risk management

Is empathy finite? Part Two: Brock Turner

This is the second of two blogs about recent sex offences that have made the news, and is about Brock Turner. The prior blog was about prolific child abuser, Richard Huckle and can be found here. In that case, my ability to have any empathy for the perpetrator was severely tested. In this case, it isn’t my empathy that is under question (because I don’t have the same discomfort in trying to understand the position of all the different parties in this case), but that within our whole culture.

I’m sure you will all have read the story about how Brock Turner sexually assaulted an unconscious woman outside a frat party and her eloquent response to his six month sentence.

What was notable was that the case polarised the world into two camps. Either this was the fault of one individual who did something awful, or he was just the unfortunate example that got punished of a problematic culture of drinking and promiscuity amongst young adults at American universities. Here is how the two alternative stories are framed:

1) Everyone was drunk at the party and coupling off with strangers for casual sex, and that was part of what is expected at frat parties, everyone knows that. The guy was very drunk and paired off with the girl by mutual agreement. They were kissing and she consented to go back to his dorm, but they fell over and were kissing and fumbling on the ground mutually enjoying the sexual activity and he didn’t notice that she lost consciousness at some point before vigilantes interfered. He was a promising scholar and sportsman who has lost a prestigious place at Stanford and will serve six months in jail and be on the sex offenders register for life. He has been an unfortunate example of taking accepted culture one step too far and the poor guy will be paying for that for his whole life in the change in his career trajectory.

Or

2) The victim was really really drunk whilst the perpetrator was just a bit drunk, and he had a pattern of being sexually aggressive to women in similar circumstances. He had made sexual approaches towards the victim’s sister and was knocked back, so he tried it on with her and realised she was too drunk to resist (despite having a long term boyfriend she was committed to) so he led her off and she fell down unconscious by some bins on the way out. Instead of calling for help for her he sexually assaulted her injuring her genitals and would have raped her if not for the intervention of two passing cyclists who noticed her being obviously unconscious. She regained consciousness three hours later with no memory of what had happened, injured and bleeding in a hospital where she then had to be forensically examined for evidence of rape, whilst he expressed no concern for her during several hours of being questioned by police, claimed she gave consent and denied she was unconscious. She then had a year of stress building up to the trial, where she was cross examined and blamed for what happened to her. She has been traumatised for life, and this sentence sets a precedent of rape culture on college campuses being not such a big deal.

I think the evidence best supports the latter version, and the conviction suggests that the court agreed. But I think there is some truth in both stories, because as I have often said before, behaviour almost always reflects the person’s experience and the context as well as the choice that they made. There is a massive problem in modern western culture, particularly amongst young adults, in which sexual coercion is normalised and blamed on alcohol, which is consumed to excess. It is also scarily prevalent. You might call it a rape culture. About 20 million out of 112 million women (18.0%) in the United States have been raped during their lifetime. Only 16% of all rapes were reported to law enforcement. In 2006 alone, 300,000 college women (5.2%) were raped. Among college women, about 12% of rapes were reported to law enforcement. There are similar figures for the UK. And it makes me wonder – why do we not have basic empathy and respect for each other, even when we are intoxicated and disinhibited?

The culture of deifying talented sportsmen in American universities and the tendency for athletic teams to spend a lot of time together and sometimes live together also appears to have contributed to the answer. A recent study shows that male intercollegiate athletes accounted for 19% of all sexual violence cases reported but only comprised 3% of the student populations. Amongst these groups, attitudes to women are problematic. The researchers found many more “beliefs and situational definitions that excuse rape or define assaultive situations as something other than rape” in athletes. Amongst sportsmen there were also distinctive narratives. The researchers reported that amongst athletes “hypermasculine discourse includes war-like, misogynistic, and sexually violent analogies” and that this was directly related to the difference in attitudes towards sexual coercion. 29.5% of college men in the study sample had insisted on having sex when their partner did not want to, and 5% have used force and 5% have used threats to get a partner to submit to sexual activity. Attitudes toward women were less progressive and rape myth acceptance was more prevalent amongst athletes. You can see echoes of this in the letter from Turner’s father, which blames a culture of drinking and promiscuity rather than his son’s actions and displays no empathy for the victim. Likewise the same theme is present in Turner’s testimony, and in the (repugnant) letter sent to the judge by a childhood friend of Turner who claimed that the accusations levied against him were down to “political correctness”.

The truth is that whilst we can take actions to help reduce the availability and vulnerability of potential victims by helping to educate teens and young adults about the dangers of binge drinking, the main problem is in the attitudes and actions of those who use coercive sexual behaviour. In the words of an infographic from facebook, the causes of rape are 0% slutty clothes, 0% alcohol, 0% college culture and 100% rapists. And in the words of another infographic:

“She was drunk, what did she expect?” “A hangover, that’s what she expected.” Drinking isn’t a crime, rape is. Stop victim blaming.

Whatever else contributed to Brock Turner being in that position, let me quote the letter from the survivor of this incident, “we should not create a culture that suggests we learn that rape is wrong through trial and error”. We need to teach every child about privacy and consent from when they are very small to when they are adults. Here is how I explain it to young children: If somebody wants to touch a part of you that is covered by your swimming costume or to put anything in your mouth, then they need to ask you and not do it unless you say it is okay. And if you want to touch any part of another person that is covered by their swimming costume or put anything in their mouth then you need to ask them, and only do it if they say it is okay. You should only say yes to someone doing that if it is someone who needs to touch you to help with an illness or injury and Mummy or Daddy are with you and say it is okay. If anyone does something like that when you don’t want them to or it doesn’t feel right, you should always talk to me about it or someone else that you trust”. Here is how I explain it to a teenager “Don’t ever pressure anyone else or let anyone pressure you to do things that don’t feel right or comfortable to you. If you aren’t sure, you can always talk to me about it. That includes anything about sex or relationships”.

Whilst the mythology of false allegations implies otherwise, and real life is always more ambiguous than it appears in theory, consent is actually pretty simple. If somebody is in a fit state of mind to make decisions and actively says yes and reciprocates, then they consent. If that isn’t the case then they don’t. When this video came out I wondered why they needed to spell out that if a person is unconscious they can’t consent. Now we know why. It is only a basic level of empathy that is required. The golden rule of do as you would be done by. But it involved placing yourself in the other person’s perspective and understanding that the person you really want to have sex with might not really want to have sex with you, and if they did they might want to do so after a gradual progression of the relationship and without intoxication that would impair their judgement.

On the other hand, one bit of empathy is transparently clear from this case. The judge, a former Stanford athlete himself, appears to have had too much empathy for the impact of the sentence on the life of Brock Turner, perhaps because of over-identification. Whilst I respect that he was a prosecutor of sexual offences, and may also be comparing this assault (which was interrupted, and thus never progressed to what we in the UK would define as rape) to other cases from his career that involved violence or threats, and whilst it may well be that Turner has now learned his lesson and will be very clear about obtaining consent in the future, I was not persuaded by anything I have read that Turner accepts responsibility for his actions. In fact, it appears he only accepts responsibility for drinking, and not for any sexual offence. He pleaded not guilty, and amazingly, he is going to appeal even this remarkably light sentence. On that basis I believe it is important that the sentence reflects the gravity of sexually assaulting an unconscious woman, and his lack of genuine insight or remorse, as well as setting an important precedent to show that college culture or use of alcohol is not an excuse for sexual assault.

In my next blog I may talk about my own experiences of unwanted sexual contact. But for now I want to finish by remembering that two students noticed what was happening and intervened. Many people would ride right on by, and it may be that their Swedish rather than American/British norms were part of what protected this woman from being raped, but in this instance two people saw what was happening was wrong and they did something about that. And the victim has not only become a survivor, she has found her voice and used it amazingly articulately to become an advocate for all women who have experienced unwanted or coercive sexual interactions. I think that is a salient reminder that no matter how skew the norms can get within certain small pockets of society, the rest of us can still recognise right and wrong, and protect each other. However dark the world is, we are not entirely powerless. We can prevent some people from being harmed, and can help others to recover from these experiences. We might not be able to change the world immediately, but we are making slow steady progress over time, and at an individual level and at a societal level, things can be better if the rest of us play our part. No matter how overwhelming the rape culture might feel, we can all be part of the solution.

Edit: I have since read that Brock Turner may have photographed the breasts of the victim whilst she was unconscious, and another stranger may have seen him do so, then checked she was still breathing and put her into the recovery position prior to the sexual assault. If this is true, then any pretence that Turner was unaware of her being unconscious is thrown out the window. It would also appear that he had a history of drinking and using drugs prior to attending Stanford, so the attribution of the cause to the culture of drinking and promiscuity at the college seems like even more of a red herring than it did before.

Is empathy finite? Part One: Richard Huckle

There have been two challenging stories in the news this week. In the UK Richard Huckle was given 22 life sentences for sexually abusing around 200 Malaysian children, and in the USA Brock Turner was given 6 months in county jail for sexually assaulting an unconscious woman outside a frat party. Each of them has been hard to read and aspects of each case have brought me to tears. The stories have made me feel grief for the victims and anger at the perpetrators, frustration about the cultural norms that gave them opportunity and in their mind justification for their actions, and vexed at the justice systems that somehow seemed inadequate in the face of each situation. And in each case, it has been really hard to hold on to any empathy for the perpetrator, despite my strongly held belief that people are the product of their experiences and influenced by the context, rather than ‘born evil’.

Because I have read and thought so much about these two cases, and discussed them online, I thought I would write a blog post about each. This is the first of those two blogs, and is about Richard Huckle.

Make no mistake, what he has done is unthinkably awful. Genuinely evil, to the point it is hard to even comprehend. He deliberately targeted vulnerable children and babies in deprived communities for his own gratification, and shared his activities with others for financial gain through the dark web. He even wrote a manual advising other paedophiles how to sexually abuse children in less developed countries. He was clearly without conscience or empathy, or able to override any remaining scraps of either in favour of sexual gratification. The psychiatric assessments were reported to say that he justified his actions and showed no remorse. His ledger and writings on the dark web boasted about his activities. So I can understand why he got such a hefty sentence, and why many people feel he should have been tried in Malaysia where he could have got a death sentence. He has harmed hundreds of children and families, and changed the course of their lives for the worse. No sentence can ever compensate for that.

I found myself thinking that if he committed suicide or was killed by other inmates very few people would be sorry to hear the news. In fact many would argue that the cost of 25+ years in prison is money that will be wasted on an individual that is beyond rehabilitation. Comments on the internet below the breaking news stories said things like:

“Hope he rots in hell he doesn’t deserve to breath air”

“It’s time to bring in capital punishment for paedophiles. Why should we pay for his upkeep? Death is the only appropriate punishment for this creep”.

“How tragic for his father and mother, who were obviously conscientious and committed parents. It just goes to show, you can give your children a good upbringing but you simply can’t control how they turn out. This guy is a slave to his perverted sexuality and his condition is incurable. He really should be locked up for the rest of his life because he will always be a danger to children. What a terrible affliction for any human being to be born with”.

And a woman in the public gallery shouted “a thousand deaths is too good for you” as he was led away from court.

Despite all of my psychology and experience with child protection issues and knowledge that most people who harm children have been harmed themselves, I found myself hating him and feeling no empathy whatsoever. It was as if he had stepped outside of the range that my empathy could stretch. I wanted him to suffer because he had made others suffer. If I’m honest, I’m still very conflicted about it.

However, like the awesome film Arlington Road illustrates, there is rarely a lone gunman. As much as it is an attractive narrative that distances us from responsibility, I don’t think that one person in a million is randomly born evil and will inevitably do things like this. I believe there are things we can do to make such events less likely to recur over time, and it is that belief that stops me feeling hopeless and helpless when the news constantly bombards me with all the evil in the world.

When I took a step back from the emotions raised by the awfulness of what this man did and thought about what I have learned from both research and practice, I found that there are in fact lots of pieces of knowledge that can help us to make sense of what happened and what we can do to reduce the chances of it happening again. In other words, I started to think like a psychologist again, and I wanted a formulation that would help me to reach some understanding of how he got to the position of doing such evil things. Such an understanding would let me sidestep my helplessness, anger and desire for retribution, and instead focus on something constructive; doing something positive to prevent similar cases from occurring again in the future.

As I mentioned earlier, I believe that people like Huckle are a product of their experiences as well as their innate character, and their offending happens within a context. Of course I still believe in free will, and that people are culpable for the outcomes of the choices they made, and clearly Huckle made very very bad choices again and again and deserves to face the consequences of that. But we don’t make those choices in isolation. Although he was particularly prolific in his offending, Huckle was far from the only person to perpetrate child sexual abuse in the UK. In fact, there are over 100,000 people in the UK who have committed a sexual offence against a child and around 5000 new convictions are made each year. About a fifth of the population have experienced some form of unwanted sexual contact before they reach adulthood. Police recorded 36,429 sexual offences against children in the UK in 2013-14, and estimates suggest that only one in eight offences are reported. So this is a massive problem. (To put it into context, 1600 children per year are diagnosed with cancer, so sexual abuse is more than 20-180 times as prevalent). I believe that when it comes to any form of antisocial behaviour, violent or sexual crime, particularly on this scale, such actions are also an indication something is wrong in our society. It doesn’t surprise me that numbers on the child protection register are rising during this decade of ideological austerity that is widening the wealth gap in the UK. Just as suicide rates, substance use, homelessness and the incidence of mental health problems are increasing as a result of political decisions, so domestic violence and child maltreatment is rising as people fail to cope with the additional stressors imposed by benefit cuts, sanctions and reductions in public services.

There are several likely risk factors that relate to the abuser. First we know that whilst experiencing sexual abuse is neither necessary nor sufficient to create a perpetrator, the chance of sexually abusing children is increased threefold if he was sexually abused in his own childhood, and that experiencing sadistic emotional or physical abuse can also increase risk. We know little about Huckle’s family, but attachment disorganisation and the absence of any secure attachment figures seems much more prevalent amongst abusers. It is known that many sex offenders have sexual dysfunction. Isolation, low mood, loneliness and lack of social skill seems to also contribute, as do neuropsychological impairments – and Huckle was described as a loner who spent most of his time on the computer, as well as “uncharismatic” and on the periphery of things. Finally, the majority of people who sexually abuse children are religious (studies show 93% of abusers to report a strong religious identity, and around 5% of priests have been named in disclosures of sexual abuse). In between trips to Malaysia to abuse children Huckle was actively involved in the church and described himself as a devout Christian. Was that just an act, designed to gain the language and credibility to access children, or was there another motivation? Was he perhaps conflicted about his actions and trying to compensate or seek forgiveness? Or did he believe he was already going to hell, so he might as well do what he wanted in the meanwhile? Or did he have outwardly strong morals as compensation for lacking an internalised moral code? I suspect we will never know.

The part of this picture that is less often a focus of attention is the contribution of online communities to the normalising and even encouragement of abusive activities. However, we know that using the internet gives people an (often false) sense of anonymity and privacy, that brings out certain traits in their behaviour that might otherwise be inhibited because of the social consequences. On top of that certain communities have developed that collect and exaggerate certain types of behaviour. For example, the notorious bulletin board 4chan has boards within which particular patterns of behaviour from trolling to internet vigilantism (such as the hacker group Anonymous) have become the norm. Likewise certain boards have allowed the gathering of gamergaters, men’s rights activists, furries (people who like to role play anthropomorphised animals), bronies (adult male fans of the children’s cartoon My Little Pony), otaku (Japanese nerds), toonphiles (people who want to have sex with cartoon characters), adult babies, truthers (people who believe in elaborate government conspiracies, such as that 9/11 didn’t happen), those trying to give up masturbating to pornography, and many other quirky groups that would not be able to express themselves within a mainstream community. There are groups that advocate in favour of all kinds of risky behaviour from anorexia to suicide, drink-driving to barebacking (unprotected sex between men, which includes “bug-chasing” – having unprotected sex with men who are HIV positive with the intention of gaining HIV positive status). Online people can present with whatever persona they want to create. Instead of being lonely and powerless they can be charming and popular. In that context, it is not surprising that there are websites that normalise and encourage child pornography, and create demand for more content (including a financial incentive, which Huckle had used to seek crowd-funding for pornographic material he had made related to his abuse of a 3-year-old girl).

However, there is much that is unknown about the relationship between use of the internet, viewing child pornography and sexual abuse of children. Does the availability of “edgy” content pull users of legal pornography towards more extreme material that they would not otherwise access? Does the market create an increase in abuse to provide the materials that can be sold? Does viewing child pornography online become a stepping stone to contact abuse? Or does it allow potential contact abusers to meet their needs without harming additional children? Is it related to the grooming of children online? One in eight people convicted of viewing child pornography on the internet had a known history of offending against children in person but it is still unclear which is chicken and which is egg when it comes to a sexual interest in children and viewing of child pornography. But it is clear that law enforcement resources are totally outnumbered by the prevalence of child pornography online.

Finally, there are factors which make some children more vulnerable to become victims of child sexual abuse than others. These include the lack of a secure attachment figure, shame, isolation, neglect, disability, the presence of other forms of child abuse, socioeconomic deprivation, stressors placed on the family (eg unemployment, bereavement, divorce), cultures in which secrecy is encouraged or permitted, prior sexual abuse in the family (particularly if this was not reported and discussed), alcohol or substance misuse, domestic violence, and settings in which there is sexual language, pornography or exposure to adult sexual activities. These same factors make it harder for children to disclose what has happened to them, and for such a disclosure to lead to suitable protective action. Only one in eight children who experiences abuse receives any professional input to assess or intervene with it.

So there are things that we can do to mitigate the risk of future harm. We can protect future children by addressing inequality, providing more support for parenting and attachment, providing more prosocial opportunities for engagement for disenfranchised young people, being more proactive about responding to child abuse, having more investment in policing the internet so that access to child pornography reduces or is perceived as more risky. We can help victims of abuse to speak up early, to the right people, and to be believed. We can encourage the investigation and prosecution of sexual offences against children, and ensure that conviction rates and sentences are sufficient to act as a deterrent. We can specifically develop international policing solutions to address sex tourism. And most importantly of all, we can also help victims to recover from the abuse they have experienced, to feel safe and protected and develop healthy norms about relationships.

Huckle has done evil and unforgivable things. I still can’t find much empathy for the person he is now. However, if I think back to him being born, and the experiences that must have taken place to take him to the point at which he could abuse children, I am able to feel sad for that baby and angry at those who harmed him and failed to protect him or to intervene much earlier to divert him from his path and recognise their contribution to his development and the harm that he then perpetrated. And if behaviour is learnt, then no matter how unlikely, there may be a future point at which it can change. So maybe in 25 years from now it is worth reconsidering whether he still presents a risk, or whether he has gained insight and empathy that he is currently lacking. Perhaps new treatments will have emerged by then to make it possible. It seems hard to imagine that being the case. I’m usually an optimist, but for Huckle, I can’t foresee a happy ending – and I’m not sure I want to.

But there is a note of optimism in the bigger picture. Despite all the evils of austerity, and the massive burden that is creating on the wellbeing of the world population, and a few horrific cases that have been well-publicised in the media there is some progress. Sexual abuse is being talked about more, and more resources are being targeted at prevention and intervention. And there is fairly solid evidence that although there has been a dramatic spike of reports of abuse in the UK over the last two years, the overall prevalence of sexual abuse in the western world appears to be decreasing over time. Hopefully, that decrease will continue to accelerate over time, until sexual abuse really is the one in a million exception, rather than an all too present reality for a significant proportion of children.

 

Where have all the flowers gone?

This week Liam Fee’s name was added to the list of toddlers killed by their caregivers, alongside Peter Connolly, Victoria Climbie, Daniel Pelka, Ayeeshia Smith and Keegan Downer. And the newspapers have turned their gaze to their favourite post-mortem task of placing the blame. The conclusion, as ever, will be the ‘born evil’ women who killed him, and social workers who ‘failed to prevent’ the death. But that doesn’t tell the whole story.

Firstly, how can social workers prevent child deaths when their services have been cut back so much that thresholds for intervention have risen ever higher?  Social workers are over stretched and morale is at an all time low. When they intervene too much they are demonised by the press as baby-snatchers. When they don’t intervene enough they are demonised as failures who didn’t protect children. Since legal aid was slashed, court proceedings expect them to be both case worker and to cover the role of expert to the court. The social workers I know are amazing people, dedicated to helping make a difference with families, but tell me that some workplace cultures focus on form-filling and don’t allow as much time out in the field intervening with families as they would want.

Personally, I think prevention takes more than reactive services like the current remit of social work. We need proactive screening services to spot where there is need much earlier, when interventions for families are cheaper and more effective. In my opinion we need universal health visiting back, for every birth registered to be followed by mandatory visits twice a year until the kid starts school and for that to include weighing and measuring the child and seeing them in just their pants. It will also see the home environment and the relationship between parent and child. Old fashioned, maybe, but it would hopefully catch malnutrition and serious injuries earlier, and save lives in cases like these.

Secondly, what kind of lives must those two women have had that they were so un-empathic that they could witness and ignore such suffering, let alone create it? There must have been great trauma to end up like that, and a total absence of nurture. Of course no experiences are an excuse for the sadistic things they did to the children in their care. But they can help us to understand what happened, and in doing so to help prevent a future recurrence of similar issues. If we just blame it on innate characteristics of the individual perpetrators there is little we can learn to prevent the same thing happening again (except perhaps chase the fallacy of a genetic marker for evil, which I’m almost surprised is not already being done, given the overly biological focus of research topics that are clearly more influenced by experience).

I’m not convinced that anybody is ‘born evil’. I think people are born with the capacity to be a wide range of things, and their experiences (particularly their early experiences with their caregivers) determine the direction of travel, the types of skills they develop and the behaviours that are in their repertoire. Given exposure to enough trauma, a total lack of safe attachment figures, few skills and loads of dysfunctional strategies, people can end up doing awful things, particularly with a hair-trigger tendency to fight or flight under stress.

This is an evidence based position, not just my opinion as a clinician. We have known for at least a decade that childhood experience is the leading predictor of the health and social well-being, and that this applies on the individual level as well as for the nation. But as well as the self-evident human cost, there is also a huge economic cost to society. Studies show that the financial impact of child maltreatment on the economy amounts to billions of pounds per year, and the impact on lifetime health and employment is equivalent to a diagnosis of diabetes. However, the costs are hard to measure, and occur throughout the person’s lifetime so they are not as obvious.

Violence in society is neither universal nor inevitable (in fact it is almost absent amongst central Thai or Lapp society). Violence is a behaviour that is caused and can be prevented. When it comes to predicting violence, it is clear that the propensity is hugely influenced by experiences in the home before the age of 3. We also know that various interventions to improve care and the quality of the attachment relationship, or the more drastic intervention of removing the child and placing them in a household with better care are highly effective. However, there are also sociopolitical factors at play. Once the use of violence is established in a society, the levels are influenced by many factors, including:

  • Economic inequality
  • Unemployment
  • Alcohol consumption
  • Violence in the media
  • Poor housing
  • Availability of weapons

And yet, over the last decade economic inequality has increased, social housing has been sold off, and more violence has been shown in the media. More hopelessness has been created by the cuts to benefits for people with disabilities, or living in homes with an extra room. Services for people using drugs and alcohol have been cut by austerity measures whilst the need for them has increased. So the government has increased the risk of violence, whilst (as with immigration, single parents or benefit fraud) blame is being directed onto vulnerable individuals and public services.

Liam Fee, Peter Connolly, Victoria Climbie, Daniel Pelka, Ayeeshia Smith and Keegan Downer are the tip of the iceberg. There are many child deaths from maltreatment that never make the news. Best estimates based on serious case reviews suggest 40-80 deaths of preschool children are caused by their caregivers per year. And of course, many more children are injured physically or emotionally every day. For every child experiencing abuse who is known to services, eight more are going unseen. But this is not down to individuals who are born evil, and it is not down to negligent social workers. It is a socioeconomic and political problem. And whilst the media propagates the narrative of individual blame and politicians turn a blind eye, children will continue to die.

Where have all these children gone, long time passing?
Where have all these children gone, long time ago?
Where have all these children gone?
Gone to graveyards every one.
Oh, when will we ever learn?
Oh, when will we ever learn?

Falling through the cracks – the current state of NHS mental health services

Recently I spent sixteen hours trying to get an acute mental health assessment for a someone. The details of the case are not what matter here, but I want to talk about what I learnt from the process, and to do that I’ll need to give some context. It is necessarily vague and some information has also been changed to protect confidentiality.

However, as a pen picture it is fair to say that there was a combination of a severe deterioration in mental health with risk to others (the person had bizarre beliefs that led them to want to injure/kill people within particular demographics). The person did not want any mental health input, but I felt that the risk issues were so acute that it was necessary to override the lack of consent and request that an urgent mental health act assessment be undertaken. The other members of the household were keen for this to happen, as were various professionals who were already involved from the health, social care and criminal justice sectors. The person was open to a locality mental health service, but after the initial assessment identified various needs nobody had been allocated to undertake the work, so although it was an open case there had been no service for several months.

So, I rang the local service to ask for a psychiatric assessment. It wasn’t an area where I have worked before or a service that I had any prior experience with so I rang the number on their website. I explained I felt that there was acute risk coupled with obvious decline in mental health, but a lack of consent to treatment, so I enquired what kind of urgent services could be triggered, suggesting that the person involved would be difficult to approach and it would almost certainly be necessary to undertake a mental health act assessment and an admission against the person’s will might be necessary to safeguard others. And that is where I hit a brick wall.

The local service told me they were not commissioned to have a crisis service, and that unless the person involved had self-harmed they did not meet the urgent criteria. No amount of risk to others, or deterioration in mental health would qualify for their service, unless there was self-harm, or the person presented at A&E themselves, or we waited the timescales of their routine service (which had no capacity to allocate a worker). Pointing out the NICE guidance required a same-day response didn’t shift their position. Highlighting the risk to others or the individual likewise seemed to go unheard. The Approved Mental Health Professionals team said that the person met their criteria, but they could not get involved unless there was a psychiatrist from the locality team who had seen the person and would identify the bed if it was necessary to use a section. The psychiatrists said they were not resourced to go out and see people, and that they were not prepared to put themselves at risk by attending a person who presented a risk to others, even though I had arranged for the police to be present. They said the only way they would see the person was if the police used section 136 to bring them to the hospital as a place of safety, where they could then provide an assessment. They suggested that we call 999 to ask for ambulance and police assistance. The ambulance and police said they were not there to provide transport, and if the person was calm and inside the house, they did not present an imminent threat that required removing them using section 136.

Deadlock.

The next day I phoned the local mental health team again and asked to speak to someone senior to raise my concerns about the case. The duty clinician called me back several hours later. I got asked “what do you expect us to do on a Friday afternoon?” and “why is this our problem?” and then got talked over loudly again and again as I tried to explain the issues with risk and mental health. I asked politely four times for the person to stop talking over me, without effect and then asked her name. She refused to tell me and ultimately hung up on me. Her service wouldn’t tell me who I had spoken to, or give me any information about the complaints procedure beyond telling me to write a letter to their postal address. I asked to speak to a service manager. Unavailable. To a psychiatrist. Unavailable. I asked for someone to call me back. at 4.45 I got a return call with the same content as the previous conversations. No crisis service. Doesn’t meet their urgent criteria. A&E, the police bringing in under a 136 or nothing. I wrote a report giving all of my concerns to the whole network in writing.

In supervision I talked about my anxiety about a serious incident, and my fear that nothing would be done, and everyone would pass the buck. I was supported that my concerns were legitimate, and made the decision to try to take it up the chain of command. I called the department again. Then I called the directors of the trust involved, and the complaints department. I made calls all morning with no response, having already had no response for over a fortnight to concerns I felt were so acute they needed a same day response. So I called the CQC.

The CQC were very helpful, and made me feel that it was the right place to raise my concerns. I feel that the systemic issues will eventually be addressed because of the CQC having sufficient power to influence commissioning decisions, but that doesn’t help in the timescale of the individual. Likewise someone near the top of the trust concerned did get back to me the next day, and want to learn from the process (perhaps motivated by awareness of the CQC being involved). Hopefully we’ll look at the pathway, and address the various issues that my experience flagged up*. But again, that’s fixing the stable door after the horse has bolted. At the individual level, the outcome was disappointing. The person is moving to a different area within the next few weeks, and the service have decided that means that they don’t have to do anything, whilst the new area will only act if concerns are raised once the person arrives.

So the story doesn’t have an ending yet. There wasn’t a happily ever after, because the service I felt was required within a matter of hours hasn’t been provided, despite several weeks having passed. However, there hasn’t been a serious incident either. I’m keeping my fingers crossed the former happens before the latter.

But it was a pretty weird experience for me. Normally, if I raise a concern people take that pretty seriously. I’m a fairly senior clinician with the titles Dr and Consultant by my signature. I’ve been an expert witness in 200+ court cases. And I’ve had 20 years of experience against which to judge risk and after 16 years in the NHS I also think I have realistic expectations of services. I’ve never made a complaint about an NHS service before, and I hope I never have to again, but I didn’t feel like I had any other option. I was genuinely horrified to see defensive service specifications being used to deny a person with clear acute mental health needs a service. I felt like my concerns were ignored and dismissed because they were inconvenient and didn’t fit within existing pathways.

I’m not sure that my involvement did any good at all for the person in the end, despite spending hours and hours on the phone and writing emails and letters. But it made me wonder, what if I wasn’t there? What if there wasn’t someone with a title and qualifications and NICE guidelines to cite to try and agitate for the services to do the right thing? What if a family member or friend of the individual rather than a professional was trying to express their concerns? Why are the barriers so high when it comes to accessing mental health services? Why have services got specifications that exclude people in serious need? Why are the processes to raise concerns so opaque and so slow? Why don’t services join up better? Why are services always reactive and so rarely proactive? Are age, gender, race or other demographic characteristics a barrier to accessing treatment? Why are we still so far from parity between mental and physical health services? Why does mental health still not have the kind of services there are for acute physical health needs? Most of all, why does common sense and compassion get lost in pointless bureaucracy when it comes to referral pathways and criteria?

I used to be so proud to be part of the NHS. Now I wonder about what it has become. Is this just what is left after decades of cuts and reorganisations, or was I always a roll of the dice away from hitting a dead end?

*this was never followed up, so in retrospect it seems it was just platitudes to shut me up