Right now in England, there are hundreds of people who haven’t committed a crime but who are – through no fault of their own – being detained. These are people like you and me, who are considered unwell enough that they are being held in hospital for their mental health, waiting until someone else decides they are allowed to go back to their everyday lives. We all know that it happens – but very few of us think about what it really means.
When someone is considered to be unable to keep themselves or others safe, Section 136 of The Mental Health Act gives authorities the legal power to remove them to a place of safety. Then, based on an agreement between a number of mental health professionals, these people can be held in a place of treatment until it’s agreed that they are well enough to look after themselves. This is what is known as being sectioned.
“We don’t think you can go home, you have to come with us”
Now in his 50s, Gary has been sectioned “twenty times, maybe more,” in numerous situations over the last two decades, sometimes when suicidal. “I was detained on a [section] 136. The police handcuffed me and rugby tackled me to the ground, when I found myself on a train line preparing to jump in front of a train,” he says. Taken to be assessed, he was strip searched; he says he has “no idea what happened during this assessment” as he had “lost touch with reality.”
Gary, who hears voices and experiences dissociated periods, says that the fear of getting sectioned means he sometimes avoids seeking help from his GP. “One time when I was detained by the police on a section 136 the police threatened to taser me,” he remembers. “I was surrounded by police with taser guns, ambulance staff. I felt trapped, I didn’t know what was happening. People were yelling at me. I tried to fight. I was handcuffed, put in the back of an ambulance.” On this occasion, the decision was made that Gary could return home after seeing the psychiatric liaison team at the local A&E department.
Although Gary is in touch with mental health services, he doesn’t feel there is anything in place that helps when things get really bad. “I know when I am heading towards a mental health crisis,” he says. “I’m not eating or sleeping, I begin to drop down that all familiar dark hole where there is often only the cacophony of negative thoughts and feelings within me; despair, self-loathing, voices I hear get louder, dissociation, self-injury and suicidal thoughts. I try to get support but often there is no support that helps.
“It takes a great deal of trust and courage to ask for help and when the ‘help’ actually makes me feel more despairing… this adds to my agonising despair, makes me more paranoid, my voices get louder, I get more suicidal.”
“Each time I have been sectioned, I felt trapped, powerless and unsafe”
The first time Gary was sectioned, 20 years ago, he sought it voluntarily after being told that hospital treatment would help. Being an “informal” or voluntary patient is different to being held under section. You can refuse treatment and can, in theory, leave if you want. However, if staff are worried about your safety or the safety of others you can then be sectioned.
“I asked to go out for a cigarette but was told that if I tried to leave I would be sectioned against my will. I argued that I was there of my own free will and could leave at any time. I was sectioned,” Gary says. When a person is detained, despite a code of practice that stipulates otherwise, they can have very little control over what happens to them. “Each time I have been sectioned, I felt trapped, powerless and unsafe,” Gary says.
“There is little communication by staff other than at medication times. There is little access to fresh air. Restraints by staff and attacks by other patients are common place. Coercion to take medication. No one tells me how to appeal my section. My family don’t want to visit as they don’t feel safe on the ward either.” Gary says he has felt “humiliated”, “powerless” and “violated” when sectioned, on occasions feeling like “some kind of non-human”. He also notes there is little in the way of follow up care. “After months of being locked away. I’m suddenly free and alone at home.”
In October 2017 Prime Minister Theresa May launched an Independent Review into the Mental Health Act, after listing the way that people with mental health difficulties are treated as one of her “burning injustices” in the speech she made upon taking her role as Prime Minister. In the interim report of review, published in March 2018, the authors state “detained patients are vulnerable to potential coercive mistreatment, abuse and deprivation of human rights, leading to physical and psychological harm… We have heard examples of excellent care, where service users reported that they were treated with dignity and respect throughout their detention. However, just one third of those that expressed a strong view to our survey felt they were treated with dignity and respect and two thirds did not.”
NHS Digital, the body responsible for statistics about the NHS, reports that in England during 2016-17, a total of 45,864 new detentions were made under the Mental Health Act. The rate of detention was higher for men (83.2 per 100,000 population) than women (76.1 per 100,000 population). Rates of detention for black people (272.1 detentions per 100,000 population) were over four times those of white people (67.0 per 100,000 population).
“I thought I was playing out this storyline of cosmic significance. I thought it was a testing process with angels”
“I wasn’t expecting to end up in a psychiatric hospital,” says Olivia (not her real name), a student who was sectioned after experiencing depression and anxiety symptoms at university. Olivia’s medication wasn’t helping, so her doctor upped the dosage. What neither Olivia nor her doctor knew at the time was that she actually has bipolar disorder, which is characterised by depression interspersed with elevated moods that sometimes lead you to lose touch with the world around you. The medication Olivia was on pushed her from depression into mania and psychosis.
“I became psychotic quite quickly,” she says. “I was feeling great because that’s what mania is about. I was having religious delusions and feeling like I was in a movie or a dream kind of state where I was feeling quite happy. Everything was really significant and meaningful and I felt I was about to make great discoveries. I wasn’t expecting to end up in a psychiatric hospital. I thought everything was coming together and I was cured.”
Attending an outpatient’s appointment, staff became worried about Olivia’s wellbeing. “They got what I now know were two doctors and a social worker to come and assess me. I was just told these people want to talk to you and they want to help you. I was a bit oblivious and then they said at the end ‘We don’t think you can go home, you have to come up onto the ward’.”
Being sectioned can last for different amounts of time, Olivia ended up in hospital for five and half months. “For the first few weeks when I was still really psychotic, it was all just like almost being in a dream so I wasn’t feeling particularly traumatised by it. I just thought I was playing out this storyline of cosmic significance. I thought it was some sort of testing process with angels.”
Olivia says it was only when she came down from the florid psychosis that the situation began to feel worse. “By that time I’d been moved to a psychiatric intensive care unit away from the open ward. I was very bewildered, I didn’t even know where the hospital was in relation to the town I was in. It was very dislocating. It was more a kind of holding pen. Previously I had a lot of trust in NHS staff as most of the people in the UK do and it came as a huge shock to not be treated well by them.”
Olivia says she expected it to be something like an American TV show – with lots of intensive therapy and people to talk to – but “you get in and you realise there’s no therapy, there’s nothing apart from the TV most of the time.”
Sectioning will always be contentious. The purpose is to keep people safe, and sectioning undoubtedly saves lives by preventing people from killing themselves, by de-escalating situations where a person’s behaviour may be threatening to others, or, as in Olivia’s case, by stepping in when others doubt you can look after yourself. Yet all of the people I spoke to for this article said that they found it very hard to trust that they would be looked after well in future. Not everyone has a bad experience being sectioned, but too few people have an excellent one.
“The hospital staff always say ‘this isn’t a hotel, love’…Well, it’s not meant to be prison”
“It’s not just a case of paranoid disgruntled patients not realising what’s good for them getting angry and blaming NHS professionals who only want to help,” Olivia argues. “There’s widespread evidence that there are these failings.”
The Interim report of the Independent Mental Health Act review suggests that others have had similar experiences to Olivia and Gary’s, with the authors stating: “We have been made aware of a wide variety of distressing experiences including but not limited to, experiencing or witnessing physical violence, verbal abuse and threats, bullying and harassment, sexual predation, pain-based restraint, coercive reward and punishment systems for access to open air, leave or family contact.”
Olivia says she appreciates officials stepping into help her when she is “very ill” but says it shouldn’t be “the kind of punitive experience that detention is at the moment.”
“The hospital staff are always ‘this isn’t a hotel, love’,” she says, “Well, it should be, it’s not meant to be prison.”
We don’t like to think of our public services harming people or failing them. It is an awkward reality that the state can take away the freedom of someone who is unwell. As Gary explains: “People don’t know what happens when I’m sectioned and locked away against my will. They may think that I am getting the help I need and that I am safe. They don’t know what really happens behind locked doors.”
The Independent Mental Health Act Review is expected to make wide-ranging recommendations for better funding and for better practice when it it delivers a final report in the autumn of 2018. Although being held under section to be treated is often an uncomfortable necessity, this does not mean that the way that we approach such care cannot be better. Gary and Olivia took pains to stress that they don’t want to put people off seeking help for their mental health but admitted that at present good care when held under section seems to be a lottery.
“There are times when I would say that being sectioned has been warranted. When I am not in control of my thinking, have lost sense of reality and am a danger to myself without knowing it,” Gary says. “There are many more times when I feel like there should be alternatives to being sectioned that are caring and compassionate.” The care people currently receive when they are detained isn’t always what anyone would hope for when they are vulnerable, scared and having the worst time of their life. We must resist the urge to look away.
If you have been affected by any of the issues raised in this article please contact the Samaritans helpline on 116 123 or visit their website.