"There's something intrinsically mad about taking people who are having the worst time of their life and putting them in one building together," says Dr Mark Salter, who has spent the last 20 years working on the frontline of adult psychiatry across East London – one of the most ethnically, economically and mentally mixed-up areas in the UK. A big part of his job is deciding when people need to be detained in hospital or a police cell under the 1983 Mental Health Act – a process otherwise known as sectioning.
Last year, the Act was used over 50,000 times, an increase of 30 percent over the last ten years. One in a hundred of us will develop a psychotic illness in our lives. But whether we're becoming madder, badder or sadder (or just better at treating mental health) for many people, this stay in psychiatric hospital still carries a huge stigma, despite it often being a major turning point in a person's life after months, and sometimes years, of mental anguish.
Part of the problem is that sectioning remains widely misunderstood, even though overall society is much more aware of mental health conditions. It's the last taboo, characterised by jokes about "loony bins" and "men in white coats". But for Dr Salter, it's a vital tool to treat mental ill health. "I would say that sectioning saves lives," he says. "In Hackney we probably save three lives a night"
Juno, a 24-year-old with paranoid schizophrenia, started hearing voices and hallucinating when he was just 14. "I'd see beetles crawling around on the floor and hiding in my food, and see a large scarecrow hiding in shadows, behind my bed and even out in the street among people." By the time he was 16 he was sent to a psychiatric hospital, and he's constantly surprised by people's preconceptions. "Films are awful at showing psychiatric hospitals. They make out like people are put in straitjackets, thrown in padded cells and just left to die or rot. I'm amazed that people actually think that's what happens!"
The reality is that it's actually very difficult to get sectioned, and to stay sectioned. By law, detaining someone on mental health grounds, because they can no longer make decisions for themselves and pose a risk to themselves or those around them, is an act of last resort.
Jo hit her lowest ebb late one night in January 2013, when she called the police to section her own daughter. Nikki, now 28, was walking down the side of the A143 clutching a suitcase packed with a couple of odd items, saying she was going to London (she lives in Norfolk). When Jo reached her, Nikki started veering into the middle of the road. "Nobody wants to have their loved one sectioned but I just felt at that point it was the only way forward," Jo said.
In fact, Nikki had been suffering with undiagnosed bipolar disorder for nearly eight years, repeatedly presenting herself at the local A&E in mental distress. She was kept in for short periods as a voluntary patient, which means she was free to leave at any point, and the hospital was free to discharge her if they needed the bed, without any care plan in place. Given we've lost nearly 2000 mental health beds in the last five years, space is at a premium. In some parts of the country, only the most acute cases can stay. According to Dr Salter, "if not quite snake pits, the wards are something approaching our equivalence of Bedlam. The wards are more turbulent and more chaotic, but we do our best to cope with that."
"Sectioning saves lives. In Hackney we probably save three lives a night" – Dr Mark Salter, frontline Adult General Psychiatrist, Hackney
Jo admits she didn't think Nikki could be helped. "I thought maybe the best thing to do would be to let her commit suicide," she says.
Nikki was placed under Section 136, which is the Section used by the police to take you to a place of safety when you are in a public place, like the middle of a major A Road. Fortunately for Nikki, because of lack of beds in her local area, she was taken to a psychiatric hospital in the next county, where she finally got the bipolar diagnosis and, being under section, was forced to take medication.
Nikki was also lucky that she didn't spent the night in a police cell, which happens more often than it should as beds are squeezed. One woman I spoke to, Claire, was traumatised by her admittance into police custody, which included a strip-search. "I felt I was a bad person for having mental health problems anyway. But being put in a cell I felt very embarrassed and ashamed of myself."
Ali Fiddy is the Head of Legal at Mind. She says detention of people with mental health problems in cells is a major issue for them. "Just being in a police cell can make you more distressed. You're not being accused of committing a crime, you're unwell and a police station is not a suitable environment."
A Section 136 only lasts a maximum of 72 hours, at which point you are released, or, like Nikki, placed on a Section 2, which gives your mental health team up to 28 days to assess and treat you. Jo says Nikki quickly improved and become more communicative than she had been in months, but Nikki didn't feel the same way. Instead, like most of the people I spoke to, she appealed her Section.
Embedded in the Mental Health Act are laws to protect us from the abuse of these powers to detain people. Under a Section 2, people have a right to appeal within 14 days, which will be heard in a court attended by a judge, a psychiatrist and one other mental health worker as well as someone's own psychiatrist and a solicitor paid for by legal aid.
Nikki's appeal failed, and in fact she was kept under Section in two hospitals. Doctors are not surprised that people resist treatment. Dr Dele Olajide is a Consultant Psychiatrist at the South London and Maudsley NHS Trust. "If you admit someone against their will, it's unreasonable to expect them to cooperate with you." This is especially true because of the separation between community care and in-patient treatment, so the chances are, when you're admitted, you won't know anyone. "It can be a very frightening place to be, if you're coming straight from the community to a ward where people are very disturbed."
Dr Olajide told me the period of 28 days given in a Section 2 was the vital time needed for a person's mental health team – including the psychiatrist, nurses and psychotherapist – to gain the trust of the patient and work out what the problem is. And if they can't make a person safe in that time, they can turn a Section 2 into a Section 3, which gives clinicians up to six months to treat someone, and can be extended beyond that, but each time with provisions for appeal by the patient or challenge by the nearest relative, which is a long, ordered list of people stretching from partner or cohabiter through extended family. While that process of assessment and treatment is going on, medication is a vital tool of the ward.
Laura, 24, has been diagnosed with schizoaffective disorder, which is a combination of schizophrenia and mood disorder, and can make life pretty unpredictable for her if she doesn't take her meds. But it took a long time for the hospital to diagnose her condition and then find the right combination to treat her. In the meantime, she was hellbent on killing herself, to the extent that she was moved from an open ward to a secure unit.
For most people, being sectioned is not the end of the story, but a turning point. "It's a comma in a sentence," says Dr Salter. "And then?"
"As safe as they tried to keep us I'd always find ways around it. At one point I got hold of a razor blade and cut into my neck above my jugular to the point I needed external and internal stitches. I was a millimetre away," she tells me. "I ingested poisons. I self-harmed and caught a vein. It was really dangerous stuff, so I do understand why they needed to move me. I could have easily died."
When I asked Dr Salter what the challenges were of working on a psychiatric ward, it sounded like Laura's behaviour was his bread and butter. "Shouting and screaming, the constant need to monitor people who are at risk, people refusing to eat and drink, the relentless need to be kind. Can you imagine having to use the battering ram of kindness? It's exhausting."
Laura found life in a secure unit very different to an open ward. "I was restrained and injected a lot. They'd hold you down and inject you in the leg just below your bum. Other sedatives would be brought with your normal medications three times a day and you'd just have to take it." It's not something she ever got used to, she says.
Laura unsuccessfully appealed four times against her section, but today she says, "I dread to think what would have happened if I hadn't gone into hospital. A lot of what happened might not have been necessary, but the whole experience was, because I honestly don't think I'd be alive now." She told me that she kept diaries all the way through her stay in hospital, and it's obvious when things started getting better because she started to write about the future. At her worst, she said, she couldn't see beyond the minute.
"Relinquishing control is very often, to a confused person who has only a small amount of insight into the mess that they're in, something they are grateful for later on," said Dr Salter. Most people I spoke to believed their stay in psychiatric hospital had been vital to their recovery, even if they hadn't much enjoyed their time there.
Where they could, they'd sought out friendships. "Luckily the other patients weren't the kind of people think would be on a psychiatric unit. They were poorly but still functioning, friendly and nice," Laura told me. While Claire, who after her night in a police cell was eventually sectioned in hospital, says patients would gossip about staff members.
Many people I spoke to felt that their discharge was too soon or that there wasn't the right care on the outside. For anyone who is discharged after a Section 3, they're guaranteed aftercare under Section 117, which can range from a place to live to someone ensuring medication is taken every day. But Dr Salter admits, "Meanwhile, in the real world where there's not a lot of money sloshing around, it's not always that easy." Dr Olajide acknowledged, "the pressure now is to discharge patients as soon as they are well enough." This can lead to a revolving door between community and in-patient care, which he believes frays the relationships with friends and family that are so vital to staying well.
For most people, being sectioned is not the end of the story, but a turning point. "It's a comma in a sentence," says Dr Salter, "and then...?" For Nikki, the "and then" involved another voluntary stay in hospital and new medication, but she's now expecting a baby and is a mental health advocate. Laura works closely with her community mental health team and is at university studying psychology. The purpose of sectioning isn't to institutionalise people, it's to get them back into the real world. "You've got to take a risk at some point," says Dr Salter. "Remember, the aim of the game is not to bang them up forever."
If you are concerned about the mental health of you or someone you know, talk to Mind on 0300 123 3393 or at their website, here.
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