Approved Mental Health Professional: More than a legal role? The need for critical reflection

By Jill Hemmington,

Introduction

Despite there being almost forty years’ potential for research, materials and understanding based on a deeper critical evaluation of the practice of AMHPs (and ASWs before them), practice takes place in the absence of any established theory or evidence-base. This is despite the statutory competences for qualifying and post-qualifying AMHP work being based on the ability to ‘evaluate critically’ local and national policy or to base AMHP practice on critical evaluation of research and practice.

AMHPs are required by law to act autonomously and to make independent decisions, whilst working in complex and changing systems. As such, decision-making is informed by features of our professional and personal self and values, our knowledge base and, potentially, other variables. There are different styles of decision-making (e.g. Peay, 2003) and variations in AMHPs’ professional backgrounds, geographical location, position within different service models and time spent in practice. Simultaneously (and perhaps consequently) outcomes of MHA assessments are understood to be inconsistent, variable and influenced by many factors (Huxley et al, 2005; Davidson and Campbell, 2010) and disproportionately affect some groups or indirectly discriminate, particularly around aspects of race (DoH, 2015).

I found all this both fascinating and perplexing in my own AMHP work. When I came to also work as an AMHP educator and trainer I realised that I felt such a lack that I undertook a PhD to help with my own thinking and to try to make sense of the depth and breadth of the role. It was hard work, but it was a cathartic process.

Background to the AMHP role

The AMHP role is a blend of professional, administrative, practical and legal functions which has been developing from as far back as 1808 in the County Asylums Act where the parish Overseers of the Poor would identify those considered to be lunatics, sometimes bringing them before the Justices and obtaining a warrant, arranging transport to the asylum and making provision from parish funds to support them. Across statutory and policy developments, the role subsequently became the Duly Authorised Officer, the Mental Welfare Officer and, the immediate predecessor to the AMHP, the Approved Social Worker (ASW) via the 1983 Act (Hargreaves, 2000). These early roles were, to an extent, organisational and unconnected to the later development of psychiatry. Similarly, the role was always more than a legalistic one. A Local Authority Circular from 1986 (LAC (86) 15) summed the ASW role up nicely:

ASWs should have a wider role than reacting to requests for admission to hospital, making the necessary arrangements and ensuring compliance with the law. They should have the specialist knowledge and skills to make appropriate decisions in respect of both clients and their relatives … They must be familiar with the day to day working of an integrated mental health service and be able to assess what other services may be required and know how to mobilize them … Their role is to prevent the necessity for compulsory admission to hospital as well as to make application where they decide this is appropriate (para.14).

This has remained the case for AMHPs.

There is a lot to do and a lot to think about! Yet books about ASW and AMHP practice have, until very recently, only been law texts. This is starting to change but, for a long time, only very few pieces of research or reflection pieces acknowledged the on-the-ground complexities of the role. Parkinson and Thompson (1998) talked about ‘uncertainties, mysteries and doubts’ in their (then) ASW training roles. Here, ‘crisis, mess and muddle’ underlined MHA assessments which were ‘situations of panic and confusion’ where difficult decisions had to be made at the same time as coordinating doctors, police, ambulance crews and so on. They described the need to have familiarity with the law, organisational deftness, skills in crisis management and interpersonal sensitivity but stressed that our reflective capacities (as both trainees and practitioners) need to be developed in order to manage this. I believe that almost twenty-five years later this is even more pressing.

There are several domains influencing AMHP work, and these are set out in diagrammatic form, below:

Hemmington and Vicary (forthcoming, 2023)

Certainly, it is a statutory and legal role and AMHPs are seen as having expert knowledge of relevant statute. Yet there is more to it.

The professional aspects of the role involve the AMHP’s social perspective, anti-oppressive and anti-discriminatory practice and the requirement to maximise service users’ self-determination. The AMHP role was, from its inception, intended to counterbalance the narrow clinical psychiatric model with the hope that a more holistic social perspective and social assessment would enable less restrictive, community-based alternatives to hospital (Gostin, 1975; Walton, 2000). It is ‘a social counterweight to the medical viewpoint in the detention’ (Bartlett and Sandland, 2014 p.259), a unique social lens, and a role which complements the clinical assessment (Social Services Inspectorate, 2004).

The moral and ethical dimensions arise from the independence of the role and the need to balance state paternalism – being an advocate for someone and upholding their rights - whilst simultaneously being the applicant. Here, the values-based aspect of the work comes to the fore. The National Workforce Plan for AMHPs (DHSC, 2019) speaks of the need to promote the dignity, and human and civil rights of those being assessed. The plan also underlines the aim to reduce stigma, in particular in tackling racial and cultural disparities (which I believe is to take an active anti-racist stance and see AMHP work as a political activity). More broadly, the plan speaks of embedding the principles of co-production and to ‘ensure the person’s experience and perspective is captured and harnessed’. This also makes the work relational, interpersonal and involving a critical awareness of the use of self in practice. When people with lived experience are asked about involvement in MHA assessment and detention the focus, understandably, is on relationships, listening and warmth (Louise Blakley’s blog reinforces some of these points).

AMHP work is practical and processual with our role around coordinating MHA assessments and attempting to find alternatives to admission. It is my belief that this  coordinating process extends into and throughout the MHA assessment where AMHPs are also overseers of communication (Rob Manchester’s blog has an interesting and important position on how to do this effectively).

It is easy to say that AMHP work is practical and processual, yet this is in a context of the rates of MHA detentions increasing, inpatient services consistently running over capacity, and with the number of available hospital beds decreasing leading to a preponderance of out of area placements for many people. These have a profound impact on the AMHP role where AMHPs are under ‘extreme pressure’ and even ‘feel forced’ to compulsorily detain people in the absence of a less restrictive option (BASW, 2016). AMHPs’ moral injury (arising from their inability to do their main job of finding reasonable alternatives to hospital detention) has been increasingly apparent and is evidenced in high levels of stress and burnout – a point that cannot be understated.

There is a lot to think about. When I have interviewed AMHPs for my own research, all of this has been discussed in many different ways. Crucially, there are many similarities with the things that are important (in terms of what works and what is difficult) for people with lived experience of assessment and detention. Time as a resource, for example. One thing in particular that stuck in my mind was one AMHP who asked ‘What are we? Who are we for?’ It’s a question of cosmic proportions. AMHPs’ invisibility and feelings of being misunderstood are all around us. When I spend time speaking to groups of AMHPs or people with lived experience of AMHP work, there is reflection, contemplation, complexity, richness and depth. Sometimes it’s passed on like folklore to others, but more often it stays in the room, diffuses and disappears. Where do we capture all this? Where do we share this? How do we start to explain what we are, what we do, who we are for? How do we begin to make sense of, and put a name to, some of our daily experiences? How do we manage service users’ as well as our own distress and moral or psychological injury?

AMHP work is often described as being a ‘political activity’, mainly around the rights-based, justice-focused aspect of the work. But perhaps we need to be more activist? AMHPs’ social perspectives are often aligned with a critical, if not any-psychiatry, position. We could reflect on Helen Spandler’s (2016) concerns that psychiatric abuse has been over-emphasised at the expense of psychiatric use, and a new phase of resistance is borne of a recognition of a shift to ‘psychiatric neglect’. This means demanding better psychiatric services and real alternatives. It seems like a good time for AMHPs to embrace a critically reflective approach and to explore each and every one of these practice dimensions (and their challenges) in detail. This way, AMHP practice becomes a form of practice wisdom and artistry that we can articulate well.

These are just my thoughts, but I don’t want to be a lone voice. I’d like to have AMHP colleagues to share these reflections with. One thing I’m sure about, though, is that the AMHP role is far more than a narrow, legalistic role and this needs to be embraced and nurtured – by our own community of AMHPs and by people who experience them.