Category Archives: Medical

The AMHP as Officiant: hospitalisation as a transitional event towards the end of life

By Rob Moore, Approved Mental Health Professional (AMHP)

The recent blogs by Christine Valentine and Jeremy Dixon made me reflect on my role as an Approved Mental Health Professional (AMHP).  Jeremy questioned how people towards the end of their lives might experience the legislative framework of the Deprivation of Liberty Safeguards (DLOS). Christine described feeling at the mercy of the disparate ‘system’ of professionals and agencies that became involved prior to her mother’s death. In my role as an AMHP I am very much part of the system, at times using legal powers towards the end of people’s lives.  This process is not however simply a technical activity but in my experience can feel like participating in an important ritual of transition.

The AMHP Role

AMHPs are predominantly social workers who have undertaken further specialist training so that they are qualified to assess people for detention under the Mental Health Act 1983 (commonly known as ‘sectioning’).  The AMHP has an overall role to coordinate assessments that usually also involve two doctors. The AMHP is able to make an application for detention in hospital if she is satisfied that, taking into account all the circumstances of the case, this is the most appropriate way of providing the care and medical treatment that the person needs, and both doctors recommend detention under the Act. Under the broad definition of ‘mental disorder’ people with dementia can be detained in hospital if the risks warrant it and there is no less restrictive option.

If someone lacks capacity it may under certain circumstances be more appropriate to use the Mental Capacity Act 2005 to admit someone to hospital or a care home in their best interests, at which point DOLS may come into play.

This is a complex legal landscape in which different Acts and changes in case law all need to be considered. The recent update to the Mental Health Act Code of Practice gives some valuable guidance on the use of the Mental Health Act vs the Mental Capacity Act [1].

Alongside a good working knowledge of the legislative landscape, an AMHP will often find themselves needing to operate in emotionally charged circumstances. Almost by definition we are called upon urgently in times of crisis when someone’s situation has taken a significant turn for the worse. Towards the end of life we are most likely to be called when it is suspected that as a result of dementia the person is now posing a significant risk to themselves (for example, by wandering out at night or into the road) or to others (for example, as a result of violence or aggression). Sometimes those around the person can manage such changes, perhaps with additional support or a change of medication. On other occasions this is not possible and a carer or care home are unable to keep going.

Hospital admission and lifecycle transitions

When assessing someone with dementia for hospital admission, carers and professionals are often aware that the proposed admission is a highly significant moment in the lifecycle of the individual and their family. Broadly speaking, for other mental disorders detention is seen as a chance to intervene in the person’s situation so that they can leave hospital in improved circumstances. For someone with dementia, hospitalisation for assessment or treatment of their illness can often signal a permanent and significant reduction in independence. It comes with a real possibility that discharge will not be to the environment from which they were admitted but to a more specialist placement. In this way hospitalisation can mark a transition from people living in their own home, possibly with family, to an institution; or from a general care home to a specialist dementia care or nursing home.

Family members are often present who are likely to have been hugely involved in supporting their loved one and to have multifaceted experiences of this as burdensome but also important and possibly rewarding [2]. Perhaps understandably, when the person I am assessing has significantly reduced agency and capacity, more focus is given to those around them than might otherwise be the case.

Bloomer et al 2014 [3] found that carers hugely value the opportunity to talk about their experiences of the hospitalization. I have noticed how with overwhelming sadness but also conviction family members will talk of no longer being able to manage the caring role and of how the unique personhood of their loved one has reduced, perhaps to the point at which ‘you could say the man I married died years ago’. On occasion carers have spoken to me about how they can now start looking after themselves and get on with their lives: ‘it’s time for me now’. Such comments invite me as an ‘expert’ to validate the complexity of their experience and legitimate thoughts that that have perhaps hitherto been unspoken and unspeakable. These conversations might take place in snatches as I try to coordinate a bed or transport or perhaps over the kitchen table with a wife or a son after the ambulance has taken their loved one away.

Rituals of transition

Much more than simply a technical medico-legal process, the above scenarios speak of a multi layered social reality. In our society certain points of transition in the family lifecycle, for example marriage, have widely recognised and culturally available rituals attached, while others such as a miscarriage do not [4]. It seems to me when I am involved in admitting someone with dementia to hospital I am taking part in a ritual of transition. It is a process on the cusp of change, full of unknowns and fears for the participants. However, as anthropologists have described [5], as with all liminal periods in rituals this openness is limited by a prescribed sequence and rules (the medico-legal attention to diagnosis and the appropriate legal framework) and by an ‘officiant’ (the AMHP).

In my experience, the transitional aspect of hospitalisation has been minimally recognised and explored and is a long way from anything covered by legislation or codes of practice. I think that it is important how we conceptualise events. Solely focusing on the technical-legal aspects of hospitalisation increases the chances that people will feel processed by the system. One alternative for me is to be mindful of the role of officiant, particularly when people with dementia are admitted to hospital. Doing this helps me to consider the weighty significance of the event for all involved. In a job that contains significant and often unacknowledged ‘emotional labour’ [6], it also helps make sense of how these types of circumstances are some of the most affecting that I experience as an AMHP. When I leave an assessment I often do so with a sense that I have born witness and hopefully helped bring about a safe transition: a significant step in the process of someone’s social as well as biological death and also a profound moment of transition within their wider family lifecycle.

References 

[1] https://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983

[2] Sutcliffe, C.L., Giebel, C.M., Jolley, D., & Challis, D. (2015). Experience of burden in carers of people with dementia at the margins of long-term care. International Journal of Geriatric Psychiatry

[3] Bloomer, M., Digby, R., Tan, H., Crawford, K., & Williams, A. (2014). The experience of family carers of people with dementia who are hospitalised. Dementia

[4] Burnham, J. (1986) Family Therapy: First steps towards a systemic approach, 36-39 Routledge, London

[5] Szakolczai, A. (2009) Liminality and Experience: Structuring transitory situations and transformative events. International Political Anthropology 2:1, 141-172

[6] Gregor, C. (2010) Unconscious aspects of statutory mental health social work: emotional labour and the approved mental health professional. Journal of Social Work Practice, 24:4, 429-443

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