Friday, 30 May 2014

Section 117 Aftercare and the Meaning of “Residence”: Recent Case Law

On 22nd May 2014 the Court of Appeal heard the appeal by Wiltshire Council ([2014] EWCA Civ 712), who were in dispute with Hertfordshire County Council over who was responsible for Sec.117 aftercare for SQ.
It’s sometimes astonishing to see the lengths (and legal expense) that local authorities go to in order to avoid accepting responsibility for Sec.117 aftercare. But then providing aftercare can be a very expensive business.
It’s not unknown for local authorities to place troublesome Sec.3 patients in care homes in neighbouring authorities under Sec.117 aftercare, in the knowledge that the placement is of dubious suitability and may quite possibly break down. This then precipitates an assessment under the Mental Health Act conducted by the local AMHP service and a fresh detention under Sec.3 in the new local authority’s area – who then have to take responsibility for future aftercare.

I know this sort of reprehensible behaviour is hard to believe, but it does happen from time to time.

Anyway, to get back to Wiltshire v. Hertfordshire. SQ was born and lived in Wiltshire until 1995. He had been an adult mental health service user since 1989. In 1995, a court made him subject to Sec.37 with restrictions under Sec.41. He remained detained under Sec.37/41 in various hospitals outside Wiltshire until 2009, when he was discharged with a condition that he reside in a staffed hostel in Hertfordshire.

Two years later, in 2011, he was recalled to a hospital in Hertfordshire. On 20th February 2014 he was again conditionally discharged to the same accommodation in Hertfordshire.
Following his recall, Wiltshire attempted to transfer Sec.117 aftercare responsibility to Hertfordshire. Hertfordshire refused to accept this.

Wiltshire requested judicial review of this decision, which was rejected twice. They then appealed to the Court of Appeal.

People who make a study of these cases will be aware of the intricacies of the meaning of the word “residence”. Local authorities, used to, and strangely often still do, try to apply the term “ordinary residence” to the duty of provide aftercare under Sec.117.

In fact, “ordinary residence” has nothing to do with the Mental Health Act at all. It is a definition which only has meaning under the National Assistance Act 1948.

There’s a rather useful Department of Health Publication called Ordinary Residence: Guidance onthe identification of the ordinary residence of people in need of communitycare services, England. This document states:

“Responsibility for the provision of accommodation and community care services under sections 21 and 29 of the 1948 Act is largely based on the concept of “ordinary residence”. However, there is no definition of “ordinary residence” in the 1948 Act. Therefore, the term should be given its ordinary and natural meaning subject to any interpretation by the courts.”
It goes on to say that ordinary residence “is the place a person has voluntarily adopted for a settled purpose for short or long duration. Ordinary residence can be acquired as soon as a person moves to an area if their move is voluntary and for settled purposes, irrespective of whether they own, or have an interest in, a property in another local authority area. There is no minimum period in which a person has to be living in a particular place for them to be considered ordinarily resident there, because it depends on the nature and quality of the connection with the new place.”
The document goes on to point out that with Sec.117 the duty falls on the authorities “for the area in which the person concerned is resident or to which the person is sent on discharge by the hospital in which the person was detained.” It stresses (using bold type) that: “the term “resident” in the 1983 Act is not the same as “ordinarily resident” in the 1948 Act and therefore the deeming provisions (and other rules about ordinary residence explained in this guidance) do not apply.”
So what of this recent judgment? This case shows Wiltshire trying desperately to extricate themselves from their Sec.117 duties.
Wiltshire was seeking decisions on “whether the recall to hospital in 2011 resulted in SQ being owed a fresh duty under section 117 on leaving hospital in 2014; and secondly, if so, whether SQ was for the purposes of Section 117 “resident” in Hertfordshire’s area as at the date of the recall in 2011.”

While there was “no dispute that, when SQ was conditionally discharged from hospital for the first time on 2nd March 2009, he was “resident” in Wiltshire for section 117 purposes”, Wiltshire was keen to establish that his prolonged residence in the accommodation in Hertfordshire meant that he was now “resident” within the meaning of the MHA in Hertfordshire.

The Court of Appeal gave this short shrift. It observed that “Wiltshire did not suddenly cease to be the local services authority in whose area SQ was “resident” for section 117 purposes because on discharge he was sent to an address in Hertfordshire”.

They also dismissed the contention that there were two distinct periods of detention, on the basis that, unlike a Sec.3, where someone can be discharged from the order, then detained again following a fresh assessment, the recall of a conditionally discharged patient continues to arise from the original court order, and “the chain of causation has never been broken.”

The judgment concludes: “I consider it clear that where a person has been made subject to a hospital order with restrictions, then conditionally discharged, then recalled to hospital, and then conditionally discharged for a second time, for the purposes of s 117(3) of the Act he is still to be treated as “resident in the area” of the same local authority as that in which he lived before the original hospital order was made. This makes it unnecessary to consider whether or not a fresh duty to provide after-care services arose on SQ’s second discharge earlier this year. Whether the duty is a fresh one or a continuing one, on the facts of this case it is Wiltshire’s duty.”

Using the same argument, these residence issues could equally apply to a patient made subject to Supervised Community Treatment following detention under Sec.3.
What is clear from this case is that, despite a growing body of case law establishing the meaning of “residence” for Sec.117 aftercare, local authorities are still trying to evade their duties.

Tuesday, 20 May 2014

Rubbed Up the Wrong Way? Difficulties with the MCA/MHA Interface

I am very grateful to the eminent Lucy Series, who writes the amazing The Small Places blog, for drawing my attention to a very recent judgment from the Court of Protection (Northamptonshire Healthcare NHS Foundation Trust and Northampton & Nene CCG v. ML, EL & BL: [2014] EWCOP 2). I will summarise it as best I can.

The case, which was published on 16th May 2014, concerns ML. ML is a man of 25, with severe learning disability, developmental disorder, autism, epilepsy and diabetes. He lives with his parents, EL & BL, his mother, EL, being his primary carer. He attends a National Autistic Society day centre 3 days a week.

It appears that between the mother and the committed staff of the day centre, there is evidence that ML is being appropriately cared for, and the treatment programme he is receiving is suited to his needs and is showing an improvement in his behaviour problems.

Mr Justice Hayden observes:
“Some aspects of ML's behaviour are very challenging, inevitably these have to be the focus of my attention when I come to consider the issues before me, but I should like to emphasise, that which BL has properly insisted upon at this hearing, there is a great deal more to ML than either his raft of problems or his, at times, violent outbursts. He is a young man who often radiates a sense of his own happiness and contentment to others; he has a real capacity for enjoyment, especially swimming. He can be warm and affectionate to those he trusts and knows well, particularly his mother. He has a sense of humour that is entirely his own, which occasionally has a subtlety and nuance to it that both delights and sometimes inspires his parents.”

Nevertheless, ML’s local Trust and CCG maintain that:
“i) ML lacks capacity to litigate and/or to make decisions about his care and /or residence;
ii) it would be in ML's best interest to reside at Bestwood Hospital;
iii) it would be in ML's best interest to undergo treatment at Bestwood Hospital until such time as he is able to be discharged to a suitable assisted living package in the community.”

To put it bluntly, they were seeking to remove ML from his loving parents and supportive day care centre, and place him in a hospital for an unspecified time.

This appears to be on the grounds that a nurse consultant concerned with ML’s care considered him to be “one of the most dangerous patients she has encountered still living within the community”. In her evidence to the Court she declared that "If ML is not transferred out of his current environment and routines his world is going to continue to decrease". She expressed concern about his diet, which she said consisted entirely of jam sandwiches, and she was very critical of the day centre.

In 2012, ML spent several months in a learning difficulties hospital detained under the Mental Health Act. The Judge noted a range of concerns about the extent and length of time that ML was placed in seclusion.

A psychiatrist who gave evidence to the Court said that he “saw no evidence that during the 5 months in hospital ML had learnt new self care skills sufficient to change his care needs.” He went on to say that he had often had to be restrained for long periods of time, and when finally placed in a seclusion room was so aroused and angry that he “then kicks and headbangs in a way that he was not prone to do – to the point of knocking himself unconscious and giving himself black eyes".

ML’s parents became so concerned about his treatment in this hospital that they applied to a Mental Health Tribunal for his discharge. The Tribunal discharged him.

ML’s parents were concerned that, despite the reputation of the hospital to which it is proposed that he should be admitted, it would “weaken his relationship with his family, who he does not respond to well out of the context of the home environment. It is distinctly possible he will not want to see them in hospital. If his behaviour were to deteriorate, as it did following the Vale admission, he would potentially be entirely unmanageable in the community… and there would in effect be no way back. ML would have lost the delicate security of the present status quo and be consigned to permanent institutional care. For BL that heartbreaking prospect is simply too great a risk.

So in a nutshell: ML has severe learning difficulties and challenging behaviour. The local Trust and CCG want him to be placed in a hospital for probably 2 years or more, in order to rehabilitate him in some way, on the basis it appears that sooner or later his parents will be unable to care for him. Aware that this may amount to a deprivation of liberty, they want to do this under the MCA. His parents, however, want him to continue to live with them, where he is patently happier than when in a hospital setting, and the National Autistic Society are supporting him and working with him on a behavioural programme.

Mr Justice Hayden then concludes that it is nevertheless in ML’s best interests to be placed in this specific hospital resource, and then goes on to examine under which regime this should be facilitated. He identifies 3 options: the MCA, the MHA – or the Inherent Jurisdiction.

Being a humble jobbing AMHP not familiar with all the ins and outs of the legal system, I was not familiar with the term “Inherent Jurisdiction”. There is a simple definition of this: under English common law, a superior court has the jurisdiction to hear any matter that comes before it, and it allows it to control its own processes and to control the procedures before it.

The Official Solicitor’s representation argues that using these powers “would be to subvert the will of Parliament as expressed in the MHA and … would be an unlawful use of the inherent jurisdictional powers”. The Judge agrees with this analysis.

The Judge also concludes that, in accordance with another Court of Protection case, AM v SLAM, the MCA can also not be used in this case. This would be, as in the case of AM v SLAM, because ML, whether or not he lacks capacity, would be highly likely to object to being a patient in hospital and/or receiving the treatment that the hospital would wish to give. (For a detailed discussion of this case law see this blog post).

The Judge having already concluded that ML should go into this hospital and receive treatment, this leaves only the MHA.

Since the purpose of ML going into hospital is for treatment rather than assessment, this renders detention under Sec.3 more appropriate. The Judge anticipates that the Nearest Relative is likely to object to detention under Sec.3. Even if the NR does not object, they would be likely at some stage to apply to a Tribunal for ML’s discharge. He therefore concludes by stating:

“I propose to take an unusual course. As I have foreshadowed above, any application to displace the nearest relative is to be reserved to me (upon the relevant authorisation to sit as a County Court Judge). I also propose to release this judgment to the President of the First Tier Tribunal with an invitation to him to allocate a judge of the First Tier to hear any applications in this case, to ensure judicial continuity. I will provide that a copy of this judgment follows this case.”

What are we to make of this quite extraordinary judgment?

Is the Judge, having made his decision, seeking to interfere, or intervene, in future anticipated legal hearings connected with M?. He appears to be setting himself up to hear any application for displacement of the NR, and making it very clear what his decision would be likely to be. Is he seeking to place some pressure on the President of the First Tier Tribunal, almost as if to warn any Mental Health Tribunal that might hear an appeal against detention at some point in the future to heed his detailed arguments for continued detention?

Would another reader of this judgment come to this conclusion?

It appears likely that, having received this judgment, the local Trust’s next step would be to arrange an assessment under the MHA for ML.

How, then, should an AMHP respond to this hypothetical request?

An AMHP would, of course, have to consider whether there is an alternative, less restrictive alternative to hospital admission. In this case, there are parents who appear to be reasonable, intelligent and caring, who have provided a home for ML, and are more than willing to continue to provide a home for him.

In addition, there are resources in the community which profess to be able to provide a treatment regime in a community setting, with evidence that this regime is gradually producing an improvement in ML’s behaviour.

There is also the evidence relating to a poor outcome from a previous detention in hospital, where the patient showed no improvement despite being detained for several months, and indeed was secluded in such a manner that he injured himself. On top of that, a Tribunal concluded that the grounds for continuing detention were not met and discharged him from detention under the MHA.

If the NR concurred that ML required compulsory admission for treatment and did not therefore offer any objection, then I suppose that an AMHP might consider that, in all the circumstances of the case, detention under Sec.3 was the most appropriate option.

But if, as seems very likely, the NR did object, could the AMHP conclude that, taking into account all the circumstances of the case, the NR was acting unreasonably? Probably not, if they had read this Judgment. So it would be unlikely that an application for displacement of the NR would be deemed a necessary and proportionate response.

So I am driven to repeat: what are we to make of this quite extraordinary judgment? And what are the potential consequences for others in ML’s position?

Saturday, 17 May 2014

What’s the Rush? Little Known Timescales for Compulsory Admissions

When a patient is assessed in the community and then an application is made for their detention either under Sec.2, for assessment, or Sec.3, for treatment, the next step is generally to arrange for their admission to hospital as quickly as possible.

There may be delays; the most common, once a bed has been obtained and an application made, is the wait for an ambulance. It is not uncommon to have to wait for 2-4 hours before an ambulance arrives, and then there can be further delays while the patient is persuaded to get into the ambulance, and then there can be a long drive to the hospital.

Some areas have a specific contractual agreement with the local ambulance trust, or even a private ambulance service, to provide an ambulance within a set time frame. There are also some local agreements which have a Traffic Light Risk Categorisation System, which sets response times according to the level of risk (Red, Amber or Green) the AMHP has assessed.

Our local pilot scheme has a 20 minute response time for the Red category (the patient is highly agitated, lacks insight and there is a potential risk of violence, self-harm or suicide). There is a 2 hour response time for Amber (patient lacks insight and presents with changeability of agitation, anxiety and distress, and may also threaten self harm and potential risk to others), and up to a 4 hour wait for an ambulance for a patient identified at Green (patient is settled, has good insight of probable informal admission, and minimal risk is identified).

Prior to this agreement, the local ambulance trust did not regard the conveyance of mentally disordered patients, whether detained or informal, as a high priority, and there was generally a default timing of 2 hours, however agitated and risky the patient might be.

But there is no legal requirement to facilitate a formal admission within such a narrow timescale.

Sec.6 Mental Health Act states clearly that a patient liable to detention under Sec.2 or Sec.3 can be conveyed to hospital at any time within “the period of 14 days beginning with the date on which the patient was last examined by a registered medical practitioner before giving a medical recommendation for the purposes of the application”.

Even when a patient has been detained under Sec.4, which is only for cases of dire emergency, Sec.6 allows a period of 24 hours “beginning at the time when the patient was examined by the practitioner giving the medical recommendation or at the time when the application is made, whichever is the earlier.”

The Reference Guide to the MHA goes into some detail about these, and other, time limits. Table 2.3 states:  “If the patient was last examined on 1 January, the patient can only be taken to or admitted to hospital if that happens on or before 14 January. The application must also have been signed before they can be taken to hospital.”

Additionally, the Reference Guide also states that “no more than five clear days must have elapsed between the days on which the separate examinations took place”. In other words “if the first doctor examined the patient on 1 January, the second doctor’s examination must take place on or before 7 January”.

This could theoretically lead to some curious consequences.

Let’s say Mavis Cruett’s GP goes out and sees her on Wednesday, 1st January. As it’s a Bank Holiday, he can’t get hold of an AMHP until 2nd January. The AMHP goes and visits Mavis to see if an alternative to hospital admission can be arranged. Mavis is an elderly lady, and the AMHP arranges for the local Later Life Team to assess. They visit on Friday, 3rd January, but they don’t notify the AMHP that they are unable to help until after the weekend, on Monday, 6th January. The AMHP arranges to assess her with the Later Life psychiatrist the following day.  On Tuesday 7th January, the psychiatrist then makes a recommendation of admission under Sec.2 MHA.

The AMHP pops round to the GP’s surgery and gets him to complete another medical recommendation, based on his assessment on 1st January. The AMHP then completes an application, rendering Mavis liable to detention under Sec.2. At this point, the AMHP actually has until midnight on 21st January to admit Mavis. That’s three full weeks since the GP first assessed her. And it’s all completely legal.

Although the Code of Practice says in Para 4.87 that “most compulsory admissions require prompt action”, it does acknowledge that these time limits exist, and observes: “there may be cases where AMHPs conclude that they should delay taking a final decision, in order to see whether the patient’s condition changes, or whether successful alternatives to detention can be put in place in the interim.”

Nearly all the AMHP’s with whom I have discussed this rule don’t like it. Some have said that if you as an AMHP think someone needs to be detained in hospital, then you shouldn’t be delaying the admission, and if you think that the admission can be delayed for a fortnight, then you shouldn’t be making an application in the first place.

But that’s not actually what the law says.

One last thing: when I was looking all this up in the Reference Guide, I came across this. It relates to the timing of the medical recommendations.

“If the application is signed by the nearest relative or AMHP at noon on 1 January, the medical recommendation must be signed by the doctor(s) concerned before midnight on that day.”

For as long as I have been making applications under the MHA (which is for over 30 years), I have always taken the view that an application for detention has no legal standing unless the AMHP has two completed medical recommendations. After all, the form itself says: “This application is founded on two medical recommendations in the prescribed form”.

However, there is the Reference Guide stating unequivocally that the AMHP (or NR) can complete an application up to 12 hours before the doctors complete their recommendations!

Does this  mean that legally an AMHP can admit and detain a patient in hospital, perhaps with only one recommendation (and I’m not talking about Sec.4), as long as the hospital psychiatrist provides a recommendation before midnight (when presumably the patient, the AMHP, or both, will turn into a pumpkin)?

Surely not!

Thursday, 8 May 2014

Review: Approved Mental Health Practice, edited by Sarah Matthews, Philip O’Hare & Jill Hemmington

The subtitle of this new book is “Essential Themes of Students and Practitioners”, and I would certainly endorse this. This is the only serious text of which I am aware that focuses entirely on professional practice under the Mental Heath Acts of the United Kingdom.

The authors grapple with the conflict between the social work role of empowerment and the AMHP powers that can lead to coercion and the imposition of social and medical control, and this book provides an excellent examination of the tensions existing in the role of the approved mental health practitioner, allowing the student and practitioner to reflect on the role in the context of the wider social perspective.

As the book is directed at an examination of practice under all the UK’s mental health legislation, they generally describe the professional as an “approved mental health practitioner”, so I will continue to use this terminology in this review, and the abbreviation of “AMHP” should be read in this way.

Sarah Matthews starts by posing the question, “Do social workers as approved mental health practitioners struggle to promote a model that views the manifestations of mental health in any way other than the dominant and, some argue, pathological one?” She goes on to outline the fundamental aspects of approved mental health practice. These include the social perspective as being central, as well as the independent nature of the role. She also stresses the importance of emotional engagement, containment and the concept of “dirty work” as contributing to the unique role of the AMHP. She states: “The mother, it is suggested, contains others’ distress without appearing to be affected by it herself and it is this which an approved mental health practitioner might also accomplish.”

I was particularly intrigued by her discussion of work under the MHA as being “dirty work”. Dirty work “describes the notion that people are compelled to play a role in work about which they ought to be a little ashamed, morally… A profession embraces unpleasant tasks as a means of establishing its credibility or undertakes such tasks as a necessary, albeit difficult, element.”

Tim Spencer-Lane provides an analysis of the legal and political factors in England and Wales that led to the revision of the 1983 Act and the creation of Approved Mental Health Professionals. Having practiced under Mental Health Acts since 1981, I have lived through these changes, and have been professionally associated with the issues which eventually led to the 2007 Act. He makes the interesting point that the MHA 2007 “was the result of a long and embittered battle between the Government and the major stakeholders about the fundamental purpose of mental health law”, whereas the Mental Capacity Act 2005 was developed in broad consensus and was the culmination of a long consultation process.

Jean Gordon and Roger Davis go on to compare and contrast mental health law in Scotland and Northern Ireland (although omits the Isle of Man Mental health Act 1998, which, like Northern Ireland, retains the Approved Social Worker).

David Pilgrim makes interesting points about the way in which mental health professionals can make basic assumptions about mental health practice which may be at odds with reality. He makes the point that "third-party interests constantly shape professional decision making and action. Indeed, at its most coercive, mental health work considers the needs of the identified patients only after others are protected from their prospective presence and actions... It is soon evident that public safety and institutional order can dominate staff decision making."

He argues, with some justification, that the MHA in England and Wales is more concerned with controlling mental disorder than with the promotion of mental health. This makes the AMHP role innately coercive, and he poses some challenging questions about the validity of enforcing compulsory treatment with drugs which are at best only moderately effective, and at worst can cause serious harm or even death.

Helen Spandler tackles problems around psychiatric diagnosis, wishing to "equip approved mental health practitioners with the knowledge to question, challenge and understand the broader meaning of mental disorder and diagnosis," in order for us to be "more cautious and thoughtful about the language we use to describe mental health crises."

She reviews the different approaches to diagnosis, from psychiatric, psychological and service user perspectives, often using as examples the ways in which the long term effects of childhood trauma can be interpreted as either normal reactions to extreme life events, or pathology indicating mental illness or disorder.

She suggests that a more useful, and service user centred approach for an AMHP to take is to assess levels of impairment and functioning, rather than diagnosis, to determine access to services and using mental health legislation. While expressing scepticism about the use of diagnosis, she states that "it is important not to let the endorsement or criticism of diagnosis get in the way of decision-making." Any alternative to conventional diagnosis "must result in better consequences for people in terms of gaining the more appropriate support and assistance."

Daisy Bogg examines ethics and values in the context of approved mental health practice, tackling in the process some of the ethical dilemmas inherent in the use of Community Treatment Orders, observing that "approved mental health practitioners serve as a counterbalance to a single dominant medical perspective and are required to provide a more holistic view, and account for the whole circumstances of an individual's situation before making a decision to apply for compulsory admission."

Amanda Taylor and Jill Hemmington's chapter on Diversity in Mental Health sets out to "challenge notions of diversity being simply and solely located within traditional, fixed dimensions and to alternatively view it as being unique to the individual, group and community." They warn that approved mental health practitioners need to be aware that they "belong to a 'dominant social group' that 'maintain systems of privilege and oppression'".

They give as an illustration an in depth analysis of Deafness, including specific case studies, using these to show that "it is vital that as practitioners we can seek that which is outside of the self and consider not only the diversity relating to the other but go some way to working within their 'internal frame of reference' to understand the layers that exist."

They conclude: "Empathy, 'tuning in' and constantly asking oneself questions are the starting points to a thorough, effective assessment that has honesty and collaborative work at its core."

I was particularly intrigued by Anthea Murr and Tamsin Waterhouse's chapter on "The Impact of Time and Place", as it focused on assessments in rural areas. Readers of this blog will be aware that I work predominantly in a rural area; even the towns in my area have populations of less than 30,000. They outline the special factors that can impact on the mental health of people living in rural areas, such as physical, social, cultural, psychological and geographical isolation, as well as the problems of rural poverty, and conclude that practitioners working in rural areas need to have special training and acclimatisation to prepare them for these particular challenges.

Julie Ridley outlines a study of service users’ experiences of mental health legislation in Scotland. Although specific to Scotland, this study is also of relevance to professionals working throughout the UK.

Experiences of compulsion varied from the positive to the negative, perhaps not unexpectedly. Some service users welcomed having “‘responsibility taken away’ and a structure to daily life imposed”, while others described it as a “nightmare” experience.

Philip O’Hare and Gavin Davidson devote a chapter to the role of the Nearest Relative, tracing the history of this role in mental health legislation going back to the 18th century, and its evolution in more recent Mental Health Acts. They make the point that improvements in social work training and the changes to practice brought about by the Seebohm in the 1970’s added to pressure to replace the 1959 Mental Health Act with legislation that recognised the professional competence of social workers. This led to the 1983 Act, where the Approved Social Worker became the preferred applicant in applications for detention.

I was intrigued by the statistic that in the early years following the introduction of the 1983 Act only 1.6% of application were made by Nearest Relatives. I suspect that this figure is now even lower.

Practicing exclusively in England, I did not realise that legislation in Scotland had ended the Nearest Relative role as applicant for detention. I was interested to read that the other parts of this role have been replaced by a “named person”, who is nominated by the patient. Although this seems like an admirable idea, and would obviate the current difficulties that AMHP’s can find in identifying and consulting with the Nearest Relative, this idea was unfortunately not taken up when drafting the 2007 Act.

Philip O’Hare discusses to what extent evidence-based practice can inform approved mental health practice. There is a paucity of evidence on which to base evidence-based practice within mental health legislation,; evidence-based practice is essentially based on the medical model, which can be hard to replicate in a social care context.

O’Hare asks the question “How to AMHP’s make sense of their legal roles being informed by practice, and looks at making decisions based on least restrictive concepts, applying this in particular to the AMHP role in Community Treatment Orders: “how does an AMHP make a distinction between justified and unjustified CTO’s?”

Unfortunately, despite rather sketchy research into the efficacy of CTO’s, it is very difficult to assess the likely beneficial impact of a CTO on any particular individual, other than anecdotal evidence relating to length of time without a hospital admission. How can you test whether the conditions of a CTO have positively influenced a specific patient?

Jill Hemmington examines how AMHP’s have to manage uncertainty, and how one can develop practice wisdom. She makes the point that approved mental health practice “has been described as ‘crisis, mess and muddle’ where Mental Health Act assessments often arise from and within situations where there is ‘panic and confusion’”. She makes an interesting attempt to apply crisis theory to AMHP work, and also points out that “because something is lawful, it is not automatically ethical”.

She poses a number of pertinent questions for an AMHP to consider relating to their practice, for example, “How did I influence the situation through: my presence, my actions, my preconceptions or assumptions, other people’s perceptions of me, my physical well-being on the day?”

The editors conclude that “for an AMHP the focus is on how to interpret and analyse appropriately and avoid any illusion that there can be certainty.”

Each chapter contains reflective questions, which are designed to provoke stimulating discussions in student seminars, and which would also be useful for AMHP’s who are preparing reapproval portfolios to evidence reflective practice and to elicit learning points from professional experience.

I found the book as a whole stimulating and thought-provoking. It was a pleasure to read a book that directly addresses the dilemmas with which I am faced every day of my professional life.

I wholeheartedly recommend this book to anyone interested in the AMHP role, including those undergoing AMHP training, AMHP’s preparing for reapproval, and social work and mental health nursing students who seek to obtain a deeper understanding of the moral and legal complexities of the role.

Approved Mental Health Practice: Essential Themes for Students and Practitioners
Edited By Sarah Matthews, Philip O'Hare and Jill Hemmington
Palgrave Macmillan, April 2014
ISBN: 1-137-00013-9, 978-1-137-00013-2