Have you heard this phrase before? A concept quite often referred to in mental health care – it refers to an approach by mental health nurses to defuse situations of potential violence and resolve them without the professionals resorting to the use of coercion or physical force. De-escalation is something that is trained to staff who are employed in mental health units, an adjunct to training received control and restraint and to be preferred to it, whenever possible.
Last year, I gave evidence to the Home Affairs Committee during their inquiry into policing and mental health and I was directly asked about whether the police service needed to learn from the mental health system. After the tragedies we’ve seen in policing where officers are confronted with violent situations – vulnerable people exhibiting significant levels of resistance to lawful detention or a broader public threat – there are predictable questions if officers have resorted to the use of force and disaster has resulted. Did they have to use force? – couldn’t they have negotiated or persuaded to a non-violent outcome? These are understandable questions if someone has died under restraint and families in particular suffer acute anguish wondering if any more could have been done to effect a different outcome (and indeed, securing answers about what was, in fact, done). So the question at the Home Affairs Committee was whether police training is “adequate in terms of trying to de-escalate a situation where somebody suffers from a mental health condition?”
There are few things to say about all of this and my answer to the committee is something I stand by even after a year’s further reflection and work at the College of Policing. I think we train police officers to de-escalate – emphasis on verbal communications which attempts to influence people without resort to force and to contain a situation where possible, to allow for negotiation and persuasion, as long as this is consistent with public safety. We can even point to incidents that made national news to demonstrate this: a couple of years ago, the M42 motorway (near my house!) was brought to a standstill on a Saturday afternoon whilst officers attempted to negotiate and de-escalate a situation where a man was threatening to jump. They worked hard at this for 27hrs before making a break-through without any use of force. When I first arrived at the College of Policing in September 2014 one very early meeting included discussion about the police use of taser, which is of particular concern to many mental health and human rights groups, because of disproportionate deployment where people are in crisis. It was replete with emphasis about verbal communications and tactics to de-escalate.
It’s just that the word de-escalate was NEVER used.
HERE’S THE PROBLEM
This is not language that the police use to describe what they train people to do, but we do emphasise de-escalation wherever possible and many of my colleagues are very good at it. I’ve seen some police officers at work and concluded that they could sell snow to Eskimos, such are their persuasive skills and like the M42 incident, I have seen individuals who are threatening serious harm either towards themselves or others and officers have influenced them to do otherwise, without a finger being laid upon them or force being threatened. Other police officers struggle in that regard – but to imagine it would be otherwise is ridiculous because this variance is also true within mental health services.
To an extent, it surprises me to hear that the police are being encouraged to look at mental health nurse training in the development of their own. This is for a few reasons. Firstly, mental health nurses work in very different environments to police officers and are often permitted and encouraged withdraw from certain types of situation the police are obliged to walk towards. It’s one thing to hope to influence a person who is unwell in a mental health ward who is threatening violence; another to do so in wasteland with a man who is covered in petrol and threatening to set himself on fire. Nurses and healthcare assistants do, from time to time, face people with weapons but their role in such a situation is different to that of a police officer – the dynamics change when you’re obliged to de-arm that person, whether by negotiation or otherwise. Secondly, if de-escalation training is a package of objective skills that have been designed on the basis of evidence and then taught to relevant staff, I do wonder why some things I’ve seen on mental health wards have involved what must only described as ‘escalation techniques’? – I’ve more than once been called to a psychiatric unit and seen nurses engaged in exchanges with the potentially violent patient they had called us about and seen things that took my breath away. Nurses stood in the personal space of a patient, shouting orders at them shortly after demanding a 999 call to the police. It does make you wonder: if you say this patient is potentially violent and ‘smashing the ward up’, why are you within arms of length of them and shouting loudly, therefore placing yourself at raised risk of assault?! I actually suspect if I were a patient and you did that to me, I’d exercise my legal rights to put distance between us (section 3 of the Criminal Law Act 1967 refers.)
Finally, these issues around techniques and training aren’t actually regarded as effective! There is research from as recently as last year, that training in so-called de-escalation techniques is not effective; and there is other research that de-escalation techniques themselves are not effective. Oops! – this goes someway to explaining the varying skill base you see in police officer and in mental health nurses. Some people are naturally capable in environments where it would be preferable to all concerned if threats and risks could be mitigated without the use of coercion and physical force. For every mental health nurse I’ve seen acting somewhat bizarrely by agitating and aggravating a patient, I’ve seen others who are very patient and restrained – I’ve no doubt there are countless incidents on mental health wards every day that the police are never called to because a nurse has calmly resolved issues by de-escalating a crisis, including some that will have involved weapons and other serious risks. I’ve also wondered whether de-escalation techniques been seen as a package of objective tools and tricks that can be taught is the reason why some mental health nurses have asked the police to move straight to a use of force when they arrived?
YOU’LL HAVE TO TASER HIM!
More than once in my career I’ve entered a mental health unit and been told, “You’ll have to Taser him!” or similar – only to then resolve the incident without touching anyone. It’s almost as if the nurse has thought, “We’ve done our de-escalation stuff and it hasn’t worked so now the police will have to use force” and there are two things to say about that —
- Attempts by a mental health nurse to persuade someone to do anything and attempts by a police officer are two seperate dynamics – the officer will usually have instruments of coercion hanging off their utility belt, the skill to use them and a power of arrest and we cannot pretend this doesn’t alter the way in which persuasion is contextualised even if the two professionals have broadly undertaken the same tactics in hoping to influence. (This point is unaltered even in situations where nurses are attempting to administer medication without consent and have colleagues on hand to assist, if need be.)
- The police are not just here to do as they’re told by the mental health system – in fact, history shows they would often be very unwise to do so. It is for police officers themselves to judge whether or not to use physical force and many will be aware that the presence of a uniform can often ‘promote compliance’ even after the best nursing efforts have failed. It’s back to that point about context and it is also about remembering what policing is *for*. The last time a mental health professional asked me to coerce a patient, I refused and I’d happily account for why I refused.
Taiichi OHNO (of Toyota Production System fame) used to talk about change thinking in manufacturing and said, “Don’t give it a name – people will want it to come in a box.” In other words, learning how to improve systems, lower costs and improve quality is about understanding the system you operate and improving it where it is; not in bringing to bear external, generic techniques that may not be as relevant as first thought. I think of that when I hear talk about de-escalation techniques because the interaction with an acutely unwell patient (or for that matter, a criminal who is attempting to evade arrest by the police) is a human interaction, not a systemic one – it is situationally specific not just to that patient and the professional (of whatever hue), but also to the context of its occurrence; like a bridge over a motorway, or a room in psychiatric unit. If training is not especially effective at instilling appropriate professional responses in nurses and if those responses are not especially effective to begin with, then we have to question the relevance of them to policing when we know that policing is qualitatively different anyway.
None of this should be construed to mean that there will be nothing of relevance, but what seems common across nursing and policing when it comes to defusing incidents that involve acute risks to human beings is that ability to build a quick relationship with someone and use it to persuade and accepting it won’t always work. The last time I was negotiating to influence by hoping to de-escalate a crisis, it failed spectacularly but the personal and legal position around that person made it extremely likely to fail. I know that I’ve been in situations where I’ve struck up a great relationship with some vulnerable people and influenced them; I also know that I have, from time to time, been seen by others as an antagonist and a colleague of mine has been far better placed to take the lead.
People are peculiar: whether patients, professionals or police officers. We need bespoke responses that reflect individuals – not standardisation.
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