Coercing Other People

Policing and mental health services have many things in common (as well as some potentially insurmountable differences) but I want to consider one issue that is arguably the most controversial aspect: they are each systems of social control which involve the coercion of other people, by the threat of and the use of physical force. It is when force is being considered, threatened and used that we see these social infrastructures at their most controversial and we have noted for decades the tragic outcomes from restraint related deaths in both our police and health services. We have also come to learn how the misapplication of force can erode trust and confidence in these institutions, both in terms of affecting towards whom force was deployed and the confidence that the general public have arising from that.

Using force directly usually does one of two things: it hurts (or kills) people and it damages (or destroys) things. In civil institutions like these, hurting people and damaging stuff is never the objective in itself so whether a use of force is successful is judged in whether it is seen as legitimate in helping achieve other objectives. This is usually assessed with reference to whether conditions were created by a use of force within which other more desirable outcomes arise.

  • A police officer punching a member of the public in the face sounds like a truly abhorrent notion, but let’s imagine we were to see on CCTV that an officer had done such a thing in order to stop that person from stabbing someone else with a knife? Imagine that we saw an armed agitator advancing towards a victim and an officer with only seconds to make a judgement who did so and successfully – would we view this use of force as successful and legitimate? Very probably.
  • A mental health nurse restraining a patient by declining to allow them to leave a ward, physically obstructing them from trying to do so because of fears for their safety. All sounds very reasonable, doesn’t it? What if the patient was there voluntary and has every right, in law, to leave? We see this use of force in a different light, unless done after the nurse has applied a holding power under s5 of the Mental Health Act, to render their actions lawful.

CRIMINALISATION

The ideas I’m flirting with above are not my own: I have written before about the influence upon me of a book by General Sir Rupert SMITH – The Utility of Force. It was one of those reads that shifted my thinking in a major way about how we ensure the legitimate use of force and how we judge its utility. Whilst policing is not warfighting, General SMITH’s main argument about the shift in the paradigm of war – to a form of war amongst the people – sees many parallels with policing because he argues in this book that the use of force in modern conflict is not an end in itself, given that we do not see (very often) country-on-country interstate war. We are seeing states and multi-national organisations like NATO or the United Nations conducting operations and engaging in conflict of a very different kind, where force used must be done in such a way as to capture the will of the people whom it effects.

You only have to hear this to recall the words of Sir Robert PEEL in his nine principles of policing. PEEL wrote about the use of force in two of his principles, both of which are worth bearing in mind when we consider how the police are used in supporting our mental health system —

1 – To recognise always that the extent to which the co-operation of the public can be secured diminishes proportionately the necessity of the use of physical force and compulsion for achieving police objectives.
2 – To use physical force only when the exercise of persuasion, advice and warning is found to be insufficient to obtain public co-operation … and to use only the minimum degree of physical force which is necessary on any particular occasion for achieving a police objective.

So there are two things to say about the legitimacy, or the utility, of force. Firstly, we see a very genuine difficulty in the use of force by the police within our mental health system and you only need to survey social media and patients’ experiences to see this – calling in the Rozzers is usually seen as inherently heavy-handed and a stigmatising, criminalisation of vulnerable people. Secondly, we can see that mental health services themselves must wrestle with this issue –

LEGITIMACY

I admit to having often wondered about the mindset that sits behind a desire to be involved in the coercion of other people, where there is little or no willingness to actually do the coercing. I’ll admit to also wondering why someone would wish to be employer in a role where they coerce at the whim of others, without insight into why that would be appropriate – this is the position in which the police are often invited to stand when being asked to take direction from mental health professionals and it’s a very odd place to be; not least because the legitimacy is not just in force used, but in the way it is used. The decision to potentially hurt or damage is inextricably linked with the extent to which that impact is minimised in the particular circumstances. Separating the two carries all the potential for two mindsets to undermine the overall point.

When I have made this point previously, some have suspected I’m having a direct dig at mental health professionals when in reality staff are not recruited or deployed with the equipment and training to undertake these functions. I do recognise that perspective – but this is neither my point nor my intention. Our mental health services are large organisations, many of them employing thousands of people with budgets of hundreds of millions of pounds. We know that it is within the core business of such organisations that from time to time, they will need to take decisions to coerce other people. So my concern is that we do not design the organisational need to coerce and use force into the way these organisations operate, with the one exception of administering medication forcibly under Part IV of the Act.

It has long been remarked that our mental health trusts lack the ability to coerce the admission to hospital of a passively resistant, elderly dementia patient (implied by s6 MHA); they lack the capacity to coerce the return to hospital of an AWOL patient whose location is known (implied by para 22.13 MHA Code of Practice); and difficulties in ensuring that where Part IV of the Mental Health Act is going to be used to force medication upon others, that there are sufficient nurses available to do so. Bear in mind at all times, that there is a difference between people being violent and dangerous, with those who are resisting. This is not a point about ending all police involvement in supporting the NHS.

But there is an additional and particular challenge for psychiatry which remains unaddressed: the increasing challenges being made to the claims upon which psychiatry ultimately rests as the basis for legitimate coercion. We are hearing more and more from a range of professional sources, including some psychiatrists, but also psychologists and sociologists, that the evidence base for a predominantly medical, drug-centred model of mental health care lacks evidence and is, at best, ineffective in the long-term. At worst, it is actually capable of being seen as causing more harm than good. For as long as such debate is able to rage, we can expect to see some survivors of mental health services claiming that they have suffered long-term irreversible damage.

So in the end, this point is not really about ensuring that the police are not sucked into a training vacuum to undertake tasks officers would prefer not to do. It is more about achieving legitimacy and utility, in the use of force: by ensuring that when force is used, it builds public confidence in both policing and mental health care. This is achieved by ensuring that where the police are called into a mental health unit to use force, it can be seen as a legitimate decision to do so – for example, because of a serious disturbance involving barricades, weapons or hostages on a ward. It is also achieved by ensuring that where lower level incidents require coercion, our mental health services are prepared to manage it themselves, in accordance with the key professional principles that govern mental health care – for example, the principles of least restriction and the preservation of dignity.

If we are to ensure legitimacy in the occasionally coercion of vulnerable people, it is important that we strike this balance. If we fail to do so, people will just end up wondering why we keep hurting people and damaging things whilst doing more harm than good.


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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6 thoughts on “Coercing Other People

  1. Thanks for flirting with the topic of force and for raising various points worth considering.

    As a psychiatric survivor I’ve been at the receiving end of coercive treatment in psychiatric settings (1978, 1984, 2002). Not by police as I was never aggressive when mentally unwell (I’m much more assertive when in my right mind!). I resisted drug treatment because I don’t like to swallow pharma drugs, they are unpredictable and cause me to be depressed, take away my decision-making abilities and to have suicidal impulses (on venlafaxine).

    I didn’t like being drugged in psych wards where I had to live with strangers, some of whom were drug addicts and alcoholics, others with criminal tendencies. I thought it very risky when my capacity was compromised by psychiatric drugs. I don’t drink alcohol or take recreational drugs in “normal/real” life as I don’t like the effects of those either. I particularly didn’t like the mixed gender psych wards, especially in earlier years when I had to wear pyjamas, our clothes were locked away.

    So I am against forced psychiatric treatment. On principle. And because I don’t want it done to me and mine. There has to be a better way of working with people in mental distress and altered mind states/psychoses, which is what my family all experience. It’s normal for us. The “mental illness” label wasn’t helpful and the disorder label I have seen used to declare “incapacity” and to force treatment on the “non-compliant”, or in my case non-conformist. I’ve always been non-conformist, now in my 62nd year, so being in a psychosis won’t change that.

  2. On the subject of coercion, how does the law view when patients with full capacity make a judgement that is deemed to be a poor one and people attempt to convince them to change it?

    Is there any guidance/legislation on when/if this is acceptable and at what point it crosses any boundary that may/may not exist.

    One I’ve seen used before and have never been comfortable with is “do this or we will phone the police and they will arrest you” for example

    1. All depends on the circumstances but it’s certainly possible to say that the law allows for unwise, potentially foolish decisions by adults who have the mental capacity to talk those decisions. So where an unwise decision may be taken, it falls to whoever is there to decide whether they think the person has capacity and to seek support of some kind if they think they don’t. You’re then off down the ‘assessment of mental capacity’ route. It was notoriously argued in the Kerrie WOOLTORTON case that even where someone had consumed enough anti-freeze to kill them by renal failure, DRs were obliged to respect that decision.

      1. Not so sure about the Kerrie Wooltorton case… She had a diagnosis of BPD which meant exclusion from services (including other services like homelessness services) until 2007, and it happened in 2009… as we know the wheels of change can be slow to turn. It’s highly likely there was no treatment offered at all, and if there was it would have been DBT which can make things worse for some people (I don’t buy that it’s inventor had BPD, at least not in the same way other people do – DBT is all about not SHOWING signs of distress, re-programming your mind, without much chance to work through things that have traumatised you). In addition she would have had cruel comments from staff, and be viewed as an ‘attention-seeker’ (this is getting better but it seemes to be because older prejudiced staff are retiring as much as actul change in the system!)

        I would be willing to bet that if she’d had a diagnosis of depression she’d have been saved – and offered treatment and support in the longer term. But because she was ‘just’ BPD it’s viewed as ‘behavioural’ not a ‘mental illness’ in the same way (no matter what the law actually says now; this is the attitude of staff). Being suicidal is seen as a ‘symptom’ and thus a normal state of affairs and not to be taken seriously.

        In this case it wasn’t necessarily a ‘foolish’ decision either, the chances of her getting the treatment she needed to end the painful misery of her existence are very low. Services focus on not showing distress rather than reducing it – long-term, compassion-led therapies are like gold dust (if they exist at all in the NHS?) However, given than BPD is now included as a mental illness, and by it’s very nature is long-term and enduring, then she WOULD have been experiencing BPD symptoms at the time of writing the ‘living will’. So really, the question is…. why is it considered to be a lack of capacity if someone with schizophrenia has symptoms that make them want to kill themselves, whereas someone suffering symptoms of BPD – which are directly making them want to kill themselves – is deemed to have capacity? What is the difference?

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