Posted by: ayrshirehealth | December 7, 2012

Care and control by @bettygudrun

Care and control.

As an MHO (Mental Health Officer), sometimes I have to take decisions about someone’s life which may mean the control is taken out of their hands. Examples include, consenting to the person being detained under the MHA (Mental Health Act) or making an application for a welfare guardianship order (where, if granted by the Sheriff, either the local authority or another proxy then becomes responsible for making decisions in the adult’s best interests).  As a forensic MHO, I am frequently responsible for making decisions which effect the lives of service users which they may not like nor agree with, but which are necessary to manage risk and protect both them and members of the public.

  •  Balancing the need

One of the issues often debated amongst health and social work professionals is, how can we best balance the need for care and control whilst ensuring the relationship between us and the patient is best preserved? minefield

I have lost count of the times I have sat in meetings to be advised by various colleagues that they will leave ‘delivering the bad news’ to me because they cannot risk damaging their good relationship with the service user.

When someone is unwell and unable to make informed decisions to safeguard their wellbeing, it can be a challenging and fractious time and an ethical minefield for the professional involved.

What decisions do you take out of the person’s hands and why? What level of risk is acceptable to allow the person to place themselves (or, much more rarely, others) in, to order to allow them a degree of autonomy? And most pertinently, how do you advise the person of what you have done and why?

Restricted access

In most situations, I am comfortable (as any one individual can be given the ethical complexities) with having open discussions with patients. I see it as my absolute duty to be transparent with people where I am making decisions about their lives, why I am doing so and my reasons (if applicable) for having overridden their wishes. It is an enormous power and not one I take lightly.  Removing someone’s autonomy will never sit easily with me (and rightly so, I should always be mindful that I use this power only when absolutely necessary). Medical record

I am very considered when it comes to deeming information ‘restricted access’ (withheld from the individual) and only do so where it could cause serious harm to the person or where it concerns personal information about another person.

Not wishing to cause upset or feeling uncomfortable with sharing it with the patient is not an acceptable reason to withhold information.

I am clear with myself and others that where a decision, any decision, is made in respect of a service user they should always be involved in the process as much as they are able, even if this takes a great deal more time and effort.

A debate to be had

That all said, I do not see myself as the fall guy for passing on information to patients from other professionals who proclaim they cannot because to do so would irrevocably damage their relationship. There may, in certain situations, be a debate to be had though. Often people’s continued ability to remain safely at home is dependent them continuing to engage with one individual professional who has fostered good relations over some time. The risk of losing that and the person potentially requiring to be readmitted is not worth it and in these circumstances I have no issue with taking on this role.

The rules I live by

For the most part, I have enjoyed positive relationships with the service users I have worked with, even where I have had to make difficult decisions and ones that I know they have not liked. I have definitely made some errors over the years and I like to think that having reflected upon these, my practice has improved.

The following are rules I try to live when having difficult discussions with service users about issues affecting them.

  • Involve the individual in discussions. Don’t just ask them in to a meeting once a decision has been made. Actually talk openly about the positives and negatives of any one issue with them there. You might be surprised by what they say / contribute.
  • Always be open to changing your mind. You may have decided something is so, but information the individual provides may change this picture. Don’t be so pig-headed you can’t let go of your original viewpoint.
  • Let the person know the decision as soon as possible. If the person is unable to engage in the decision-making process (because they are too unwell) and it cannot be delayed, ensure the decisions and the reasons behind them are explained fully to them as soon as practicable.
  • Allow the person a right of reply. Where people vehemently disagree with a decision you have taken but through a degree of incapacity you have had to override their wishes, it is important the person’s views are still heard. Record it in a case note or in your report but acknowledge somewhere that the person disagreed with you & why.
  • Be honest. Sounds simple enough this but it’s worth stating anyway. Like any reasonable person, service users do not like feeling as if they have been misled or lied to in some why. Of course they don’t. Who would? However uncomfortable it is for you, remember it’s not your life. Just be honest with people about what you are thinking or doing it’s ALWAYS better in the long run.

@bettygudrun (Elizabeth Stirling) is a senior social worker in a busy mental health service. She is a qualified Mental Health Officer and is responsible for supervising the social workers in the forensic service where she works.  In addition to this she also carries a caseload of forensic MHO work.


  1. […] Care and control by Betty Gudrun on the Ayrshire Health blog. […]

  2. I really enjoyed reading your utter honesty, and emphasis on providing it with reciprocity. …Thank you 🙂

  3. The issue of ‘dis-ownership’ highlighted by your blog disappoints me. It disappoints me that this continues to feature as an abdication of responsibility and an underlying dishonesty in the ‘care relationship’. Hiding behind not wanting to damage the therapeutic relationship is, in my view, a feature of a poor relationship, or indeed no real relationship other than one of control. What does the professional say to the individual – it’s the bad social worker or the bad doctor that’s doing this to you? Do they dis-own the decision? Do they say – If it was up to me I wouldn’t section you? I have never in my own practice hidden behind another professional – I’ve been in police cells and in the back of police vans with people explaining why I see their reality differently. Trust – it comes before, during and after the process – it’s never taken lightly, precisely as you’ve described. Loved the blog.

  4. […] moving post, All I want for Christmas is work by Janet Davis. Difficult decisions were relevant in Care and control by Betty Gudrun on the Ayrshire Health blog. I suppose most of the individual decisions that we make […]

  5. Thanks for your comments, Derek. I think sometimes people lack confidence in the way they communicate so feel they cannot be honest. But yes, sometimes I think it is about wanting to be seen as the good guy and play off professionals against each other. But people who use services are like everyone else, they can spot this a mile off and will inevitably feel the person is not being genuine. For all the difficult decisions I have had to take, it’s been very rare that my relationship with the person has suffered to the extend I cannot continue therapeutic work. People appreciate honesty, even if they don’t like what you’re saying. Only one thing worse than being lied to and that’s *feeling* like you’re being lied to!!

    • I agree where lack of confidence is the contributing factor. That’s where role modelling is critically important from seniors such as yoursf and, dare I say it, myself when I was more actively involved day to day

  6. I think you would be a great role model! Good to be able to see the bigger picture, I think. Very much enjoyed this blogging experience, thanks for the opportunity!

  7. Johnson said if you didn’t write for money, you were a fool. Of course, what he didn’t foresee, was the formation of a slave-hack culture. He’d be horrified, I would expect, by the willingness and the lack of Electro-Smog protection.

    We are all graduates of the University of Youtube now so the idea that we need bother with Continuing Professional Development other than reading blogs can’t be far away. Wikipedias dumbing up exercise shortly to be seen as elitist and the wisdom of mobs via tweets the authentic article. Half an hour reading comments on Guido Fawkes trumps your degree in politics every time.

    I’m barking at shadows.

    However, out of the sludge something of merit appears and slave-hack meets slave-reviewer. I don’t expect to be served free foie gras out of the back of a burger van but this post makes me think it might happen one day. 10/10

    Readers, award yourselves 30 CPD credits and take the rest of the day off.

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