Thinking Correctly Under Pressure

A couple of years ago I worked for two years with @UKprisonhealth on the West Midlands s136 place of safety work – trying to get NHS provision, of the right standard, in all local authority areas across the region.  He is a psychiatric nurse by background, working at the time in Offender Health in the Strategic Health Authority, now working in a prison healthcare setting.

During that time we became a bit of a double act – very similar in our outlook to s136, despite coming at it from two very different professional perspectives.  Frankly, as I was first getting to know him, I spent time wondering whether he would also be one of the “Violence goes to the cells” type of mental health professionals that I’d met so many times. “Can’t assess unless sober – to the cells”; “Can’t have children in an adult PoS – it’s a safeguarding issue.” etc., etc..  I feared the usual exclusion criteria.

The opposite proved to be the case and I found a natural ally, now a friend.  He taught me that there are actually sound clinical and therapeutic answers to those objections and they can be knocked down.  When we then ‘went in to bat’ against NHS managers in local areas who came up with the usual objections: we were able to knock them down with legitimate argument.  He also had backing from his managers around certain clinical issues and arguments that buttressed the whole thing even further.  It got to the point where if one of us could not make a meeting around s136, we just represented each other – I spoke for him and the SHA, he spoke for the police which I’m sure you’ll agree is proper partnership.  Frankly – and this is no slight upon my colleagues as MH is a niche area of policing in many regards – he understood the police arguments far better than other police officers and was a better representative of our position.  I hope he feels the same.

Any rugby fans out there? … bear with me on this: I’m taking it somewhere relevant!  I’m especially thinking about those who watched England lift the World Cup in 2003?!  The England rugby team in the build up to the World Cup actually practised “Thinking Correctly Under Pressure” otherwise referred to as T-CUP.  Clive Woodward actually talked about the 30 seconds leading to Jonny Wilkinson’s famous drop goal as being the most intense example of England employing their T-CUP strategy.

In the build up to that drop goal, Steve Thompson had to decide whether to go for the easy, safe throw or – as he did – throw it to the very back of the lineout; Matt Dawson had to decide whether to throw it straight to Wilkinson or judge whether he was close enough to the posts and run the gap gaining precious yards; Martin Johnson recycled the ball and took forward just a few more yards so that Dawson could get back in position for the crucial throw to prevent Neil Back making it … ALL OF WHICH was necessary to put Wilkinson in the right place with the maximum chance.  Any other decisions by the lot of them may well have diminished Wilkinson’s chance of making it.  Team game.  They won … and I got to watch it with a very unamused Welshman!

So why not think about this in policing where many decisions are taken under pressure; why not have mental health professionals understand that decision-making and applying the T-CUP strategy?

In 2010, @UKprisonhealth and I were invited to run a workshop at a mental health and social care conference in the East Midlands and this came at a point where we were making real progress with s136 and had ‘delivered’ in our first (major) area – Birmingham.  If you can sort s136 in Birmingham, you can sort it anywhere as demand, acuity and diversity is high.

We decided to run a simulation exercise for the (predominantly mental health and social care) delegates on police s136 decision-making.  It was not focussed upon MHA assessments, but upon whether to arrest and for what; and where to go with them and why; and how to cope with a non-responsive or obstructive NHS system or individual professional, etc., etc..

We did it by having a power-point that had time-exposure slides so that there was only a certain amount of time to reach judgements and then it wasn’t time for more discussion – it was time for a decision: are you going to do THIS or THAT? Are you going HERE or THERE … why?! … and what happens if THIS is  the consequence?!!  How will you defend it?

We used our voices ‘tactically’ – OK, we shouted some parts of our information feed to give an urgent, pressurising effect; we more quietly spoke other information and understated it although it was important people took heed.  I think we managed to create pressure, urgency, uncertainty and confusion.  Within this, we needed THIS or THAT; HERE or THERE.

Decision time.

Predictably, the ‘hypothetical’ problems we threw in were not unrealistic: they were of the type described on this blog many times before when discussing s136 and to which I’ve alluded, above.  Equally, the negative consequences to some decisions were not actually hypothetical at all: medical catastrophe, death in custody; degrading, undignified conditions, etc., etc..

The result was startling:

The professionals were placed under time pressure with brash alarms going off.  The inability to continue any discussion but to be forced into a decision was not without worry, uncertainty and frustration for them.  The intakes of breath and protests when the not-very-hypothetical disasters kicked in were palpable.  The whole thing lasted no more than 10 minutes, but we blasted them through a not untypical s136 job with common issues.

At the end, people commented upon how they’d been ‘put through the mill’; how they felt worried, pressured and had undergone an emotional reaction to the exercise.  Of course, this was exactly what we wanted and discussion around it revealed that the laws, considerations and inquiries that influenced how the exercise was put together were actually a very real set of considerations to officers who are thinking about pitching up on an A&E who insist they are not a place of safety or who are faced with place of safety staff who want to turn away a patient who is far from intoxicated but who has used drugs or alcohol.

As we walked out, I think I said something like, “I think they got the point!”

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Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award

 

All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2012

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