Approved Mental Health Practice

Essential Themes for Students and Practitioners

Sarah Matthews, Philip O'Hare, Jill Hemmington

• Publisher: Bloomsbury Academic
• Year: 2014
• ISBN:
  9781350313064
• Edition: 1
• Topic: Psychology
• Subtopic: Movements in Psychology
• Index: Psychology

Drawing on a wealth of experience from both current and past practitioners in mental health, this book is a handbook for Approved Mental Health Practitioners at a time of uncertainty and change. The book considers the themes and issues relating to the role, the present day challenges and future directions for the profession.

1

Underpinning Themes, Theories and Research

Sarah Matthews

Editors’ Voice

The remit of the opening chapter is to introduce the reader to the core underpinning themes, theories and research of approved mental health practice. As is the case throughout the book, readers are asked to reflect upon what it means to be an approved mental health practitioner. Here the author focuses on areas which as editors we feel are the foundation of approved mental health practice; the social perspective and independence. We were also mindful of the sociological and psychological influences that underpin the responsibility, whether consciously or not, and these are also introduced. No book on approved mental health practice can ignore the political context; the responsibility is sanctioned in legislation and based upon decisions that reflect a wider political environment. Devolved nations add to this complexity. The chapter, therefore, asks the reader to consider the impact of political decisions, in particular the opening up of the responsibility of approved mental health practice beyond social work. Mirroring a policy of the redistribution of mental health roles in England and Wales, this change was also based on research reporting the negative impact of approved mental health practice on social workers including high levels of stress and a ‘disappearing’ workforce. The chapter, therefore, asks the reader to reflect upon the influence of research. These themes, theories and research add to the uncertainty common to approved mental health practice and are revisited throughout the book.

There is no doubt that the responsibility of approved mental health practice courts debate. Empirical research also reinforces what is, in effect, an underlying uncertainty. This chapter will précis the main themes, theories and research of approved mental health practice, which have hitherto neither been gathered together, nor fully explored. This, along with the relative paucity of research into responsibility is a flaw, and one which was identified as such by policy makers during the reviews of mental health legislation. This chapter contends that, to be effective, all approved mental health practitioners, regardless of their legal, national or professional background should engage not only in the requirement to apply the law effectively but also in critical reflection of the underpinning themes, theories and research identified here. This chapter therefore provides a foundation upon which the remainder of the book rests.

Themes

The social perspective

Understanding and engaging in the social perspective is generally agreed by all interested commentators to be the cornerstone of approved mental health practice and the primary model for understanding mental disorder, or providing a non-medical viewpoint. In essence, the social perspective refers to the focus on the social determinants of mental ‘ill health’. These determinants are taken into consideration by approved mental health practitioners in order to highlight a different perspective, usually as a balance to the medical one, and in order to pursue alternatives to formal detention. This consideration is primarily achieved in practice by an overt assessment of social circumstance and is referred to as the approved mental health practitioners’ social lens. The social perspective is a thread that permeates all formal manifestations of approved mental health practice. Preservation of this perspective is indicated in research studies (Hatfield, 2008) and its retention remains a current concern (Bogg, 2012) In addition regulations include it as a key competence and Codes of Practice also spell this out: in England the role of Approved Mental Health Professionals is to ‘bring a social perspective to bear on their decision’ (Department of Health, 2008, p. 36). In Scotland medical and social factors are central: there has to be a ‘consideration of as much available and relevant information on the patient’s medical and social circumstances’ (Scottish Executive, 2005c, p. 28).

Perhaps most readily associated with social work, understanding and engaging with the social perspective is the crux of the deliberation about which profession, if any, is best able to conduct effective approved mental health practice. Nathan and Webber (2010, p. 16) view the primary function of mental health social workers as ensuring ‘the long held tradition of promoting psychosocial perspectives’ or ‘an alternative to psychiatric hegemony’. Nonetheless, as we shall see in Chapter 2, some social work roles in mental health have been opened up to allied professionals. The review of mental health legislation in England and Wales, known as the Richardson review (outlined in detail in Chapter 2), recommended such an outcome for approved mental health practice based on the reported difficulty in retention and a disappearing workforce. The Richardson review was persuaded that the skills of Approved Social Workers were available across the mental health workforce. The redistribution of the role can, therefore, also be seen as a consequence of ‘new ways of working in mental health’ (Department of Health, 2007a); a progression of a policy whose rationale is to assign roles on the basis of competency rather than professional status.

The impact of opening up the responsibility of approved mental health practice in England and Wales has been greeted as both an opportunity and a threat and is primarily discussed within nursing and social work literature. Some mental health nurses were keen to embrace the responsibility as a ‘sensible extension to their repertoire’ (Allen, 2002). Others, such as Hurley and Linsley (2006) maintain that mental health nurses already engage in restrictive care and can easily transfer skills and knowledge from the hospital environment. To equate restrictive care with approved mental health practice is a contentious assertion, intimating as it does, a pre-emptive outcome. Nonetheless, it cannot be ignored that nurses do already work with detained patients. The responsibility of approved mental health practice, when first proposed, was, on the other hand, also perceived by nurses as potentially negative, compared with what was perceived as their therapeutic relationship with a patient; a concern that was highlighted in the Royal College of Nursing’s response to the draft Mental Health bill (Royal College of Nursing, in Allen 2002). Empirical research does not wholly support this fear. Hurley and Linsley (2006) conclude that being involved in coercion could be both positive and negative; echoing earlier work which found that ‘being there’, through bad times as well as good, could actually strengthen any therapeutic rapport (Bowers et al., 2003, p. 965). Early indications also show that some nurses who are undertaking the responsibility are optimistic about its impact on their relationship with service users (Laing, 2012, p. 237). Further evidence is required however before any meaningful conclusion can be reached about the way in which nurses ‘do’ approved mental health practice, and the impact whether positive or negative this has.

From the standpoint of social workers, opening up the responsibility was initially viewed by some as a threat, and in particular, as a ‘watering down’ of the social perspective. In other words, the social perspective was perceived to be social work’s prerogative and that without exclusivity its influence would diminish. Some even feared the end of the social work profession in mental health. There is no evidence yet to suggest that any such outcome has been realized. On the contrary, the social perspective remains embedded in the approval frameworks. The debate about the future of social work in mental health continues to occupy current commentators. Nathan and Webber (2010, p. 16) have defined the three distinct stances. The first of these they describe as traditionalist, or those who argue that social work needs to retain its distinct identity and return to its local authority location. For them this traditionalist viewpoint reverts to ‘ghettoisation of mental health social work as a professional backwater’ (Nathan and Webber, 2010, p. 16). Moreover, they suggest, it leaves the Health Trusts in an even stronger position to promote a bio-medical model without challenge. The second stance Nathan and Webber describe as genericist, or those who suggest that retaining distinctions between professions has no purpose. Genericists predict that there will be a mental health professional able to undertake all roles; a standpoint which mirrors contemporary policy in relation to new ways of working in metal health. But, for Nathan and Webber generic roles would mean an end of a professional base in mental health social work. The ‘best’ future for mental health social work they contend is eclectic, or integrated; that is they anticipate a merging of roles between social work and heath, while maintaining professional diversity (Nathan and Webber, 2010, pp. 16–17).

The future of social work in approved mental health practice where the role has been distributed is likewise occupying commentators; will practitioners be able to retain a professional diversity despite a merging of the responsibility? This question currently remains unanswered. The current evidence is that social workers make up the biggest proportion of Approved Mental Health Professionals being trained in England and Wales (General Social Care Council, 2012). Interestingly, no psychologist has yet trained while occupational therapists are also few in numbers; according to these latest statistics there are just eight occupational therapists, a figure representing just 1 per cent of the total (General Social Care Council, 2012). Initial findings into sites involved in the early implementation of new roles in mental health, including that of the Approved Mental Health Professionals, provide some insight into the reasons for uptake, or indeed lack of it! The primary reason for uptake was reported to be the need to respond to a shortage of social work applicants. Other factors such as senior management support and staff (nurses) attitudes were also highlighted. Aside from lack of interest where recruitment was not a problem, factors which mitigated against uptake included difference in remuneration and difficulties covering absence when training was being undertaken (National Institute of Mental Health England, 2009). It is not yet known whether current proportions will become the norm nor is it fully understood what the possible impact might be.

The extent to which consideration of the social perspective influences outcomes in approved mental health practice remains open to further exploration. The unspoken assumption here of course is that social workers are somehow naturally professionally ‘versed’ in the social perspective of mental health. This assertion also attracts dialogue in the literature. In basic social work education, the attention given to social perspectives of mental health is said in some quarters to be at best inadequate, or too simplistic. Moreover, this is in contrast to the education received by nurses, who, even at the basic level, have a specialist branch in mental health. Far from being trailblazers for the social perspective, social workers might instead be viewed as ‘sorting out the practical problems around the edges while doctors (and nurses) undertake the core business; of diagnosis, treatment and management’ (Tew and Anderson, 2004, p. 232). On the other hand, social workers have a basic education which is underpinned by social sciences, including an appreciation of the impact of social factors. In addition, Laing argues that the social perspective does not feature in the initial training of nurses and that such an omission will need to be addressed if they are to succeed in ‘fully harnessing’ approved mental health practice (Laing, 2012, p. 236). Finally, professional skills including the assessment of the impact of social factors are undoubtedly specific to social work education and it is upon this which the training for approved mental health practitioners is based.

The perspective that social work brings to approved mental health practice is challenged in other ways. Commentators are beginning to question that if a profession, such as social work, claims to have a knowledge base and in turn a desire to bring a different perspective to the medical norm, then there should be greater evidence of refusal to apply for admission (Campbell, 2010). In short, requests for an application for detention should be ‘turned down’ more often than the available statistics about the outcome of assessments currently suggest; numbers of detentions are reported to have ‘hit record levels’ with an increase of 5 per cent since 2010 (Health and Social Care Information Centre, 2011). Campbell (2010) also wonders why, if social workers as approved mental health practitioners recognize the potential for discrimination in the use of compulsory powers, are the attributes of those detained under mental health legislation ironically mirroring those of the socially disadvantaged. Extensive work carried out by Hatfield and colleagues during the 1990s and 2000s, a time when social workers were exclusively carrying out this responsibility clearly show this to be the case (Hatfield, 2008; Hatfield and Antcliffe, 2001; Hatfield and Robinshaw, 1994). Do social workers as approved mental health practitioners, then, struggle to promote a model that views the manifestations of mental health in any way other than the dominant and, some argue, pathological one?

The focus on the social perspective has also been seen as a paradox, suggesting, as it does, that the responsibility enables an approved mental health practitioner to consider a ‘least restrictive alternative’ based, not just on the assessment of social circumstances, but on active diversion to alternatives. Some authors argue that such an expectation is unrealistic as such alternatives do not really exist (Prior, 1992). Prior was of course writing at the beginning of the 1990s, at a time when community mental health services were developing. Since then alternative services, primarily in the form of crisis intervention and resolution services have developed, and as one might expect the use of them has increased. Ironically, such services are now viewed as gatekeepers to approved mental health practice, referring a person for assessment only when, in their opinion, detention is needed, thereby negating any outcome other than the required administrative legal function.

Independence

An underpinning theory of approved mental health practice is that it should be enacted independently. There are two aspects to this independence; of the influence of medical views and of the influence of the employing agency. As is the case with the social perspective, the notion of the maintenance of independence in decision making is required (General Social Care Council, 2010; Matthews, 2011). Early commentators, when reflecting upon this attribute, referred to independence as a ‘creative tension’ between the social worker and the doctor (Bingley in Brown, 2002). Others contend that independence from medical opinion is both a sign of effectiveness and a necessary check, ’the involvement of mental health social workers in the use of compulsory powers is an indispensable component of quality mental health services’ in particular because this maintains ‘an independent voice outside of medical hegemony’ (Manktelow et al., 2002). The concern that such independence might be lost is the second most debated threat of the opening up of the responsibility to others. The British Association of Social Work in its response to the consultation on the proposals to reform the Mental Health Act in England and Wales feared that the inclusion of other non-social work professionals to conduct approved mental health practice would result in insufficient independence from medical influence (British Association of Social Workers, 2005).

Let us examine such claims of independence and question whether this ‘creative tension’ is merely rhetoric. Independence has, it is argued, never existed. Rather, approved mental health practitioners, mostly agree with medical opinion and sign an application for admission. Research carried out into decision making supports this view. Based on an inspection of the Approved Social Worker service in 10 local authorities, one report concluded that disagreements (between medics and social workers) were reputedly rare, with negotiation rather than conflict being the norm (Social Services Inspectorate, 2001). Roberts et al. (2002, p. 81) also report ‘concordance rather than conflict’ although do not view this evidence as grounds for saying that independent decision making is not retained. In their words ‘there will be situations where one profession will act as a brake for another in respect of compulsion’ (Roberts et al., 2002 p. 81; Peay, 2003).

Others conclude that approved mental health practitioners are primarily administrators who ‘merely transport’. Hargreaves in clarifying what he refers to as the several strands of approved mental health practice suggests that this concept is a simplistic one and that other strands including ‘crisis manager’ and ‘social assessor’ are present. However, none of these he argues requires independence but rather this is negated by the overarching policy that in contemporary mental health work no major decision should be taken without prior consultation with other professionals (Hargreaves, 2000, p. 143). Even in relation to his ‘protecting rights’ strand, Hargreaves contends that this is essentially an administrative function shared with a Mental Health Act Officer’ (2000, p. 143). He believes that only an external body can be truly independent. Commenting on the outcome of the review of mental health legislation in England and Wales, he condemns the decision as prioritizing collective decision making over quasi-judicial principle and also questions who will actually continue to undertake the responsibility. He argues that the outcome misses the opportunity for ‘true’ independence but that possibly different professionals will be doing the same job (Hargreaves, 2007).

Does Hargreaves’s view pander to those who perceive the responsibility as ‘simply’ a bureaucratic task? Arguably this view is also retrograde and based on an assumption that the responsibility is a purely legal one. It may also be the case that more robust investigation might uncover instances where avoidance of compulsion is more prevalent than the evidence which is cited would suggest. Walton, for example, when checking the approved mental health activity of team local to her found that 18 per cent of patients for whom two doctors had already recommended compulsory admission were being dealt with in an alternative way by the approved mental health practitioners, in this case Approved Social Workers (Walton, 2000). Might we then be looking in the wrong place for the evidence? High admission numbers may not mean that there are not also high ‘diversion’ numbers. Independence in decision-making, while central, is contested.

When considering which profession is best placed to ensure independence, the debate continues. The future participation of mental health nursing in approved mental health practice is viewed with some apprehension, primarily based on this perceived inability to make independent decisions. Hurley and Linsley regard the opportunities for engaging in approved mental health practice as a challenge to the ‘legislative passivity’ of mental health nursing (2007, p. 535). It is however also suggested by them that mental health nurses risk being taken to, rather than embracing new roles, as to engage in such might be an ‘evolutionary change too far’ (Hurley and Linsley, 2007, p. 536). This is an interesting viewpoint pertinent to the discussion here. Does mental health nursing need to adapt and undertake new perspectives? In particular should it do so in order to be able to make decisions in approved mental health practice independent of medical influence? Hurley and Linsley contend that nurse’s caring skills equate to those of social workers and therefore this should be possible (Hurley and Linsley, 2007, p. 536).

Turning to the second element associated with the theme of independence, that of independence of the employing authority. The concern is whether professions aligned closely to each other and accountable to the same employer can be expected to make decisions that differ. A difference in decision outcome might involve a challenge by someone who had been deferential to a previously dominant other. Opening up the role to other professions, and thereby opening up this possible dilemma, is however not an entirely new employment situation. For instance many Approved Social Workers in England and Wales were employed by Mental Health Trusts, albeit seconded back to Local Authorities w...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Abbreviations
• Notes on Contributors
• Introduction
• Chapter 1. Underpinning Themes, Theories and Research
• Chapter 2. UK-Wide Perspectives: England and Wales
• Chapter 3. UK-Wide Perspectives: Scotland and Northern Ireland
• Chapter 4. ‘Mental Health Law’ and ‘Mental Health Policy’ in the UK
• Chapter 5. The Problem of Psychiatric Diagnosis
• Chapter 6. Ethics and Values
• Chapter 7. Diversity in Mental Health Assessment
• Chapter 8. The Impact of Space and Place
• Chapter 9. The Experiences of Service Users
• Chapter 10. The Role of the Nearest Relative
• Chapter 11. Evidence-Based Practice
• Chapter 12. Managing Uncertainty and Developing Practice Wisdom
• Conclusion: Old Values, New Problems?
• Bibliography
• Index