The Prevention and Management of Violence

I recently spent twenty pounds on a new publication from the Royal College of Psychiatrists on the “Prevention and Management of Violence”.  An edited compilation of short essays by various mental health professionals, mostly psychiatrists, the document seeks to update us all on the College’s view of this important topic.  It admirably lists a range of important issues in its contents: risk assessment, violence in community settings, acute settings and liaison with the police and MAPPA, amongst others.

Most importantly: this is a document for mental health professionals by mental health professionals.  Much of it is pitched at them doing their jobs and I assume, where it does not relate to the police, that it is both helpful and expertly written.  I have no reason or qualifications to think otherwise and I’ve heard a doctor say so today.  This blog is entirely pitched at those aspects of the document which relate to policing.  So in what I’m about to cover, remember that I’m not reviewing the whole document: just those parts of it that relate to mental health professionals’ interface with the police and the law.

I immediately poured a coffee and settled in for a long read.  I hit concern at paragraph three of page one where, for me, the credibility was dented surprisingly early.  It starts by listing the important legislation across the various jurisdictions of the UK and we read that the mental health legislation in Northern Ireland comprises the Mental Health (Northern Ireland)(Amendment) Order 2004.  Am I being picky here? – no mention of the Mental Health (Northern Ireland) Order 1986 which is the main body of law surrounding compulsory admission, discharge and transfer; as well as orders from the criminal courts including hospital orders as well as various remand provisions and the powers for the police to remove to a place of safety.

I’m either being picky or it’s a really basic error and although it doesn’t alter many of the subsequent points, I also felt it immediately undermined credibility of this “expert working group” given that the prevention, management and response to violence and aggression is so often, a legal issue.  So I went back to the contributors list: mostly psychiatrists of various kinds, plus a nurse, an AMHP lead and safeguarding manager – all edited by two consultant psychiatrists.  None of them from Northern Ireland; no lawyers and bearing in mind what it touches upon for what I’m about to write here: no police officers, despite being “multi-disciplinary.”

The purpose of the document is stated as being an update to the Royal College’s position since their previous documents from the turn of the century and in light of new evidence which has emerged since the NICE Guidelines of 2005 on the Management of Acutely Disturbed Behaviour.  Fair enough – we learn as research develops our understanding.

THE POLICE

We read of the police doing various things in this document: there is a whole chapter on liaison with Police, CPS and MAPPA, but perhaps of more interest are the things that are within other chapters where the role of the police is assumed or where we fail to make links to policing that have implications for mental health professionals.

Page 72 is contained with a chapter on “Managing Violence in the Community” and with regard to routine community visits for ongoing MH assessment – NB, not Mental Health Act assessments:  “consider whether the police should also attend, or if in a public place [sic] whether it may be more appropriate to ask the police to detain them and take them to a place of safety where the assessment can take place.”

Consider whether the police should attend and do what?!  It’s like listening to the political debate on Syria – “Do Something!”  Remember, the police service have no powers at all in someone’s private dwelling unless there is a criminal offence or an anticipated breach of the peace; and how would you ensure a section 136 detention in a “public place” [sic] except by chance or by breaking the law?  If we’re planning a visit to someone’s home and there are high risks, presumably we think that the patient is “being kept otherwise than under proper control” … sounds like we should be thinking of asking an AMHP (ASW – NI) to get a section 135(1) / article 129(1) warrant for a MH assessment which means the police could remove to a place of safety whether the person is found by chance outside the address OR whether they are inside the premises.  Taking the police into an environment where they lack any meaningful powers risks them criminalising the high-risk vulnerable person by them ending up in the cells to “prevent a breach of the peace” or with people getting hurt because the police lack any powers to stop something from happening.  Let’s plan this properly, shall we!

Page 25-26 talks about restraint within a chapter on “Risk prevention and non-pharmacological management”.  Rightly referencing the recommendations from the Rocky BENNETT Inquiry, it’s a frustrating aspect of this document that it doesn’t lead anywhere else to discussion of police-led management of restraint with which mental health services must become involved.  If you accept what’s written on these pages, one logical next step must be “and if my patient comes to police attention and is detained or re-detained, for example under s18, s136 or s138 – a29, a130 and a132 in Northern Ireland – what do these things mean for safe management of vulnerable people either in A&E, a place of safety or police custody.”  Perhaps something for one of the other chapters, but that’s what editors are for: to weave it all together.

Mostly likely, you’d have to acknowledge that mental health patients in need of ongoing restraint could not be safely managed in police custody because, as this report acknowledges, the longer restraint goes on the more the risks build and the greater the likelihood of injury or untoward outcome.  Let us remember: Rocky BENNETT died under restraint in NHS care, unconnected to policing.  Restraint risks are restraint risks regardless of who is doing it: clinical issues arising and the need for effective management of violence and the prevention of untoward outcomes arise whether you’re being restrained by nurses or police officers – or anyone else.  It looks like the timing of this document is just too early for the Adebowale Report and I think that is a real shame, because there are so many implications for health and social care organisations in this area.

This point about not making links to police business that has implications for mental health or health services, continues on page 65: this calls for post-incident review of restraint not only in terms of ensuring wellbeing, but also of future prevention and / or criminal proceedings that may arise; page 98 calls for healthcare professionals to monitor the clinical welfare of those in prison with mental health problems during and after restraint, but nothing, anywhere in the document about such care for those in police detention.  Why all this when restraint is done by healthcare professionals in hospitals or prison officers in prisons with NHS oversight but not when detained restrained by the police when the risks, by definition, are less knowable?!

Page 103 contains a list of protocols that should be agreed with the police within a chapter on “Police Liaison, CPS and MAPPA.”  Thirteen of them, to be precise.  Whilst managing to omit the need for a protocol on a “Place of Safety” process, required by the Code of Practice to the Mental Health Act, it includes suggestion for agreed protocols that I have never, ever seen or heard of.  If any potential respondent’s reply to this criticism is to point out that there is a recommendation on p103 for a Mental Health Act assessment protocol, including for police stations, I point out that section 136 of the English and Welsh Act – and article 130 of the Northern Irish 1986 order! – is about so very much more than the assessment that occurs after detention: it is about quick decision-making in the street and the identification of proper clinical pathways into care leading to assessment under s136 / a130 which is not a Mental Health Act assessment.

“The content of the protocols will vary from trust to trust?”  Why?!!! – the law is the law all over the country and it is the very existence of such variations that cause endless problems in the real world.  I worked the first ten years of my operational police service in Birmingham but have spent the last few years working in the Black Country: I might as well have transferred to another country in terms of mental health procedures.  This is why you get AMHPs in one area arguing that black is white about s135(1) warrants whilst the AMHPs in another area just quietly nod – it genuinely puts lives at risk when assessments are being done and I can name you the seriously injured police officers to back this up if it helps?  The only thing that should vary is the name of hospital buildings, the contact phone numbers and the nominated lead professionals in NHS / police areas whose job it is to liaise about affective operations and potentially training.  Why would searching patients in Wolverhampton be appreciably different to that in Warrington or Woolwich?  Why would a place of safety procedure or the circumstances in which a s135(1) / a129(1) warrant would be sought vary so much, if at all.  Either the circumstances of your patient’s assessment give rise to the grounds for it, or they don’t.

Page 76-77 relates to planned Mental Health Act assessments in a chapter on “Managing Violence in the Community”.  Given that throughout the book, reference to MHA procedures does relate to the law that applies to it, I was amazed to find that this section, which refers to police attendance to manage risks doesn’t mention s135(1) MHA / a129(1) at all – not once.  It does manage to mention s137 / a131 and the condition of legal custody that patient is entered into if the AMHP decides to apply for someone’s admission to hospital.  I am over 1,000 words into a blog, which I’m all too aware is largely critical of the police related dimensions of this document, but I can’t help wonder whether this is an omission?  If this book is about mental health professionals’ prevention and management of risk, s135(1) / a129(1) needs mentioning: it is the only legal mechanism available to officers to prevent the very risks that the chapter discusses without waiting for offences to be committed, which we can all agree hardly amounts to prevention, the first objective of the whole book.  And a chapter written by an AMHP lead, too!

POLITICS – STRATEGY – OPERATIONS – TACTICS

That’s enough for now – I could but won’t go on about the political posturing of Zero Tolerance and various aspects about the presumed possibility or impact of prosecution, which obviously has a role to play.  I didn’t focus on those aspects because it strikes me that the points made are those where the issues arising from policing are directly connected to mental health professionals – towards whom this book is pitched.  This book is not about policing: it’s about how policing interfaces with mental health professionals but how we write something like this without substantively talking about section 136 MHA and equivalent powers: I don’t not know.

My summary is that this all too casually assumes what the police do and what they can do, officers’ responsibilities appearing to have been considered with insufficient precision to foster a real understanding of the legal mechanisms that are available to get things done.  It assumes that the presence of the police will always be factor that mitigates risk, whereas those of us working this area know we can quite easily ignite latent risks at the cost of criminalising people, as mental health charities often point out.  Some patients suffer paranoid delusions about what the police are up to and even the best, most patient officers are still standing there in a uniform wearing handcuffs and quite possibly a taser implying “or else” which all rather makes a mockery of “least restrictive principles” when not properly considered.

So this document ends up being a broad brush strategic overview of something that is inherently very tactical –  it’s far from being a “tactical implementation plan” where it very obviously seeks to be; and if we know anything at all about policing and mental health we know it’s all about the tactics, not strategy.  The strategic intent of our NHS seen through documents like this and other Royal College and NICE Guidelines is consistently undermined by services which are not staffed, available or flexible enough to absorb the nature and variety of demands which arise for this most important of subjects.  So again, we come back to shoving the police in and busking against a background of not defining what we want them to do or equipping the professionals who want them to do it with actual knowledge.

NB: So many other Royal College Reports are free to download on their website – like the Standards on s136.  I would have preferred to download this for free, especially as it takes me for granted, seeks to put me at risk and contains basic errors I would expect to avoid if I’m paying for it.


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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4 thoughts on “The Prevention and Management of Violence

  1. Time and time again I hear from officers their involvement is assumed/implied without prior agreement, discussion or rationale. It is worrying a professional body of the RCPsych’s standing did not include the views of Police Services given the premise of the document. It would appear this is a clinical protocol rather than multi-agency response document, a missed opportunity in my opinion.

  2. Think it’s about time that there was a module within mental health nurse training about the law and mental health and working with the police force. The comment about protocols being the same everywhere is very insightful. When I was working in acute services we were often told there were different protocols across the county!

    1. Cheers – the reason there is encouragement for variation, in my view, is because CCGs are allowed such huge variation in how they provide what they provide and unless variation was tolerated (or encouraged?!) an awful lot of CCGs would have to find an awful lot of money to bring their services in to spec.

      You just need to look at s136 provision: how many of these things are staffed in such a way as to mean there is even a snowball’s chance in hell of working as the RCPsych multi-agency standards suggest they should? I suspect the answer is ‘zero’!

  3. Thankyou for continuing to speak out on this. As someone with personal experience of the sorts of attitudes in these essays I often don’t feel anyone would listen to my views. It is a great relief to hear someone else raising concerns. Mental health services have called the police to detain me in my home and in public places (including while I was at work) a number of times. The police have treatment me with respect and compassion but often confusion as to why mental health services could not themselves try talking to me or supporting me first. Currently my CMHT threaten to call the police to my home almost weekly – e.g, if you don’t attend the clinic to collect your medication we’ll send the police to your home. If you don’t turn up to your appointment we will send the police. To do what?, I want to ask, but I don’t. The police seem to be seen by some in mental health services as a threat to coerce patients to behave in a desired way, regardless of patient capacity. The criminalisation of distress and mental ill health is also a real concern. I’ve never committed an offence yet have been cuffed, restrained and transported in police vans to hospital more than 10 times in my life. This has caused extreme public stigma effects for me, and I have had to move home twice. As you also point out, the presence of the police now terrifies me (even passing sirens can make me cry) and significantly escalates my anxiety and distress, not because of the way police have ever treated me, but because of the way they are used by the mental health team. I hope people listen to you.

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