The article by Reference Roberts, Dorkins, Wooldridge and HewisRoberts 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.
Proactive discussion
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; Reference CopelandCopeland, 2001, Reference Copeland2002) and also the Intentional Peer Support programme (Reference Copeland and MeadCopeland & 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 (Reference Mead and HiltonMead & 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
None.
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