Surveillance, CCTV and body-worn cameras in mental health care

We live in a surveillance society. If you live or work in a town or city, wherever you go, whatever you do, your actions are likely to be captured on camera. This is no more so than in London, UK, the world’s surveillance capital.

Researchers estimate that there are over 7 million Closed Circuit Television (CCTV) cameras in the UK, with just under one million of those in London. This means there is 1 CCTV camera for every 11 people in the UK and you are likely to be captured on CCTV up to 70 times per day (Clarion Security Systems, 2022). CCTV cameras are being operated by the police, government, local government, the transport industries, businesses and, increasingly, by the public.

Most of us now carry sophisticated digital technology in our mobile cell phones that enables us to take high quality videos at the touch of a button. Social media is awash with our images; TV stations buy-up citizen videos of extreme weather events or cute cats; and concerned members of the public or citizen activists can feel empowered by filming and sharing interactions that cause concern or to hold public officials to account. In the USA, shocking camera footage of police officers squeezing the life out of Eric Garner led to a global slogan of ‘I can’t breathe’ and fuelled the Black Lives Matter movement.

When people go missing or are found murdered, the police now routinely call for businesses and the public to check their security cameras, car dashcams, bikecams and doorcams for possible sightings of the missing person or the perpetrator of a crime. When my partner intervened in a violent dispute on a bus, at the subsequent court case video images were shown of the incident inside and outside the vehicle from numerous angles.

If you go on Google maps and search ‘street view’ for a particular road in a small Somerset village, you will find a frozen image of an elderly couple, the man wearing a cap and leaning on a walking stick, peering out from behind a hedge to look for oncoming traffic. That man is my dad, captured by a passing Google Street View camera vehicle. He died ten years ago. I have saved the image but to date, if I refresh that Google Street View search, he is still there, walking with my mum.

When I first lectured students about the use of camera technology in mental health services, I used that image of my dad as a humorous and emotional touchpoint. But after a while I realised it carried a deeper meaning. For many people, there are concerns about who is recording us, what they are doing with the images, who has access to them and for how long will they be stored?

If you are in a heightened state of emotional distress or experiencing a frightening psychotic episode, is that something you want filmed? Yet, in England at least, we are enthusiastically installing closed circuit television (CCTV) on our mental health wards and nurses are now wearing body-worn cameras (BWCs) in many of our inpatient mental health settings. Wykes (2019) has outlined many of the challenges around therapeutic digital technologies that includes concerns around security of data, and this is particularly pertinent where film of people in distress is concerned.

The key policy driver for the use of these surveillance methods in mental healthcare (and in emergency department and ambulance services) appears to be the prevention or reduction of violence and aggression against staff (Bowers, 1999; NHS, 2019). Numerous reports internationally highlight the increased risks faced by staff working in psychiatric care (Iozzino et al., 2015), though studies have reported that both ward staff and mental health patients experience violence and feeling unsafe on inpatient wards (Cranage & Foster, 2022; Jenkin et al., 2022). Digital surveillance technologies are seen as a new method of preventing or reducing aggression. In England now, mental health service providers are exploring wider use of CCTV to review incidents of seclusion or restraint in response to high-profile abuse of vulnerable patients with learning disabilities and/or mental health problems in institutional settings (Townsend, 2023). Perhaps unsurprisingly, this followed the vivid and shocking exposure of bullying and abusive behaviour by staff, when undercover television reporters working as healthcare staff wore hidden digital cameras.

So what evidence is there that modern surveillance methods reduce violence and aggression?

In the UK, the UCL Jill Dando Institute summarised the results and quality of evidence from three published systematic reviews and meta-analyses on the effectiveness of CCTV in public areas (College of Policing, 2021). The largest and most recent review included 76 studies, most of which (34) were conducted in the UK and the USA (24 studies) (Piza et al., 2019).

Overall, the evidence suggests that CCTV has reduced crime, but there is some evidence that it has increased crime. The meta-analysis in Piza et al. (2019) found that overall CCTV was associated with a statistically significant decrease in crime. Across a range of settings, crime was found to have decreased by 13% in places with CCTV compared to those without. Three of the 76 studies reported a statistically significant increase in crime. However, the impact of CCTV was heavily related to location of the CCTV, whether CCTV was used alongside other measures, and type of crime. Of most relevance to mental healthcare settings, no overall statistically significant effect was observed for violent crime (29 studies) or disorder (6 studies).

CCTV was first introduced in mental health services in England around 2005 as part of a ‘zero tolerance’ campaign to reduce violence and aggression in healthcare settings. They were described as a tool for ‘maximising safety’ for patients, staff, and visitors. Initially, CCTV was used in external areas such as car parks and reception areas, and then in common areas on wards, in therapy rooms and even in bedrooms. However, as Desai (2009) highlighted in a thoughtful paper, there had been no comprehensive evaluations of the ways in which CCTV was used, and consequently a lack of evidence that it would be effective in psychiatric settings.

Desai (2009) draws on the literature about the use of surveillance cameras in other settings (such as public streets) as well as on psychiatric wards, and concludes that CCTV monitoring is fraught with difficulties and challenges, and that ‘watching’ patients and staff through the lens of a camera can distort the reality of what is actually happening within a ward environment.

In her recently published book, Desai (2022) develops this theme to explore the impacts of being watched on both patients and staff through her ethnographic research in psychiatric intensive care units and using theory. In a detailed and illuminating work, she highlights concerns over the criminalisation of patient behaviour, safeguarding concerns in relation to the way women’s bodies and behaviours are viewed and judged, and the undermining by CCTV of ethical mental health practice by staff who attempt to engage in thoughtful, constructive, therapeutic interactions with patients in face-to-face encounters.

In Appenzeller et al. (2020) earlier narrative review of the literature on video surveillance in psychiatric institutions, they identified just 16 papers (in English and German), with most of limited quality and just 7 containing empirical data. They recognised that attempts to improve safety and security using CCTV was at the expense of privacy. Despite this, they recounted incidents of neglect and abuse that had been captured on camera but not always acted upon.

Appenzeller et al. (2020) found that whilst the presence of CCTV appeared to increase subjective feelings of safety amongst patients and visitors, there was no objective evidence that video surveillance increases security. Several small studies found no association between the occurrence of violent incidents and the presence of video technology on psychiatric wards. This echoes findings in other public areas which found no correlation between violent crime and the presence of cameras (Piza et al., 2019). Paradoxically, the use of CCTV may have negative effects on security. An over-reliance on video surveillance systems was one of the main criticisms from an investigation of a mental health ward in the UK after the death of a staff member as the result of assault by a patient.

Body-worn Cameras (BWCs) were first used by police in USA and introduced to police in the UK in 2005 (Home Office, 2007). It is now estimated that over 70% of police forces have started to adopt the use of BWCs (Lum et al., 2020). Lum et al. (2020) published an extensive systematic review of the international literature on the police use of BWCs and found that the use of BWCs by police officers had no significant impact on police (mis)use of force or assaults against officers. They may reduce complaints against the police, but the mechanism of change is unclear; are police moderating their behaviour or are the public making fewer vexations complaints against police?

Building on this work, Wilson et al. (2022) conducted a systematic review and narrative synthesis, investigating the effects of Body Worn Cameras in all public sector services. These are defined as central government, local government, and public corporations delivering services to citizens, including healthcare, law enforcement, and public transportation. A total of 52 papers were included, focusing on law enforcement settings (police officers, prison guards, traffic wardens; N = 43) healthcare (including physicians, frontline clinical staff, paramedics, and family carers; N = 8) and transportation (railway ticket inspectors; N = 1). The review included randomised controlled trials, pilot evaluations, and qualitative interview studies, with only 5 rated high quality.

Key implications for mental healthcare settings were identified. There was no generalisable evidence supporting the use of BWCs to reduce patient violence against staff; despite the large evidence base examining BWC use in law enforcement settings, it is unclear if or how BWCs may enhance safety for either citizens or police officers. The heterogeneity of the samples, study settings, and cofounding factors also meant it was impossible to draw conclusions on the use of BWCs in a mental health setting based on law enforcement outcomes. It is important to recognise the different environments in which police officers and mental health staff work – and the different and longer-term relationships mental health staff often have with the people being cared for.

Just two studies in mental healthcare settings were identified (Hardy et al., 2017; Ellis et al., 2019); mixed results were reported with both increases and decreases in violence and aggression found, and variation between types of wards. There is some suggestion of a reduction in more serious incidents and the use of restraint, but quality of evidence is low.

Further to this, in a recent qualitative interview study, Wilson et al. (2023) reported on the views of over 60 mental health patients and staff concerning the use of body-worn cameras. Both patients and staff highlighted the complexity of the issue and the need for consideration of the varied reasons for violence and aggression in inpatient mental health settings. The subjective nature of how violence and aggression is defined shapes how staff and patients view the prospect of using BWCs. Across the interviews, both staff and patients cited issues resulting from an underlying culture of mistrust in inpatient settings that leave staff and patients feeling unsafe. Trust is an essential if often neglected concept in providing mental health services (Brown et al., 2009).

Wilson et al. (2023) also reported that there was a risk that body-worn cameras may intensify power dynamics between staff and patients and undermine the therapeutic relationships that are at the heart of respectful, compassionate, and effective therapeutic care and treatment. Participants felt that engaging with existing evidence-based interventions such as Safewards (Bowers et al., 2015) and addressing systemic causes of violence and aggression should take priority over introducing body-worn cameras.

The study concluded that there is little indication that staff or patients believe that body-worn cameras will deter violence and aggression on inpatient mental health wards. They may serve as a tool for safeguarding and staff training, but there are still unexplored ethical concerns about their use and a lack of evidence to support use of this technology to deter violence in mental health settings.

These concerns were echoed by the National Service User Network (NSUN, 2021) in their written evidence to the UK Parliament’s Joint Committee on Human Rights (JCHR) inquiry into the protection of human rights in care settings. The submission focussed on surveillance (including body-worn cameras and CCTV in rooms, wards, and common areas) as restrictive practice and the criminalisation of distress in relation to securitisation and racial disparities. NSUN were concerned at the increasing use of blanket 24-hour surveillance in mental health settings and that surveillance may be used in lieu of adequate and safe staffing levels.

The advances in digital applications and immersive technologies show promise of therapeutic benefits for patients and staff (Riches et al., 2023). Whether CCTV and BWCs are to be part of that picture remains to be seen and needs to be informed by high-quality, co-produced research that focuses on wider therapeutic aspects of mental health healthcare.

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