Reflecting on Toronto

Late last year, I was fortunate to be invited to Toronto, for the 4th Law Enforcement and Public Health conference to help co-convene a two-day event on ‘law enforcement and mental health’ with Professor Stuart Thomas from RMIT, Melbourne.  We got to spend two days with a range of police officers, mental health professionals but in particular some services users from Toronto talking about the kinds of things police services around the world are doing to face their challenges and what the evidence is for those interventions.  This looked at two things in particular —

  • Co-responder models – things like street triage, as we’d call it in the United Kingdom.
  • Specialist training – ideas like Crisis Intervention Team training, Mental Health First-Aid and various others.

By the time I came away from Canada, I had an overwhelming feeling of various pennies having dropped, of being a bit energised around this stuff in way I hadn’t felt for a while. So it occurred to me I should write down my reaction by synthesising my thoughts, limited to two pages of A4. Although done immediately afterwards whilst everything was still fresh in my mind, I just decided I should publish it and see if it causes any discussion.

What follows is just my own reflection.  It’s not necessarily agreed by Stuart, by any of the other wonderful  colleagues and others I met and with whom I spent an enthused pair of days and nights discussing this stuff in a way I rarely have chance to in the UK. That said, LEPH will hold its 5th conference later this year in Edinburgh and I’m looking forward to continuing the discussion.


All over the world, the criminal justice system plays a role in the response to or the detention of those of us in acute distress or living with psychosocial or intellectual disabilities – whether for good or ill.  Policing in particular, often fulfils a de facto role, twenty-four hours a day, of providing crisis responses and most jurisdictions empower their police service to take decisions about human liberty arising from healthcare issues, even where no crime is involved and often in circumstances where qualified mental health care professionals could not do so.  Social and medical emergencies connected to mental health problems area part of the core business of policing because not everything is predictable and preventable and most countries report problems of access or availability which drive unmet needs to emergency systems. History has given rise, however, to concerns about the size and scope of the policing role – whether connected to crisis incidents gone awry, where fatal outcomes have occurred by the use of firearms or restraint; OR following the criminalisation of vulnerable people for a want of any other options to ensure safety.

And despite the cultural, political and other differences across the world, there are common concerns about the need to improve criminal justice responses; and concerns about over-policing, in lieu of appropriate care or support. In October 2018, a group of interested police professionals, clinicians and academics, in conjunction with service users and others, gathered in Toronto, Canada ahead of the 4th Law Enforcement in Public Health conference. This summary document emerges from a two-day discussion of the evidence on current practice around the world and offers suggestions of policy imperatives which still must be addressed in order to ensure effective responses to those of us in mental health crisis; but more importantly to prevent the unnecessary criminalisation of vulnerable people.

SUMMARY

  • There are a range of high-profile reports and thematic reviews which have examined the criminal justice / mental health interface.
  • In addition, all countries have seen critical incidents, legal inquiries and other proceedings which examine this interface in the context of a specific incident.
  • The outcome from that, across the world, is essentially two types of response – ­ Liaison services working in real-time collaboration with the police – ­ Nurses (or other professionals) in police cars, control rooms or custody settings.
  • Specific mental health training for officers – Crisis Intervention Training (CIT); Mental Health First-Aid; other, non-branded or bespoke, training specific to mental health or to mental health in policing.
  • The specific problem(s) being addressed by these initiatives around the world are often not specified in policy and strategy.
  • These initiatives largely focus upon improving the police response, through these training or collaboration approaches – or a combination of both approaches.
  • These initiatives are largely reactive and responsive, rather than inherently preventative and adopting a public health approach.
  • Evaluations of impact are limited in number, scope and quality – demonstrating some clear but limited benefits; whilst leaving some wider questions about impact and unintended consequences almost entirely unaddressed.
  • We must call for more:
  • Recognition that societies tend to over-police (or are at risk of over-policing) those of us affected by psychosocial and intellectual disabilities;
  • Recognition that this occurs because of world-wide difficulty in securing timely and relevant access to appropriate mental health care or support, 24/7.
  • Policing, by default, should be expressly recognised as a restrictive intervention which reduces autonomy.
  • Appreciation this should be reduced to the absolute minimum possible in that society, consistent with personal and public safety.
  • Acceptance that all countries should actively minimise the extent to which the criminal justice system is a gatekeeper for access to mental health care services, whilst ensuring that it is equipped to do so, where unavoidably necessary.

THE FUTURE OF POLICING & MENTAL HEALTH

This post considers the need to call for a limited number of more strategic considerations to influence how the tactical approaches seen across the world can be helped to have greater impact –

  • The extent to which societies need to police vulnerable communities living with psychosocial and intellectual disabilities is inversely relative to the alternatives available – policing research has known and suggested this for over 50yrs.
  • Where sufficient, relevant and accessible alternatives do not exist, policing and criminal justice will be called upon to respond to behaviours considered inconvenient or frustrating, mischaracterised as criminal or anti-social conduct.
  • The challenge for the police is to help health and social care agencies understand the dynamics driving police and justice system contact, especially connected to those who present repeatedly and chaotically across emergency systems.
  • This is done by understanding demand, data and diversity to a far greater degree across public agencies so that they can work preventively in ensuring people’s needs are met, in a public health approach.
  • It is vital policy leads in health and justice agencies understand criminal justice systems do always play a part – international criminal codes reserve certain powers under mental health legislation to criminal judges, after trial processes are complete.
  • It is therefore necessary for policing and public prosecutors in particular to understand when it is appropriate, in extremis to prosecute those of us with mental health conditions who are doubly vulnerable because behaviours seriously or repeatedly violate criminal laws and social norms.
  • This is especially true where attempts to divert people from the justice system because of unmet health or social care needs have proved unsuccessful or simply not possible because of a lack of relevant, accessible services.

Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award

 

All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2019


I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

Government legislation website – http://www.legislation.gov.uk


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