s13 Consideration and Solution Focused Practice – the ‘why’ and the ‘how’?
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By Nick Perry
I never had the privilege of meeting with, or talking to, Matt Simpson, for whom the recent AMHP Leads Conference was a dignified and quietly emotional tribute. From what people have said about him, and his way of working, I think he would be very pleased if AMHPs continued to wrestle with his writing about s13 consideration and practice, in a critical way.
Barbara Swan in her recent post on here reflects both on Matt’s work and her own sense that there are systemic pressures on AMHP autonomy. She says Matt’s article – Changing Gears and Buying Time, published in the British Journal of Social Work in early January 2024 – ‘explores AMHPs decision making at the point of referral and offers a different way of working which is thoughtful, comprehensive, strengths based and person-centred’.
Whilst I agree that a focus on s13 consideration is important, necessary, and suggests a different way of working, I think the usefulness of Matt’s article is in his exploring the ‘why’ of us doing it, rather than the ‘how’.
In the abstract, Matt reports a strengths-based methodology of Appreciative Inquiry, which was ‘positioned in a social constructionist paradigm’.
‘During four one-day workshops over five months participants defined their best practice, analysing emerging data together within the workshops using nominal group technique. Service developments included the creation of a triage role and a bespoke report to prioritise this decision within the service, opening avenues to change gears and buy time for a more thorough assessment at this point, and promoting greater collaboration with those referred. A multi-agency approach to searching for less restrictive options was advocated within an assessment pathway.’
In their summary paper provided to the AMHP Leads Conference on s13 consideration in March 2024 (it is hoped that this can be circulated on this site and elsewhere in the near future), John Mitchell and Robert Lewis synthesise the approach into seventeen points. This summary provides a very helpful landscape in which to consider how best to evaluate an AMHP Service; the acculturated ways of working that will have developed over time; and to think about any required restructuring in such a way as to be able to make AMHP practice slower, more deliberative and least restrictive (fitting nicely with the National AMHP Service Standards (2020) that Robert was also involved in drafting).
What is also noticeable about the summary, is that it does not teach a way of practising that will obtain the new, strengths-based information that can help balance the old (sometimes decades old) problem-focused risk history that comes with a relapsing, well-known client at a point of referral (or indeed a recent history, laden with professional anxiety, of someone who is not known at all)…
There have been other pieces of work produced during and post-pandemic, which are of this AMHP zeitgeist, and put down on paper new ways of doing (and thinking about) least restrictive AMHP practice across the country. Rob Manchester’s work on dialogical approaches (2022; mentioned by Robert and John) and Jill Hemmington’s advocacy for a broader research base for AMHP practice (2023).
This is where, I believe, my own work (with David Watson, 2022) on Solution Focused Practice fits with the thoughts of Matt and John and Robert, and their exhortation for AMHPs to slow down the process of considering referrals and use (Barbara’s) AMHP autonomy in the best interests of clients.
AMHPs across the country appear to agree that there is not sufficient focus in pre-warranted AMHP training and ongoing CPD regarding therapeutic techniques to be deployed in the 1:1 time recommended by the Code of Practice at 14.54 (AMHPs lack time for 'extremely important' pre-assessment work with people in crisis, finds survey - Community Care).
In my view we should continue work to include such requirements in forthcoming Social Work England guidance, and start to develop a research base that will bolster a collective belief that therapeutic communication skills should be a taught part of an AMHP’s training and ongoing CPD.
Solution Focused Practice is a way of working derived from a Family Therapy tradition, honed over four subsequent decades, across different continents, into simple questions that can be asked in a one-off session. Through my Solution Focused training with BRIEF (2013), I have begun – in my 1:1 time as encouraged by the Code – to be able to keep the client’s focus on what we might have agreed as their best hopes, (our loose contract for working together) perhaps with the development of detail about a preferred future; perhaps with a scaling question or two along the way.
These questions can provide a simple structure for obtaining new information about a client’s best hopes for an AMHP’s involvement in their case; new information about their history of strength and capability; new information about the support available in their network and can (when used mindfully) assist an AMHP to practice in anti-racist ways.
Here is an anonymised example of Solution Focused Practice within a piece of s13 consideration work. I was doing a shift for our Emergency Duty Service and a referral for MHA assessment came in from a Liaison nurse at the local general hospital. This is my case record, written in the style I have been developing which twin-tracks my role as an AMHP, and whatever Solution Focused questions I have been able to ask. I hope you find it interesting and thought-provoking:
‘AMHP has undertaken pre-assessment screening visit as planned at A&E - client was in bed 23 supported by Queensbury staff member Jon; Peter asked for Jon to support him during our conversation and opted for us to go to the Liaison interview room for more privacy.
Asked what might be his best hopes for us talking together, Peter said that he would like to get some help. At various points during the conversation he referred to the fact that he must be annoying to work with because he says that he wants help, but then he refuses support when it is offered, or tries to sabotage support.
At present he is stressed about losing his placement at Queensbury - he says that this might be as soon as 15th June; it is not clear as yet whether there is any possibility that his leaving Queensbury might be delayed, but Peter has said that he will agree to a realistic repayment plan for the client contribution arrears that he is in; he says that he has £500-600 in the bank and he may get some back payment of PIP (from 25th September, 2023) if he gets an award.
Asked what he might notice if things started to go in the right direction for him - towards him getting the kind of support he needs to make tiny changes for the better - Peter said that he would find himself being more affable and friendly; more honest about his real feelings; that he might be able to work with Queensbury and ASC staff towards move-on accommodation after Queensbury. He went on to give some instances of this already happening.
Whilst his facial tics at the moment are disabling - and he finds them embarrassing - Peter was cogent and articulate during our conversation. He did not present as though he was distracted by any unusual experiences and the content of what he was saying was absolutely relevant.
He has a diagnosis of clinical depression and his social circumstances - particularly the stress around his accommodation, as well as the longer standing issue of lack of contact with his daughter - may well be resulting in lower mood; also his relapses with alcohol will not help. These will have added to his extreme anxiety and suicidal feelings. Whilst his sleep is broken, his appetite is generally good.
Asked to score his mood out of 10 today (where 10 is the best possible version of himself, mood-wise) Peter scored himself as 4 or 5. He said that yesterday he had been at zero. He said that bumping into a friend of his sister's in A&E, the support from Queensbury deputy manager Alan, and the ability to challenge some of the unusual thoughts he has had about his family have helped him. He accepted that he could work with staff towards 6/10, and that it would be useful to think with them about what might tell him that he had arrived at 6.
Peter has not had any withdrawal medications whilst in A&E; he says that he has access to Acamprosate at Queensbury. He says he has not been offered Antabuse. He would like to know if there is any medication that he can have to reduce his tics. He does not want to come into hospital voluntarily for a medication review. AMHP has considered whether a referral to [Crisis & Home Treatment Team] would be helpful at this point but Peter says he has a good relationship with Dr Gower at Cornwall House and would prefer an urgent review with her. The recent access to Lorazepam that he has had (following Dr Howard's July 2023 review) has been discontinued.
Peter feels safe to be able to return to Queensbury with the support of Jon; AMHP has agreed to send a record of the conversation to deputy manager Alan, as well as to [the doctor] and Tony Barrow for Adult Social Care. It seems that a further MDT meeting would be useful next week as it would be detrimental for Peter to become street homeless - this would no doubt trigger a major relapse in his alcoholism.
Asked for five things that symbolise Peter making progress (albeit with ups and downs) whilst at Queensbury, Jon said that Peter's socialisation with staff has improved; his communication with other residents has improved; his little actions to show that he wants to make changes for himself (like using the photocopier the other day); his commitment to eating better; and his willingness to spend time on the ground floor at Queensbury. Peter has some evidence that he is able to make small changes, and says that he would like to make more.
AMHP has declined to convene a full MHA assessment as a result of the conversation with Peter. [The client can] understand and weigh information in respect of his care and treatment needs and express his wishes effectively - he has mental capacity and is willing to accept support over the coming hours and days.’
References
Blakeley, L., 2023, Truly listening to accounts of Mental Health Act assessments: Reflections on my practice, British Journal of Social Work, Volume 53, Issue 7
Department of Health, 2015, Mental Health Act 1983: Code of Practice, London: The Stationary Office
George, E., Iveson, C., & Ratner, H., 2013, BRIEFER: a solution focused practice manual, London: BRIEF
Hemmington, J., 2023, Approved Mental Health Professionals’ Experiences of Moral Distress: ‘Who Are we For’? British Journal of Social Work, 00, 1–18
Manchester, R., 2022, Could these be the key elements of dialogical Mental Health Act interviewing?, www.the-critical-amhp.com/blog/blog-post-two-x437a
Mental Health Act, 1983, UK, Available at: Mental Health Act 1983 (legislation.gov.uk)
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
Perry, N, 2023, Give AMHPs the therapeutic tools that they need to underpin least restrictive practice, www.communitycare.co.uk
Samuel, M., 2023, AMHPs lack time for ‘extremely important’ pre-assessment work with people in crisis, finds survey, www.communitycare.co.uk
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