FREQUENT DETAINEES UNDER SECTION 136 OF THE MENTAL HEALTH ACT (1983): LIVED EXPERIENCE AND SERVICE PERSPECTIVES ON REPEATED DETENTION

CLAIRE ANDREA WARRINGTON

A thesis submitted in partial fulfilment of the requirements of the University of Brighton for the degree of Doctor of Philosophy

June 2019

ABSTRACT Section 136 of the Mental Health Act (1983) is a highly controversial police power, often used as suicide prevention, which enables the detention of a person who appears mentally disordered and in need of immediate care or control. Legislative change in 2017 appears unlikely to have resolved widespread concerns over the unsustainably high national rates of use. Understanding why some individuals are detained repeatedly is therefore vital if Section 136 numbers are to be lowered. Mixed-method research combined three data streams: • Narrative interviews of participants with lived experience of recurrent suicidal crises and multiple detentions, which were jointly analysed with advisors who identified as having complex mental health needs • A dataset of over 500 repeat detentions in Sussex • A national police survey and further data from neighbouring areas A realist-informed approach revealed how recurrent detention is triggered by a chain of interrelated factors. Nationally, the phenomenon is widely recognised and appears to constitute a third of Section 136 use. Most recurrent detentions in Sussex were characterised by slightly more men than women being detained twice, however a small but stark proportion represented the police intervening in the frequent suicide attempts of a few individuals, who were almost exclusively women. Most in this high frequency repeat group had received diagnoses of borderline or emotionally unstable personality disorder. The lived experience accounts described how the impact of unresolved trauma could be exacerbated by the disempowering medicalised approaches employed by mental health services. An unmanageable sense of hopelessness was recurrently provoked by the perception that these circumstances could not be changed. When this despair became overwhelming the police were forced to contain the resulting suicidal crises, fulfilling the position of always-available protector. However for some individuals, a multilateral trauma-informed approach had disrupted the cycle.

Repeated detention can thus be viewed as a lens through which to identify some of the most vulnerable people, who have found themselves experiencing frequent suicidal distress through serial societal disregard. This study makes a direct contribution to understanding this neglected area of research from a psychosocial perspective. The implications for practice and social policy are that consistent and empathetic support structures are necessary to enable individuals to develop stable, trusting relationships and a belief in having a future. This work also contributes to the ongoing debates regarding the limitations of the biomedical model of mental health care.

CONTENTS

CONTENTS ...... 4 List of Tables ...... 8 List of Figures ...... 8 ACKNOWLEDGEMENTS ...... 9 DECLARATION ...... 10 1 INTRODUCTION: SECTION 136, REPEATED DETENTION AND SUICIDE ...... 11 1.1 Chapter Overview ...... 11 1.2 Section 136 of the Mental Health Act ...... 12 1.3 ‘The Cinderella Section’: Issues Surrounding S136 ...... 14 1.3.1 Data Recording ...... 14 1.3.2 Places of Safety...... 15 1.3.3 Detention Rates ...... 16 1.3.4 Police Assessment of Mental Health ...... 18 1.3.5 Detention Outcomes ...... 21 1.3.6 Sociodemographic Details of People Detained ...... 23 1.3.7 Macroeconomic Context of S136 ...... 24 1.3.8 Summary ...... 26 1.4 S136 in Sussex: Spotlighting Repeated Detention ...... 27 1.4.1 Lived Experience of Detention ...... 27 1.4.2 Detention Data ...... 29 1.4.3 Repeated Detention in Other Research: Hidden in Plain Sight ...... 29 1.4.4 Policy Acknowledgement ...... 30 1.4.5 People who Repeatedly Come to Police Notice ...... 32 1.4.6 Frequent Attenders to Healthcare...... 34 1.4.7 Summary ...... 35 1.5 Suicide and Self-Harm ...... 36 1.5.1 Suicide: International and Domestic Concerns ...... 36 1.5.2 Self-Harm ...... 38 1.5.3 Suicide, Self-Harm and Mental Health ...... 39 1.5.4 Social Factors, Trauma and Diagnosis ...... 40 1.6 Chapter Summary ...... 42 1.6.1 A Psychosocial Approach ...... 44

4 2 CARE OR CONTROL? SHIFTING ATTITUDES TO MENTAL ILLNESS ...... 47 2.1 Chapter Overview ...... 47 2.2 The Evolving Societal Response to Mental Illness ...... 48 2.2.1 The Rise of the Asylums ...... 49 2.2.2 Progression in Language, Laws and Practice ...... 52 2.2.3 Beyond the Asylums ...... 54 2.2.4 Policing ‘Insanity’: The Case of Suicide ...... 56 2.2.5 Psychiatric Coercion: Control as Care? ...... 60 2.2.6 Summary: The Tensions Between Care and Control ...... 63 2.3 Diagnosing Difficulties: The Controversial Dominance of Biomedicine ...... 64 2.3.1 Biomedical Psychiatry...... 64 2.3.2 Psychiatric Diagnosis and the March of Medicalisation ...... 67 2.3.3 Diagnosis: Controversies and Debates ...... 69 2.3.4 The Contentious Field of Personality Disorders ...... 73 2.3.5 Social Causation of Mental Illness ...... 78 2.3.6 Summary: The Present State of Controversies in Biomedical Psychiatry ...... 80 2.4 Progressing from the Biomedical Model ...... 82 2.4.1 Critical Psychiatry: Postpsychiatry and Values Based Medicine ...... 82 2.4.2 The Recovery Movement ...... 84 2.4.3 Patient Involvement Movements ...... 87 2.4.4 Reclaiming the Prerogative of ‘Expertise’ ...... 90 2.4.5 From Survivors to Providers: Changing Perspectives and Expanding Choices ... 92 2.5 Chapter Summary ...... 94 3 METHODOLOGY & METHODS: A REALIST-INFORMED INQUIRY ...... 97 3.1 Chapter Overview ...... 97 3.2 Epistemological and Ontological Perspective ...... 97 3.2.1 My Context ...... 97 3.2.2 Realistic Evaluation as Methodology ...... 100 3.2.3 Summary: A Realist-Informed Study of Repeated Detention ...... 106 3.3 Methods ...... 108 3.3.1 Research Aims ...... 108 3.3.2 Research Questions ...... 109 3.3.3 Explanation of Research Streams ...... 110 3.3.4 Recruitment ...... 114 3.3.5 Justification of Approach ...... 115

5 3.3.6 Managing Interview Data ...... 116 3.3.7 Analyses...... 117 3.3.8 Summary: Constructing the Programme Theory ...... 123 3.3.9 Ethical Issues ...... 124 3.4 Chapter Summary ...... 130 4 FINDINGS I: DEFINING REPEATED DETENTION ...... 133 4.1 Chapter Overview ...... 133 4.2 Data Sources...... 134 4.2.1 Data Stream One: Exploration of Local, Regional and National Practice ...... 134 4.2.2 Data Stream Two: Repeat Detainee Characteristics ...... 138 4.3 What is Repeated Detention? ...... 138 4.3.1 Recognition of Repeated Detention ...... 139 4.3.2 Defining Repeated Detention ...... 140 4.3.3 Extent of Repeated Detention ...... 141 4.4 Who is Repeatedly Detained? ...... 142 4.4.1 Home Areas of People Repeatedly Detained ...... 143 4.4.2 Gender and Number of Detentions ...... 145 4.4.3 Gender and Age ...... 147 4.4.4 Ethnicity and Number of Detentions ...... 147 4.4.5 Type and Number of Diagnoses and Detentions ...... 148 4.4.6 Sub-groups within Repeated Detainees (Cluster Analysis) ...... 151 4.5 Under What Circumstances are People Repeatedly Detained? ...... 154 4.5.1 Reason for Detention ...... 154 4.5.2 How Police Were Alerted ...... 155 4.6 Chapter Summary ...... 162 5 FINDINGS II: LIVED EXPERIENCE OF REPEATED DETENTION ...... 163 5.1 Chapter Overview ...... 163 5.2 Lived Experience Interview Data ...... 164 5.2.1 Interviewee Participants ...... 164 5.2.2 Deliberative Workshop Consultation...... 165 5.2.3 Lighthouse Member Interviewees ...... 166 5.2.4 Out of Area Interviewees...... 169 5.3 Context – Mechanism – Outcome Configuration ...... 171 5.3.1 Outcome: Hope - “I have a total lack of hope” ...... 172 5.3.2 Context: Relationships - “I’m just completely at home here” ...... 178

6 5.3.3 Mechanism (Resource and Reasoning)...... 187 5.4 Chapter Summary ...... 197 6 DISCUSSION: A REALIST CONCEPTUALISATION OF REPEATED DETENTION ... 199 6.1 Chapter Overview ...... 199 6.2 A Psychosocial Consideration of Repeated Detention Through a Realist Inquiry Lens ...... 200 6.3 Trauma and Gender ...... 200 6.4 Influence of the Biomedical Paradigm...... 208 6.5 Section 136 and Repeated Detention in the Broader Context ...... 211 6.6 Chapter Summary: Breaking the Cycle with a Community of Consistent Care ...... 214 7 CONCLUSIONS ...... 217 7.1 Chapter Overview ...... 217 7.2 Summary of Key Findings ...... 217 7.3 Research Limitations ...... 218 7.4 Contribution to Academic Literature and Research ...... 219 7.5 Implications for Policy and Practice ...... 223 7.6 Recommendations for Further Research ...... 225 7.7 Concluding Comments ...... 227 8 REFERENCES ...... 231 Appendices ...... 264 Appendix A: Email Chain with Inspector Michael Brown, College of Policing & National Police Chiefs Council Mental Health Coordinator ...... 265 Appendix B: Risk Management Protocol ...... 268 Appendix C: Consent Form ...... 270 Appendix D: Participant Information Sheet ...... 272 Appendix E: Cluster Analysis Model Summary ...... 275 Appendix F: Charts for Distribution of Age (By Clusters) ...... 276

7 List of Tables

Page Table 1.1: Reported Rates of Detention to both Police Custody and Health Based Places of Safety (England and Wales) 17 Table 1.2: S136 Detentions to Health Based Places of Safety 23 Resulting in Hospital Admission (England only) Table 4.1: Police Survey Respondents 135 Table 4.2: Proportion of Repeated Detentions in 141 Collaborating Areas Table 4.3: Home Area and Number of Detentions 144 Table 4.4: Age of People Detained by Gender and 147 Number of Detentions Table 4.5: Average Age by Cluster Membership 153

List of Figures

Page Figure 2.1: Principles of the Recovery Movement 85

Figure 2.2: Components of the Power Threat 94 Meaning Framework

Figure 3.1: Visual Representation of Context, Mechanisms and 103 Outcome in Realistic Evaluation

Figure 3.2: Data Streams of Study 109

Figure 4.1: Number of Detentions by Gender 146

Figurer 4.2: Number of People and Detentions by Diagnosis 150 Category

Figure 4.3: Cluster Analysis Best Model 152

Figure 4.4: How Police were Alerted 157

Figure 4.5: How Police were Alerted by Clusters 151

Figure 5.1: Proposed Context Mechanism Outcome 172 Configuration

Figure 6.1: Proposed Ripple Effect Programme Theory of 205 Repeated Detention

8 ACKNOWLEDGEMENTS

I would like to express my sincere gratitude to Wellcome Trust, especially to Dan O’Connor and Paul Woodgate, for funding me to complete this work and for immeasurable support throughout.

I am hugely grateful to my supervisory dream team: Professors Gillian Bendelow and Phil Haynes and Dr Julia Stroud for all you have taught me through your invaluable guidance and continued encouragement.

Thank you to my collaborators Marian Trendell, Sarah Gates, Alison Naylor and Paul Jennings who have made this research possible, your passion and dedication are truly inspiring.

Thanks are also due to Inspector Michael Brown and everyone who has taken part in this research. Above all, I am deeply indebted to the people whose pain is written into these pages, especially to those who gave their time to participate in interviews and to advise on the study and analysis.

I am greatly appreciative of the encouragement and friendship I have received from colleagues in the School of Applied Social Science. I would especially like to thank Toby Leyton for patiently and promptly dealing with each IT crisis; Lizzie Mingeaud for sourcing my endless interlibrary requests and Fiona Sutton for smoothing over each administrative wrinkle with poise and equanimity.

My wonderful family of friends have kept me going with love, laughter, unwavering support and fresh perspectives: Vic, Karen, Charmaine, Dee, Rob, Sue, Kris, Rasa, Gita, Jay, Sherryn, Andy and Tim.

Finally, my heartfelt thanks to four phenomenal women who are no longer here but whose lega