Criminal Behaviour and Mental Health 24: 81–85 (2014) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/cbm.1897
When two worlds collide: A twenty-first century approach to mental health and policing JANE SENIOR, HEATHER NOGA AND JENNY SHAW, Offender Health Research Network, University of Manchester, Manchester, UK How best to deal with people with mental health problems in contact with the criminal justice system (CJS) has been a thorn in the side of politicians, clinicians, police, prison staff and social commentators for centuries and across many jurisdictions. As early as 1784, John Howard described prisons as ‘crowded and offensive, because the rooms which were designed for prisoners are occupied by lunatics’ (p.10). In terms of healthcare services for this group, Sim (1990) noted the rise of medical power in prisons in England throughout the nineteenth and twentieth centuries whereby doctors claimed expertise in the treatment of ‘criminal lunatics’, administering a range of crude and often barbarous physical treatments designed to rid prisoners of the joint demons of mental illness and criminality. In the latter years of the twentieth century, the continued separation from mainstream National Health Service (NHS) provision of care for prisoners in England and Wales was tackled through the establishment of a formal partnership arrangement between Her Majesty’s Prison Service and the NHS. The core aims of the partnership were to raise standards of care, reduce the economic inefficiencies inherent in running a parallel, but generally perceived as inferior, health service, and reduce the health inequalities experienced by a socially excluded population (Her Majesty’s Prison Service and NHS Executive, 1999). Of course, for people with mental health disorders to be in prison, they must, by necessity, have had earlier contact with the police. Mental health services for detainees in police custody have, however, to date, been subject to less scrutiny and critical debate than those for prisoners. Healthcare provision in police custody suites in England and Wales traditionally consisted of cover by ‘forensic medical examiners’, commonly doctors in general practice/primary care with some specialist post registration training or experience. Forensic medical examiners deal primarily with physical injuries, determination of detainees’ fitness to detain or interview and assessments for detention under mental health legislation for those thought to be most floridly disturbed. Latterly, police services across England and Wales also commonly entered into contracts with private healthcare providers to ensure full-time or part-time nurse attendance within
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
82
Senior et al.
custody areas, again mainly tasked with physical healthcare and matters pertaining to ensuring fitness for participation in the criminal justice process. This largely process-driven provision was highlighted by Lord Bradley (2009), in his review of offenders with mental disorder, who recorded his surprise ‘that the police stage is currently the least developed in the offender pathway in terms of engagement with health and social services… (although) this point in the offender pathway provides the greatest opportunity to effect change’ (p. 34). As an important step to tackle this, Bradley recommended that the ‘NHS and police should explore the feasibility of transferring commissioning and budgetary responsibility for healthcare services in police custody suites to the NHS at the earliest opportunity’ (p.48), thus reiterating the crucial need for partnership working, which drove the policy regarding prison-based health care services exactly a decade earlier. So, what are both the challenges and opportunities inherent in addressing people’s healthcare needs whilst they are in police custody? And can police contact really be a means of effecting positive change, as posited by Bradley? In common with prisons, the core purpose of any police service is not to provide healthcare. The police exist to detect and investigate crime and aid the prosecution of suspected offenders. It is true, however, that dealing with people with healthcare needs, especially mental health and substance misuse needs, becomes central to policing, given the nature of the clientele, and that in many cases there are potentially lifelong implications for those with whom they come into contact. In the USA, Lamb et al. (2002) noted that ‘the police often fulfil the role of gatekeeper in deciding whether a person with mental illness…should enter the mental health system or criminal justice system. Criminalisation may result if this role is not performed adequately’ (p.1266). Similarly, and also in the USA, Teplin and Pruett (1992) described the police’s role as one of ‘streetcorner psychiatrist’, managing the ‘complex social process(es)’ inherently involved in the decision making around whether to arrest, hospitalise or informally deal with people suspected of mental disorder. These complex social processes are in play because, in spite of the legal structures within which the police operate, decisions around ‘madness’ and ‘badness’ are routinely based on individual officer discretion, influenced by levels of training, experience, professional cultures and personal attitudes. So, how can police officers be supported in this role? Our work with the police, in line with published research (Borum et al., 1998; Moore, 2010), shows that training in mental health issues is the key. Officers report receiving very limited training in mental health matters during their initial training, coupled with little or no opportunity to update or learn new skills once they are operational. It has also been highlighted that the current systems in place to support officers in identifying mental ill health may not be fit for purpose. McKinnon and Grubin (2012), for example, reported that routine screening procedures upon entry into custody in two police stations in London detected only 52% of
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
Mental health and police custody
detainees with a mental health problem and 48% of those with current suicidal ideation. These findings, supported by work in Australia (Ogloff et al., 2006; Baksheev et al., 2011), highlight the need for improved screening procedures, using standardised and validated tools, administered to all detainees, which unambiguously identify those who should be further assessed by a mental health clinician. Our research team has been developing such a tool (Senior et al., 2013), which we believe will assist in meeting a vision of police custody as an ideal opportunity for the early identification of mental disorder in socially excluded individuals who are often very difficult to engage in mainstream health services. Achievement of comprehensive screening of all detainees will, however, require fundamental service reconfiguration, at least in England and Wales, effective across multiple organisational boundaries. Currently, many police custody suites in England and Wales have access to criminal justice mental health liaison and diversion teams (CJMHL&D), which routinely operate during standard office hours on weekdays. Police contact with people with suspected mental health problems, however, does not conform to this neat pattern, and ‘out of hours’ cover is often provided through a complex matrix of non-CJS specific professionals and on-call services, which can be hard for police officers to penetrate. During office hours, CJMHL&D customarily rely on unproven methods of identifying those with possible mental health problems, including searching for detainees’ names in local NHS mental health service databases and/or responding to referrals from police officers based on concerns around an individual’s behaviour. Obviously, these methods offer a far from reliable or comprehensive approach to identification. The former approach can identify only the ‘known knowns’ and is wholly ineffective in identifying those in contact with services in other geographical areas, whilst the latter is heavily dependent on the training, experience and diligence of individual officers, at worst leaving the fate of detainees potentially within the hands of a ‘few good men’. The introduction of an efficient screening tool raises many issues for mental health providers and the police. Such a tool needs to be accompanied by appropriate, responsive and proactive clinical services working hand-in-hand with well-trained police officers to facilitate access to treatments which match people’s needs. Our experience of working with mental health clinicians operating within police and court settings has uncovered real anxieties around the workforce implications of introducing universal mental health screening for all detainees which, inevitably, would generate a much larger volume of referrals for detailed assessment than are currently received. CJMHL&D teams already feel overstretched, reporting that there are too few clinicians dealing with too much demand. This is not unique when considering the operation of mental health services within the CJS; data from a national study of the prison-based mental health in-reach teams in England and Wales found teams feeling overwhelmed by the size of the problem they faced, problems with staff recruitment and retention because of
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
83
84
Senior et al.
the nature of the work undertaken and issues around maintaining professional standards and fidelity to appropriate models of care (Shaw et al., 2009). We acknowledge the concerns of mental health professionals about the potential for universal screening to ‘open the flood gates’ of referrals and subsequent demand on community mental health services or in-patient beds. However, burying our heads in the sand and continuing with practices we know to be poorly targeting the population in need is no more acceptable in police-based mental health services than it is in any other NHS services. CJMHL&D services continue to suffer a legacy of being viewed as very separate from mainstream NHS provision, poorly linked with wider community-based mental health services and with unclear commissioning and reporting models (Sainsbury Centre for Mental Health, 2009; Senior et al., 2011). This is unacceptable in the modern NHS. Progress needs to be made to agree appropriate measures of success for liaison and diversion services, informed by the development of data recording and reporting mechanisms, which allow commissioners to understand their work fully, including the true size of the task they are undertaking. The introduction of universal mental health screening for all detainees in police custody is a good place to start. It needs, however, to be accompanied by willingness on the part of government, commissioners, clinicians at all levels of service and the police to tackle honestly, and with credibility and compassion, the issue of what should happen to people with mental disorder who find themselves in contact with the police.
References Baksheev GN, Ogloff J, Thomas S (2011) Identification of mental illness in police cells: a comparison of police processes, the brief jail mental health screen and the jail screening assessment tool. Psychology, Crime & Law 1–14. DOI: 10.1080/1068316x.2010.510118 Borum R, Williams Deane M, Steadman HJ, Morrissey J (1998) Police perspectives on responding to mentally ill people in crisis: perceptions of program effectiveness. Behavioral Sciences & the Law 16: 393–405. DOI: 10.1002/(sici)1099-0798(199823)16:43.0.co;2–4 Bradley K (2009) The Bradley Report: Lord Bradley’s Review of People with Mental Health Problems or Learning Disabilities in the Criminal Justice System. London: Department of Health. HM Prison Service and the NHS Executive (1999) The Future Organisation of Prison Health Care. London: Department of Health. Howard J (1784) The State of the Prisons in England and Wales (3rd ed.). Warrington & London: T. Cadell. Lamb RH, Weinberger LE, DeCuir WJ, Jr (2002) The police and mental health. Psychiatric Services 53: 1266–71. DOI: 10.1176/appi.ps.53.10.1266 McKinnon IG, Grubin D (2012) Health screening of people in police custody - evaluation of current police screening procedures in London, UK. The European Journal of Public Health 23(3): 399–405. DOI: 10.1093/eurpub/cks027 Moore R (2010) Current trends in policing and the mentally ill in Europe: a review of the literature. Police Practice and Research: An International Journal 11: 330–41. DOI: 10.1080/ 15614261003701756
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
Mental health and police custody
Ogloff J, Davis M, Rivers G, Ross S (2006) Identification of mental disorders in the criminal justice system. Centre for Forensic Behavioural Science, Monash University. Sainsbury Centre for Mental Health (2009) Diversion: A Better Way for Criminal Justice and Mental Health. Senior J, Lennox C, Noga H, Shaw J (2011) Liaison and Diversion Services: Current Practice and Future Directions. Manchester: Offender Health Research Network. Senior J, Noga H, Shaw J, Tighe S, Walsh E (2013) The development of a referral decision screening tool to allow the early identification of mental health problems in police custody. Final Report to the National Institute of Health Research. Shaw J, Senior J, Lowthian C, Foster K, Clayton R, Coxon N, King C, Hassan L (2009) A National Evaluation of Prison Mental Health In-Reach Services. Manchester: Offender Health Research Network, University of Manchester. Sim J (1990) Medical Power in Prisons: Prison Medical Service in England, 1774–1988, Maidenhead: Open University Press. Teplin LA, Pruett NS (1992) Police as streetcorner psychiatrist: managing the mentally ill. International Journal of Law and Psychiatry 15: 139–56. DOI: 10.1016/0160-2527(92)90010-X
Address correspondence to: Dr Jane Senior, Offender Health Research Network, Institute of Brain, Behaviour and Mental Health, 2.317, Jean McFarlane Building, The University of Manchester, M13 9PL, UK. Email: [email protected]
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
85
When two worlds collide: A twenty-first century approach to mental health and policing JANE SENIOR, HEATHER NOGA AND JENNY SHAW, Offender Health Research Network, University of Manchester, Manchester, UK How best to deal with people with mental health problems in contact with the criminal justice system (CJS) has been a thorn in the side of politicians, clinicians, police, prison staff and social commentators for centuries and across many jurisdictions. As early as 1784, John Howard described prisons as ‘crowded and offensive, because the rooms which were designed for prisoners are occupied by lunatics’ (p.10). In terms of healthcare services for this group, Sim (1990) noted the rise of medical power in prisons in England throughout the nineteenth and twentieth centuries whereby doctors claimed expertise in the treatment of ‘criminal lunatics’, administering a range of crude and often barbarous physical treatments designed to rid prisoners of the joint demons of mental illness and criminality. In the latter years of the twentieth century, the continued separation from mainstream National Health Service (NHS) provision of care for prisoners in England and Wales was tackled through the establishment of a formal partnership arrangement between Her Majesty’s Prison Service and the NHS. The core aims of the partnership were to raise standards of care, reduce the economic inefficiencies inherent in running a parallel, but generally perceived as inferior, health service, and reduce the health inequalities experienced by a socially excluded population (Her Majesty’s Prison Service and NHS Executive, 1999). Of course, for people with mental health disorders to be in prison, they must, by necessity, have had earlier contact with the police. Mental health services for detainees in police custody have, however, to date, been subject to less scrutiny and critical debate than those for prisoners. Healthcare provision in police custody suites in England and Wales traditionally consisted of cover by ‘forensic medical examiners’, commonly doctors in general practice/primary care with some specialist post registration training or experience. Forensic medical examiners deal primarily with physical injuries, determination of detainees’ fitness to detain or interview and assessments for detention under mental health legislation for those thought to be most floridly disturbed. Latterly, police services across England and Wales also commonly entered into contracts with private healthcare providers to ensure full-time or part-time nurse attendance within
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
82
Senior et al.
custody areas, again mainly tasked with physical healthcare and matters pertaining to ensuring fitness for participation in the criminal justice process. This largely process-driven provision was highlighted by Lord Bradley (2009), in his review of offenders with mental disorder, who recorded his surprise ‘that the police stage is currently the least developed in the offender pathway in terms of engagement with health and social services… (although) this point in the offender pathway provides the greatest opportunity to effect change’ (p. 34). As an important step to tackle this, Bradley recommended that the ‘NHS and police should explore the feasibility of transferring commissioning and budgetary responsibility for healthcare services in police custody suites to the NHS at the earliest opportunity’ (p.48), thus reiterating the crucial need for partnership working, which drove the policy regarding prison-based health care services exactly a decade earlier. So, what are both the challenges and opportunities inherent in addressing people’s healthcare needs whilst they are in police custody? And can police contact really be a means of effecting positive change, as posited by Bradley? In common with prisons, the core purpose of any police service is not to provide healthcare. The police exist to detect and investigate crime and aid the prosecution of suspected offenders. It is true, however, that dealing with people with healthcare needs, especially mental health and substance misuse needs, becomes central to policing, given the nature of the clientele, and that in many cases there are potentially lifelong implications for those with whom they come into contact. In the USA, Lamb et al. (2002) noted that ‘the police often fulfil the role of gatekeeper in deciding whether a person with mental illness…should enter the mental health system or criminal justice system. Criminalisation may result if this role is not performed adequately’ (p.1266). Similarly, and also in the USA, Teplin and Pruett (1992) described the police’s role as one of ‘streetcorner psychiatrist’, managing the ‘complex social process(es)’ inherently involved in the decision making around whether to arrest, hospitalise or informally deal with people suspected of mental disorder. These complex social processes are in play because, in spite of the legal structures within which the police operate, decisions around ‘madness’ and ‘badness’ are routinely based on individual officer discretion, influenced by levels of training, experience, professional cultures and personal attitudes. So, how can police officers be supported in this role? Our work with the police, in line with published research (Borum et al., 1998; Moore, 2010), shows that training in mental health issues is the key. Officers report receiving very limited training in mental health matters during their initial training, coupled with little or no opportunity to update or learn new skills once they are operational. It has also been highlighted that the current systems in place to support officers in identifying mental ill health may not be fit for purpose. McKinnon and Grubin (2012), for example, reported that routine screening procedures upon entry into custody in two police stations in London detected only 52% of
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
Mental health and police custody
detainees with a mental health problem and 48% of those with current suicidal ideation. These findings, supported by work in Australia (Ogloff et al., 2006; Baksheev et al., 2011), highlight the need for improved screening procedures, using standardised and validated tools, administered to all detainees, which unambiguously identify those who should be further assessed by a mental health clinician. Our research team has been developing such a tool (Senior et al., 2013), which we believe will assist in meeting a vision of police custody as an ideal opportunity for the early identification of mental disorder in socially excluded individuals who are often very difficult to engage in mainstream health services. Achievement of comprehensive screening of all detainees will, however, require fundamental service reconfiguration, at least in England and Wales, effective across multiple organisational boundaries. Currently, many police custody suites in England and Wales have access to criminal justice mental health liaison and diversion teams (CJMHL&D), which routinely operate during standard office hours on weekdays. Police contact with people with suspected mental health problems, however, does not conform to this neat pattern, and ‘out of hours’ cover is often provided through a complex matrix of non-CJS specific professionals and on-call services, which can be hard for police officers to penetrate. During office hours, CJMHL&D customarily rely on unproven methods of identifying those with possible mental health problems, including searching for detainees’ names in local NHS mental health service databases and/or responding to referrals from police officers based on concerns around an individual’s behaviour. Obviously, these methods offer a far from reliable or comprehensive approach to identification. The former approach can identify only the ‘known knowns’ and is wholly ineffective in identifying those in contact with services in other geographical areas, whilst the latter is heavily dependent on the training, experience and diligence of individual officers, at worst leaving the fate of detainees potentially within the hands of a ‘few good men’. The introduction of an efficient screening tool raises many issues for mental health providers and the police. Such a tool needs to be accompanied by appropriate, responsive and proactive clinical services working hand-in-hand with well-trained police officers to facilitate access to treatments which match people’s needs. Our experience of working with mental health clinicians operating within police and court settings has uncovered real anxieties around the workforce implications of introducing universal mental health screening for all detainees which, inevitably, would generate a much larger volume of referrals for detailed assessment than are currently received. CJMHL&D teams already feel overstretched, reporting that there are too few clinicians dealing with too much demand. This is not unique when considering the operation of mental health services within the CJS; data from a national study of the prison-based mental health in-reach teams in England and Wales found teams feeling overwhelmed by the size of the problem they faced, problems with staff recruitment and retention because of
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
83
84
Senior et al.
the nature of the work undertaken and issues around maintaining professional standards and fidelity to appropriate models of care (Shaw et al., 2009). We acknowledge the concerns of mental health professionals about the potential for universal screening to ‘open the flood gates’ of referrals and subsequent demand on community mental health services or in-patient beds. However, burying our heads in the sand and continuing with practices we know to be poorly targeting the population in need is no more acceptable in police-based mental health services than it is in any other NHS services. CJMHL&D services continue to suffer a legacy of being viewed as very separate from mainstream NHS provision, poorly linked with wider community-based mental health services and with unclear commissioning and reporting models (Sainsbury Centre for Mental Health, 2009; Senior et al., 2011). This is unacceptable in the modern NHS. Progress needs to be made to agree appropriate measures of success for liaison and diversion services, informed by the development of data recording and reporting mechanisms, which allow commissioners to understand their work fully, including the true size of the task they are undertaking. The introduction of universal mental health screening for all detainees in police custody is a good place to start. It needs, however, to be accompanied by willingness on the part of government, commissioners, clinicians at all levels of service and the police to tackle honestly, and with credibility and compassion, the issue of what should happen to people with mental disorder who find themselves in contact with the police.
References Baksheev GN, Ogloff J, Thomas S (2011) Identification of mental illness in police cells: a comparison of police processes, the brief jail mental health screen and the jail screening assessment tool. Psychology, Crime & Law 1–14. DOI: 10.1080/1068316x.2010.510118 Borum R, Williams Deane M, Steadman HJ, Morrissey J (1998) Police perspectives on responding to mentally ill people in crisis: perceptions of program effectiveness. Behavioral Sciences & the Law 16: 393–405. DOI: 10.1002/(sici)1099-0798(199823)16:43.0.co;2–4 Bradley K (2009) The Bradley Report: Lord Bradley’s Review of People with Mental Health Problems or Learning Disabilities in the Criminal Justice System. London: Department of Health. HM Prison Service and the NHS Executive (1999) The Future Organisation of Prison Health Care. London: Department of Health. Howard J (1784) The State of the Prisons in England and Wales (3rd ed.). Warrington & London: T. Cadell. Lamb RH, Weinberger LE, DeCuir WJ, Jr (2002) The police and mental health. Psychiatric Services 53: 1266–71. DOI: 10.1176/appi.ps.53.10.1266 McKinnon IG, Grubin D (2012) Health screening of people in police custody - evaluation of current police screening procedures in London, UK. The European Journal of Public Health 23(3): 399–405. DOI: 10.1093/eurpub/cks027 Moore R (2010) Current trends in policing and the mentally ill in Europe: a review of the literature. Police Practice and Research: An International Journal 11: 330–41. DOI: 10.1080/ 15614261003701756
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
Mental health and police custody
Ogloff J, Davis M, Rivers G, Ross S (2006) Identification of mental disorders in the criminal justice system. Centre for Forensic Behavioural Science, Monash University. Sainsbury Centre for Mental Health (2009) Diversion: A Better Way for Criminal Justice and Mental Health. Senior J, Lennox C, Noga H, Shaw J (2011) Liaison and Diversion Services: Current Practice and Future Directions. Manchester: Offender Health Research Network. Senior J, Noga H, Shaw J, Tighe S, Walsh E (2013) The development of a referral decision screening tool to allow the early identification of mental health problems in police custody. Final Report to the National Institute of Health Research. Shaw J, Senior J, Lowthian C, Foster K, Clayton R, Coxon N, King C, Hassan L (2009) A National Evaluation of Prison Mental Health In-Reach Services. Manchester: Offender Health Research Network, University of Manchester. Sim J (1990) Medical Power in Prisons: Prison Medical Service in England, 1774–1988, Maidenhead: Open University Press. Teplin LA, Pruett NS (1992) Police as streetcorner psychiatrist: managing the mentally ill. International Journal of Law and Psychiatry 15: 139–56. DOI: 10.1016/0160-2527(92)90010-X
Address correspondence to: Dr Jane Senior, Offender Health Research Network, Institute of Brain, Behaviour and Mental Health, 2.317, Jean McFarlane Building, The University of Manchester, M13 9PL, UK. Email: [email protected]
Copyright © 2013 John Wiley & Sons, Ltd.
24: 81–85 (2014) DOI: 10.1002/cbm
85
