Recognising Vulnerability

I recently saw a police training video on social media from Epilepsy Action UK, aiming to raise awareness of the forty or more different kinds of epileptic seizures. The video begins with what is known as a focal seizure, in a nightclub based scenario where the obvious point is being made that assumption should not be made that the young woman is drunk. This is all fair enough: many people are familiar with the sorts of seizures that lead to quite significant convulsions, but less familiar with what can look like someone staring at a fixated point. In the video, a member of club security comes over and touches the young woman on her arm, prompting a sudden physical reaction. It made me think for some reason, of the ZH ‘swimming pool’ case – a young man with severe learning disabilities and autism in London who brought a case against the Metropolitan Police. He was described in the judgment as fixating on the water at the swimming pool in the lead up to the unlawful action by the police. Subsequently, for very understandable reasons, charities highlighted the need for more autism awareness training the police.

Brief epilepsy awareness does feature in the police Taser training curriculum. I was interested to know why epilepsy and not, for example, autism or Asperger’s. Or for that matter, why not include dementia awareness – remember the incident in Humberside where an officer used a Taser on a man in his fifties with dementia who had just badly assaulted the officer’s colleague? The Alzheimer’s Society said it “showed a lack of  awareness of dementia”. As you survey ever more incidents, you hear ever more calls for greater awareness of particular conditions: PTSD, bipolar disorder, schizophrenia, learning disabilities, ADHD, specific learning difficulties, personality disorders, peri-natal mental health, Asperger’s, acquired brain injury, acute behavioural disorder and more besides. Then we often hear calls for greater awareness for particular groups that deemed especially significant: children and adolescents being the first obvious groups, bearing in mind that 75% of adults with mental health problems first experienced difficulties when they were children or adolescents. For reasons I think we all fully appreciate, there are particular mental health sensitivities on these issues for military veterans, pregnant or new mothers and for the elderly. And of particular complexity and relevance to policing, those vulnerable people who have a ‘dual diagnosis’ or comorbid mental health diagnosis with a substance abuse problem.

So how do you decide what awareness training police officers need? By “awareness training”, I mean information about particular mental disorders or how such disorders affect particular groups of people.

RESPONSES TO EVENTS

In response to things that have gone awry, I’ve often seen calls for greater awareness from a particular charity around the particular condition that a vulnerable person had. The ZH case was a good example of this and indeed that argument is reinforced by the Autism Act 2009 – the only condition to have its own legislation. But most other conditions are covered by equality and human rights legislation and specific cases aside, how would a police officer tell the difference between someone fixating on water because of autism and someone else having a focal seizure because of epilepsy who is fixating? Maybe the situation would allow that information to be known: ZH was accompanied by teachers from a special school who could have explained if only the officers had attempted to discuss the matter before intervening. Epilepsy features in the Taser curriculum because of an event where a man with epilepsy was Tasered by the police – in fairness, the gentleman involved was exhibiting significant violence after a seizure and had bitten, punched and kicked paramedics attempting to deliver medical care.

Following the Hull Taser incident, there were calls for greater dementia awareness training – but every time I hear this I keep coming back to the same questions –

  • To what extent do police officers need to respond differently when dealing with someone who is in distress because of a mental, cognitive or other medical problem?
  • To what extent does that answer change where particular mental disorders are known to the officers?

So if the police meet an apparently suicidal person on a bridge who seems intent ending their, are there particular things to be aware of for any of the conditions I’ve listed above that does not apply to the other conditions listed above? If so, what are they – because we’ll need to factor that into police training; if not, that has a quite different set of implications.

RECOGNISING VULNERABILITY

The law implies it can sometimes take a consultant psychiatrist possessed of a medical degree and fifteen years of post-qualification experience and post-graduate education to identify a particular mental disorder (and it’s proposed follow-up). Indeed, we know some mental health patients have lived with a a particular diagnosis for years, only to have it altered some way into their care, perhaps when treatments for the original diagnosis prove inappropriate. What chance that the police can always ge this right when they turn up to a pair of paramedics being kicked and bitten; or to a person on a bridge whose identity and medical background is not yet known?

So it begs the question to different support groups: what do you want the police to aim to do when responding to an incident? Generally, they all want the same things –

  • Recognition of that person’s vulnerability,
  • Create time and space, wherever possible,
  • Patience, empathy and compassion,
  • Diffuse and de-escalate the situation,
  • Contain rather than restrain,
  • The least restrictive, least coercive option possible.

So what initially looks like a world of complexity can start to look more straight-forward: train officers to recognise generic indicators of vulnerability, accepting that they will never reach the level of our clinical colleagues in the NHS. We need to be realistic about what officers can achieve and I was therefore pleased to see common sense prevail during an inquest a few weeks ago into the tragic death of Toni SPECK in York in 2011. The jury determined that she died from serotonin toxicity after being detained by officers under s136 of the Mental Health Act and that it would not have been reasonable for police officers to recognise that she needed urgent clinical care at the point of arrest or at the point where the custody sergeant was authorising her detention in custody.

IMPLICATIONS OF THIS DEBATE

As the College of Policing have been researching the development of guidance and training, we’ve had to confront this head on. Many of the organisations who represent particular sub-categories of mental health issues have excellent awareness packages which last just a couple of hours. But last time I checked, there were at least twenty-four different conditions that stand out as worthy and interesting in their own right, as well as a handful of population groups who deserve particular consideration. If we delivered a two-hour input on each, we would need a two-week training course for every officer before we had even begun to mention mental health and capacity law.

So we have decided to base guidelines and training on a general approach: generic indicators of vulnerability, making use of information sources to potentially nuance a response; recognition of what we are expecting officers to actually do; ie., the bullet points, above.

The College of Policing public consultation on mental health guidance (known as Approved Professional Practice) is out until the end of 2015.   Please do take the time to look at it if you’re interested, but when it comes to thinking about whether we have enough detail in the there about autism, or serotonin syndrome(!), just bear in mind what we’ve set out to try and achieve. By the time the document is finalised for publication in the first quarter of 2016, it will be replete with links and resources from specific charities and groups that will allow individuals officers or entire police forces to do more on specific issues where that is especially relevant to them and if you think we’ve got this wrong, please tell us!  You can leave a comment below or formally respond to the APP consultation, which you can do by opening the hyperlink at the start of this paragraph.


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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7 thoughts on “Recognising Vulnerability

  1. All very valid points and I totally agree with your conclusions. Many anorexics also suffer from seizures along with Borderline Personality Disorder. Sometimes many Social Workers are reluctant to disclose conditions without the legal proceedures that entails. Sometimes families are not “let in” on the conditions. My heart goes out mto the police when they face these dilemas. The police will do whatever they can to resolve an incident quickly and with least amount of “force” as they can. Quite often they have to make snap decisions to the best of their knowledge with what they are presented with. I am not giving excuses just facts. Give the officer a break, he is doing the best he knows in the cases.

  2. •Create time and space, wherever possible?
    •Patience, empathy and compassion?
    •Diffuse and de-escalate the situation?
    •Contain rather than restrain?
    •The least restrictive, least coercive option possible?

    Isn’t this what officers a duty bound to do in ALL potentially volatile incident anyway?

    1. Have said the same thing many times for many years: and whether or not they are duty bound, we also know it doesn’t always happen with mental health. But, I totally agree with your point and only wish it were more widely appreciated.

  3. To me the bullet points fairly sum it up, does the consultation want to look at increasing mental health training for police or does it have a different remit?

  4. My specialist area is now autism. I’ve always felt that autism should be included in awareness training alongside the other neurological differences (dyspraxia, ADJHD etc) but this takes it much further … the generic criteria for doing so set out here look sound to me and the suggestion that what is needed is a list of exceptions and/or additions to these criteria for specific areas such as autism that may not apply in other cases (“are there particular things to be aware of for any of the conditions I’ve listed above that does not apply to the other conditions listed above?”) seems very sensible indeed. One would need to get a group of representatives of all the areas together, get them all to list ‘their’ vulnerabilities, and cross reference all the data obtained. Could the College of Policing make this happen? I would be more than happy to assist from the perspective of autism and risk management (my former specialism).
    Nick Chown (Dr)
    Autism specialist and previously Director of Risk Management for the Metropolitan Police

  5. I agree entirely with your very informative and useful article, and with the comments. I’m on the autism spectrum, and the human mind is one of my great interests. I read as many published research papers as I can.

    I’d just like to respond to Ian Moulding’s comment: “Many anorexics also suffer from seizures along with Borderline Personality Disorder”. This is true, but recent research has also uncovered a significant correlation between anorexia and autistic traits – so significant that it’s been recognised that the standard approaches to the treatment of anorexia are ineffective for patients who have this ‘female presentation’ of HF autism (which is not entirely confined to females). Had this been known years ago, many lives could have been improved and deaths could have been prevented.

    Another related point is the alleged co-morbidity between anorexia and BPD. BPD is notoriously difficult to diagnose and predominantly occurs in females (75% of diagnoses). However, most of these diagnoses are very likely to be misdiagnoses, where the true underlying condition, i.e. autism, has been overlooked by ‘generic’ clinical psychologists/psychiatrists, untrained in the ‘subtle’ female presentation of AS/HFA. Many are not even aware it exists. So therefore, the BPD-anorexia connection, is probably more often a misinterpreted autism-anorexia connection. A misdiagnosis can blight a person’s life, and can be particularly dangerous when inappropriate treatment is involved. Experience of others who have suffered in this way, makes me very wary of BPD diagnoses, at least until I can discount autism.

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