Could these be the key elements of dialogical Mental Health Act interviewing?

26 Sept

Image Source: Creative Commons pgCulture2c_talkcircle.gif (304×304) (muiniskw.org)

By Rob Manchester

There is a growing need and a desire to re-orientate professional practice in Mental Health Act interviews towards a more fundamentally relational and dialogical approach. I set out the case for this in an article last year entitled ‘It’s time to make Mental Health Act interviews more dialogical’ and also in an episode of the Relational Psychiatry vlog by Russell Razzaque (link below). It has been brilliant to receive so many supportive responses from AMHPs and indeed psychiatrists around the country, and although anecdotal, I get the distinct sense that dialogical ideas are strongly resonating with AMHPs as we seek to freshen up our practice in the face of new and old problems in the mental health system.

It is a well-trodden path in AMHP meetings that AMHPs often encounter resource barriers in our quest to secure good outcomes for people in crisis – whether this is frustration with the paucity of meaningful alternatives to psychiatric admission or with the inability to secure timely admission when it is really needed. Yet what has perhaps been overlooked for too long is that the most important resource in AMHP work is actually oneself. AMHP work is a deeply relational activity – it demands that we get alongside people and their families quickly and sensitively during a period of significant distress and upheaval in the social system so that we may understand how and when to intervene. It demands that we listen, listen and listen some more – not only to those with loud and strident voices, but to those who may struggle to be heard despite often having equally compelling things to say. And it demands that we listen to ourselves – to our own conflicts, to our own internal voices, and to our biases and vulnerabilities as we wrestle with the messy realities of making complex decisions about people’s lives and care.

When the Devon AMHP Service sat down in the ‘Conversations across the Divide’ project in 2018 the experts by experience turned the mirror on to ourselves by asking us to discuss what we considered to be the key characteristics of a good Mental Health Act assessment from an AMHP point of view. This was such an interesting exercise because it naturally turned our attention to the constituent parts of the assessment process including the MHA interview itself – the part of the assessment that is directly experienced by the person of concern. This interview represents their opportunity to be heard at a really critical moment - to develop and share meanings and understandings from multiple perspectives, and to be responded to. Sadly, this was not widely reflected in lived experience of MHA interviews, something which Louise Blakely also found in her unique research (featured on this blog site).

Likewise, a key issue running thematically through the Independent Review of the Mental Health Act is epistemic injustice – in other words, that the knowledge, experience, beliefs and perspectives of those people receiving services under the Mental Health Act is all too often not being afforded the value they deserve when it comes to decisions around care and treatment.

As AMHPs we can make a massive contribution to correcting this epistemic injustice at the front door of the Mental Health Act. We may do this by robust triage of MHA assessment referrals so that we divert care away from possible compulsion where appropriate before a traditional MHA assessment is even convened (please refer to John Mitchell’s excellent piece on s13(1) on this site). However, there will continue to be thousands of MHA interviews each year and there is huge scope to develop the ways in which we approach these interviews so that quality of the conversations and the quality of the experiences in them are significantly improved. Colleagues in Devon and elsewhere have taken some of the key elements from dialogic practice (see Olson et al, 2014 detailed in Further Reading below) and sought to apply these in direct AMHP work. Our experiences suggest that the following elements could represent;

The possible key elements of dialogical Mental Health Act interviewing

1) Approach a MHA interview with the curiosity of a ‘not-knowing’ stance: there is a key distinction between arriving prepared for a MHA interview and arriving thinking you already know what is going on for a person and what it is they need. Collecting information and different perspectives beforehand is likely to be important but if you allow these pre-conceptions to dominate your interactions with a person in an interview you will not be as open as possible to listening to the person’s own narrative and to the new ways of thinking and feeling about a problem that can emerge through good dialogue. Go with an open mind and be humble – be prepared to know that you don’t really know.

2) Where possible, the AMHP ought to meet the person to be assessed without the medical assessors before the MHA interview formally takes place: this is one of the few pieces of guidance that AMHPs receive in the Code of Practice about the MHA interview process (albeit the Code does not specify the precise timing of this AMHP-client meeting). It can be really beneficial for an AMHP to take the time to introduce her/himself before the formal interview process to break the ice, build a little rapport and to orientate the person to the process ahead. Again, Louise Blakley’s study directly supports this.

Unlike in an Open Dialogue network meeting, the person being assessed under the MHA is not usually actively choosing to be present, making it all the more important to explain what is happening and why. Initially meeting one unfamiliar person with a lot of power has to be better for most people than meeting three unfamiliar people with a lot of power all at once. Research seems to suggest that many people who have experienced MHA interviews often do not recall there was a non-medical person present at all at the point of being sectioned. We can potentially help people in this regard by not all arriving together as a ‘team’ or ‘wall’ of undifferentiated assessors – the barrage of three.

This is also potentially your opportunity to be transparent about what you think you have understood of the person’s situation, how this has led to the MHA assessment, and what sources of information you have used and who you have spoken to beforehand.

3) The AMHP should spend some time with the medical assessors before the MHA interview to ensure that there is some commonality of purpose and approach around the style of the MHA interview rather than simply ‘hoping for the best’. Explain to the doctors how you would like to conduct the MHA interview with Elements 4 -6 outlined below and that you can take the lead on this initially. Of course, rarely will it be possible to go into great detail but rather it is about conveying the essence of the approach: prioritising listening and transparency, including at the end. Most of the doctors I have worked with have embraced this way of working once I have talked to them about the main elements and how we might implement them in the interview we are about to undertake together. Remember that thought must also be given to the environment and the ‘choreography’ of the assessment – being seated in a circle, for example, is likely facilitate dialogue better than if the assessors line up in front of the person of concern.

4) Encourage the client to fill the MHA interview space themselves. This should be facilitated for as much of the interview as possible, and at least in the early part, by using a combination of:

i. Open questions. The opening question is especially important. Something like, ‘Can you tell us how and why you think we came to be having this meeting today?’ – this allows the person to start from where they are.

ii. Repeating the person’s last words. This sends a strong signal that you are listening and encourages them to say more.

iii. Asking regularly, “can you say more about that?

iv. Utilising silences. Try not to step in too soon when silences occur and, instead, use them as a means to prompt the client to say more. It can be uncomfortable but it is important not to rush.

v. Avoid jumping in with technical talk around symptoms and diagnostic labels, or with judgements, ideas or solutions early on. Inevitably a MHA interview has to arrive at an outcome later but as the conversation unfolds tolerate some uncertainty and respond, instead, by showing genuine interest in their story and their words and in learning more from them.

5) Bring in a relational focus by asking relational questions. In MHA interviews, clients are all too often seen without family and friends present. This is something we ought to work hard to change because there is so much value and richness in including and hearing the voices of significant people in a person’s life - bringing these out into the open in a MHA interview can change the dynamic and the course of the conversation, and can contribute to shared meanings and greater understanding for all being developed (this can and should include hospital and other clinical settings).

However, it is still very much possible to bring in a relational focus by asking about an absent social network member: “What would your mum/sister/daughter/partner … say if she were here now?” This is a way of bringing other voices into the space. When there are other members of the patient’s network present then ask them what they thought about comments made by another person in the room.

6) Concluding the meeting with full transparency where possible:

We can utilise some of the reflective processes from dialogic practice in the discussion at the end. Perhaps start by inviting the person to the listen to the professionals discuss what they have heard with the hope that the person will feel able to comment on what is discussed and expressed afterwards. This professional discussion comes with the expectation that it is opened with:

i. Some positive component about the person or experience - this could simply be an expression of gratitude from the AMHP or doctor for what the person has been able to share.

ii. What struck the assessors and why about what was said in the room. You can share what feelings you may have noticed inside yourself such as a sense of sadness, or feelings of anxiety or worry, or hope.

iii. Each assessor to share their sense of whether detention is proportionate and appropriate and why, including honest reflections around risk.

Difference in opinion may of course occur, but by using this approach the differences may be held and understood and with transparency worked through. It is critical that the person being assessed has the opportunity to respond to the assessors following their discussion, and perhaps he/she may offer clarification of their own views, and the discussion and assessment then may proceed further and the cycle continues should the professionals feel this is necessary. This process enables transparency and polyphony (capturing multiple voices).

All of this can feel uncomfortable and strange at first but if we are taking away a person’s liberty then the least we can do is to show how we have arrived at this conclusion, and this includes how we have resolved differences of opinion between assessors. This way we can show the thought, the care, and the uncertainty that lie behind MHA decision-making, and hopefully as a result, there will be a deeper sense of being heard and being more fully involved in what can be a bewildering process for so many.

Could these be the key elements of dialogical Mental Health Act interviewing?

An AMHP’s Journey Through s.13(1) MHA