Person‐centred care planning as foundational to clinical practice

The World Health Organization recently issued new guidance and technical packages for community mental health services, entitled “Promoting Person‐Centred and Rights‐Based Approaches” ¹ . As these documents make clear, within the sphere of mental health, the provision of person‐centred care is itself an issue of human rights. This is not only true in the cases of involuntary or coercive treatments – when precautions and oversight must be exercised to ensure preservation of dignity and respect under exceptional circumstances – but with regard to all forms of mental health care. All mental health care, including clinical practice, needs to be fundamentally re‐oriented toward the protection and extension of each individual's right to self‐determination. Re‐oriented, that is, to preserving the person's integrity as an individual while facilitating and promoting the person's pursuit of his/her own unique life goals.

In terms of practice, it is important that this re‐orientation takes place in the realms of both care planning and care delivery. It is not enough for care to be offered in a dignified and respectful manner if the care planning process is directed solely by the clinician, oriented toward symptom and deficit reduction, and dismissive of the person's everyday life pursuits. In the same vein, it is not enough for the care planning process to be conducted in partnership between a clinician and a patient (and possibly his/her loved ones), using a shared decision‐making format, if the care that is offered is then delivered in a disrespectful manner. Person‐centred care thus involves both the acknowledgement of the individual's right to self‐direction with respect to the goals of care, and the protection of this right in ongoing service delivery. In these regards, mental health care does not differ substantially from person‐centred care for any other medical condition, save in cases of imminent danger of death or disability.

But this does differ substantially from the ways in which mental health care has been planned and provided in the past. Compared to traditional methods of care planning, a person‐centred approach: a) aims to promote the recovery of a meaningful life in the community of the person's choice rather than solely minimizing symptoms and impairments; b) is based on the pursuit of each individual's own unique life goals and aspirations; c) clearly defines the person's own role, the roles of the clinician and other staff, and the roles of various natural supports in the person's life in assisting the person in achieving these goals and aspirations; d) focuses and builds on the person's own capacities, strengths and interests; e) emphasizes to the degree possible the use of natural community settings and supports rather than segregated mental health programs and paid staff; and f) expects and allows for disagreement, uncertainty and setbacks as natural steps on the path to recovery and greater self‐determination (see Roe et al ² in this issue of the journal).

In this sense, using the metaphor of recovery as a life journey results in the care plan being used as a roadmap by which to navigate one's life and experience in care. Such a person‐centred plan transforms what had been primarily viewed as a bureaucratic requirement, taking time away from the practitioner's clinical responsibilities, into what may be regarded as the essence of the work of recovery: that is, creating, implementing and modifying in an ongoing manner the person's roadmap to a fulfilling life.

Successfully forging a pathway to that life requires that an individual's rights be respected not only within the context of clinical and rehabilitative services, but in the community at large. Despite substantial progress in systems transformation around the globe, there remain limits to what formal treatment systems can do, as recovery does not happen in a vacuum but in people's day‐to‐day lives in their communities.

The most person‐centred vocational rehabilitation program is not enough to help a person get a real job for real pay; the most person‐centred residential program is not enough to help a person build a true home in his/her community; and the most person‐centred supported education program is not enough to help a person feel genuinely welcome on a university campus. These programs, while valuable, are simply not enough if people continue to be discriminated against by employers, neighbours, or fellow students based on their label of a “mental illness”. Realizing the true potential of person‐centred care thus requires a commitment on the part of mental health systems to protect human rights not just within the context of formal services, but across boundaries to local communities and society as a whole.

It also requires acknowledging that the protection of human rights is an ethical imperative now more than ever before. At its core, person‐centred care is about freedom – freedom to build a fulfilling life in the community; freedom to realize one's full potential; freedom to be free from discrimination; freedom to control choices that impact one's life and experience in care.

Both the COVID‐19 pandemic and recent episodes of violence against people of color have made it painfully clear that not all people are equally free. Even in systems that strive to be person‐centred, we continue to have staggering disparities in access to care, health and recovery outcomes, and the use of involuntary and restrictive treatment interventions. Truly committing to person‐centred care means acknowledging the fact that we are not immune to the types of discrimination that plague our broader communities. If our goal in person‐centred systems is to help all people live a fulfilling life in their chosen community, we cannot stay silent in the face of injustices nor perpetuate injustice in our own systems of care.

It is worthwhile noting that, although our argument above has been that person‐centred care and planning are first and foremost issues of rights, there also happens to be an accumulating research evidence that transforming mental health care to be recovery‐oriented and person‐centred, emphasizing the role of the individual in directing one's own care, including taking on responsibility for self‐care, leads to improved adherence and outcomes and decreased costs.

Recent reviews have found that person‐centered and self‐directed care approaches, along with the incorporation of shared decision‐making and psychiatric advance directives – all of which allow individuals to exercise greater choice and control over their own care – show benefits over usual care3, 4. These benefits are found in rates of adherence and self‐management as well as in medical and mental health outcomes, yielding improved cost‐effectiveness, service satisfaction, and quality of life, as well as reduced inpatient and emergency room use5, 6, 7 and possibly involuntary care ⁸ . These benefits appear to be even greater when interventions are more comprehensive, intensive, and integrated into routine care3, 9.

The international recovery movement has in many ways always been rooted in a human rights mission, yet that mission has most often identified formal service systems as the primary target for change. In doing so, we have failed to realize the full potential of recovery‐oriented systems transformation. The recently released guidelines of the World Health Organization reaffirm this commitment to human rights. In order to honor that commitment the field must now grapple with the many structural and social factors that often place people on the margins of society and limit their opportunities for community belonging. Person‐centred care planning represents one tool that the field can use to address these challenges in supporting the whole person on his/her chosen pathway to recovery and community inclusion.