CHCMHS003 Learner Guide V 2

Learner Guide
CHCMHS003
Provide recovery oriented I n s ti t u t e o f He a l t h a n d
Nursing Australia
mental health services Legal entity: Health Careers
International Pty Ltd
ABN: 59 106 800 944
ACN: 106 800 944
CRICOS Code: 03386G
RTO ID: 21985
www .ih n a.ed u .au
Learner Guide
CHCMHS003
Provide recovery oriented mental health services
Table of Contents
1. Share and collect information to collaboratively inform the plan for recovery.................................................7
1.1 – Work in a recovery oriented framework that respects the person’s experience, culture and unique
recovery journey and the agreed recovery alliance relationship............................................................................9
Types of mental illness........................................................................................................................................9
Recovery alliance theory (RAT)...........................................................................................................................9
Assessing a unique recovery journey................................................................................................................10
Defining a recovery journey..............................................................................................................................11
1.2 – Use a collaborative approach to discuss and determine information to be collected and sources of
information to be accessed..................................................................................................................................13
Mental health data...........................................................................................................................................13
Using a collaborative approach to discuss and determine the gathering of information.................................14
1.3 – Explain any organisation or program requirements including the commitment to access and equity, and
limits to confidentiality.........................................................................................................................................16
Privacy and confidentiality law.........................................................................................................................16
Mental health and privacy and confidentiality.................................................................................................18
A person’s rights and the limits to privacy and confidentiality.........................................................................18
Communicating rights and restrictions to privacy and confidentiality..............................................................18
Access and equity.............................................................................................................................................19
1.4 – Obtain consent from the person according to organisation policy and procedure......................................20
Advising a person on giving consent for the sharing of information.................................................................20
Organisational policy and procedure................................................................................................................21
1.5 – Gather and document information from the person and other agreed sources to explore and clarify the
person’s preferences, meanings and needs..........................................................................................................22
Person-centred care.........................................................................................................................................22
Gathering and documenting information.........................................................................................................23
1.6 – Apply best practice principles, if formal assessment is to be conducted, and work within organisation
policy and procedures relating to assessment protocols......................................................................................25
Formal assessment...........................................................................................................................................25
Best practice principles of formal assessment..................................................................................................26
Version 1 June 2021 Page 2 of 108
En h an ci n g Li ves th r ou gh Tr ai ni n g
Legal entity: Health Careers International Pty Ltd | ABN: 59 106 800 944 | ACN: 106 800 944 | RTO ID: 21985 | CRICOS Provider Code: 03386G
Learner Guide
CHCMHS003
1.7 – Together identify the range and potential effects of social and other barriers that are impacting on the
person................................................................................................................................................................... 29
Social and other barriers...................................................................................................................................29
Identifying barriers together.............................................................................................................................29
2. Facilitate collaborative planning process for recovery....................................................................................31
2.1 – Work collaboratively to develop a plan for recovery and transition based on the person’s choices,
preferences, values, needs and goals and discuss different planning options and tools......................................33
Self-determination in recovery.........................................................................................................................33
Planning tools...................................................................................................................................................33
2.2 – Facilitate planning sessions using effective communication strategies in a manner that respects the person
as their own expert, fosters their strengths and supports them as the driver of their recovery journey.............36
Facilitation through effective communication strategies..................................................................................36
Communication strategies................................................................................................................................37
2.3 – Discuss and confirm the person’s choices for personal wellness, development of self-efficacy, cultural
requirements, values, meanings and purpose in life............................................................................................40
Definitions........................................................................................................................................................40
Discussing and confirming choices....................................................................................................................41
2.4 – Work collaboratively with the person to identify strategies and priorities to achieve goals including self-
advocacy strategies and transition beyond the service........................................................................................42
Self-advocacy and transition.............................................................................................................................42
Identifying strategies and priorities..................................................................................................................42
Working collaboratively....................................................................................................................................43
2.5 – Work collaboratively with the person to identify strategies and priorities to achieve goals including self-
advocacy strategies and transition beyond the service........................................................................................44
Possible barriers or risks...................................................................................................................................44
Outside agencies...............................................................................................................................................44
Strategies for overcoming barriers...................................................................................................................45
2.6 – Develop and document personal wellness plan, risk plans or other plans to meet the person’s priorities, as
appropriate...........................................................................................................................................................46
Personal wellness plan......................................................................................................................................46
Risk plans..........................................................................................................................................................47
2.7 – Work collaboratively with the person to identify and balance duty of care and dignity of risk
considerations whilst promoting independence from service..............................................................................49
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Duty of care......................................................................................................................................................49
Dignity of risk....................................................................................................................................................50
Balancing duty of care and dignity of risk.........................................................................................................50
Promoting independence from service.............................................................................................................52
2.8 – Identify and document the person’s and worker’s roles and timelines for action.......................................53
Roles and responsibilities of mental health worker and client.........................................................................53
Identifying roles and timelines for action.........................................................................................................55
3. Collaboratively implement plan for recovery..................................................................................................56
3.1 – Discuss with the person their interest and readiness to initiate their plan for recovery.............................57
The Stages of Change (Transtheoretical) Model...............................................................................................57
Readiness assessment......................................................................................................................................58
3.2 – Undertake service actions as agreed in the plan in a timely manner...........................................................59
Service actions..................................................................................................................................................59
3.3 – Facilitate access to information, resources and education about opportunities and service options
relevant to the persons aspirations......................................................................................................................60
Service options.................................................................................................................................................60
Facilitating access to information, resources and education............................................................................60
3.4 – Support person’s decision making and self-advocacy..................................................................................62
Creating a balance between support and self-advocacy...................................................................................62
3.5 – Support person’s positive risk taking and resilience building.......................................................................64
Positive risk taking............................................................................................................................................64
Resilience building............................................................................................................................................66
3.6 – Maintain regular contact with the person, and be available to offer support and follow up on actions.....68
Maintaining regular contact.............................................................................................................................68
Offer support and follow-up on actions............................................................................................................68
3.7 – Maintain records and progress notes in collaboration with the person......................................................70
Maintaining records..........................................................................................................................................70
Working collaboratively with the person to maintain records..........................................................................71
4. Develop and maintain effective working relationships with care support network.........................................72
4.1 – Determine with the person who else they choose to involve in their recovery process and the roles they
want them to play................................................................................................................................................73
Persons involved in the recovery process.........................................................................................................73
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Involving family members.................................................................................................................................73

Determining the roles others should play.........................................................................................................75
4.2 – Obtain consent specifying what information can be shared with specific members of their care network
and the circumstances in which the information can be released........................................................................76
The care network..............................................................................................................................................76
Privacy and confidentiality................................................................................................................................76
Defining the circumstances in which information can be released...................................................................76
4.3 – Identify the information and support needs of family, carer/s and friends.................................................77
Information and support needs........................................................................................................................77
4.4 – Establish rapport and build an effective working relationship with relevant members of the care network
.............................................................................................................................................................................. 79
Establishing rapport..........................................................................................................................................79
Building effective relationships.........................................................................................................................79
4.5 – Provide and communicate information so that it is readily understood by members of the care network.81
Making information understandable................................................................................................................81
Communicating information.............................................................................................................................81
4.6 – Work from a strength based approach and communicate in a manner that respects the rights, dignity,
choices and confidentiality of the person with the mental health condition while facilitating the care network to
support the person...............................................................................................................................................82
A strength-based approach..............................................................................................................................82
Communicating in a manner that respects the rights, dignity, choices and confidentiality of the person.......83
Facilitating the care network to support the person........................................................................................83
4.7 – Facilitate support, training or services to family, carer/s and friends based on identified needs................84
Identifying needs and facilitating support........................................................................................................84
5. Support person during challenges...................................................................................................................86
5.1 – Respond proactively to potential obstacles, challenges and barriers that arise, working with the person to
identify ways to proceed and to reduce the likelihood of occurrence..................................................................87
Potential obstacles............................................................................................................................................87
Planning a proactive response..........................................................................................................................87
Reducing the likelihood of occurrence.............................................................................................................89
5.2 – Maintain an empathic, supportive and hope inspiring approach as challenges occur seeing challenge as
part of the recovery journey and sources for learning.........................................................................................90
Showing empathy and support, and inspiring hope.........................................................................................90
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Seeing challenge as part of the recovery journey and sources for learning......................................................91
5.3 – Respond promptly, positively and supportively to person in distress or crisis and support access to
required services..................................................................................................................................................92
Responding to a person in crisis.......................................................................................................................92
Supporting access to required services.............................................................................................................93
5.4 – Respond promptly to de-escalate potential incidents or risks and promote safety.....................................94
Recognising risk................................................................................................................................................94
Techniques for de-escalating risk......................................................................................................................95
6. Collaboratively review the effectiveness of the plan and support provided....................................................96
6.1 – Review recovery plan and alliance regularly with person to ensure continued relevance and effectiveness
.............................................................................................................................................................................. 97
Review recovery plan regularly.........................................................................................................................97
Frequency of review.........................................................................................................................................97
6.2 – Gather feedback from the person at key milestones about the effectiveness and progress in implementing
their recovery plan...............................................................................................................................................99
Recovery tools to gather feedback...................................................................................................................99
6.3 – Identify new directions and areas for change in the recovery plan and amend plans and transition
strategies............................................................................................................................................................101
Identifying new directions and areas for change in the recovery plan...........................................................101
Amend plans and transition strategies...........................................................................................................101
6.4 – Continue implementation and review cycle for the recovery plan until outcomes have been achieved and
no further service or support is required............................................................................................................103
Implementation and review cycle...................................................................................................................103
Outcomes of a recovery plan..........................................................................................................................103
6.5 – Gather and respond to feedback from the person on their satisfaction with the service and support
provided.............................................................................................................................................................105
Gathering feedback from the person..............................................................................................................105
Respond to feedback......................................................................................................................................106
6.6 – Reflect on work practice and feedback and identify opportunities for enhancing empowerment and
improved processes............................................................................................................................................107
Reflective practice..........................................................................................................................................107
............................................................................................................................................................................ 108
References..........................................................................................................................................................109
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1. Share and collect information to collaboratively inform the plan

for recovery
1.1. Work in a recovery oriented framework that respects the person’s experience, culture and unique
recovery journey and the agreed recovery alliance relationship
1.2. Use a collaborative approach to discuss and determine information to be collected and sources of
information to be accessed
1.3. Explain any organisation or program requirements including the commitment to access and equity, and
limits to confidentiality
1.4. Obtain consent from the person according to organisation policy and procedure
1.5. Gather and document information from the person and other agreed sources to explore and clarify the
person’s preferences, meanings and needs
1.6. Apply best practice principles, if formal assessment is to be conducted, and work within organisation
policy and procedures relating to assessment protocols
1.7. Together identify the range and potential effects of social and other barriers that are impacting on the
person
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1.1 – Work in a recovery oriented framework that respects the person’s experience,
culture and unique recovery journey and the agreed recovery alliance relationship
By the end of this chapter, the learner should be able to:
 Identify types of mental illness and stages of the Recovery Alliance Theory
 Identify considerations that may be taken into account when assessing a recovery journey and
ensuring that it is unique to the individual.
Types of mental illness

The Australian Department of Health defines a mental illness as a health problem that significantly affects how a
person feels, thinks, behaves, and interacts with other people. A mental health problem also interferes with how
a person thinks, feels, and behaves, but to a lesser extent than a mental illness. (The Department of Health,
Access date: 20/13/17)
Types of mental illness (or mental health problems) include:

 Anxiety disorders
 Depression
 Schizophrenia
 Bipolar mood disorders
 Personality disorders
 Eating disorders.
Some mental illnesses include symptoms of psychosis, such as hallucinations, delusions, and false beliefs. This is
more common in illnesses such as schizophrenia and bipolar mood disorder.
Recovery alliance theory (RAT)

The Recovery Alliance Theory of mental health nursing is a branch of mental health treatment which is
humanistic. (‘The recovery alliance theory of mental health nursing’, Dec 2007.)
Recovery alliance theory has six key constructs:

 Humanistic philosophy
 Recovery
 Partnership relation
 Strengths focus
 Empowerment
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 Common humanity.
A recovery alliance may also refer to the network of mental health practitioners and other wellbeing specialists
involved in the process of enabling a person to recover from a mental health illness/problem.
Assessing a unique recovery journey

Each person’s mental health problem and consequent road to recovery will be unique to them.
Considerations may include:

 Diagnosis
 Phase of illness
 Culture
 Personal experiences
o history
o support networks
o stressors
o lifestyle.
For example, a person who is not currently in an acute phase of their illness, with a strong support network
around them, and with a large degree of control over personal circumstances, will require a vastly different
recovery plan from someone who is in an acute stage of illness, isolated, and the victim of circumstances outside
their control.
Furthermore, the culture and lifestyle of a person must be taken into account, as this may affect how a course of
treatment will be mapped.
The culture of a person may influence:

 How they relate to mental
illness
 How they define mental illness

and recovery
 Personal circumstances
o different familial roles
o experience of
racism/discrimination.
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 Spirituality and faith
 Specific needs
o language, etc.
All of these things must be taken into account to ensure that the recovery journey of each person is unique to
them and self-determined.
Defining a recovery journey

According to a publication by the Department of Health (‘Recovery: the concept’), the concept of recovery was
conceived by, and for, people with mental health issues to describe their own experiences and journeys and to
affirm personal identity beyond the constraints of diagnosis.
The same publications states that:
“The recovery movement began in the 1970s primarily as a civil rights movement aimed at restoring the human
rights and full community inclusion of people with mental health issues.
Recovery approaches are viewed by the consumer movement as an alternative to the medical model with its
emphasis on pathology, deficits, and dependency. There is no single description or definition of recovery because
recovery is different for everyone. However, central to all recovery paradigms are hope, self-determination, self-
management, empowerment, and advocacy. Also key is a person’s right to full inclusion and to a meaningful life
of their own choosing, free of stigma and discrimination.”
Some characteristics of recovery commonly cited are that it is:

 A unique and personal journey
 A normal human process
 An ongoing experience and not the same as an end point or cure
 A journey rarely taken alone
 Nonlinear—frequently interspersed with both achievement and

setbacks.
https://www.health.gov.au/internet/main/publishing.nsf/content/
67D17065514CF8E8CA257C1D00017A90/$File/3.pdf (Access date: 20/03/17)
The recovery journey

All of these things form the recovery oriented framework that should be used as the basis for determining an
individual’s recovery journey. The constructs of Recovery Alliance Theory, as well as the personal experiences,
culture and uniqueness of each person should all be taken into consideration when determining how to map a
recovery journey.
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1.2 – Use a collaborative approach to discuss and determine information to be

collected and sources of information to be accessed
 Identify National Minimum Data Sets and the information that they gather
 Identify information that might be gathered in addition to the National Minimum Data Sets
 Identify the stages of an initial assessment and what may be covered
 Identify sources of information in addition to that provided by the person receiving care.
Mental health data

National Minimum Data Set (NMDS)
A National Minimum Data Set is the minimum information that must be collected during the provision of a service
as agreed by the National Health Information Management Group. Additional data may also be collected by any
agencies and/or service providers for mental health services, but the NMDS are the minimum information
requirements. This data is used to provide a uniform basis for healthcare provision in Australia.
NMDSs include:
 The Admitted Person Mental Health Care NMDS – this includes information on persons who are
admitted to hospital to receive psychiatric care, either in the psychiatric ward of a general
hospital or in a public psychiatric hospital. Information includes:
o date
o age
o sex
o mental health legal status
o hospital type
o principal diagnosis.
 Community Mental Health Care NMDS – this includes information on those who make use of
government-provided mental health services as outpatients. Information includes:
o date
o sex
o age
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 Residential Mental Health Care NMDS – this includes information on those who make use of
government-provided residential mental health services. Information includes:
o date
o sex
o age
Australian Institute of Health and Welfare, http://www.aihw.gov.au/mental-health-data-cubes/
(Access date, 20/03/17)
The National Health Data Dictionary can be used to access definitions of NMDS data elements. The full version of
this can be viewed on the Australian Institute of Health and Welfare website.
(http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737422824 Access date: 20/13/17)
Additional data
In addition to NMDS data, mental health practitioners may also need to gather information about the personal
experiences of persons, any substance abuse issues, and about their lifestyle, culture, and relationships. This type
of information is sensitive and must be handled professionally and in keeping with all applicable confidentiality
and privacy laws, which are reviewed in the next section of this Unit (1.3).
Using a collaborative approach to discuss and determine the gathering of information

The required information may be gathered through the filling out of written medical/information forms and/or
through a verbal initial assessment.
An initial assessment might cover:

 Current mental state
 Whether a person is currently at risk to

themselves or others
 Personal experience and history
 Whether the person suffers from substance

abuse issues
 Mental health history
 Physical health
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 Personal and/or social circumstances.
This initial assessment must be carried out be a mental health professional. This may be an allied health
professional or medical expert. The initial assessment will likely involve a conversation between the person and
mental health professional.
This will include questions from all of the above categories, such as:
 Do you ever feel like giving up?
 Have you experienced feelings like this before?
 What prevents you from acting on your thoughts?
The answers provided by the person will determine the severity of their mental health problem at the time of
consultation and will be used as the initial basis for a treatment plan.
Gathering information from persons other than the person

In the context of mental health, there will be occasions where the
individual is unable to answer questions for themselves, depending on their
emotional and physical state. In these instances, a collaborative approach
may require drawing on information from persons close to the individual
such as family members, caregivers, and the authorities.
Even in situations where the person is coherent and able, gathering

information from these secondary sources can help to ensure that a well-
rounded perspective is given of the person’s state and wellbeing, as a
person might choose to omit information that family members or
caregivers will provide.
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1.3 – Explain any organisation or program requirements including the commitment to

access and equity, and limits to confidentiality
 Identify privacy and confidentiality laws which apply in their states or territories
 Identify circumstances in which it would be acceptable for a mental healthcare professional to

share a person’s information
 Identify access and equity measures, which might include provision of extra services, such as
translation or transportation services, or financial aid.
Privacy and confidentiality law

All gathering of information and exchange of personal or sensitive information must be handled in accordance
with State/Territory confidentiality and privacy laws.
These include:
Jurisdiction Privacy/Confidentiality Law
Commonwealth Privacy Act 1988 (Clth)
Australian Capital Territory Health Records (Privacy and Access) Act 1997
Privacy Act 1988 (Clth)
New South Wales Health Records Information Privacy Act 2002 (in force 2004)
Northern Territory Privacy Act 1988 (Clth)
Queensland Privacy Act 1988 (Clth)
South Australia Privacy Act 1988 (Clth)
Tasmania Privacy Act 1988 (Clth)
Victoria Health Records Act 2001

Western Australia Privacy Act 1988 (Clth)

Confidentiality of Health Information Committee
Source: National Health and Medical Research Council,

‘The Regulation of Health Information Privacy in Australia’, 2004
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Mental health and privacy and confidentiality

In general, information gathered for the treatment of mental health issues should be kept confidential. However,
there are some exceptions.
They include:
 The sharing of information with the consent of the person
 The sharing of information between members of the treating team. For example:
o the disclosure of necessary health information from an organisation to a caregiver.
 To prevent harm to the person or any other person(s). For example:
o contacting the police or paramedics for assistance
o consulting with child protective services to protect a child.
A person’s rights and the limits to privacy and confidentiality

The person receiving care should be aware of their legal and ethical rights in regards to how their personal and
medical information is handled.
Disclosures and written consent forms can be used to ensure that a person is aware of how their information will
be used and that they consent to this use. They should also be made aware of the circumstances in which their
information might be shared, such as when a subpoena has been issued by the court.
Communicating rights and restrictions to privacy and confidentiality

Information about how personal information is handled, used and shared may be provided to the
person through:
 Publications
o pamphlets
o documents
o information booklets.
 Expressed by their doctor (or other health care

practitioner)
 Reiterated on the website of the organisation
 Outlined in disclosure and/or consent forms.
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Access and equity

Access and equity refers to the equal provision of services to people from a diverse range of backgrounds,
including those from CALD backgrounds (culturally and linguistically diverse), as well as those of different genders
and those with disability.
In order to provide an equal service to all, extra provisions, assistance or resources may be required to meet
specific needs.
For example:
 The use of an interpreter/translator
 Materials adapted for those with physical impairment
 Specialised services e.g. out-of-hours appointment times for women whose cultural background
requires them to attend appointments with a male chaperone
 Transportation
 Communication with a caregiver and/or legal guardian
 Financial aid.
Persons should be informed of any extra services or assistance available to them in order to ensure that they
receive an equal quality of service. This information may be expressed verbally by a doctor or healthcare
practitioner or provided in a written format, such as in an information booklet or guide.
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1.4 – Obtain consent from the person according to organisation policy and procedure
 Complete necessary processes with the person receiving care before information is given and
consent obtained
 Identify and apply organisational policy relating to obtaining consent from persons receiving
care.
Advising a person on giving consent for the sharing of information

The Australian Medical Association gives the following guidance for advising persons on whether or not to give
consent for their information to be shared.
This includes undertaking the following (doctor and person receiving care):
 Understand and agree on the nature of the third party’s request for the person’s medical record
(e.g., why the third party has requested the medical record in the first place);
 Discuss the content and details of the medical record;
 Understand the implications for the person of

disclosing (or not disclosing) the record to
the third party;
 Agree on the scope and format in which the

medical record should be provided; for
example, the full medical record, an extract of
the medical record, or a summary of the
medical record;
 Where a summary or extract of the medical

record is provided, agree on what
information from the record will be disclosed;
 Agree on to whom the medical record will be

disclosed (e.g., the details of the third party), for what particular purpose, and for how long the
person’s consent to the disclosure remains relevant; and
 Agree on the timeframe in which the medical record should be disclosed to the third party. Once
the person has consented to the disclosure of their medical record, the doctor should usually
obtain the information within reasonable timeframe - preferably no more than 30 days after the
person has consented (unless there are compelling reasons why the disclosure should be
undertaken earlier).
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‘Guidelines for Doctors on Disclosing Medical Records to Third Parties 2010’, Australian Medical Association,
https://ama.com.au/article/guidelines-doctors-disclosing-medical-records-third-parties-2010 (Access date
21/03/17)
This consent discussion should be recorded by the relevant health care practitioner. A consent discussion may
take place between a doctor and a legal guardian in instances where a person is unable to give consent for
themselves.
Medical information of minors

Confidentiality and privacy laws also apply to minors, when they are old enough and capable of expressing their
desire for confidentiality (i.e. that information is not revealed to their parents). However, the permission of
parents may be sought when providing treatment to a minor during an emergency situation.
Deceased persons
Confidentiality and privacy laws also extend to deceased persons. This means that
the medical records of a deceased person should not be shared with any third
party, except in allowable circumstances (i.e. a post-mortem review).
Privacy and confidentiality guidelines

The Australian Medical Association provides a complete guideline for how to
respect the privacy and confidentiality of persons’ information at
https://ama.com.au/article/guidelines-doctors-disclosing-medical-records-third-
parties-2010 (Access date 21/03/17).
Organisational policy and procedure

You should provide the person with information about their rights and obtain
consent in accordance with organisational policies and procedures. It will also be necessary to fulfil all legal and
professional requirements. A person may need to give consent for their information to be shared with others
and/or for a treatment plan to go ahead. In both cases, there are a number of considerations to keep in mind.
These may include:

 Ensuring that the person understands that they are giving consent and exactly to what they are
consenting
 Following your own organisation’s procedure for obtaining consent, e.g. talking through the
situation with the person and then getting their signature on a consent form and recording the
discussion
 Consulting with legal guardians and/or caregivers when the person is unable to give consent
 Giving full and accurate information to persons
 Documenting interactions.
You should refer to your organisation’s own documentation and published policies and procedures in order to
ensure compliance with the relevant and most current obligations.
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1.5 – Gather and document information from the person and other agreed sources to
explore and clarify the person’s preferences, meanings and needs
 Identify and demonstrate understanding of ‘preferences’ and meanings in the context of mental
health care
 Identify specific needs of persons receiving care
 Gather information from persons receiving care using appropriate methods of gathering and
documenting information.
Person-centred care
Person-centred care (patient-centred care) is care which values the preferences, meanings, and needs of
individual persons in order to deliver treatment that is most suitable for them and which respects their values.
Preferences
Preferences may include:
 Which treatments are received and how they are administered
 Choice of strategy
 Cultural requirements, e.g. male/female doctor
 Medication/therapy balance
 Who is involved in the treatment process.
Meanings
In the context of mental health care, people may attribute different meanings to certain terminologies and values.
For example, there may be a differentiation between the interpretation of persons from different cultural
backgrounds towards concepts such as ‘mental illness’ and ‘treatment’. People of devout faith, for example, may
relate great spiritual significance to an illness or event, whereas for an atheist there may not be any association
between their condition and beliefs.
Person’s definition of terms relating to their conditions and treatment can affect the level of success in
responding to treatment. It is important to ensure that there is a mutual understanding of meanings between
doctor and the person receiving care when planning a course of treatment. Both should share the same
understanding of an end goal.
Needs
The specific needs of individuals can be diverse.
For example:
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 Communication with a third-party e.g. social worker, legal guardian, caregiver, etc.
 Transportation to and/or from a service centre
 Financial aid
 Language requirements
 A support network (if a person lives alone, for example).
It is important that the needs of individuals are met in order to ensure that their treatment is effective and
suitable.
Gathering and documenting information

Gathering and documenting information from persons regarding their care may be done through:
 Initial and ongoing assessments
o verbal
o written
o observation.
 Self-assessments by the person receiving care
 Discussion with person and/or other involved

parties, e.g. family members, caregivers, etc.
o this will require consent from the person

and the identification of involved parties.
 Information forms, e.g. documenting

age/sex/ethnicity etc.
Privacy and confidentiality

Information should be gathered and used in accordance with the governing privacy and confidentiality policies
and legislation as they relate to your State/Territory and/or organisation. Information should not be shared with
third-parties except in permissible circumstances (e.g. with another member of the care team, or with a legal
guardian when a person is not able to sufficiently comprehend their treatment, etc.).
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1.6 – Apply best practice principles, if formal assessment is to be conducted, and work
within organisation policy and procedures relating to assessment protocols
 Identify principles of formal assessment and discipline specific documents which apply to their
organisation/job role
 Identify and apply organisational policies and procedures relating to assessment protocols.
Formal assessment
The formal assessment of a person (as opposed to an informal assessment) should have an organised interview
plan and use tools such as checklists, questionnaires, and rating scales to obtain relevant information for
assessment interview (Psychiatric and Mental Health Nursing, see References). Formal assessments can be more
effective than informal assessments as they remove bias and what is known as ‘value judgements’. This means
that the assessor’s personal views do not conflict with the provision of an objective evaluation of an individual’s
mental health.
A formal assessment aims to determine:

 Does the person have a mental illness?
 Does the person pose a risk to themselves or others?
 Is the person aware of their illness and to what extent are they
aware?
 Will the person accept treatment or follow a treatment plan?
 Does the person require care as an in-patient or out- patient?
According to the Textbook of Adult Emergency Medicine, a formal

assessment allows mental health first aid to be delivered.
The principles of this are:

 Assess the risk of suicide/harm to others
 Listen non-judgmentally
 Give reassurance and information
 Recommend professional help
 Encourage self-help strategies.
Textbook of Adult Emergency Medicine, Elsevier Health Sciences, 18 November 2011.
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Best practice principles of formal assessment

The National Practice Standards for the Mental Health Workforce 2013 identifies six principles of providing
mental health care, which should be applied during a formal assessment.
These are:
 Uniqueness of the individual (which includes empowering the individual to be the centre of care)
 Real choices (which includes achieving a balance between duty of care and support for an
individual to take positive risks)
 Attitudes and rights (which includes listening to, learning from, and acting on communications
from the individual and their carers)
 Dignity and respect
 Partnership and communication (which includes acknowledging each individual is an expert on

their own life,involves working in partnership with individuals and their carers)
 Evaluating recovery (which includes measuring outcomes on a range of indicators in addition to

health and wellness, such as housing, employment, and social relationships).
Department of Health | Part 1: Introduction. (n.d.). Retrieved from

http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pub (Access date: 24/03/17)
Discipline-specific documents
The guideline (National Practice Standards, see References) also identifies discipline-specific documents that may
apply.
There are:
 For psychologists
o The Australian Psychological Society’s:
 Code of ethics
 Ethical and practice guidelines and procedures.
 For social workers
o The Australian Association of Social Workers’:
 Australian Social Work Education And

Accreditation
 Standards (2012)
 Code of Ethics (2010)
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 AASW Practice Standards For Mental Health Social Workers (2008)
 For occupational therapists
o The Australian Association of Occupational Therapists’:
 Code of Ethics (revised 2001)
 Australian Minimum Competency Standards For New Graduate Occupational

Therapists 2010
o The Occupational Therapy Board of Australia’s:
 Code of conduct for registered health practitioners (2012)
 For Psychiatrists
o The Royal Australian and New Zealand College of Psychiatrists’:
 position statements
 clinical practice guidelines
 ethical guidelines
 Code of conduct
 Code of ethics.
 For Nurses
o The Australian College of Mental Health Nurses’:
 Standards of Practice for Australian Mental Health

Nurses: 2010
o The Nursing and Midwifery Board of Australia’s:
 Code of Ethics for Nurses in Australia (2008)
 Code of Professional Conduct for Nurses in Australia

(2008)
 National Nursing Competency Standards for the

Registered and Enrolled Nurses.
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National Practice Standards for the Mental Health Workforce 2013,

https://www.health.gov.au/internet/main/publishing.nsf/content/5D7909E82304E6D2CA257C430004E877/$File/
wkstd13.pdf (Access date: 21/03/17).
You should take care when treating persons receiving care to ensure that you know which of these apply to your
own organisation and/or job role and that you have access to the most current versions. These guidelines should
be used as a best practice framework to guide your interaction with persons, along with any organisational
guidelines for best practice that exist in your place of occupation.
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1.7 – Together identify the range and potential effects of social and other barriers that
are impacting on the person
 Identify barriers that might impact on persons receiving care.
Social and other barriers

There are multiple barriers that might prevent a person from seeking help for a mental health issue. These might
stem from a social problem, or be related to another issue. There might also be barriers in the life of an individual
preventing them from benefitting from treatment or moving forwards in their lives.
Barriers might include:

 Social stigma
 Homelessness
 Substance abuse
 Lack of awareness of issues and sources of help
 Preference for self-reliance
 Lack of trust in healthcare professionals
 Feelings of hopelessness, ‘What’s the point?’
 Lack of knowledge regarding eligibility for services
 Lack of support from family, etc.
 Life and work pressures
 Past experiences/trauma.
Identifying these barriers is the first step to overcoming them and it is important that these barriers are identified
in the early stages of treatment.
Identifying barriers together

Discussing the individual circumstances of a person with them can help you to address their fears and concerns
and begin to build a network to help support them through their recovery journey.
The person may be aware of the barriers in their lives preventing them from moving forwards in their recovery
journey. Alternatively, they may lack insight, which will require the healthcare practitioner to uncover barriers
through discussion and/or consultation with the person and with the person’s network of family, friends and/or
guardians and carers.
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Depending on the circumstances of the individual, the next steps may involve:
 Involving family members/partners in the recovery process
 Contacting outside agencies for further information and support, e.g. social workers, family
planning clinics, substance abuse support groups, etc.
 Providing targeted therapy to help persons overcome past traumas
 Providing emotional support and directing persons to further support beyond the service centre
 Assessing eligibility for services, providing information and helping persons to access help
 Making adjustments to suit the person’s cultural and/or religious needs
 Providing resources and/or financial aid
 Informing the person of practical support services, e.g. childcare, transport, etc.
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2. Facilitate collaborative planning process for recovery

2.1. Work collaboratively to develop a plan for recovery and transition based on the person’s choices,
preferences, values, needs and goals and discuss different planning options and tools
2.2. Facilitate planning sessions using effective communication strategies in a manner that respects the person
as their own expert, fosters their strengths and supports them as the driver of their recovery journey
2.3. Discuss and confirm the person’s choices for personal wellness, development of self-efficacy, cultural
requirements, values, meanings and purpose in life
2.4. Work collaboratively with the person to identify strategies and priorities to achieve goals including self-
advocacy strategies and transition beyond the service
2.5. Identify possible barriers or risks with the person and the strategies and/or other people who can assist in
responding to or overcoming these challenges
2.6. Develop and document personal wellness plan, risk plans or other plans to meet the person’s priorities, as
appropriate
2.7. Work collaboratively with the person to identify and balance duty of care and dignity of risk
considerations whilst promoting independence from service
2.8. Identify and document the person’s and worker’s roles and timelines for action
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2.1 – Work collaboratively to develop a plan for recovery and transition based on the
person’s choices, preferences, values, needs and goals and discuss different planning
options and tools
 Identify and apply the concept of ‘self-determination in recovery’
 Develop WRAP plans with service users, working collaboratively and taking preferences and
needs into account.
Self-determination in recovery
According to the National Framework for Recovery Oriented Mental Health Services: A Guide for Practitioners and
Providers, self-determination, personal responsibility, self-management, regaining control, and choice are vital to
mental health recovery services and are the right of all people regardless of their legal status.
Source:
https://www.health.gov.au/internet/main/publishing.nsf/content/67D17065514CF8E8CA257C1D00017A90/$File
/recovgde.pdf
Self-determination means the right of the person to incorporate their own

choices, preferences, values, needs, and goals into their own recovery. This is a
key feature of person-centred care.
Working collaboratively with the person to enable self-determination when

planning recovery is, therefore, an essential part of the recovery journey.
Planning tools
Planning tools are the tools which can be used to help develop a plan according to the mutually agreed goals of
person and doctor and to measure progress throughout the recovery journey.
The following are examples of tools that can be used to develop recovery plans:
 WRAP (Wellness Recovery Action Planning)
 Recovery star.
WRAP (Wellness Recovery Action Planning)

The WRAP framework was developed in America in 1997 by sufferers of mental health issues. It is a self-
management style of recovery planning that emphasises that people are experts in their own experience and
consequently should take control of their own recovery.
A person engaging in the WRAP process may develop their plan collaboratively with mental health practitioners.
However, their recovery plan should ultimately be self-directed and help them to develop methods of coping
long-term with life’s daily challenges.
Each WRAP plan should contain the following components:
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 Wellness toolbox
 Daily maintenance plan
 Identification of triggers and associated action plan
 Identification of early warning signs and associated action plan
 Identification of signs that things are breaking down and associated action plan
 Crisis planning
 Post-crisis planning.
More information about WRAP and resources for practitioners can be sourced through the Copeland Center for
Wellness and Recovery. (https://copelandcenter.com/wellness-recovery-action-plan-wrap Access date:
21/03/17).
The Recovery Star

The Recovery Star is a visual aid which can be used to help persons identify the ten key areas of their life and to
assess the progress they are making within each area.
The ten key areas of the Recovery Star are:

 Managing mental health
 Self-care
 Living skills
 Social networks
 Work
 Relationships
 Addictive behaviour
 Responsibilities
 Identity and self-esteem
 Trust and hope.
These ten areas are further assessed on the following scale:

 1-2 Stuck
 3-4 Accepting help
 5-6 Believing
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 7-8 Learning
 9-10 Self-reliant.
A recovery star may look something like the following diagram:
Collaboration and planning tools

The above are just examples of planning tools that can be used to help an individual develop a self-determined
recovery plan. However, others are available. A sound knowledge of which resources are available to you and
which tools are used most frequently by your organisation can help you to match persons with recovery plans
that will be most effective for them and which will ensure that their preferences are met.
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2.2 – Facilitate planning sessions using effective communication strategies in a manner

that respects the person as their own expert, fosters their strengths and supports them
as the driver of their recovery journey
 Identify and demonstrate the effective use of communication strategies.
Facilitation through effective communication strategies

The ability to facilitate planning sessions means ensuring that all barriers are overcome and that an atmosphere is
created that is most suited to making the person feel motivated and comfortable to work collaboratively on a
recovery plan with their healthcare practitioner.
This involves using effective communication strategies that respect the person as their own expert, fosters their
strengths, and supports them as the driver of their own recovery journey.
Effective communication strategies may involve:

 Active listening
 Attending skills/use of body language/non-verbal communication
 Paraphrasing
 Reflecting feelings
 Open and closed questioning or probing
 Summarising
 Reframing
 Exploring options
 Normalising statements.
Communication strategies
Active listening
Active listening means ensuring that you really hear what is being said by the
person and that you truly understand their meaning. This may involve reiterating,
paraphrasing, or repeating what the person has said. You may then ask clarifying
questions to confirm understanding.
Additionally, part of active listening is conveying interest to the speaker, so that the
person knows that you are engaged with them and care about what they are saying.
This may involve using verbal and non-verbal communication signs to show that
what the person is saying is being heard and taken in.
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Attending skills
Attending skills relate to active listening. Attending skills/behaviour include the ways in which you show the
person that you are engaged in what they are saying and that you respect their input.
Attending skills may involve:

 Giving the person a warm welcome
 Giving the person your full attention throughout the session
 Picking up on body language and non-verbal cues as well as what is said aloud
 Adjusting your own tone of voice/body language to put the person at ease
 Staying focused.
Paraphrasing, reflecting and summarising

Paraphrasing, reflecting, and summarising are all methods of showing the person that you have heard and
understood what they have said and that you can effectively comprehend the emotions that the person feels.
Paraphrasing is to repeat back what the person has said to you in your own words. This demonstrates that you
have listened to what they have said.
Reflecting is very similar to paraphrasing. However, it may also involve interpreting the feelings of the person and
relating this back to them. This gives the person an opportunity to clarify meaning or think more carefully about
what they mean to say without you pushing them towards expressing a particular feeling.
Summarising takes place at the end of a session and involves reiterating the main points of the discussion in a
brief review. This ensures that the session ends with both doctor (or other mental health professional) and person
knowing that they are on the same page.
Example of paraphrasing/reflecting
Person: My son has been acting up since the funeral. I don’t know
how to help him and I’ve been so busy making
arrangements and sorting out my husband’s affairs that I haven’t
had the time or energy to talk things through with him.
Doctor: You’ve noticed that your son is struggling with handling

his father’s funeral, but you’re feeling too overwhelmed to support
him.
Example of summarising
Doctor: So, today we’ve spoken about the progress you feel you’ve
made since our last session. Things have improved in your
relationship with your husband, but you’re still feeling overwhelmed by pressures at work. We’ve agreed that
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continuing with the joint counselling for you and your husband is a good way to continue and we’ve developed a
new action plan to put in place some coping strategies at work.
Open and closed questioning or probing

Open questions are questions with no ‘yes’ or ‘no’ answer. This means that the person is required to speak at
greater length in order to answer a question and can be useful for helping to assess the person’s emotions, fears,
and concerns.
Closed questions have a very short (often ‘yes’ or ‘no’) answer. These can be useful for drawing out specific
information and for encouraging the person to focus on and analyse their feelings when struggling to express how
they feel.
For example:
 ‘Does it upset you when he says you’re needy?’ (Closed question)
 ‘Why?’ (Open question).
Reframing
Reframing is the art of showing something from a different angle in order to gain a new understanding or develop
a new perspective. This can be very useful in counselling and other mental health practices to help people to
change their perception of relationships and other events in their lives.
For example:
Person: My husband doesn’t seem to care that I’m ill. He never offers to help with anything or makes a fuss. It’s
like it doesn’t matter. I thought the diagnosis would hit him like it’s hit me, but he’s just going on like normal.
Doctor: Sometimes when a loved one gets ill a person doesn’t know how to behave. If your husband never used to
help you or make a fuss, then perhaps he’s continuing to do so to try
and preserve a sense of normality. This may be his way of
protecting himself – and you – from the reality of the
situation. It doesn’t necessarily mean that he doesn’t care and
could very well be a sign that he’s struggling to process the news
himself and doesn’t know how to change his behaviour without
upsetting you. So, he chooses not to change anything and carry on
as normal.
Exploring options
Exploring options is an aspect of person-centred and self-
determined person care. This allows the person to work
collaboratively with a doctor or therapist to look at a variety of ways of approaching their problems and
overcoming them.
Normalising statements
Normalising statements are similar to the art of reframing, except normalising statements are specifically
designed to help persons see their thoughts and/or patterns of behaviour as human or to help reframe a situation
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as understandable, relatable, or to de-escalate its status as a crisis in the mind of the person. They can also be
used to help negative thoughts and/or behaviour be seen in a positive light.
For example:
Person: I’m not sorry for stealing the money. My Mum’s never been there for me and she deserved it.
Doctor: You recognise that there are issues between yourself and your mother and that’s a good thing. Do you
think that the stealing was more about the money or about your feelings towards your mother?
Or:
Person: I’m fed up of dealing with my son’s rebellion. Why can’t he just behave?
Doctor: Many teenagers resort to rebellion at this time in their lives. It can be seen as a sign that he’s struggling
with something in his life. It’s an opportunity to talk with him and find out what’s going on in his life.
Using communication strategies

All of these strategies can be used to help facilitate
planning sessions by ensuring that you are engaged with the
person, responding to their fears, concerns, and
preferences and working collaboratively towards
recovery.
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2.3 – Discuss and confirm the person’s choices for personal wellness, development of
self-efficacy, cultural requirements, values, meanings and purpose in life
 Hold discussions with persons who are being cared for and address the following subjects:
o personal wellness
o self-efficacy
o cultural requirements
o values
o meanings
o purpose in life
Definitions
When discussing a person’s choices with them, it is important to have in mind your own definitions of the
terminology you are using.
Here are some possible interpretations of the following terms:

 Personal wellness - this is the most general term, which may cover all aspects of a person’s
emotions, relationships, work-life balance, and addictions
 Development of self-efficacy - self-efficacy is an individual’s belief in their own capabilities to

complete tasks or achieve goals. People with mental health problems may find that they feel
incapable of even simple daily tasks. Developing self-efficacy can help them to cope and move
forward in their lives
 Cultural requirements - a person’s cultural

background might give them specific needs, such as
language requirements, or the need to be
treated by a male/female practitioner or under
certain circumstances. This will affect how
treatment is planned and carried out
 Values - an individual’s values might relate to the

things that are significant to them, such as family or
career, and/or their ethical and religious beliefs
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 Meanings - meanings can relate either to the definition of terminologies, or to how concepts are
interpreted. For example, one person might accept depression as a mental illness, whilst another
might view their low mood only as a side effect of present circumstances and reject a diagnosis
 Purpose in life - in the context of mental health, life purpose is often defined as the thing(s)
which makes a person feel that their life has meaning. This may be rooted in a person’s
relationships, career, or hobby. Alternatively, it may be considered when suffering from certain
mental health conditions. A person may feel that their life has no purpose in such a situation.
Discussing and confirming choices

All of the above should be brought into discussion with the person during planning sessions and throughout the
recovery journey in order to ensure that their personal preferences and values are incorporated into their
treatment.
These subjects can be written into action plans and can be reviewed throughout the recovery journey.
Discussion with a person in the planning stage of the recovery journey can help to identify potential barriers. For
example, a therapist (or other mental health professional) would not necessarily advise a person to relate to their
condition and/or treatment in a way that contradicts their religious or cultural beliefs and the need to alter a plan
to be suitable for a person from a particular cultural background can be identified at this stage.
Similarly, it is important that the person has a say in defining the pace and type of treatment as it relates to their
personal wellness, development of self-efficacy, cultural requirements, meanings, and purpose in life in order to
feel comfortable and capable of moving forward.
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2.4 – Work collaboratively with the person to identify strategies and priorities to
achieve goals including self-advocacy strategies and transition beyond the service
 Explain and apply the principles of self advocacy
 Identify strategies for treating mental illness, which may include WRAP strategy, the I’M TUFR
strategy, and cognitive behavioural therapy
 Discuss treatment strategies available to service users and decide on courses of action.
Self-advocacy and transition

Self-advocacy is the ability to independently identify obstacles and develop strategies to overcome them, as well
as actually applying them to manage change. This is an important skill to have in order to transition beyond a
mental health service and to be able to manage mental health issues in the long-term. Self-advocacy is also vital
as the lives of no two people are the same. People are experts in their own experiences and are the best qualified
to address their obstacles once they are equipped with the techniques to do so.
Self-advocacy requires:
 Self-belief
 Assertion
 Anger management
 Problem-solving ability
 Recognition of ‘rights’, e.g. I have the right to feel this way.
When collaborating with a person to achieve their goals, it is important to ensure that they have the necessary
self-advocacy skills in order to continue to apply the coping mechanisms and techniques that they have learned
during the course of their treatment.
This may involve providing resources, guidance, and teaching techniques for self-advocacy skills that individuals
can use and apply in their daily lives. Existing resources may be found within your organisation, or may require
further research and training by the mental health professional.
Identifying strategies and priorities

The priorities of individuals on their recovery journey will vary greatly from one another, as will the strategy to
tackle issues depending on the diagnosis of the person, their personal preferences and the severity of their
condition.
For example:
 The WRAP strategy, developed in the USA, can be used to help sufferers of a number of mental
health conditions to develop coping mechanisms and work towards recovery
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 I’M TUFR is a strategy developed in the UK that can be used to help sufferers of schizophrenia.
The acronym stands for:
o I need
o minimum medication
o talking therapies
o useful occupation
o family and friends’ support
o rest and relaxation.
 Cognitive-behavioural therapy is a type of treatment that might be used for a range of mental
health problems, including eating disorders and social anxiety.
Strategies should be chosen in collaboration with the person and they should be achievable and targeted in order
to best facilitate recovery.
Working collaboratively
Working collaboratively with a person to help them achieve self-advocacy and other transitional skills
may involve:
 Discussions
 Observation
 Self-assessments
 Reviews
 Creating action plans together
 Reviewing progress together
 Identifying potential obstacles and working towards

developing techniques to cope and overcome them
 Identifying priorities
 Developing and/or implementing strategies.
All of the above will require the knowledge and skills outlined in sections 2.1-2.3 of this Unit.
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2.5 – Work collaboratively with the person to identify strategies and priorities to
achieve goals including self-advocacy strategies and transition beyond the service
 Identify potential barriers or risks to persons receiving care
 Research and identify external agencies which may offer support.
Possible barriers or risks

As well as barriers and risks directly associated with the mental health problem of the person, outside factors can
also pose potential barriers or risks to them.
For example:
 Lack of social support
 Substance abuse issues
 Financial difficulty
 Domestic violence
 Parental rights acting as an obstacle to treating minors.
These are just a few of the numerous external factors that can affect a person’s capacity to follow a treatment
plan.
Outside agencies
In situations where the provision of aid is beyond the expertise, ability, or authority of the mental health
professional, the person may be directed to seek additional support from outside agencies.
For example:
 Relationships Australia, http://www.relationships.org.au/ – provides relationship support
services
 Family Drug Support Australia, http://www.fds.org.au/
 Rape and Domestic Violence Services Australia, http://www.rape-dvservices.org.au/
 Australian Centre for Grief and Bereavement, https://www.grief.org.au/
 Travel Assistance Schemes,

http://www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/Content/
Patient_Assisted_Travel_Schemes
 Respite care services, http://www.myagedcare.gov.au/caring-someone/respite-care
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 Department of Human Services, www.humanservices.gov.au
o separated parents
o migrants, refugees and visitors
o job seekers
o indigenous Australians
o rural Australians
o carers
o families
o disabled persons.
Access date: 21/03/17
Many support services, resources, and sources of funding available will be available through State/Territory
agencies. A sound knowledge of which support agencies can collaborate with your mental health team to help
support persons with mental health conditions needing additional aid in other areas of their life is vital. Having a
portfolio of contacts and a library of relevant information at your disposal can help to ensure that you can always
offer relevant and beneficial advice.
Strategies for overcoming barriers

Strategies for overcoming barriers should form a part of
every recovery plan may include:
 Identifying triggers
 Supporting persons to seek help from outside

agencies
 Cognitive-behavioural therapy
 Coping mechanisms, etc.
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2.6 – Develop and document personal wellness plan, risk plans or other plans to meet
the person’s priorities, as appropriate
 Apply best practices for risk management in accordance with the Recommendations for Best
Practice in Managing Risk (Department of Health, 2007a)
 Ensure that appropriate contents are contained within risk plans.
Personal wellness plan

Personal wellness plans are used to ensure that a person takes steps to ensure their personal wellbeing. The way
that this is done will depend on the diagnosis of the person, their personal circumstances, and/or experiences,
and their priorities.
For example, a person suffering from anxiety whose main concern is keeping their job might have a main priority
of dealing with stress at work and not becoming overwhelmed by their workload.
In this instance, a personal wellness plan might involve techniques for dealing with stress as well as incorporating
time for rest and relaxation into their schedule in order to ensure that they don’t become overwhelmed.
Contents of a wellness plan

The contents of a wellness plan might include an outline of:
 Personal goals
 Triggers
 Warning signs
 Support networks
 Crisis plans.
A person might be encouraged to develop their wellness plan by being invited

to fill out questionnaires and self-assessments that evaluate the areas of their
life in which they find satisfaction and those which they find overwhelming or distressing. They can also be
encouraged to identify those activities that they enjoy and which relationships in their lives are healthy and
fulfilling. A wellness plan can help a person to focus on and develop positive aspects of their life and to develop
coping mechanisms for areas of stress, as well as seeking help and support for any areas where they are
struggling.
The WRAP strategy and Recovery Star can be useful visual aids when creating a wellness plan.
Resources for wellness plans

 Workbooks to fill in
 Written plans/goals
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 List of tools/resources/people that provide support
 Worksheets
 Feelings tables
 Schedules
 Wellness journals.
Risk plans
Risk management is an important part of mental health care,
even though it may seem contradictory to create safety plans
when trying to inspire hope in a person. The reality is that
there are certain risks that may present themselves in the
lives of those suffering from mental health conditions and
managing these is vital to protect the person and others.
In recent years a patient-centred and collaborative

approach to risk planning has been encouraged, with the inclusion of the person in the process of managing their
own risk being seen as a positive thing.
For this reason, risk plans can be undertaken with the person (in accordance with policy and legislation).
Best practice in risk management:

Department of Health Guidance: Recommendations for best practice in managing risk (Department of
Health [UK], 2007):
 Positive risk management as part of a carefully constructed plan is a required competence for all
mental health practitioners
 Best practice involves making decisions based on knowledge of the research evidence,
knowledge of the individual service user and their social context, knowledge of the service user’s
own experience and clinical judgement
 Risk management should be conducted in a spirit of collaboration and based on a relationship

between the service user and their carers that is as trusting as possible
 Risk management must be built on recognition of the service user’s strengths and should
emphasise recovery
 Risk management requires an organisational strategy as well as efforts by the individual

practitioner
 Risk management involves developing flexible strategies aimed at preventing any negative event
from occurring or, if this is not possible, minimising the harm caused
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 Risk management should take into account that risk can be both general and specific, and that
good management can reduce and prevent harm
 Knowledge and understanding of mental health legislation is an important component of risk

management
 The risk management plan should include a summary of the risks identified, formulations of the
situations in which identified risks may occur, and actions to be taken by practitioners and the
service user in response to crisis
 Where suitable tools are available risk management should be based on assessment using the
structured clinical judgement approach
 Risk assessment is integral to deciding on the most appropriate level of risk management and the
right kind of intervention for the service user
 All staff involved in risk management must be capable of demonstrating sensitivity and
competence in relation to diversity in race, faith, age, gender, disability, and sexual orientation
 Risk management must always be based on the capacity for the service user’s risk level to change
over time and recognition that each service user requires a consistent and individualised
approach
 Risk management plans should be developed by multidisciplinary and multi-agency teams

operating in an open, democratic ,and transparent culture that embraces reflective practice
 All staff involved in risk management should receive relevant training which must be updated at
least every three years
 A risk management plan is only as good as the time and effort put into communicating its
findings to others.
Best Practice in Managing Risk - The National Archives. (n.d.). Retrieved from
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/groups/ (Accessed 24/03/17)
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2.7 – Work collaboratively with the person to identify and balance duty of care and
dignity of risk considerations whilst promoting independence from service
 Apply the concept of ‘duty of care’
 Apply the concept of ‘dignity of risk’, allowing people freedom of choice and the opportunity to
learn from mistakes
 Take steps to support transition away from the service.
Duty of care
According to the National Mental Health Consumer and Carer Forum:
“In practice, a Duty of Care means that all clinical and non-clinical staff, collectively and individually, has a
responsibility to take reasonable steps to ensure mental health consumers are:
 Safe;
 Unharmed;
 Protected from abuse;
 Receive a standard of care and treatment that is evidence

based; and
 Receive a quality of care and treatment that complies

with profession specific and generic standards of practice.
If subject to a state/territory Mental Health Act, a duty of care exists to ensure that the above care is
delivered, and that:
 Consumers are treated with respect and dignity;
 Consumers’ rights are protected and respected;
 The standards of care and treatment are equal to that of patients in the general health care
system; and
 Clinical compliance with all the provisions outlined under Mental Health Act.”
NMHCFF Advocacy Brief, November 2011, http://nmhccf.org.au/sites/default/files/docs/a_duty_to_care-

duty_of_care_brief_2011.pdf (Access date 21/03/17)
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Dignity of risk
Dignity of risk is a term used to describe the right of individuals receiving care to take risks in their own lives. In
mental health care, especially, this is a right which individuals often feel is taken from them in the process of
receiving care, when family members, clinicians and therapists intervene in the decision-making processes.
However, the dignity of risk is a right for all people. Although a doctor has a duty of care to each person with
whom they interact, this does not necessarily mean denying the right of a person to take risks and even make
mistakes. This is part of the human experience and a necessity for self-determination; a key feature of person-
centred care.
Balancing duty of care and dignity of risk

It is important that every healthcare professional is able to suitably balance their duty of care to their clients,
whilst respecting their dignity of risk. It is important to keep service users safe. However, it is equally important to
equip them with the skills to live independent lives in which they manage their own triggers and can make their
own decisions; and, also, deal with the consequences of their decisions effectively.
This may involve:

 Working with the person to develop their skills
o coping mechanisms
o crisis plans
o using support networks
o identifying triggers
o overcoming barriers.
 Offering reasonable support and assistance in the decisions that the individual makes, rather
than making decisions for them
 Developing an understanding of what ‘duty of care’ means to you; recognising that it does not
mean restricting or limiting a person from living a normal life, but rather encouraging them to
live a normal and fulfilling life, which may involve taking risks and making mistakes
 Helping adult service users to learn from the results of their

decisions; to understand why problems may have
arisen and how to prevent them in the future
 Understanding the strengths and desires of an

individual and empowering them to be independent in
their choices
 Being positive about potential risks.
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Promoting independence from service

In addition to working with an individual to view risk positively and learn from their mistakes, it is also important
to work towards developing a level of self-advocacy and self-efficacy that will allow an individual to continue their
recovery journey without the use of the service at a point in the future.
This may involve:

 Gradually withdrawing services that promote dependency, in collaboration with the client
 Transition planning
 Discussing the role of the client’s

support network in continuing to
support the client after they have
stopped using the service
 Developing the client’s skills and

capacity to cope without the service
in the long-term; empowering them.
Regular assessment in accordance with organisational procedure will help determine when the client is ready to
withdraw from some or all services and support.
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2.8 – Identify and document the person’s and worker’s roles and timelines for action
 Identify the responsibilities which fall under the roles of clients receiving mental health services
 Identify responsibilities of the mental health worker, as outlined in the Mental Health Statement
of Rights and Responsibilities 2012
 Agree timelines for action with clients according to organisational policies and procedures.
Roles and responsibilities of mental health worker and client

The treatment of mental health problems is a collaboration between the person receiving care (client/service
user) and the mental health worker. Both the client and the mental health worker will have a role to play in the
development and implementation of a recovery plan.
Role of the client

The role of the client may include:
 Keeping records of their medical history, progress, and emotional/physical states
 Agreeing on decisions for strategies for care
 Taking responsibility for educating themselves about their condition and managing their progress
through following a recovery plan
 Identifying triggers and risk factors and using the skills they
have learned and the support services available to prevent
harm to themselves and/or others
 Asking questions when unsure
 Taking any prescribed medications correctly
 Becoming familiar with their healthcare providers and the

support services available.
Role of the mental health worker

According to the Mental Health Statement of Rights and Responsibilities 2012, the responsibilities of
the mental health worker are to:
a) Provide the highest quality, evidence-based, best practice, assessment, individualised care
planning, support, care, treatment, rehabilitation and recovery services to mental health
consumers without stigma and discrimination
b) Provide the least restrictive assessment, support, care, treatment, rehabilitation, and recovery
responses
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c) Ensure mental health consumers and/or their carers and support persons participate in the
decisions that affect them
d) Respect the wishes of mental health consumers, unless legislation requires otherwise
e) Take into account the wishes, lived experiences, skills, and abilities of mental health consumers
f) Take into account the economic, social, cultural and geographical factors relevant to each mental
health consumer having particular regard for the needs and experiences of Indigenous people
g) Take into account the sexuality, gender and gender identity of mental health consumers
h) inform mental health consumers and/or their carers and support persons about the services that
are available to them
i) Be responsive to the diverse social, cultural, spiritual, emotional and physical experiences, needs
and disabilities of mental health consumers and their carers and support persons
j) Inform mental health consumers and their support persons, carers and advocates about their
rights and responsibilities, including mechanisms of complaint and redress
k) Recognise the role of carers and support persons and be responsive to their needs
l) Respect the privacy of mental health consumers
m) Respect the
confidentiality of mental
health consumers
n) Respect the privacy of

carers and support
persons
o) Respect the confidentiality of carers and support persons Mental health statement of rights and
responsibilities 2012 | 23
p) Deal with the care complaints of mental health consumers fairly, promptly, and without
retribution
q) Deal with the care complaints of carers and support persons fairly, promptly, and without
retribution
r) Promote the best interests of children or young people when a family member, guardian or carer
is suffering from mental health problems or a mental illness
s) Ensure the involvement of mental health consumers and their carers and support persons in the
planning, management and evaluation of social support, health, and mental health services
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t) Keep adequate information systems including accurate and timely record keeping and to monitor
the outcomes for mental health consumers
u) Ensure their own knowledge base reflects current accepted best practice in assessment,
individualised care planning, support, care, treatment, recovery, and rehabilitation
v) Participate in the development of professional ethical standards that accord with international
human rights principles
w) Ensure consideration of the physical wellbeing and physical health needs of mental health
consumers in their care.
Mental Health Statement of Rights and Responsibilities 2012,

http://www.mentalhealth.wa.gov.au/Libraries/pdf_docs/Mental_Health_Statement_Rights_and_responsibilities.
sflb.ashx (Access date 06/01/16)
Identifying roles and timelines for action

The mental health worker and client should each be aware of their roles and responsibilities when starting on a
recovery journey. This information may be provided through discussion between the mental health worker and
client and through the provision of handbooks, publications, and information booklets.
The mental health worker and client should also agree on timelines for treatment, such as target deadlines for
achieving goals and scheduling reviews.
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3. Collaboratively implement plan for recovery

3.1. Discuss with the person their interest and readiness to initiate their plan for recovery
3.2. Undertake service actions as agreed in the plan in a timely manner
3.3. Facilitate access to information, resources and education about opportunities and service options
relevant to the persons aspirations
3.4. Support person’s decision making and self-advocacy
3.5. Support person’s positive risk taking and resilience building
3.6. Maintain regular contact with the person, and be available to offer support and follow up on actions
3.7. Maintain records and progress notes in collaboration with the person
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3.1 – Discuss with the person their interest and readiness to initiate their plan for
recovery
 Identify behavioural expectations in accordance with the stages of change model
 Assess the readiness of clients to implement change and apply standard

procedures/assessments/surveys/observation techniques, which may include paper
assessments, assessment scripts, and visual aids.
The Stages of Change (Transtheoretical) Model

The Stages of Change (TTM) Model is used in relation to a number of mental health issues and in treating persons
with addiction. This theory teaches that intentional change is not a linear journey, but rather a cyclical one, where
a person’s motivation can peak and wane, and where relapse into old behaviours is pre-anticipated. However,
using the TTM model can help mental health workers to prevent relapse into old behaviours and to encourage
clients to maintain new behaviours.
Precontemplation stage
In the precontemplation stage, people have not even thought about
changing; they may not know that there is an issue and have not
recognised the need to change. This might be the case for people
who have never received a diagnosis of a mental health issue before,
for those who have rejected a diagnosis, or for those who lack insight
into their issues and how their mental health issues may be
negatively impacting their lives.
Contemplation stage
At the contemplation stage, a person may recognise that there is a problem and even recognise that there is a
need for change. However, at this stage, a person has made no commitment to implementing recovery plans and
may be ambivalent when it comes to discussing change.
Preparation stage
In the preparation stage, a person might be making small changes to test the waters or making themselves
comfortable with the idea of change. For example, a person suffering with addiction might reduce their
consumption of alcohol or drugs in readiness for giving them up altogether, or researching the location of local
support groups.
Action stage
The action stage is the point at which people being to implement changes in their lives, such as a person with an
anxiety disorder putting into practice techniques learned in session with a therapist or a person with a drug
addiction attending support group meetings and quitting their drug consumption.
Maintenance and relapse prevention stage
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This is the stage in which change has been implemented and now needs to be maintained. This means dealing
with triggers and managing risk, preventing a relapse through ongoing care and adherence to a recovery plan.
Identifying the stage of readiness of a person can help to determine the best point at which to begin
implementing change and applying strategies. Knowing a person’s stage of readiness can help to pace change at a
suitable level for the client and prevent early relapse into old behaviours.
Readiness assessment
As well as using the Stages of Change Model when assessing a person’s readiness for change a mental health
worker could use any suitable assessment. Your organisation may already have protocol regarding readiness
assessment and procedures in place for handling this evaluation.
A readiness assessment can help a mental health worker to establish whether a person is ready to begin to
implement a recovery plan or whether there are barriers left to overcome.
A readiness assessment might evaluate:

 Need and/or current satisfaction with
life
 Awareness of own values and

interests
 Commitment to change
 Awareness of personal circumstances

and potential for change
 Relationship with mental health

worker; trust.
Identifying the readiness of a person for change is important in facilitating the success of treatment, as it ensures
that the person is motivated to change and engaged with the recovery plan. It also provides an opportunity for
concerns and issues to be raised, so that these barriers can be overcome and allow the person to move onto a
point where they are ready for the action stage of treatment.
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3.2 – Undertake service actions as agreed in the plan in a timely manner

 Identify and apply service actions as they relate to their own organisation and/or job role.
Service actions
Service actions might include:
 Making referrals to specialists/other agencies
 Talking therapy
 Counselling
 CBT (Cognitive Behavioural Therapy)
 Developing recovery plans (in collaboration with the client)
 Scheduling reviews
 Supporting applications for support services
 Communicating with other members of the mental healthcare

team
 Any other actions which fall under the responsibility of the mental health worker or service
provider.
All service actions to be taken should be outlined in the recovery plan, as agreed collaboratively with the client in
planning sessions.
Undertaking service actions in a timely manner

It is vital that service actions are undertaken in a timely manner. This preserves the trust in the service by the
client and is also an important part of risk management, as any delay in delivering service could have a negative
impact on the wellbeing of the client.
Timely service action will be:

 Completed in accordance with the timelines of organisational policy, protocol and procedure
 Completed in accordance with deadlines agreed in the recovery plan between mental health
worker and client.
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3.3 – Facilitate access to information, resources and education about opportunities and
service options relevant to the persons aspirations
 Identify and take opportunities to facilitate the client’s access to information, resources, and
education about opportunities and service options relevant to their aspirations.
Service options
Service options are the variations between services provided and some of these can be offered to a person based
on their personal preferences.
These might include:

 Type of therapy and/or treatment
 Pace of treatment
 Who is involved in treatment
 Additional support services.
Facilitating access to information, resources and education

It is important that clients are aware of the services available to them. This includes knowing for which services
they are eligible, where they can seek additional support for contributing issues (e.g. family issues, childcare
issues, sexual issues, financial difficulty, etc.) and which resources are available to meet specific needs, such as for
those with physical impairment or with English as a second language.
In order to facilitate access to information, resources and education, a mental health worker might:
 Process referrals
 Provide written support for application by client for

support services
 Provide literature for external agencies and support

services
 Contact external agencies and support services on behalf

of the client (where appropriate)
 Provide details of external agencies and support

services, including contact information
 Provide additional resources, such as materials in a second language or adapted for those with
physical impairment
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 Require a thorough knowledge of the services the organisation provides and the ability to relate
these to clients
 Assess client’s eligibility for services and advise them to seek appropriate support
 Communicate with carers/legal guardians/social

workers etc., with the consent of the client.
The aspirations of the client

When facilitating the client’s access to information, resources and
education, it’s important to keep in mind the aspirations of the client,
as uncovered in the initial assessment and/or planning sessions. The
advice given should support the client in achieving their own goals,
whilst respecting the mental health worker’s obligation to provide a
duty of care and to respect the client’s right to dignity of risk.
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3.4 – Support person’s decision making and self-advocacy

 Identify the difference between taking a client’s side and being ‘beside’ a client, showing support
and avoiding bias where possible
 Identify and apply methods in order to support a client’s self-advocacy and decision making.
Creating a balance between support and self-advocacy

Person-centred care will support a person’s decision making and self-advocacy, recognising that the client is an
expert in their own experience and that they have the right to self-determine their care. Additionally, as part of
respecting a person’s dignity of risk and as part of risk management, it is important to support a person in making
decisions. This will provide an opportunity for the mental health worker to act as an advisor and part of a support
network as the person moves forward. This can help to safeguard the person in the long-term.
Being ‘beside’ the client

According to Dave Mearns, author of Developing Person-Centred Counselling, it is important not to take the side
of a client when they are making decisions, but rather to be ‘beside’ them; acting as a companion and a resource
for their own exploration of their needs and issues, without showing any bias. This is an important part of
establishing a working relationship with a client because – as Mearns points out in his book – if the client has
changed their mind by the following session, the mental health worker has already shown a personal view, which
might now cause the client to feel judged and uncomfortable in expressing their current opinion.
It is important not to become over-involved in the decision making process of the individual, as this can create a
dependency on the mental health worker when the client is making decisions that should only be influenced by
the facts of their situation. This can be damaging in the long-term; for example, when the client has withdrawn
from the service, or if circumstances mean that they are no longer working with you as their mental health
worker. This may leave them feeling unable to make decisions on their own. To prevent this dependency on the
mental health worker, it will be necessary to encourage the client’s independence and self-advocacy in making
decisions, acting as a listening ear, rather than a second opinion.
When supporting a person’s decision making and self-advocacy it is important to be professionally supportive, but
to also refrain from putting too much weight on the client’s decisions.
Appropriate methods of support

It is not advisable for a mental health worker to express their personal
view when discussing decision-making with a client. Nor should the mental
health worker take the side of or be against the client.
Instead, the mental health worker can:

 Use communication strategies to reframe ideas in order to ensure that the client has considered
matters with a full and clear perspective
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 Refer the client to suitable external support

agencies, where beneficial
 Incorporate the client’s goals into their

recovery plan, considering potential triggers and
creating a crisis plan to minimise the risk of any
decision they make
 Develop the client’s self-advocacy skills so that they can make good decisions
 Use the client’s past experiences as learning opportunities for future growth; avoiding repetition
of previous mistakes and safeguarding them
 Empower the client with knowledge and encouragement
 Discuss potential risk in a positive light so that the client anticipates and is prepared to deal with
possible failure
 Ensure that the client is aware of their support network and how to use it to assist them in their
decisions.
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3.5 – Support person’s positive risk taking and resilience building

 Identify ways in which persons can promote their well-being, nurture their social networks, and
learn psychological coping strategies, providing appropriate forms of support in accordance with
individual situations.
Positive risk taking

According to Steve Morgan (Practice Based Evidence):
“Positive risk-taking is weighing up the potential benefits and harms of exercising one choice of action over
another. This means identifying the potential risks involved, and developing plans and actions that reflect the
positive potentials and stated priorities of the service user. It involves using available resources and support to
achieve desired outcomes, and to minimise potential harmful outcomes.”
‘Positive risk taking: an idea whose time has come’, Health Care Risk Report, October 2004.
In the Health Care Risk Report (October 2004), Morgan provides a guideline for supporting positive risk taking.
This involves:
 Service-user experiences and understanding of risk
 Carer experiences and understanding of risk
 Clear definition of risk-taking in context
 Clear articulation of the desired outcomes
 Identification of strengths
 Planned stages for risk-taking
 Awareness of potential pitfalls (and estimated likelihood).
 Potential safety nets (including early warning signs, crisis, and contingency plans)
 Outcome of previous attempt(s) at this course of action
 How was it managed, and what will

now be done differently?
 What needs to, and can, change?
 How will progress be monitored?
 Who agrees to the approach?
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 When will it be reviewed?
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When discussing positive risk taking, it is important that the mental health worker acts as a reality-check when
individuals are projecting aspirations that are idealistic in order to manage their expectations. The mental health
worker should support the individual’s decision to take risks. However, they also there to help maintain
perspective and safeguard the individual from harm, which means helping them to minimise risk by taking risks
on the correct scale and being mentally and emotionally prepared for the possibility of failure. This includes
identifying triggers and developing crisis and contingency plans in collaboration with the individual in order to
ensure that the potential for harm is absolutely minimised.
Morgan’s full article on positive risk taking can be read in the Health Care Risk Report 2004,
http://static1.1.sqspcdn.com/static/f/586382/9538512/1290507680737/OpenMind-PositiveRiskTaking.pdf?
token=rSsTKF9p%2F1Yeo4nHCz%2Ft1LikTSM%3D (Access date: 21/03/17).
Resilience building
Resilience can be built through:
 Promoting well-being
 Nurturing social networks
 Learning psychological coping strategies.
Promoting well-being
Well-being relates to physical and emotional wellness.
This may involve:

 Developing and maintaining social connections and
social inclusion
 Being active and taking care of physical health
 Developing an appreciation for the positive aspects of life and relationships.
Nurturing social networks

Nurturing social networks may mean spending more time with or improving the quality of our relationship with
existing family members, friends, and colleagues. It may also relate to the development of new relationships.
This may be done through:

 Joining new groups/making new social connections
 Establishing peer support groups
 Evaluating issues in existing relationships and working towards overcoming them.
Learning psychological coping techniques

 Cognitive Behavioural Therapy (CBT)
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 Talking therapy
 Recovery plans
 Problem-solving skills
 Identifying triggers and warning signs
 Establishing routines
 Allowing time for rest and relaxation
 Expressing feelings as they arise
 Developing self-advocacy skills.
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3.6 – Maintain regular contact with the person, and be available to offer support and
follow up on actions
 Ensure that they stay in regular contact with a person, and that they are offering sufficient
support and follow-up on actions.
Maintaining regular contact

As a mental health worker, you have a full-time obligation to offer a duty of care to your clients, which means
being available for regular contact, or ensuring that there is somebody for your client to talk to when they are in
need.
This may involve:

 Providing appropriate contact details to your clients with
information about your hours of availability
 Being available at designated times and responding to

contact from clients as soon as possible if unavailable at the
time of their call/email, etc.
 Providing information about alternative support

services available at times of crisis, such as suicide
prevention hotlines or out-of-hours services
 Providing more than one means of contact, e.g. office telephone, email, etc.
 Regularly checking for messages and missed contact
 Initiating contact with client at regular intervals or if you have cause for concern
 Scheduling regular progress reviews and follow-ups.
Offer support and follow-up on actions

Users of the service may have questions or concerns at any point during their recovery journey, and as their
mental health worker, it is important that you are available to answer them. This means responding promptly and
in full to their questions and providing further information and support when required.
This may involve:

 Scheduling extra sessions or rescheduling sessions to support individual
 Providing resources, information, or education about services or treatments of interest to the

patient
 Ensuring that the person is feeling comfortable and confident in their course of treatment
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 Processing referrals/prescriptions/services when promised and agreed upon with client and
informing them of the results of any actions taken where feedback is required.
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3.7 – Maintain records and progress notes in collaboration with the person
 Identify differences between client service records and a confidential client files and the types of
information that each should contain
 Work collaboratively with a person to maintain records.
Maintaining records
Maintaining records of interaction with clients is a legal requirement for mental health workers, comprising of an
administrative (Client Service Record/Unit Record) and confidential component (Confidential Client
File/Practitioner Notes).
Client Service Record

This is administrative information which covers:
 Dates of service
 Nature of service
 Client demographics
 Contact details
 Formal correspondence with third parties.
Confidential Client File

This is sensitive information which may cover:
 Intimate information about:
o the client
o the client’s family members.
 Diagnostic material
 Test records
 Medico-legal reports
 Formal treatment plans
 Formal evaluations.
All information in the confidential client file must be kept confidential and adhere to the terms of the APS Code of
Ethics.
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Working collaboratively with the person to maintain records

Shared documents
A recovery plan is just one of the records that might be completed collaboratively by mental health worker and
client. This may involve joint discussion before filling out any worksheets, assessments, or spaces for
contemplation.
Other shared documents might include those which require signatures from both mental health worker and
client, such as disclosure and/or consent forms.
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4. Develop and maintain effective working relationships with care

support network
4.1. Determine with the person who else they choose to involve in their recovery process and the roles they
want them to play
4.2. Obtain consent specifying what information can be shared with specific members of their care network
and the circumstances in which the information can be released
4.3. Identify the information and support needs of family, carer/s and friends
4.4. Establish rapport and build an effective working relationship with relevant members of the care network
4.5. Provide and communicate information so that it is readily understood by members of the care network
4.6. Work from a strength based approach and communicate in a manner that respects the rights, dignity,
choices and confidentiality of the person with the mental health condition while facilitating the care
network to support the person
4.7. Facilitate support, training or services to family, carer/s and friends based on identified needs
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4.1 – Determine with the person who else they choose to involve in their recovery
process and the roles they want them to play

Persons involved in the recovery process

The mental health worker and client are not always the only people involved in the recovery process. Others
might include other mental health professionals, legal guardians/social workers, and/or family members, friends,
and partners of the client.
It is the choice of the client who is involved in their recovery process, to what extent, and which roles they play.
Involving additional persons in the recovery process can be useful in a number of ways, including:
 Increasing the person’s social support and sense of social inclusion
 Additional persons to recognise warning signs and respond to prevent relapse
 Persons to provide practical support (e.g. with household chores, groceries, etc.) to help reduce
the pressure on the individual
 Persons to act as advocates for the

person receiving care; to seek extra
information and support when the
person receiving care is unwilling or
unable
 Persons to support the person

receiving care in following a treatment plan
and/or course of medication.
However, it is important to provide sufficient

information and advice to family members on how to best support their loved ones, in order to prevent ‘support’
from being perceived as control, or actually turning into controlling behaviours that actually reduce the person’s
self-advocacy.
Involving family members

In Margaret Leggatt’s article ‘Families and mental health workers: the need for partnership’ (World Psychiatry),
she emphasises the need for families to be involved in the recovery process of individuals and cites the concern
over patient confidentiality as being one of the main causes for their exclusion.
However, Leggatt states that family members can, and should (with the consent of the person) be involved in the
recovery process and that certain things are necessary to ensure that family members provide appropriate
support. Her findings are based on positive evidence found in research.
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This includes:
 Coordinating all elements of treatment and rehabilitation to ensure that everyone is working
towards the same goals in a collaborative, supportive relationship
 Listening to families and treating them as equal partners
 Exploring family members’ expectations
 Assessing the family's strengths and difficulties
 Helping resolve family conflict by providing sensitive response to emotional stress
 Addressing feelings of loss (of hope and expectations)
 Providing relevant information for patient and family at appropriate times
 Providing an explicit response plan for crises (so that family members can respond to warning
signs of relapse)
 Encouraging clear communication among family members
 Providing training for the family in structured problem-solving techniques
 Encouraging the family to expand their social

support networks
 Being flexible in meeting the needs of the

family
 Providing the family with easy access to a

professional in case of need if work with the
family ceases.
The same principles could be applied to other significant people in the client’s life, in addition to family members.
Determining the roles others should play

Determining and confirming the roles that others should play might involve:
 Identification of significant persons in the client’s life
 Strengths and weaknesses of persons in the client’s life
 Discussion of which roles the client wants people to play; how they feel they might be best
supported
 Inclusion of others in discussion; group meetings
 Establishing routines and responsibilities.
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4.2 – Obtain consent specifying what information can be shared with specific members
of their care network and the circumstances in which the information can be released

The care network

The care network may include:
 Relatives
 Friends
 Mental health workers
 Social workers
 Legal guardians
 Carers
 Doctors.
Privacy and confidentiality

Privacy and confidentiality law was discussed in section 1.3 of this Unit and information about obtaining consent
from individuals for the sharing of their information in section 1.4. All of the principles of these two sections apply
in obtaining consent from persons for the sharing of their information with specific members of the care network.
Defining the circumstances in which information can be released

There are some circumstances in which the sharing of information can be considered reasonably expected. For
example, between members of the healthcare team for the planning and delivery of services. However, consent is
required before information is shared in most circumstances.
For this, it is necessary to agree with the person:

 With whom information can be shared
 When information can be shared
 What type of information can be shared.
When conditions are agreed, it may be confirmed with the signing of a consent form. Record should be made of
all discussions regarding consent agreements.
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4.3 – Identify the information and support needs of family, carer/s and friends
 Identify negative impacts that a person supporting someone with a mental health condition
might experience
 Identify types of support that are available for the family, carers and friends of a person with a
mental health condition.
Information and support needs

There is a wide variety of information and support needs that may be required by the family, carers, and friends
of a person with a mental health condition.
A person supporting someone with a mental health condition may experience:

 Emotional distress
 Feelings of loss of hope or helplessness
 Resentment towards the person with the mental health condition
 Feelings of being overwhelmed
 Fear of the person with mental health condition (during a

psychotic or violent episode, for example)
 Reduction in social opportunities
 Difficulty balancing responsibilities
 Misunderstanding about the condition of the person and how to help them.
Providing support for family members, carers and friends

Supporting someone with a mental health condition can be a challenge. However, there are things that the
mental health team can do to support family members, carers, and friends.
This may include:

 Support groups
 Information about the person’s diagnosis and treatment plan
 Guidance about online forums and peer support
 Crisis plan
 Contact details for mental health workers
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 What to do when warning signs are recognised
 Social care support
 Talking treatment
 Developing strategies for managing the behaviours of persons with a mental health condition
 Information-technology based support
 Formal approaches to planning care.
The support needs of family members, carers and friends should be identified. This may be done through informal
or formal assessment in the early stages of treatment.
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4.4 – Establish rapport and build an effective working relationship with relevant
members of the care network
 Establish rapport with the care network
 Build effective relationships with the care network.
Establishing rapport
Establishing a strong rapport with relevant members of the care network is important to ensure that they are
trusting of the service and have confidence in the mental health team.
Rapport can be established through:

 Showing empathy
 Respect
 Providing information, resources, and education
 Being approachable
 Being inclusive; consulting members of the care

network for their input
 Using effective communication strategies
 Following through on agreed action in a timely

manner.
Building effective relationships

After the initial rapport between the mental health worker and relevant members of the care network have been
established, it will be important to build a long-term effective relationship with them.
This may involve:

 Being available to answer questions
 Keeping the care network well-informed with relevant information (as given consent by the client
to release)
 Completing service actions in a timely manner
 Assisting members of the care network with formal approaches to planning care
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 Effective communication
 Anticipating needs.
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4.5 – Provide and communicate information so that it is readily understood by

members of the care network
 Communicate client information so that it is understood.
Making information understandable

Part of effective communication in the healthcare system is making sure that information can be readily
understood.
This may involve:

 Avoiding the use of complex terminology; speaking
in plain English
 Encouraging questions to be asked
 Providing information in more than one format
 Directing members of the care network to other

sources of information, such as that found on
support group websites.
The ability to understand health information is known as ‘health

literacy’ and improving the health literacy of the care network by implementing measures such as using plain
English and avoiding jargon can help persons to better understand their role in supporting a person with a mental
health condition, as well as better understanding the condition itself.
Communicating information
Other considerations related to the communication of information may include:
 Consideration of how and when to communicate information
 Recognising cultural differences and ensuring that the way information is communicated and the
information provided is suitable
 The provision of supporting literature
 Sharing professional documentation with relevant members of the care network
 Effective communication strategies.
The information that you communicate must be honest and factual. Any information regarding the person
receiving care can only be released with the consent of the person.
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4.6 – Work from a strength based approach and communicate in a manner that
respects the rights, dignity, choices and confidentiality of the person with the mental
health condition while facilitating the care network to support the person
 Adopt the strengths based approach, focussing on the strengths of individuals, rather than their
deficits, and encouraging them to play an active role in their own treatment, rather than being
passive recipients of care
 Reframe statements made by people with mental health conditions in a positive light, to
highlight their strengths rather than their deficits.
A strength-based approach
A strength-based approach in the treatment of mental health
conditions is an approach which focuses on the strengths of an
individual, rather than their deficits. Traditionally mental health
workers have looked for the negative symptoms of a person’s
condition, such as a low mood, or anxiety. The focus of treatment has been
reduction in these symptoms.
Conversely, in a strength-based approach, a mental health worker will

look for the positive qualities of a person’s condition, such as their ability
to hold down a job or care for their children, despite their condition. This
suggests that even though the person is affected by a mental health
condition, they have strengths that can assist them in coping with that
condition and overcoming their negative symptoms. In a strength- based
approach, this is the focus of treatment and is a much more
collaborative way of working with a client, in which the person plays an
active role in their own treatment, rather than being a passive
recipient of care.
Encouraging clients to recognise their strengths

Many people are unable to identify or take ownership of their strengths and this can have a negative impact on
their self-esteem and contribute to mental health conditions. When taking a strength-based approach, a person
should be encouraged to recognise and take ownership of their strengths and use them as a basis for progress.
One method of helping people to recognise their strengths is to reframe their deficits in a positive light.
Example one:
Negative light: I feel depressed all the time.
Positive light: You manage to persevere every day, despite the feelings.
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Example two:
Negative light: I don’t want your help.
Positive light: You value your independence.
Example three:
Negative light: I often take drugs.
Positive light: You have periods where you do not take anything.
A mental health worker can also integrate a number of exercises and techniques into sessions to help a person
recognise their strengths and use them as a focus in recovery. This can include encouraging clients to make lists of
their strengths and to evaluate what they accomplish in their daily lives.
Communicating in a manner that respects the rights, dignity, choices and confidentiality of the
person
Communication that respects the rights, dignity, choices, and confidentiality of the person will:
 Be non-judgemental
 Be respectful
 Make use of communication strategies (as outlined in section 2.2 of this Unit)
 Not share information that infringes the privacy or confidentiality of any person.
Facilitating the care network to support the person

The care network should equally embrace a strength-based approach and respect the rights, dignity, and choices
of the person.
Facilitation can be achieved through:

 Cultivating a formal approach to planning
 Supporting the care network in establishing roles,

responsibilities, and routines (where applicable)
 Developing the skills of the care network in respecting and

supporting the self-advocacy of the person.
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4.7 – Facilitate support, training or services to family, carer/s and friends based on
identified needs
 Identify and facilitate forms of support, training or services that might be provided to the family,
carers and friends of a person receiving care for a mental health condition
 Ensure access to support for family, carers and friends of a person receiving care for a mental
health condition.
Identifying needs and facilitating support

The needs of family, carers and friends can be identified through:
 Formal and informal assessment
 Discussions
 Self-assessments.
Support may include:

 Introduction to peer support groups
 Talking therapy
 Skills training to help carers, friends, and family

members cope with their own stressors and
manage the behaviours of the person with the
mental health condition
 Financial or social support, where eligible
 Education about the mental health condition

of the person receiving care and how to best
support them
 Assistance with formal care planning.
Ensuring access to support

Once needs are identified, it should be ensured that family,
carers and friends have access to the support training and services they need.
This may involve:

 Assessing the eligibility of family, carers and friends for certain services
 Making carers, family, and friends aware of the services available
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 Referring carers, family, and friends for the appropriate services and/or training
 Providing supporting literature, so that the care network can access services at any point during
the course of treatment
 Being available to answer questions and adjust the training, support, or services provided to the
care network.
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5. Support person during challenges

5.1. Respond proactively to potential obstacles, challenges and barriers that arise, working with the person to
identify ways to proceed and to reduce the likelihood of occurrence
5.2. Maintain an empathic, supportive and hope inspiring approach as challenges occur seeing challenge as
part of the recovery journey and sources for learning
5.3. Respond promptly, positively and supportively to person in distress or crisis and support access to
required services
5.4. Respond promptly to de-escalate potential incidents or risks and promote safety
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5.1 – Respond proactively to potential obstacles, challenges and barriers that arise,
working with the person to identify ways to proceed and to reduce the likelihood of
occurrence
 Take proactive responses to potential obstacles, challenges and barriers
 Ensure that appropriate contents are included in crises and contingency plans.
Potential obstacles
Potential obstacles are those obstacles that the person can foresee. They may be problems that have arisen
before, or problems that the person anticipates due to their current circumstances.
Potential obstacles might include:

 Financial difficulties
 Relationship problems
 Work stress
 Relapse into old behaviours
 Time management issues.
The first step towards overcoming these obstacles is identifying them. This may be done through formal and
informal assessment, self-assessment, and discussion with the person and the person’s family members, carers,
and friends.
Planning a proactive response

A proactive response is one that foresees obstacles and acts to minimise risk, or prevent them altogether.
This may include:

 Psychological coping techniques
 Financial planning
 Crisis plan
 Contingency plan
 Support networks
 Incorporating risk into recovery plan.
Crisis plan
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A crisis plan is one which sets out how to recognise when a person is heading towards a mental health crisis and
what action should be taken should they reach this point. A crisis plan is usually in place to create an action plan
for when a person’s state of mental health rapidly or suddenly deteriorates and may be used to give the person
an opportunity to state their preferences in advance, so that these are honoured should they become
incapacitated in a crisis. A crisis plan should be developed collaboratively between the mental health worker and
person receiving care.
A crisis plan may cover:

 Triggers and warning signs
 People that the person wants

involved/does not want involved
 Options for treatment
 Previous strategies that have been

successful
 Who to contact and when in a crisis situation (names and details of specific members of the
mental health team/support agencies/authorities)
 Medical details in case of admission
 Advanced statements of treatments the person does and does not want to receive
 Information about the person’s support network.
People other than the mental health worker and the person receiving care may be involved in the development
and implementation of a crisis plan. Family members, carers, and friends can all help to recognise the early
warning signs in the mood and behaviour of the person receiving care and take responsibility for contacting the
correct personnel for emergency care and/or intervention. It is up to the person receiving care to decide who may
be involved in their crisis plan and information should not be shared with the family members/carers/friends of
the person without their prior knowledge and consent.
Contingency plan
A contingency plan is a plan that’s put in place for situations when the original care team has changed or is
unavailable to meet with a person needing attention, such as if a person requires care on short-notice or on an
alternate scheduling than usual.
The contents of a contingency plan might cover:

 Essential elements of the care plan
 Warning signs
 What the substituting mental health worker should do/whom to

contact if further action is necessary.
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Reducing the likelihood of occurrence

There are a number of ways to reduce the likelihood of an obstacle occurring, including:
 Developing the person’s psychological coping techniques
 Outlining how risk will be managed in the care plan.
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5.2 – Maintain an empathic, supportive and hope inspiring approach as challenges

occur seeing challenge as part of the recovery journey and sources for learning
 Use appropriate strategies to show empathy/support and demonstrate hope.
Showing empathy and support, and inspiring hope

Showing empathy
Showing empathy can help to build a rapport with your client and create an atmosphere of trust and
understanding. Empathy is different to sympathy in that empathy is not about feeling sorry for a person. Rather it
is about showing an understanding of how the person feels.
Empathy can be shown through:

 Responding to the person’s situation/emotion with appropriate intensity
o e.g. If a person states that their husband has been imprisoned, a response of ‘I’m sorry to
hear that’ may make the person feel that you do not comprehend the magnitude of their
emotion or the impact of this event on their life.
 Avoiding parroting what the person says – this seems insincere and as if you are not really
listening. Use paraphrasing or summarising as an alternative communication strategy
 Taking into account how the personal circumstances of the

individual drive their decisions and behaviour. Actions that may
seem inappropriate or offensive may be viewed as more
understandable when the context of those actions (e.g.
homelessness, a serious health condition, going through a
divorce, etc.) are taken into account
 Being ‘beside’ the client, rather than taking their side
 Understanding the person in their own terms; attempting to

understand their perspective
 Attending behaviours and active listening.
Showing support
Support may be provided through:
 Respecting and nurturing the person’s self-advocacy and decision making
 Assisting the person in accessing appropriate support services
 Creating recovery plans that take into account the person’s values and preferences
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 Building an effective relationship with the person; providing a reliable and person-centred
service.
Inspiring hope
Hope can be inspired in a number of ways, including:
 Motivational interviewing
 Showing belief in the person’s potential and

strength
 Incorporating the person’s values into their

recovery plan
 Focussing on positive achievements
 Adopting the strength-based approach
 Using peer role-models
 Person-centred planning.
Seeing challenge as part of the recovery journey and

sources for learning
Everybody will face challenges in their recovery from mental health conditions. It is important that these
challenges are addressed and framed as a normal part of the recovery journey.

 Using past experiences as learning opportunities
o what went well?
o what didn’t go well?
o how can the same mistakes be prevented in the future?
 Using peer models
 Anticipating challenges in planning sessions and viewing them in a positive light.
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5.3 – Respond promptly, positively and supportively to person in distress or crisis and
support access to required services
 Respond appropriately to persons in crisis
 Support a person’s access to required services.
Responding to a person in crisis

A person in crisis might require immediate or emergency support. This may be either practical support, or
mental/emotional support.
Responding to a person in crisis may involve:

 Use of crisis and/or contingency plan
 Encouraging the person to engage with their support

network
 Making urgent referrals for further treatment or services
 Assessing the state of the person’s mental health and

acting appropriately in their best interests
 Being available to reassure and advise the individual and/or members of their care network; able
to answer any questions and address any concerns
 Making sure that support is available to the person; both emotional and practical.
Communicating positively and supportively

When a person is in crisis, it is vital that the way you communicate with them is positive and supportive.
This may involve:

 Using normalising statements
 Being ‘beside’ them, rather than on their side or against them
 Attending behaviour and active listening.
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Supporting access to required services

A person may be unaware of or unable to access services for which they are eligible. As a mental health worker,
you can support them in accessing required services.
Supporting a person’s access to required services may involve:

 Assessing their eligibility for services
 Writing referrals/making contact on their behalf
 Educating the person on which resources are

available and how to access them
 Providing supporting literature
 Providing contact details for outside agencies that

can provide additional support.
Being able to support a person’s access to required services

requires that you have a strong understanding of and familiarity
with all the services provided by your organisation and who is
eligible for them. You should also know which services from
external agencies can be used to provide additional support to the
individual and/or their family members, carers, and friends.
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5.4 – Respond promptly to de-escalate potential incidents or risks and promote safety
 Identify variables that could act as warning signs for dangerous behaviours
 Identify and demonstrate use of techniques to de-escalate risk.
Recognising risk
A mental health service user might demonstrate behaviours that could pose a risk to themselves or others during
the course of treatment. There will be risk of escalation into violent or aggressive behaviours.
According to the Department of Health (Western Australia) Guidelines: The management of disturbed/violent
behaviour in inpatient psychiatric settings, there are a number of variables that can act as warning signs of
dangerous behaviours.
These include:
 Facial expressions tense and angry;
 Increased or prolonged restlessness, body tension, pacing;
 General over-arousal of body systems (increased breathing and heart rate, muscle twitching,
dilating pupils);
 Increased volume of speech, erratic

movements;
 Prolonged eye contact;
 Discontentment, refusal to communicate,

withdrawal, fear, irritation;
 Thought processes unclear, poor

concentration;
 Delusions or hallucinations with violent

content;
 Verbal threats or gestures;
 Replicating, or behaviour similar to that, which

preceded earlier disturbed/violent episodes;
 Reporting anger or violent feelings; and
 Blocking escape routes.
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The full guidelines, which give details of further warning signs and possible intervention techniques can be viewed
at: http://www.health.wa.gov.au/docreg/Education/Population/Health_Problems/Mental_Illness/
HP8973_The_management_of_disturbed_violent_behaviour.pdf
Techniques for de-escalating risk

The following techniques are some that may be used to de-escalate situations which present a risk to the person
or others. When deciding which technique to use it is vital that your decision is based on proper assessment and
that you have the proper training and/or authority to intervene. In situations where the person’s behaviour has
escalated beyond your training, authority and/or control, the suitable personnel should be contacted for
assistance. If you do not know who these personnel are, you should research the correct procedure for managing
risk as it applies within your own organisation.
Techniques for de-escalating risk include:

 Using a measured and reasonable response to the person’s
behaviour
 Avoiding provocation
 Self-control of body language, tone of voice, eye contact, etc.
 Understanding a person’s unique triggers and using knowledge

of their care plan to calm them
 Encouraging the person to manage their own risk by

recognising early warning signs and triggers
 Verbal de-escalation:
o self-control of emotions, language and behaviour
o appropriate physical stance
o de-escalation discussion.
Other interventions such as seclusion, medication or physical restraint should only be employed by mental health
professionals with the necessary training and only after sufficient assessment has been carried out and de-
escalation techniques have been tried. You should familiarise yourself with the risk management policy,
procedure, and protocol of your own organisation to ensure that you are aware of the correct way to manage risk
in your own job role.
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6. Collaboratively review the effectiveness of the plan and support

provided
6.1. Review recovery plan and alliance regularly with person to ensure continued relevance and effectiveness
6.2. Gather feedback from the person at key milestones about the effectiveness and progress in implementing
their recovery plan
6.3. Identify new directions and areas for change in the recovery plan and amend plans and transition
strategies
6.4. Continue implementation and review cycle for the recovery plan until outcomes have been achieved and
no further service or support is required
6.5. Gather and respond to feedback from the person on their satisfaction with the service and support
provided
6.6. Reflect on work practice and feedback and identify opportunities for enhancing empowerment and
improved processes
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6.1 – Review recovery plan and alliance regularly with person to ensure continued
relevance and effectiveness
 Take relevant steps during the review of the recovery plan.
Review recovery plan regularly

Taking short steps within a recovery plan is one way to help make change manageable. It is also important to
review the recovery plan regularly to ensure that the possibility of meeting goals remains realistic under changing
circumstances and that potential obstacles can be addressed as they arise.
Steps taken during a review of a recovery plan might include:

 Record achievement of goals
 Identify areas of difficulty which

remain/goals which have not been met
 Confirm and review remaining goals
 Review crisis and contingency plans
 Discuss the role of others in the recovery

process; where this has been helpful and not
 Discuss changing values and/or

preferences.
Reviewing the recovery plan will allow the mental health worker
and person with a mental health condition identify areas of the plan
that have become irrelevant, due to changing goals, for
example. It will also allow for ineffective practices to be
identified and new strategies trialled.
Frequency of review
The regularity with which a recovery plan is reviewed will depend on the person, the severity of their condition,
and their personal circumstances.
Someone in an acute phase of a mental health condition, for example, may require weekly sessions and very
regular review. Someone who is managing their condition very well may only require review once every few
months or if circumstances change.
Whatever the diagnosis and stage of a person’s condition, service users should always have access to information
and support and be able to contact a mental health worker if they are in distress.
The service user should be aware of when their recovery plan is scheduled for review.
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6.2 – Gather feedback from the person at key milestones about the effectiveness and
progress in implementing their recovery plan
 Identify and demonstrate effective use of recovery assessment tools such as Recovery
Assessment Scale (RAS), the Illness Management and Recovery (IMR) Scales, the Stages of
Recovery Instrument (STORI), the Recovery Process Inventory (RPI). Alternative use may be made
of the organisation’s own assessment tools.
Recovery tools to gather feedback

Recovery assessment tools
There are a number of tools that can be used to assess a person’s stage in recovery from a mental health
condition. These can be used as one method to gather feedback from persons about the effectiveness of
programs and their progress in implementing them. All of these tools can be used to evaluate recovery from the
perspective of the person with the mental health condition, which is essential in recovery-oriented and person-
centred care.
These include:
 Recovery Assessment Scale (RAS)
This assesses recovery from the perspective of the

service user, measuring recovery in the spheres of
personal confidence and hope, willingness to ask for
help, goal and success orientation, reliance on
others, and no domination by symptoms.
 Illness Management and Recovery (IMR) Scales
There are two versions of the IMR scale; one from the person’s perspective and one from the
perspective of the clinician. It was originally designed to evaluate the results of the IMR program.
 Stages of Recovery Instrument (STORI)
The STORI recovery tool evaluates the following domains:

o moratorium (a time of withdrawal characterised by a profound sense of loss and
hopelessness)
o awareness (realisation that all is not lost, and that a fulfilling life is possible);
o preparation (taking stock of strengths and weaknesses regarding recovery, and starting to
work on developing recovery skills)
o rebuilding (actively working towards a positive identity, setting meaningful goals and
taking control of one’s life)
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o and growth(living a full and meaningful life, characterised by self-management of the

illness, resilience and a positive sense of self)
 Recovery Process Inventory (RPI)

This tool evaluates the following domains:
o anguish
o connectedness to others
o confidence/purpose
o others care/help
o living situation
o hopeful/cares for self.
Australian Mental Health Outcomes and Classification Network, ‘Sharing Information to Improve Outcomes’,
Version 1.01, February 2010
Positive results in these evaluations would suggest that treatment is effective and progress is being made.
However, scores that drop or stay the same throughout treatment may suggest that the current recovery plan
should be reviewed.
Other methods of gathering feedback can be employed, such as formal and informal discussion and review of
complaints and suggestions. In person-centred care, the subjective feelings of service users are just as important
as objective results.
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6.3 – Identify new directions and areas for change in the recovery plan and amend
plans and transition strategies
 Identify and follow appropriate steps for the amendment of plans/transition strategies.
Identifying new directions and areas for change in the recovery plan
A review of the recovery plan is an opportunity to identify new directions and areas for change.
This may include:

 Trying new treatment strategies
 Reprioritizing goals
 Adjusting medication
 Changing the structure of support

networks and how they are used
 Using new services or existing services in

new ways
 Adjusting balance between treatments.
New directions and areas for change should always be identified in collaboration with the person with a mental
health condition as part of person-centred care.
Amend plans and transition strategies

Amending plans and transition strategies may involve:
 Adjusting the timeline for treatments; increasing or decreasing pace to suit the needs of the
person
 Withdrawing ineffective services and/or introducing new ones
 Involving new and/or different members of the mental health team
 Acting on the preferences of the person receiving care to ensure comfort and confidence in
treatment.
As changes are agreed, they can be incorporated into the existing recovery plan. New ones can also be created
and implemented. It is important at every stage that the client is aware of the next steps and of their own role
and responsibilities in the process.
Where changes to treatment plans are made the client should be provided with appropriate and sufficient
information about what to expect and who their main contacts are within the service.
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6.4 – Continue implementation and review cycle for the recovery plan until outcomes
have been achieved and no further service or support is required
 Identify and take necessary steps as part of the implementation and review cycle
 Ensure that the implementation and review cycle is continued until the outcomes of the recovery
plan have been achieved.
Implementation and review cycle

In many ways finding a treatment that is effective for a person coping with a mental health problem is a process
of trial and error. This is especially of person-centred care, in which the subjective feelings of the individual are as
important as reduction in the visibility of negative symptoms.
The implementation and review cycle involves:

 Identifying issues, creating goals, and developing a recovery plan which incorporates agreed
strategies
 Implementing strategies of the plan into

daily life
 Reviewing progress at regular intervals to

assess the effectiveness of the current plan
and course of treatment
 Adapting the recovery plan in order to

meet the changing needs and condition of
the person
 Re-assessing recovery plans and reviewing

once more.
This is a process that will need to be repeated as many times as necessary until outcomes have been achieved.
Outcomes of a recovery plan

The precise outcomes of a recovery plan will depend on the person and their diagnosis.
However, generally desired outcomes of a recovery plan are:

 To assist person suffering from a mental health condition to live with greater autonomy and self-
advocacy
 To reduce the risk of harm to the person and others
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 To empower the individual and enable them to maintain good mental health and recognise their
own warning signs and triggers to prevent relapse
 To help the person lead a life that is satisfying and fulfilling
 To empower the individual to achieve their personal goals.
Other outcomes may be specific to the person and their diagnosis, such as eliminating the negative impact of
certain symptoms of particular mental health conditions, overcoming personal traumas, and fulfilling personal
goals.
Achieving outcomes of a recovery plan

It can be difficult to know when a person is ready to withdraw from mental health services. However, there are a
number of things that a mental health worker can do to assess how close a person is to achieving the outcomes of
their recovery plan. This might include assessing the person with the use of organisational or governmental
evaluation tools and taking into account the person’s self-assessment and readiness to withdraw from the service.
It may also be beneficial for the mental health worker to speak with the family members, carers, and friends of
the person to get a fuller perspective of where they are in their recovery.
Withdrawal from services

A person’s withdrawal from services may be
something that is done gradually as their condition
improves, or anticipated in the original timeline of the
recovery plan.
Review may be necessary months or even years after a

person withdraws from the service in order to manage
risk and ensure that the person is not facing relapse.
The person may also benefit from information about

how to manage their condition long-term and how to
seek support if they recognise warning signs.
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6.5 – Gather and respond to feedback from the person on their satisfaction with the
service and support provided
 Identify and make effective use of outcome scales to measure consumer satisfaction in their
organisations, including the Mental Health Inventory (MHI, the Behaviour and Symptom
Identification Scale (BASIS-32), the Kessler-10 (K10), the Strengths and Difficulties Questionnaire
(SDQ) and/or the organisation’s own evaluation tools for gathering feedback and assessing
progress in individuals.
Gathering feedback from the person

Service users can be consulted both informally and formally to gather feedback on the service and support
provided. This feedback can be used to improve the quality and range of services provided by the organisation
and to ensure that the organisation is meeting governmental standards for the treatment of those with mental
health conditions and for providing mental health services.
Gathering feedback might involve:

 Surveys
 Formal and informal discussion
 Analyses of outcomes
 Evaluation of complaints.
Consumer self-report outcome scales

Consumer self-report outcome scales are instruments that mental
health service providers can use to gather feedback from their
users, in accordance with the National Mental Health Strategy.
Outcome scales that may be used in your

jurisdiction include:
 Mental Health Inventory (MHI)
The MHI is a self-rated questionnaire comprising of 38 questions which ask the service user to
rate their symptoms and state of mind on a scale of 1-6 (with the exception of two items, which
are rated 1-5). It is used to assess the general mental health and wellbeing of consumers. It is
used to measure outcomes over the last month.
 Behaviour and Symptom Identification Scale (BASIS-32)
BASIS-32 is a self-report measure comprising of 32 scales to measure. These fall under the sub-
categories of 1) Relation to self and others 2) Daily living and role functioning 3) Depression and
anxiety 4) Impulsive and addictive behaviour 5) Psychosis. For the questions in each of these
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categories, consumers are asked to rate how much difficulty they are having, from ‘no difficulty’
to ‘extreme difficulty’. It is used to measure feelings over the last two weeks
 Kessler-10 (K10)
The K10 is a self-rated questionnaire which measures the frequency of psychological distress on a
scale of 1-5, from ‘none of the time’ to ‘all of the time’. Two different versions of the K10 exist;
one which includes questions relating to disability (K10+ LM), and one which does not (K10 L3D).
The former rates the consumer’s psychological distress over the last 4 weeks, and the latter rates
it over the last 3 days.
 Strengths and Difficulties Questionnaire (SDQ)
The SDQ is a behavioural screening questionnaire for 4-17-year-olds which includes three to four
of the following components, depending on the version: 1) 25 items on psychological attributes
2) An impact supplement 3) Cross informant information 4) Follow-up questions.
The choice of which self-report measure to use and when will be dependent on a number of circumstances and it
is important that you familiarise yourself with these. Further information and resources can be accessed through
the Australian Mental Health Outcomes and Classification Network, http://www.amhocn.org/.
Organisational surveys
It is likely that the organisation will also have its own surveys and outcome measurements instruments for
gathering feedback. You should familiarise yourself with these and any policies, procedures, or protocols relating
to the gathering of feedback.
Respond to feedback
A response to feedback may be a change in the service and support provided to the individual and/or greater
changes within the organisation as a whole.
For example, if a person gave feedback that they felt they were unable to make contact with appropriate
personnel within the service during the course of the treatment, the service might respond in two ways.
These are:
 Respond immediately to the individual;
increasing contact and making sure that
greater support is provided to them
 Reviewing systems of contact within the

organisation and developing more
effective and reliable communication
between service users and members of the
mental health care team.
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6.6 – Reflect on work practice and feedback and identify opportunities for enhancing
empowerment and improved processes
 Demonstrate effective use of reflective models and their application in the context of mental
health care.
Reflective practice
Reflective practice is the act of studying the way you work in order to improve your work practice and provide a
better service. Reflective practice is important within the context of person-centred care as a means of ensuring
that you are constantly improving the skills and techniques that make a person feel comfortable and trusting in a
mental health care setting.
Models of reflective practice

A model of reflective practice is a method of self-reflection that may be applied to mental health services or more
generally applied.
The following models are example models of reflective practice that can be used:
 Gibbs’ reflective cycle (1988)
 Atkins and Murphy Reflective Model (1994)
 Burton’s Reflective Model (1970).
Gibbs’ reflective cycle

Gibbs’ reflective cycle involves six steps.
These are:
1. Description – What happened?
2. Feelings – How did you feel about it?
3. Evaluation – What went well and what did not?
4. Analysis – How do you understand what has happened?
5. Conclusion – What else could you have done?
6. Action plan – What will you do next time?
Atkins and Murphy Reflective Model

Atkins and Murphy’s reflective model involves six steps.
These are:
1. Action or new experience
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2. Awareness of uncomfortable feelings and thoughts
3. Description of the situation, including thoughts and feelings
4. Analyse feelings and knowledge relevant to the situation
5. Evaluate the relevance of knowledge
6. Identify any learning which has occurred.
Burton’s Reflective Model

Burton’s reflective model involves asking oneself three questions to help analyse experiences.
These are:
 What? – Descriptions of what you were trying to achieve and what actually happened
 So what? – Analysis of what actually happened
 Now what? – Determining alternative courses of action for the future.
Using reflective models

Reflective models, along with feedback from service users can be used to help a mental health worker identify
their own areas for improvement and issues within the system. When reflective practice is consistently
implemented in this way, it allows for empowerment and improved processes.
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References
These suggested references are for further reading and do not necessarily represent the contents of this unit.
Websites
The Department of Health – What is mental health?
http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-w-whatmen-toc~mental-
pubs-w-whatme what
Queensland Government, ‘Hospital admissions for mental illness’:
https://www.qld.gov.au/health/mental-health/rights/hospital/index.html
Australian Institute of Health and Welfare – Mental health data cubes:
http://www.aihw.gov.au/mental-health-data-cubes/
The Copeland Center for Wellness and Recovery:
https://copelandcenter.com
Living with Schizophrenia:
http://www.livingwithschizophreniauk.org/
Counselling connection:
http://www.counsellingconnection.com/
Publications
‘Recovery: the concept’:
https://www.health.gov.au/internet/main/publishing.nsf/content/
67D17065514CF8E8CA257C1D00017A90/$File/3.pdf (Department of Health)
‘Recovery and resilience: African, African-Caribbean and South Asian women’s narratives of recovering from
mental distress’:
http://mentalhealth.org.uk/content/assets/PDF/publications/recovery_and_resilience.pdf
‘The recovery alliance theory of mental health nursing’, School of Nursing Midwifery & Health Systems, University
College Dublin, Dublin, Ireland, Journal of Psychiatric and Mental Health Nursing, December 2007
‘The Regulation of Health Information Privacy in Australia’, National Health and Medical Research Council, January
2004
‘Mental health risk assessment: A guide for GPs’:

http://www.racgp.org.au/download/documents/AFP/2011/June/201106balaratnasingham.pdf
Mental Health Statement of Rights and Responsibilities 2012, Commonwealth of Australia 2012
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‘Families and mental health workers: the need for partnership’, Margaret Leggatt, World Psychiatry. 2002 Feb;
1(1): 52–54.
McCormack, J. (2007) Recovery and Strengths Based Practice. SRN Discussion Paper Series. Report No.6.
Glasgow, Scottish Recovery Network.
‘100 ways to support recovery: a guide for mental health professionals’, Mike Slade, 2013 (Second Edition)
Australian Mental Health Outcomes and Classification Network, ‘Sharing Information to Improve Outcomes’,
Philip Burgess, Jane Pirkis, Tim Coombs, Alan Rosen, Version 1.01, February 2010
‘Mental Health Information Development: National Mental Health Information Priorities’ (2 nd Edition), June 2005,
Commonwealth of Australia
Guidelines
‘Guidelines for Doctors on Disclosing Medical Records to Third Parties 2010’, Australian Medical Association
‘Guidelines: The management of disturbed/violent behaviour in inpatient psychiatric settings’, Government of

Western Australia Department of Health, 2006,
Training Manuals
Australian Mental Health Outcomes and Classification Network, ‘Mental Health Inventory: Training Manual’,
Commonwealth of Australia 2005
Australian Mental Health Outcomes and Classification Network, ‘Behaviour and Symptom Identification Scale
(BASIS) – 32: Training Manual’, Commonwealth of Australia 2005
Australian Mental Health Outcomes and Classification Network, ‘Kessler -10: Training Manual’, Commonwealth of
Australia 2005
Australian Mental Health Outcomes and Classification Network, ‘Strengths and Difficulties Questionnaire: Training
Manual, Commonwealth of Australia 2005
Books
Psychiatric and Mental Health Nursing, Ruth Elder, Katie Evans and Debra Nizette, Elsevier Health Sciences, 25
May 2012
Textbook of Adult Emergency Medicine, Peter Cameron, George Jelinek, Anne-Maree Kelly, Lindsay Murray,
Anthony F.T.Brown, Elsevier Health Sciences, 18 November 2011
Developing Person-Centred Counselling, Dave Mearns, SAGE, 27 November 2002
All references accessed on and correct as of 20/03/2017, unless other otherwise stated.

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Involving family members.................................................................................................................................73

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1. Share and collect information to collaboratively inform the plan

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Types of mental illness

Types of mental illness (or mental health problems) include:

 Bipolar mood disorders

Recovery alliance theory (RAT)

Recovery alliance theory has six key constructs:

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Assessing a unique recovery journey

Considerations may include:

The culture of a person may influence:

 How they define mental illness

o different familial roles

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 Spirituality and faith

Defining a recovery journey

The same publications states that:

Some characteristics of recovery commonly cited are that it is:

 A normal human process

 An ongoing experience and not the same as an end point or cure

 A journey rarely taken alone

 Nonlinear—frequently interspersed with both achievement and

The recovery journey

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1.2 – Use a collaborative approach to discuss and determine information to be

 Identify the stages of an initial assessment and what may be covered

Mental health data

o mental health legal status

o mental health legal status

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o mental health legal status

Australian Institute of Health and Welfare, http://www.aihw.gov.au/mental-health-data-cubes/

(Access date, 20/03/17)

Using a collaborative approach to discuss and determine the gathering of information

An initial assessment might cover:

 Whether a person is currently at risk to

 Personal experience and history

 Whether the person suffers from substance

 Mental health history

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 Personal and/or social circumstances.

 Have you experienced feelings like this before?

 What prevents you from acting on your thoughts?

Gathering information from persons other than the person

Even in situations where the person is coherent and able, gathering

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1.3 – Explain any organisation or program requirements including the commitment to

 Identify circumstances in which it would be acceptable for a mental healthcare professional to

Privacy and confidentiality law

Jurisdiction Privacy/Confidentiality Law

Commonwealth Privacy Act 1988 (Clth)

Northern Territory Privacy Act 1988 (Clth)

Queensland Privacy Act 1988 (Clth)

South Australia Privacy Act 1988 (Clth)

Tasmania Privacy Act 1988 (Clth)

Victoria Health Records Act 2001