Models of Illness

There was a point in my journey into policing, mental health and criminal justice where ongoing debates about biology, psychology and sociology were just of passing interest.  They seemed a touch too abstract to be of particular importance and somewhat detached from the realities of whether officers should detain someone under s136 MHA or whether they would divert from justice someone who had been detained for an offence.  Every now and then, we see these debates erupt in the media and they are constantly simmering in social media.

We’ve seen books published by psychiatrists, psychologists and sociologists about the potential causes of mental distress and about the classification of human experience.  We see debates conducted with some ferocity about it all and it took me a while – too long, actually – to realise that this stuff is actually at the heart of why some police officers find mental health professionals’ responses to cases that we refer to them for assessment.

It is personality disorder and substance abuse that often raises questions from cops – those scenarios where people have been (repeatedly?) detained whilst engaged in risky behaviours whilst intoxicated like threatening to jump from a bridge or engaging in significant self-harm.  We saw in the recent episode of Panorama how the worlds of policing and social work view the same people: whilst officers were busy talking earnestly to camera about the people they’d detained who were “mentally ill”, I was reading on social media that AMHPs were busy turning off their televisions because the examples used were “behavioural” and connected to substance abuse.

Of course, the AMHPs declared victory when there was further footage of sober people drinking tea and talking about the previous evening.  But then broke out the social media debate and officers quite rightly pointed out that it is not their role to diagnose whether behaviour that falls within the scope of s136 MHA arises from organic or functional conditions, or whether it is explained or aggravated by substance misuse / abuse alone.

TREATING A PATIENT’S ILLNESS

The use of the word “illness” in particular, seems very controversial for many.  Richard BENTALL and several others have written about how unhelpful it is to talk of mental distress as “illness”.  Others like Tom BURNS have argued that it lends validation to those who live with mental distress to have their difficulties recognised as an illness.  Thus you then get into philosophical debates about what an “illness” is and into fairly pedantic debates about heritability, genetics and lifestyle.  If you really want to get deep into the philosophy of all this, I recommend an excellent book by Derek BOLTON called “What is Mental Disorder?”

If you get into that debate, numerous others naturally follow about words like “patient” and “treatment” – we know how difficult this is, because organisations have issued guidelines about language in mental health in order to assist.  Time for Change have a brief language guide advising us to stay of certain phrases.  But it is right that they do: we don’t want to unnecessarily stigmatise or criminalise people, but policing is there to criminalise some people.  That’s what the justice system does.  Obviously, it should only do so based upon evidence and a public interest in doing so.  How we assess those things is crucial.

But assess them, the police must: the person standing on a bridge threatening to jump scenario has become something of a classic dilemma.  You will recall criticism of a police officer who had stated whilst an incident was still in progress that if the person could be persuaded down without jumping that they would be prosecuted.  There was a superficially understandable outcry to what appeared to be a casual disregard for “obvious” unmet need.  It transpired that many, many attempts had been made following previous similar events to signpost, support and assess need and ultimately, the person did not have a condition that warranted detention in hospital and was offered various other supports on a voluntary basis.  And yet the incidents kept happening, bring roads and railway lines to a halt.  So the underlying aetiological debate about biology, psychology and sociology suddenly does become important to the policing decisions — an established absence of certain kinds of conditions means the police needed to stop looking at this behaviour as something which section 136 of the Mental Health Act could assist with.  They needed to think about the criminal law, both as a safeguarding tool for the individual and for the broader protection of the public.

NB:  If we don’t recognise the potential impact upon the public of these kinds of events, just imagine the impact upon you of being an HGV driver, progressing along a quiet motorway in the early hours of the morning, unable to swerve out of the way of a person who jumped from a bridge ahead; or one of the hundreds of train drivers a year faced with similar incidents on the rail network.

DOES THIS MATTER?

Well, it does raise profoundly interesting and difficult questions about policing when we think about the origin of someone’s mental distress.  Where someone, for example, has dementia and it is advanced to a stage where the patient can’t look after themselves, does not recognise their immediate family and very occasionally lashes out when distressed, punching their spouse or adult son – we understand the issues that arise in looking at that assault from a criminal law perspective.  If you repeat a vignette with a similar criminal act set against a different background, our perspective and our reaction starts to change – what about a 37yr old bipolar disorder patient suffering a depressive episode who assaults a paramedic trying to help them to hospital for assessment; what about a 14yr with ADHD who assaults a special educational needs teacher who is trying to help them with work they find difficult; what about a 26yr old man with schizophrenia and a very long history of voluntarily (ab)using controlled drugs that he knows worsen his paranoia who assaults a police officer attempting to detain him under s136 MHA?

The first patient is suffering from a progressively worsening, organic condition who has hurt a loved one who will be understandably reluctant to criminalise them; the second is suffering from a functional mental disorder who has hurt a professional less likely to be prepared to shrug off a violent assault.  The third patient is a juvenile who also hurt a professional, but perhaps one less likely to think of criminalisation as being an option of first resort.  Finally, what does voluntary (ab)use of drugs or alcohol do to our attitudes about violence by those living with mental health conditions?

I submit that attitudes towards patient 1 and patient 4 will vary, very significantly:  we look differently towards elderly dementia patients than we do to adult men whose excessive use of intoxicating substances contributes to their condition, whether by cause or by effect.  Some people look differently upon conditions like bipolar disorder and ADHD because of perceptions of validity – bipolar as a diagnosis is much less often questioned as valid, compared to ADHD which some clinicians argue does not exist.  Of course, others argue it does.  That debate is important if it may lead to some mitigation for a criminal act or an alternative form of sentencing.  It is about understanding whether crime and “illness” is causal, contributory or coincidental?

FIX ME / HELP ME

I mentioned briefly in a previous blog a health consultant from Vanguard who bemoaned the “fix me” system that is trying to respond to “help me” patients:

Whether the person who hangs off a bridge and cries for help is there because they are suffering clinical depression, whether they have suicidal ideas because of bipolar disorder, whether their life is being slowly ruined by a progressively worsening anxiety disorder – if they are there at that place and time, interacting with a police officer or paramedic who is trying to talk them down, they are potentially looking for help.  Whether “help” is a “fix” may not necessarily matter.

Think about last nights episode of Bedlam on Channel Four — various patients recognised that they may always live with anxieties like OCD.  What mattered to some was not a “fix” but that the extent of their anxieties became manageable – something they could live with in the context of a normal life, whatever that is.  We also hear the “fix me” or “help me” debate when people discuss mental health medication — those who question mental distress as “illness” often go on to point out limitations, problems and side effects of psychiatric medication.

Why wouldn’t you?  If schizophrenia is not a disease entity – and a professor of psychiatry said exactly that to me in a lunch queue at a conference a few years ago – it must follow that drugs are not the long-term solution that they could be if it were.  Whatever it is that’s going on, I know that various mental health professionals repeatedly saying, “Yes, it is!” and “No, it isn’t!” doesn’t alter the legal duties of your police service: to prevent crime and bring offenders to justice; to protect life and property; and maintain the Queen’s Peace.

We have to work out how this is best done against the uncertain background of several health and social care models which are in a state of constant tension.


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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2 thoughts on “Models of Illness

  1. Years ago i wrote an article for American Jails called Jail As a Psychiatric Emergency Room. It seems strange that this was my only professional article given my background in psychology and my penchant for writing, but sometimes things turn out that way. More important than my article is this book, which is one of the most important works on the history of the destruction of our mental health system and how the criminal justice system inherited the load. It is also very readable. Regards from a mental health pro!

    http://www.amazon.com/Madness-Streets-Psychiatry-Abandoned-Mentally/dp/0967993903/ref=sr_1_1?s=books&ie=UTF8&qid=1383418519&sr=1-1&keywords=madness+in+the+streets

  2. I love your work here and I think this piece is very good.
    I’m originally from UK but live in Toronto the last ten years. The difficulties you write about are, I think, common to many societies. Certainly here in Toronto we have a very great and very real difficulty figuring out how police can best work with people who are distressed. Its not made easier by the fact Police carry guns routinely and get little training in dealing with situations.
    We do have “Mobile Crisis Teams” -a police officer and mental health nurse team – but not across the city and not round the clock. Despite their unequivocal success, a string of many deaths in the last ten years, subsequent inquiries and coroner recommendations to deploy more such teams and improve training for all officers it’s not happened.
    There is a major inquiry ongoing right now into police procedures in three recent cases.
    Currently Toronto Police Service’s response is that they want extra cash to equip officers with Tasers at $20k each.

    Here’s a piece I blogged today, I’d be interested to hear your view.
    http://recoverynetworktoronto.wordpress.com/2013/11/05/california-police-use-of-body-cameras-cuts-violence-and-complaints/

    I can have “strange” experiences myself and have been diagnosed, know and work with many who have and become involved with the mental health and criminal systems. I’m well and know how to stay well. I use that now in peer-led education and Toronto Star calls me an “activist”.
    http://www.thestar.com/news/gta/2013/03/31/hearing_voices_need_not_mean_youre_crazy_says_activist.html

    Also, my sister was a police officer – her husband too, between them they had over well over 40 years on the job, so I know a bit from that side too about just how difficult policing is.

    I’m wondering if you’ve discovered the work of David Eaglemann? he’s researching perception and especially brains and law. I think you’ll find him interesting – don’t think he has any answers but he’s asking some mighty powerful questions.
    Kevin

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