Thursday, 14 January 2016

What is “Mental Disorder” Within the Meaning of the Mental Health Act?

Stephen Fry simulating the "head clutch" stock photos
used to illustrate any article involving mental disorder
The legal definition of “mental disorder” for the purposes of the Mental Health Act has evolved over the years to reflect changes in Society and the liberalisation of psychiatry.
 
The Mental Health Act 1959 began a major process of revision in the way people with mental disorder were treated by the law. Indeed, one of the first things the 1959 Act did was to repeal ancient legislation. The long title of the 1959 Act was:
 
“An Act to repeal the Lunacy and Mental Treatment Acts, 1890 to 1930, and the Mental Deficiency Acts, 1913 to 1938, and to make fresh provision with respect to the treatment and care of mentally disordered persons and with respect to their property and affairs; and for purposes connected with the matters aforesaid.”
 
It is salutary to realise that in the early part of the 20th century people with a learning disability were officially classified as “mentally deficient”.
 
The 1959 Act, however, in defining mental disorder, introduced different legal terminology. There were now two terms to be used for such people: “subnormality” and “severe subnormality.”
 
“Subnormality " meant “a state of arrested or incomplete development of mind (not amounting to severe subnormality) which includes subnormality of intelligence and is of a nature or degree which requires or is susceptible to medical treatment or other special care or training of the patient”, while "severe subnormality" meant “a state of arrested or incomplete development of mind which includes subnormality of intelligence and is of such a nature or degree that the patient is incapable of living an independent life or of guarding himself against serious exploitation, or will be so incapable when of an age to do so.”
 
The original MHA 1983 changed the terminology again. “Severe subnormality” was now known as “severe mental impairment”, and “subnormality” as “mental impairment”, but in order for such a patient to be regarded as mental disordered and therefore eligible to be detained under the MHA their impairment also had to be associated with “abnormally aggressive or seriously irresponsible conduct”.
 
The 1959 Act also had a category of “psychopathic disorder”. This was defined as “a persistent disorder or disability of mind (whether or not including subnormality of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient, and requires or is susceptible to medical treatment.”
 
This meant that for a person to be detained in hospital for treatment under Sec.26 (the forerunner of Sec.3), they had to be suffering from mental disorder, the definition of which was regarded as either “in the case of a patient of any age, mental illness or severe subnormality”, or “in the case of a patient under the age of twentyone years, psychopathic disorder or subnormality”. The Mental Welfare Officer (the predecessor of the AMHP) had to specify which of these applied to the patient on their application form.
 
Indeed, I recall on one occasion many years ago detaining a 17 year old female under Sec.26 MHA 1959 on the grounds of psychopathic disorder. She had been an informal patient on the local psychiatric ward, which at that time was a ward within the local general hospital. The application was precipitated by her sneaking out of the ward onto the maternity ward, which was upstairs, and attempting to abduct one of the babies.
 
“Psychopathic disorder” remained one of the specific grounds for detention under Sec.3 MHA until it was finally removed by the 2007 Act.
 
The full definition of mental disorder in the 1959 Act was: “mental illness, arrested or incomplete development of mind, psychopathic disorder, and any other disorder or disability of mind “. This definition remained unchanged when the 1983 Act was introduced, and was only altered by the 2007 Act. The current definition is now “any disorder or disability of the mind”.
 
Both the 1959 Act and the 1983 Act specified certain exclusions. The 1959 Act stated that behaviour consisting “only of promiscuity or other immoral conduct” could not be construed as mental disorder, while the 1983 Act additionally excluded “sexual deviancy or dependence on alcohol or drugs”.
 
Curiously, the original Sec.1(3) stated:
“Nothing in subsection (2) above shall be construed as implying that a person may be dealt with under this Act as suffering from mental disorder, or from any form of mental disorder described in this section, by reason only of promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs.”
 
But the 2007 Act replaced this subsection with: “Dependence on alcohol or drugs is not considered to be a disorder or disability of the mind for the purposes of subsection (2) above.” This appears to imply that promiscuity, immoral conduct and sexual deviancy can now be regarded as a mental disorder.
 
So what is now meant by “mental disorder” within the meaning of the Act?
 
The Code of Practice goes into this at some length. It notes that: “Relevant professionals should determine whether a patient has a disorder or disability of the mind in accordance with good clinical practice and accepted standards of what constitutes such a disorder or disability.”
 
It then goes on to give an extensive, but not exhaustive, list of “clinically recognised conditions which could fall within the Act’s definition of mental disorder” (para2.4). These include:
·       Affective disorders, such as depression and bipolar disorder
·       Schizophrenia and delusional disorders
·       Neurotic, stress-related and somatoform disorders, such as anxiety, phobic disorders, obsessive compulsive disorders, post-traumatic stress disorder and hypochondriacal disorders
·       Organic mental disorders such as dementia and delirium (however caused)
·       Personality and behavioural changes caused by brain injury or damage (however acquired)
·       Personality disorders
·       Mental and behavioural disorders caused by psychoactive substance
·       Eating disorders, non-organic sleep disorders and non-organic sexual disorders
·       Learning disabilities
·       Autistic spectrum disorders (including Asperger’s syndrome)
·       Behavioural and emotional disorders of children and young people
 
There are, however, extensive caveats regarding the use of compulsory powers for some of these disorders, giving very useful guidance on how such disorders as Autistic Spectrum Disorder, Asperger’s Syndrome and personality disorder should be approached. These are covered at length in Chapters 20 & 21.
 
The Code suggests that in relation to people with learning disability or autism “evidence-based good practice is that most of their needs can best be met at home or in community settings” (para20.5). It goes on to say that “compulsory treatment in a hospital setting is rarely likely to be helpful for a person with autism, who may be very distressed by even minor changes in routine and is likely to find detention in hospital anxiety provoking” (para20.20), and encourages less restrictive approaches to managing such people.
 
We now have a situation in which almost any mental health problem can be considered to be a mental disorder within the meaning of the MHA. This is not to suggest that the requirements for detention under the Act have been compromised, as in many ways the new Code has imposed further restrictions of the use of the Act, especially stressing the impact of Human Rights legislation on AMHP practice.
 
The new Code sets out from the first paragraph that practice should always begin with the “least restrictive option”, on the basis that “where it is possible to treat a patient safely and lawfully without detaining them under the Act, the patient should not be detained” (para1.1). That should always be the first guiding principle informing AMHP practice.
 

Friday, 11 December 2015

Review: Deprivation of Liberty Safeguards: A Best Interest Assessor Time Study


Cornwall Council’s much anticipated study, compiled and written by Emma Goodall and Paul Wilkins, was published at the beginning of December 2015.

This has obtained empirical evidence of the impact on BIA’s of the Supreme Court judgment that came out last year (2014). I wrote about this judgment, which it was anticipated would have far reaching effects on the workloads of AMHPs and BIAs, here. Cornwall’s research complements the College of Social Work’s document assessing the impact of this judgment on AMHP practice, about which I wrote here.
So that’s enough of the links for now. What did this Time Study actually find?
Since the Cheshire West Judgment extended the qualifying criteria for incapacitated people who might be in situations where they are being deprived of their liberty, it was thought extremely likely that there would be a huge increase in requests not just for formal assessments under the Mental Health Act, but also for requests for Deprivation of Liberty Authorisations, which have to be undertaken by Best Interest Assessors.
As this report highlights, “The first annual statistics published by the Health & Information Centre in September 2015 reports that there has been a “tenfold increase” in new referrals, with 137,540 DoLS applications received by councils between 1st April 2014 and 31st March 2015.” I am certainly aware that it is not uncommon for local authorities, who are responsible for conducting these assessment, to have backlogs of 2,000 or more.
The research took the form of asking practicing BIAs via a wide range of social media to complete a questionnaire relating to their practice and experiences. They received responses from a total of 507 BIAs, which I think is a remarkable achievement.
The study focused on the overall time that each assessment took, looking in particular at time taken in traveling, gathering information and consultation prior to and following the assessment, the length of time spent at the hospital obtaining necessary information, consultation with other relevant assessors, writing up the necessary documentation, and giving feedback to interested agencies and individuals.
The study found that the overall average time taken to conduct a DoLS assessment was 726 minutes, or 12.1 hours. This compares with an average of 600 minutes, or 10 hours, that local authorities estimate that an assessment should take. Some of the BIAs in the study reported a considerable discrepancy between the hours what they were paid for, and the actual length of time taken, for example one BIA saying: “I’m paid for 7 hours but each assessment takes at least 11 hours”.
While it may be tempting for local authorities to attempt to quantify the time taken and set a standard timescale for completion of assessments, the study points out that, while DoLS assessments can vary widely in complexity, “in all cases the BIA must involve the relevant person in the assessment process, consult widely and gather information relevant to their decision-making and  provide a report that explains their conclusion and their reasons for it. This work can be time consuming, particularly when there are several consultees or extended travelling times.”
The study also makes the point that BIAs have enormous responsibility in making their assessments, as they can be open to legal challenge.
The Law Commission recently published its consultation document into mental capacity and deprivation of liberty, which I considered here. Among its recommendations, the first of which is the abolition of DoLS as incomprehensible and unworkable, is the proposal to create the Approved Mental Capacity Professional. AMCPs would have more far reaching powers than BIAs, and would carry even greater responsibility.
Were these proposals to be made into law (through amendments to the Mental Health Act), it would be interesting to see the impact both on the work of this new professional compared to the BIA, and the overall bombardment rate of local authorities for people lacking capacity.
 

Sunday, 6 December 2015

Review: The Mersey Care Annual Mental Health Social Care Conference 2015

Peter Beresford giving a rousing address to the conference
 
The Mersey Care Trust’s annual conference was held in Liverpool on 6th November 2015. This year the theme was Service Users’ Voice: Change, Rights and Advocacy: What is the Reality?
 
I have reported at length on two previous Mersey Care conferences; I am afraid that this report will necessarily have to be briefer on this occasion.
 
The event was oversubscribed, with well over 200 delegates squeezing into the venue. As ever there was an impressive list of scheduled speakers, including Professor Martin Webber, Professor Peter Beresford, the human rights lawyer Peter Edwards, the Community Care journalist Andy McNicoll, and the erstwhile chair of the mental health steering committee of the now defunct College of Social Work Dr Ruth Allen. Indeed, it appeared as if there were almost as many speakers as there were delegates!
Roger Phillips, a presenter on Radio Merseyside with a keen interest in mental health, opened the conference. Emad Lilo, the intrepid organiser and manager of the Mersey Care Integrated Care Demonstrator Site Project, along with several of the Trust AMHP’s then outlined projects and other development work they had undertaken during the year.
Peter Edwards discussed the thorny issue of whether the rights of service users could actually be exercised, or were in effect illusory, then the Masked AMHP himself presented a case study of an assessment under the Mental Health Act, arguing that the AMHP has an advocacy role, and that an AMHP can successfully take a deliberately low key approach to assessment. A version of this case study was subsequently published in Community Care Magazine. You can read it here.
The morning was rounded off by an extraordinary presentation by members of the People First Merseyside organisation. This is a user led self advocacy organisation for people with learning difficulties. It has been in operation for over 25 years.
The staff and volunteers (most of whom were service users) gave an excellent dramatised presentation on the right (and wrong!) ways to approach people with learning difficulties who require assistance with a health problem, as well as showing exactly what people with learning difficulties can achieve when given encouragement and empowerment. It was entertaining, educational, and moving.
Peter Beresford kicked off the afternoon with an, as ever, eloquent, incisive and stirring dissection of the failings of current mental health policy and practice, tearing into the current Government plans and exposing an apparent deliberate intention to dismantle the NHS and marginalise disadvantaged people.
Ann Williams, Commissioning & Contract Manager for Liverpool City Council, gave a presentation on the roles of the Independent Mental Capacity Advocate and the Independent Mental Health Advocate, followed by Jake Mills.
Jake Mills is a stand up comedian. In 2013, he experienced a severe period of depression, during which he came close to committing suicide. As a result of this, he set up the mental health charity Chasing the Stigma which aims to “normalise and humanise mental illness.” He gave an intensely moving, but also funny account of his experiences.
The last session was Naomi Good, Regional Development & Research Manager of the National Survivor User Network for Mental Health. Her presentation was entitled Survivor Voices: Re-authoring Disrupted Identities. She outlined research she had done into the experiences of mental health service users.
Unfortunately, time constraints meant that some speakers, such as Professor Martin Webber, literally only had five minutes to speak, and of three intended Q&A sessions, only the one featuring Andy McNicoll and Ruth Allen actually went ahead. This meant that a number of prominent people in the mental health field did not have an opportunity to be heard.
I suppose this is a consequence of the popularity of these annual conferences, not just for delegates, but for speakers as well. Emad Lilo, who organises these events, appears to have boundless energy and enthusiasm, and this is reflected in the very real buzz that permeates the day.
 
This was the third Mersey Care Conference I have attended, and I very much hope to have the opportunity to speak at future ones. 

Sunday, 1 November 2015

Sec 13(4): The Right of the Nearest Relative to Request a Mental Health Act Assessment


Relatives are frequently unaware of their right under Sec.13(4) MHA to request an assessment of their relative under the Mental Health Act.
Those who are aware of this, are often under the misapprehension that this will inevitably trigger a visit to their relative by an Approved Mental Health Professional and two doctors.
Sec.13(4) states:
(4) It shall be the duty of a local social services authority, if so required by the nearest relative of a patient residing in their area, to make arrangements … for an approved mental health professional to consider the patient’s case with a view to making an application for his admission to hospital; and if in any such case that professional decides not to make an application he shall inform the nearest relative of his reasons in writing.
The new extended 2015 Reference Guide has very little to say to enlarge upon this, other than referring the reader to the new 2015 Code of Practice, and stating that “the nearest relative can require the local authority (verbally or in writing)…to arrange for an approved mental health professional (AMHP) to ‘consider the patient’s case’ including whether there is a need for compulsory admission to hospital.” (p.21).
The Code of Practice only refers to this section in two paragraphs, at para14.36, and para14.102. The only thing that para13.36 adds is to state that the local authority must respond not only to a direct request from the Nr, but also to a request “on behalf of” the NR.
So what does all this mean to the nearest relative and to the AMHP receiving a request under Sec.13(4) from the nearest relative?
The NR does not need to put the request in writing, but can make a request by phone. They can also ask someone else to make a request, such as another relative, or their GP, and this must be considered as if  it were a direct request from the NR.
The local authority AMHP service has to respond to this request. But this does not necessarily mean that they will conduct a formal assessment. An AMHP only has to “consider the patient’s case”. If, having done this, they do not think that an assessment is merited, there is no requirement to assess.
From the AMHP point of view, there may be many reasons why it is not appropriate to assess the patient under the MHA. A typical reason may be that other arrangements are being, or have been made. This might include a GP referring the patient to the local crisis team for assessment. It would therefore be wrong to pre-empt this assessment, under the principle of the least restrictive option.
Another reason might be that the patient is already involved with a community mental health team, who are managing the patient’s condition and would not welcome and AMHP’s intervention, or do not consider that a MHA assessment is necessary.
It may be that, while the relative is concerned about the patient, the patient has not actually seen a doctor recently. In which case, I would always advise the relative that they should arrange for the patient to see a doctor first.
In some cases, the request may be “mischievous”; in other words, the relative may have made frequent or recent requests for their relative to be assessed, and unless there has been any significant changes in the patient’s condition, it would be oppressive to keep formally assessing the patient.
I recall one such case, where the mother of the patient, a pregnant single parent with a young child, reported that she was expressing a range of alarming paranoid delusions, especially around her unborn baby. The ex-partner of the patient also corroborated this.
I went out with the GP and a psychiatrist, to find her preparing tea for her daughter and a school friend. Everything appeared completely normal, and she spoke politely and rationally to us for about an hour. We were unable to elicit any symptoms of mental illness, but based on the reports of the relatives, we rather heavy-heartedly decided to detain her, and she was detained under Sec.2 for 28 days.
During that time she was not given any medication, and did not provide any evidence to ward staff of any mental illness.
On another occasion, I received a request from the husband of a woman. They were recently separated. His concerns seemed to boil down to the view that since his wife did not want to talk to him, and would not agree to what he wanted to happen to the property and children, then she must be mentally ill. I did not respond to this request.
Once an AMHP has considered the case, and has either decided not to undertake a formal assessment, or has assessed and has decided not to detain, they have a legal requirement to write to the referring relative. These letters have to be very carefully written. The Code of Practice states: “Such a letter should contain, as far as possible, sufficient details to enable the nearest relative to understand the decision while at the same time preserving the patient’s right to confidentiality.”(para14.102)
Sec.13(4) requests from nearest relatives always used to be a fairly rare occurrence. Recently, however, our local AMHP service has received a mysterious increase in these requests. Could it be that relatives are becoming better informed about their rights under the Mental Health Act?
I don’t actually think so. We have discovered that relatives have been contacting the patient’s community mental health team because of concerns about their mental health, who have then advised them to make a referral to the AMHP service.
This appears to be due to service cuts or staff shortages. It appears that increasing numbers of patients are active to community teams, but have not got an allocated care co-ordinator, and the over worked duty worker has the idea that, if their team cannot make a timely response, then the AMHP service can always conduct an assessment under the MHA.
We have been working hard to disabuse community mental health services of this notion.

Thursday, 22 October 2015

Origins 8: My First Caseload: Margaret and her Cats

This post contains lots of cats. But not in a good way
Part 8 in an occasional series about my early years as a social worker in the 1970’s and 1980’s.

Since my last post, I’ve been continuing to reminisce about my past as a social worker. Social work has changed a lot since I started in the mid 1970’s, in some ways for the better, in other ways for the worse.

When I started, our local social services office would receive a request for assistance, the case would be allocated to a social worker – and, er, that was about it. Unless there were very clear identified needs, for example a need for residential care, for aids to daily living, or a child subject to some form of abuse, the social worker would just tend to, sort of, bumble along, visiting the client, as they were referred to back then, developing a relationship, maybe sometimes doing something practical, like helping them claim benefits.
Most clients did not have any sort of formal care plan. Occasionally, in supervision, your team leader would ask you what you were doing with a particular client. Then you had to think hard and say something that sounded worthy and useful.
My first caseload was very mixed. I had a few children and family cases, some elderly people, some people with physical disabilities, a few people with learning difficulties or mental health problems, and one or two who defied categorisation.
Margaret was one of the latter. She was in her early sixties, and lived alone in a local authority house in a small village a few miles outside Charwood.
I was never clear about how she ended up a client of the social services department. It may have been a referral from the local housing authority, who was certainly concerned about her ability to manage her tenancy. It may have been because of complaints from neighbours.
It’s possible she may have had mild learning difficulties, although she had no formal diagnosis. She had lived all her life in that house, taking over the tenancy when her parents had died over twenty years previously, and perhaps they had been her carers. She certainly had no obvious mental illness. But she was deemed to be a vulnerable person, and hence worthy of having a social worker, even if that social worker was unqualified and completely inexperienced.
Or maybe it was because she was a witch.
She certainly looked like a witch. She had snaggle teeth, a long nose with a wart on the end, and matted hair. It was thought that the last time her hair had been washed was over 20 years ago, when she had had to go into hospital when she’d had a fall. I could believe it; her hair had become felted. She had probably also not had a bath for twenty years, and her face and hands were black with dirt.
And she had cats. I never knew how many cats she had, and I don’t think she knew either, but there must have been somewhere between 20 and 40. They lived in the house, never leaving it, and freely interbreeding. She seemed to have no arrangements for their toileting, with the result that they defecated anywhere and everywhere.
See if you can imagine the experience of visiting her house.
I always went in through the back door, which was never locked. The hallway was comparatively free of cat faeces, as she tended to keep them in the living room and kitchen area. But she made up for this omission by having piles of newspapers at least 4 feet high lining both walls of the hall. As she lived and slept in the living room, she never went upstairs. I have no idea what the bedrooms were like, as it was impossible to go up the stairs because each step was piled high with old newspapers.
I was told that a previous social worker had attempted to clear the house of newspapers by diligently putting them into an outhouse, but Margaret had then brought them all back in because she was afraid they’d get damp outside.
Festoons of ancient cobwebs hung from the ceiling, some hanging so low you risked getting them in your hair unless you ducked.
Having negotiated the hallway, you finally entered the living room. Winter or summer, Margaret never opened the windows, so the temperature in there could get quite high during the summer months. But not as high as the stench.
It was impossible to tell what the original floor covering in the living room was, as it was completely covered with cat faeces to an unknown depth. My shoes tended to stick to the floor as I walked through. There was an audible noise as I picked my feet up step by cautious step.
The smell was almost unbearable. In those days I smoked a pipe, and used to smoke furiously throughout my visits in a futile effort to mask the ghastly smell.
Margaret would be sitting at the head of a table covered with old papers and cats. Her matted and filthy hair was partly covered with an equally filthy headscarf. She generally ate white bread straight from a bag during my visits, tearing it into smaller pieces with her black hands before putting it into her mouth. Sometimes she would offer me a biscuit. I always declined.
During the summer months she would be surrounded by a halo of flies.
I never sat down in her house. This was partly because any seats were always covered with cats, but mainly because they were so filthy that I would have needed a change of clothes afterwards.
So what social work tasks was I undertaking with Margaret?
Did I try to improve her living conditions? Not really. Her file catalogued the efforts previous social workers had made, all of which were futile. Margaret did not want to change.
Did I support her within her community? I guess so; people seemed reassured that a social worker was visiting her. But if they hoped that it would effect any perceptible change, they were sadly disappointed.
Issues of capacity were barely talked about back then. Apart from her appalling living conditions, I never had any feeling that Margaret was not mentally able to make decisions about her lifestyle. Nowadays I could explicitly assess her capacity, and conclude that she had the right to make unwise decisions, but there was no legislation that covered Margaret’s situation in the 1970’s.
She appreciated my visits, and liked to talk to me, so I suppose I fulfilled some welfare purpose. Again, nowadays that befriending role could either be provided by a voluntary organisation or supplied via a personal budget under the Care Act. But back then, the main resource was social workers.
One thing I learned from Margaret was not to be phased by extreme housing conditions. In later years, when people complained of patients living in squalor, I set Margaret as the benchmark. That was squalor.
During the two years Margaret was on my caseload, I achieved one traditional social work task; I arranged for a neighbour to be paid as a home help in order to do her shopping once a week. So I suppose I did do something to improve her life.

Friday, 2 October 2015

No Happy Endings: Stories from an Out-of-Hours Social Worker


There’s been quite a lot of discussion lately about the nature of social work and the social work task, and this has got me thinking about my years as a social worker, which has covered 5 decades.

I started as a generic social worker in 1976, and continued to hold a generic caseload, consisting of a mixture of mental health, elderly, child protection and children and families, until my local authority elected to operate with specialist teams in 1988. It was then that I became a specialist mental health social worker, working in a multidisciplinary community mental health team (one of the first in the country).

In addition, throughout the 1980’s and 1990’s, I also worked one or two shifts a week on the out-of-hours standby duty team. This team dealt exclusively with emergencies and crises that arose outside normal working hours.

This seemed to me to be the essence of social work: working in crisis, having to make independent executive assessments and decisions on the hoof with hardly any backup, and having to be prepared to live with the consequences of those decisions.

It was during this time that I encountered similar issues to those reported in Rotherham.

The child protection failures in Rotherham were by no means unique; there were a few occasions when I was called out to the city police station to act as an appropriate adult under the Police and Criminal Evidence Act (PACE) for teenage girls who had been picked up for soliciting.

I recall one occasion in the early 1990’s when I was called out during the evening to deal with two 14 year old girls. They had been arrested following a tip off from a much older prostitute to the vice squad.

She had reported them, not because they were taking business from her, but because she was rightly concerned that such young girls should not be attempting to solicit. She was primarily concerned for their safety.

But the police did not really see it like that. They did not see it as a child protection issue. That was not why they wanted a social worker. They regarded these girls as juvenile offenders. They simply wanted to process their cases by giving them a caution and then getting them out of the station as quickly as possible. So they needed a social worker, in the role of appropriate adult, to be present while the formal procedure was conducted. And so that I would then be officially responsible for their disposal once released.

Tracey and Tanya were waiting in the custody area when I arrived. They looked as if they were going to a “tarts and vicars” fancy dress party, with ridiculously short skirts and exaggerated makeup.

But they also looked like children rather than adults, and like children, they seemed to have a startlingly naive picture of the reality of prostitution, and were actually grossly unprepared, both practically (no condoms or other protection) and emotionally (they appeared to think that they would get spending money in return for little more than a kiss and a cuddle.)

They were reluctant to talk to me about their motivation or the circumstances that had led them to take to the streets (this was the first time they had tried it), and actually seemed to regard it as a bit of a laugh. The custody officer told me that the mother of one of the girls was a known prostitute, but it was unknown whether the mother knew what they had been trying to do, or indeed if she had actually encouraged them.

They were duly given a caution in my presence, and then released to me. I was unhappy about taking them home, as none of their parents could be contacted, and eventually obtained agreement to place them in a local children’s home, at least until the day time children’s services could assess the situation.

As so often when working out of hours, I never heard what happened toTracey and Tanya.

But I did find out what eventually happened to another lost girl I had involvement with, called Naomi.

Naomi was 16 and over school leaving age. She was on a Care Order to the local authority, and had been in a children’s home for a considerable time, until she had decided to leave the home and move in with someone she described as her boyfriend, a man in his twenties. She had been picked up for soliciting, and I was again called out to act as an appropriate adult.

As she was actually on a Care Order, I felt that I had to ensure that she had a safe place to stay tonight, and arranged for her to have one of the leaving care beds at the local YWCA.

I went to the police station. Naomi was an intelligent, likeable girl. But she had the manner of someone much, much older than 16. She came across as weary and hopeless, and had no interest in what I might be able to do to help her, other than to get her released from police custody.

Once the police had cautioned her, I told her that I was going to take her to the YWCA.

“I’m not going,” she said. “Just take me home. Take me back to my boyfriend.”

I had the strong suspicion that her “boyfriend” was actually her pimp. I was very reluctant to take her there.

“Look,” I said. “It’s just for tonight. I’d just like to feel you were in a safe place.”

She looked at me with 1,000 year old eyes.

“No,” she said finally. “I know you’re just trying to help. But I don’t need any help. Just take me home.”

Although she was on a care order, I had no powers to compel her to live in any particular place, so I reluctantly took her to her stated home address.

Two weeks later her dead body was found on wasteland on the edge of town.

To this day, her murder remains unsolved.

Monday, 28 September 2015

Book Review: Independent Mental Health Advocacy, Karen Newbigging et al


The role of the Independent Mental Health Advocate (IMHA) was created by the 2007 amendments to the Mental Health Act 1983. The role is enshrined in the guiding principles to the Act, one of which is empowerment and involvement. The new Code of Practice states that:

“Patients should be informed of the support that an advocate can provide, including carers or, if they are eligible, an independent mental health advocate (IMHA)... Local authorities should ensure that timely access to IMHAs is available and that IMHAs have appropriate training and skills to support the patient effectively including where a patient has particular needs.” (para 1.12)

In view of the fact that IMHAs have existed since 2008, this book is well overdue, as it is a thorough and detailed guide to everything that an IMHA requires in order to discharge their functions in the most empowering and equitable way. As the authors point out, the year on year increases in the use of the Mental Health Act powers to detain people means that there has never been a greater need for independent advocacy.
 

While this book is clearly primarily designed for Independent Mental Health Advocates (and should be an essential set text for IMHA training courses), it is also of relevance not only for Independent Mental Capacity Advocates (IMCAs) and Best Interest Assessors (BIAs) operating within the Mental Capacity Act, but also for AMHPs.

As the book points out, “advocacy has long been recognised as central to the social work role, with effective social work advocacy practice being fundamental to promoting individual rights and social justice”(p.247). I have long maintained that the AMHP role itself is not merely one of asserting control over people with mental disorder, but has advocacy as an integral part of the legal functions of the AMHP, who are required always to look at the least restrictive option when assessing the need for a patient to be detained under the MHA.

However, the nature of the AMHP role in no way reduces the need for IMHAs, as the AMHP role cannot be “independent” of the legal process, as it is by its nature an integral part of the MHA control mechanisms, no matter that AMHPs are there to assert a social perspective within an overwhelmingly medical system. As this book says:

“Health and social care professionals’ claim that advocacy is inherent to their professional role cannot be seen to replace the need for truly independent advocacy to support the service users’ voice within disempowering systems... Professionals need to recognise the limits of their ability to advocate from within systems, of their tendency towards best interests advocacy, and to recognise that they are often part of the problem and not just the solution.” (p261)

The book has been cowritten by a total of nine authors, whose backgrounds range from the largely academic to people who have had firsthand experience of being service users. The book is all the stronger for this. The authors draw on extensive personal research to make their points; the chapters detailing the service users’ perspective are of particular interest.

The book is split into two parts: the first part provides an overview of the historical and legal context of advocacy in a mental health setting, while the second part concentrates on practice and experience. There a useful and thought provoking reflective exercises at the end of each chapter.

While I am not an IMHA, I found much of interest in the book; for example the chapter giving an historical overview of the evolution of independent mental health advocacy traced it back as far as the 16th century. I also found the chapter looking at research into the experience of detention from the service user perspective enlightening, and gave me much to think about in my approach to my work as an AMHP. This section would be equally helpful for social work and AMHP students.

The authors make frequent cogent points relating to the underlying philosophy and intention of the Mental Health Act, suggesting that the 2007 amendments introduced an increased medicalism of practice in mental health. While I had felt that the broader but vague definition of mental disorder was overall of benefit to patients (in particular people with diagnoses of personality disorder, who had often been excluded from treatment). As they say, this “leaves the task of diagnosis to clinicians, so that no one needing treatment is excluded, thus favouring a duty of care over self-determination.”
 
Concern is also expressed that “the widening of the definition of mental disorder, reducing the thresholds for treatment and extending compulsory powers to the community, in the form of supervised community treatment, would have a disproportionate impact on people from Black, Asian and minority ethnic communities.” (p.89)

The book raises equally challenging questions concerning what the role of the IMHA should be, for example, making a clear distinction between the IMHA role and “best interests” practice. They contend that IMHA’s “need to be alert to the overarching themes of autonomy, participation, care and recovery, how these relate to people’s experience of coercion and detention and the contribution they can make to promoting self-determination in the most challenging of circumstances” (p.125)

In conclusion, I do think this book provides an essential text for people training and practicing as IMHA’s. I would also recommend the book to mental health nursing and social work students, and will certainly be recommending to my own AMHP trainees that they read this book.