A Study Exploring How Social Work AMHPs Experience Assessment under Mental Health Law: Implications for Human Rights-Oriented Social Work Practice

Abstract

There is little empirical research focusing on how social workers experience the law in their everyday professional practice, and still less on how mental health social workers experience assessment for compulsory admission under mental health law. The article is informed by a hermeneutic phenomenological approach, drawing on in-depth interviews and practitioner diaries with social work Approved Mental Health Professionals (AMHPs), providing exploration of how social work AMHPs experience compulsory assessment under mental health law in practice. This is revealed as a socio-relational process, involving a focus on the person in their environment in relation to others, such as family and professionals. Ethical challenges realising human rights social work practice are illuminated. This draws attention to how space for such practice can be eroded by systems conditions. The importance of amplifying the voice of the person assessed is highlighted in the context that their voice is severely diminished during the process of assessment. The article provides insights on the complexity involved in compulsory mental health practice, drawing attention to trust as an important concept. Finally, the article argues that realising human rights-oriented AMHP practice requires social work to challenge systems conditions that erode the ability to do so.

Introduction

Approved Mental Health Professionals (AMHPs) in England and Wales have statutory powers under the Mental Health Act 1983 (as amended) (MHA) to detain people in hospital for assessment and/or treatment. These powers are based on certain statutory criteria (Department of Health, 2015). In England and Wales, social work is the lead profession for AMHPs (Stevens et al., 2019). The role of an AMHP is to bring a social perspective to bear on whether-or-not someone ought to be detained in a mental health hospital, based on two medical recommendations, taking into consideration all the relevant circumstances of the case including less restrictive alternatives (Department of Health, 2015). The stakes in this area of law and social work are high: practitioners deal with important issues concerning individual liberty with profound implications for the power of the state to intervene in the lives of citizens. This involves contrasting standpoints where contested concepts of mental disorder, autonomy, protection and coercion sit in tension (Rogers and Pilgrim, 2014; Rose, 2018).

These dynamic and often shifting tensions manifest for social work in the context of a relationship between the law and social work practice; a relationship of ‘considerable complexity’ (Braye and Preston-Shoot, 1990: 335). Previous studies illuminate the complex nature of the relationship between law and social work practice; arguing for connections between legal rules and the priorities of ethical practice (Braye et al., 2013). This has led to appeals for an exploration of how law translates into social work practice (Braye et al., 2013; Preston-Shoot and McKimm, 2012). Tensions between care and control are consistently identified in the literature on mental health social work and mental health law (Brophy and McDermott 2013; Morriss 2016; Maylea, 2017). International law imperatives on the UK (UN, 2007) highlight the discriminatory nature of compulsory mental health law, calling for social and rights-based approaches for citizens experiencing mental distress. Developments in social work AMHP systems and practice have been slow to respond to the changing policy and practice landscape, requiring robust person-centred and rights-based compulsory mental health practice (Campbell et al., 2018).

It has been suggested that the role of the mental health social worker in compulsory admission represents an important component of quality mental health services as an independent voice outside of the medical model (Manktelow et al., 2002). It has also been argued that their role is compromised by organisational systems and scarce resources, limiting their potential to meaningfully engage service users and carers in less restrictive community alternatives to coercion (Campbell, 2010). This area of social work practice has raised questions about whether it is ever ethical to detain someone under compulsory mental health law (Kinney, 2009), and that mental health social work needs to reject involuntary treatment out of hand (Maylea, 2017). It has also been argued that resort to coercion involving detention in hospital represents a failure of care by mental health services (McSherry and Freckelton, 2015). These tensions invoke a struggle for social work to achieve the aspirations that it espouses, such as empowerment and a commitment to human-rights approaches. Such tensions are largely masked by policy guidance on the role of mental health social work (Department of Health, 2016). It is argued that tensions occur in the context of a lack of community-based options to support citizens experiencing acute mental distress (Campbell and Davidson, 2009). The core professional characteristics of social work include a commitment to empowerment and social change, underpinned by principles of social justice and human rights (IFSW, 2014). This highlights an awkward tension for social work AMHP practice, exercising legal powers in an unjust mental health system, evidenced by racial disparities in compulsory admissions, with higher rates of detention in more deprived areas (NHS Digital, 2020). The social work role in reinforcing such unjust systems has been illuminated by Maylea (2021), generating timely impetus to explore how social workers experience compulsory mental health assessment in practice.

The context of AMHP decision making has included analysis of the emotional labour involved in compulsory mental health assessments (Morriss, 2016), and the complexity of AMHP practice (Leah, 2020). The literature includes interrogation on how decisions under compulsory mental health law are made. Quirk et al. (2003) explored non-clinical and extra-legal influences on professionals’ decisions about compulsory admission to psychiatric hospital. O’Hare et al. (2013) explored social work views about the context of risk, decision making and compulsory intervention across the three jurisdictions (England, Wales and Northern Ireland) using survey vignettes. Differences in perceptions of risk and decision making in the context of compulsory mental health law have been explored and compared between participants from different mental health professional backgrounds (Peay, 2003; Hall, 2017; Stone, 2019). Very few studies focus on the experience of assessment for compulsory admission. Buckland (2016) explored the processes involved when AMHPs use compulsory powers, focusing on contextual processes, including how individual values, interpretations of the MHA and contemporary societal discourses were described by participants. Vicary et al. (2019) explored how AMHPs from different professional backgrounds experienced their relationship with doctors during the process of MHA assessments, applying the sociological theory of dirty work. One of the few studies examining how AMHPs understand the concept of a social perspective suggests that it is applied in a creative and nuanced way (Karban et al., 2020).

Mental health law reform in England and Wales recommends greater choice and autonomy, and a reduction in compulsion for those assessed under mental health law (Department of Health and Social Care, 2018). Subsequently, it is surprising how little is known about the social work AMHPs experience enacting mental health law in practice

Methodology

The methodological approach utilises hermeneutic phenomenology. Subsequently, the methodological framework is attentive to how social work AMHPs interpreted and made meaning of their experience using compulsory mental health law in practice. According to Van Manen (1990:180) ‘hermeneutic phenomenology is attentive to both terms of its methodology, it is a descriptive phenomenological methodology because it wants to be attentive to how things appear, it wants to let things speak for themselves; it is an interpretive hermeneutic methodology because it claims that there are no such things as un-interpreted phenomena’. The connection between a hermeneutic phenomenological research paradigm and the semi-structured interview method used in the research is captured by Langridge (2007) who proposes that the hermeneutic turn of phenomenology is based on the view that our experience can best be understood through stories we tell of that experience. Therefore, I argue that to understand how law is used in practice we need to explore the stories told by people about their experience. Ethics approval was granted by University of Sussex (1112/05/04).

Eleven social work AMHPs, from three different local authorities in London, participated in the study, which used qualitative in-depth interviews and practitioner diaries to collect data about using the law in circumstances where compulsory admission to hospital was a possibility. The in-depth semi-structured interviews were held in participants’ workplaces. Participants recounted a recent assessment under compulsory mental health legislation from start to finish. This encouraged a rich description of events as they unfolded over time. The use of hermeneutic phenomenology, drawing on semi-structured interviews aimed to elicit the taken for granted aspects of using the law in practice, enabling understanding of how participants experienced compulsory mental health assessment.

Practitioner diaries captured the experience of undertaking a MHA assessment, asking participants to make diary entries following one assessment over a two-month period, outlining their feelings and impressions with the aim of capturing contemporaneous experience. This involved a diary entry accounting for one MHA assessment. These were written electronically and anonymised before being sent to the researcher by secure email, in accordance with data management requirements. This method provided insight into how individuals interpret situations and ascribe meanings to actions and events (Alaszewski, 2006). Participants were introduced to the diary template after the in-depth interview. The eleven interviews had their own structure and operated separately from the diary.

Participants were selected on the basis that they were social work AMHPs in the geographical area where the research was conducted. All social work AMHPs in the three geographical areas were approached to participate. Final sampling was determined by who responded to volunteer to participate in the research. All were social work AMHPs: seven male and four female. Their experience as mental health social workers ranged from five to thirty years, with AMHP practice experience ranging from six months to twenty-two years. All participants were undertaking regular centralised AMHP duties, stepping outside of their individual teams and covering their relevant borough where they receive referrals for MHA assessments at one central location.

The method of data analysis used for the study was ‘framework’ analysis (Ritchie and Spencer, 1994). This is a method developed as an approach to qualitative data analysis for applied policy research, resonating with the focus of this study. Framework analysis can be differentiated from thematic analysis in the emphasis placed on systematic application of a series of steps, enabling a transparent audit trail leading to final themes. These steps involve familiarisation with the data; listing initial concepts; constructing an index to ensure clarity of concepts within the framework. The index was then applied to the raw data of the interview transcripts. The next step involved ordering the data so that material with similar properties was located together to develop a thematic structure. The next stage in the analysis involved refining categories and classifying data that were now contained on each separate chart with the aim of finding themes. Framework analysis involved using the framework grid to identify themes.

Computer-assisted qualitative data analysis in the form of Nvivo was utilised to manage the data. The interviews were recorded on an mp3 recorder and transcribed strictly verbatim. The transcripts were then examined and re-examined to enable familiarisation with the interview data. Following Ritchie and Spencer (1994), a thematic framework was built. This involved the identification of initial concepts, constructing an index with a hierarchy of main and sub classifications. The index was then applied to the raw data of the interview transcripts using Nvivo. This process was applied systematically across the entire data set. The next step involved ordering the data so that material with similar properties was located together to develop a thematic structure. Each main category and associated subclassifications were plotted on a separate thematic chart, synthesising the data. The final stage of the analysis involved defining elements and dimensions, refining categories and classifying data that were now contained on each separate chart; with the aim of finding themes (Ritchie and Spencer,1994).

Findings

Themes were derived following the process of framework analysis (Ritchie and Spencer, 1994), the final step involved mapping and interpretation, comparing data and identifying themes. The logic that the themes follow is based on a cross-sectional analysis of the data. This illuminates that a key feature of participants’ experience of assessment for compulsory admission involves a socio-relational endeavour, interacting with others to find meaning about individuals and situations causing concern, together with consideration of the wider community where the individual resides. Consequently, findings are organised thematically under four themes: ‘understanding the referral situation’; ‘understanding the individual’; ‘understanding the situation causing concern’ and finally, ‘community versus containment’.

Understanding the referral situation

This theme deals with how participants describe the process of understanding and meaning-making when receiving the referral, which was normally received from another professional. Receiving the referral requires the AMHP to interpret the current concerns about the person referred; this runs alongside the AMHP encountering the complexity of the referral situation and challenges. All the participants interviewed recounted that receiving the referral was accompanied by something serious in the recent past that framed the current concern about the person.

For most of the AMHPs, an oppositional atmosphere was experienced because of disjunction between the behaviour and beliefs of the person assessed, which were considered unusual, and those of family members who struggled to cope with them. Professionals struggled to be able to respond other than by requesting a MHA assessment, usually because of a lack of meaningful dialogue with the person, based on difficulty achieving this in the context of the person showing signs of acute mental distress. Added to this, the person was usually referred because they opposed other less restrictive alternatives offered. For example, an AMHP described such opposition where family could no longer cope with the behaviour and beliefs of the person because of the impact on family life. A community mental health team had been working with the person but was now opposing their continuation at home because they believed that the person’s mental state was deteriorating. Opposition occurred here because the person assessed held very contrary views about what they considered best and crucially were opposed to being admitted to hospital. This opposition occurred in the context of experiencing mental distress:

Things appeared to come to a head in the last three months when he was beginning to think in a very strange way, that in itself sounded more like psychotic phenomena. However, there were other bits to his presentation which meant that even though he was not presenting with significant self-neglect, he was not, but he was not allowing his family to support him in aspects of his personal hygiene that he needed to address. (Participant 8)

Participants encountered systems and organisational factors, highlighting a difficult terrain of practice. The work was complex and often fast paced. Time was a significant factor as a back drop of additional pressure, where finding out about family and locating the Nearest Relative were priorities. These were made more challenging by issues such as poor timing of referrals and the AMHP experiencing distractions. All the AMHP participants completed the MHA assessment on the same day as they commenced, except for one who used twelve days to make an application, having received two medical recommendations on the first day of the assessment.

Pressures were intense:

I’m overwhelmed actually because I do so many assessments! (Participant 5).

On the whole, participants described a deficit in organisational planning of referrals made to them, most often attributed to assessments in hospital under section 3 MHA when the person was already subject to section 2 MHA. They highlighted that these assessments were referred at the last minute, thereby placing the AMHP in a position where they described feeling up against the clock in relation to a section 2 expiring. Participants described a clear tension between adhering to timescales, on the one hand, and on the other the legality and legitimacy of consulting and undertaking the assessment in a way that adheres to the promotion of the person’s rights, such as consultation with their nearest relative. The AMHP participants described anchoring themselves to the statutory requirements to buffer against or rebutt organisational challenges, for example not feeling the need to compromise or cut corners in consulting with a nearest relative when a section 2 was about to expire, despite the pressure they experienced because of referrals that were poorly timed.

This example illustrates the poor timing of referrals to AMHP participants:

The Section 2 was about to expire. This is an on-going issue. The Section 2 was about to expire and for whatever reason the ward staff hadn’t allowed enough time for us to consult, arrange things and get over to a faraway place in this instance (Participant 1).

In some of the assessments recounted, the noticing of trouble that required a referral to an AMHP occurred in the context of the community mental health team being aware of a problem in relation to a person disengaging from contact with mental health services, and in the process stopping their treatment for mental disorder. One such case was exemplified where the AMHP sets the scene by describing that the mental health team had lost contact with the person; she highlighted that she sees this a lot where teams lose track of someone who has disengaged from contact and treatment. The AMHP describes that by the time the team had made contact and seen the person the only response considered available was a referral to an AMHP.

A complex network of relationships is encountered at the early point of assessment. This involves relationships connected with competing standpoints and needs.

Understanding the individual

This theme deals with how participants describe participating in the process of understanding and meaning-making about the individual person referred to them. This relates to how participants described gaining information about the person assessed from different sources, including from the person assessed under the MHA.

The points addressed here are the AMHPs’ inter-relational understandings of the individual combining collateral views and individual impressions, the difference in the approach to using the law where risks are predominantly to self as opposed to others, and the interview as a site where the law weaves between coercion and collaboration with the person assessed. The temporal experience of using the law in practice highlights the significance of the past in terms of the history of the person assessed, the present in terms of the demeanour of the person and their unusual beliefs or behaviour, and the future in terms of the impact of the mental disorder and implications of risks.

The relevance of temporality is illustrated by the following example:

You feel someone is damned by their history, to some extent (Participant 2).

Searching for an understanding of the individual involved the AMHP interpreting background information about the person provided by other sources, combined with their own face-to-face interaction with the person assessed. This was a non-linear process in which the two different perspectives are informing and informed by the other. Stories told by family members and professionals usually carried a lot of weight in comparison to the views of the person assessed. Although this was not always the case, the relationship between the AMHP, family and professionals was nonetheless most often situated in terms of an unequal coalition that underpinned the AMHP’s understanding of the individual at the centre of the MHA assessment. An example in the data where this was not always the case involved, one participant (7) who closely questioned and challenged the family’s perceptions about the person being assessed under the MHA. It is also very likely that the perspectives of others could be given less priority in referrals that are not accepted by AMHPs or do not result in detention.

A lack of dialogue with the person assessed is a source of frustration for AMHPs. The significant issue in terms of giving more weight to the story of the close family member than to that of the person assessed is that the close family member could engage in dialogue with the AMHP; this contrasts with the person assessed whose initial dialogue consisted of shouting ‘go away’ as the AMHP tried to speak with him through a letter box before the police forced entry into his home where further attempts to engage in dialogue were attempted. The context of the contrasting ability to form dialogue is striking, demonstrating how this renders the views of family members as holding more weight.

The participation and perceived demeanour of the person during the face-to-face interview with the AMHP was a related factor, further informed by an emerging understanding of the individual. The face-to-face interviews were an important component in the assessment, but the AMHP participants undertook a much wider assessment overall, which involved calibrating different stakeholder views, with their own impressions of the person during a face to face meeting with the person. These encounters were situated in tension between the AMHP duty to follow the law by interviewing the person in a suitable manner and the search for a constructive and meaningful dialogue with the person, which was often characterised as being difficult to achieve. The interview itself was often characterised as a site of distress for the person being assessed, where the AMHP is situated in a coercive role. Participants acknowledge that the assessment is often experienced as coercive for the person being assessed, and there is also a sense of inevitability in the view that the law will be experienced in this way.

So, it’s a kind of tricky thing between getting enough evidence to decide to detain, and if you decide not to detain, making sure you’ve got all the evidence and you’ve made that decision based on all the evidence. But once you’ve got enough evidence for this person, unless there is a therapeutic reason – and to be fair, that should be the care team doing that, although you can try and make it therapeutic as well, we’re all mental health practitioners, we should be trying to interact in a therapeutic and meaningful way and you always have this dream that could be a transformative experience then, but mostly they’re not, they’re emotionally pretty administrative and quite distressing for clients and not. So, there is that tension. (Participant 4)

Contradictions in understanding between the person assessed and others were a prominent feature that emerged from the data. These contradictions surfaced during the face-to-face interview with the person. They involved a disjunction between the views about the person, notably from professionals and family members, and those of the person being assessed, leading to contradictions in perceptions about the troubles and problems from different standpoints.

Understanding the situation causing concern

This theme deals with how participants describe participation in the process of understanding and meaning-making about the situation causing concern that has led to a MHA assessment. This relates to how participants describe putting the pieces of the referral together in their search for understanding about what has led to the MHA assessment. This captures how participants talk about the relevant circumstances of the case. The role of perspectives on risk and the community, and questions of feasibility and the availability of community support options, were concepts put to work by participants in their interviews.

It was not merely the presence of risk that influenced how AMHPs understood and responded to the situation, but mainly concern about how the risk impacted on others, considering the proximity to harm of people affected, including the proximity to harm of the person referred. Preventing tangible harm was the focus as opposed to preventing the existence of the idea of risk. Some risks could be tolerated, such as the case of the young person who had tried to hang themselves; here the AMHP was willing to seek alternatives to hospital admission if the person was able to establish a therapeutic alliance with practitioners. In the event, this alliance was not possible so a compulsory admission was followed. The AMHP determined this in the face-to-face interview with the person where effort was made to offer less restrictive options to hospital admission. This approach contrasted with other cases where harm to others was a more prominent issue, for example, where a person assessed had physically assaulted his partner; here the AMHP was less inclined to pursue alternatives to hospital admission. Both cases resulted in the same outcome: detention under the MHA. However, the process was more likely to include a serious pursuit of alternatives to in-patient admission where harm to self was the risk in question, and where communication was not compromised by acute mental distress.

The data highlighted that AMHPs were faced with a call from referrers that ‘something needs to be done’ in relation to a problem situation, based on concerns about the feasibility of allowing it to continue to evolve that was called into question by other people involved. Understanding the situation causing concern is a relational process where AMHP participants took into consideration different perspectives such as those of family members or mental health professionals. Using the law in this terrain of social work is a situated practice: situated in the context of other peoples’ stories about someone’s troubles and problems.

Views of family or a carer were influential when considering whether the person met the criteria for detention under either section 2 or section 3 MHA. The AMHP obtained a story from the carer or family member and interpreted the concerns against the feasibility of these people being exposed to the risks in question in the short-term future. The emphasis was not only on whether the statutory criteria of the MHA 1983 fitted with the pathology of the person being assessed under the MHA; it also comprised a wide-angle perspective on whether the statutory criteria fitted with the stories told by others. The statutory criteria were therefore applied to the individual based on relational understandings obtained about them from other people. The needs and rights of family members and others were given a prominent position where AMHPs privileged protecting them from harm that was foreseeable, outweighing a right to liberty of the person assessed. Fear plays an important part in the quote below:

There were reports of physically aggressive behaviour towards his mother who is the main caregiver and he lives at home. There were reports of an assault on mother in the summer, kind of lashed out at mother. So, since that incident, mother got really frightened and stopped actually challenging him on certain things to do with his personal hygiene (Participant 8).

The quote by Participant 8 highlights a nuanced coercion over autonomy. For all participants, this involved a complex juxtaposition of coercion and autonomy where privileging the needs and rights of family members was aimed at protecting them from harm. This involved the person assessed having their right to liberty outweighed. However, this was often to promote the autonomy of the person assessed in the longer term and to restore the social relations that had been ruptured. In this way, coercion and autonomy are closely related and intertwined with both complementary and competing imperatives.

Community versus containment

This theme deals with how participants describe weighing up the choice between detaining a person in hospital against them being in the community. Trust is an important concept in participants’ interviews. In weighing up where the person assessed should be located, AMHPs acknowledged that hospital was not a desirable outcome for the person assessed because it would be distressing, inconvenient and disruptive.

The notion of trust appears to be important for participants when thinking about community on the one hand and containment on the other. It operated at several different intersections between the juxtaposition of community and containment. There was, for most participants, a lack of trust in the hospital as an institution; however, this was nuanced to some degree as there appears to be a higher level of trust in ‘our’ ward, by which participants referred to the admissions ward in their local area. Paradoxically there is also a lack of trust in the person assessed to be able to leave hospital. Trust also operates in relation to whether the person assessed can be trusted to engage with mental health services in the community, a lack of trust here indicating consideration and justification of the need for containment. This also included a general sense of whether the person could be trusted to be in the community per se. In the quote below, the participant seems to equate the use of detention as a response to the idea that ‘being voluntary’ leads to ambiguity, whereas being detained is equated with eliminating uncertainty:

We were all concerned that in the light of his history he could well change his mind and try to leave if he were voluntary, and however much you try to plan these things, we all know that things go wrong on wards. So, there’s an element sometimes of safety first, particularly almost certainly going to somewhere away from here. If it had been our triage ward I could gone up and said, ‘look, this is what we’re doing’ (Participant 2).

Participant 2 highlights that the person could change their mind and try to leave the hospital if admitted voluntarily. The implication of this is that the person could, in theory, leave the hospital in a vulnerable state, or might need to be detained under short-term holding powers to enable another MHA assessment. If the person left hospital, then the crisis that led to the admission might re-occur. If they are detained under holding powers then another MHA assessment might lead to a suggestion by other professionals that the person should have been detained in the first place. There is also a suggestion that no amount of planning or communication with the ward would be enough to contain the person, there is also the sense that something could go wrong if the person was admitted informally. The AMHP was concerned that not being detained left the situation uncontained, despite that the person would be admitted to a psychiatric ward. This might suggest a sense that Participant 2 would be less likely to be blamed if things went wrong if the person was detained. When Participant 2 makes a distinction between a local and an out of area ward he appears to be suggesting that things would be less likely to go wrong, and therefore enable an informal admission, if the person was admitted locally. An admission to an out of area bed could involve admission to a hospital hundreds of miles away where the AMHP has no relationship with staff. Here, trust operates in several different layers. There is distrust in the person admitted because ‘they might change their mind’, distrust in the hospital to manage the person informally ‘because things go wrong on wards’, and a sense that trust in the process of admitting the person informally would increase if they were admitted to a local bed.

The ability, or conversely the inability, of family to cope with the person was strongly associated with lack of trust in the person to be in the community and was outlined by all participants in their interviews. All participants were influenced by this, and in most cases it was a key component in deciding between the person being detained in hospital or being discharged to or remaining in the community. An inability to cope was not only associated with an inability to sustain a role as a carer because of concern for the person’s mental health. It was also associated with family members being concerned for their own safety, being unable to trust the person assessed, as illustrated in the quote below from Participant 9:

Um, she was worried about being left on her own. She said, ‘I don’t stay with him on my own’, um, cos he, threatened her but in a psychotic kind way because of his thoughts or his delusions that he’s having, so she’s unsure. She didn’t know what he was doing, he’s unpredictable (Participant 9).

Discussion

The article draws on a hermeneutic phenomenological study, providing in-depth exploration of how social work AMHPs experience compulsory assessment under mental health law in practice. This illuminated the experience of assessment from the social work AMHP perspective. Answering the call for studies exploring how law translates into social work practice (Braye et al., 2013; Preston-Shoot and McKimm, 2012), the article reveals this as a complex socio-relational endeavour. This refers to the processes, connections and relations involved in such decisions. In doing so, the findings articulate the complexity of the social work role in translating legal rules and their ethical application. The findings provide empirical evidence supporting Campbell’s (2010) enduring observation that the social work role is compromised by organisational systems and scarce resources, limiting their potential to meaningfully engage service users and carers in less restrictive community alternatives to coercion. Furthermore, the findings extend understandings of the ethical challenges realising human rights and recovery-focused practice working with involuntary service users in mental health (Courtney and Moulding, 2014). This draws attention to how the space for human rights-based social work practice can be eroded by systems conditions. This adds to evidence highlighting a gap between social workers’ ability to understand principles central to social work in the AMHP role, and the challenges translating these into practice (Karban et al., 2020). The findings reveal that participants experienced compulsory assessment interfacing mental health systems with few answers to acute mental distress and risk of harm occurring in the community, other than calling for the person assessed to be detained. Carers had often been left to pick up the pieces for too long, struggling to cope. Mental health services had sometimes lost contact with the person assessed, lacking resilience to provide care for acute mental distress in the community. By the time the AMHP was called to assess, there was often difficulty establishing a dialogue with the person in the context of them experiencing acute mental distress.

Previous studies (Quirk et al., 2003; Peay, 2003; O’Hare et al., 2013) focus on reasons for someone being detained under the MHA, presenting a more calculative scenario following on from the framing of assessment under compulsory mental health law as an event that is focused primarily on the individual characteristics of the person assessed. The findings shed light on the emergent and contingent nature of the reasons to detain someone or not, underpinned by organisational deficits and challenges. This captures how the views of professionals making these decisions are related to the bidding, for example, from family members and other professionals who may articulate good reasons to detain the person, in the context of a mental health system ill equipped to provide less restrictive alternatives. Consequently, the voice of the person at the centre of the assessment was normally severely diminished, in the context of experiencing mental distress. A lack of resilience in mental health systems funnels people into assessment under compulsory mental health law, framing the feasibility of a person remaining in the community. Acknowledging that such practice is situated in an unjust mental health system is important for social work, in the light of contemporary international law obligations (UN, 2007) enunciating the discriminatory nature of compulsory mental health law. A commitment to human rights practice in social work, applied to the findings, involves an imperative to amplify the voice of the person assessed during assessment under compulsory mental health law. Campbell et al. (2018) reinforce the need for human rights practice to be at the heart of mental health social work practice in compulsory decision making. The findings suggest that such a shift towards realising human rights practice requires social work to challenge systems conditions that erode the ability to do so.

Finally, the findings further illuminate understandings on the complexity of inter-agency co-operation involved in social work practice within compulsory mental health law (Davidson et al., 2019), drawing attention to trust as an important concept. The importance of trust in the experience of social work AMHPs undertaking assessments under mental health law has not previously been highlighted in the literature. This operated at several different intersections in the juxtaposition of community and containment. This involved interpersonal trust (trust in people) and systems trust (trust in more abstract systems/institutions). Where participants spoke about the notion of community versus containment, there was lack of trust in the hospital where the person was detained. A paradox exists here in the apparent lack of trust in the person assessed to be able to leave hospital, as interpersonal trust operates in relation to whether the person assessed can be trusted to engage with mental health services in the community and be trusted per se to being in the community. Distrust in the person to be in the community because of the perceived need to do something to contain the situation results in preference for containment of the person, and indeed the situation causing concern. This occurs in the paradoxical state where there is distrust in the institution that is proposed as offering the most preferable solution. Therefore, the role of trust and distrust in the findings reveals an additional layer of nuance and complexity implementing mental health law in social work practice.

Limitations of the study

Limitations impact the study. It involved a relatively small number of participants, purposively sampled. Involvement in the study was therefore limited to those who chose to take part. Subsequently, the sample size means that the findings cannot be generalised and sampling raises the risk of including biased participants. All participants chose to discuss assessments where the person was detained. Studies exploring the experience social work AMHPs in assessments where the person is not detained would therefore be valuable.

Conclusion

The article provides empirical findings on how social work AMHPs experience assessment under compulsory mental health law. This is revealed as an inherently socio-relational endeavour, interacting with others to find meaning about individuals and situations causing concern, together with consideration of the wider community where the person assessed resides. Subsequently, the findings illuminated the ethical challenges realising human rights-oriented practice in an unjust mental health system. The findings also highlight that the voice of the person assessed is diminished in the process of assessment. Finally, the complex nature of this role was discussed, drawing attention to trust as an important concept. It was argued that realising human rights-oriented practice involves implementing developments in social work practice and systems.

Acknowledgement

I would like to acknowledge the generosity and expertise of Emerita Professor Suzy Braye and Dr David Orr, University of Sussex. I thank them for their support and guidance with the research.

References