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.

What if "Restraint" was not an option?

by Freda Lacey

About this time last year the Minister of State for Care and Support, Norman Lamb, wrote about “Positive and safe: reducing the need for restrictive interventions” within health care. Mind’s report from the year before on “physical restraint in crisis” clearly outlined that the use of restraint was used to varying degrees and “face down” (or “prone” restraint as it’s sometimes called) was still being used despite the knowledge that it can cause serious harm and, in some situations, death.  The report made recommendations to the Government that the use of “face down” restraint should never be used in care and treatment settings.

The Mental Health Act Code of Practice, (currently being revised in Wales) devotes an entire chapter to “Managing behaviours that challenge,” and it clearly states that the least restrictive option(s) must be explored and restraint used only as a last resort.

The use of “restraint” and the “how”, when managing patients in hospitals, has been the topic of numerous blogs, reports, white papers, and news articles, particularly over the last few years. The Winterbourne Review spurred a great deal of investigation into the use of restraint, the Care Quality Commission specifically reporting on “Monitoring the Mental Health Act” in 2012/2013” and the use of restraint in hospitals. One of my favourite blogs is written by Mental Health Cop and he has his own views about restraint which may add texture to the topic. I am not going to write about how, when and where restraint is used in mental health settings, this has already been done by people far more knowledgeable than myself.

What I really want to highlight is how I’ve been affected by the topic of “restraint”. During my attendance at the Department of Health’s revision of the “English Mental Health Code of Practice” Expert Reference Group with Jan Rogers, I was privileged to sit in on several of the group meetings discussing changes to “the code”. The chapter called “Safe and therapeutic responses to disturbed behaviour” in the new Code of Practice made the experiences of restraint very real to me.

It was the first time where I listened to people’s direct experiences of being “restrained” in high, medium and acute wards whilst experiencing care under the Mental Health Act. I listened to family members speak of their experiences of witnessing their children’s restraint and the distress this has caused. People openly shared feelings of humiliation, trauma (some of this due to physical injuries they had sustained) and feelings of distrust in the people caring for them. They made direct links to the “way” they were physically restrained, sometimes stating they didn’t know “why” it had happened. I imagined how children or young adults may feel experiencing restraint and the trauma this may hold for them, particularly if abuse has been experienced. What is felt by people with a dementia, what comes up for them as a result of being restrained? As I listened, I wondered what would have happened had restraint never been an option. 

Interestingly around the same time, I caught sight of a national workshop on the management of violence in hospital settings. The workshop was pulled together by the “All Wales Senior Nurse Advisory Group for Mental Health” and their call to action really struck me. “The management of violence and aggression in mental health settings is a key issue for practitioners and educators. The Department of Health have recently consulted on restrictive practices in England along with the Mind publication in 2013; and we want to be at the forefront of planning developments and actions in Wales on behalf of our service users and our staff”. 

Having heard the recent stories from people who had experienced being restrained, I was curious to see and hear how staff approached the subject of restraint. The workshop was well attended by national ward management teams, general nursing staff, senior nurses and senior management.

 

One of the things that became apparent was that a good many staff felt the need to move away from restraining people and advocated “de-escalation” techniques, or “conflict resolution”. Basically, talking people down from a heightened sense of anger. I could see the difficulty experienced by staff when faced with a patient who is throwing punches and hurting them (one nurse spoke of being punched and having to be off work for some time) where the instinct is to restrain the patient so as to prevent being hurt. If restraint had to be used, then the workshop advocated using “supine” restraint or “face up” which is deemed less injurious and safer for the patient.

I volunteered to experience what it felt like to be restrained as in the afternoon we had a demonstration of using various methods of restraint for adults and older adults with dementia, (for example). Whilst the demonstrators were very careful with me (I was held down by two men and one woman), and pinned down so I couldn’t move and injure myself (and/or them), I was not trying very hard to be aggressive. I could imagine that if someone was very angry and aggressive that it may take some time of being held down and spoken with before the situation may diffuse. I was also startled at how quickly I went from standing to down on the floor and wondered if I was really emotional, angry and distressed, what effect the entire process might have on me. Also, if I were to be restrained by male nurses, how might this feel as a woman and similarly for men.

Hospitals are required to have policies on how to “manage” aggressive behaviour and in reading some policies from different areas I was struck by the following list of some of the things that staff should look out for as factors that may provoke disturbed or violent behaviour:       

• boredom and lack of environmental stimulation;
• lack of access to external space;
• personal frustrations associated with being in a restricted environment;
• difficulties in communication;
• emotional distress, e.g. following bereavement;
• antagonism, aggression or provocation on the part of others;
• physical illness;
• and an unsuitable mix of patients. 

It is worth noting that most of the above factors have been encountered by patients we see as part of the Powys Patients’ Council meetings and come up in patients’ feedback to us, so I wonder if these factors will always exist, to some degree, within in-patient units. If they do, then perhaps it’s not a matter of “may” provoke aggression, but that these are constantly having to be managed by staff in ways other than restraining patients.

One staff nurse mentioned that he worked within a high secure unit and that the staff never used restraint, that “conflict resolution” techniques were consistently used successfully. Here in Powys, ward management have mentioned that they don’t use restraint although staff are trained in Safe Physical Intervention Techniques or SPIT as it’s called. In fact, one of the staff on the ward here in Powys is the trainer for all Aneurin Bevan staff (including Gwent) in SPIT.

Another option for all psychiatric patients is to complete what is known as an “advance directive”, or here in Wales: “wishes known in advance” statement (we will be exploring this in more detail in a future blog post). This allows patients to state how they would like to be treated (or not treated) if they are detained by the Mental Health Act. They could quite clearly say that they don’t wish to be physically restrained and whilst an advance directive is not a legally binding document it would be good practice for hospital staff to respect the person’s wishes.

So, what’s the answer to restrain or not to restrain? It may be that while the Mental Health Act (and requisite Code of Practice) results in feelings of deprived liberty by people, there will always exist factors which may provoke people to behave aggressively. If this is the case, then ongoing debate and engagement on this topic will continue to be needed.

Finally, I’m curious to see if people may read something further into the paper outlined from the Department of Health mentioned at the very beginning of this blog post. It states, “This guidance forms a key part of the wider new Positive and Safe programme, which aims to end the unnecessary use of restrictive interventions across all health and adult social care." I wonder….