By Nick Perry, AMHP and visiting lecturer
In February 2023, Community Care reported concerns from the Approved Mental Health Professionals (AMHP) Leads Network about the risks to people in crisis from severe delays to Mental Health Act (MHA) assessments, on the back of rising demand since the Covid-19 pandemic.
As someone working full-time in a dedicated local authority AMHP team, this was a picture I recognised. My own MHA assessment numbers skyrocketed from 94 assessments in 2019, to 179 in 2020, coming back down to 159 in 2021 and 135 in 2022.
I can also attest to the network’s observations regarding the difficulties accessing beds, doctors and transport, and generally delivering on the least restrictive option principle set out in the MHA code of practice.
‘A system more stretched than ever’
Citizens in mental health crisis face a system more stretched than ever and the pressures are also taking their toll on the AMHP workforce.
Back in September 2022, Community Care reported that AMHP numbers had decreased by 3% from 2020-22, amid long-term retention issues arising from an ageing workforce and a lack of take-up from professions other than social work.
I am 47 this summer. I started warranted AMHP practice when I was 31, having been qualified as a social worker for five years prior to that. My retirement age is projected (at the moment in any case) to be 67. I cannot see myself being able to work for another 20 years in this role, given the increased intensity and emotional impact of the work.
What has sustained me in my AMHP practice over the past few years is undertaking more therapeutic training, and bringing this perspective to bear on my work. With resources so stretched, giving AMHPs the skills to make the best use of their client contact is hugely important to their resilience.
This isn’t only my view. Research with child protection practitioners in Tenerife found how a solution-focused approach could help protect workers from burnout (Beyebach & Medina, 2014).
New standards – and opportunities – for AMHP training
Last year, Social Work England consulted on revising the approval standards for AMHP training courses, publishing finalised standards in November 2022. At the time, it said it would “prepare supporting guidance to give more detail about how course providers can demonstrate that they meet the standards”.
It is not yet clear whether the guidance will make recommendations on course content – but what an opportunity to do so?
Not only could this help AMHP training programmes provide trainees with specialist legal expertise in relation to the MHA, and a solid knowledge base on mental disorder. It could also help them deliver the therapeutic training that will enable AMHPs to make best use of pre-assessment contact; to keep assessments firmly focused on the client’s best hopes, and to deliver as anti-oppressive an experience of the MHA assessment process as possible.
At the turn of the year, David Watson, a teaching colleague from the AMHP training programme at Brighton University, and I had an article published in the Journal of Ethics & Social Welfare – Solution-focused practice and the role of the approved mental health professional.
Benefits of solution-focused practice
The main contention of this article was that learning the techniques of solution-focused practice could assist AMHPs to deliver least restrictive (and least oppressive) outcomes and experiences, and that these skills should be a mainstay of the training and the CPD of AMHPs in England and Wales.
The article highlights some of the key questions and techniques of the solution-focused approach, such as asking the client about their best hopes going forward, and what might be the tiny signs of moving in the right direction. It then shows how these can be applied in an AMHP’s pre-assessment contact with a client, via a case study example
It seems to me that with the Social Work England guidance to come, and a bill to reform the MHA expected before the next election, due in last 2024, we are at a moment of real opportunity.
There is the possibility of making serious and important decisions to invest in the education, therapeutic skills and future resilience of our AMHP colleagues to come.
As a follow up to our article I have begun to collate views from AMHPs across the country on some of these issues. It seems clear from the headline responses that there is much support for more focus within AMHP qualifying (and ongoing) training on the pre-assessment contact with clients, and the possible benefits that this can bring, not only in respect of assessment outcomes and person-centred practice, but also in respect of AMHP wellbeing and retention.
Nick Perry is a senior practitioner and AMHP at East Sussex County Council and visiting lecturer on the AMHP course at the University of Brighton
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Why is it that for every “challenge” the response is for more ‘training’? Why not start by looking at the structural problems that support and encourage willful ignoring of law? Why not start by critically appraising the misuse of law and the manipulation of nearest relatives to perpetuate a mental health system stacked in favour of ‘professionals’ rather than appropriately addressing of distress? AMHP’s are an integral cog of a racially and gender discriminating ‘care’ system. No amount of empathy affirming therapeutic tools can address the denial of human rights, violence and forced medical treatment that AMHP’s collude in perpetuating. The starting point should be critical appraising of the role of the AMHP irrespective of how they are trained. That AMHP’s constantly bat away the reality of what they’re a part of by shifting the narrative on to difficulty accessing beds, ambulances and doctors is always telling. An honest debate about “pre-assessment contact” would show that there is nothing meanigful or person specific happening. Why? Because if the first response to a MHAA request is to ask if there is a “bed available” than the assessment is already framed around admission and application to detain. Whatever thay say, and I work alongside them, AMHP’s see hospitals as the place where mental health care takes place. Change that mindset, move away from the expedient intervention and you might just shift the narrative onto therapeutic interventions.
A bit harsh on the collusion bit but essentially this is spot on. It’s a little perplexing to tout “pre assessment contact” as a point of therapeutic contact when almost all AMHP involvement ceases after an assessment is done. Post admission visits to wards, contact with the NR and family carers beyond the consultation, involvement in discharge planning are virtually zero from AMHPs. To admit or not isn’t solution focused work. Staying in the lives of people subjected to a MHAA could be.
I have been an AMHP for 11 years now and strongly feel and often verbalise that little mentl health care takes place in hospital it feels that its more about containment than anything else. AMHPs are not a homogeneous group!
we should be spending more time challenging the societal structures and inequality that keep people in a state of mental distress
Thanks both for taking the time to comment.
Tahin, whilst I absolutely agree that AMHPs work in a system that is full of racial and gender discrimination, and that we will all have our own prejudices (acknowledging this is the cornerstone of anti-oppressive reflexivity), our statutory mandate is to look for the least restrictive way of delivering the help and support that somebody needs, safely.
I think many AMHPs – if you ask them – will be extremely circumspect about the therapeutic benefit of inpatient admission for many people. Our difficulty – right across the country – is the lack of alternative (less restrictive) options where the risk threshold is such that clients can be accepted and helped in their time of crisis, outside of hospital. This is something that needs urgently to be addressed.
Janet, you are right to say that AMHPs don’t often have the capability of following up on the people that they assess, nor provide a level of continuity. In my service, where we have five full time (daytime) AMHPs, we do try to do this. The reason that SF practice feels such a good fit with, and to be ‘twin-tracked’ with, the statutory work we do, is because of exactly the possibility of a one-off intervention being useful – particularly if framed by the client’s best hopes for our talking together… I hope that you will find the article by David Watson and I interesting in that regard.
Hi Nick, I have read the article, I would not have commented without doing so. This is why I still.struggle to understand how looking at tomorrow stories in isolation from the whole system inversely not buying into this is therapeutic. Home Treatment Teams work to a very prescriptive, and short, time frame. Wards have their own priorities about best treatment options which may not correspond to the narrative of the AMHP. You will be aware of the negative experiences families and inpatients consistently tell us. I would be a bad social worker if I didn’t advocate therapeutic interventions but I would also be failing if I didn’t recognise how AMHP services, community services and hospital services seldom agree on a common language let alone are inclined to put the person in distress central to their silo planning. Good practice by individuals doesn’t compensate for systemic authoritarianism.
This article is a breath of fresh air. As a social worker who struggled in an assessment-dominated system with children and families, I recognise the issues here so clearly, and it is great to read how Nick – and his colleagues and service users – has benefited from coming across solution-focused practice just as I did all those years ago. It really does have something to offer here, and I hope that the moment of opportunity identified is fully grasped.
It would be churlish to quibble too much with the aim of improving experiences of and outcomes for people in contact with AMHPs. That said to bat away the inequities of that relationship and the power embedded often against the well being of people by reframing it as “circumspect” doesn’t cut it. Today as every day people will be traumatised by being removed from their accommodation, sometimes by force, sometimes in handcuffs, with little privacy and not much dignity because 3 professionals deem admission to be the desirable option. It makes no difference that this is done because there is no alternative community option. AMHPs handwring about this constantly but I see no real effort made by them and their managers to agitate for better alternatives. Saying and doing are not the same. I was an AMHP until I could no longer pretend that seeing people pinned to the floor and forcibly injected, witnessing people being intimidated and threatened if they didn’t comply with often arbitrary and contradictory demands, listening to AMHPs say once too many times “not xxxxx again” on receiving a referral had nothing to do with my role. The system isn’t about care and not necessarily about treatment either. I’m afraid the untold is that AMHPs are an integral part of a ‘risk management’ factory where quality control is about how to avoid adverse scrutiny of services and individual professionals. Ofcourse many AMHPs are exhausting themselves to be better than this but their good practice doesn’t compensate for the inbuilt negatives of their network. Hope is a tad hollow when after the flurry of professional activity to ‘co-ordinate’ the assessment, people return to the very same circumstances that raised the “concern”. Do something with good intent is better than doing nothing but when something doesn’t compensate for the isolation, the poor diet, the lack of meaningful support and the loneliness, it just a salve for the professional conscience really isn’t it?
There is privilege and professional status in the titles of Senior Practitioner/AMHP and Vsiting Lecturer not afforded to those of us who aren’t. Some months back I was hauled into the rather splendid glass panelled office of the Head of Service to a ‘meeting’ that included the AMHP lead and PSW. Apparently I had committed the unacceptable sin of declining to make an application to detain and the Consultant Psychiatrist was less than happy. In the monologue that was the ‘meeting’ I was told that my bosses had reviewed the complaint and agreed with the Consultant that admission should have happened. Apparently their risk assessment concluded that the partner of the person was not a suitable alternative nor the wider family who live nearby as I
had suggested. Accordingly another AMHP had been asked to do a new assessment. I was not asked to explain let alone justify my decision. So I ask, if our bossess think appeasing health colleagues is the priority, where is the scope for professional autonomy let alone the possibility of therapeutic thinking? I’m humble enough to consider that I might err in my practice but confident enough to know that in the 4 and a half years I have been working with this family I made a considered and well supported decision. If our Leads and PSWs lack the confidence and courage to insist they are not second fiddle to doctors than no amount of training can recalibrate that. When social workers are pitched against each other under an instruction you end up with a detention which is discharged by the Tribunal in a withering summary. That is dispiriting. So it’s not just about resources, it’s not just about numbers of AMHPs, it’s not just about alternative community options. Would I have detailed my experience here if I wasn’t retiring in 2 months? That might be a question the next study, the next survey might want to consider.
I am so very sorry and sad to hear of your experience Soon Ex, and the fact that you are no longer working as as AMHP, Antony.
I do understand the disillusionment.
And how desperately do we need brave managers, steeped in a commitment to least restrictive practice; prepared to defend their AMHPs to the hilt?!
I hope, to paraphrase Plato, you become changemakers in other ways. More power to your elbows.
When AMHPs and their colleagues are happy to receive the services they impose on distressed people those of us on the outside might come to beleive that they are serious about improving those experiences.