Tuesday, 10 July 2012

Should an AMHP Assess Someone They Know under the Mental Health Act?

Approved Mental Health Professionals can work in a wide variety of settings, ranging from community mental health teams, through to older people’s or learning disability social work teams, and some (although not many) even work  in children and family teams. Many social workers in Emergency Duty Teams, which provide emergency social work services out of normal working hours, are also AMHP’s.

Generally speaking, AMHP’s have to be on a duty rota as a requirement of approval. This can mean either setting aside a day a week when you are available in your work place to take calls for Mental Health Act assessments, or sitting in an AMHP office with a group of other duty AMHP’s, ready to take whatever chance throws at you.

Some AMHP’s take the view that they should only deal with MHA assessments when they are on the duty rota. If that is the case, it is fairly rare for anyone with whom they have been professionally involved to need to be assessed on the specific day that they are on the rota.

Some AMHP’s take the view that it is a matter of best professional practice to “consume their own smoke”, especially if they are based in a mental health team. In this case, they would expect to provide an AMHP service to the team’s service users. I tend to take this view.

There is a lot to be said for sitting in an AMHP office, mingling with your colleagues. You can enlist their advice or support when dealing with a call. If you don’t get a call, you can drink coffee and swap anecdotes. You can gain a great sense of camaraderie from being in the AMHP office.

But if you work in a community mental health team, in a way, you are always on call. You always have your AMHP hat on, or at least, you can whip it on and off at the drop of a hat, so to speak.

There are advantages to this. You can act as a consultant, giving a professional opinion in team meetings and case discussions. In a multidisciplinary team, you can be made aware of a situation which could potentially lead to a formal assessment and suggest ways to avert it. If your advice is taken, and it still ends up with you having to initiate a formal MHA assessment, then you can feel confident that all other avenues have been explored, and that there is no alternative.

If you have care coordination responsibility for the service user, you can make judgments as to whether at any particular moment in time that service user might need a formal assessment, and then act accordingly. If you have a rapport with the service user, then you can discuss your concerns with them, and may be able to persuade them to take action to avoid a potential admission, or at the very least to persuade them to accept admission informally.

But there are also disadvantages to this approach. A service user may be suspicious of you if they think that at any time you might whip out some pink forms and section them. You may also take the professional judgment that it may damage your ability to work with them afterwards if you are the AMHP who detains them.

In my experience, I have found that some service users have never forgiven me for sectioning them, and it has been difficult, if not impossible, to work with them afterwards.

However, I have also found that some service users have been very thankful that I took the action I did, and have continued to work with me afterwards. It can even work to our mutual advantage. If I am very familiar with someone’s relapse signature, then I can be frank with them and share with them the concerns I have if I see their early warning signs. They are more likely to take heed if they know that I know.

I have been in some situations where I am able to make judgments about someone’s mental state based on my extensive past knowledge of when they are well or unwell, being able to detect dangerous signs that an AMHP or other professional who does not know the patient might misinterpret.

Some of the people I have worked with exhibit signs that include extreme rudeness when they are unwell. One example that springs to mind is attending a ward review in which the patient refused to leave their room. We therefore took the ward review to him. He lay in bed looking at us for a few moments, then pointed to the alarm button on the wall and said, “If I want to see a doctor, I press that.”

However, when this person is well, he is warm, amiable and polite. But if you were not intimately aware of his relapse signs, you might simply regard him as being sullen and uncooperative.

(I expect there are some service users reading this who right now are fulminating and shouting at their computer screen: “Of course he’s rude! He didn’t want to be sectioned did he? And the only reason he’s polite later is that he wants to avoid being sectioned again!” To those people, I can only say that after a lot of experience you can learn to tell the difference. I do not automatically think that someone being rude to me is a sign of mental illness. If that were the case, a lot of Department of Work and Pensions officials would be languishing in hospital.)

Another area where acting under the MHA can be an integral part of your ongoing role as care coordinator/AMHP is with Community Treatment Orders. Increasingly often, I am finding that a potential eventual discharge on a CTO is being considered almost as soon as a patient has been detained under Sec.3. It can become part of the long term discharge planning process. It would therefore seem to me to be appropriate for me as their care coordinator to undertake the AMHP role in the CTO process, rather than someone coming in cold to make that decision.

I am currently managing several patients who are on CTO’s, where I was the AMHP that endorsed the application. It means that when the time comes to review the CTO, with a view to either discharging or extending it, I am fully aware of the past risk history, the progress and effectiveness of the CTO during the previous months, and am in a better position to assess the usefulness or otherwise of extending it. I can also better “own” the inevitable report for either a managers’ hearing or a Tribunal. Curiously, some of these patients see being on a CTO as a wholly positive experience; they seem to see it as insurance against returning to hospital.

Overall, then, I regard the AMHP role in connection with service users with whom I am professionally involved as a positive thing. It can, perhaps strangely, make the professional relationship stronger, and even lead to an increase in trust. I’ve written quite a lot in this blog about people I have assessed and/or detained on more than one occasion. The evidence I have is, that as long as you act with honesty and integrity, the service user will respect you for it.


  1. Despite your explanation, I still find it unfair that you would use a patient's rudeness against him because it is out of the ordinary. People should be allowed to have mood swings without being diagnosed or forced to undergo treatment. Every month, I tend to get a little depressed immediately before my period. I would get lazy and a little sad. Before that, on the contrary, I'm aggressive (not physically, just assertive, active and a little rude). I'm sure you would say that I must be bipolar (or whatever you call such moodiness if it does not quite reach the duration or intensity for that diagnosis) and that it is a shame that I am not getting treatment. I do not even miss work on those days. Stop medicalizing human existence. People have the right to be in a sulky mood.

  2. I in part agree with your assertions explaining the pros and cons of assessing people who are on the AMHP caseloads. On the otherhand and particularly in this day and age working in an inner city borough, the situation is far from straight forward.
    I work in a home treatment team based in a hospital setting it is inevitable that I will come across clients I have assessed under the mental health act when going about my duties. Whilst I would entertain working automously as an AMHP
    working in a centralised extremely busy AMHP duty system wins hands down in terms of peer support and a dedicated level of expertise second to none I would never come across if working independently. I have been qualified for 1 year and have never come across any incidences of AMHPs sat waiting twiddling their thumbs with nothing to do.We are always on the go,dealing with very complex situations having enviable task of trying to co ordinate multi professionals in one place at the right time.Secondly working in home treatment, I have observed first hand when professionals often take the lead with arranging admissions for clients based on the fact that they have worked with those said clients before. There is little attention paid to this prior acquaintance skewing the profesionals view of risk and subsequently there has been some serious untoward incidents. My point is if not mindful, we can underestimate risk, the fact that we are taught from very early on that risk is dynamic and forever changing. Someone in the acute phase of a psychotic episode may well be testimony that.
    Not wanting to throw a spanner in the work, if you have a good relationship with a client and extensice knowledge of thier distress then that can be an added bonus.