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‘Shifting sands and thinking on your feet’: a day in the life of an AMHP
This is a guest blog by Frances Folkard, an Approved Mental Health Professional (AMHP).
Our days are mostly about arranging and conducting Mental Health Act Assessments. Any AMHP will tell you “a day” is never the same as any other.
Conducting a Mental Health Act Assessment is like setting off on an expedition. The AMHP thinks: “I am trained for this, I have some tools, I am as prepared as I can be. I have gathered the troops and 2 doctors, I have a destination sorted, the bed and the possibility of assistance, with an ambulance if needed” and off you set.
But what you don’t know is: “how is this going to end, or when?” – so many dilemmas & variables ahead, ‘shifting sands’, thinking on your feet; unanticipated things presenting.
And you hope for some good luck, because you’ll need it!
Let me tell you about a situation I was recently involved in. We received a referral for a 28-year-old woman who lives alone – we will call her Kiri. She has a diagnosis of bi-polar disorder, has cardiac problems and has a mild Learning Disability.
Kiri started becoming unwell a few weeks ago and is now beyond treatment in the community. The referral tells me she “is paranoid, suspicious & aggressive – believes food is poisoned and has stopped eating”. Kiri rings her Mother constantly throughout the day.
Was there need for a Mental Health Act Assessment? Yes. I emailed doctors, none were available that day.
Thursday. One Psychiatrist could do 5pm. I finally found another who could do that time too.
I met one Psychiatrist outside the woman’s home. We waited. I texted the other, she was delayed getting PPE. I rang and asked if she could get some for us and the patient – a kind woman, she already had. She arrived. The patient’s mother said she has a key and could let us in. I reserved that as a fallback preferring to knock and see if Kiri would let us in herself.
We could hear loud talking. We knocked and knocked, called through the letter box, telephoned. No reply.
I rang the patient’s mother, she came, opened the door with her key and disappeared again. We entered the hall and said hello, heading towards the stairs thinking she was upstairs. But no, Kiri was in a room to the left back of house, sitting on sofa with cat on her lap. She jumped up, slammed the door, and shouted at us to get out. We explained why we were there and wanted to talk to her – “No, get out. You’re Nurses, you’ve lied to me, go away”.
Dr A has a soft kind voice and told Kiri she was a doctor. She became aggressive in manner, shouted at us to leave and said she knew us very well – we had not met her before. She told us to go or she would call the Police. We said to call the Police and tell them we are here. She rang 999. We could hear her giving her address. We ask: “Please tell them Dr A is here”.
I went outside and rang 101; I told Police that Kiri was on a 999 call to them and that we were in attendance for a Mental Health Act Assessment. I asked them to link both calls on their system. We told her we were leaving and left.
The Psychiatrists felt they had enough to write a joint medication recommendation. We sat in Dr A’s car. We then heard Kiri’s voice shouting on the street saying that her father had raped her. Dr A approached the patient’s gate smiling and said: “I am Dr A, we have not met before, I am very pleased to meet you”. Kiri shouted back: “you are my father”. Dr A, from Nigeria, said: “look at the colour of my skin, do you really think I am your father?” Kiri replied: “you are a cross dresser, you are a fake, you are my father” and went inside.
The exchange confirmed our assessment. Back to the car to continue. A Police car then arrived. It was a PC responding to Kiri’s call to Police. He knocked on the door, but she did not reply. I asked for his mobile number as I might need his help when the ambulance arrived – Kiri’s mother told me she put up a lot of resistance last time.
He gave me his number. Papers were completed at 19:15. I rang SWAS (South Western Ambulance Service) and requested an ambulance. They said they would try to attend within the hour. The Psychiatrists left.
The Police officer stayed on the street. At 20:00 lots of people in the terraced houses on both sides of the street came out and clapped for the NHS, but Kiri did not emerge. I rang the ambulance for an ETA – it had not yet been allocated. I was told that one was on its way to us at 19:50, but it had been diverted to a cardiac patient.
At 20:10 a triage doctor from SWAS rang me and asked if a PTV (patient transport vehicle) would suffice. I explained that Kiri has a cardiac condition and I wanted a paramedic crew in attendance in case anything happened on the way, short journey as it was.
From the moment I signed the AMHP application form the patient was in my custody.
I stood there thinking not only: “what if she doesn’t answer the door and let us in?”, but: “what if she locks the door from the inside so her mother’s key won’t be able to open it from outside?”.
Would we have to go to court & get a S135(2) warrant? Oh no.
The PC and I shared concerns and all kinds of anticipated problems.
At 20:45 the ambulance arrived. A 2-person crew. A woman driving & a tall dark-haired young man to approach the patient. He geared up. We agreed the PC would go in first, me behind him. I was going to tell Kiri that the doctors and I are concerned she is not well and that we think she needs a period of assessment on X Ward etc. I would not tell her she was detained, for fear of increasing her stress or affecting her cardiac condition.
We knocked on the door. No response. The PC talked through door, all quiet. I rang the patient’s mother – she had been parked nearby; she came and gave me her key, then she ran off again (fortunately she owned the house).
Phew! Kiri had not locked the door from the inside and left the key in the lock. We got in.
Kiri was standing on the second from bottom step on the stairs. She looked cross. I explained what was going on and ended saying: “so Elliott has come with an ambulance to take you there”.
She took one look at Elliott, the male paramedic, and her face broke into a wide beam. She trotted towards him in bare feet, not interested in finding slippers or shoes. She boarded the ambulance without difficulty.
At that point she looked like a young girl, a hint of her learning difficulty becoming apparent.
And that was the luck. Had it been Elliott driving and his female colleague approaching the patient – it could have been a completely different set of circumstances.
Kiri was admitted to hospital safely.
Share your social work story at email@example.com telling us your name, job, contact details and social care number (just so we know you’re a social worker, we will keep it private).
A Plumber’s bag and ten extra minutes
I will always remember my consultant social worker comparing social workers to plumbers. ‘Just like a plumber can’t do their job without their plumber’s bag, said Jo, ‘a social worker can’t do their job without their social work toolkit’.
A plumber needs a range of tools and equipment to successfully change that pipework, install your new sink or unblock your washing machine. Armed with knowledge and skill, they also need various tools such as a pipe wrench, faucet key and plumber’s tape to get the job done.
Just like our social work training equips us with the theoretical knowledge and skill to work as social care professionals, social workers too need their own toolkit bags. Taking a few moments to reflect that I was indeed working in a social work team and not a building site, it all clicked into place when I started to build my own social work tool bag. No one can tell you what to put in your tool bag, it’s your bag. Some may have support plans, a pen and a consent form. I had colouring pens, an A1 size flip chart pad and Sharpies.
I was privileged to work in a new, social work-led mental health, forensic and substance misuse team for my first year as a qualified social worker. In this team we worked with people and change; we would work with resistance, distress and ambivalence.
We ran social work and peer-led groups sessions weekly and linked with our local community to offer opportunities to adults living with mental illness. We also supported people with enduring mental illness into voluntary work and some into paid employment – it was the best year a newly qualified social worker could ask for.
An alternative approach
In this team, I was introduced to an alternative (or creative) approach to social work under the tutorage of my assessed and support year in employment (ASYE) practice educator Lawrence Taylor.
He always helped me try and see and feel what it would be like to be in the shoes of the people I work with. How would I want to be treated or assessed?
I recall once time working with Sam, a 18-year-old adult with autism, obsessive compulsive disorder and bulimia. Sam rarely spoke but when he did, it was only about philosophy or space. Sam preferred texting, emailing or drawing, but again it was mostly around his areas of interest.
I opted one day to bring in my brand new pack of Sharpies and an A1 flipchart pad; we had a semi directed session about the future and goals and each took it in turns to ‘share and tell’ out picture with a narrative.
At the end of a 60 minute assessment, Sam has drawn what his worries were, his fears, his plans for the next six months, his five-year goal and what he wanted to achieve from his social worker.
They were all pictures, but Sam was empowered to tell me in his narrative whilst I quickly jotted down these important points on my pad. When reflecting back to me what each picture meant to him, we were able to hold a short, but meaningful conversation about what would evenly lead to his support plan.
I was able to complete a detailed assessment of his needs, wishes and goals and we worked closely for the next few weeks towards getting Sam back to college. The A1 pad and Sharpies were now my wrench in my social work tool bag. As the months and years pass, I’ve added small figurines, toy cars, characters from the film Inside Out, MoodCards and a pair of magnets.
Time to plan
Fast forwording four years to 2020, I had moved on from my social care mental wellbeing team into a seconded Approved Mental Health Professional (AMHP) Hub. Along with this came the more legalist approach of social work assessment in the form of Mental Health Act Assessments.
I feared my ‘Plumber’s bag’ would be out of action for some time, having to coordinate the detailed assessment undertaken with doctors under the Mental Health Act and facilitate the safe admission or home care of individuals in a mental health crisis.
As Covid-19 restrictions came into place, the AMHP hub continued to operate 24 hours a day, seven days a week. As other friends and colleagues were working from home, reviewing individual and families remotely, AMHPs were still very much out conducting face-to-face assessment (or interviews).
The county I serve is a mixture of rural and urban, the drives often require a scenic and traffic heavy route through the South Downs. During the Covid-19 restrictions with less traffic on the road, I found myself getting to places with extra time to spare (which in reality meant on time, as a social worker, I’ve always been working 10-15 minutes late since starting this career).
Having this extra time meant that I had opportunities to plan for my intervention a little more.
Alternatives to talking
I recall one day planning to assess Betty, who was in hospital under section 2 of the Mental Health Act 1983. Her consultant has asked for an AMHP and second doctor to assess to consider if Betty should now become subject to the provision under section 3, as she required a longer period of treatment.
Betty was 40-years-old. I was fortunate to have assessed her the previous month, so knew a little about Betty’s history. She was assessed under the Mental Health Act and detained under section 2 following a lapse of her illness and what is being described as selective mutism. She would not talk.
When I assessed Betty the previous month, I tried a variety of different approaches including writing, drawing and eventually using my laptop to type a variety of closed and open questions to which Betty was able to respond – this indicated to me that she was able to read and felt more comfortable responding to written questions / using alternative communication methods.
Whilst waiting for my independent section 12 approved doctor, I was thinking about how I could be as inclusive as possible to Betty in her assessment rather than reply on my laptop. The Code of Practice for the Mental Health Act chapter 14.42 directs AMHP is to consider alternative communication methods to increase participation of the assessment and to break down barriers to maximise the person’s involvement in the assessment.
I decided to have a look in my Plumber’s bag in the boot of my car. I found my MoodCards; I selected a variety of moods and emotions from the pack (which you can see from the picture range from positive moods/emotions such as happy, hopeful, satisfied to negative moods/emotions such as sad, worried, depressed et cetera).
At the beginning of the assessment MoodCards were introduced to Betty along with the purpose of the cards. I made sure they were in reaching distance from Betty and I also made no further reference of drew any attention to them for the rest of the assessment (as a means of using them as a semi-directed prop).
After approximately 30 minutes, and during a protracted period of silence, Betty reached for the blue ‘Sad’ card and said: “I feel sad,”. She then replaced this and picked up the orange anxious card and Betty said: “I feel anxious too”. These two cards open a meaningful, but limited dialogue with Betty talking further about the feeling of unease and worry on the ward.
An extra ten minutes
You may not see from the picture, but unease and worry were not emotions or mood that were on these cards. We had a small conversation and the doctor made some suggestions about medication which could reduce her feelings of anxiety.
This intervention worked particularly well at encouraging Betty to talk about her emotions, which had been unsuccessful in previous standard assessment approaches. By unpicking her emotions, I was able to glean an understanding of her current thinking pattern without the need for a protracted and detailed dialogue, which Betty has previously found difficult.
Whilst Covid-19 has impacted a range of services which has been awful and distressing for many, I have found having those extra ten minutes to plan for my intervention has been an opportunity for me to rekindle creative approaches to my practice as a social worker and an as AMHP.
This is Hope: a poem by Katy Else aka The Unheard Bird
Katy Else aka The Unheard Bird, a social worker at Livewell Southwest and talented poet, has written ‘This is Hope’ for the people of Plymouth in response to the COVID-19 Pandemic, and to illustrate how communities have come together to support each other during lockdown.
Tell us your social work story at firstname.lastname@example.org telling us your name, job, contact details and social care number (just so we know you’re a social worker, we will keep it private).