Patient Preferences Largely Overlooked During Psychological Crisis

When a person is discharged from a psychiatric inpatient facility, the hope is that he or she will receive the necessary outpatient mental health care to avoid future hospitalization. In England, many procedures are in place to assist with this goal, including the Care Programme Approach (CPA), which provides a plan for outpatient mental health care, social services, care workers, and reviews. However, high rates of readmission still occur.

To address this issue, England recently implemented a Joint Crisis Plan (JCP) which is a collaborative effort negotiated by the client and the mental health staff to ensure that a client’s preferences are carried out in times of psychological crisis. The JCP is aimed at preserving the wishes of client when they are unable to make healthcare determinations for themselves. In this regard, a JCP may provide a window of opportunity to address serious mental challenges before they progress to a point of crisis and hospitalization.

To determine if this collaborative approach results in better readmission outcomes among the seriously mentally ill than CPA alone, Professor Graham Thornicroft, PhD, of the Health Service and Population Research Department of the Institute of Psychiatry at King’s College in London recently enrolled 569 participants who had been inpatients at mental health facilities in the previous 24 months. Half of the participants received CPA alone while the other half received JCP and CPA. Outcomes were measured based on future admission, therapeutic relationship, and overall well-being. Thornicroft discovered that although the therapeutic relationships were stronger for the JCP participants, readmission rates were similar in both groups.

The lack of reduced readmission rates was discouraging and could be the result of several factors. First, participants reported that their wishes were not carried out when they reached a crisis point. Second, they did not have dedicated JCP meetings with staff and healthcare workers, but rather had brief JCP discussions during the course of CPA meetings. Further, many times, key mental health workers were absent from JCP meetings and overall, the mental health professionals did not see JCP as specialized but merely as an obligatory adjunct to the CPA.

Finally, “Qualitative analysis found that although some patients had a positive experience of JCP, many described how clinical services struggled to put it into practice,” added Thornicroft. In sum, the results of this study show that the JCPs have the potential to help reduce readmission rates and benefit mental health clients, but their significance must be emphasized and their stipulations more stringently adhered to in order to provide the maximum benefit possible to the client.

Reference:
Thornicroft, Graham, et al. (2013). Clinical outcomes of joint crisis plans to reduce compulsory treatment for people with psychosis: A randomised controlled trial. The Lancet 381.9878 (2013): 1634-41. ProQuest. Web.

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  • Jill

    Jill

    September 3rd, 2013 at 4:24 PM

    How are patients ever supposed to learn how to manage on their own during a time of crisis if their needs are not being acknowledged and the things that they perceive will work for them are not being taken into account?
    I realize that in many cases there is some frailty there that had to be managed and dealt with, but if you think that a patient is strong enough to be released froma program then you should also feel that he is strong enough to make some critical decisions about his future treatment planning as well.
    I think that in many cases these patients are not being given the credit that they deserve for the work that they have put into healing and this could very easily make them feel slighted and that what they have done is not being treated seriously.

  • Kane

    Kane

    September 4th, 2013 at 3:51 AM

    A large part of this boils down to someone else being in charge and thinking that they automatically know what is better for this client than the client knows.

    And we have to admit that in many cases this could be true, a professional is going to know a lot better about what could work and not work for the patient. But it is also important to strike that balance of discovery in learning what the patient needs to feel safe in recovery and treatment as well. I think that we will see that many times when the patient feels that he is being heard and that he is being listened to then he is going to be much more likely to adhereing to the plan and doing the things that have been suggested he do. If you ignore those needs and feelings then you are only belittling him or her, and there is not one of us who wants to be made to feel like this.

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