Key workers at the front line of the criminal justice system shaping referrals into prisons (or not) are the police. They operate with a lay conception of mental health problems (this does not imply a lack of sophistication, merely an absence of the discourse of the expert ‘psy complex’).
They can adopt a rationale born of experience (this practical wisdom was called ‘phronesis’ in Greek philosophy). The dilemmas of policing mental health at the front line are evident in the blog and social media presence of MentalHealthCop, who describes his work in the following way:
I’m a serving 24/7 police inspector blogging in a personal capacity. I’ve had more than my fair share of policing & mental health incidents and I continue to get them daily on the frontline of British policing. It was the overwhelming feeling when I joined of not knowing what on earth I was doing, that got me asking questions about this stuff. I asked them of other police officers, including supervisors, but it emerged they often knew little of use. I have made it my business to ask psychiatrists, forensic psychiatrists, A&E doctors, paramedics as well as
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psychiatric nurses and AMHPs (or ASWs as they were) how we should operate in this area of policing. Anyone who would stand still long enough and talk to me, frankly.
http://mentalhealthcop.wordpress.com/about The police are at the front line of making decisions about who enters the mental health system, who is diverted to mental health services and who, when circumstances allow, is returned to a domestic setting. In sociological terms the police can be viewed as what Lipsky terms ‘street-level bureaucrats’ or as ‘public service workers who interact directly with citizens in the course of their jobs, and who have substantial discretion in the execution of their work’ (Lipsky 1980: 18).
The characteristics which Lipsky considers define street-level bureaucrats include:
• a focus on the need to process workloads expeditiously;
• a substantial amount of autonomy in individual interactions and dealings with clients (in this case members of the public);
• an interest as part of a professional or occupational project in maintaining and maximiz- ing their own autonomy;
• conditions of work that include inadequate resources (both monetary and in terms of personnel and time);
• a context of demand that will always exceed supply;
• ambiguous and multiple objectives;
• difficulties in defining or measuring good performance;
• a requirement that decisions should be taken rapidly;
• clients who are what Lipsky calls ‘non-voluntary’ (1980: 56).
In the latter regard, these ‘clients’ have limited (or a non-existent) choice over whether, where or how they present to the service involved.
Lipsky suggests that ‘the decisions of street-level bureaucrats, the routines they establish, and the devices they invent to cope with uncertainties and work pressures effectively become the public policies they carry out’ (1980: xii). In other words, the pragmatics of an open system, with different and particular constraints and opportunities from one situation to another shape what happens, independently of the abstraction of policies and ideal procedures. In a study of decision- making about psychiatric referrals from the police Rogers (1990) identified this pragmatic process occurring as police officers make decisions about the management of patients they encounter on the street. These are not specified explicitly in the legal terms underpinning the policy but exist in the discretion of the particular contingencies available to help people or simply to deal with an uncertain scenario of personal vulnerability or social threat.
In these conditions of uncertainty police officers try to apply where possible their own version of a routine that works for them in practice. Lipsky pointed to how street-level bureaucrats respond to pressures placed on them by processing people in a routine and stereotypical way. In the Rogers study just noted police officers referred to the need for a routine psychiatric and physical health check, which they called a ‘nut and gut’, when deliberating on whether to refer a person to hospi- tal or the criminal justice systems. However, as we just noted above there are limits to this police discretion and ability to act autonomously. The latter is constrained by the social context, within which officers become involved in incidents which are constrained by the external influences impinging on police decision-making, such as resources available and immediate competing tasks.
Discussion
This chapter has dealt with a number of ambiguities. First, there is the matter about whether crimi- nality is a version of mental abnormality in principle because it reflects a failure of socialization.
This invites the question about whether all criminal deviance could or should be medicalized.
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Second, however we might answer that question, it is clear that criminality and mental abnormality often overlap and coexist and, accordingly, it is not clear whether it is easy empiri- cally to separate mentally abnormal offenders from normal offenders. For example, diagnoses such as ‘psychopathic disorder’ or ‘antisocial personality disorder’ or ‘substance abuse’ together would account for the bulk of the male prison population, in the case of the first two because they are defined tautologically mainly by criminal conduct. In the case of substance abuse, criminality is a common source of income generation in terms of the frowned-upon trade in illegal substances and other forms of activity pursued to sustain a habit. The decriminalization of recreational drug use would alter that criminal justice landscape and allow for a clear offer of a policy of voluntary treatment for addicts. Under current legislative arrangements, crimi- nalization inflates the prison population and offers treatment in a coercive, rather than a more auspicious voluntary, setting.
Third, although intuitively we may consider that a psychiatric approach in detention will be more humane, this is not necessarily the case. For example, such an assumption legitimizes the idea that prisons can and should remain brutal for the normal prisoner (which is open to challenge) and that a health disposal will not be brutal (which empirically is not defensible). On the first count, how exactly will a brutal regime encourage pro-social conduct on the release of a prisoner?
On the second count, we have noted the many scandals in high-security psychiatric provision, sug- gesting that it does not protect patients from an oppressive regime.
Fourth, simply being detained and subjected to institutional routines, in either penal or health settings, may be inherently detrimental to mental health, despite the advantage of stability offer- ing a window of opportunity for intervention being available in a closed system. The latter policy shift we address in this chapter seems to be making a virtue out of necessity. Generally coerced relationships are not the best starting point for personal change, a point noted already in relation to the treatment of drug addiction.
Fifth, any putative advantage of a health setting is offset by the personal costs attached to there being no estimated time of discharge in advance. Those detained in prison know in principle when they will be released (within a range of time). Those in a high security hospital do not. The latter is thereby more offensive to a rights-based approach to care than the former, and so which is the more desirable setting for people with mental health problems who have committed a criminal offence? We weighed up that question in the section on psychiatrization and criminalization of mental abnormality.
Overall, we can conclude that the double deviance of being an ‘offender patient’ or ‘mentally abnormal offender’ brings with it a double disadvantage of multiple and sometimes competing rationales from the State apparatus of social control. That double deviance also ensures that the mentally abnormal offender will be subjected to a double rejection by society.
Given that the general public are suspicious of both ex-prisoners and former psychiat- ric patients, then that double role implicates particular considerations about public policy. For example, many in the non-criminal population think that people should be sent to prison not just as a punishment but to be punished. A discourse of care and treatment inherently conflicts with such an attitude. Likewise the crimes of sexual and non-sexual violence, which are the typical index offences that invite the criminal justice system to define an offender as ‘mentally abnormal’, are the very offences which tend to provoke public anger and demands for severe retribution.
Those demands, fuelled by the popular press depicting mentally abnormal offenders as animals and monsters (i.e. not human), include expectations of permanent detention (and for some even capital punishment). In the light of these public reactions, few politicians are likely to prioritize the liberalization of the regimes of detention discussed in this chapter or address the human rights questions we note.
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Questions
1 To what extent can criminality and mental illness be seen as overlapping categories?
2 To what extent can the management of mental health problems in criminal justice systems be determined by the activities of agents such as the police or prison officers?
3 Is there a justification of arguing for more humane treatment for those with mental health prob- lems over those detained for criminal offences alone?
4 can total institutions, whether hospital or prisons, ever be therapeutic environments for those with mental health problems?
For discussion
consider what the merits and disadvantages would be for dealing with mentally disordered offend- ers if special hospitals were closed down. What would be the implications for inmates of prisons, politicians, policy-makers and health professionals.