A Benign Presence

Have you ever had an unexpected knock on your door from the police? I haven’t, thankfully – and long may it remain to be so. I’ve actually been the unexpected knock on the door from the police on more occasions that I’m comfortable with and I’m not sure you ever forget the first one – I certainly haven’t. We were asked to attend an address on my area in Winson Green in Birmingham to inform a woman who her elderly mother had unexpectedly died in hospital – and this task fell to me on the morning of Mother’s Day. I could still take you to the address now, almost eighteen years after this responsibility and I’ll never forget the look in her eyes when she first opened the door. That was actually worse than her reaction when I said the words, at least for me – it bordered on terror.

Far more frequently and more recently, I’ve had a different version of a similar thing – being an unexpected presence on the door step on a mental health service user. This has been in a few situations over the years: being asked by mental health professionals to accompany them to a Mental Health Act assessment because it is claimed that there are inherent risks that will require police support; being asked by mental health services or out-of-hours GPs to undertake an urgent welfare check on a patient, because of concerns – and both of those without the patient or service user having an idea at all that the police are being brought or sent. More recently, there is a third variation on a theme – street triage (ST). In a similar way that I could take you to that first address, I could take you to another where the police were told a service user was suicidal. The look on that young woman’s face when she opened the door was, again, one of sheer terror. It’s always been my experience that sending the police to an address is not without an emotional impact on those who are there, regardless of the reason. Let’s remember what the police do: they often break terrible news; investigate criminal offences, occasionally by arresting people; and they are a ‘just in case’ service where it is predicted that risks may emerge that require the police to manage them in ways that only the police can: by the threat or the use of coercion, for example under the Mental Health Act. Officers, of course, try their best to be decent and humane and proportionate, but we all know the mere impact a uniform can have when it is unexpectedly introduced into our reality.

Of course, some service users have stated that they have good experiences of the police responding to a mental health crisis, either on their own or as part of a MHA assessment or street triage intervention. So this post, whilst aiming to prompt a discussion about whether the unexpected involvement of the police in a mental health related incident is an entirely benign thing, is not assuming that we can reach a simplistic answer. Some people observe paradoxically that unnecessary policing is stigmatising but that they’d rather deal with officers when they’re in crisis than mental health professionals – others vehemently disagree. Maybe we could do with proper research on service users properly about their experiences, not just about police attitudes; but about their involvement at all. And these questions have to sit within the overall public and political debate about what we want the police to spend their time doing – Chief Constables could choose to offer themselves up for all manner of tasks: the question is whether they should and what factors they should consider in reaching those decisions. This is about whether unnecessary involvement of the police in the provision of mental health care is entirely without impact on those in contact with mental health services.

INTER-AGENCY PERCEPTIONS

Earlier this week I took two police officers and a paramedic from a West Midlands Police street triage scheme to the South London and Maudsley NHS Trust to go through some training simulations on mental health. It’s was a testing ground to see whether NHS simulation training for mental health professionals can useful apply to 999 emergency services. We were joined in that trial by the London Ambulance Service and the Metropolitan Police. The idea was that two members of the course were given a small background briefing on a situation and they then walk in to a room where a professional actor with relevant professional MH experience acted through a situation, responding to the professionals attempts to manage a situation. The first situation involved a man calling 999 for the ambulance service after he had a taken five paracetamol tablets whilst drinking and whilst becoming mentally unwell. His flatmate had called the police about the situation also and we end up with one paramedic and one officer at the same location. As soon as the officer walked in to the room, which represented the patient’s flat, he said, “What are the police doing here? I haven’t done anything wrong!  They shouldn’t be here.” and he become verbally agitated for a while.

In the debrief of the incident, we got in to the discussion about what the police were doing there. Obviously, they were called by the flatmate and it was unclear whether the police knew that paramedics were also at the scene or on the way – this mimics reality all too often. But on arrival, the officer found a paramedic already dealing with a patient and no-one has flagged any aspect of the incident involving anything that you would immediately think of as a police responsibility – no imminent or immediate threat to life; no crime by or against this member of the public; and no Breach of the  Queen’s Peace. I wondered why the police wouldn’t just make sure the paramedic was aware we were there, but remain outside the incident until asked to do something that required the police to prevent the possibility that the officer’s mere presence aggravated an already difficult situation?  Obviously, if the police had arrived at the incident first, this wouldn’t have been possible – officers would have had to start establishing what was going on until the ambulance service had arrived.  Mental health first aid, if you like.

This phrase parity of esteem is used a lot, to argue for equity in mental health care, comparable to that seen in physical health. If this situation had involved an accident or physical injury, we could expect the police to lead, only until such time as an ambulance arrived and then to take a back seat, or even leave the incident. If officers arrived and found the paramedics dealing, they would check whether or not there was anything in the incident requiring police support and if not, standby back or leave the incident. We also have to remember this reality about mental health care in particular: the police are possessed of coercive powers of arrest and detention under the Mental Health Act – the dynamics in play are just not the same as officers providing first aid to someone who has fallen and broken their arm.

AGGRAVATING FACTOR

A paramedic at the simulation training offered the view, based on her own experience, that police officers – more often than not – were professional at incidents where she had found herself dealing with mental health crisis incidents. However, on balance, she argued that the introduction of police officers without an obvious purpose was usually an aggravating factor, despite an officer’s best efforts. I have heard similar things said by service users: that they don’t want routine involvement of the police in their healthcare and this is often for a variety of reasons. There have been previous concerns that incident records end up influencing things like DBS checks for future employment; concern is often voiced that it makes people feel stigmatised or criminalised for have a mental, as opposed to a physical, condition; and finally, that it does affect the ability of the police to prioritise against their broader obligations.

Street triage schemes often turn up to support at incidents where the police were the agency called and they often make a better fist of things when they do. However, we are starting to see they are also sent to patients who merely require from by a mental health nurse what the NHS would call ‘unscheduled care’. This is the case because CrisisTeams, community mental health teams and out of hours GPs often lack the capacity to provide this kind of response and have realised that triage exists so we see triage asked to undertake unscheduled visits to service users in their homes.  (The reduced capacity of CrisisTeams and CMHTs of various sorts to provide unscheduled care; and their increasingly frequent policy of only seeing patients out of hours in A&E is probably another BLOG altogether but suffice to say here, that in the last decade, the number of patients requiring secondary (ie, specialist) mental health care has risen by 60% according to the Royal College of Psychiatrists, and outpatient crisis care has reduce in many areas to a third of its previous level. Arguably, it’s no wonder that demand upon our emergency system – police, ambulance and A&E – has risen and we have seen a development in support by mental health trusts to those processes.  We now see MH nurses in ambulance control rooms, in A&E departments as part of psychiatric liaison services; and in policing – control rooms, custody and triage.)

I would like to see this examined more thoroughly in proper research, not just with reference to triage but evaluations of such schemes do seem one obvious place to consider this and it’s often unmentioned (in the ones I’ve seen). How to service-users perceive the routine involvement of the police in their healthcare pathways where that is unconnected to statutory duties under the Mental Health Act or broader police responsibilities around crime, disorder and safety? Mental health is core police business and officers need to be better at it: I suspect this may also mean better at recognising when not to get involved as well as better at understanding how to get involved when it is appropriate.

Perhaps we should start simply: by asking each time the police are deployed on an unexpected basis, “What do you expect to be the reaction here? – have you considered this request in terms of its unintended but inevitable impact?”


IMG_0053IMG_0052Awarded the President’s Medal by
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


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5 thoughts on “A Benign Presence

  1. I have what are referred to as severe and enduring mental health conditions, and started hurting myself when I was five. Over the thirty years since, I’ve had a lot of contact with police because of my mental health. Police have saved my life more than once. They’ve listened to things no one else has, stepped into my flat when everyone else has walked away, seen me at my most terrified and vulnerable, and selflessly got themselves into trouble arguing for me to have mental health assessments when other services were trying to shift responsibility. They’ve also restrained me for hours, detained me in cells, vans, handcuffs and leg restraints, unwittingly contributed to the destruction of my career, and a hate attack by my neighbours. Police intervention when I’ve been unwell has left me at times too frightened to stay in my own home, with a front door that didn’t close. It’s fair to say our relationship is uneasy.

    Changes to the way mental health care is provided and policed where I live over the last 10 years have not helped me. In crisis I need help from clinicians who know me, can recognise I’m ill and respond early. But now early intervention is rare, and crises are left to escalate. Care occurs in extremis rather than being preventative. My care plan states that if I call mental health services unwell out of hours in crisis, they are to advise me to call police if I think I’m at risk. If others call mental health services worried about me, they are advised to call police too. Sometimes it’s the mental health staff, sensing risk and needing to do something with the responsibility, who call the police. This has sometimes been because it’s near the end of the working day, because there are no appointments left, or because the home treatment team don’t think I meet their eligibility criteria, and they perceive there to be outstanding risk to my safety. A “welfare check” by police is seen as a health intervention. This normalisation of police as the first responders to mental health is stigmatising, distressing, and for people like me who are known to be unwell, just adds to the resource ultimately used in a crisis.

    I’m not sure police being the planned response to people who are looking for mental health help is a good thing in a sophisticated society. As someone on the receiving end of that shift from health holding responsibility for mental health response to police, it frightens me, and when I’m ill, has caused me distress.

    From my perspective, it seems that police are very good at short term, immediate resolution, but for long term mental health conditions, short term thinking for long term problems is not always a good fit.

    Many mental health conditions, by definition, are not one off events. Most people with mental ill health will have more than one mental health related crisis in their lifetime. In responding to mental health crisis there’s a need to consider both immediate need and also the longer term implications of that response. My experience of police in mental health crisis is that they are good at thinking in immediate terms, especially when dealing with someone at risk to themselves, but that this short term thinking can sometimes take over, which can lead to consequentialist ethics – as long as the immediate crisis is resolved, it doesn’t matter what you do to get there. Short term focus applied to a long term or recurring condition can create problems in future.

    In mental health crisis the focus from police I’ve met has sometimes seemed to be to contain and transport me to the hospital as swiftly and by whatever means possible. This has often involved transport in police vans or cars, handcuffs, even though I’ve never been violent to another person and there has been no crime. Although I can guess some of the pressures that might make the quickest form of transport seem like the best, be aware of the effect very public police interventions for mental health can have at somebody’s home.

    For example, I live in a tenement building, when attending my flat, police have had discussions with bystanders including my neighbours where police have disclosed my history of mental health problems. More than once I’ve been filmed by people on my street being put into a van for transport to hospital. There is a stigma to being with the police; people assume you are criminal, dangerous, disruptive, undesirable. I’ve lost professional status and career because of stigma that still exists about mental health. Police aren’t responsible for my neighbours’ intolerance of people with mental ill health, or their subsequent attack when I returned from hospital, but protecting me isn’t just about containing me in a van and waiting with me at hospital until I’m detained, it’s also about being aware of the impact you’ve had on my life and my community, and leaving me a life to go back to.

    One of the hardest things about living with long term mental ill health is what you lose. There are two distinct themes associated with my suicidal behaviour. One is when I’m so unwell I can’t remember or don’t fully realise what I’m doing, and harm myself without meaning to. The other is later, after what may seem like the worst of the crisis, when I’m more aware, but having to face up to the destruction a period of illness has caused. Being discharged from hospital I often feel too ashamed to go back to my home. You may just be there for one evening in the initial crisis, but I have to go back to that place and try to rebuild my life. Loss of dignity is one of the hardest things to come to terms with, and is one of the biggest ongoing risks for me. Even when I’m most unwell, be aware of the effects of stigma that exists around mental health, the assumptions people make about criminality when police are involved, and where you can, try not just to protect my immediate physical safety, but leave me some dignity and a life I can face again after the crisis is over.

    I’m really glad you’re suggesting research with service users on the impact of police involvement. It’s urgently needed.
    @DrEm_79

  2. I’m afraid I can’t match the brilliant comment above by Em but like her I’m classed as having severe and enduring mental health problems but that has only been in the last 12 years. Before then I might have been regarded as a pillar of the community – editing the local newsletter and a member of the neighbourhood police liaison group. I minuted police public meetings and went to the police station for meetings. My neighbour is still the local police contact. And now it’s all changed I’m recognized by the local police for different reasons and when my son reported a crime he was asked if I was his mum.

    I am a frequent flyer in A&E and a frequent flyer as a missing person. Sometimes I’m at risk when I go missing but sometimes I just want to be left alone but that never happens. Sometime I’m aware of what I’m doing other times not. If I don’t answer the phone then I can get the knock on the door and see a uniform through the glass. I have been known to take the back route out of my home. Sometimes I feel like a hunted animal. The local police inspector became so frustrated a couple of years back that he threatened to charge me with wasting police time – said not to my face but to my community nurse. That has made me very fearful of the police. Although it’s not been me calling 999.

    Increasingly over the years that I’ve been ill it has become common practise for the mental health service to ring the police rather than offer to come out to see me if I try to speak to the crisis team. They have neither the time nor the resource to respond quickly enough. Twice I’ve had my back door broken down and my car window smashed to see if I was in the boot. My door now has a note saying next door has a key, please don’t break my door down. My husband has returned home to find police and paramedics there. My neighbour opposite often stands on his doorstep, arms crossed just watching the proceedings.

    I was discharged from psychiatric hospital a month ago at lunchtime. By 5pm the crisis team had called the police for a welfare check!? I was out walking, my car in the middle of a public car park. I had to sit in my car while people stared at me as I had a police van and car and 4 police officers surrounding me. Eventually I was persuaded to go back to the hospital but the crisis team paid for a taxi to take me back to my car. The officer who had stood talking for 3 cold hours would have been disappointed.

    I have lost count how many times I’ve been put on a section 136 but I do know that 16 times I’ve been held in a police cell instead of a POS. Usually for many hours and one time 36 hours. So the sight of a police car fills me with fear even if I’ve done nothing. Indeed once I was blue lighted off a dual carriageway by 2 cars because the missing flag had not been taken off the national database from 2 weeks previous. I got asked my name and immediately 136’d despite my protests. Another 8 hours in a police cell and an apologetic MHAA. I have always been transported like a criminal in the police vehicle rather than an ambulance but fortunately only one face down restraint and handcuffed when I was lurching around on the top of a car park. I got broken ribs too for my sins.

    I am now so terrified of ending up in a police cell that I would rather take a load of pills than be found by the police and indeed I’ve done that while officers hammered on my car windows. Don’t get me wrong the police are unfailingly kind and genuinely want to help but I know and they do too that usually I will not get the help I need from mental health services but as the officer said to me in that car park recently ‘If I leave you here and you kill yourself within the next few days then I lose my job’.

    I don’t want the bother the police, I want help to manage my crisis from the appropriate service. I don’t want them and the ambulance service in my house saying ‘mental capacity act’ we’re taking you to A&E. They are the wrong services and they don’t have the training. They have better things to do I’m sure but the buck stops with the police and no matter how much I say I’m ok once called they have to see me and then I know because of my long history of suicide attempts I’m never going to be left.

    Now I’m just the mad woman at number 53 and oh look the police cars are outside again.

  3. I have a strange relationship with the police, mainly it is one of slight fear but quite a lot of respect but that’s when I’m well. When I’m unwell the police turn into a very powerful force, I have delusions that they and only they can save me, that no-one else will ever be able to help me with anything. Other delusions I have involve things like believing I have supernatural powers, that I will commit certain crimes or behave in certain ways. I have, in the past, walked into a police station and begged them to arrest me because I believed I was not in control of my own behaviour and that the mental health team were somehow poisoning my thoughts and meds. The police were very understanding and got me the help I clearly required and for that I am very grateful. I have never had the experience of them breaking my door down or showing up at my front door but I have been picked up in the street a couple of times and both of those times they were respectful, patient and kind. They were going to put me in the back of their van but I was terrified of being locked up (long story why this is the case) and when they realised through my garbled pleas and begging them to let me walk rather than be put in what to me looked like a cage they let me travel with escort in the back seat. It’s small things like this that make me realise what police officers deal with on a day-day basis and make me realise that even if I was well I could never do their job. I don’t know if it’s appropriate for me to say this, I’m based in Scotland, but thank you and your colleagues for your support and patience but also for your humanity.

  4. As I sat with police odficers who i hadnt wanted to b involved waiting for an ambulance that I didn’t need I showed them this blog. The officer hadn’t heard of you MHC. The officer passed no comment then threatened me with driving under the influence of drugs which I hadn’t done and then later with wasting police time while in A&E. The officers made the situation infinitely worse and I become more distressed than ever.

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