The United States of America

We’ve been seeing interest in the US approach to policing and mental health for some while now – more recently, since these issues became a feature of interest in British policing and as part of the continuing interest that British policing generally has in American law enforcement.

There is much of interest in the United States and much I would like to see for myself, but there are certain reasons why I suspect a lot of it may not translate easily to the UK.  In 2013, two Winston Churchill Fellowships were awarded for travel to the US (and elsewhere) to examine mental health provision in policing and broader criminal justice.  I’m looking forward to reading the reports but I’m especially keen to understand whether potentially good ideas could shift across the pond.

HEALTH AND MENTAL HEALTH

Firstly, let’s focus on the US health system and their approach to mental health.  The US does not have a publicly funded free-at-the-point-of-delivery oriented health system.  This can mean that those of us who live with mental health problems cannot access any kind of mental health service whatsoever – the New York Times reported that in 2012, just over 15% of Americans had no health insurance cover at all and until 2008, it was legal for insurance companies to exclude mental health care from their policies, without further reason.  Many reports exist of people in need having no access to any level of mental health care unless they happen to be in an area where there is charitable or third-sector provision.

Secondly, the US approach to mental illness is somewhat at odds with many other countries, not least since the publication last year of the fifth edition of the Diagnostic and Statistical Manual, the DSM5.  It is published by the American Psychiatric Association and was subject to fierce debate in the years leading up to 2013 for its system of classification.  The DSM5 is the basis of many US health insurance approaches care – unless you are diagnosed as having a condition listed in the DSM5, your health insurance does not cover you and it would cover you only to the extent of delivering treatment the DSM endorses as valid.  This is (more?) often connected to prescription of psychiatric medication.  The scientific under-pinnings of the DSM have been criticised since the third edition was published in 1980 – criticised by many as almost entirely invalid from  scientific point of view.  Noteworthy amongst the criticis of the fifth edition is Professor Allen FRANCES who was the chair of the DSM-IV taskforce.  He produced an article at the time of publication stating, “Psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests” and he “unpredictable overdiagnosis.”  It is worth remembering, that most British clinicians prefer to refer to the World Health Organisation International Classification of Disease, known as the ICD-10.

Thirdly, and a point that will be objected to by many is that if we read the work of US journalist Robert WHITAKER and of US sociologist Allan HORWITZ, we will see argument that within the US itself, the medical model of biological psychiatry over the last fifty years has coincided with an incredible rise in the number of people who are long-term disabled with mental health problems and in receipt of state and federal disability provision.  Both authors cite various studies – and not just from the US – suggesting that psychiatric medication, especially antipsychotics and antidepressents, are widely over-prescribed in the US and have potentially contributed to exacerbating a public health crisis in the country.  Many object to their analysis, accusing them of mis-representing studies and selectively citing what suits a pre-determined position.

But in terms of highlighting difference of approach, it remains important to remember that the concept of schizophrenia in the US means something different to a concept described by the same name in the UK – it is a much broader condition as defined in DSM5 along with a load of others that are simply and quite flatly rejected as scientifically valid by many in British psychiatry.  Make of all that, whatever you will.

POLICING AND CRIMINAL JUSTICE

American police are routinely armed – let’s start with the most obvious and important difference in the relationship between officer and citizen (or subject).  Some US policing catastrophes in this arena of mental health have come from fatal shootings and to put things in context: the British police did not fire a single shot in 2012, the US police shot and killed at least 400 people.  That is not adequately explained purely by population size.

Figures are not routinely collected on a national level, but if they killed hundreds can we assume they injured thousands either by firearms or by the use of tasers?  Who knows, but we do know that there are significant differences in our two societies when it comes to gun laws, gun possession and and the police use of force – it is a discussion about apples and pears.

The US criminal justice system incarcerates people at an absolutely enormous rate – it is the highest documented rate in the world with 743 people per 100,000 of population being imprisoned.  Compare this with the United Kingdom at a rate of 154 per 100,000 of population and a European average of 102 per 100,000.  The incarceration rate is more than double that of South Africa (331) and such is the effect of mental health and criminal justice policy in the United states that three of the largest institutions providing specialist mental health care are in fact prisons:  Cook County Jail in Chicago; Rikers Island, New York and Los Angeles County Jail.

We know also know that the kind of offending and violent crime we see in the United States is significantly different to the kinds of crime we seen in the UK and that the incarceration policy does not necessarily impact upon this in the way that right-wing criminologists would hope.  For example, there are 4.8 homicides in the USA for every 100,000 people and approximately 70% of them are committed with a firearm.  Compare that with 1 homicide per 100,000 for the UK where 2.4% of them involve a firearm.  You could go on to make various other comparisons on crime levels, but I provide homicide purely as an example – the substantive point is the frequency and nature of crime in the USA is very different.

POLICE MENTAL HEALTH UNITS

Who knows the combined effect of all of this? – but on almost every level, the United States is a very different place to the United Kindgom, both structurally in terms of health and criminal justice as well as socially, in terms of attitudes and approaches to crime, mental health and the role of the state.

What we know of how the US police have approached the issue of demand connected to mental health, is that some of the larger police departments, like Los Angeles, New York and Chicago invested a significant amount of resource in establishing mental health units.  The LAPD for example, has a “Mental Evaluation Unit” of approximately 60 people and it has existed for over forty years.  This includes a number of trained mental health professionals, employed directly by the police and not seconded from any health provider.  Within the MEU there is a Case Assessment Management Programme to proactively attempt to reduce demand from “recidivist high utilizers of emergency services” via 911.

To put the size of that unit into comparison, the LAPD serves an area about one-third larger than West Midlands Police, both in terms of resident population and number of officers.  So it would be like WMP employing 30 officers and 10 mental health nurses to target mental health related demand.  Imagine the reaction of the NHS to the idea of it!?

CRISIS INTERVENTION

We have also seen considerable investment in the United States in Crisis Intervention Training.  Arising from an initiative in Memphis, Tennessee, CIT programmes began as a way of improving police training to de-escalate mental health crisis situations and reduce instances of the use of force.  The need for such a programme arose in Memphis in 1987 following a particularly controversial fatal shooting of a mentally ill man.  By combining with local universities, mental health providers and others, CIT programmes overtly “badge” and brand officers as CIT staff as a way of reducing fear in those of us who live with mental health problems.

Such programmes involve a percentage of front-line officers undertaking a 40hr training programme and taking on CIT responsibilities in addition to their core duties.  Such programmes claim to have reduced the instances of people with mental health problems being arrested for offences and in situations resolved by a use of force, with accompanying reductions in injuries to both police officers and the public.

Heather BARR, a US lawyer and human rights advocate, wrote a chapter entitled Policing Madness in a 2002 book on Police Zero Tolerance in New York, which interestingly charts the withdrawal of community mental health services and the drawing of the NYPD into the vacuum that remained.  It is a short picture of the dynamics at play in the US in recent decades and CIT is designed to improve how that works. << You'll recognise this as an example of “trying to the wrong thing, righter.”

Crisis Intervention Training has become a brand that is now exported around developed countries.  Versions of it, often under the same name, have emerged in almost all states of the US as well as in Canada and Australia.  The United Kingdom has not attempted to do it in the same way, although similar kinds of ideas have been implemented in specialist firearms units, for example in Northumbria Police.  Again, one can see issues of utility: British firearms units are more likely to lead on the kinds of incidents which in the US, Canada and Australia are led by first-response officers who are armed.  The imperative is a different one in the UK and New Zealand where officers are not routinely armed.

SEPARATED BY A COMMON LANGUAGE

I have said for years we need to do more on mental health training for officers, but for these reasons and all those differences mentioned above, I am cautious about how directly American ideas on policing and mental health would translate across the Atlantic.  One thing that is massively under-researched is the interplay between all of this: if the US are adopting a more biological approach to mental distress as illness and relying to a greater degree upon psychiatric mediction like anti-psychotics and anti-depressents, what impact does this have on policing and crime?  Something I need to know far more about, is akasthisia as it has been speculated and some studies have suggested that this may be linked to suicidal and homicidal ideation.

And so we need to be careful on several levels about how we handle good ideas for US cities without working on assumptions that things will be transferable because we all speak the same language, more or less.  The good ideas that are then will just need carefully translating, as we often see with our joint approaches to the use of English!


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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