The chapter looks at the ways in which decision makers (in this case Approved Mental Health Professionals [AMHPs]) construct and deconstruct their frameworks of understanding relating to the assessment of people who are diagnosed with personality disorders. It focuses on the assessment of service users who are subject to a high number of assessments and appear to occupy a disproportionate amount of mental health professionals’ time, both literally and emotionally.
The chapter is based on extracts from the author’s own research and explores the risk paradigm that AMHPs believe shapes the work that they do – in particular, a culture of blame. The factors that AMHPs believe prevent them from making decisions that they feel are in the best interest of the people they are assessing will be explored and contextualised.
The chapter also explores how theories of alienation – in particular, malignant alienation – can help AMHPs and other mental health professionals understand the negative relationship cycles that reinforce unhelpful coping strategies. A critical approach is taken towards the medicalisation and pathologising of what are essentially psychosocial behavioural reactions, and alternative interventions for managing what are perceived as service users’ unhelpful or self-defeating coping strategies are discussed.
In a timely and innovative chapter, the author (a practising occupational therapist and Approved Mental Health Professional [AMHP]) acknowledges and responds to the structural barriers and professional boundaries relating to occupational therapists undertaking the AMHP role in England and Wales. Specific professional frames are presented and the suitability and convergence of occupational therapists’ practice and values as part of compulsory decision making are outlined. The case for occupational therapist AMHPs is made creatively and with profession-specific detail. The chapter sets out how occupational therapists can continue their health-enabler role into their AMHP practice in the ways in which they consider alternatives to hospital and promote people’s independence through their clinical reasoning, decision making and communication skills. The chapter raises awareness about occupational therapists’ values and skills and how they relate to human rights work in a mental health context; in so doing, it serves as a vehicle to promote the profession and inspire therapists to train in these roles and thereby improve AMHP recruitment.
This chapter revisits, synthesises and reconciles the ideas raised in the introductory chapter and throughout the book. It summarises how the different frames connect and reviews how to practice across boundaries, emphasising that there are alternatives to rigid thinking where there is seemingly no middle ground. Suggestion are made for ongoing professionalism and practice wisdom, in keeping with policy and statutory reforms.
The subject of race inequality in mental health has been scrutinised by policy makers and researchers for decades. Despite government initiatives such as ‘Delivering Race Equality in Mental Healthcare’, there seems to be an intractability in relation to the closing equality gaps. In the midst of this, one of the decision makers in compulsory mental health work – the Approved Mental Health Professional (AMHP) – is at the sharp end of the data that attracts the sternest criticism: the higher-than-average rates of detentions of racialised minorities. Though solutions may be found in attending to socio-economic obstacles to equality in mental health, practising AMHPs need to have the skills to critique and amend their own practice so that they can take account of the antecedents of poorer mental health in the lives of racialised people whom they assess, and to mitigate against the impact of their own unconscious bias and prejudices. This chapter revisits the data in relation to ethnic inequality in referrals, pathways and outcomes from Mental Health Act (MHA) assessments for racialised minorities. Drawing on the latest research, key decision-making points are analysed to identify where biases may be affecting practice. Attention is given to unconscious bias and individual skills in challenging models, practice and policies that institutionalise the disadvantage of racialised minorities.
The interface between mental capacity and mental health legislation can present a challenge for decision making. It requires a depth of thinking and a viewpoint that goes beyond a legalistic one. The reader is invited to reflect on the spirit of the legislation and on their own position and interpretations. There is an emphasis on emancipatory, values-based practice and a focus on choice. The chapter supports professionals to frame their own decision-making orientation and to use existing models, practice, policy and legal imperatives to support this. The chapter suggests that practitioners need to strike a balance between enabling people and sanctioning people, and that balance sits on a very fine line. The chapter therefore asks the reader to be aware of professional, organisational and legal boundaries and frames and to acknowledge and understand the complexities and nuances of decision making. Historical, contemporary and future frames are addressed.
The chapter evaluates the experiences of coercion inside a mental health inpatient unit. It looks at the use of seclusion and organisational responses to self-harm and aggression using a gendered analysis. The author considers reputation, where women are referred to as being ‘difficult to manage’, and their conflicts and ‘dramas’ are interpreted from a framework that values a masculine type of conflict resolution in a predominantly male environment.
There is very little in the way of research and literature in this area and this is a refreshing contribution. There is a lot of transferable knowledge here, and the reader will be further enabled to reflect on the relevance of gender and power as part of their own assessments and interventions
The opening chapter provides a rationale for the underlying themes around practice boundaries and introduces the reader to concepts such as framing, frame reflection and policy drama. These ideas have relevance for compulsory mental health work whereby outcomes are understood to be disproportionate, variable and subject to biases. Boundaries are usually subjective, representing rules (formal or informal), safety, or a theoretical, interpersonal, literal or metaphorical divide. There is a need to frame and deconstruct these binary approaches to look at different frames for critical reflection. It goes beyond viewing scenarios in terms of lawful or not lawful; ethical or not ethical; ill or healthy; powerful or powerless; medical or social; us or them; rational or irrational; health or social; mad or bad; self-determination or social control – all ideas that are ubiquitous within psychiatry. The chapter acknowledges boundary work as the different positions competing for authority in mental health. Yet differences that seem insoluble can sometimes be resolved pragmatically by ‘reframing’ the issues and understanding the taken-for-granted assumptions around policy, statements of fact and value judgements. The chapter advances Peattie’s ‘double vision’ – the ability to act from one perspective while being aware of other perspectives.
Written by authors with direct lived experience, this chapter brings a perspective of being a Nearest Relative – a statutory role under the Mental Health Act 1983 (MHA) (amended 2007) that carries specific roles and responsibilities – and of being assessed and detained under the MHA. Experiences are compared and contrasted, and clear themes are apparent. Different types of power are at play in the way that relatives, carers and service users are communicated with. Like actors playing a role, there are clear expectations around behaviours, opportunities, rights and responsibilities. It is particularly important to look at the ways in which mental health professionals and service users are able to understand how to navigate and cross the bridge between them, and this may in particular be the case where one of these people is experiencing psychosis. The chapter authors use their experiences to suggest ways in which all parties might be better able to use an open approach where honesty and integrity is respected and meaningful. Boundaries between formal and informal roles, and the professional’s and service user’s positions are addressed.
Designed to support training and CPD in compulsory mental health work, this book looks at assessment, detention, compulsion and coercion in a variety of mental health settings. It focuses on decision making in a variety of professional roles with people from a diversity of backgrounds including contributions from people with lived experience of mental health services. With emphasis on theory into practice, the book is essential reading for those looking to develop their reflexive and critical analytical skills.
Relevant for all professionals making decisions under mental health legislation and those developing, teaching and supporting practitioners in the workplace, it includes:
critical reflection techniques;
‘editors’ voice’ features at the start and close of each chapter, summarising key themes.
This chapter asks the reader to consider communication needs at the point of decision making during statutory assessments. It focuses on participation of the person, framed here as shared decision making (SDM). Providing first the policy context and principles as to why this should happen, the chapter explores ways in which SDM can be supported for those who are deemed to have capacity, and also for those who may not. Discussing concepts such as insight and the use of jargon, the author explores the paternalism that can affect decision making, which in turn leads to a person not being meaningfully included in decisions made about them. Given the seriousness of the outcome of a Mental Health Act (MHA) assessment, such participation is key. It is argued that developing and enabling reciprocity is fundamental to SDM, and that the navigation of these boundaries is underpinned by attitudes, styles and skills. Concluding with a discussion of their own research, and developments such as Open Dialogue, the author looks ahead to the emerging shifts that may be seen in forthcoming changes suggested for mental health legislation in England and Wales.