Following various discussions on Twitter about crisis care responses and policing, @DrEm_79 has undertaken a short study to gauge the views of the most important people of all: those who rely on public services when things become very difficult. This is the first of two posts resulting from that research survey and I hope you will agree it demonstrates much that should give us pause and thought. I’m therefore delighted to host Em’s write-up of her findings about which you will hear more if you’re attending the above conference in Warwickshire on 24th May —
If you or a loved one were unwell at home or in a public place, who could you call for help?
For people with mental ill health, the reality is that often police are involved in responses to health crisis. Services talk about keeping people safe in crisis, and the police are seen to have a role in this in a variety of mental health situations, but this only usually encompasses physical safety. Few studies have looked at the psychological impact of police involvement on people who are unwell.There’s ongoing debate about police involvement in mental health, much of it framed in economic terms, or measured by numbers of detentions under section 136 of the Mental Health Act (Heslin et al., 2016, Irvine et al., 2016). As someone personally impacted by mental ill health, and with much more experience of police response to crisis than I’d like, those outcomes aren’t the ones that matter to me. Yet reading the various reports and papers about policing and mental health crisis, service user voices seem to be almost unheard, some evaluations consulting only with professionals not service users, and where there is service user feedback, it being collected and filtered by those delivering services.
Two million pounds has been spent on pilot studies looking at Street Triage schemes (Reveruzzi and Pilling, 2016) – where police and health services respond together to mental health crisis incidents – they have received media attention, claim wide ranging successes, and there have been recommendations to extend the pilots (Reveruzzi and Pilling, 2016). There is an assumption that attempts to reduce detentions in cells and reduce the use of s136 will decrease harm to service users, but no studies have examined in depth potential harm to services users from police involvement in first line responses to mental health crisis, and no Street Triage studies have looked at who service users want to respond to them in crisis
To better understand the experiences people with lived experience of mental ill health have had with police response to crisis, I conducted an online pilot survey. The study was not funded, and independent of services. It was a short survey, just five questions long to enable people in lots of different situations, including people who might be unwell currently and find it difficult to concentrate, to be able to take part. The survey can be found here – http://www.surveymonkey.co.uk/r/VDPNSLJ
What did the study look at?
The aim of the study was to explore experiences of police responses to mental health crisis from the perspective of those with lived experience of mental ill health, either themselves or as a carer.
The study questions looked to answer three research questions:
1. Do police responses to mental health crisis have a helpful or harmful impact on people who are unwell? Are these impacts different in the short and longer term after the event?
2. What are people’s experiences of police responses to mental ill health?
3. Which services do people with lived experience of mental ill health want to respond to them when they are in crisis?
How was the study conducted?
The survey was online only and cross sectional in design. No incentives were offered for participation. A small pilot was conducted to ensure the questions did not cause distress.
Study recruitment was completed by sharing the link to the online survey on Twitter and Facebook. Within two days of the survey link being shared, 100 people had responded.
The five questions in the survey looked at whether people had experienced a police response to themselves, or to someone they cared about; whether people had experienced helpful or harmful short and long term effects from police responses to crisis; and who people wanted to respond to them in crisis. There was also a question where people could talk about what had happened to them and the impact of police responses in more detail.
So what can 100 people tell us about police responses to crisis?
Who took part?
94 of 100 people who completed the study said that they had experienced a mental health crisis which had involved a police response, either themselves or to someone they care about. Four people said they had not experienced this, and two people did not answer this question.
Of the 94, 70% had experienced the crisis themselves and 30% as a carer.
What impact did police involvement in crisis have? – Short term impacts of police response to mental ill health:
When asked what impact police involvement in the crisis had in the short term, 95 people answered the question.
- Of these 95, 5 people (5%) said the police involvement had no impact.
- 44 people (46%) said the police involvement had either been helpful or very helpful.
- 46 people (48%) said police involvement had been either harmful or very harmful.
Eight people added comments to the question. One of these said the question was not applicable to them, and another contained factual information about the outcome. One response was very positive about the impact the police response had:
“They couldn’t have done more to find my friend (they had gone missing with fears for their safety) and they couldn’t have been more caring & helpful when they found them.”
The other six comments described negative impacts from police involvement. These included feelings of criminalisation, increased mental health stigma, loss of trust in police, worsening of distress, and worsening of suicidal thoughts. One comment described a 14 year old being kept in a police cell for 26 hours.
“They made sure I was physically “safe” and alive but they made my suicidal feelings and distress worse. After they left I went from feeling suicidal to determined and making plans to end my life.”
“Scary. Felt criminalised afterwards lost all trust in police and stigma from people who’d seen me out in the van.”
Longer term impacts of police responses to mental ill health:
Participants were also asked what impact police having been involved had in the longer term, 97 people answered this question.
- Of these 97, 27 people (28%) said the police having been involved had no impact in the longer term.
- 17 people (18%) said the police having been involved was helpful or very helpful.
- 47 people (48%) said the police having been involved was harmful or very harmful.
The question also had an option for people to not answer harmful or helpful but add their own comment instead. 6 people (6%) did this. Of these one person felt the question didn’t apply, one was positive about the involvement of the police:
“[…] the brilliant way they dealt with the incident gives us great confidence.”
Four of these comments from people who had not completed the scale of helpful to harmful indicated the response had been harmful:
“Long term trauma from being locked up”
“An increase in medication. leading to excessive amounts of prescribed drugs. suicidal thoughts. fear and anxiety. PTSD.”
“Scared of police. Don’t tell anyone and try to hide when am in crisis, scared it will happen with police again”
Which services do people with lived experience of mental ill health want to respond to them when they are in crisis?
This question asked: If you or someone you care about were mentally unwell in a public place or in your home and needed help because of your/their mental health, which of the following services would you most like to come to help?
100 people answered this question, cross referencing this with the first question this means that four of those responding did not have lived experience of police responses to crisis either themselves or as a carer, and a further two people may not have.
The question asked people to pick the service they would most like to respond. The options were: mental health services, general health services, social work, police, a combination of police AND health or social work (similar to a Street Triage team), a combination of health and social work but NOT police (similar to high fidelity models of some mental health crisis teams), or other.
Participants indicated the following preferences for response:
- Mental health services, e.g. mental health nurses or doctors – 31%
- General health services, e.g. ambulance or GP – 7%
- Social work, e.g. AMHP or MHO – 4%
- Police – 6%
- Combination of police AND health/social work – 16%
- Combination of health/social work, but NOT police – 27%
- Other – 9%
Of the nine people who wanted a response other than those services listed:
- One person said they were now reluctant to engage with any service.
- One person suggested an Independent Mental Health Advocate.
- Four people suggested family, along with Samaritans (two people), staff already paid to look after the person (one person), and the early intervention mental health team (one person).
- One person differentiated between locations, saying police should respond in public places and mental health professionals should respond to incidents at home.
- One person said police and ambulance.
- One person said health professionals only, and suggested a mental health paramedic service made up of mental health nurses and social workers, and a mental health A&E equivalent,
What are people’s experiences of police responses to mental ill health?
Participants were asked if they would like to say more about the impact of police involvement. 61 people answered this question using free text with no word limit. These answers have been analysed thematically. Themes emerging included: loss of trust in police or in health services, impact on health behaviours – disinclination to seek help again in future and trying to conceal symptoms to avoid a further police response, feeling let down or betrayed by health services, criminalisation including impacts on work and volunteering, worsening of symptoms, associations with trauma both with the police response as a source of trauma, and as a trigger to previous trauma, detention in cells, stigma, physical restraint and containment and physical injury, short and long term distress, and shame. These will be discussed in a follow up blog looking at the qualitative analysis in more detail.
What do these results mean?
Only 16% of participants, given a choice, would choose police and health/social workers to attend together to a mental health crisis, and only 6% would choose police. This means that given a choice 78% of people would not choose for the police to be involved in a response to them in a mental health crisis. Mental health services were the most popular choice to respond with 31% of participants preferring this. The second most popular option was a combination of health and social work but not police with 27%. These findings have implications for those who commission services for mental health crisis, and those involved in frontline services making decisions about how best to respond to incidents. There is a disconnect between what service users want and current trends in service provision.
Many people (46%) rated the impact of police response as helpful in the short term. This is reflected in the comments people made describing kindness and compassion of individual officers. However in the short term, more people (48%) found police involvement to be harmful than helpful. When this question was extended to the longer term impact of police involvement, the results are striking, only 18% of people finding police involvement in the crisis response to have had a helpful impact in the longer term, and 49% of people considering it to be harmful. This matters because almost half of people say they have been harmed by the police response, yet little work has been done looking at what aspects of response cause this harm. Also feedback with service users rarely looks at longer term impacts of contact with services, so these longer term harms may be missed by some service evaluations. It also raises questions about the types of harms people are experiencing, and how these can be prevented.
The qualitative analysis of the free text question provides some initial answers to these questions about the types and causes of harm, and will feature in a follow up blog. The comments left on the questions analysed here also provide insight into this, with descriptions of longer term traumatic effects of police involvement, and in the short term, worsening of suicidal thoughts. These suggest that despite an emphasis on safety in police responses to mental health crisis, paradoxically responses in some cases cause harm, and the psychological safety of people in mental health crisis needs to be better understood. Impacts on health behaviours and criminalisation of service users are also concerning, and are discussed more fully in the follow up blog.
What are the limitations of this study?
This was a small study without funding, and it has some limitations. Sharing the study on social media only will have limited the range of people who could take part and may have introduced bias, although question answers did indicate that people in a range of situations, including people currently detained in hospital under the Mental Health Act had participated.
As a service user who has my own experience of police responses to mental health I may also introduce bias into the design and analysis of the study, and positioning it as service user led research may also have limited or influenced who took part. However the responses describe a range of positive and negative experiences and some participants were keen to praise police responses. The independence of service user led research could also be seen to attract responses from people who might not take part in research conducted by services. If the study was extended and funded these biases could be addressed more fully.
How were ethical considerations addressed?
As a small service user led study this study was independently conducted and not approved by an institutional ethics committee, however ethical considerations were important to this study, and the study was conducted according to ethical good practice. No service user data were collected so participants are not identifiable. The survey was piloted with a small group of people with lived experience of mental ill health to ensure the questions did not cause distress. It was designed to be short and easy to complete and the Samaritans number was given at the start of the survey so even people who did not complete it would have a route to get help if thinking about the issues caused them distress. The introduction to the study also explained who was collecting the data (a service user) and why, and offered an opportunity to ask questions.
Following the survey being shared several service users tweeted me and said it had been interesting or easy to complete. No questions were compulsory so people could take part in the study even if they did not want to answer particular question,
Despite investment in Street Triage schemes, 84% of those with lived experience of police responses to mental health crisis would prefer other services respond to them if they had a choice. The study suggests some individual police officers are having positive impacts on individuals, and 46% of people find police response to crisis helpful in the short term, however this impact changes, and only 18% of people found police responses helped in the longer term. People also described longer term traumatic effects of police involvement, and worsening of distress and suicidal thoughts in the short term. .This study points to the need for better understanding of the impact of police responses on people in mental health crisis, including both short and longer term effects. It also highlights the importance of service user involvement in service design and research.
Coming up – Qualitative analysis of participants’ experience of the impact of police involvement in mental health crisis
HESLIN, M., CALLAGHAN, L., PACKWOOD, M., BADU, V. & BYFORD, S. 2016. Decision analytic model exploring the cost and cost-offset implications of street triage. BMJ Open, 6.
IRVINE, A. L., ALLEN, L. & WEBBER, M. P. 2016. Evaluation of the Scarborough, Whitby and Ryedale Street Triage Service, Department for Social Policy and Social Work, University of York.
REVERUZZI, B. & PILLING, S. 2016. Street Triage – Report on the evaluation of nine pilot schemes in England. University College London.