Tuesday, 21 June 2011

Why Be An AMHP?

Blogger provides a lot of interesting data relating to the readership of one’s blog, not least of which is the rough geographical location of visitors. Although predominantly my readers originate in the UK, there are a lot of people in the USA who follow The Masked AMHP, and I even seem to have a significant readership in South Korea, among other more unexpected places. One of the other interesting pieces of data is the search keywords that people have used that have led them to the site. “Diogenes Syndrome” somewhat surprisingly is by far the most popular search term (I suppose people living voluntarily in squalor worries a lot of people), but quite close behind is the question: “Why be an AMHP?”

I suppose that most of the people asking search engines this question are British mental health practitioners trying to make up their minds about whether or not it’s worth undergoing the fairly extensive training necessary to become an Approved Mental Health Practitioner. When the new role of the AMHP was created, it meant that not just social workers, but also nurses, occupational therapists and clinical psychologists could all apply to become AMHP’s.

I have to say that of the numerous occupational therapists I have met and worked with over the years, none have ever shown the slightest inclination to undertake this function. It’s just not really the sort of thing someone wanting to be an OT would tend to consider.

(Mischievous imaginary scene #1: 
CMHT Manager: “What was the outcome of your assessment of Joe Bloggs under the Mental Health Act yesterday?”
Occupational Therapist: “We had a lovely discussion about arts and crafts and then we made a macramé plant pot holder together.”)

I also cannot imagine a clinical psychologist wanting to take on this role – most psychologists I know only ever see patients in their clinical base, and then only if the patient actually wants to see them.

(Mischievous imaginary scene #2: 
CMHT Manager: “Could you go out and assess Joe Bloggs under the Mental Health Act?”
Clinical Psychologist: “I can put him on my waiting list, but does he actually want to be sectioned?”)

Our local AMHP course, which has just finished, had 3 community mental health nurses. While I and other AMHP’s involved with the course, were initially sceptical that nurses could take on board the social perspective that is second nature to most social workers, and were particularly worried that nurses might have difficulty in adopting the autonomy that is essential in the AMHP role, we were impressed and reassured at the enthusiasm and willingness to learn new skills that the nurse candidates displayed during their practice placements.

So why be an AMHP, then? Perhaps I can begin to answer that question by giving some of the reasons why I am an AMHP.

Some of the service user readers of this blog might suggest that the main reason why anyone would be an AMHP is so that they can fascistically exert power over helpless mental patients who don’t really have anything wrong with them and are just trying to get on with their lives in their own idiosyncratic ways. Surprisingly enough perhaps, that is not why I am an AMHP.

The AMHP role is a complex one. It is also unique among the tasks of social workers (and other mental health professionals) in that the AMHP is acting as an autonomous professional rather than an agent of their employees, whether is be a local authority or an NHS Trust. An AMHP cannot be told by a manager to “go out and section” someone. All they can be asked to do is to conduct an assessment under the MHA and reach their own conclusion based on all the evidence.

Going back to my time as a generic social worker in the 70’s and 80’s, I recall in child protection meetings being told to go out and apply for an Emergency Protection Order on a child, or to initiate care proceedings. In those circumstances, the social worker is merely doing what they are told, executing the corporate decision of the agency, regardless of their own possible misgivings.

I have to say that one of the things I enjoyed about working as a generic out of hours emergency duty worker was the autonomy. Whatever the case, whether it be a report of child abuse, a elderly person requiring emergency care, or a request for a Mental health Act assessment, there were no managers around to tell you what to do or what not to do. You could make your own executive decisions, carry them out, then pass the case on to the local area the following day.

If you would like more autonomy in your job, then being an AMHP can provide that. Of course, a consequence of the autonomy you have as an AMHP is that you have to take full professional responsibility for your decision, whatever it may be, and its consequences.

AMHP’s have an in depth knowledge of law and have a responsibility for upholding the law when conducting assessments under the MHA. They can use that knowledge to ensure that the rights of those being assessed are protected, and can provide a counter to the medical model of mental health, introducing a more rounded social perspective to the process. They need to use their knowledge not just of mental health legislation but also the Human Rights Act. This can give them the confidence to disagree with the doctors, and to seek out and suggest alternatives to hospital admission.

Even though some patients subjected to this assessment process may regard that assessment as a foregone conclusion, the AMHP will draw on all the information available on that individual, not just the medical and clinical factors. This includes their individual social and cultural circumstances, the possible risks and protective factors, as well as their knowledge of mental illness and the legal process, in order to try and reach a just and equitable conclusion which will balance the rights of the patient with their possible need for protection and treatment. As a social worker, if you can pull all that off, I think that’s pretty cool.

The AMHP role does indeed consist of a range of powers, but the AMHP has a range of duties as well. The following lists are not exhaustive, but include the main powers and duties.

Powers include:
  • The power to make an application for compulsory admission to hospital under Sec.2, Sec.3 or Sec.4
  • The power to make an application for guardianship under Sec.7 
  • The power to convey the patient to hospital or to authorise others to do so 
  • The power to enter and inspect premises – other than a hospital - where someone is not receiving proper care 
  • The power to apply for a warrant to search for and remove patients or persons living alone in need of care under Sec.135(1) 
  • The power to remove and return patients within UK, or to take or re-take detained patients absent without leave (S.18 and S.138) 
Duties include:
  • The duty to interview the patient “in a suitable manner” (Sec.13(2)) 
  • The duty to respond to a request by a Nearest Relative to assess someone under the MHA (Sec.13(4)) 
  • The duty to consult the patient’s Nearest Relative when considering a Sec.3 (or guardianship) 
  • The duty to inform the patient’s Nearest Relative when detaining under Sec.2 
  • The duty to interview a person removed to a "place of safety" by police under S.136 
  • The duty to consider an application for a patient to be made subject to Supervised Community treatment under Sec.17A 
That’s quite a list, I suppose. There are some fairly awesome powers in there (as well as some onerous duties), but of course power does not come without responsibility, and if you do not feel comfortable with the idea of exerting some of those powers when absolutely necessary, or of having to carry the can for those decisions, then being an AMHP is probably not for you.

The training is fairly rigorous. Our local AMHP course is based in the School of Social Work at the local university. It is equivalent academically to post graduate level, and can give credits towards a higher degree. That may be both an incentive and disincentive, depending on how much you might enjoy academic work. The course extends over several months, including taught modules and a practice placement, which means that candidates are away from their normal workplace for an extended period. Candidates have to submit a number of written assignments, as well as a portfolio giving evidence of their competence to practice. And they have to take a law exam.

However, at the end of all that, the new AMHP is in possession of an impressive breadth and depth of knowledge and skills, which they can then use and develop in their day to day work, as well as when being called upon to undertake AMHP duties. I have said before on this blog that your skills and knowledge as an AMHP can inform and enhance your entire professional outlook.

Qualifying as an AMHP and being Approved is not, however, the end of it. AMHP’s have to be re-approved every 5 years. They have to show evidence throughout that time that they have practiced as an AMHP, that they have had regular supervision of their practice, and that they have undertaken at least three days’ refresher training each year during that time. That may be regarded as onerous, but it also allows the luxury of uninterrupted time when you only have to consider matters of pure professional interest, unhindered by the pressures of one’s day to day job.

And what about the pay? Although contracts for AMHP’s vary with different employers, there is always an acknowledgement that the AMHP has a senior and exacting role, and AMHP’s are rewarded monetarily in various ways, either through enhanced increments to basic pay, or by a separate monthly AMHP payment. But when you consider that I as an AMHP receive less per month for all that responsibility and expertise than a Sec.12 approved doctor does for making a single recommendation under the MHA, then it is not exactly a way to get rich quick.

So why be an AMHP? For me, I like the autonomy, the ability to reach my own conclusions independently of outside pressures, the use of knowledge and experience in a crisis, the necessity to think on my feet, to manage situations of extreme stress while remaining calm and in charge of the process, and the satisfaction of knowing that I have done the best I can in often very difficult situations. And then, hopefully, to see someone recover and be able to function as an individual again.

One day I was in conversation with a woman whom I had assessed under the MHA in the past on several occasions. Sometimes I had had to detain her against her will, and on other occasions she had agreed to informal admission. She suddenly said to me: “I want you to know that I’m really grateful to you for sectioning me. I was really ill then, but didn’t know it. I couldn’t have been left like that. You helped me to get better.” That’s what makes it all worthwhile.

Tuesday, 14 June 2011

Should People Be Stopped From Committing Suicide?

I still remember, during my training as an Approved Social Worker back in 1984, being told that, just because someone wanted to kill themselves, it didn’t necessarily mean that they had a mental disorder or that they ought to be detained under the Mental Health Act. This informed (and at times complicated) the decisions I had to take under the MHA over the years.

I was once asked to assess a man who had been detained under Sec.136 after he had tried to hang himself. He had made a serious attempt. He meant to do it. But when I assessed him in the police station I could find no evidence at all of any mental illness. He was distressed that his wife had left him. He had wanted to show her how her decision to leave him had made him feel. He was likely to make some further attempt on his life. But he wasn’t actually depressed, He was reacting to an adverse life event. My impression was that, even though he presented a significant suicide risk, it would be through petulance rather than mental disorder. I did not feel that I could justify detaining him under the MHA, even for assessment.

He succeeded in killing himself two weeks later.
Fortunately, I had arranged for him to have a medical review. On the day he killed himself, he had been assessed by both a junior doctor and a consultant psychiatrist. They both also concluded that, despite a significant suicide risk, he did not have a mental disorder.

On another occasion I was asked to assess another man who was an informal patient in hospital after having made a suicide attempt. When I assessed him, he presented with a perfectly normal mood and no discernible evidence of depression or other mental disorder. He said that he had had an enjoyable life up until then, but told me matter-of-factly that it would only go downhill from here and he therefore did not see the point of continuing to live. He was 30 years old.

This was a difficult decision. There were two medical recommendations for assessment under Sec.2 MHA, but I was struggling to justify to myself detaining him in the absence of any evidence that I could find of actual mental disorder. In the end, I concluded that, in view of the fact that two doctors were prepared to state that he was “suffering from mental disorder of a nature or degree which warrants the detention of the patient in hospital for assessment”, the safest option was to detain him. This was a case of deciding whether I would rather justify my decision to a Tribunal or an Inquest.

I once worked with a service user who suffered from chronic and disabling osteoarthritis. She was largely confined to her home, needed considerable support with day to day living, and was often in extreme pain. She confided in me one day that she had been studying efficient and painless methods of suicide, and that she had stockpiled a supply of the medication necessary to dispatch her with as little fuss and disturbance as possible. She explained that this was her insurance, that if she considered that her quality of life was so impaired by her condition as to be worthless, then she knew she could quietly and discretely end her life.

I respected this. She had capacity, she had a chronic condition, which although not necessarily life threatening, could at some stage make her life intolerable – and knowing that she had some control over her destiny actually allowed her to keep on. It never crossed my mind to consider the use of the Mental Health Act.

But I have been troubled for some time by the implications of another case which made the headlines a couple of years ago.

Kerrie Wooltorton was 26 when she committed suicide in September 2007. She had swallowed antifreeze, and although she had herself called an ambulance and had allowed herself to be taken to hospital, she had refused the treatment which would have saved her life. The doctors in charge of her treatment allowed her to die.

Why had they done this? Because three days before she had written what was described in press reports as a “living will” in which she stated that she was “100% aware” of the consequences of her actions and that she did not want to receive treatment.

When I read the reports of the Inquest into this case, which was concluded two years later in September 2009, I was aghast.

It was stated that she had an “incurable emotionally unstable personality disorder”, that she had a long history of self harm (she had taken 9 similar does of antifreeze in the year before her death), and that she had been sectioned and admitted to psychiatric hospital on a number of occasions in the past. Nevertheless, despite this history of mental disorder and extensive past use of the Mental Health Act, her renal consultant stated in the Inquest that “she was in no state to resist me and I could have forced treatment on her, but I don't think it was the right thing to do. I feel it would have been assault.” A spokesman for the hospital said: “It is a double-bind for doctors. She was very clear in her wishes. To have forced treatment on her would have been unlawful.”

The coroner concluded: “My judgement is that Kerrie had mental capacity. She had the right to refuse treatment and could not have been treated without her consent. Her decision to refuse treatment was consistent and she never changed her mind. The doctor went over and above what was required of him. He discussed the case with clinical colleagues, took a second opinion from a fellow consultant and sought advice from the medical director. A deliberate decision to die may appear repugnant, but any treatment to have saved Kerrie's life in the absence of her consent would have been unlawful.”

Being an AMHP, I was virtually shouting out as I read this report: “Duh? What about the Mental Health Act? Was an AMHP (or ASW, as 2007 was before the creation of AMHP’s) involved in this decision? Were two Sec.12 approved doctors asked to give an opinion? What about “mental disorder” within the meaning of the Act? And what’s a “living will” when it’s at home?"

After I’d had a lie down, I looked more closely at this case. It appeared to hinge on the issue of capacity and her “living will”. By the time of the Inquest, the Mental Capacity Act had been in force for a couple of years. The issues that this Act brought to bear were blamed for this bizarre decision to allow her to die. An analysis of the case by Professor Sheila A M McLean, a Professor of Law and Ethics in Medicine, published on the BMJ website, assumed that the “living will” was in fact an “advance directive” covered by the Mental Capacity Act. She concentrated on issues of mental competency and concluded that:

“A doctor who imposes treatment in the face of a competent refusal would be guilty of assaulting the patient. However dreadful it must be for healthcare professionals to watch a person who could be saved die for want of available treatment, they have no alternative but to do so… Ms Wooltorton was adult, competent and able at the relevant time to reject treatment. This was her right and, as such, had to be respected.”

However, Stuart Sorensen, writing in Community Care, came to what I would consider to be a more reasonable conclusion. He pointed out that the Mental Capacity Act's Code of Practice “is clear that the Act does not support suicide, assisted dying or mercy killing”. His conclusion was that her clear intention to end her life:

“means that she cannot be seen as decision-maker in the eyes of the law. The power to decide passes to the care team who have to act in what they reasonably believe to be her best interests. It seems reasonable to doubt that best interests means watching her die slowly and presumably painfully from acute poisoning.”

No-one at the time appeared to have considered the dubious legal basis on which Kerrie had written her “living will”. The Government’s own guidance to the implementation of the MCA issued in July 2007 stated that the section of the MCA covering advance decisions would not come into force until 1st October 2007 and that “most advance decisions, refusing life-sustaining treatments, made before October 2007 are unlikely to meet the specific requirements of the Act.” Not only would Kerrie Wooltorton’s advance decision not have complied with the Code of Practice to the MCA, but since it was written and executed in September 2007, it would not have been valid in any case. That in itself should have provided sufficient justification for the hospital to have disregarded her “living will” and to have provided her with treatment.

So what conclusions should an AMHP reach when confronted with a similar situation?

The case of GJ v The Foundation Trust (2009) EWHC 2972 (Fam), although relating to Deprivation of Liberty under the Mental Capacity Act, presents a potentially relevant finding that “the MHA has primacy” over the MCA: that essentially, where both the MHA and the MCA may apply to a case of “detention”, whether through Sec. 2 or 3 of the MHA or Deprivation of Liberty under the MCA, then the MHA should be used. In other words, the MCA could legitimately be disregarded in a case such as Kerrie Wooltorton’s, and an assessment could take place under the MHA with an AMHP and two psychiatrists.

Advance decisions and issues of capacity do not necessarily have much bearing on decisions taken under the MHA, and the concept of “capacity” is not a factor which has to be taken into account when reaching a conclusion about detention under the MHA, providing the other factors were established.

Were such an assessment to take place today, all that the assessment team would need to establish would be:
  • Is the patient suffering from mental disorder of a nature or degree which warrants the detention of the patient in hospital for assessment (or assessment and treatment)?
  • If so, is it in the interests of the patient’s health or safety? 
I’m fairly sure of the conclusion I would reach were I to be confronted with a case such as Kerrie Wooltortons’ today.