Key messages in later life mental health care: New directions and new ambitions
In the Introduction to this book, we stated that our aim was to link the work of multidisciplinary services with realistic evaluations of the complexities of living with mental health needs in later life. In the ﬁnal production of the book, this link was predominantly illustrated through detailed case study work where the specialism of the multi-disciplinary team, such as psychosis in later life (Chapter 5), was the diagnostic focus and the person living with the condition the focus of care. In order to tie the book together, this brief concluding chapter distils the key messages of the text to help shape thinking and debate in later life mental health practice. Through the editorial process, four key messages emerged that transcended each
chapter to provide a cohesive link throughout the book; we have named these four key messages as: 1 Biographical Mapping; 2 Integrative Team Working; 3 Generating an Evidence Base; and 4 Challenging Stigma. In addition, each of the four key messages has been ascribed ﬁve challenges that summarise our aspirations for new directions and new ambitions in later life mental health care. Naturally, these four key messages and ﬁve challenges are not the ﬁnal word on the topic; rather, we see them as stepping stones for consensus to emerge, which, in turn, can help bridge reﬂection and practice change.
Given the instructions to authors for the development of their chapters, it is perhaps no surprise that the older person’s voice and lived experience is heard throughout the book. That was our intention, as mental health work across the life-span is all about people and their lives, relationships, social circumstances, beliefs, values and culture. To lift a person out of the context of their life story is to fragment a life. This was acknowledged in the New Horizons report (Department of Health 2009a), and it has been known for some time that a biographical approach to mental health practice is essential if shared decision-making and meanings are to guide intervention (Butler 1963, 1975, Johnson 1986). Indeed, as Bury (1982) himself identiﬁed nearly 30 years ago, chronic and adverse events experienced during the life course will cause a biographical disruption for the individual and this disruption is assimilated into the person’s identity. Arguably, the work of mental health services and practitioners is to then identify, recover (where possible) and heal such a fracture. Grounding understanding and intervention within a biographical approach was seen repeatedly in this book. To take but one example, the work of Karin Terri Smith and Lorna Mackenzie of the Newcastle Challenging Behaviour
Team, outlined in Chapter 9, demonstrated the importance of knowing who Rebecca is/was in order to make sense of her presented behaviour and communication pattern. Without knowing Rebecca, the intervention and case formulation that was then enacted would be meaningless and rooted only in a professional construction of need. Older people living with mental health needs have a signiﬁcant part to play in
developing and shaping their own care agenda. Indeed, each chapter in the book revealed rich and varied personal biographies that informed care practice with teams (and individuals within teams) working hard to locate the meaning of their intervention so that it was co-terminus with the understanding of the person living with the condition. As Richard Ward and his colleagues described in the opening chapter, from the perspective of older mental health service users effective participation in mental health practice is likely to be co-created. Consequently, the determinants of a successful intervention will be layered with the multiple meanings that this has for the person living with the condition. Spending time to map a person’s biography, in whatever way possible, becomes a cornerstone of mental health practice in later life; without it, clinical decision-making is not personalised and, instead, is reduced to narrow generic diagnosis-based packages operationalised through custom and practice. What becomes unclear is how this biographical mapping then travels with the older person in the journey through their condition(s) and/or is used to inform future care planning. Perhaps this is a next step in clinical decision-making.