“Section 136 ‘decline in psychiatric beds’ ” ?

 The amendments made in 2007 to the 1983 Mental Health Act caused considerable controversy due to fears that they would make more people subject to its provisions and the latest figures suggest those fears have been partially realised.

During the last five years more people in England have been subject to the restrictions of the Act. The number of detentions rose 6% from 46,539 in 2006/07 to 49,365 in 2010/11, the latest year we have figures for. However, it is not possible to attribute this rise solely to the amendments that came into force in 2008.

The largest increase during this time was in the use of police detention or Section 136, which rose 135% from 6,004 in 2006/07 to 14,111 in 2010/11. While studies of Section 136s are typically small and the findings are often contradictory, they consistently find only a small proportion of Section 136 detentions (about 25%) result in formal detention in hospital.

A 2011 study of the use of Section 136 in Trafford found threats of self-harm and aggressive behaviour were the most common reasons for detention. Of those detained under Section 136 who were known to mental health services, only 4% had a diagnosis of a psychotic disorder. Most had a diagnosis of mood disorder (22%), personality disorder (20%) or a drug and alcohol problem (18%).

The rise in Section 136s could be due to increased mental health awareness among police officers, but it could also mirror the decline in psychiatric beds in the same period and the relative inaccessibility of mental health crisis services, particularly to those without a diagnosis of psychosis.

A second trend in detentions under the Mental Health Act is the increase in Community Treatment Orders (CTOs). Just over 10,000 CTOs have been made since supervised community treatment was introduced in 2008 by the Act’s amendments. Although the number of new CTOs is not increasing, only 40% have been discharged or revoked, leading to a 29% rise in the total number of people on a CTO between 2009/10 and 2010/11.

This increase can be explained by concerns about risk. Glover-Thomas (2011) analysed the narratives of psychiatrists and approved mental health professionals and suggests that discourses of risk have supplanted ideologies of need or welfare provision. Assessing, managing and monitoring risk has become the raison d’être of mental health services.

Perhaps that is not too surprising, but Glover-Thomas noted with some concern that the mental health professionals who she interviewed did not seem overly concerned about the extension of compulsory powers to a much wider group of individuals following the 2007 amendments. She concluded that the decision-making process about the use of the Act could become more influenced by the public protection agenda if the rights of the individual being assessed are not at the core of decisions about detentions or use of CTOs.

Finally, admissions under Section 2 (for assessment) rose 30% between 2006/07 and 2010/11 to 19,163, but Section 3 admissions (for treatment) fell 18% over the same period to 8,174. Section 3 admissions for treatment are typically used for so-called ‘revolving door’ patients who require repeated compulsory admissions to stabilise their mental health. It appears that the introduction of CTOs has partially helped to reduce the need for repeated admissions. However, this could be a statistical artifice as 64% of recalls of people on a CTO to hospital resulted in a revocation of a CTO, which would have been counted in the official statistics as a repeat Section 3 admission prior to 2008.

The increase in Section 2 admissions could potentially be attributed to the discourse of risk prevalent amongst mental health professionals. Interestingly, though, there is a correlation between rising use of the Mental Health Act and falling suicide rates from 1988 to 2006 (although the trend has continued since then). It is not possible to determine cause and effect in this association, as suicide prevention strategies and other policy initiatives may account for this decline. However, it is a possible indication that the rising use of the Act may have a positive outcome.

The impact on practice

Three potential implications for social work practice could be drawn out from these trends.

1. There is anecdotal evidence that mental health training for police officers can reduce inappropriate use of Section 136s. There is a role for mental health social workers in providing this training and liaising with local police officers to help reduce inappropriate use of Section 136.
2. Mental health social workers can help to challenge the prevalent discourse of risk in mental health services. In the context of CTOs, this could mean providing evidence to psychiatrists about individuals’ progress to help speed up discharges rather than retaining the restrictive measure for longer than is necessary.
3. When AMHPs assess people under the Act they are charged with considering the least restrictive alternative to detention. This is particularly important for people who are not known to mental health services as the risk-averse culture prompts caution, potentially leading to more detentions than are necessary. Although the risk vs rights argument is always present in an AMHP’s mind, it is perhaps important to bear the potential outcome of detention in mind to consider the extent to which they are necessary in the first place.

Questions for practice

• Will the withdrawal of mental health social workers from integrated mental health trusts empower them to challenge the prevalent risk discourse and uphold people’s rights when undertaking the approved mental health professional role?
• To what extent can mental health social workers influence psychiatrists in the discharging of people from a CTO when the risk of relapse is low?
• Are increasing restrictions on liberty – as indicated by more Mental Health Act detentions – worthwhile in the context of falling suicide rates (although the two may not be related)?

References and further reading

Glover-Thomas, N. (2011) The age of risk: Risk perception and determination following the Mental Health Act 2007. Medical Law Review, 19, 581-605

NHS Information Centre (2011) In-patients formally detained in hospitals under the Mental Health Act 1983 – and patients subject to supervised community treatment, Annual figures, England 2010/11. London, NHS Information Centre for Health and Social Care
Office for National Statistics (2012) Suicide rates in the United Kingdom, 2006 to 2010. London, Office of National Statistics

Sadiq, K. T., Moghal, A. & Mahadun, P. (2011) Section 136 assessments in Trafford Borough of Manchester. Clinical Governance, 16, 29-34

Shah, A. (2012) The relationship between the use of Mental Health Act and general population suicide rates in England and Wales. Journal of injury & violence research, 4, 26-29