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.
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
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 
this is a very thought provoking article and i agree it is very difficult for the police in particular but i think if two pyschiatrists(required by law)concur there is a probable or even possible mental health issue i believe but i am sure so of my own colleagues will disagree then the only way is coercively because the option of prison just passes the burden to prison officers which is unfair or the option to agree to engage in a programme by the accused also means they can walk away from it and may be returned to court where the whole thing begins over again and increases the cost involved but also uses the resource of time
no easy answers its a battle we’re still fighting against the “medical” model recently i was asked by ward staff why I’d sectioned a patient as they weren’t mentally ill they had a narcissistic personality disorder, but it has improved as medics get on board with psychosocial interventions or as i like to call it social work and the change from treatment test to appropriate treatment been available has helped in some cases.
im rapid cycling bipolar when i was very suicidal all they did was get me to go to their offices once a week to pick up a prescription of tablets, like i couldnt do that myself at my much closer local chemist!. it seems very much that even if you are gonna kill yourself they wont bother with you unless youre bothering other people. seems i was too nice to be sectioned
Excellently written as always.
If all our police are even half as well-informed or half as curious to learn the aetiology of behaviours as you are then we are very fortunate.
I would suggest (simplistically) that we focus on the externalities and the resulting effects. The police are certainly not equipped to deal with the causative aspects.
Problem is that psychologists are (at least in educational circles) widely known to be as useful as a wet cloth to dry the dishes and psychiatrists are generally bonkers. The pessimist in me says: We’re stuffed. The optimist congratulates you on your personal efforts and hopes you will continue to be influential.
I very much understand the ‘personality disorder’ issue as I have been in the middle of it. Especially the ‘borderline personality disorder’ diagnosis which is slapped onto people who have ususally had a difficult life, and feel things so much more deeply than others – in fact a history of abuse or trauma + dealing with the inner pain by self-harming pretty much guarantees a BPD diagnosis, regardless of the other symptoms.
What I have also observed is that the incredibly frustrating way services treat/ignore someone (and in many cases are actually verbally abusive and definitely neglectful) make them feel angry, desperate, lost, and rejected. This is then interpreted as being ‘manipulative’ (by ‘hurting others feelings’ when they self harm, or self-harming, or even asking for help when their pain is too much), or ‘innapropriate anger’ (I have never seen anger directed at MH services that wasn’t utterly appropriate!), or ‘paranoid thoughts’ (when in fact they are right about being singled out and treated badly by professionals who don’t hide their dislike of them), and these things are then counted as ‘symptoms’ of BPD despite being provoked by services!
Also, having ‘unstable interpersonal relationships’ (because their nearest and dearest are obviously affected by their problems and frustrated at the lack of support) and ‘repeated suicidal thoughts and behavoirs’ (because they are left to rot alone with their pain) are also symptoms in part invoked by services.
One reason services don’t like them is that their is no straightforward medical way to treat BPD (or PD’s in general), and the prevailing model used in MH service is the medical model. What is needed is a psychotherapeutic approach – long term (not the standard CBTish therapies rolled out under IAPT) which is another reason they’re disliked, there is no ‘quick fix’ and no-one wants them on the books while they wait many months, often years for this treatment.
As I mentioned, these people often have very traumatic pasts, and have no ‘template’ for an adult, non-abusive, loving relationship – they have not learned some very basic things like emotional regulation that children learn, because they have not had the opportunity. Also, a widely-held theory is that they (BPD only here) are innately more sensitive than others, thus smaller events will affect their development (as children) more than would usually be expected. Interestingly, there have been several studies that show they are especiallly gifted at recognising other’s emotions, picking up on subtle social cues etc (though this does get sidelined when overwhelmed in a distressed state).
Here we get on to the idea of psychiatry as social control. As someone once diagnosed (wrongly) as BPD, I was left to rot by services, actively abused at points. I felt things very deeply, I could easily pick up if someone didn’t like me, I was often accused of ‘overreacting’ because the pain I felt was so deep. On the plus side, this meant I cared very much for other people, I could never walk by and leave someone needing help, I was very forgiving (though too much, leading to abusive relationships) and loving, always tried to put people at their ease socially and encourage them, and overall felt my role in life was to help people. Obviously these traits are good things for the world and other people, nice things you want in society. However, according to the psych types, this was wrong. I wasn’t supposed to feel things deeply, despite the plusses. Who cares if I can never leave someone hurting alone, if the downside is feeling strong emotion that interferes with the rigid way we must live?
So, I was never ‘diverted’. I was up in court. For, essentially, being rather angry (verbal only) with MH services, and the horrible way they treated me. (Including ignoring any requests for help yet constantly sending the cops to check I was alive!) The judge recommended mental health treatment which was a bit pointless in the circumstances!
A few years later, having found my own way somewhat, I applied to uni to train as a nurse – a long-held dream. I was, in their words, an ‘exceptional candidate’ and was offered a place there and then (they don’t normally do this). But later, the place was withdrawn due to my previous convictions.
So, those nurses who treated me like scum are able to continue their abuse and neglect of desperate, vulnerable people, whilst myself, who cares about people so much, is excluded from working in any care environments (I have done previously but rules get ever tighter).
So please think before criminalising someone, and remember to take people as you find them, not on what Mh services have labelled them!
Another observation I have made is that the CPS seem to be happy to prosecute people with MH problems (esp. those left out of services) when it is clear they need help, whilst declaring it ‘not in the public interest’ to prosecute neglectful and abusive MH staff. This is a scandal but sadly too many rules/laws prevent me from writing specifics!
…important to note that the 2007 act didn’t “expand” the definition of mental disorder, it did away with it completely. There is now no legal definition of what a mental disorder is, or what treatment is. And also ECT can still be forced on people without their consent. People can request not to have it but at the end of the day with no definitions of what mental disorder is, it’s terrifyingly easy for a psychiatrist to “prove” a person in need of such “treatment”, and the capacity act provides little protection either – I have seen too many people formally declared to be “lacking capacity” over a certain issue if they disagree with the psychiatrist.
The medical model remains fraudulent, unproven and very damaging to individuals and society as a whole. For all the talk of biopsychosocial models of working, in reality psychological interventions are so rationed as to be meaningless for the majority of patients (and also as I’ve noticed, tend to be resevered for white middle-class patients) as the practice of “get-people-hooked-on-benzos-to-calm-them-down”, “prescribe-them-benzos-rather-than-talk-to-them” and then “refuse-them-psychology-until-they-come-off-benzos-but-continue-prescribing-them-just-in-case” has meant there are thousands of people desperate for, and continually declined psychological work. And as we’ve seen already this year, social workers are being forcibly removed from multidisciplinary teams to encourage people to take up Direct Payments (and it seems that the one thing you can’t use direct payments for is counselling or similar psychological input, which is the one thing most people are desperate for, believe they will receive from MH services and instead are silenced with a chemical cosh designed to keep them as helpless and addicted as possible) – dispiriting for the social workers but lethal for the continuation of the biopsychosocial model, which has now been sacrificed almost completely to the whims of the pharmaceutical industry.
We have been led gently back into eugenics, which has been sold to us as therapeutic, de-stigmatising and beneficial. This is more subtle than gas chambers and yellow stars but the insistence on an unproven internal “flaw” which robs us of our individuality and free will is the most damaging act I can think of.
Thanks for this, genuinely! Will ammend when get chance. 🙂