Abstract
Discretion is often discussed in terms of the authority conferred on, or exercised by, actors in context and with varying effects. But what of the drivers of discretionary activity? How does knowledge shape professional work? This chapter draws on an ethnography from the field of mental health, to critically interrogate the normative foundations of discretion. Two aspects of practice are highlighted which generate differentiated knowledge and subsequently shape discretion. Firstly, the generation of ‘bottom-up’ knowledge is presented in contrast to ‘top-down’ mandates. Secondly, the ways in which practitioners may be role rather than profession oriented are discussed, as well as the implications this has for the forms of knowledge used when exercising discretion. These observations of ‘street-level’ practice are contrasted with the dominant narrative of mental health services, in which professional freedom is described as restricted by the prime position of the biomedical model.
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Notes
- 1.
For readers from outside the UK, it is worth noting that although there is a broadly similar basis for the use of mental health law across the UK, there is also regional differentiation. The legal framework for England and Wales is the Mental Health Act (1983, amended in 2007); for Scotland it is the Mental Health (Care and Treatment) (Scotland) Act (2003, amended in 2015); and for Northern Ireland it is the Mental Health (Northern Ireland) Order (1986). This chapter focuses on mental health provision in England and therefore further references to mental health law are to the framework for England and Wales.
- 2.
Defined as ‘any disorder of disability of the mind’ as determined by relevant mental health professionals.
- 3.
The role of the AMHP is usually taken by social workers (Mackay 2012), despite the Mental Health Act (2007) opening up the role to other allied mental health professionals (with the exclusion of psychiatrists to ensure the role remains non-medical). To become an AMHP, mental health professionals must complete specialist training in mental health law.
- 4.
The first Diagnostic Statistical Manual of Mental Disorders was published in 1952 by the American Psychiatric Association. It should be noted that it reflected both psychodynamic and biomedical frameworks, with the former being gradually superseded in later versions. Despite the USA now being at the forefront of biological psychiatry, psychodynamic approaches were more influential in American psychiatry than in the UK during the early to mid-twentieth century, and remained so for a longer period of time. There was significant scepticism towards psychodynamic approaches within the British psychiatry community (Tyrer and Craddock 2012).
- 5.
Community Treatment Orders were enacted under the Mental Health Act (2007) and work by imposing conditions that clients have to adhere to (usually medication compliance) or face being recalled to hospital for enforced treatment.
- 6.
Payment by Results (now called Mental Health Payment Systems) was introduced to UK mental health services in 2012. Essentially Payment by Results is a commissioning and service provision system where provider organizations are paid according to their ability to meet certain pre-determined outcomes. In mental health services, this entailed separating service users into 1 of 21 ‘care clusters’, differentiated by diagnosis and level of need, for example, ‘ongoing psychosis with high disability’. Each cluster has an associated care package and tariff which is paid to the provider per service user.
- 7.
Including mental health nurses, social workers, occupational therapists and psychiatrists.
- 8.
For a more detailed description of methodology, including selection, analysis and ethical issues/approval, see Jobling (2014).
- 9.
Where names are used, they are pseudonyms.
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Jobling, H. (2020). Discretion from a Critical Perspective. In: Evans, T., Hupe, P. (eds) Discretion and the Quest for Controlled Freedom. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-19566-3_13
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