Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial

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A Randomised Controlled Trial of Joint Crisis Plans for people with psychotic illnesses

Training Pack for the development of a Joint Crisis Plan

Developed by Kim Sutherby, Claire Henderson and Chris Flood, Section of Community Psychiatry, Institute of Psychiatry

Training Pack for the development of a Joint Crisis Plan

Introduction

Flowchart; Stages of Development of Joint Crisis Plan

Guidelines for mental health professionals

• preparation
• the crisis planning meeting
• completing the card

Secretarial notes

Advance Directives

Information for users

Appendix

• menu
• template
• examples of completed cards

Introduction

Crisis cards have been in use in the voluntary sector since 1989. The first card was launched by Survivors Speak Out and this has been the prototype for most others in circulation. Crisis cards allow a user to fill in details of a nominee to be contacted in a crisis, and have a variety of headings with space to allow a user to provide statements about their care or any information they feel would be useful in a crisis. The original aim of crisis cards were to enable self advocacy, in the event that the user was unable to make their wishes known in a crisis. The crisis card is designed to be carried with the user and is usually small enough to fit into a wallet or pocket.

In contrast to the crisis card which is developed solely by the user, a Joint Crisis Plan is developed jointly between the user and their mental health team. Rather than negotiating with the mental health team at the point of crisis (as the crisis card does), the aim is to negotiate in advance when the user is most able to discuss their needs and concerns. The mental health team can help the user consider and make informed choices about what they include on their card, and would be most likely to help them cope, remain well and influence their care in a crisis.

The Joint Crisis Plan is developed collaboratively, but it is important that the final choice of what is included on the card is determined by the user. It is only likely to be of value if users want to carry it with them because they feel it is their card, and primarily has a useful function for them rather than for the services.

Stages of development of a Joint Crisis Plan

Recruitment to trial; explanation of JCP and control (CH)

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Randomisation

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CF to arrange meeting with keyworker and participant

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Control group: service information Intervention group: CF will check

pack instead of Joint Crisis Plan still want to develop a joint crisis

CF will give these out plan

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Yes

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CF to give the user a menu. Keyworker to offer time to help go through the menu with the user in preparation for the Crisis Planning Meeting

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Arrange Crisis Planning Meeting. The user needs to be present at the meeting, and is encouraged to invite anyone else they feel would be helpful, such as a friend, relative or formal advocate. The keyworker and doctor are invited from the team. It is important to have a facilitator who is independent of the clinical team wherever possible.

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At the meeting either the user or facilitator reads through the sections that have been selected encouraging an open discussion and finalising the wording that the user wants for each entry.

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After the meeting the individualised card is printed and sent to the user for checking

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Once checked, copies are distributed to the people agreed by the user

Guidelines for mental health professionals

In contrast to other procedures such as the Care Programme Approach, the development of a Joint Crisis Plan aims to be more user lead. The meeting is intended to allow an informed discussion for the benefit of the user, so that they can decide what they would like included on their card.

Preparation

The user is first offered a menu to help them think about what sort of information they would like on their card. They can choose which sections are appropriate for them, and can include as much or as little information as they like. It is often helpful if the keyworker offers to go through the menu with the user to explain and help them think about what they want in advance of the meeting.

There are four sections on the menu;

1. Contact information
1. Current Care and Treatment Plan
2. Care in a Crisis
3. Practical Help in a Crisis

Sections 1 & 4 (Contact Information, and Practical Help in a Crisis), are straightforward and can be completed in advance of the meeting to save time. However it is worth reminding the user that they need to ask the permission of a friend or relative if they wish to include their name and contact details on the card (either as a nominee, or, as a person to be contacted to carry out practical tasks if they are admitted to hospital).

Chris Flood will arrange a Crisis Planning Meeting at a time that all key members can attend and send out invitations. The user needs to be present at the meeting, and is encouraged to invite anyone else they feel would be helpful, such as a friend, relative or formal advocate. The keyworker and doctor are invited from the team.

The Crisis Planning Meeting

The average time for a meeting during the pilot study was 50 minutes. This could be reduced to about 30minutes if sections 1 and 4 of the menu are finalised in advance.

The role of the facilitator, Chris Flood, is to chair the meeting, to encourage a discussion, to prompt either the user or the team to consider issues that may not have been addressed, to ensure that the user feels able to express their views and that the final decision about what is to be included is that of the user.

At the meeting either the facilitator or user should read through each section that the user has chosen to be included, pausing after each entry to allow any issues to be raised and discussed. The final wording should be agreed and written in clearly so that the secretary can type up the version to be printed.

Entries are usually recorded either in the first person or as short statements. Technical shorthand is avoided as the card is primarily for the user e.g. record medication dosage as "twice a day" rather than BD.

These meetings can be stressful for the user because it involves considering the possibility of becoming unwell in the future, and recalling past relapses. It is helpful to review past relapses in order to identify triggers for relapse, early signs of relapse, things that have been helpful or unhelpful when unwell and

other factors relevant to their care in a future crisis. The team need to be supportive and it may be appropriate to offer to resume the meeting at a later point if the user is finding it particularly difficult. This only happened on one occasion in the pilot study.

The user may want to include a statement that the team feels would be detrimental to their care in the future e.g., refusing all drugs or refusing admission under any circumstances. It is helpful to enquire why the user has these views and discuss the implications in a neutral fashion without putting the user under pressure. It may be that there are specific side effects they cannot tolerate and they can be informed about other more suitable alternatives. They may have had a bad experience on a previous admission and can consider making a statement about the type of care they do or do not want rather than refusing admission altogether.

It may also be necessary to explain that although the team will try and carry out the plan wherever possible, if the user requires admission under the Mental Health Act, this will overrule the Joint Crisis Plan. However in the event of an admission under the Mental Health Act the Joint Crisis Plan can still influence the decisions the team make.

If after discussion the user still wants to include a plan that the mental health team feels they cannot agree with (e.g. that would be detrimental to their health or could not be achieved, the team have the following options; 1) they could suggest that the plan is called a crisis card as it expresses the views of the user, or 2) if disagreement relates to only one part of the card the user may prefer to have a note inserted under that particular statement explaining that the team do not feel they can agree on this point.

Completing the Joint Crisis Plan or Crisis Card

Secretarial

Chris will use the menu completed in the crisis planning meeting to type up the Joint Crisis Plan. Any headings for sections that have not been completed by the user will be deleted from their version of the card. For the section on "Practical Help in a Crisis", and "Agencies that I would like to have copies of this card or agreement", any requests that have not been ticked will be deleted.

The final version will be printed or photocopied on both sides of a sheet of A4. This single sheet can then be folded into a plastic wallet for users, or filed unfolded. A draft version is supplied for the user to check before final versions are sent out.

Advance Directives

The principle of an advance directive is that a user can refuse or consent to a treatment in advance if they demonstrate capacity to make that decision. If they subsequently become unwell and loose capacity to make decisions the advance directive would still be effective. This directive would then bind the user and the health care provider to the decision. The legal precedent has been established in case law, but statute law regarding capacity is not yet in place and the implications of these directives in the area of mental health is not well understood.

A joint crisis plan is an informal agreement based on trust. We feel this is necessary in order to encourage a creative and flexible approach to planning, in which both the user and health care provider participate collaboratively and not defensively. The joint crisis plan will include a statement stating that "any crisis plan is not legally binding and treatment may change if necessary". A joint crisis plan is therefore not an advance directive but the team should endeavour to carry out the agreed plan wherever possible.