Risks vs rights: how social workers handle one of the toughest jobs in mental health

Today is National Approved Mental Health Professional Day. Community Care visited AMHPs in Birmingham to see how the role works in practice.

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Photo: Time to Change

One of the most important roles in our mental health system is also one of the least known about. Every day, approved mental health professionals (AMHPs) have to assess whether a person’s mental health crisis has become so severe that they need to be detained for their own safety, or that of others, under the Mental Health Act.

This complex and finely balanced judgment call is often made in difficult circumstances. It demands AMHPs weigh up the risks against a person’s human rights. Detaining a person against their will takes away their liberty. But if they are refusing care, it could be the only way to get much-needed, potentially life-saving, support.

AMHP day

Most AMHPs are social workers who have completed specialist training. Tom, an AMHP in Birmingham, says that when AMHPs first qualify they can be “terrified of getting it wrong or making a terrible decision”. While the role has a lot of power, it doesn’t always feel like that when you’re armed with just the Mental Health Act manual, a diary and a phone, he says.

“I think you become more comfortable with making the decision and living with the consequences. You can’t be right all of the time. It goes horribly wrong sometimes. But it also goes right sometimes as well – I’ve certainly been thanked by people.”

‘Least restrictive option’

One of the key principles of the work is to try and find the least restrictive way of getting someone the help they are assessed as needing. If someone requires hospital admission, where possible AMHPs will look to agree with the person to go voluntarily.

Improve your AMHP practice

Improve your Mental Health Act assessments with Community Care Inform Adults’ guide to the AMHP role, which is available to all subscribers to the site.

“Our job is about trying to meet people half way,” says Tom. “I always say, let’s try not to make the Mental Health Act assessment a bad thing. It’s a ‘taking stock’ and an opportunity to say what has happened here and can we solve this without detention?

“Our starting point should always be: we don’t want to detain someone until we think we need to. Then we negotiate what that need is and then think about risk.”

Keith, an agency AMHP working in the city, agrees that one of the best parts of the job is when someone agrees to go into hospital informally, without being detained.

“That’s when you know you have used those communication skills, when the person may not fully accept that they are unwell, but you can talk to them and get them to go in informally. When that happens, you walk out of the door feeling totally different.”

‘An isolating dilemma’

The AMHP role sits under the responsibility of local authorities, deliberately so that it acts as a check and balance to decisions made by the NHS about someone’s care. At each Mental Health Act assessment, doctors will provide a recommendation as to whether someone should be detained. It’s up to the AMHP to weigh up these recommendations alongside their own assessment and come to their own view.

Geraldine, another of the Birmingham AMHP team, says there can inevitably be situations where the professionals disagree and it can feel like “us and them” with health.

“We are dictated by the legislation and I don’t think our health colleagues always understand that, so we can find ourselves being pulled from left to right.

“It does create pressures for us and anxieties as well.”

Geraldine recalls the case of a woman in A&E, who was “clearly unwell, but she had insight and she acknowledged she was unwell and wanted the help”.

“The two doctors were adamant that she needed to be detained and at that initial point I felt quite isolated. I was in the dilemma of shall I, shan’t I? But I had to take into consideration how she presented and the views of the carers at that time.

“I refused to do the application and the woman went in to hospital informally. When I went home I felt like I’d done the right thing. I called the hospital and they said she was doing fine. I knew then I’d achieved something by following what I felt was appropriate.”

‘Cat and mouse’

Tom and Geraldine say the demands on their team are ever-increasing. In each of the last three months, Birmingham’s AMHPs have received more than 500 referrals. Agencies request everything from a full Mental Health Act assessment to the authorisation of a community treatment order, which compels a person to receive supervised treatment out of hospital.

Alongside the rising demand for services, the AMHPs face a daily struggle of trying to coordinate partner agencies, including the police and the ambulance service. Tom recalls waiting more than seven hours in the community for “the magic ambulance” to turn up.

Geraldine says that once a decision has been made to admit someone to hospital, it can be like a game of “cat and mouse” getting the other agencies on board.

“The ambulance won’t come if the police aren’t there and the police aren’t coming if the ambulance isn’t there and we are kind of caught in the middle of that really.

“There’s some ongoing policies and procedures that we’ve been trying to put in place so we can all work together and communicate, but it can be difficult on a daily basis.”

‘Traumatic experience’

Much like other parts of the country, Birmingham’s AMHPs are also faced with a shortage of inpatient beds. It means an increasing number of patients, particularly those under the age of 25, are being sent to hospitals miles away from the city.

Dee, another AMHP on the team, says that as far as the out-of-area problem goes, “the most uncomfortable feeling is when it’s a young person”.

“I know it’s a national problem, but for the young person and their families it is a traumatic experience to be admitted to hospital, whether it’s informally or under section, and for them not to be able to have regular, daily contact with their family.

“The families also don’t know or are unsure about what goes on in the psychiatric hospitals and so of course they are worried about the young person while out area.”

It is the responsibility of the NHS to find the bed, or the “where” as the staff here say. But the AMHPs are often the professionals left to manage the situation in the interim.

Keith has spent the last four years working with Birmingham’s 136 suite, the ‘place of safety’ where people who are detained under section 136 of the Mental Health Act are brought for assessment, instead of being taken to a police station or A&E department. Police can use this section if they think a person is mentally unwell and needs care or control.

He says he sometimes faces the dilemma of assessing someone at 9am and they are still waiting in the place of safety at 11pm because there are no beds. He remembers the case of a man who was very unwell, but there were no problems or risks.

“The next thing I knew it was 11pm and he’d got quite aggressive, mostly through frustration because he’d waited that long and then was told he was going to Weston Super Mare. So things can change from someone being quite okay and then because of how long they’ve waited for a bed, their mental health deteriorates.

“That annoys me, but there is nothing you can do.”

Compassion and warmth’

Despite the challenges, Birmingham has made progress to cut the number of people being taken to a police station when in a mental health crisis. The place of safety was set up seven years ago by the Birmingham and Solihull Mental Health Trust and other agencies. At the time, more than 500 people a year were being assessed at a police station, something bed manager for the trust, Richard, describes as “scandalous”.

“It was shocking really, for a city of our size. But in September, our seventh anniversary, we won’t be far off having 4000 people through here,” he says.

“So while we’re not perfect by any means, that is 4000 people away from a police station when in mental health crisis and last year no one was taken to a police station at all.”

Richard adds that the place of safety wouldn’t work without the AMHPs, and his own learning from “a legal point of view is better for sitting and listening to these guys”.

“We are very lucky to have the AMHPs that we have, they have all bought into what we do, their response time is phenomenal and the way they respond to people as well – they treat the patients that come here with compassion and warmth.”

He gives the example of one case where a woman was detained under section 136 – “she  was really unwell, floridly psychotic, really poorly and really vulnerable,” he says.

“I can only describe her as someone who had escaped the net of services. She was brought here, she had a full MHA assessment and she was on a ward starting her treatment all in 48 minutes. We can’t do that every day, but it shows what we can do.”

‘Imperfect world’

These types of cases, and often the AMHP role itself, are largely absent from public discussions about mental health services and certainly in dramatized versions of the Mental Health Act process, which are often viewed by millions. The AMHPs all talk about an episode of EastEnders where Stacey Slater was “sectioned”.

“There was no mention of us, you find that happens most of the time,” Geraldine says.

“I don’t think social workers get recognition unless it’s something negative and it always seems to steer towards a children and families team.

“I don’t actually hear anything about mental health social workers and the pressures, the dilemmas, the stress and anxiety we face – that’s not weekly, monthly or yearly either, it’s a daily occurrence we come across all of the time.”

Tom adds that the portrayal of mental health social workers on TV can often be “wishy-washy”, but says there are very few professionals like AMHPs who get the legal training, understand the law and then have to make it work in an “imperfect world”.

“I think we try and hold onto the fact that we are being invited into people’s lives at a time when they might be at their lowest ebb and we need to be mindful of that.

“We don’t want to do any more damage. We are there because we’ve got a job to do, but we should try and do that job in as reasonable and gentle way as we can.

“Ultimately no matter how difficult I see it as, or as AMHPs describe how difficult it is to coordinate and do it, it is always more difficult to be on the receiving end of it.”

Thursday 29 June, is National Approved Mental Health Professional Day, a day organised by thePAdult Principal Social Worker Network to celebrate AMHPs and raise awareness of what they do. Join in the conversation on Twitter #AMHP17. 

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