امداد رسانی بهداشت روانی و پلیس خیابان در مرکز شهر شهرستان های بزرگ فرانسه

Context Marseille, the second largest city in France, has a large population of homeless persons. A mental health outreach team was created in 2005 as a response to high rates of mental illness among this group. In a national political context where security is a government priority, a new central police station was created in Marseille in 2006 to address robberies, violence and illegal traffic in the downtown area of the city. While not directly related to such crimes, police also are responsible for public safety or behavioral issues related to the presence of individuals who are homeless in this area. Objective This report on a two-year pilot study (2009–2011) addresses collaborative work between a mental health outreach team and the police department responding to the clinical needs of persons who are homeless with serious psychiatric disorders. It also describes the homeless persons' interactions with, and perceptions of the presence of, police and mental health professionals on the streets. Methods Investigators adopted a mixed-methods approach. Data were collected on 40 interactions using brief standardized report for each interaction. Focus groups were conducted with police officers, outreach team members, peer workers, and service users. Minutes of partnership meetings between police officers and outreach workers also served as a source of qualitative data. Results Outreach workers initiated just over half (n = 21) of the encounters (n = 40) between police and outreach workers. Interactions mainly involved persons with psychosis (77%), the vast majority (80%) of which involved persons in an acute phase of psychosis. Two key themes that emerged from data analysis included the violent nature of life on the streets and the high percentage of ethnic minorities among subjects of the interactions. In addition, it was found that the practices of the outreach workers are sometimes similar to those of the police, especially when outreach workers use coercive methods. “Users” (homeless persons) described police as sometimes using less coercion than the outreach team, and noted that they were more fearful of psychiatrists than police. Conclusion Formal initiatives between mental health outreach teams and police departments involve some common street practices. This study demonstrates the potential for closer working relationships between the two parties to help persons who are homeless with mental illnesses rece

Street homelessness among persons with psychiatric disorders has been identified as a serious social problem in large French cities (Girard, Estecahandy, & Chauvin, 2010). In the past two decades, homeless people have become increasingly visible in public spaces in spite of growing state investment (almost 3 billion Euros/year) to address this issue (Damon, 2009). In 2006 and 2007, a social movement organized by an activist group set up tents in the centers of large French cities and, in the middle of a presidential campaign, pressured politicians to endorse a right to housing that would be enforceable through the courts (Loison-Leruste & Quilgars, 2009). French epidemiological studies show a significant over representation of people with severe mental disorders among the homeless population compared to that of the general population (Guesdon et al., 1998, Kovess and Mangin Lazarus, 1999 and Laporte et al., 2010). These findings are consistent with those of a meta-analysis recently conducted on Western cities (Fazel, Khosla, Doll, & Geddes, 2008). Persons with severe psychiatric disorders are at risk of violent victimization (Lovell et al., 2008 and Maniglio, 2009) arrest, and inadequate mental health treatment (Swanson, Swartz, Elbogen, Wagner, & Burns, 2003). Studies have also documented high rates of incarceration for persons with severe mental disorders (Baillargeon et al., 2009 and Falissard et al., 2006), who are homeless (Greenberg & Rosenheck, 2008) and who have co-occurring addiction problems (Hawthorne et al., 2012). Homeless people with psychiatric disorders are in need of care, but jails often are the de facto institutions that address, or fail to address, their needs, including those of persons with co-occurring substance use disorders (Baillargeon et al., 2009, Fischer, 1992 and Greenberg and Rosenheck, 2008). In France, a sense of insecurity has been increasing for the past two decades (Robert & Pottier, 1997) and public safety has become a central electoral campaign issue both nationally and locally (Le Goff, 2005). People who commit murder are regarded by the public as being “mentally ill” and “crazy” (Caria, Roelandt, Bellamy, & Vandeborre, 2010) in spite of research evidence that alcohol use carries a higher risk of crime than schizophrenia (Fazel et al., 2009 and Walsh et al., 2002). People living with schizophrenia face major stigmatization (Van Zelst, 2009), and are at far greater risk of criminal victimization than members of the general population as a whole (Lovell et al., 2008). In this paper, we report on a police department–mental health outreach team partnership aimed at protecting vulnerable people from victimization, preventing unnecessary incarceration, and increasing access to mental health care for, among persons with mental illnesses who are “street homeless” (Fournier & Mercier, 1996). More than 60 mental health outreach teams were created in France between 2005 and 2008 (Mercuel, 2008). Most of the professionals were working at the public psychiatric hospital as nurses, social workers and psychiatrists. To date, there has been no published research on partnerships or other encounters with police. More generally, little research has been conducted on any form of collaboration between the police and psychiatry in France. Marseille (population 800,000) has the poorest downtown area of any French city, and has sharp social disparities (Bras, 2004 and Donzel, 2005) including a large homeless population. A mental health outreach team provides services in downtown Marseille for a caseload of approximately 200 people who are homeless and who are routinely charged with disorderly public conduct for “nuisance behavior” such as urinating in public and talking and screaming to internal voices. This categorization of “nuisance behavior” treats symptoms of mental illness as criminal matters. In addition to mental health outreach, the team runs a “squat” — a collective place to live that serves for some persons as an alternative to psychiatric hospitalization (Girard et al., 2012). The outreach team has attempted to develop a community health approach consistent with recovery-oriented mental health practices inspired by the work of Davidson and colleagues (Davidson, Tondora, & O'Connell, 2008). A new central police station of the national police was created in 2006 in the center of Marseille. This station was charged with reducing crime and robberies in the downtown area. During this same period a new management structure for the national police was initiated. Consequently, arrests for minor crimes and for identity checks increased significantly throughout the country (Muchielli, 2008). The impetus for collaboration between the outreach team and the National Police Department of Marseille came primarily from the outreach team (team). The team hoped that by establishing ongoing communication with the police it could foster better relations with the police and between the police and the team's target population, leading to fewer arrests and incarcerations of people who are homeless with mental illnesses. The team tried at the same time to have some contact with municipal police, but without success. On the streets of Marseille, national police are 10 times more numerous, and responsible for most of the arrests. For that reason, partnership with the national police seemed to be a good starting point for the outreach team. The team also hoped the police would help them locate hard-to-find at risk people with psychiatric disorders who are living on the streets. Contacts between the team leader, a psychiatrist with the public assistance division of the Hospital of Marseille, and the Chief of Police led to the initiation of an ad hoc task force composed of police and outreach team staff aimed at facilitating cooperation between the two groups. Early consensus guidelines were that the team would contact the police for help in finding missing persons, and the police would contact the team when they observed strange behavior in homeless persons that suggested the need for mental health intervention.

This pilot study provides initial support for the prospect of mental health outreach team–police force partnerships. In spite of stark differences in professional culture, training, and practices, the two parties can work collaboratively to extend themselves beyond their traditional and strongly defended roles in order to develop common in vivo strategies and interventions for working with persons who are homeless with mental disorders. Further research and program partnerships will help us understand the possible reach and extent of such collaborative efforts in meeting the needs of persons who are homeless, especially those living “on the streets,” while at the same time recognizing and respecting the overlapping but different missions of outreach teams and the police. Finally, the question of elaboration of choice in the context of encounter between outreach worker and homeless people in psychotic crisis is a central research question both practical and ethical.