The Mental Health Act (1983) (MHA) is seeing rising detentions and inequalities (Blakely et al., 2021). Reports reveal the process of detention as confusing and service users face potential long-term negative impacts (Newbigging et al., 2015; Smyth et al., 2017). Upon the request for reform advice, argument arises for the prioritisation of service user experience and the need for their perspective (Haynes, 2018; Trewin, 2018; Wessely et al., 2019).
Key to the MHA is the Mental Health Act Assessment (MHAA), which determines whether detention is needed. This is done by an Approved Mental Health Professional (AMHP) and two doctors, one being Section 12 approved, and, ideally, acquainted with the person under assessment (Blakely et al., 2021).
The minimal research there is on the process of the MHAA (Hall, 2017; Matthews et al., 2014) brings the voices of professionals to centre stage (Leah, 2020; Morriss, 2016; Stone, 2019; Vicary et al., 2019) and leaves service users unheard (Akther et al., 2019).
To improve care, we must understand the subjective experience (NICE, 2011) and, to make studies more relevant and well-informed, research should be done in collaboration with service users (Hughes et al., 2009; Ridely & Hunter, 2013).
The researchers behind a recent qualitative study (Blakley et al, 2022) sought to explore the subjective experience of the MHAA from the perspective of, and in collaboration with, service users.
Prioritisation of service user experience is vital for service development, particularly in relation to the Mental Health Act Assessment (MHAA).
Methods
The research team consisted of an AMHP, Assistant Psychologist, Nurse academic and, three people with lived experience of the MHA (Service User Researchers; SUR) who were active consultants and collaborators throughout the study. Due to resource limitations, they did not interview participants.
Ten participants were recruited from the south of England. Included were adults (under 65), who had experienced MHAA in the last six months. Excluded was anyone who could not agree to participate or who had any diagnosed organic mental health issue. The interview questions were developed from the experiences of the SUR (Tew, 2008) and research on involuntary admission and coercion. The interviews took place in the participants’ choice of venue, were conducted by two researchers and were recorded and then transcribed. Framework analysis (Ritchie & Spencer, 2002) was adopted for its systematic coding and use of charting (i.e., rearranging data to create order) and it enabled full team involvement (Gale et al., 2013).
Results
Most participants were women from diverse backgrounds with various experiences of the MHAA. To avoid stigma, the SUR directed diagnoses were not collected.
The central theme that emerged was the person-centred approach, which was divided into four sub-themes.
1. Information and options
All participants reported a lack of understanding of the MHAA process, even when they had multiple experiences. They described lack of information, options, and knowledge on the assessors; some could not even see the process as a MHAA.
It’s like it’s deliberately secretive…
Patient understanding of detention and their possible options are key to MHAA, yet the participants recount that “information’s thrown at you, you don’t have time to think” and a sensation of not being involved.
2. “The barrage of three”
Being assessed by three people was depicted as “daunting”, “intimidating”, and “oppressive”. The participants described feeling judged and not listened to. They felt unable to speak for themselves nor their preferences of outcome. The way the decision is made is that an assessor will step out of the room to decide, and this too was described as upsetting.
3. “Someone to sit and listen”
The importance of positive interactions, such as having a professional to sit, listen, and talk to the individual under assessment was described as fundamental to the overall experience of MHAA.
4. Service user voice
Participants reported lack of opportunity to have their voices and wishes heard and a sense of powerlessness throughout the MHAA. They also expressed having little or no discussion with professionals about the process afterwards. Any discussion recounted was badly received with concerns swept aside.
The participants called for the possibility of support from family and friends to feel safe from unfairness or being silenced. They also suggested to be given a warning of possible MHAA to collect personal belongings and that assessors ask how people are feeling:
I felt degraded. I felt completely humiliated, ashamed, embarrassed. It was awful. It was like the worst thing that could happen to anyone anywhere.
The participants’ accounts reveal lack of information, opportunity to express their wishes, and a sense of powerlessness throughout the MHAA.
Conclusions
Mental Health Act Assessment (MHAA) is not experienced as person-centred. Although not explicitly set as a specific standard of the assessment process (DoH, 2018), the overarching principle is of empowerment, involvement, and increased personalised care (DoH, 2015).
The participants expressed difficulty in understanding the process and their options, lack of voice, and disempowerment.
Thus, this study supports that throughout the MHAA, information be delivered more effectively, repeated discussions on options be had, and emotional support be offered.
Person-centredness is valuing a person’s experience and placing their preferences at the centre when making decisions about their care.
Strengths and limitations
This study finds strength in its under-researched focus: the voice of the service user within the MHAA process. Relevant exploration was strengthened by having Service User Researchers (SUR) in the research team and by including varied mental health professionals.
Limitations arise with the small sample size and that neither assessors, professionals, nor families were interviewed, thus limiting viewpoints. Moreover, exploring feelings of injustice amongst marginalised groups may have offered further insight. SURs did not act as interviewers, which could have reduced the power dynamic between interviewer and participant. As participants reported a lack of voice with professionals, possible performance bias and sample bias emerge. If people felt their views were unimportant or would not be taken seriously, they would be unlikely to participate.
Considering power dynamics when conducting interviews is key to increase the quality of qualitative data and sense of safety amongst participants.
Implications for practice
Public health
To reduce the inherent power dynamic between assessor and assessee, use clear introductions and explanations, have fewer assessors and more support from family or friends, and ensure openness to a patient’s views.
Clinical
Understanding service user experience and valuing their wishes is person-centred care. Professionals must talk appropriately with people in distress and address confusion. Throughout care, professionals should do everything possible to render options clear, offer space to address concerns, be open when making decisions, and help individuals reach an understanding after any tough situation.
Research
Future research could employ a similar methodology with a larger sample to widen the understanding of the experience. It could also assess for differences between minority groups and the majority. To tackle sample bias, people advertising the study could explain the value of the service user voice and how it will be used. Small-scale research should be used at each attempt of reform, guided by service user experience, their supporters, and mental health professionals.
In my view, this paper revealed the intense confusion, disempowerment, and isolation that can emerge during the MHAA process and highlights the importance of reform. Thank you to those who shared their experiences.
It is paramount for service users to be empathetically supported to understand their situation and have their wishes heard.
Statement of interests
None.
Links
Primary paper
Blakley, L., Asher, C., Etherington, A., Maher, J., Wadey, E., Walsh, V., & Walker, S. (2022). ‘Waiting for the verdict’: the experience of being assessed under the Mental Health Act. Journal of Mental Health, 31(2), 212-219.
Other references
Akther, S. F., Molyneaux, E., Stuart, R., Johnson, S., Simpson, A., & Oram, S. (2019). Patients’ experiences of assessment and detention under mental health legislation: Systematic review and qualitative meta-synthesis. BJPsych Open, 5(3), E37.
Department of Health and Social Care. (2018). Modernising the Mental Health Act: Increasing choice, reducing compulsion, Final report of the Independent Review of the Mental Health Act 1983. Department of Health and Social Care.
Department of Health. (2015). Mental Health Act 1983: Code of practice: Presented to parliament pursuant to section 118 of the Mental Health Act 1983. TSO (The Stationery Office).
Gale, N. K., Heath, G., & Cameron, E. (2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology, 13(1), 117.
Hall, P. (2017). Mental Health Act Assessments – Professional narratives on alternatives to hospital admission. Journal of Social Work Practice, 31(4), 445–459.
Haynes, L. (2018). How enhancing patient rights and safeguards is top priority for Mental Health Act review. Retrieved June 09, 2022, from https://www.communitycare.co.uk/2018/09/05/enhancing-patient-rights-safeguards-top-priority-mental-health-act-review/
Haydon, G., Browne, G., & van der Riet, P. (2018). Narrative inquiry as a research methodology exploring person centred care in nursing. Collegian, 25(1), 125-129.
Hughes, R., Hayward, M., & Finlay, W. M. L. (2009). Patients’ perceptions of the impact of involuntary inpatient care on self, relationships and recovery. Journal of Mental Health, 18(2), 152–160.
Leah, C. (2020). Approved mental health professionals: A jack of all trades? Hybrid professional roles within a mental health occupation. Qualitative Social Work, 19(5–6), 987–1006.
Matthews, S., O’Hare, P., & Hemmington, J. (Eds.). (2014). Approved mental health practice: Essential themes for students and practitioners. Macmillan International Higher Education.
Morriss, L. (2016). AMHP work: Dirty or prestigious? Dirty work designations and the approved mental health professional. The British Journal of Social Work, 46(3), 703-718.
Newbigging, K., Ridley, J., McKeown, M., Machin, K., & Poursanidou, K. (2015). When you haven’t got much of a voice’: An evaluation of the quality of Independent Mental Health Advocate (IMHA) services in England. Health & Social Care in the Community, 23(3), 313–324.
National Institute for Health and Clinical Excellence (NICE). (2011). Service user experience in adult mental health: Improving the experience of care for people using adult NHS mental health services. Retrieved June 10, 2022, from https://www.nice.org.uk/Guidance/CG136
Ridley, J., & Hunter, S. (2013). Subjective experiences of compulsory treatment from a qualitative study of early implementation of the Mental Health (Care & Treatment) (Scotland) Act 2003. Health & JOURNAL OF MENTAL HEALTH 7 Social Care in the Community, 21(5), 509–518.
Ritchie, J., & Spencer, L. (2002). Qualitative data analysis for applied policy research. The Qualitative Researcher’s Companion, 573(2002), 305–329.
Smyth, S., Casey, D., Cooney, A., Higgins, A., McGuinness, D., Bainbridge, E., Keys, M., Georgieva, I., Brosnan, L., Beecher, C., Hallahan, B., McDonald, C., & Murphy, K.. (2017). Qualitative exploration of stakeholders’ perspectives of involuntary admission under the Mental Health Act 2001 in Ireland. International Journal of Mental Health Nursing, 26(6), 554–569. https://doi.org/10.1111/ inm.12270
Stone, K. (2019). Approved mental health professionals and detention: An exploration of professional differences and similarities. Practice, 31(2), 83–96.
Tew, J. (2008). Researching in partnership: Reflecting on a collaborative study with mental health service users into the impact of compulsion. Qualitative Social Work, 7(3), 271–287.
Trewin, M. (2018). Mental Health Act review: How would recommendations affect frontline social workers? Retrieved June 09, 2021, from https://www.communitycare.co.uk/2018/12/12/mha-review-recommendations-affect-frontline-social-workers/
Vicary, S., Young, A., & Hicks, S. (2019). Role over’or roll over? Dirty work, shift and mental health act assessments. The British Journal of Social Work, 49(8), 2187–2206.
Wessely, S., Lloyd-Evans, B., & Johnson, S. (2019). Reviewing the Mental Health Act: delivering evidence-informed policy. Lancet Psychiatry, 6(2), 90-91. https://doi.org/10.1016/S2215-0366(18)30477-2
Photo credits
- Photo by Ben White on Unsplash
- Photo by Debby Hudson on Unsplash
I have for a long time (since qualifying as an AMHP in 2005) been uncomfortable with the practice of stepping out of the room to make the decision about admission or not. I have over the years attempted to include the person in the discussion if they are well enough. There are certain people who cannot contribute but for others even if they are relapsing it is important to them to know they were included in the reason why we felt admission was needed and it is important that the doctors were there to explain this as well. Too often – over the years the AMHP was left to explain this and for some elements quite rightly so, but mental illness is an illness and to have a doctor explaining why you need an admission is reflected in all categories of illness isn’t it? It just makes sense to explain to the person what will happen next, just as if you had a physical problem that needed an admission.