An AMHP’s Journey Through s.13(1) MHA

By John Mitchell

I am an agent of social control: the bailiff of mental health services. I walk past your Skoda, your sofa, and your speakers. I take you away instead. I take you because you don’t understand the risks that you face. You are in debt to psychiatry without realising it:  you lack insight. We could have helped you, come to an understanding, but you were non-concordant, you disengaged…

As someone who has been subject to the MHA as both detainer and detained, I have known many kinds of pain around compulsory admission. At worst, there can be something more akin to execution than to mere removal. Frequently there is bewildered grievance, a sense of powerlessness that may find words only when there is no-one left to listen. Sometimes the process of assessment feels even worse than the outcome.

I first accepted that detention might be necessary (although not in my case, of course) when I spent much time with other inpatients. I was puzzled though why some people were detained. Who made such decisions, and how did they make them? The ward’s copy of Jones gave me interesting legal detail but little sense of the process that I assumed must inform these judgments

I became an ASW, then an AMHP. Each year I found myself able to detain fewer people than the last but having to be braver to achieve this. Gradually absorbing more about psychiatry than some would say is wise for AMHP, I also learned much from individual psychiatrists, as professionals and as people. I saw the value of assessing doctors before assessing patients: will this psychiatrist be an asset in the decision about this person?

I studied AMHPs in a similar way. Their most valuable lessons were somehow never to be found in print. The best AMHPs knew enough law but could navigate distress and its consequences with their eyes raised from the legal chart: could take you to destinations other than detention. Their role was more act than Act.

Working in home treatment teams, I observed how many admissions could be prevented:  how to gain doorstep acceptance, to go slowly, to talk first about interests and identity rather than risk and risperidone. We often took bold decisions not to refer for an MHA assessment. The required dose of psychiatry was low: you knew when you needed a doctor, and why.

An MHA assessment is itself a risk. It is not a benign instrument of investigation. An MHA assessment can change behaviour, even change the person. The way we assess can destroy, or restore, confidence and capacity. An AMHP who only sees people with two doctors, in a service which permits a conveyor belt of shrink-wrapped judgments, may struggle to see the choices that we have. “This is the way it’s always been”. “This is what the law requires”.

The MHA itself contains no mention of an “MHA assessment”, instead requiring an AMHP to “consider the patient’s case”. Deciding against detention purely on the available information, after phoning people, or after seeing the person without doctors (but perhaps with someone else), can often meet the requirements of s13 MHA more appropriately than a “full” MHA assessment. It’s the involvement of an AMHP, considering the patient’s case that’s crucial to fulfilling the demands of s13(1), not whether doctors are present. S136 aside, a doctor should be in attendance only because the AMHP thinks it necessary.

There is an unending appetite for assessments. Struggling and risk averse mental health services make many suspect referrals. A strong AMHP service must be clear about the need for triage, with leadership from experienced staff. A triage culture needs to be developed in which we consistently say “no” to many referrals at an early stage, but hopefully do so in a spirit of risk management partnership. Each “no” needs adequate reasons, should be clearly identifiable as a s13(1) MHA decision, and recorded on IT systems alongside other AMHP reports. A simple, brief s13(1) report format enhances the credibility of those decisions. The Code has little to offer us about this. We need to learn from existing best practice.

Such a culture can attract controversy. Indeed, managing “the politics of care” is amongst the principal challenges of AMHP services. Many professionals demand a “full” MHA assessment even when they are unconvinced that detention is necessary. Accepting the “two doctor” assessment as the default model wastes scarce resources. The quality of assessment may suffer as, crucially, may service user experience. We should recognise when assessment is about meeting the needs of professionals. When mental health services are more disordered than the service user.

Even when two doctors are necessary, we need to make changes in the way we assess. Rob Manchester outlines an inspiring model of practice informed by Open Dialogue in another piece on this blog. Two key features are the engagement of an AMHP in spending better quality time alone with a person, and the move towards open decision making in their presence. As psychiatrist Dr Russell Razzaque puts it: “the more we widen our horizon when it comes to helping someone in distress, the more profound that help will be”.

We may not fully appreciate the intimidating potential of an MHA assessment. The number of assessors, our gender, ethnicity, personality, and how we work together all have an impact. If this assessment is to be your assessment when the odds are already stacked against you the AMHP had better think carefully. Quite unintentionally, we can make you more “detainable”.

Aside from s136, I often favour an MHA assessment without doctors. I will go to see the person with someone familiar, or on my own, aiming to be human before I become an AMHP.  Mindfulness of presence, even before a word is spoken, can have power and possibility. Explaining my role, and the concerns which have brought me to your door, I try to create the illusion that I have all the time in the world to listen. I may express uncertainty about what needs to happen, saying that I need your help to understand what is happening for you. People frequently respond if you can win their trust: you have around 30 seconds to make a good impression.

I seldom detain those that I visit in this way: I will have read the record carefully and consulted beforehand. I may, heaven forbid, find myself practicing social work… Often, I will spare the person even this intrusion: I will write a detailed s13(1) decision without an interview. I have done so even in response to s5(2) on occasion. Sometimes there is fury, but more often silence. Even psychiatrists who have provided a medical recommendation often say nothing: someone else has now taken responsibility.

The option of detention is needed, but less frequently than either we, or those who make referrals, imagine. Effective triage means that we can often tell when this is more likely to be required. We detain many people because the form of our assessment, and the habits of mind that go with this, aren’t helpful to understanding either the person or ourselves. We should undertake fewer (and different) “two doctor” MHA assessments, investigating in a more versatile way. Take more time! The unavailability of a bed may itself lead us to a better decision.

“But how can we remotely hope to meet these challenges? There could scarcely be a worse time to be an AMHP, except there probably soon will be. More referrals. No beds, doctors, resources. Teams with the lights on but no-one at home. Staff burnout. Sorry, love to stay, but must get to my next s136…”.

AMHP services need to be proactive, undertaking fewer assessments through rigorous triage, and preventing repeated cycles of futility by contributing to multi-agency care and contingency planning. We must detain fewer people. The Act, existing or amended, won’t do it for us. With “Less is More” as our motto, and a recognition that non-intervention can sometimes be less risky for the potential service user than the service itself, the way ahead, much like the path behind us, might well be an uncomfortable one.

S13(1) MHA offers AMHPs far more flexibility than we typically use. But that flexibility requires courage, from AMHPs and from services.  You need to decide what kind of AMHP you want to be. However, it is hardly realistic to expect individual AMHPs to rise to the challenge in isolation.  Such a journey asks questions about the leadership of AMHP services, post-qualifying development, standards of co-production and staff care. Positive AMHPs are more likely to mature in positive AMHP services: services where AMHPs are confident in responding to people in creative and sensitive ways which challenge the necessity of detention from the outset: AMHPs who can imagine what it might feel like to be judged, to be taken away.

I spread out this map of s13(1) just as you are walking past my Skoda, my sofa, my speakers, my pile of unpaid bills. Tread softly….