S13 Consideration and Solution Focused Practice – further reflections on a very good fit.
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By Nick Perry
The more I use Solution Focused Practice in my AMHP work, the more I see its very good fit with the kind of s13 consideration that we have been talking about so much recently in AMHP circles. This is, of course, entirely due to the hard graft of Robert Lewis and John Mitchell, and the recent launch of their eBook, in memory of the work of Matt Simpson.
And it's for this reason that I have sent in another blog, in quick succession to my April offering, because I want to do two things. First, to put a spotlight on paragraph 17 of the eBook; and then to talk about a recent piece of Mental Health Act work with a young adult held under s136.
‘Rather than [succumb to] pressure at the point of referral, leading to a reactive one-off MHA assessment interview that involves doctors and likely detention, AMHPs [feel] that they are practising at their best when they critically analyse risk. They do this within the context of a higher level of risk tolerance, built upon their experience and validated by their peers. Often participants felt the result of this analysis is the ability to slow down the process, and a graded pathway can be created where AMHPs begin to collaborate with the person referred, their family, and other services. […] Practising in this way is likely to improve the experience of the assessment process for those subject to it, as well as enhance the prospect of less restrictive outcomes’.
This is the excerpt from Matt Simpson’s January article[i] used at Paragraph 17 of the eBook.
It is the slowing down of the process – taking a more deliberative approach to our decision-making under the Act – that, I believe, is one of the hallmarks of the approach that Robert and John are advocating.
And it has struck me just this last week that one of the clearest indicators of us getting this right is when there begins to be a level of resistance to this ‘new’ way of practising – when our work disturbs the homeostasis of the professional systems of which we are part, and there is some pushback from them.
Here is an anonymised example which I hope will demonstrate what I mean:
On Monday evening a young adult was detained under s136. There had been some expressions of distress and suicidality from this young adult. And there was some discussion between the Police and a mental health nurse on duty as to whether or not a s136 detention should be imposed. The advice was that it shouldn’t, but because of the young adult’s behaviour, and a refusal to come to A&E any other way, the s136 detention was indeed used.
By the time the young adult got to the Emergency Department; the clock had started on the s136; and the referral had made its way to the out of hours AMHP on duty, it was nearly midnight. On the basis of this, a decision was taken to hold off on any Mental Health Act work until the daytime service could take over in the morning.
It was busy the following morning, and the referral only got allocated at about 11am – in the middle of a quarterly AMHP forum.
After a quick review of the local authority and mental health trust information, it seemed that the person was quite well known over the past little while, and had an allocated lead practitioner (LP). An email and call later revealed the LP’s best hopes for the outcome: that the young person would not be detained.
I knew already that doctor availability would be an issue. And I knew that the Police had made it clear that they wanted a fast response. So I told my colleague on the front desk to tell whoever was keen to know that I would be arranging a doctor for 2.30pm.
In the meantime, and following the call with the LP (who was able to make herself available), I decided it was important to have them there – as part of the work at ED. But they had a meeting in the early afternoon and had no car that day. So I decided to go and collect them from the community hub after their meeting; have them spend some time with the young person; and I would arrive later with the s12 doctor that I had booked for 2.30pm, and then delayed until 4.30pm.
This gave me some time to go and spend some 1:1 time – as per the advice of the Code of Practice (14.54) – at A&E, and to attempt to ask some Solution Focused questions.[ii]
When I got to the hospital at 2pm, the (very nice) Police officers on duty checked that the ‘assessment would start at 2.30pm’. I said – and I hope you will be proud John and Robert – “The assessment has already started! And I have come to speak to the client… But I have also arranged a medical examination for later in the afternoon, and – as luck would have it – the client’s lead practitioner will come and help us too!”
The officers, to their credit, seemed to see the practice logic of this plan, but warned me that it might not be how their sergeant would see it.
I went to speak to Hayley*.
Here is the case record that I made:
AMHP has attended for 1:1 as per the recommendation of the Code of Practice; Hayley did not want to go down to the Liaison interview room so the AMHP was able to pull up a chair and have a conversation by her bedside (Police officers stood away and a curtain was drawn to give some privacy).
The AMHP has explained the reason for attending and checked Hayley is aware that she is detained under the s136 holding power. AMHP has also asked how talking together might be useful? Hayley has said she doesn't know and that 'I don't care about myself anymore'. Asked how long this has been for, she says about one month. Hayley confirms that before then, she did used to care about herself.
Asked what used to help her, when she did used to care about herself, Hayley said things ‘just weren't so bad’; and now she doesn't care. Asked what told her things weren't so bad back then, Hayley said that she was able to cope, and she was more talkative.
Asked who knows her best, Hayley says her mum. The AMHP asked how mum might describe Hayley when things weren't so bad – what she might have noticed her doing that she isn’t doing so much of now? Hayley found it hard to answer the question. Asked what her mum might say were some of Hayley's qualities back when things weren't so bad, Hayley thought her mum would say she is good with children.
The AMHP then asked a scaling question where 10 on the scale is Hayley coping as well as she has ever coped, and zero is when she has given up hoping altogether: she scored herself at 2/10.
Asked what has helped her to keep going and be at 2/10 rather than any lower, Hayley was not able to answer. Asked how she might know she had reached half a point up the scale, Hayley said that she might be seeing herself go out more with friends and she might ‘speak more to everyone’ (in this way people might know how she was feeling, and she might not need to express her distress through actions); at 2.5, mum might notice that she is looking after herself a bit better (basic things) and that she ‘seems better’; Tanya (a good friend) might notice her talking a bit more and coming to visit her.
Asked what difference it might make if Hayley was able to speak a bit more, she says that people might end up being more supportive and more pro-active - so that she can get some help with her mental health needs.
Asked what has helped her mental health in the past, Hayley says good listening has helped; medications haven't necessarily helped; Hayley thinks that supported accommodation might be a good idea.
Hayley isn't clear at the moment what she thinks might be the best outcome for the MHA process but she wonders about being sectioned. AMHP has explained that it would be really helpful if Hayley could let us know what help and support would be useful at the moment.
AMHP has updated Hayley that her lead practitioner will be coming to see her later this afternoon and that there will be a specialist doctor coming also.
I left Hayley with this thinking to do and went, as planned, to go and pick up her lead practitioner.
After we got back to the hospital the LP had some time with Hayley and then I briefed the s12 doctor as to the plan for the joint interview at 4.30pm.
The record of the joint interview is as follows:
AMHP has summarised the conversation with Hayley earlier in the day and checked its accuracy - Hayley gave her confirmation that the information being shared with the other assessors was accurate.
The AMHP then asked [the LP] to give an update as to their conversation with Hayley – [LP] reported that Hayley has found it hard to identify a trigger for her deteriorating mood and impulsive wish to self-harm late yesterday evening, given that she was positive in conversation with [LP] mid-afternoon.
Some discussion about the possibility of neurodiversity affecting Hayley's impulsivity and [the s12 doctor] is keen for there to be a review of medication - to stop the Duloxetine and to start Quetiapine. [LP] will attempt to book a psychiatry slot via the daily clinic at [the community hub].
[LP] has been asked by the AMHP about the need to refer to the Crisis Team and [LP] is of the view that the risk is manageable for [the community team]. Hayley has been given some homework: to begin to plan a structure for her days. [LP] will meet with Hayley tomorrow in the middle of the day and they will re-visit Hayley's safety plan.
Hayley confirms that supported accommodation could be a helpful part of her support plan and she will attend the meeting with [the intended provider] on Thursday.
The AMHP asked about the possibility of Hayley returning to her accommodation tonight and she says that she can. Asked what could be helpful to her if she ended up feeling stressed unexpectedly, Hayley says that she will listen to music, or phone her mum and she will aim to get an early night in any case (taking her night time meds at around 8pm).
The AMHP has written the plan for the next three days down and given it to Hayley; the AMHP has signed it and Hayley and [LP] have co-signed it.
[Unexpectedly, the s12 doctor returns us to the coping scale with a question about how Hayley is scoring herself now, and she says 6/10].
Decision taken that the s136 detention will be ended and the AMHP will take Hayley back to her temporary accommodation with the help of her LP.
On the same day, our manager received an email from a senior leader in the Police raising concerns about the delay to the start of the assessment (for which read the delayed arrival of the doctor).
We reflected on this in a group supervision the same week; and a colleague made the important observation that we need to explain the changes in our AMHP practice – the slowing down of our decision-making – to our partner agencies.
So, we have sent a copy of the eBook to Police colleagues, asking how best this information could be shared with deploying sergeants; and, at the time of writing, Hayley is continuing to stick to her support plan.
References:
[i] Simpson, M., 2024, Changing Gears and Buying Time: A Study Exploring AMHP Practice Following Referral for a Mental Health Act Assessment in England and Wales, British Journal of Social Work, 00, 1–20
[ii] For more information about Solution Focused questions, please my April 2024 blog on the Critical AMHP site and also: Perry, N. & Watson, D., 2022, Solution-focused Practice and the role of the Approved Mental Health Professional, Ethics and Social Welfare, Volume 17, 2023 – Issue 3.
* Names and some details in this piece have been changed to protect anonymity.