Mental Health Act Assessments: No trace of race. The Role of the AMHP in antiracist practice.
By Hari Sewell
Mental Health Act (MHA) assessments are challenging. By their nature they indicate that some kind of crisis is occurring. Time is often limited in the MHA assessment interview. Questions put to the patient by the Approved Mental Health Professional tend to be restricted to those evidently pertinent to the decision regarding whether an admission is necessary.
Race is always present in encounters because we are now all racialised beings. The times when it potentially becomes most invisible are when all those present are white. The presence of anyone from a minoritized racialised group in any situation forces race to be visible.
The discourse in mental health services often reduces the MHA assessment to the face-to-face interview with the person being assessed. The narrowing of the frame of a MHA assessment to the interview may legitimise a claim that opening race conversations with the patient is unfeasible. This is notwithstanding the critique that the default response to the possibility of conversations about race in mental health settings is avoidance (Ellis, 2021). A consequence of race being off the agenda is that the assessment and resultant documentation potentially does not move on from race as an aspect of identity to the impact of racism in the person’s life. The former is likely to include completing ethnicity data, possibly without verifying this in the assessment. As stated in research on NHS data gathering “.. accuracy is often low, with 20–35% error in coding of major ethnic minority groups in NHS hospital records when compared to self-reported ethnicity.” (Khunti et al 2021, p270). Even this basic level of taking account of ethnicity and race may be flawed on a third of occasions.
Where racism is incorporated into an assessment it may be articulated as the impact of incidents of unequivocal racism that have occurred in the person’s life. In the absence of any such incidents, the assessment interview and any professional considerations or recommendations are easily silent on racism.
Two acts of narrowing may occur: reducing the assessment to the interview and reducing considerations of racism to race as identity, or racist incidents.
There are opportunities for improving antiracist practice by AMHPs in mental health act assessments by:
a) development an understanding of racism as systemic and structural;
b) apply such an antiracism analysis to all aspects (phases) of the assessment and
c) lead beyond the obvious authority of the AMHP role.
Racism is more than racial discrimination. Racial discrimination or racist incidents tend to be easily identifiable and occur between individuals or groups at a point in time in a specific location.
Racism is global, systemic and structural. It relates to how the world is structured at the geo-political level. This will include trading arrangements that discriminate against racialised minorities. Racism includes the way in which curricula in the United Kingdom does not routinely identify the source of knowledge systems that were developed by racialised minorities, knowing that silence on this leads to an unconscious belief that major knowledge was developed by white people.
An antiracist critique will be interested in bigger issues than the interpersonal racial discrimination; for example, how non-personalised geo-political racism affects racialised minorities.
Non-personally directed racism forms part of an everyday experience of being reminded that there is a racial hierarchy with whiteness at the top (Grandison, 2021).
Being mindful of this and its psychological and material impact is important in understanding factors that may be relevant in why a person is being assessed.
Structural factors can be understood beyond the existence and impact of the racial hierarchy, though they are likely to be connected. Migratory patterns may reflect structural inequalities globally such as trading arrangements (the International Monetary Fund and the World Trade Organisation set terms of control and conditions on lower income countries for the benefit of richer countries) and systems of production that mean goods are available cheaply only because people at source and in the supply chain (disproportionally from minorities communities) are not appropriately compensated. (Garfolo and ĽHuillier, 2014).
The education and living conditions of people being assessed may reflect structural racism that manifests in decisions about investment in communities and local services, alongside political tolerance for conditions that people with lived experience argue would not be tolerated in relation to middle class white people. The Grenfell Tower disaster of 14th June 2017 is analysed and Ohana (2021) argued based on research, that racism was present in the local authority actions prior to the fire and the conduct of the Government inquiry.
The overarching argument here is that racism is pervasive and pernicious and appears as everyday interpersonal experiences as well as structural racism that shapes histories, choices and opportunities. Broadening the perspectives to include structural analysis helps to underpin a trauma-informed approach.
There is scope for applying an analysis of racism that includes structural analysis to the MHA assessment more broadly than the interview. The interview is likely to be a challenge if, as would be expected, the person being assessed is in some sort of crisis. There is scope to intentionally apply a structural perspective to information gathering and engagement with people in the social network prior to the interview. This may be helpful in the conversations with other professionals before the interview and during it. This advance context setting may help a trauma-informed decision-making either collectively or individually by the professionals.
Recording is a key tool for change. It can be used to disrupt records that engage in the adultification [1] of young racialised people. Recording can be used to document a trauma-informed perspective that takes account of the impact of racism and invites further work on this. Recording can be intentionally inclusive of the voice of the person who was assessed with regard to their lived experience of racism without seeking to record only what has been verified. I wonder how AMHPs may sensitively and skilfully seek to capture these voices with regard to lived experience of racism? Is this something AMHPs could/should address directly with the person being assessed or is it more about being attuned and present in the moment with the person to experiences of racism coming through in their narratives?
Leading beyond authority (Middleton, 2007) may be a form of activism for an AMHP. Evidence of social injustice is usually available in patterns. Some patterns will be present in existing data sets. Some may require service evaluations or additional work, which statutory services may argue they are insufficiently resourced to engage in. There are options for a motivated AMHP with capacity to shine a light on patterns, even if those patterns do not provide answers by curiosity alone. There may be patterns in postcode mapping. There may be patterns in terms of the racialised identities that are responsible for a large proportion of admissions in a given year. Available data on repeat admissions, s136, s4 amongst other may hold opportunities for learning. It may take time and pushing against unwelcoming doors but the nature of antiracism as opposed to non-racism requires some disrupting. Disrupting may be achieved by joining a local community group as a local citizen and may inform freedom of information requests and analysis. An AMHP may pursue further study as a researcher with a goal of illuminating patterns in existing data or primary research data.
The reflections in this piece recognise that as with many of the issues presenting in the lives of people being assessed by an AMHP, they reflect bigger structural challenges. Responding in a crisis is a key part of the role of an AMHP but structural change that reducing the flow of people being assessed required action set out in these concluding paragraphs. Antiracist AMHP practice is distinct in its attention to causes and not solely crisis.
References
Ellis, E. (2022) The Race Conversation: An essential guide to create life-changing dialogue. London: Confer Books.
Garfolo, B.T. and ĽHuillier, B. (2014) Economic Colonialism: The New Empire Building of the 21st Century. Academy of Business Journal, 1.
Grandison, C. P. (2020) The Racial Hierarchy. Anti-Blackness Culture and Anti-Black Racism: The Causes and Consequences. United Kingdom: Xenogenesis Limited
Khunti, K., Routen, A., Banerjee, A. & Pareek, M. (2021) The need for improved collection and coding of ethnicity in health research in Journal of Public Health, Volume 43, Issue 2, pp e270–e272, https://doi.org/10.1093/pubmed/fdaa198
Middleton, J. (2007) Beyond Authority: Leading in a changing world. Hampshire. Palgrave Macmillan
Ohana, N. (2021) The politics of the production of knowledge on trauma: the Grenfell Tower Inquiry. Journal of Law and Society,48(4), pp.497-523.
[1] The process by which young people from racialised backgrounds are not afforded the same compassion and empathy as their white peers but held to account as if they were adults. This sometimes relates to professionals viewing young people from racialised backgrounds through a prism of an adult body size equating to adulthood..
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