Monday, 28 September 2015

Book Review: Independent Mental Health Advocacy, Karen Newbigging et al

The role of the Independent Mental Health Advocate (IMHA) was created by the 2007 amendments to the Mental Health Act 1983. The role is enshrined in the guiding principles to the Act, one of which is empowerment and involvement. The new Code of Practice states that:

“Patients should be informed of the support that an advocate can provide, including carers or, if they are eligible, an independent mental health advocate (IMHA)... Local authorities should ensure that timely access to IMHAs is available and that IMHAs have appropriate training and skills to support the patient effectively including where a patient has particular needs.” (para 1.12)

In view of the fact that IMHAs have existed since 2008, this book is well overdue, as it is a thorough and detailed guide to everything that an IMHA requires in order to discharge their functions in the most empowering and equitable way. As the authors point out, the year on year increases in the use of the Mental Health Act powers to detain people means that there has never been a greater need for independent advocacy.

While this book is clearly primarily designed for Independent Mental Health Advocates (and should be an essential set text for IMHA training courses), it is also of relevance not only for Independent Mental Capacity Advocates (IMCAs) and Best Interest Assessors (BIAs) operating within the Mental Capacity Act, but also for AMHPs.

As the book points out, “advocacy has long been recognised as central to the social work role, with effective social work advocacy practice being fundamental to promoting individual rights and social justice”(p.247). I have long maintained that the AMHP role itself is not merely one of asserting control over people with mental disorder, but has advocacy as an integral part of the legal functions of the AMHP, who are required always to look at the least restrictive option when assessing the need for a patient to be detained under the MHA.

However, the nature of the AMHP role in no way reduces the need for IMHAs, as the AMHP role cannot be “independent” of the legal process, as it is by its nature an integral part of the MHA control mechanisms, no matter that AMHPs are there to assert a social perspective within an overwhelmingly medical system. As this book says:

“Health and social care professionals’ claim that advocacy is inherent to their professional role cannot be seen to replace the need for truly independent advocacy to support the service users’ voice within disempowering systems... Professionals need to recognise the limits of their ability to advocate from within systems, of their tendency towards best interests advocacy, and to recognise that they are often part of the problem and not just the solution.” (p261)

The book has been cowritten by a total of nine authors, whose backgrounds range from the largely academic to people who have had firsthand experience of being service users. The book is all the stronger for this. The authors draw on extensive personal research to make their points; the chapters detailing the service users’ perspective are of particular interest.

The book is split into two parts: the first part provides an overview of the historical and legal context of advocacy in a mental health setting, while the second part concentrates on practice and experience. There a useful and thought provoking reflective exercises at the end of each chapter.

While I am not an IMHA, I found much of interest in the book; for example the chapter giving an historical overview of the evolution of independent mental health advocacy traced it back as far as the 16th century. I also found the chapter looking at research into the experience of detention from the service user perspective enlightening, and gave me much to think about in my approach to my work as an AMHP. This section would be equally helpful for social work and AMHP students.

The authors make frequent cogent points relating to the underlying philosophy and intention of the Mental Health Act, suggesting that the 2007 amendments introduced an increased medicalism of practice in mental health. While I had felt that the broader but vague definition of mental disorder was overall of benefit to patients (in particular people with diagnoses of personality disorder, who had often been excluded from treatment). As they say, this “leaves the task of diagnosis to clinicians, so that no one needing treatment is excluded, thus favouring a duty of care over self-determination.”
Concern is also expressed that “the widening of the definition of mental disorder, reducing the thresholds for treatment and extending compulsory powers to the community, in the form of supervised community treatment, would have a disproportionate impact on people from Black, Asian and minority ethnic communities.” (p.89)

The book raises equally challenging questions concerning what the role of the IMHA should be, for example, making a clear distinction between the IMHA role and “best interests” practice. They contend that IMHA’s “need to be alert to the overarching themes of autonomy, participation, care and recovery, how these relate to people’s experience of coercion and detention and the contribution they can make to promoting self-determination in the most challenging of circumstances” (p.125)

In conclusion, I do think this book provides an essential text for people training and practicing as IMHA’s. I would also recommend the book to mental health nursing and social work students, and will certainly be recommending to my own AMHP trainees that they read this book.