Taking back control in crisis

Crisis carries risks but it may also be an opportunity for people to make changes for the better. Often people with mental distress in crisis feel an unwelcome loss of control within themselves and in relation to others who take control. It is easier to negotiate safety in a crisis with people if they feel safe in their relationships with others. Planning in advance helps people to stay in control during a crisis.

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Taking back control in crisis: What works?

Crisis and opportunity

Crisis has many risks but it is also an opportunity to open up new possibilities. It may also be a time when someone is able to speak of issues that are troubling them that they are usually either unable or unwilling to talk about.

Crisis and control

Crisis is a time of heightened emotion and uncertainty for everyone involved. Against this backdrop, the person at the centre of the crisis may find themselves losing control of their situation, especially when other people take control. Often crisis responses are driven by a desire to keep someone ‘safe’. However, what makes one person feel safe, such as having family members around or being locked in, may make another person feel unsafe. Supporting someone to take back control can be challenging when they are in great distress, suicidal, asking others to take control, or in an environment where control is vested in other people, such as in hospital. Responses to crisis that emphasise external control rather than collaboration can unwittingly traumatise people.

The person in crisis needs to be in control of responses to their crisis as much as possible. This may include crisis planning and advocating for their involvement in decision-making in environments where they may not otherwise be listened to. Clear communication about caregiver responsibilities and limits is essential. For example, it is important to be clear about the caregiver’s availability, the need to involve others, and what someone might do if key supports are not available when needed.

The importance of relational safety

It’s useful to have a conversation about what safety means for the individual. Discussions about risk and safety are most effective in a transparent, trusting relationship that fosters collaboration and open dialogue, and is not focused on rules and restrictions. This can be thought of as relational safety—when people who use services feel safe in their relationships with workers, and the workers can take more risks, such as asking challenging questions, trying something new or expressing disagreement.

Crisis planning

It’s easier to plan and make decisions about a crisis situation when someone is not currently in a crisis. People commonly believe that they will never be in crisis again, so they may be reluctant to plan for another one. However, the process of crisis planning can be useful, even when there isn’t another crisis, as it opens up discussions on experiences, fears and possibilities, as well as the factors that influence mental wellbeing. Crisis planning is proven to increase a person’s control in a crisis. When planning for a crisis, it’s useful to articulate both what someone does and doesn’t want. It may also be useful to involve people close to them.

There are many tools to suit different people and circumstances, for example:

  • Advance statements and advance directives are recognised in the law and tend to focus predominantly on treatment and medication issues, although in many jurisdictions they may include anything that is useful for the person, such as instructions for childcare or paying bills.
  • Mad maps are a creative, social-justice-oriented approach to exploring self-determined wellbeing, various ways to navigate crises, and personal and social transformation.
  • Wellness recovery action plan (WRAP). This is an evidence-based wellness-planning tool used in many different settings—from facilitated WRAP groups to a mobile phone app.

More information

Websites:

Advance health directives (Australia):
http://www.health.wa.gov.au/docreg/education/population/OA004251_preparing_an_advance_health_directive.pdf

Advance statements in mental health (Victoria, Australia):
http://www.mindaustralia.org.au/resources/about-mental-ill-health/advance-statement.html

Advance directives in mental health (New Zealand):
http://www.hdc.org.nz/publications/resources-to-order/leaflets-and-posters-for-download/advance-directives-in-mental-health-care-and-treatment-(leaflet)

Mad maps:
http://theicarusproject.net/content/mad-maps

WRAP:
http://www.mentalhealthrecovery.com
http://www.tereowrap.info/index.html (Maori version)

Apps:

WRAP: Wellness Recovery Plan


References

Ambrosini, D.L., Bemme, D., Crocker, A.G., and Latimer, E., 2012, ‘Narratives of individuals concerning psychiatric advance directives’, Journal of Ethics in Mental Health, vol. 6, pp. 1–9.

Cook, J.A., Copeland, M.E., Floyd, C.B., Jonikas, J.A., Hamilton, M.M., et al., 2012, ‘A randomised controlled trial of effects of wellness recovery action planning on depression, anxiety and recovery’, Psychiatric Services, vol. 63, no. 6, pp. 541–47.

The Copeland Centre, ‘Wellness recovery action plan’, viewed 30 May 2015, http://www.mentalhealthrecovery.com.

Farrelly, S., Brown, G., Rose, D., Doherty, E., Henderson, R.C., et al., 2014, ‘What service users with psychotic disorders want in a mental health crisis or relapse: Thematic analysis of joint crisis plans’, Social Psychiatry Psychiatric Epidemiology, vol. 49, pp. 1609–17.

Farrelly, S., Lester, H., Rose, D., Birchwood, M., Marshall, M., et al., 2015, ‘Improving therapeutic relationships: Joint crisis planning for individuals with psychotic disorders’, Qualitative Health Research, [epub ahead of print], viewed 30 May 2015, http://www.ncbi.nlm.nih.gov/pubmed/25583956.

Icarus Project, n.d., ‘Navigating the space Between brilliance and madness: A reader and roadmap of bipolar worlds, viewed 30 May 2015, http://theicarusproject.net/files/navigating_the_space.pdf

Jankovic, J., Richards, F., and Priebe, S., 2010, ‘Advance statements in adult mental health’, Advances in Psychiatric Treatment, vol. 16, pp. 448–55.

Jonikas, J.A., Grey, D.D., Copeland, M.E., Razzano, L.A., Floyd, C.B., et al., 2011, Improving propensity for patient self-advocacy through wellness recovery action planning: Results of a randomized controlled trial’, Community Mental Health Journal, vol. 49, no.3, pp. 260–69.

Katsakou, C., Rose, D., Amos, T., Bowers, L., McCabe, R., et al., 2012, ‘Psychiatric patients’ views on why their involuntary hospitalisation was right or wrong: A qualitative study’, Social Psychiatry Psychiatric Epidemiology, vol. 47, pp. 1169–79.

Mead, S., 2014, Intentional Peer Support: An alternative approach, Shery Mead Consulting, New Hampshire.

Saakvitne, K.W., Gamble, S., Pearlman, L.A., and Lev, T.B., 2000, Risking Connection: A training curriculum for working with survivors of childhood abuse Sidran Press, Baltimore.

Scott, A., and Wilson, L., 2011, ‘Valued identities and deficit identities: Wellness recovery action planning and self-management in mental health’, Nursing Inquiry, vol. 18, no. 1, pp. 40–49.

Weller, P., 2013, New Law and Ethics in Mental Health Advance Directives: The convention on the rights of persons with disabilities and the right to choose, Routledge, London and New York.

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Taking back control in crisis: Having the conversation

1. Initial response and general approach

Supporting people in crisis can be difficult, when you’re perhaps working to support them to maintain as much control as possible. Consider your own support needs during these times to ensure you are best able to support the needs of the person in crisis. The following information may assist you to work effectively with them.

  1. Listen without judgement. Talking can help people make their own sense of what is happening and become less overwhelmed.
  2. Connect with them and validate their experience. What do they need? What are they feeling? What is going on? What might help? Supporters often assume what the person in crisis needs and forget to ask.
  3. Avoid arguing with people in crisis. Their thinking might be unusual but their feelings are real and need to be listened to. (Challenging conversations are more useful outside of crisis.) Endeavour to engage without invalidating their reality or your own, for example, ‘I can hear that you feel constantly under scrutiny; you mentioned security cameras were installed in your room. That sounds really frightening and invasive. I can’t see the cameras and can’t do anything about them, but I wonder if there’s something else we can do? Maybe there is somewhere else you could stay for a few nights?

Sometimes you just need to support someone to wait out the crisis, but at other times you need to intervene strongly and swiftly because the situation is truly dangerous. The differences between the two can be extremely subtle. Check in with the person, ask others for advice and use your judgement. Even if intervention is needed, endeavour to keep as much control as possible in the hands of the person in crisis.

2. First questions

'It seems like things are really difficult for you right now. Can you tell me a bit about what’s going on for you?'

'Sometimes it can be difficult to ask for help when things are getting out of control. Previous experience might make you think it’s not a good idea. Perhaps we can talk about what has and hasn’t worked for you in the past.'

'What have you learned about yourself through your experiences of crises? How can we support your efforts to get through this?'

3. Further conversations

I’m getting into a crisis.

Do you have a crisis plan?’ While most people don’t have one, it’s worth checking as they are invaluable tools to better understand someone’s wishes and support them to stay in control during a crisis. If they don’t have a crisis plan, conversations can be based on these questions: ‘What has helped you in the past?’ ‘What has been unhelpful?’ ‘What do you need right now?’ ‘What could we put in place so that things unfold differently if this ever happens again?’

I can’t cope with this on my own.

‘Who else could we bring in to support you through this difficult time?’ Support the person to reach out to other people they trust, acknowledging that this may be hard. If they are very isolated, this may involve some creative thinking—perhaps a neighbour or a member of their religious faith would be willing to help. Be clear about your own needs too, for example, ‘I need to be honest that I can’t be the only support person involved in this situation. Is it okay if I speak with your GP or case manager, or do you have any other ideas?’

Things are getting out of control.

‘Can we talk about how you’d feel about hospital or involvement of the crisis team?’ ‘Have these types of services been helpful in the past?’ ‘Where do you feel safe?’ ‘What kinds of services could help you feel safe?’ Losing a sense of control can exacerbate the crisis and have an impact on trust. As much as possible, involve them in these decisions. It can also be useful to get input from other people who know them well.

I want to stop this getting worse.

Look at the range of factors that can contribute to crises. Lack of sleep, drugs and alcohol can be major contributors. Many people come out of crisis once they get some good sleep or can think more clearly without drugs. Introduce these issues without being dismissive of their concerns. Connect, listen and validate first: ‘I can hear how distressed and angry you’re feeling about this. I also want to check about sleep, because good sleep could increase your resources to get through this.’

4. Ongoing work—preventing and planning for a crisis

Once the crisis has been averted or resolved, it can be helpful to talk with the person about it. This will provide an opportunity to debrief, to evaluate what worked for them and what didn’t, to discuss alternatives and develop a plan for any future crisis, should one occur. A crisis-planning tool provides a helpful framework for having this conversation. Advance statements, wellness recovery action plans and mad maps are different types of tools that are available to help in planning to prevent crises and/or increase personal control during crises. If someone uses a crisis-planning tool, make sure there is some discussion about who should have a copy and the role of others in providing support.

5. Further information

Websites:

Mad maps:
http://theicarusproject.net/content/mad-maps

WRAP:
http://www.mentalhealthrecovery.com

Apps:

WRAP:Wellness Recovery Plan

PsychwebMD

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Taking back control in crisis: Maria’s story

I’ve had multiple admissions to hospital. Before I did a crisis plan, I lost so much control over what happened to me — sometimes with really bad consequences. I react badly to risperidone. Once, when I was admitted to another hospital, they didn’t know about my reaction and prescribed it to me. I was too out of it to know what I was taking. Then my heart started galloping. They didn’t listen to me. It was terrifying. Another time I lost my flat because I didn’t have any arrangements for payment of my rent when I went to hospital. After that I was homeless for a year—sleeping on sofas and in people’s garages. That really mucked up my mental health big time.

A couple of years ago, my new psychiatrist and my support worker suggested I work on a crisis plan with them. They gave me a form to take away and think about. The form asked about early warning signs and triggers, which really made me think about the things that bring about a crisis for me and how I could minimise them. The form also asked about things like medications I didn’t want; where I prefer to go to when I’m in a crisis; the friends or family I want the hospital to contact; and what my contact people need to do to make sure my cat is fed, the rent paid and my boss informed I’m sick.

I brought my two contact people (my brother and my best friend) to the next appointment, where I discussed what I wanted with them, the psychiatrist and the support worker. No one pressured me or tried to tell me what I needed when I filled in the form. Then they copied the form, gave me one, gave one each to my brother and friend, and put one in my file.

I’ve had one crisis since then. It was a horrible experience but all the instructions in my crisis plan were followed. No risperidone this time. No rental arrears. My brother fed the cat and even watered the plants. He rang my boss the day I was admitted to say I was unwell. It meant I felt in control and didn’t pace around the ward worrying that everything in my life was falling apart. It was enough that my head was falling apart without the rest of my life crapping out as well. I’ll never be without a crisis plan again and will keep updating mine every year.

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