This essay is going to reflect upon the tensions of care versus control and related dilemmas of rights versus risks that mental health social workers, particularly those who are Approved Mental Health Professionals (AMHP), face in practice. These issues shall be considered predominantly in relation to “applications for compulsory admission to hospital for assessment or for treatment under Part 2 of the [Mental Health Act 1983] (s13)” (Brown, 2009, p. 63). First the role of AMHP, the MHA and policy guidance will be outlined. Due to limited words, issues associated with questions over capacity and the Mental Capacity Act 2005 (MCA) will not be discussed, nor will Community Treatment Orders despite their great relevance to this discussion. The term ‘patient’ will be used for consistency with the language of the legislation.
Approved Mental Health Professional, Mental Health Act and Code of Practice
Rapaport and Manthorpe (2008) explain that social work recognised the potential for oppression and discrimination in mental health services and that the role of Approved Social Worker (ASW) came about to safeguard against the power of medical professionals, bringing an alternative perspective. The Mental Health Act 1983 (MHA) was revised by Mental Health Act 2007 where the role and powers of ASW was replaced by AMHP, which means that some nurses, occupational therapists and psychologists, as well as social workers, can undertake training to become ‘approved’. This was a controversial with some social workers asking whether these professions, given differing value bases, could “stand up for service users suffering an acute mental health crisis” and if they would “inevitably succumb to the medical rather than the social model of care” (Hunter, 2009:online)
AMHP have several roles and responsibilities, sanctioned under the MHAs (1983 & 2007) and Code of Practice (2008) (COP) which place the social worker in a powerful position in relation to the patient; they contribute to decisions which may jeopardise an individual’s liberty and rights or care. Roles of AMHPs include making applications for guardianship, applications to displace nearest relatives as well as in making applications for compulsory admission to hospital for assessment or treatment (Brown, 2009). A ‘nearest relative’ can also make this application however as reflected in 4.28 of the COP (2008) usually an AMHP does. Different sections 2, 3, or 4 of the MHA detail the specific limitations placed on a ‘patient’: Section 2 is compulsory admission for assessment (possibly followed by medical treatment), it is for up to 28 days and is not renewable; Section 3, compulsory admission for treatment (possibly without consent under s. 58 MHA 1983) is for up to six months and is potentially renewable (Brown, 2009); Section 4 is emergency admission for up to 72 hours.
Within the MHA (1983/2007) and COP (2008) there are criteria, safeguards and guidance around an individual’s compulsory admission, not all can be relayed here but a few key principals and roles of the AMHP will be highlighted. The key principals in the COP (2008:5) include: Purpose – decisions must be related to minimising distress and risks while maximising welfare; Least restriction – the AMHP must consider alternatives to detention ; Respect – recognition of diversity and listening of the views of the patient; Participation – of patient and relatives in care planning and development; Effectiveness, efficiency and equity – use of resources to meet patient’s needs.
When making an application under sections 2 or 3 of the Act an AMHP must provide recommendations from two doctors who meet criteria and one doctor for a section 4. These recommendations in the MHA 1983 s. 2 (2a,b) 3(2a,b) are concerned with the need for admission on the grounds of the ‘nature or degree of mental disorder’ in relation to the reason for the admission and in relation to 3 aspects of risk – the patients “health or safety or with a view to the protection of other persons …”. Significantly for a section 3 the 2007 Act (s.4) amended the 1983 act requiring that ‘appropriate medical treatment is available’ but with no test of its effectiveness.
Peay (2003) suggests that the considerations for AMHP are more social than medical in nature. For example, assessment of environmental or relational issues, values and knowledge of service that are available are fundamental to what an AMHP contributes. The AMHP must interview the patient in “a suitable manner” to be content that the criteria set out in the Act for compulsory admission are met and conclude it is “ … the most appropriate way of providing the care and medical treatment …” (MHA 1983: s.13(2))
Despite guidance in the COP on the nature and degree of mental disorder, considerations when assessing the 3 areas of risk, and what constitutes interviewing in a ‘suitable manner’, ultimately, the AMHP must use their skills and knowledge to interpret the law to make good judgements about whether someone’s right to freedom (Article 5, Human Rights Act 1998) can be ‘trumped’ (Yianni, 2009). Peay (2003:14) describes a problem of with this,
… the act fails to specify any particular threshold that has to be satisfied before the presence of risk meets the notion of ‘necessity’, the terms remain a matter of individual interpretation. For this reason they are also vulnerable to an understandable tendency for professionals to find them satisfied by meagre evidence in circumstances of uncertainty.
Social Work Values
An essential part of this debate lies in the recognition of ‘overlapping but competing goals’ of public protection (which the public and politicians are preoccupied with), access to care and services for those with mental health problems and protection of the patients civil and human rights (Hale, 2003).
The GSCC provides a Code of Practice which Social Workers should work within. Statements 1,3 and 4 out of only 6 statements are particularly relevant to the tensions AMHP face when considering compulsory admission. These include:
1. Protect the rights and promote the interests of service users and carers;
1. Promote the independence of service users while protecting them as far as possible from danger or harm;
4. Respect the rights of service users whilst seeking to ensure that their behaviour does not harm themselves or other people
Yanni (2009,340) suggests that “Social work’s goal is to minimize input in service users’ lives, thereby minimizing the control it might exert” and highlights the ‘emancipatory’ values: He notes that in most practice areas social workers would “advocate on behalf of those who might be subject to social injustices and infringements upon their human rights” , and yet in mental health part of the role and values of an AMHP is involvement in denying individuals their liberty on the basis of care or protection and right to refuse treatment, a right which is attributed to anyone else (with capacity) in relation to medical treatment (McLaughlin, 2006). Yanni (2009:340) summarises that “… the occurrence of one phenomenon being trumped by another is evident when discussing values as it was in a discussion regarding legislation.”
Care versus Control
Braye (2010:56) explains, “Intervention can be warranted either to provide care and protection or to control a person’s behaviour”. Care for the wider community may mean control of the individual (Thomson, 2000), or the controlling measure may be taken in the interests of care. Additionally Braye (2010) notes the need for consideration of evidence provided by mental health service users describing adverse effects and experiences of hospitalisation when thinking about care through control: Feelings of lack of safety, boredom and issues relating to powerlessness – lack of information, involvement and opportunities for interaction with staff were reported in a Department of Health paper cited by Golightley (2004). Cantor, (1999: 303) in discussing compulsory admission and suicide argues that
Therapeutic relationships may be damaged and the mode of care may deter patients from seeking help in the future. The price of reducing short-term risk may be that of increasing long-term risk. In addition, paternalistic care can foster regression.
The Mental Health Alliance (online) sets out specific suggestions of legislative changes which would increase the protection of ‘patients’ rights. For example, where detention is for protection of others it ought to be from “significant risk of serious harm”, compelled treatment should only be where the patient has “significantly impaired decision-making capacity” and the use of compulsory powers must have a therapeutic benefit for the patient. They argue that
The purpose of mental health legislation should not be to detain people with mental health problems for whom no beneficial treatment can be found, and where no health benefit may result.
It is also important to note the point that Yanni (2009:342) makes within his conclusions that care and control are not always opposed in the role of an AMHP, “the former is sometimes only facilitated by use of the latter.” It is widely recognised that there are situations where there is necessity for detainment. Compulsory treatment (which can have severe ‘side’ effects) may be seen as more controversial, but even so there remains wide spread support or perceived ‘need’ for this also demonstrated by the relatively high numbers of Community Treatment Orders (The NHS Information Centre, 2010).
‘The dilemma for social work … is to determine the point at which the balance should swing from self-determination to protective intervention’ (Braye, 1992:55). This is done through risk assessment, which leads us to a central part of this debate.
Risk (versus rights)
As mentioned above when looking at the MHA and COP, compulsory admission is largely based on assessment of risk – to self, others and perhaps even the risk services (including admission) poses; AMHPs complete risk assessments in the context of the values of the profession, social and political views and pressures and legislation. It is widely recognised that over the past decade society has generally become more sensitive to risk, with risk assessments, risk management, minimisation et cetera becoming common place. Golightley (2004:23) notes, “Even though the risk of a stranger who is mentally ill killing you is very small, some press coverage suggests that it is a common occurrence”; portrayals in the media of relatively rare tragedies as something that we may all have to fear, contributes to culture of precaution and attempts to eliminate risk. Social workers have often become the focus of blame rather than the perpetrator of the crime, as was the case with the baby P tragedy. Thomson (2003:36) notes, “If a case goes well, no fuss is made. If a case goes wrong all hell is let loose by newspapers and media.” A month after the Baby P tragedy there was a sharp rise in December 08 of applications for care proceedings (Butler, 2009): this may be what Yanni (2009:338) describes as an “… attempt to become insured against the negative aspects of the risks inherent in the profession.”
The number of people compulsorily admitted to hospital each year continues to rise, up 7% in 09/10 from 08/09, this is even with the use of CTO’s (3325 in 09/10) which were argued would reduce the number (The NHS Information Centre, 2010). Braye (2010:57) notes, “the MHA 2007 … makes it possible to detain individuals previously excluded from the remit of the 1983 Act, on evidence that relies on predictive risk of harm”; this could be seen as unjust given evidence which McLaughlin (2006) points to suggesting that risk assessment is not even accurate in assessing those who actually go on to commit homicide. Other evidence suggests that risk of violence from those with diagnoses such as schizophrenia are relatively low, with “being young, male single, lower class, and substance abusing or substance dependant” (Swanson et al) being more common ‘risk’ factors.
McLauglin (2008:1265)notes that “The dangers of an obsession with risk avoidance for the liberty and autonomy of service users has been pointed out”; at the same time it seems it may undermine social works value base. The Code of Practice itself recognises that people have a right to take risks and acknowledges that social workers will be involved in managing risks. Carson (1995, cited in Thomson, 2003) describes risk as “An opportunity to gain possible benefits where harms are also possible”; positive risk-taking is important to the care and rights of patients. It seems that thorough risk assessment and good judgements based on relevant evidence is important for balancing risks and rights, with an acknowledgement that “… it is impossible to remove uncertainty in decision making” (Parrott 2006, cited in Yanni,2009:342).
Decisions, ADP and AOP
Peay’s study of social workers and psychiatrists and the decisions they would make in regards to compulsory admission in a case study of a man with schizophrenia had some interesting results. Peay (2003:14)notes there was “considerable variability in outcomes both within and between the two professional groups”. When asked to make the judgement alone 75% of the psychiatrists said they would compulsorily admit, over 40% on a section 3; in contrast more than half of the ASW’s were not ready to use compulsion and only 10% said they would admit on a section 3. The paired decisions “more clearly reflected the decisions the ASW would have made individually” – 50% were not ready to compulsorily admit, with 20% admitting on a section 3. Overall it reflects the differences you may expect to find between those coming from a medical and those coming from a social model and it seems to reflect the fact that ASWs in practice who decide whether or not to apply for compulsory admission. It perhaps indicates the value of an AMHP perspective; however the study also demonstrated that in some cases the ASW was persuaded by the psychiatrist that admission under a section 3 was necessary.
The variations of decisions within the ASW’s is also interesting, with one being ready to admit on a section 4 while another perceived no urgency and would have persisted over weeks to re-engage the man. This reflects the fact that no matter how much training or guidance one gets the decision comes down to the assessment and judgement of an individual AMHP where their knowledge, skills, biases, assumptions, perceptions, values, personality, pressures – of employer, other processionals, public as well as the availability of local alternative services will all come into the decision about the patient’s care, autonomy, rights and risks they pose. The implications for the patient depending on which AMHP they have assigned to their case may be great – loss of liberty, subjection to treatment, or not.
Of particular relevance to this point is the issue of discrimination in relation to compulsory admission. Webber (2008) refers to studies which link assessment under the MHA 1983 to social disadvantage and, significantly, the continuing disproportionate numbers of people from African and Caribbean origins being detained, who are least 3 times more likely to be than someone who is white British. Bennett (2009, cited in Gilbert, 2010) claims “Black and mixed heritage service users report a far worse experience of hospital care than other ethnic groups.” Others point to tendencies of stereotyping black men or making assumptions about someone family support due to their cultural background. Golightley (2004) points to a need for social works to be familiar with data and information about minority groups and an appreciation of diversity, social and cultural issues that may affect a person generally or specifically affect their mental health is widely recognised.
It seems that the role of an AMHP, the perspective and values it brings, go some way to being effective safeguard under the MHA to protecting the care and rights of those who may be subject to compulsory admission. It seems the complexity of managing the tensions of risks and rights and care versus control in relation to several areas of mental health social work will never be straightforward or risk free. The holding onto of social work values including independence, inclusion, rights and maximising them even when the risks are so great there is a need for compulsory admission is important to this role. Use of evidence and clear awareness of why one is making a decision to make and application or not – pressure from doctors, fear of risk, personal biases – is central to ADP and AOP: I would suggest reflective practice and supervision is important to challenging assumptions, biases and the ‘isms’ and even to unpick relevant research based evidence. At a more structural level social work as a profession must bring its values and experience, and continue to engage in critique of mental health legislation and policy.
Braye, S. a.-S. (2010). Practising Sociak Work Law (3rd ed.). Basingstoke: Palgrave MacMillian.
Brown, R. (2009). The Approved Mental Health Professional’s Guide to Mental Health Law. Exeter: Learning Matters.
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