Review: The Approved Mental Health Professional Practice Handbook

The Approved Mental Health Professional (AMHP) Practice Handbook, Kevin Stone, Sarah Vicary, Tim Spencer-Lane; Policy Press, 2020

I will begin by saying that I think this is a very good book. I'm in no doubt that it will be an invaluable resource to assist trainee AMHPs in understanding and learning the AMHP role, and will also serve as a useful reference guide for practicing AMHPs to assist with certain aspects of mental health law.

The book is divided into three parts: the AMHP in context, the AMHP in practice, and AMHP theory.

The first part covers the unique practice context of the AMHP, the ethical context, and social perspectives in mental health, including the multi-professional context of the AMHP role, this role being open not just to social workers, but also mental health nurse, occupational therapists and clinical psychologists.

The second part focuses on practice issues. This includes the process of completing an assessment under the Mental Health Act, including the sections of the Act involved in detention in hospital; the associated risks and challenges; the interface between the MHA and the Mental Capacity Act; and the AMHP's involvement in community provisions under the MHA, including CTO's guardianship and s.117 aftercare.

The third part examines upholding rights and anti-oppressive practice; the importance of resilience, in managing to survive in this demanding role; and decision-making, including involvement of family members and other professionals, arrangements for transport to hospital and facilitating reflection on the role.

Each chapter begins with a clear explanation of the aim of the chapter, including explicit notes on relevant law, which AMHP competencies are covered by the chapter, and case studies to aid reflective activities, concluding with key messages of the chapter, a brief review of knowledge, and recommended further reading.

The book combines sound academic principles with reference to competence indicators, skills and practice, providing copious and relevant referencing throughout, as well as reference to other related legislation. There is throughout a good selection of practice examples to aid learning and reflection.

There are a few other handbooks for AMHPs, most notably The Pocketbook Guide to Mental Health Act Assessments by Claire Barcham, which is now into its second edition.. The Pocketbook Guide is more basic than the book in question, and perhaps more explicitly practice oriented, and is aimed more at students than practitioners. This book, by comparison, takes an academic research led approach but directly applies this to practice.

The structure of the book is clear and logical, leading the reader from the basics of Mental Health law and practice through to an analysis of theoretical perspectives of mental health and mental disorder, and into actual practice considerations and the application of theory to practice.

Throughout, there is a logical connect with the core AMHP competences, which will be very helpful for trainee AMHPs to evidence their competencies for their coursework, as well as assisting experienced AMHPs to compiling an AMHP Record of Achievement for statutory reapproval. It will also provide a very valuable resource for AMHP courses.

TheApproved Mental Health Professional (AMHP) Practice Handbook, Kevin Stone,Sarah Vicary, Tim Spencer-Lane; Policy Press, 2020

Review: Deprivation of Liberty Safeguards: A Best Interest Assessor Time Study

Cornwall Council’s much anticipated study, compiled and written by Emma Goodall and Paul Wilkins, was published at the beginning of December 2015.

This has obtained empirical evidence of the impact on BIA’s of the Supreme Court judgment that came out last year (2014). I wrote about this judgment, which it was anticipated would have far reaching effects on the workloads of AMHPs and BIAs, here. Cornwall’s research complements the College of Social Work’s document assessing the impact of this judgment on AMHP practice, about which I wrote here.

So that’s enough of the links for now. What did this Time Study actually find?

Since the Cheshire West Judgment extended the qualifying criteria for incapacitated people who might be in situations where they are being deprived of their liberty, it was thought extremely likely that there would be a huge increase in requests not just for formal assessments under the Mental Health Act, but also for requests for Deprivation of Liberty Authorisations, which have to be undertaken by Best Interest Assessors.

As this report highlights, “The first annual statistics published by the Health & Information Centre in September 2015 reports that there has been a “tenfold increase” in new referrals, with 137,540 DoLS applications received by councils between 1st April 2014 and 31st March 2015.” I am certainly aware that it is not uncommon for local authorities, who are responsible for conducting these assessment, to have backlogs of 2,000 or more.

The research took the form of asking practicing BIAs via a wide range of social media to complete a questionnaire relating to their practice and experiences. They received responses from a total of 507 BIAs, which I think is a remarkable achievement.

The study focused on the overall time that each assessment took, looking in particular at time taken in traveling, gathering information and consultation prior to and following the assessment, the length of time spent at the hospital obtaining necessary information, consultation with other relevant assessors, writing up the necessary documentation, and giving feedback to interested agencies and individuals.

The study found that the overall average time taken to conduct a DoLS assessment was 726 minutes, or 12.1 hours. This compares with an average of 600 minutes, or 10 hours, that local authorities estimate that an assessment should take. Some of the BIAs in the study reported a considerable discrepancy between the hours what they were paid for, and the actual length of time taken, for example one BIA saying: “I’m paid for 7 hours but each assessment takes at least 11 hours”.

While it may be tempting for local authorities to attempt to quantify the time taken and set a standard timescale for completion of assessments, the study points out that, while DoLS assessments can vary widely in complexity, “in all cases the BIA must involve the relevant person in the assessment process, consult widely and gather information relevant to their decision-making and  provide a report that explains their conclusion and their reasons for it. This work can be time consuming, particularly when there are several consultees or extended travelling times.”

The study also makes the point that BIAs have enormous responsibility in making their assessments, as they can be open to legal challenge.

The Law Commission recently published its consultation document into mental capacity and deprivation of liberty, which I considered here. Among its recommendations, the first of which is the abolition of DoLS as incomprehensible and unworkable, is the proposal to create the Approved Mental Capacity Professional. AMCPs would have more far reaching powers than BIAs, and would carry even greater responsibility.

Were these proposals to be made into law (through amendments to the Mental Health Act), it would be interesting to see the impact both on the work of this new professional compared to the BIA, and the overall bombardment rate of local authorities for people lacking capacity. 

Review: The Mersey Care Annual Mental Health Social Care Conference 2015

Peter Beresford giving a rousing address to the conference

 

The Mersey Care Trust’s annual conference was held in Liverpool on 6^th November 2015. This year the theme was Service Users’ Voice: Change, Rights and Advocacy: What is the Reality?

 

I have reported at length on two previous Mersey Care conferences; I am afraid that this report will necessarily have to be briefer on this occasion.

 

The event was oversubscribed, with well over 200 delegates squeezing into the venue. As ever there was an impressive list of scheduled speakers, including Professor Martin Webber, Professor Peter Beresford, the human rights lawyer Peter Edwards, the Community Care journalist Andy McNicoll, and the erstwhile chair of the mental health steering committee of the now defunct College of Social Work Dr Ruth Allen. Indeed, it appeared as if there were almost as many speakers as there were delegates!

Roger Phillips, a presenter on Radio Merseyside with a keen interest in mental health, opened the conference. Emad Lilo, the intrepid organiser and manager of the Mersey Care Integrated Care Demonstrator Site Project, along with several of the Trust AMHP’s then outlined projects and other development work they had undertaken during the year.

Peter Edwards discussed the thorny issue of whether the rights of service users could actually be exercised, or were in effect illusory, then the Masked AMHP himself presented a case study of an assessment under the Mental Health Act, arguing that the AMHP has an advocacy role, and that an AMHP can successfully take a deliberately low key approach to assessment. A version of this case study was subsequently published in Community Care Magazine. You can read it here.

The morning was rounded off by an extraordinary presentation by members of the People First Merseyside organisation. This is a user led self advocacy organisation for people with learning difficulties. It has been in operation for over 25 years.

The staff and volunteers (most of whom were service users) gave an excellent dramatised presentation on the right (and wrong!) ways to approach people with learning difficulties who require assistance with a health problem, as well as showing exactly what people with learning difficulties can achieve when given encouragement and empowerment. It was entertaining, educational, and moving.

Peter Beresford kicked off the afternoon with an, as ever, eloquent, incisive and stirring dissection of the failings of current mental health policy and practice, tearing into the current Government plans and exposing an apparent deliberate intention to dismantle the NHS and marginalise disadvantaged people.

Ann Williams, Commissioning & Contract Manager for Liverpool City Council, gave a presentation on the roles of the Independent Mental Capacity Advocate and the Independent Mental Health Advocate, followed by Jake Mills.

Jake Mills is a stand up comedian. In 2013, he experienced a severe period of depression, during which he came close to committing suicide. As a result of this, he set up the mental health charity Chasing the Stigma which aims to “normalise and humanise mental illness.” He gave an intensely moving, but also funny account of his experiences.

The last session was Naomi Good, Regional Development & Research Manager of the National Survivor User Network for Mental Health. Her presentation was entitled Survivor Voices: Re-authoring Disrupted Identities. She outlined research she had done into the experiences of mental health service users.

Unfortunately, time constraints meant that some speakers, such as Professor Martin Webber, literally only had five minutes to speak, and of three intended Q&A sessions, only the one featuring Andy McNicoll and Ruth Allen actually went ahead. This meant that a number of prominent people in the mental health field did not have an opportunity to be heard.

I suppose this is a consequence of the popularity of these annual conferences, not just for delegates, but for speakers as well. Emad Lilo, who organises these events, appears to have boundless energy and enthusiasm, and this is reflected in the very real buzz that permeates the day.

 

This was the third Mersey Care Conference I have attended, and I very much hope to have the opportunity to speak at future ones. 

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 16^th 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.

Independent Mental Health Advocacy: The Right to be Heard, Jessica Kingsley 2015

Review: A Practical Guide to the Mental Capacity Act 2005, by Matthew Graham & Jakki Cowley

As an Approved Mental Health Professional, practicing under the Mental Health Act 1983, I am well aware that it is impossible to discharge the functions of the AMHP competently without a working understanding of the Mental Capacity Act 2005. Indeed the new MHA Code of Practice devotes a whole chapter to mental capacity and deprivation of liberty, stating:

“A sound understanding and application of the principles and provisions of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS) and of the common law relating to consent, is essential to enable decision makers to fulfil their legal responsibilities and to safeguard their patients’ rights under the European Convention on Human Rights (ECHR).”

The Mental Capacity Act, and the later Deprivation of Liberty Safeguards, which was included in the Mental Health Act 2007 (which amended the Mental Health Act 1983 – do keep up), were designed to address gaps in the law which had been identified by a number of legal decisions in Europe and the UK relating to the treatment of people who lacked capacity to make their own decisions.

This new book by Matt Graham and Jakki Cowley is described as “a practical guide”, and it certainly is: it is written in order to be easily understood, and the authors take pains to explain the core essence of the MCA. They also make it clear that knowing about the MCA is not only important for professionals, but for everyone; they make the useful point that “when we consider the term ‘service users’ or ‘people who use services’ we are not referring to an exclusive group of people who might use specialist services...the term ‘service user’ means everybody, because we all use health and social care services.”

The basic purpose of this book is to provide “accessible information as to what the MCA ‘looks like’ in practice and to offer something which the readership can easily digest and apply in practice in order to enhance the experiences of people who require support with making decisions or who require decisions to be made for them in their own interests.” Its 180 or so pages proceeds to do just that.

The 7 chapters cover various aspects of the MCA, beginning with an overview of the Act, then a chapter each on maximising capacity and assessing capacity, and chapters on advocacy and empowerment, advance care planning, best interests, and finally liberty and choice, which covers restriction and deprivation of liberty.

Each chapter includes illustrative case studies, as well as references to relevant case law, and there are a number of useful checklists for practice and decision making.

I very much like the way the authors constantly distil the essence of the MCA, such as suggesting that the MCA is:  “about two things and two things only:

1.      People’s rights to make decisions.
2.      People’s rights to have decisions made for them if they lack the capacity to make the decision themselves.
Confidence, competence and compliance with the MCA can be demonstrated if practitioners know the differences between the two and can remain mindful of the tensions that exist when trying to work out the difference.”

Even more profoundly, the authors aver that, regardless of the decisions being made relating to people lacking capacity, professionals ought to ask themselves: “On what authority am I making this decision?”

The chapter on maximising capacity is based on the implications of the first principle of the MCA, which is: “A person must be assumed to have capacity unless it is established that he lacks capacity.”

This naturally puts the necessity to assess capacity at the forefront. The authors again pose useful questions:
What is the decision that needs to be made?
What problems or difficulties is the person having relating to this decision?
What support do they need?

They point out that “there is a risk that a presumption of incapacity is what starts the process and an immediate move towards considering best interest decision-making takes place. This is not the intention of the Act.”

The chapter on assessing capacity poses another useful question for the assessor right at the beginning: “What right do I have to assess this person’s capacity and why would I even do so?” Such questions compel the assessor to examine their motivations and the reasons for the capacity assessment, and make them confront a major potential problem in capacity assessments, which is that the assessor is in a position of power over the person being assessed, because “to hold the keys to making a decision that someone lacks capacity is a powerful act”.

Each chapter is full of statements designed to make the professional think critically about their practice. One such statement in this chapter is: “You are always assessing capacity – whether you know it or not!” The authors suggest that it is important, when it is suggested that someone lacks capacity, to ask the questions, “what for?” and “what evidence do you have?”

This chapter goes on to guide the assessor, in everyday language, through the process of assessing capacity. It concludes by offering useful tips for recording your conclusions.

The chapter on advocacy and empowerment goes into detail about the functions of the Independent Mental Health Advocate, while the chapter on advance care planning looks at advance decisions, including decisions to refuse treatment, and the role of the lasting power of attorney.

Setting up a lasting power of attorney, giving instructions for another person to make decisions on your behalf if you lack capacity, is extremely important for everybody. If you decide to leave it till you or someone close to you begins to lose capacity, it may already be too late; then it would be necessary to go to the Court of Protection if major decisions needed to be made on your behalf. My wife and I have both set up lasting powers of attorney, for the eventuality that at some point in the future one or both of us might lose the capacity to advocate on our own behalf.

Chapter 6 is devoted to best interests, and is designed to demystify this area of the MCA, and reassure professionals about how to decide on someone’s best interests. The authors make the suggestion that competence to make these decisions is not necessarily the issue, but confidence is. They point out that many professional just get on with the job in hand, “but when we have to justify our decisions, evidence how we have reached them and then go forth with authority given to us by law to enact them, then the confidence drops and we start to question whether we know what we’re doing.”

Again, they pose questions, this time the question, “how do I know what is in this person’s best interests?” They answer this by reformulating the question to: “Why does a decision need to be made in this person’s best interest and what must be considered in order to achieve this?”

They break down the decision making into two categories, less complex decisions, and complex decisions. What sort of decision that needs to be made depends on “the complexity of who is consulted, who is involved in the decision-making process, how urgent the decision is and what the decision specifically involves”, for example, whether it is to do with day to day living decisions, or major life decisions with legal implications.

This chapter also looks at how to manage best interests meetings, and suggests a simple balance sheet for weighing up the advantages and disadvantages of the various options.

The final chapter concentrates on liberty and choice, which is mainly concerned about restriction of liberty and deprivation of liberty. The Deprivation of Liberty Safeguards, and the considerable amount of case law that has accumulated (and continues to accumulate:  the very recent case of Bournemouth Borough Council & PS & DS [2015] EWCOP 39 appears to fly in the face of the far reaching Cheshire West judgement) is not only complex but at times impenetrable, and while this chapter attempts to address this, I would have liked more of the book to have been devoted to this fraught area.

Nevertheless, they attempt to shed light on the difference between a restriction and a deprivation of liberty, for example dispelling the myth that the MCA prohibits the restraint of people. They make the point that, for example,  “paramedics who use reasonable and proportionate restraint, including sedation, to convey someone who lacks capacity to hospital and who is resisting, following a road accident, will be protected from liability unless that act demonstrates negligence.”

Elsewhere in the book, the authors give an example of an elderly woman who had incurred a head injury in a care home and an ambulance was called. Although she needed to go to A&E, the lady stated that she wanted to remain at the home. The ambulance crew left her, saying that “they couldn’t make someone go to hospital against their will.” The authors point out that “there is this myth in practice that appears to be part of the culture of care that practitioners cannot act if someone refuses.”

This scenario is one that will be familiar to AMHPs, who are often asked to undertake assessments under the MHA for patients who ought to be dealt with within the MCA. I hope that ambulance crews and others in the medical frontline will hear the message the authors are trying to get over, which in this sort of scenario is that “the MCA permits the use of reasonable and proportionate force in exceptional circumstances if it is in someone’s best interests if they lack capacity and the criteria are met.”

While some reference is made to the Mental Health Act, I would have liked to have seen more discussion and guidance on the interface between the MHA and the MCA, which frequently causes AMHPs much confusion and frustration. However, despite this minor niggle, this book is a considerable achievement.

A Practical Guide to the Mental Capacity Act 2005 is a very readable and informative book, and of much more practical use than Jones’ rather drier and legalistic Mental Capacity Act Manual. I would wholeheartedly recommend this book to all who find themselves in a position of having to make decisions relating to people who lack capacity, and I have already recommended to my AMHP colleagues that they should get this book.

A Practical Guide to the Mental Capacity Act 2005, by Matthew Graham & Jakki Cowley, published by Jessica Kingsley (http://www.jkp.com/)

Review: Approved Mental Health Practice, edited by Sarah Matthews, Philip O’Hare & Jill Hemmington

 

The subtitle of this new book is “Essential Themes of Students and Practitioners”, and I would certainly endorse this. This is the only serious text of which I am aware that focuses entirely on professional practice under the Mental Heath Acts of the United Kingdom.

The authors grapple with the conflict between the social work role of empowerment and the AMHP powers that can lead to coercion and the imposition of social and medical control, and this book provides an excellent examination of the tensions existing in the role of the approved mental health practitioner, allowing the student and practitioner to reflect on the role in the context of the wider social perspective.

As the book is directed at an examination of practice under all the UK’s mental health legislation, they generally describe the professional as an “approved mental health practitioner”, so I will continue to use this terminology in this review, and the abbreviation of “AMHP” should be read in this way.

Sarah Matthews starts by posing the question, “Do social workers as approved mental health practitioners struggle to promote a model that views the manifestations of mental health in any way other than the dominant and, some argue, pathological one?” She goes on to outline the fundamental aspects of approved mental health practice. These include the social perspective as being central, as well as the independent nature of the role. She also stresses the importance of emotional engagement, containment and the concept of “dirty work” as contributing to the unique role of the AMHP. She states: “The mother, it is suggested, contains others’ distress without appearing to be affected by it herself and it is this which an approved mental health practitioner might also accomplish.”

I was particularly intrigued by her discussion of work under the MHA as being “dirty work”. Dirty work “describes the notion that people are compelled to play a role in work about which they ought to be a little ashamed, morally… A profession embraces unpleasant tasks as a means of establishing its credibility or undertakes such tasks as a necessary, albeit difficult, element.”

Tim Spencer-Lane provides an analysis of the legal and political factors in England and Wales that led to the revision of the 1983 Act and the creation of Approved Mental Health Professionals. Having practiced under Mental Health Acts since 1981, I have lived through these changes, and have been professionally associated with the issues which eventually led to the 2007 Act. He makes the interesting point that the MHA 2007 “was the result of a long and embittered battle between the Government and the major stakeholders about the fundamental purpose of mental health law”, whereas the Mental Capacity Act 2005 was developed in broad consensus and was the culmination of a long consultation process.

Jean Gordon and Roger Davis go on to compare and contrast mental health law in Scotland and Northern Ireland (although omits the Isle of Man Mental health Act 1998, which, like Northern Ireland, retains the Approved Social Worker).

David Pilgrim makes interesting points about the way in which mental health professionals can make basic assumptions about mental health practice which may be at odds with reality. He makes the point that "third-party interests constantly shape professional decision making and action. Indeed, at its most coercive, mental health work considers the needs of the identified patients only after others are protected from their prospective presence and actions... It is soon evident that public safety and institutional order can dominate staff decision making."

He argues, with some justification, that the MHA in England and Wales is more concerned with controlling mental disorder than with the promotion of mental health. This makes the AMHP role innately coercive, and he poses some challenging questions about the validity of enforcing compulsory treatment with drugs which are at best only moderately effective, and at worst can cause serious harm or even death.

Helen Spandler tackles problems around psychiatric diagnosis, wishing to "equip approved mental health practitioners with the knowledge to question, challenge and understand the broader meaning of mental disorder and diagnosis," in order for us to be "more cautious and thoughtful about the language we use to describe mental health crises."

She reviews the different approaches to diagnosis, from psychiatric, psychological and service user perspectives, often using as examples the ways in which the long term effects of childhood trauma can be interpreted as either normal reactions to extreme life events, or pathology indicating mental illness or disorder.

She suggests that a more useful, and service user centred approach for an AMHP to take is to assess levels of impairment and functioning, rather than diagnosis, to determine access to services and using mental health legislation. While expressing scepticism about the use of diagnosis, she states that "it is important not to let the endorsement or criticism of diagnosis get in the way of decision-making." Any alternative to conventional diagnosis "must result in better consequences for people in terms of gaining the more appropriate support and assistance."

Daisy Bogg examines ethics and values in the context of approved mental health practice, tackling in the process some of the ethical dilemmas inherent in the use of Community Treatment Orders, observing that "approved mental health practitioners serve as a counterbalance to a single dominant medical perspective and are required to provide a more holistic view, and account for the whole circumstances of an individual's situation before making a decision to apply for compulsory admission."

Amanda Taylor and Jill Hemmington's chapter on Diversity in Mental Health sets out to "challenge notions of diversity being simply and solely located within traditional, fixed dimensions and to alternatively view it as being unique to the individual, group and community." They warn that approved mental health practitioners need to be aware that they "belong to a 'dominant social group' that 'maintain systems of privilege and oppression'".

They give as an illustration an in depth analysis of Deafness, including specific case studies, using these to show that "it is vital that as practitioners we can seek that which is outside of the self and consider not only the diversity relating to the other but go some way to working within their 'internal frame of reference' to understand the layers that exist."

They conclude: "Empathy, 'tuning in' and constantly asking oneself questions are the starting points to a thorough, effective assessment that has honesty and collaborative work at its core."

I was particularly intrigued by Anthea Murr and Tamsin Waterhouse's chapter on "The Impact of Time and Place", as it focused on assessments in rural areas. Readers of this blog will be aware that I work predominantly in a rural area; even the towns in my area have populations of less than 30,000. They outline the special factors that can impact on the mental health of people living in rural areas, such as physical, social, cultural, psychological and geographical isolation, as well as the problems of rural poverty, and conclude that practitioners working in rural areas need to have special training and acclimatisation to prepare them for these particular challenges.

Julie Ridley outlines a study of service users’ experiences of mental health legislation in Scotland. Although specific to Scotland, this study is also of relevance to professionals working throughout the UK.

Experiences of compulsion varied from the positive to the negative, perhaps not unexpectedly. Some service users welcomed having “‘responsibility taken away’ and a structure to daily life imposed”, while others described it as a “nightmare” experience.

Philip O’Hare and Gavin Davidson devote a chapter to the role of the Nearest Relative, tracing the history of this role in mental health legislation going back to the 18^th century, and its evolution in more recent Mental Health Acts. They make the point that improvements in social work training and the changes to practice brought about by the Seebohm in the 1970’s added to pressure to replace the 1959 Mental Health Act with legislation that recognised the professional competence of social workers. This led to the 1983 Act, where the Approved Social Worker became the preferred applicant in applications for detention.

I was intrigued by the statistic that in the early years following the introduction of the 1983 Act only 1.6% of application were made by Nearest Relatives. I suspect that this figure is now even lower.

Practicing exclusively in England, I did not realise that legislation in Scotland had ended the Nearest Relative role as applicant for detention. I was interested to read that the other parts of this role have been replaced by a “named person”, who is nominated by the patient. Although this seems like an admirable idea, and would obviate the current difficulties that AMHP’s can find in identifying and consulting with the Nearest Relative, this idea was unfortunately not taken up when drafting the 2007 Act.

Philip O’Hare discusses to what extent evidence-based practice can inform approved mental health practice. There is a paucity of evidence on which to base evidence-based practice within mental health legislation,; evidence-based practice is essentially based on the medical model, which can be hard to replicate in a social care context.

O’Hare asks the question “How to AMHP’s make sense of their legal roles being informed by practice, and looks at making decisions based on least restrictive concepts, applying this in particular to the AMHP role in Community Treatment Orders: “how does an AMHP make a distinction between justified and unjustified CTO’s?”

Unfortunately, despite rather sketchy research into the efficacy of CTO’s, it is very difficult to assess the likely beneficial impact of a CTO on any particular individual, other than anecdotal evidence relating to length of time without a hospital admission. How can you test whether the conditions of a CTO have positively influenced a specific patient?

Jill Hemmington examines how AMHP’s have to manage uncertainty, and how one can develop practice wisdom. She makes the point that approved mental health practice “has been described as ‘crisis, mess and muddle’ where Mental Health Act assessments often arise from and within situations where there is ‘panic and confusion’”. She makes an interesting attempt to apply crisis theory to AMHP work, and also points out that “because something is lawful, it is not automatically ethical”.

She poses a number of pertinent questions for an AMHP to consider relating to their practice, for example, “How did I influence the situation through: my presence, my actions, my preconceptions or assumptions, other people’s perceptions of me, my physical well-being on the day?”

The editors conclude that “for an AMHP the focus is on how to interpret and analyse appropriately and avoid any illusion that there can be certainty.”

Each chapter contains reflective questions, which are designed to provoke stimulating discussions in student seminars, and which would also be useful for AMHP’s who are preparing reapproval portfolios to evidence reflective practice and to elicit learning points from professional experience.

I found the book as a whole stimulating and thought-provoking. It was a pleasure to read a book that directly addresses the dilemmas with which I am faced every day of my professional life.

I wholeheartedly recommend this book to anyone interested in the AMHP role, including those undergoing AMHP training, AMHP’s preparing for reapproval, and social work and mental health nursing students who seek to obtain a deeper understanding of the moral and legal complexities of the role.

Approved Mental Health Practice: Essential Themes for Students and Practitioners
Edited By Sarah Matthews, Philip O'Hare and Jill Hemmington
Palgrave Macmillan, April 2014
ISBN: 1-137-00013-9, 978-1-137-00013-2

Possibly the best Social Care Conference in the UK? Review of Mersey Care Trust Annual Social Care Conference 22nd November 2013

I was fortunate enough to be ambushed by Emad Lilo, the conference organiser, back in March of this year, when I was appearing at a North Wales and North West AMHP Association Conference in Manchester. He booked me for the Mersey Care Trust annual conference, and I’m very glad he did, because what a memorable day it turned out to be!

The theme of this year’s conference was “Service Users’ Experience – Social and Medical Models: Exploring What Service Users Say”. Over two hundred social workers and social work students, as well as a scattering of other mental health professionals, attended. The programme was crammed with speakers of the highest calibre, including Professor Peter Beresford, Annie Hudson, the Chief Executive of The College of Social Work, and Professor Sue Bailey, Chair of the Royal College of Psychiatrists. There was even an unexpected, but very welcome, appearance at the conference of Lyn Romeo, the Chief Social Worker for adults.

So far, it might look as if I have been hired by the Mersey Care Trust to promote them, but my enthusiasm is entirely genuine, as this was certainly the most stimulating and inspiring conference I have attended. The commitment and concern to promote the needs of mental health service users was palpable from the speakers and the conference delegates.

The programme was crammed, with over a dozen speakers, not to mention an eminent panel that included Professor Michael Lavallette (oh, and The Masked AMHP, but I didn’t get to say much: there were too many others with important things to say.)

Joe Rafferty, the Chief Executive of the Trust, began by stressing that service user involvement is integral to the way the Trust works – and I believe him. He posed the question: if perfect care isn’t the right goal, then what is? He meant that “good enough” was not actually good enough, that mental health services should aim to eliminate suicide, not just to set goals for a reduction in numbers. He pointed out that a 95% perfect safety record for the Mersey ferry would mean that 4 ferries would sink each year.

He was followed by the double act of Jenny Robb, the director of social care and safeguarding in the Trust, and Iris Benson, a service user. Jenny continued the theme of the importance of service user involvement at all levels, while Iris gave the conference an articulate and truly inspirational personal story of recovery, outlining her severely abusive past and her efforts to overcome the mental health problems she experienced as a result.

Iris gave an enthralling account of her journey to recovery, and the many and varied psychiatric diagnoses, ranging from paranoid schizophrenia to depression to dissociative identity disorder, that she had received over the years. It is encouraging to hear from someone who has had positive experiences of mental health services, and is prepared to share that experience, as well as to challenge poor practice.

Neil Allen is a barrister at the legendary Thirty Nine Essex Street Chambers and a lecturer at the University of Manchester. He discussed the implications of living with mental health, including the fact that people with mental disorder have a responsibility to manage their disorder as best they can, including using any support and treatment available, not just for their own wellbeing, but for carers and others as well. He suggested that, while a social model can be usefully applied to improving attitudes to people with physical disabilities, mental disorder does not fit so well into the social model.

Peter Beresford is both Professor of Social Policy at Brunel University and a mental health service user. He continued and extended Neil’s theme of service users’ experience of mental illness, stressing the value of lived experience, and pointing out that the medical model still dominates mental health services. He was wary about the “new idea” of the Recovery Model, suggesting that this could be as potentially limiting and oppressive, and could disable rather than enable. He outlined the movement of “Mad Studies”, and promoted what sounds like a fascinating book called “Mad Matters”, a book published in Canada consisting of writing that “presents diverse critical voices that convey the lived experiences of the psychiatrized and challenges dominant understandings of mental illness."

And then it was lunchtime.

Annie Hudson, Chief Executive of The College of Social Work, started off the afternoon session, touched on the knotty problem of whether or not social workers should be integrated into Mental Health Trusts, or separate from them. My own view is that this is a Good Thing, as long as a social worker’s core role and identity is protected and maintained. She stressed that mental health should be an integral part of all social work training, as it was equally important for social workers in children’s services to have a knowledge of mental health issues. She also considered that good practice arises from a combination of knowledge, skills and research.

She was followed by the Chair of the Royal College of Psychiatrists, Professor Sue Bailey, whose presentation was both entertaining and humorous. She talked about parity of esteem between different professions working in mental health, noting a marked variability of service between different Trusts. She talked about the recovery model needing to address the quality of life for someone with mental illness within the society in which they live.

Sue raised the interesting point that clinicians and cancer pressure groups stimulated intensive research into the causes and treatment of cancer, with the result that there are now many effective treatments for cancer, and a diagnosis of cancer no longer has the stigma attached to it that it did 20 or 30 years ago. Compare that with treatments for mental illness and disorder – there has been comparatively little research into developing more effective drugs for what can be equally debilitating and life threatening illnesses.

Malcolm Jones and Roger Lewis then addressed the question: what can we do about austerity? Both Malcolm and Roger are major advocates for the rights of disabled people. Malcolm is a social worker and AMHP, as well as being a political activist and a member of the Social Work Action Network (SWAN), while Roger, who is visually impaired, is on the steering committee of DisabledPeople Against Cuts (DPAC). Between the two of them, they gave an electrifying performance, cutting through the cant and ideology of the current Coalition Government to expose the hypocrisy and double standards that is currently driving social policy and seeking to marginalise and disempower disabled people.

The afternoon concluded with presentations from two psychiatrists, Sam Vovnik, who gave a presentation on spirituality in psychiatric care, and Manoj Agarwal, who discussed ways of adopting a more holistic approach to psychiatric care. Rather than following reductive psychiatric diagnosis in the manner of the American Diagnostic Statistical Manual, Manoj preferred to use a grid, which was better able to reflect an individual’s mental health problems. I liked this so much, I will reproduce it here:

	Predisposing factors	Precipitating Factors	Perpetuating factors
Biological factors
Psychological factors
Social factors

Catherine Mills, a mental health service user and one of Dr Agarwal’s patients, then gave a moving and illuminating account of her own journey through treatment and recovery.

Delegates left the conference invigorated and encouraged, while recognising that the struggle to maintain and improve services for mental health service users was going to be long and strenuous. We were also under no illusion that the professional status of social work itself is potentially under threat, and the maintenance of social work as a profession has to be fought for.

I hope I am invited to next year’s conference!

Review of Bedlam, Episode 3, Channel 4 14th November 2013

Jim Thurkle, the social worker featured in the programme

You can read The Masked AMHP's review of this programme, featuring a social worker from a community mental health team in South London, in Community Care.

Review: The Pocketbook Guide to MHA Assessments

 

Claire Barcham is an AMHP who has been closely involved for a long time with the development of AMHP practice, including involvement with The College of Social Work as a professional practice development advisor. Based on her own experience, she has written a clear and concise guide to Mental Health Act Assessments.

 

The book is very easy to navigate (take note, Richard Jones). Of course, it is not purporting to be as painstaking and detailed as the Mental Health Act Manual, but is more designed to provide a practical guide to the basic process of assessing people under the MHA.

 

The book is in five parts: The Legal Landscape; Setting up Mental Health Act assessments; Managing MHA assessments and making decisions; Implementing decisions and admission to hospital; and rounding off with the newest addition to the MHA, Community Treatment Orders, in a section on Working with Compulsion in the Community.

 

The first section places the MHA within the wider legal context, including the Human Rights Act and the Mental Capacity Act. It also usefully looks at the interface between the Children Act 1989 and the MHA when considering detaining a child.

 

The second section concentrates on the process of setting up assessments, including the gathering of relevant information, making assessments of risk and urgency, and looking at alternatives. She then reviews the different sorts of situations in which MHA assessments arise, eg following Sec.5(2) and Sec.136, whether the assessment is in hospital or in the community, and also looks at Sec.135. There is a good analysis of issues relating to the Nearest Relative, including identification and displacement.

 

The third section concentrates on the actual assessment. This includes interviewing in a suitable manner, a breakdown of each individual section that involves detention, and the necessary criteria for admission under the MHA.

 

The fourth section looks at the process once a decision has been made. This importantly includes what needs to go on the section papers in order to ensure that they are legal and valid. Guidance on conveyance to hospital is included, as well as a helpful guidance for nurses and staff who receive the patient and the paperwork.

 

The final section compares and contrasts the various methods by which patients can be maintained in the community. This includes appropriate use of Sec.17 leave, guardianship, and of course, Community Treatment Orders.

 

Each section is heavily interspersed with examples from practice, as well as explicit references to legal issues, and also helpful reminders about other relevant legislation to bear in mind in certain situations, in particular, where the Mental Capacity Act may be considered, as well as checklists to guide one through each part of the overall process.

While experienced AMHP’s would probably not need to dip into this book that often, I would wholeheartedly recommend it as a very useful resource for AMHP trainees, social work and mental health nursing students, nurses, police, service users, and indeed anyone with a personal or professional interest in mental health  and the Mental Health Act.