Risk Management Begins at Home

Keir provides therapy, training and consultancy via www.beamconsultancy.co.uk

For a while now I’ve been writing about the impact of overly defensive and restrictive practices on the people that I work with (like here and here).  The usual story that I tell is of people being at risk in the community but that risk increasing massively when in hospital.  Unable to see that the ‘help’ seems to putting the service user in greater danger, the answer is seen to be more restriction, greater security and eventually a few years locked rehab unit.  

While many people can recognise the pattern described above, it’s not something that gets promoted a great deal in services where the message of ‘doing whatever it takes’ to keep people safe is often repeated.  It was interesting then to read the Independent Review of the Mental Health Act and to see  Sir Simon Wessely expanding on these very themes right at the beginning of the document.  

My MSc dissertation (which I will publish at some point) concluded that it was fear of what clinicians might be blamed for that led to some of the most restrictive practices in the organisation.  The MHA review begins by talking about Fear – 

“Professionals are fearful that unless they adopt a cautious, risk averse approach to their patients, they will find themselves being publicly shamed for those occasions when those same people cause serious harm to themselves or others”

While it is rarely said out loud, this means that people who are in services to receive care and support, can instead be viewed as people who are dangerous to those who should care for them.  The danger is not so much about what service users might do to a clinician (although this fear is not uncommon) but what clinicians might be blamed for.  The service user moves from being a focus of support, to a threat that can damage or destroy a clinician.  It is unsurprising then that the way service users experience ‘care’ is often not perceived as kindness. 

One way that clinicians can rid themselves of any blame for the actions of those in their care is to pass the responsibility for their care onto others.  I have observed and been part of too many unenthusiastic interactions where someone has been referred for an assessment just so that someone else can make a decision (Sometimes with the full knowledge that it’s a waste of time, but at least it’s the other team that has said No rather than us).  It is dispiriting for all concerned and can too often lead to an inappropriate level of restriction because anything less restrictive ‘isn’t worth losing my badge over’.  Bethany’s dad (@jeremyH09406697) is an avid campaigner against restrictive practice and his experiences seem to echo Wessley’s sentiments that –

”some people with a learning disability, autism or schizophrenia are being “warehoused” as we now call it in locked rehab wards, or unsuitable long stay wards which exacerbate and not ease their problems”

I wish that the chair of the review saying that what we do to people in the name of safety is making things worse had excited the media and society a bit more.  Sadly at the time it was released we were too focused on whether to throw rocks or olive branches towards Europe.  

“So whilst fear of the mentally ill has decreased in the public, parliament and media, a different kind of fear has increased – the fear of making a faulty risk assessment that influences many professionals.”  

The consequence of this is that for many professionals, risk management has “slipped into ‘managing risk to themselves”.  This makes sense as the consequences for a wrong decision can be catastrophic, but to look after ourselves before the person we are being paid to care for is a perversion of our duty of care.  

Wessely suggests that this practice can explain some of the rise in detentions under the mental health act, the sterile nature of many inpatient units and some of the more baffling “just in case” interventions that can take place (No shoe laces for someone with no history of ligaturing?).  I agree with him.  He goes on to suggest that clinicians and services need help from the government and the law to ensure that ‘positive risk’ (which can often mean anything other that the most restrictive practice) is supported.  I hope this can happen, but at the moment, its only @normanlamb I ever see talking about this issue.  

Much of my work over the past few years has been around helping organisations question and avoid some of the more restrictive options available when caring for people who cope in ways that can be dangerous to them.  There’s a range of things that can be done to relieve some of the anxiety in the system and to ensure that the needs of the service user are kept at the forefront of the minds of the people involved in their care.  I may expand on these in future posts but briefly…

  • Too often decisions about how to manage someones risk are made without them.  When they are made an equal partner in decision making, most people can describe their wishes and aims in ways that can reassure people.  We don’t need to agree with people’s decisions, but if we give people all the information at our disposal then we should respect what they want and think about how to support them with their goals.  Where the service user isn’t able to articulate a view, it’s useful to have the input of an Expert by Experience who can help staff teams make sense of why people do what they do.  

 

  • We are often quite poor at giving people information.  I’ve never had anyone respond to the rationale “it’s for your own good”, but I have had people respond to genuine dilemmas where we weigh up pro’s and cons together.  

 

  • We can often have a fantasy about what ‘the next level up’ will be like.  In my experience the extra level of restriction either exacerbates the current difficulties or needs to use increasingly potent cocktails of medication to achieve the desired response.  The intensive therapy supposedly on offer is rarely available and when it is, there’s little benefit from being forced to do therapy.

 

  • Clinicians should never feel that they’re alone in making decisions.  The backing of senior managers and most importantly the service user themselves can take away a lot of anxiety.

 

  • We need to learn from the past.  If someone presents for the 20th time we need to use the knowledge that we have rather than act as if it’s the first time it has happened.  Thinking about crisis when not in crisis is essential and being able to communicate the plans we have made so that people aren’t ‘thinking on the spot’ is really useful too.

 

  • A good risk formulation can again take away a lot of anxiety.  This can help us move from “What’s the worst thing that can happen?” To “What is likely to happen given our past experience?”.  The service users I work with and I have used this to help teams see that for some, admission is likely to result in more lethal methods of coping.  Equally it has helped others recognise that after self harm is a time when the urge to harm has been reset, rather than the time to restrict.  There is little substitute for a coproduced formulation in helping everyone understand the risks and thus agree how to move forward.

There was a post on twitter recently that likened positive risk taking to clinicians neglectfully gambling with peoples lives.  I hope that people can see that this isn’t what I’m advocating.  Trying to eliminate risk can paradoxically put people in danger and we need to keep an awareness of this as we balance the need to support people with the need to keep them safe when they have lost the ability to do it for themselves.  If we can recognise when the focus of our work is protecting ourselves then we can step back and refocus on the person we are supposed to be helping.  If we can do this, the chances of our input being perceived as kindness is substantially increased.  

If you or your organisation would like to talk about how we can help with any of the above please get in touch via the website.  Keir provides therapy, training and consultancy via www.beamconsultancy.co.uk

Use A Little Restraint: Why People Who Self Harm Must be Forced to Stop.

Lets start by saying that I self harm.  I self harm regularly in a way that society tends to approve of.  Most Saturdays  I strap on my rugby boots and on a good day,  for 80 minutes large, hairy men will charge at me while I try to knock them over.  On other days I am punched, stamped on, scraped with studs, or just hurt.  Over the years I have broken my nose, chipped my teeth, ripped the skin under my chin open, split my forehead and all last week, sported a big purple eye.  I play rugby every week, not seeking pain but knowing full well that it is inherent in this activity.  The pain and damage that it gives me is worth it in terms of the other benefits that I receive. Now obviously playing rugby isn’t the same as cutting lines in my thigh, but I’m arguing that that both activities are on a spectrum of things that damage you but come with some reward that makes it worthwhile.

Now its interesting that nobody cares about my self harm in the slightest.  In work I spend a lot of time with people who regularly self injure, where others aren’t that bothered about their self harm either.  At work I try to point out the link between self harm and suicide, offer to help and support people who want to stop and encourage them to care for themselves in ways that don’t involve hurting or punishing themselves.  I never forcibly stop them. The people I work with all live in the community and can make informed decisions about how to live their lives.  If they want to stop self harm I’ll  do my best to help.  If they don’t I’m  still there (although I might let them know how I’m  affected by it).  Self harm is their understandable way of coping which they do because it works.

On the ward, it is a different story.  The people I work with tend to have long standing thoughts of suicide.  When that chronic risk becomes acute they might be admitted.  What is interesting is that it becomes an unspoken part of someone’s care on the ward that they must immediately stop all forms of self harm.  It doesn’t matter that self harm wasn’t a factor in their admission, it has become one now.  Usually the acute period of suicidality passes fairly quickly, but because those who have self harmed for years have suddenly lost their only way of coping the risks go through the roof. Those who cut carefully with blades are ripping cans open, smashing crockery, banging their heads on the wall and (potentially most lethally) tying things around their neck in a quest to get whatever benefit they usually receive.  It is at this point the person tends to want to get out of hospital asap and it is at this point that the enforced self harm abstinence really comes into its own. While the client articulately tells people they don’t want to die and just wants to go home, we can’t let them go until they fit our model of wellness, which tends to involve them presenting with healthier coping methods than they have used in years. 

With people who don’t want to stop self harming (and weren’t admitted to do so) psychological intervention to help them stop rarely works.  Instead we prescribe different intensities of observation ranging from being checked on once an hour to being followed constantly by 1 or more staff.  At times we can administer a PRN dose of heavy staff to physically stop whatever behaviour we find intolerable.  As the risks increase the number and weight of the staff rises proportionally and eventually we decide that the only solution is large staff in an environment far away from us.

We can wonder about why MDTs need someone who has no intention of stopping self harm to be self harm free before they are discharged.  We can spend even longer wondering how a period of stability can be achieved when long standing coping mechanisms are forbidden, everything is scrutinised, no leave or time alone is allowed, any emotional response to this treatment is written off as part of the diagnosis and if you do try to hurt yourself in a way that no one would have batted an eyelid at in the community, 3 heavy men will hold you on the floor in a vague reanactment of one of your most traumatic experiences. 

Looking at this rationally we can see that if you want to seriously upset and disregulate someone, following the above “care”plan might well be the perfect way to do it. 

 

Its worth thinking about why situations like this come about.  I hear others say that they are kicked off the ward as soon as they self harm but for some clients, ward based self harm is more effective at keeping you on the ward than locking yourself in the nursing office.    It makes sense that we let people make their own decisions about how to manage their distress in their own homes, but why do we have to forcibly prevent them on the ward?

There’s two main factors at play for me. The first is that the majority of mental health staff come to work to make people better.  Our training prepared us for people who would come in with simple problems, we would dispense our wisdom and they would recover and be grateful.  It is almost impossible for staff to look at someone under their care bleeding profusely and feel they are doing a good job.  Stopping self harming is a kind of recovery and if people won’t get better, we will make them better.  I’m sure this starts out with the most caring and compassionate motivations but after a few weeks of wrestling much of the empathy will have evaporated.

The second is how painful it is to see someone hurting themselves.  There is the immediate visceral impact of seeing damage occurring, the emotional reaction to seeing someone in so much distress and the psychological trauma of watching someone causing damage to themselves. When we combine people who see their role as preventing harm with people who use harm as a way of coping we manage to whip up a perfect storm where the more we help, the more abusive we are perceived. Given no obvious other way of helping we do everything we can to prevent harm occurring and lose sight of how much added distress, trauma and risk our help is causing.  Regardless of the clients wishes, we will join the long list of other people in their lives who forced them to do what we wanted.

I see the above frequently and I suspect it is replayed across the country. I worked with a man recently who was only ever violent when he was in hospital.  He was no longer suicidal but couldn’t be let off the ward until the behaviour that only occurred on the ward had stopped occurring on the ward.  

My solution is for organisations to have a team to think about these complex dynamics that are so hard for us to see when we are caught up in them.  The NICE guidelines for borderline personality disorder describe teams who support the organisation to formulate, assess and respond to complexity and risk in thoughtful ways.  A 3rd mind that can ask the question “Why do we keep doing this when it makes it worse?” can be invaluable.  

So often I find that staff caught up in these situations are utterly miserable.  They can see that they are actively harming someone with their help but feel powerless in a system that knows only higher levels of restriction in response to risk.  In my ideal world admission would rarely be used and when it was, the benefits/costs would be thought about beforehand.  At the very least on every care plan we would rubber stamp “do not detain in hospital for behaviour we wouldn’t consider detention for in the community”. In models of organisations that work with people, a strong emphasis is placed on the value of a thinking space.  I regularly hear that this can’t happen and that action is valued much more.  If staff can’t be given space to think and reflect then specialised teams might need to do their thinking for them.  This might involve changing the culture of the organisation so that risk is thought about in a different way.  I have 2 fears.  One that this will only begin to happen after someone who is far more dangerous as an inpatient accidently kills themselves on the ward.  My other fear is that this happens time after time and we still can’t learn from it.

Now blanket approaches to managing risk are rarely successful and its most beneficial to think about everyone individually.  I’m not advocating for inpatient environments where anything goes, but for thoughtful consideration of how people respond to an environment and how we respond to their presentation.  If nothing else, let’s think about our role in someone’s change in presentation. Most importantly, lets ensure we are never a part of someone being sent miles from home to be forced to stop something that was never a factor in their admission.

All thoughts appreciated @keirwales

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

 Much of this was inspired by a conversation with @graffiticymraeg who’s blog https://themainoffenderblog.wordpress.com/ is far better than mine

All the above reflects themes expressed much more articulately in The Ailment 

https://www.google.com/url?sa=t&source=web&rct=j&url=http://www.ljaa.lv/download/dokumenti/the_ailment_by_t_main.pdf&ved=0ahUKEwiHwLmDx6nSAhUhLMAKHRoqDcYQFggaMAA&usg=AFQjCNGrZVjErJGBfwhJE2BxcI7ug01wrQ&sig2=-tsrJcsIbiSxsXYXIKp5Vg