The paper explores the notion of ‘dirty work’ in relation to the newly created role of the Approved Mental Health Professional (AMHP). An AMHP undertakes various duties set out in the 1983 Mental Health Act, as amended by the 2007 Act, in relation to assessments to make applications for compulsory admission to psychiatric hospital. It has been argued that undertaking this social control function is ‘dirty work’. However, the findings from a study of social work AMHPs in England suggest that the picture is more complex. Extracts from narrative interviews are analysed using dialogical narrative analysis. Rather than being designated as dirty work, AMHP duty was presented as prestigious and as advanced social work. However, through their storytelling, the social workers clearly delineated the aspects of AMHP work that they did designate as dirty, specifically the lack of beds, the complexities of co-ordination and the emotional labour which is an inherent part of the work.
Introduction and background
The paper explores the notion of ‘dirty work’ in relation to the newly created role of the Approved Mental Health Professional (AMHP). Specifically, the focus is whether the decision by an AMHP to make an application for compulsory detention to psychiatric hospital is ‘dirty work’. The 2007 Mental Health Act, implemented in November 2008, made a fundamental change to the role of mental health social workers by extending the unique functions of the Approved Social Worker (ASW) to health professionals. This means that mental health and learning disabilities nurses, occupational therapists and practitioner psychologists, registered with their respective regulators, can also take on the role of what is now called the AMHP. AMHP work in the very narrow and specific sense is the duty to undertake an assessment and then consider whether application for compulsory admission under the Mental Health Act is appropriate. This duty is enshrined in section 13 of the 1983 Mental Health Act as amended by the 2007 Mental Health Act.
The specific role of the AMHP is explained in detail in subsection 4.48 to subsection 4.110 of the Mental Health Act Code of Practice (Department of Health, 2008). The AMHP has the overall responsibility for setting up and coordinating an assessment under the Mental Health Act. This will involve numerous tasks, such as arranging for two doctors to assess the person, deciding whether the police should be present and arranging for an ambulance to convey the person to hospital. There is also a legal obligation to attempt to identify the person's Nearest Relative as defined in section 26 of the Act and the AMHP also has to consult other people who are involved in the person's life. An AMHP can only make an application for compulsory admission to hospital if they have interviewed the patient in a ‘suitable manner’; are satisfied that the statutory criteria for detention are met; and are satisfied that, in ‘all the circumstances of the case’, detention in hospital is the most appropriate way of providing the care and medical treatment that the person needs. An important point to note is that, although an AMHP acts on behalf of the local authority, they must exercise their own judgement, based on social and medical evidence, when deciding whether to apply for a patient to be detained under the Act. The role of the AMHP is to provide an independent decision about whether or not there are alternatives to detention under the Act, seeking the least restrictive alternative and bringing a social perspective to bear on their decision (Department of Health, 2008, 4.51).
The concept of ‘dirty work’ was introduced by Everett C. Hughes in a public lecture at McGill University in 1948. Hughes (1971, p. 95) noted that there are in and out groups; the ‘greater their social distance from us, the more we leave in the hands of others a sort of mandate by default to deal with them on our behalf’. Arguably, people experiencing mental distress are considered to be an out group and it is AMHPs who hold this social control mandate. In a later article, Hughes explained that every occupation contains a bundle of activities, some of which are the ‘dirty work’ of that group. He defined several ways in which work might be dirty:
It may be simply physically disgusting. It may be a symbol of degradation, something that wounds one's dignity. Finally, it may be dirty work in that it in some way goes counter to more heroic of our moral conceptions. Dirty work of some kind is found in all occupations (Hughes, 1971, p. 343).
Hughes (1971, p. 340) argued that, even in the lowest occupations, people develop ‘collective pretensions’ or ‘dignifying rationalizations’ in order to give their work, and consequently themselves, value in the eyes of each other and outsiders. He identified the relevance of the difference between doing something for someone and doing something to someone, and showed how this can be ambiguous as the line between them is ‘thin, obscure and shifting’ (Hughes, 1971, p. 305). This is highly relevant to AMHP work; the AMHP might conclude that detention is in the person's best interests, whereas the service user may completely disagree. While people attempt to delegate this dirty work to others, there are some prestigious professions (such as a doctor) in which this is only possible to a limited extent. Here, the ‘dirty work may be an intimate part of the very activity which gives the occupation its charisma’ (Hughes, 1971, p. 344).
Robert M. Emerson and Melvin Pollner applied Hughes's concept of dirty work to their study of a Community Mental Health team (CMHT). In a footnote, Emerson and Pollner (1976, p. 243n) clarify that their focus is on dirty work designations, where work is labelled as dirty, rather than simply ‘dirty work’ per se. Thus, the aim of their paper was to explore the nature and meaning of these designations of dirty work for the social workers, psychologists, nurses and psychiatric technicians who staffed the psychiatric emergency team (PET). The role of the team was to respond to emergency calls received by the clinic for either crisis intervention or assessment for hospitalisation. The team members had the power to order seventy-two-hour involuntary hospitalisation, like AMHPs, the only non-medical personnel able to do so. The staff members soon identified PET activities as a form of dirty work: ‘On the first day in the field … a psychiatric social worker, deeply committed to the ideals of community psychiatry … characterized the job to us as “shit work”’ (Emerson and Pollner, 1976, p. 245).
For the staff, work was ‘shit’ when there was a lack of opportunity to help or do anything for a client in a therapeutic sense and having to do something to them in a coercive sense where the intervention seemed to serve nothing but social control purposes (Emerson and Pollner, 1976, p. 246). Interestingly, Emerson and Pollner (1976, p. 246n) argued that this was directly reflected in the PET's use of the terms ‘client’ and ‘patient’: client was used when doing for; patient was used when doing to. Thus, crisis intervention and avoiding hospitalisation were seen as therapeutic work. In contrast, involuntary detention was frequently designated as ‘shit work’, as it ‘stripped away any remaining sense of doing for and made it starkly obvious to all that the patient was being done to’ (Emerson and Pollner, 1976, p. 250).
There were ‘noticeable variations’ between different professional groups in the use of the term ‘shit work’. Significantly, the term was most ‘frequently and vociferously’ used by the social workers, regarded by Emerson and Pollner as the highest-status professionals regularly performing PET duties (Emerson and Pollner, 1976, p. 246). Thus, dirty work can be seen as much stemming from the perspective of the worker as from the inherent qualities of a task. Emerson and Pollner (1976, p. 244) concluded that, in designating involuntary hospitalisation as dirty work, the worker is declaring ‘a kind of moral distance from that dirtiness … [and] reaffirms the legitimacy of the occupational moral order that has been blemished’.
Over a decade later, Phil Brown (1989) ‘revisited’ psychiatric dirty work. Like Emerson and Pollner's PET staff, the staff in the CMHT demarcated what they deemed to be ‘proper’ work, namely the acquisition of good psychotherapy candidates and in-depth intake evaluations. The psychiatric clinic staff considered external non-psychiatric referrals—seeing homeless people referred by shelters, determining welfare and disability eligibilities, and making pre-release prison evaluations—to be dirty work. The staff members were ambivalent about the social control function; while they accepted that they were playing such a role for wider society, they recognised that this work was unpleasant and generated a ‘dirty label’. The staff members considered the provision of insight-orientated, psychodynamic therapy as the ‘best’ part of the service (Emerson and Pollner, 1976, p. 196) and felt that people needed to attend voluntarily. As such, the external referrals and those subject to the social control function were not seen as ‘suitable patients’.
To summarise, the studies by Hughes, Emerson and Pollner, and Brown have demonstrated that dirty work designations are more likely when the staff were not engaged in what they deemed to be ‘proper’ work, namely therapeutic work with service users. Thus, exercising social control was designated as ‘dirty’ because it deviated from therapeutic work. Using these insights, the discussion will now move on an examination of talk about exercising the social control function from interviews with social work AMHPs.
The empirical work presented here is taken from a wider ESRC-funded doctoral study exploring the identity of social work AMHPs seconded to Mental Health Trusts (Morriss, 2014). The study was approved by the University of Salford's Research Ethics Panel (REP11/067). Using a narrative approach (Mishler, 1986; Riessman, 2007), seventeen mental health social workers from across England were interviewed, either individually or as part of one small group interview. All were practising AMHPs. The interviews were audio-taped with the consent of the participants, transcribed in full, fully anonymised and analysed using dialogical narrative analysis (Riessman, 2007). The emphasis on detailed analysis of talk is especially relevant as ‘talk and interaction are the backbone of social work’ (Hall et al., 2014, p. 2).
Findings and discussion
This section will explore AMHP work and the possible connection with dirty work in more depth using extracts from the interview data. The first extract is taken from an interview with an AMHP I have called Frank. Frank presented AMHP work as a high-status role, repeating the word ‘status’ twice in the first part of his reply: Frank depicts the AMHP role as providing social workers with more ‘kudos’ within the CMHT, compared to being a non-AMHP social worker. For Frank, it is a ‘crucial role’ and a role he enjoys. He argues that the legal knowledge required in interpreting the Mental Health Act adds prestige to the social work profession. Later in the interview, Frank explains why he sees AMHP work as having status. Undertaking Mental Health Act assessments is portrayed here as an important societal role and as a role that ‘most people’ would want to be involved in. Thus, for Frank, the social control function of AMHP duty was not designated as ‘dirty’, but as a prestigious role. The distinction between AMHP and non-AMHP social workers was also highlighted by other participants. Cath, for example, presented AMHP work as requiring a development of professional skills, including something as inherent as ‘the way that you think’: Here, Cath uses the idiom ‘step up a gear’ to depict AMHP work as involving a jump in performance. Like Cath, Ed represents AMHP work as being more advanced than ‘ordinary’ social work: It is notable in the last two extracts that we display affiliation (Stivers, 2008) as social workers. Cath uses the phrase ‘don't you’ (line 3) and I endorse Ed's stance before recognising this and asking for clarification (line 2). It is also notable that Ed denotes AMHP work as advanced social work, which is interesting now that nurses, occupational therapists and psychologists can also train as AMHPs. For these social workers, then, being an AMHP was far from being designated as dirty work. Indeed, becoming an AMHP seems like a rite of passage whereby the social worker joins a higher-status AMHP group. However, this notion of AMHP work as purely positive was not the complete picture. The discussion will now move on to examine some longer extracts from the interview data in which the complexity and ambiguity of AMHP work become more evident.
Frank: And I found it gave me more status within the team and among
the medical, you know, people. That sort of dedicated role. I still really
like AMHP work actually and probably for those reasons [laughs] I like to
be taken seriously in what I'm doing and have some sort of status.
Lisa: And do you feel that other than that role if it wasn't for that role
that social workers wouldn't be seen in the same way?
Frank: It's yeah I expect so. Yeah it is an area of social work which is a
crucial role which has to be done and because it's got that legal sort of
tag with it I think it does give the profession a little bit of kudos.
Frank: I think it is something you know you are part of something.
Something really quite important in society almost umm by being very
involved in Mental Health Act assessments so I think that most people
want to be part of it.
Lisa: And did you think that it [AMHP work] changed your social work
role at all?
Cath: I think that you step up a gear, don't you, in the way that you think.
Ed: The world of AMHP is very different isn't it?
Lisa: Yeah. Well tell me what you think the difference is?
Ed: It's just very it's kind of like an advanced social work isn't it?
In the interview with Andrew, I ask a direct question about the apparent dichotomy between social work values such as social justice and empowerment and the more controlling aspects of undertaking AMHP duty: For Andrew, there is a perfect fit between social work and AMHP work (line 2). Here, Andrew alludes to the widening of the role to health professionals; for him, being an AMHP requires reflective practice (lines 4 and 9) which he aligns with social work. Again, AMHP duty is described as involving increased skills in that it ‘really, really’ requires ‘more mental power’. Andrew then goes on to discuss the emotional impact of detaining someone, stating that he feels ‘very guilty’. The use of the phrase ‘really weighs on me’ evokes an image of an intense, almost physical, impact, as does repeating the word ‘liberty’. It is interesting that he describes this feeling as ‘right’, implying that it is necessary for AMHPs to physically experience the gravity of the decision to detain. For Andrew, undertaking AMHP work for a number of years may lead to becoming ‘burnt out’.
Lisa: How have you found that sits in with your social work background?
Andrew: I think it fits in perfectly actually and that then kind of
reinforces to me why social workers should be doing it umm because it's
about reflecting on why you're doing it. I think it's about making sure
that the decision that you're making are based on the right reasons umm
and I feel I felt very guilty sectioning people and I think that's right, you
know, and I've felt about the impact I've only been doing it a year and
maybe in another ten years I might feel a bit more burnt out but I hope
not, you know [pause]. But it draws on those reflective practices really,
you know, are you making the right decision, are you approaching this in
the right way, so it just requires more mental power really to umm think
about the implication of what you're doing. It really, really does. The
gravity of removing somebody's liberty liberty really weighs on me, it
really does [pause]. So I think that it fits perfectly with my social work
values but it's got to be done. It's a very very important job and some
people need to be in hospital I mean even if they don't want to be and
you can see the good of it at the other end because people come out of
it better than when they went in. There's damage done, there's always
damage done but ummm, yeah [pause].
Andrew then reiterates that AMHP duty ‘fits perfectly with my social work values’ (line 14). However, it is interesting here is that this sentence is then concluded with ‘but it's got to be done’ (line 15). The use of ‘but’ seems incongruent here. This conjunctive is used when two individual components on either side of the ‘but’ in a sentence are contradictory. It would make more sense if Andrew had said AMHP duty does not fit with my social work values but it's [a role that has] got to be done. While it may just be a slip of the tongue, it may also suggest that Andrew is aware of some disjuncture here. The latter interpretation appears to correspond with an ambiguity in the final part of Andrew's reply to this question. Andrew begins with a positive view of the impact of detention on service users [‘people come out of it better than when they went in’] but ends by acknowledging that it also has a negative impact. Indeed, repeating the phrase ‘there's damage done’ accentuates the notion of the negative impact of compulsory detention on service users. The reply then seems to peter out which, again, may be as a result of the implicit disjuncture.
Thus, in his story, although Andrew describes the act of detention as necessary at times and as aligned with his social work values, he also depicts some elements of AMHP work as dirty, notably the ‘damage’ done to service users. Additionally, there is an emotional, almost physical, impact on the AMHP of the ‘guilt’, ‘mental power’ and ‘gravity’ involved in removing someone's liberty. This notion of the work having an emotional impact has been explored in a qualitative study by Claire Gregor (2010) based on interviews with ASWs. Gregor concluded that a significant amount of emotional labour was required as the ASWs unconsciously processed a wealth of powerful emotions and feelings. However, Gregor found that the ASWs were largely unaware of the emotional labour that they were undertaking. For the ASWs, a key factor was the immense support that they received from their ASW colleagues in order to carry on with the role—something that was also highlighted by the AMHPs in my study (see Morriss, 2014).
Later in the interview with Andrew, I return to this theme of the impact of compulsory detention. Andrew had just described the impact on the relationship with a service user after the use of compulsory detention. I note: While acknowledging that there can be a negative impact on relationships with service users, Andrew presents the view that this does not happen in all cases. He ‘authorises’ (Smith, 1978) this claim by referring to the experiences of other AMHPs, telling a story using reported speech which portrays service users as being thankful. This is presented as a collective view by making reference to ‘people’ rather than individual named service users. Moreover, the story presents detention as preventing the service user from engaging in ‘such risky behaviour’ which can be seen as an extreme-case formulation (Pomerantz, 1986). Finally, Andrew introduces another example, once again referring to ‘people’, where the relationship has ‘actually been reinforced’. However, prefacing the claim with the word ‘actually’ hints at a possible disjuncture from what might be expected. Indeed, this might be seen as a form of what Hughes (1971, p. 340) called ‘dignifying rationalizations’, namely an attempt to present AMHP work as valued by service users. Andrew ends by using a number of words and phrases which align with social work values: ‘participation’, ‘less disempowered and in control’ and ‘working in partnership’. It is arguable that many people including service users would not equate these terms with the social control function of compulsory detention. However, this perspective that the AMHP is doing something alongside with the service user is interesting. Here, AMHP work is presented as not the doing to identified by Hughes (1971, p. 305) and Emerson and Pollner (1976, p. 236), or even as the doing for. For example, the service user in Andrew's story is depicted as requesting specific practices for any future occasion when he is again going to be detained under the Mental Health Act. This demonstrates how social work language has changed from the therapeutic for to working in partnership. Thus, here, the social control function of AMHP work is not being designated as dirty and this may be due to this notion that the social worker is not doing something to the service user, but is working alongside them by using means such as Advance Directives.
Lisa: So that you, you can see that there is an impact there then?
Andrew: Yeah but it's definitely on a case by case basis really. Some
people are so unwell that they don't recognise it. But when I've spoken
to other AMHPs what they've said is that they're had a mixture of
experiences where people have thanked them in the long run because
they were engaged in such risky behaviour that umm when they're come
out the other side and regained capacity and well enough to reflect on
what had happened, they've kind of said, ‘oh my God, what was I
doing’, you know, and I've spoken to people who have said it's actually
reinforced the relationship and it's that thing about Advance Directives
too, once people have put on paper, you know, ‘if you're going to
section me, can you do it like this instead, can you do this instead’. So
that's a really good positive way of doing it, I think. Participation makes
people feel less disempowered, more in control. It's a recognition that
they're probably going to get unwell again because that's unfortunately
the nature of their illness. So they're taking a degree of control back on it
and that's working in partnership with the person
I ask Ben the same question about the more controlling aspects of AMHP work. Ben begins by pointing out that acting as ‘backup’ (i.e. an assistant) to the AMHP on duty enables an introduction to the work. Ben continues by acknowledging that AMHP work is difficult and seems to be implicitly distinguishing this from the work which attracts people to become a social worker. Thus, unlike Frank, Cath, Ed and Andrew, Ben presents the AMHP role as not only different to, but seemingly more undesirable than, the social work role. He continues by outlining what is difficult: it is the lack of beds that is more frustrating than the social control element of the role. This is an example of the use of the ‘indexicality’—the ‘essential incompleteness’ of language (Garfinkel, 1967, p. 29) where the meaning is intrinsically linked to the context in which it is said. However, the ‘transient circumstances of its use assure it a definiteness of sense … to someone who knows how to hear it’ (Garfinkel and Sacks, 1970, p. 161). Ben does not have to clarify what he means when he says ‘not being able to use it … and you're having to walk away’; as a former ASW, I understand that Ben is referring to the lack of psychiatric beds. An AMHP may assess someone under the Mental Health Act and decide that the person does need to be admitted to hospital but a bed in a psychiatric ward is not available at that specific time. Thus, the person cannot be immediately admitted and the AMHP is forced to try and find alternatives which may leave the person in a situation of risk. This was mentioned by almost all the AMHPs as one of the most difficult issues of undertaking assessments under the Mental Health Act. I acknowledge the seriousness of the problem in my reply by using a very emotive word (‘cruel’). Again, this demonstrates the ‘emotional labour’ inherent in AMHP work. Ben illustrates the degree of the emotional impact through a narrative about the bed manager. Here, the AMHP is the person who is physically present with the service user and their carers, and is the one left dealing with a particularly distressing and risky situation. Thus, through his story, Ben can be seen as designating this aspect of AMHP duty as ‘dirty’. In the coda to his reply, Ben returns to my original question, again using the metaphor of social workers making the transition to becoming an AMHP with ‘their eyes open’.
Ben: I think that you have that your eyes are open really before you actually
do the role. But it's difficult, isn't it, the role? It's certainly not what you
come in for really. I think a bigger frustration really is not being able to
use it when you see that people very unwell who are potentially very
vulnerable and you're having to walk away. That's more of a frustration
really than the actual control.
Lisa: It just seems cruel, doesn't it?
Ben: Yes. And it's you're the one there with the family and sort of umm
[pause]. I had a discussion with the bed manager who has been very
angry recently as a family member had got hold of his number and was
giving him a hard time about not having a bed and we need to sort this
person out. This happens every day for us. We are the people at the
house not just on the phone. We're the one who's having to walk away
and explain the reasons why. I'm not sure if I have brushed over the
power issues but I think [pause] I'd hope that social workers come in to it
with their eyes open.
The next example that the participants did not see the social control function of enforced detention as dirty work is from the interview with Eva: Eva explains that she does not struggle with the social control function of compulsory detention under the Mental Health Act. For her, it is the person's situation that is upsetting, not the act of detention. Using reported speech, Eva acknowledges that the admission to hospital is ‘awful’ but, at the same time, it allows for some respite from a crisis situation. This elucidates the ambiguity and contradiction inherent in AMHP work; although compulsory detention is incredibly difficult and undoubtedly has a negative impact on people's lives, the alternative might be that person coming to harm.
Lisa: And how did you find detaining somebody, taking away someone's
liberty, the first few times you did it, or even before, the thought of it?
Eva: Do you know, I don't, I know some people get really upset about
doing it [pause] I I get very upset about people's lives but I never think
well I if you think you're doing the wrong thing in detaining someone
then you shouldn't be detaining them. It's you're going in and there
should be a dreadful situation and the outcome of putting someone into
hospital means it's the best thing to do for the person. If you don't do
that then their life's going to get worse than they already are. I never I
never grapple with the act of detention itself. I mean sometimes I think
‘I'm going to detain you and you're going to this horrible hospital, you're
going to hate it and it's going to be awful but I hope that you get some
sleep. I hope that you get’, you know, ‘you get some time away from the
crisis that's caused this’. You hope for the best and I for lots of people
it's [pause] if you talk to them about being detained and obviously
they're not very happy about it but they don't hate it as much as you
think they do. There're a lot of people that develop an understanding.
You know, I was talking to one of my patients the other day and she was
saying ‘I lost my mind. I didn't know what I was doing’ and if I said ‘do
you wish I hadn't detained you?’ she wouldn't say ‘no’, she would wish
she hadn't got ill in the first place but would say ‘that's what they had to
do otherwise I would have killed myself’. So yeah I don't I don't mind it
at all really.
Eva clarifies this perspective by introducing a story about a service user. What is interesting here is that Eva is not merely reporting a conversation she had previously had with this service user; instead she is voicing what the service user would have said had she been asked. This is a very good example of why Wooffitt (1992) introduced the term ‘active voicing’ to replace the term ‘reported speech’. Rather than faithfully reporting what a speaker actually said at the time, in active voicing, ‘speakers are designing certain utterances to be heard as if they were said at the time’ (Wooffitt, 1992, p. 161, emphasis in original). Indeed, Eva is describing an entirely fictional exchange as denoted by the phrases ‘if I said’, ‘she wouldn't say’ and ‘would say’. In fact, the only part of the conversation which is presented as reported speech was the first utterance attributed to the service user (line 19). Here, the use of active voicing can be seen as a way of providing evidence for Eva's claim that service users ‘develop an understanding’ that detention can be necessary. Buttny (1997) showed how quoting another's words can convey an air of ‘objectivity’ about what happened, strengthening the claim. Again, the story about the service user can be seen as a ‘dignifying rationalization’ (Hughes, 1971, p. 340). Indeed, the story presents detention as preventing the service user from killing herself which can be seen as an extreme-case formulation (Pomerantz, 1986). In other words, the serious consequence of not detaining the service user is made clear in the story, adding weight to this being the right decision. The coda to the story reiterates that, in terms of undertaking compulsory detention, ‘I don't mind it at all really’. Thus, for Eva, it is not the social control function of AMHP work that is dirty. While she acknowledges that detention can have a negative impact on the service user, she presents this as necessary to prevent serious harm.
The final extract is from the interview with Grace. I ask Grace whether she enjoys undertaking AMHP work. There are two parts to Grace's answer. In the first part, Grace describes herself as passionate about AMHP work, which she summarises as the ability to make clear decisions about what actions would be in the best interests of a vulnerable person. She depicts herself as having the ‘best personality type’ to undertake AMHP duty because she is strong, assertive and able to challenge doctors. It is interesting here that Grace presents her personal identity and her social work identity as congruent: it is more than just a role that she carries out; it is intrinsic to her identity. This viewpoint is encapsulated in the words of Payne that ‘every social worker, every time they are doing social work: they represent social work, they become, embody, incorporate, they are social work’ (2006, p. 55, emphasis in original). This sense that social work identity comes from a correspondence between professional and personal values was also identified in the study by Gregor (2010), discussed earlier. Gregor found that the ASWs appeared to ‘embrace and personalise the role, rather than attempt to separate it off as a part that they were required to act by their employer’ (Gregor, 2010, p. 435).
Lisa: Is that a role now that you enjoy doing, that AMHP role?
Grace: I I ok when I do the debate of what do I why am I passionate
about AMHP work is because I think that there needs to be somebody
there who is really making a clear really rounded decision of what is in
the person's best interests. I think it needs to be done. When somebody
is at their weakest it needs to be somebody at their strongest who's
going to challenge the doctors, who's going to say ‘no that's not right’,
who's going to be, who's going to act for you when you can't. And I think
I'm absolutely the best personality type for that. Do I like what's
happening now? No. You can't get a bed, the ambulance crews don't
want to use the Mental Capacity Act, you might not get the police. I do
out of hours work so I get the whole 360 view of everything you know
sitting somebody in the leather chair down at A and E with a sandwich
because that's all you've got doesn't feel nice. Umm being shouted at by
A and E staff because there's no beds. That's made it not so nice. Umm
yeah the sort of systemic pressure of trying to coordinate is not very nice
In the second part of her reply, Grace outlines the difficult aspects of being an AMHP: the lack of beds; the lack of knowledge about the 2005 Mental Capacity Act by ambulance crews; the unavailability of the police; being ‘shouted at’ by Accident and Emergency staff because there are no psychiatric beds to transfer the service user to; and the lack of facilities in the Accident and Emergency department for a service user. In the coda to her reply, Grace summarises these difficult aspects as the ‘systemic pressure of trying to coordinate’. As explained earlier, it is the AMHP's duty to coordinate the assessment under the 1983 Mental Health Act. Therefore, for Grace, it is these systemic pressures that make being on AMHP duty difficult and not the act of detention. This is the ‘dirty work’. Again, this emphasises the emotional impact of AMHP work.
The emotional impact of working as a social worker in a mental health team has been highlighted by numerous studies (see, e.g. Onyett et al., 1995; Mauthner et al., 1998; Peck et al., 2001; Carpenter et al., 2003; Evans et al., 2005; Gregor, 2010). The earliest of these studies was in 1995 and the last in 2010, so it seems clear that emotional impact has been a constant and enduring theme over the years. Overall, social workers in these studies were burnt out, emotionally exhausted and experiencing high levels of stress. ASWs were much more likely to have a potential psychological disorder and common mental disorder when compared to their social work colleagues in the mental health team (Evans et al., 2005). Thus, the dirty work of being an AMHP has a clear emotional and physical impact on those undertaking this role. It is clear that AMHPs need to be supported in their work. However, Bailey and Liyanage (2012) concluded that the mental health social workers seconded to Mental Health Trusts in their study were ‘disempowered’ (p. 1125) and have been ‘abandoned’ by their local authority employers (p. 1124). While this may not be the case in every Mental Health Trust, the social workers in my study also reported retaining only minimal links to their local authority employers. This is a worrying finding.
It is important to acknowledge that this study differs from those undertaken by Emerson and Pollner (1976) and Brown (1989) in that they both took an ethnographic approach. Thus, unlike these studies, I did not observe the AMHPs actually undertaking Mental Health Act assessments. The sample size of seventeen was small and all were social workers, as the wider study focused on social work identity. It may be that AMHPs from other professional backgrounds may have given a different perspective.
Conclusions and implications for social work practice
To conclude, then, far from being simply designated by the social workers as ‘dirty’ or ‘shit’ work, AMHP work was portrayed as high-status work, requiring advanced skills, and the ability to manage very complex situations. Furthermore, it is interesting that, unlike the workers in the study by Emerson and Pollner (1976), the social workers did not see detention in terms of doing something to a service user in a coercive sense, but depicted AMHP work as working with people in crisis. Thus, to view AMHP work in its entirety as dirty work ‘seems unduly pessimistic’ (Matthews et al., 2014, p. 17).
However, the work clearly contains tensions; for example, although the AMHPs believe that the person needs to be in hospital, they are also aware that the wards are often bleak and sometimes dangerous places to be. Moreover, through their storytelling, the social workers clearly delineated the aspects of AMHP work that they did designate as dirty. The lack of beds, the complexities of co-ordination and the emotional labour of engaging with people experiencing mental distress mean that being an AMHP on duty is emotionally difficult and mentally draining. This finding aligns with Hughes's (1971) argument that every occupation contains a bundle of activities, some of which are the dirty work of that group.
Thus, applying the concept of dirty work allows for a deeper understanding of the complexities and apparent contradictions of AMHP work. Hopefully, this knowledge will allow practising and trainee AMHPs to reflect on the inherent ambiguities in the work and develop a greater awareness of the myriad elements—some dirty, some prestigious—that shape the role. As Ramon (2009) has argued, a much greater collaboration between researchers, practitioners and employers, as well as mental health service users and carers, could lead to improvements in the understanding of undertaking mental health social work. Finally, the social workers were undertaking the dirty work of the systematic pressures of coordinating a Mental Health Act assessment in an environment where they feel isolated and unsupported. As such, as well as focusing on the introduction of new ‘fast-track’ routes into mental health social work such as Think Ahead (Clifton and Thorley, 2014), perhaps the government also needs to concentrate on supporting the existing workforce.
The research was funded by a Ph.D. studentship awarded by the Economic and Social Research Council. The author would like to thank all the social workers who gave their time to be interviewed for this study and Jadwiga Leigh for her constant support and encouragement.