The article by Roberts et al
(2008, this issue) marks the beginning of a critical dialogue about
decision-making in high-risk situations. We offer a commentary based on many years
of experience with both self-help and peer-run alternatives in situations of
crisis. Roberts and his co-authors bring together perspectives of both
professionals (whom we might think of as ‘outsiders’, who are traditionally the
only decision makers) and people who have experienced detention (‘insiders’, who
have lived with the decisions made for them).
We see the article as containing a combination of outsider knowledge, representing
what might be described as fear-based decision -making, and insider knowledge,
representing the beginning of what we might call hope- or recovery-based
decision-making (choices that lead to hope and increased feelings of well-being).
The next step is to ask the question, ‘What responses would lead to the
development of hope and increased feelings of well-being as an outcome?’ One way
of considering these conversations is in terms of discussions embarked on
proactively, of dialogues in the moment and of dialogues after the event.
In thinking about proactive approaches to ensuring choice, the dialogue might
include self-care, prevention and crisis planning, which are the main focus of
two US initiatives: the Wellness Recovery Action Plan (WRAP; Copeland, 2001, 2002) and also the Intentional Peer Support programme
(Copeland & Mead, 2003; Mead
& McNeil, 2005, 2006; www.mentalhealthpeers.com).
Crisis planning in WRAP gives individuals with mental illnesses the ability to
think about how to deal with a crisis and who and what might be needed, and to
put this into a document that others can use as a guide in difficult
situations. Other parts of the plan help them to develop self-care and
prevention strategies that will help them avoid crisis.
The Intentional Peer Support programme offers a relational dialogue about what
might work for everyone. It involves considering crisis as an opportunity to
break patterns and habits, stay connected and even to act reciprocally by
negotiating fear, power and meaning (Mead
& Hilton, 2003). An example (using the scenario in Roberts
et al's Box 2) might be having a clinician talk to Stephen
when he is feeling well about the types of conversation that are useful when he
is angry or withdrawn. They might discuss what he would like from the hospital
if and when he should use it, but most importantly, they would let each other
know what creates disconnection for him.
Discussion in the moment
An example of dialogue about what would help in the moment would be members of
staff talking to Stephen (or any person who has been detained) in a way that
includes him in decision-making. They might acknowledge their own fear and
discomfort and ask what he would like from them when he is frustrated. As
regards getting out of bed, they could find out more about what interests him
and strategies that he feels might work. They might also uncover justifiable
reasons for his refusal to get out of bed such as extreme lethargy caused by
medications or fear of the events of the day.
Discussion after the event
Discussions after the person leaves the hospital that might better inform
future strategies might include talking about what worked well, what did not
work and why, from the point of view of the person being served and of the
people responsible for their care. In the example of Michael (Roberts
et al's Box 5), the staff might ask him what was useful
about his hospital stay and what he will need to continue moving ahead.
Enabling shared risk
We hope that this beginning of a developing dialogue will expand over time and
we believe that acting on what is learned will result in services that better
meet the needs of people being served, making choice possible in even the most
difficult situations. This will not happen overnight, but with practice we may
just see the day when shared risk becomes a reality.
Declaration of interest
Copeland, M. (2001) Winning against Relapse.
Copeland, M. (2002) WRAP: Wellness Recovery Action
Plan (2nd, revised edn). Peach
Copeland, M. & Mead, S. (2003) WRAP and Peer Support: A Guide to
Individual, Group and Program Development. Peach
Mead, S. & Hilton, D. (2003) Crisis and
connection. Psychiatric Rehabilitation
Mead, S. & MacNeil, C. (2005) Peer support: a systematic
approach. Family Therapy Magazine,
Mead, S. & MacNeil, C. (2006) Peer support: what makes it
International Journal of Psychosocial Rehabilitation,
Roberts, G., Dorkins, E., Wooldridge, J. & Hewis, E. (2008) Detained – what's my choice? Part
1: Discussion. Advances in Psychiatric