The AMHP Report – who is it for?

By Tom Woodd

Four years ago I took on a role developing a separate social care function within a Mental Health Trust. 

As many of you will know, the framework of the Care Act 2014, encourages a focus on relationship and strengths-based conversations to help individuals' tell their story, identify their best hopes and the means by which they wish to achieve them.  Care planning then involves exploring with the person what resources they have available and what else might be available to help them. 

In developing this new service, we seized the opportunity and the values of the legislation to use an open and collaborative approach, challenging practice that is all too common still -  prescriptive, paternalistic, authoritative, not transparent in decision making, and doing to, rather than with.

In the face of legal challenges we knew that the recording and documents shared had to demonstrate that we were "Care Act compliant".  Yet we identified that these documents are not actually for the lawyers at all.  Neither are they for auditors or the CQC, managers or providers or other professionals.  They are useful for all these readers but the records that we make are primarily for the person that they are about.  A record for them of their journey and how those with professional responsibility towards them explain what they did and why, what they recommend, what resources are available to help and what expectations the person might have. 

So, as well as encouraging open, collaborative conversations we explore with the person what they want in terms of documentation (and when).  We share a draft assessment with the person for them to comment on and correct. We also began to write these records to the person themselves, in the second person.

We have found that if you write in the second person it reminds you that this document is for them and helps you to write as though you may be the one receiving it yourself. It allows you to take a personal approach that builds relationship and shared understanding rather than a formal, distant one that too easily becomes prescriptive and authoritative. It encourages you to explain what you mean in simple terms rather than hide in legal or clinical language. It helps you to show appreciation of their words and language, their story. Perhaps most importantly it results in not shying away from sharing.

I've also found it helps me practice the vocabulary and tone to explain verbally during those assessment conversations what I am thinking about, what I've noticed and what appears important and how this fits with the legislation.

The anecdotal feedback has been overwhelmingly positive.  "No-one's ever listened like that". "No-one's every explained it like that". Misunderstanding and/or mis-recording what someone has tried to communicate is easily done and still happens regularly in our assessments.  It obviously erodes trust.  However, making mistakes and then giving the person the chance to correct and comment builds trust and shows respect and dignity.  Sometimes it almost feels helpful to make some deliberate errors to give us the opportunity to build trust through making sure of corrections.   Facts are easy to agree on (usually) but acknowledging when perspectives and views differ can be difficult, but it is more honest and more collaborative to be open about these differences. Explaining how you reach your view, how a decision is made, in simple terms is really important in helping everyone understand together.

With this experience to build on I have long been questioning if my AMHP reports could or should be more regularly shared with the person and re-styled.  For many years it has been standard practice for the assessing team to take itself off to discuss the decision behind closed doors. Thankfully this is changing.  But in the same way, I question shouldn't the documents and decisions we make be more openly and directly shared? Isn't that one of the reasons why this role exists within Health and Social Care professions? Aren't we in this position to take a more open, reflective, accountable, inclusive and socially minded approach?

AMHP training (powerpoint slide after powerpoint slide, year after year) has encouraged me to think of myself as a "court on wheels", a makeshift judge or lawyer, increasingly able to repeat all the different "what ifs" of Jones and caselaw.   We are trained to ensure our documentation and practice is robust in the face of legal challenges. We regularly deal with complex elements of law whilst not actually being a lawyer!

I have rarely, if ever, shared my report with the person and if I’m honest, until recently never written with the person in mind as the primary reader. I’m not sure, but I think I write for that lawyer in a tribunal that tried to unravel me fifteen years ago.   I am writing to my AMHP supervisor, my Legal Update Training Day Trainer, or myself as my own auditor.  I am uncomfortable admitting it but I think I might be seeking job satisfaction, healing of the vicarious trauma, through neat words and legal references.  The boxes ticked.

I have reflected a little with other AMHPs that it is difficult to imagine the right time when you could share a report and perhaps difficult to imagine how it can be a useful part of the process for the person.  In the immediate aftermath of being detained the person may be focussed on coping with whatever crisis they are experiencing.  Reading about what could be traumatic events may not be helpful.  Furthermore, the decision, especially if the person is detained, is overwhelming, absolute and unchallengeable (in the short term at least).  The AMHP report is perhaps just a record of that decision to show that due process was followed. There are already checks and balances: the Nearest Relative role, the scrutiny of receiving authority and MHA administrators. There is a clear challenge and appeals process for the individual.  We signpost them to solicitors/advocates to help with the appeals process.  Perhaps scrutiny of process by legal professionals at Tribunal at a safer distance and later date is the appropriate mechanism and forum for AMHP reports to be considered.

Another doubt comes from the feeling that the AMHP role and even more so the reports do not have therapeutic benefit in themselves.  There's no language of formulation or treatment or care plan.  The relationship and communication with those offering support or treatment (community or ward) is much more significant than the input and report of an AMHP who breezed in and out. We're there to check due process.

But there's a slowly rising murmur amongst AMHPs highlighting something more, remembering or pointing out the other parts of the role. There are therapeutic elements that we should not down play.  The MHAA is an intervention in itself.  The AMHP report can be that too. Why have we forgotten this? Have we been working alongside the medical model and got sucked in? Have we imagined ourselves (and been trained too much) as bureaucrats or lawyers?  Are we being restricted by something wider – cultural or political?

Even if you still feel that it is going to be pointless or harmful writing to the person who is in a crisis and distracted by voices or unusual beliefs or high levels of distress, what about those MHAAs that don't fit that description?  Not all MHAAs (perhaps very few) involve someone who is so distressed or distracted they can't understand or read an explanation. 

I tried it recently.  I shared my report and to help me think about it as a document that was intended to help the person I wrote to them in the second person. It was a s136 assessment where the plan we developed was for discharge.   The duty to make other arrangements for the person’s care, was in line with the way I am used to working within the Care Act.  I can't say whether this had a positive impact on this particular person.  But it felt like a more open, clearly explained approach. I sent it to her and followed up a few days later.  I wonder if it will help her understand future crisis scenarios and what she might expect? Who knows?

Here are some phrases I have anonymised to give you a flavour of how the letter sounded...

You were open about how you have been experiencing ups and downs in your mood and mental health recently with sudden unexpected crisis every 3-4 days in last two weeks.  You have had some bad experiences seeking help in the past ... example/summary.

You were struggling last night and called [phoneline]. The response was slow and this triggered more negative feelings. You called an ambulance as you were feeling increasing desperation and  wanting to harm yourself and end your life. They attended with police who were concerned for your safety and detained you under s136 Mental Health Act.  You were brought to the Place of Safety by Police with the purpose that you were offered assessment with mental health professionals.

We met in a private side room initially alone and then later with a Psychiatrist and a Crisis Team worker.
I explained about the process involved in a Mental Health Act Assessment, that I was an Approved Mental Health Professional trained in mental health law and that along with two psychiatrists (one independent and one employed by local Mental Health Trust) I was keen to talk with you about what led to you being here and to explore what support you might need and want for your mental health.

You were clear that you want to move forward and address your mental health but you are also wanting some more consistency and respect and understanding from services. 

You didn't feel there was a specific trigger for last night's crisis and you were keen to return home.

You talked about a number of things that have happened that may have been a factor…

A number of long-term factors were also discussed…

You talked about some things that were going well…

We discussed the following things that help or could be of help in the future…

Views of others:
We spoke to your daughter/mother/son/partner together by phone after the assessment...

Views of Medical Assessors
The Psychiatrists gave the following thoughts and recommendations...

Outcome and Rationale:

You were clearly distressed and the Police believed you to be acting unsafely last night. They were so concerned they believed you needed detaining under s136 for your own safety.  After meeting with the assessing team you were discharged from s136 with the plan detailed below in place.

While feeling exhausted and overwhelmed, you told us that you felt it would be most helpful for you to return home. You have some past experience of depression/anxiety and at times have had thoughts of wanting to harm yourself or end your life.  You indicated that while you felt unsafe last night you did not feel so desperate now.

You appeared to have capacity to make decisions around your care.  You were able to understand, retain and weigh up the risks involved including that your mental health fluctuates.  You had a range of resources and ideas about what is helpful for you e.g....

You were frustrated but reflective that services don't always meet your expectation but it appeared helpful for you to meet someone from the Crisis Team and have the opportunity to start to build a better understanding of what works for you in managing your mental health. 

The Crisis Team indicated they would make contact and visit you at home to continue this support...

I am not sure if I will convince many other AMHPs with this.  I am not sure if I've convinced myself to be honest.  But perhaps we only need to think in small steps.  Why do all reports have to be the same? Why not be brave and ask the next person you assess whether they would like a copy of your record of their assessment and when? Why not try writing to the person themselves rather than about them?

Picture - Changed Priorities Ahead by R/DV/RS is licensed under CC BY 2.0