The Barrage of Three

By Louise Blakley,

“Your idea about different structures of AMHP teams is okay but what was important to me is no one has ever asked me about my experience of being assessed. When I have had poor experience, I go into hospital and do not speak to staff and take longer to recover”

I was in a meeting to discuss my research idea of comparing service models for AMHP services with a group of research experts and people with lived experience when Valerie shared her experiences of being assessed and detained. It was a true light bulb moment and subsequently, I have a lead a research study exploring service user experience of MHA assessments with Valerie and other Service User Researchers as part of the team.  They have given me the impetus and support to help me get funding (four sources in total), navigate ethics (failed first time) and challenged my “AMHPness” (my professional bias) when we analysed the interviews.   

Given that there are a number of studies out there which focus on service user experience of detention in hospital (see Akther, 2019), I was surprised that there was little, if anything, published on service user experience of MHA assessments themselves.

Ten service users were interviewed about a recent MHA assessment (in the previous six months).  There were a range of experiences: some were detained, two people were assessed for the first time whilst another person had had over ten assessments. These assessments happened in different locations: on the ward, in homes, in Places of Safety and general hospital. 

I have learnt so much from just sitting and listening to their varied experiences. I have written one journal article with the research team, about broad findings that apply to AMHPs and wider mental health services (Blakley 2021). Currently, I am in the throes of reflective writing on my own AMHP practice.  In this blog, I wanted to discuss one thing that struck me – the general lack of discussion about what it is like to receive a MHA assessment.    

“You don’t really talk about it to be honest …think mum and I talk about it…. but I haven’t really talked about it with like professionals or anyone” (Katie) 

Katie has had four MHA assessment experiences.  She talked about how angry she felt about the social worker contacting her mother at work.  Later she mentioned that her mother being at the assessment would make it fairer as her mother would support her views and make sure nothing bad happened.  What Katie discussed reflected other participants’ experiences. 

Not talking about MHA assessments

Only two participants had previously spoken about their experiences of receiving a MHA assessment with one reporting the care coordinator did nothing about the anger and confusion he felt.   As I was struck by how uncommon it seems to be to talk about MHA assessment experiences, I have made a point of asking about it when talking about the research and in different settings.   I have found only five out of thirty people have talked to mental health staff about this experience. Making decisions on someone’s liberty is a very key part of mental health services and it seems odd that this is rarely discussed. There is a growing recognition of the benefits to staff and service users of discussing other coercive events like restraint and seclusion although MHA assessment are not viewed similarly.   Listening to the service user accounts highlighted to me that their experience is important and should be heard for the following reasons. 

Not understanding or learning about MHA assessments

As no one is talking to service users about this experience, we are not hearing their positive or negative experiences to foster greater mutual understanding.  With Kate, we did not explain to her why we were contacting her mother and she did not understand family involvement and rights like the Nearest Relative role.  Most of the participants mentioned experiences that could be a complaint or an avoidable harm like Linda who was distressed by staff swearing in the Place of Safety. 

For AMHPs who often only have fleeting contact with service users, we do not get to hear about the difference we can make.  Like in the case of Alice who had time alone with the AMHP and described the AMHP supporting her to express her views to the doctors and the AMHP for the first time. 

As a group, the participants have collectively experienced thirty-five MHA assessments.  With this level of experience, I was surprised how little they understood the process and who the professionals were and their roles.  An AMHP was variably described as a support worker, student and a child care social worker.  Some people did not understand they were having an MHA assessment and were then subsequently shocked to find out they were detained. Importantly, it could also affect their sense of whether the process is fair. Research into involuntary admission highlights that service users are less impacted if they feel the process has been done fairly and with proper authority.   How are service users able to get a sense of fairness if they do not understand the basic process and why three people have turned up to their house to make a decision about their liberty?  

Service users felt there were few, if any, options with one person saying she only learnt about different options through being assessed so many times such as the possibility of home treatment, informal admission and agreeing to medication.

As no-one seems to be talking about MHA assessments outside of MHA assessments, service users are not gaining knowledge, and this reduces their ability to have involvement and power in the process.

Not improving or increasing involvement

In contrast to this perceived lack of understanding, as a group they suggested over fifty ideas to change the MHA assessment process!  These ideas included suggestions for individual crisis plans or advance statements like Katie having her mother present and others like Charlotte not wanting a certain doctor, or Alice preferring at least one female.  Other ideas were simple changes that AMHP could make like giving service user written information about who was there and reasons for detention or offering breaks and time to speak alone.  One important message for AMHP is that time alone with AMHP was highly valued by participants with benefits of feeling listened to and greater understanding what was happening. Other ideas were deeper changes to all assessments like not having three professionals interviewing together as participants found this daunting and intimidating or having representation of the service user views and wishes within the process.

By not talking to each other we are losing valuable insights into the experience including understanding how to improve the experience on individual level and looking at how custom and practice in MHA work could be more service user focused. 

After this research study, I am now dedicated to getting MHA assessments discussed more in the mental health system more broadly.  As AMHPs, we can be part of this through encouraging care co-ordinators to have discussion later on in their recovery to understand more of the person’s perception of their MHA experience. Another option could be to facilitate conversations whilst the person is still on the ward about what happened in the assessment and the impact on person. Another crucial way in which AMHPs can contribute is at the point of referral, when we should encourage an honest discussion between the referrer and the service user about the nature of their concerns. Also we can learn from service users through talking with them at a later date about their experience or having opportunities as AMHP Services to have open conversations and listening opportunities to these experiences. 

For further information on the study  

Blakley 2021 ‘Waiting for the verdict’: the experience of being assessed under the Mental Health Act Waiting_for_the_verdict.pdf (port.ac.uk)

Akther 2019 -  Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis. S205647241900019Xjrv 1..10 (cambridge.org)

Louise presented a webinar for BASW Success in Social Work series where she discusses more her pathway (more like hike over the mountains) to completing a research study as a social worker. She is happy to discuss what opportunities there are to get involved in research or complete your own study.  Louise has also written about failing the ethics process or how working with the experts by experience supported her succeeding get ethical approval.