People, process, and power: implementing advance choice documents for Black people in mental healthcare

Advance Choice Documents (ACDs) have been recommended for inclusion in new mental health legislation for England and Wales based on evidence they reduce compulsory psychiatric admission, with particular benefit for Black people. As Black people disproportionately experience compulsory psychiatric admission in the UK, our aim was to explore potential barriers and enablers to effective ACD implementation for Black people with previous experience of compulsory admission.

Six stakeholder workshops and one consensus workshop were held with: Black service users who had previously been involuntarily admitted, carers/supporters of Black service users, and mental health staff. Thematic analysis was conducted on workshop transcripts.

Participants were service users (n = 13), carers/supporters (n = 7), service users and carers/supporters (n = 3), and staff (n = 18). Thematic analysis identified themes of 'training', 'completion', 'access', and 'use' concerning ACD implementation. Stakeholders highlighted the importance of understanding the racialised experience of Black service users for effective ACD implementation. Strong communication between and amongst stakeholders and helpful systems for access were also emphasised. Stakeholders also recommended joint training and independent facilitation of ACDs to address Black service user-staff power imbalances.

Known enablers and barriers to ACD implementation are important when considering ACDs for Black people, as is explicitly engaging with their experiences holistically, including racialised historical and individual experiences that underline some treatment preferences. Independent facilitation and shifts in service user-staff power dynamics present as key to realising the potential of ACDs to empower Black service users in relation to their care, and in turn to potentially reduce coercive care.