Autonomy and AMHP Practice. Is it Dead in the Water?
Photography Credit: Nandhu Kumar (Free to use CCO)
By Barbara Swan
Introduction
Autonomy is a fundamental legal principle of mental health law and AMHP practice. There is no settled legal definition of autonomy; synonymous with self-determination, it’s traditionally described as the individual being sovereign over their own mind, body and self (Mill, 1859). Autonomy is important because it promotes the person’s wellbeing, integrity, dignity and self-respect and ensures the person’s voice is not ‘drowned out’. (Hughes, 2013). Throughout mental health law and practice the autonomous rights of the individual are considered significant in, for example, the guiding principles to the Mental Health Act (MHA), such as empowerment and involvement and the Mental Capacity Act (MCA) principles including the presumption of capacity and making as much effort as possible to help the person make their own decisions (Department of Health, 2015). Furthermore, competent AMHPs are obliged to demonstrate their ability to act autonomously and make informed independent decisions based on their knowledge and understanding after considering all the circumstances of the individual’s case (Social Work England, 2020). This critical piece of reflective writing was equally inspired by my deeply held respect and value for the independence of the AMHP role and my frequent frustrations in not being able to implement autonomous rights and practice into my everyday work as an AMHP. This short piece will consider how the legal principle and value of autonomy is embedded in AMHP practice and the current barriers and challenges to respecting it. Consideration will also be given to what changes can be made to ensure the person being assessed is kept centre-stage and the professional’s autonomy remains inherent to the AMHP role and their informed decision-making throughout.
i) Value of autonomy
Government health and social policy has evolved over the last fifty years with an increasing appreciation of the rights to self-determination and autonomy of disabled groups (Law Commission, 1995; Law Commission, 1991) as well as a move away from medical paternalism and ‘doctors know best’ attitude’ (Law Commission, 1991). Following publication of the Independent Review of the MHA in 2018 further progress has been made to consolidate rights-based practice models and a steer towards embedding the legal principles of autonomy and choice in statute for people being assessed and subject to the legal provisions of the MHA. Although reforming the MHA is no longer on the agenda for this government, the direction of traffic clearly indicates that mental health law and practice requires respect, and considerable weight given to the autonomous rights of the individual. The inherent value of the AMHP role and the importance of protecting the needs, wishes and values of the person involved in assessments is moving beyond a narrow medical appraisal of concerns and should include a holistic, social and relational perspective (DHSC et al, 2019).
ii) Current challenges to autonomy in AMHP practice
It will come as no surprise to anyone currently working in mental health services that our systems are under considerable pressure and are buckling under strain. These pressures include a general trend of rising detention rates for twenty years, with a disproportionate number of people from ethnic minorities being detained, over use of community treatment orders, lack of community resources and alternatives to admission (DHSC, 2018; CQC, 2018), as well as a lack of beds for people who need one and challenges coordinating partner agencies to identify a bed and being able to convey to a one in a timely, safe and efficient manner.
In AMHP terms, we have a shrinking and ageing workforce which lacks diversity and performs an increasingly complex and demanding role, often without the necessary supports in place to do so (DHSC et al, 2019). Furthermore, there is no sign that these systemic problems will abate anytime soon; more likely, they have become common place and a new reality with the potential for worsening given recent developing protocols such as Right Care, Right Person policing (DHSC and Home Office, 2023). It is no wonder then that the AMHP Leads Network recently called on the government to reconsider its decision to abandon all reforms in an attempt to salvage some cultural shifts in practice (Samuel, 2023).
iii) Consequences for people being assessed and for AMHP practice
These systemic challenges and pressures are impacting on the person with lived experience of mental distress and the AMHP role. The person being assessed is less likely to have their needs met in the most empowering, least restrictive and person-centred way. Resource driven practice dependent on the availability of beds, doctors, police and ambulance can often mean that our practice is steered, if not coerced into more restrictive and intrusive interventions, such as seeking warrants to ensure police attendance at the outset if risks are considered significant at the point of referral.
An AMHP making independent informed decisions which are grounded in a relational, social perspective can more-often-than-not feel aspirational rather than a reality. As well as significantly impacting on the rights, needs and wishes of the person we are seeing, research suggests that these circumstances are taking their toll on the individual AMHP; often feeling stressed, isolated and dissatisfied in their role (SWE, 2021). This resonates with my own ever more frequent experience; often feeling like I am an instigator of superficially lawful, coercive, oppressive and often traumatic experiences for people we are assessing and more-often-than-not, detaining, rather than a coordinating navigator of routes to a well thought-out and considered outcome.
iv) Tackling the challenges
These challenges can be met head on and there is tangible impetus in the AMHP workforce to do so. By nature, AMHPs are not the sort of workers who comply and fall into line; AMHPs have an ability to observe, reflect and challenge injustice and the marginalisation of the people we serve. AMHPs are an incredibly valuable resource and can be nurtured, empowered and supported to practice in a way which carefully considers, respects and defends autonomous rights. The specialist career development and welfare of the AMHP must be taken seriously by employers and local authorities from the preliminary stages of training, through early years and throughout their working life. AMHP services have a chance to appraise and develop their services in line with national AMHP service standards which address governance, professional development and the breadth of AMHP welfare and safety concerns (DHSC and HEE, 2020).
Our partner agencies could be better informed of our role, responsibilities and duties. AMHPs are often viewed as mere administrators and I’ve frequently been asked to ‘come and complete the paperwork’, provide the correct form, or even provide the doctor with something to lean on while he writes his recommendation! This can demean the AMHP and their role. We need to inform and remind our colleagues of the uniqueness and value of our profession. This is not an arrogant assertion of our skills and knowledge, but rather a reminder that effective collaborative working requires an understanding and respect for each other's roles.
AMHPs can re-boot the foundations of our practice in a collaborative way, ensuring the fundamental principles of the role and our practice are acknowledged and adhered to. We do not have to fall in line with the established way of doing things, led by the availability of resources and colleagues. Our role is working alongside and considering the care, support and treatment needs of a person most likely in mental health crisis, not feeding a bureaucratic and procedural system desperate for efficient throughput on the periphery of the person in mental distress.
We need to be able to develop mechanisms and strategies which tolerate friction and discomfort, which is the most likely consequence of our resistance to conventional practice. I have been inspired by the research and writing of the late Dr Matthew Simpson whose recently published article in the British Journal of Social Work explores AMHPs decision making at the point of referral and offers a different way of working which is thoughtful, comprehensive, strengths based and person-centred (Simpson, 2024).
Our well-informed, up-to-date knowledge and skills will ensure we can challenge coercive and oppressive ways of working. On a larger scale our objectives have been clearly identified by the recommendations outlined in the independent review of the MHA: strong anti-racist AMHP practice; tackling the overuse of coercion; increasing the rights of people being assessed; and embedding guiding principles into our everyday practice which include respecting the individual autonomy of the person being assessed and carefully considering their choices.
Our allies in changes to AMHP practice are people with lived experience (as service users and carers) whom we should be working with to develop services, approaches, practices and interventions which meet needs and respect individual rights. Coproduction should be engaged in a meaningful way and on the agenda of every strategic AMHP service development plan.
Concluding comments
In summary, although I do not underestimate the magnitude of the current challenge for AMHPs to assert their autonomous independent decision-making role in a broken mental health system and for the rights and voices of people in mental distress to be respected and heard, I am not without hope; with some steely ongoing determination, focus, commitment and resilience we can ensure autonomy remains on the agenda both now and in the future and is not dead in the water for AMHP practice.
References
Care Quality Commission. (2018) Mental Health Act. The Rise in the use of the MHA to detain people in England. CQC
Department for Constitutional Affairs. (2007) Mental Capacity Act 2005 Code of Practice. London. The Stationary Office
Department of Health. (2015) Mental Health Act 1983: Code of Practice. London. The Stationary Office
Department of Health and Social Care. (2018) Modernising the Mental Health Act. Increasing choice, reducing compulsion. Final report of the independent review of the MHA 1983. OGL
Department of Health and Social Care, Social Work England, Skills for Care et al (2019) National AMHP Workforce Plan. OGL
Department of Health and Social Care and Health Education England (2020) Approved Mental Health Professional (AMHP) National Service Standards. HEE
Department of Health and Social Care and Home Office (2023) National Partnership Agreement: Right Care, Right Person (RCRP). Available at National Partnership Agreement: Right Care, Right Person (RCRP) - GOV.UK (www.gov.uk).(Accessed 27-02-24)
Hughes, A. (2013) ‘No Man Is an Island: Relational Autonomy and Dementia', Elder Law Journal, 2013 (165), pp. 77-84
Law Commission. (1995) Mental Incapacity. Item 9 of the Fourth Programme of Law Reform: Mentally 6 Incapacitated Adults, No.231
Law Commission (1991) Mentally Incapacitated Adults and Decision-Making: An Overview, No 119
Mill, J.S.(1859) On liberty
Samuel, S (2023) ‘Mental Health Act reform ditched, King’s Speech Confirms’, Community Care. Available at Mental Health Act reform ditched, King's Speech confirms - Community Care. (Accessed 27-02-24) 8
Simpson, M. (2024) ‘Changing Gears and Buying Time: A Study Exploring AMHP Practice Following Referral for a Mental Health Act Assessment in England and Wales’, British Journal of Social Work, 2024, (00), pp.1-20
Social work England, (2020) ‘AMHP course guidance-Social Work England Approved Mental Health Professionals Course Guidance’, Social Work England, available at AMHP course guidance - Social Work England (Accessed: 27-02-24)
Social Work England (2021) ‘AMHPS, BIAs and people with lived experience. An exploration of professional identities and practice’, Social Work England, available at AMHP, BIA and people with lived experience research - Social Work England (Accessed: 27-02-24)
About the Author: Barbara Swan is an AMHP at Northumberland Council and Associate Lecturer at Northumbria University.