Carers and supported decision making mechanisms

Recognising the role of carers in supporting their family members with severe mental health problems to make decisions about their treatment is a key objective underpinning supported decision making mechanisms established by the Mental Health Act 2014 (Vic) (section 10(h)). The Act also emphasises one of the main objectives is to ‘enable and support persons who have mental illness… to make, or participate in, decisions about their assessment, treatment and recovery’ (section 10(d)).

The Act enables people with severe mental health problems to make an advance statement about their treatment preferences (sections 19 and 20), including in relation to compulsory mental health treatment. While not specified under the Act, advance statements may also include other information the person concerned would like the team treating him or her to know about, such as arrangements for the care of dependents or a pet. Under the Act, people may also nominate a person to represent their interests (section 24) should they become subject to a compulsory treatment order. A nominated person must be consulted about treatment (section 23(c)) and their role is to provide support and to represent the interests of the person who has nominated them (section 23(a)), but a nominated person cannot make a decision on behalf of persons being treated.

The Mental Health Act 2014 (Vic) also includes the right for people diagnosed with ‘mental illness’ to be provided with a statement of their rights (section 12) which must be explained to them (section 13), to seek a second psychiatric opinion (section 79), and to make a complaint to the newly established Mental Health Complaints Commissioner (section 232). They may also access Independent Mental Health Advocacy, a newly established service to support people on compulsory treatment orders.

Supported decision making mechanisms put into practice two of the Act’s guiding principles that people receiving mental health services should ‘be involved in all decisions about their assessment, treatment and recovery and be supported to make, or participate in, those decisions, and their views and preferences should be respected’ (section 11(1)(c)); and ‘be allowed to make decisions about their assessment, treatment and recovery that involve a degree of risk’ (section 11(1)(d)).

The mechanisms that have the most bearing on what carers can do to support the person being cared for to make decisions about their treatment are advance statements and nominated persons. This Talking Point is about how carers interviewed learned about advance statements and nominated persons, and about factors they thought could influence the usefulness of these mechanisms for carers wishing to support the person cared for’s decision making about their treatment. For carers’ views on advance statements and nominated persons, see Carers’ views on advance statements and nominated persons.

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How carers found out about supported decision making mechanisms
The importance of ‘insight’
Losing or gaining control


Tracey said she thought supported decision making and a ‘collaborative care team’ were ‘vital’ for recovery.

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How carers found out about supported decision making mechanisms

In order for carers to make informed use of supported decision making mechanisms such as advance statements and nominated persons to help support the person being cared for, they must first be aware that the mechanisms exist. Of the carers interviewed, a few were well informed, some had partial knowledge, and many heard about the mechanisms and the Mental Health Act (2014) for the first time when we interviewed them. Those who knew about the Act had mixed views. For Rowan, the new laws allowed more ‘input’ from the carer than in the past: ‘people are taking carers a little bit more seriously now than they ever did, because it’s legislated… they’re trusting carers more, I think’. However, Marta described how she and other carers felt the legislative changes were going to make things ‘more difficult’ for carers: ‘already the carers did say, you know, that they all feel it’s in favour of the consumer and there’s nothing in it for the carer, I would say, nothing’.

People we interviewed who already knew about advance statements and nominated persons said they found out about them through mental health organisations, carer support groups, the internet and through work. None of the carers we interviewed said they learned about these mechanisms from the person cared for’s treating mental health practitioners. Katherine attended ‘talks’ on nominated persons put on by a carer support group, while Elena and Alexia, who worked in the mental health system as carer consultants, found out about the mechanisms through their paid and voluntary work. Rowan said he came across information about them on ‘the Victorian State Government’s website’.

Lisa told her brother about advance statements after she went to a ‘focus group’ on them run by a mental health organisation.

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Jeannie first heard about nominated persons when her son appointed her as his nominated person on ‘paperwork’ he filled out when he was admitted to a mental health unit.

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The importance of ‘insight’

Many people thought the usefulness of advance statements or nominated persons for assisting carers to support the people they cared for depended on whether or not the person cared for had ‘insight’, as Kate put it, into their mental health. Some said the mechanisms might, in Alexia’s words, ‘work’ for people diagnosed with ‘mental illness’ who had come to an ‘acceptance’, as Kate described it, of their mental health problems. However, a few, like Sasha, felt the mechanisms would help her support her son even though she thought he had ‘no insight’ into his ‘own mental health’.

Supported decision making mechanisms were less ‘valuable’, Alexia suggested, for carers of people with severe mental health problems who ‘live in denial’.

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Instead of an advance statement, Iris thought there should be ‘a document’ that enabled people with ‘mental illness’ to appoint their carer to ‘make decisions for them’ should they become ‘unwell’.

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A few carers said the mechanisms seemed to assume there were times when the person cared for was ‘well’. However, in Dianne’s experience, her son, who had been diagnosed with a particularly ‘severe’ form of schizophrenia, was ‘never really well’. Iris, too, said she had not seen her son ‘really well for years’. She thought there would be cases where it would be difficult to identify when a person was ‘well enough to decide’ what his or her preferences were in order to include them in an advance statement or to appoint a nominated person.

Others talked about how the usefulness of the mechanisms for carers might depend on whether the person cared for was happy for him or her, as a carer, to be involved in discussions around treatment. For example, Kate said her brother was not comfortable talking about his treatment with her and her mother. This meant they felt a ‘bit of fear’ that he would ‘crack it’ if they broached the possibility he could be made subject to compulsory treatment in the future, which they would need to do in order discuss advance statements or nominated persons with him.

Losing or gaining control

For many carers, the usefulness of mechanisms such as advance statements or nominated persons to support the people they cared for depended in part on whether the person cared for saw the process as one where they exercised or gave up ‘control’, as Tracey put it. Ballagh thought her son would see the process of preparing an advance statement or appointing a nominated person as one that required him to ‘relinquish control of his mental health care’. However, many carers, including Sasha, said they thought their loved ones could derive ‘a feeling of power’ from the process of setting the mechanisms in place.

Sasha thought her son would find the process of preparing the supported decision making mechanisms empowering.

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Lisa said her brother had asked her to help him write an advance statement and they planned to have a ‘dialogue’ about it when he was more ‘well’.

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