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‘RECOVERY’ AS THE FUNDAMENTAL AIM IN A/NZ MENTAL HEALTH SYSTEM

“Recovery is a deeply personal, unique process changing one’s attitude, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying hopeful and contributing life. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of psychiatric disability.”

(William Anthony, 1993: 12-13)

POSITIVE RISK MANAGEMENT IS NEEDED:

…decisions about risk management involve improving

the service user’s quality of life and plans for

recovery, while remaining aware of the safety needs

of the service user, their carer and the public… Over

defensive practice is bad practice. Avoiding all

possible risks is not good for the service user or

society in the long term, and can be

counterproductive, creating more problems than it

solves (UK DoH 2007, cited in Woods 2013: 808.)

COLLISION BETWEEN RECOVERY ORIENTATED PRACTICE AND CORPORATE RISK MANAGEMENT• Corporate risk management designed to protect organisations

and their workers from error and blame.

• This can lead to development of a ‘blame culture’, with ‘defensive practice’.

• Special significance given in such a culture to critical and adverse incidents . They come to define in retrospect what constitutes acceptable or unacceptable practice.

• Workers come to rely on routinised procedures to protect themselves in relation to idiosyncratic practice problems, instead of their experience and judgement.

• These routinised procedures often developed in relation to inquiries and courts of review outcomes.

Sawyer and Green 2013

Tickle, et al 2012: 5

WE ATTRIBUTE BLAME NOT – OR NOT JUST – TO THE

PERSON WHO HAS COMMITTED AN ACT BUT TO THE

AUTHORITY WHO SHOULD HAVE FORSEEN AND PREVENTED

IT. ONCE IT SEEMS POSSIBLE TO PREDICT THE FUTURE

THROUGH THE APPLICATION OF KNOWLEDGE, ONCE IT

SEEMS POSSIBLE TO TAKE ACTION IN THE PRESENT TO

AVERT A POTENTIAL UNWELCOME FUTURE, THEN FAILURE

TO DO SO CANNOT BE ASCRIBED TO CHANCE. EVEN A NON-

DECISION IS A DECISION. SOMEONE HAS DECIDED,

SOMEONE COULD HAVE DECIDED OTHERWISE, SOMEONE IS

THEREFORE CULPABLE.

Rose 2005: 8-19

RISK CULTURES CREATED

Adverse incidents occur…

Coroner’s reports, HDC reports, litigation, media outcry…

Policies to protect organisations from institutional liability created (corporate risk management)…

Defensive practice develops…

Freedom and autonomy lost to patients…

Iatrogenic risk: trauma, suicidality and loss…

TRAGIC OUTCOMES…

25% of people committing suicide (England and Wales) have had recent contact with mental health services.

160-200 mental health inpatients (England and Wales) die by suicide annually.

About 50 homicides per year committed in England and Wales by people who have had recent contact with mental health services

Tickle, et al 2012: 3.

CLOSED DOWN ENVIRONMENTS

The tea and coffee making facilities in the patients’ lounge were kept locked away. As a result, patients had to use the kitchen to make tea and coffee, which wasn’t always open to them. When it wasn’t open, they had to ask a staff member to make them a hot drink. I asked why the tea and coffee making facilities in the patients’ lounge were locked, and was told that the hot water was a risk.

The courtyard off of the second patient’s lounge was kept locked. Patients weren’t allowed to use it at all. I asked the reason for this, and was told that it was a risk as patients might hang themselves from a fence ligature.

When patients want to wash their coffee mugs, they have to ask a staff member to open the locked cupboard under the kitchen sink, which contains nothing except washing up liquid. I asked why this was kept locked, and was told it was a risk.

The windows in the main part of the ward only open a few millimetres. This means that it is impossible to generate a flow of cool air on hot days.

SOME QUESTIONS

Is it possible to prevent all adverse incidents, if somebody is determined to harm themselves?

How much control would be required to achieve this?

What are the consequences for the patient’s sense of emotional wellbeing, of being subjected to this level of surveillance and control?

What does ‘safety’ mean? Who is it for?

RECOVERY AS A SYNONYM FOR ‘LEARNING’

“Peer support is a very deep thing, you know. And recovery and wellbeing’s a very deep thing as well. You know you could say recovery’s almost like a spiritual experience but it’s certainly, I would say, a critical learning experience. It’s an experience of true learning. And if you look at learning environments and recovery environments, they’re the same thing.”

(Geoff, peer support manager, cited in Scott et al 2011a: 21).

A CULTURE OF FEAR…

Because I was waking very early during my time on the ward in November 2013, my consultant charted early morning walks for me, before the ward doors opened. I went for one early walk, at 7 am, without incident. When I tried to go the next morning, I was told that this wasn’t allowed by ward policy, and I had to wait until the doors opened at 8 am. When I asked the reason for this prohibition, I was told that it was because early morning walks were risky, since few people were out and about.

MORE QUESTIONS…

How does one balance the desire to support autonomy, healthy activity and creativity, along with the need to ‘protect’ very unwell people?

How does litigation, and media reporting, around adverse incidents drive defensive practice?

Is it easier to deal with one’s guilt feelings over not preventing a suicide, or other blatantly harmful event, or one’s feelings about ongoing repression of choice and freedom?

How does the making of ‘ward policy’ allow the personal divestment of such guilt feelings?

RISK CULTURES ARE DRIVEN BY FEAR…

…it seems, on balance, better to take some well judged, carefully worked out risks than to lock everybody up and throw away the key, that’s crazy. (Angela, cited by Tickle, et al 2012:7).

…assessment is only as good as the minute and day that you do that assessment, and the assessor who’s doing it, and an hour later, 5 minutes later, things can change enormously. (Trish, cited by Tickle, et al 2012: 7)

LACK OF TRUST LEADS TO ‘NOTHING TO DO’

During my March-May stay, there were no games on the open shelves in the lounges where patients could access them. I asked the reason for this, and was told that patients might ‘lose’ or ‘break’ the pieces. I was told that there were games available to patients. I asked where these were, and was shown a locked cupboard in the intensive care wing of the ward. The cupboard was not labelled, and there was no indication of what games were there, or indeed if games were there at all. Most patients are not allowed on the intensive care wing. During the two months I was on the ward, the only game to come out of this cupboard was scrabble. This was played extensively by patients. Most of the patients were entirely unaware that there were any other games anywhere on the ward.

YET MORE QUESTIONS…

How does a ‘culture of risk’ build on itself?

Can restrictions intended to prevent suicide or other major events lead to restrictions focused on much smaller ‘risks’? How and why does this happen?

How does development of a ‘culture of risk’ affect therapeutic relationships?

HOW CAN A RISK CULTURE BE ‘TURNED AROUND’?

“We work on relationship; I think that’s the thing that we do really

well. And when those relationships are working well, we’re checking

in with the people all the time and we’re seeing whether they’re

eating, drinking, doing all the normal things or not. And you know,

if the person stops eating and drinking and stuff like that, you

might think, ‘What’s going on with them?’, and you can check it out

and see if they’re ok. It’s that relationship, and we put a lot of

intense hours into just chatting with people… and it’s really great to

get people reporting for themselves and taking responsibility for

themselves to say, “hey, I’m feeling a bit unsafe”. You know,

recognising it first themselves, before they do anything.” (Maya,

peer supporter in a crisis house; Scott, et al 2011a: 55).

AGENCY IS CENTRAL…

“It is important to understand that persons with a disability do not ‘get rehabilitated’ in the sense that cars ‘get’ tuned up or televisions ‘get repaired’. Disabled persons are not passive recipients of rehabilitation services. Rather they experience themselves as recovering a new sense of self and of purpose within and beyond the limits of the disability. ... It is through the process of recovery that disabled persons become active and courageous participants in their own rehabilitation project.”

(Deegan 1988: 12).

“One team’s coming from a very risk averse medical

model approach. And we’re coming from an

opportunity, risk is opportunity and if you don’t take

any risk you don’t learn anything, sort of approach.

And, but the safety’s in… I guess safety’s not quite

the right word. The container is the relationship,

really, the peer relationship.” (Geoff, peer support

manager of a crisis house; cited in Scott, et all

2011a: 57).

SOME THEORETICAL QUESTIONS…

How and why are patients ‘governed’ in the mental health system?

If selves are constructed through discourse, what are the ‘selves’ that are available to patients in a risk culture?

What sort of self can be constructed in a recovery environment?

How can fear of suicide, self harm and harm to others be addressed when constructing such regimes of governance?

REFERENCES

Patricia Deegan (1988) ‘Recovery: the lived experience of rehabilitation’; Psychosocial Rehabilitation Journal 11(4): 11-19.

William Anthony (1993) ‘Recovery from mental illness: the guiding vision of the mental health service system in the 1990s.” Psychosocial Rehabilitation Journal. 16: 11-24.

Anne Scott, Carolyn Doughty and Hamuera Kahi (2011a) Peer Support Practice in Aotearoa New Zealand. Available online on HDC website: http://www.hdc.org.nz/media/199065/peer%20support%20practice%20in%20aotearoa%20nz.pdf

Anna Tickle, Dora Brown and Mark Hayward (2012) ‘Can we risk recovery? A grounded theory of clinical psychologists’ perceptions of risk and recovery-oriented mental health services’; Psychology and Psychotherapy: Theory, Research and Practice.

Nikolas Rose (2005) ‘In search of certainty: risk management in a biological age’; Journal of Public Mental Health 4(3): 14-22.

Woods, P. (2013) Risk assessment and management approaches on mental health units. Journal of Psychiatric and Mental Health Nursing 20: 807-813.

Sawyer, A.M. and Green, D. (2013) Social inclusion and individualised service provision in high risk community care: balancing regulation, judgment and discretion. Social Policy and Society 12(2): 299-308.