Street triage and mental health: giving a voice to those in crisis at the heart of the system

What is Section 136 of the Mental Health Act 1983 (England and Wales)?

Section 136 deals with the removal of mentally disordered persons, without a warrant, if a police constable thinks it is necessary in the interests of their own safety or that of others. The increase in cases prompted growing scrutiny. Research piloted by Professor Gillian Bendelow had already broached the possibility that, outside London and other large conurbations, Section 136 had long been the default response for police to manage highly distressed members of the public when no other services were available. Gillian Bendelow, together with Dr Claire Warrington, investigated current practice to challenge simplistic perceptions with observations that gave prominence to the lived experience of those who had previously been detained. Interviews and analyses revealed that in one year 80 per cent of all Section 136 detentions across Sussex took place 'out of hours' and appeared to be a compassionate means of suicide prevention in the face of no available alternative.

Reinforcing this finding, 81 per cent of those detained were deemed by police to pose an immediate risk to self through suicide or severe self-harm and many interviewed in the study had sought help from other sources before the incident, while 30 per cent of incidents were individuals being detained repeatedly. Individuals detained repeatedly described being disenfranchised from mental health services, often having a diagnosis of personality disorder and many disclosing histories of trauma, such as sexual abuse. Some individuals felt that the police were the only people who saw them as ‘human beings’ and who responded to their distress, praising officers’ compassion as opposed to being treated as a diagnosis or ‘nuisance’. The research also highlighted the use of alcohol being one the biggest barriers to receiving help before escalating to crisis as many safety suites would not take those under influence of alcohol.

'If you found me in agony on the street with a broken leg would you put me in a police cell?'

Being detained in police custody also added considerably to the stigma and humiliation of people’s experience. This was vividly expressed in the interview of a young woman who had been detained on several occasions: ‘If you found me in agony on the street with a broken leg would you put me in a police cell?’

Mental health professionals’ definition of a mental health crisis differed greatly from that of the lay public or the police. The research repeatedly highlighted that these differing conceptions of a ‘mental health emergency’ have become a fundamental dilemma for consideration by a wide range of stakeholders at both the local and national levels. Despite the historically effective joint working between police and mental health professionals in Sussex, the research demonstrated some entrenched positions expressed by both sides of the front line.

The evidence continued to develop through research, specifically examining the complexity relating to individuals experiencing ongoing suicidal crises resulting in multiple police detentions. The lived experience accounts revealed complex histories of unresolved trauma and showed how unsupported individuals come to rely on police intervention in repeated suicidal crises.

The research shed light on the complexities at the core of the detention rates, and the interventions being put in place to improve experiences. It highlighted successful joint working initiatives and emergent interventions with the data key to the process of embedding alternatives into current practice. In 2014, East Sussex became the first county to implement a Street Triage scheme, where a highly experienced mental health professional accompanies police response officers on mental health emergencies to provide on-the-spot support and access to resources. The term ‘Street Triage’ now covers a range of activity nationally that helps frontline and community policing meet the needs of people in crisis.

Street triage: Improved practices increased the wellbeing of both the public and service personnel

Research and workshops were instrumental in shaping the delivery of a more integrated emergency mental health service in Sussex. Detention to police custody as a Place of Safety in Sussex was reduced by 80 per cent from 984 in 2012 to 188 in 2015 and there was a 77 per cent increase in the use of health-based suites from 437 to 775, meaning vulnerable people were being placed in appropriate settings to support them during their crises. The use of police custody as a place of safety for minors under detention was completely eradicated across Sussex more than a year before this was nationally mandated in the Policing and Crime Act (2017). The improved practices increased the wellbeing of both the public and service personnel including the psychological benefits of avoiding the stigma of compulsory Mental Health Act detentions and improving the experience of highly distressed and suicidal individuals.

The research was instrumental in the formation of a new SPFT research theme: Personality, Emergency and Complex Care, with its own dedicated Lived Experience Advisory Panel (LEAP) comprising people with lived experience of complex mental health diagnoses and mental health crises and partly founded by participants from this work. This has opened up opportunities to improve engagement and to continue to acknowledge the lived experience of those on all sides of the service. This led to a recommendation in national policy in 2019 that all forces should evaluate their mental health triage services to embed the valued outcomes and patient feedback further and to deliver sustainable future services.