More compulsion in the community
Here is the unedited version of a research digest I wrote for Community Care which was published today (30th August). It includes links to the full-text PDFs of the papers I refer to and links to the posts on s.136 which originated from this article.
There was considerable controversy surrounding the amendments to the Mental Health Act 1983 (MHA) made in 2007 amidst fears that they would increase the number of people subject to its provisions. These fears have been partially realised.
During the last five years there has been an increase in the number of people subject to the restrictions of the MHA in England. The total number of detentions has risen by 6% from 46,539 in 2006-7 to 49,365 in 2010-11 (the last year we have figures for) (NHS Information Centre, 2011). However, it is not possible to attribute this rise solely to the amendments in the MHA which came into force in 2008.
The largest increase during this time came in the use of section 136 with a 135% increase from 6,004 police detentions in 2006-7 to 14,111 in 2010-11. Studies of section 136 are typically small and the findings are often contradictory. However, they consistently find that only a small proportion of section 136 detentions (about 25%) result in a formal detention in hospital.
A recent study of the use of section 136 in Trafford, Manchester, for example, found threats of self-harm (35%) and aggressive behaviour (22%) to be the most common reasons for detention (Sadiq et al., 2011). Of those known to mental health services only 4% had a diagnosis of psychotic disorder, with most having a diagnosis of mood disorder (22%), personality disorder (20%), or a drug and alcohol problem (18%).
The increase in section 136 detentions could be a result of increased mental health awareness amongst police officers. However, it could also mirror the decline in psychiatric beds over the same period and the relative inaccessibility of mental health crisis services, particularly to those without a diagnosis of psychosis. For further discussion of research on s.136 see this previous post and subsequent discussion.
A second trend observable in the increase of detentions under the MHA in the last five years is the increase in the number of people on Community Treatment Orders (CTOs). Just over 10,000 CTOs have been made since supervised community treatment was introduced in 2008 by the MHA amendments. Although the number of new CTOs is not increasing, only 40% of them have been discharged or revoked, leading to a 29% rise in the total number of people on a CTO between 2009-10 and 1010-11.
The increase in the number of people subject to the powers of a CTO can be explained by concerns about risk. An analysis of the narratives of psychiatrists and Approved Mental Health Professionals (AMHPs) (Glover-Thomas, 2011) suggests that discourses of risk have supplanted ideologies of meeting 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. However, the author 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 MHA 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 by 30% between 2006-7 and 2010-11 to 19,163, but section 3 admissions (for treatment) fell by 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 in order to stabilise their mental health. It appears that the introduction of CTOs has partially helped to reduce the need for these 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 MHA and falling suicide rates from 1988 to 2006 (although the trend has continued since then) (Shah, 2012). 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 MHA may have a positive outcome.
Three potential implications for social work practice could be drawn out from these trends. Firstly, there is anecdotal evidence that mental health training for police officers can reduce use of section 136 MHA. There is a role for mental health social workers in providing this training and in liaising with local police officers to help reduce inappropriate use of section 136.
Secondly, 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.
Finally, when AMHPs assess people under the MHA 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.
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.