Cognitive Dissonance

Two things happened to me recently to cause my head a brief period of cognitive dissonance as I unwound from my LATE shift last night.  I recently went to work to find a person in the cells who had not long been arrested under section 136 of the Mental Health Act.  I noticed when I got home from work yesterday, a Twitter remark from an A&E Consultant questioning why he and his staff should have to put with aggressive behaviour from the public and being shouted at?

These two things got me thinking –


The person detained under s136 had been removed to the cells because the Place of Safety in the area concerned had been telephoned by the police control room after arrest to notify them that officers would be heading towards them with a detainee and were asked, “Have they been violent?”  In fairness, the person concerned had displayed some agitated behaviour.  Actually, they were screaming very loudly in distress and had been doing so before the police arrived – that’s the reason the police were called in the first place: members of the public concerned about the individual and their behaviour in a public place.

When detained by the officers, the person had been resistant – frankly, very frightened by what was going on – and had been handcuffed by the officers in order to maintain the safety of the person.  There is one other dimension to the incident I’m afraid I can’t recount as it would potentially be an identifiable factor, but I’d ask you to just believe that it would be something causing additional distress and the officers had to manage that too.

The phone call lead to the receiving nurse saying that because violence was an exclusion criteria, the person could not be taken to the place of safety and would need to be removed to the cells.  Paragraph 10.22 MHA CoP anyone?  (This is now paragrah 16.38 under the new Code of Practice – see below).


Meanwhile, in Accident & Emergency in another part of the UK, our Consultant colleague is being shouted at by aggressive patients and their family members whilst attempting to deliver healthcare.  Why should they have to put up with that?  Why, indeed, DO they put with that?!

So, I asked him!  Various responses to his question “Why do we put up with it?” came back with clinical reasons and an underlying fear of rare events leading to professional misconduct allegations, etc..  Maybe the aggression was attributable to underlying organic disease and premature dismissal of the patient for their opprobrious behaviour could lead to undiagnosed disaster?  Even though this is a rare possibility, it is a possibility and goes a long way to explaining why A&E staff suck up a level of personal abuse and threats that most of us wouldn’t stand for: even in the face of threats to their safety, they are attempting to assess their potential and their professional need to care.  Perhaps they’ll have A&E security standing nearby and sometimes they will call the police and staff will continue to treat people even after assaults have occurred – believe it or not.

If you want to see this for real, look at the case of Christopher ALDER in Humberside. The events leading to the police arresting Mr ALDER who subsequently died in the police station, was that A&E dismissed him without adequately evaluating a head injury that had been sustained when he was assaulted.


So here’s my question for place of safety services who decline to accept patients following a third-party telephone triage because of violence that they haven’t seen:

How much violence is too much violence, where’s the evidence base for that line being drawn and how do you know whether or not the violence is clinically attributable?  Where is the level of anxiety about undiagnosed, unidentified threats leading to professional disaster that appears to exist in A&E?  How do you tell all of this when you’re not actually seeing the patient but are speaking to a police control room operator who isn’t with the patient either?  Are we ever going to get that right, except by chance?!

Actually, one of my main objections is that it wasn’t violence at all, it was resistance predicated upon very real fear and a case of being very, very “shouty”.  The fear in this person was no less real for the fact that it was all clinically attributable to psychosis – in the opinion of the s12 Doctor who saw the person in custody.  All were agreed:  police custody was making things worse but because we still have a level of “Doctor knows best” respect for our NHS, the officers concerned had removed that person to the cells.

My questions when I took over as duty inspector included –

  • Was the person transferred from arrest to custody by ambulance? – if not, why not?!  See Chapters 10 and 11 of the MHA Code of Practice.
  • Has anyone asked the question about “RED FLAGS“?
  • If the detainee has not been seen by any healthcare professional, can we be sure they are safe in custody? – if so, how?!  Remember: almost half of all deaths in custody involve people with mental health problems, often complicated by drugs and / or alcohol.
  • Unless the FME is getting out of their car in the police station car park, should we not think about transferring the person to hospital?

As it happened, the FME was nearby and the first thing he said after examining the person was “being here is making it worse”.  There were reports of psychosis, hallucinations and paranoia – fear that officers were going to inflict injury or death, a total lack of communication with anyone in custody.  I mean that literally.  There were suggestions that sedation may be required.

The first thing I did, was send two officers to custody and tell the custody sergeant to ring the relevant area’s place of safety to inform them that the doctor had authorised a transfer to them because the person was not violent and was being made worse and being made to suffer in custody.  Within a couple of hours of being detained, they were in that area’s PoS facility and any ongoing concerns for staff safety arising from the patient’s presentation would be mitigated by officers remaining at the PoS to support NHS staff.

Of course, we’d also “breached the protocol” by transferring someone to a PoS in another area – the person’s home area.  Normally, everything happens in the local authority area where the police detention occurred.  Oops! – but of course, no laws were broken in doing so, everyone agreed it was right and it expedited the persons MHA assessment.

Incidentally, I got shouted at and very personally abused last night by a young man who took a dim view of police actions at a job, but then we are trained and empowered to deal with this in a variety of ways.  I couldn’t manage to get myself into the position the young man had suggested whilst wearing a protective vest so I just ignored him and cracked on … but our colleagues in the NHS don’t have that luxury.

So the cognitive dissonance is at the organisational level of the NHS: how can we think it is simultaneously OK to dismiss some patients to police cells for resistant or aggressive behaviour that has not gone anywhere near a healthcare professional AND think it acceptable that NHS staff continue to suffer abuse and assaults because of fears that such obnoxious conduct may have an underlying clinical cause?

Leave it with you …

Update on 01st April 2015 – since writing this article, a new Code of Practice has come into effect in England.  It doesn’t substantially alter the post but certain reference numbers have changed.  My summary post about the new Code of Practice (2015) is here, the new Reference Guide is here and the full document is here.  The Code of Practice (Wales) remains unchanged.

The Mental Health Cop blog

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– was referenced in the UK Parliamentary debate on Policing & Mental Health
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10 thoughts on “Cognitive Dissonance

  1. This sort of situation drives me crazy, working with it must be a nightmare. Having been ‘rescued’ by the police and seeing the struggle they had getting me support, I can only say that I appreciate the arguments put forward in this blog and congratulate the police, as ever, for demonstrating common sense.

  2. Why are the police even having to deal with these people? they should be fighting crime surely not doing the work of the NHS. I’m sorry but perhaps society needs to take a step backwards and institutionalise these individuals on a perm basis if they are dangerous why are they being let out into the world in the first place???? Safety of the public is paramount. There are workers who work in these frameworks who themselves have mental health issues why should someone with a mental health issue be allowed to make decisions which could endanger the public’s safety when they themselves have problems? Is that not ludicrous, are we not shooting ourselves in the foot so to speak?

  3. I am shocked by Anon4cec. I don’t believe for a second that anyone with mental health issues should be ‘these people’? Each person is an individual.. And should be treated as such surely? Fear of mental health seems to be the issue here, Michael has clearly stated this man was not aggressive but was ‘shouting’ ..Is shouting so socially unacceptable now people like anon see them as dangerous and not belonging in “this world” no one seems to be bothered why? What causes his pain? I guess it’s easier for people to believe they are all dangerous mad people rather than someone with an actual physical illness (archiac opinion in my mind).
    As far as policing is concerned I believe sociology and mental health awareness and training are imperative and the only way forward.. We have moved from a local village bobby who used to know most of his area and act as someone they could approach now everything and every system has become so impersonal we now view people in numbers, stats, and groups.
    When I hear Policemen complain they are more social workers than police, I think it’s part of the job surely? It always has been? But I do agree they seem to be used more and more this way due to a woeful mental/social health system.
    As for Accident and Emergency it’s the same, to much emphasis on mechanics and life saving to realise a mental health crisis can be just that. Much like an insulin hypo/hyper. Immense mental stress can and does cause life threatening situations, such as heart attack.
    I will never forget attending a motorway accident back in the 80s of a mini bus full of teens. One was incredibly combatitive due to head injury the other had a broken ankle. we passed her over to A & E and they ignored head injury as troublesome, I remember my very experienced colleague arguing that she had a head injury and that she wasn’t being difficult on purpose!
    Maybe I’m different, I see each person as person..a fellow human. If I haven’t done all I can to engage with that person without judgement then I’m not happy with myself . But that’s just me.

    1. Sorry but I have to disagree. I’m more than happy stepping in and assisting or being the first on the scene of an incident where somebody suffering from a MH problem is at the centre. I’ll spend hours talking somebody down from a ledge or from behind a baracaded door before I’ll use force. However over the past decade there has been a mission creep which expects police never to say “no”. in addition MH services have become more and more reliant on police to resolve issues that have traditionally been there responsibility. How can it be right that a person feeling suicidal can be left waiting alone in A&E for 8-9 hours and when they get impatient and leave all of a sudden become a high risk missing? Or how about the AWOL patients who ward staff know the whereabouts of reported them as missing so police will go and get them? Or Out of hours crisis teams telling patients to call police because they feel down and said they might self harm? I’m 6’2″, large build and carry a Taser yet MH services think I’m the most appropriate person to remove a dementia suffering 80+ year old from their own home!

      Officers are not saying they regard helping MH sufferers as not part of their job what they are asking is are they really the best people to be resolving this issue. In most cases they’re not which is why they feel like social/MH workers.

      Also you can train police all you like but if hospitals turn us away at the drop of a hat it will count for nothing. NHS trusts need to look a little more inwards if they hope to provide the best possible service.

      1. I agree with what you say, mainly because it has happened to me to often. I was resuscitated and had major facial surgery after walking in front of a car, not really to kill myself but as a way of self harming. A couple of days later the MH specialist came to see me and told me to stop wasting there time. After many years untreated i had become a large problem to the police, mainly because of my condition was becoming way to extreme for me to handle. A few Officers who arrested me on many occasions began to understand my problems and fought with GP services to get me seen by a proper MH Hospital. Although the Hospital said were not trained to deal with me, and did not do much in the way of treatment. Leaving me back on the streets to be a pain again. It eventually came down to me sitting down with the officers and came to the conclusion that the prison service was really my only hope of getting any proper help.

        I am currently living away from that town now, and am actively involved with MH service in the area. Although under strict supervision ( I have to be watched almost 24/7 etc ). But it was the Police who fought constantly to get me the proper help, because the Health service was under staffed to deal with the problem in that area. So it meant me moving 150 miles away from my home town to get the proper help. But Again it was all down to the police how it all happened.

  4. I agree with what you say and certainly didn’t mean police should resolve the issue, I personally think the Police are making the best of a bad job and if care within the health service was adequate. But the Officer is the first point of call at times and can make or break a situation. I have known a police man to jump ontop of an actual train after someone who had just jumped. But the kindness of that officer gave the person hope.
    What I’m saying is that referral services don’t match the dedication from the Police. It feels as though one service is working against the other to the detriment of the person they are there to help?
    If health and social services stepped up and take over care when necessary then we wouldn’t all be here discussing this would we?
    I’m not an expert, it’s just my opinion I’ve been on both sides kind of..

  5. I understand the frustration everyone feels but it also highlights the lack of understanding around mental illness in society. If it’s just an illness why do we need MH Law and if it is just a behaviour why do we need mental health care? When we fix the stigma that exists within society then we will also fix some of the things mentioned above until then it will always be a political and societal hot potato that different professional groups will always want to ‘refer on’.

  6. I understand that it’s not as simple as ‘Mad’ v ‘Bad’ but we have to asses the ‘Mad’ first before we can resolve the ‘Bad’. But that doesn’t negate the issues I raised above and probably more persuasive is the accounts from the MH users above. When the police are sitting down with MH sufferers and putting a plan together as to how they can best get treated, independently of MH services, then there’s a huge gap in what’s expected and what’s provided. I would NOT expect a MH nurse to create a file for prosecuting an offence that occurred on your ward so why is it reasonable to expect me to collect a not violent AWOL patient. If the answer is resources then I’ve a few files I need completing while I do it.

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