Close
Involving and working with key supporters
Target
a) Initial assessment or treatment plans identify the key people in service users' family or social network.
b) The CRT have documented attempts to contact at least one key family or other person in their social network for all service users.
c) At least one involved family member or other person in the social network is invited to care planning or review meetings, where the service user's consent is given.
d) An individualised role for at least one involved family member or other person in the social network in treatment plans is identified in service users' treatment plans/case notes, where the service user's consent is given.
e) There is all-source agreement that the CRT works closely with families in supporting service users.
Why this is important
The CRT model was initially envisaged as a social systems intervention. If service users are to be treated at home during a crisis, pro-active efforts by the CRT to improve the living environment or increase the available social support may well be necessary. Government guidance recommends identifying involved carers at first point of contact with a service user. Bridgett & Polak (2003) looks specifically at the way in which crisis working benefits from an understanding of social systems both at assessment and during the crisis intervention (see links below). There was widespread agreement from staff, service users and carers in the development work for the CORE CRT Fidelity Scale that CRTs could helpfully place more emphasis on family work than was often the case.
In the video below, carers discuss the importance of involving the family and/or carer(s)of the person in crisis, both as a means of obtaining useful information, but also how they can be used to help support the individual experiencing the crisis.
Ways of doing this well
Dr Christopher Bridgett produced a training video which aims to train CRT's staff to use social systems interventions. You can also view a video of a workshop about social systems interventions conducted by Dr Paul Polak.
Listen to the audio clip below of Dr Bryn Lloyd-Evans (CORE Programme Manager) talking about the role families can play in supporting service users.
Find out who could be involved
John Hoult, who led on setting up CRTs in Australia and then in the UK, advocated making three phone calls to family or other key supporters when setting up an initial assessment - to gather information and identify potential sources of help with treatment.
Dr Bryn Lloyd-Evans talks more in the clip below about the idea of making three phone calls, and about social systems working.
CRT staff could pro-actively contact close family (where permission is given), whether or not they are currently actively engaged in a caring role, to seek their views and explore if/how they might help. The NICE guidance below gives
Social Systems Mapping
Creating a social systems map of key family members or other involved people at initial assessment can be useful to ensure that everyone is identified. Social systems mapping can also be a very useful way of gaining insight into service users' social worlds and the impact their networks can have on their well-being, both for staff and service users themselves. Research carried out by McPin Foundation and Plymouth University, Peninsula Schools of Medicine and Dentistry forms the basis of this briefing paper Wellbeing Networks and asset mapping (pdf). Below is an illustration used in the paper showing an example of asset mapping.
Individualised roles
- [Examples of "individualised role" for families: Great if we can get a carer or service user to talk about this. But we've also seen lots of good examples in the fidelity reviews (e.g.asking the adult son to bring his grandkids to visit granddad to reduce his suicidal ideation, increase hope etc. Asking husband to hug his wife more.. We could also see if Baindu or Lindsay could come up with any good examples to talk about. Good to communicate it doesn't have to be about monitoring medication..]
Carers Trust's Triangle of Care document provides a useful overview of the importance of involving carers and highlights some best practice examples.
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
- Dudley CRT, Dudley and Walsall Mental Health Partnership NHS Trust
- Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
- Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
- North Devon CRHTT, Devon Partnership NHS Trust
Relevant reading
McGlynn (2006) CRHT: A Practical Guide
Involvement of social network at every phase
There are mutually beneficial reasons for involving the social network. The network can give important information about the client that the client does not disclose. It will help the team to assess the impact of the various members on the client (and the client's impact on them) and find out problems that need to be addressed. The network can help in planning what interventions to make and in implementing those interventions through monitoring and providing practical and emotional support. CRHT teams in turn should inform, advise, educate and generally support the social network.
A client's crisis is rarely due to the illness alone; almost always there is an interplay between the individual and their social network. (p.17)
Bridgett & Polak (2003) Social systems intervention and crisis resolution Part 1: Assessment
The 'story so far' can be profoundly enriched by asking for more information, not so much from the patient, but from significant others. Who else can say more about what is already known? How can they be contacted? How does their point of view raise further issues to discuss with the patient? With which of the patient's social systems can the referral crisis be most closely identified? (Box 8) (Polak, 1967; Fish, 1971; Polak & Kirby, 1976; Polak et al, 1977).' (p.428)
Bridgett & Polak (2003) Social systems intervention and crisis resolution Part 2: Intervention
…identifying the causes of illness relapse and agreeing indicators of relapse will establish a 'relapse signature'. This knowledge can usefully be shared with significant others (Birchwood & Drury, 1995). (p.436)
NICE (2011) Guidance on involving families and carers
Discuss with the person using mental health services if and how they want their family or carers to be involved in their care. Such discussions should take place at intervals to take account of any changes in circumstances, and should not happen only once. As the involvement of families and carers can be quite complex, staff should receive training in the skills needed to negotiate and work with families and carers, and also in managing issues relating to information sharing and confidentiality.
A. If the person using mental health services wants their family or carers to be involved, encourage this involvement and:
- Negotiate between the service user and their family or carers about confidentiality and sharing of information on an on-going basis
- Explain how families or carers can help support the service user and help with treatment plans
- Ensure that no services are withdrawn because of the family's or carers' involvement, unless this has been clearly agreed with the service user and their family or carers.
- Give the family or carers verbal and written information about:
- the mental health problem(s) experienced by the service user and its treatment, including relevant 'Understanding NICE guidance' booklets
- statutory and third sector, including voluntary, local support groups and services specifically for families and carers, and how to access these
- their right to a formal carer's assessment of their own physical and mental health needs, and how to access this.
B. If the service user does not want their family or carers to be involved in their care:
- Seek consent from the service user, and if they agree give the family or carers verbal and written information on the mental health problem(s) experienced by the service user and its treatments, including relevant 'Understanding NICE guidance'
- Give the family or carers information about statutory and third sector, including voluntary, local support groups and services specifically for families or carers, and how to access these
- Tell the family or carers about their right to a formal carer's assessment of their own physical and mental health needs, and how to access this
- Bear in mind that service users may be ambivalent or negative towards their family for many different reasons, including as a result of the mental health problem or as a result of prior experience of violence or abuse.
C. Ensure that service users who are parents with caring responsibilities receive support to access the full range of mental health and social care services, including Information about childcare to enable them to attend appointments, groups and therapy sessions. (p.1)
National Audit Office (2008) CRHT: The Service User and Carer Experience
Involving carers contributes positively to their experiences of the service
2.23 Carers unanimously emphasise the importance of carer involvement. They value being included in the treatment and care plan of the service user. The chief benefits of carer involvement are twofold. The carer is often the person most in tune with the service user and aware of their behaviours, their needs and their relative states of mental health. A carer can offer the CRHT team a great deal of knowledge based on this close understanding and experience, and carers feel that teams should make the most of this extra insight whenever they can:
'There should be much more co-operation between medical staff and carers, because carers can give information about the patient that's not available to them. I see my daughter sitting opposite her CPN. The CPN says, 'You're looking well today, how are you today?' She says, 'Fine', whereas I know she hasn't been fine at all.'
Sarah (carer)
Source: NAO carer focus group
'They take the word of the patient. What the patient thinks isn't always true […] But they listen to the patient and think the carer's trying to make trouble'
Catherine (carer)
Source: NAO carer focus group
'For me it was hard at the beginning […] They didn't want to talk to me. They just said, 'I won't talk to you without your son being present.' They didn't understand my son's illness, but he used to tell me every single thing [… Eventually they came to the understanding that we are partners in this, working together.'
Akram (carer)
Source: NAO carer focus group
2.24 The second reason why carer involvement is so important is because it allows the team to instruct and guide the key person responsible for the welfare of the service user about issues, side-effects or changes they should watch out for. This is especially important when the carer is new to the role, and may not have a great deal of understanding about their loved one's illness or how to deal with situations arising from it. If the carer is well informed and given basic guidance about what to expect or how to deal with certain situations, they are much better placed to work effectively with the team in managing more acute phases. Some carers, while acknowledging that they found home treatment a preferable option to admission, felt that more information and support was needed to help them manage their role:
'We would really welcome help on how to handle things like hearing voices; I've had no idea in the past. Do I say, 'That's rubbish!' or do I say, 'That must be very difficult for you'? I've learned over the years how to support her, but early on a bit of advice on how to respond would have been so helpful.'' (p.13-14)