Police and mental health clinicians co-located
This is such a good idea. Following my recent research about the emergent mental health problems of young rural people, and based on my finding too – I agree that this is an important way forward for rural communities.
Mental health nurses should be co located in police stations to improve the care of young rural people with acute mental health problems, and who as a result, become involved with the police.
Nurses are great at listening, caring and finding ways forward to improve the well-being of others – co-location with police who come into contact with young people with mental health problems is a far better way forward.
Congratulations to ACT police for piloting there program. Wishing them great success for the long haul!
Sending the challenge out to rural and regional police commands in all rural and regional centres to find a way to replicate the concept in their centres and stations!
This link takes you to a brief media review of the Canberra police program – watch it for inspiration!
Here are some facts about mental health and policing/justice….. (extracted from my almost completed PhD thesis…)
- The NSW Law Reform Commission undertook a general review of criminal law and procedures that are applied to people with cognitive and mental health impairment in NSW, and they reported that in NSW of all the young people (less than 18 years of age) detained in custody in NSW, 87% have at least one mental health problem and 73% have two or more mental health diagnoses (New South Wales Law Reform Commission., 2012).
- Young people with mental illness are over-represented in the criminal justice system compared with the wider population, where 22% of the general population have a diagnosable mental health problem and with the total prisoner population in NSW experiencing mental health problems at a rate triple that of the general population (New South Wales Law Reform Commission., 2012).
….The stated goals of policing and justice are diversionary wherever it is possible, however that requires sophisticated referral mechanisms between justice, social and health services, and these services are not always available or accessible, especially in rural regions, and so young people are not always able to engage with diversion options, and therefore are detained in custody, either because no other option is available to them, or because they have a history of offending (New South Wales Law Reform Commission., 2012).
- The average age for a young person with a mental health problem to be remanded in custody for the first time is 18 years of age and on average they will have had 15 police events recorded by that time, with a first police event occurring at an age of between 12-14 years likely; coincidentally an age where onset of mental illness is also noted (Kessler, et al., 2005; New South Wales Health., 2012; New South Wales Law Reform Commission., 2012).
It is difficult for non-mental health professionals to identify emerging mental health problems, and this is especially challenging in the context of the criminal justice system, however a mental health assessment service is available to some offenders who are fortunate enough to be dealt with by Statewide Community and Court Liaison Court Locations (CCCLS), however only 20 of these locations exist in NSW, with the service not available to the remaining 128 local court locations (New South Wales Law Reform Commission., 2012). The disparity of this service provision has been recognised by the Law Reform Commission and it has recommended an expansion of this program to all 148 local court locations (New South Wales Law Reform Commission., 2012).
- Police have powers to detain a person who they believe to be mentally ill or mentally disturbed, under the Mental Health Act 2007 (NSW), and police can formally request that the person be admitted to a involuntary mental health facility. This mode of request for admission makes up 23% of all police requests for admissions to mental health facilities, however 26% of police requests do not meet medical criteria for involuntary admission to a mental health unit (New South Wales Law Reform Commission., 2012).
- This leaves a substantial number of people who may have a mental health problem, but do not meet extreme criteria for involuntary treatment in a compromised position of not being able to access mental health help when it is needed, and at risk of reoffending and further complicating their offending track record (New South Wales Law Reform Commission., 2012).
- Collaboration between State governed Police, Health & Ambulance services in regard to supporting people with a mental health problem to access appropriate care is ideal and fits neatly with the ideals of ‘no wrong door’ to seek mental health help which are aspired to by State & National Mental Health Commissions.
- There are significant limitations within clinical decision making capabilities which need to be considered. In particular, no clinical risk assessment tools exist with adequate specificity, sensitivity and accuracy to predict harm to self or others (for example violence) by people affected by mental health disorder or illness (Ryan, Nielssen, Paton, & Large, 2010). It is not possible to accurately conclude that current clinical assessment of risk investigations will be sensitive enough to predict which clients will need higher levels of resource-heavy interventions and restrictive care, which people will require fewer and less expensive clinical resources and less restrictive care to achieve safety outcomes (Ryan, et al., 2010).
- Ryan et al (2010) reviewed the efficacy of the most commonly used risk assessment instrument, that is, the Macarthur Violence Risk Assessment, which is regarded widely as a valid for use in the prediction of violence amongst people who are acutely mentally ill (Monahan, Steadman, & Robbins, 2005). Ryan et al (2010) re-examined the data in the original study and found that the level of sensitively for accurate prediction was ambiguous and that it had very poor sensitivity in regard to accurately detecting risk related to future violence. In fact, the sensitivity of the instrument produced 9% incidence of false-negative cases, where people were categorised as being low-risk and went on to commit violent acts to themselves or others in the 20 weeks immediately following the assessment (Ryan, et al., 2010). Thus, 9% mentally ill people considered to be ‘low-risk for harm to self or others and in fact ‘high-risk’, and these people will slip through gaps in service streams of all types despite having been provided with a clinical mental health risk assessment, because to current instruments available are not sufficiently accurate to detect risk, yet they are in common use despite this paradox (Ryan, et al., 2010).
- Health services are adverse to risk events and wish to be seen to be doing everything popularly possible to reduce risk of harm to people. However Ryan et al (2010) have been able to demonstrate that based on the fidelity of the most common risk assessment tool, and the incidence of annual homicide rates by people with schizophrenia of 1 in 10,000, and if the risk assessment was conducted on every person with schizophrenia that annually 4117 people would be detained for up to a year in mental health bed-based facilities because they would achieve a ‘high-risk’ category, in order to prevent one person committing a homicide (Ryan, et al., 2010).
- However, of those people assessed as low-risk, 1 in every 22,421 people would in fact go on to commit homicide (Ryan, et al., 2010). The health resources and cost absorbed by keeping false-negative cases in hospital detract from the finance and recourse available to provide care to the low-risk cases, and some of the low-risk cases require high levels of care (Ryan, et al., 2010).
- The dispersal of health resources could be better allocated across a broader mental health agenda, and support the mental health of more people if the use of clinical risk assessment was abandoned as having any role in the clinical decision making process (Ryan, et al., 2010).
Given the frequency with which young people with mental illness are involved in justice and policing matters, and with a lack of accuracy and sensitivity in detecting risk related to acute mental ill-health, it is evident that the challenges in regard to helping young people with mental health problems and who are violent, and who do not wish to participate in mental health care, have little support available to them, and this circumstance perpetuates the problem of high number of young people with mental health problems in custody in Australia.
More research is needed to better understand how young people with emerging mental health problems can be helped earlier so that fewer young people are subject to custody arrangements related to their mental health state.