Independence under fire

The government has signalled the end of the line for approved
social workers. So will the demise of the ASW mean the end of a
mental health system that looks beyond an individual’s physical
symptoms?

Despite strong criticism of the proposal to abolish the ASW role
when it first reared its head in the controversial 2002 draft
mental health bill, the government has stood firm. Estimates
suggest as many as three-quarters of the respondents to the
consultation on the first draft bill favoured maintaining the ASW
position. But their voices have had no effect in persuading the
government to reconsider.

In its revised draft bill published last month it states that
approved mental health professionals (AMHPs) will “effectively
replace” social workers approved under the Mental Health Act 1983.
While social workers will be able to take up the new role, they are
not the only professionals who can do so. The plan is for other
mental health workers, such as nurses and occupational therapists,
to also become AMHPs.

The duties of the AMHP will be similar to those carried out by
ASWs. Their chief function will be to co-ordinate initial
examinations of individuals to see whether they meet the conditions
for compulsory treatment under the Mental Health Act 1983. In a
similar way to the 1983 Act, two doctors and the AMHP will be
involved in the assessment. As with ASWs, they will be expected to
provide a non-medical view – easy enough for the social worker
AMHPs, but perhaps less so for health professionals.

Robert McLean, chair of the Approved Social Worker Interest Group,
thinks the proposed system will be disastrous.

“You’re going to have community psychiatric nurses and OTs who are
from the medical model and who will find it hard to take a
non-medical view,” he says.

Under the 1983 Act, ASWs must be “officers” of a local authority
social services department. Not being employed by the same health
trust as the medical staff allows them a certain autonomy. Under
the plans, AMHPs will still have to be approved by local
authorities, but given that some will be employed by health bodies
it is unclear whether they will retain the same independence.

“As the social worker is employed by a different authority and
comes from a different professional background, they find it easier
to go against a consultant’s view than someone who is from within
the same organisation. If all three are from the same profession,
then multidisciplinary working will not be as effective,” says
McLean.

To become an ASW, a social worker must undergo specialist
post-qualification training lasting at least 60 days. In a report
published last year,¹ the Mental Health Act Commission
stated that the training undertaken by ASWs is the most thorough
Mental Health Act training available to mental heath professionals
and that rigorous training would be needed if the role were to be
extended to other workers.

The government appears to have heeded this advice. In an open
letter to social workers, health minister Rosie Winterton says that
ASWs are “highly valued” for their knowledge and skills and that
other practitioners will be able to become AMHPs only if they have
the relevant professional competencies. But achieving this in the
near future is somewhat optimistic – a report from the Royal
College of Psychiatrists found that the ASW role “will not be
adopted easily by other professionals”.²

Even if other mental health professionals were adequately trained,
would they want to undertake the role? As far as nurses are
concerned, the answer is no, according to Brian Rogers,
professional officer for the Mental Health Nurses
Association.

“Most people don’t want to get involved. They don’t see any reason
to move away from the identified ASW role as it works. The only
reason for extending it to others is that there are not enough
social care professionals who can do the job, so they are trying to
find someone else to fill the gap,” he says.

Nurses often do not want to section people because of the impact it
could have on therapeutic relationships.

“Nurses work closely with service users who are often difficult to
engage. That relationship takes a long time to build and nurses are
concerned about interfering with it,” says Rogers.

OTs, however, are more amenable to taking on the role. Debbie
Green, mental health professional affairs officer for the College
of Occupational Therapists, says that some OTs, particularly those
working in crisis resolution and assertive outreach teams, will be
more in favour of becoming AMHPs. She has no doubt that mental
health OTs have the right qualities for the role, but worries that
there are not enough OTs as things stand.

“OTs have the right values in terms of looking at the social
aspects of someone’s life in a similar way to social workers. But
OTs are in short supply in mental health. It may mean that there
are fewer OTs doing occupational therapy,” she says.

OTs are also worried that their role could change for the
worse.

“At the moment OTs are not ASWs and service users do not consider
them a threat. OTs could lose that distance,” she says.

Since they were unleashed, the proposed changes to mental health
legislation have unified professionals from across the mental
health spectrum. Even psychiatrists are sorry to see ASWs go.

Tony Zigmond, vice president of the Royal College of Psychiatrists,
says that ASWs play a vital role.

“The ASW listens to me as the patient who is not mentally ill would
have done. It allows a broader view to be taken rather than just
the medical one,” he says.

And he doubts whether other professionals will be suitably
equipped.

“If you could have a profession which by its training from the
beginning could take the bigger picture and have a semi-independent
stance then that would be fine, but I don’t think at the moment
there’s another profession that could fulfil that role,” he
says.

Nothing in the draft bill is yet set in stone, as it is now being
scrutinised by MPs. However, given the fears about increased
compulsion and community treatment orders, it is unlikely that too
much attention will be dedicated to AMHPs. So the proposal is
likely to go through as it is.

Whoever takes on the role in the future has a hard act to follow.
What is paramount is that these new workers follow the example set
by ASWs and cling to the independence that lets them stand up to
doctors and fight for the rights of the patient.

¹ Mental Health Act
Commission, Placed Amongst Strangers, MHAC, 2003

² Royal College of Psychiatrists’ Research Unit,
Performing the Act, RCPRU, 2000

The proposals

• Approved social workers to be replaced by approved mental
  health professionals.
• The competence of an AMHP to be “broadly similar” to that
  required of an ASW.
• Social workers can take up the AMHP role, as can other mental
  health professionals such as mental health nurses and occupational
  therapists.
• AMHPs to be responsible for co-ordinating the initial
  examination.
• AMHPs to provide a non-medical view when considering whether
  someone meets the conditions for treatment.

What do service users say about the plan?  
 

• David Smurthwaite, psychosis, sectioned three
  times:  “You want as diverse a range of people involved as
  possible, as essentially the three individuals are being a jury.
  Mental health isn’t just about understanding the psychiatric
  issues, it’s about real life. You might as well have a social
  worker involved as they take a more grounded approach and are not
  so interested in the dynamics of diagnosis or medication.   “It’s
  not a good idea for nurses and occupational therapists to play that
  role because in psychiatric hospitals nurses and OTs are part of
  the team in which the doctors and consultant psychiatrists work. It
  would be like replacing social workers with someone from the
  psychiatric camp.   “Also, within psychiatric hospitals there’s a
  hierarchy – consultant psychiatrists and doctors, then nurses, and
  then OTs and additional workers. OTs and nurses are essentially
  going to nod at whatever the psychiatrist says.” 
• Cathy Walsh, Suffolk User Forum, qualified social
  worker, sufferer of post-traumatic stress disorder, depression and
  anxiety:  “I think it’s a very bad move. Social workers in
  the mental health system have a degree of autonomy and therefore
  any decisions they make are more objective. At the moment the
  consultant holds an awful lot of power and if OTs and nurses were
  doing the ASW job, those people work under him. We could lose the
  independence that ASWs bring, and that’s very scary.   “I’ve known
  cases where the ASW has stopped somebody being sectioned. Unless
  other professionals do a social work degree and the approved
  training after that, they are not going to possess the same
  values.   “The system will become totally dominated by the medical
  model if this goes ahead, and that will be very bad for service
  users. If you take away the ASW role you lose a very valuable
  perspective. That makes a mockery of having a multidisciplinary
  team.” 
• Paul Jones*, sectioned three times, various diagnoses
  including manic depression and borderline personality
  disorder:  “ASWs are not independent enough because they
  are employed by the organisation that wants to do the looking
  after. They can’t be that objective. Who pays their wages? Social
  workers are influenced by doctors. OTs and other professionals who
  work along psychosocial lines might be a good thing if the holistic
  side of a person’s personality is taken into account rather than
  just their symptoms. But maybe it would be better if it was an
  advocate.” 
• Jason Pegler, chief executive of Chipmunkapublishing,
  former sufferer of manic depression, sectioned twice:  “My
  experience of social workers is that they were no better than any
  doctors. I’ve met one social worker who’s helped me, out of seven
  or eight. An OT might be the sort of person that might be good
  idea. If you did a survey of mental health patients on who their
  favourite staff are in hospital, OTs would come at the top. It
  wouldn’t concern me if it was an OT as they have a compassionate
  role – more so than social workers. Perhaps the answer would be to
  have an OT who is independent from the NHS. It would definitely
  concern me if it were two doctors and a nurse. That isn’t right.
  But what’s more important is the way that sectioning is
  done.” 

* Name has been changed