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.
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).
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.
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.
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.
Implications for practice
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.
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.
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.
Statement of interests
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