Noble calling or dirty work? - Anxiety in the AMHP role
By Alastair Beach
The tall police officer overseeing the execution of the s.135 warrant reminded me of the callous prison guard from The Shawshank Redemption. There was a facial resemblance, for sure, but also something in his manner; how his communications were laced with orders, as well as the impression that he would brook no dissent.
We were on a busy London high street outside the flat of *Andy, a 40-year-old black British man who lived alone and had been referred to our AMHP service following concerns about his deteriorating mental state.
I was midway through my AMHP training and was leading the assessment for one of my direct observations. I had been surprised to see the police arrive in a group of eight. I had, after all, done my own risk assessment. There was no suggestion Andy was a threat to professionals.
During my training one of the tutors had insisted, only half-jokingly, that the AMHP role was characterised by “anti social work” – but somewhere at the back of my brain this large police presence got those rusty old “social work values” whirring into gear. Eight officers? Would there have been so many if Andy was white? I doubted it.
So I suggested politely to one of the officers that perhaps we could try initially engaging Andy accompanied by two of her colleagues. The Shawshank guard was having none of it. He stepped in: “Any decision about police numbers will be taken by me. I need to think about my own risk assessment and we have information there may be knives in the flat.” I felt he had taken a dislike to me. I had certainly taken a dislike to him.
At this point I noticed my heart pounding a little. A confrontation with the police. With power. I was not comfortable. Still a bit wet behind the ears, I was not as sure footed as my more experienced colleagues. There was an imbalance that made me anxious. I asked the policeman where he had got his information from, and he replied that the building manager (who was also present) had told them there may be a knife “somewhere in the building”.
At the time, I did not have the wherewithal to point out the yawning hole in his risk analysis (“yes, like every bloody home in the land!”). My heart was still racing. I have noticed it tends to do this when confronted with what I perceive to be “figures in authority”. It’s interesting who these figures are – often police or certain doctors. And the anxiety is often triggered when I have the sense I might (as I see it) be about to throw some kind of spanner in the works – by contesting an assumption, perhaps, or questioning a particular point of view.
Reflective readers will at this point have identified several areas ripe for unpacking (“What does the Shawshank analogy say about this writer’s subconscious? Perhaps he is trapped in a panopticon of his own poor self-esteem!”) In fact there are so many reflection points it is difficult to know where to start.
But if locating the start is difficult, I at least know for certain where the end needs to be. It has to rest with the individuals and families I am called upon to assess – with people like Andy and others compelled into the unforgiving frame of the Mental Health Act assessment.
For in delving into my own anxieties about power, and the narratives and assumptions that underpin them, I hope it can somehow bring me closer to the people I assess. I hope it will help me support them to the best of my ability, and in a way that is consistent with my values.
And therein lies my biggest fear – the fear that AMHP work, certainly in the current service climate, is not consistent with my values. That in becoming an AMHP, I have somehow betrayed the principles that I have long trumpeted to anyone unfortunate enough to have ever feigned an interest.
Like many other enthusiasts of social models of mental distress, I question the very existence of the so-called “mental disorders” defined by the Mental Health Act. I am enthusiastic about models like Open Dialogue (discussed elsewhere on this blog by Rob Manchester), which suggests we engage dialogically with people’s expressions of distress (aka “symptoms”) rather than quell them through medication.
Yet here I am, “complicit” (as I sometimes see it) in diagnosing “disordered” people and committing them to often overstretched wards where the biomedical model prevails. It is sometimes difficult to shake the mocking words of a social worker colleague of mine, who once described AMHPs to me as “police officers with velvet gloves”.
Why do I do it? I need to be honest and say I am still figuring that out. When I qualified as an AMHP earlier this year, I had secretly hoped I would finally feel an uncomplicated sense of pleasure about the prospect of taking up the role. That feeling is yet to come.
I am now resigned to the fact that it probably never will. But I am also beginning to feel that this state of perpetual ambivalence is not necessarily a bad thing. After all, who would ever embrace unequivocally the prospect of taking someone’s liberty away following a traumatic or highly charged assessment? A bad AMHP, I reckon. At least, that’s what I tell myself.
But back to the question of why do I do it. There are the obvious answers. In spite of my enthusiasm for social models of mental distress, I have now come to see that there are clearly times when compulsion is the least bad option for someone. I still believe that medication is overused and social alternatives to care underfunded and undervalued – but I also understand that medication can have a positive effect in relieving distress.
More importantly, I hope that my own battles with the role can somehow be reflected in the ways I engage with people using the Mental Health Act.
It is no secret that imbalances of power, particularly early in life, can have a great and lasting impact on the development of mental distress (see the comprehensive Power Threat Meaning Framework for more on this). Whether that imbalance is reflected in racism, poor housing, abuse or toxic discourse vis-à-vis gender or sexuality, it can shape a person’s outlook for a lifetime.
The next time I feel my pounding heart, perhaps I could view it as an early warning system; a red flag heralding a challenge to the perceived dominance of police or medical power.
But what of the fears of the people I am assessing? The individual who might hear voices that are rooted in childhood bullying? Or the person who uses razors to bleed the pain of abusive parenting? The behaviours and experiences we call “symptoms” are like my beating heart but on a scale most of us, thankfully, will never be able to fully comprehend.
On the one hand I hope this knowledge can foster empathy towards the people I assess under the Mental Health Act, and help make a top-down interrogative process feel more relational and human.
But on the other I think it is a reminder about one of the central duties of the AMHP: the empowerment principle laid out in the opening pages of the Code of Practice. After all, if I – a male, middle class, university-educated professional – can occasionally feel wary about questioning perceived authorities, I need to remember what power and authority can feel like for those who have often been on the sharp end of it for much longer than me.
More than that, I would like to be able to utilise the power I do have as an AMHP – to question, query, and if necessary to challenge – in the service of those who have fewer levers at their disposal.
Which brings me neatly back to the Shawshank prison guard. Sadly, the assessment that day did not end well. After executing the s.135 warrant and assessing Andy in his bedsit, a decision was taken to detain him under section 2 of the Mental Health Act. But rather than help bring the intervention to a respectful conclusion, the policeman began shouting orders at Andy and telling him that he had to leave his home immediately.
I stepped in, saying that Andy needed to be given time to pack – but five minutes later the officer was shouting again. He then told two officers to grab him and bring him down the stairs. This all felt too much. Angered, I told them to stop, saying something about the fact Andy had just had his liberty taken away and deserved to have time to pack his bags and ready himself.
Despite the slightly pompous wording of my intervention, it seemed to work. The shouty officer was not happy with me, but they relented and let go. In the process, I hoped a little bit of Andy’s dignity was salvaged.
Despite how it might appear, I am not a professional who eagerly scouts for conflicts with the traditional bastions of power. In fact, I feel in general I would do better to see my police or medical colleagues as a support network – there to learn from and consult with in the service of the people we assess.
I hope that with time and experience, I will also feel more confident asserting my own social work expertise when necessary - and in a way that helps project the values of my true professional self while supporting the rights and dignity of the individuals in my care.
*Andy – not his real name
Picture used with permission
Attribution (CC BY 2.0)