Abstract
Background
Section 136 (S136) of the Mental Health Act (1983, as amended by the 2007 Act) empowers the police to detain those suspected of being mentally disordered in a public place and to convey them to a place of safety (POS) for further assessment. Gloucestershire has not had a specialist facility for S136 detentions and individuals were taken to the police cells or occasionally A&E departments for assessment.
Aims
This paper forms one part of three aspects under investigation. Two companion papers by the authors describe the use of S136 using anonymised audit data and the experiences of detainees. The objectives of this paper have been to assess the responses of the different professional groups involved in the process of S136.
Method
An anonymous postal questionnaire was distributed to eight groups of professionals who were identified as having the potential to be involved in part of the process of a S136 detention. Results were collated and analysed, and formed the basis for a series of follow-up focus groups within groups to explore themes that warranted further investigation.
Results
An overall response rate of 59% was achieved. Seventy-four per cent of participants thought that there should be an alternative POS to the police station. A&E was thought to be an unsuitable alternative POS, with a psychiatric hospital being the first choice for 58%.
Conclusions
There is a gap in the expectations of the different agencies involved in the S136 process, which have the potential to be divisive if interagency pathways and agreements are not in place.
Introduction
Section 136 (S136) of the Mental Health Act (1983, as amended by the 2007 Act) gives a Police Constable the power to detain an individual whom they find to be mentally disordered in a public place, whom they consider to be in need of care and control. The individual is then conveyed to a Place of Safety (POS) to allow for further assessment by an Approved Mental Health Practitioner (AMHP) and Medical Practitioner(s). The POS is usually either the police cells or a hospital. Police officers are often the first professionals to be called to a person experiencing a mental health crisis, although they receive very little mental health training as part of their role. 1 More recent guidance states that police stations should only be used as places of safety in ‘exceptional circumstances’ 2 and within the county of Gloucestershire it had become common practice for the POS to be the police station. Police custody is widely viewed as an unsuitable environment for people with mental disorder, not least because it has the effect of criminalizing individuals who have a health need, but also the environment may in fact exacerbate their mental state. 3 The small number of published studies on the use of S136 may reflect neither the current situation nor the true national picture as most of the research comes from large urban centres and was published before 1997. To advance knowledge and to develop local practice we studied the use of S136 in Gloucestershire, a rural English county, between 2002 and 2006. This paper forms one of three papers which also describe findings from an audit of the use of S136 in Gloucestershire and experiences of detainees and their carers. 3,4
Aims
The study aims were to explore the attitudes and perceptions of the different professional groups involved in the process of S136. This included their responses to the characteristics of those individuals detained and also the use of this section of the Act within Gloucestershire.
Sample
The sample frame consisted of professional groups most closely involved with S136 at their place of work within Gloucestershire. Table 1 shows each group. Owing to the exploratory nature of the research design and the limitations of staff numbers within the county, formal sample size calculations were not carried out. All staff who met the inclusion criteria (potential involvement in the process of S136, with a place of work in Gloucestershire) were invited to take part in the research. However, Police Operational Officers represented a larger population than the other professional groups, and therefore every third officer was systematically selected from an alphabetized list of 350.
Professional groups sample size and response rates
Method
The study used a dual methodology comprising a cross-sectional, anonymous postal questionnaire which was sent to the eight groups of professionals most closely involved with S136, and follow-up focus groups. Staff were asked to complete the questionnaire, with consent to participate implied through its completion and return, with a separate enveloped postcard if participants were happy to be contacted for follow-up. These staff were later invited to attend a focus group to follow up on data generated from questionnaire responses. A reminder postcard was sent two weeks after the questionnaire. Data from the questionnaires were collated and analysed both as a combined group set and separately. Descriptive statistics have been used to illustrate the findings. Focus group transcripts were transcribed verbatim and analysed using a grounded theory approach. 5 Grounded theory is a systematic qualitative research methodology in the social sciences emphasizing generation of theory from data in the process of conducting research. It is a research method that operates almost in a reverse fashion from traditional research and at first may appear to be in contradiction of the scientific method. 5 Rather than beginning by researching and developing a hypothesis, the first step is data collection, through a variety of methods. The key points are marked with a series of codes, which are extracted from the text. The codes are grouped into similar concepts in order to make them more workable. From these concepts, categories are formed, which are the basis for the creation of a theory, or a reverse engineered hypothesis. A detailed analysis of the transcripts was undertaken by GR and EF using a line by line approach, working first independently and then together, to explore those attitudes and perceptions of professionals involved in S136. QSR NVivo 7 software 6 was used to identify codes, categories and themes in data-sets. Illustrative quotations which exemplified the emerging themes were identified and imported into Microsoft Word files. Once a favourable opinion for the research was obtained from the local Research Ethics Committee, along with the sponsoring Trust approval, the study commenced.
Results
An overall response rate of 59% was achieved; all groups (with the exception of psychiatric nurses) achieving 58% or greater. Sixty-eight per cent of participants had five years or more involvement in S136 cases, 32% with five years or less. Staff were asked to score by level of agreement to a series of statements beginning ‘people detained under section 136 in Gloucestershire are…’. These statements were categorized by staff attitudes towards detainees and the process of detention (Table 2). The last section asked about alternative places of safety to the police station. Data generated a wealth of information, much of which cannot be presented in this paper. A selection of results is presented here, along with qualitative data results from the follow-up focus groups conducted for each professional group (with the exception of A&E Doctors and Nurses).
Ninety-eight per cent of participants described detainees as vulnerable, and 98% believed that detainees were either sometimes or frequently a danger to themselves. However, when asked about whether detainees were a danger to others, 91% of participants answered that sometimes this could be the case, but only 8% thought it would be frequently.
People detained under Section 136 in Gloucestershire…
Participants were asked if they believed detainees were already under the care of mental health services; 68% reported sometimes and 26% frequently. Ninety-eight per cent of participants believed that detainees were intoxicated with drink or drugs at the time of their detention; similar levels of agreement were found between the A&E doctors and nurses groups. Ninety-eight per cent of respondents described detainees as either frequently or sometimes aggressive during their period of detention, with similar figures reported for unpredictable or difficult to contain behaviour during detention.
The questionnaire was also designed to elicit responses about alternatives to the police station as a POS. Differences between professional groups became more apparent at this stage, within an overall combined 74% of staff answering that there should be an alternative POS to the police station. Responses from different groups are shown in Table 3. It was of interest at this stage that 67% of mental health nurses (MHNs) did not feel that there should be an alternative POS to the police station; a theme that warranted follow-up within the focus groups, and contrasts starkly with 98% of police participants who felt there should be an alternative. MHNs cited both A&E and a psychiatric hospital as acute settings, which were not suitable environments for a person to be brought to, when accompanied by police, with concerns that those detained on a S136 could potentially put others at risk such as staff, patients and visitors. This risk was not considered as high in the police station.
Do you think there should be an alternative to the police station as the only place of safety?
Staff were then asked the acceptability of suggested alternative POS to the police station, and to comment on the reasons behind their answers (Table 4). Only 42% of MHNs thought that a psychiatric hospital was an acceptable alternative, whereas 100% of police custody sergeants answered it as their first choice, highlighting a wide gap in the expectations of the different professional groups. Section 12 doctors (S12 doctors are medically qualified doctors, usually psychiatrists, who have been recognized under section 12(2) of the Act; they have specific expertise in mental disorder and have additionally received training in the application of the Act) gave similar responses to MHNs, with some citing concerns that there was no appropriate suite, concerns about levels of staffing and physical safety to both staff and detainees.
If alternative place of safety (POS) were available, which would you prefer?
GP, general practioner
The alternative of a general practitioner (GP) walk-in assessment centre was the least popular of alternatives suggested. Fifty-seven per cent of participants thought it was an unacceptable option. Participants were concerned that staff in this option would not have experience of mental illness, and the unpredictability of detainees might place themselves and others (including members of the public) in danger. A&E was also not considered to be a suitable alternative as a POS, with 57% answering it was unacceptable. Participants considered an A&E department to be overstretched and busy with members of the public requiring emergency treatments, although it should be noted that some health professionals believed A&E to be the most appropriate POS for occasions when a detainee requires emergency treatment, which is not actionable within a mental health facility.
Follow-up focus groups were carried out to further elicit the understanding behind questionnaire responses from within each group. Five focus groups were held, with participant numbers ranging from four to eight in a group.
The assessment process
Who assesses for mental disorder?
When considering the process of assessment, mental health professionals felt that
detainees should receive a full psychiatric assessment that encompasses examination
of the detainees’ vulnerability, aggression, thoughts, feelings and social
relationships as examples. MHNs felt that it is only by taking this holistic approach
that a proper assessment can be achieved, which is something the police are unable to
do when they use S136 to detain an individual. ‘So rather than thinking about specific mental illness symptoms… we look at the
risk assessment, don't we? The vulnerability, aggression… full mental state
examination, full behavioural state examination, look at thoughts, feelings,
processes, social relationship…’ (MHN 3).
Some S12 doctors felt it was inappropriate for detainees to go straight to hospital before an assessment, as S136 is an arrest rather than a treatment order and that it is more important that detainees get assessed by the ‘right person at the right time, as quickly as possible’.
Urgency of assessment
The urgency of assessment was also thought to vary in individual cases. A prompt assessment was considered helpful by S12 doctors, and at other times, a delay could give a detainee time to reflect or calm down. One Approved Mental Health Practitioner (AMHP) (but formerly this role was fulfilled by an Approved Social Worker) was also concerned that rushing an assessment might result in a lack of expertise suitable to the detainee's needs, such as for those with a learning disability, so there was a preference to wait longer for the assessment, if it meant the most appropriate experts were conducting it.
Assessment, drugs and alcohol
S12 doctors and AMHPs expressed frustration at being called to an assessment when a
detainee is ‘too drunk to be assessed’, and expressed a reliance on custody sergeants
to often make a judgement about the sobriety of a detainee and whether a doctor can
make a proper assessment, or if a delay is appropriate. Yet Police Custody Sergeants
expressed concern at having to try to ‘read someone, who is on drink
or drugs’. They saw their role as securing detainees and keeping them safe, until
they could be assessed. Police participants felt that their job was to set up the
arrangement for an assessment and that how long it took to happen was out of their hands. ‘We just try to keep them secure, keep them safe, keep an eye on them, monitor
them …you might have to wait for a period of time for the intoxication to
dissipate a little bit, in order that you can then see what is going on
underneath’ (PC 3).
AMHPs felt they had become more proactive in asking questions thoroughly when someone is referred late at night or in the early hours of the morning, because of the likelihood of being under an influence. Some S12 doctors felt that in cases where alcohol was not a factor, there was a greater opportunity to ‘do something’ to help a detainee. Some described detainees as people who are not in need of urgent psychiatric care, but with social problems or alcohol problems, giving examples such as breakdown or separation of relationships as triggers for events that may lead to a S136 detention. When asked about experiences with detainees under the influence of alcohol, several professionals considered it to be more frequent than incidences with drugs. These staff could see a clear divide between those are detained because they act ‘irresponsibly through choice and control … and those who are acting irresponsibly by virtue of having a mental health problem’. Choice and control included voluntary intoxication. It was felt that detainees who are under the influence of alcohol or drugs are very unpredictable.
Views on follow-up
In some S136 cases participants felt that follow-up would not be offered unless it is needed. Doctors may write to the detainee's GP if there is, for example, an alcohol issue that needed to be addressed. If detainees are already under the care of a mental health team the doctor will inform the team, although sometimes it can be a few days after the S136.
AMHPs described follow-up in three different groups: those who go to hospital (formally or informally), those without mental disorder who are released, and those who will be referred back to a mental health team or GP by the S12 doctor. AMHPs also felt the implementation of Crisis teams had helped, by allowing them to be involved in the assessment straight away. Police professionals felt they had less involvement in follow-up after a S136 detention, unless they felt an individual was particularly dangerous, in which case they might follow it up through police procedures.
S12 doctors found it hardest to offer follow-up to detainees who are homeless, and felt that the reality is that there is not much they can offer as appropriate follow-up for these individuals. For others, it was more a case of signposting to a more appropriate agency.
Conflict between police and health professionals
Several police participants described a conflict between police and health
professionals in the responses to detainees with personality disorders. They
described experiences where police have detained someone whom they believe to be
mentally disordered, but were frustrated, at a subsequent assessment, when health
professionals are unable to refer a detainee, who may then be released and then found
behaving in the same way the next day in a public place. ‘Then you are presented with a situation where you have the same individual a
week later, presenting themselves in the same way, clearly there is something
not right about them. There's clearly something strange about their behaviour,
they're vulnerable because they are clearly not able to sort of look after
themselves, attention is being drawn to them. But you know that only a few days
before they've been brought in, and professionals have said that they are not
fit to be detained, or that they don't need to be detained because they don't
have a disorder that fits in with the definition of the MHA, as described for
detention. So we are between the devil and the deep blue sea, literally’ (PC
3). ‘One of the main differences, is where the police are completely convinced the
patient is… mad… generally it's the opposite. Where they don't think there's a
problem, often again it's the opposite, they are the ones we end up admitting,
because their view and our view is so radically different’ (S12 Dr 3).
Similarly, concern was expressed by MHNs when police leave detainees in the care of nurses at hospital, having brought a potentially dangerous individual in for assessment in handcuffs, but subsequently release them to the hospital care and depart from the premises.
Provision of training
Mental health training for police was identified as a key finding by the study team, and
will be explored further in the discussion. The conflict described above highlights
areas of gaps in the knowledge of police into mental disorder, and some health
professionals felt that this was an area where greater training should be offered to police. ‘No, training is minimal, unless you've got previous experience, um, knowledge to
fall back on, um, it's you pick up that experience as you move along, as you… on
the hoof.’ (PC 2).
Health professionals felt that robust training would help police to underpin some the
decisions they have to make when they find someone they consider to be mentally
disordered in a public place. ‘I feel that this leads back into the need for constant increased training of
police officers out in the community around the appropriateness of the
circumstances where they choose to detain people on Section 136 rather than doing
something else’ (AMHP 4).
This also included greater knowledge about the links between mental illness and drug or alcohol taking. One MHN participant was a mental health trainer and commented that training given to Custody Sergeants was 1.5 hours, with one hour for tactical firearms officers to cover all areas of mental health. In contrast Police Custody Sergeants described their current mental health training as being at a good level and better than five years previously, and that much is learnt as part of ‘on the job’ training. Yet Police Operational Officers described receiving minimal training, and again learning ‘on the job’. These police participants felt that as an organization they are in place for the prevention and detection of crime, and that training is prioritized according to their own organization's needs, such as keeping up to date with current or changing legislation.
Use of cells as a POS
Results from the questionnaires highlighted that police participants supported an
alternative to the cells as a POS. Officers expressed feeling guilty at times, when
detaining individuals who could be ‘their mum or your mum’; people whom they
described as being from ‘nice, middle England backgrounds’, who are then put in a
cell because of their mental illness. Normally police work would bring them into
contact with alcohol or drug users, people who are violent or commit crimes, and in
these situations the use of cells was deemed appropriate, but for mental health it
was felt disproportionate, though police participants did recognize the cells did
still offer some degree of protection for a detainee. ‘I find it really hard to get someone like that and have to keep them locked in
a cell, because they are mentally ill, I just feel that there must be somewhere
more appropriate to keep people like that. And they start crying, hysterical
and it just seems wrong to me that you keep people like that, in a police cell,
I find it really hard to do’ (PC 4).
Originally over two-thirds of MHNs had expressed their opinion that there should not
be an alternative to the cells as a POS. When this finding was followed up within the
focus group setting a contrasting picture emerged to this questionnaire response,
providing a more in depth picture emerged of why this might have occurred. MHN
participants described their own experiences of cells being unpleasant, dirty, grubby
places, lacking in privacy and in the company of others who are not always well
behaved. This view was similarly endorsed by S12 doctors. They also recognized that
detainees have not committed a crime and yet are locked away within a criminal
setting, potentially making an individual more likely to be violent or abusive, and
possibly leading to the creation of an automatic hostility towards those in a
position of power. ‘The assumption we make now is they're a danger, therefore they need to be
locked in a secure place. The switch over is the automatic assumption that they
might be mentally unwell and need to come to us, which in itself is just as
dangerous an assumption as the previous one…’ (MHN 4).
However, MHNs had clear concerns about issues with security for all parties, and the
ability to have support from police officers, should a detainee become violent or
aggressive. It was felt that police have greater powers of physical force available
to them, which are not available to health professionals. S12 doctors felt that the
POS should remain within a police setting but in a more suitable environment,
equipped with safe furniture, so that detainees can feel safe, as well as the people
interacting with them. Health professionals felt that detainees should not
automatically be assessed in a hospital setting, especially psychiatric, because of
stigma attached to mental health problems, when it could be just as stigmatizing as
assessment in a police cell. Many participants felt that a police setting in itself
is not an inappropriate POS, and offers a level of security and presence that health
professionals felt should be in place during assessments. Security issues were also
raised as a concern with alternative choices for a POS. But there was also an
acknowledgement that the current practice of detaining individuals in police cells
can lead to a distressing experience for the detainee, with the possibility of
increasing levels of hostility. ‘I suppose in a way I agree with AMHP5, in so much as that wherever somebody
goes in those circumstances, there'll be some stigma attached to it, er… If
it's somebody who has a mental illness, you know, a police cell isn't as
appropriate as somewhere else’ (AMHP 2).
Discussion
It is clear from our findings that the inter-agency nature of the use and application of S136 of the Mental Health Act relies on a complex series of interactions between the police, health professionals and detainees. These interactions are often a source of conflict and tension between different parties, despite their common aim to provide appropriate care for the individuals being detained. Despite S136 being an under researched area, the responses to this study have shown that it has been a topic worthy of investigation, as well as helping to improve practice locally between agencies.
The response rate to questionnaires from MHNs was lower than had been anticipated in comparison with other professional groups. While not a poor response rate, when considering the nature of a POS as a ‘hot topic’, the authors had hoped for a greater level of interest from this particular group, since any new service provision would be most likely to affect them. However, the time frames for the study implementation conflicted with a period of service re-organization within the hosting Trust, and this may have affected levels of interest in this work. This similarly applies to the Forensic Physicians (FP), a role typically filled by GPs. A change of contract with the police force had led to a change in the role of FPs, and we were unable to conduct a follow-up focus group, with participants no longer interested in the study because of this change in their role. Data from the focus groups are also lacking the views of A&E department staff, as the authors were unable to schedule a focus group within the tight schedule for research. It is therefore acknowledged that both of these groups' views are not included in the qualitative data achieved from focus groups.
Detainees are clearly thought of as vulnerable individuals needing an appropriate form of social care, whether they may or may not have a mental disorder. This was reflected by the Independent Police Complaints Commission (IPCC) where the identified age range for S136 was from 12 to 89 years, illustrating the potential vulnerability of those at either end of the spectrum. 6 Professionals in our study had clear concerns about the detention of individuals who appear intoxicated by alcohol or drugs, along with the implications that arise during the process of detention and assessment. There was a consensus that rapid assessment is not always appropriate where alcohol or drugs are involved.
Lynch et al. 7 cite a number of studies criticizing the use of S136 by the police, such as patients taken unlawfully to hospital, or subjected to undue physical force. Yet previous studies have shown that police make quite an accurate assessment of patients needing psychiatric care. 8,9 Our findings do highlight a perceived gap in the level of knowledge of mental health disorders by the police. A recent review of police custody as a POS by the IPCC suggests that while it is not appropriate or desirable for police officers to be experts in mental health, it is important that officers have a basic understanding of possible signs of mental disorder. 10 This will help them to ensure that S136 is used appropriately. This does not, however, alleviate the problems police officers have in discerning the difference between individuals who are intoxicated or those who are mentally disordered, which we have found to be a cause of tension. Jones and Mason 11 used qualitative methods to investigate the disparity in the quality of treatment following S136 detention between police and health professionals. The authors believed that the police have an important part to play at this crucial point when patients begin to interface with the psychiatric services. While our companion study found that detainees felt powerless during the S136 process, they did report that the police seemed to care about what happened to them, giving them constant attention. 3 Once again this highlights the multifactorial aspects to the policing role, from public safety, law and order to moral welfare. Mental health training for police officers was considered in our findings to be a valuable tool and thought to allow for better collaborative working between all parties.
During the time period of this study the police cells were the only designated POS in Gloucestershire. The IPCC report found that despite a broad consensus that the police cells should only be used in exceptional cases, it was in fact used as the main POS when studied over a one-year period, with the strongest factor affecting the number of detentions being the availability of an alternative POS. 10 Our findings also found the use of cells as a POS to found to be a contentious issue of concern, with health professionals citing concerns about security in alternative settings, but also the stigma of detention in hospitals. Across all professional groups, participants did, however, recognize the detrimental impact an experience in the cells can have on individuals detained, when no crime has been committed. The IPCC found that the availability of an alternative POS was strongly linked to better multiagency working and agreements. 10 Since this research was undertaken a new ‘health based’ POS has been developed on the site of our local psychiatric hospital. The facility opened in early 2009 and has provided an alternative to the exclusive use of the local police cells as POS. It is manned by mental health Crisis teams and is separate from the main psychiatric facility. 12
Conclusion
Despite a paucity of research into S136 over the last 20 years, there has been a spate of more recent investigations into its use and the alternatives to police cells for a POS. 6,13,14 Our findings have added to this body of work, revealing the complexities of this particular route of entry into the mental health system. There is a gap in the expectations between different agencies involved, which have the potential to be divisive if better interagency pathways and agreements are not implemented. The use of this act should be better monitored to ensure it is used appropriately.
Footnotes
ACKNOWLEDGEMENTS
We gratefully acknowledge the help and support in designing and conducting this research that we received from the following individuals: Sergeant Julie Gardener (Gloucestershire Constabulary), Julie Hapeshi and Chris Foy (Research Development and Support Unit, Gloucestershire Hospitals NHS Trust), Dr Rhys Watkins (General Medical Practitioner and former Forensic Physician, Gloucestershire Constabulary), Dr Delia Parnham-Cope (Consultant in Emergency Medicine, Gloucestershire Hospitals NHS Trust).