This is a guest post by Em, or @DrEm_79 from Twitter – our various discussions on there made me realise she has a lot to say that is important and relevant for police officers responding to mental health crisis incidents. I think there’s a lot going on here and much of it is contradictory: but that seems to me to be precisely the point Em is trying to make – the normalisation of the police as a de facto mental health service is something to caution against and worry about
I’m giving a trigger warning, too: Em’s post contains descriptions of suicide attempts and restraint that may disconcert some who read this —
It takes eleven minutes to walk to the GP surgery, but I only made it halfway. I don’t remember deciding to die. I don’t know why I chose the wooded embankment, and I’d lost consciousness before the police search helicopter, the ambulance and resus. When you’re unconscious in intensive care, as well as the life supporting interventions, they remove your contact lenses. Several days later, when I woke up, it was to a blur. There was a tube and ventilator supporting my breathing, fluorescent light and blurry hi-viz. The hi-viz turned out to be police, still waiting in the relatives chairs opposite my bed.
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. The intersection of mental health and policing is complex, and there are as many experiences of mental health as there are people. I can only speak from my own perspective. Changes to the way mental health care is provided and policed where I live over the last ten 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.
My mental health care plan stated that if I or others call mental health services because I’m unwell, mental health services are to advise calling police if I’m at risk. Sometimes it’s the mental health staff, sensing risk and needing to do something with the sense of responsibility, who call. A “welfare check” by police is now 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 at times has made me more unwell.
Over all of the contact I’ve had with police when I’ve been unwell, there are some things that have helped, and there are others, both at the individual and systems level, that haven’t.
Things that can help –
Beware short term thinking for long term problems –
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.
For example, last year the mental health team reported a concern for my welfare. I wasn’t at home. A police sergeant called me and asked me to tell them where I was and for me to meet with them. They promised I wouldn’t be made to go to the hospital, that all they wanted do was talk. On meeting them, I was immediately put into the police van and taken to hospital. I can see this may seem justifiable; a promise they were never going to keep achieved the short term outcome they were looking for, but longer term what that created was a person with severe and enduring mental health problems, very likely to have further crises in future, who no longer believes the police will tell them the truth. In the long term it has made things harder for everyone. Many people with mental health conditions have experience of trauma and trust in others may be fragile. Expediting an outcome by not telling the whole truth may jeopardise the only opportunity for that person’s trust.
Radios, the third person, and remembering I’m there –
When I’m experiencing hallucinations and delusions, routine aspects of police work can be menacing and frightening. Being aware of this and making even small allowances can help.
For example: radio use. When I’m hearing voices, and may be paranoid that people are talking about me and planning to hurt me, disembodied voices coming from radios or officers repeatedly leaving the room to talk into the radio, often only partially out of earshot, can add to the fear and beliefs I already have. You can’t stop the voices I’m hearing or the delusional ideas I have when I’m unwell, but if you’re able to, explaining what you’re doing and why, as you’re doing it, can help: “I’m just going to speak to my Sergeant on the radio, to let him know where we are..”
I often don’t feel in control when I’m ill. That’s part of what is frightening. You may not feel able to let me have control over what happens, but keeping me informed and talking to me rather than about me in my presence can help. Even if it doesn’t seem like I’m taking in what you’re saying please keep talking to me, acknowledging my presence, and telling me what’s happening as much as is possible. Try not to talk in the third person about me when I’m there, it can worsen feelings of paranoia and threat. Many people’s experience of voices is a commentary in third person. Even if someone isn’t interacting, talking to them about what you’re doing as you’re doing it, letting them know and including them can prevent the situation from becoming worse.
Unless you’ve experienced hallucinations, flashbacks, or other perceptual disturbances, it can be difficult to imagine what it’s like, but we all know what it is to feel afraid, or that you can’t trust someone. When I’m unwell that fear can exist at another level, which is partly why I think restraints can often go so wrong. Whereas someone who isn’t experiencing a disturbance to reality might observe they are being restrained, perhaps in a cell, and realise they aren’t going anywhere, and eventually relax, the things I am frightened of in crisis often aren’t proportional to what is being done to me. When I fear someone is trying to hurt me, that belief doesn’t just go away if my movement is restricted. The fear will likely be escalated by restraint. It isn’t ‘acting up’; it’s terror.
Some of the times I’ve been restrained by police were before anybody even tried alternatives such as talking to me. Restraints have lasted hours, with me becoming more and more frightened, but once restraint is started I become so much more afraid the only option to stop is chemical sedation or further restraint. Restraint while mentally unwell is confusing, terrifying, and traumatic. Where it is not essential, avoid it, or at least know what you are getting into, and have a plan as to how you’ll get out of it.
Stigma; and leaving a life to go back to –
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 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.
Think about language –
I don’t expect police to be therapists, or have endless time and full knowledge of a situation, but thinking just a bit about the words you use and the way you ask questions can make a difference to the responses that you get when I’m unwell, and ultimately can make a difference to the amount and reliability of information you can gather to help decision making.
For example, when there has been a call with concern for my welfare and police want to ascertain whether I am at risk. Commonly, officers do this by asking: “Are you planning to do anything silly?”
This tells me a value judgement the officers are making about self harm and suicide. It makes me less likely to think that person understands, wants to help, or can be trusted. It also directly impacts the content of my answer. When I’m unwell often nuance and turn of phrase are lost and I interpret things quite literally, or ascribe them more meaning than I might on a day I am well. I also don’t think suicide is silly, and at times I’ve been unwell I have felt it is the most sensible thing in the world, either because I’ve felt compelled to do it by external forces, or because I’ve felt so depressed it has seemed a rational choice. The answer you get can depend on how you ask.
Other ways to explore suicidal feelings are, if there is time, gradually in a stepwise way. Start by showing you are interested, there aren’t set words, if it doesn’t sound authentically from you that’s easy to pick up, but things like: How have you been feeling today? … Have things ever been this bad before? … You said you can’t cope, are you having any thoughts of ending your life? Ask explicitly about suicide. There’s good evidence it doesn’t put the idea in someone’s head, and there is a lot of stigma, suicidal thoughts may not be volunteered if you don’t ask directly.
If someone does say they are feeling suicidal be aware that’s an incredibly difficult thing to say; it’s taboo in society, and there are even more barriers to talking to police about it. So often if I have spoken about suicide to officers they don’t even acknowledge it, as soon as they have that information their next movement is to press the button on their radio and start talking to their Sergeant “Yes, yes, admits is suicidal..”. It would have taken a few seconds longer to acknowledge to me that they’d heard that and that they wanted to help. Those few words can make a massive difference. In crisis it is easy for the needs of the person who is unwell to become peripheral to service protocols and needs. Try to avoid this.
Say you want to help –
Professionals often implicitly and sometimes explicitly assume when a person is in crisis that the person will trust them because of who they are, and that the person will believe that the professional’s motives are to help. This often could not be further from what the person believes. It isn’t enough to assume that I think you want to help, you need to say that, and act in a way to back that up.
People without mental health training often feel uneasy talking to people who are mentally unwell. Often this comes from a place of concern – they don’t want to make anything worse, but it has an isolating, dehumanising effect on people who are unwell, and in crisis can increase risk. In an acute crisis listening to someone who is ill is one of the best strategies to help them feel calmer and start to trust, and may be the difference in making it possible to help them.
Filling out a form does not make somebody safe –
Beware mistaking following process for mitigating risk. After being called out to me, police almost always have to fill out a form for their vulnerable person database. I’m seen as a vulnerable adult, and coming to my home they’ve often had concerns for my welfare – risk of harm to myself, lack of food and heating, lack of security, risk from others. There have also been many forms submitted to report adult Protection Concerns under the Adult Protection act with concerns about self neglect and risk from others. These forms are sent to social services. Yet despite dozens of these forms, and hours of police time, not one of these concerns has resulted in changes to my treatment or care. There are complex reasons for that – uncertainty over which service, if any, holds responsibility for care and treatment and crisis response. Even when Adult Protection meetings have been held there has often been ambiguity, obstacles, or no outcome. Yet because it is procedure, still the forms are completed and sent.
It seems the process was followed and there was a partnership in place, but nobody had oversight as to what impact that process had on the risk it was trying to manage. Even the fact the forms contained the same concerns over and over didn’t alert anyone that the situation hadn’t been addressed. I don’t know if there are other systems like this, where ticking a box or completing a form gives mistaken reassurance that risk has been managed? Protecting someone may involve a form, but the form alone does not help me.
Planning and prevention –
Although uncertain and frightening for me, and often portrayed by the media as unpredictable and dangerous, there is a predictability to mental ill health. If police are going to be part of the response to mental ill health, could planning and prevention have a bigger role?
For example: When unwell my awareness and perception of the world around me can change. This can lead to me travelling miles and finding myself somewhere, often with physical harm, sometimes unaware how I’ve got there. If police are alerted by somebody concerned where I am, I become a resource intense high risk missing person. Yet there is often a predictability to my travel. In the days or hours before I become unwell I have sometimes tried to seek help but not been able to access it. There are also patterns. I’ve been missing and unwell and hurt a number of times, but for years nobody sat down with me afterwards when I was more well to talk about what the triggers were, the types of places I found myself, or tried to ensure there are safeguards in place so the situation could be managed more safely if it recurred.
I don’t think providing mental health care is the role of the police, but this is the sort of area where working with me has benefitted everyone. A few months ago a local Sergeant spent time talking with me, being reliable and straightforward, and rebuilt some of the trust I had lost in police. He listened (a lot) and started to understand what was going wrong in responses to me, what helped and didn’t. It’s far from fixed, but that time has helped police start to develop a more informed, safer response. They understand more where I am likely to be when unwell and the safest ways to respond, and have saved resource in doing so. It isn’t a high profile media lauded scheme, and that Sergeant has had no recognition; but by gaining my trust, getting to know me and what happens to me, and thinking with me about how police can help me to be safe, he’s helped police to save my life more than once.
Don’t give up hope –
I’ve been critical of police responses to mental health, but there is one way in which police response has been consistently more helpful than many other services, including mental health services. And just now, I’m worried this may soon be lost.
When someone has been ill for a long time, health services can sometimes develop something called therapeutic nihilism, a feeling that nothing is going to help the person. Unfortunately sometimes without realising they then stop trying to help. This is often seen at suicide inquests, when people report clinicians having said to the person who has now died that they could not help them, or other negative or very hopeless statements.
Hopelessness is associated with completed suicide, and this type of response can be immensely damaging. Clinicians also have a different view on responsibility of people who are unwell to the police, again we know from inquest evidence and service user experience that with some disorders in particular, professionals may say things such as: “it is up to you whether you die”, “we can’t stop you” (which may be true, but..), “if you wanted to do it you would have”. Such negative statements may not be said with harmful intent, but that is often their effect.
Yet the response of the police, perhaps because of their duty to protect life, seems more hopeful. They will keep trying to intervene, keep trying to help, and don’t refuse to come to help people as health services may end up doing with some patients. This persistence can be lifesaving. When a person is totally without hope it can help, even fractionally, for someone else to believe they are helpable, and importantly that they are worth helping. People who are feeling suicidal often feel they don’t deserve help. One of the best ways to challenge this is to show them you want to help and you aren’t giving up on them. I wonder if this is one of the reasons service users report contact with police in crisis is often positive, in some cases beyond the time that the police are with them. Just acting as though there is never no hope at all sends a message that may make a crucial difference to somebody.
This is one of the reasons I’m not entirely convinced about some of the current co-response plans between services. I hope they won’t lead to the nihilism some other services show to people with the most complex problems starting to affect police response. Police are good at not giving up in mental health crisis in a way that other services are sometimes not. It can be harder to give up on yourself when there is someone else not giving up on you. I hope that isn’t lost.
Even when I’m most unwell, treat me like a human, talk to me and listen, and be as compassionate as you can to another person who is suffering. Even when unwell I can sense hostility and value judgements and they do not help. 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.
Winner of the Mind Digital Media Award.