Broadening access to Independent Mental Health Advocates

Support each other

The statutory role of the Independent Mental Health Advocate (IMHA)  grew from the 2007 amendments of the Mental Health Act in England and Wales (with a start date of 2009).  IMHAs have particular status in terms of rights to information and access that other advocates may not have within Mental Health services.  Currently commissioned by PCTS, from 2013, Local Authorities will take over commissioning of IMHA services and the right and access to good services is intended to be a safeguard within compulsory mental health services.

Last week, Community Care reported on a study conducted at the University of Central Lancashire about the use and understanding about the use of Independent Mental Health Advocates (IMHAs)  among Mental Health Professionals in England. The study has (not, I suspect, coincidently) come at a good time for the change in commissioning arrangements and a look at where things are and where they should be going.

The article itself draws attention to the conclusions that

Some professionals saw advocacy services “as challenging, even irritating and inappropriate”, the research found. One professional told researchers advocates were “amateurs meddling” and a “bloody nuisance”. Others, particularly approved mental health professionals (AMHPs), supported advocacy “but had little or no direct experience” of service users using it.

As a Mental Health Professional (and AMHP) who has had some experience of uses and referring to IMHAs, I was disappointed by this initially. Particularly the terms with which advocates were mentioned. ‘Nuisance?’, I hope so. ‘Meddling?’ well, why on earth not? Surely being a nuisance to professionals and meddling is exactly what a decent advocate should be doing – however I would find the distinction between so-called ‘mental health professionals’ and ‘amateurs’ as advocates offensive and an indication of scant respect. Respect at every level in mental health services, social services and health services has to exist.

Community Care in a blogpost have put together some of the quotes pulled from the report by social workers and AMHPs in relation to advocates which makes interesting reading alone.

My experiences have been mixed to be brutally honest. Working predominantly with people with cognitive impairments which are significant and may not be able to instruct an advocate, I’ve found our IMHAs who have come from a mental  health advocacy background, have been less than understanding of the need for non-instructed advocacy skills. I have been told following a referral I made, that they would not work with ‘Mr Brown’ because he has an advanced dementia and they were only able to do what he asked as his advocate.

I felt some of the attitudes I’ve seen by a couple of our IMHAs towards older adults with cognitive impairments have been less than positive – and I do feel quite protective towards my client group and want to ensure equal access. If only, I have thought to myself on many occasions, our IMCAs (Independent Mental Capacity Advocates) were also our IMHAs (I can’t praise our IMCAs highly enough – even (or perhaps especially) – when we disagree!).

I am always (in a nice way, of course) a little jealous of the advocates I work with. I think their job has a lot more credence than mine in some terms because while I can advocate for my clients to a point, there’s a point at which I am a part of the oppressive systems that need to be advocated against.

I understand that and respect it. I’d certainly not see advocates as any less ‘professional’ than other members of the team I work in. There has to be a distance though – which doesn’t need to stop us being friendly, personable and pleasant to each other – but does demand that sometimes we will be coming from different angles. That’s important to protect the rights of those being advocated for.

The report itself can be read here.  It explains the context of. It explains that access to an IMHA service which should be offered to everyone who is subject to a detention over 72 hours or a Community Treatment Order/Guardianship – is sparse which particular under-representation in the following areas

There was a strong consensus that those who need the IMHA service the most,access it the least. Specific groups of people that may be under-served by IMHA
services are:
 People from BME communities
 People with learning disabilities
 Older people, with dementia
 People who are hearing impaired or deaf
 Children and young people
 People on CTOs
 People placed out of area

And the issues which have coloured my own personal experiences of using IMHAs was mentioned in the report

The development of IMHA services is based on a model of instructed advocacy provided by mainstream advocacy providers. This may inadvertently disadvantage qualifying patients who have specific needs including people from BME communities, older people, children and young people and those with sensory impairments ..


There was little evidence of commissioning based on needs assessment and equality impact assessment and there was evidence in the case study sites that specific needs had not been considered. In particular, gaps were evident in relation to people from BME communities, people with learning difficulties, older people, children and young people. Further, it was evident that generally service users, particularly qualifying patients, were not being directly involved in the commissioning process or in
monitoring contracts.

So it would be unfair of me to lay the blame at the lack of capabilities of particular advocates and more on the commissioning process which sees ‘Mental Health Patient’ as a block group of people with similar needs and commissions accordingly.

The report makes a number of useful recommendations and is a good read for anyone involved and engaged in the provision of mental health services in England and Wales, whether as a professional, user, advocate, carer or commissioner.

The role of the advocate was strengthened by legislation and it is important that the benefits are not lost. I have seen such incredibly useful work done by advocacy services locally that my main gripe is that there should be an equality of access and opportunity for all who are treated compulsorily by mental health services in society.

I want more ‘nuisances’. I want more ‘irritants’. I want more challenges.

That’s what an advocacy service should be about.

pic by sparkypics at Flickr

AMHP training – What it is and How it is – A Review by the GSCC

Law books 1

The GSCC published a report yesterday (pdf)  which is a a review of their inspections of AMHP (Approved Mental Health Professional) courses. My experience of my training as an Approved Social Worker (as it was when I trained) is that, without doubt, it was the highest quality training course I have ever undertaken. It was tough. Very tough. But it needs to be. The role of making such important decisions which affect the liberty of those who are in moments of need, illness and distress is not something which can be glossed over.

In some ways, I’m surprised there isn’t an equivalent, high quality, intellectually rigorous post-qualification course in children’s services before social workers are able to remove children – maybe it would be too costly – but it’s an interesting reflection on the ways in which the different ‘streams’ in social work have progressed.

The report reflects on the GSCC role in approving AMHP training, despite the fact that the training is no longer restricted solely to Social Workers (Psychiatric Nurses, Occupational Therapists and Clinical Psychologists are also able to train up to this role).

There are some interesting tidbits in the summary that caught my attention. There are 22 AMHP courses running in England. Of those who have undertaken them (936 since 2008 when the switch from ASW to AMHP occurred) there have been 936 people who have completed the course. 84% of those completing the course have been social workers and 15% nurses (I’m presuming the overlap is down to some people who are dual trained – I’ve come across a few people who are both nurses and social workers). There have been no psychologists training (surprise) but there are some OTs ( I have personally met one OT AMHP) but it is given as <1%.

The gender breakdown is a 70% female to 30% male of those who have completed training. It would be interesting to compare this with the Social Work training as a whole.

So what are the courses like?

Recruitment is generally by employer sponsorship and some areas have been better at promoting cross professional access to the training than others. There have been issues regarding payments and increments which more often than not have affected whether a nurse or a social worker might be put forward by employers to train but the universities have been willing to accept applications across the eligible professions.

There are very low ‘fail’ rates, possibly due to the selection which would take place in-house before a candidate is interviewed by the university.

Content I’ve had a few people ask ‘how long’ the training to be an AMHP is and explain how it was in the course I did but different courses manage the learning in different ways. For example, I did a full time course. The actual requirements are 600 hours of study with at least 150 of those hours as taught. It is delivered at ‘Masters’ level – but usually needs a ‘top up’ of other modules (which may or may not be offered’ to make a ‘full’ Masters degree.

The emphasis on knowledge of mental health law was considered in the report as it is fundamental to being an AMHP. Universities assess this knowledge in different ways, between exams – either open or closed book – case studies or classroom work.  As an AMHP it is necessary to continue to attend legal updates regularly.

Training in safeguarding legislation as it pertains to children and adults also has to form a part of the course.  This may be a precondition to attending the course – ensuring that this training has been undertaken ‘in house’. It’s also important that Mental Capacity, Equality and Human Rights legislation is covered.

It is also a requirement that social perspectives on mental distress is covered sufficiently.  Indeed, the report comments that while

Traditionally social workers have been viewed within mental health services as the champions of the social perspective model of mental distress

This has needed to be covered extensively in the AMHP training as other professions are being drawn in. Interesting perspective though when you consider the move in some areas to shifting social workers OUT of mental health teams and what that might mean.

But back onto the topic at hand.

User/Carer Involvement in Courses This was an area I felt was strong and particularly useful in the course I undertook. I think it is also worth noting that social workers can be users and carers of mental health services too and certainly the course I was on some people attending the training self-identified as such which was really very useful for us to gain these perspectives.  Formally though, 20 out of 22 courses met the requirement for involving users and carers in the training of AMHPs.

Universities used different models from commissioning teaching directly to drawing on a pool of identified users and carers to participate or commissioning a local user network to be involved in course planning and assessment.  Only half the courses involved users on the selection panels. I was surprised this wasn’t higher.

Being Approved The ‘approved’ part of the name comes back with the Local Authority when the course is completed and we would go our separate ways. Different local authorities have different ways of approving but it is always for a maximum of five years before re-approval is necessary.  Most graduates were approved within three months of finishing the course – that was the case within  my LA where I was expected to conduct a specific number of assessments with an experienced AMHP and then come to a panel with my reflections and face another legal test before being approved. However some LAs will approve more quickly than others.

Practice Assessors – AMHP candidates are ‘on placement’ and have a supervisor who themselves, are an AMHP. Few courses require any qualification from their Practice Assessors (other than. of course, being an AMHP themselves). I’ve never taken this role on specifically for AMHP training but it’s something I’m vaguely interested in doing at some point. Interestingly the GSCC acknowledge that these roles of ‘practice assessors’ may be underappreciated by the universities and the GSCC is recommending that some of the ‘Practice Educator’ standards for Social Workers extend into AMHP training.

The report makes interesting reading for anyone who is curious about the AMHP role and what the training actually involves. Reading it made me reflect both on my role as an AMHP and the training I undertook and continue to undertake to carry out the role to the best of my ability.

Actually, it made me quite proud. I know I’m biased but it is a rigorous system but it was the best training I ever did. It’s not a role I’d say I like or enjoy but it is something I feel I can do with sensitivity, thought and care.

There is a strange kind of ‘camaraderie’ among AMHPs that I’ve not experienced in any other situation. Possibly because it’s so hard to explain to other people what we do and how and why we do it.

photo Eric E Johnson Flickr