I’m sure we all recognise that officers handle things in different ways, which inevitably means some will resort to force sooner than others. There may well always be just some circumstances where police officers are going to have to get ‘hands on’, to protect people from themselves, or to protect the public and I can’t help but keep thinking about this and remember the Independent NHS Inquiry following the death of David (Rocky) BENNETT. I keep thinking about it because it was not a police case:
Rocky BENNETT died following a restraint incident at a psychiatric hospital in Norwich in 1998. During the Inquiry which followed, there was a considerable focus upon restraint techniques, medical implications, safety and clinical management, etc.. It also focussed upon various issues for the NHS around race – indeed, it may be argued to be the ‘Stephen Lawrence Inquiry’ for the NHS, which explored the concept of ‘institutional racism’.
Rocky had been racially abused on his ward by another patient during the course of a day and his representations for protection from this led to a perverse decision that he would be moved to another ward. Not the perpetrator. He resisted this and was restrained. He was held in the prone position for a long period of time and died before he was moved.
Here are various things that were said during the Inquiry:
- Any patient who required physical restraint was by definition in a medical emergency – p52.
- Wherever a mentally ill patient is detained there should be a fully equipped resuscitation trolley;
- There should also be people who were capable of giving drugs and using the equipment, including a defibrillator. – p55.
- There should be a doctor in every place where mentally ill patients are detained, or if that is not possible foolproof arrangements should be in place twenty-four hours a day to ensure that a doctor will attend within twenty minutes – p55.
Think about the medical implications for the police service picking up violent, resistant patients – irrespective of whether there could or should have been any form of ‘upstream intervention’ – and then think about the clinical care that will be provided in custody. We couldn’t deliver on any of this – not even nearly. Think about the physiological implications of restraint, especially where it may potentially continue for more than a few minutes now that you’ve reflected upon this incident.
THE ROLE OF THE AMBULANCE SERVICE
If a patient in hospital requires restraint by nursing staff and they are a medical emergency, why wouldn’t a similar patient in the community who ‘requires’ restraint by the police also be? And if we regard that they are, what medical input do we need and when? We know that if you try to leave things until you are in police custody, you can have already had a disaster. So it has to be faster than that. Quick run in a police car to A&E? We know that if you do that, you can have had a disaster by the time you get there. So we need emergency medical care to the scene. Would you agree with me, that can mean only one thing: the ambulance service?
If force is going to have ‘utility’ and public support, it will have to able to be seen during the sharp light of hindsight as being the least restrictive option, other methods of ensuring safety having been dismissed or even tried and failed. And once done, such interventions will have to be managed and be seen to be managed as medical emergencies – and this is not easy, which is why we need our colleagues in green. We need an acceptance that when the police are required because of safety concerns to become a lead agency in the response to psychiatric emergency, that they recognise this and / or can absorb and act upon information. We then have to manage such interventions quickly and by bringing the detained person before competent medical authority as quickly as possible – or preferably bringing that authority to them.
I recently delivered some awareness training to a multi-agency audience and when I said, “Call an ambulance to every s136 detention and to every detention of any kind involving RED FLAGS which are connected to mental ill-health.” The room looked at me like I was unwell. There were various ‘reality’ checks offered – that their ambulance wouldn’t come, hadn’t agreed, didn’t see the need, etc., etc., etc.. I’m not actually sure I care – if we are dealing with complex needs and significant vulnerabilities that can be raised significantly by police interventions, we need medical support and the ambulance service is the NHS on wheels. Officers have got a right to call for them, when they think it is appropriate. Whether they come or not, if we are talking about restraint, especially where it is prolonged restraint, then we need to give that person and emergency medical authorities the chance to assess whether this patient falls within NHS guidelines for the management of acutely disturbed behaviour AND / OR whether the police or paramedics have misjudged a presentation that is attributable to something else – like head injury, diabetes or a stroke, etc..
This requires proper commissioning, but it also requires frontline knowledge and there are already too many cases where this has not occurred and we can name the patients and frontline professionals who have been let down by a non-integrated police / health / social system.
Incidentally, in case you were wondering – Mrs MentalHealthCop took some books on honeymoon that I thought were truly awful too! … and read them!!
The Mental Health Cop blog won the Mind 2012 Digital Media Award, in memory and in honour of Mark Hanson.
The Awards celebrate the “best portrayals of and reporting on mental health in the media.”