“AMHP Number Two Please….”
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By John Mitchell
AMHPs vary, not just in the decisions we take, but in how we learn, practice, cope with stress and distress: deal with the dysfunctional pressures of our very own theatre of the absurd.
We differ too in why we became AMHPs in the first place, and in what we now make of ourselves in the mirror of those preconceptions. If we dare search there at all.
Part of the challenge of that looking glass may be that the AMHP role is only just beginning to recognize you: your racialized identity; your resilience in facing domestic violence, harassment, persistent microaggressions; your traumas transformed; your hidden experiences, unspoken of at work, but which speak clearly in all you do.
In both of my earlier pieces for the Critical AMHP blog I tried to reflect that, when I look in the mirror, I see the detained man of yesteryear as well as the AMHP of today. This isn’t easy. As some survivors would point out, I was long ago co-opted by the system, so my self-concept is unlikely to hold both views in balance. Yet my determination to detain as infrequently as I can has little to do with any sense of personal grievance. It is rather that, as a companion detainee, I learned to sit down, listen, open a conversation free of the observer effect: of causing fear, suspicion, paranoia: of being on stage.
Over the years, I’ve tried to combine that experience with slowly acquired skills in assessing psychiatry and psychiatrists. In doing so, I’ve gradually understood that, if we can see people more as they are, rather than as framed by the MHA and the anxieties of our fellow professionals, then outcomes can be different. I’ve also appreciated that, in some cases, it might be better for the person to be assessed without being seen by doctor or AMHP: less can be more. Accordingly, I’ve tried to hone my absence as much as my presence.
The AMHP role is, of course, a uniform creature of the law. But a legalistic image of what it means to be an AMHP can limit our view of ourselves, and of those we assess: diversity of practice, and of people; differences in how and why we do things; professional styles and strengths that make a personal impact; understandings that may prevent detention without interview or examination. All of this is on display in AMHP teams but absent from the job description.
We are often too busy reacting to situations that need slower, more considered responses. I may assess, then you reassess ‘because there might be a bed’, or I simply sign days later, in a way that doesn’t connect with the changing reality of the person left in limbo. ‘The next s136’ may be someone that a colleague saw yesterday, and yet another AMHP merely days before that, with no plan to prevent these cycles of futility: of finding the world of someone caught in her own revolving door.
Wherever mental health services are more disordered than those they should serve, a legalistic view of the AMHP role is likely to aggravate, especially when we’re dealing with situations where the law has little to teach us. It’s as if we accepted an unwelcome subtext: ‘One AMHP’s much like another. We’re interchangeable: mechanical components of the MHA conveyor belt. Here’s the MHA on/off switch so: are the criteria met, or not? Adebola not at work? Paul will do just as well. AMHP number two please…”
The idea that there are choices to be made, linked to who you are, in becoming (and then remaining) an AMHP, raises the question of what kind of AMHP you want to be. There is also the question of what kind of AMHP your service will allow you to be. AMHP services have had to adapt to an often-surreal dysfunctionality in wider mental health services. Entering a hall of mirrors, we are deceived by distortions that we then expect others to share. We may doubt but not challenge a view of someone as ‘disengaging’ and ‘non-concordant’ where these descriptors more fairly belong to the referring service. We may still convene a ‘two doctor’ assessment where reflection reveals a psychiatrist who doesn’t believe in her own referral. We may become dealers in human diazepam.
Your AMHP service needs to support differences in practice and outlook. It needs to support you. If so, do we understand and adequately reflect upon the differences in AMHP services and how they nurture or constrain AMHP practice?
No two AMHP services function in quite the same way. They may contrast enough in operational style and culture that you doubt aspects of your own experience, until you adjust to ‘the way we do things here’ and forget what was troubling you.
It’s not easy to see those differences, let alone comprehend their significance. Services which look similar on paper may be poles apart in spirit. Organisations which host AMHP services regard us primarily through the lens of their core priorities. We may be seen as an appendage of home treatment, enforcing where persuasion fails. For others, we’re an adult social care team that plays, inconveniently, by special rules. One of the most important factors is the historical legacy. Not just the scars of macro-wars: of partnership, divorce, and redefinition, but the countless local micro-strategies and relationships that have always tended to escape print, and senior management. We rarely fit the corporate vision or feel embraced by it. Wisely maybe.
Some capable leaders, perhaps AMHP qualified, champion the AMHP cause, fight for resources, connect our own initiatives with developments elsewhere. Often, our role, wired to the clamour and broken glass of alarm, attracts attention primarily when others feel something is wrong with us: “why aren’t you going now? This person needs to be detained”. In our case too, disagreement with psychiatry may be taken as a sign of madness, if more often one of laziness, truculence, or ignorance.
The confident expression of dissent needs to be at the heart of all things AMHP. The quality of that dissent, its creative scepticism, needs to be promoted and protected. This takes commitment and courage, from individual AMHPs, and from those who manage them.
Unless we resist being defined as The Detainer, we can hardly be surprised at being typecast. The Act, The Code, AMHP training: all tell us how to detain. Mental health services running low on resources and imagination divide the recalcitrant into dischargeable and detainable. We’re expected to know what’s needed. After all, we’re the ones with the forms and the phone numbers.
We may also be expected not to ask too many questions. Referrers can struggle to find the right words to justify their concerns. That’s what they want us to do, but not before the holy trinity of two doctors and AMHP have gathered together in the name of the MHA. The idea that, under s13(1) MHA, an AMHP can say ‘no’ at the point of triage may be troubling and lead to ‘referral games’ of overstated risks and symptoms, designed to ensure that a ‘real’ assessment takes place. Where AMHPs fail to deliver, complaint, perhaps disguised as ‘escalation’, may arrive at the ear of managers.
A key test of an AMHP service is whether it helps to develop a triage culture more about skilled conversation than about referral forms, or worse: prefabricated med recs and pizza delivery MHAAs. We may have to fight to achieve this.
An AMHP service needs to recognize different kinds of AMHP and create an environment where an AMHP can ‘consider the patient’s case’ in any way she sees necessary. This may involve rota designs which maximise worker continuity and allow slower responses. More importantly, AMHP managers need to tolerate tensions of view within the team, encouraging supportive discussion and debate, but demanding respect for individual decisions, for your methods, for you. Above all, we need to resist tenuous re-referrals, post-MHAA autopsies disguised as professionals’ meetings, and shopping for the ‘right’ AMHP.
“We detain too many people” versus “there aren’t enough beds”. This is one continuum on which we might place ourselves. For the former kind of AMHP, her actions may look quite different to her aspirations, because it will cost her far more to be the bolder, risk positive decision maker that her values ask of her.
Why should that be? Surely national policy demands fewer detentions, not just in the prime case of racialised people, from whom there may be most to learn, but across the board?
Detention is so often the easier option. Faced with risks we were trained to shudder at more than understand, uncertainties of resource, intention, outcome, other professionals more concerned to protect themselves than to reach the person, it can feel difficult not to detain.
Sample the decision-making section of AMHP reports across authorities and you will see, with honourable exceptions, that it takes no great quantity or quality of words to justify detention: detention speaks for itself. No-one will raise an eyebrow, let alone a voice, against you. You are a detainer and you have detained.
When you make a habit of not detaining, each decision gradually extending the boundaries of the possible, you will have to write cogently and more extensively, make long and difficult phone calls, use different methods, such the dialogical MHAA, to get to the heart of the person, the system, the situation. You will often feel you are being required to explain yourself. (You’re letting this person walk, homeless, through the rain? But they’re unwell. What kind of an AMHP are you? An antisocial worker?)
Any form of MHAA is potentially a risk, because of the stress it can cause the person, thereby creating new possibilities of incapacity and ‘detainability’. The more intrusive an examination, the greater need to justify that form of assessment as proportionate. When you use s13(1) MHA more radically, understanding that even a dialogical MHAA may be too great a risk for this person, that what is needed here is not a psychiatrist, but an option that keeps the doctor away, then you are unlikely to be popular. Which is why, as an AMHP lead or manager, it is our job to defend, and help everyone learn, from these assessments.
But why my emphasis on individual AMHP identity? Surely any AMHP should simply strive to understand and implement the law consistently? Doesn’t an AMHP service need cohesion rather than idiosyncrasy?
Legal literacy is crucial. But someone may have exceptional knowledge of the law and still be a mediocre AMHP or AMHP lead. No algorithm can resolve our exacting perplexities. s13(2) MHA requires that, if an application is to be made, this AMHP must be satisfied before the law can be. The MHA looks to us to find the person, the words, the agonies that it cannot, then leaves us stranded on the quicksand of the peculiar. It doesn’t tell us, in any form at all, how to not detain. Looking for our way there, we must seek footprints, not footnotes. We need a friendly face. Or inspiration.
The author and broadcaster Horatio Clare is someone who has previously been detained, as I have been. He came to my home, in search of me, but without any warrant other than his imagination. Knowing my involvement with the deep ends of detention he asked me, pointedly, amidst a host of other, more technical issues, how I would advise someone trying to support a friend or family member struggling with their mental health. A telling question for that moment. One of many that are so basic, yet so difficult to keep in focus within an AMHP identity.
Over the quicksand the tide is coming in with its shadows and salt mirrors.
There are no answers here. Go home. Take more time. Think it over. Reflect.
Sorry to have left you with all this. I should have written a better report for you too but, well… you know how it is. Won’t detain you further.
“AMHP number three please…”
Influences, Inspirations, Points of Reference
Louise Blakley, Carolyn Asher, Angela Etherington, Joanna Maher, Emma Louise Wadey, Valerie Walsh and Sandra Walker (2021): ‘Waiting for the verdict’: the experience of being assessed under the Mental Health Act. Journal of Mental Health 31 (3) 1-8.
Horatio Clare (2021): Heavy Light: A Journey Through Madness, Mania and Healing. London: Chatto & Windus
Robert Lewis (2020): National AMHP Service Standards. DHSC.
Rob Manchester (2022): Could these be the key elements of dialogical Mental Health Act interviewing? The Critical AMHP Blog 26/09/2022.
John Mitchell (2022): An AMHP’s Journey Through s13(1) MHA. The Critical AMHP Blog 26/09/2022.
Hari Sewell (2023): Frames and Boundaries of Race and Ethnicity. In Jill Hemmington and Sarah Vicary (eds): Making Decisions in Compulsory Mental Health Work. Bristol: Policy Press
Matt Simpson (2022): An Appreciative Inquiry into Approved Mental Health Professional Decision-Making at the point of referral for a Mental Health Act assessment. PhD thesis. Bournemouth University
*image provided by author