Tuesday, 7 March 2017

Therapeutic Engagement within Acute Inpatient services – A personal Interest

  Since 2003 I have been employed by the NHS on the strength of my ‘lived experience.’ An essential criteria of the role was an acute admission, a fact in my life which at the time felt like a barrier to ever working again. The Mental Health Trust in Leeds was forward thinking and my peer worker style role was really quite revolutionary. There were 12 of us who started together and we called Service User Development Workers, each of us was allocated to an acute ward. My role is now much broader but I am still privileged to work with people within acute wards and I facilitate a group within which people can discuss their experiences and beliefs in a non-judgmental environment. 

  When I was admitted in 2001, I was told, tomorrow you will see the psychiatrist. Naively this conjured up an image of a leather sofa, a highly trained listening ear with time to hear my story and help to confirm my theory about how a traumatic event early in my life had left me broken. No, that wasn’t what happened, I spent about 5 minutes in the company of this man, he handed me haloperidol and said I would be better if I took this. I asked what would happen if I did not and was told I would be restrained and forcibly medicated. Within only a few days I was experiencing the extreme end of too much haloperidol and no words can describe the terror of that. A state in which it is hard to speak let alone engage with the challenge to unravel your mystery. Simply put I was re-traumatised by the very service which claimed to be helping me. Everything I did or spoke about became a symptom.

In truth it was a symptom! A symptom of a broken system

  I had hoped that people would have time to talk to me, help me work out the mysteries life had hidden in the hand dealt to me, to unpick my metaphors and paradoxes, but what we find is a lack of Therapeutic Engagement which is widely acknowledged and documented. In 2011 Edwards said

'The culture of acute wards needs to be kept under constant scrutiny so that the notion of therapy rather than containment is the philosophy of care'
Edwards ‘What prevents one to one care?  Mental Health Nurses 10 January, 2011

  We can see from published literature that the importance of Therapeutic Engagement is not new, back in 1952 Peplau stated that

 ‘…the general conditions that are likely to lead to health always include the interpersonal environment’

Given how long this has been known, why then does it still not exist within present  Patient Experience, while service users have been asking for it for so long?

I would like to share some of the research I have made and would welcome any comments you may have to aid developing the understanding of this issue from both a service user and staff perspective. This isn't intended to become a stick to hit people over the head with. I would like to share what I have found to develop the understanding of all the issues involved and see how together as staff and service users we can begin to improve this situation.

What do we already know from published literature

  • In 2008 the Mental Health Act Commission (MHAC) recommended that all units with patients detained under the Mental Health Act 1983 should implement a system of  patient –protected time (MHAC 2008)
  • Research shows persistently that patients in mental health wards are deprived of therapeutic interaction (Sharac et al 2010) and this situation was highlighted by England’s chief nursing officer (CNO) (Dept. of Health 2006) 
  •  Moyle (2003) found a discrepancy between friendly relationships wanted by patients and the detached stance of nurses; while the patients expected psychiatrists to focus in illness and symptoms, they did not want this from nurses.
  •   Peplau (1952) states that the general conditions that are likely to lead to health always include the interpersonal environment
  •    According to a review of patient’s experiences on MH wards (Quirk and Lelliot 2001) the desired characteristics of nurses are empathy, listening, tolerance and knowing individual needs. However patients in the review often perceived custodial or punitive attitudes in nurses; patients also observed nurses lingering in the office.
  •   Importantly they note, ‘the mental health system often diverts nurses from individualised care towards procedural priorities and maintaining order and safety. A major issue for nurses therefore is role conflict between their dual responsibilities for care and control. ‘


  •   Goffman (1961) observed that nurses maintain a social distance from their ‘stigmatised’ patients
  • Peplau (1952) acknowledges that in general personal relationships with patients are taboo in nursing.
  •   Menzies (1960) identified unconscious defence mechanisms in nurses who protect themselves from anxiety by denying involvement in their work.
  •   Handy (1991) found despite potential satisfaction from interaction with patients, MH nurses derive comfort from order and thereby they maintain an impersonal regime that ultimately causes job dissatisfaction.
  •   Bowers et al 2009, Johnson et al 2011 recognise good morale among nursing staff in acute MH units but contributory factors for lack of nurse-patient contact are not difficult to find and include high acuity, an increasing proportion of patients detained under the mental health act 1983, understaffing and bureaucratic burden.
  •   Quirk and Elliot (2001) argue that the rapid patient through put in acute psychiatric units has an adverse effect on quality of care. Reduced hospital provision has led to a higher proportion of detained patients and reliance on pharmacological rather than interpersonal therapeutic interventions.  Patients are not always amenable to therapeutic interaction because of their condition or of the medication they receive.
  •   Edwards et al (2008) examined a PET scheme and found while nurses acknowledged their responsibilities in providing time for individual patients, staff shortages and other issues made it difficult to fulfil this expectation. Nurses observed some patients did not want one-to-one sessions, and there was a lack of supervision to support the practice.

Next Steps 
  • A first step would be to define Patient Engagement Time, purpose and scope Nolan (2013)
  • An important stage is defining who within the nursing team are appropriate for delivering patient engagement time. I.e. Peer Support Workers, Nurses, Health Support Workers, Occupational Therapists
  • The Productive Ward project also known as Releasing Time to Care, focused on improving ward processes and environments to help nurses and therapists spend more time on patient care. Perhaps it is an ideal time to rerun the process.
  • Guidance should be produced for therapeutic engagement sessions based on empirical evidence. Nolan (2013)
  • Access to training and supervision. Nolan (2013)
  • Staff supervision needs to be consistent, supportive and carried out by appropriately trained, competent and experienced staff. Edwards (2011)
  • Likely to fail if it becomes another task in the daily routine and if nurses and patients are insufficiently motivated to embrace the opportunity for better engagement. Nolan (2013)
  • Mental Health Nursing lacks a distinct theoretical framework.  Formulated by Hildegard Peplau in 1948, published in 1952.    
John Thorpe - Recoveryleeds.blogspot


Department of Health (2006) From values to action: The chief nursing officer’s review of mental health nursing. DH, London
Edwards K, Dhoopnarain.  A Fellows J et al (2008) Evaluating protected time in mental health acute care. Nursing Times 104, 36, 28-29
Edwards K (2011). What prevents one to one care?  Mental Health Nurses 10 January, 2011
Goffman. E 1961 Asylums: Essays on the social situation on mental patients and other inmates. Doubleday, New York NY.
Handy J (1991) Stress and contradiction in psychiatric nursing. Human  Relations. 44, 1, 39-53.
Menzies IEP (1960) The functioning of social systems as a defence against anxiety. Tavistock, London
Moyle W (2003) Nurse-patient relationship: a dichotomy of expectations. International journal of mental health nursing
Nolan F, An evaluation of protected engagement time on staff and patient outcomes in acute mental health inpatient wards in England. Presented at the 19th International Network for psychiatric nursing research. Royal College of nursing, Warwick
Peplau. H. (1988). Interpersonal Relations in Nursing. The Macmillan Press. London. First published 1952
Quirk A and Lelliot P (2001) What do we know about life on acute psychiatric wards in the UK? A review of the research evidence.  Social Science and medicine. 53, 1565 – 1574.
Sharac J, McCrone P, Sabes-Figuera R et al (2010) Nurse and patient activities and interaction on psychiatric inpatient wards: A literature review, International Journal of nursing studies, 47, 909-917

Saturday, 7 February 2015

Within you lies the way of growth

Post by John Thorpe
 I just re-read my last post, slightly startled how it kicks off with a list of what I don't do enough of, channelled, without doubt, by my inner critical parent, I can hear the voice now, I hear it everyday. I have over time learned to recognise, that that voice, is the voice of all who sought to teach me, both things I asked to learn and things they wanted me to learn, how I should be and what I shouldn't be. It speaks, almost always in my own voice, it is, I have no doubt, my own inner dialogue, ensuring I adhere to what I have been taught and what I have been shown to be important, whether I agree or not, one simply does not question the voice of experience and wisdom.

  From an early age I was uninspired with the experience of education and developmental emphasis, my free child knew of a world vast and exiting where within each moment the universe itself articulates, inspires and guides the open heart and mind to a place where miracles can happen. Unfortunately the free child is not welcome in this culture, it has to be controlled and subjugated, to conform and develop in line with what is acceptable and laid down by convention, for most this experience is not a positive one;

                  As soon as you're born they make you feel small,     
By giving you no time instead of it all
                  Till the pain is so big you feel nothing at all
                                                                                                                                John Lennon

  ...But where there is life there is the free child. My free child, I recognise, is more than a voice informed by last years convention in this infinite ocean. My free child holds a magnetic compass, which sits at the heart of my being, when I become aware of this polarity I am naturally drawn to people and things which resonate with this growing aspect of me, the world becomes interesting and I am naturally educated by it. 

  How then do I grow beyond the script I have been living, the impasse within which I have always remained bound? The answer lies not only in how we move beyond self limiting beliefs but in how much we desire it and what we have invested in staying the same, searching the same mistaken places, drawn to the same impossible relationships and situations. After all change is scary, right? Better the devil we know right? or so our self limiting and critical voices tell us but if like me you are tired of the limits, the fear and anxiety, you need look only to yourself, for within you is the way of growth.

  The journey has been hard, we have travelled long and only on occasion has our destination come into view, our belief in reaching that place tested daily. Look at how far you have travelled, where you have come from and what you have already been through, you have already garnered enough wisdom and experience to make real your hopes and dreams. When we try to move beyond the conditioning which our inner critics impart freely, ours is to challenge gently, after all we are only challenging our selves, and we are but weary of this inner and seemingly eternal tension. The wisdom of our inner child is eternal and boundless, the wisdom of the inner critic is rooted in fear and conformity, I stress that it does have its place, it is a protector after all, but ironically it protects us from the self realisation expressed in Eastern religion, spirituality and more recently psychology. To move toward our ultimate destiny then is a process of growth akin to unfolding and as our own protective responses voice their concerns ours is to recognise their origin, express our gratitude and compassion toward how they have served us thus far and all turn and take the out stretched hand of the inner child who has walked every step of this miraculous journey.

Tuesday, 1 July 2014

Autobigraphy of the Medication Trolley

 Poem by Terry Simpson

My ancestor was a wooden horse,
innocent on Troy’s hot plain,
deceptive and ambivalent.

I am a dream of science,
restless on a stormy, medieval night,
my mother a witch who must be tamed,
screaming down the hallway
at furious priests.

I am related to the drinks trolley
Edinburgh to London,
Hot tea and coffee,
crisps and Danish,
chocolate and Heineken,
need a receipt mate?

My arrival on the ward is the climax of the day.
They line up like penitents to Mass, 
craving forgiveness.
Nurses hand down the Holy Tablets,
(sometimes too the Syrup),
and the patients are redeemed.
They go back to doze before Deal or No Deal,
or to their beds to dream of Salvation,
(known as Discharge
in contemporary parlance).

My ancestor was a wooden horse.
Now I sit on the beige linoleum,
inside me psych-active warriors
Waiting their chance to subdue
The tiresome barbarians.

Thursday, 26 June 2014

A search for self

                                                  By Recovery Leeds

I don't blog enough. I don't read enough or tweet enough. I don't train enough or reflect enough. In fact, I seldom feel I do enough of anything. Lily urges us to love ourselves, but how? Where do we start?

"I the unkind, the ungrateful"   George Herbert

Life has conditioned me to lower my eyes, beyond humility, a place more akin to shame. It is many moons since I tried to write anything down. Lily frequently encourages me to let pen and paper meet where thought and form take shape. Whilst self, too often defeating and jeering, fills my head and drowns those still quiet places where inspiration whispers softly and kindly. I long to dwell in that place, I have sought it in varying ways: the way of Zen; the way of Aikido; the way of the Gardener; the way of Recovery and Growth. All very grand with their carefully assigned capital letter, but what of self and the Way to Self. This is the path we all walk, sometimes unwittingly, in a search for something that may have already found us, the return to something never truly lost, a memory shrouded in fog, calling out through our days and nights. As Gibran puts it:

"....a shapeless pigmy that walks asleep in the mist searching for its own awakening."

Perhaps awakening lies on a pathway which becomes clear with the light of love. The only entrance to this pathway is in seeing the working of love in others, in nature and in things. The gift of sight which allows us to see love in all that is around us begins when we begin to love ourselves.

I would like to share with you one of my favourite poems.
Please forgive this indulgence.


George Herbert. 1593-1632

Love bade me welcome; yet my soul drew back,
Guilty of dust and sin.
But quick-eyed Love, observing me grow slack
From my first entrance in,
Drew nearer to me, sweetly questioning
If I lack'd anything. 

'A guest,' I answer'd, 'worthy to be here:'
Love said, 'You shall be he.'
'I, the unkind, ungrateful? Ah, my dear,
I cannot look on Thee.'
Love took my hand and smiling did reply,
'Who made the eyes but I?'

'Truth, Lord; but I have marr'd them: let my shame
Go where it doth deserve.'
'And know you not,' says Love, 'Who bore the blame?'
'My dear, then I will serve.'
'You must sit down,' says Love, 'and taste my meat.'
So I did sit and eat.

Tuesday, 24 June 2014

Saying No To Bullying

What happens when someone unfairly bursts into your world with aggressive energy? 

Bullying can feel like a physical attack, like a gong being banged loudly in my ear, like someone jumping on me, or jumping down my throat, like being crushed or trodden on. These are all things I have heard bullying or power misuse, described as. And what does it look like:

  • ·         Shouting or using the voice with aggression;
  • ·         Using body force or posturing;
  • ·          Making direct or indirect threats.

It can also be subtle. Someone who constantly assumes a right, a preference or a control over my rights, time or belongings, is also oppressive. This can be insidious, and it’s tricky to think straight about, but the discomfort is my instinct telling me that the power balance is wrong.

When someone uses power against me unfairly, it invites me to take a “one down” or an “I’m not ok” position. It’s as if the person, and the words they bring, crash into the space around me that I would usually want to keep safe. It throws me off kilter. At certain times, if I’m already struggling to maintain balance, it can feel worse. It’s like riding a uni-cycle in heavy traffic when a car gets way too close and I fear falling. Or that I am trying to steer a boat in rough seas with a stick instead of a pair of oars and an aggressive intrusion can feel like the person has taken the stick. The last straw! 

You know those days. Even on a good day unfair use of aggression triggers adrenaline. I feel threatened, shake, get butterflies, feel confused about the ground I’m standing on, and worst of all, lose my, often tenuous sense that I am acceptable to the world. If I also find I’m unacceptable to myself, I’m much more likely to swallow and accept the aggression as deserved. I yield to it and bare my neck and hand the authority of the space and my self, over to that person or power. 

My memory recognises that pathway and it reinforces earlier experiences of bullying, abuse and oppression and I find myself in that old place again, feeling diminished with fewer or no rights and it eats away at dignity, self-esteem and confidence and I know I lower my eyes to others and shame myself in our my own eyes. Even as I’m describing this internal process, my stomach is knotting and sinking. The saddest thing is that I know I’m not alone and come across others that feel this cycle regularly, especially because we’re susceptible to being drawn to that kind of person. Why???? Because we want to have a different ending and finally experience respect and equality from the original bully? Because it’s familiar and we “know” this energy? Because you just can’t avoid some bullies, even when you try and they always manage to press those same buttons?

I hate bullying and the behaviours that go along with it because it is corrosive to the human psyche, to a person’s life path and the free choices and rights to be fully who we are. Bullying and oppression impacts a person’s internal and external world. Everyone has the right to stop bullying from coming inside themselves.

What do we do with the feelings that we are left with, if someone bullies us?

When somebody attempts to over-power me, for whatever reason, it can throw me for hours or days. I can feel very dejected. At times, I’ve responded to repetitive bullying with an over-reaction of rage which leaves me feeling absolutely horrible. Because I then know that I am bullying too! It’s an over-reaction because it’s triggered by old experiences of bullying and I know I’m reacting from that place too. I don’t want to do that and only want to give back today's negativity. 

The point where the aggression hits me and knocks me off balance is the point I start with. You can rarely stop a bully from bullying, although that can come later with some, if you really empower yourself. What is important in the moment is to take charge of my response. “No-one has the right to de-stabilize me by using power unfairly.” I’ve tried all sorts over the years to regain my balance quickly when this occurs, so that it doesn’t resurrect those old ghosts. I rarely manage to catch it in the moment, by having the right thing to answer back with, or let it slide off me as “that’s not my stuff”!!! but when I do, it can help stop that internal chain of self-criticism and the desire to crawl under a stone! 

After a meeting with a bully’s energy, I find the most useful thing is to find some privacy and stand back and visualise the person putting their words and energy on an imaginary table in front of me. It helps me separate from them immediately. I then have a choice as to whether I pick up this attack or not. If I feel some is deserved, I can take that bit, but leave the aggression, diminishing and controlling behaviours on the table. At the same time as visualising this, I stand up straight and strong in my spine and breath slowly in and out, repeating something self-supportive either in my head or out loud.  “I deserve respect”, “I am as good as every other person”, “I have good instincts”, “I have a right to be treated in a respectful way”, “I will not be bullied”, “I do not accept oppression and I’m leaving it on the table”. You can define your mantra for whatever is right for the moment as a counter to whatever the bullying person is attempting to throw into you.

When someone repeatedly crashes your respect boundaries, it is an invitation to re-evaluate the relationship. Sometimes, this is really hard, especially if it’s a relative or a boss, a neighbour or a care-giver. Get support, good support. Friends that are really in your corner, or professionals that you’re in touch with. Don’t continue to tolerate being bullied. It is destructive to your internal and external world and can stop you being who you are meant to be. As much as you can, spend time with people who build you up by being respectful rather than being out to exploit you. You’re worth much, much more than where bullying energy puts you. Let the dejection help you to make a decision to commit to resilience and to not continue the bullying by bullying yourself and accepting the negative and misplaced attack. 

Love yourself