Monday, 14 June 2010

This Much I Know Part 2

Be aware of your body language and general demeanour
• It is usually best to maintain good, although not too intense, eye contact. However, people who are plainly paranoid may find this threatening, in which case, avoid too much eye contact when talking to them.
• Appear to be relaxed – even if you aren’t. Sit down if possible, although it is generally better to perch than to be enveloped in a saggy armchair, in case you need to make a quick exit.
• Do not get into the personal space of the patient.
• Maintain an even tone when talking, even if the patient is shouting.
• Do not show that you are frightened or intimidated by a patient.

A foot in the door can be a lot quicker than a Sec.135 warrant
• Remember that under Sec.115(1) of the MHA: “An approved mental health professional may at all reasonable times enter and inspect any premises (other than a hospital) in which a mentally disordered patient is living, if he has reasonable cause to believe that the patient is not under proper care.”
• This is one of the powers of the AMHP, and does give a degree of authority to enter a patient’s house. It may be worth pointing this out to an uncooperative patient before going off to the magistrate.
• It is also worth remembering Sec.129 MHA relating to obstruction:
“(1) Any person who without reasonable cause
(a) refuses to allow the inspection of any premises; or
(b) refuses to allow the visiting, interviewing or examination of any person by a person authorised in that behalf by or under this Act or to give access to any person to a person so authorised; or…
(d) otherwise obstructs any such person in the exercise of his functions,
shall be guilty of an offence.”
• I have to say, however, that I have never had to make use of that particular section, and I am not aware of anyone actually being arrested in connection with this offence. But there’s always a first time.

Try to give the patient choices
• Always show respect for the patient.
• Depending on the degree of capacity of the patient, it is reasonable to explain the choices available to them. You will of course explain the purpose of the assessment. This can include explanation of the options available, such as home treatment, informal admission to hospital, or admission under the MHA.
• Once a decision has been made to admit, offering a choice of admission by ambulance or car, for example, can often result in the patient feeling they have some control over the process and they are then more likely to make a positive choice to go to hospital and can be less likely to object when the time comes to be admitted.

Know when to use the police
• Don’t expose yourself to an unacceptable degree of risk.
• If you have evidence of violence or aggression, arrange for the police to accompany you.
• The police may not actually be required, but it is good to at least alert the police to the possibility that they may be required and to get an incident number, or ideally to have them nearby.
• In my experience, a police uniform, rather than provoking a patient, can be very calming to an agitated or hostile patient.
• Patients will often be more amenable to cooperating with the assessment in the presence of the police.
• Police can be good intermediaries when the AMHP is being seen as the villain of the piece.
• The Police are often very good at explaining to the patient the necessity of cooperating with the admission process.
• In my experience it is rare for the police to actually have to use physical restraint to facilitate an admission.

Never be alone
• Once the assessment has been concluded, and the papers have been signed, doctors are usually very keen to be off. Make sure they don’t leave you on your own with a patient. At the very least, make sure there are relatives or other professionals with you (students can be useful in these circumstances!). Involve the police if you need to.

A Mental Health Act assessment, especially when it takes place at the patient’s home, can be very distressing for the relatives as well as the patient
• Don’t forget the likely distress the relative already has, or the additional distress the relative may have witnessing the actual process.
• Try to spend time explaining to the relative what is happening, the reasoning behind any decisions, and what will happen next.
• It may be appropriate to give the relative the option of accompanying the patient to hospital: this can also assist in reassuring the patient.
• Make sure the relative knows where the patient is going, and other information, such as the phone number of the ward, visiting times, etc.

When dealing with situations of high risk, at times I ask myself the following question:
• “Would I rather justify my decisions to an Appeal Tribunal or to an Inquest?”
• This does not necessarily mean you should always take the “safe” course, but this question can concentrate your mind.
• There are occasions when it’s definitely in the interests of the patient to return control to them (even if you do have a sleepless night!). It may even restore their faith in Mental Health Services.

You’re always an AMHP
• Once you become an AMHP, it begins to pervade your day to day practise.
• You may be sitting chatting to a service user. Something they say sets alarm bells ringing, and suddenly the interview takes a different course. Suddenly you have your AMHP hat on. But equally suddenly, (and undetectably) you can take it off again.
• If you work in a Mental Health Team, it soon becomes second nature to see case discussions in the light of duties and powers under the Mental Health Act (and the Mental Capacity Act). You may not even say anything differently; but you are thinking differently.
• You find yourself contributing to discussions in ward rounds or team case reviews in the context of possibilities under the MHA.
• Do these discussions and interviews constitute Mental Health Act assessments? In a way, yes. But they can also remove the need to go down the MHA route. It can save a lot of time when a quick chat with a Consultant removes the need for a full blown assessment.

Occasionally, I entertain a little fantasy
• I am in a theatre, watching a play.
• One of the actors begins to behave erratically. They fluff or change their lines, they interrupt other actors when they’re not supposed to, they laugh inappropriately, they don’t respond to cues, they move round the set knocking things over. They start fighting with other members of the cast. Eventually, the curtain falls prematurely.
• A murmur rises from the audience, wondering what has gone wrong, wondering what is happening.
• After a few minutes, the director parts the curtains and stands at the front of the stage.
• “Excuse me,” he announces, his voice rising over the audience. “But is there an Approved Mental Health Professional in the house?”


  1. As an AMHP trainee currently hearing ticking clocks to portfolio submission deadline date, I just want to how much I enjoy your blog. Reading this has made me smile today, as I have indeed used the foot in the door technique very recently, but it still didn't get us in! That took another day's persuasion...(and I didn't detain) But you're interrupting me from my portfolio! And I'm so keen to qualify...

  2. Ooh wow, these posts have been interesting! I don't know if this sounds strange or not, but it makes me want to be an AMHP even more..

    outwardly x

  3. Mental Health Inspector15 June 2010 at 18:54

    "Know when to use the police ... don't expose yourself to an unacceptable degree of risk ... if you have evidence of violence or aggression, arrange for the police to accompany you."

    If you have evidence of violence or aggression, you should arrange to secure a warrant under s135(1) MHA, to ensure that the police officers actually have some powers to manage the violence and aggression you are anticipating. Police officers in private premises, only have powers to use force to arrest someone for an offence or an attempted offence, or to use force to prevent a crime. Whilst this would include powers to prevent a s129 MHA offence and powers to arrest someone for that offence, it doesn't give them any powers to control the service-user themselves, or to restrict the movement of persons in the premises when behaviour is at the sub-offence level.

    Obviously, this means there are NO powers for police officers (without warrant) to control the movements of people inside the premises, (ie, what if the service wants to lock himself in the bathroom?); there would be no power to restrict access to anything that could be used as a weapon (kettles, cutlery, knives, golf-clubs) until that access or behaviour constituted a criminal offence (do we really want people standing with boiling kettles and actually TRYING to throw them before the police have the power to stop them?); no powers to prevent the service-user (or anyone else, for that matter) from actually just deciding to leave the premises (note; the criteria for arrest under s136 MHA may but may not be met, if they do).

    There are MANY misunderstandings about warrants under s135(1), such as the common fallacy that you need to be able to demonstrate that you have already attempted to secure access and failed, or that you reasonably anticipate that access would be refused. Neither of these are true, whereas they are true of warrants under s135(2).

    I think this is an area of business made complicated by poor law, but made worse by poor understanding of the law on all sides of the partnership but let's not forget that we can name, MH professionals, police officers and service-users who have died where entry to private premises has been poorly planned.

    I really enjoy the blog, hope you don't mind my chipping in the police points, because I want to engage so we support each other as best we can.

  4. Mental Health Inspector15 June 2010 at 18:58

    PS: I can give you an example of somebody being restrained by the police to prevent a crime under s129 and threatened with arrest. As it actually did the trick and the person calmed down and backed off, an arrest wasn't required.

    AMHP with s135(1) warrant, executed by me and my team for a very resistent MH patient who the AMHP already intended to section with a very uncooperative family ...... door destroyed upon entry, family up in arms, mother of service-user very obstructive, restrained and removed to another room by an officer, threatened with arrest under s129 MHA.

    Job done.