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Approved Mental Health Professionals, Best Interests Assessors and People with Lived Experience An Exploration of Professional Identities and Practice A report prepared for Social Work England

Authors:

Abstract

The research was commissioned by Social Work England to enable a more in-depth understanding of professional identities. The research includes aspects of education, stress and an original fine-grained understanding of practitioner perspectives.
Approved Mental
Health Professionals,
Best Interests Assessors
and People with
Lived Experience
An Exploration of Professional Identities and Practice
A report prepared for Social Work England
May 2021
Jill Hemmington, Matthew Graham, Alan Marshall,
Andy Brammer, Kev Stone and Sarah Vicary
Research team details
2
Research team details
3
Jill Hemmington
Jill is a Senior Lecturer and course leader
for the University of Central Lancashire’s
Approved Mental Health Professional
(AMHP) qualifying and post-qualifying
refresher training and education, both of
which are delivered nationally. Prior to this
Jill worked in and managed a Community
Mental Health team, acted as an Approved
Social Worker (ASW) and she is now a
practising AMHP. She is completing a PhD
in AMHP (shared) decision making and
power in Mental Health Act assessments.
Jill is published in the eld of statutory
mental health work.
Matthew Graham
Matt is a Senior Lecturer in social work at
the University of Central Lancashire. He is
course leader for the Best Interests
Assessor (BIA) qualifying programme and
is a module leader and tutor on the AMHP
qualifying programme. He specialises in
teaching, training, and is published in the
area of the Mental Capacity Act 2005. Matt
is a registered social worker and previously
practiced as an Approved Social Worker.
Alan Marshall
Alan is a Senior Lecturer in social work at
Shefeld Hallam University. He runs the
BIA and AMHP qualifying programmes as
well as teaching law, mental health and
safeguarding across social work and
nursing courses. Alan has previously
worked as an AMHP for over 10 years.
Andy Brammer
Dr Andy Brammer is an Associate Lecturer at
Shefeld Hallam University. He teaches on
the AMHP and BIA courses and other post
graduate adult social work modules. He is
the AMHP lead for Wakeeld Council and a
qualied AMHP and BIA. His substantive role
is in the MHA/MCA professional support
team. He has completed a PhD in the
decision making of AMHPs undertaking
community assessments.
Kev Stone
Dr Kev Stone is an Associate Professor and
Lead Social Worker at the University of
Plymouth. He is a practicing AMHP, qualied
BIA and was a university AMHP programme
leader. His research interests include the
changing landscape of the mental health
workforce and the socio-legal effectiveness
of mental health legislation. Kev delivers
CPD education and has published widely in
these areas, notably the AMHP and BIA
Practice Handbooks.
Sarah Vicary
Dr Sarah Vicary is Associate Head of School
at The Open University. Prior to her
academic role she worked in mental health
services, including as an ASW and manager
of a mental health crisis service. Sarah was
for 9 years a Mental Health Act
Commissioner. Her PhD explored the role
and experiences of AMHPs. She is widely
published in social work and mental health
including the AMHP Practice Handbook. She
was academic adviser on the award-winning
BBC documentary Psychosis and Me.
Dina Poursanidou
Dr Konstantina (Dina) Poursanidou is a
Service User Researcher in mental health.
Her doctoral and post-doctoral research
has spanned a range of elds including
mental health, education, child health,
youth justice and social policy/social
welfare.
Darrell Brooks
Dr Darrell Brooks is a Senior Lecturer
(Physiology) with the Bachelor of
Medicine and Bachelor of Surgery (MBBS)
and Physician Associates programmes
with the School of Medicine at UCLan. He
is interested in clinical and health
physiology and the use of ‘Extended
Reality’ technologies for data visualisation
in medical education and training.
Research team details: Participant
acknowledgements:
Data Analysts:
The research took place during the
COVID-19 pandemic which made
demanding lives, jobs and circumstances
even more challenging. We acknowledge
that, for many, time was very limited and
also that, for others, many of the topics
were difcult to discuss. The research
team would like to thank all who
supported this research project.
Workstream 2 BIAs: .................69
Overview of the role ............................69
Review of the literature ......................72
Findings from the survey ....................76
- Demographic data ..............................76
- Qualication details ............................77
- Employment and workforce details .....78
- Professional identities ........................79
- Challenges of the BIA role .................86
- Health and wellbeing .........................88
- Rewards of the BIA role ......................90
- Leadership, support and supervision ...90
- Professional regulation .......................92
- Education and training .......................92
- Dual specialisms: BIAs who are
also AMHPs ........................................96
People’s experiences of BIA
interventions .........................................98
Experiences of family members of
people receiving BIA interventions ....98
BIA focus group themes ......................101
- Motivation ..........................................101
- The independence of the role ........102
- BIA work as varied work ...................103
- BIAs and professional identities .....104
- Values, rights-based work and
advanced practice ............................105
- Maintaining knowledge and skills ..106
Workstreams 1 and 2:
Summary of AMHPs and BIAs 108
- Demographic comparisons ............108
- Did the regulated professions make a
difference to the AMHP or BIA role? ..110
- What the professions bring to AMHP
and BIA practice ................................111
- Support ............................................112
- Rewards of the work .........................112
- Challenges of the work ....................113
- Empowerment and involvement:
working with people ........................115
- Independence, autonomy, power
and the capacity to challenge .......115
- Stress, burnout, support and retention 116
- Training, education and knowledge
development .....................................117
- People with lived experience
of the roles ........................................117
- Dual specialisms ...............................119
AMHPs and BIAs:
looking to the future ..........................120
- AMHPs and legislative reforms .......120
- BIAs and legislative reforms ............121
Reference list .........................................124
Annex ......................................................133
- Focus group participant proles ....133
Background to this study .........6
Overview of project .....................7
Approach ...............................................8
Overview of methods ...............8
- Quantitative approach ..........................8
- Qualitative approach ............................9
Workstream 1 AMHPS: ...........10
Overview of the role ..............................10
Review of the literature .........................14
Findings from the survey ......................24
- Demographic data ..............................24
- Qualication details ............................24
- Employment and workforce details ....26
- Professional identities .........................28
- Challenges of the AMHP role ............37
- Health and wellbeing .........................38
- Rewards of the AMHP role .................41
- Leadership, support and supervision ..41
- Professional regulation .......................43
- Education and training .......................44
- Dual specialisms: AMHPs who are
also BIAs ...............................................47
People with lived experience of MHA
assessment and AMHPs ......................48
- Communication and the assessment ..48
- Admission to hospital .......................50
- Power, stigma and ambush ................50
- AMHPs’ workloads and time ..............51
- Resources to meet need ....................51
- The impact of trauma .........................52
- Professional identities .........................52
- Training and education ......................54
Nearest Relatives’ experiences of MHA
assessments and AMHPs .......................55
AMHP focus group themes
- Motivation ............................................57
- Rights-based, justice-focused and
advocacy work .....................................58
- Power and challenge ..........................59
- AMHP work as varied work ................59
- Resources to meet people’s needs .....59
- Pressures of time and workload ........60
- Empowerment, involvement and
working with people ...........................60
- The personal toll of AMHP work .......60
- Service and team structures ..............61
- Professional differences or
organisational differences .................61
- AMHP identities and ‘cross-fertilisation’ ...62
- Shared training and shared workplaces ..63
- Structural barriers for non-social
work AMHPs .........................................64
- Rewarding AMHP work .....................64
- Emotional aspects of the work ..........65
- Being invisible or misunderstood ........67
- Support .................................................68
Table of contents
4
Table of contents
5
Table of contents
Aims of this research project were
to further understand:
• AMHPs’ and BIAs’ views and feelings
on their professional identity (in terms
of their regulated profession) and the
effect it has on their practice
• Whether AMHPs’ and BIAs’ views and
approaches to their practice differ
across the regulated professions,
as well as any impact this might have
on people’s experiences of the
support provided
• The experiences of people who have
received services from AMHPs and
BIAs, or those who work with them,
and whether their experiences
and perceptions differ across the
professions
• Whether BIAs intend to convert their
status to AMCP1 and ways in which
this has been inuenced
Two workstreams were established:
• Workstream one: Experiences of
AMHPs, their colleagues and people
with lived experience of AMHPs
• Workstream two: Experiences of BIAs,
their colleagues and people with lived
experience of BIAs
The research was carried out with these
overarching objectives in mind and key
insights are set out below. The report sets
out brief literature reviews which
underpin the ndings from all stages of
the research project.
The project was planned and designed
co-productively with people with lived
experience of Mental Health Act
assessments. The planning phase
indicated people may not know the
professional background of the AMHP or
BIA undertaking the assessment. We also
know that AMHPs’ and BIAs’ professional
identity is highly nuanced and is
inuenced by many variables including:
• Professional (in terms of their
regulated professional background as
social workers, registered nurses,
occupational therapists and
psychologists)
• Organisational (for example, where
team setting or type may have an
inuence), and
• Personal (including where core values
inuence the work)
The research team therefore developed
a project that was designed to explore
these various nuances and variables and
to provide all participants with an
opportunity to reect on and discuss the
nature of the work quite broadly.
1 We do not currently know exactly what the conversion process will be as it is still
being developed at the time of writing
Social Work England was established
under The Children and Social Work Act
2017. It is the specialist regulator for
social workers in England. Social Work
England ofcially took over from the
Health and Care Professions Council
(HCPC) in December 2019. It is a non-
departmental public body, operating at
arm’s length from the government. Social
Work England has become the
professional regulator for Approved
Mental Health Professionals (AMHPs) and
Best Interests Assessors (BIAs). In 2020-
21, Social Work England has been
developing the regulatory framework to
support AMHPs and the new specialism
of Approved Mental Capacity
Professional (AMCP), which will succeed
BIAs from April 2022. This includes the
development of education & training
approval standards as well as specialist
standards for AMHP and AMCP practice.
Social Work England commissioned this
piece of work as part of a commitment to
learning about the professionals in these
specialisms and people’s experiences of
them. The objective of this research was
to undertake a study into the experiences
of AMHPs and BIAs and those who have
experience of their interventions. Existing
research is generally inconclusive and
little is known about this area.
Background to this study
6
Overview of project
7
Background to this study Overview of project
AMHP Survey
All 258 respondents were qualied and
practising AMHPs. There were 247 social
workers, 10 nurses and 1 occupational
therapist. There was a mix of types of
service or team structures that the
participants worked within.
BIA Survey
All 248 respondents were practising
BIAs. There were 221 social workers, 22
nurses and 5 occupational therapists.
There was a mix of types of service or
team structures that the participants
worked within.
As there was a survey for both AMHP and
BIA it is possible that a participant
completed both surveys if they were
practicing in both roles.
Two BIAs and one AMHP explicitly stated
that they practiced in Wales.
Qualitative Approach
Qualitative research was undertaken with
AMHPs, BIAs and people with lived
experience of their interventions.
All interviews were undertaken using
online (Microsoft Teams) meetings or
by telephone.
Focus groups
All AMHPs and BIAs who volunteered and
were available on the pre-arranged dates
took part in the focus groups. There were:
• Four 90 to 120 minute focus groups
with an overall total of 21 qualied,
practising AMHPs (19 social workers
and 2 nurses)
• Four 90 to 120 minute focus groups
with an overall total of 28 qualied,
practising BIAs (23 social workers and
5 nurses)
Interviews
• Fourteen individual 30 to 60 minute
semi-structured interviews with people
with experience of Mental Health Act
assessments with AMHPs or ASWs (the
forerunner to the AMHP role)
• Two individual 30 to 60 minute semi-
structured interviews with people who
have acted as Nearest Relative (a legal
role under the Mental Health Act 1983
as amended 2007)
• One individual 30 to 60 minute semi-
structured interview with one person
with lived experience of being
assessed on their capacity to make
a decision
• Two individual 30 to 60 minute semi-
structured interviews with relatives of
someone who has had an assessment
of capacity
We analysed this data for the key themes
arising from AMHPs’ and BIAs’
perceptions of their own and their
colleagues’ identities and practice. We
were keen to understand – from all
perspectives – whether it matters that an
AMHP or a BIA is from a social work,
nursing, occupational therapy or
psychology background. If so, we aimed
to explore how it inuences the way that
the work is carried out and the way that it
is experienced by people with lived
experience of the work. Given the
complexity involved we aimed to explore
these from a subjective, experiential point
of view. We wanted to understand where
experiences were shared and what the
data revealed around differences.
Approach
A multi-method approach was used so
that we could hear from as many people
as possible whilst also capturing some
depth and trying to understand people’s
experiences and perceptions about
AMHP and BIA work in detail.
We opened the project with a quantitative
research approach. We carried out a
survey with AMHPs and a separate survey
with BIAs so that we could develop a
general understanding of the work
environment and to seek to understand
key themes as identied by AMHPs and
BIAs themselves. We used these key
themes to inform our qualitative approach
with AMHPs and BIAs.
Our qualitative research approach then
enabled us to add depth and detail to the
survey data. We held focus groups with
AMHPs and BIAs to explore professional
identities, challenges, motivations and
what could be learned from their
experiences and views more broadly.
At the same time, we interviewed people
who have lived experience of Mental
Health Act assessments, assessments of
capacity and those who were relatives or
carers of people who have experienced
assessments. We approached existing
networks and organisations for people
with lived experience and we interviewed
all of those who volunteered to take part.
Overview of Methods
Quantitative Approach
The survey was distributed through the
national networks of professional leads for
AMHPs and BIAs. The networks are self-
organised groups of professional leads
operating regionally and nationally with a
reach of 343 local authority areas. The
survey was sent to these professional
leads and then cascaded to individual
BIAs and AMHPs. This enabled an
extensive national approach to
professionals from different local
authorities, healthcare Trusts and
independent practitioners undertaking
work within these organisations. Surveys
were carried out between 22nd February
2021 and 8th March 2021.
At the end of each survey, respondents
were invited to take part in a focus group
by clicking an ‘opt in’ button and
expressing an interest. Prospective focus
group participants were then invited to
attend on the pre-advertised dates.
Approach
8
Overview of Methods
9
Guiding Principles
All those undertaking functions under the
Mental Health Act 1983 (as amended)
have specic responsibilities to follow the
overarching guiding principles of the Act,
as laid out in its Code of Practice
(Department of Health, 2015). In practice,
it is the AMHP who most closely applies
the principles which ‘should always be
considered when making decisions in
relation to care, support or treatment
provided under the Act’ (Department of
Health, 2015 para 1.1). The overarching
principles are:
• Least restrictive option and
maximising independence
• Empowerment and involvement
• Respect and dignity
Purpose and effectiveness
• Efciency and equity
Independence
As an independent statutory role, ‘nothing
[…] shall be construed as authorising or
requiring an application to be made by an
AMHP’ (s.13(5) MHA). The Code of
Practice to the Mental Health Act in
England (Department of Health, 2015)
conrms that:
Although AMHPs act on behalf of a
local authority, they cannot be told
by the local authority or anyone
else whether or not to make an
application. They must exercise
their own judgement, based on
social and medical evidence, when
deciding whether to apply for a
patient to be detained under the
Act. The role of AMHPs is to
provide an independent decision
about whether or not there are
alternatives to detention under the
Act, bringing a social perspective
to bear on their decision, and
taking account of the least
restrictive option and maximising
independence guiding principles
(para.14.52)
Independent from health services by
design, the AMHP role also brings with it
an imperative to protect people’s rights
within a social model of mental health
provision (Department of Health and
Social Care, 2019). AMHPs’ duties and
powers are therefore intended to be
complementary rather than subordinate
(Walton, 2000) and to support the
safeguarding of the civil rights of people
who use services.
In addition to independence from medical
practitioners there is also independence
from employers or organisational
management structures. Although the
AMHP is acting on behalf of the local
authority, they act independently when
performing functions under the Act. The
Code of Practice in England asserts that any
undue pressure that might undermine
independence should be challenged
through relevant local channels
(Department of Health, 2015 para. 39.18).
The AMHP should exercise their own
judgement, based upon social and medical
evidence, and not act at the behest of their
employer, medical practitioners or any
other persons who might be involved with
the patient’s care (see Jones, 2020 pp. 130-
131 for more detail around the
independence of the AMHP role).
Approved Mental Health
Professional: overview of
the AMHP role
Under the Mental Health Act 1959 the
role of the Mental Welfare Ofcer (MWO)
included the coordination of doctors and,
where necessary, ambulance and police
as part of an individual’s admission to
hospital. The review of the 1959 Act
acknowledged the relative independence
of the MWO from healthcare settings and
accepted the need for a counterbalance
to medical opinion (Hargreaves, 2000). It
acknowledged that the role should be to
continue to make an ‘independent
evaluation […] focusing on the person’s
family and community environment’ and
that it should include the ability to ‘refuse
to authorise an admission if there are less
restrictive community settings in which
treatment can be provided’ (Gostin, 1975
p.37). This view was endorsed by the
British Association of Social Workers
(BASW) who noted that the mental health
social worker has a role which
complements medical opinions but that
must be from a basis of professional
autonomy and independence as a
valuable safeguard for the person. The
government accepted the case for a
parallel ‘social assessment’ and the MWO
role became that of the Approved Social
Worker (ASW) within the Mental Health
Act (1983) with local authorities retaining
oversight of the role. The AMHP role was
created with the 2007 amendments to the
1983 Act, replacing the ASW, and is no
longer limited to social workers. Instead,
they can be registered social workers,
mental health or learning disability nurses,
occupational therapists, or chartered
psychologists. AMHPs continue to
undertake the statutory role on behalf
of local authority social services
departments who remain legally
responsible for AMHP services.
AMHPs must demonstrate competence by
completing a course that has been
approved by the appropriate regulatory
body (Social Work England or Social Care
Wales) and must satisfy the competencies
and values set out in Schedule 2 of the
Mental Health (Approved Mental Health
Professionals) (Approval) (England)
Regulations 2008 in order to be approved
(or re-approved) to act as an AMHP by a
local authority in England2. They must
maintain alignment to these
competencies throughout their practice in
order to be re-approved by the local
authority every ve years (Department of
Health and Social Care, 2019).
2 In Wales the Mental Health (Approval of Persons to be Approved Mental Health
Professionals) (Wales) Regulations 2008 apply
Workstream 1
10
Workstream 1
11
Workstream 1:
Approved Mental Health Professionals (AMHP)
Nearest Relative
Communication with the Nearest Relative
is a signicant part of AMHP work. When
undertaking Mental Health Act
assessments AMHPs are required to
identify a person’s Nearest Relative from a
list dened within section 26 of the
Mental Health Act 1983 (amended 2007).
The AMHP is expected by law to have
regard ‘to any wishes expressed by
relatives’ (section13) and to inform the
Nearest Relative that a detention for
assessment has been or is about to be
made. In some circumstances, including
detentions for the purposes of treatment,
the AMHP is required to consult with the
Nearest Relative to seek their views and
establish whether they object, in which
case the detention can not go ahead.
The legislation intended that every person
who is subject to a Mental Health Act
assessment should have a Nearest
Relative and, if a suitable one cannot be
identied, a Nearest Relative should be
appointed by the Court.
The Nearest Relative has specic rights
and powers, such as the right to be
informed or consulted when their relative
is to be detained, and the power to make
an application for their relative’s discharge
from hospital. Whether or not these rights
and powers actually protect people from
unwarranted compulsory hospital
admission is an area of tension (Laing &
Dixon et al., 2018), although AMHPs
generally see it as such (Dixon &
Wilkinson-Tough et al., 2019).
The social perspective
The ASW role (which preceded the
AMHP role) was created under the Mental
Health Act 1983 to counterbalance the
existing clinical psychiatric model with a
more holistic ‘social perspective’ which
would enable less restrictive, community-
based alternatives to hospital (Gostin,
1975). Decision-making goes beyond
legal and medical perspectives (or
tensions) with a third element,the social
perspective, acting as a balance (Hateld
et al., 1997). The Mental Health Act
Commission (1995) advised that the
ASW’s role should be wider than merely
responding to crisis requests for
admission and the AMHP role is still
intended to be ‘a social counterweight to
the medical viewpoint in the detention’
(Bartlett & Sandland, 2014 p.259). Recent
research concluded that the social
perspective was embedded in the
practice of the AMHPs studied (Karban
et al., 2020).
Coordination
It is the AMHP who has overall
responsibility for coordinating the process
of assessment (Department of Health,
2015 para. 14.40). Their role is to ‘arrange
and coordinate the assessment taking into
account all factors to determine if
detention in hospital is the best option for
the patient or if there is a less restrictive
alternative’ (Jones, 2020 p.127). This
entails navigating complex inter-agency
arrangements (Department of Health and
Social Care, 2019).
With the exception of emergency
detentions, or statutory interventions
within the criminal justice system,
decisions involve three professionals:
an AMHP;
• a doctor approved under section 12(2)
of the Mental Health Act 1983
(amended 2007) with specialist
knowledge in treating mental disorder
(known as a ‘section 12 approved
doctor’); and
• a doctor who has previous
acquaintance with the person where
possible or, if a doctor with previous
acquaintance cannot be found, a
second section 12 approved doctor.
Alternatives to admission
In keeping with the principle of ‘least
restrictive option and maximising
independence’, before it is decided that
admission to hospital is necessary,
decision-makers should always consider
whether there are less restrictive
alternatives to detention. This would
include informal admission or support in
the community, for example from a crisis
team or crisis house (Department of
Health 2015, paras 14.7; 14.11).
Workstream 1
12
Workstream 1
13
AMHP work is experienced as emotionally
difcult and mentally draining (Evans et
al., 2005; Morriss, 2015). Stress and low
morale (often attached to recruitment and
retention problems) has continually been
cited as a core problem with the work
(Huxley et al., 2005; Evans et al., 2005;
Care Quality Commission, 2016; BASW,
2016). Perceptions of fear and risk related
to coordination responsibilities and the
use of coercion have been identied
(Coffey et al. 2004; Huxley et al., 2005,
Buckland 2016). The same has been
found for equivalent roles in Northern
Ireland (Manktelow et al., 2002) and
Scotland (Allen and McCusker, 2020).
AMHPs expend large amounts of
emotional labour coordinating complex
and risky situations, supporting people
who use services and their families, trying
to mobilise support and resources and
often waiting for beds or ambulance
transport (Allen et al., 2016). AMHPs are
also required to be ‘task jugglers’ with a
range of roles (Quirk et al., 1999; Leah,
2020). Quirk et al (2003) indicated a ‘hate
gure’ or ‘social policeman-executioner’
identity attached to the role, illustrating
the ways in which stress and pressure
arises from the perception that AMHPs are
‘agents of social control’ and are often
challenged when trying to balance the
needs of the state, the wider public and
the person themselves (Campbell 2010).
Multidisciplinary and multiagency working
have consistently been recorded as
problematic, with difculties in
coordinating the ambulance, doctor(s)
and police (Prior, 1992; Bowers et al.,
2003; Fakhoury and Wright, 2004;
Furminger and Webber, 2009; Morriss,
2015). Interprofessional tensions are also
likely to be exacerbated in organisational
contexts where resources are scarce, for
example around transporting detained
individuals to hospital, particularly if both
police and ambulance ofcers are
required (Quirk et al., 2003; Department
of Health and Social Care, 2019). AMHPs
show frustration at being ‘abandoned’
where they are literally left on their own at
the scene, experiencing this as being left
to undertake tasks with low prestige
(Matthews, 2003, Vicary et al., 2019).
AMHPs work within complex
organisational systems and it is widely
recognised that they operate most
effectively within a whole-systems
approach where the NHS, local
authorities, police and other agencies
work together (Care Quality Commission,
2018). Difculties accessing section 12
approved doctors, liaising with the police
and ambulance services and uncertainty
about working hours are further factors
(Stevens et al., 2018).
Research undertaken during the planned
revisions to the 1983 Act (Evans et al
(2005; 2006; Huxley, 2005) found low
morale and high levels of stress
(particularly among men), with over two
thirds of ASWs experiencing a high level
of emotional exhaustion. This workforce
was more vulnerable to common mental
health problems, with 43% at the
threshold for depression and anxiety.
They were more dissatised and more
likely to want to leave their job, with a
quarter having clear plans to leave. There
were physical health impacts, particularly
Alternatives to hospital have consistently
been lacking and there has been a
signicant reduction in mental health
resources within both hospitals and the
community which has profoundly affected
the AMHP role (Barnes et al., 1990;
Hudson and Webber, 2012; Crisp et al.,
2016; Care Quality Commission, 2018;
Stevens et al., 2018). This is particularly
acute in relation to access to hospital
beds, the availability of alternatives to
admissions and the functioning of crisis
and home treatment teams (Morriss,
2015; Hall, 2017). Assessments are
frequently delayed with people’s needs
not being met (Department of Health and
Social Care, 2019).
Inadequate provision of resources and
alternatives to hospital, combined with an
increase in social stressors and mental ill-
health risk factors, lead to a mental health
system which is overly reliant on
hospitalisation (Care Quality Commission,
2019). Without a range of suitable
resources people risk being detained by
default rather than by necessity (Care
Quality Commission, 2018) as detention is
an ‘overused last resort’ (Bonnet and
Moran, 2020). AMHPs are under ‘extreme
pressure’ and ‘feel forced’ to compulsorily
detain in the absence of a less restrictive
option (Care Quality Commission, 2015).
AMHPs have argued that greater
investment in preventative mental health
services and ‘low intensity’ support and
crisis services (including non-medical
alternatives to hospital) would help to
mitigate the impact of social risk factors
on mental health (Bonnet and Moran,
2020).
There is a widespread view that the AMHP
role is low prole and has not been given
the full support, recognition, review and
structure that it requires in order to be
completely effective (Evans et al, 2005;
2006; BASW, 2016; ADASS, 2018; Care
Quality Commission, 2018; Stevens et al.,
2018). There is a perceived lack of
understanding or support for the role by
NHS Trusts and a lack of support for
‘health-based’ AMHPs from some local
authorities as well as cultural issues
between health and social care (Stevens
et al., 2018). Many ASWs also believed
that their role was misunderstood by
people who use services and their
families (Gregor, 2010). ASWs and AMHPs
have reported feeling undervalued,
receiving little recognition and feeling
poorly paid, both in comparison with
other professionals involved in Mental
Health Act assessments and given the
level of responsibility the role confers
(Huxley et al., 2005; Department of
Health and Social Care, 2019).
Inconsistent levels of supervision and an
over-dependence on peer support has
been a longstanding theme (Gregor,
2010; Furminger and Webber, 2009;
Hudson and Webber, 2012).
Review of the literature
14
Review of the literature
15
Approved Mental Health Professional:
Review of the literature
with not all AMHPs receiving individual
supervision and with stress and anxiety
not being sufciently acknowledged by
managers (Gregor, 2010). The ‘emotional
challenges’ have been recognised as
ranging from ‘horror’ (around the
detentions and loneliness) to the ‘buzz of
the job’ (within the context of providing
good care in challenging circumstances)
(Hurley and Linsley, 2006). In parallel,
AMHP work has also been viewed as
prestigious (Gregor, 2010; Morriss, 2015)
and encompasses a sophisticated use by
AMHPs of emotion in the fullment of
their role (Vicary, 2021).
Albeit rst suggested in the mid-1990s,
when there was a suggestion that
probation ofcers undertake the work
(Huxley and Kerfoot, 1994), the change
from ASW to AMHP from 2007 occurred
within the context of increasing numbers of
detentions, the rising shortages of ASWs,
an ageing and depleting workforce and the
need to make appropriate use of relevant
skills that were already available in the
workforce (Laing, 2012; Coffey and
Hannigan, 2013; Huxley et al., 2005; Mental
Health Act Commission, 1999). Further, the
creation of the AMHP role was a response
to ASWs’ high levels of stress and burnout
(Huxley et al., 2005 Evans et al, 2005) and
the notion that they were difcult to recruit
(Audit Commission, 2008).
The broadening of the AMHP role to
include other non-medical professionals
created mixed views and some unease
(Jackson, 2009; Rapaport, 2006; Jones et
al., 2006). Concerns were expressed that it
would compromise the unique
knowledge and value-base that promoted
anti-oppressive and anti-discriminatory
practice and would not be sufciently
independent of medical inuence, thereby
weakening people’s safeguards at such a
critical time (Bartlett and Sandland, 2003;
NIMHE, 2006). Early reviews questioned
the extent to which nurses could promote
a social perspective (Rapaport, 2006) and
mental health nurses highlighted potential
challenges in balancing medical and
social roles, where independence from
medical colleagues may mean crossing
into ‘social work territories’ and values,
creating tensions and identity confusion
(Coffey and Hannigan, 2013).
It was feared that clinical team collusion
might increase (at the expense of the rights
of people being assessed) as it could
intensify the power of the consultant
psychiatrist and the biomedical perspective
(Nathan and Webber, 2010). The increased
legal responsibility and accountability
might potentially be difcult for nurses to
shoulder and a signicant concern for
nurses has been that this type of statutory
work would damage therapeutic
relationships (Holmes, 2002; Laing, 2012;
Knott and Bannigan, 2013; Coffey and
Hannigan, 2013; Hurley and Linsley, 2006).
On the other hand, the AMHP role could be
seen as a new workforce opportunity that
would be welcomed by health
professionals as a step away from medicine
which increases autonomy and confers
additional prestige, as it was viewed within
social work (Coffey and Hannigan, 2013;
Stone, 2019). The Mental Health Act
Commission (2003) recommended that the
potential loss of the particular social work
perspective must be countered by
stringent training requirements.
among males, and a high level of burnout
(exhaustion from excessive demands on
energy and personal resources) with
depersonalisation in relation to people
who use services being more common.
Fifteen years later this remains the case.
There are substantial pressures including
workload, complexity, the effects of
austerity and social issues all of which
affect morale, recruitment and retention.
The inability to meet service users’ needs
affects stress and morale (CQC, 2018;
Skills for Care 2018).
Finding a hospital bed for those liable for
detention is consistently identied as the
most problematic practical aspect of the
assessment, even though this is not
actually part of the AMHP’s duties
(Department of Health, 2015 para. 14.77).
AMHPs report feeling vulnerable due to
isolation, exposure to violence and
aggression and lone working (Bowers et
al., 2003; Coffey et al, 2004; Hudson and
Webber, 2012) with the absence of a lone
working policy being a concern in some
areas (Department of Health and Social
Care, 2019; Stevens et al., 2018).
The concept of emotional labour has been
used to further explain and explore the
ways in which AMHPs process intensely
powerful emotions and feelings whilst
managing individuals’ and families’ stress
and trauma, co-ordinating complex
assessments and containing individuals
and their families while they wait for other
professionals and agencies to offer the
necessary resources and support (Hudson
and Webber, 2012). The emotional impact
of detention can be experienced as guilt,
although the lack of beds and having to
walk away and leave a person in a situation
of risk is equally problematic (Morriss,
2015). The social control function of the
role has been explored within a context of
‘dirty work’, explained as the lack of
opportunity to help or to do anything for
someone in a therapeutic sense and,
instead, having to do something to them in
a coercive sense (Hughes, 1971). Difcult
and ‘dirty’ work concerns the lack of beds,
the complexities of coordination (including
the lack of availability of the police), the act
of detention, the lack of legal knowledge of
some colleagues, being ‘shouted at’ by
Accident and Emergency (A&E) staff due to
the lack of transfer beds and facilities. Quirk
et al. (2003) likened this aspect of the work
to the morally dubious and anomalous
nature of the ‘policeman/executioner’.
Conversely, crisis intervention and avoiding
hospitalisation were seen as therapeutic
work (Morriss, 2015).
Although AMHPs may believe that the
person needs to be in hospital they are
also aware that the wards are often bleak
and sometimes dangerous places to be.
Morriss (2015) and Webber (2016)
suggested that AMHPs are seen to
provide only a ‘sectioning service’ at the
expense of therapeutic work. The Care
Quality Commission’s Chief Executive
spoke of a service where ‘control and
containment are prioritised’ over
treatment and care (Care Quality
Commission, 2016).
The emotional demands of carrying out
statutory work are often unacknowledged
and unrewarded. AMHPs often do not feel
valued by their managers, with support
more likely to come from other AMHPs,
Review of the literature
16
Review of the literature
17
Ideological differences between health
and social services has led to
communication being dened in terms of
a struggle for control with AMHPs
occasionally deliberately using their
power in Mental Health Act Assessments
to minimise the inuence or dominance of
the ‘medical model’ (Colombo et al.,
2003; Rabin and Zelner, 1992). AMHPs
consider their use of power in a way that
distinguishes them from other
professionals at Mental Health Act
assessments and their unique role in
these assessments has been considered
in these terms (Gregor 2010; Morriss
2015; Buckland 2016). The lack of
resources renders AMHPs’ power and
independence ‘illusory’ in that it has
always been dependent on the
development of community care and the
availability of resources (Prior 1992, Quirk
et al., 2003).
Within the broad range of research
literature, AMHPs have identied
signicant motivating factors to undertake
the work as:
• Career progression
• Independence
• Further training
• Professional development and status
• A clearer professional role within
multidisciplinary services
• The opportunity to ‘sensitively’ apply
the power and authority of the AMHP
to complex real-life situations
• Enhanced job security
• Mental Health Act assessments as
contained pieces of work
Some value the Mental Health Act
assessment as a contained piece of work
with a high degree of professional
discretion and giving scope to exercise
independent judgement and authority in
a time-limited intervention which is
emotionally and professionally rewarding
and an opportunity to resolve crises for
individuals and their families (Watson,
2016; Gregor 2010). Gregor (2010) also
found that a common motivation for
AMHPs undertaking the work was
‘contractual obligation’, in that it is
usually a requirement of employment and
career progression for local authority
social workers whereas this is not the case
for nurses.
As indicated above, the widespread
shortfalls in the recruitment and retention
of AMHPs has been a longstanding
problem (Mental Health Act Commission,
1999; Huxley et al., 2005; Department of
Health and Social Care, 2019). The most
recent data from the Department of
Health and Social Care and Skills For Care
(2021) does however suggest a small
increase to a headcount of 3,900 AMHPs
who are approved by local authorities
from the 2019 survey (Skills for Care,
2019). Previously, the Association of
Directors of Adult Social Services (ADASS
2018) snapshot survey indicated that
there were around 3,250 authorised
AMHPs in England which had been a 17%
drop in AMHP numbers from the previous
survey. At the same time there are
increasing numbers of applications for
detentions in England under the Mental
Health Act (NHS Digital, 2020).
Possible connections have been explored
between the regulated profession to
which an AMHP belongs, their
experiences of the role and the ways in
which they carry out the work. Bressington
et al. (2011) explored differing
professional viewpoints and levels of
knowledge held by social workers and
nurses during training concluding that,
initially, social workers had a greater
understanding of the role but, on
completion, both groups demonstrated
similar levels of learning. They suggested
that alignment to the ‘medical model’
does not of itself prevent understanding
of the concepts required to practice
as an AMHP.
Stone (2018) explored the differences
between social workers and nurses, and
the ways in which socialisation through
AMHP training has an impact on
professional values, principles and
paradigms. AMHPs’ decisions around
least restrictive options and risk may differ
according to the professional background
of the AMHP but this is related to a variety
of individual subjective differences,
experience, human agency and individual
construction of risk rather than necessarily
being about professional background. In
contrast to the stereotypes, nurses were
not preoccupied with medication in their
risk assessments, while social workers
seemed more focused on medication
than anticipated. Social workers did not
highlight social factors to a greater
degree than nurses in their assessments
and all participants demonstrated their
adherence to the principle of least
restrictive practice when looking for
proportionate alternatives to detention.
Overall, the human rights approach, social
perspective and specic value base does
appear to have been retained, regardless
of professional background (Buckland,
2016; Dixon et al., 2019; Laing et al.,
2018). The fundamental concern about
the professional’s background only
matters in two respects: rstly, that of an
attribution or the quality or characteristic
of an individual, and secondly the
capacity to manage emotions in the
fullment of the role (Vicary, 2016). This
research concluded that it is a person’s
attributes that attract them to the role.
Overall, AMHPs emphasise that their
professional value base is unique but
aligned to the social work professional
value base. This is founded on anti-
oppressive and anti-discriminatory
practice as well as the requirement to
challenge where necessary (Morriss,
2015; Gregor, 2010). They also have a
propensity to act as a ‘brake’ on clinicians’
decision to detain (Peay, 2003, p.46).
AMHPs described a unique form of
practice wisdom, expressed as ‘the way
that you think’, and report that becoming
an AMHP is a rite of passage, with the
worker achieving a higher status arising
out of the additional ‘mental power’ and
reective practice required to manage the
complexity and ambiguity of the work.
The work is seen as prestigious and
higher-status, requiring advanced skills
and the ability to manage very complex
situations (Gregor, 2010). The ‘best
personality type’ for the work is to be
‘strong, assertive and able to challenge
doctors’ (Morriss, 2016 p.714).
Review of the literature
18
Review of the literature
19
Models include teams dedicated only to
Mental Health Act work from daytime
(with support from emergency duty teams
outside these hours) through to 24-hour
services. Some ‘hub and spoke’ models
have part-time AMHPs who support an
assessment rota alongside their
substantive role. AMHP services can also
be supported by sessional or
independent AMHPs to be called upon
when needed (ADASS, 2018). Having non-
integrated teams makes the work more
isolating (Stevens et al., 2018).
It has long been recognised that the
AMHP workforce is ageing (Evans et al.,
2005; ADASS survey, 2018; Department
of Health and Social Care, 2019; Skills for
Care, 2021). Current estimates are that
33% of AMHPs are over 55 compared to
23% of social workers (Skills for Care,
2020). The AMHP role continues to have a
higher proportion of people identifying as
male (27%) compared to social workers
overall (18%). Recent research suggests
that 73% of social workers identied as
being of White ethnicity and 27% of Black,
Asian, mixed or minority ethnicity. AMHPs
are less ethnically diverse than social
workers overall (with 21% recorded as
having Black, Asian, mixed or minority
ethnicities) (Skills for Care, 2021).
Concerns have therefore been expressed
about the age and lack of diversity within
the AMHP workforce – particularly given
the specic role in reducing
discrimination and supporting a human-
rights led approach for people being
assessed or detained (Department of
Health and Social Care, 2019).
The Mental Health Act is known to
disproportionately affect some groups
and to indirectly discriminate
(Department of Health, 2015). In the year
to March 2020, Black people were more
than 4 times as likely as White people to
be detained with Black Caribbean people
having the highest rate of detention out of
all ethnic groups (NHS Digital, 2020). This
again highlights the ways in which the
AMHP workforce could be more aligned
with the people it works with in terms of
culture, race and ethnicity and to
understand the effects of discrimination
upon such groups (Department of Health
and Social Care, 2019). The independent
review of the Mental Health Act was
commissioned by the government as an
acknowledgement of the inequalities that
exist for people from minority ethnic
groups in terms of access to treatment,
experience of care and quality of
outcomes (Department of Health and
Social Care, 2018).
Despite this, uptake of non-social work
AMHPs has been limited. Following the
revisions to the Mental Health Act 1983
few, if any, occupational therapists took
on the role and no psychologists
expressed an interest (NIMHE, 2008).
There was no inux of nurses into the new
role as had been anticipated (Rapaport,
2006; Campbell, 2010; Bailey and
Liyanage, 2012; Bailey, 2012).
Following the introduction of the 2007
amendments to the 1983 Act, an informal
survey of national AMHP local authority
leads (Bogg 2011) found that 72% of local
authorities had not extended their
recruitment of AMHPs to non-social
workers. To date, registered social
workers make up the vast majority (95%)
of the AMHP workforce with 4%
registered nurses and less than 1%
occupational therapists. Over half (59%)
of local authorities employ only social
workers (Skills for Care, 2020). Only one
psychologist was found to have been
approved to undertake the role (NHS
Benchmarking and ADASS, 2018). The
majority of AMHPs are employed in the
local authority sector (80%), 15% in the
NHS and 4% are agency and freelance.
Around two thirds (65%) of AMHPs
combine their role with another role while
around one in four AMHPs (24%) act
solely as an AMHP. The remainder are not
primarily or regularly working as an AMHP.
Only 15% of AMHPs work out-of-hours, for
example in emergency duty teams (EDT)
(Skills for Care, 2021).
The AMHP role is often not attractive to
nurses, occupational therapists and
psychologists for personal, cultural and
structural reasons (Stevens et al., 2018).
Nurses and occupational therapists
experience the following issues: structural
barriers affecting access to training;
contractual agreements with balancing
the AMHP and nursing role creating
conict (the AMHP function is a local
authority responsibility); and disincentives
around equal or competitive salaries
(Bogg, 2011; Stone 2019; ADASS, 2018;
Stevens et al., 2018).
Uptake of occupational therapist AMHPs
has remained low. There is some
coherence and overlap between the
respective value bases of social work and
occupational therapy and it is more likely
that structural issues, rather than
incongruent values, are impeding uptake
(Knott and Brannigan, 2013). The small
number of occupational therapists who
have qualied as AMHPs have not always
felt valued and the pressures arising from
the nature of integration in mental health
services have been noted (Morriss, 2015;
Woodbridge-Dodd, 2018). Explanations
for the low uptake by clinical
psychologists are sparse but one
suggestion is that using compulsion
would adversely affect a relationship
which rests on a basis of informed
consent, trust and disclosure rather than
acting as an ‘agent of the state’ of whom
people are very wary (Holmes, 2002).
AMHP services have more recently been
undergoing transition and reorganisation
and there is an increasingly wide variation
in the models of delivery of AMHP
services in England (ADASS, 2018).
Review of the literature
20
Review of the literature
21
All these issues clearly have relevance for
AMHPs’ decision-making and are bound
to create difcult dilemmas for AMHPs,
especially when there is a lack of
alternatives to involuntary hospitalisation
and inpatient beds are dangerously
scarce. Buckland (2020) also recognises
that the real threats and potential traumas
of hospital environments have a unique
prominence in the mental health user and
survivor literature. Further, she highlights
the ways in which research by and with
users and survivors shows relationships
with professionals to be deeply unequal
and to have the potential to be incredibly
positive or incredibly damaging on
personal and emotional levels and in
terms of future consequences and
relationships. Mental Health Act
assessments and their wider contexts are
often deeply unequal in their power
dynamics and as such are at odds with a
broader policy rhetoric of collaboration
and recovery (Buckland, 2020).
The voice of people with lived experience
within research relating specically to
Mental Health Act assessments and
ASW/AMHP practice is limited, if not
‘completely lacking’ (Akther et al., 2019).
Buckland (2020) undertook a scoping
review of the qualitative literature relating
to those who fall under the scope of
Mental Health Act assessments. This
included the person being assessed,
friends and relatives, AMHPs and doctors.
The literature, however, conates
detention under the Mental Health Act in
hospital with assessment under the
Mental Health Act and there is also a
specic research gap around assessments
not resulting in detention (Buckland,
2020). This, in itself, is indicative of the
comparative value assigned to different
types of evidence (Barnes et al,, 2000).
More generally, people have reported
different levels of understanding about
the difference between ‘voluntary’ and
compulsory admissions, with some
experiencing coercion as part of an
informal admission (Manktelow, 2002).
Previous literature reviews relating to a
person’s experience of assessment and
detention (combined) have identied a
lack of autonomy, a lack of information
and involvement in decision-making and
a distinct lack of good, therapeutic care
(Katsakou and Priebe 2006; Seed et al.,
2016; Akther et al., 2019).
The signicant emotional impact of
detention, sometimes experienced as
a highly traumatic event, has been
acknowledged (Katsakou and Priebe
2006; Seed et al., 2016; Akther et al.,
2019). In parallel, people report
ambivalence towards involuntary
hospitalisation: although involuntary
admissions are on the whole strongly
associated with coercion and trauma,
between 33% and 81% of patients have
been found to retrospectively regard their
involuntary treatment as justied and/or
benecial. The wide span here is due to
studies having inconsistent methods or
research aims in a variety of contexts.
There are very few, if any, validated
instruments to assess people’s attitudes
as to the justication of their (involuntary)
admission and treatment, or their
perception as to benets from it (Priebe
et al., 2009; Katsakou and
Priebe, 2006).
Review of the literature
22
Review of the literature
23
People with lived experience of
Mental Health Act assessments:
Review of the literature
For comparison, statistics from a survey in
2018 indicate that for people who are
assessed under the Mental Health Act,
76% were from a White British background
and 9% were from a Black British
background with the remainder being
from an ‘Other or Mixed Race’ category
(Care Quality Commission, 2018).
34% of AMHPs were in the 41-50 age
range, 35% were in the 51-60 range
and 7% were over 60. Of those that
responded 76% were over 40, in line
with the national picture (Skills for
Care, 2021) where our representation
conrms the ageing demographic of the
AMHP workforce.
We asked our respondents when they
were rst approved and we had
representation across a broad range with
the majority having been approved within
the last decade. Nurses’ AMHP
qualications range from 2012 to 2021
and the occupational therapist AMHP
respondent qualied in 2016, which
would be in keeping with the 2007
revisions to the Mental Health Act (1983).
We asked AMHPs which academic award
they gained as part of their AMHP
qualication. The majority had qualied as
ASWs, a qualication that was not
embedded within an accredited university
qualication. The second largest group
qualied with a Postgraduate Certicate
followed by a Postgraduate Diploma and
the smallest group qualied with a Masters
degree. One person qualied as a Mental
Welfare Ofcer, the precursor to the ASW
role, and a small number did not know.
Survey respondent
demographic data
The AMHP survey received 258
completed returns.
Regulated professional role
We received survey responses from 247
social workers (95.74%), 10 nurses
(3.87%), 1 occupational therapist (0.39%)
and no clinical psychologists. This is in line
with the national demographic which is
95% social work, 4% nursing and 1%
occupational therapy (Skills for Care,
2021). All were based in England apart
from one who identied that they were
based in Wales.
The declared gender for AMHPs was 55%
female (142), 24% male (62) and 21% (54)
did not share this information. From those
who reported their gender, this would
equate to 70% female and 30% male. The
national representation is 73% female and
27% male making this survey generally
representative of the AMHP population
nationally (Skills for Care, 2021).
70% described their ethnicity as White,
2.8% British, 2.4% Black/African/
Caribbean/Black British, 1.6% Asian/Asian
British, 21% did not declare their ethnicity
and the rest were from mixed/multi-ethnic
backgrounds or other ethnic groups.
According to national data, 79% of AMHPs
are White and 21% from racialised
communities (Black, Asian, mixed or
minority ethnic backgrounds) (Skills
for Care, 2021). This data is not
disaggregated further.
Findings from the survey
24
Findings from the survey
25
Approved Mental Health Professionals:
Findings from the survey
55 Female 24 Male 21 Not reported
55
21
24
Gender % Reporting
White
Not reported
British
Other ethnic group
Black/African/Caribbean/Black British
Asian/Asian British
Mixed/Multiple ethnic groups
70.2
21.4
2.8
0.8
2.4
1.6
0.8
AMHP: What is your Ethnicity?
% Reporting
21-30 31-40 41-50 51-60 60+
80
60
40
20
0
Age groups
Age in years
Not
reported
1972-
1981
1982-
1991
1992-
2001
2002-
2011
2012-
2021
120
100
80
60
40
20
0
Year rst approved as an
ASW/AMHP
0
4
48
87
112
MA or
MSc
PGDip PgCert ASW MWO Don’t
know
17
12
34
25
Academic award from qualifying
AMHP programme
% Reporting
12
Social workers work mostly for a local
authority (81%), with 24 (10%) working
for a Mental Health NHS Trust,
1 employed by a local authority but
seconded to a Mental Health NHS Trust,
whilst 2 were self-employed and
1 employed by a local NHS Trust (not
mental health). Of the 10 nurse
participants, 4 stated that they work for a
local authority and 6 for a Mental Health
NHS Trust. The occupational therapist
stated that they work for the local authority.
Given the historic difculties for AMHPs’
workload balance, the recent workforce
reorganisations and increasingly wide
variation in the models of delivery of
AMHP services in England, we wanted to
understand whether AMHPs were in
primary (full-time) roles or whether their
AMHP role was shared with other
responsibilities (mixed role AMHPs). 36%
of respondents stated that they were full-
time AMHPs which is above the national
average of 24%. Part-time or mixed role
AMHPs made up 64% of our sample
which is lower than the 74% national
average (Skills for Care, 2021).
Where AMHPs were not full-time, they
outlined a range of other responsibilities
including Care Act activities,
safeguarding, case management, duty or
triage work and care coordination.
We asked which professional backgrounds
were represented in the AMHPs’ own
workforce. They were able to select more
than one professional background and the
ndings indicate that social workers are the
predominant profession within AMHP
workforces, but also that many respondents
also have experience of working with
AMHPs from other professions.
The following graph indicates the
number of professions selected by
each respondent. 119 selected only
1 profession, 78 selected 2, 27 had
three professions represented whilst
4 respondents selected 4 different
professions.
We asked AMHPs to conrm their current
employer. 80% were employed by a local
authority, which is exactly in line with the
current national statistic, and 16% were
employed by a mental health Trust, in line
with the 15% of the national picture. Our
sample had 1% self-employed or
independent AMHPs which compares
with 4% in the national demographic
(Skills for Care, 2021). The same national
survey indicated that 38% of local
authorities also employ sessional AMHPs
to cope with peaks in demand.
Findings from the survey
26
Findings from the survey
27
Social
Worker
Nurse
Occupational
Therapist
Chartered
Psychologist
Don’t
know
No Yes
246
100
2
3
41
AMHP workforce details
Professional background
represented in the AMHP workforce
(392 responses)
Local
Authority
Mental
Health NHS
Trust
Self-employed
independent
AMHO
Other
80
13
16
1 profession 2 professions 3 professions 4 professions
119
27 4
78
Professional backgrounds represented in
the AMHP workforce
(Number of selections made by each respondent)
AMHP service congurations
(% total)
Care Act
activities
Care
coordination
Case
management
Duty/Triage
worker
Safeguarding Other
How would you dene the
remainder of your role?
(% total)
100
80
60
40
20
0
Is working as an AMHP your
primary role?
(% responses)
64
36
35 9
15
15 9
17
9
59
24
8
Dedicated AMHP team which considers and
undertakes all assessments
Mixture of dedicated AMHP service and
AMHPs who have other duties
AMHPs who have other roles and work on
a rota basis
Other
Who is your current employer?
(% total)
AMHP respondents described the ways in
which their services operate in a variety of
models. Only 9% worked in a fully
dedicated AMHP team whilst 24% had
other roles and worked on a rota basis.
59% worked in a service providing a
mixture of dedicated AMHP and other
duties. Although not directly comparable,
the national statistics from the ADASS
(2018) survey did outline different models
of duty rotas, suggesting that 19% of
areas had a central AMHP ‘hub’ only, 36%
had developed a ‘hub and spoke’ model
(with a mix of full-time and part-time
AMHPs), 16% had locality teams and the
remaining 29% had other models.
AMHPs and professional
identities
To begin to explore AMHPs’ views on their
own professional identity and what being
an AMHP means to them, we asked
whether they viewed it as a profession,
a qualication, both or something else.
Only 16% see the AMHP role as a
qualication alone so we were keen to
understand the elements of
professionalism that paralleled this.
To explore subjective views we asked
respondents whether they see their
AMHP role differently to their regulated
professional role (social worker, nurse or
occupational therapist). We were seeking
to understand any aspects of divergence
as well as areas of overlap in the ways in
which the AMHP role aligned (or not) with
their regulated professional role.
Four fths (80%) of social workers did see
their AMHP role as being different to their
regulated professional role compared to
one fth (20%) who did not. The
perceived differences were articulated in
numerous ways. Overall, the main areas of
difference were where the AMHPs
perceived it as a specialist role requiring
additional knowledge and skills, with
greater power and status and with
requirements over and above their
professional social work role. The
responses highlighted a perception of
greater autonomy, independence and
decision-making latitude. The role was
also often associated with short-term
interventions and distinct statutory work
with greater interface with legislation.
A few respondents mentioned that they
also assess people outside their usual
practice specialism or service area3.
Alongside this, however, sits a perception
of greater risk (both personal and
professional), personal responsibility and
accountability. To illustrate the
distinctions, respondents highlighted that:
“It is a specialist role that focuses
[at the point of mental health crisis]
on ensuring that the law is
followed and [people’s] rights are
protected. The role requires
specic knowledge and expertise”
(social work AMHP)
“It feels a bit “special forces’’ (if that’s not
too grandiose) with regard to “standard”
social work. It feels like we go to places
and make decisions about things that
“regular” social workers don’t or can’t
make. The fact that we are personally
liable for our own decisions is part of this,
and one I personally relish”
(social work AMHP)
Of the 20% of respondents who reported
no difference between the roles they
suggested that the skills, knowledge and
professionalism are transferable and
applicable to each role. Both roles are
intrinsically linked with upholding human
rights and focusing on liberty. Being an
AMHP was described as core traditional
social work practice which was not
different to, but just an extension of, their
social work identity:
“I believe that a human rights focus
should be at the core of social work.
I see my AMHP status as indelibly linked
with my social work identity. As a matter
of course I will always refer to myself as a
social worker who is also an AMHP”
(social work AMHP)
“I am still a social worker as well
as being an AMHP. Completing
my AMHP training was something
I view as continuing my professional
development in mental health social work”
(social work AMHP)
3
The ADASS (2018) survey made reference to AMHPs being based in particular service
areas, where 86% of AMHPs were reported to work in adult mental health services, 7%
within older adults, 3% within children’s services (albeit probably Emergency Duty Teams)
and 4% within learning disabilities. This also illustrates the range of services and the broad
range of requests for Mental Health Act assessments from these areas.
Findings from the survey
28
Findings from the survey
29
Central
AMHP ‘hub’
only
‘Hub and
spoke’
model
Locality
teams
Other
models
Duty rota models ADASS (2018) survey
(% total)
36
16
29
Profession Qualication Both Other
Do you think being an AMHP is a:
(% total)
19 3
31
16
50
100%
80%
60%
40%
20%
0%
Do you view your AMHP role any differently
to your regulated professional role?
48 1
199 9
Percentage each
profession total
Social
Worker
Nurse
Yes
No
respondents) indicated a nursing
inuence, 18 (8%) occupational therapy
and 14 (6%) psychology. The 6.5% of
respondents who chose ‘other’ are
explored in the qualitative data below.
All 10 nurse AMHPs identied social work
as informing or inuencing AMHP work
with 6 also choosing their own profession
in the same regard.
What social work brings to
the AMHP role
The responses indicate that AMHPs draw
on the inuences of all professions to a
greater or lesser degree. Social work is
seen to have the greatest inuence with
a ‘natural correlation’ due to the ‘strong
social model approach’, an ‘awareness,
understanding and need to challenge
multiple forms of discrimination’, a
‘strong focus on person-centred practice’,
where ‘social work values and
professional views come to the fore’ and
where ‘there is a strong human rights
based approach’. There was an
acknowledgement of the fact that the
AMHP workforce is led and strongly
inuenced by social workers. The stress
was laid upon the continuity from ASW
training and practice and the
maintenance of the statutory
competencies which underpinned both
roles. This legacy, along with the
symmetry between the core values of the
profession and the legislative frameworks
was reiterated throughout.
What social work brings to AMHP work
was articulated in numerous places within
the survey and included the social model
of disability, social perspectives, seeing
the person holistically and having a
viewing point which is distinct from
psychiatric and clinical approaches
(although some still highlighted the
crossover of knowledge). For the majority,
anti-oppressive practice, human rights
perspectives and the inherent advocacy
of the role represented the reasons that
One area where there was some
divergence in views was related to the
alignment between AMHP and social
work values with some believing there
was synergy whilst others strongly
suggested it was less so:
“Often being an AMHP is
incompatible with what social
work values are: [it is]
discriminatory and oppressive.
I believe social rather than health
policies would help most people
I see [...] Detention is traumatic.
I frequently privilege the
information of a family member
over the person, [which is]
necessary as part of society’s
intention to “contain risk” [which
is] my de facto role as AMHP”
(social work AMHP)
To understand the perceived inuence of
each of the regulated professions on
AMHP work we asked survey respondents
to tell us how AMHP work is, in general,
informed or inuenced by the ethos and
values of each of the regulated
professions. We invited comments on any
observed differences in the way different
professions undertake the role.
AMHPs were asked to select all the
professions that they thought had an
inuence on AMHP work. Respondents
could select as many different professions
as they wished and there was a strong
response rate of 94%. The 231 social work
respondents provided a total of 326
selections. Almost all (225) perceived that
AMHP work was informed or inuenced
by social work. 54 (23% of social work
Findings from the survey
30
Findings from the survey
31
250
200
150
100
50
0
225
54
18 14 15
Number of responses
Social
Worker
Nurse Ocupational
Therapist
Chartered
Psychologist
Other
Do you think AMHP work generally is informed or inuenced by the
ethos and values of the following professions?
(Social Worker respondents - 231)
10
8
6
4
2
0
10
1 1 1
Number of responses
Social
Worker
Nurse Ocupational
Therapist
Chartered
Psychologist
Other
Do you think AMHP work generally is informed or inuenced by the
ethos and values of the following professions?
(Nurse respondents - 10)
6
it is unnecessary, although this was
strongly countered elsewhere by a
nurse AMHP.
Occasionally, nurses’ observations about
social workers’ practice indicated that it
was not always necessarily effective:
“High legal literacy, but can [this]
sometimes be at the expense of
clear communication with the
individual and their network”
(nurse AMHP)
What other professions bring
to the AMHP role
Nurse AMHPs
Views about the inuence of the
nursing profession on AMHP work were
articulated although, due to the lower
numbers of nurses in the survey, our
respondents’ experiences in practice were
to some degree limited. The inuence
from nursing was perceived to arise from
medical knowledge and models,
particularly in relation to medication,
although some respondents recognised
that nurses bring other perspectives and
values of care and compassion that afford
an opportunity for the AMHP role to
be enhanced:
“Nursing [has] values around
kindness, preserving safety
[and] collaborative working”
(social work AMHP)
“Nurses apply social
perspectives but are also more
often able to bring psychological
and medical perspectives”
(social work AMHP)
Some nurse AMHPs’ practice observations
were offered:
“My knowledge of health
trust pathways and processes
is a strength. The holistic training
provided to nurses is also
a signicant benet as I feel
that I have a broader foundation
of assessment skills”
(nurse AMHP)
“My experience as a mental health
nurse helps me evaluate risks and
benets of hospital treatment”
(nurse AMHP)
Opinions were expressed in relation to
the values of nursing:
“I do […] believe that other
professionals can and do
carry the same values”
(social work AMHP)
AMHP work historically links to
social work ethos and values, but
social work does not retain a
monopoly of such now. [There are]
common themes of person-centred
[and] strengths-based practice,
co-production, valuing rights
and autonomy etc”
(social work AMHP)
AMHP work was inuenced by the values
of social work:
“Detaining someone is the
most oppressive thing you can do.
My professional ethos and values
support me to see this as a
last resort”
(social work AMHP)
AMHP training focuses on
the social perspective, social
justice and rights and is central
to my AMHP practice”
(nurse AMHP)
As a nurse AMHP I practice
with the values of least restrictive
options always being explored,
value and include family input,
advocate for the patient [and]
acknowledge that all areas of
a person’s life can impact on
their mental health”
(nurse AMHP)
There were some observations that non-
social workers’ lack of practice knowledge
around social care and legislation other
than the Mental Health Act may be
limiting factors. A small number of social
work AMHPs suggested that, in their
experience, nurses do not always
recognise safeguarding issues or aspects
of child criminal exploitation and that
‘NHS staff are not decision-makers when it
comes to the Children Act’. There was also
an observation from a nurse AMHP that
social workers have a ‘better knowledge
of support packages funded by local
authorities’. This was in keeping with a
perception elsewhere that a lack of
knowledge or access to community
support compromised nurses’ ability to
explore the least restrictive alternatives to
hospital where they have no social care
experience. One or two social work
respondents observed that nurses would
refer to a social worker rather than do it
themselves. It was suggested that without
this practice knowledge nurses may
be limited to ‘health options’ and a focus
on medication. It is not altogether clear
if this was a feature of the way services
were congured or if it arose from
the knowledge and training of the
differing professions.
There were some perceptions expressed
about core differences in values and
approaches such that one AMHP
believed that:
“There is something about a
social worker that makes us
advocate more for a person [...]
Our profession is about
engagement with the person at the
centre of the process. The other
professions do things to people”
(social work AMHP)
There was a suggestion from a social
worker that the social perspective was
stronger for nurses because it is a new
approach to their practice, however, this
was coupled with the idea that they can
sometimes struggle to maintain
independence in the role. There were a
small number of suggestions that social
work AMHPs may be better at
withstanding pressure, for example
around not accepting a referrer’s request
for a Mental Health Act assessment where
Findings from the survey
32
Findings from the survey
33
Psychologist AMHPs
There were limited experiences of
working with psychologist AMHPs,
although there was conjecture that as they
would be knowledgeable about mental
distress and different types of
interventions this could be a positive. This
expertise included the ability to help the
person and work through trauma or
generally exploring alternatives to
medical perspectives. One respondent
spoke of a potential incompatibility
between the AMHP role and psychology
due to the act of compulsion, but they
balanced this within a context of the
AMHP’s statutory imperative to ‘consider
all the circumstances of the case’. Other
comments made reference to
professional traits and perceptions that
psychologists may be more risk averse
or patriarchal.
AMHPs’ professional differences:
Real or illusory?
Following the early debates within the
literature around the AMHP role being
opened to non-social workers, in many
respects it remains a complex and, at
times, thorny issue. A reading of our data
suggests that mental health settings and
their inconsistent (and in some areas
controversial) approaches to integration
signicantly inuence and inform ideas
on the ground.
Some did frequently question non-social
workers’ ability to balance medical
approaches:
“Social workers’ training and
background provide the balance
to the medical model during
assessments. The underpinning
values of the other professions are
still quite hierarchical and my
experience has been that the
majority of AMHPs from other
professional backgrounds are less
committed to anti-discriminatory
and anti-oppressive practice and
more willing to be swayed by
authoritative medical
professionals”
(social work AMHP)
However, we heard some rejoinders from
a nurse AMHP perspective:
“I don’t believe the differences
between nursing and social work
are as great as social workers
like to think they are”
(nurse AMHP)
“Having worked alongside them
[social workers] for years, I have
absorbed some of their thinking
and can talk the anti-discriminatory
talk with the best of them”
(nurse AMHP)
Some responses suggested individual
attributes were the same:
“On the whole, [nurses are]
professional, committed workers
who want the best least restrictive
outcomes for people who use
services and their families”
(social work AMHP)
Nurses’ views of the inuence of their own
profession included:
“Less knowledge about social
services and alternatives to
health-based interventions”
(nurse AMHP)
“Legal literacy is lower and
therefore learning curve steeper”
(nurse AMHP)
“Better understanding of mental
disorders and treatments likely
offered in hospital”
(nurse AMHP)
Occupational therapist AMHPs
It was acknowledged in the responses
that occupational therapy AMHPs are rare.
On the whole, responses painted a
picture of little to no experience of this
profession undertaking the role.
Nonetheless, the limited responses did
acknowledge the thoroughness of their
approach and that there was a place for
them in AMHP work:
“Occupational therapists have
broad and varied training that
would be benecial to the
AMHP role and AMHP practice”
(dual registered nurse and
social work AMHP)
Perceptions of the contribution from
occupational therapy were
understandably often hypothetical but it
did appear that differences were seen to
be less stark in relation to social work and
occupational therapy (where professional
values seemed more aligned) than with
social work and nursing. Occupational
therapists were understood to take a
strengths-based and problem-solving
approach, to promote independence and
to address community alternatives to
hospital – all attributes that lend
themselves well to the AMHP role.
However there was a recognition that
because their number is small, few people
value their perspective:
“[I’m] the only one in the service,
so not having a massive inuence”
(occupational therapy AMHP)
Where occupational therapy’s specic
contribution came to the fore it generally
concerned the functional, practical
aspects of the role:
“For example, you often hear
someone is non-compliant with
medication: they cannot open
their medication? Do they have
the ability to distinguish between
tablets? Is their sleep/wake
pattern unusual meaning they
miss medication?”
(social work AMHP)
Findings from the survey
34
Findings from the survey
35
AMHPS as independent, autonomous
and individual
As their numbers remain so small within
the workforce, it may be the case that
views around non-social work AMHP work
are still, at times, based on hypothetical
rather than experiential knowledge.
Where this experience existed, there
seemed to be a recognition that
differences are entirely individual and not
based on the regulated professions:
“I don’t think my comments are
profession specic, more
‘individual people’ specic”
(occupational therapist AMHP)
“I have found that it very
much depends on the individual’s
attitudes, work ethic, enthusiasm,
knowledge etc. rather than
their profession”
(nurse AMHP)
Challenges of the AMHP role
AMHPs were asked if they found any
aspects of the work challenging and were
invited to highlight which aspects were
the most difcult. Here there were no
differences between regulated
professionals’ experiences. The greatest
and ever-present challenges are
summarised in the box.
Little or no alternative to detention
(a situation which has worsened during
periods of austerity and through the
current pandemic)
High number of assessments coupled
with insufcient AMHP numbers
leading to fatigue
Report writing having to be done
within time constraints leading to
compromises to thoroughness
Securing services out of area
Long waits for services, the
coordination thereof and the feeling
of being “stuck in the middle”
Others’ lack of understanding of the
AMHP role and a medicalisation of
the situation
Assessments with language barriers
Staying abreast of the law, particularly
in relation to the Mental Health Act and
Mental Capacity Act interface
Negotiating with doctors who are not
invested in looking at alternatives and
difculties reconciling outcomes with
the statutory guiding principles
Time pressures and difculty in being
able to slow the process down
The person not being as involved in
the decision-making as the AMHP
would wish (due to time and
workload pressures)
‘Invisibility’ of the role and a lack of
representation from within their
services and beyond
Compromised authority and
independence: being perceived as a
doctor’s secretarial support or being
subject to ward manager instruction
(regardless of profession)
Hierarchy as a recurring theme
Organisational hierarchies (and the NHS
and healthcare Trusts were frequently and
resoundingly referred to as being
hierarchical throughout the project) are
seen to represent unshakeable
organisational cultural inuences. This
linked very clearly to a robust assertion of
the AMHPs’ imperatives around
independence, autonomy, power and
capacity to challenge:
“It’s about social factors and
social workers are better
decision-makers due to [their]
independence from medical teams
and NHS hierarchical structures”
(social work AMHP)
Many social work AMHPs made reference
to the need (and capacity) to ‘shake off
the hierarchical structures’ in their
practice. One particularly strong comment
focused on a fundamental difference
regarding responsibility:
“My experience has been that
nurses take less personal
responsibility for situations. I am
assuming [this is because] their
training is much more team and
hierarchy based. Nurses seem
more able to walk away from
situations saying they have done
all they can do, and handing
over to other services to
take responsibility”
(social work AMHP)
Elsewhere, however, there was an
acknowledgement that nurse AMHPs can
maintain the independence that is
required of the role and that they can
assimilate AMHP professionalism:
“Many nurses now sound a
bit like social workers in their
understanding of the social model
as distinct from the medical
perspective which is reinforced
by the hierarchy within the
health service.
(social work AMHP)
One respondent recounted a nurse
colleague being described by a doctor as
a ‘turncoat’ perhaps suggesting that the
nurse has somehow betrayed the health
profession. It seems a fundamental point
here, illustrated by the frequent return to
the need for independence and
challenge, that this issue might be less to
do with nurses’ knowledge and ability and
more to do with relationships with the
infrastructures and hierarchies of an
organisation upon which many AMHPs
direct their frustrations. Nurses
recognised and responded to the
critiques and opinions about the inuence
of hierarchies:
“[Social workers are] disparaging
of other professionals -
believing nurses to be
subservient to medics”
(nurse AMHP)
One nurse did, however, ‘appreciate
social workers’ sense of being apart from
doctors’ in their approaches to the work
suggesting that nurses could follow suit.
Findings from the survey
36
Findings from the survey
37
We wanted to understand the source of
the stresses and whether these remained
consistent with the literature. In the survey,
AMHPs were asked to what extent (if any)
their AMHP work affects their physical,
psychological, emotional and mental
health. We asked them to rate these on
a scale of 1 to 10 (with 10 representing
‘a lot’) and to explain their response.
Responses to this question were spread
fairly evenly but a slightly higher number
highlighted the effects on their
psychological and emotional health.
Bearing the weight of responsibility for all
aspects of the Mental Health Act
assessment was highlighted as
particularly difcult as was the conict
experienced with other professionals and
organisations. The intensity of the work
came through clearly and, for some,
AMHP work felt like ‘risky’ work.
AMHPs frequently stated that there was an
impact on their ability to achieve a
reasonable work-life balance. Several
mentioned childcare problems due to the
long hours and (for some) the impact on
family life was cited as a reason for ending
their AMHP role in the near future. AMHP
work led to poor eating habits, poor sleep
prior to and following assessments,
feeling physically drained, negative
impacts on family life and a lowering of
mood. Community assessments can mean
there is no opportunity to take breaks and
sometimes no toilets are available.
AMHPs spoke of feeling unsupported,
undervalued and under-appreciated and
this was compounded by poor or absent
supervision opportunities which led to
anger and frustration. A lot of people
talked about the emotional aspects of the
work in relation to emotional labour and
trauma. A powerful account of AMHP
work was as follows:
“It is a stressful role, so days I am
on AMHP duty are usually the most
exhausting physically and
emotionally. We are often with
people at their most distressed and
at times alone with them in their
homes […] Being party to and
witness to distressed people being
physically restrained or […]
dragged away from loving and
upset family members affects my
wellbeing - it’s not something I am
comfortable with. My loved ones
often tell me that after an AMHP
shift I come home ‘spaced out’ and
detached. It’s not a role they think
Practice challenges associated with
additional stress were:
Lone working and the feeling of
working in isolation, especially
“holding” situations when awaiting
services or colleagues
Other professionals’ negative attitudes
Levels of violence and risk
Lack of recognition or respect from the
organisation and senior managers
Finding it difcult to make a decision
where there is ‘no good outcome’
Emotional drain involving long hours,
sometimes out of hours, and impacting
on work/life balance
Intensely emotive situations which are
sometimes traumatic
Depriving someone of their liberty
whilst knowing the therapeutic benet
of admission is questionable
Identifying with the family’s distress
Having no time to process the
emotional impact of the decision
Worrying about the ‘right decision’
Fear of repercussions if reports do not
explain decision making sufciently
AMHPs spoke of the burdens of the very
nature of the work and of people’s
experiences:
“I am often plagued by the
injustice of the circumstances [from
which the person has] developed
mental ill health (abuse or
exploitation) which then lead me
to detain [them] further adding to
their feeling of worthlessness and
injustice. I am often disturbed
by the negative attitudes of
other professionals”
(social work AMHP)
Overall, AMHPs clearly wanted to do the
best for the people they were assessing
but they were continually thwarted by the
lack of services and resources. Many
expressed worries that they were
increasingly being asked to ‘do more with
less’. Some expressed fears that, at times,
the system they worked in seemed on the
brink of collapse with colleagues leaving
through burnout and with an insufcient
number of colleagues being trained. This
was compounded by a feeling that they
were often forgotten about in public
policy discussions around mental health
and in reforms of legislation.
Health and wellbeing
Given the ongoing association of stress
and burnout with recruitment and
retention we wanted to understand how
AMHP work affected respondents’ health.
Findings from the survey
38
Findings from the survey
39
10
8
6
4
2
0
Average Likert scale
Physical
health
Psychological
Health
Emotional
Health
Mental
Health
To what extent does your AMHP work
affect the following?
Rewards of the AMHP role
Whilst some individuals expressed
profound health impacts, there were also
AMHPs who identied fewer health
concerns and said that they enjoy their
work. Again there was no difference
between the regulated professions or with
any other area. Where people did not feel
affected, one or two mentioned the use of
support networks that were part of this.
Others enjoyed the challenges and
experienced their professional autonomy
to be a rewarding aspect of the role.
Positive perceptions were generally allied
to a satisfaction that the work can have
good outcomes for people:
“I really enjoy the work. It can
be interesting and it can allow
creativity when trying to nd
alternatives to detention”
(nurse AMHP)
“Overall I nd it a challenging,
but rewarding role. I benet from
the autonomy of the role and
having the power to intervene
in a positive way”
(social work AMHP)
For those who stated that the role did not
negatively impact upon them, they
indicated that the independence,
autonomy and mentally stimulating
benets of the role were a change from
routine casework which served to mitigate
the demands described above. Negative
effects were further ameliorated by having
good peer support, having a break from
the AMHP rota or reducing the frequency
of duty shifts. Some AMHPs thrive on
challenges and their ‘expertise’ leads to
a sense of accomplishment.
Leadership, support and
supervision
We wanted to understand AMHPs’
experiences of support and supervision.
We asked AMHPs if they received
professional supervision to which 69%
answered yes, with 25% saying no and 6%
choosing to leave this blank.
Drilling down into this data by profession,
of the 231 social workers who responded
74% (170) answered yes but fully 26% (61)
stated that they did not receive
professional supervision. 9 out of 10
nurses and the occupational therapist
indicated that they did receive
supervision.
We then asked all AMHPs if they have a
dedicated AMHP lead or AMHP manager.
The majority (95%) stated that they did,
with the remaining 5% answering no.
is good for me, but I feel it’s a role
that no one can enjoy and it needs
doing by compassionate and
committed social workers so
I want to continue to do it”
(social work AMHP)
The ability to continue to carry on with the
role was an ongoing concern:
“I have gained knowledge
and skills which help me but the
level of stress and worry has
continued and not got any better
over the last two years since
I was rst warranted”
(nurse AMHP)
The difculties affected all professions
equally. Interestingly, and illustrative of
the shared problems, one nurse AMHP
found that:
“It is stressful when resources
are not available. It can feel like
we have all the responsibility and
no power and are alone going
against a tide of other agencies
which lack understanding of
the law or their duties”
(nurse AMHP)
Organisational uncertainty was referred
to were one AMHP unexpectedly found
the consistency of AMHP work something
of a comfort:
At a time when services were
being recongured and teams
splitting up, the straightforward
aspect of the AMHP role, that is
assessing people under the
Act, was quite comforting”
(nurse AMHP)
Many identied that the most stressful
and difcult part of the work was around
the lack of ability to meet people’s needs:
“I often feel frustrated, sad,
anxious, tired after an assessment -
especially when we have not been
able to complete the assessment
[or] get the required outcome […]
Having to leave situations that
feel unsafe can take its toll on
the AMHP [creating] mental
strain [and] anxiety”
(social work AMHP)
“Lack of beds is very stressful
with the AMHP often holding
responsibility for the client while
a bed is identied. I have, at times,
waited for up to 7 days for a bed
to be identied”
(social work AMHP)
Here, and across the research project
as a whole, the different aspects of full-
time and mixed role AMHP work were
raised and it was difcult to discern
whether either was more or less
rewarding or stressful:
“Sometimes it is difcult leaving
your “day” job to go onto the
Duty Rota […] especially at busy
times and [with] pressures
from your case load”
(social work AMHP)
Findings from the survey
40
Findings from the survey
41
Yes No Blank
69
6
25
Do you receive professional
AMHP supervision?
(% total)
Consistent with the literature, the chart
indicates that the majority nd their AMHP
peers and colleagues to be the most
welcome and effective source of support.
The next most welcome was dedicated
supervision, which highlights the
signicance of the fact that one in four
AMHPs do not receive any such dedicated
supervision. Training and team meetings
were seen as the least valuable strategies.
When looked at by profession, the
marginal preference amongst nurse
AMHPs was for dedicated supervision
followed by peer support and team
meetings equally whilst social work
AMHPs had a signicant preference for
peer support ahead of dedicated
supervision. Responses to the ‘other’
section included ad hoc supervision and
reective practice groups where these
were available.
AMHPs and professional
regulation
To further examine AMHPs’ perceptions of
the support they receive we asked them
who their professional body is. We used a
free text approach so that participants
could apply their own understanding and
interpretation around professional
representation and regulation.
207 social workers responded to this
question with 185 stating Social Work
England as their professional body. The
question was asked in the singular and so
respondents provided only one response
to this. Other responses included Health
and Care Professions Council (HCPC),
Social Work England/British Association
of Social Workers (BASW), BASW, local
authorities, local authority/Social Work
England, AMHPA (a North West England
AMHP forum), Care Council for Wales and
there were 5 who were unsure or didn’t
know. As can be seen, respondents did
not have consistent answers and this is
one area in which AMHPs have a
perceived role separate from that of
their regulated profession.
Of the nurse AMHP respondents 9 (90%)
stated the Nursing and Midwifery Council
(NMC) and the occupational therapist
identied Health and Care Professions
Council (HCPC).
We also asked AMHPs how their
professional body understands or
supports them with their role, inviting
them to add detail or suggestions. On the
whole, respondents strongly indicated
that they thought their professional body
did not understand and support their
AMHP role, although some were pleased
that this survey had been launched as a
As would be expected, the vast majority
of these AMHP lead/managers were
from the social work profession (95%).
4% were nurses and 1% ‘other’ AMHP
lead/managers.
We analysed the correlation between the
professions of the AMHP lead manager
and the AMHPs. Of the 233 social workers
who indicated they had a dedicated
lead/manager 97% (225) said their lead
was a social worker. Of the remaining
social worker AMHPs, 6 (3%) said they had
a nurse manager, 2 had ‘others’ and 10
said that they had no lead/manager. The
majority of nurse AMHPs (80%) had a
social work lead/manager, one (10%) had
a nurse lead/manager and one (10%) had
no lead/manager. The occupational
therapist was managed by a nurse
lead/manager.
We asked all AMHPs which of the options
outlined in the table below were the most
welcome or effective support strategies.
They were asked to rank these in order of
importance with 1 being the most
welcome and 5 being the least welcome.
Findings from the survey
42
Findings from the survey
43
Yes
95
5
Do you have a dedicated
AMHP lead/AMHP manager?
120
100
80
60
40
20
0
Number of responses
Rank: 1=Most welcome, 5=Least welcome
12345
Which are the most welcome or effective support strategies?
Dedicated supervision
Peer support
Team meetings
Training
6
Who is your professional body?
(% total)
Social
Work
England
NMC HCPC SWE/
BASW BASW Other Unsure
96455
185
3
How education and training
could be improved
The 14% who answered no were asked
how training and education could be
improved. Responses to this question
were split two ways. Some respondents
think that university-led courses are ‘too
academic’ and that the accompanying
portfolio is too onerous, should be
assessed by the line manager and only
ratied by the university as opposed to
the current situation where universities
mark and grade portfolios. Others
thought the opposite: that the portfolio
was ‘too light’ and that teaching should
include more social work theories. The
differences of opinion here are indicative
of the variation in modes of delivery, level
of partnership working and duration of
the programme and placement, with no
minimum standard and curriculum
content across different university
programmes. It may even reect
individual learning styles. Interestingly,
some respondents thought trainees
should be more experienced prior to
undertaking the training and there were
concerns that they may be forced to
undertake the training too early in
their career.
Suggestions for developments in
teaching and training included:
Greater emphasis on the emotional
aspects of the role and managing the
personal toll of ethical dilemmas. This
included aspects of effective supervision
Support to challenge the dominance
of the medical model which does not
acknowledge a psychosocial
understanding of mental distress and
the ways in which it informs AMHPs’
choices and decisions around
alternatives to coercion
A meaningful implementation of social
perspectives and how this translates in
practice to least restrictive alternatives
to hospital
Advocacy training
Assertiveness training, particularly in
relation to challenging colleagues
more robustly
Joint training, for example with section
12 approved doctors
Meaningful inclusion of people with
lived experience to enable a clearer
focus on the human aspects of the work,
including trauma and distress
More time spent on how the AMHP can
involve the person in the assessment
with perhaps some modelling as to
what this might look like
Some suggested that supervision
should be guaranteed for those who are
newly qualied or, possibly, for trainees
to continue to be observed post-
qualication or to have access to
a mentor.
means of developing an understanding.
Some participants indicated that there
was a need for AMHP regulation and saw
the benet of their regulator capturing
their continuing professional
development (CPD). It was seen as
something that is positive and potentially
an aid to further reection.
Some suggested that their regulator
could provide access to on-line resources,
training, links and webinars. There were
overlaps with BASW who were
highlighted as a source for resources and
there were suggestions that more links be
established between Social Work
England, BASW and the national AMHP
Leads Network.
Apart from one nurse AMHP who said that
the Nursing and Midwifery Council had
been ‘accessible and supportive’, nurses
appear to have experienced some
shortcomings in the detailed
understanding of AMHPs within their
professional bodies:
“When I rst approached the
NMC [...] they did not know what
an AMHP was”
(nurse AMHP)
“Currently it doesn’t
acknowledge my AMHP training
and I can’t add this qualication
to my Nursing and Midwifery
Council registration”
(nurse AMHP)
The occupational therapist had a similar
view of the Health and Care Professions
Council (HCPC).
Education and training
Finally, the survey asked AMHPs whether
their qualifying training and education
adequately prepared them for the AMHP
role in terms of content and placement.
The majority (75%) believed that it did,
14% thought not and 11% left this blank.
In terms of the professions 183 (74%) of
social workers answered yes and 36 (15%)
answered no, 90% of nurses (9) answered
yes and 10% (1) answered no and the
occupational therapist answered yes.
Findings from the survey
44
Findings from the survey
45
Yes No Blank
25
Do you think current AMHP
training and education
prepares trainees adequately
for the role (in terms of
content and placement)?
(% responses)
11
14
75
of refresher training is delivered by
private companies followed by in-house
training (29%) and universities (17%).
Dual specialisms: AMHPs
who are also BIAs
We asked AMHPs whether they were also
BIAs and 31% of our respondents said
that they were. The only available national
statistic is from 2018 which indicates that
the average is 38% of AMHPs who are
also trained as BIAs (ADASS, 2018).
We asked those AMHPs who are also a
BIA how the roles relate to each other.
There was overwhelming positivity and
recognition from participants that this
dual specialism has benets.
Understanding the interface between
the Mental Health Act and the Mental
Capacity Act improves their
understanding of options arising from a
Mental Health Act assessment and
provides a fuller legislative picture4.
AMHP/BIAs gained a greater
understanding of mental capacity in
assessments and it enhanced their legal
literacy and concentration on
communication:
4 The recent review of the Mental Health Act (Department of Health and Social Care, 2018)
found that it is not always clear to professionals whether the MHA or DoLS should be
used if a person lacks the relevant capacity and does not appear to be objecting. Some
believe that the Mental Health Act is too restrictive and constitutes a form of
discrimination when DoLS might apply to the person. The White Paper has indicated that
reforms will seek to clarify this ‘grey’ area by developing a clearer dividing line between
the two Acts (Department of Health and Social Care, 2021)
Overall, there was a clear message that
training and education should support
critical reection and thinking skills (as a
means of developing their distinct
professionalism) and not just teaching
how to follow statute and codes of
practice in a limited legalistic fashion. The
need for time and space for learning and
critical reection was highlighted as part
of respondents’ opinions on the duration
of AMHP training courses. Some
suggested that the training was too short
(e.g. where the training is three months)
and there was a call for more dedicated
time in mental health settings.
Where education and
training works well
Where training is well received and
deemed to prepare trainees adequately,
which was the perception of the
signicant majority (75%), it is viewed as
being at the right academic level. Tutors
who are seen to be knowledgeable and
supportive, particularly where they either
have been or are still practising AMHPs,
are well received.
Examples of good practice include:
Practice focus of the course
Placement including the opportunities
to shadow AMHPs throughout
Quality of academic lectures and legal
professional input
Protected study time
Dedicated supervisors/practice
educators
Scenario based discussions
Enabling the AMHP to advocate
more robustly
Close relationship between the
university and the employer
Tools such as training videos
AMHP refresher or
CPD training
The majority of respondents were positive
about the post-qualifying refresher
training they received and indicated that it
was effective. Some thought the 18-hour
requirement had been ‘watered down’ to
include topics not traditionally included in
AMHP focused training and education.
Some appreciated training that involved
professionals from other key areas of
the work.
There was, however, a parallel perception
that post-qualifying training lacks variety
and consists of little more than legal
updates. Suggestions included
opportunities to enhance supervision and
to be able to access reective sessions
offering a safe space to explore the
emotional aspects of the role. There were
a number of observations that some
negative consequences of the COVID-19
pandemic were that online training had
limited opportunities to build
relationships and offer mutual support.
We asked AMHPs who delivers their
refresher training and they were able to
select more than one provider. Nearly half
Findings from the survey
46
Findings from the survey
47
In-house
training
Universities Private
companies
Other
Who delivers your refresher training?
(357 responses)
23
103
61
170
Yes No Blank
Are you also a BIA?
(% responses)
13
31
56
Researching and having adequate
knowledge of the person’s history and
biography was seen by most of the
people as being very important
or essential:
AMHPs need to be aware of the
service user’s life […] the AMHP
needs to come to see the patient
individually before the doctors.
They don’t do that, most of them
anyway”
“It’s just these random people
waltzing into my house who I’d
never met before and just
introducing themselves and
making a big decision about my
life at that time. I didn’t think that
was particularly fair”
Being honest and transparent was
important:
“[AMHPs should] give you some
indication as to what sort of
decision they might be coming to
at the time rather than just impose
it on you right at the end. Giving
you some idea about what might
happen and what they’re thinking
at that moment is important”
Going into an assessment with an open,
non-judgemental mind when it comes to
decision making was also important:
“I think there’s sometimes they
[AMHPs] know their decision
before they even go in there […]
and they already had the
ambulance and the police waiting
outside. So how can that be that
they haven’t [pre-judged] me?”
This correlates strongly with the clear
themes articulated by AMHPs around
information sharing, inclusion and the
Empowerment and Involvement principle
and an aspiration for shared decision-
making. Many people said they had not
been involved in decision-making:
“They always asked me lots of
questions and stuff and then they
always go off to have a
conversation, so I’m rarely involved
in the actual discussion”
“I can remember a few times where
my parents have wanted to be
involved in the discussion, but
they’ve been told to wait outside
or vice versa […] they’ve [the
professionals] all gone into my
garden”
“No options were explained
[during the Mental Health Act
assessment]”
There was an acknowledgement,
however, that where people are
particularly unwell or distressed this can
be difcult. Being offered the option of
voluntary hospitalisation or informal
admission may not be in their best
interests or lead to the right outcome:
“[Being sectioned] saved my life
basically because I’m not in my
right mind when I’m doing these
sort of things […] so, thankfully, the
last time they didn’t even give me
the option to go voluntarily […]
looking back it was the right
decision, even though I’ve hated
being in hospital”
“[It] informs the AMHP role and
the boundaries of the Mental
Health Act. The deeper knowledge
of BIA has helped me to
understand the complexity […]
and the importance of taking time
and care to try and engage and
have a dialogue and narrative with
the person being assessed”
(social work AMHP)
A small number thought that AMHPs
should also be BIAs as a matter of course.
However, some stated that although dual
trained they only practice as AMHPs,
which may be explained by the way that
services and teams are congured.
People with lived
experience of Mental
Health Act assessments
and AMHPs
Fourteen people with lived experience of
Mental Health Act assessments and
detentions were interviewed. To analyse
interview data, Thematic Analysis (Braun
and Clarke, 2006) was used and a
thematic coding framework developed to
illustrate overarching themes, with sub-
themes exploring these further. These are
set out below with participants’
experiences added for illustration.
Communication and the assessment
Elements and characteristics of good
AMHP practice were identied. These
included the importance of a caring and
compassionate attitude, treating people
as human beings and allowing those
being assessed to tell their stories without
imposing prescribed questions on them.
This ‘tuning in’ was seen as having respect
for the importance of peoples’ stories:
Just gauge the mood of the
patient […] and know as much as
you can. Let the patient relax and
tell their story […] And I think it’s
important not to ask questions
from a list […] that detracts from
the human level”
“One thing I didn’t like is that the
AMHP sat there scribbling all the
time rather than looking at [me] […
] Whereas the next time it was
totally different. It was a discussion
[…] They listened to me […] Eye
contact [is very important] […] It’s
about the conversation […] It’s
what I call ‘a joint venture’”
In agreement with the opinions
expressed by AMHPs, people highlighted
the importance of giving time.
The importance of the relationship and
having an understanding of the person
was stressed:
“Having one-to-one time is really
important […] if they’re in your
house [for a short time] then
they’ve made their decision that’s
not good”
Findings from the survey
48
Findings from the survey
49
“There’s a lot of prejudice [...]
towards people with borderline
personality disorder. There’s a lot
of misunderstanding […] and
sometimes quite a critical
approach”
This was also linked to burnout:
“Prejudices [are from] a lot of the
older experienced nurses and
social workers [who] have been
doing it for a lot of years who
seem tired by the system […]
and the reason is, it’s a very
stressful role”
AMHPs’ workloads and time
People saw how AMHPs’ workloads
prevented time for meaningful, holistic
and relational assessments:
“The AMHP forgot to mention the
outcome of it when he left he was
that rushed. He had to get to the
next appointment. He failed to tell
me what was happening. I had to
ask the police ofcers what was
going on”
“The AMHPs [are] there for ve
minutes to ask questions and gain
the information from you […] They
get the information and then go
and make their decision elsewhere
[…] Or just not having the time […]
because they are pushed and
rushed and ‘later but today I have
loads of people to see’”
Resources to meet need
People spoke about the lack of resources,
including the shortages of inpatient beds
and the lack of choice:
“I always feel very out of control
where I’m going [when sectioned].
I’m normally being sent to a PICU
or something far away […] so I wish
that I could stay closer to home”
“I think AMHPs struggle with the
role because they don’t have [any]
alternatives to hospital […]
Community services are so
stretched with what they can do
[…] to be fair how are they ever
gonna get this correct?”
“My aim [now] will be to go into a
Soteria house and work through
my psychosis there and like come
out the other side, not medicated
[…] but obviously that’s not
available at the moment, so that
makes it really hard”
Fostering hope for recovery was
acknowledged as valuable and aspects of
AMHP’s power, ability to challenge and
advocate were also noted - including the
potential to use power for good:
“I don’t know whether it’s the thing
about doctors because of status or
something, they seem to have the
power […] I think AMHPs need to
rise up to the mark and become
more powerful with the doctors
[…] I’m thinking there needs to be a
bit of training for the AMHPs to go
‘don’t overrule me’ kind of thing’
[…] Another good idea […] if you
One person had suggestions for practice:
“If anything I would like changing
it’s to have a summary by the
AMHP about why they made the
decision they did […] I wish I had
more written information to look
back at […] I think we have a right
to know why they made the
decision they did”
Admission to hospital
Hospital was seen as being problematic
for most and this affected perceptions of
the assessment:
“[I felt anger] […] Because when I
was last hospitalised I had an
horric experience […] that I found
really traumatic last time […] and I
was worried that they were going
to send me back. I was furious. I
was really, really angry. And really
sort of scared”
This was linked to AMHPs’ decision
making, whereby:
AMHPs don’t see you once they’ve
shipped you off into hospital and
you’re drugged up to the eyeballs.
They don’t come back. They don’t
see that side of you or that side of
the care”
There was some ambivalence around this,
however, as over two-thirds saw it
(retrospectively) as being the right
outcome, with one person describing
hospital as being something they liked.
Power, stigma and ambush
Assessments have been experienced as
intrusive or, worse, as an ambush, a threat,
or a means of wielding power:
“It’s been done kind of covertly […]
It’s always felt like the outcome is
already predetermined […] All of a
sudden they all kind of ambush me
at the same time […] And the next
thing I know is I’m being sectioned
[…] I don’t think I’ve ever been
involved in this”
The stigma of mental ill-health and
psychiatry is also noted:
“If I’m a problem, they can section
me. I always thought it was a
threat. Your fault because you
challenge them then they come
back with a threat […] If you don’t
do what they want me to do then
yo3u know we can section you […]
We don’t have power. We are
mental patients”
Insights into discrimination, including
organisational prejudices and poor
practice, was observed:
If you get a student or a newly
qualied worker and they go into a
unit to work with others, they
adopt the stuff of the older one.
They need to move forward and
say this is how we do it now but
they fall into that pattern […] they
pick up on the sort of traditional
ways. I suppose it’s about calling
out and recognising it when you
see something that’s not on and
having the condence to do that”
Findings from the survey
50
Findings from the survey
51
People considered the ways in which
workers from different professional
backgrounds would hypothetically bring
different skills to AMHP work:
“I think I would have loved to have
been assessed by an occupational
therapist AMHP ‘cause I’ve met
some fantastic occupational
therapists in the past. [What has
been good about OTs?] I think
they’re […] non-judgemental, so
to speak”
A number of the people interviewed
indicated they prefer AMHPs to be
social workers:
“The different AMHPs I have had
have tended to be social workers
[…] social workers tend to know
more about what’s available in the
community”
“Social workers engage at the
human level and not the conditions
[…] I think that’s massively
important […] and I’m not overly
convinced about psychologists
being AMHPs, you know […] For
me they are like psychiatrists and
[…] you’ve got to be very careful”
“Nurses go into specialist elds
and then go onto nursing
management. Nurses would be
engaged with patients in a very
different way to [...] social workers”
As highlighted elsewhere in this report it
appears that there is a conation of
perceptions of nursing with their medical
and clinical organisational settings as well
as with doctors. Note that the participants
here were not describing nurse AMHPs
(this is not information they had) but their
experiences of mental health services
more broadly (and historically):
“Social workers seem to have a
more social background and
looking at us […] you know […] for
the person […] The medical thing is
what I’m against. ‘Cause you’ve
already got two doctors in there,
you need one with a different
perspective. If you put a nurse in
there, which they can do, or a
psychologist or an occupational
therapist, they are kind of adding
to the medical model”
“It’s about how they react. Social
workers tend to be more laid back
and chilled out, dress like normal
people [...] Occupational therapists
are even more [...] normal! Nurses
are like medics […] If I’m off it the
social worker will say ‘what’s
happened’? The medical
profession will say ‘pop a couple of
extra smarties”
However one person was not
encouraged by non-clinical assessors:
“I’d be thinking of the hierarchy –
you’re just a social worker. The
doctor is higher level so how can
you section me? I wouldn’t have
accepted it if an occupational
therapist tried to section me.
‘Cause of the little knowledge I had
of mental health services and the
way they work and the techniques
and the way they go about it.
I’d have wanted the psychiatrist –
I thought they were the head
doctors”
could have two AMHPs to level out
the two doctors!”
Alternatives to hospitalisation […]
don’t exist in a lot of places but
[have] the ability to campaign for
alternatives and stand up and be
counted for the fact that not
everyone needs hospitalisation.
“One thing [the AMHP] did that
was good [...] the psychiatrist
wanted to put me on Clozaril [...]
[and] he was trying to force his
perspective on me […] And she
did say it sounds like you’ve got
capacity to refuse Clozaril because
I wasn’t refusing medication
full-stop [...] And she backed me
up on that”
The impact of trauma
The need to be trauma-informed came
through relatively strongly, with 5 people
stressing the importance of this:
“Not everyone, but a good
proportion of people, have got
some history of some kind of
childhood abuse […] Across the
board, from police to ambulance
men to nurses, and A&E, to
psychiatric nurses […] [there
needs to be] training about the
effects of trauma”
Some people described detention –
or the prospect of detention – in terms
of trauma:
“I remember […] being terried
[…] I think it was a complete sense
of loss of control […] something
was happening to me and it was
very scary”
“I remember feeling quite
intimidated in a room full of
people I’ve never seen before, and
some of them were ready to sort of
[…] in case anything kicked off sort
of thing. So yeah, I kind of dreaded
seeing those people if I saw them
in any other setting ‘cause it was
so […] traumatic”
Professional identities
This project was co-produced with
people with lived experience of
assessments of Mental Health Act
assessments. In most cases the people we
interviewed were not aware of the
professional background that the AMHP
came from, which is likely due to the fact
that the AMHP will be introducing
themselves as an AMHP only without
sharing their professional background.
Only 3 people knew about the AMHP’s
professional background and this
knowledge appeared to have been
gleaned retrospectively, or coincidentally,
rather than it being routinely shared.
During the interviews some people did
share views about the professions, albeit
not from their experience of Mental Health
Act assessments but rather from their
knowledge and experiences of mental
health professionals more generally.
Findings from the survey
52
Findings from the survey
53
We interviewed two people who had
experience of the Nearest Relative role in
Mental Health Act assessments. In keeping
with the message from AMHPs and people
with lived experience there is a
recognition that AMHPs are very busy and
don’t always have time to do things in the
way they would like to. Both recognised
AMHPs’ aspirations to communicate
effectively, offer time and be supportive,
but also that they are ‘often doing
impossible tasks on their own with no
support’. Both people were aware of the
AMHP role to a greater or lesser degree:
both were aware of the legal functions
around consultation, but not necessarily
that AMHPs were the applicants and
decision-makers. Both knew that the
AMHP had to be there with a doctor in
order for a person to be detained in
hospital and that they were part of the
assessing team but neither were sure what
the job actually involves. There was
general speculation that the AMHP would
need to agree with the doctor’s statement.
The fact that AMHPs have very few
alternatives to hospital admission was
picked up and there was some regret that
there were no less restrictive alternatives
to hospital such as adequate and effective
crisis services or houses, including
Soteria houses.
Both Nearest Relatives had a different
experience of their relative’s hospital
admission: for one, it was seen as being a
‘huge relief’, helpful and conducive to
recovery; for the other, hospital wards
were powerfully described as ‘the land
that time and conscience forgot’ and
which are not always therapeutic or even
safe in the way they can re-traumatise
people who are experiencing extreme
states of mental distress. Again, in
keeping with our interviews with people
with lived experience of assessment and
detention, there was a recommendation
that AMHPs spend time in hospital wards
to further appreciate the implications of
their decision to detain.
Recommendations for training,
knowledge or skills development
incorporated aspects of communication,
for example Open Dialogue techniques,
to further work with the different dynamics
and differences of opinion that can be
part of a Mental Health Act assessment.
One person spoke about a ‘hierarchy of
involvement’, expressing their observation
that inclusion and decision-making
operates from a ‘top down’ perspective. In
general terms, both perceived that they
had been involved with the decision-
making although one believed that there
was a tendency to treat the relative as a
problem (particularly if they disagree) and
that the experience of Mental Health Act
assessments and detentions can be
dehumanising for Nearest Relatives and
for the individual person.
Both people understandably described
the circumstances as having moments that
were dramatic, stressful, difcult and
exceptionally worrying. Some regret was
expressed that Mental Health Act
Overall, the professional background and
identity of AMHPs does not seem to make
a difference and people in acute distress
may not be interested in this:
“I would have to say no [there isn’t
any difference] because I mean they
all do the same course don’t they […]
And they must be trained in the same
approaches, assessing patients”
“I wasn’t bothered by it […] it didn’t
bother me because things were so
desperate. I didn’t care who it was as
long as […] If it’s somebody who’s
got a lot of learned understanding
about the complexities of mental
health and how all that works then it
doesn’t really matter”
Some insights were particularly revealing.
Adding to AMHPs’ own concerns about
their invisibility, for people with lived
experience it was highly likely to be the
case that they did not know what an AMHP
was, the fact that they had an independent
role or that there was one present:
“I didn’t know [until now] that they
were independent […] I don’t really
have much knowledge of what
they’re there for other than […] a
third pair of eyes almost”
‘[AMHPs] […] just kind of stay quiet
and have the doctors to do most of
the talking … whenever I’ve been
sectioned the AMHP’s involvement
has always been […] just part of
going through the motions really”
“I guess with the AMHPs […] they kind
of fall into the shadows a lot. I think
that they’re like background people for
me. It’s much easier to remember the
consultants that were there […] I think
it’s because they seem to play second
ddle to the psychiatrist […] The
AMHPs blended in the background”
Yet this perceived powerlessness of
the AMHP stands in stark contrast to
the notion of the AMHP as a more
powerful gure:
“I used to regard [the AMHP] as the
Grim Reaper! […] It just makes sense
because after all your liberty […]
you get that taken away and the
human rights”
Training and education
People were asked for their views or
suggestions for AMHPs’ training and
education and were invited to comment on
what they saw as being essential knowledge:
“I suppose […] education about what
it actually feels like to be an inpatient
[…] You can go on inpatient units
today and still see the way that
bullying happens. And you know
the stuff around the power. That and
how we take people’s power away
from them”
Having people with lived experience
contribute to AMHPs’ training was seen as
essential by several people:
“I will go there and say you can ask
me whatever you like and I will
answer you … Get them to talk to
people it’s happened to […] get their
point of view. I asked them what
they want to know […] I don’t mind
what they ask me, but I […] can help
communicate and help them do it a
different way. Sometimes it’s how
you ask a question, isn’t it?”
Findings from the survey
54
Findings from the survey
55
Nearest Relatives’ experiences of Mental
Health Act assessments and AMHPs
At the end of the survey, AMHPs were
invited to take part in online focus groups
to further explore some of these
emerging themes. There was an
interesting pattern in terms of
representation5. With all four focus groups
combined, there were 19 social workers
(90%) and 2 nurses (10%) which is a
higher proportion of nurses when
compared with the national
representation of 4% (Skills for Care,
2021). There were 10 females (48%) and
11 males (52%) which, given the national
weighting of 73% female and 27% male,
gives an overall picture of almost double
the representation for men6. In terms of
ethnicity, 16 (76%) described themselves
as White, 1 Black (5%), 1 Euro/British
Asian (5%) and 3 (14%) were not
disclosed. Of those that disclosed their
ethnicity, this is an over-representation of
White AMHPs.
Motivation
We were interested in exploring the
reasons AMHPs went into the work so that
we could understand key motivating
factors and examine whether this was
different across the professions. For many,
it was explained as a contractual
obligation whilst a small number
indicated that they were required to
undertake the training due to a shortage
of AMHPs on their rota, a longstanding
issue. This also raised questions around
suitability and links to retention problems.
A common theme was the way in which
AMHPs were inspired by colleagues:
“When I was a young social
worker [...] you looked around
[and] saw these ASWs and they
were what you wanted to be”
(social work AMHP)
A small number enjoyed academia and
education and were in pursuit of further
training. An ever-present theme
throughout the AMHP focus groups was
the way in which AMHP training is, for
social workers, seen as being a ‘natural
progression’, part of ‘career enhancement’
and, in many respects, the only
opportunity for social workers to be able
to progress their careers without
becoming managers:
“I don’t feel the need to get up the
greasy pole, that doesn’t interest
me at all. Organisations […] need
experts and we are all experts in
[mental health law]”
(social work AMHP)
5 Demographic details for individual focus groups can be found in the Annex
6 Previous explanations for an over-representation of men in this eld of work have
focused on pay, power and masculine notions around risk (Rolph et al, (2003))
assessments are ‘one-off’ activities which
limits communication and the opportunity
for debrief. The level of worry and
helplessness, when recognising your
relative’s distress, can be exhausting and
not something you can prepare for with
an instruction booklet. One person
thought that relatives’ psychological
difculties and uncertainties are not very
well documented or accounted for. There
was a recognition that AMHPs are busy
and concerned with the process and
legality of the situation but that they don’t
always check in with the ‘difcult side of
things’ and leave room for talking. Both
found other means of support such as
self-help groups or networks. The
message for AMHPs and mental health
professionals generally is that it would be
helpful to nd time to talk, including after
the assessment, and perhaps to consider
a form of debrief. Interestingly, one
person pointed to the training that
medical staff receive around
communication and breaking bad news
and that effective communication
techniques should perhaps be something
that are taught on AMHP programmes.
From their experiences, the AMHPs had
always been social workers, although one
was not clear whether they were
attending in the role of a social worker or
as an AMHP. When asked if it would make
a difference if the AMHP was a social
worker, nurse, psychologist or
occupational therapist, one person
thought that as they all presumably have
the same sort of training they would
probably trust anybody from any
discipline that had the qualication.
The other believed that social workers
were better placed to undertake the work
as they saw things from a non-medical
perspective, could take a more critical
approach and could advocate for more
appropriate crisis housing.
Findings from the survey
56
Focus Group themes
57
Approved Mental Health Professionals:
Focus Group themes
AMHP work, power and
challenge
Associated with the striving for equity, a
strongly recurring theme throughout all
focus groups was the use of professional
and statutory power as a means to level
perceived professional hierarchies and to
challenge poor or oppressive practice.
This was about relationships with medical
colleagues at an interpersonal level but it
was also clearly and consistently about
relationships between healthcare trusts
and local authorities at an organisational
level. The frequent references to ‘power
dynamics’ were interwoven with the
perceived high status where AMHPs are
seen as having expertise and specialist
knowledge which they use to level the
playing eld. They have the ‘clout to
properly hold people to account’ as they
strive for equity within organisations that
were seen as hierarchical. Further, one
social work AMHP summarised the ways
in which they may even ‘say something
provocative to get people to reappraise
and rethink what they are doing’ for the
greater good – this power was
consistently expressed as being exercised
on behalf of the person.
AMHPs’ statutory and professional
independence was strongly factored into
this: they did not perceive that they were
‘bound by hierarchies’ and their
independence from organisations was
referred to as a ‘no mans’ land’ (which was
not conveyed as being problematic).
For a small number, this extended to a
motivation to work out of hours, as its
associated freedoms were attractive.
AMHP work as varied work
AMHPs enjoy the variety and spontaneity
of the work and the fact that every day is
different. This was seen as a break from
the more boring aspects of computer or
desk-based work and was illustrated by
reference to the ‘twists, turns and
evolution of assessments’ that were ‘never
dull’. Some enjoyed the fact that it is a
more discrete role, compared with long-
term casework, as it consisted of ‘one-off’
pieces of work.
Resources to meet
people’s needs
Inevitably the lack of resources was an
ever-present theme and there was a
constant striving for alternatives to
admission and a sense of failure and ‘guilt’
around being unable to achieve this. The
AMHP role offers a clarity of decision
making within a framework of legal
obligations and duties but this is clearly
constrained by a fundamental inability to
meet people’s needs due to a lack of
resources. People being sent to out-of-
area beds is a problem in some areas
leading to lengthy travel and time-
consuming problems in terms of trying to
ascertain whose responsibility it is to
undertake associated work. Where there
are no beds, people are being assessed
‘over and over and over again’ and these
repeat assessments are time-consuming
but, more fundamentally, they represent a
failure to meet someone’s needs where
they are left waiting in inadequate,
unsuitable and sometimes unsafe
environments. This was the prevailing
view that was a priority concern in all
focus groups for all areas nationally.
AMHP work as advanced
social work
As with the survey ndings, most of the
social workers who took part in the focus
groups made reference to the ways in which
AMHP work was advanced or ‘proper’ social
work and that it was an opportunity to
promote a social perspective in mental
health settings. It also added weight to their
perceived advocacy role. Some had
observed poor or unlawful practice and,
motivated by their professional social justice
agenda, they saw the AMHP role as key in
building on their legal knowledge and
having additional powers and authority to
be able to address this:
“Work kind of was under,
unfortunately, psychiatrists in the
power dynamic and I really like the
idea that this was a role that would
offset the medical model and
champion the social perspective”
(social work AMHP)
Many appreciated the ways in which their
AMHP role keeps their knowledge up-to-
date, speaking of ‘sharper’ skills and
practice, condence, ‘practice wisdom’
and the ways in which the AMHP Practice
Educator role keeps you ‘on your toes’.
The combination of power, authority and
expertise meant that they were practising:
“[…] advanced social work and the
three pillars of social justice,
human rights, and professional
integrity all in one; forcing others
to look at the bigger context: the
poverty, the inequality, the trauma
and not just that individual person
[…] it’s cutting edge social work”
(social work AMHP)
Nurse AMHPs all related to the idea that it
was advanced practice with one adding ‘it
just seemed absolutely essential
knowledge and I couldn’t believe I didn’t
know it’. There were clear overlaps in
terms of the knowledge and role
requirements but nurses did not
specically locate it within an ‘advanced
social work’ model. AMHPs also
recognised their need to be assertive in
the role, with this relating to their having
a ‘rm-footing’, being ‘sure-footed’
and ‘steadfast’ in their role in a multi-
disciplinary scenario where a lot was
at stake.
AMHP work as rights-based,
justice focused and advocacy
AMHPs were asked what they value about
the work and there were clear and
ongoing references to aspects of justice
and an ever-present focus on people’s
rights. The striving for fairness came
through very clearly and strongly:
“I have got this burning
desire for things to be fair”
(social work AMHP)
“You’re with this person
against the system”
(social work AMHP)
This absolute commitment to justice
and fairness led to AMHPs ‘holding
systems to account’ and challenging
language and attitudes that they saw as
being oppressive or discriminatory (or at
times unlawful), being assertive and
having people with whom they work
‘have a voice’.
Focus Group themes
58
Focus Group themes
59
Lone working concerns were expressed,
along with a sense of abandonment,
whereby
“Nobody addresses the fact that
two doctors can sign a
recommendation to say that a
person is so mentally unwell that
they need to be in hospital yet
we’re going to leave them in the
sole custody of this AMHP for ve
hours while they wait for an
ambulance or a bed”
(social work AMHP)
Service and team structures
There were questions raised as to the
impacts of full-time AMHP roles or roles
where AMHP work is split with other
duties. The restructuring of AMHP services
needs a greater understanding as to its
impact: there were conicts around
whether full-time or split roles were more
or less stressful.
Professional differences or
organisational differences
There was no clear way for us to discern
whether AMHPs’ regulated professional
roles made a difference to practice as all
AMHPs generally had shared experiences
of the work and they coalesced around
their shared AMHP professional identity
and experiences. We did hear some
mixed views and it is possible that our
focus groups had different types of
discussion depending on whether they
were social work AMHPs only or were
made up of a mix of professions.
Organisational and multidisciplinary
factors did, however, frequently come to
the fore and this seemed to distil into a
perception that healthcare trusts have
power and inuence at both a micro and
macro level. The ways in which ‘health
systems’ hold the resources is ‘stacked
against AMHPs’ who are not enabled to
do their jobs but yet are simultaneously
held to account.
In relation to professional identities, there
were mixed views around AMHPs being
from a social work or nursing background.
When this was explored in-depth some
saw differences whilst others believed that
nurses undergo a form of transitioning:
“When nurses become AMHPs
they see things in a slightly
different way”
(social work AMHP)
There were worries about what the
organisations (and thereby employees of
these organisations) represent:
“We were concerned that perhaps
nurses were […] because of the
hierarchy of the NHS […] more
likely perhaps to rubber stamp,
and that was a real concern of
ours. But my experience of nurses
here […] it’s not that”
(social work AMHP)
Nurses also picked up on this stating:
“There is a kind of a narrative and
concern that nurses are trained to
say yes to doctors. I’ve been told
that face-to-face and that’s
people’s understanding of what
nurse training is, and it really, really
is about 50 years out of date.
Pressures of time and
workload
Having no time to do the work, feeling
rushed and the fact that ‘everyone is
swamped’ was a frequently expressed
concern and source of stress. This was in
relation to the volume of work and
number of referrals to process but it also
related to pressure from others. AMHPs
felt rushed and pressured even where
there were serious implications such as
seeking a warrant to enter people’s homes
with the police. They wanted to be able to
say no, advise on alternatives and
ultimately to ‘slow things down’. AMHPs
believed that their role is to act as a brake
and prevent oppressive outcomes but
they very often felt under pressure around
their decision-making. One AMHP
expressed regret that at times the work
seemed to be ‘an exercise in who can do it
the quickest’ and others spoke of the ways
in which their assessment requests ‘go
from one to another to another’. This was a
shared theme that led to many AMHPs
describing how it limits family involvement
and reduces opportunities for debrief or
discussions with colleagues who need
them to ‘just get on with it’. Signicantly,
there is no time for report-writing, where
catching up on reports can take days or
are completed in the AMHP’s own time.
Empowerment, involvement
and working with people
Many AMHPs expressed great concern
and deep regret that the fast pace of the
work - potentially including the
assessment itself - meant that they were
not able to spend time with the person,
support shared decision-making and
embed the Empowerment and
Involvement guiding principle. Being
rushed into decision-making was at the
expense of a good outcome for the
person. Several AMHPs echoed the
statement that they ‘shouldn’t be a
conveyor belt’ and are ‘working with
people, not les and bits of paper’. The
tension between the idea of advanced
work and the inability to complete this
thoroughly was a clear source of stress.
AMHPs said they would welcome more
time to speak to people and their relatives
and generally ‘do a bit more signposting
but then a new assessment comes so
there isn’t time for that’.
The personal toll of
AMHP work
Linked to workload concerns were the
sheer demands of the work and the
personal toll it takes. AMHPs spoke of
being out throughout the night (including
where this followed on from a day shift)
with no-one to relieve them and
“even things like getting food and
going to the toilet – I can’t think of
any occupations where you can’t
take a break because there’s no
cover. We are an anomaly”
(social work AMHP)
One social work AMHP suggested that we
should ‘apply Maslow’s hierarchy of needs
to ourselves’ as they can not get the
profound self-awareness and relational
work right if they don’t have their basic
workplace needs met.
Focus Group themes
60
Focus Group themes
61
“When I talk about nurses I’m not