This blog is specifically aimed at those attending the biennial conference of the International Council of Police Representative Associations in June 2014. The ICPRA have been kind enough to invite me to speak at the their gathering in Cape Town. Yes, really! This is a particular honour, to return to this wonderful country to talk about policing and mental health at an international conference – I could hardly be more chuffed at the chance to go!
Those attending this conference should consider this to be background material for two weeks’ time! —– I hope those who are not going may find it interesting anyway.
TWENTY PERCENT OF DEMAND
Mental health has for a long while been an increasing proportion of police work in almost every country and it is directly connected to some of the most sensitive and controversial incidents we encounter – fatal police shootings, restraint related deaths in police custody ranking amongst them. Regardless of particular legal, political or cultural jurisdictions, police forces around the world report large proportions of high-profile, untoward events involving vulnerable people with challenging, complex needs.
- A half of fatal police shootings are thought to involve vulnerable people in distress.
- A half of deaths in police custody, often whilst under restraint, involve vulnerable people in distress.
- More than half of deaths following police contact, often by suicide, involve vulnerable people in distress.
- A third to a half of people arrested are those of us with mental health problems, learning difficulties or disabilities.
- All of this is made more far complex by substance misuse or abuse which can confuse and conflate the recognition and identification of people.
- All of this is made far more complex given that science is very far away from reaching anything like a settled view across all mental health professions about ‘what works’ in mental health care.
- There is even research from the World Health Organisation – much debated as it is – which indicates recovery from mental distress is more likely in countries that do not have developed psychiatric healthcare systems.
So where does this leave policing and criminal justice when most countries seem to suggest we should be diverting vulnerable people into appropriate health care, where available? It leaves police officers standing at the interface of two massive systems of state coercion and control, making decisions that are the most complex of all those professionally required of us. I will outline at the Conference why it this leaves us highly uncertain of how policing should operate and how partnerships with mental health care should be structured given how fragile scientific discourse actually is about mental distress, but it is against this uncertainty that police officers are required to turn endless shades of grey into black and white, yes or no decisions.
And all too frequently, police officers are seeking to find nothing more than the least worst option.
HOW DID WE GET HERE?
Many countries’ mental health services around the world began a process of deinstitutionalisation approximately sixty years ago – after World War 2 and especially following the development of anti-psychotic medication in the 1950s. Police forces were not aware of how fundamentally this shift in mental health care would affect their profession and did not prepare for it. In fairness to the criminal justice system, promised investment in community mental health services did not appear and contributed to a process whereby vulnerable became increasingly criminalised in order to access care, or as proxy for care. Using our host country as an example, South African mental health services began deinstitutionalising mental health care somewhat later, following the end of Apartheid – and the process continues today – but community mental health services in the country have not expanded to take account of this and there is a considerable shortage of mental health professionals, especially in rural, poorer communities.
So it’s back to policing and we know from research in the US, that police officers’ decision-making when dealing with encounters where they recognise people are suffering from mental health problems will be affected by the options available to them to avoid arrest or prosecution. If police officers do not have health related options to keep people safe or to refer them to relevant services, they will opt to criminalise them where this is necessary to protect the public. Hence we see high rates of mental disorder in imprisoned populations and this is true in South Africa just as it is in the United Kingdom and elsewhere. This fairly notorious graph of US mental health care and the imprisonment rate of those US citizens who have mental disorders betrays a very clear trend –
You could probably draw a similar graph for the United Kingdom, for Australia or Canada – certainly the UK there are three times as many people with severe and enduring mental health problems in British prison system than within the UK’s secure mental health services. You would have to have quadruple the health service capacity to transfer those people from prison, but the cost per person of care, rather than incarceration would also quadruple, at least. This gives us something of a clue as to why it does not happen! And none of this takes account of those in prison with less serious mental disorders that would not require inpatient mental health care and it does not take account of how the criminal justice system itself can cause or exacerbate mental distress.
Around the world we see policing playing its part in two contexts of mental distress: and this is a very imperfect distinction –
1. Responses to mental health emergencies
2. Responses to criminal suspects who are mentally ill.
POLICING MENTAL HEALTH
So we’ve seen officers around the world responding to situations involving risks and public disturbance, encountering people with unknown backgrounds possibly involving mental health, drugs, alcohol and social problems, having to take blunt decisions about whether or not to detain, whether or not to use force and whether to choose mental health or criminal law. We know that officers are taking these complex judgements without clinical training and with comparatively little mental health training. Initiatives around the world like ‘Crisis Intervention Training’ are seeking to improve this situation, but it remains far from settled as to what’ good’ looks like in policing and mental health. We are yet to see schemes properly evaluated by good quality academic research.
Meanwhile, our hosts are undertaking high-profile trials where Oscar PISTORIOUS and Shrien DEWANI are being tried for homicide offences in hearings which have become embroiled in difficult questions about the interface between law and psychiatry. We’ve seen in these cases that definitions of ‘mental disorder’ vary between lawyers and doctors and this says much about the interface of law and psychiatry where police officers often find themselves standing. A must-read academic analysis of this for those who are interested in greater knowledge, is Mental Health and Crime by Professor Jill PEAY. To see the extent to which these problems can cause crippling political problems, read Neither Mad nor Bad by Deidre GRIEG which highlights the case of Garry DAVID in Australia in the 1990s.
And finally, we must look at ourselves –
- In most countries, 25% of the public will suffer from mental health problems in the course of their lives.
- Research suggests police officers are around four times as vulnerable to suffering from mental problems such as stress, depression and anxiety.
- We know there are particularly problems in achieving proper psychological support for officers suffering from PTSD.
- We know that suicide rates in policing are way above that seen in society as whole.
- We know that men are more likely to die from suicide than woman, as much as three times as likely.
- So in a male dominated profession that operates a culture where admitting to experiences of distress may well be met with negative organisational as well as peer responses, why aren’t we fighting stigma and discrimination internally?
- We could learn a lot about ourselves by recognising that very few police officers are open about their experiences of mental illness.
- Why do we think this is?!
RESOURCES FOR SOUTH AFRICA
Here are some resources and policing, mental health and criminal justice in South Africa and a documentary that is well worth watching.
If you’re going to be in Cape Town for the conference, I look forward to meeting you in a beautiful city that you’re bound to love, as I do.
- The South African Mental Health Care Act 2002
- Dr Vikram Patel talking about global mental health in developing countries.
- The PRIME website.
- Taking Stock: Mental Health in South Africa
- Suicidal Ideation in the South African Police Service
- The Mental Health Gap in South Africa: a Human Rights Issue.
- The South African Mental Health Federation – an umbrella organisation for mental health charities.
- The World Health Organisation (UN) report on South Africa’s mental health system.
- Recent research article on the South African Police Service’s use of “Section 40″ MHCA 2002.
NB — I want to provide a background note to my attendance at this event, in order to head off certain questions that may naturally arise.
Firstly, I am attending this conference entirely in my own time – I have taken two days’ of annual leave in addition to the four days off afforded by my shift pattern to create the opportunity to go. Secondly, all travel and accommodation costs are being met by the organisation who have invited me to talk to them on policing and mental health. It has therefore cost the British taxpayer nothing in terms of time or money for me to attend this event.
Winner of the Mind Digital Media Award.