AMHP Practice – towards a language of deeds?
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By Mark Pilkington
Morals come from mores - customs and conventions of behaviour within a group and Ethics from ethos – for the character of a community – we must choose a language of deeds as we choose a language of words (“Morality” by Jonathan Sacks, 2021, p285).
At the heart of this reflection is something to do with the ethical contradictions we tussle with as AMHPs and the effect of these on our decision-making. I pick out themes of power, the imposition of the state apparatus and legally informed duties creating issues of professional coercion and control for service users and AMHPs alike. All of these occur amidst the intent to uphold human rights, protect characteristics and meet unmet mental health needs at times of crisis (the search for appropriate treatment). Underlying all of this is a commonly held belief about equitability and social justice for all.
In the blog “Tolerating Uncertainty “ (Teams Call AMHP, 29/04/23) the author, in a reflection on decision-making, asks “have we called this right?” I see this injunction as not just about legally sound decision-making and the justification through our words or rationalisations, but also about being reflexive about the morality and ethics of the deeds or actions taken in the line of duty. The same piece ends with recognising “a thirst for certainty in a transactional drama that doesn’t always offer such relief”. On reflection, I see it as problematic the characterisation of our AMHP experiences as transactional. Such exchanges, practically and communicatively, are not reciprocal or on an equal footing between active participants, namely the service user and the professional. So, it is for me about considering how we are enacting an open dialogue in our work. Rob Manchester has spoken about this in his insightful blog (26/09/22). Whether this offers more relief in the drama and theatre of AMHP work is subjective. Worrying about this however is fitting at least, as it is said that an AMHP needs to be ‘angst ridden but strangely decisive’ (Brown, 2016). We perhaps need a capacity for an “Appreciative Angst” (Matt Simpson, 07/10/22). I also think that we do need a “radical spirit” and “a commitment to renewed ways of thinking about our role” (Alan Bristow, 02/12/22). The blogs on this site seem to reflect this as a shared undertaking.
The environment in which the AMHP works is formatted by a regulatory narrative of mental disorder, dominated by formal rules originating from political, legal, social, historical and bureaucratic systems. These shape performative role expectations of us ‘professionals’ and those labelled ‘patients’ alike - working with other professionals to achieve positive outcomes for service users when “faced with the disjuncture between the experienced realities of the AMHP role and tensions of working with a broken ‘rule book’” (Norrie and Steils, 2018). This means common rules of justice are hard to apply where the impact of austerity and cutbacks find their litmus test in how the AMHP provides an independent decision when there are limited alternatives to detention under the Act. The limitations in finding the least restrictive alternative and bringing a social perspective to bear on our decisions becomes something of a double bind in practice. Hence an ethical issue more often than not is with our weighing up the question concerning the potential iatrogenic harms of an admission against the current and potential risks in the community.
So in explaining my disquiet it has been argued that the issue with AMHP work is its conflicted status - a conflict arising from being seen as ‘dirty’ or conversely ‘prestigious’ work (Morriss, 2016) The blog entitled “Noble calling or dirty work? - Anxiety in the AMHP role” (Alastair Beach, 12/12/22) taps into this identity issue. We struggle with the intent to practice with a duty of care, an ethical code of practice and the legal frameworks for protecting people’s human rights. We struggle with feelings of a cognitive dissonance when dealing with a broken rule book, where advocating for service users is hindered or obstructed by fewer community mental health services. We should be humble, as with humility comes an ability to listen, to inform and to support those we assess at times of crisis. There is no science in our decision-making. We are like cosmologists really, working to distinguish portents, signs and symptoms of madness, to prove the legitimacy of need for someone with a mental disorder. We uphold a S/social order where we are co-opted as society’s state social police and yet ourselves part of the social order of things, trapped in the Panopticon (Foucault’s was touched upon in Bristow’s December blog.). Yet it seems as if we are responding to socially prescribed traumas and needs with the associated inequality and inherent injustice of this. Am I an Agent of a Welfare State or a Wellbeing state - are the name of laws entitled ‘Care Act’, ‘Mental Health Act’, suitable or becoming an oxymoron perhaps, government Orwellian double speak in practice?!
I am casting (forging a space for debate?) a critical reflection on the myriad factors which problematise our ability to feel confident in our role. There is an unavoidable bias which impacts on the way in which I gather information both professionally and personally – such as confirmation bias, anchoring, the availability heuristics in risk assessment, to name just a few. John Mitchel’s blog piece “AMHPersonality: Disordered? (08/02/23) struck a chord with questions I have about “What prejudices, anxieties, and habits, professional and personal, am I bringing to this assessment?” In the eligibility criteria of a metal health diagnosis, risks and the weighing up of social circumstances, we have to contend with ascribing social values for a threshold criteria to access support from services. It feels like an allocation meeting rather than meeting the need for care. I think about how information is gathered and formed as a narrative or a story. How it is then viewed through a particular set of critical or philosophical lenses to make sense of it all. How this often leads to a decision which rests on achieved practice wisdom or the culture and consensus around suitable risk-taking. Something John Mitchell has problematised in his blog.
In my own playful way, I think of how my anxiety at the time of a referral (contemplating the barrage of the unknown) creates affective symptoms in me. I perhaps become unwell for a time and yet my duty towards my s.13 considerations pushes me to build and construct reasons and justifications for my interventions. These often result in a mostly ‘healthier’ confidence in my decision-making by that time. I think I am using terms and words linked to perceptions of health or ill-health, to highlight the relativism of them and so at times, in the inhumanity of it all, it becomes implicit to our practice without being sensitive to it. There is a need to problematise the labels we put on situations and on people to feel more in control of them. The binary opposition between a medical and social model is well rehearsed in AMHP training. Labels have power. In ancient cartography, the unknown risky places were liminal spaces, filled with sea monsters and characters from myths, to manage a social anxiety in our experiences of the unknown. They set limits to how those spaces affected or imposed themselves on our understanding and knowledge of the world around us. So too with navigating the swampy lowlands of social work practice, an uncertainty principle forms the basis of all decision-making around the impact of someone’s mental health diagnosis on self and others. We must avoid labels which cause stigma and so act to discriminate; must navigate uncertain territory at times using our humanity, relevant policy, Code and Law; infused with our own subjective moral and ethical reasoning. The use of judicio-medical terminology in rationalising our practice decisions tends to obfuscate our social directives of course but I recognise we need a defensible practice.
I am a relatively newly qualified AMHP of nearly three years now. This piece (like Alistair Beach’s) is me buoyed by curiosity, seeking different perspectives, new horizons and stories shared with colleagues. I am looking for potential explanations rather than answers at the moment. I would ask the readers’ licence to have my critical play in this blog. It is meant to be a mechanism to create alternative readings that are open to challenge and discussion. This piece is not me drowning but bobbing up and down; striking up conversation here; perhaps waving to you….
….what are you doing
over there?
References
Brown, Rob (2016): The Approved Mental Health Professional’s Guide to Mental Health Law, 4th Edition. London: Sage.
Morriss, Lisa (2016), “AMHP Work: Dirty or Prestigious? Dirty Work Designations and the Approved Mental Health Professional”, The British Journal of Social Work, Volume 46, Issue 3, April 2016, Pages 703- 718 https://academic.oup.com/bjsw/article/46/3/703/1754040?login=false
Norrie, Caroline and Nicole Steils, (2018), The Role of the AMHP: A Fool’s Errand? | Health & Social Care Workforce: (kcl.ac.uk) – posted by Stephen Martineau 12/09/2018 to the blog of the NIHR Policy Research Unit in Health and Social Care Workforce at King's College London.
Sacks, Jonathan, 2021 – Morality: Restoring the Common Good in Divided, Times, 2020, Hodder: Uk.