An Evaluation of Mental Health Triage version 1.0
Research type
Research Study
Full title
Policing Mental Health: A realist exploration of Mental Health Triage
IRAS ID
207992
Contact name
Alice Park
Contact email
Duration of Study in the UK
0 years, 7 months, 30 days
Research summary
Research Summary
Police officers regularly come into contact with people who experience mental health issues, despite concerns that they are not the most appropriate response. This is concerning as the police have legal powers enabling them to detain individuals against their will under Section 135 and 136 of the Mental Health Act 1983. To address this, police forces in the UK have implemented an initiative known as Street Triage, where trained mental health professionals assist police or advise them where mental health crisis, or concerns about the individual’s mental health arise. This may be done in a public or private place, and the assistance from the mental health professionals may be in person or over the phone. Some Street Triage initiatives also have extra mental health professional(s) assisting in the Police Force Control Room or similar site.
Very little is still known about these schemes, particularly in relation to service user experiences. This project aims to evaluate two sites in the North of England.This project will use quantitative and qualitative methods. Routinely collected data will be examined before and after the individuals contact with Street Triage to illustrate the short and long term criminal justice and mental health service contact of individuals who have come into contact with Street Triage. Routinely collected data collected by the Street Triage and Force control room teams regarding the immediate outcome of the Street Triage and Force Control Room intervention will also be analysed. This will be supplemented by qualitative interviews to help understand the processes that occur in the initiative to produce such outcomes. Police staff and the Triage teams will be interviewed. Users of Street Triage and where possible carers will also be interviewed. Observations will also take place of the Triage teams working and team meetings, as well as document analysis.
Summary of Results
Brief aims and approach of the study
This study explored an intervention called mental health triage, where mental health professionals support the police to respond to individuals experiencing mental health crisis. This study aimed to explore how this intervention works, specifically asking:
● How has mental health triage come about ?
● What do participants think mental health triage is addressing and what is its purpose?
● How is mental health triage understood and implemented, and what informs this?
● How does the mental health triage process work, and why?
● How are the key decisions made in the mental health triage process and what informs this?
● What are the experiences of those who encounter mental health triage?
● How do micro, meso and macro contexts affect the delivery of the service and outcomes for participants?
● How does mental health triage fit into police and mental health systems?
● How do the models of mental health triage compare?Two mental health triage teams were evaluated to be referred to as site 1 and site 2. This combined interviews and observation of different people involved in the delivery of mental health triage including police and mental health professionals, and those who encounter mental health triage. This facilitated an in-depth exploration of social behaviours and the processes of mental health triage.
Results
The purpose of mental health triage:
• Mental health related work was seen as a major part of the daily work of the police, including response police and community support officers. It was perceived this type of work had increased, and that the role of the police was where they have a more responsible role and understanding approach. Some officers however did express some resentment here, as they didn’t feel they joint the police force to deal with mental distress, while others felt it was part of their role due to Article 2 of the Human Rights Act, meaning by law, the police have a duty to protect individuals whose life may be at risk.
• Mental health triage was perceived to be needed to improve the experience of those who encounter the police, experiencing mental distress, as the outcomes of police encounters can be restrictive, distressing and lead to poor or no support. Numerous diagnosis and social circumstances were thought to be appropriate when referring to mental health triage, especially in site 1. There was an emphasis on the need to support those repeatedly encounter the police.
• The police were viewed as not being the right people to respond to mental distress given their expertise and lack of training, resources and knowledge of the processes to support individuals. The police felt they needed support with decisions around detaining individuals under s.136 of the Mental Health Act 1983, risk, as well as criminal justice and mental health matters.
• Participants felt that there was little support for the police from other mental health services and health services, they often spent long periods of time trying to secure the right support for those experiencing mental distress.
• There were some differences between site 1 and site 2 with regards to the nature of the work they would get involved in. Site 2 perceived they were a short-term crisis service, while site 1 also had input in longer term community work, especially with community support officers.Before mental health triage: The ongoing role of the police where they encounter an individual’s experiencing mental distress was demonstrated, which led to questions around the acceptability of this where mental health triage aims to improve the experience of crisis care.
• It was not inevitable that mental health triage would be utilised by police who were effectively gatekeepers to mental health triage.
• The decision to refer an individual was multifaceted and differed among officers, raising questions about the consistency of the utilisation of mental health triage. Decisions could pertain for instance to the confidence and experience of the officers, their familiarity with the individual experiencing mental distress, perceived risk, instinct, as well as previous their perceived use of mental health triage.
• In site 2 most officers interviewed felt the service was well utilised however some officers felt this wasn’t the case due to old routines, perceiving they could manage alone, manage better or couldn’t get a response from them. The availability of the team was a widespread concern among the police, this could cause frustration among triage staff who felt this may be discouraging their utilisation, there was a feeling the triage team could be better integrated with police in this site.
• In site 1, while practitioners felt demand on their service was decreasing. This is because previously officers had contacted them directly but were now being asked to contact the police force control room, who would then direct them to the team. This caused frustration among triage staff and officers who perceived jobs were being missed and resulted in some of them bypassing this procedure. There was a pronounced enthusiasm amongst officers for utilising the mental health triage team whom appeared to be very integrated into the police service delivery. The officers and triage staff had very positive working relationships which contributed to a joined-up approach to policing and mental health support.
• Across both sites, it was not always the case that mental health triage would accept referrals. However, the sense of relief for officers where they knew they were going to be supported was emphasised, which in turn changed their practice with those experiencing mental distress. It was perceived to raise their confidence and improved their communication.
• In site 2 officers felt that the criteria for a response from the team was strict, which interviews showed related to different ideas about what constitutes as a mental distress and their understanding of the nature of certain diagnosis. Practitioners in this site also noted they were pragmatic about the referrals they would take, avoiding cases where numerous social factors played a part, or where an individual was known to mental health services and could contact professionals they already worked with.
• In site 1, the team were more open to referrals as long as the police perceived mental distress was a concern and as such there was little apprehension from officers about contacting them. However issues did arise where practitioners were asked to do assessments over the phone, which were seen as risky.
• The continued role of the police raises questions given officers reflected on the nature of a police presence with regards to stigma and exacerbating the distress of individuals. The ongoing power of the police to control individuals through mental health and criminal legislation was also emphasised, which can have detrimental consequences for individuals experiencing mental distress, even where mental health triage is operational.
• The police had a continued role in the triage encounter especially in relation to obtaining consent for individuals to speak to the mental health practitioners.
• Numerous factors influenced weather individuals would consent to seeing the triage team. These included previous experience with the team, perceived availability through the police and presenting characteristics of the individual.
• In site 1, individuals requested the triage team through the police, or visited police premises to do this. There were mixed views from officers pertaining to if these encounters were because of, as described by officers, a ‘genuine’ need for support or ‘attention seeking behaviour’. There was feeling among practitioners in site 2 that accessing mental health services through the police was inappropriate. However ongoing dilemmas here were highlighted for instance pertaining to the criminalisation of repeated callers who were described as not having insight into their distress, who refuse to engage with mental health services, despite the nature of their distress leading them to contact the police.
• Familiarity with the team was discussed by participants as being a help and a hinderance where engagement was concerned. In site 1 officers emphasised that individuals need little encouragement to engage. Familiarity can benefit such situations as there is a relationship present, this could deescalate situations. However one practitioner emphasised where individuals have had what they perceive to be a poor experience with the team, consent will not be given for the team to engage with them. The notion that previous experience with mental health triage could encourage take up amongst service users was echoed by some officers in site 2, but in general there was less of a sense of familiarity between the triage team and service users in the area.
• Where gaining consent to speak to individuals who had encountered the police, the importance of the autonomy of individuals was respected by triage practitioners, especially where they were perceived as safe and being supported by other services. It appeared from the data that many individuals were happy to have support from the triage team. However, where considerations around capacity, risk and best interests were considered by the triage or police staff, the autonomy of the individual could be constrained. In both sites manoeuvring and persuasion could be used by officers when trying facilitate access for the mental health triage team. There was also some discussion about the potential power of officers to detain individuals which may also facilitate consent. It was also the case that where a certain level of risk was perceived by triage practitioners, collaboration with the individuals had to be balanced with their level of need.
• In site 1, some supplementary work was done by the triage team to access mental health care for individuals where they would not engage with the team. This included persistence with trying to visit individuals, gathering evidence about individuals from the police. This was justified by their duty of care, one practitioner reflected that this type of activity would be to establish why the individuals had come into contact with the police and to try and establish a relationship with them. This type of work does perhaps raise questions around transparency and the privacy of individuals, versus their dignity and wellbeing, but also how the respective organisations are using one another.The triage assessment
• Because of the therapeutic support they offered and their perceived utility in getting a better outcome for individuals, the triage team was perceived as the appropriate agency to attend to those experiencing mental distress who had encountered the police.
• One of the first and most crucial phases for practitioners was the information gathering and sharing phase. Here information was pooled by discussing with the police what had happened for that individual to come to their attention, use of databases and knowledge of the practitioners. This phase had to be balanced with the timeliness of the response.
• Indeed, in both sites, interviews and observations suggested that database information facilitated the encounters by making them more informed, both where the triage team attended, and where police needed quick time mental health information over the phone or over the police logs.
• This did however have to be balanced with remembering the individual at the heart of the encounter and adapting the information to the encounter as appropriate. At times the database information may not be accurate, here local knowledge of the individuals in the area was helpful.
• During the assessment, therapeutic engagement with the individual was highlighted as key to the triage process. For instance an assessing practitioner in site 1 emphasised the importance of establishing engagement with their communication skills, whilst officers in this site observed these were important to facilitate the exploration of issues the individuals were facing, as they had a more therapeutic approach than the police. Validating the feelings of the individuals experiencing mental distress who had encountered the police was crucial. However, the potential for escalating a situation was also there, especially for instance where individuals didn’t agree with the triage team.
• Risk and determining the needs of individuals were key to the assessment. For professionals in the triage teams, operational, institutional guidance and policies, as well as legislation were used to inform their work. Additionally, they appeared to draw on tacit knowledge, such as previous professional and job specific experience. The main assessing practitioners registered as Band 6 workers directed the assessments, whilst support workers also had a role in contributing to the assessment as well as feeding into plans for individuals, due, for instance, to their knowledge of local services as well as observations and interpretations from the assessment.
• Face to face assessments were preferable to those conducted over the phone for practitioners due to the limited information they could gather over the phone. The police echoed this and felt they retained responsibility for phone assessments. In site 1 the human contact of street triage was emphasised. This helped them build a relationship and trust with the team, which appeared throughout the interview to instil confidence in their joint policing approach.
• While some officers remarked that they let the triage team take over, practitioners in both sites also emphasised that the police had continued involvement in the assessment by sharing scene information such as the setting; how the individual was presenting; past contacts; the background information they retain; their concerns for the individual and what the individual wants to happen. Officers were at times viewed as the eyes and ears of the triage team.
• Positive risk taking was seen to be difficult for officers across both sites, with one officer noting that their method of risk assessment was very different from the triage team. Sharing the rationale for decisions was seen as important to officers. Officers also had the right to disagree and sometimes the level of risk of a situation would override the decision of the triage team. There were differences in opinion as to where the responsibility of the triage contact rested.
• In terms of the individual experiencing mental distress, there was a lot of responsibility on the individual to engage in their own care planning. It appeared across both sites that the role of the assessing practitioner was to strike a balance between informing the individual of their options and the individual leading the assessment and subsequent planning. However depending on the scenario, the practitioners could be more paternalistic where the level of risk increased. The perspectives of service users and carers here are warranted here in order to gain their interpretations of the triage contact given the inherent power dynamics at the intersection of policing and mental health, however unfortunately few individuals could be recruited for this study.
• Where criminal justice matters arose the police were described as responsible here, however it was the case that the mental health practitioners maintained a role. Practitioners across both sites also noted that the police could be reluctant to prosecute where an individual was perceived to have committed an offence, and that mental health could be used literally as a ‘get out of jail card’ by some individuals, though such considerations often pertained to lower level crime. The capacity of individuals to offend and the consequences for individuals were emphasised by practitioners, including the importance of consequences for behavioural change. On the other hand, there were scenarios where criminal justice matters arose but practitioners felt they were not there to gather information for the police, demonstrating the dilemmas involved in this type of work.After the triage encounter
• The shorter-term outcomes of assessment differed by each case but generally entailed safety planning in the immediate sense where risk assessment was key, as well as safeguarding referrals. The teams also worked with individuals on their own resources for coping and helping themselves. Additionally, they could outline service options available to individuals, upcoming appointments and had the potential to refer individuals more efficiently to a range of services due to the team being part of the mental health system. This input was seen by practitioners and police as reassuring and as a safety net for individuals, as well as being a bespoke pathway of care for individuals.
• It was also perceived this could save time for other services such as the police and A&E, but also services working with the individual by liaising with them about an individual’s care. However, it was felt that at times other services would purposely transfer their work to street triage, by continually expecting the police to respond to mental health concerns.
• It was also the case that the teams did a lot of case management and liaison work, especially where other services would not accept their referrals. It did appear that at times the different thresholds between triage and other services in site 1 could almost lead to blockages, which may at times created a feedback loop where waiting to find an appropriate service or waiting for individuals to be taken from them.
• Some of these individuals may come back to the attention of the police. In both sites, the individuals described with reference to having reoccurring issues were those with complex needs, chronic needs, substance use issues, and those with personality disorders.
• In site 1 and 2 there were different approaches to follow up work. In site 1 up to three follow up sessions were offered. This could involve ongoing assessment, therapeutic support, and supporting the transition to other services. In site 2 however follow up was less frequent where individuals were encouraged to take responsibility for their care going forward.
• Some interviews also suggested that the officers would develop their knowledge of mental health by working with the triage teams.REC name
North East - York Research Ethics Committee
REC reference
17/NE/0262
Date of REC Opinion
8 Sep 2017
REC opinion
Further Information Favourable Opinion