Distress, uncertainty and frustration: nearest relatives’ experience of Mental Health Act assessments

AMHP training has traditionally focused more on identifying nearest relatives than supporting them. However, there is much that can be done to improve nearest relatives' experience of MHA assessments, research finds

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By Jeremy Dixon, Judy Laing and Kevin Stone

During approved mental health professional (AMHP) training, the importance of the nearest relative role is frequently highlighted.

The role was introduced through the Mental Health Act 1959 and gave specific family members rights and powers during an assessment, in which a person with a mental disorder may be detained in hospital against their will.

Guidance on nearest relatives

You can find out more about the nearest relative’s roles and responsibilities by reading Community Care Inform Adults’ quick guide to the issue, which is available to subscribers. It is written by Mental Health Act trainer Rob Brown.

Under the Mental Health Act 1983 (MHA), nearest relatives may ‘object’ to an admission for treatment by an AMHP, which could stop the admission from taking place. They also have powers to request that an AMHP considers a request for an MHA assessment and may order that their relative should be discharged from hospital.

Nearest relatives are often seen as a brake on medical power and are viewed as key in protecting the rights of people who are being assessed under the MHA (Laing et al, 2018). A great deal of attention within AMHP courses is given to correctly identifying the nearest relative, which is often a complex task. However, far less is given to thinking of ways to support the nearest relatives who are undertaking this role.

We have recently conducted research on this issue, consisting of face-to-face interviews with 19 nearest relatives on their experiences of the role. While many of our questions focused on their views of their legal duties, most of the people we spoke to described the emotional impacts of carrying out the role.

Distress

These impacts manifested in several ways. First, half of the participants in the study told us the MHA assessment was a distressing experience. One interviewee described the sense of chaos in the home during the formal assessment:

The actual sectioning process was as horrible as it ever could have been. It was possibly the worst experience of my life…one minute there were police cars and half a dozen doctors and lots of shouting and stuff going on and then the next minute I was just there on my own and that was a bit kind of challenging, difficult.”

Others attributed feelings of distress to uncertainty about the nearest relative role or because they felt it had impacted negatively on their relationship with the service user.

Secondly, other participants described feeling relieved following the assessment, seeing it as  a helpful response to their relative’s behaviour, though some also highlighted the kindness shown to them by mental health professionals or their employers.

Thirdly, some reported conflicted emotions, primarily linked to their powers to act as nearest relative, specifically, the tensions between having the right to request an assessment, the power to object to an admission and the power to discharge from hospital.

Frustration with services

A final dominant theme was feelings of frustration with mental health services. This was either because nearest relatives felt that staff had ignored or minimised their concerns, or due to lack of information sharing by professionals about the progress of their relative’s compulsory admission and subsequent care or discharge arrangements. Some nearest relatives also reported frustration due to the lack of support offered to them by professionals during the assessment process. For example, one participant said:

They just have their little platitudes that say, ‘oh you can call the crisis number’, or ‘you can call the police’. They don’t actually know what that means.  They tell people to do things that aren’t going to help…. because they think they’ve ticked the box.”

Nearest relatives suggested that being provided with more information about the role would be useful, coupled with the offer of emotional support, both prior to and following the compulsory admission.

Our findings highlight that most nearest relatives are committed to their role, but many report feeling distressed by the MHA assessment process. While some nearest relatives reported feeling relieved that their relatives had been detained, it was common for individuals to report frustrations with the degree of support they received from mental health services and staff.

How AMHPs and social workers can help 

AMHPs and social workers need to recognise the challenges that nearest relatives face. There are also a number of practical steps that they can take.

Providing nearest relatives with clear information in advance about the role and what is expected of them can reduce the pressure on them. Time should be given to provide nearest relatives with emotional support, particularly after an MHA assessment has taken place.

Nearest relatives should also be informed in good time of plans to discharge the person who has been detained. There may also be benefit in local authorities commissioning education programmes and support groups for nearest relatives.

From nearest relatives to nominated persons

The government has proposed that the law should be changed, with nearest relatives being replaced by a new nominated person role. Its 2021 white paper says that these changes are necessary so that service users can choose who they would like to represent them.

If the proposals are accepted, nominated persons will have the same powers as nearest relatives but also some additional ones. These may include the right to be consulted about care and treatment plans, hospital transfers and renewals or extensions to detentions or community treatment orders (CTOs). They may also be given powers to appeal clinical decisions at tribunals, in cases where service users lack capacity to do so, and to object to CTOs.

These proposals should be welcomed as they provide service users with improved representation. However, our research indicates that they are only likely to be effective if nominated persons are given sufficient support.

This support should be both practical and emotional. Nominated relatives could benefit from courses or online materials explaining their legal rights and how they exercise them. They should also be offered emotional support, particularly at points where service users are being detained or when discharge from hospital is being considered.

The full article, Beyond the call of duty: A Qualitative study into the experiences of family members acting as a Nearest Relative in Mental Health Act assessments, can be accessed for free from the British Journal of Social Work.

Jeremy Dixon is senior lecturer in social work at the University of Bath, Judy Laing is professor of mental health law and policy at the University of Bristol and Kevin Stone is associate professor of social work at the University of Plymouth

References

Laing, J, Dixon, J, Stone, K and Wilkinson-Tough, M, 2018. The nearest relative in the Mental Health Act 2007: still an illusionary and inconsistent safeguard?  Journal of Social Welfare and Family Law40(1), pp.37-56.

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20 Responses to Distress, uncertainty and frustration: nearest relatives’ experience of Mental Health Act assessments

  1. Patricia May 3, 2022 at 9:37 am #

    Ah but if you see your job as being the second league lawyer rather than social worker than it makes perfect sense to pass the Nearest Relative to someone else to “support”. As oft repeated by an AMHP when I have actually managed to speak to one “do you know how many mental health acts I am doing.” When people become numbers to boast about how busy you are it’s spot on to say platitudes and ticking boxes is the result.

  2. Sad May 3, 2022 at 11:09 am #

    I am a social worker who has personal experience of how AMHP’s interact with a NR. Every word of this article is true. The whole process is not only distressing but dehumanising. I have many things I could add about my AMHP colleague but the most upsetting was the obvious irritation they didn’t even try to hide when my mum wanted to ask questions. Whether it’s the numbers of MHAA they do simultaneously or stress because of that, as the article hints at, AMHP’s seem desensitised to the experiences of “patients” and families. We are individuals and our families have gone through much agony before an AMHP gets involved but doing a MHAA should never become a routine task. I know organising an assessment is a complicated and perhaps dispiriting but we on the other side feel much much worse. My mum spent 4 days in bed because of the guilt she felt at having my brother admitted to hospital. Not one social worker phoned or visited her even after me trying to get a response. I don’t beleive the rhetoric of human rights and social justice often given as the unique quality AMHP’s bring to mental health. Our experience is sadly not unique. It breaks my heart to see fellow social workers so inured to pain infront of them.

  3. Andy May 3, 2022 at 2:26 pm #

    I am truly sorry that your mum and you have had such a poor experience. It is true that we are mostly conducting multiple assessments. But the challenges of identifying a bed and getting doctors and police to respond should never take our focus away from the person and their family. Personally I don’t think responding defensively as some of my fellow AMHP’s no doubt will helps us understand the impact we have on lives and how we can improve AMHP practice. I hope there will be a thoughtful and open response to this important study from the AMHP Leads Network. Nobody should have a negative experience least of all one of our own.

  4. Greg May 3, 2022 at 4:12 pm #

    There is always a bigger picture when we conduct MHAA and perhaps it’s our fault that we haven’t explained that picture better. Families only see a fraction of what AMHP’s do. Because of that they only have a limited understanding of what is involved and what our role is. I don’t know what the circumstances Sad is recounting and unlike Andy I will not pile on my AMHP colleague and accuse them of conducting their assessment poorly. That’s not a defensive response but one based on my professional experience. Being subjected to an MHAA is sometimes unwanted by families and because of this they can have a negative experience and blame us AMHP’s unfairly. We do what we do in good faith. But we have to comply with the law which sometimes puts us in conflict with others. In all likelihood your mum was neglected by a community team Sad. They are a different kettle of fish to us altogether.

  5. James May 3, 2022 at 8:08 pm #

    This article is so accurate. I’m a social worker and encountered incredible problems trying get a MHA assessment completed for my relative. I felt that all my concerns were minimised by the AMHP and they were not detained until after days of manic and dangerous behaviour. He finally arrivied at an A&E department in a critical medical state due to self neglect. If I ‘speak the same L professional anguage’ and was dismissed, how on earth does anyone else try to evoke their rights as NR?

  6. Ian May 3, 2022 at 11:51 pm #

    Other AMHP’s might not thank Greg for being so honest about their certainty about their professional superiority but they are, in my experience, the majority AMHP view regularly expressed in private. I say this from the loud conversations I frequently hear as I sit two desks from the revolving entity that is the “Duty AMHP.” How apt that for all of Andys emphatetic response the cat is nevertheless out the bag and their their prediction of such a response from Greg is borne out. AMHP’s really are a different kettle of fish it seems. Patricia, Sad and James can’t all be misguided can they?

  7. Shaun May 4, 2022 at 9:38 am #

    I don’t question that’s how people feel. However what people forget is the AMHP is the end of the line. You should refer for an AMHP when all other pathways have been exhausted because involving an AMHP means formal detention under the MHA (1983) is being considered (I emphasise CONSIDERED not automatic or mandated). By that point the situation will already be heightened and fraught emotionally. Before seeing the AMHP the person may/should have seen possibly a GP, almost certainly some kind of mental health crisis team often coordinated by the NHS, a psychiatrist provided by the NHS. Possibly they may have been under a community mental health team before then. They may have an allocated social worker. At least some of these professionals as well as the AMHP should be sufficiently legally/procedurally literate to be able to explain accurately the expectations of the NR role, empathise with their challenges and difficulties and where/how additional support can be accessed to support them. Yes there are requirements of the AMHP, and they should be empathic and person centred. Yes some AMHPs have a superiority complex. Let’s be honest here though, there are better AMHPs and not such good ones, better SWs and not such good ones, better CPNs and not such good ones and better psychiatrists and not such good ones etc. There are some people in all the health and social care professions that could do better.

    • Taylor May 4, 2022 at 8:20 pm #

      But only AMHP’s seem to find it an affront and an irritation that we dare to refer to them. Not even the dreaded psychiatrist in my locality starts with hostility and turns every conversation into a confrontation.

      • Craig May 5, 2022 at 8:11 am #

        The discussion here is not about CPN’s, SW’s and Psychiatrists though is it?

        • Shaun May 5, 2022 at 2:00 pm #

          I am sorry for your experience Taylor, but that doesn’t happen everywhere and it doesn’t happen all the time. Yes it doesn’t change your experience but as an AMHP of 15 years (previously ASW) I have seen a whole variety of practice….some wonderful, some far from it.

          Craig the article on which this thread is based refers to SWs as well as AMHPs, see “How AMHPs and social workers can help ” in the piece. Secondly having done this job for a very long time there is a gross over assumption that engagement with NR and how that is done solely sits with the AMHP. The amount of MHA (1983) assessments for s3 that have been requested, sometimes as an inpatient having been detained under a s2, and the inpatient Consultant Psychiatrist/RC has not even spoken with NR and family upto 28 days after admission, but is expecting AMHP to manage situation immediately. I am not justifying poor practice….where there is poor practice by AMHPs it should be called out. However what I do challenge is the notion that it is only AMHPs that could improve their practice.

          • Taylor May 5, 2022 at 3:32 pm #

            Ofcourse it’s not just AMHP’s who.could improve their practice and from another perspective my own might be short of brilliant to others. But I acknowledge that for all my experience, I can improve. I have not met one AMHP who readily admits that they may not be an “expert.” That was never my experience with ASW’s and perhaps its because you were one previously that you have a different mindset to the Portfolio clutching. I read Craig as commenting on the comments not the research but point taken.

    • anon person May 6, 2022 at 5:43 pm #

      Don’t know where you are practising but almost ‘certainly’ see by some kind of crisis team is so far from the norm this part of London where refusal to accept referrals is the usual experience and the stuff of CCG GP forums.

      How about we talk about the not so transparent barred lists of those who crisis teams automatically refuse to see whatever and wherever the presentation in order to gatekeep.

      How about those the crisis team also refuse to see for spurious reasons that include too suicidal or not suicidal enough. Whilst not ever providing the criteria for when they do accept referrals. And where the too suicidal are not referred on to an AMHP/MHAA team. Leaving in dangerous limbo assuming family will carry the burden acute services run away from.

      And the cap on referrals to the crisis team from MH trust crisis line – again to gatekeep instead of say, a streamlined coordinated response and make sense approach.

      Until professionals call out their professional colleagues nothing gets better. Just more and more anguish, trauma and preventable deaths.

      Transparency is missing from the entire process. and for a NR yes, traumatising with long lasting impact on both the ability to ever support the person again and trust of professionals .

  8. Patricia May 5, 2022 at 8:33 am #

    Where I work the biggest cheerleaders for AMHP’s are the psychiatrists. How interesting that in a forum for social workers there doesn’t appear to be the same level of enthusiasm. Might that have something to do with the self regarding abilities of AMHP’s to unerringly reframe peoples experiences into “feelings”? And their yearning for validation from psychiatrists. “Legal and procedural literacy” indeed.

  9. Christopher May 5, 2022 at 1:04 pm #

    While I accept that all professions have peculiar practitioners, AMHP’s do seem to relish promoting a weird authority obsession. I wish they would just be content with being social workers so we can be true colleagues. That said its the Leads Network we need to hear from really. Do they agree with the points raised by this research? If yes, how are they going to address them? If no, why?

  10. Colin May 8, 2022 at 8:18 pm #

    As social workers we are the handmaidens of the authoritarian state so are unlikely to be loved. Most of us struggle to reconcile this with our hand wringing liberalism but AMHP’s seem to relish the power dynamic. How else to explain the incessantly repeated mantra that their role is to “discharge their duties under the Mental Health Act”. Or put simpler, they are functionaries of ‘the law’, just like the police.
    Ofcourse it might just be that AMHP’s are more honest about being agents of State control of individual lives than us permanently conflicted social workers are.

  11. Tomy May 11, 2022 at 10:57 am #

    The Government is reforming the MHA. I am sure ministers will listen carefully to what the AMHP Leads Network has to say. And the “patient” will be at the heart of the debate because AMHP’s uphold civil liberties and promote medical and culturally appropriate treatment. They do right?

  12. Lee May 11, 2022 at 11:07 am #

    Social workers doing the fluffier bits of social work need to take a step back. Or spend a day doing what an AMHP does to earn the privilege to vocalise their prejudice.

    • Anon May 15, 2022 at 9:52 pm #

      You are not some kind of heroes and some humility would be helpful. Try being the NR try being the terrified traumatised P possibly losing their liberty ,being sent hundreds of miles away to violent abusive settings… You get extra pay to be on the duty roster so not quite an altruistic offering .

      As an NR and NHS professional who has to work and negotiate with social workers with both hats on, would go as far to say the AMHP neither transparent or accountable. More like a hit and run driver for my family. But hey, nothing like power to invalidate the real life experiences of others- including those left to pick up the pieces after MHAAs.

      You know what the biggest complaint about AMHPs this area is? The arrogance.

  13. Jeremy Dixon May 12, 2022 at 5:06 pm #

    I am one of the authors of the article. I thought I would pick up on a few points which have been raised (although I will have to be brief because of the character limit).

    Participants’ experiences of AMHPs were mixed and the full article gives more details of this. Our participants indicated that they felt frustrated in cases where they felt that they were being fobbed off by services or that their concerns were being minimised. This criticism also applied to community and hospital services.

    From my perspective the key problem is that we expect nearest relatives to perform an important and stressful role without building in any training or support mechanisms.

    It is interesting to see the debates on the AMHP role. We covered AMHP perspectives on the nearest relative role in another article published in Health & Social Care in the Community in 2020. This can be accessed for free if you look me or Kevin Stone up on the Researchgate website. It can also be accessed for free on my University of Bath profile page which you can find if you Google me.

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