What will the announcement that community psychiatric nurses are to be posted in criminal justice settings do to psychiatric services and patients?
Today it was announced that mental health nurses are to be posted in police stations and courts in 10 areas across England in a long campaigned for ‘liason and diversion’ strategy. The nurse’s role in these situations will be to respond to calls alongside officers wherever there is a suspicion that someone engaged in criminal activity has a mental health problem. The rationale is that with so many people who experience mental suffering being convicted of often relatively minor crimes, such as breach of the peace or trespassing, that prison populations are full of the undiagnosed mentally ill.
In 1998 the Department of Health, via the ONS, published a report into the mental health composition of the prison population and found that up to 70% of prisoners in England had ‘two or more mental disorders’ . The same report also found that suicide rates among prisoners were 15 times that of the general population. So it seems obvious that this news should be welcomed: sufferers will no longer be left to languish in prisons, exposed to the risks that go along with it, will no longer be left with the double stigma of mental illness and a conviction, and will receive the psychiatric help that they need sooner. From a therapeutic perspective, I can’t help but see all this as positive. If I can help any of the people I work with avoid being incarcerated I will, and if this project means people get the help they need sooner all the better. I remain doubtful about the long-term likelihood of either of these scenarios.
From the perspective of the English state apparatus this is likely motivated by not entirely therapeutic intentions. In October of the year just gone a pilot study conducted in Stoke-on-Trent and North Staffordshire found that diversion strategies significantly reduced recidivism among populations with mental health diagnoses, learning disabilities and/or a substance misuse disorder (together known as “mental disorders”). This study reported an astonishing 42% reduction in reoffending among persistent offenders categorised as mentally disordered within 3 months of engaging with a community psychiatric nurse . If this could be replicated on a national level it is estimated that it could save the British state anywhere up to £11billion a year, a significant saving to make at a time of austerity when all public services are being run down to a minimal operational cost or else are being farmed out to the private sector via a staged marketisation strategy.
Beyond the walls of the police station cells, the prison, the court, and the psychiatric hospital, a separate scheme has also been running in the streets. The Street Triage Scheme sees CPNs responding to calls with police across the UK and leaves many unanswered questions about whether therapeutic need or civil order take precedence. While a discussion of that scheme is beyond this piece, it should be noted that at least one police officer who works in mental health has raised significant doubts about whether the triage scheme changes anything it claims. This is important because the triage scheme is largely about placing nurses in police cars to respond to emergencies in order to get people access to treatment sooner and to avoid criminalisation and/or improper responses to florid mental suffering by officers who might not be trained adequately in working with people experiencing psychoses or other mental crises. As that blogger-officer puts it
I can’t help but conclude from the above exercise, that it would alter fewer than half the scenarios and whilst welcoming a reduction in 136 usage... it also gives rise to extra pressures for that situation to go awry by doing the wrong thing... No-one could object to a scheme which brings about better or faster referrals ... but I ask whether a nurse in a car with a cop is necessary to make that happen? In some of those situations, available, accessible and responsive health services (whether that is a GP, a mental health community or crisis team or the ambulance service if we feel we should ring 999) could potentially achieve the same thing. I also wonder whether it would achieve it at less cost? 
My continuous worry about street triage has been the conflation of therapeutic power and police power. While these two forms of state power are obviously finally indistinguishable in situations where psychiatric treatment is compulsory and enforced by treatment orders, whether in hospital or the community, there nonetheless remains a separation in how these powers operate, and how they are perceived. There is no comparison between the hatred of the police and the suspicion often made of psychiatric workers; no one has yet announced that all psychiatric nurses are bastards. How long will it be before this comparison is made when CPNs are everywhere seen as part of the police, when the nurse dressed in her own clothes emerges from a police car, accompanied by uniformed officers who increasingly embody the open repressive force that they wield? I don’t ask this because I want to help psychiatric power appear as a kind soft power but because in the absence of a genuinely therapeutic regime we are left with the mental health system that exists. A massive proportion of the help that people can and do receive within that system, against all the systemic forms of abuse it also deploys, comes from the development of a therapeutic relationship between the workers and the patients. A therapeutic alliance, in which each party is working for the good of the patient, requires a level of trust as its sin qua non. The minute that psychiatric workers are embedded within the police force whatever possibility of that alliance developing exists is placed in immediate jeopardy.
When the police function is wedded to the therapeutic on the street, in the courts, and the prisons then we also have a combinatory intersection that produces something new. All fields become suffused as part of a psycho-police order, an new alignment of state power that aims at controlling populations more efficiently and at a saving for the state-as-capitalist. Among the chief functions of both police and psychiatry is the assessment and surveillance of risk. As such this hybrid form of power is a perfection of surveillance. At first I had suspected that police and nurses would clash, having different priorities, but the report on the diversion scheme’s first year indicate that the police overcame their initial suspicion of these interlopers and quickly came to see them as valuable colleagues.
The question must be how it could be that psychiatric and police workers could slot together so well so quickly, and my immediate suspicion is because they fit together like a lock and key. After all, it should be recalled that the role of psychiatric nurse began its existence as the hospital attendant, little more than a jailer and police office maintaining the order of the old Victorian Asylums by any means deemed necessary. At the same time, the police and psychiatry also exercise an enormous amount of ability to detain bodies, or to set them into thoroughly regulated movement between institutions in coordinated multi-agency patterns of control. In the case of psychiatry the ability to determine lived movement and to restrain extends beyond power enacted on the surface of the body via nightsticks, CS spray and handcuffs, and reaches inside that body to its molecular composition.
Psychiatric medications are such an effective form of control because they are so blunt but also because their assault occurs in the field of the invisible, at the level of the synapse, as a form of endocolonisation. If Kafka’s story about the writing machine seemed horrific, a machine in which the body of criminal was literally one whose crime was written on, over and over again, causing vast pain that would eventually become a docile expectance, then the psychiatric machine has no such literary ambition. Instead the crime, the illness, who can say which, is indirectly punished or treated, who can say which, by the introduction of neurotoxic medications that produce altered states of consciousness that may or may not have a therapeutic effect, depending on dose, polypharmacy use, and length of time they are prescribed. I call these drugs neurotoxic because they are eventually toxic to the brain and the body.
Once a psychosis or a mania is stabilised these medications are rarely withdrawn, instead they will be taken as prophylaxis, in most cases on an indefinite basis, and will produce all kinds of horrific adverse effects without any guarantee of any therapeutic benefit. Many of these drugs kill the libido, the appetite, make you look like a “junkie”, increase the risk of diabetes, prevent you from working, from living because of the sedative effects, make muscles behave strangely, and increase the risk of death. If Kafka’s writing machine introduced the criminal’s embodied mind into a literary world, that is a symbolic world, then the psychiatric machine works to undo the literary world of the patient and replace it with a network of biochemical apparatus, adjustments and techniques. Kafka’s criminal was forced into a new order of meaning, the psychiatric patient is removed from it forcibly.
As one interlocutor put it to me on twitter, here we see the meaning of policing and caring merge as capture. My point here is that this is nothing new; far from being a shocking development this is conflation of powers is really little more than there recognition of self in the other. The criminalisation of pathology is mirrored in the pathologisation of criminality, and a particular therapeutic nihilism becomes a nihilistic therapy.
Part of the evidence rolled out in support of this programme is that those on the receiving end have reported satisfaction with the way the new service operated. Some 95% reported the service ‘exceeded their expectations’ whilst 93% of ‘detainees’ were ‘very satisfied’ . While this sounds like a high figure it is based on only 42 respondents out of 1,200 people whose referrals ended in assessment for treatment. Of those who replied, it is hardly surprising that having their suffering acknowledged and support discussed with them was preferred to custody or prison services as usual. Yet such a poor response rate begs the question of whether satisfaction really was as high as all that. It is also telling that newspaper responses include those of the police, the mental health services, courts and mental health charities but none from service-users themselves. Of those replying from mental health charities, those organisations that set themselves up as advocates for service-user rights, Paul Jenkins, CEO of Rethink, stated that
"There's immense potential to divert people away from expensive prison sentences," he said. "But in the short term we might just see it be less hassle for the police in terms of processing people, which will also save money." 
This response, emphasising the cost of prisons and apparently wasted police time, is hardly surprising given that Rethink also uses workfare. Elsewhere on Twitter, a government advisor on mental health and offending tweeted that
We don't know #diversion of offenders is cost-effective: but it is humane, pragmatic, better use of resources & based on right values. #nhs
— louis appleby (@ProfLAppleby) January 4, 2014
It is hard to disagree that it is more humane than languishing in prison but it is clear that this move is far from straightforwardly progressive. Part of the problem is that this system will provide people with diagnoses and treatment as if these alone were magical technological fixes, and as if there were some direct causative relationship between mental suffering and criminality that existed in a vacuum to the socioeconomic conditions that people experiencing that suffering find themselves living through. Rather than extending a recovery agenda, as ambiguous as that is, these new systems will only serve to extend the prevailing pragmatism of symptom management and risk management. Serious questions also need to be asked regarding the possible national rollout of these new systems: given the massive shortages and ongoing cuts to hospital beds, and a lack of CPNs where will those identified as suffering be referred to for treatment? Would a model like Scotland’s community based Persistent Offenders Project make more sense? Given the privatisation of some mental health and custody settings who will these new teams be managed by and accountable to? With suspicions that the NHS is to become a paid-service following the announcement of charges for immigrants and suggestions of charging GPs it is unclear who will be funding this new system in the future.
As anarchists and communists we must realise that while there are on the ground gains here for people with mental suffering this is a situation in which psychiatric sovereignty is extended. Just as is the case with the compulsory treatment orders that produce the community as itself an entirely mobile and fluid clinic (wherever I am, there is the clinic), so this conflation of two forms of power is a mutual extension of one into the other. To a large degree when it comes to treatment the psychiatrist is the sovereign who decides on the exception: the suspension of law as the law. While it is true that psychiatry is still regulated by juridical decrees and oversight bodies, it nonetheless remains the case that it’s particular juridical order is one that enjoys a freedom to remove basic political rights that is only paralleled by anti-terrorism agencies. As the Rosenhan experiment made clear, to paraphrase philosopher Giorgio Agamben,
every gesture, every event in the psychiatric clinic, from the most ordinary to the most exceptional, enacts the decision on bare life by which the sane biopolitical body is made actual .
At its root this new system of mental health care and treatment obliterates the conditions of existence that give rise to the production of suffering, and criminality, in the first place. The regime that decides and separates the sick from the sane, that detains rather than imprisons, that forces psychiatric treatment but so often isn’t capable of genuine therapeutic work, that secures rather than offers sanctuary, is left unchallenged It presupposes that mental illness is the cause of criminal behaviour, rather than socioeconomic conditions, and perpetuates the public conception of the mentally ill as dan. Meanwhile the sufferers welcome this new way of working as a step in the right direction, happier to work with nurses rather than cops. The question that no professional involved in reporting this news is asking, is why it is that a service like this is needed in the first place? Capitalist society actively produces suffering and tips it into crisis, only to bring in the heavy mob with the needles and the compassionate voices when someone finally explodes.
 Mental Health Foundation. 2013. Mental health statistic: prisons. [Online]. Available at: http://www.mentalhealth.org.uk/help-information/mental-health-statistics/prisons/ [Accessed 04.01.14].
 NHS North Staffordshire combined trust. 2013. Mental health diversion pilot project releases positive 12 month report. [Online]. Available at: http://www.combined.nhs.uk/news/Pages/MENTAL-HEALTH-DIVERSION-PILOT-PROJECT-RELEASES-POSITIVE-12-MONTH-REPORT.aspx [Accessed 04.01.14].
 Michael Brown. 2013. Eight dimensions to street triage. MentalHealthCop. 2013. [Online]. Available at: http://mentalhealthcop.wordpress.com/2013/09/14/eight-dimensions-to-street-triage/ [Accessed 04.01.14].
. NHS North Staffordshire combined trust. 2013. 2013-2014 Stakeholder Report. [Online]. Available at: http://www.combined.nhs.uk/ourservices/adultmentalhealth/specialistteams/Documents/2013%20to%202014%20Q1%20Staffordshire%20Police%20Custody%20Mental%20Health%20Diversion%20Project%20Report.pdf [Accessed 04.01.14].
 Jenkins, P. 2014. Mental health nurses to be stationed in prisons. Guardian. 04.01.14. [Online] Available at: http://www.theguardian.com/society/2014/jan/04/mental-health-nurses-police-stations-pilot-scheme [Accessed 04.01.14].
. Amended quotation from: Agamben, G. 1998. Homo sacer: sovereign power and bare life. Stanford: Stanford University Press.
Another great, thought-provoking blog, thanks!
admin: trolling removed. This
admin: trolling removed. This is a final warning.