What does a Mental Health Social Worker do?

I think there’s a lot of misunderstandings about what I actually do at work. What do social workers who are in mental health services do? What do social workers who work in adult services do?

I hope by reading, some people get to learn a little of my day to day role but I also thought it might be useful to set it out more explicitly.

I’ve worked in adult services and I’ve worked, as I do now, in mental health services but I’ve never worked in childrens’ services so I can’t comment at all about the work that is done there. This is my attempt, not to explain social work as a whole, but to explain the bit of social work that I’m familiar with.

I work in a multidisciplinary Community Mental Health Team. We have a consultant psychiatrist attached to the team as well as a few (the amount fluctuates!) other doctors. We have occupational therapists, clinical psychologists, assistant psychologists, community psychiatric nurses and of course, social workers. We always seem to have students around, whether psychology trainees, OT students, nursing students or social work students (and even some medical students pop in occasionally).  I sit opposite a psychologist and between an OT and a nurse.

Although no week is typical, I’ll give a few examples both of the generic role and the way that social work fits into a mental health setting, in England, at least (because I’m not sure if there are differences in Scotland, Wales and Northern Ireland).

Work is allocated for ‘care co-ordination’. Care co-ordination is akin to what we would have called ‘care management’ in Adult Services although there are some differences and responsibilities under the Care Programme Approach.  It basically means we take responsibility as a kind of ‘key worker’ for individuals who are ‘taken on’ by our service.

Allocation should be done on the basis of appropriate professional expertise so for some issues that have a more ‘social work’ tilt about dynamics, organising personal budgets or residential placements might be preferred as allocated to social workers, some that are more rehabilitation orientated might be allocated to an Occupational Therapist and more medical or medication management might be allocated to a CPN but that is a very broad brush to paint and in practice – most people are a mixture of all the different needs and so are allocated generically. If I have need a of specific OT assessment for one of the people that I am care coordinating, I will ask one of our OTs and similarly, I care coordinate one person who receives a monthly depot injection from one of my nursing colleagues.

So what is care coordination/care management about? Well, we start by working with and on a care plan and this should be led by the user of the service. If there is a carer involved it would also involve them and we put together plans. In my service which works predominantly with older adults, there may well be care services needed and this is now all delivered through personal budgets so I would take someone through the supported self assessment questionnaire, the resource allocation system and develop with them and/or their carers, depending on capacity issues on a support plan and way that services would be delivered. This would be reviewed and implemented in partnership.

I will also arrange respite placements  and services when they are needed and review services as they are delivered.

Alongside this, I would also be responsible for monitoring any changes in mental state and might provide some brief therapeutic interventions mainly through basic CBT type models according to additional training which has been given in the NHS Trust I work in as they are trying to ‘skill up’ all care coordinators!  When I meet with someone, my discussion ranges for more broadly than about their care needs specifically. Sometimes it is about sourcing and finding ideas, services and people that might be able to help, namely through group work which is run across the service or through referrals to specific psychologists attached to the team. Sometimes it is much more difficulty to quantify – and log – and record.

I work with carers and work through carers’ assessments and services such as they are. Often I feel one of the most important aspects of my work is carer support as we rely so heavily on some carers. I might liaise with different organisations on peoples’ behalf if they can’t manage or need some assistance. Sometimes I help with Attendance Allowance or Disability Living Allowance claims but there are council teams that do that so it would only be in circumstances when I might know someone particularly well and be concerned that someone who doesn’t know them that well might ‘underplay’ some of their needs.

Sometimes it is about liaising with creditors, gas and electricity companies, housing etc with various degrees of success. I like to think of myself as an advocate at times.

Although at times, I am very far from an advocate. I am subject to specific ‘terms of reference’ of my job and have no control over things like budgets that can be assigned to various people with various needs. I would ‘present’ the needs of service users I work with to various internal funding panels so on that basis I need to advocate clearly.

We have to review the services that are in place regularly. I would attend meetings at day hospitals and on wards when I am allocated to people who currently attend or are inpatients.

I work to plan and organise discharges from hospitals both the psychiatric hospitals and the general hospitals when people whom I am allocated to are inpatients. There are some very obvious time limitations on these pieces of work and no-one wants anyone to be in hospital any longer than they have to – but equally no-one wants someone to be discharged from hospital before they are well enough to be – which is another very important consideration.

I conduct safeguarding investigations as well. Alerts come up with what can be surprising frequency and there are prescribed procedures through which we approach these investigations. It’s hard to generalise as they can be very different. Interestingly most of my recent ones have involved residential services in some way or another. I think I’ll come back to the process of investigating abuse in another post as it is altogether a subject in its own right. We tend to get more of these investigations in older adults services than occur in the working age adult services.

I am an Approved Mental Health Professional (AMHP). That means that I am on a rota to carry out Mental Health Act (MHA) Assessments . There is an important difference between a Mental Health Assessment which is a more generic term for an assessment of someone’s mental health and a specific ‘Mental Health Act Assessment’ which is a formal assessment under the 1983 Mental Health Act which can result in a compulsory admission to hospital without consent.

The role of the AMHP could be a post all of its own and it probably should be so I’ll condense here for clarity because it has increasingly become a part of my day to day role. I organise and arrange these assessments by arranging for ambulance service and doctors attendance (there have to be two medical recommendations written by doctors – one should know the patient (usually their own psychiatrist or GP along with an independent doctor who has had additional training). I also attend a magistrates’ court to obtain a warrant to enter if it is likely that we would not be allowed access to a property. I  arrange police support if necessary and would also organise a hospital bed if necessary.

There are legal forms to complete and I have an obligation to be mindful and respectful of legal rights and human rights when involved in these processes.  I am obliged to attend a specified amount of ‘legal updates’ every year to maintain my approval as an AMHP and every five years I have to be ‘reapproved’ which involved me taking a legal test and submitting some reflective pieces and examples of my work as well as carrying out a set number of assessments per year (no problem with the numbers – I’ve done the requisite annual number in the past week!).

I’m also a BIA (Best Interests Assessor). This means I have specific duties and responsibilities to carry out assessments under the ‘Deprivation of Liberty Safeguards’. Again, that probably demands a post or two of its own. Suffice to say that every so often I am called out to do a specific type of assessment on this basis.  I had to attend additional training to be able to do this and have to attend update workshops and training to retain my approval.

Apart from the things I’ve listed, my job involves other pieces of work. I write social circumstances reports for tribunals. I occasionally have been involved in assessments and writing reports for Guardianships and in taking part in the process of approving or extending a Community Treatment Orders. I frequently carry out Capacity Assessments for various reasons.

I’m a practice assessor too so when I have a student, well, I have a student to supervise. I tend to enjoy having students around. It does create more work though and there’s no recompense in terms of reduction of caseloads! And the universities and local authorities wonder why we can’t offer as many statutory placements!

My work is often one of juggling and trying to prioritise and reprioritise on the basis of risk management. What is more important for me to complete on any given day.

I haven’t even mentioned data input or writing case notes but takes a fair bit of time. We have regular audits of our ‘productivity’ – we have to input our ‘outcome measures’ and re-input them regularly so our management overlords accept that we are actually spending our time at work, working effectively and not just twiddling our thumbs and playing Facebook games.

The amount that we have to ‘report back’ is, of course, growing at an exponential rate.

So that is my job – as briefly as I could manage and I have missed out some of the million subtleties that might change on a day to day basis.

I generally enjoy it. I love the variety that is thrown my way on any given day. Some days it frustrates me and there are rarely enough hours in the day to get what I want done, done. This may explain some of my frustration with the bodies who all say they ‘speak for social work’.  Have they explained the role of social work outside child protection? Would you know, if you are not involved in the ‘system’ what a mental  health social worker actually does?

But really, that’s another fight for another day. For now, well, I need to go to work!

But I had over to you, dear reader. Is there anything that surprises you? What you expect? What have I left out – as I’m sure I have missed a lot of things!

Guilt, Work and Switching Off

Over the weekend, I was reading Dorlee, from the ‘Social Work Career Development’’s guest post ‘The ABCs of Self-Care for Psychotherapists’ on ‘Private Practice From the  Inside Out’.

It is a useful and interesting list that can be extrapolated for many in the social work and social care sector – and probably many other sectors and areas where we work in stressful environments to be honest.
Libby's Guide to Total Relaxation

hewgriff @ flickr

It made me reflect on some of the ways in which our organisations work and are structured here in the UK and how unhealthy some of the ways we are forced to work are.

It is easy to blame poor management in the public sector (and that’s what I’m concentrating on, because honestly, that’s what I know) and in many cases it would be a fair place to apportion blame.

I have seen so many friends and colleagues ‘burn out’ by being almost criminally unsupported in the work place – ‘learning by doing’ through the false assumption that employers make that somehow social work graduates are immediately ‘ready for practice’ due to having one statutory placement.

Placements during the course are good arenas for training but they aren’t any more than a stepping stone to practice which is one of the reasons I am so strongly in favour of an assessed year of practice prior to registration as a social worker in the UK.

The real area for exploration though is the assumptions that are made at higher management levels about what work can and is safely carried out ‘on the front line’. I wonder sometimes what happens in the higher echelons of the Adult Services (and Childrens Services) directorates in the local authorities when they set some of the strangest and oddest targets and keep feeding the pressure on to the front line managers. It seems so very very distant.

So back to ‘self-care’ and ‘switching off’ from work.  It is something that, I think, for me anyway, takes practice.

I sometimes draw on my A level economics recollections of ‘Cost Benefit Analysis’ but instead of ‘costs’ and ‘benefits’ – I have the two ‘mental columns’ of ‘Things I can change’ and ‘Things I can’t change’ (without the financial implications!)

I can’t change whether Mrs M is going to have a fall this weekend. I felt that although she lacks capacity to make a decision as to her care and placement needs, it was in her best interests to stay at home in potentially risky environment as she had, prior to her dementia taking hold, indicated she never wanted to ‘go into a home’. She knows her way around her own home and while some ‘trip hazards’ may have been removed through an Occupational Therapy assessment and actions resulting from that, she remains a bit wobbly on her feet. Do I think about her when I go home on a Friday – sure, maybe a little – but I know I’ve done everything I could and I can’t stop her falling on a Friday evening or even on a Monday morning.

Am I worried about Mr Y who I assessed last week and made a decision not to admit to hospital under the Mental Health Act? Well, a little – after all, he wasn’t well and was disturbed – but I have to follow the criteria of the Act and I genuinely didn’t feel that he met them. Yet. I can’t ‘save the world’ or prevent all the accidents and incidents that might have adverse effects happening – so I try not to over-worry about them.

I am bound by the law of course and if someone doesn’t meet the criteria for compulsory admission to hospital under the Mental Health Act and they retain capacity – there’s nothing I can do. Quite rightly. Although sometimes, that instinct that drove me into this job – the ‘wanting to help’, the ‘wanting to make things ‘right’’ – it tries to pull me in another direction and those seeds of worry can be planted to blossom through the evenings and early mornings or over the weekend.

Sometimes I have to do this consciously and logically tell myself to evaluate situations.

Sometimes the worry comes because there are things that I haven’t done at work – telephone calls I haven’t made – reports I haven’t sent – visits I haven’t made.

Time is limited. As long as I can justify the time I do spend at work, I try to detach myself from these thoughts. I could always do more but the job is one of constant re-prioritising. Sometimes I forget to do things I’ve said I’d do or follow up on things I said I would. It happens. While it is my ‘fault’, I don’t necessarily see it as my ‘failing’. I know I can account for every single minute that I’m paid to be at work – even those minutes that I’m sitting chatting to colleagues about the weekends’ television or having a cup of coffee – because if we don’t have those minutes, we run the risk of further rushed, unreflected, unthoughtful pieces of work.

Colleagues have told me since my first social work job how important it is to look after ourselves in this profession.  The spur that often drives people into social care is a wish to make a difference and perhaps a desire for self-validation – the odd pat on the head of feeling that you made a positive difference to someone’s life. Unfortunately that same trait which is usually a force for good can be used and manipulated by managers to force people to work overlong hours, not take breaks throughout the day, push people to take work home because, you know, Mr K will suffer if you aren’t able to finish the paperwork this week. They know well how to pull on our ‘conscience’ because the same happened to them when they were mere practitioners.

It’s hard to say ‘no’ when you know the people involved. I’m drawn into some of the guilt because I promised to visit Mrs P last week. Well, I won’t say promise, because I don’t put things in those terms, but I said I would – then things happen and other things seem to take over and the telephone call about this or that suddenly has to take priority – and before I know it the week is over and I haven’t seen Mrs P or written up the report that I should have or telephoned a family member to confirm dates for respite.  It’s hard not to feel that I haven’t done my job.

But by weighing up what I did and how I prioritised, I can, at least switch off and learn to ease some of the personal responsibility by redrafting and reframing it as organisational guilt and responsibility.  That isn’t to say that I slack off or try and push the blame on others – to be clear, I never do that with a service user – and always take personal responsibility there as the last thing anyone ever wants to here if they are upset, disappointed or distressed is a social worker trying to fob them off on someone else – but mentally I try and differentiate between ‘things I can change’ and ‘things I can’t’.

For me, it works. But sometimes it’s something that has to be learnt each for themselves.

Ethical Practice in the Face of Cuts

How can I compute the process of going into peoples’ homes, often relying on good relationships which have been built up over weeks, months or years and telling them that there is no money left, that services need to be cut with my ethical compass and my adherence to a code of practice for a profession which has, at its heart, a struggle for social justice?

It’s something I’ve been toying with mentally over the past few weeks and months. I suppose in some ways this post is an attempt to become an apologist for my own practice but while I know many would argue against my justifications I can’t honestly afford to throw away my job so what can I do to ensure that my moral compass is retained.

Well, I can do my best to advocate. I can tell people about complaints procedures and urge them to use those self-same procedures to make their voices heard. Maybe when council members see the letters flowing through their respective mailboxes from constituents they will pay heed to the effects of the decisions they are taking but I’m not confident that many will take that path. Complaining, unfortunately, is too closely associated with negativity. It shouldn’t be. A complaint is, in some ways, the best way of learning about what a service needs and lacks. I wish everyone complained more. I have been subject to a fair number of complaints over the years and after the initial jolt of damaged pride, I honestly think they have been extraordinarily helpful in the long run.

The last complaint I received which referred specifically to me was from a woman I had been seeing for a while and we went through the process together of setting up a personal budget and support plan. The indicative budget though, was not enough to provide the services that she felt she needed and so the support plan was lacking in some areas that she felt were important to her – simply because there were limited resources. So she complained. She complained that I had not been able to meet her needs and also that I didn’t visit her often enough.

By the time I had explained my actions to my manager and written a draft response to the complaints department, I had been able to give everyone along the way an earful about exactly why I felt the process of determining an indicative budget from a Self-Assessment Questionnaire was fundamentally flawed and discriminated against people with mental health needs.

Her complaint gave her and others like her a louder voice.

I object and shout and discuss the processes that I see within the local authority systems but I still implement them. Does that make me less of a social worker? Again, other issues that I ponder aloud. I have tended to think that outside statutory services one might be able to take a more idealistic view but the building of competence, relationships and understanding within statutory services are a key part of the role as well.

Interestingly, when I think about the moral dilemmas of my work and how I practice, it is far more the issues that come up on the care management side that vex me because they are about the scarcity of resources. It might be more obvious for me to think about the controlling statutory role and power that I have as an AMHP (Approved Mental Health Professional) to deprive people of their liberty by making applications to detain them in a psychiatric hospital without their consent.

I find that part, ironically, a little easier to equate with my role due to the best interests aspect and knowledge that decisions that I make under the Mental Health Act as an AMHP are ones that I, alone, am responsible for and in that role I am not a functionary of a local authority machine but I am responsible for my own decisions to admit or not to admit.  While there is, without doubt, an ethical dilemma present in almost every compulsory admission, it feels different when I am solely responsible for taking that decision and can weigh up the issues myself.

So is this post an apology for the actions I take on a day by day basis in being an instrument of some of the harshest cuts in the social care systems? Yes I think it is.

As much as I strongly disagree with the way that the cuts have been weighted against those who have least, I am still instrumental, amid growing caseloads and shrinking resources in being the front ‘face’ of them to many people I know and who know me. I’m the one who tells them respite services are closing. I’m the one who tells them they have to have a pre-cooked meal delivered rather than a carer actually making a meal for them.

If everyone had what they needed though, it would be a delightfully easy job.  As it is, I continue in my role and yes, complain about it, but try and use all my energies outside my work to take the  fight back to the politicians and the officials who rely on people like me to implement the cuts they decide on behind the closed doors of power amongst themselves.

I genuinely think that it is not possible to be an effective social worker without a thought or concern for promoting social justice and both equality and equity of resource distribution.

And with that, I try to ease my struggling conscience.  It is a struggle though.

On Being Shadowed

Beckenham Hospital. Located in Croydon Road an...

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Last week, I had the pleasure of having a second year social work student shadow me as I worked. She was a student in a voluntary agency that I had come across because she had been doing some work with one of the service users I work with. I asked her if she wanted to come and join me to see ‘the statutory side of things’. Bless her, but she almost bit my hand off.

We usually have students in our team but we don’t at the moment. I have had students shadowing me from time to time and  I try to give people the opportunity when I am asked and am happy to offer the opportunity to students I come across if they are interested in seeing how we work.

I miss having students. I really enjoy the teaching element of the practice teaching but, as I explained to the student herself, the reas0n I didn’t take a student in this ‘round’ of placements was because I was not convinced I would be able to protect them from the pressure of work in the office at the moment and I was concerned that they might be used as an ‘extra pair of hands’ in an extremely sparse office. It might not have been the best learning environment, although, come to think of it, it would have likely been a realistic one.

I am toying with the idea of being an off-site practice teacher next time round.  I enjoy talking students through linking theory with practice. I enjoy discussing recent policy and research and the implications for practice. I enjoy teaching all in all, actually. I enjoy the enthusiasm and the realisation what they learn at university can be used to practical effect.

There is something wonderfully invigorating about showing an enthusiastic student the work that makes up practice. We visited a couple of people and she watched as I completed some paperwork – ok, that bit might not have been so thrilling – but it allowed me to talk through the process of writing and the reasons that the forms are compiled in the way that they are.  It allowed me to reflect on some of the tasks I might ordinarily take for granted or complain about and step back with a realisation of what a well-completed and well undertaken assessment can mean.

We had lots of conversations about law. I think there was a law exam coming up. My particular joy was looking at the case study they had been given for their law test and being able to talk my way through it without barely catching  a breath. I clearly haven’t forgotten as much as I thought I had about Community Care Law (I’m fairly hot on Mental Health Law if I do say so myself – simply because I use the Acts (Mental Health and Mental Capacity) literally on a day by day basis in my job).

We also had a Mental Health Act Assessment come up while the student was around and I left her behind to read up on the codes of practice. I won’t take students to shadow Mental Health Act Assessments. I remember being pulled up on this while doing my Practice Assessor Course but I stand by my principle.

Firstly, Mental Health Act Assessments take place by their nature at a time when the person being assessed is in a high state of distress or illness and whether they would be able to give their consent to someone ‘observing’ is questionable. Personally, I believe strongly that the Assessment is about the person being assessed and not for me as a professional to control any more than I do through legal measures. So much control is taken from the individual that having students around reinforces the already massive power imbalance.

Finally, there’s no need for a student to attend. Of course AMHP trainees have to attend. They need to carry out observed assessments of Mental Health Act Assessments in order to complete the qualification but general social work students do not. Just as general medical students do not.

I explained to the student that I did not want her to come with me. She showed some disappointment but this is an area I feel very strongly about on an ethical basis and I promised when I returned that we would have a long discussion about the use of the Mental Health Act. Which we did.

I thought about how often the student/practice teacher relationship emphasises the student as the recipient of ‘knowledge’ but in practice, the teaching is a two-way process. I learn a lot from every student that comes. I learn about the impact of different lived experiences and different viewpoints. I learn about how my work is perceived by different cultures and communities. Things that I  might take for granted, I learn to challenge.

The teaching and learning relationship allows more considered reflection and while the nature of the role is that the experienced practitioner is placed in the position of ‘expert’, we can look at the same theoretical bases that we use in relation to students as the experts of their own learning and experiences.

As for the student, she seemed bright and enthusiastic. She wanted to do well and I have no doubt she will.  She had a background in a completely different area but she showed an empathy and understanding that will serve her well in the future. When she thanked me at the end of the day, I think I might have well forgotten to thank her.

I am sure I got as much, if not more, from the day as she did. She probably didn’t realise that.

Weekend Links 8

I want to start in solidarity with a couple more British Mental Health Social Work blogs – go and visit them and comment as an incentive for them to continue writing. I really want a community of blogging social workers to grow! I think that nothing will raise the profile and voice of our profession like a strongly networked and linked community of active and aware social workers who engage with social media.

So there’s Ladybird who works in an Early Intervention in Psychosis Team and has a really helpful weekly post of ‘useful links’. Last week she concentrated on carers and mental health. The nature of her job is that the carers and users will be young adults so the concept of ‘carer’ can be quite different to mine as I am used to working with older adults. She collates genuinely useful links and I have the page bookmarked.

Jamie Middleton is an AMHP and a member of the Interim Board Member of the College of Social Work.  It’s vitally important that the needs of Mental Health Social Work are expressed and actually the subject of his post last week was the announcement that the Isle of Wight is considering ‘de-integrating’ their integrated teams and moving social workers out of the CMHTs (Community Mental Health Teams) and back to social services offices. I’m biased but there is a massive need for social workers to remain in CMHTs (disclosure, I work in a CMHT!) to promote a multi-disciplinary approach and to be mindful of the social models in mental health work and care. I agree with Jamie.  On that note too, I’m really toying with the nature of the anonymity of the blog. It would be wonderful to write without a pseudonym but I’m not quite sure how to address the issue with management!

I also came across this blog by S.Wangene in Kenya. It’s good to get a social work perspective outside the anglo-centric world view and it was interesting to read of parallel issues about promoting good end-of-life care in Kenya.

Still in my trip around the virtual world, SocialJerk shares a great post about the links between films and social work in an Oscar-themed post. As someone who has made a concerted effort to avoid Black Swan because it sounded like it might have overplayed the mental health stuff, I’m actually reconsidering after her post!

I loved this post by Melinda at Classroom to Capitol about ‘starting where the client is’ in the context of growing activism. Rising political engagement and activism is something I’m exploring at the moment and it was a very timely and beautifully written reminder of the context that occurs in and the context around peoples’ lives.

On A Case Manager’s Verse there is an interesting question posed about whether it is helpful for a practitioner to  have a shared experience with the client. I haven’t responded yet to the post as I’m honestly not sure.

And in a similar fashion, Fat Social Worker discusses the issue of when a social worker has or has had mental health problems and  how to manage that.

And at ‘Always Something to Complain About’ she talks about her own experience of withdrawal from Cymbalta. She also has a great post where she links to a site that has been helpful to her in providing inspiration. I won’t link it here, you’ll have to go to her site and find out about it. It’s worth doing though!

Kryss at the New Social Worker has just passed her exam to be licensed. Well done to her and her post gives some advice to those who take these exams in the US.

Possibly useful for Dorlee at Social Work Career Development who is contemplating her upcoming exam and looking for advice!

Finally, I know this goes beyond my usual ten links but I can’t leave it out.

How not to do Social Work has a really interesting insight into age assessments which mean something very different in his service area.  When I see ‘Age Assessment’, I think about some of the horrendous BIA forms.. but that’s another story for another day. His story is far more interesting.

And although I know she isn’t a social worker but I include The Small Places  here anyway because the blog is so enormously useful to social workers like me (who work a lot with the mental capacity legislation), comments on the Stephen Neary case.

If you don’t know what that is, do click on the link to read about it. I’ve purposely refrained from making any comment about it in the past.

And that’s my slightly over-extended round up of links of the week in my own personal view. I’m in a chattier mood today!

Have a good weekend all!

Deprivation of Liberty Safeguards – a few thoughts

I’ve written about the Deprivation of Liberty Safeguards (aka DoLs)  and Best Interests Assessments before but the last time I touched on them in detail was a back in 2009 when I looked at some of the initial assessments I had done.

Now, almost two years down the line, there is a slightly better understanding of the process and it is something I’ve been asked specifically about so I thought I’d run through a few thoughts on the issue.

The Deprivation of Liberty Safeguards were introduced as a part of the Mental Capacity Act 2005 and ‘went live’ in April 2009.

They were introduced as the government’s response to a European Court ruling on the HL v Bournewood case. The details are in the link but very very basically, it involved a man who was an informal patient at the Bournewood Hospital and the illegality under the European Convention of Human Rights, to be deprived of his liberty in ‘informally’.

Article 5(4) of the European Convention of Human Rights – now (and since the incident at Bournewood) incorporated into UK law as the Human Rights Act 1998 – states that

Everyone who is deprived of his liberty by arrest or detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful.

Article 5 is a limited rather than universal right – meaning that  had HL been held under the Mental Health Act this would not have applied (and in any case, he would have had the right of appeal through the tribunal process). However as an informal patient he had no such right.

The Deprivation of Liberty Safeguards were an attempt to bridge the so-called ‘Bournewood Gap’ so that there was a legal framework which applies to people who are detained without consent and capacity and who are being deprived of their liberty and who are not subject to the Mental Health Act.

The process of identifying a Deprivation of Liberty falls on what is the ‘management authority’. This would be the care home or the hospital. Deprivations of Liberty must be instigated by a ‘public authority’ so this law does not apply to private homes or supported housing.

One of the biggest dilemmas for someone involved in the process is deciphering what a ‘deprivation of liberty’ actually is. There is little guidance and a little case law.

I tend to refer back to the Deprivation of Liberty Safeguards Code of Practice which attempts to give some examples. For me, the important thing to consider (as one of the ‘assessments’ I complete as a Best Interests Assessor involves establishing if a Deprivation of Liberty actually exists) is the difference between a restriction of liberty and a deprivation of liberty – one of which is liable to the legal framework and the other not. Chapter Two of the DoLs Code of Practice is useful in identifying some of the main issues to be aware of but as it emphasises each decision is unique in the way it plays out for that individual.

Incidentally – for those who were asking about the locked doors and keypads to ‘keep residents/patients’ in in residential homes and hospitals – this is dealt with in the Code of Practice. The existence of the locks themselves would not alone be a deprivation of liberty but there may be deprivations due to cumulative effects of ‘full and effective control’ by care staff or nurses on someone’s activities or by the degree and intensity of other co-existing controls.

Jones as well, in his commentary in the Mental Capacity Act Manual gives some examples of differentiation between restrictions and deprivations of liberty. This is something that we frequently discuss when we, as Best Interests Assessors meet and share practice and experience. Two people may not make the same judgement as to whether there is a deprivation or not.

So if the managing authority believes there to be a (or that there will be)  Deprivation of Liberty – they request an authorisation. These can either be urgent or standard. They can allow themselves a few days if they see an immediate deprivation of liberty but they have to apply for a standard authorisation in the meantime which means the full assessments.

The managing authority asks the supervisory body (Local authority for care homes and PCT for hospitals) for an authorisation of the deprivation of liberty. The supervisory body arranges the assessment.

There are six assessments. Usually they are done by two individuals – they have to be done by at least two although more can be involved, I’ve never known it. The reason there have to be two is that the Mental Health Assessment has to be done by a different person to the one who does the Best Interests Assessment. The other assessments are usually done by one or the other of those assessors.

Neither assessment can be done by anyone involved in the care of the individual being assessed – although they can be done by people who are employed by the local authority/PCT etc who has asked fro the assessment.

Age Assessment – is the person over 18?  Seriously, that’s it. I quite like this one. It’s very straightforward. Particularly in older adults services.

No refusals – Advance decisions or decisions made by legal deputies or donees and lodged with the Court of Protection apply to treatment and care decisions under the Mental Capacity Act.  The wishes of the deputy or donee or the individual if they have made an advanced direction, remain valid and would supersede any Deprivation of Liberty order made.  Again, this is usually conducted by the Best Interests Assessor

Mental Capacity Assessment – The Deprivation of Liberty Safeguards only apply to people who lack the capacity to make decisions about their care needs and/or placement of treatment. This would be done in the same way that capacity decisions are made in other areas – starting from the base of an assumption of capacity. The Mental Health Assessor or the Best Interests Assessor can do this.

Mental Health Assessment – Any person that this applies to has to be have some kind of ‘disorder or impairment of the mind’ as defined in Section 1 of the Mental Health Act. The assessor must be a doctor with additional training completed. The assessment must take into account how that person’s mental health may be affected by the proposed deprivation of liberty.

Eligibility Assessment – if someone is subject to detention under the Mental Health Act or may meet the criteria for detention under the Mental Health Act they are not eligible for an authorisation of a deprivation of liberty. This assessment must be completed by a suitably trained doctor (s12 doctor) or an AMHP – because the assessor has to be familiar with the Mental Health Act.

Best Interests Assessment – this has to be carried out by someone who is registered as an AMHP, a social worker, an occupational therapist or a chartered psychologist who has more than two years post-qualifying experience and has undertaken additional training specifically for this purpose. They would be ‘approved’ by the supervisory body on an annual basis.

They must determine whether there is a deprivation of liberty existing and also if it is in that person’s best interest and/or if there is any less restrictive option that could be taken.  It can be a lengthy process and always involves family members, care staff/nursing staff, contacting anyone with any involvement with that person to get significant background information etc.  There are some situations in which an IMCA (Independent Mental Capacity Advocate) has to be employed.

If a decision is made to authorise a deprivation of liberty, the person to whom that refers has a ‘representative’ who would have the right to appeal. The representative is appointed by the supervisory body. Usually it is a relative but if there are no relatives, the supervisory body would employ an IMCA in that role.

Chapter 7 of the DoLs Code of Practice gives guidance about the role of the representative.

For me while understanding it is a protection for someone who may be deprived of their liberty, the actual process is remarkably (although unsurprising clunky). The paperwork (in England, at least) is a horrific mash up of tick boxes that seem to lend themselves to repetitiveness. Assessments I have completed as a Best Interests Assessor are generally very interesting as I quite enjoy the process of trying to find out as much about a person as possible and digging around for information, the forms suck any interest in the process straight out of my every pore.

Personally, I think the whole process could have been better thought through. The ‘review’ and ‘appeal’  are much less accessible than the Mental Health tribunal systems which are in place and in my mind, there is less protection under the DoLs framework when compared to the protections under the Mental Health Act.

Relying on managing authorities (residential and nursing homes and hospitals) to identify there own deprivations of liberty has led to some unusual interpretation of the law. Particularly as they are reluctant to refer as they can feel that there is an implied criticism.

I  have  no doubt whatsoever there are many many of these deprivations of liberty that exist and are not referred.

Usually, you’d think the CQC might pick them up on inspection but the CQC don’t seem to inspect any more.

Has it actually helped practice? I’m not sure.

Generally, I’m a great fan of the Mental Capacity Act but this part of it I have many reservations about. I think it was actually poorly drafted and no-one thought through the practicalities before implementation but it isn’t going anywhere so we might as well deal with it.

For further reading, I’d definitely recommend the

Deprivation of Liberty Safeguards Code of Practice – it’s remarkably easy reading for a government document. And it’s free to download.

Jones Mental Capacity Act Manual – has the text of the Act and some useful commentary.

The Mental Capacity Act 2005  –  A Guide for Practice (actually, I don’t have this book, but I have the previous edition which has been very useful for putting the some more difficult concepts into easier to manage forms – and I’m a great fan of Robert Brown’s books so I would happily recommend it even though I haven’t read it!).