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Police Crisis Care Responses – part 2

This post follows a short piece for service-user survey work by @DrEm_79 (from Twitter) – the nature of this is it produces a longer piece than normal BLOG post, but I can assure you it’s worth reading all the way through. Alongside the first post, it offers important insights in to crisis care responses involving the police.

Now this is complete, I just to thank @DrEM_79 for doing it: I think what she’s uncovered is very far from unimportant and given how easily social media can be deployed begs questions about why we don’t see more of this.


Incidents involving mental health issues account for 20—40% of UK police time (College of Policing 2016). Despite this there has been little research looking at how police responses to mental health crises impact service users. Some evaluations of police mental health schemes have not consulted with service users at all, speaking only to professionals.

Despite investment in Street Triage schemes where police and health professionals co-respond to mental health crisis, part one of this peer research study found that 84% of those with lived experience of police responses to mental health crisis would prefer not to have a co-response with police if they had a choice. It also found that almost half of people with lived experience of police responses to mental health found them to be harmful (48% in the short term and 49% in the longer term). Little work has been done looking at impacts of police response on service users. It is not known what aspects of response contribute most to harm, or the types of harms individuals experience. Work is also scarce looking at what it is about police responses that service users find helpful.

This peer research study of service users looked at which services people wanted to respond to them in crisis and whether they had been helped or harmed in the short and longer term by police responses to mental health crisis. It also aimed to explore people’s experiences of police responses to mental ill health in more depth and look at impacts of police response on individuals.

Part one of the study can be found here. 100 people participated in the study within two days of study recruitment commencing. As well as the questions discussed in part one, 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 were analysed thematically.

RESULTS

1. Reasons for police involvement

Thirty participants discussed the reasons police became involved in the mental health crisis. Police involvement was associated with self harm or suicidal behaviour for many. Only two people had contacted the police direct for help. The most common reason for police involvement was because the person or their carer had called mental health services (hospital, CMHT, or crisis team) requesting help with suicidal thoughts, self harm, distress, or worsening symptoms, and health services had called the police. Participants described feelings of punishment and loss of trust:

“I phoned the crisis line suicidal and they sent the police. The crisis line refused to help and no one would come to assess me. The police stopped me from leaving and tried to force me to go from my house to the hospital trying to trick me outside but I refused. Mental health services passing the buck and punishing people for being ill sending police” – Participant 1

“My relative has been detained s136 around 30 times in last 5 years. Police intervention has kept her alive, but has also been hugely traumatising. Services work on the basis that you shouldn’t need admission to hospital, which means people are left at home when they are suicidal.” – Participant 2

Other reasons for police involvement included missing persons, concerns for welfare from other agencies, police called to attend self harm on inpatient mental health units, and people absconding from mental health units and from A&E. Nine people described being sectioned under the Mental Health Act, eight of these with section 136. Four people described arrest for Breach of the Peace connected with suicidal behaviour.

Some described the actions of the police in positive terms:

“My nephew was 4 at the time (has Downs Syndrome and Autism) and escaped from home, missing for half an hour, police sympathetic and understood the vulnerability and his being unable to know his own name and address – found safe and well – very supportive throughout ordeal – Participant 3

Others described more harmful impacts from police involvement. A number of participants made comments sympathising with police but feeling let down by health services:

“The ambulance crew phoned the out of hours doctors who refused to attend and they tried to tell the police to arrest an elderly man with dementia because he was confused in his own house, the police and ambulance did all they could but were let down by the doctor.” – Participant 4

2. Loss of trust and feeling let down

Loss of trust and feeling let down was the biggest theme in the study, and was raised by more than half of those who commented. Participants described a number of different aspects to this. Feeling let down by health services was the most common impact discussed, followed by loss of trust in the police. Some people described a loss of trust in all services after police involvement in the crisis response and said that police involvement had caused them to disengage from help:

“Since then I’ve lost trust in police and the crisis line who called the police. I don’t call anyone when I need help and suffer alone as what they did made a bad situation worse and humiliated and hurt me deeply” – Participant 5

Participants described impacts of police involvement on health behaviours, with police involvement leaving them less likely to seek help in future, or altering suicidal behaviour so that there was less chance they would be found when attempting suicide in future:

“I’m […] more wary of speaking honestly to, or dealing with mental health services, in case the police get involved again.” – Participant 6

“I felt intimidated & humiliated by police. I was told to stop being “silly” (this even though I have C-PTSD & was going through a rape trial at the time. There was a complete lack of understanding, compassion or empathy. I felt totally degraded. My experience served to ensure that if/when I attempt suicide again to ensure I do it in a place I cannot be found.” – Participant 7

Participants also reported that police involvement in the crisis had made them less likely to report crime in future. People also reported fear and avoidance of the police. This is concerning as people with mental ill health are more likely to be victims of crime than the general population:

“Afterwards I had my phone stolen and was too scared to report it to police as every time in crisis they keep me trapped in my house and I couldn’t bear going through that again” – Participant 8

“Seeing police now cross street to avoid, won’t go out if police cars in the road. I don’t trust police now” – Participant 9

“After they left I was alone and in a worse state than before their arrival. I feel frightened of the police now. I doubt I’d feel able to call them if something happened to me (ie a crime, or my abuser finding me).” – Participant 6

Some participants expressed regret at having asked for help because police had been involved:

“I wanted someone to help me when I was ill not to make things worse by sending police. I wish I never asked for help” – Participant 10

Participants also highlighted inequalities or assumptions in their treatment, some contrasting this with physical health conditions, or feeling their behaviour had been wrongly labelled as due to illness:

“Damaged my trust I was ill not a criminal why do people with mental health problems get police when people with physical health problems don’t? I am scared of police now after being kept in a cell waiting for assessment. Sectioned but no rights in reality” – Participant 11

“I was arrested by police under s 136MHA but was not told this by police only by staff at hospital. I was in fact trying to leave my husband but because I had had mental illness I feel the default position was assumed. Ended with me having to return to a very difficult household. 4 years later and I still feel very raw. Just because you have had a mental illness does not mean that every unusual behaviour is down to that.” – Participant 12

People also described a lack of communication during the incident, and feeling that they did not know what was going on:

“Was a very terrifying experience. Didn’t have anything explained to me and they were already in my home when I returned home, having broken my door. Then two wrestled me and handcuffed me, again nothing was explained. I thought I was being arrested for a crime though had no idea what. Only told when got to 136 suite where I was and that I had been sectioned.” – Participant 13

Others described a lack of follow up, feeling that although there had been a response, the crisis was not resolved, and feeling the police were only interested in their wellbeing at that moment, not in the longer term:

“After police closed involvement mental health services often did not continue to offer much or any support.” – Participant 14

“But after they left I felt worse than before they arrived, less safe, like I never would be safe anywhere (I had escaped my abuser to try and find safety), and frightened that they might come back with a warrant or show up to check on me or try to intercept me when I next went out to section me. I know that sounds paranoid, but their response to my refusal to attend the hospital frightened me and I didn’t know how far they’d go. It was also upsetting having them arrive telling me they wanted to help me, but the fact was, after they left there was no referral to mental health services or follow up or anything. I was just abandoned to carry on struggling alone. It felt like a case of “make sure she’s still alive tonight, but after that we don’t care what happens to her, she’s on her own”.” – Participant 6

3. Criminalisation

The second most common theme in this study was criminalisation, and was raised by around a quarter of respondents. A number of different aspects of criminalisation were discussed. For some it was a feeling:

“I don’t trust police anymore or ask for help in crisis I try to hide it. Hospital called police when I called them for help and I felt like a criminal” – Participant 16

“The police were lovely, every time, however I’d still not like to see the boys in blue for a mh crisis, I’d feel better if it was entirely managed by Nhs staff- let the police catch criminals! Even though you’ve done nothing wrong in terms of the law, you feel like a criminal for being with the police.” – Participant 17

“Scared, betrayed, society felt I was criminal and didn’t belong” – Participant 18

Others described concerns about police involvement impacting criminal record disclosures:

“I was being held under section 136 to take me to a place of safety. As I was already going in, it seemed ridiculous and I told them that. When inside the hospital, I was upset because I was worried about it showing up on an enhanced CRB.” – Participant 19

“I was arrested for breach of the peace when I attempted suicide. Criminal record so then not allowed to do volunteer work with children.” – Participant 20

Stigma was a major factor and people felt judged or shamed by police involvement:

“I felt guilty by association, ‘mad’ by association, and degraded by having been involved in the situation.” – Participant 21

“Humiliated. Degraded. Lost confidence. Ashamed to go out. Attempted suicide soon after. Definitely made self harm worse” – Participant 22

Several people also described marked police vans being used for transport which contributed to distress:

“Crisis team called police when I told them I was suicidal. Damaged my trust in people who should be helping. Passed me off to police instead who handcuffed me and pushed me into a marked van with spectators thinking I was a criminal” – Participant 23

Participants also described Taser use, one person described the interaction of the threats of coercion with their mental health:

“My son was sectioned. The police had been called a few times before this. It’s a shame the mental health services didn’t listen to us as parents. My son ended up going manic and getting sectioned for several weeks. The police had to point a taser at him” – Participant 24

“I was threatened with a taser. It was very frightening. I already believed people were trying to hurt me and my family and police were part of that, it made the paranoia a lot worse. – Participant 25

Two participants talked about the impact of being a police officer themselves and needing help:

“I was a serving police officer , suffering from PTSD and in crisis , I was detained by colleagues I knew, placed in the same unmarked police vehicle I had placed arrested people in previously. I didn’t want to see officers I knew when I was in crisis. – Participant 26

“Because I am a police officer myself it was very awkward and distressing but the officers who helped were lovely. It only went downhill once the MH team became involved. – Participant 27

The public nature of police involvement was a concern shared by several participants:

“After hours and lots of conversations outside my house which neighbours were cross about and two police cars parked on my drive all night they left with no help not seeing anyone. Useless upsetting stigmatising.” – Participant 28

“Being held on S136 means the local police (small town) now know me and I am often stop checked while perfectly fine and just getting some shopping. It’s embarrassing” – Participant 29

Four people described having been arrested for breach of the peace:

“I was arrested for “breach of the peace” after my psychiatric hospital refused to assess me out of hours as they had assessed me previously. I appreciate (now) they were getting to keep me she and felt their options were limited by being kept in a cell overnight was not ideal.” – Participant 30

“Police unlawfully arrested me for breach of peace (there was no breach of peace at all. I didn’t even say one word to police) to get me out of my flat and into public place. Then they kept me in a cell for 8 hrs telling me to ‘get a grip’ and ‘stop attention seeking.’ Solicitor got me unarrested and despite getting compensation for unlawful arrest and false imprisonment, the mental scars from this remain 5 years on. I panic at sight of any police officer or police car. Really harmed me.” – Participant 31

“Was arrested for breach of the peace and kept in a cell for 18 hours […].” – Participant 22

Others described threat of arrest:

“Have been sometimes threatened with criminal charges which makes me scared of police involvement and also sctn 136 lead to a long stay in a police cell Other times I’ve felt the police were the only people who cared” – Participant 33

People described impacts of detention in police cells under arrest or as a Place of Safety as frightening and distressing. Some of these were for prolonged periods:

“15yr daughter held for 43 hrs in custody cell – no MH beds.” – Participant 34

“Detained under S136, as I had been reported as missing person & self harmed in public place. PoS was Police cell, I was scared & frightened.” – Participant 35

“I get locked up in a cell over night. This has happened countless times and just adds to my distress” – Participant 36

Other participants described effects of damage to their property as a result of police involvement:

“Many many ‘safe and well ‘ checks where door kicked in whether there or not. Am physically disabled and cannot reach the door quickly plus there is a keybox and police have code yet still kick door in.” – Participant 37

“Rental agency unhappy with door being forced (although I paid for repair)” –  Participant 13

Blame and accusatory language was also raised as an issue:

“For me the initial focus was quite a checklist – did I need medical attention (yes), had the terms of a restraining order been breached (yes), had I caused or collaborated with that (no, but the questioning had a repetition about it that suggested that I must have been partly to blame because a mess of that size doesn’t just appear out of nowhere), was I officially able to make a statement (yes). Then, as the ‘sectioning’ process took over the checklist changed but the tone of the questioning seemed accusatory still, as if we had wasted their time and they had to start all over again with a new set of questions. I felt bewildered, and I really didn’t understand what was going on, what to expect or how my answers would be used. It was like being held responsible for something without knowing what the consequences would be.” – Participant 38

“I was not arrested but despite no legal basis I was handcuffed and stopped from leaving my living room not even allowed to go to the toilet without male police watching me. Since then I’ve lost trust in police and the crisis line who called the police. I don’t call anyone when I need help and suffer alone as what they did made a bad situation worse and humiliated and hurt me deeply.” – Participant 39

4. Trauma

Trauma emerged in the analysis in a number of ways. This was partly participants talking about the police response triggering memories of previous trauma:

“16 year old daughter pinned down by police which gave flashbacks to previous sexual assault.” – Participant 40

“They searched me which retriggered trauma and two men held onto me and in handcuffs in my own home but I’m not violent. Not necessary.” – Participant 41

“They asked me if I would go to the hospital voluntarily and when I said no told me they might have to look at forcing me. It left me feeling violated and unsafe in my new home (some of the things they did were things my abuser did – they were aware of the background and I did specifically tell them).” – Participant 6

Other respondents described the police response itself as a source of trauma:

“First involvement with police and still traumatised now (this was Dec 2015) & have moved house as was having flashbacks etc” – Participant 13

“Police are not adequately trained to deal with mental health crisis, and being left in their care at home for over 8 hours waiting for a MHA Dr to arrive was a traumatic experience.” – Participant 43

“My relative has been detained s136 around 30 times in last 5 years. Police intervention has kept her alive, but has also been hugely traumatising. Services work on the basis that you shouldn’t need admission to hospital, which means people are left at home when they are suicidal. Could go on and on about this” – Participant 44

Trauma from the police response was described as persisting long time after the event:

“5 years on. I panic at sight of any police officer or police car. Really harmed me.” – Participant 31

5. Physical impacts

Police responses had physical impacts on participants, which were discussed in terms of restraint, physical containment to a place they did not want to be, and also physical harms. One person described a case where the person had died by suicide detained in police custody in a cell at a police station. Others described heavy handed responses contributing to problems, and physical injuries sustained:

“Erroneous claim of violence from crisis team led to heavy-handed police response. Attending officers clearly had no specialist training in mental health. Police and crisis team augmented a crisis needlessly!” – Participant 46

Four described physical harms:

“The hospital wanted to lock me in the mental health room in A&E (it’s basically a cell-sized room with high windows and a concrete bed/bench covered in a plastic-coated foam cushion). I didn’t want to be locked in (they often don’t even let you out to go to the toilet) so I tried to resist. The police and security picked me up by the arms and legs and tried to get me into the room. Once I was on the floor they repeatedly tried to shut the door with my leg in. I ended up with bruising. I’ve had some poor treatment in hospital but I never expected it from the police in a public place. I am much less trusting of the police now.” – Participant 47

“[…] All clothes taken left naked then given padded clothes couldn’t rip tried to ligature with bandages custody officer came in pulled arms back banging head on floor and called me a stupid bitch.” – Participant 22

“After Self-harming in a Psychiatric Inpatient unit, the Police were called, why? Don’t know, was assaulted by 2 Male Police officers, gave me a good kicking. Yet I had already let 2 Police women handcuff me. So I wasn’t dangerous, I wasn’t aggressive and couldn’t defend myself. The Police had a bad attitude from the first moment they came face to face with me.” – Participant 48

Limits to freedom while in presence of police were described by several people, including having to wait many hours in the presence of the police before a MHA assessment:

“I was not arrested but despite no legal basis I was handcuffed and stopped from leaving my living room not even allowed to go to the toilet without male police watching me.” – Participant 49

6. Helping

As well as the negative impacts described, people also talked about positive effects of police involvement. These included being a calming presence:

“[…] One of the youngest PCs present (I think, but don’t know for sure, she was on probation or training placement) was absolutely brilliant. A cup of tea, a smile, a reassuring comment when she said ‘it’s ok, they have it under control, just take a moment to calm down’ and offering to help call someone to be with me. She really de-escalated my fear in the moment.” – Participant 38

“Police totally calmed a very volatile situation down. Listened and talked to individual and didn’t judge.” – Participant 50

Participants also described police helping with practical arrangements:

“They took care of my pets feeding and making sure they had water while paramedics dealt with me. Other times they’ve wanted to take me to hospital but I refused.” – Participant 51

Others explained how police involvement had helped to ensure their physical safety and protect them from harm:

“During a period of mania I was extremely vulnerable during the night alone in my underwear in a notoriously dangerous park. Police brought a blanket in and encouraged me to their car where I was taken to a MH ward.” – Participant 52

“I was very depressed & suicidal, my husband (now ex) called them. They spoke to us both separately & thankfully could see through him that because I was so desperate was because of continued domestic abuse. They spoke to me & gave me contact numbers & advice & also arranged an emergency appointment with my GP.” – Participant 53

Some participants also described police involved in the response as being empathetic, kind and compassionate:

“I was taken to hospital semi conscious following an overdose, when I came to there was a policeman standing next to my door. I asked him why he was there and he said was to make sure I was ok, he contacted the detective in charge of my abuse case which was soon to go to court and he came to see me to see if was ok. When I was detained in psych hospital both previously and after this, same detective came to see me to see how I was doing and to remind me none of the traumatic events had been my fault. Initially the police outside my door in A&E frightened me, but they were lovely.” – Participant 54

“The 2 officers that attended were really good, they stayed out of the way and when they did need to interact they were really calm, polite and empathic, couldn’t have wished for better response.” – Participant 55

Participants also talked about how they felt police had been let down by other services:

“15yr daughter held for 43 hrs in custody cell – no MH beds. […] Generally police good, having to fill gap of inadequate MH Adult Services” – Participant 22

“Police have always treated me with immense kindness. They have spoken of their frustrations due to MH cuts.” – Participant 56

“Police often called by private company who have contract for his care on CTO if my son goes missing or there is a problem. They always appear to be helpful but often not their job. What is needed is more support from company who are paid massive fee.” – Participant 57

Some people who had experienced harm from the police involvement in the crisis response also described kindness from police. Compassionate and traumatic responses were not always distinct. This raises questions for those involved in collating feedback from crisis incidents, and in evaluating services. Although someone may describe individuals as kind and compassionate, that does not mean the overall impact will be helpful.

“Have been sometimes threatened with criminal charges which makes me scared of police involvement and also sctn 136 lead to a long stay in a police cell Other times I’ve felt the police were the only people who cared.” – Participant 58

Others had a different response with one respondent simply saying:

“They completely lacked compassion.” – Participant 59

7. Impact on mental health

Participants also discussed ways that police involvement in the response had impacted on their mental health. Impacts were unanimously negative, with police involvement worsening distress:

“Humiliated. Degraded. Lost confidence. Ashamed to go out. Attempted suicide soon after. Definitely made self harm worse” – Participant 34

“At an already stressful time this was unhelpful and made my recovery all the more difficult.” – Participant 60

SUMMARY

Participants described a number of short and longer term harms from police involvement in the response to their mental health crisis. These have implications for mental health services, police, and those commissioning services and developing policy. Participants often felt let down that they had wanted mental health service support and help, but instead it was police that were sent to them. This diversion of health need to the police caused distress, and in many cases seems at odds with efforts and policy to divert mental health need away from the criminal justice system.

Paradoxically, although police responses in crisis are often focussed on ensuring physical safety, survey responses suggest that involvement of police leads to behavioural and attitudinal change for some individuals which may increase risk, whether by withdrawal from services, not seeking help for health crisis in future, concealing symptoms because of fears police will become involved again, or escalation of risk in suicidal behaviour. Fear and mistrust of police is also concerning. People with mental ill health are more likely to be victims of crime than the general population, yet because of police responses to mental health crisis, participants stated they would be reluctant to report crimes against them to the police.

Criminalisation and mental health stigma are also important, causing distress and lasting impacts on individuals. Some of the examples of practices such as marked police vans being used for transport to hospital, people in private premises being tricked outside so they could be detained under s136, and people being held without apparent legal basis, also suggest policy and practice guidance (for example House of Commons Home Affairs Select Committee, 2015) are not being adhered to in all cases.

Traumatic impacts of police involvement in mental health crisis response also need further attention. Trauma is associated with a range of mental health conditions, yet this study suggests involvement with the police in crisis is retriggering and in itself can be further traumatising.

The extent of the harms described by participants in this small peer study suggests further research is urgently needed into impact of police involvement in responses to mental health. It also highlights that future evaluations of schemes designed to meet need in mental health crisis, such as Street Triage, must prioritise service user participation in evaluation if the true outcomes of the scheme or intervention are to be measured and understood. That schemes are described as successful without whilst harm is being caused to service users is concerning. People experiencing mental health crisis deserve protection, not just protection of their immediate physical safety, but also ensuring that where possible further harm is prevented, and that responses to crisis do not make things worse for the person.

References

2015. Home Affairs – Eleventh Report: Policing and mental health. London: Commons Select Committee, Home Affairs.

2016. Mental health crisis takes huge and increasing share of police time. The Guardian.


IMG_0053IMG_0052Winner of the President’sMedal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


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Police Crisis Care Responses – part 1

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:

“Very detrimental”

“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,

 Conclusion

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

References

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.

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What Cost Progress?

One of the main reasons the Home Secretary emphasised that we need to make progress on policing and mental health is to free up police time to concentrate on other issues – mainly around the broader crime prevention agenda. I don’t think she is trying to imply that police time so the most important thing in the world or that there is no overlap at all between mental health issues and core police functions. She just seems to be making the point that the police time committed to this overlap is considerable and could very obviously be reduced. So various things have been happening to deliver progress on this under the overall banner of the Crisis Care Concordat agenda. It certainly can lay a highly intuitive claim to some impressive results –

  • reliance upon police stations as a Place of Safety massively down since 2010, from over 11,000 to the cells down to about 4,000;
  • the overall use of s136 MHA in street triage areas massively down, typically by 25-33%; and
  • overall satisfaction of those professionals and members of the public who have experience of this stuff seems to be up.

What’s not to like?!

One of the main problems is that we need to fully analyse this to understand whether or not the ‘progress’ we claim is actually just making this problem worse, from the point of view of police time. If it is, it raises some interesting public policy questions for us all.

Before I get in to details, I want to make one thing clear: progress at the interface of mental health and policing is not and should not just be about saving police time. The service benefit to the public is obviously more important and nothing is free of cost or unintended consequences. Improving the experience of vulnerable people who come in to contact with the police is about far more than the amount of time the police will expend and I will highlight some examples where it will quite rightly involve greater time and effort. But what follows are mainly examples of where, in an effort to save time and resources, we’ve managed instead to spend time and resources. It begs the question: if we have also improved the experience of those vulnerable people for whom the police have had to provide a response, to what extent should a Chief Constable be paying – quite literally – to improve that crisis pathway to assessment and care for vulnerable people? My final caveat on this post, is that we still don’t have proper data on this stuff – people saw fit not to collect it, notwithstanding that they were advised, so I’ll try to bear that in mind as I am inevitably forced to generalise and over-simplify!

PLACE OF SAFETY

In an ideal world, your local police officers will use s136 responsibly and correctly, leading to the removal of vulnerable people to a Place of Safety only where necessary and that person will be handed over to the NHS within half an hour for assessment and the police will leave. Such a process doesn’t happen anywhere in the United Kingdom, to my knowledge, but it’s what we all agreed to in the Royal College of Psychiatry standards on s136 which were published in 2011 and were slightly updated in a guide to NHS commissioners in 2013.  Always amazes me that our NHS can transplant human organs and knows what will happen tomorrow if there is an Ebola patient, but we don’t know how to staff a building to accommodate a vulnerable person in crisis for an assessment of their needs and we certainly don’t know where they will go tomorrow afternoon if they’ve also consumed half a bottle of vodka to quieten the voices in their head.

Less than a decade ago, 66% of the 18,500 people detained under this power were taken to police custody; and none of the 33% who were spared this indignity benefited from a service that worked according to the national standards, referred to above.  Since then, ‘progress’ means we now see only 20% of 24,500 people taken to custody – we can agree this is a good from the point of view of more timely, dignified assessment for the person concerned (albeit someone should be examining why the use of the power has gone up by around a third in a decade).

  • The average assessment time in police custody is still around 10hrs, where the cells are still used.
  • The average assessment time in an NHS PoS is around five hours.

If the police remove someone to custody, they don’t always have to leave an officer there to undertake one-to-one or camera observations of someone. Custody staff can often do it, and if camera observation is required, one member of staff or police officer can watch multiple cameras at the same time. Where someone is taken to an NHS PoS, it is still usually necessary for two officers to remain there until the assessment is completed; and if an inpatient bed is required after admission, it will take longer again.  Do the maths on this at your leisure, but you’ll find it means more police time is invested in staffing unstaffed NHS Places of Safety than if we used the cells as often as we did a decade ago. Many NHS areas will simply say they don’t have the funds to properly staff their Place of Safety in such a way as to ensure it complies with those RCPsych standards so the police will have to remain.

In other words, the ‘progress’ we’ve made is now costing the police more than it was before, because NHS trusts often don’t staff their Places of Safety.

STREET TRIAGE

Meanwhile, of course, in an effort to reduce the use of s136 and avoid the use of custody, we have seen street triage schemes emerge.  I won’t repeat here what I’ve already covered but we know that from the point of view of s136 reduction, many ST schemes now mean the police have tripled their resource committment to managing the workload.  And we know that the very existence of triage schemes is resulting in existing NHS structures like out of hours GPs, crisis teams and community teams, asking street triage to pick up work that the police would not have previously been involved in, because nothing in the referrals is anything that you might recognise as a core police responsibility? (Yes, I’m aware of the other, non-s136 related workload in private premises but someone in the street triage world forgot to record that, never mind analyse it.)

It must be right that I acknowledge the impact of particular triage schemes varies depending on the model operated by the force you look at; and depending upon the number of days and hours that are covered. The resulting mathematics therefore varies and I’m more than satisfied that some models of triage are saving police time, but for me this only reinforces the importance of understanding not only the demands we face, but also the reasons why we face them – it’s about the overall flow of patient demand right through the mental health crisis and police system. We do nowhere near enough of this mapping, currently.

So I ask –

To what extent is it appropriate that a Chief Constable pays – both literally and in resources – to improve NHS Place of Safety and other crisis care pathways when it is also involves more demand being deflected to 999 than was previously the case?

The amount of police time spent is not the most important thing in the world – but it’s not irrelevant either and it only becomes a discussion in the first place as a result of choices some areas have made about the accessibility of the unscheduled care services they offer. When I have mental health nurses and AMHPs themselves telling me that there are conversations going on in rooms to which the police are not invited which involve explicit discussion about how much more crisis care demand can be deflected to 999 (including to A&E), then it means we cannot totally ignore the impact on police resourcing where it is connected to deliberate decisions by NHS managers*.

* If anyone is tempted to point out something political about cuts – 1) I’m a policeman, so I’m not going to do anything party political; 2) police budgets increased by less than the NHS MH budget in real terms 2001-2011; and have since decreased by more since 2011.