Over-Simplification

Even when I started writing this blog just under two years ago, policing and mental health received nothing like the coverage it now gets and there are various formal and informal ways of seeing this.  We’ve seen prime time television coverage devoted to it in last week’s Panorama, we’ve seen newly elected Police and Crime Commissioners getting interested in it, including Matthew ELLIS in Staffordshire who has hired a “mental health expert” to work for him on the issue; we’ve seen senior officers like Chief Superintendent Irene CURTIS giving the issues high-profile when she took on the job as President of the Police Superintendents’ Association.  We’ve seen the Home Secretary talking about it and her speech at the Police Superintendents’ Association Conference in 2013 including two updates on all the issues I’ve covered in almost 350 posts: “We’re talking to the Department of Health about this” and “We’re rolling out Street Triage.”  Chief Supt CURTIS called very specifically for things which stand a chance of helping: ammendment of the Mental Health Act and end to the use of police cells as a place of safety.

RISKING THE WRONG REACTION

This post argues that others risk over-simplifying complex problems and therefore we risk having the wrong reaction to them by introducing simplistic solutions and making simplistic statements.  For example, In the debate about the use of police cells, I have repeatedly heard the phrase “cells are no place for the mentally ill.”  What, ever?!

We all know what this statement probably means, it’s probably a call for the end of the use of police cells as a place of safety under the Mental Health Act.  But why over-simplify and call for an end, full-stop?  What should we do with someone with mental health problems who has murdered someone else?  It strikes me that police custody is exactly where they should be whilst that is properly investigated, with supporting mental health assessment and care whilst detained, obviously.  Indeed, if someone has been accused of an offence, taking them to police custody may be absolutely vital in terms of detention there triggering legal rights for police officers to seize evidence, take forensic samples, search premises and draw inferences from silence to questions. So where else would we ever go?

Well, some mental health presentations are so serious that people should be removed to Accident & Emergency departments after detention by the police under s136 or for offences and if that is the case after an arrest, then so be it.  The person can be transferred to police custody after the immediate medical issues are stabilised or assessed.  This is no different to if the police had arrested someone for a serious offence who injured themselves trying to escape the officers: prioritise the urgent medical issues in play at the time of arrest, custody as soon as you can once done.  Parity of esteem has to work both ways.

The reality is that about ten times as many people are arrested for criminal offences whilst mentally distressed as those detained under s136.  In the majority of those cases, their mental health disorders are not so serious as to make any difference to the criminal justice process that should subsequently follow an allegation of crime against that individual.  The outcome may or may not be different in light of any assessment or input that is undertaken by mental health services.  And again, think about parity of esteem:  the police service detain plenty of people for offences who have asthma or diabetes, cancer or heart problems – why should a person living with a mental health problem not be detained in police custody if an allegation of crime has been made against and they were lawfully arrested?  Unless their medical condition is so serious as to render this dangerous and assuming their rights and appropriate safeguards are put in place, it could be very necessary step to achieving justice for victims.  It is a complex balancing act that comes with the territory.

If this is not what was meant by “police cells are not an appropriate place for the mentally ill” (whoever they are), then we need to raise the sophistication of our public debate.

SIMPLISTIC SOLUTIONS

But this goes further —– if we are now having debate on the issues of policing and mental health, either because we want to see better integration of services, improved access to NHS services or less police time / money spent, then we need to see responses to the issues highlighted which also don’t over simplify.  It probably comes as no shock to anyone who regularly reads this blog, that I will immediately hone in on “Street Triage”.  It is a solution-version of the over-simplification in this arena:  officers dealing too frequently or too ineffectively with mental health related demand, so let’s give them a psychiatric nurse to improve things.  No doubt it does improve things – 40% reduction in s136 usage; improved access to MHA assessment pathways, etc..  Who wouldn’t welcome this?

Most of the section 136 processes that I have ever seen – and I get emails from various forces asking me to check over new policies and proposed revisions to current policies – massively over-simplify the complexity of the issues that people detained under this section of the Act actually have.  We still see NHS organisations calling for “violent and / or intoxicated people to the cells” in a place of safety process.  We see this even though officers have been prosecuted amidst suggestions of neglect that this approach placed people at risk.  We’ve seen HM Coroners criticising the failures to see through a fog of aggression and intoxication to recognise a legitimate medical emergency and we’ve seen clinicians agreeing that the police are right to think of some aggressive, intoxicated presentations as representing medical emergencies.  You need only look at the recent Royal College of Psychiatrists publication on the “Prevention and Management of Violence” to see this.  But because putting drunk, violent people in cells is intuitive to some, including to some psychiatrists and senior NHS managers, it represents an orthodoxy even though it could be clinically outrageous to do so for that vulnerable person at that time.  So how do we know what’s what?  Well we certainly don’t do it by over-simplifying the process.

These things are the solution or process equivalent of “police cells are no place for the mentally ill”.  Street Triage leaves almost totally unanswered the issue of immediate needs in private premises of some vulnerable people and triaging of need by mental health nurses leaves the question of whether they are equipped to identify what could (also) be physically unwell people.  And if we know that psychiatrists can miss underlying physical health care issues, are we confident mental health nurses will be better?  Or will we still see police officers calling ambulances?  I know I still would.

Directing aggressive, intoxicated patients to cells to contain them, leaves totally unanswered the potential of head injuries or brain tumours, diabetes or excited delirium to have brought about someone’s disturbed and / or confused state.

STATES OF COMPLEXITY

The reality is the reality: and it is complex.  We are policing in the twenty-first century, a deinstitutionalised model of mental health care which still hasn’t reached a consensus of what causes mental distress and how best to approach it by using drugs or talking therapies which were barely conceived when the laws governing police interaction were written in the 1950s.

We then give very little training to officers, watch them get it wrong and decide that the solution to this is a range of over-simplistic notions that fail to take (full) account of the complexity we haven’t yet fully understood because no-one is researching it properly.

So this doesn’t mean we can look at the equation on the left and explain anything by showing off our nine-times tables.

The police are doing what they do, whilst under-trained, alongside an entirely fragmented health system, still wrestling with the provenance and aetiology of mental health disorders and we are doing this in an era of cuts to public services and other financial cuts affecting individuals and increasing the mental health burden of disease in the UK – we see this in the rising suicide rate.  The laws we have don’t even allow our public services to keep people safe in their own homes without criminalising them and there seems little appetite to change that or do anything else to solve the issue, at the moment.

To think this is simple stuff that will benefit from simple solutions is quite naive but I will go further:  to push for simple solutions amidst that naivety is to create further problems that compound the likelihood of adverse outcomes for vulnerable people.  We know that things go wrong in policing because the mental health system we operate in the UK, implicitly wants the police to do the wrong thing because it isn’t set up to work with the police in doing the right thing.  There is just some potential for simplistic solutions to make this even more likely than it ever was before whilst superficially making it look better.  And this is why we need more proper research by world-class academics and far less over-simplification by people who choose to put their two-penneth into the public domain on issues they either don’t understand or have massively over-simplified.


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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11 thoughts on “Over-Simplification

  1. Hi, I do like the idea that the police cells should not be a place for people with mental health problems, however we replaced the big mental hospitals with big prisons at the end of the 1990’s. Men with personality disorders, alcohol abuse issues who are perceived as not having a treatable mental disorder readily end up in custody and in gaol. The system really rolled back to include less of the ‘moral treatment’ with the advent of modern psychiatry and a social policy geared towards ending the use of big expensive and abusive system of asylums. Michael Foucault and Erving Goffman & Lang being key to highlighting this. So I agree with you this is a complex issue and it requires an understanding of the whole picture all institutions from cradle to grave.

    Martin @SFBTtweets

  2. Michael,
    I am disappointed in your blog, and thought I would write to explain why.
    However, before I do, let me say I am a big supporter of what you are trying to do. We know there are very few experts in the area of mental health, who also work inside the police service. We also know that the issue of dealing with mental health issues as a society is in need of reform and law change.
    There are only a handful of police officers nationally doing what you do.
    I am sure you appreciate that you are in an enviable position to be able to do a job, that you love, both in your private and professional life. You live and breathe mental health.
    Your blog fails to absorb the real issue – That issue is that politicians and senior police officers do not have the luxury of writing 2,000 word essays every other day, drilling down into an area of huge complexity. My world, and that of Stephen Ellis, Irene Curtis and the Home Secretary, is that we get 8 seconds to soundbite the public over an issue on radio. Our world is that we get 8 lines to say a whole story, when you have 80 lines to articulate the executive summary.
    Although you didn’t name me in your blog, I am sure I am also in your sights.
    So, on behalf of the people you name, let me explain that yes, we appreciate we have complex issues, and yes we appreciate there are three clear divides – Places of Safety, people who commit crime with mental health issues, and people in private settings with mental issues who need diagnosis and treatment.
    No-one I speak to (and I have spoken to a lot) fail to appreciate the fact that custody suites are the correct place for people who commit crime. Your sub heading of “Risking the wrong reaction” comes across as demeaning, and seeks to highlight that some people don’t understand the issues. Trust me when I say we do. We just don’t have two pages to articulate them.
    You may be aware that I have put your name forward to the Government, to join in on a national debate on mental health, in the hope you could bring some clarity to the issue. However, having read this blog, I wonder whether you can be strategic enough, or detached enough, to bring that clarity. Blogs like this alienate the people that matter, alienate the movers and shakers who can start, and finish, the debate you so desperately want.
    Question – Does the law need changing in relation to mental health?
    Question – Even with pitfalls, and caveats, do we want street or home triage?
    Question – Does NHS England need to commit more resources to this issue?
    Question – Do you accept that politicians can make changes happen?
    If, as I suspect, your answer to these questions is yes, then my advice to you is don’t ostracise well meaning passionate people who are trying to make a difference, Just like you, we care.
    You appear better than that.
    Martyn Underhill
    Police and Crime Commissioner, Dorset.

    1. Martyn I was a little surprised to read your response to this blog. I think that you and I have clearly interpreted Michael’s blog very differently. I didn’t see him as challenging or alienating myself or the others he names, but as actually acknowledging the work we have been doing to try and bring about change. We all know that a little knowledge can be dangerous and that is the position I was in a year ago, but the support I’ve received from Michael (through his blogs, tweets and phone calls) in helping me truly understand the issues in what is an incredibly complex landscape (at both a strategic and tactical level) has been fantastic.

      I’m really pleased to hear that you’ve put Michael’s name forward to take part in a national debate as I don’t think we’re very good at tapping into the expertise of practitioners when developing new policy and practice, and I have every confidence from my dealings with him that he would contribute significantly to any strategic discussion.

      I appreciate your support both nationally and locally in trying to improve services for people dealing with mental health issues whilst ensuring that the police are able to use their resources more appropriately. You know that we are like-minded in our approach to this (as we are on early intervention), I hope that we can both continue to support Michael and others like him who are passionate about making a difference.

    2. So very many people were in my sights, mostly mental health professionals and service users, as the reaction to Panorama showed how much work there is to do.

      I’m not going to pretend that I didn’t know you’d made certain remarks in this agenda, but they were not the main focus, I can assure you. I also want to re-affirm what Ch Supt CURTIS has said: the words “others” at the beginning of paragraph two was deliberately there to distance the thrust of the blog from any of the people that were specifically named in the opening who are taking this agenda forward. I am not naming or alluding to anyone in particular in this blog precisely because over-simplified attitudes that I referred to are ubiquitous across police, health and social care professionals – at political, strategic, operational and tactical levels.

      I’m grateful for the support you give and for thinking I have anything to offer in this arena. Just for the record, this is not my job. My core role in the police is an operational one and nothing specifically concerned with mental health, except that I police to events that occur in my area. This is what I do in my spare time, to help frontline line officers arm themselves with knowledge to get better outcomes and keep out of the trouble that our system so often points them towards and if it also influences some others and creates debate, then that’s a bonus. It remains as true now as it was when I commenced active assertion in policing and mental health: that I’m not attempting to curry favour with anyone. It is what it is and its sufficiently important in its own right to mean we should be sorting it out before more people come to harms of various kinds.

  3. I would just like to say that I have read your post and I’m thoroughly impressed with this cogent, intelligent and well presented blog. I am a former police officer from Avon and Somerset Constabulary, left service and suffered a break down and was subsequently diagnosed with schizo-affective disorder in due course and have been receiving psychiatric and social services intervention for many years. My mental illness has, in the past , led to occasions where front line police officers have been first contact when I have been in crisis. I am writing to praise the professional, impartial and effective primary contact that I have experienced from officers concerned – and the humane but common sense discretion exercised in carrying out their duties when called to do so. As a person who has experienced working as a police officer and also has suffered severe mental illness, I feel reasonably qualified to comment on the issues you are raising and will be reading with interest your blog in future. Police officers are often caught between a rock and a hard place when considering the issues you are highlighting: thank you for these thought provoking and stimulating articles.

  4. Extraordinary criticism by Martyn Underhill!

    We all understand that in interviews people only have a short time & thus can’t expand on all the complexities (though there is always scope to include “This is really complex but here’s a few key points…”).

    When it comes to implementing “solutions” however, there is NO excuse for not taking account of all the complexities. Sometimes it may not be possible to address them all but to fail to take account of them in planning the response is simply wrong. The (artificial) constraints of the interview don’t apply & whatever time is needed to get the response as right as possible should be taken.

    To do anything less is to introduce something which looks superficially good but which doesn’t actually make much, if any difference (or which may actually make things worse). And THAT is not very strategic…

  5. WOW! The real issue is that you’ve only got 8 seconds during an interview? You can’t “drill down into the complexity” of the problem? So what do you do for the rest of your day? Michael is doing exactly what you as a PCC should be doing, bringing the issues faced by police to the public attention. Your comments have showed the role of PCC in a very bad light by suggesting the mental health crisis which is occurring in this country needs to be condensed into a soundbite. I’ve heard lots of ‘soundbites’ from MPs, PCCs and Cheif Constables yet the only person who has made a noticeable difference for frontline officers has been Michael.

    As a police officer I want better training not a soundbite. But if you want a soundbite then how about “Cops aren’t fighting crime because they’re to busy filling in the cracks for all the other services”. You’ve had your opertunity to post something constructive on a blog read by thousands of people up and down the country with an interest in MH an policing and you choose to throw a tantrum! So the ‘8 lines’ you did have (and you wrote a lot more) you’ve just wasted.

    However my problem is I’m too optimistic so I’ll give you another chance to convince me the ‘movers and shakers’ are doing not just pontificating. What have you done or are you doing to make a difference to frontline policing where MH is concerned?

  6. Michael

    As a fellow serving police Inspector, I just wanted to acknowledge the work that you do here and show my support to you for continuing to raise awareness and knowledge on this extremely complex area of our business. You are an inspiration to police officers because you strive to improve our ability to carry out our jobs in a more effective way, whilst highlighting the wider issues for discussion. I often quote you, and refer my officers to your website for further reading and practical advice. Please keep up the good work because you are making a difference. I look forward to meeting you in November in Manchester.
    Mark

  7. As someone with a mental health ‘disorder’ and who has had multiple interactions with the police I for one am damn glad that Michael airs as much as can be as am sick to death of soundbites, quick fix approaches and all that continues to perpetuate an inhumane incoherent system. Whether you like it or not Martyn it opens up the debate and stops the pretence that all is ok.

    I am terrified when in crisis . I do things that are incomprehensible to others . Bar one serious incident re s136 detention (with the subsequent complaint upheld) the majority of police officers have done their damnedest to try and get it right. However their response depends entirely on their confidence in knowing the law, being able to assert themselves to other agencies and a breadth of communication skills that the force rarely teaches. What this blog does is allow for shared experiences so thay everyone knows what problems we all face when NHS services fail and the police are left with the debris of someone’s life in a real crisis situation. Why is this a bad thing? Why can the yawning gaps in expectation and legal duties be explored.

    And you know what, I may not agree with Michael on certain issues but at least he has stepped up to the plate and opened up the conversation so that there is at least some chance that good practice can evolve somewhere even if in Dorset you dont support the idea of airing disagreemnets in public. The rest of us believe in open proces.

    1. “However their response depends entirely on their confidence in knowing the law, being able to assert themselves to other agencies and a breadth of communication skills that the force rarely teaches.”

      You show a greater understanding of the ‘critical issues’ than most.

  8. I do hope that mental health cop can both be consulted nationally and also continue to speak his mind .it would not be helpful though if the price of being consulted at Government level was for him to be quiet. How does a person from the ranks of the Nearest Relative/Next Of Kin such as myself come to be reading such a blog if not for the fact that change is so long overdue that even amateurs such as myself feel like adding their two penny worth. Why has so little occurred ? Why isn’t law as it exists explained to NHS staff ? Why isn’t the equalities act implemented ?
    Isn’t there meant to be a response to Adebowale or have I missed it ? Having been recommended to read this blog, after a while I’ve left a few comments but once said i’m mainly done. Mental Health Cop ,on the other hand, keeps going at a bi-weekly rate, sometimes saying some of the same things from different angles !! Whether or not his position is enviable is rather a moot point I would have thought. Perhaps Martyn Underhill means we should envy people who have such energy .

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