Independent Working Group on Antisocial Behaviour: review report

Health

The group heard from a range of health professionals, who identified antisocial behaviour in hospitals, hospital transport and experienced over the phone by call handlers. However, we focused, for the purposes of this work, on public health, mental health and substance abuse. Much of the behaviour that was described was criminal, where a police response was required. The medical professionals showed some sympathy to those causing antisocial behaviour, but felt on the whole that these people are generally in control of their actions. While mental health may be an issue on many occasions, there remain small areas in which capacity is clearly an issue.

The health professionals we spoke to believed that antisocial behaviour is a societal issue and that it needs to be considered as such. Causes were identified as being poverty, addictions, and mental health. What the group heard was that until these issues are tackled they won’t go away. Service cuts were also identified as having an impact, as well as lack of policing or consequences for those who cause antisocial behaviour. The question was asked, if it is not the role of the police, whose responsibility is it?

Health professionals identified themselves as being key partners to preventing antisocial behaviour. Other professionals also identified health as being key partners, although stated that at times health is missing from discussions which may be caused by their concerns over data sharing agreements, their capacity to participate, or difficulty in identifying who from health should represent them.

Taking a public health approach

Given that the underlying causes of many of their call-outs stemmed from major inequalities and from poverty, one recommendation from the health professionals was the need for further investment in a ‘prevention hub’ - as currently modelled by the Scottish Prevention Hub (SPH) based at the Edinburgh Futures Institute, University of Edinburgh. SPH is a national partnership between Public Health Scotland, Police Scotland and the University. It aims to bring together data from a range of sources to build collaborative information systems to support the reduction of health and well-being inequalities. Stakeholders considered that this type of whole system approach, focused on primary prevention, could prove a game-changer.

The group also considered taking a public health approach to prevent antisocial behaviour, similar to the approach taken by the Scottish Violence Reduction Unit and Violence Prevention Framework. The group were particularly interested in the forthcoming Marmot areas and the outcomes of taking this approach.

Case study - Marmot Principles

Public Health Scotland advised of the work of Sir Michael Marmott and health inequalities, and eight principles that should be followed. These include:

1. Give every child the best start in life.
2. Enable all children, young people and adults to maximise their capabilities and have control over their lives.
3. Create fair employment and good work for all.
4. Ensure healthy standard of living for all.
5. Create and develop healthy and sustainable places and communities.
6. Strengthen the role and impact of ill-health prevention.
7. Tackle racism, discrimination and their outcomes.
8. Pursue environmental sustainability and health equality together.

Public Health Scotland have identified three Community Planning Partnerships that have agreed to take forward work adopting these principles in tackling health inequalities in a place based approach. Although evaluation results won't be known for several months/years, this is one example of upstream prevention in action.

Mental Health

A clear theme emergent throughout engagement was the impact of poor mental health and the lack of adequate support services, highlighting the need for both immediate situational response and long-term preventative approaches.

The Scottish Health Survey suggests that mental wellbeing in Scotland is at its lowest level on record, with the poorest mental health being reported from those in the most deprived 20% of Scotland (see also above re Covid-19 impacts on mental health).

The 2022 Scottish Census also showed a stark rise in those reporting having a mental health condition - almost doubling from 2011. Director of Census Statistics, Jon Wroth-Smith, said: “In 2022, 15.4% of people aged 16 to 24 reported having a mental health condition, up from 2.5% in 2011. Females in this age group were twice as likely to report having a mental health condition at 20.4% compared to males at 10.5%. There were also increases in older age groups but the biggest increases were seen in younger groups, and it is now more common for younger people to report a mental health condition. This is the reverse of what we saw in 2011.”

Poor mental health significantly impacts how an individual perceives and interacts with their environment, peers and community and emotional dysregulation can lead to impulsivity and potentially destructive behaviours. Poor mental health can also lead to difficulties in understanding and responding to social cues. Unsupported poor mental health can create a cycle of actions for both the individual and communities - therefore comprehensive support systems are critical for supporting healthier outcomes and tackling antisocial behaviour in communities in the short and long-term.

Engagement with a wide range of stakeholders across a range of disciplines/sectors conveyed the scale of mental health challenges that are leading to behaviours perceived as antisocial, particularly when individuals are unable to access appropriate support or treatment. It is reported that every 3-4 minutes there is a mental health related call to police authorities during the day. Individuals in need of support are then labelled as perpetrators of antisocial behaviour when they require an appropriate mental health response.

The group heard of a lack of investment in mental health services but (in keeping with the research reported above) there was a greater need since the pandemic. Many individuals described as neurodivergent are being seen as being antisocial when what they need is an appropriate response. This is for young people as well as adults, and the services that are funded, like Child and Adolescent Mental Health Services (CAMHS), have large waiting lists of twelve months or more. These services have strict criteria, which many people with mental health issues struggle to meet, though, as noted above, many perceive this as a choice these individuals are making. This, we are told, can have a huge emotional impact on these individuals, which in turn perpetuates the cycle of antisocial behaviour.

Immediate responses, such as local crisis intervention teams and de-escalation techniques, are crucial for managing antisocial incidents in real time, potentially preventing harm and reducing conflict. However, our insight and engagement with stakeholders demonstrates that solely relying on reactive measures often falls short, as it fails to address the underlying root causes.

Investing in situational support and long-term preventative mental health and emotional wellbeing services is not merely a complementary approach to tackling antisocial behaviour - it is foundational. Whilst upfront investment in mental health services may be significant to tackle the scale of need identified in Scotland, it is far more cost-effective than addressing the consequences of, and not limited to, antisocial behaviour. The indirect costs of community trust and relationship damage is also to be considered in this picture.

Investment is also needed in compassionate, evidenced based community mental health services as a vital step in reducing antisocial behaviour. Such services can address underlying issues rather than just the symptoms to prevent further behaviour and are crucial to support victims with existing mental health conditions, or whose mental health has been impacted by antisocial behaviour.

Antisocial behaviour is often linked to socio-economic disadvantage, trauma and exclusion - all of which increase the risk of poor mental health outcomes. Investment in accessible, appropriate and responsive mental health services ensures that preventative support is given to build resilience and healthier coping mechanisms, reducing likelihood of antisocial behaviours emerging in the first place. By providing access to mental health support, communities can support and manage challenges which often contribute to disruptive, distressed or aggressive behaviour.

Furthermore, investment in mental health services can alleviate the strain on the Police, Local Authority/public services, creating a safer, more supportive environment for everyone.

Another option to tackle and prevent antisocial behaviour is the use of compulsion, similar to Respect Orders in England. These Orders have the ability to compel those causing antisocial behaviour to address the root cause of their behaviour e.g. through mandated alcohol or drugs treatment. Translated into a Scottish context, there is an opportunity to consider whether some form of compulsory ‘measures of care’ may be applicable in cases of non-engagement. If this was explored further, it may provide a real opportunity in Scotland to take a holistic approach - while overcoming the difficulties of non-engagement from those whose antisocial behaviour is associated with mental health problems (but their behaviour falls short of being sectionable under mental health legislation) or from those who have full capacity to declare their issues are a lifestyle choice and have no desire to amend their associated behaviours.

This in turn would give the longer-term prevention, intervention, support and rehabilitation approaches time to be effective while providing a robust response for victims of antisocial behaviour and reducing the harm, fear and distress that they suffer both on an individual level, but also in the wider community overlapping into areas such as Retail, Transport and Communities.

Substance Misuse

During our engagement with stakeholders, alcohol and substance misuse were found to significantly contribute to antisocial behaviour in communities across Scotland, often exacerbating tensions and situations. Substance misuse/addiction was found to have a particularly high impact in communities including noise complaints, neighbour disputes, public intoxication and drug-related activities in communal spaces, etc.

Understanding the mechanisms through which alcohol and substance misuse influence antisocial behaviour is crucial for developing effective interventions. Addressing these challenges requires a comprehensive strategy and joined up/multi-agency approach that combines situational response along with education/information, treatment, interventions and community support from appropriate bodies.

Time and time again we heard about cuts in substance misuse services, long waiting times and set referral criteria, with a grave detrimental impact on individuals and communities. We heard very little in the way of education and preventative action around addiction and substance misuse, many responses being reactive/situational and punitive, which does not address the underlying issues and often moves the problem, creating more victims and detrimental impact on families and communities.

Again, we heard that taking a preventive, harm reduction, early intervention approach, has been shown to be more effective in addressing the underlying causes of substance misuse and addiction. Going forward, there is a need for open access to support and treatment, making routes to support, counselling, mediation and treatment more accessible, affordable and culturally sensitive.

There is a need for community intervention, linking harm reduction strategies, community planning partnerships and community policing initiatives. This would strengthen community infrastructure and support initiatives that improve community cohesion and investment in services. Any enforcement approach needs to prioritise de-escalation and support via strong community partnerships/multi-agency and restorative approaches where appropriate.

Actions:

• Align to public health approaches around upstream prevention including further investment in models such as Scottish Prevention Hub/Edinburgh Futures Institute regarding the use of shared data.
• Ensure health sector/practitioners involved in local and national, multi-agency long term and situational approaches.
• Critical to invest in availability of mental health and substance misuse services for children and adults which meet current and future demands.
• Explore whether there are other compulsory ‘measures of care' approaches that can be adopted in relation to situational response

Case study: Compassionate Distress Response Service

The Compassionate Distress Response Service (CDRS) provides a listening service for individuals aged 16+ experiencing acute emotional distress.

The CDRS service has been commissioned by Glasgow City Health and Social Care Partnership (HSCP) and delivered by Glasgow Association for Mental Health (GAMH). The service supports Glasgow City residents to manage distress at their initial point of crisis. This is followed by short-term support, providing coping strategies and signposting where appropriate. The Out of Hours pathway is open 365 days a year 5pm to 2am. The majority of the support is provided via telephone with options for face to face if necessary.

Composite Case study X: Out of Hours Pathway

X was referred to CDRS by the Mental Health Assessment Unit (MHAU) having previously taken an impulsive overdose. There had previously been involvement with statutory services.

During the initial call with CDRS, X referenced their low mood, feelings of isolation, and suicidal thoughts. X could not commit to safety planning but was agreeable to the MHAU contacting them for another assessment. Following further assessment and safety planning, CDRS continued supporting X. Despite CDRS ongoing support, X’s level of distress remained significant.

Summary of support provided to X:

• CDRS provided regular empathetic listening and was supported emotionally through period of distress - providing X time, space and compassion in their period of distress.
• CDRS provided X with a range of coping strategies/distraction techniques and alternatives to self-harm (e.g. breathing and grounding techniques, soothing box, journaling, positive affirmations, mindfulness) which X said they found helpful.
• CDRS also highlighted positive impact of improving social supports, daily routine, exercise regime, diet, and sleep hygiene.
• CDRS signposted X to a range of services that they might find helpful.

Outcome of short-term support provide by CDRS

CDRS remained in contact with X over a four-week period during their period of intense distress. An additional two weeks were provided after discussion with MHAU. This period was to provide X support while the Community Mental Health Team facilitated additional supports to be put in place (e.g. Crisis Team/Community Psychiatric Nurse/Psychiatrist) for longer term support.

Thanks to CDRS for permission to use this case study.