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.

Mental Health & Missing Person Support Officer - Dyfed-Powys Police

Carina Giannuzzi is the Mental Health & Missing Person Support Officer for Dyfed-Powys Police. 

We recently worked with Carina, and colleagues at West Wales Action for Mental Health, to produce some mental health information cards for use by police officers who come into contact with people experiencing mental distress.

We caught up with Carina recently to find out more about this project and other vital work she is doing in Powys and Ceredigion.

Tell us more about the work you do

I started in my current role as Dyfed-Powys Police’s Mental Health & Missing Person Support Officer on the 1st September 2014, and from the start have been involved in two major projects which are ongoing.

One is the Mental Health Triage Team run in conjunction with Hywel Dda University Health Board and although the project does not cover the county of Powys, it does cover Ceredigion, Pembrokeshire and Carmarthenshire. The other is the Time to Change Wales anti-stigma campaign to tackle the discrimination surrounding mental health where I assisted Hywel Dda with a week of events they held last October.

I am a member of various mental health related groups, both internally and externally, and attend regular meetings relative to these.

I am also responsible for collating data and providing reports; receiving and identifying areas of work that require improvement to deliver change and am involved in multi-agency and partnership working.

What led you to this particular role in the police?

When I read the role profile for the post it sounded so interesting, worthwhile and rewarding that I thought “I want that job!” and thankfully I was successful in my application.

I also have a personal interest in mental health which I feel benefits that side of the role due to my understanding the impact that mental ill health can have on individuals, their family, friends, colleagues and employers.

What is the most challenging aspect of the job?

I would say juggling the two sides of the role as both aspects are equally important and demanding areas of work.

Are there particular issues which arise in rural areas for people experiencing mental distress?

Isolation is probably one of the biggest factors. Many people living in rural areas reside in remote locations and will not have neighbours close by that they can call upon. Their family and friends may not live close by and transport to visit them or just a trip to the shops can cause issues for some people, especially the elderly. Regular contact and communication is key for these people.

Why do you think the police are often the first point of contact for people experiencing mental distress?

When a person is in distress or at crisis point they want immediate assistance. They may not know who else to contact for help and by telephoning the police they know that they will get a response 24 hours a day. Many services are not available out of hours and this is another reason police are contacted.

What is the biggest issue for police officers trying to support people in the community who are mentally distressed?

Accessing the necessary services to provide them care and assistance they require in a timely manner. This is particularly prevalent ‘out of hours’.

Dyfed-Powys Police are working hard to provide better support for people in mental distress (see here for example). Tell us about the latest initiatives and any feedback you have had.

Our Chief Constable Mr Simon Prince has just signed an organisational pledge on behalf of Dyfed-Powys Police to show our commitment to the Time to Change Wales campaign to tackle the stigma and discrimination surrounding mental health. I will be putting plans in place to take this campaign forward.

We are also looking at a safety card for people with mental health, learning disabilities/difficulties and dementia who may come in to contact with the police for any reason, for example, if the person is in crisis, lost or wishes to report a crime. The card will provide the officer with their name and details of their condition. It will also provide the name and details of a person police can contact to assist them dealing with the individual they have come in to contact with. This will be of benefit to both the individual and the officer. Once the design and content have been agreed, we hope to have this in place in the next few months.

Dyfed-Powys Police, in conjunction with Hywel Dda University Health Board, has set up a Mental Health Triage Team to respond to mental health related calls received by police. The scheme commenced at the beginning of January 2015 and initial feedback and statistics are very positive. Although the project has only been running for a few months, it has already been nominated for and NHS award.

How will the mental health information card we worked on together recently help?

The cards will provide an extra 24 hour point of contact for people who do not know where or how to obtain help, with the mental health team at Powys Association of Voluntary Organisations (PAVO) and West Wales Action for Mental Health (WWAMH) providing another line of contact to advise people what is available in their communities. There are so many valuable services in the third sector that people do not know about and it will also help to raise their profiles and that of PAVO and WWAMH.

Which other organisations do you work closely with in Powys and Ceredigion to provide support to people?

Powys Teaching Health Board is the main organisation. I have recently met with HUTS (Help Us To Survive), Hafal and Noddfa at a Ceredigion Voluntary Group meeting and am hoping to work more closely with all three of them in the near future.

Where do you think the 3rd Sector fit into the picture? Would officers be confident about signposting or referring people to voluntary organisations?

The third sector can and does play a major part in mental health. There is wealth of fantastic work going on that people are not aware of that is assisting so many individuals and their families. Our Triage Team officers and Force Communication Centre staff are already signposting and referring people to voluntary organisations. It is a matter of making our staff aware of what is available throughout the Force area and what services these organisations offer. One of the ways this is being done is by adding these organisations to our internal Force Mental Health Information Page. Many have already been added and as I come across new ones, they are being added to the site.

Is there anything more the 3rd Sector could do to support the police in their work with people experiencing mental distress?

I believe the third sector is already supporting police in their work.

The only suggestion I have that may be useful in raising the profile of voluntary organisations within the police (if not already being done) would be for them to invite local Neighbourhood Policing Teams along to meetings or events they are holding.

What is the most valuable thing you have learnt since starting your role?

I am finding this very difficult to answer! I have learned a great deal, particularly in relation to the third sector and the fantastic work they do. I had no idea until I started in this role and I find it very inspiring.

When you are not working for Dyfed-Powys Police, how do you enjoy spending your time?

I have a wonderful family and friends who I love to spend time with.

I love to read books of all sorts and am keen on history, fashion and art. I also like to sew when I have the time and have just started exercising again to try and gain some level of fitness once more (said through gritted teeth)!

Many thanks to Carina for telling us more about her work. If you have any queries or comments we would love to hear from you.