Exploring the role of Approved Mental Health Professionals in relation to the detention of people from Black and Minority Ethnic groups under the Mental Health Act (MHA) 1983

Persistent inequalities in mental healthcare have contributed to the over-representation of people from Black and Minority Ethnic (BME) groups being assessed under the MHA. This was reinforced as recently as 2018 by the Independent Review of the Mental Health Act 1983, detailing how BME communities - especially people with African and Caribbean heritage - are less likely to receive person-centred or community-based social care, and likelier to be compulsorily admitted to psychiatric hospitals than white people. Despite the longstanding nature of the problem, little has been researched about the role of one of the two key professionals responsible for decision-making about compulsory admission: the Approved Mental Health Professional (AMHP). Under the Mental Health Act, AMHPs possess overriding responsibility for deciding whether someone should be detained for compulsory treatment. While the institutional dimensions of this problem have been highlighted in earlier research, this thesis focuses on the use of power and discretion in AMHP decision-making. This research's objectives were to explore the key influences professionals consider when forming judgements about compulsory detention, to examine how practitioners construct risk when arriving at a decision, and to investigate the views and accounts of Black service users concerning their detention experiences, and their level of involvement or participation in decisions determining their care and treatment. This thesis employs empirical data from an ethnographic study conducted in two London Boroughs, involving observations of professional practice and follow-up interviews with 14 AMHPs and 8 Black service users purposively selected across the two sites. Fricker's theory of epistemic injustice and the applied sociological concept of risk work provided a useful theoretical basis for developing an understanding of AMHP decision-making and Black service users' detention experiences. My analysis reveals a mutually constitutive relationship between risk and ethnicity during detention-based decision-making, describing the racialised categorisation of risk, and how AMHP decision-making continues to be shaped by a risk or public safety agenda. The analysis of my observational data generated a nuanced and complex relationship between the diagnostic practices and lower risk threshold operationalised by professionals when working with Black people. This thesis demonstrates the tensions emanating from risk work and suggests that the bureaucratic emphasis on risk management strategies designed to improve safety is paradoxically affecting trust and relationship-based practice, both of which are essential for reducing risk to Black service users. My analysis discloses that most AMHP practitioners doubt their capacity to apply social perspectives or exercise independent decisions within the context of multiagency working, organisational factors, resource implications, the dominance of risk, and "blame culture". AMHPs' inability to exercise autonomy and apply social perspectives presents profound implications for Black service users overwhelmingly faced with multiple social issues or disadvantages such as isolation, unemployment, marginalisation, low income, and social exclusion. This study provides further understanding of how epistemic injustice manifests itself within the mental health service, revealing how Black service users are more susceptible than their white counterparts because of the dual difficulties of experiencing stigma and the negative stereotypes attached to being Black and receiving a mental disorder diagnosis. There is further evidence of AMHPs from Black communities experiencing testimonial injustice from white colleagues ascribing lower credibility to their knowledge and competence due to prejudice associated with their racial identity. This study suggests numerous ways of enhancing epistemic justice, including the provision of IMHA services during MHA assessments in both the community and hospitals. It highlights that rather than adopting a position of 'knowing best', professionals must value and listen to Black service users' accounts to help reverse the stigma, sense of exclusion, and diminished control and choice that Black people with mental health problems continue to experience.