Should the police be included in mental health crisis teams?
A spin-off from the practice of police officers wearing body cams is that the footage (in the UK) provides material for fly-on-the-wall documentaries about what day-to-day police work is like. One of the insights you learn from that TV coverage is how often the police are called to incidents where a significant part of what’s going on is explained by the mental health problems of one or more of the protagonists. And one part of that work is generated by people who repeatedly access the crisis services, either by calling 999 or by presenting their distress outside the home to others who then call the emergency services.
It is widely accepted that responses to this phenomenon of frequent crisis contact are not always effective. One recent development has been the emergence of the High Intensity Network of teams delivering what is known by the (frankly silly) name of Serenity Integrated Mentoring. These teams include both mental healthcare staff and police officers, share information and decided on a plan aimed at reducing this so-called high intensity service use. That plan can include the possibility of formal action by the police, including the use of community behaviour orders or prosecution. I have recently become aware of this scheme and of some of the concerns being raised by patients who have experience of it and by service user activists. I had been alerted to it by a friend who is a service user and activist, and from my reading of social media posts by those people seeking an investigation and curtailing of this activity. I have come to the conclusion that there are indeed some important concerns being raised: this is not just a Twitter storm in a teacup. I will outline what I take to be the main issues.
First there is the practice of sharing confidential clinical information with police officers. This has been justified by an appeal to the idea that people are only included in the scheme in an emergency, and that sharing is therefore in their best interests.
Here for example is a Tweet from the Network’s director. It is clear however that this idea of data sharing as high-threshold urgent action is being stretched to justify routine sharing of clinical information on all patients managed by the team. To quote the Network’s own description of the people under consideration “They are constantly an emergency case, just fluctuating at different levels of intensity, causing varying levels of impact. Our strong argument therefore is that all agencies involved in the network can share personal data and clinical data about these service users at any time, both in a preventative capacity when they are not using emergency services and in a reactive capacity when they are.”
Second, there is a question about informed consent from patients in the scheme, who must by definition have mental capacity. There is much made in HIN/SIM documents of the need for consent, and it is said that lack of consent (telling described as “refusal to engage with mentors”) must be respected.
Here is a slide from a talk given about SIM by a team member. The nature of consent in this situation is highly problematic, since it is clear that in these integrated teams the prospect of coercion remains an active option for those who engage in what the team consider undesirable behaviour and yet who “fail to engage”.
The SIM operational delivery guide confirms this overlap of processes, with clinical staff able to contribute to the discussions about police responses to antisocial or illegal behaviour and police able to contribute to discussions about clinical risk management.
Some of the vocabulary used in HIN/SIM documents is not reassuring when seen from a service user perspective. For example stating that “The project team will be dealing with service users with often high risk, malicious and litigious behaviours.” and suggesting (as in this Tweet from the director) that patients do not have the right to share and discuss their care plan with people of their choosing. The FAQ section of the HIN/SIM website notes “Our teams operate multi-agency panels each month to assess which patients should have their consent removed…”
This approach, implying a seamless move from therapeutic responses to coercive responses, is one of the commonest complaints evident in online discussion of the scheme. Because police involvement is evident in all aspects of the process then consent to participate can hardly be given without a sense of duress.
Third, there is a question about evaluation of the scheme and especially assessment of harms. A startling number of benefits are claimed for the mentoring scheme – based it has to be said on minimal evidence: in truth there has not been a substantial independent research evaluation at all, which is surprising considering how enthusiastically the scheme has been promoted. By contrast to the claimed benefits, there is no discussion of potential patient harms such as those that might be caused for example by people avoiding seeking help in a crisis or actively being prevented from doing so. Any deaths that might occur are described as accidental, including those attributed to (a new term to me) accidental suicide.
It is hard to collect citable evidence on such outcomes from informal reading because so few people are willing to come forward in an identifiable way, but I have seen them reported by reliable sources and there is no reason to doubt that they happen, even if nobody is trying to quantify them.
Complaints are likely to be interpreted in particular ways “Making complaints against staff can often be a way in which service users (at times of stress) attempt to avoid consequences or responsibility. They can also be used in an attempt to distance themselves from the staff who are supervising them so that they do not have to continue with the programme.” And staff who have to respond to what are called allegations are invited first to watch a video prepared by HIN. “The video informs the investigators about the nature of high intensity cases and the behavioural disorders commonly found in these cases. It also explains the motivations for making false allegations and common behaviours that may be witnessed after the allegation has been made.”
In summary: the approach represented by the High Intensity Network has apparently been adopted by more than half the Mental Health Trusts in the country, despite lack of robust evidence for its effectiveness or harms. Reasonable concerns have been raised about the approach to information governance and the sharing of confidential information and about the blurring of boundaries between therapeutic (health services) responses and coercive (police service) responses.
Much of the promotion of this particular scheme has been individualised around the person of Paul Jennings, a policeman who started the SIM programme in the Isle of Wight and now directs the High Intensity Network. Jennings has a rather idiosyncratic take on the issues which no doubt influences the tone of debate: he talks about mental health problems in prisons as if they are relevant to this different context, and his rationale for SIM as a response to what he calls behavioural illness is a mixture of naïve behaviourism and a sort of paternalistic encouragement to people to give up bad habits. Nonetheless, there is more to be questioned here than can be put down to one person’s influence. The problems outlined about confidentiality, consent and coercion are inherent to any scheme in which health care staff and police staff are fully integrated into a single team. There is a serious question about whether the Royal College of Psychiatrists should be supporting such developments at all. It is a worry that so many psychiatrists are likely to be involved either directly or tangentially in this way of working, without these issues being resolved. There are other ways to develop productive working relations with the police and the other agencies involved with crisis care.
Acknowledgments: There is an impressive social media presence on this topic. As a start try searching Twitter using #HighIntensityNetwork or #Stop Sim. It is activist and service user-led work that has brought the problems to the fore – critical discussion led by mental health professionals has been bordering on non-existent. The quotes in this piece come from: HIN/SIN Operational Delivery Guide (SIM London version, March 2018); SIM Business Case and SIM FAQs (from HIN website www.highintensitynetwork.org)