Collaborative use of the mental health act (yes, really)

Before I begin, I need to let you know that this blog is not intended to be a script. You are all skilled professionals who understand the need to work differently with each situation, and each person. However, clinicians often tell us that its hard to imagine how a conversation using the model might go, so this is a walkthrough of through just one ‘open’ conversation.

Just to make it easy for myself, I’ve chosen to look at using the model when a young person is being taken into hospital under section. It might sound like this can’t be a collaborative process, but it can. Let me prove it to you, by working my way through all the steps of the model

 

Talk with me about the decision and how much say I have

This one seems a tricky place to start, but it is really important that the young person know what they can and can’t have a say in. You might say something like

“Me and the team I work with have decided you need to come into hospital, and that you are not well enough to make that decision for yourself. I really want to talk you through how we came to that decision and hear your thoughts on it. I’m afraid you don’t have a choice whether you go into hospital, but you can help us to decide other things like who goes with you and how you get there if you want to.”

This is a difficult but also really good start. The young person knows you are being clear with them about their level of control from the outset. Young people often tell us that they feel they are told they have choice until they pick the wrong option, and that this feels really frustrating and disempowering – It is better to be honest.

 

Ensure I understand the options that are available to me

The place to start here is to reiterate what the aim of the conversation is, maybe something like this:

“I’m hoping I can explain to you why we have come to this decision. We can write what we talk about down if you like because it might be difficult to grasp straight away, and you can ask me any questions..”

Then you can think about decisions that young person can make. It’s easy to think that if someone is being sectioned they have no choice. This isn’t true. Young people tell us that when the ‘if’ decisions’ (like, ‘if’ I go into hospital) are taken away the ‘how decisions’ (like what I do until the ambulance comes, who I go with, what I have for lunch) become incredibly important.

“It would also be great if we could think about any ways to make going into hospital easier. We might want to think about things like who you would like to go in with you.”

The final thing to do in this step is make the option not to decide explicit:

“If you’re finding making these decisions too stressful just let me know and I can make them for you until you feel ready to take over again.”

This might seem like an odd one, but sometimes being acutely unwell is exhausting. Some young people find trying to make ‘how decisions’ very stressful and overwhelming, so it is important that they know they are allowed a break from doing this if they want it.

 

Talk with me about the pros and cons of options available.

Clinicians tell us that when they make a decision as important as having someone assessed under the mental health act, there is a weighing up process that happens inside their head. This step is simply about making that process explicit. It might look like this

“Do you want to hear a bit about why we decided you should go into hospital?”

This is an important sub-step – the young person might not want to hear it right now, and that’s ok. Ask if they want you to write it down for them to refer back to later. If they do want to hear about your decision making process, this might look a bit like this

“I was really worried about some of the things you were telling me… XXX made me think that you might not be safe at home. I thought about things we might be able to support you at home like seeing you more often or you going to a day programme but I didn’t think these options would be able to keep you safe. I spoke to other people in my team about it and we thought you going into hospital was probably the only way you would be safe. That’s why we asked those doctors you don’t know to come and see you to see if they agreed. I understand it’s a really big decision to take away from you, which is why we have asked so many different people their opinions.”

Here, you’ve brought the young person into your logic. So often, children and young people feel that they are not only being shut out of making decisions about their lives, but also being shut out of understanding these decisions. This step might help the young people to be able to use this logic themselves in the future.

Discuss my views, values and preferences

This one is really as simple as:

“How do you feel about all of this?”

Everyone needs to feel heard, and the young person needs to know it’s ok to be angry, scared or confused. This gives them the option to tell you what they think. This is also where advance directives are a great idea. If you can speak to a young person outside of crisis about what they would like to happen if they become unwell, you can use their previously expressed views, values and preferences to inform your decision about how best to look after them and make the decisions they are too unwell to make in the moment.

 

Explain your views

This is your chance to explain why you made the decision you did. It might go along the lines of

We decided to bring you into hospital because me and all the other people you saw were so worried about you. We want you to be safe and to feel better, and we are hoping that being in hospital will help achieve both of those things.”

Here you’ve made really clear what decision has been made and why it has been made. You’ve explicitly let the young person know that you have done this to try to help, and because you are worried about them. This can help the young person to know that going into hospital is not a punishment, and that it can be a positive thing for them.

 

 

Discuss if I feel able to do this

Lets be clear, this is not an opportunity for the young person to decide not to go. It is your chance to check they understand, and their chance to ask any questions, or ask you to explain again.

“Do you want me to explain any of that again or make a note of it for later? Do you want to ask me anything?”

 

 

 

 

Discuss what we are going to do and how we are going to do it

This is the moment for the ‘how decisions’. You can explain the parts of the process which are not changeable, giving as much opportunity for the young person to make small decisions for themselves as possible. For example

“The hospital need to get a bed ready for you, and when it is ready we will call an ambulance to take you there. Would you like your mum or dad or someone else to go with you?

While we wait, would you like to hear a little bit about the hospital you are going to or look on their website?

Is there anyone you think you would like to tell or talk to before you go?

Once you get there there will be someone waiting to show you around and tell you about how it all works at the hospital. Is there anything that you would like me to try to find out for you?”

 

This whole process might seem like an extended discussion that a person in crisis might not take in, but young people who have been in this situation tell us that being brought into the decision in this way can leave them feeling more in control than when there isn’t as much communication. It is really important to go over this again once the young person is feeling better where possible, so that they can see your logic when they have a clearer head. This whole process can make being sectioned and brought into hospital a slightly less horrendous experience for a child or young person, which is why we at open talk think people who try it out are brilliant clinicians (not that we are buttering you up or anything)…

Amy, Common Room project worker

Ps. Do you have something to say about mental health? If so, we’d love you to write a blog for us! Drop us a line, [email protected] Thanks!