Creating ‘Patients’

It occurred to me recently that the actions of the police can have the effect of appearing to create a mental health patient where none really exists.  This can become a self-fulfilling prophecy of repeated interventions which creates a lot of failure demand, for both policing and health services.  Let me explain! –

EVER DECREASING CIRCLES

Once upon a time, the police detained a man who was on the wrong side of a road bridge, expressing suicidal ideas and threatening to jump.  The road has been closed, officers starting to try and persuade the man not to jump and a negotiator was called.  After a protracted discussion to persuade and influence this guy back over the railing, he was detained under s136 MHA – because suicidal ideas, hanging off a bridge may indicate the presence of mental disorder, right?  And the interaction with officers may lead to further suspicion that the man was mentally ill.  Following assessment at the “136 suite” the man was neither admitted to hospital under the Mental Health Act nor referred for mental health care or support to anyone.   <<  I have known this outcome from such incidents many times in my fifteen years’ service.  The person then having been released from section 136, the police resume and the person goes about their life.

What happens if we attend a similar job in the future? – maybe a different bridge in a different area and almost certainly different police officers; but background circumstances broadly the same.  Did the MH assessment first time around get it wrong; do the officers even know that outcome or are they simply aware from intelligence systems that the person was previously detained by the police under the MHA?  Maybe they are aware of nothing at all and simply start from the basis that the first officers did … suicidal ideas, bridge, communications and perceptions so there is a mental disorder and when they person is persuaded back over the rail, they will be detained under s136 MHA for assessment at the PoS and an outcome.  Guess what it is?  Not “sectionable” so no admission and maybe a referral to GP or CMHT; or maybe not – all depending on circumstances.

REVOLVING DOORS

We can see where this is going can’t we?  My police area are currently attempting to manage two people who fit this category and on a recent early shift one the men rang the police from his flat at 9am having been drinking heavily and as part of our response to what an officer described as “that regular mental health patient who is constantly ringing” I rang the Crisis Team to find out more about him.  Their answer motivates this blog because it suddenly occurred that we – the police – have “created” this mental health patient.

The Crisis Team had assessed this man for the first time about two years previously and had assessed him several times over that two-year period.  Every single time they assessed him, it was following a police intervention: either detaining him under s136, including whilst hanging off bridges expressing suicidal ideas; but also following him being arrested for minor offences.  They always, always found him to lack any obvious mental disorder and either released him from s136 or advised us to do what we wanted with any criminal allegation against him.  Yet look up this guy and several like him on PNC and police intel systems and you couldn’t fail to think he had a mental health history.

It becomes the “obvious” to do – to attempt to involve mental health services in the police response and think about diversion from justice and so on.  But he’s not mentally ill, except to the extent that we regard anyone who drinks a lot to be mentally ill.  He has been repeatedly offered support for alcohol related issues by both the police and the health system and declined to take up those offers.

CRIMINALISATION

The first time I came across a similar case, was about seven years ago: a female drug user who often brought the M5 to a standstill (at massive economic cost, I might add) because of her obsession with a certain bridge and the adverse of its parapet.  Repeated s136 interventions led to some frustration being expressed by the mental health trust that the police kept perpetuating this revolving door when a better approach may not involve s136 being used at all.  When we asked what they thought would be better they emphatically said, “Prosecution!”  Simple when you know how, isn’t it?!

And so we did.

Few people realise that it is an offence under s22A of the Road Traffic Act to place something (including yourself) “on or over a road” in circumstances where it causes a danger to road users.  Obviously, someone falling from an M5 motorway bridge onto a 70mph triple carriageway would be horrendously dangerous.  So after something like five s136 interventions in a short period of time – all by different officers acting in good faith – we made it more widely known that s22A was the way to go, secure MH assessment in police custody as part of the investigation if that were thought to be necessary and take a broader view than whether it is a “health or justice” issue.  It could well be both.

In these cases, criminal sanction for behaviour has been shown to be effective – at least in terms of a short-term solution.  All the mental health assessments and the criminal investigation considered the issue of drug use for the woman mentioned and alcohol support for the man.  The female drug user was prosecuted, remanded to prison (because of various other criminal justice antecedents) and subsequently found guilty.  It brought an immediate end to incidents on the bridge.  Maybe she found another bridge, some may ask how effective this strategy was in the longer-term.  All fair points, but not issues that prevent us prosecuting those who commit street robbery where we think they’ll take the consequences and just commit more robbery elsewhere on different victims.

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.


IMG_0053IMG_0052Winner of the President’s Medal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


 

 

 

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48 thoughts on “Creating ‘Patients’

  1. It seems to me that there just is no positive intervention which is both fitting and available here. Prosecution, while removing the possibility of these guys holding up traffic for the foreseeable future, fails to address the underlying disease and may just mean the revolving door takes longer to spin . Sooner or later, because their cries for help have largely gone unheard, they will be hanging from some other bridge.

    1. You mention cries for help! – unfortunately the care is so appalling and is only about drug pushing by so called professionals. When the drugs do not work and someone like my daughter is diagnosed as being “chronic treatment resistant” the answer is more and more drug pushing and to just continue with it. The problem will not go away as the drugs mask the problem not deal with it and what should have been given to my daughter, a victim herself was counselling instead of mind altering LSD-like serotonin reuptake inhibiting drugs that lead to suicide and aggression. I and other mothers of sons/daughters who are on never ending treatment orders would like to see humane care and proper assessments. What underlying disease! The worst thing they could have done is come up with one diagnosis after another which shows they do not know – the answer is drug pushing as it is easy to control someone when they are like zombies and then they are dumped back into the community in schemes like my daughter who is so vulnerable that have led to her being further abused and living in dreadful conditions – rotting food in the fridge, sitting alone in a dark room as the light bulb had gone, ending up in a crack den as the latch on the door was broken. Some of the patients were crying to go to prison as it is better in prison than on the wards! Perhaps the answer is a complete review of the current “care”. Projects like Chy Sawel, Soteria and Root and Branch set up. for £800 a week my daughter needed more support and did not get it and was isolated in the community. I ended up having to go round and do housework and shopping for her. They allowed her to spend all her money on a tattoo and a phone she did not need leaving nothing for food. It is no wonder there is constant revolving doors in the mental health. The drugs cause the suicide – prescribed drugs given by the psychiatrists that are passed in such a dubious way (Prof David Healy – Pharmageddon) and cause no end of side effects – who can blame a patient for not wishing to take them. There are no places for someone to safely come off these chemicals unlike illicit drugs and when a patient does it, skips a tablet this can cause psychosis however you can also suffer from a condition called Akathisia whilst on the drugs and other serious side effects that are all ignored by these so called professionals. There is nothing but manipulation and control and abuse of the law going on under the mental health where psychiatrists play on capacity and when someone does not have the capacity their Tribunals are held up and they are deprived this right – I believe there is a shortage of suitable housing and support in the community and so these poor patients are held forever on Enforced Treatment Orders. I am disgusted along with a group of other mothers and former patients who I am in touch with with the shocking care in the UK. Quite often people like my daughter are discharged into the community, not kept an eye on by Crisis Team and left without enough support when they cannot cope. It is very sad what is going on .

  2. There have been many times when I myself have been put on a 136 taken to hospital and released same day ….i think the police just make the situation look worse ….but that is just my opinion ….

  3. A revolving door scenario but for who? The individual, the police or mental health services. I’ve been present in many s136 assessment whereby the use of s136, given the individual’s behaviour when the police intervened, was wholly appropriate. I wonder if the creation of the patient is more down to the NHS and how they respond? I’ve seen many s136 assessments end in discharge with no mental or behavioural need or disorder but yet a referral to a CMHT is an action ‘for further assessment’ or to a crisis team for immediate follow up despite the assessed absence of need. I think that mental health services allow the door to revolve all too often.

  4. There are times when I have been in my own home, minding my own business and my CMHT have expressed concern for me and sent the police around to do a welfare check, the police have come, found me sitting quite happily watching TV or whatever and decided to take me to the police cells to ‘Prevent a breach of the peace’. This basically creates a lot of work and wastes a lot of time and resources when I was absolutely fine and created a mental health patient.

  5. Underlying issue for me is two similar sounding but very different terms … ‘mental health problem’ and ‘mental disorder’

    Someone who is using drugs/alcohol, who is having problems meeting their basic economic and social needs, who is deeply distressed is (rightly) seen by lay people, including the police, as having a ‘mental health problem’

    But that’s NOT the term used in the mental health act. To put someone on, example, section 2 of the mental health act is about ‘mental disorder’ as defined in the act, and detailed in the code of practice. That actually excludes drugs/drink, lifestyle etc.

    Personally I would really like to see seriously mentally ill people have more access to hospitals, but I wouldn’t be keen on seeing the definition of who can sectioned broadened.

    1. Hospitals are not always the answer and it has been proven that patients recover more quickly in their own homes, hospital treatment should only be used as an absolute last resort where nothing else is available or appropriate. I think they need to concentrate on improving community services and make them more accessible.

      1. Totally agree that hospitals are not always the answer – indeed they are only helpful for a small minority. Unfortunately for those people who desperately need that care, beds are often not available. Those are frequently the people this blog writes about.

    2. I totally disagree – hospitals are not the answer and can lead to some patients becoming even more disturbed. The care is just drug pushing on the part of so called professionals even if someone is treatment resistant. I have seen what goes on in those hospitals. What is needed is Open Dialogue 85% success rate in Finland, Soteria, Chy Sawel and Root and Branch Projects – I feel so sorry for these patients.

  6. I wish we knew more about the female who appeared to stop the bridge behaviour. It piques my interest as I’ve had numerous detentions under s136 in the past (a few involving various bridges). Being arrested and charged etc for an offence wouldn’t have stopped me from doing that (or other ways). In fact, it would have compunded the situation as the shame etc of being now deemed a criminal would have intensified my need to harm myself or commit suicide.

    I’m not sure about the police creating patients. From the circumstances laid out in the blog, the police were correct in detaining the persons for assessment. What the services do afterwards to help (or usually not) is not the fault of the police correctly detaining someone.

  7. hello,

    my understanding of s.22 of the RTA is to do with leaving vehicles in a dangerous position etc. and wouldn`t fit the attempt suicide on a bridge scenario.
    What`s the wording of your version of s.22 of the RTA,Please?

    1. Section 22A of the Road Traffic Act 1988 –

      “A person is guilty of an offence if he intentionally and without lawful authority or reasonable cause—
      (a)causes anything to be on or over a road, or
      (b)interferes with a motor vehicle, trailer or cycle, or
      (c)interferes (directly or indirectly) with traffic equipment,
      in such circumstances that it would be obvious to a reasonable person that to do so would be dangerous.”

      1. Can you give me some advice? My mate hates the police and when we met up at the pub a few weeks back he said that he’s sent a couple of threatening emails to the police. What would be the consequences of his actions and will the police be able to trace him (he’s made a fake email address). I’m worried for him, he has a few mental health problems

      2. I would advise him not to be so silly – fake email addresses can be traced; threats can be non-criminal, but sometimes slip over the threshold and he could, in theory, find himself investigated. If he has issues with the police, he could ask to speak to a police supervisors like a sergeant or inspector; or complain to the IPCC.

      3. It depends on the nature of the threats and the method and the impact: impossible to be precise without knowing details. It’s just best, as a general rule, not to go around threatening people, regardless of who they are because it can have unintended consequences or unexpected reactions.

      4. Hi do u know how long it wud take for ones wrists to go down on the swelling after being put in a pain compliance hold alot of times in one day? And the general pain of moving them?

        Sent from my iPhone

      5. Not in terms of injury impact or how any injuries caused may heal. Can only recommend you seek medical advice. If you are concerned about the force used in the circumstnaces, write or speak to the duty inspector in the police area where it occured. You can ring 101 to get put through to the correct police force area whose switchboard will then handle the call.

      6. Also still hvnt got the feeling back into the underside of my hand between where the thumb starts and the wrist…. Was put into this hold alot on saterday

        Sent from my iPhone

  8. I think they need to improve community mental health care, I believe that is where the problem lies, if there arent enough beds (which there clearly arent) available in hospitals then more needs to be done to successfully help and treat people in the community. Out of hours police are going to be the people who deal with mental health crisises, but these mental health crisises could be reduced if more was done to help in the community.

    1. Not disagreeing with your point – certainly if people get better care in the community then some will not deteriorate to the point of needing hospitals (or police).

      Unfortunately some people will not cooperate with that. If someone just plain says ‘NO’ then that may well be insurmountable in the community. Even the recent ‘community treatment’ orders are not an answer if the person is still determined that treatment is not them. In most cases the person in the community has every right to say no.

      Again, a minority but thats the minority that do need hospital care. (and often don’t get it)

  9. I am currently in my third formal complaint against my CMHT, and this one has been accepted by the ombudsman. The care currently available in the community is simply not adequate for someone with acute mental health problems, this is someone who does not need to be hospitalised but needs help, the CMHT offer next to nothing, this causes me to be frequently be one of the section 136 statistics, and I am always discharged and referred back to my CMHT who offer next to nothing …. definately a revolving door.

    1. Sorry to hear that – but it doesnt surprise me. Definitely agree with you on the need for good community service.

      We are only apart where I have some passion about the needs of a minority of individual people who really do need hospital care.

  10. There are times when I have begged my CMHT to admit me to hospital, only to be told to have a hot bath or read a book, something wrong there.

    1. This is when police often get involved, people know if they draw police attention it is likely they will be able to access treatment. Sadly a lot of the people I have dealt with know they need it and are pleased when police turn up.

  11. In all honestly, yes. There are times when I have been at rock bottom and the police are the only people who are available to turn up at my front door. It’s not to draw police attention, it’s because they know they are the only service who will turn up swiftly.

  12. I have actually found the police to be the most caring and sympathetic out of all the professionals and I am very grateful for that.

      1. I am very grateful to the police as they have been the only ones who have been there when I have been at rock bottom and mental health professionals have been nowhere to be seen. They treat me with respect.

  13. I think it can end up being a difficult cycle. Because the police are on the frontline, they are the people who are having to deal with a person who is very distressed and at crisis point. Taken to hospital, then potentially an 11 or 12 hour wait to be assessed (that was the norm in my uni city at least). 11 or 12 hours sitting in a room with nothing in it keeps you safe in that immediate time, but it does nothing to help your mental health and the reasons for ending up in that situation, and it gives a long amount of time for that initial ‘crisis’ to become calmer, potentially more rational and then the mental health team who carry out the assessment potentially see something completely different to when first admitted. Then it seems common for people to get discharged to no further support or referrals, and so the next time the person ends up in a crisis point, potentially the same situation happens.

    There isn’t really a ‘winning’ situation for the police I suppose, but there’s only so much that can be done if someone is consistently refusing help and criminalisation is a way to stop the situation reoccurring. From my experience though, it was very very difficult to get support from mental health services following a 136, definitely room for improvement.

  14. I think at the times the police are responsible for escalating a mental health crisis, someone could be struggling and needing help but by locking them in a police cell for 12 hours or more, that is only going to make them feel worse and show more signs of severe mental distress which werent present previously.

    1. I understand that remark and I don’t disagree – it’s only fair of me to point out that in many circumstances of people being locked in cells for 12hrs, it comes about not because of a police decision that the custody is a great place to hold someone, but from the fact that they have no alternative options whatsoever.

      There are still too many areas where PoS services either don’t exist or operate such exclusions criteria as to ensure that as many as 50% of the people detained in that area will not be able to access it. So we also need to look at the NHS for the fact that people end up in a cell.

      Your point is still correct though – on occasions the police do get it wrong and they sometimes misuse s136 for the want of better training.

  15. Dealing with a very similar set of circumstances today, man over the other side of a multi story carpark above a road in town…. Like the thought process boss.

    ________________________________

  16. I’m (very!) late into the discussion here, but couldn’t let this pass without comment.
    I think you need to be VERY careful about this train of thought/action. We know how rubbish the MH services can be about helping people… so it’s not inconceivable that their assessment of someone as ‘not suffering from a diagnosable mental disorder’ may be wrong. After all, if they admit the person needs help, they might have to find a bed for them! (A side issue here is that the exact phrasing might be “a diagnosable mental disorder” or similar, yet many fall between diagnostic cracks whilst stil clearly needing help.)

    I feel desperately sorry for the woman who was criminalised for repeatedly crying out for help in the only way she knew how. Had she been offered treatment by services? Help and support to cope with her distress? A route out of drug abuse, focussing on dealing with the problems that had led to it? Or was she refused treatment because she had a so-called ‘personality disorder’ which didn’t used to be treated by the NHS? (Despite basically being a form of PTSD – the backgrounds of those so diagnosed are heartbreaking).

    I was arrested, charged and criminlised as a vulnerable teenager with mental health problems for which I had tried to get help. I had been refused help, not only by mental health services (who instead verbally abused and bullied me) but by council/homelessness services – all this meant I was living desperately, in accomodation where I was being threatened by another tenant, with no way to escape. I was also trapped in an abusive relationship because I had no-one else to turn to. I was frequently sectioned by police and dragged to A&E to be told I was a waste of time by staff there. I literally begged for help to relieve the pain I felt inside and received nothing.
    When I finally told them what I thought of them – including the phrase “I could kill you!” – I was criminalised, despite the nurse in question stating he knew it wasn’t a serious threat. (A similar case in the news this weekend had triggerd a lot of painful memories.)

    My future was ruined as they withdrew my nurse training place years later due to this. I now struggle daily with nightmares, flashbacks, and hopelessness – ironically I am about to start NHS therapy and they have recognised the trauma caused by my previous treatment.

    1. Posted my comment below and then read yours. I wish your story sounded untypical. When you keep being told by mental health services that you need to take responsibility etc etc etc and the only reason you are there is because you can’t it makes you want to weep. My worst fear is the tip over into the criminal ‘justice’ system.

  17. Read this with horror. MHA assessment only really is to decide whether you need to be admitted to hospital – to which the answer is most frequently no. Self harm etc is not treated as a reason for admission. Crisis care is typically non-existent. So if you self harm in public you will come into contact with the police. Every time that happens you feel more and more like a criminal/ worthless human being. Some officers (hopefully a minority),paramedics, and indeed mental health staff are happy to share their views on your worthlessness at the time. So now the answer is to charge you with an offence and imprison……Solved your problem – would love to hear if it solved a single one of her problems ………..

    1. My point isn’t just about whether it solved a problem for the person concerned: the narrative is about recognising that when significant effort has been made to allow mental health services to understand what they can do and when significant opportunity has been given to individuals to engage with offers of support. I’m not passing judgement about any of that and I’m certainly not implying that people are worthless, which no-one is.

      All I am saying, is that having made those efforts by referring people for assessment and / or referral to MH services, or alcohol services or whatever is placed to help people address whatever problems there may be; there is a balance to be struck between continuing to do what has been done before, in some case several times. That balance at some point has to tip back in favour of the right of the rest of the public to drive down roads without finding that the police have shut them to prevent a horrible situation where someone takes their own life or seriously hurts themselves.

      1. I’m not entirely sure why the inability of mental health services to provide adequate and appropriate treatment for these people then makes it correct to criminalise them. In your most recent post you discuss the difference between something being legal and something being legitimate, which seems to bear some relevance here: it’s perfectly legal to prosecute but does that make it the correct thing to do?
        The most worrying thing in this is the willingness of the police to act as whip for a failing mental health service. Mental health services hold the default position that if you don’t respond to their limited range of treatments it’s because you’re not actually ill, rather than because those particular treatments don’t work for you. Why then is it o.k. to punish you further and push you into the criminal justice system?
        Put yourself in that womans place for just half a minute, working on the basis that she was genuinely suicidal and asking for help, then tell me if you honestly believe she was treated fairly by the police?

      2. You seem to assume that in all cases it is about failing mental health services and I’m not sure what you mean by “these people”. In some cases of the kind described here, the people involved engage in behaviours whilst intoxicated and have definable mental disorders whatsoever. In one case I wrote about on another BLOG, the man had been seen and assessed by MH services countless times, always after police intervention, and dozens of different kinds of MH professionals concurred that he had no mental disorder whatsoever. He was repeatedly signposted to alcohol service for support and assistance and chose, with capacity, not to engage. That is a decision he was entitled to take, that everyone else must, by law, respect and the consequences of that are for him to bear given his autonomy in our society.

        I don’t doubt that short-comings, perceived or real, in mental health services is a part of it, in some areas it may even be most of it. But in some instances, it is about choices that people make. Either way, I do think it is perfectly legitimate to prosecute people for criminal offences where behaviours are repeated on multiple occasions if previous attempts have been made to establish whether any unmet needs or vulnerabilities exist and whether they suggest it would not be in the public intrest to prosecute on the first few occasions. Where those attempts have been tried and have failed – for whatever reason about which I make no judgement – to then consider the public interest again and take action that may provide disincentives to repeat seems legitimate. It’s what the police and justice system do in almost every other area of offending behaviour from youth justice to acquisitive crime.

        Preventative legal frameworks that address those background issues in a variety of ways are available within the justice system only: (whether through mental health treatment requirements or the work that our Probation Service do monitoring drug testing and treatment orders, etc..) The criminal justice system is not (just) about doing what is right for individuals, but also balancing the impact of that for the wider public (who I notice you don’t mention at all). Individual and public interests will, from time to time, conflict and that’s why a sensible, graduated approach to liaison and diversion, choosing criminalisation only as a last resort does seem to me, to be fair. Of course that all hangs on your definition of “fair” and it’s such a subjective word as to prevent having much meaning in a discussion like this. Shutting major motorways and major rail networks costs millions of pounds per hour and these kinds of events also attract other human costs for those affected by them.

      3. I don’t disagree that, inevitably, there will be some instances where it’s about the choices that people make. I lent heavily towards the view that mental health services may have failed in their care of this person, simply because what I hear of other peoples experiences leads me to that as a likely conclusion. I know people who engage in self-injurious behaviours but can’t get help from MHS because they don’t fall into one of the ‘right’ categories. I also know of people who have been told for years that their is nothing wrong with them and they are simply attention seeking, only to get in front of a different pych and be diagnosed with a serious mental illness. Yet I’ve never heard of the opposite, people being treated even though they are fine. So, yes, I tend tend towards the idea that MHS may not have done enough. Though, as you say, in this instance that may not be true. If a person truly has capacity and continuously engages in illegal behaviour I would not for a second dispute that it’s appropriate to prosecute. But as I say, I have never seen mental health services put themselves out to try and help someone.

        I did not address the cost to the wider public, or the impact it has on them, somewhat deliberately. I would be deeply upset if I was driving home and someone jumped in front of my car, however I would also be deeply upset if someone was put in prison primarily for the convenience of the public. It makes no difference to the public whether the motorway is closed because the person threatening to jump has a diagnosed mental illness or someone who is behaving badly. Surely, by your reasoning, if you replace the woman in this situation with someone who has a diagnosed mental illness, but is not responding to treatment, it would still be fair to arrest them and have them in prison, as that’s less costly and has less impact on wider society?

        I avoided the cost aspect, as I’m not sure how you balance the worth of an individual and their freedom, against the cost of closing a motorway. Cost to benefit ratio is often best steered away from when it involves mental illness or indeed ingrained behavioural issues. There will be some individuals who cost way more to society than they ever put back. So from a cost aspect they are a drain and society would be better off without them. I felt this probably wasn’t the place to get into that as a topic, hence why I avoided cost in my initial comment.

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