Police and sniffer dogs in psychiatric settings

To study the views of staff and patients on the use of sniffer dogs to detect illicit drugs and the prosecution of in-patients suspected of taking illicit drugs. A 15-item selfreport questionnaire was given to all in-patients and staff who had any contact with patients in a mediumsecure unit. Responses to the individual statements were measured on a five-point Likert scale and staff and patients’ responses were compared.

To study the views of staff and patients on the use of sniffer dogs to detect illicit drugs and the prosecution of in-patients suspected of taking illicit drugs.A 15-item selfreport questionnaire was given to all in-patients and staff who had any contact with patients in a mediumsecure unit.Responses to the individual statements were measured on a five-point Likert scale and staff and patients' responses were compared.

RESULTS
We achieved a response rate of 63% (patient response rate, 71.6%; staff response rate, 60.7%).Overall there were fewer differences than anticipated, although, as expected, staff viewed the impact of illicit drugs more negatively than patients, and on the other hand, patients viewed the use of sniffer dogs and police involvement more negatively than the staff did.

CLINICAL IMPLICATIONS
Notice ought to be taken of the discordance between staff and patients' views (particularly in relation to consent and confidentiality) when attempting to detect and manage illicit drug use among psychiatric in-patients.
The potential impact of the use of illicit substances among in-patients is well recognised in secure forensic settings where it is thought to have a negative effect on the integrity of therapeutic regimes, patient-staff relationships, ward atmosphere, adherence with prescribed medication and risk of violence (McKeown & Liebling, 1995;Department of Health, 1999;Dolan & Kirwan, 2001;Durant et al, 2006).In addition, in-patient drug misuse increases the frequency of hospitalisation in patients with schizophrenia (Bartels et al, 1993) and is likely to increase the length of stay in secure units.
Although establishing a drug-free environment is in the interest of all patients, complete prevention of access to illicit substances among in-patients is difficult to achieve particularly within generic mental health services, where there is less physical security as compared with secure units.Most secure units, furthermore, have formal policies to prevent access to illicit drugs.These include the use of random or regular urine illicit drug screens, searching for and removal of illegal substances, exclusion of visitors who may bring them in, and sanctions such as removal of leave status (Gordon & Haider, 2004).
On-site and laboratory testing for illicit drugs are designed to detect biological indicators of illicit drug use in bodily fluids or tissues such as urine, blood, saliva and hair (Wolff et al, 1999).Urine drug testing is probably the most widely used method of detection, but it has limitations, such as a short detection time, usually of a few days but longer in the case of cannabis and diazepam; urine samples are also easily adulterated or diluted giving false negative results (Wolff et al, 1999).Therefore, the collection of a 'pure' urine sample may require close observation, although this may be somewhat undignified.In contrast, a single hair test can cover a period of several weeks (McPhillips et al, 1998), giving useful information on the severity and pattern of illicit drug use within that period (Wolff et al, 1999).Saliva testing has some advantages over urine testing in that it is easy to use and the sample can be obtained under close supervision without necessarily invading the privacy of the patient.
However, hair testing is more expensive, takes longer to undertake, and is less optimum than urine or saliva testing.
Over the past two decades sniffer dogs have been increasingly used to detect illicit drugs in secure institutions; particularly in high-secure hospitals and to a lesser extent in medium-secure units.Their use is probably a more challenging territory than laboratory tests for many mental healthcare professionals.Although the reliability of sniffer dogs is thought to be high (Gordon & Haider, 2004), little is known about other important indices such as specificity, sensitivity and predictive validity.
The use or supply of illicit drugs in secure psychiatric units is a criminal offence which may evoke a decision to involve the police (Durant et al, 2006).Such a decision (often taken as a last resort) may be influenced by the nature and gravity of the offence (Bayney & Ikkos, 2003).While critics may argue that such a process could negatively affect the therapeutic alliance, it may also have some beneficial effects.For instance, Bayney & Ikkos (2003) argued that prosecution may aid future risk management and help patients to accept responsibility for their offending behaviour -that is to say, make them realise they cannot breach the criminal law within a secure unit without consequences.
Our study was prompted by an incident at Arnold Lodge (a medium-secure unit in Leicester), where a dog search was carried out after suspicions had been raised about illicit drug use among several patients.On-site urine drug screens performed on these patients were negative.However, the dogs sniffed out five patients who were subsequently taken to a local police station and formally charged with possession of illicit drugs.This course of action was somewhat surprising as it is known that a dog sniff may give a false positive finding.This may arise when a large number of individuals are randomly sniffed (Gordon & Haider, 2004) or owing to passive illicit drug exposure.Arguably, the police ought to have carried out on-site confirmatory tests such as saliva testing prior to pressing any charges against the patients.Subsequently, the charges were dropped when the results of forensic tests and hair analyses proved negative, contradicting the dogs' initial findings.
The incident highlighted a number of important issues in relation to the unit's policy of tackling illicit drug use among in-patients and whether police involvement should be part of the process.
The overall aim of the study was to examine staff and patients' views on the use of sniffer dogs to detect illicit drugs and prosecution of in-patients suspected of taking or supplying illicit drugs.We hypothesised that patients would have a more negative response to the use of sniffer dogs and police involvement and a less negative view of the impact of illicit drugs compared with staff.

Method
The study was conducted at Arnold Lodge which had 44 beds distributed between three mental illness wards (one acute ward and two rehabilitation wards) and a 12-bed ward for people with personality disorders.
Data were collected using a 15-item self-report questionnaire adapted from existing literature (Dolan & Kirwan, 2001;Bayney & Ikkos, 2003;Gordon & Haider, 2004;Rands, 2004).The questionnaire had four sections: section one asked for basic information such as age and gender (in addition, staff were asked about their discipline and whether they had previously worked in specialised drug and alcohol services); section two concerned views on the impact of illicit drug use on the unit; sections three and four elicited views on the use of sniffer dogs, police involvement or prosecution of patients using or supplying illicit drugs in psychiatric units.All data were supplied anonymously.
The data were analysed using the SPSS version 14.0 for Windows.The median and interquartile ranges for individual questionnaire items were calculated separately for staff and patients.Comparisons were made between staff and patient responses using exact tests for differences in proportions and Mann ^Whitney U-tests.
Approval to conduct the study was obtained from a local research ethics committee.Written informed consent was obtained from all participants.

Results
The questionnaire was given to all in-patients (n=53) and all staff with patient contact (n=140).Table 1 summarises sample characteristics.
We achieved an overall response rate of 63%: 38 patients (response rate=71.6%)and 85 staff (response rate=60.7%).About two-thirds of patients' returns were from mental illness wards which broadly reflected the patient population at the unit.In the case of staff, the majority of returns were from nursing staff (n=46).The remainder were from doctors (n=11), occupational therapists (n=9), psychologists (n=5), managers (n=2) and others (n=12).
Table 2 summarises the main results.Responses to individual questionnaire items were measured on a fivepoint Likert scale (1=totally disagree, 5=totally agree).
The conventional a criterion of significance (0.05) was utilised.
Overall there were fewer differences than anticipated, although, as expected, staff viewed the impact of illicit drugs more negatively than patients, particularly in relation to questions such as whether in-patient illicit drug use would result in escalation of bullying, increased hostility towards staff or reduced engagement in treatment.Furthermore, patients viewed the use of sniffer dogs and police involvement more negatively than staff.Significant differences appeared in such issues as obtaining consent from patients prior to conducting dog searches, linking the use of dogs with punishment or hazards (e.g.dog bites, causing distress to patients who might be afraid of dogs), and viewing the police involvement as a breach of patient's right to confidentiality.

Impact of in-patient illicit drug misuse
A number of potential explanations exist as to why staff and patient views differed in relation to the impact of in-patient illicit drug use.First, it may reflect a knowledge gap, with the patients not being fully aware of the negative effects of illicit substances.However, this is unlikely as most forensic units (including Arnold Lodge) have substance misuse programmes (Durant et al, 2006).Second, it may indicate a difference in values, with patients believing that members of staff are overestimating the negative impact of illicit drugs on the ward atmosphere.Finally, some patients may be aware of the negative impact that taking/distributing illicit drugs has on the ward environment, but are unable to resist because of their addiction.

The use of sniffer dogs
Regarding the impact of the use of dogs on the therapeutic alliance, our results did not support the notion that patients would view it more negatively than staff.While both staff and patients agreed that the use of dogs was necessary to maintain a safe environment, discordance was apparent in relation to a number of other items, including obtaining consent from patients, perceiving the use of dogs as a punishment and linking the use of dogs with hazards such as dog bites, transmitting infection and causing distress to patients.The issue of consent continues to be the subject of much debate in the existing literature.While some commentators argue that conducting sniffer dog searches without a patient's consent is unethical (Nash, 2005), others argue that obtaining consent prior to a search would defeat its purpose and might allow some patients to dispose of illicit drugs prior to the search (Gordon & Haider, 2004).Moreover, a finding of no illegal drugs may either indicate that the unit's policy on preventing access to illicit substances is effective or that there were no illicit drugs at the unit at the time of the search.Since the creation of a drug-free environment is beneficial for all patients, we would suggest informing patients that a dog search is to take place and that any patient who refuses the search would be presumed to be positive and sanctions would be imposed.

Khalifa et al
The legality of random searching was disputed in a court case against Broadmoor hospital [R.v. Broadmoor, 1998], where three patients challenged the hospital policy to introduce random searches; the Court of Appeal ruled that: ' . . . in the interests of all, in particular the need to ensure a safe therapeutic environment for patients and staff, that the express power of detention must carry with it a power of control and discipline, including where necessary of search with or without cause and despite individual medical objection.It was plain common sense that, on occasion, an individual patient's treatment might have to give way to the wider interest.'Following this ruling, the Code of Practice (Department of Health, 1999) provided further guidance on the issue.Chapter 25 of the Code states that routine and random searches without cause should only be applied in exceptional circumstances and that in all cases the consent of the patient should be sought before a search is attempted.When this is not forthcoming, the Code of Practice stipulates that the search may still go ahead provided there is no clinical objection from the patient's responsible medical officer, but 'the search should be carried out with due regard for the dignity of the individual and the need to ensure maximum privacy'.
Routine use of sniffer dogs without obtaining the patient's consent is therefore consonant with the Code of Practice but only if it is conducted in 'exceptional circumstances.'

Police involvement
While both groups agreed that staff had a duty to report in-patient illicit drug use to the police, patients were more likely to view this as a breach of their right to confidentiality.This highlights the need to have clear guidance on police involvement, which should ideally be developed in consultation with the police and service users.Future guidance in this area should provide a fine balance between the need to protect staff from prosecution and the patient's right to confidentiality, as it has been legally established that 'knowingly permitting' drug dealing is a criminal offence (www.cambridgetwo.com).

Limitations
Our survey had the following limitations: a small sample size, a sample from a single unit, and the use of an unvalidated questionnaire.Nevertheless, our results provide some useful insights into staff and patient views on the use of sniffer dogs and prosecution of in-patients suspected of using illicit drugs.

Conclusion
Notice ought to be taken of the discordance between staff and patients views (particularly in relation to consent and confidentiality) when attempting to detect and manage illicit drug use in psychiatric setting.This is particularly important when unconventional methods of detection (such as sniffer dogs) are being used.Moreover, clinicians and managers should be mindful that there currently exists very little (if any) data on the sensitivity and specificity of the use of sniffer dogs in situations such as this.Furthermore, there should be clear guidance on police involvement when illicit drug use is detected among in-patients.A balance needs to be struck between the patient's dignity and the right to confidentiality, and the maintenance of a drug-free environment.

Declaration of interest
None.Funding detailed in Acknowledgements.The working group prepared a report for the Irish College of Psychiatrists, which covered the following areas: a review of legislation and guidelines on safety for trainees, a literature review of the area, a review of professional organisations and their responses to violence Khalifa et al Police and sniffer dogs in psychiatric settings original papers Khalifa et al Police and sniffer dogs in psychiatric settings original papers BAYNEY, R. & IKKOS, G. (2003) Managing criminal acts on the psychiatric ward: understanding the police view.Advances in Psychiatric Treatment, 9, 359-367.DEPARTMENT OF HEALTH (1999) The

Table 1 .
Police and sniffer dogs in psychiatric settings original papers Sample characteristics

Table 2 .
Comparison of staff and patients' views The Trainee Section of the Irish College of Psychiatrists formed a working group on safety issues and training in 2004 to review the current status of safety at work, to explore the associated training issues for psychiatric trainees working in Ireland and to make recommendations regarding any deficiencies discovered in relation to the desired standards.The group was established following an increase in anecdotal reports of violence among trainees.