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About this book

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.

Table of Contents


This book sets out to explore a range of issues as they affect the particular statutory responsibility of approved mental health practice. As editors, we agonized over how best to refer to this responsibility; it is undertaken in a range of countries and under a variety of Mental Health Acts; it involves statutory duties which differ, albeit slightly, and it also attracts different titles. We finally settled on the phrase approved mental health practice, which for us best captured the essence of ‘the doing’. Additionally, we know that the responsibility can be undertaken by a range of qualified professionals and, therefore, we decided to use the term approved mental health practitioner to refer to ‘the doer’. We acknowledge that our chosen terminology is closely matched with the role title, Approved Mental Health Professional (AMHP), as it is currently known in England and Wales, and that while this might be the biggest readership, the proximity could have two consequences; first that the book will be perceived as being relevant only to this group — it is not — and, second, that individual authors and in turn the reader might conflate both, giving rise to confusion and irritation. We trust that our explanation and editorial stringency assuages both.
Sarah Matthews, Philip O’Hare, Jill Hemmington

1. Underpinning Themes, Theories and Research

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.
Sarah Matthews

2. UK-Wide Perspectives: England and Wales

Chapter 2, along with its companion Chapters 3 and 4, sets the political and legal scene across all four nations of the United Kingdom. As editors we were keen to examine approved mental health practice from an intranational perspective and in so doing explore any divergence and convergence. Approved mental health practice does not happen in a vacuum but rather reflects a wider political context. Of most relevance here are the increasing moves towards devolution and the policyled decision to modernize mental health services. Paradoxically as intranational perspectives are diverging, policy makers are recommending converging professional roles. This chapter focuses on a further tension; the legal changes within mental health law both in England and Wales depicting the bitter contemporaneous debate about the state’s role in protection of the individual. We are also reminded that such tension is not inevitable. One aspect, law based upon principles, is mostly in union. Other aspects, such as those professions deemed most suitable to undertake designated roles are at variance. This chapter, therefore, continues the discussion of the underpinning themes in Chapter 1; discussing the possible impact of departing from a social work specific role in one nation while retaining it in another. Concluding with the Welsh context, the chapter brings this discussion to the fore and provides a springboard for consideration of the Scottish and Northern Irish contexts discussed in Chapter 3.
Sarah Matthews, Philip O’Hare, Jill Hemmington

3. UK-Wide Perspectives: Scotland and Northern Ireland

Chapter 3 continues in the practical vein of Chapter 2 but in this instance considers the convergence and divergence of approved mental health practice from a Scottish and Northern Irish perspective. As we have commented earlier, intranational considerations are of increasing importance in approved mental health practice. This chapter, like its predecessor therefore, focuses on such matters, but it also has another function; it continues the thread which began in Chapter 1 and picked up in Chapter 2 of the evolution of approved mental health practice. The influence of principle based legislation is revisited, and it is also reinforced that these mirror social models of mental health. Furthermore, the ‘local’ debate as to whether to open up approved mental health practice to other professions, and the subsequent dismissal of this, is pertinent. It is seen that the notion of independence, the second underpinning theme of Chapter 1, is fundamental. Intranational perspectives also bring into sharp focus how policy is inspired by and reflects social and cultural contexts peculiar to local developments. In so doing a platform is provided for Chapter 4 in which the author debates the influence of policy in depth. Lastly, Chapter 1’s underpinning theme of the influence of research on approved mental health practice continues here as further research into approved mental health practice is urged.
Jean Gordon, Roger Davis

4. ‘Mental Health Law’ and ‘Mental Health Policy’ in the UK

Chapter 4 sets out to provide a space for the reader to recognize and also reflect upon the ‘taken for granted’, or doxa. Here law and policy is not simply a matter of rules to be followed; instead the author asks the reader to look beyond any superficial acceptance of the legal and policy framework and question its very existence. This chapter especially asks that this questioning needs also to done by specialist professionals who might otherwise not allow themselves this opportunity. How do practitioners, as the author asks, come to be doing what they are doing and thinking what they are thinking. Arguing that professional practice is a result of the societal context in which they exist and in which they are educated, the author debates the social construction of normal behaviour. In turn he questions society’s way of coping with abnormal behaviour, especially where psychological ‘abnormality’ demands that help is provided even when not asked for. Picking up on the turmoil surrounding the reform of legislation in England and Wales, the author discusses in more detail the debate around underpinning principles of statutory mental health care and in particular the reason in England and Wales why the Government did not accept the reciprocity principle. Ideological uncertainty is a central theme for approved mental health practice to which this book returns.
David Pilgrim

5. The Problem of Psychiatric Diagnosis

This chapter reflects on the approved mental health practitioner’s approach to diagnosis and its significance. It recognizes that this is more than an academic debate in that the degree to which a practitioner accepts a diagnosis will have a clear impact on the outcome of assessment and their understanding of appropriate treatment. As the author indicates, approved mental health practitioners are not asked to take a ‘pro’ or ‘anti’ stance in relation to diagnosis, but to search out and embrace the complexity of any service user’s lived experience. Sadness, madness and distress are very much a part of this, but these can be masked or overlooked by the diverting aspects of diagnosis. Being diverted in this way limits reflection and continues to give priority to all that follows from this — including loss of meaning and understanding within assessment. The author locates the process of diagnosis within a social context and recognizes the inherent undercurrents of power. The author goes on to balance these ideas with arguments that exist in defence of diagnosis, and also then to review some viable alternatives. Clearly, approved mental health practitioners will not in the short term be enabled to overhaul the systems and processes as they currently exist. However perhaps simply accepting that there is an alternative will enable them to use a language that influences their understanding of human suffering and any consequent ideas around treatment. As the author concludes, the way that we conceptualize mental ill health and its attendant crises structure how it can be understood, experienced, assessed and addressed. An approved mental health practitioner who is unable to embrace an appropriately critical perspective risks colluding with a rigid, limited perspective that affects their ability to act creatively when considering alternatives to hospital and treatment options.
Helen Spandler

6. Ethics and Values

This chapter is concerned with the values and ethics underpinning approved mental health practice, these terms are often used interchangeably and it should be noted that while linked they are in fact separate considerations. The understanding of both is crucial for any textbook exploring the complexities of approved mental health practice. Here, the author considers how ethics and values are subject to changes over time and are dependent on context. Mental health legislation is underpinned by principles. In turn, approved mental health practice is based on a values-based approach. But, does it follow that approved mental health practice is therefore always ethical? This chapter seeks to discuss the dilemmas that this question poses. It discusses the balance required between personal values and the requirements of approved mental health practice alongside the impact of professional and organizational perspectives. In addition other considerations such as economic pressures and practical considerations complicate decision making. A balance is not always possible and conflict can emerge. Underpinned by philosophical considerations pertaining to risk taking, the chapter concludes with a discussion about the needs of the individual and those of society. Consideration of the literature concerning the use of Community Treatment Orders is provided as a contemporary challenge to ethical decision making. As is the case throughout the book this chapter raises the issues for consideration and concludes that there are no certain answers.
Daisy Bogg

7. Diversity in Mental Health Assessment

This chapter recognizes that the concept of diversity is not always well understood or defined at either a theoretical or a practice level. A task for the author, and then the reader, is to find the middle ground between a hazy, theoretical or academic understanding of diversity that focuses on abstract concepts of identity, and a basic, crude, demographic classification system or mind-set around how individuals or groups behave by virtue of a specific characteristic. It is a particular viewpoint that deliberately does not aim to be definitive, but rather recognizes that diversity means different things in different contexts. This concept is introduced and explored, and then a case study — that of a young man who is deaf (or ‘Deaf’, from a cultural perspective) — is used to break down the many facets and components of who we are, and how our identity is formed. The learning around deafness is in many respects transferable. However, diversity is not just about individuals and their identity, as there is a social context and perspective whereby issues of power, oppression and inequality are evident. An approved mental health practitioner will need to bear in mind that their interpersonal encounters with service users have the potential to compound these factors within their assessments and choice of outcomes. Acting in a way that empowers service users, through collaborative and partnership working, can go some way to addressing this. Approved mental health practitioners must deconstruct the idea that issues of diversity or culture only affect a few people or minority groups, or that such groupings inevitably have the same experiences, beliefs or values and are affected in similar ways. Each assessment, and each individual service user is different — and it is this difference that needs to be explored.
Amanda Taylor, Jill Hemmington

8. The Impact of Space and Place

Consideration of approved mental health practice, as this chapter highlights, tends to have the urban context as its default. Here the authors challenge this default by asking the reader to contemplate what constitutes mental health in a rural context, and also the psychological, physical and practical impact of delivering services in such environments. The chapter echoes an earlier thread in this book which seeks to understand the influence of evidence and of research, here the notion that proximation and remoteness are key concepts and underpin approved mental health practice. Of particular note is the way in which default concepts need to be challenged. Notions of communities and boundedness, confidentiality and anonymity, and an understanding of what constitutes normal behaviour are reconsidered. For us as editors it felt important to look anew at how these concepts are considered and in particular to consider evidence outside of the usual. This chapter does both and as a result helps its readers to reconsider received wisdom, confront value stances and challenge any default. Lastly, this chapter echoes the challenges that working across borders bring; another important consideration in light of the increased divergence resulting from devolution.
Anthea Murr, Tamsin Waterhouse

9. The Experiences of Service Users

To reflect upon the experience of service users who have been formally detained is clearly important for any approved mental health practitioner; ultimately the final responsibility for such an outcome rests with them. In the light of increased numbers of detained patients, such reflection continues to be paramount. This chapter draws on the evidence collected in a participatory research study undertaken in the wake of the implementation of the Mental Health Act in Scotland; an Act which heralded high expectations among all stakeholders, including service users. The research reveals the experience of detention as a non-linear journey and is vividly illustrated with the use of direct quotes. These we suggest are essential reading for any practitioner providing a powerful insight into the process and reality of detention from the most important perspective, that of the affected person. In particular the feeling of powerlessness, lack of understanding about what was happening and loss of control are fundamental considerations. Building on the questions raised in preceding chapters it is clear that approved mental health practitioners do not have easy decisions to make. Of particular relevance to the reader will be the views expressed about approved mental health practitioners not least because the evidence mirrors the debates to which this book continually returns namely what is the role of the approved mental health practitioner? This chapter rightly urges the need to guard against complacency.
Julie Ridley

10. The Role of the Nearest Relative

The particular focus of this chapter concerns the Nearest Relative, a legally defined role in mental health law and a controversial one which all approved mental health practitioners need to be aware of and understand. Underpinned by a dispute as to whether the use of a relative was, or ever has been, an appropriate way to provide a check on decisions made under mental health law, this chapter offers a necessary précis of the role’s progression. A historical account provides the reader with a vivid insight into the deliberations. Moreover the reader is alerted to the gradual development of social work’s role and the increasing influence of it especially in relation to how a relative should be viewed and in what respect they retain involvement. Emerging from the blurring of these roles, approved mental health practitioners nonetheless are obliged to be mindful of the Nearest Relative and engage with them, but this can cause confusion. This chapter weaves its way through this confusion by discussing the individual review and differing outcomes by each of the nations of the United Kingdom. Lastly case law developments while aiming also to help clear this confusion provide not only a real sense of the fluidity, but also as the authors put it the ‘sharpness’ which any contemporary effective approved mental health practitioner needs.
Philip O’Hare, Gavin Davidson

11. Evidence-Based Practice

The penultimate chapter picks up on the influence of research; a theme which the reader was first asked to consider in Chapter 1. Evidence-based practice is a contemporary phrase that began life among medical circles but has since been adopted more widely. In this chapter the reader is asked to consider evidence; is it, put simply those facts that are found in research upon which approved mental health practitioners base decisions, or is this description too simplistic? In order to explore further, the author uses evidence arising from research relevant to approved mental health practice. Initially, as in Chapter 1, the reform of mental health legislation highlighted the limited availability of research, or evidence, about approved mental health practice. In turn its use resulted in different outcomes in each nation; such divergence a recurrent strand in this book. The reader is encouraged to reflect upon what evidence is and question whether approved mental health practitioners make decisions based upon evidence made available from research or rather is the process a more pragmatic one based on circumstance? Ultimately practitioners do make decisions but are these based on any certainty arising from the evidence or are other factors also important. The author in this chapter suggests that evidence even if used does not bring certainty and in so doing produces a platform for the final chapter.
Philip O’Hare

12. Managing Uncertainty and Developing Practice Wisdom

Approved mental health practitioners are required to act autonomously and make independent decisions, free from the influence of others. Decisions must clearly be lawful, and they must also rest on good practice as defined by the respective Codes of Practice. It is a principal aim of this chapter to reflect on ways of making sense of practice and instilling, maintaining and advancing competence and confidence in approved mental health practice. The chapter starts with an acknowledgement that approved mental health practice is not straightforward, and uncertainty is an inherent feature of the work. The focus will be on how the practitioner navigates this, and how they are enabled to move from ‘novice’ towards expert with the use of critical reflection. Practice wisdom is explained and promoted. An aspiration within practice is to feel comfortable with this uncertainty and complexity and be accepting of the idea that there are no clear answers — but this does not need to lead to a sense of helplessness. Rather, an approved mental health practitioner can become more confident — and move towards this expert practice — if critical reflection underpins their overall assessment and decision making.
Jill Hemmington

Conclusion: Old Values, New Problems?

This endnote reflects on the changing nature of approved mental health practice from an organizational and political perspective, and considers its legacy in terms of the value base and the psychosocial orientation to practice. It views the changing organizational landscape through this lens and evaluates the impact of some of the issues raised within this book.
Jill Hemmington, Philip O’Hare, Sarah Matthews
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