This is the Faith from which we start... From bitter searching of the heart... We rise to play a greater part... L Cohen
Wednesday, 26 July 2017
Who Am I
Tuesday, 7 March 2017
Therapeutic Engagement within Acute Inpatient services – A personal Interest
- 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.
- 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.
References
Tuesday, 30 April 2013
This is my Church, This is where I heal my hurts
From the first class I was hooked, the principles and practice of Aikido fed a hunger which began in my childhood. I trained under my instructors as often as possible, even setting up a small dojo in my house where I could practice daily. In 1994 it was my honour and privilege to be asked to teach my first class and soon I began to make plans to set up my own local ‘Leeds’ class.
He grasped my wrist firmly, my body turned as he did so and I felt the authentic power of good posture and breathing, he allowed me to practice the exercise over and over and I began to feel strong again, a strength I thought was lost forever. I understood the role my Aikido would take in this battle. We practiced some sword exercises together and when he left I remained for some time lost in bokken suburi, a solitary exercise. The next day I was as before yet the memory of that authentic empowerment remained.
Through the course of my training mental health episodes have taken me away from the dojo, so it was to my great surprise and joy that the principal instructor of our club promoted me to the rank of Sandan, 3rd Dan, in December 2012. That day was a huge milestone in my recovery.
Friday, 12 March 2010
Interpersonal Relations in Nursing: A Conceptual Frame of Reference for psychodynamic Nursing: Hildegard E. Peplau
Peplau Interpersonal Relations
Coatsworth-Puspoky, Forchuk, and Ward-Griffin conducted a study on clients’ perspectives in the nurse-client relationship. Participants in a study were asked about experiences at different stages of the relationship. The research described two relationships that formed the ‘bright side’ and the ‘dark side’. The ‘bright’ relationship involved nurses who validated clients and their feelings. For example, one client tested his trust of the nurse by becoming angry with her and revealing his negative thoughts related to the hospitalization. The client stated, “she’s trying to be quite nice to me…if she’s able to tolerate this occasional venomous attack, which she has done quite well right up to now, it will probably be a very beneficial relationship” (350). The ‘dark’ side of the relationship resulted in the nurse and client moving away from each other. For example, one client stated “the nurses’ general feeling was when someone asks for help, they’re being manipulative and attention seeking” (351). The nurse didn’t recognize the client who has an illness with needs therefore; the clients avoided the nurse and perceived the nurse as avoiding them. One patient reported, “the nurses all stayed in their central station. They didn’t mix with the patients…The only interaction you have with them is medication time” (351). Neither trust nor caring was exchanged so perceptions of mutual avoiding and ignoring resulted. One participant stated, “no one cares. It doesn’t matter. It’s just, they don’t want to hear it. They don’t want to know it; they don’t want to listen” (352). The relationship that developed depended on the nurse’s personality and attitude. These findings bring awareness about the importance of the nurse-client relationship.
Coatsworth-Puspoky, R., C. Forchuk, and C. Ward-Griffin. “Nurse-client processes in
mental health: recipient’s perspectives.” Journal of Psychiatric and Mental
Health Nursing 13 (2006): 347-355. EBSCOHost. McIntyre Lib., UW-Eau
Claire. 12 Nov. 2006
Wednesday, 2 December 2009
Spiritual Emergence and Spiritual Emergency
A Literature Review and Discussion paper
Dr. Patte Randal and Dr. Nick Argyle
When spiritual development is gradual and occurs in a context which can support the personal changes in worldview that it brings, there should be no crisis of transition. When it is sudden, or the higher stage is experienced intermittently there can be uncertainty or crisis. In this context, Grof and Grof [35, 36] write about spiritual development using the term "spiritual emergence". By this, they mean "the movement of an individual to a more expanded way of being that involves enhanced emotional and psychosomatic health, greater freedom of personal choices, and a sense of deeper connection with other people, nature, and the cosmos". They go on to make a distinction between this natural process, and a more difficult and sometimes traumatic experience, ".When spiritual emergence is very rapid and dramatic, however, this natural process can become a crisis, and a spiritual emergence becomes a 'spiritual emergency'". Episodes of this kind have been described in the sacred literature of all ages as a result of meditative practices and are signposts of the mystical path.
In a psychosis formulated as a spiritual emergency best care will both use the spiritual sphere to speed recovery and avoid iatrogenic damage. There are some similarities to general crisis intervention that sees crisis as a time of opportunity. Psychosis appropriately framed as "spiritual emergency" can be seen as an opportunity for further personal growth, if responded to in appropriate ways.
Treatment of spiritual emergency is supportive, does not usually involve medication (other than occasional use of a minor tranquilliser or hypnotic to ensure sleep if necessary). Care is usually undertaken by people who have a transpersonal understanding and some experience themselves of these phenomena. It involves "being with" the person, usually in a tranquil environment, doing everyday things to help "ground" the person. Reception of the altered state is characterized by trust rather than fear, with the expectation that healthy, natural resolution will occur in time, with a beneficial outcome in terms of personal growth. Sometimes constant supervision can be necessary to help prompt care of basic needs, such as eating and drinking, if these are being neglected. Cessation of intense spiritual practices at this time is usually recommended, but prayer support may be offered. Explanation of the psychotic experience in terms of the spiritual domain is helpful. The person is supported in expressing the content of their inner world at their own pace, and when
appropriate, the psychospiritual roots of the problem can be addressed. For this type of care to become available within general mental health services, clearly appropriate staff selection and training would be required [65, 66].
The danger for people being diagnosed as having a serious form of psychotic disorder is that they will be subjected to perhaps unnecessary, suppressive antipsychotic medication, with its potentially serious side effects. If psychosis can be seen as "a state of aberrant salience", and a central role of dopamine is to mediate the "salience" of environmental events [67] it may be that the "salience" of the experience of spiritual emergency is inappropriately suppressed by dopamine blockade. In addition, there may be the social isolation, stigmatisation and self-stigmatisation associated with the label of mental illness. This may leave the person not only with the need to integrate the spiritual emergency experience without a context in which to understand it, but also having to recover from the trauma of these consequences.
On the other hand there are risks associated with not treating psychosis with medication soon enough related to on-going distress, potentially unwise or dangerous behaviour, and effect on prognosis. Current best practice recommends early use of antipsychotics for all acute psychosis in an attempt to prevent the deteriorating pattern of chronicity [68]. With the burgeoning of early intervention programmes this balance of risks is an aspect which needs urgent attention. The concept of spiritual emergency is a potentially useful explanatory model which might assist in the recovery process because it is normalising and not stigmatising. It remains unclear how large the sub-group of patients is for whom this explanatory model, and an approach which supports spiritual development and understanding of the psychotic phenomena in this light, might be more useful either in the acute management phase or recovery phase. Further research is recommended in order to assess whether the notion of spiritual emergency might have diagnostic utility in improving clinical outcome for this sub-group and how cases can be identified in terms of past history, phenomenology, continuity with prior spiritual life, and personal explanatory model. To what extent spiritual emergency may be 1) a separate diagnosis strongly related to causal factors and best treatment or 2) an explanatory model that is useful for some people recovering from psychosis, regardless of cause, which can be included along with other treatment approaches, are important questions to be answered.
35. Grof C, Grof S. The Stormy Search for the Self - A Guide to Personal Growth through Transformational Crisis. New York: Jeremy P Tarcher, 1990.
36. Grof S. Spiritual Emergency. When Personal Transformation becomes a crisis. Los Angeles: Jeremy P. Tarcher, 1989.
65. Nelson J. E. Healing the split: Integrating spirit into our understanding of the mentally ill (Revised ed.). New York: State University of New York, 1994.
66. Grof S. Psychology of the Future. Albany, New York: State University Press, 2000.
68. Remington G; Kapur S, Zipursky RB. Pharmacotherapy of first-episode schizophrenia. British Journal of Psychiatry 1998; 172 (Suppl. 33), 66-70.
Spiritual Emergency
Spiritual Crisis Network
Spiritual Emergency Resource Centre
Spiritual Emergence
'Psychosis or Spiritual Emergence?
Spiritual Competency Resource Centre
Thursday, 19 November 2009
Dial House: Celebrating 10 Years.
Visitors can use the house as time out from a difficult situation or a home environment where they may feel unsafe or that may exacerbate their difficulties. Visitors can relax in a homely environment and can also gain one to one support from the team of Crisis Support Workers.
At Dial House we have a family room, so parents in crisis can bring children with them. We also transport visitors to and from the house by taxi, to make their journey safe and comfortable.
History of the Organisation
The Leeds Survivor Led Crisis Service was set up in 1999 by a group of service users, who had campaigned for five years to develop the service. Initially, the service was run in partnership with Social Services, becoming a registered charity in 2001. The service was set up to be a place of sanctuary, which was an alternative to hospital admission and statutory services for people in acute mental health crisis. The service was established, and continues to be governed and managed, by people with direct experience of mental health problems. We have our own unique perspectives on what it feels like to be in crisis and what helps and does not help. We have developed our service based on this knowledge and experience, while responding to the needs articulated by our visitors and callers.
We are part of a network of mental health services in Leeds. We liaise with and undertake joint work with other services, while maintaining our identity as an innovative, service user led voluntary sector organisation.
Philosophy of the Leeds Survivor Led Crisis Service
Each individual has their own experience of crisis. The causes and impact of crisis will be different for each person. We believe that people are expert in knowing their own situations and with the right kind of attention and support can find their own solutions.
Our definition of crisis is…
People have told us that some of the characteristics of crisis are:
An overwhelming experience
More than the person can deal with
Not one’s normality
Usually intolerable
Highly stressful
Having nowhere to turn
Having exhausted all one’s coping strategies.
Crisis is sometimes described as a time of change or a turning point in one’s life: a period of breakthrough or breakdown.
Crisis can be a liberating or learning experience.
People in crisis should have a range of choices for dealing with a crisis. Our services may be used as an alternative to statutory services, or may complement involvement in mainstream services. We believe that to deal with a crisis, a person must feel safe, listened to, and connected to other people.We want to know about the person, not the label they have been given.People in crisis are not essentially different from anyone else and everyone in his or her life will experience crisis at one time or another.
We recognise that the city of Leeds is made up of many different groups, traditions and cultures. We respect and are responsive to the fact that social factors in a person's life shape both their understanding of crisis and their way of dealing with crisis. We also recognise that deprivation and oppression not only impact on people's ability to cope with distress, but can be the cause of distress.
Therapeutic Approach of Leeds Survivor Led Crisis Service
The paid staff within the organisation are qualified or qualifying counsellors, or receive training in the Person Centred Approach. This is the primary therapeutic approach we use.
The key principles of this are:
The person providing support demonstrates empathy, congruence and unconditional positive regard towards the client
A belief in the actualisation tendency – that is, a belief that people do the best they can in the circumstances they are in and have an inherent tendency to try to achieve their full potential
The principle of non directivity. Work is led by the client, in the belief that they have the resources within themselves to find their own solutions.
We also draw on other therapeutic approaches, such as Solution Focused Brief Therapy. We provide a compassionate, respectful, empathic and consistent service, with the aim of supporting visitors to identify their own solutions to their difficulties.
Within both Dial House and Connect, we work with people in acute states of crisis. Many of our visitors are suicidal and/or self harm and we are skilled and experienced within these areas of work. Over the time we have been open, we have successfully worked with people who have been excluded from other services, or who other services have been unable to engage.
10 years on Leeds Survivor Leed Crisis Service has grown from strength to strength and has a very special place in the hearts of those who visit and work there. It stands as an ideal that should one day be available to all regardless of postcode, the present manager Fiona Venner travels the UK giving lectures on the unique philosophy and practice of Dial House. The project has been awarded several highly prized awards including being the winner of the Gaurdian Public Sevice Award in 2006.
For more details contact survivor.led@lslcs.org.uk
0113 260 9328
Here is the article in the Guardian newspaper about Leeds Survivor Led Crisis Services Public Services Award.
06 Dec 2006: The Guardian
Public services award: The client knows best
Innovation and progress, customer service winner: Leeds Survivor Led Crisis Service This user-led service offers a non-residental safe house for people experiencing a mental health crisis.
Andrew Cole reports:
Everyone who turns up at the door of the Leeds Survivor Led Crisis Service on the outskirts of the city has one thing in common: they are at the end of their tether. All will be facing acute mental crisis, ranging from attempted suicide to self-harm and family break-up. And most will already be feeling bruised by their experiences of the statutory services.
What they find at the crisis service is very different. For a start, nearly all the managers, frontline staff and volunteers have experienced mental health problems themselves. Just as importantly, the therapeutic approach they follow is based on the radical notion that the users know what's best for them.
The principle tenets of this philosophy are "unconditional positive regard", "actualisation" and "non-directivity". But, says project manager Fiona Venner, this simply means treating people with warmth, kindness and honesty. "Rather than telling people what to do or giving advice or saying 'I'm the expert', it's very much about supporting people to bring out and develop their inner resources. People ultimately know what's best for them."
So clients will be offered one-to-one support from the team of crisis support workers. They can also take part in the weekly group sessions. But if they simply want to listen to music, have a bath or make a meal in the adjoining kitchen, that's fine too.
"We give people a lot of freedom and choice. Many of the people have not always had a lot of experience of feeling in control in their lives." Venner says.
This freedom even extends to accepting individuals' self-harming, which the team see as a coping mechanism in the face of unbearable distress. Nevertheless, there is a limit to the permissive approach. If someone is judged to be at real risk of suicide, the team will intervene, as they will if they learn about adult or child abuse. But this only happens rarely.
Between 30% and 50% of all clients who come to the service are suicidal, and many have actually tried to take their lives. "But if someone is here, there's always hope," says Venner. "Part of them might want to die, but part of them wants to live and that's the part that's with us."
The service was set up in 1999 as a result of a campaign by users to find an alternative to hospital for people in acute mental health crisis. After initially working in partnership with social services it became an independent charity in 2001, but is still largely funded by the local health trust and social services.
In the last year the numbers attending the service have shot up from fewer than 250 to around 1,000, mainly as a result of the decision to extend the opening hours - now from 6pm to 2am between Friday and Sunday. The service provides a well-used telephone helpline every night from 6pm-10.30pm. There is also a family room for parents in crisis and users are offered a taxi service if required. Importantly, everyone comes of their own volition. Most self-refer, though a few are referred by GPs, A&E or specialist services such as the city's crisis resolution team.
The pattern of attendance varies hugely. Many have very chaotic lives and will return again and again before moving on. Others will turn up once and that will be enough. Sadly, high demand means many have to be turned away, so visitors are prioritised according to their level of desperation and isolation. "If they're in a hostel or have friends or family, they may be safer than someone who's completely on their own. But," Venner adds, "there is a huge amount of unmet need."
She has no doubt the service has kept many people out of hospital and gives them safety and sanctuary when they are at their lowest ebb. "People often say to us: I would be dead if you hadn't been there," she observes.
Despite the volatile nature of many people's problems, there has not been a single violent incident in the service's seven-year history, says Venner. "People love the service and are very respectful of it and don't want to jeopardise it. The fact that we provide genuine kindness, warmth, affection and respect seems to mark us out as different from other services."

Form; Leodis, A photographic archive of Leeds.
Thursday, 9 April 2009
Recovery and the Symphony for a Sea Bird

In 1988 Deegan stated that recovery is about
‘…moving away from professional definitions towards self determination.’
You cannot put a big load in a small bag,
nor can you with a short rope,
draw water from a deep well.
Have you not heard how a bird
from the sea was blown inshore
and landed outside the capital of Lu?
The prince ordered a solemn reception,
offered wine to the seabird
in the Sacred precinct,
called for musicians to play
the compositions of Shun,
slaughtered cattle to nourish it.
Dazed with symphonies,
the unhappy seabird died of despair.
How should you treat a bird?
As yourself or as a bird?
Ought not a bird to nest in deep woodland
or fly over meadow and marsh?
Ought it not to swim on river and pond,
feed on eels and fish,
fly in formation with other waterfowl,
and rest in the reeds?
Bad enough for a seabird to be surrounded by men
and frightened by their voices!
That was not enough!
They killed it with music!
Water is for fish, and air for man.
Natures differ, and needs with them.
Hence the wise men of old
did not lay down
one measure for all.
Chaung Tsu

Wednesday, 21 November 2007
What qualities do you value in Mental Health Staff

In 2001, the Workforce Action Team [WAT], set up to consider the workforce implications of the Mental Health National Health Service Framework, [MHNSF] and the NHS Plan [NHSP], commissioned and received two pieces of work: the Capable Practitioner Framework [CPF] and the Mapping of Mental Health Education and Training in England.
The shift in culture in services towards Choice, person-centeredness and mental health promotion is a key imperative. People who use services and their families continue to report not being listened to, being marginal to assessment and care planning and being rendered helpless rather than helped by service use. Tragic events, evidenced by the Bennett inquiry, illustrate that there is a significant need to ensure that all staff have training in what is described here as the Essential Shared Capabilities [ESC].
The Aim of the ESC is to set out the shared or common capabilities that all staff working in mental health services should achieve as a minimum as part of their pre-qualifying training. Thus the ESC should form part of the basic building blocks for all mental health staff whether they be professionally qualified or not and whether they work in the NHS or social care field or the statutory and private and voluntary sector.
In 2003, a national steering group was established to guide the development of the ESC (see Appendix C). The ESC were developed through consultation with service users, carers, managers, academics and practitioners. To facilitate this process, a number of focus groups were held across England in order to sample opinion and seek feedback. In the main, they have what might be termed an "outward focus" and are explicitly and deliberately centred upon the needs of service users and carers.
The Ten Essential Shared Capabilities for Mental Health Practice.
1.Working in Partnership. Developing and maintaining constructive working relationships with service users, carers, families, colleagues, lay people and wider community networks. Working positively with any tensions created by conflicts of interest or aspiration that may arise between the partners in care.
2.Respecting Diversity. Working in partnership with service users, carers, families and colleagues toprovide care and interventions that not only make a positive difference but also do so in ways thatrespect and value diversity including age, race, culture, disability, gender, spirituality and sexuality.
3.Practising Ethically. Recognising the rights and aspirations of service users and their families,acknowledging power differentials and minimising them whenever possible. Providing treatment andcare that is accountable to service users and carers within the boundaries prescribed by national(professional), legal and local codes of ethical practice.
4.Challenging Inequality. Addressing the causes and consequences of stigma, discrimination, social inequality and exclusion on service users, carers and mental health services. Creating, developing or maintaining valued social roles for people in the communities they come from.
5.Promoting Recovery. Working in partnership to provide care and treatment that enables service users and carers to tackle mental health problems with hope and optimism and to work towards a valued lifestyle within and beyond the limits of any mental health problem.
6.Identifying People’s Needs and Strengths. Working in partnership to gather information to agreehealth and social care needs in the context of the preferred lifestyle and aspirations of service userstheir families, carers and friends.
7.Providing Service User Centred Care. Negotiating achievable and meaningful goals; primarily from the perspective of service users and their families. Influencing and seeking the means to achieve these goals and clarifying the responsibilities of the people who will provide any help that is needed, including systematically evaluating outcomes and achievements.
8.Making a Difference. Facilitating access to and delivering the best quality, evidence-based, values-based health and social care interventions to meet the needs and aspirations of service users and their families and carers.
9.Promoting Safety and Positive Risk Taking. Empowering the person to decide the level of risk they are prepared to take with their health and safety. This includes working with the tension between promoting safety and positive risk taking, including assessing and dealing with possible risks for service users, carers, family members, and the wider public.
10.Personal Development and Learning. Keeping up-to-date with changes in practice and participating in life-long learning, personal and professional development for one’s self and colleagues through supervision, appraisal and reflective practice.

Box 3 Dimensions of hope-inspiring relationships
(from Repper & Perkins, 2003)
1 Valuing people as human beings
2 Acceptance and understanding
3 Believing in the person’s abilities and
potential
4 Attending to people’s priorities and
interests
5 Accepting failures and setbacks as part of
the recovery process
6 Accepting that the future is uncertain
7 Finding ways of sustaining our own hope
and guarding against despair
8 Accepting that we must learn and benefit
from experience
Box 5 New Zealand guidelines on recovery competencies for mental health workers (adapted from
O’Hagan, 2001, with permission)
A competent mental health worker:
1 understands recovery principles and experiences in the national and international contexts
2 recognises and supports the personal resourcefulness of people with mental illness
3 understands and accommodates the diverse views on mental illness, treatments, services and recovery
4 has the self-awareness and skills to communicate respectfully and develop good relationships with
service users
5 understands and actively protects service users’ rights
6 understands discrimination and social exclusion, its impact on service users and how to reduce it
7 acknowledges different cultures and knows how to provide a service in partnership with them
8 has comprehensive knowledge of community services and resources and actively supports service
users in accessing them
9 has knowledge of the service-user movement and is able to support its participation in services
10 has knowledge of family perspectives and is able to support the family’s participation in services. `*

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