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.


  1. If the person you are writing about could recognise themselves then get consent. This is today's standard in journals and conferences.

  2. I agree. You really should be obtaining consent. I say this as a medical professional and as someone with mental illness.

  3. Whilst I do agree generally with what you say, as a mental health researcher I always find it funny the stringent ethical procedures we go through and the constraints placed on what we can and can't do, as seems to be compared to the TV programmes etc that represent mental health (a case in point being the recent documentary series on life in a young person's unit). I think gaining informed consent is pretty crucial, and although I appreciate this is not always possible for you (e.g. when discussing historical cases), I agree with the above commentators that you should get it when you can. At the end of the day we are still appropriating people's stories, however sensitively done, and they have a right to have a say in how those stories are used.