30 December 2012 
We’re just in the process of collecting the Wildcard votes in the TWIM Awards. Rather aptly, several of this week’s blogs featured in TWIM are award nominees, including Mental Health Cop, Chaos and Control and You Don’t Look Jewish. Tune in on New Year’s Day when we’ll be revealing the winners.
This TWIM includes possible triggers for restraint.
A topic that’s been rumbling through the blogotweetowebs this week has been the use by police of tasers on people with mental health problems. I work very much at the “nicey-nicey” end of mental health nursing, doing psychological therapies in a community clinic. I don’t restrain anyone. However, there are unfortunately times when mental health nurses are called upon to restrain people who are presenting a risk to themselves or others. It’s an uncomfortable topic, and in fact I think it’s something that every restraint-trained nurse should feel uncomfortable about, and it should only be done when absolutely necessary. Even so, there are sadly times when it is necessary.
There’s all sorts of debates about how to restrain people in the safest and least distressing way. In Britain, nurses tend to react with horror to the idea of mechanical restraints, the modern day equivalent of the old strait-jackets. They’re seen as a cruel and archaic throwback to the asylums of yesteryear. By contrast American and European nurses argue that a well-designed mechanical restraint can be safer and more comfortable for both patient and staff than being held down by five nurses. European nurses in particular tend to be appalled by the British use of rapid tranquilisation (an intramuscular injection of medications such as lorazepam or haloperidol). They see this as shockingly invasive. Brits then respond by pointing out that by not using rapid tranquilisation, European nurses often wind up restraining people for a longer period of time. And so the debate rumbles on…
When the police become involved, perhaps because a situation in a mental health unit has escalated beyond the capacity of the nurses to deal with it, or because they’ve come across somebody in crisis in a public place, then a whole arsenal comes into the equation. Batons, handcuffs, CS sprays and, as I mentioned before, tasers.
Paul Jenkins of Rethink has condemned their use.
“If someone is clearly in great mental distress, having a Taser gun used on them will seriously exacerbate their condition. People who take antipsychotic medication may also be vulnerable to suffering a fatal injury if Tasered, as some medications greatly weaken the heart.
“If police are called out to a situation where someone has threatened to self-harm, there are other steps they can take without needing to resort to extreme force.
“Firstly, it is extremely important to try to talk to the person who is in distress, and police should consider bringing a properly trained crisis negotiator to help with this.
“They should also call an ambulance and speak to a mental health crisis team, who are better placed to act in a mental health crisis and who will be able to provide crucial advice and support in this situation.”
Vicki Nash from Mind raised concerns about tasers.
“Tasers are extreme and controversial weapons that we believe should only be used as a last resort by police.
“Tasers can cause extreme distress so to use them on people who are experiencing a mental health crisis, and already displaying signs of distress, can make things even more traumatic.
“We urge police to ensure they are equipped with the tools they need to make difficult decisions quickly. A better understanding of mental health problems would allow police to recognise those experiencing a mental health crisis, and de-escalate a situation before resorting to weapons such as tasers.
“There is no substitute for comprehensive mental health training.”
Commenting on the controversy via Twitter was Sophie Khan, a solicitor who specialises in suing the police. Unfortunately her responses suggested a rather poor understanding of mental health issues.
I would have debated further with Ms Khan, but couldn’t do so as within seconds of making the above tweet I discovered she’d blocked me on Twitter, along with just about everybody else who’d responded. Charming.
Mental Health Cop has provided a response to Mr Jenkins and Ms Nash, giving a dissenting view. He questions the practicality of some of Mr Jenkins’ suggestions.
Firstly, in the continuum of force available to the police, Taser is never going to be the last resort, although usually close to it. Earlier this month, my team took a 999 call from the Ambulance Service regarding a mental health service user and the very first thing I did was instruct taser officers and a sergeant to the scene. Why? Because 999 services frequently deal with this particular man and he has a long and predictable history of getting drunk whilst ill, self-harming and then attacking paramedics and police officers with razor blades. Sending taser officers does not mean they will even use that equipment, but it gives them the option, if required. Officers who have known him for years will say that attending to him with a tazer drawn has reduced the instances of him attempting to hurt people, paramedics won’t go near him without police support anyway and here’s the key: he has never actually been tasered. Officers have fixed an aim on him – known as being ‘red-dotted’ – but they have never needed to discharge the equipment. This is an example of taser being ‘used’, despite not being fully utilized.
Secondly, hostage negotiators are fine ideas. I personally have never, ever known a situation last long enough for them to arrive although I know of plenty of incidents where they have been invaluable and have patiently negotiated difficult situations to a conclusion. In my experience, some front-line cop has always managed to “talk them down” or bring about a resolution first.
Thirdly, whilst calling ambulances and mental health crisis teams are noble notions, there is a practical reality that makes police officers read such ideas and – I’m afraid to put it so bluntly – laugh out loud at the thought of it. As a police officer put it recently “We can’t get the ambulance service to heart attacks and car crashes, never mind mental health jobs.” Mental health crisis teams are a step further, like throwing the meta-physical “seven”.
He concludes,
No one thinks tasering ‘the vulnerable’ is inherently good, but just every now and then – very, very rarely – it may be the least worst thing to do with officers facing risks that could kill them or inflict life-altering injuries. I say this in knowledge that using taser may well exacerbate someone’s condition but repeat the point that by the time the police are crisis managing risk situations where people are self-harming, non-communicative and posing a risk to themselves or others, it might – just might – be the the least worst option available.
Also giving a police viewpoint is Nathan Constable, who points out that just as tasers carry risks, so too do other forms of intervention. He gives an example of how a taser was used to successfully resolve a crisis.
The only option which was most likely to cause an IMMEDIATE deescalation of the situation and cause her to drop the knife with minimal injury was:
TASER
This is what happened. It was immediately effective. The effects lasted seconds but it caused her to drop the knife, drop to the floor and allowed me and colleagues to step forward and restrain her in handcuffs.
No rolling round on the floor struggling. No prolonged restraint bringing the risks of positional asphyxia or cardiac arrest. No injury to her or us.
I took no enjoyment from that scenario but what other viable options existed?
What Mr Jenkins is suggesting is that when faced with a suicidal self harmer the only option is to keep talking to them. Even the most highly trained mental health practitioner runs out of talking after a while.
I suspect this is a debate that will carry on for some time, as there are no easy answers.
Given that we’ve been talking about people with mental illnesses acting aggressively, I think it’s important to have a sense of proportion about these things. Which makes it rather timely that the Madosphere’s favourite data hound Neuroskeptic has reported on a study into the relationship between mental illness and crime.
Overall this confirms that the great majority of crimes, including violent ones, are not committed by people with mental illness, and that your chance of getting ‘murdered by a lunatic’ is incredibly low. This strikes me as the only statistic that matters to most people.
There’s a long-standing debate over whether people with various disorders are more likely to commit crimes than they would be if they didn’t have one, the relative risk. While interesting, this is a purely academic question. What the rest of us need to know is the absolute risk, and this is low.
Chaos and Control reflects back on a saga from a year ago, when she was prevented from writing her blog while a psychiatric inpatient.
What I experienced was not physical abuse, I would recommend checking out@Sectioned_ on twitter and their blog for more thoughts on that. Instead, I would suggest the way I was treated was ?misinformed ?misguided.. no, none of those words work. Well, the way I was treated was wrong. In April I met up with the Ward Manager and received an apology from Oxford Health Trust regarding their actions. I am glad that there has been recognition and acknowledgement that asking me to stop blogging while I was an inpatient was not the best course of action.
On multiple occasions (via twitter, in person and on the phone) I have offered to help Oxford Health write a policy surrounding the use of social media on inpatient wards. I am saddened that, as yet, they have not taken me up on this offer. In addition, the last time I checked in with the trust (via twitter), they had not written the policy. This seems like such a wasted opportunity to me. Social media is not going to go away.
You Don’t Look Jewish (who has just renamed her blog to Sharks in the Deep End) has created a Sims Mental Health Unit.
As we approach the unit, it becomes obvious that no expense has been spared on fancy doors and big windows, these have been shown, through an evidence base to not only improve patient care (just don’t ask to see the evidence), but also increases mental health within the community by creating employment for otherwise idle glaziers – this is what makes this unit a true community-enhancing venture™ - I shall invoice the Simlish NHS Foundation Trust accordingly…
A large waiting room for visitors is provided, with a giant bulletin board full of exciting research projects to choose from and there’s even some magazines lying around, though I suspect not for much longer as no doubt they are an infection control hazard… The tissues are still around after the whole zombie-flu epidemic, which would have caused the end of the world had it not been for anti-bacterial-alcol-gel and kleenex (which the Mayan’s hadn’t predicted)… But having provided all the necessary equipment to delay if not prevent the apocalypse I shall invoice the Simlish NHS Foundation Trust accordingly…
This week’s wildcard was suggested to me by Chaos and Control, who pointed out a lovely selection of knitted Star Wars characters.
You know, I cant say anything about any situation other than the ones Ive experienced myself, but both times I was brought into the ER for mental health reasons, everyone that was supposed to be there to help, seemed to think of it as more of an opportunity to abuse someone when they were vulnerable. I received extremely poor treatment from almost everyone involved. On this subject though, I did refuse to leave with the paramedics, but I in no way became violent. I basically became a ragdoll, just dead weight, as to make it as hard as I could for them to carry me out but during this process the cop that was there threatened to tase me because I wasnt being cooperative. I dont know what to say about if a taser should be used if someone has become violent, but I do think that because theyre aloud to be used, some police will take advantage of that situation.
Yes, that does sound like an inappropriate use of a taser, regardless of what one thinks of its use when dealing with violent situations.
One thing that’s struck from the times I’ve read Mental Health Cop’s blog is that it never occurred to me just how much mental health issues are dealt with by the police, which shows the need for police officers to have understanding of mental health. Fortunately MHC is doing some good work in that direction.
i found myself in the position where the police used cs gas on me, i was at home and self-harming, they broke the door down and sprayed the gas to make me drop my knife. it was very unpleasant but i dont feel any other forms of restraint were used nor was it a last resort, they just came in asked me to drop the knife, i was on my chair and i just looked up at about 4 policemen in riot gear coming towards me and one sprayed his gas, they flung me to the ground and hit me constantly then dragged me out into the communal hall by my shoulders. I also had an incident where i was so uncooperative they used 3 different meds injected into my rear to sedate me (im a heavy girl so small doses prob wouldnt have worked). im pleased to say iv not had any other instances in the past 2 years or so where i have had to be restrained.