Approved Mental Health Professionals and Mental Health Act Assessments: A Study of Power, Structures, Communication and (Shared?) Decision-Making

Approved Mental Health Professionals (AMHPs) undertake Mental Health Act (MHA) assessments and have overall responsibility for deciding to detain, or indeed to not detain, an individual in hospital without their consent. They are required by law to act autonomously and make independent decisions, free from the influence of others, whilst working in complex and changing systems. Outcomes of MHA assessments are understood to be inconsistent, variable and influenced by many factors and, further, the MHA is known to disproportionately affect some groups or to indirectly discriminate (DoH, 2015b; DHSC, 2018). Within psychiatry, any focus on power has generally been on the overt, structural or ‘macro’ aspects of control and coercion rather than the more subtle forms of manipulation at the ‘micro’, individual level of negotiated decisions. Yet AMHPs are required to embed the statutory guiding principle of ‘Empowerment and Involvement’ (DoH, 2015a) into their practice whereby service users should be ‘fully involved in decisions about care, support and treatment’ (para.1.8) and little is known about this in practice. The forthcoming reforms to the MHA are understood to have the new set of guiding principles on the face of the MHA (not just within guidance) and the new ‘Choice and Autonomy’ principle speaks of a ‘move to mandatory recording of shared decision-making’ in order to improve outcomes, acknowledging that culture change is required to ensure that it becomes routine practice (DHSC, 2018 p.36). Yet if MHA assessments are to be a place for shared decision-making (SDM), more needs to be understood about effective techniques and aspects of communication and involvement. This, along with the many variables influencing AMHPs’ practice and decision-making has, to date, attracted very little research. This study was conducted with AMHPs and service users from one Local Authority area in England. A qualitative methodology was employed, within a social constructionist paradigm, to gather in-depth information about AMHPs’ experiences and perspectives and to consider the impact of the surrounding imperatives on their practice in general, and on their decision-making more specifically. An ethnographical study was undertaken within an AMHP service where a variety of different AMHP team structures provided an opportunity to consider their respective influences on practice. This was followed by observations and audio-recording of MHA assessments. Conversation Analysis was used to analyse aspects of the content and style of communication within interactions, with particular regard to power relations and the extent to which Empowerment and Involvement and SDM is (or is not) enabled in MHA assessments. AMHPs and people with lived experience were interviewed and a thematic analysis of the data was undertaken. As the study was adversely impacted by the global COVID pandemic, the research was augmented with a reinterrogation and thematic analysis of findings from a national research project with similar research questions, led by myself, focusing on people with lived experience of MHA assessment and detention (a further under-researched area). The study addresses both a research gap and a gap between policy aspirations and current practice. Findings offer a refined understanding of the influences on AMHP practice and decision-making and specific ways to enhance involvement with people with lived experience to improve subjective outcomes. This study is original in its combination of qualitative methods using Conversation Analysis to study the in-situ dynamics of the MHA assessment process. Different AMHPs both perceive and apply their power and authority in different ways and perceive the empowerment and involvement aspects of the role to be enacted in different ways, leading to an inconsistency in both objective and subjective outcomes

Approved Mental Health Professionals, Best Interests Assessors and People with Lived Experience: An Exploration of Professional Identities and Practice

Social Work England was established under The Children and Social Work Act 2017. It is the specialist regulator for social workers in England. Social Work England officially took over from the Health and Care Professions Council (HCPC) in December 2019. It is a non-departmental public body, operating at arm’s length from the government. Social Work England has become the professional regulator for Approved Mental Health Professionals (AMHPs) and Best Interests Assessors (BIAs). In 2020 -21, Social Work England has been developing the regulatory framework to support AMHPs and the new specialism of Approved Mental Capacity Professional (AMCP), which will succeed BIAs from April 2022. This includes the development of education & training approval standards as well as specialist standards for AMHP and AMCP practice. Social Work England commissioned this piece of work as part of a commitment to learning about the professionals in these specialisms and people’s experiences of them. The objective of this research was to undertake a study into the experiences of AMHPs and BIAs and those who have experience of their interventions. Existing research is generally inconclusive and little is known about this area

Approved Mental Health Professionals’ experiences of moral distress: ‘Who are we for’?

In England and Wales, Approved Mental Health Professionals (AMHPs) undertake interviews with service users as part of wider Mental Health Act assessments. AMHPs act as the ultimate decision-maker in relation to statutory detentions. They have legal duties to consider the least restrictive outcomes for service users, including alternatives to hospital. Yet they are increasingly unable to act on this, resulting in conflicting pressures. This article draws on a qualitative research study incorporating ethnographic research and interviews with AMHPs. Evidence suggests that service restructures are creating different approaches to practice with contradictory priorities, for example, whether the work is values-driven and relational or whether approbation is attached to a ‘need for speed’. AMHPs are increasingly deliberating about what makes ‘proper’ or ‘good’ AMHP practice, asking ‘who are we for?’ and referring to their work as ‘political activity’. AMHPs’ sense-making and language is indicative of moral distress. Organisational politics may lead to the work being seen as a technical-rational endeavour, not a moral one, leading to dissonance. More broadly, AMHPs and service users are, together, bearing the brunt of austerity measures and there are increasing unmet needs. Overall, there is a need to establish an ideological, theoretical and political base for practice

Research Informed Practice; Practice Informed Research [Editorial]

An inaugural conference was held in May 2019 which had as its theme research informed practice; practice informed research. The aim of this conference was to encourage practitioner researchers to engage with and share research from their own practice, in this instance exploring various aspects of one particular role undertaken by social workers, the Approved Mental Health Professional (AMHP) of England and Wales and of equivalent roles in other countries in the United Kingdom namely the Mental Health Officer in Scotland and the Approved Social Worker in Northern Ireland (the AMHP role is also undertaken by other non-medical professionals, but the uptake is low). The conference proved to be hugely successful, feedback indicating that it was very inspiring for all delegates who attended because it provided a positive environment for AMHP research informed practice to be debated which in turn supported good practice.It was anticipated that the joint university funded conference would offer potential for ongoing collaborations to be forged through the establishment of mutual interests and so it has proved; there has been a steady momentum building around AMHP practice and research amongst practising AMHPs, AMHP doctoral and academic researchers, and key stakeholders within the Department of Health and Social Care, the AMHP leads network, and British Association of Social Workers. The guest editors of this issue, also the conference organisers, were especially keen to build on this momentum and set out to collate and publish papers. As a result, we are delighted to offer this special issue. Such contributions also echo the themes of this journal which are: to translate practice-based research into a format relevant to practising social workers, whatever their role and task.Debate is current regarding the ongoing need to support these roles. In England, for example, the Chief Social Worker for adults highlighted in her annual report 2017–18 an ambition to support the development of the AMHP role (Department of Health 2018b). In addition, that same year, the Care Quality Commission (CQC) published a briefing report on the pressures of the AMHP role (CQC, 2018) providing an in-depth study into the AMHP role in twelve different geographical areas. One of the issues this report highlighted was the lack of regular data about the AMHP role and of the need to address well documented workforce issues. Moreover, the independent Review of the Mental Health Act commissioned in 2017 and whose final report was published in late 2018 highlighted the role of AMHPs (Department of Health 2018a). At the time of writing the Department of Health and Social Care is coordinating the development of a national plan for the AMHP workforce to support the development, recruitment and retention of AMHPs (Department of Health and Social Care, 2019) A key element of the review is ensuring the AMHP workforce are competent to undertake their Mental Health Act duties. A requirement of the AMHP training is that AMHPs are ‘able to draw on, and evaluate critically, a range of research relevant to evidence-based AMHP practice’ as part of their informed decision making (Schedule two of the Mental Health (AMHP) (Approval) (England) Regulations 2008; Key Competence 2 (g) (Statutory Competences 2019: Regs 2 g) The workforce plan also wishes to maintain alignment to the competences throughout practice. The AMHP Workforce plan recommends that the AMHP workforce is supported to maintain alignment to the AMHP competencies throughout its practice (Department of Health and Social Care, 2019, 31). The conference was organised and partially aligned to some of the national workforce context for AMHP practice. However, importantly, the conference organisers sought to move the agenda beyond workforce issues to enable an exploration of AMHP research informed practice and practice informed research.The special issue call attracted twelve papers, which is testament to the interest generated from the inaugural conference, from which four have been peer reviewed and accepted. These now make up this special issue. Each of the four nations of the United Kingdom has a legislative framework and role whose responsibility it is to exercise within the civil law the functions of that law. In Northern Ireland Approved Social Workers fulfil their functions under the Mental Health (Northern Ireland) Order 1986 (MH(NI)O 1986), similarly in England and Wales the Approved Mental Health Professional exercises their duties under the Mental Health Act 1983 and in Scotland Mental Health Officers under the Mental Health (Care and Treatment) (Scotland) Act 2003 (MH(S)A 2003) and the Criminal Procedures (Scotland) Act 1995 (CP 1995). Functions of these roles relate to decisions made about individuals with mental disorders, including the decision to apply for compulsory admission to hospital. Also involved is the assessment of individuals experiencing mental disorders who may need compulsory measures of care, treatment and, in some cases, detention. These roles carry considerable autonomy and responsibility and involve working alongside medical and legal professionals. Our special issue has three papers which explore AMHPs and a fourth the MHO.Our first and insightful paper by Simpson explores the factors influencing AMHPs’ decisions about detention under the Mental Health Act 1983 (amended 2007). Twenty-five papers relating to ASW and AMHP decisions were analysed thematically and risk, accountability and morality were dominant themes. Decisions about risk, rather than being technical judgements, are subjective, interpretive and ‘infused with morality’ in the way they draw together AMHPs’ personal and professional domains, using themselves to understand service users when making decisions. ‘Sub-themes’ include emotions, intuition, uncertainty and coercion and these further influence ideas about accountability and its juxtaposition with fear of responsibility. Given this sharper focus on morality and the self in practice – an area hitherto relatively unexplored - Simpson questions whether services support this. Here, he engages with contemporary developments around the advancing of AMHP professionalism (Department of Health and Social Care, 2019).Next, Rooke’s article provokes critical debate on whether the authority of section 115 can be utilised by AMHPs under the least restrictive option and maximising independence principle. This is an important focus due to the limited research on the application of section 115 from either an AMHP or a service user perspective. Through the utilisation of section 115 via two illuminative case studies, she convincingly makes the case for its application to promote and recognise the preventative work undertaken by AMHPs, sharing good practice. A reflective examination ensues of the extent by which the AMHP role is applied to avert a deeper, more acute mental health crisis. The recent review of the Act made recommendations to facilitate ‘least restriction’ (Department of Health 2018a, 23) but without reference to how AMHPs may affect this in their wider role. Section 115 is clearly a contested power that some argue reduces rights, due to the absence of legal safeguards. Rooke’s argument on applying section 115 poses ethical and practice dilemmas that will stimulate debate on issues of care, coercion and control when supporting individuals in mental health crises. This should help AMHPs to reflect on the complexities involved when working within legally contested boundaries.The third paper written by Allen considers the impact of professional fear in the context of mental health decision-making in high risk scenarios relating to compulsory detention under the Mental Health (Care and Treatment) (Scotland) Act 2003. The study draws on data from eight semi-structured interviews with Mental Health Officers (MHO). Narrative enquiry was used to consider any factors which were felt to mitigate, control or heighten fear, alongside a vignette to explore the emotions that were experienced. The findings indicated that fear was a factor that had a marked impact on the decision making of Mental Health Officers. They conclude that both intrapersonal and wider structural influence for contributing factors arising from doing harm, to fear of scrutiny by the public or other bodies if harm should occur. The study highlights that the quality of MHOs’ relationships with healthcare professionals and support from managers and colleagues also emerged as key factors capable of increasing or relieving fear in the assessment process. The findings raise a number of recommendations for policy and practice in the statutory mental health field, in particular, the importance of acknowledging fear and identifying strategies to manage fear in training and post qualifying practice for MHOs and equivalent roles in the UK and other jurisdictions.Our last paper ends as we began, with a literature review. In it Buckland explores a range of literature specifically to explore multiple perspectives and experiences of power within Mental Health Act assessments. This she does by relating it to the usual participants within MHA assessments including the person assessed, friends and relatives, AMHPs, doctors and others such as police and ambulance personnel. Through this review Buckland aims to reflect on how power relationships within these assessments have been conceived and highlights that MHA assessments and their wider contexts are often deeply unequal and experienced as such. This she suggests is at odds with a broader rhetoric of collaboration and recovery for service users and concludes that the main preoccupations of the different groups of people at MHA assessments are vastly different; for example, risks associated with admission to hospital are central for service users and carers, whereas risk for professionals, and particularly doctors, is generally interpreted as risks associated with not going to hospital. The article considers the implications of these different perspectives in relation to the contemporary context of MHA assessments.In terms of research informed practice, it is evident that AMHP practice needs to be supported and informed by relevant research. Yet very little published material or empirical research is available to support AMHPs in their articulation of the role and demonstrating good practice that moves beyond a legalistic framework, although this is now starting to increase as this special issue attests. AMHP trainees and practising AMHPs (and equivalents) are asked to undertake ongoing critical analysis and to demonstrate that their practice is informed by a research evidence base. In view of these two interrelated issues, the conference organisers will now build a yearly conference on specialist themes that invite contributions that seek to address the practice/research gap. Sadly, the current pandemic has meant that this year’s 2020 conference is now delayed. Nonetheless, the publication of this special issue is, we hope, testament not only to the success of our inaugural conference but a way of accessing unmined practice based expertise that advances the recognition and importance of research to inform practice, as is also the remit of this journal. We hope it provides inspiration to other groups of practitioners in social work