Monday, 29 July 2013

Should Professionals Write Publicly About Real Cases?

Some sort of visual metaphor
I had a very interesting and thought provoking email correspondence with a reader of The Masked AMHP blog recently. The reader initially found the accounts on the blog of real situations interesting and at times amusing, but then started to think about how they would feel if they were reading about themselves. The reader raised issues of privacy, confidentiality, ethics and the power relationship inherent between a mental health professional and a service user.

Regular readers of this blog will be aware that I often write about actual cases I have been involved with as an AMHP and a social worker. There are a number of reasons why I do this.

Probably the primary reason is to provide a window into my professional life in order to inform service users, other professionals, and the public in general – to demystify working with people with mental health problems.

Most people will never come across an AMHP in their daily lives, and will have little if anything to do with the Mental Health Act. The role of the Approved Mental Health Professional is therefore little known to the general public and even less understood. And yet, AMHP’s have wide ranging powers and duties, which can seriously impinge on the freedom of people who experience mental disorder.

I think, therefore, that giving case studies from the point of view of the AMHP/social worker, in which I explore the thought processes and decision making that goes on during an assessment under the MHA, can be helpful, and perhaps can go some way to dispelling the common belief among some service users that AMHP’s are interested in nothing more than exerting power. One reason why I write therefore is to try to counter the beliefs exemplified in this recent comment on the Blog:

“Your disgusting and pathetic idea that you have the right to detain people against their will based on their mind even if they have not committed any crime is disgustingly pitiful. Anyone who is a believer in "psychiatry" "mental illness" "mental disorders" is no different than bigoted racists and concentration camps. You think you have a right to play God over another person's life based on their difference in mind? You'll go down as nothing more than a discriminatory bigot.”

Another reason is to provide information likely to be useful to students, AMHP trainees and other professionals. It seems to me that a good way of providing that information is to show how theory and legislation is actually applied in real life situations.

Academics may be able to describe the theoretical application of law, but when you are working in the real world, where they may be no beds, long delays waiting for an ambulance, problems in getting help from other professionals, then applying the law in those circumstances can appear very different.

Another reason why I write about real cases with which I have been involved is that it can be therapeutic to me. Sometimes I need to talk about situations I have been in. it helps me to debrief, to make sense of some of the things that have happened to me.

And another reason is simply because sometimes I think people’s stories need to be told. Some of the people I have written about are deceased. They have led remarkable or tragic lives, but these lives, and their life stories, would be forgotten if they were not written about somewhere. I hope I always write with empathy for the person, and I always make great efforts not to be patronising.

Of course, when I am writing about real people, I always change their names, and I also make other changes to the details of people in order to make them less identifiable. Everything I write about is set in the fictional town of “Charwood”. And of course, my real name is not “The Masked AMHP”. But I do take on board my email correspondent’s concerns that individuals may still be identifiable.

So how can I justify my blog?

For a start, there are many precedents. It is not uncommon for doctors, especially psychiatrists, to write about real cases. Many medical journals recount detailed, although anonymous, case histories of people with unusual medical conditions. There is so much detail in these that the patient should be able to identify themselves. Perhaps the doctor hopes that they will be unable to access the particular medical journal in which their case histories are detailed.

Although written by a journalist, Flora Rheta Schreiber, a good example of a whole book devoted to a single patient is Sybil, the story of a woman with dissociative identity disorder. This book was published in 1973 and later made into a film.

The eminent and humane neurologist Dr Oliver Sacks has written many books about his patients, including Awakenings, about his attempts to help patients with encephalitis lethargica, and The Man Who Mistook His Wife for a Hat. The latter book consists of a series of true stories of patients of his with a range of unusual neurological conditions. The patient referred to in the title is a man with visual agnosia, who was unable to distinguish between inanimate objects and people. However fictionalised these accounts may be, these people must still have been identifiable to themselves and their relatives.

The established and extensive literature of case studies, both academic and commercial does therefore lead me to believe that there can be a justification as long as it is done with respect and sensitivity.

I have also had many positive comments from service users about the contents of the blog. Here are a couple of comments I have received on the blog. The first is from a service user:

“Having been detained 3 times under section 3, to be honest its nice to read accounts from the other side instead of seeing the other side as the enemy, like you do when you are unwell. And the endings may seem sad & unfortunate, but often the people are ending up receiving the help they need even though they may not want it.”

And here is one from the relative of someone with mental health problems:

“Incredible - after YEARS and YEARS of trying to understand the CRAZY behaviour of a relative - this is it. Thank you for this blog, it doesn't change anything but to read this happens... it's felt like a never ending nightmare and at times as if I was the crazy one for imagining what was happening.”

These sorts of comments do help me to think that it is worthwhile and ethically justified writing The Masked AMHP blog.

The British Association of Social Workers (BASW), as well as The College of Social Work (TCSW) and the Health and Care Professions Council (HCPC) all have policies about the use of social media.

The BASW Social Media Policy encourages positive uses of social media. Its policy document states: “Social media can help individuals and organisations to better understand, engage with and respond to people. It can contribute to making services more transparent and accountable. The use of social technology and social networking enables people to collaborate, build relationships and share information and resources.”

It goes on to say: “Social workers should use social media as a positive platform for exchanging ideas and knowledge and to promote the social work profession, being aware that they are acting as ambassadors for social work when they are on-line.”
Rebecca Joy Novell, in a recent Guardian article, writes: “The largely negative portrayal of social workers in mainstream media has a palpable effect on the confidence of practitioners. When the public see a social worker on TV show EastEnders unfairly and without query removing a child from Lola, a capable mother, it's no surprise that their understanding of our role is warped. The damaging consequences should not be underestimated.”
She goes on to observe: “Challenging these negative portrayals and presenting an honest picture of what we do is essential for restoring confidence in our profession. The media is central in shaping public perception and, subsequently, in shaping local and national policy. While it may not be possible for every social worker to represent their profession on prime-time television, it is possible for every social worker to have an online blog and a Twitter account.”
Rebecca argues that social workers (and indeed other professionals) writing about their jobs on social media sites almost amounts to an obligation, and can have very positive benefits for promoting a job that is often misunderstood and sidelined by the media and Parliament.
The feedback I have had from The College of Social Work indicates that my blog presents social work in a positive light. I hope that I can continue to do that while also respecting the people I write about.

Thursday, 25 July 2013

What Is An AMHP?

It's not compulsory for AMHP's to wear this T-shirt
Well I’m glad you asked me that. AMHP is an acronym of “Approved Mental Health Professional”.
Is that it?
Do you want more?
Well, yes.
(Sighs). OK, here goes. The Mental Health Act 2007 amended the Mental Health Act 1983. One of the amendments was to create the “Approved Mental Health Professional”. The AMHP has a very important role to play in the functioning of the Mental Health Act.
Hang on a minute. The Mental Health Act. What’s that exactly?
(Sighs even more deeply). OK. The Mental Health Act lays down the legal framework in which people can be compulsorily admitted and detained in psychiatric hospitals. It covers ordinary members of the public who might become mentally disordered, as well as “mentally disordered offenders” – people who have committed criminal offences and who have gone to court, but who may need assessment or treatment for mental disorder.
Except for people who are dealt with through the courts, the involvement of an AMHP is necessary in order to make decisions about whether or not someone needs to be admitted to hospital for assessment or treatment.
So why do you need an AMHP then?
I was coming to that. An AMHP helps to provide a remedy to excessive medicalisation of the process of assessing and treating people with mental disorder. Doctors can make recommendations that someone should be detained in hospital, but it is up to the AMHP to make the final decision. It is also the responsibility of the AMHP to ensure that the law is being applied correctly.
So what is an AMHP then?
An AMHP can be a social worker, a psychiatric nurse, an occupational therapist or a clinical psychologist. A doctor cannot be an AMHP. Before the 2007 Act, only social workers could do the job. Then, they were called “ASW’s”.
Tell me more about what an AMHP actually does.
With pleasure. The AMHP role is a complex one. It is also unique among the tasks of social workers and other mental health professionals in that the AMHP is acting as an autonomous professional rather than an agent of their employees, whether is be a local authority or an NHS Trust. An AMHP cannot be told by a manager to “go out and section” someone. All they can be asked to do is to conduct an assessment under the MHA and reach their own conclusion based on all the evidence.
AMHP’s have had to undergo extensive specialist training, and therefore have an in depth knowledge of law and have the responsibility for upholding the law when conducting assessments under the MHA. They can use that knowledge to ensure that the rights of those being assessed are protected, and can provide a counter to the medical model of mental health, introducing a more rounded social perspective to the process. They need to use their knowledge not just of mental health legislation but also the Human Rights Act and other legislation, such as the Mental Capacity Act. This can give them the confidence to disagree with the doctors, and to seek out and suggest alternatives to hospital admission.
The AMHP will draw on all the information available on that individual, not just the medical and clinical factors. This includes their individual social and cultural circumstances, the possible risks and protective factors, as well as their knowledge of mental illness and the legal process, in order to try and reach a just and equitable conclusion which will balance the rights of the patient with their possible need for protection and treatment.
Shall I tell you about the powers and duties of the AMHP?
I’m beginning to wish I’d never asked you a question in the first place. But go on.
I could do a Powerpoint presentation if you like.
Please don’t.
Very well. As briefly as possible then.

 AMHP powers:

  • The power to make an application for compulsory admission to hospital under Sec.2, Sec.3 or Sec.4
  • The power to make an application for guardianship under Sec.7
  • The power to convey the patient to hospital or to authorise others to do so
  • The power to enter and inspect premises – other than a hospital -- where someone is not receiving proper care
  • The power to apply for a warrant to search for and remove patients or persons living alone in need of care under Sec.135(1)
  • The power to remove and return patients within UK, or to take or re-take detained patients absent without leave (S.18 and S.138)
AMHP duties:

  • The duty to interview the patient “in a suitable manner” (Sec.13(2))
  • The duty to respond to a request by a Nearest Relative to assess someone under the MHA (Sec.13(4))
  • The duty to consult the patient’s Nearest Relative when considering a Sec.3 (or guardianship)
  • The duty to inform the patient’s Nearest Relative when detaining under Sec.2
  • The duty to interview a person removed to a "place of safety" by police under S.136
  • The duty to consider an application for a patient to be made subject to Supervised Community treatment under Sec.17A
Do you have any more questions?
Not now, thanks. I really must be going. Actually, I do have one: how do you actually pronounce “AMHP”?
I’m really glad you asked me that. On a day to day basis, you obviously don’t want to be saying “Approved Mental Health Professional” all the time. You could pronounce each initial, eg. “Ay Em Aitch Pee”, or you could just pronounce it “Amp”. Personally, I favour “Amp”, as “The Masked Amp” sounds cool, but “The Masked Ay Em Aitch Pee” just sounds silly.
So you think that “Masked Amp” sounds cool, do you?
Yes I do. You can go now.

Wednesday, 3 July 2013

If The Masked AMHP Blog was Written by Sir Arthur Conan-Doyle

The Masked AMHP sucked contemplatively on his electronic Meerschaum pipe as he leafed through a well-thumbed copy of The Mental Health Act Manual. A shaft of sunlight shone through the office window and illuminated his Stetson.
“Fascinating,” he said eventually, blowing out a pollution-free smoke-like substance into the atmosphere. “Jones suggests that the design of door handles or the use of key pads making it difficult for a confused patient to leave the hospital or care home would not constitute a deprivation of liberty, and yet I have seen many such godforsaken individuals clawing hopelessly at the exit doors who are clearly making patently clear their wish to leave their place of incarceration. Would it not be more legally sound for such persons to receive the legal safeguards afforded by detention under the Mental Health Act?”
Tonto, the Masked AMHP’s faithful and attentive, although not that bright, AMHP trainee, looked up from his iPad, on which he had been diligently reading the latest post on the Masked AMHP blog while furiously taking notes for one of his assignments and gazed in awe at his mentor.
“By Jove, Masked AMHP,” he exclaimed. “I do believe you may be correct! I am quite certain that Jones will have to amend his next edition in the light of your observation!"
“Indubitably, my dear Tonto,” The Masked AMHP replied insouciantly, tapping away at an email to Richard Jones.
Just then the phone rang.
“Allow me to get that, Masked AMHP,” Tonto intoned, anxious to be of use, picking up the receiver. He listened intently, then passed it over to the Masked AMHP.
“There’s a distraught woman in reception,” he said. “She’s concerned about the mental state of her partner. I’m a little out of my depth with that, I’m afraid, just being a humble trainee.”
“Ah, Section 13 brackets 4,” The Masked AMHP muttered. “Let’s go down and see her, shall we?”
A few minutes later The Masked AMHP and his humble AMHP trainee were ensconced in an interview room with a tearful young woman.
“I’m so worried about Johnny,” she sobbed pitifully. “At first we had such a wonderful relationship, but lately he’s been shutting himself away in the study for hours on end. He tells me to go away if I put my head round the door, and I can hear him shouting and muttering to himself. I fear that he is hearing voices that no-one else can hear, which must mean he is developing schizophrenia and must be incarcerated in a psychiatric hospital under Section 2 of the Mental Health Act for assessment!
The Masked AMHP sat deep in thought, while the AMHP trainee tried to comfort the poor woman by dabbing at her eyes with his pocket handkerchief and offering her an extra strong mint.
At last he said, “Tell me, my dear young lady, how long have you lived with your, ahem, fiancĂ©?”
“It’s 5 and a half months to the day,” she replied, blowing her nose loudly but at the same time daintily on Tonto’s handkerchief.
“And what did he do to occupy his free time before you began to share a house?”
“I believe he owned a Playstation 3. But he put it away in the attic when I moved in with him.”
“And how does his visage appear currently?” The Masked AMHP enquired.
“When I have seen him, he has a terrible haunted look, as if he is being pursued by all the demons in Hell! Oh, sir, do you suppose he is having visual hallucinations? That would be just too, too terrible.”
“Aha! I believe we have the solution to this little problem,” The Masked AMHP said triumphantly. “I do not need to interview your partner in a suitable manner, or indeed in any manner at all. For it is plain to see that he is not mentally ill in any way!”
Tonto and the young lady gazed in amazement at The Masked AMHP.
“By Jove, Masked AMHP!” Tonto pronounced. “How can you tell that without even examining the poor chap?”
“It’s simple,” The Masked AMHP continued. “He likes to play games on the Playstation 3, but infatuation for this young lady has led him to abstain for several months. But The Last of Us has just come out on the Playstation, and he just had to play it, didn’t he? Of course he has a haunted look! It’s a terrifying game! But he’s no more mentally disordered than most of the current Cabinet!”
Back in the office, The Masked AMHP sat back and fired up his electronic Meerschaum pipe, as he dictated his AMHP Assessment Report to his AMHP trainee.
“And of course,” The Masked AMHP concluded, “I didn’t need to interview him in any case, because it wasn’t a Section 13 brackets 4 nearest relative request at all! She couldn’t be his nearest relative – because they hadn’t been living together as husband and wife for at least six months!”