On Monday 11th December 2017 new changes to the Mental Health Act come into play with regards to Section 136. This blog post is not about that – I am not a trained professional, and there are far better explanations of it already available than I could ever give. I very much recommend the Mental Health Cop blog for full explanations and guides to s.136 law (nd pretty much anything else you need to know about policing and mental health law!) For an example, see https://mentalhealthcop.wordpress.com/2017/03/03/the-new-section-136/.
For those who are unaware of Section 136, this section of the Mental Health Act gives a police officer the power to detain somebody and take them to a place of safety if they are found in a public place and believed to be suffering from a mental disorder and in need of immediate care and control.
There are significant issues with the s.136 process, and more generally, media and police attention has focused particularly on the resources taken up by mental health incidents for the emergency services. From a police perspective, if an officer is required to sit for many hours in a waiting room, A&E department or private place until mental health care can be put in place, this takes officers away from the street and from responding to other emergencies. From an individual perspective, to be in crisis and faced with police officers can be incredibly traumatic. However, the duty of the police to protect life means that there will always be times when police become involved in responding to mental health emergencies.
That could be the subject of a whole different blog post. But with that in mind, these are some thoughts on the most helpful (and unhelpful) things you can do when responding to a person in a serious mental health crisis. Whilst some of these points relate specifically to police responses, I hope other points may be useful also to paramedics and/or other professionals who come across mental health emergencies.
As a disclaimer: I am using the terms ‘You’ and ‘I’ generally in this post. All situations and individuals will of course vary, and what is appropriate and helpful for one person or in one situation of course may not be feasible or helpful in another.
- When you (police or paramedics) arrive at a situation with an individual in crisis, please introduce yourself. Whilst this may not be practical if you are thrown into a dificult situation, if you can calmly introduce yourself, this can help to build a rapport. An obvious one, but one that is commonly forgotten! It is very hard to trust somebody and begin to open up to them when you don’t even know their first name.
- In crisis it can be very difficult to take in what is being said. Think about when you are trying to concentrate and somebody keeps interrupting you and talking to you. Sometimes all I can hear or focus on is the need to get away or to hurt myself. I may need to be told the same thing multiple times. This may be frustrating or ‘boring’ for you, but please keep telling me. It helps to take things in if I keep hearing it.
We’re here to help
- ‘You’re not in any trouble, I’m here to help you.’ Even if you are with an individual who has been detained before, emergency service (and especially police) involvement is terrifying. I am frightened of you, I am scared out of my mind of being in trouble, I don’t trust you, I am terrified that you think I am attention-seeking or wasting your time. Reassurance helps.
- Remind me that I am not well. This may seem very obvious, especially if someone is diagnosed with a mental health problem, if you ‘know’ somebody regularly, or if somebody is clearly distressed. But in crisis, we can lose insight. I can plan my suicide in detail, prepare the most distressing aspects of this with absolute calm, be absolutely certain of the decision to do this, and talking ‘rationally’ and matter-of-factly about this, but lack the insight to see that it is my severe depression that is making me see this as the ‘right’ decision, and not something that I would do if I were truly well. I can genuinely believe that I do not need or deserve to eat, despite being totally aware that all humans require nutrition. I can genuinely believe that my selfharm needs no treatment and that it is just a scratch, despite it being plainly obvious that it requires medical care. I can be genuinely confused about what is going on in my head. Please keep reminding me that this is my illness taking, that I am feeling the way I do at times because I am unwell, and that I need some help and treatment to get well again.
- Keep reminding me that you are here to help. A big, big fear in mental health is often the fear of taking up time, being a burden, being seen as attention-seeking or time-wasting. Reassuring me that you are here to help helps me to accept that and trust that you are doing what is best for me.
Self-harm and suicidal thoughts
- Self-harm, suicidal feelings and suicidal attempts are generally not attention-seeking or ‘cries for help’.
- The term ‘cry for help’ often has negative connotations. Asking for help is not a bad thing – although there are more or less helpful ways to do so – and if somebody is telling you that they want to hurt themselves or that they want to die, they are almost certainly desperate for help to stop feeling the way they are feeling.
- Even for those cases which are ‘attention-seeking’, serious help is still needed if someone is turning to harming themselves.
- ‘Attention-seeking’ is not in itself necessarily a bad thing. We all, when we communicate with people, wish for a response. If you spoke to somebody and they blanked you, how would you feel? For some, self-harm is a form of communication. We all desire human contact and interaction. We all need support at times. Whilst some people are able to communicate effectively with words, others – for various reasons – may not be able to do so, and may communicate their distress in other ways.
- For many, self-harm and suicidal thoughts are deeply private and shameful. To reach out and tell somebody that you feel like you want to die is a very vulnerable position, and to be put down to ‘not really serious’ or a ‘cry for help’ is extremely invalidating of very distressing thoughts.
- Labelling self-harm or suicidal attempts as ‘attention-seeking’ or ‘cries for help’ can seriously increase the risk of stigma with mental health problems. I have come across people who have been refused treatment or pain relief in A&E, on the basis that they ‘must enjoy the pain anyway’ or that it will ‘reinforce’ the behaviour. I have been told by a nurse in a s.136 suite that self-harm is an ‘attention-seeking teenage behaviour that most people grow out of’. There are no words for how unacceptable this is. Just as smokers are still given medical treatment for smoking-related illnesses, just as drivers who don’t wear seatbelts are treated after car crashes, just as somebody who chooses to participate in a sport and receives a sporting injury deserves care and treatment, those who injure themselves as a result of a mental health problem deserve the same care, empathy and treatment as anyone else. None of us can judge for that: We never know what has brought a person to that point. Some will have been sexually abused. Others may have been bullied to the point of feeling absolutely worthless. Others will have suffered devastating bereavements, experienced other severe traumas, or simply have a severe illness which impacts their daily life and thoughts.
What not to say
- Please do not ever tell somebody that ‘If you really wanted to die, you’d have done it’ or that ‘It’s your decision, we can’t stop you if you really want to do it.’ This is about as close as you can get to telling somebody to ‘do it properly’ next time. It is absolutely not the case that you don’t really want to die if you don’t take that final step, or if you reach out for help, just as it is not true that ‘Truly suicidal people don’t talk about it.’ I have wanted to die to the point of researching it, preparing amounts, Google-searching experiences to find out what it will feel like, looking up train timetables in order to work out the most ‘convenient’ time in order to inconvenience as few people as possible, written letters and lists of Direct Debits to cancel, planned how to make things easier for my family. And yet I try everything I can to stop myself, to reach out and beg for help to stop the thoughts. This doesn’t mean I don’t want to die. It means I am taking every step to help myself not want to die. It’s a sign that I am desperately holding on through immense pain because I love my family to pieces. It takes everything in me to fight sometimes. Please don’t say things that make it sound like I am exaggerating or overreacting by asking for help or keeping myself alive. Tell me it’s a positive thing. Tell me there is a part of me still fighting, and that that is a sign that there is hope, that I can get through this.
- Despite having severe mental health problems and having experienced suicidal thoughts for a very long time, I am often a believer that ‘suicide is selfish’ (for myself). The majority of suicidal people are not planning to end their lives to hurt anyone else, and many will have thought long and hard about other people, truly believing that other people would be better off without them, that they would be taking the ‘burden’ off people, stopping people worrying, or that people would be ok. Suicide may seem objectively ‘selfish’, but to a person in that state of mind, it is genuinely seen as the ‘right’ or ‘only’ thing to do. Please do not try to make me feel guilty about the effects on people. Having said that, talking about the impacts on others – on family and friends, and on the individuals such as train drivers, the divers who would have the job of recovering my body if I were to use water, and the police or ambulance staff who are called out to deal with this – can be a very effective way of halting the intention to act on these immediate urges, enough to listen to you and accept your help. But please understand that, however much I try and think it through and however much I can prevent myself from acting on these urges, having those thoughts in itself is extremely distressing and frightening and requires urgent support. As one officer told me ‘You shouldn’t have to be having these thoughts in the first place though. You’ve obviously planned it all out in detail, but it’s very sad that you’ve got it all thought out so thoroughly.’
- If I attempt to harm myself or run and you have to restrain me, please do not tell me to: ‘Stop being silly’, ‘Stop messing around’, ‘Don’t start that’. It may be a general, common phrase, but it can be incredibly frustrating and incredibly patronising. If it seems ridiculous or annoying to you that I am attempting to run or harm myself in a situation where it clearly won’t work, well…it probably is ridiculous, rationally. The well, rational, healthy me would never consider it. The fact that I am still attempting it is a sign of how irrational and out of control things are in my head. I am not doing this to be ‘silly’ or cause problems for you. I am struggling because I am terrified and everything in my head is telling me I need to get away or that I need to harm myself.
What it can help to say
- Ask directly if the person is having thoughts of suicide or self-harm. It will not ‘put ideas in their head’. Keep asking that where appropriate. If you ask directly, or if you can encourage an individual to tell you the thoughts they are having before they act on it, the situation may be de-escalated at an earlier point
- Talk about ‘normal’ things. These are the things that can important in life, and sometimes it is hard to remember them when I have reached crisis point. This doesn’t have to be anything particular. In the past, officers have had success in building a rapport with me by talking about football, kickboxing, fidget toys. As well as helping me to relax, this helps me see that you are just a human, and that you can see me as a ‘normal’ person too.
- Remind me of any rapport we have built. One officer told me when I tried to hurt myself: ‘Come on, we’ve build up a rapport now. I thought you trusted me – and I’m giving you trust in return’ This supported me to trust him again, to listen to what he was telling me and let him have control of that situation. Use that rapport as much as possible: If possible, so that an officer who has built up a rapport can accompany the individual in an ambulance, sit beside them or explain decisions, for example.
- Where appropriate, self-disclosure can be really beneficial. A lot of people suffer from mental health problems at some point, and it is so reassuring to know that people can get through these and find something they love in life.
- Please help me to try and see that I am not a bad person, that I am not worthless and that I am not wasting your time. I am struggling and I am ill, but I need help.
- If you have found me in a public place, where appropriate please try to take me somewhere quieter. It has been my experience that many members of the public will slow down or stop to watch what is going on in a public place, and being watched like this only adds to my distress.
- I am aware that in recent years there has been common agreement that ambulances should be used to transport detained mental health patients, rather than police vehicles. Whilst this may often be more helpful and appropriate (and the only option in some circumstances), please know that in that situation, any vehicle is upsetting. In many instances it would be preferable compared to waiting for an hour for an ambulance, when we could have arrived at a PoS earlier within that time.
- If appropriate, it can help to have something to do with your hands. For me, this is a bouncy ball, a tangle, and a fidget cube. I am calmer when I have something in my hand to hold and to focus on. After being detained by BTP, I was restraned by two officers when I tried to harm myself. An officer placed a bouncy ball in each of my hands and told me to squeeze, to focus on holding on. It meant I couldn’t harm myself, and it relaxed me enough that they were able to stop restraining me.
- If you have to handcuff me, please reassure me. I feel unsafe if my hands aren’t free. I understand why you have to do it, and handcuffs are not designed to be pleasant for anyone, but please try to give me trust if appropriate. I personally find it more helpful for someone to actually hold onto my hands/arm (again, where appropriate), rather than handcuffing me. Please remember that anything can become a method of self-harm when distressed, and that it is possible to take handcuffs off yourself!
- When you have to search me, please reassure me. It is not pleasant for anyone, but for some being searched can be incredibly traumatic and distressing, particularly being touched in certain ways with no control. Tell me what you are doing. Tell me that I’m doing well. Tell me that you’re nearly finished. Tell me I’m safe, that it’s ok. The most helpful circumstance I had was an occasion where, whilst a female officer searched me, a second officer held my hands and let me squeeze his hand, kept me looking at him, listening to his voice and helping me to breathe slowly, telling me that I was safe.
- ‘Try and calm down, take a deep breath.’ If panicking or very distressed, focusing on breathing with you but help somebody to calm down. Keep repeating short, brief, direct statements like in in a calm, reassuring tone.
- One of the most helpful things I have heard from an officer is ‘I’m not going to let you hurt yourself. I’m not going to let you do this.’ The way he said this, calmly, caring but firm and direct, was the best thing anybody could have said. It allowed my head to let him take over the responsibility for me temporarily, to keep holding me to keep me safe until I was able to do so myself again, and to know, when things were so desperate in my head, that he was in control of that situation.
- ‘Focus on my voice’. The other most helpful thing anybody can say to me in crisis. Four very simple words, but in mental health crisis you can be totally consumed by disordered thoughts. The sound of a calm, firm, direct voice can help me to feel safe and grounded, and to listen to your voice and what you are saying. I find this especially helpful if I am actively trying to hurt myself, if I am being restrained or searched, and if I am very low or very consumed by disordered anorexic thoughts.
- Try to give me options where appropriate, and try to guide me towards making the ‘best’ choice. Where possible, ‘having a voice’ to release my thoughts or to have some control in what happens next can be a huge benefit. Help me to focus on the positives, and to take control back from my head and my illness.
- However, please also be aware that at times I am so consumed by my illness that I cannot make a decision. At times, I need you to take control away from me and make the best decision, even if I can’t see it at the time.
- Be honest with me about what is going on. Being transparent with me helps me to trust you far more than if you don’t tell me what you are going to do.
- Help me to communicate with other services if appropriate. The first time I ever had contact with police, they helped put me in touch with a crisis team over the phone. I struggle very much with speaking to people, so an officer put the phone on speakerphone, sat on the floor with me, and as I whispered answers to the questions the Crisis Team asked, he sat and spoke every word out loud for me in order to allow the Crisis Team to hear. Without his help, I would not have been able to get across what was going on in my head to the CT.
- Consider your body language. I may have mental health problems, but I am also perfectly capable of reading obvious body language which shows that someone doesn’t want to be dealing with me, can’t be bothered, thinks I am being ridiculous, stupid or annoying, or doesn’t want to be spending time dealing with this. Use responsive body language. Be open with me, calm, and reassuring. Keep eye contact with me – encourage me to make eye contact with you if this seems appropriate. Use positive body language – nod and reflect back words to show that you understand.
- Take time to listen to me, understand me, to build up trust and show me that you will try to help. And if you say you will do something, please, please stick to it. If you say something will happen and it doesn’t happen, that trust is undermined.
- Keep things calm and slow. In emergency situations it can be tempting to deal with things as quickly as possible and move on. But in mental health crisis, adopting a slow pace of conversation, being patient, asking simple, direct questions and giving the person sufficient time to respond can be useful.
The place of safety
- When we arrive at the Place of Safety and you hand over to the nurses, please try and allow one officer to stay with me while the other does the handover, particularly if you have built up a rapport with me.
- Whilst I am aware that there is a lot of discussion over when police should be released and able to get back to normal duties, and that the longer you spend with me the fewer officers are out there on the streets, it helps more than you can believe to have someone reassure me and help me ‘settle’ there. 136 suites are not pleasant places to be. Unfortunately, it is also my experience that mental health staff provide far less care, understanding and empathy in crisis situations and at 136 suites than do police officers. The likely scenario is that once you have handed over and left the PoS, I will be left in a room with nothing but a chair and possibly a bed and a blanket if I am lucky, with nothing to do to distract me, no medication to help me relax until a doctor has seen me some hours later, no idea of when an assessment will take place – probably at least 12 or so hours away – and often, with no one to talk to me or listen. Instead, the common experience I have had is that staff will sit in the office next door, reading paperwork or sitting at a desk, while I am locked in a room. Once you have left, I am on my own. So please, please, if you can take the time before you leave to just reiterate what you have said, to encourage me to be honest in the assessment, and to reassure me that I can get through this, and that you are not judging me… you will almost certainly be the most caring, calm and understanding voice I hear during this process.
- Finally, please, please, please say goodbye to me before you leave the PoS. It is not all that uncommon for officers who have spent up to 2 or 3 hours with me in a crisis situation, talking to me, restraining me and keeping me safe, to then hand over to mental health staff at the place of safety and then leave without another word to me. Whilst to you this may be a daily occurrence, and to you I may be just another mental health patient, for me, this situation is a big, big deal. I have (hopefully) trusted you enough to listen to you, to tell you the deepest, most distressing thoughts in my head, to cooperate with you and trust you enough to let you help me, to let you take me to a hospital where I am terrified that I will be sectioned and locked up, unable to even go outside without permission. I have trusted you to help me. To then leave without saying a single word of goodbye after handing over massively undermines that trust, in a way that could be so quickly and simply avoided.
And finally…always remember the difference you make
- The impact you have will stay with someone forever. I know at times it is frustrating for you to deal with mental health crises, particularly if there are repeated incidences and nothing seems to be happening as a result, and particularly where the system is clearly failing. Maybe at times you think ‘What’s the point, it’s clearly not making a difference, why are we bothering?’
- Just know: The words you use stay with me. And the impact you have is massive. Not just the night you meet me, when you may directly have saved my life or prevented me from harming myself, but on future nights when I am struggling alone, and can hold onto the words you used with me. You may not see me those future nights. But the words you use the times you do see me can stay with me, and sometimes those words can help me to keep myself safe alone when I may otherwise have turned to self-harm.
- You are in a unique position where you can help keep me safe when I am unable to do this alone, you can give me hope for the future when I am unable to see it for myself, and you can reassure me that I am not as worthless and horrific a person as I truly believe myself to be. I may not seem to be responding to your efforts at the time. It may take a while for me to begin to take in what you are saying. It may take time for my health to improve. It is likely to be a slow journey, a long road with many ups and downs. But you are making a difference. I will remember the care you provide to me, be that good or bad. And good care can be a life-changer. I will never ever forget the things you say to me, the effort you put into helping me and building a rapport with me, and I cannot put into words how truly grateful I am to you for this.