Fear and Anger

Can you tell the difference between fear and anger in the aggression you’ve seen? Does it matter whether there even is a difference when it comes to responding to incidents where people may be non-cooperative, for whatever reason?  This is an issue I’ve touched on before – in fact I’ve done so a few times.  When considering the use of force by the police: traditional thinking has always been that you assess the threat before you and respond to it using the lowest level of force, consistent with safety to the officer and others affected by the situation.  Hence criminal law concepts like reasonable force and mental health law principles like the least restrictive practice.  Are these concepts not the same thing, when all is said and done?  Could you not also say that the police must arrest criminals in the least restrictive way and that mental health nurses can only use reasonable force when administration medication without consent?  Maybe.

THE POLICE USE OF FORCE

But when it comes to that traditional approach to the police use of force, we know that the service has been encouraged again and again – by Lord ADEBOWALE and by the Home Affairs Committee of the House of Commons, amongst others – to consider the particular challenges that emerge when deciding whether and how to respond to mental health emergencies.  What if the police are a part of the problem and we have to send them into a situation because of perceived levels of risk and threat?  This seems to matter to me for one very simple and important reason:  the potential for an exit strategy from the incident.  How do you get out of using force once you’ve started when the merest fact of police involvement or of coercion is going to cause fear and panic by the person at the centre of the incident?

There is an inquest occurring in Biongham as I type this, following a death after police restraint of a detained mental health patient which occurred after staff on a mental health ward called 999 asking for support.  We will see in a few weeks how the Coronial system has viewed that particular incident, the reliance upon the police by mental health services and the use of force.  I’m not an expert in restraint or the use of force:  I’ve done my officer safety training courses, my public order training courses and I’ve had to put what I’ve learned in them into practice on many occasions – including during mental health emergencies.  I’ve had to do things in the course of my job that would have seemed highly counter-intuitive to me when I was a music student, even though policing was always my career path.  As my operational experience grew and having dealt with various resistant offenders, including enough of them who have been armed with various things, I started to see a distinction between them and the mental health emergencies I was attending.

Where you are detaining a resistant person who is a suspected criminal, without the kind of cognitive dysfunctions that may arise from drugs, alcohol or mental distress, there is a qualitative difference to any resistance exhibited after arrest.  Essentially and perhaps simplistically, once they’ve realised they are properly secured, they start to turn the physical resistance into verbal abuse and into other disruption strategies – they were trying to avoid arrest and when realisation sets in that this has not been successful, the objective changes.  Where you are attempting to secure someone who is intoxicated by drugs or alcohol, or who is in extreme mental distress things are very different.  Resistance often becomes more pronounced and more desperate as time goes on and it gets harder and harder to stop what you’ve started.  Mainly, in my view, because avoidance of detention is not the objective – it is avoidance of what is feared will happen after detention along with a dangerous mix of medical, cognitive and psychiatric factors.  Some people think the police and mental health services are literally trying to kill them and detention, restraint or medication is seen as just one step in that process.

CONTAIN OR RESTRAIN

I accept agai, I’m generalising here – very obviously I am.  For the purpose of the point I’m trying to make in this post, it potentially doesn’t matter.  Police interaction with some vulnerable people where they are called upon to use force to contain or restrain someone begins a process that can very quickly and directly lead to disastrous outcomes.  We’ve seen this throughout the course of my career and examples go back even further than the death of Kingsley BURRELL in Birmingham – Michael POWELL, Sean RIGG and Olaseni LEWIS, to mention just a few.  There are loads more besides, very sadly.

My argument is – if we understand the difference between fear and anger and recognise that the mere presence of police officers can cause exacerbated levels of fear and anxiety amongst some vulnerable people, we start to understand why some things can go badly awry.  We might also understand how reliance upon police officers in some situations might be best avoided, the importance of prevention in mental health services and the importance of other approaches.  We know that there has been considerable focus in both policing and in mental health about the use of the ‘prone’ position.  This is where a group of professionals force a person face down on the floor for various purposes – it is taught in police officer safety training because it can make it far easier to handcuff someone.  It is taught as part of a cell-extraction technique whereby a group of officers can place a person in police cell before exiting the room and closing the door, without allowing the person a change to get to their feet and prevent the door being closed.  It is also a thing that has been incredibly discouraged in mental health settings where different restraint techniques are often taught.

So there is a difficulty when we hear about the police use of force in psychiatric settings.  More than one of the controversial deaths in police custody have involved calls to the police for support on mental health wards which led to disaster.  I’ve already mentioned the ongoing inquest into the death of Kingsley BURRELL but we should also see an inquest into the death of Olaseni LEWIS later this year and we are yet to learn what the IPCC have concluded in each case.  Given that police techniques and the use of force are controversial enough, when considered in the context of mental ill-health and vulnerable people detained in hospital, the stakes are raised both in terms of risks and in terms of perception.

RESPONDING TO FEAR

Extant training on conflict management is about using a graded approach to assess risks and threats and then attempting to de-escalate situations verbally, wherever possible.  Then, it is about responding with reasonable force to situations where risks or threats are presented.  I wonder whether we need to think of a few more things when it comes to what might well begin as low-level restraint, without using police equipment like batons, cuffs or irritant sprays –

  • Will it remain safe and proportionate given the potential psychiatric and other medical risks that may emerge if restraint becomes prolonged?
  • What is the exit strategy to get out of using force if it does become prolonged?
  • What are the links, needed or existing, to other NHS services?
  • How often might it be appropriate to just do nothing? … or to create a contained or a more-or-less contained space, inside which we do nothing?!

More than once, when looking at other incidents, I’ve wondered about the this last point – doing nothing.  I’ve made sure in some operational incidents that officers have actually done nothing, or next to nothing when called upon to act.  I recall the incident at a residential care home for young people with learning disabilities – a young woman had smashed up the kitchen, resulting in a 999 call and by the time we got there, the room was fairly trashed. She was completely naked and still throwing broken furniture around the same room.  Staff were able to give us enough information quickly for me to say that the approach would be to do nothing.  Actually, we did something that was next to nothing – have a female officer monitor the situation for any developments where the young woman was starting to hurt herself or come to harm and we would reassess if this happened.

It didn’t – and twenty or so minutes later, she had exhausted her desire to cause damage.  My best guess is, there was no more damage caused by waiting than there had been when we turned up.  Even if there had been, it would have been marginal.  The young lady was seriously overweight, increasing the risk that if restraint had been prolonged after trying to intervene, officers would have had to be extra-cautious about the dangers of positional asphyxia.  So is it worth taking that chance to stop £2,000 worth of damage becoming £2,100?  My judgement was no – so we monitored and ensured the broader safety around the incident.

This is highly anecdotal, of course – I could have given you the medium secure unit story of the guy who had barricaded himself into a room with a weapon and we were being implored by nursing staff on arrival, “You’ll have to Taser him!”  We got him into the seclusion room without touching him.  This involved me asking police officers to get out of sight in the unit, getting other nurses and patients moved and giving him time.  When we eventually opened the (anti-barricade) door, all he saw was two police officers who had been chatting to him for a while and one nurse that everyone knew he liked.  We removed, or at least mitigated, his fears.

We need to think about this – I don’t think the traditional police approach to the use of force is flawed, it just needs to have a far clearer purpose and an obvious exit contingency when it is applied to mental health emergencies.

COLLEGE OF POLICING

Starting in June, the College of Policing will be drawing together an expert reference group of police officers, mental health professionals, service-users and others to look at these issues: what is the role of the police when called into inpatient psychiatric settings and how does that fit into the duty of care owed by the hospital to their patient?  It will be independently chaired by a leading QC and aims to clarify when and where restraint is undertaken, whether we need additional guidelines and / or training to ensure that police officers do so in full recognition, as the Rocky BENNETT report told us in 2000, that the restraint of acutely unwell mental health patient is a medical emergency.

And as the police don’t just work in clinical settings, we need to have this conversation in conjunction with the whole emergency system, including paramedics and emergency departments — there is LOADS to do!


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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4 thoughts on “Fear and Anger

  1. Excellent post! Can I ask how you are intending to involve service users in this research. This is an area I’m hugely interested in. I’m recently discharged from services and am now doing lots to help others who are going through the same as I have experienced. I’m personality disorder and spent many years struggling to deal with things and during that time had plenty of dealings with the police and was restrained many times. I’m now training professionals in an expert by experience role, about personality disorders. I’d love to be involved in this research if that’s possible.

  2. Great post. In my limited (second hand) experience, some of the issues in inpatient units seem to be related to the prevailing atmosphere. Staff sometimes seem to fail to appreciate that a ward can be a very scary and intimidating place with little to do and less freedom than most people will ever have experienced. You are then expected to cope with all of that and masses of strangers and losing all your normal daily routines, while also being mentally ill. There seems to be a world of difference between wards on when restraint, seclusion etc is used.I certainly know of a couple where it seems to never be used, and others where it seems to be almost the first response. For the police it is very hard as they don’t have the option of using medication if deescalation fails…… as you say backing off can be a good option, but difficult if people are determined to self harm. Again I have known the police use imaginative solutions to give some of the power back to the person who is detained which can help to defuse the situation……..

  3. I am a serving PC.

    The instances where police deploy to assist with any non – crime incident in a MH unit should be vanishingly rare. It should be seen as a serious failure on behalf of the service provided if it happens. MH proffesionals are trained in restraint techniques etc. If they are unable to manage violent patients appropriately the primary response should be to improve their training and capabilities, not try and facilitate the police to paper over the cracks.

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