Tolerating Uncertainty
By Teams call AMHP
I’m never quite sure whether there is a collective noun for AMHPs. If not, then I hope this suggestion gains some traction – a ‘rectification’ of AMHPs.
As a ‘rectification’ I’m sure we all have an assessment that stays with us. An experience that is omnipresent, pinballing through one’s mind. The assessment I consider in this piece I regularly think about due to the multiple dynamics and narratives intertwined into the assessment.
At 4:30am, I was called by the Police. They were on-site at a private address. The concern related to a young man in his twenties. The officers on-site were concerned that the individual was presenting as psychotic and was presenting a risk to his mother – also at the address. Of note when taking the referral was how quickly the situation circumvented discussions around lesser restrictive approaches to assessment under the Act. I’ve reflected a number of times regards the role I played in this. I continuously come back to the same conclusion: I was unable to achieve a mutual perspective around level of risk and urgency and as such my response was effectively dictated by the officers on site. My narrative coherence regards the assessment was evolving from a process which could potentially be the first step in promoting an individual’s recovery to contemplating whether I was about to make my first application under S4 of the MHA. The manner in which I interpreted the Officer’s request for an assessment meant that to me the purpose principle now only existed in the context of safety and was divorced from the true aims of this principle – minimising the undesirable effects of mental disorder, by maximising the safety and well-being of the patient, promoting their recovery and the protection of others from harm.
Prior to setting off to begin the assessment I contacted the crisis team to enquire about bed availability. The assessment pre-dated the arrival of enhanced bed management arrangements through the provider trusts. It also was in advance of the Council taking a firm chapter 14 MHA CoP position regards the Doctor finding a bed. In this instance, however, the structural inversion of the guiding principles of the Act did not matter – the crisis team were able to give me that instant hit of relief – there was not one, but two acute in-area beds available. One in the West and one in the North. I effectively had my pick and the fact that I had articulated to the team that this was going to be “4” meant there was no risk of my bed going anywhere. Everything was falling into place and my mental schema was getting harder and harder – this individual had to come into hospital! At this juncture I possibly could have justified under the Effectiveness, Efficiency and Equity principle, that it represented value for money for me to call NWAS in advance of actually conducting the assessment, to set off ready to pick the individual up for the conveyance.
Driving to the assessment I began to reflect on my initial decision making and the mental picture I had started to paint in my mind. Why was I so focused on a S4? The officer had not told me that the individual continued to be threatening. The officers were not being asked to leave the property. Nothing about the initial referral had suggested that S135(1) might even form part of the conversation. The short journey to the individual’s home allowed me to compose my thoughts and I began to consider aspects of the CoP such as 14:10 – the reliability of available evidence, including any relevant details of the patient’s clinical history and past behaviours.
Arriving at the property I was met by the S12 Doctor. By now the sun was starting to peer through the gaps of the houses. Feeling the light on my face made me feel that I was effectively leaving a cocoon of hasty decision making and was now, hopefully, about to embark on a journey that would enable me to understand the individual’s situation as part of the ‘whole picture’ of their life and empower them to have as constructive a role as possible in their assessment.
On entering the property, the Doctor and I were escorted into the kitchen by the Police. Moving through the long corridor to the kitchen I saw an individual sat in the living room out of the corner of my eye. It was a fleeting glimpse, however, enough for me to determine the individual looked much younger than their 20 plus years and also, they had some form of blanket around them.
When conducting a Mental Health Act assessment, I always find the initial moments the most awkward and bashful. Assessments always have some form of ushering into a separate room; a moment when the relevant individual notices one’s presence and yet external forces unintentionally deprive the AMHP and Doctor(s) of making even the slightest of acknowledgements to the person about to be assessed. These flirtatious moments are usually a combination of hastily recited collateral history from parents, carers or loved ones as well as an overview of risk and physical health observations if police or paramedics are there. These urgent exchanges always reach the same climactic point – The ‘what do you do moment’ – the point where relevant parties become curious about what a mental health act assessment ultimately entails. As an AMHP I believe it is imperative one never tires of this conversation and readily accepts this discussion might need to take place a number of times during an assessment. Such a conversation has multiple functions; it can be the start point around dispelling long held societal prejudices around the function of a mental health act assessment, through to helping a Nearest Relative make a fully weighed up decision around whether to agree or object to someone being detained under S3 of the Act. At the heart of these conversations is always 24.34 of the CoP – consent.
The Supreme Court ruling of Montgomery vs Lanarkshire Health Board provides a clear framework around the process of establishing consent. I was just in the process of discussing the importance of providing information pertaining to nature, purpose and consequence when I was joined at the kitchen table by the individual we had come to assess. The individual sat down next to me and politely asked my name and where I was from. I saw the officers on scene start to assert their dominance in the environment by slowly standing up straight and both tucking their thumbs under their fluorescent stab proof jackets. I’m still haunted by the idea that all I needed to do in that moment was gesture to the officers that I somehow felt intimidated by the individual and they would have physically intervened. Instead, I offered the individual my warrant card and told them my name. The Doctor then offered the individual their ID and explained who they were.
What unfolded over the next 60 minutes I believe exemplified the importance of the AMHP role and how the Act exists in a maelstrom of fear and confusion. The Police officer’s concern about the threat of violence towards the individual’s mother, evolved into a discussion around how a loving father had died only weeks before and an individual’s desire to free themselves from a prison of pent-up emotions. A tacit reference to “smashing the place up,” became a confession regards how unbearable they found being in a room without the all-encompassing fun and silliness of their dad. The “suspected psychotic presentation” which had triggered my S4 senses earlier that morning gave way to an acceptance that any person wrestling with grief has the right to talk about their dearly departed in the past, present, and future tense.
S1 of the Act provides (a non-exhaustive) list of what constitutes a mental disorder. Whilst it was not inappropriate for us to contemplate whether the individual’s presentation was clinical evidence of an affective disorder such as depression, the doctor and I both recognised the risk of constructing the individual’s pain as an abnormal or inappropriate grief reaction. The openness of the discussion provided us both with clarity around issues such as risk, past contact with mental health services (none recorded) and safeguarding concerns (no domestic violence markers on the home address – police called due to neighbour concerns around shouting). I find that when concluding a mental health act assessment, there is always the temptation to go ‘belt and braces’ and offer home treatment input; the AMHP taking out an insurance policy in case their appraisal of the situation is completely incorrect. In this instance there was no justification. To offer such support potentially could have been a further imposition into this individual’s right to a private and family life. The purpose principle of this assessment was clear – allowing a family the space, time and privacy to grieve.
Preparing to leave the property I had a brief final discussion with the officers. Such final summary discussions can be imbued with the same degree of awkwardness present at the very start of the assessment process. The officers agreed with the assessment of the situation and the clinical view that these expressions of grief did not exist within the constructed realms of a mental disorder. However, even with such a consensus the officers were desperate to know what actions could be taken if there were reports of a further disturbance. This led to the officers enquiring whether there needed to be “a safeguarding.” When such words are uttered, devoid of understanding of the functions of safeguarding or responsibilities under S42 of the Care Act 2014, it is difficult not to construe this as a plea to an AMHP to utilise another power to take control of the situation and get round the fact the MHA is not an option. In truth, at that moment I don’t think the Police were looking for other social care powers to be utilised. Such a questions when condensed down to its truest form is so honest and pure in intent – “have we called this right?” The conversation concluded with a discussion around how services could be contacted again if needed as well as discussing with the officers their available powers under PACE and common law powers to prevent a breach of the peace.
I recognise that such discussions exist within the wider context of effective multi-agency working, however, at a very basic level I think they represent the need for fellow humans to come together and try and make sense of what just happened – a thirst for certainty in a transactional drama that doesn’t always offer such relief. As I set off back home to start completing my AMHP report all I could think was “I think I’ve called this right” – the burden of the AMHP…..something I so desperately still wish to be.