On 27 November a teenage girl experiencing a mental health crisis had to stay in a police station for two days, due to a lack of psychiatric places. This inappropriate interim placement is a bleak indicator of the state of affairs in child and adolescent mental health services (CAMHS) in the UK.
There is growing evidence that the state of mental health among children and young people in the UK is in decline, exacerbated further by the Covid-19 pandemic. CAMHS is seriously overstretched, having to turn away patients in need of support to deal with the most severe cases. This has a direct impact on the experience of young people who are detained under the Mental Health Act (1983).
Detention under the Mental Health Act
The Mental Health Act asserts that a child can only be detained for assessment and/or treatment if they are demonstrably suffering from a mental health condition and pose a threat of harm to themselves or others. Nonetheless, it is generally accepted that sectioning under the Mental Health Act should be regarded as a last resort.
Children and young people may also consent to admission, or parental consent can be granted where the child does not have the capacity to make this decision. This is known as informal admission. In practice, cases of informal admission raise some concerns: the threat of detention may coerce individuals into so-called “voluntary” admissions. Moreover, there is controversy regarding a parent's right to consent to what is an effective deprivation of the child's liberty. While admissions under the Mental Health Act have explicit safeguards in place, it is unclear if and how these relate to cases of informal admission.
Experiences of Detention
Generally, there is a lack of academic literature on mental health detention of children and young people. To address this, Coram International conducted a research study on the mental health detention of young people in England and Wales, funded by the Chubb Rule of Law Fund. This in-depth qualitative study concentrated on the admissions process and young people's experiences during their stay, with a focus on informal admissions to psychiatric inpatient units. Six participants aged between 17 and 21 were interviewed, whose stays ranged from three to 16 weeks.
The study found that although the research participants had entered the unit under the guise of informal admission, all felt they had no choice, and some had been threatened with being sectioned. The coercive nature of their entry to the unit means this can hardly be considered voluntary.
Participants generally had negative experiences of the staff, ranging from finding them manipulative and abusive to uncaring or untrained. The young people resented punitive measures in place to deal with misbehaviour, which made them feel like prisoners. Additionally, five of the six young people reported feeling a sense of powerlessness due to their lack of involvement in key decisions concerning their care.
Several participants did acknowledge the life-saving nature of the units. However, they expressed frustration that they had to wait until “breaking point” before receiving adequate support. The overstretched nature of CAMHS had repercussions on the participants’ access to and experience of inpatient care. With staff members stressed and under pressure, they are effectively unable to provide adequate support to the young people. According to the participants, the main positive component of their time on the units was the friendships made with other inpatient peers. They felt a sense of community and their shared experience was particularly bonding. The key role of peer relationships during psychiatric inpatient care is supported by previous studies, which have found that these relationships have a direct impact on patient satisfaction. Since inter-patient relationships played such a key role for the participants, the potential for building more positive relationships with staff could be significant.
It is vital that young people have some agency and control over the nature of their own care and should be given age-appropriate information about their condition and treatment to ensure they can properly grant consent. Collaborative care establishes shared decision-making and more positive relationships for young people within their experience of mental health care. Although the implementation of this type of care is not straightforward, it certainly merits effort and investment to ensure that staff and patients have more collaborative relationships.
At present, the current system of mental health detention for young people does not allow for adequate protection of children's rights. There is much to be done to ensure that psychiatric units in the UK are fit-for-purpose and function in the best interests of the children admitted. Furthermore, the additional impact of being admitted “voluntarily” through the informal admissions process must be further explored to consider appropriate safeguards.
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Lauren Morling is project management officer and Sihana Bina is research intern, at Coram International. Special thanks to Elizabeth Yarrow and Alanah Bagwell whose dissertation “I came out a very different person, probably for good and bad reasons”: Young People's Experiences of Psychiatric Inpatient Units in England and Wales’, submitted as part of her MSc in Developmental Psychology and Clinical Practice in 2021, provides the basis for this article
