Practice example: the approved mental health professional as an advocate

By Steve Matthews (The Masked AMHP)

Note: names and details have been changed

Approved mental health professionals (AMHP) are sometimes seen as intimidating agents of social control, enforcing a medical model of care and treatment on people with mental disorder against their will.

But that’s actually far from the truth. The AMHP’s imperative is only to consider compulsory admission to hospital if there is no alternative. It is the role of the AMHP to bring a social perspective to the Mental Health Act (MHA) assessment, to counter a purely medical approach to people experiencing mental distress.

Rowena’s case

I remember being asked to assess Rowena* under the MHA. She was in her mid thirties, married to James*, a sales rep for a national company. Rowena had twin boys, born two weeks previously. She had had to have an emergency Caesarean Section. Other information included that:

• The health visitor had visited and reported that Rowena had cut her chest with a razor blade.
• She noted Rowena was not engaging and would not go to her doctor about the cuts on her chest.
• She felt Rowena’s husband wasn’t coping.
• Rowena had refused to speak to the health visitor.
• Rowena had told her that she objected to the Sun newspaper’s habit of publishing pictures of naked women and had complained to the paper.
• The health visitor decided Rowena was incoherent, and it was impossible to follow her train of thought.
• She interpreted all this as possible signs of puerperal psychosis.

Initial view

It’s the AMHP’s job to look at all the circumstances of the case, and to obtain as much information as possible.

• Another AMHP had made initial contact with Rowena.
• This AMHP reported that Rowena had said she had an axe hole in her stomach, and she looked disgusting and socially unacceptable.
• She explained that she had long term body image problems, and that she had not wanted to have a Caesarean. She felt traumatised by the wound.
• The AMHP had concluded that Rowena was not psychotic, thinking possible childhood abuse trauma had surfaced as a result of the Caesarean and the general experience of childbirth.
• A children’s social worker had visited Rowena, and reported no concerns for the welfare of the twins.

The options

So what was I to do? There was a formal request for assessment. Serious claims had been made about Rowena’s welfare and the safety of her infants. Puerperal Psychosis was potentially very dangerous.

I could go down the standard route and knock on Rowena’s door unannounced with two doctors in tow. But Rowena was already distressed, and having three strangers arriving at her front door threatening to put her in hospital could in itself precipitate a crisis which could result in compulsory admission.

There was also the likelihood that a hospital admission could result in Rowena being separated from her babies.

A low key response

So I decided to respond in as low key a way as possible. Section 13(1) MHA states only that the local authority “shall make arrangements for an AMHP to consider the patient’s case”. It is for the AMHP to decide how to proceed.

I phoned Rowena. I explained who I was, told her about the request to assess her under the MHA, and asked to see her. At first she refused.

I explained that the purpose of my visit was to establish what her needs were, and if at all possible to allay people’s concerns. We had a reasonable conversation, and she eventually agreed that she would see me.

I and a female AMHP visited her at lunchtime, when James would be there. Rowena readily allowed us in. The twins were settled, changed and fed. The room was clean and warm. All was calm and under control.

Rowena was wearing makeup, and smartly dressed. She cooperated with the interview and showed warmth and appropriate responses to questions. There was no evidence of thought disorder.

She was clearly preoccupied about pornography and the Sun newspaper, but she said that she had always felt strongly about pornography, and had campaigned against the Sun in the past. All was within the bounds of normality.

She had always had problems with self esteem and her appearance, and her pregnancy and the changes to her body had been difficult to manage. She hated the caesarean scars, and felt she had to have plastic surgery on her stomach.

There was no evidence of suicidal thoughts, depression or delusions, and her concerns did not constitute evidence of puerperal psychosis. She felt the problem was stress, anxiety and trauma relating to her pregnancy and childbirth. I agreed with her.

Conclusions

So what were my conclusions?

• The twins were well nourished, healthy, and well cared for, in a comfortable environment under the supervision of their mother.
• There was clear evidence of a warm relationship and bonding with the twins.
• The risk to the twins, the patient, and her husband of Rowena being admitted to hospital far outweighed any risks of her remaining at home.
• It was completely inappropriate to consider admission to hospital.

We agreed the following plan. Rowena would be assessed by her locality mental health team, as talking therapy might help her deal with low self esteem; a psychiatrist could support her having plastic surgery on the basis of mental health. James might be able to get extra time to support his wife.

Rowena wasn’t sectioned, she wasn’t bundled against her will into an ambulance, and she was not separated from her family. Result.

Steve Matthews writes The Masked AMHP blog and has been an ASW and AMHP for far longer than he cares to remember. He also teaches mental health law on the University of East Anglia AMHP qualifying course.