The Emperor’s New Clothes

Earlier today a mental health professional engaged in research described many efforts to arrange and develop Liaison and Diversion services as “The Emperor’s New Clothes” because they too often rely upon models which do not operate when people find themselves arrested and which sometimes fail to ensure the public interest is met by engagement with the services to which people were ‘diverted’.  All too often, the whole thing relies upon police officers to identify those potentially suffering from mental health problems and then has the potential to regress into an ineffective, half service which is more about the police than mental health.

Have I mentioned how I deplore the term ‘diversion’?!

Of course, we know that leaving identification to police assessments and / or to self-declaration is prone to problems – just like investigation of crime by nurses is prone to problems of competence.  It’s not what they are trained or constituted for.  I’ve always worked on the idea that around 12-15% of people arrested and brought into police custody are ‘thought’ to have a mental health problem.  This would include: police suspicion based upon behaviour or information from police systems; self-declaration by individuals and / or information from third-parties at incidents.

This figure is mentioned in published research (JAMES, 2000; RIORDAN et al, 2000) as well as found by me when I did research for an MSc dissertation some years ago.  However, we always thought that this would under-identify mental disorder, because some less obvious conditions; including non-psychotic conditions, some learning disabilities and / or autism.  We know that sometimes such conditions are not identified by mental health professionals with time to examine people against a background of years of training.  Not really surprising that the police miss things when some decision must, of necessity, be taken quickly without time to check, ask or refer.

I heard last year of a criminal justice mental health team in the south of England who used to get a daily fax from their local police listing names, dates of birth etc., of all people arrested by the police.  They found that 50% of arrested people were currently known, previously known or should be known to and engaged with mental health services.  So the police are potentially spotting less than a third of people coming through custody who should be considered for assessment, referral or diversion.  One third.

So what does this mean for Liaison & Diversion Services, delivered to the vision of Lord BRADLEY?

Ideally, we’d hope to see mental health professionals deployed to screen everyone in police custody, with the benefit of access to health records systems like Epex.  Of course, the police arrest people 24/7 all year round.  In my force alone there are thirteen 24/7 custody offices and in my borough, we arrest about 750-800 a month.  To have a professional available to see everyone, it’s quite possible you’d need psychiatric nurses or other appropriate mental health professionals working 24/7 covering two custody blocks.  Regardless of which grade of nurse / professional used, it’s going to be expensive business and this is usually where the vision falls flat and thoughts turn to cheaper alternatives.  This is where ‘The Emperor’s New Clothes’ comes in, because in reality diversion services often seek to turn 24/7 business into something that can be managed without face-to-face screening and on more of an ‘office hours’ basis and that’s where initial problems start to emerge.

How else would you do it?

  • What about an L&D scheme operating 15hrs or 8hrs a day?
  • What about attempting to use police bail to delay investigative decisions until a person has been ‘referred’ to an L&D type screening or triage service, operating office hours Monday to Friday?
  • What about importing a screening tool developed by MH professionals, but administered by the custody sergeant or custody staff around MH?
  • What about linking the development of police healthcare commissioning by the NHS to improved training for police custody nurses / doctors, to screen all patients for mental health and / or allow them access to medical records for secondary mental health care?
  • Why can’t the police share information ‘fast-time’ with mental health services about people under arrest in the first couple of hours of their detention and then have an assessment response based upon that information sharing?  For example: if the person is / has been known to MH services; OR is suspected by the police to be suffering mental ill-health, then a response is configured.
  • Well, if you’re screening on a less-than-24/7 basis you risk missing something: clearly, the more hours covered, the less would be missed and you cannot hold someone in police custody just to screen them for mental ill-health when the professionals come back on duty in the morning.
  • This is fine, as long as the person is not a ‘bail risk’ – is it a responsible CJ decision to bail someone, if they have a history of offending on bail, failing to surrender back to custody, etc., etc..  Some people cannot and should not be bailed before or after charge.
  • Screening tools are being trialled and / or used around the UK for various reasons to identify various things – not just in the police station, but also in other parts of the CJ system, including prisons.  Of course, some tools take 30mins per person to administer; some are better than others at identifying generic mental health concerns; others may be good for identifying certain problems, like learning disabilities.  Of course, you couldn’t possibly have two screening tools to use as they aren’t enough hours in the day or in the ‘PACE clock’ (custody time limits).
  • I think the NHS becoming responsible for commissioning healthcare in police custody has lots of opportunities, if it is done correctly, to improve the extent to which screening and mental health identification is then integrated into wider health provision.  But we know there can be difficulties for experienced mental health professionals identifying the correct cohort, so generic medical / nursing staff may also reasonable be expected to miss some identifications.
  • This fifth option does still leave a gap, but it risks missing people who are and never have been known to MH services and about whom there is no suspicion at all of mental ill-health.  Maybe THAT is where you then apply a screening tool?  Of course, best of luck persuading the NHS that it would be legal to share this information: which it would.

Whichever you may prefer, you still end up back at the heart of the dilemma for Liaison and Diversion: once you’ve identified someone with mental health problems – whether unmet need or not – what is the ‘right’ criminal justice decision and how do you ensure that diversion ‘worked’ before you surrender the possibility for prosecution of positive criminal justice action?

I know from my MSc research, that the practical determinant of whether someone is prosecuted for an offence whilst mentally ill is “whether they are sectionable under the Mental Health Act on the day they were arrested”.  If you are sectionable, you will most likely be diverted; if you are not, then you probably won’t be.  This discovery invites consideration of why people with enduring mental illness, who do not happen to be so acutely unwell upon arrest to require immediate admission, are not also considered for the potential to be ‘diverted’.  It also invites consideration of why we are not seeing more serious offences prosecuted of those who are mentally ill.  Insanity is a defence to be raised in court and “every man is presumed to be sane and responsible” according to law.

This comes back to the false dichotomy of the ‘mad / bad’ debate: we seem to have ingrained an approach which says you are either criminally responsible OR you are mentally ill.  In fact, you could be both.  Or neither and we more urgently need a criminal justice decision-making model which reflects this.

Finally, failure to get this right in police custody is not without cost.  I’ve mentioned elsewhere that the costs of high-secure and medium-secure care for convicted offenders is considerable <<< understatement.  A primary care trust once told me that they spend around 55% of their budget on 3% of the patients – those detained in secure care.  However, a separate mental health trust once explained that an investment in proper Liaison and Diversion had paid for itself within two years, because of earlier identification of unmet mental health needs which subsequently reduced the number of people requiring secure care after prosecution for offences.

In other words, as I’ve said before, when you consider all of the costs, including the costs of failure demand and the obvious service-delivery costs across the health / justice systems:  it’s cheaper to do it properly.


8 thoughts on “The Emperor’s New Clothes

  1. I’m impressed you’re a cop with an MSc relating to MH. I suppose you’re fully cognizant of Szasz’s argument as laid out in Myth of Mental Illness. As someone with 33 years’ history of police now and again referring me to MH services, I wonder whether I would have been better off in prison now and again, pace Szasz. At least prison is time-limited which a diagnosis of schizophrenia is not.

    1. Criminology and Criminal Justice thing, not specifically on mental health but did my dissertation and module options to allow as much study as possible within that. Would love to do a Forensic MH MSc … maybe some day?! That said, I think a sociological type approach / perspective has been a very refreshing one from which to learn this stuff.

      Very familiar with Szasz and have read Myth of Mental Illness. Only came to it via others, though: Creating Mental Illness by Allan HORWITZ and also Madness Explained & Doctoring the Mind by Richard BENTALL.

      If you haven’t read those, go get them from Amazon as they’re better in my view, by virtue of being written more recently and expanding on Szasz’s ideas.

      Thanks for feedback – grateful for your taking the time to do so.

  2. 6 April 2012

    Dear Mental Health Cop

    As always, I find myself in agreement with you. How many people commit crime of any type who have “mental health issues”?

    Is crime actually a result of mental health disorder? or mental illness? or is it a cultural mix? Is a crime a crime in one society but NOT in another? Who defines what a crime is in the first place? Is killing always a crime? Or can it be ever justified? I note your next blog about “suicide by cop” and begs the question of mental health of the person wishing to be killed by police. How recent a phenomenon is this? Or is this an age-old problem?

    1. I too find myself wondering why those deemed mentally ill are favoured over criminals. One doesn’t choose to be ill but perhaps one can’t help turning to crime. There but for the grace of God? However there are good and bad mental patients. Can one say the same about criminals?


    6 April 2012
    I note that Laura Johnson was a Mental Health patient of Oxleas NHS Foundation Trust before this incident took place. Was Laura Johnson a “vulnerable adult” and if so, what care package did she have in place?

    Where is her Care Co-ordinator from Oxleas? Was Oxleas a witness in the Crown Court Trial? As she was a Bromley resident, what part in her care treatment did London Borough of Bromley take?

    Was London Borough of Bromley a witness in the Crown Court Trial?
    Was there any character witness of Laura Johnson from Newstead Wood Grammar School and/or St Olave’s?

    Was there any character witness of Laura Johnson from Exeter University?
    Was there any Social Circumstances Report of Laura Johnson from Oxleas/London Borough of Bromley?

    Was there any MEDICAL REPORT from Oxleas NHS Trust re Laura Johnson?
    Were Laura Johnson’s MEDICAL RECORDS sought by her Counsel as evidence in the trial?
    Did the CPS and MPS have Laura Johnson’s FULL MEDICAL RECORDS FROM BIRTH?
    Did Laura Johnson have a CT brain scan to check what was wrong with her?
    Or an MRI scan of the brain?

    Was Laura Johnson a patient of Oxleas at the time of the incident?
    Did Laura Johnson take any Anti-depressants or Antipsychotics at ANY time in her life?
    Did Laura Johnson get professional advice as to how to recover when she went to Green Parks House? If so, what was it?

    Mentalhealthcop is a blog I recommend.

    Is this person a victim or a criminal?
    Is it in the public interest to place her in jail?
    Or would mental health rehabilitation be preferable?

    I HOPE SO.

    1. An interesting aspect of all this is the diagnosis of ‘personality disorder’.
      It sounds like Laura Johnson would have been diagnosed with this – whether correctly or not one can’t tell without futher investigation.
      Anyway, this diagnosis is often given somewhat hazily to ‘difficult’ or ‘complex’ patients who don’t fit into other diagnoses, and as some of the symptoms for various personality disorders include things like ‘chaotic lifestyle’ or ‘unreasonable anger’ it is potentially very easy for someone who disagrees with their psychiatrist, complains about their care, has a chaotic life due to others etc. to be labelled with this.
      It’s very vague as to whether personality disorder is considered a mental illness or not – they certainly include mental distress, are often co-morbid with other ‘established’ mental illnesses suxh as depression. In addition there is a very strong link with childhood abuse.
      When personality disorders are considered more as a mental DISORDER, and a behavoiral problem, assumptions are made which stigmatise and blame patients for their intolerable and often traumatic mental states.
      Thus, personality disorder does not count as a mitigating factor in court in the same way other mental illnesses might do. This obviously reflects back in any supporting evidence mental health professionals might provide – they deem someone with a PD diagnosis responsible, whatever overwhelming mental state they were in at the time.

      I have researched into this, and it’s heartbreaking.
      I have also been the one in the dock.

      1. I believe it is time for a radical thinking about what is a crime.
        And how people are perceived.
        Queen Elizabeth I expressed no desire to make windows into men’s souls.
        I would like to know if we are a more or a less liberal society than in the first Elizabethan era.
        There was a time of religious turmoil just as in the current Elizabethan era.

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