So, we’re still discussing the fallout of Sir Tom Winsor’s comments almost one week after they were made. A few of us have blogged our thoughts on this and many of you have commented on those posts and social medica more generally. We all share a view that there is a problem, but I’m not sure we share what it is, never mind a shared sense of what we should do about it. Some people have spent the week arguing that we are criminalising mental health and mental illness by relying upon the police to the extent that we do, but what I think has been interesting this week is the number of representations that we’ve got this the wrong way ’round: we’re not criminalising illness, we’re medicalising human behaviours.
Look at the literature on this stuff and you’ll see both positions well represented. The US academic Professor Linda Teplin did a lot of work in the 90s arguing about criminalisation; another US professor, Allan Horwitz wrote a book called ‘creating mental illness’ which argued we over-medicalise behaviour. Australian academic Deidre Grieg devoted a whole book to the discussion of one man and his journey through the mental health–criminal justice interface: Garry David from Melbourne ended up having a whole Act of Parliament targeted at him and him alone, given that politicians were unable reconcile the public safety issues that arose from their perception that neither system was able to keep citizens safe from obvious risks. Less academically, we see a public narrative about the relationship between mental health and crime that seems all too often to assume that if someone with a mental health problem has offended, they must have offended because they have a mental health problem.
Then we need to remember we’re not always discussing things fully: acuity of someone’s condition is rarely discussed – not everyone who is mentally ill is psychotic and unable to lead a full and meaningful life full of employment, family and personal responsibility. But a few are. When you compare a range of issues for those who are often unable to function because of serious mental illness you see differences in approach by mental health services and by the police and prisons, compared to where we see the police called to a person with a non-acute illness that neither affects their personal responsibility for actions undertaken or means they should necessarily be treated any differently by the police.
This word is used in a couple of different ways, so as ever, we need to be careful with this kind of terminology – apart from anything else, some people just don’t like it. I’ve been told to remove this word from reports I’ve written on a couple of occasions, because it’s a bit opaque unless you spend time explaining it. Do we mean a) whether a person’s attempts to secure care occured via the police or criminal justice system when they were prevented from just accessing it directly? Or do we mean b) the extent to which the police and criminal justice agencies take different types of decisions when in contact with someone who is thought to have a mental health condition than they otherwise would – and of course this could be to a greater or to a lesser extent than they otherwise would.
It’s certainly true to argue that we have some set-ups which now mean patients and mental health professionals think it’s easier to access care via the police than otherwise. Street Triage schemes have often reported that they feel other parts of the health system, from GPs to Community and Crisis Teams, are occasionally pushing demand towards the police for someone who is not what you might think of as someone needing policing services. This ‘normalises’ the involvement of the police in healthcare, about which many patients have things to say, if you ask them! It’s also true to argue
However, if you have a situation in which 100 people are alleged to have committed an offence, you’ll see the range of responses from the police from arrest, to warnings to cautions or criminal charges, as thought appropriate. However, if those situations involved individuals suspected to be mentally ill, we are less likely to see arrest and / or prosecution outcomes because of diversion or referral to health services. Does this mean we ARE criminalising illness because care access was via the police or NOT criminalising because the officers took punitive CJ decisions less often? Depends on your politics (small p).
The other perspective is to look at whether we’re medicalising behaviour. I will admit, I’m less aware of any research that has been done on this issue so if anyone reading this knows of any, please leave a comment below and let me know. But yet again, this could mean one of a few things. Are we a) providing a non-CJ services response to someone who has a mental health issue (of whatever kind or severity) because they have offended in the hope that by addressing unmet mental health and social care need, we can correct the propensity to offend? Or are we b) assuming a causal relationship between someone’s condition and their behaviour, thus again thinking that if you address the underlying condition, you affect future behaviour – there is some evidence that this is true, however, but not for all types of mental health condition, all of the time. But finally, are we c) encouraging police officers to think of the mental health system as the appropriate response or seeing police officers over-assuming that behaviour can be affected by ‘intervention’ of whatever kind.
Human beings will suffer very bad events in their lives which are entirely predictable and awful: bereavement is one that will affect most of us at some stage. Other people suffer from traumatic accidents and injuries, redundancy, abuse or divorce to list just some examples. All of us will struggle to some degree to cope with such matters when they happen, but this does not automatically mean they ill. A few of us may need additional, sometimes professional support to handle our live experiences and some may become ill, usually for more than one reason as people are complicated things. But the difficult issue is where you draw the line between looking at someone’s behaviour and choosing whether to see it as ‘crime’ or ‘illness’. Indeed, there may be a need to see it simultaneously as both: the dichotomy between ‘mad’ and ‘bad’ is false one, both medically AND criminally! But however interesting this is, however philosophical you want to get about it and however much academics have written, if you’re a front line police officer and you’re going to have 43 seconds to take a decision as profound as this, we may have to accept here people are going to get it ‘wrong’ from at least some people’s subjective perspective.
THE 9 AM JURY
It’s quite easy to walk in as the morning hindsight squad and have a view about what some frontline cop should have done last night, in the dark, but always fascinating when you ask people to put themselves in the officers position. What the reaction this week has shown me, categorically and beyond doubt, is that there are a wide range of passionately held, solid views that officers are over-medicalising behaviour AND that they are over-criminalising the vulnerable; AND they are making these calls in situations most of us aren’t prepared to place ourselves. The person in the high street who is waving a knife around, you have a minute to think about it: should they be arrested for possession of the knife or detained under the Mental Health Act. No, you can’t have any more information, you have to decide and you have thirty seconds left. Have you decided yet? … not easy, is it?!
In other words, this touches upon my very favourite question in all of policing and mental health and the very thing that could be profoundly interested in this stuff when I was custody sergeant fifteen years ago: when is it “right” to prosecute someone for a criminal offence if we know they have a mental health problem? The public policy answer (in Home Office circulars 66/90 and 12/95 as well as the DPP’s Code for Crown Prosecutors) is “the more serious the offence, the less relevant a person’s mental health issues are to the police / CPS decision to prosecute.” This is my attempt to summarise pages and pages of stuff in to one sentence, so please forgive the deliberate over-simplification! Where someone is stealing food whilst psychotically unwell and living rough in crisis, we probably don’t want them prosecuted for being hungry and very poorly. However, if they stabbed a supermarket security guard whilst doing so, it becomes a different assessment to make. If that assessment were influenced by a history of non-engagement with mental health services, absconding from hospital and / or a background which showed they posed a serious risk to the public as a whole, it becomes easier still to start taking these decisions. But make that a less serious but non-trivial offence, mix in social distress and substance use? How easy is it now?! … you have thirty seconds to decide.
Remember, only the criminal courts can issue certain kinds of protective orders under our mental health legislation which balance an individual’s right to treatment with the need to protect the public, where necessary – that’s true in most jurisdictions around the world. But given how far apart the views were this week – we need decide what we want our police to do and back them because whatever they get right or wrong, I know this: frontline officers only have blunt tools to take decisions that require sophistication and finesse. Have you ever tried playing a musical instrument gloves?
Winner of the President’s Medal from
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award.