Approved Mental Health Professionals and Mental Health Act Assessments: A Study of Power, Structures, Communication and (Shared?) Decision-Making

Approved Mental Health Professionals (AMHPs) undertake Mental Health Act (MHA) assessments and have overall responsibility for deciding to detain, or indeed to not detain, an individual in hospital without their consent. They are required by law to act autonomously and make independent decisions, free from the influence of others, whilst working in complex and changing systems. Outcomes of MHA assessments are understood to be inconsistent, variable and influenced by many factors and, further, the MHA is known to disproportionately affect some groups or to indirectly discriminate (DoH, 2015b; DHSC, 2018). Within psychiatry, any focus on power has generally been on the overt, structural or ‘macro’ aspects of control and coercion rather than the more subtle forms of manipulation at the ‘micro’, individual level of negotiated decisions. Yet AMHPs are required to embed the statutory guiding principle of ‘Empowerment and Involvement’ (DoH, 2015a) into their practice whereby service users should be ‘fully involved in decisions about care, support and treatment’ (para.1.8) and little is known about this in practice. The forthcoming reforms to the MHA are understood to have the new set of guiding principles on the face of the MHA (not just within guidance) and the new ‘Choice and Autonomy’ principle speaks of a ‘move to mandatory recording of shared decision-making’ in order to improve outcomes, acknowledging that culture change is required to ensure that it becomes routine practice (DHSC, 2018 p.36). Yet if MHA assessments are to be a place for shared decision-making (SDM), more needs to be understood about effective techniques and aspects of communication and involvement. This, along with the many variables influencing AMHPs’ practice and decision-making has, to date, attracted very little research. This study was conducted with AMHPs and service users from one Local Authority area in England. A qualitative methodology was employed, within a social constructionist paradigm, to gather in-depth information about AMHPs’ experiences and perspectives and to consider the impact of the surrounding imperatives on their practice in general, and on their decision-making more specifically. An ethnographical study was undertaken within an AMHP service where a variety of different AMHP team structures provided an opportunity to consider their respective influences on practice. This was followed by observations and audio-recording of MHA assessments. Conversation Analysis was used to analyse aspects of the content and style of communication within interactions, with particular regard to power relations and the extent to which Empowerment and Involvement and SDM is (or is not) enabled in MHA assessments. AMHPs and people with lived experience were interviewed and a thematic analysis of the data was undertaken. As the study was adversely impacted by the global COVID pandemic, the research was augmented with a reinterrogation and thematic analysis of findings from a national research project with similar research questions, led by myself, focusing on people with lived experience of MHA assessment and detention (a further under-researched area). The study addresses both a research gap and a gap between policy aspirations and current practice. Findings offer a refined understanding of the influences on AMHP practice and decision-making and specific ways to enhance involvement with people with lived experience to improve subjective outcomes. This study is original in its combination of qualitative methods using Conversation Analysis to study the in-situ dynamics of the MHA assessment process. Different AMHPs both perceive and apply their power and authority in different ways and perceive the empowerment and involvement aspects of the role to be enacted in different ways, leading to an inconsistency in both objective and subjective outcomes