Advance Statements for Crisis Planning

by Janet Rogers and Derek Turner

Possibly for the first time in history, the new Mental Health Act Code of Practice (April 2015), for England, has included a section that puts a responsibility on Mental Health Practitioners to encourage ‘patients’ to set out their wishes in advance as ‘statements’ or ‘decisions’. While advance statements are not legally binding professionals are advised that they ‘should make all practical efforts to comply with these preferences and explain to patients why their preferences have not been met.’

Within the Code Advance Decisions relate to medical treatments and should be adhered to by practitioners whenever possible, whereas Advance Statements can be used to cover a wide range of factors that might affect the life of a person who experiences difficulties as a result of their mental health, and how other people, as a result, become involved in the person’s life. This article aims to explore the rational for writing an Advance Statement to assist Practitioners in supporting a person who might experience a mental health crisis at some point in the future. The history of psychiatry has been dominated by Practitioners who have tried to design interventions that can be used to control/manage/support/treat a person whose behaviour is deemed to be ‘insane’. It may seem to some pointless, or at best counter-intuitive, to ask someone who is ‘insane’ to plan their own crises, however with some 30 years or so of learning to listen to, and learning from, people planning their own mental health recovery journey, a realisation is slowly beginning to dawn that this is the only sane way forward. The early pioneers of recovery have not only engineered fulfilling lives for themselves but have given new insights that are now at the forefront of what is considered to be ‘best practice’.

The key to ‘recovery based practice’ for Practitioners is developing a capacity to think differently about ‘how’ to use hard earned skills and expertise. Perversely it has been the drive towards ‘evidence based practice’ that has embedded a culture that suggests that ‘what’ Practitioners do is important. Interestingly it has been the Police who, in becoming increasing dissatisfied with ‘what’ they have been doing, have become open to different ways of working that are more concerned with ‘how’ they engage with the person.

More often than not it is the Police who are the front line service when a person is in crisis. The Mental Health Act gives the Police powers to ‘arrest’ the person and ‘remove’ them to a ‘place of safety’ where they can be assessed by other Practitioners. In the past this has often meant that the person has been bundled into a Police van and transported to a Police Cell. The Triage Pilot, currently being run by Dyfed-Powys Police, has already shown that the numbers of people traumatised by such an experience can be dramatically reduced by engaging with the person and their particular circumstances. The Pilot includes a follow-up visit to each person and it is here that the potential for encouraging people to write and agree their Advance Statements could potentially reduce trauma even further.

Advance Statements can be very simple agreements or more complex arrangements. An example of a very simple statement was told to me recently by a lady who has been prone to panic attacks when out shopping. These are very distressing to her and worry people who are near her. Recently a member of the public called the Police and a female Community Constable arrived. The Constable was not fazed by the situation and encouraged the lady to go with her to a local café. With a cup of tea and a bit of a chat the panic subsided. The lady was then able to tell the Constable that if she had been ‘arrested’ and taken to a Police cell she might not have been able to go out shopping again for many months as she would be fearful that this might happen again. They agreed together that a note would be put on her file saying that going to a café and having a cup of tea and a chat was the best way to deal with a situation like this if it happened again in the future. In telling this story the lady was able to say that she now felt more confident going out shopping knowing that, if she had a panic attack and the Police were called, she would be treated in the same way by any Police Constable.

Another situation involved a woman who had had many ‘arrests’ by the Police, some were very traumatic and others were less so. In talking things over with an advocate this woman was very clear why some Police Officers found her very difficult to manage while others treated her as a member of the community who needed some support to get through the current crisis. In trying to manage her distress she needed to move around and she would be aware that her fists were clenched. Police Officers who did not know her often interpreted this behaviour as aggressive while those who knew her allowed her space to work things through. Police Officers were often at a loss to know what to do with her as her thoughts made no sense to them at all. As a consequence she frequently found herself bundled into a van and transported for anything up to 2 hours in order to be assessed by other mental health Practitioners. The woman understood why the Police behaved this way but she was keen to write an Advance Statement that, if agreed, might mean that she could manage the crisis with the help and support of the Police and other important people. She knew that the person who would have the most calming effect on her behaviour was her husband. He was prepared and willing to be contacted by the Police and to come at short notice. She had this agreement with her husband already and so she needed the Police to agree to make the phone call when required. She also recognised that she sometimes needed a ‘place of safety’ but travelling long distances was very difficult for her and her family. She needed a separate agreement with her local Community Mental Health Team if she was to be able to use one of their rooms to fulfil this purpose.

It can be seen from this example how a range of other factors might need to be considered. Each of these may require separate agreements with the people involved if the Advanced Statement is to have the desired outcome.

Even with the full support of the Code of Practice the introduction of Advance Statements is likely to be slow. There are several reasons for this:

• Trust is probably the biggest factor for most people. Survival in the mental health system has, for many people, been closely linked to keeping Practitioners in the dark about the reality of their mental health systems.
• There is a more general scepticism in society about voluntarily sharing personal information with the Police.
• Another survival strategy that many people use is denial: “It won’t happen again.”
• There are currently no support systems in place to help people to make an Advanced Statement.

Developing a culture where people retain control and responsibility for their mental health, even at times of crisis, will take time, experience and evidence. Investment is needed, whether this is investment of time to encourage people who have had a good experience to embed this in future practice, or financial investment in advocacy services, there is now an opportunity, with the backing of the Code of Practice, to build a future where trust is rewarded, where the Police can work cooperatively, where crisis becomes the trigger for ‘recovery’, and where support is common practice.

Janet Rogers is a trustee at the mental health charity Ponthafren Association, and has previously written for this blog on Volunteering whilst getting benefits and Mental Health 1983: Code of Practice - the review (in England). 

Derek Turner worked for the PAVO mental health team for many years. He is now retired, and runs The Thomas Shop in Penybont with his wife Liz.

Hafal's All Together Now! Campaign Rocks at the Royal Welsh!

 Aims to unite people through music

Glynis Luke (PAVO mental health team - far right) being photographed
with an army dragon mascot and Hafal staff

High summer is here - time for shows and festivals and having fun. My colleague Glynis Luke was at the Royal Welsh Show earlier this week, and met up with staff and visitors at the stand of the mental health charity Hafal where she was introduced to a giant blue dragon and listened to some banjo playing amongst other things...

A visitor to Hafal's stand plays the banjo!  Photo courtesy Hafal

"We get by with a little help from our friends"

The Beatles

I visited the Hafal stand at the Royal Welsh Agricultural Show earlier this week to find out more about their All Together Now! Roadshow. The campaign is promoting opportunities for peer support and wider social integration for both clients and carers with a priority to develop the social life sections of individual care and treatment plans and sharing information of appropriate agency referral. Run by service users and carers, and supported by Hafal, Bipolar UK, the Mental Health Foundation and Diverse Cymru, the All Together Now! Roadshow is currently travelling across Wales and calling at music festivals and events taking place in each of the 22 counties. 

The Hafal staff were all wearing annotated All Together Now! purple T-shirts (the colour of recovery). There was a huge welcome at their Royal Welsh stand, including a cup of tea, and the sun was shining (I was ignoring the slight drizzle of rain). 

Gill Colerick, Hafal's Powys Family Support Officer  Photo courtesy Hafal

I met up with Gill Colerick, a former colleague from PAVO. She introduced me to her colleagues and told me more about the campaign and her work in Powys. Gill is Hafal's Powys worker, setting up groups for carers of those with "serious mental illness" in the county. Gill and I chatted about the benefits of both music and animals as good therapy when connecting with people experiencing mental distress.

I haven't played any musical instruments since the recorder at school, but I love to hear music and will dance around the house to my favourite songs. I will sing away in the car too when I don't think anyone can hear me! It's universal - it touches everyone's heart. It can bring all sorts of different emotions to the surface. I grew up in a musical family, my Nan used to play the piano. I have an image of people gathering round the piano as she played, and we would sing. My father used to sing for Brighton & Hove Opera, he used to be in all the musical shows and knew all the words to the songs.

"I like to boogie!"

T-Rex

I was able to speak to other visitors to the stand, including the wife and carer of a gentleman with dementia. She shared with me a variety of the difficulties that had been encountered since his eventual diagnosis of dementia, as well as the impact on family and friends. She said, “It’s difficult to know where to go to get help, what is ‘out there’ and when it's available, we ‘alternate’ between good days and not so good days…… Weekends are the hardest, it can be quite lonely.” I was able to share details of the Welsh Dementia Helpline with her. 

Visitors to the Hafal stand    Photo courtesy Hafal

Getting out and meeting people at events like the Royal Welsh Show can reduce isolation and that feeling of loneliness. There are practical, achievable things you can do now which could reduce your chance of developing dementia or, at the very least, improve your general health and wellbeing, and I was able to share some of these with her. Research has identified many risk factors associated with dementia, you can find out more at The Alzheimer’s Society website.

The famous Hafal VW camper!

I popped inside the VW camper to take a look. There were boxes of toys for children playing in there. You could measure your height against the blow up green snake and try out a pedometer. If members of staff were around children were allowed to sit in the front! It was a great way to keep youngsters busy while people were talking to the Hafal staff.

"If we hold on together"

Diana Ross

L-R: Dawn Williams (Hafal), army dragon mascot, Gill Colerick (Hafal),

Glynis Luke (Mental Health team - PAVO)   Photo courtesy Hafal

All Together Now!, was officially launched at the Norwegian Church Arts Centre in Cardiff Bay by Health and Social Services Minister Mark Drakeford AM. 

Launching the event the Minister said: “Music has an ability to connect to the emotional side of our lives in ways that very few other things do. And we know this very well in the field of mental health.

“This campaign, as it goes around Wales, will use the All Together Now! strap line to draw people into a much wider set of discussions about their own place in the world and about connecting to people who have shared their own experience, but do it in a way that has a lot of joy!”

"Take a chance on me"

Abba

Health & Social Care Network events - a mental health perspective

PAVO teams in Health & Mental Health
L - R: Ruth Middleton (Health, Social Care team), Anne Woods (Mental Health team),
Pete Lathbury (Head of Third Sector Support), Freda Lacey (Senior Officer HSC),
Jackie Newey (MH), Claire Powell (Third Sector Broker & Info-Engine Officer)

Have you come across the PAVO Health & Social Care Network events? I was asked to help out at the latest one (well, it does say Health in our team title) along with colleagues from Mental Health and Health & Social Care. The event took place at the Subud Centre in Brecon last week on 8 July. Anyway, whilst I was more than happy to help shift tables, take photographs and scribe for part of the day, it also seemed like the ideal opportunity to find out more and share any updates to the wider world - so, here we go! I hope you find it useful.

Three of the key benefits available to members of the Health & Social Care Network, (which is open to any voluntary sector organisation providing support to individuals and those close to them) are:

• Opportunities to contribute your views and those of the people you support on current and future health & social care services.
• Networking opportunities with other third sector organisations and key partners.
• A catalyst for cross agency collaboration to meet changing health and social care needs.

Top table, L - R: Pete Lathbury, Gloria Powell (PAVO Trustee & HSCN Chair),
Freda Lacey, Jayne Bevan (Strategic Programme Manager, Powys County Council).

This particular event provided an opportunity to question Commissioners on procurement and commissioning strategies for Powys, to hear updates from the Welsh Government about new procurement regulations and how that would impact locally, to find out more how Primary Care services are interacting with the voluntary sector, and the key aims and objectives of Powys teaching Health Board, specifically in relation to working with the sector.

First up was Jayne Bevan, Strategic Programme Manager at Powys County Council. Jayne led on the consultation around proposed changes to the Eligibility Criteria for Adult Social Care in Powys which took place earlier this year. Welsh Government's aim was to ensure an equitable service across the country, and on 1 April this year PCC decided to change its eligibility criteria which means that access to some social care support services will only be available to those with critical and substantial needs (previously it was available to those with moderate needs). Those with low or moderate needs will be signposted to universal services, such as services to prevent social isolation. This change comes into effect on 1 April 2016, but prior to that there will be engagement with people in contact with services and local organisations in Autumn 2015. Find out more in Jayne's presentation here.

Jayne was followed by Pete Lathbury, Head of Third Sector Support at PAVO, who spoke about the recent survey on the Third Sector's capability in Powys in relation to health and social care. The survey looked at three service areas: formal advocacy, specialist information and supported independent living. Questions drilled down to explore who provides mainstream services, to look at the health and resilience of the services both now and in the future, and to explore the support needs of organisations looking to provide a strong and healthy service. Pete's presentation is here.

L - R: Trish Buchan, (Independent Member Powys teaching Health Board)
and Freda Lacey, her successor at PAVO as the new Senior Officer Health & Social Care.

Trish Buchan, Independent Member Powys teaching Health Board, recently left her role as Health & Social Care lead at PAVO to focus on her position with the Health Board, and at this event she introduced everyone to the PtHB Strategic Plan. With the help of some new acronyms (Integrated Medium Term Plan - IMTP), and a Vision - "truly integrated care based on the needs of the individual", we then found out more about the key aims and themes of the strategy. Two headlines - 'care closer to home' and 'an increased use of technology' were particularly relevant to mental health. We have already written about the computerised Cognitive Behavioural Therapy scheme called Mastermind, currently being rolled out in Powys.

Trish emphasized the need for increased effective partnership working, with a specific mention of mental health again here. You can read Trish's presentation here.

Pete followed with the Third Sector perspective on the new health board strategy (read here). With the move to more localised services, there was a sense that there could potentially be more activity for voluntary sector intervention. Pete then discussed in more detail specific issues relating to this, including volunteering, community capacity, co-ordination and integration and commissioning. If I remember one fact from this presentation it is that there are over 26,000 volunteers in Powys - the physical and emotional wellbeing impact from that is clearly huge.

Alan Lawrie (pictured above left), Director of Primary Community Care (South) followed with an update on Primary Health Care & Third Sector Engagement. Alan has worked in health services for 33 years now, and said that the situation in Powys "is generally pretty good" compared to other parts of the UK. However, there are vulnerable areas, especially around recruitment, and he supported adoption of new workforce models, so for example, pharmacists would be able to prescrible independently, and advanced paramedics taken on in certain situations. Alan was clear about what the NHS wanted from the voluntary sector, solutions around: social isolation, admissions prevention, discharge support, transport, chronic disease support and links to social enterprise. No pressure there then! Read Alan's presentation here.

Nicola Maliphant (above) is a Senior Project Manager, Policy, at Value Wales, Welsh Government. She was at the event to give us an overview of Public Procurement Policy in Wales, and specifically further details of the new European Commission regulations which came into effect on 26 February 2015. This is particularly relevant for those organisations which will be taking part in a tendering process with either Powys teaching Health Board or Powys County Council over the coming months. Nicola was keen to impress upon her audience that Value Wales is there to provide support, in particular sessions on joint bidding and consortia are recommended. Read more here.

So we'd heard the national policy around procurement, and it was time for a more local view of things. This was supplied by Shelley Davies - pictured above (speaking on behalf of Dominique Jones, Health & Social Care Implementation Manager), who gave an update on Powys County Council's Commissioning Strategy. Shelley explained that good practice in the Children & Young People's team (her speciality) was being brought across to adult services. It was particularly interesting to hear about the aim to develop more social enterprises in the sector, though Shelley had some valid questions around - who would facilitate these social enterprises and who are the people to kick start activity? 

Alan Lawrie then summarised Powys teaching Health Board's Procurement Strategy (slides 12 - 14). Alan again talked about applying the children's model around procurement to an Older People's Perspective.

Powys teaching Health Board's Integrated Services Wellbeing Wheel

Throughout the day Freda scheduled a number of question and answer sessions with the speakers which gave everyone the opportunity to get involved. There are also some additional documents available on this PAVO webpage.

So, is this kind of information of interest to your organisation? Please let us know by commenting below, or join other mental health organisations such as Hafal, Ponthafren Association, Mid Powys Mind and Brecon & District Mind, who all attended this HSCN event to find out more about current issues relevant to them.

Five top sportsmen and women talk about mental health

It’s one of my favourite times of the year – Wimbledon fortnight! Sport plays such a big part in so many people’s lives, whether as participants or spectators or both. For me – well, playing tennis is definitely not one of my strengths – but I just love to watch or listen on the radio. You can’t help but admire the abilities of top sportsmen and women at the peak of their game.

But there is another side to sport, and particularly over the last few years we have become more aware of the impact that the pressures of playing at the top of your game can potentially have on your mental health. Organisations such as Mind have written on the subject. And it is summed up well by Liz Lockhart on Mentally Healthy:

"We see pictures of athletes enjoying a celebrity life-style, out on the town, mixing with the ‘beautiful people’ but we rarely stop to consider the downside to the pressure that comes with success. Players must feel dreadful ‘lows’ when they are not selected and a huge emptiness when they face retirement.

The message, which must reach the ears of sportsmen and women at all levels in their game, must surely be that they need to recognise when they are having difficulties. To seek help without fear if they feel the need for it, and to realise that their mental health is as paramount as their physical health. You can’t have one without the other."

Here in Powys we have found that when people tell their stories it can be enormously helpful, both to those doing the telling and those listening or reading. So here are links to the stories of five top sportsmen and women who have talked openly about being touched by issues relating to their mental health. Their coping strategies can help all of us looking to improve our own mental health.

Frank Bruno – boxer

Frank is a former British professional boxer who competed for over thirteen years. He won 40 out of 45 bouts, including the World Boxing Council world heavyweight championship in 1995. He retired in 1996 after receiving a serious eye injury during a fight with Mike Tyson.

Rachel Bruno, Frank’s daughter, was 16 years old when her father was first sectioned, aged 41, in 2003. She and her father talk openly and honestly about the impact his mental distress has had on the family on the Time to Change website.

Frank also spoke in 2013 about how returning to boxing training was helping his mental health.

"If you can do some form of exercise, it clears your head, sets you up and paves the way for you….Try and go to yoga, try and do a bit of walking, a little bit of jogging, go to an aerobics club, go to a gym, go to a sauna or swim. Just think healthy and try and do healthy things. Sometimes it clears your head.”

Clarke Carlisle – footballer

Clarke played for a number of top clubs during his 16 year playing career including Queens Park Rangers and Burnley before retiring in 2013. He was also chairman of the Professional Footballers’ Association. In 2013 he presented the BBC’s Football’s Suicide Secret programme. 

"I still bear the scars from my battle with mental health. I kept my depression a secret from clubs and teammates for almost two decades and it almost cost me my life….. (Now) I want to do all I can to raise awareness of the importance of mental health - not only to break down the stigma and taboos but also to make sure people know where they can find support."

Clarke now talks about his experiences at conferences and events. In October he will speak about mental well being in the workplace, at a conference in Jersey organised in conjunction with MIND Jersey.

Clara Hughes – cyclist and speed skater

Clara has won medals at both the Winter and Summer Olympics for her home country of Canada. Then her life took a different turn when she began to feel depressed.

“I felt ashamed of how I looked and how I was. It was easier not be around people. I was really afraid and alone.”

She now fronts a national campaign called Let’s Talk, set up to spark a conversation about the realities of mental health and ending the stigma – covering issues just as relevant in the UK as in Canada. She describes how poor mental health impacted on her sport and what happened next in a TV interview.

“More than anything I have ever done in the Olympics this has affected people.”

Sir John Kirwan – rugby player

John played rugby union and rugby league for New Zealand for many years and is now a Rugby Union coach. But he received his knighthood in 2012 for services to mental health as well as rugby.

“One day I was happy go lucky JK … (then) the biggest fear for me was that I was never going to be well again…. " Now he says: "Hang on to hope, grab hold of it.”

Originally he saw seeking help as a weakness, and that he would be regarded as a failure. But then he reached out – he now recognises that depression is not a weakness, it is just something that happens.

John fronted a series of TV interviews in his native New Zealand to combat the stigma associated with depression.

John’s story also features on Whirlwind Stories, a website set up to help enable men to positively embrace their mental health through the sharing of stories.

You can watch a longer interview with John Kirwan at his home in Italy where he shares his strategies for living with depression.


Rebecca Marino – tennis player

Rebecca Marino played tennis professionally for Canada and took on the likes of Venus Williams at the 2010 US Open. A year later, in 2011, she was on the courts at Wimbledon. But she was due at another tournament in the UK when she first spoke to her coach about her depression.

“I was just sad and I couldn’t contain it.”

At first she found it hard to talk to her family and friends about her distress. But when she did, she realised: “Opening up to them was the best thing I’ve ever done.”

Rebecca was at the top of her game, number 38 in the world, and yet the saddest she had ever been. At the age of 22 she decided to retire from professional tennis and go to university instead. You can watch her TED talk about her experiences "Slipping Through the Cracks: Pro Athletes and Mental Health".

Rebecca wants to highlight that it’s OK to feel weak or sad and share your feelings. She feels people are slipping through the cracks, even though there are organisations to help people, she feels individuals are scared or do not know where to go for help. This is why she told her story.

Has sport played a role in your mental health journey? Let us know in the comments box below, or email: pamhinfo@pavo.org.uk