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. ‘

Barriers

•   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

References

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 19^th 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

Asylum Mind

My own experiences of hospitalisation have been that of a being subject to a great power,  like so many, I had no words to describe it, nor the courage to question it. I understood the term ‘Therapeutic power’ (Dr Maxwell Jones) long before ever hearing it's name. Described by John Perceval and further confirmed in the of writings Michele Foucault we arrive at the notion of Asylum mind, described in the book 'The seduction of Madness' by Dr Edward Podvoll.

• ·         Asylum mind embodies the idea that madness must be subjugated for recovery to take place. The mind of insanity must learn to bow before the superior power of reason and logic.
• ·         Asylum mind preserves what is called ‘nonreciprocal observation’ One is observed without being able to observe properly. Mistakes, awkwardness, transgressions are catalogued, diagnosed and studied. One’s own observations are called unsound, resistance, arrogance, transference. Examination of one’s conditions or caretakers is prohibited a situation bound to evoke paranoia.
• ·         Asylum mind treats madness as childhood. Relegates confines to the status of minors- intellectually, morally, judicially. A prejudice stemming from what has been called ‘damage theory’ that people in psychosis are under developed, arrested, deficient or defective. All of which have for too long excused insufficient care.
• ·         Asylum mind manifests in an organisation of people whose hierarchy is based on a conviction of its moral sovereignty over the insane.
• ·         Asylum mind sees spirituality as ‘religiosity’ and as dangerous to the welfare of the patient, here the ageless understanding of insanity as a spiritual crisis has been lost.
• ·         Asylum mind poses itself as rescuer, to which one should be grateful and obedient.
• ·         Asylum mind demands a confession to the error of arrogance and to the ancient crime of spiritual self exaggeration. The residue of guilt is to last far into the future, to be an armour and reminder against any excessive self presumption in the future.
• ·         Asylum is fundamentally a medical space. Somewhere around the turn of the 18C medical specialists took complete responsibility for care of the insane. New territory sanctioned when the lunatic doctors were royally sanctioned to treat George III
• ·         The asylum mind vision is that recovery cannot take place without sufficient inner self mortification and an attitude of apology.

This is my Church, This is where I heal my hurts

 After being diagnosed with one of those ‘severe and enduring’ mental illnesses many begin to define themselves by their psychiatric label. They may call themselves schizophrenic or manic depressive and in so doing often confirm the chronicity inherent to those labels. I am by way of being a martial artist and when I found myself subject to the mental health system, severely labelled, medicated and without hope, I fought a personal battle in a mental landscape, the battle to define myself.

                                                                             

            

  “Your true battle is with your own mind of discord”

Morihei Ueshiba

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.

Just when, the elated moods began I am not sure or whether my fascination with spiritual aspect quickened the process or kept me well may never be known. The high mood increased over time until they were somewhat out of control. Hospitalisation followed and it was at this point that the true battle for which I had trained began. I was told, as I entered hospital that although not under a section of the mental health act, if I tried to leave I would be sectioned. It was explained to me that should I refuse medication I would be restrained and injected against my will, the power invested in the hands of those around me was horrifying, I no longer had any choice but to nod at the right time, remain silent and hope for a quick discharge. Within a few days of entering the ward I shuffled around dribbling, held my hands out in front of me unable to hold a drink without spilling it. I could not distinguish between illness and the medication side effects; this it seemed was how my life would be from now on.

After being discharged the adverse effects of too much haloperidol were still evident, if it were not for my wife I doubt I would have been discharged at all. I shuffled round the house with an ashen face set in a haloperidol ‘death mask’, there was nothing I could do for myself apart from sit on the edge of my seat like some withered emaciated ghost of who I had once been. A hungry ghost still haunting it's old life, lost  somewhere between desperation and longing, this was to be my lot.

A friend called, a fellow Aikidoka, he was shocked at what I had become. We talked briefly and then he took me outside. Tai no Henko he called out, a blending exercise in Aikido.

The founder of Aikido Morihei Ueshiba practicing Tai no Henko with Chiba Sensei

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.

Eventually I returned to the dojo, this time with my eldest son by my side. I believe it is the training, discipline and respect martial arts demand which had fostered in me the spirit to challenge the stigma of living with a serious mental health condition and to face further relapse. My diagnosis defines me less than my martial art.

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.

"Your heart is full of fertile seeds, waiting to sprout." Morihei Ueshiba



Recovery and the Symphony for a Sea Bird

In 1988 Deegan stated that recovery is about

‘…moving away from professional definitions towards self determination.’

Symphony for a seabird

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

Time To Change

We have a dream that one day it will be possible to talk openly about mental health problems to friends, neighbours and colleagues without fear of being devalued and excluded and without attracting those delicate 'changes of subject' that indicate that such issues should be kept firmly behind closed doors.

We have a dream that one day derogatory and pejorative descriptions of people with mental health problems - and use of 'nutter', 'mental' 'schizophrenic' etc as terms of derision and abuse - will be as unacceptable as derogatory racist language.

We have a dream that people with mental health problems will be able to talk of their experiences, dreams and aspirations without these being ignored and written off as unrealistic, lacking in insight, or the ramblings of a deranged mind.

Taken From Repper and Perkins' Social Inclusion and Recovery'

From their website

Stigma and discrimination still have a huge impact on the lives of people with mental health problems, even though one in four people will experience a problem at some time in their lives.

It’s time to tackle this last great taboo.

Over the last decade, there have been huge advances in our understanding and treatment of mental health problems and increased investment in services. We are moving closer to a society where recovering a full and meaningful life from mental health problems is the norm rather than the exception.

However, there remains one massive barrier – discrimination.

People with mental health problems consistently identify discrimination as one of their biggest issues and almost nine out of ten people affected by mental health problems have experienced discrimination.

Attitudes need changing

Until now, England has lacked a long-term campaign to raise public awareness about good mental health, counter pervasive negative stereotypes and challenge discrimination.
Despite attitudes about sexuality, ethnicity and other similar issues improving, research shows that prejudice against people with mental health problems is actually increasing.
But there is a climate for change. The government has recognised the impact of stigma and that public attitudes are not improving.

Setting standards

New Zealand and Scotland have set the standards internationally for public anti-stigma campaigns, while the research community has been contributing to a growing knowledge base of what works.
In England there have been relatively small-scale, piecemeal attempts to challenge the stigma and discrimination around mental health. But there has not been one coordinated, long-term, well-funded approach to combating stigma, with the reach and expertise to really make a difference.
That is why Mental Health Media, Mind, Rethink and the Institute of Psychiatry have come together as Time to Change, to combine their knowledge and expertise in the biggest ever England-wide attempt to end the discrimination around mental health.
Our funders have recognised the importance of this issue, and it is the English public, through the National Lottery Fund and Comic Relief, who have made this vital work possible.

Click here to download their brochure.

Click here to order Social Inclusion and Recovery

Click here to find out more about shift

RECOVERY BY PETER CAMPBELL


Some years ago, when I read that Recovery “is the new paradigm shift in mental health”, my reaction was fatalistic. During my time as a service user great new ideas have regularly swept across the face of mental health services: therapeutic communities, assertive outreach, cognitive behavioural therapy etc. There doesn’t seem to be much service users can do to stop this phenomenon even if we wanted to. It’s a bit like the weather. I actually do believe Recovery could mean fairer weather for service users but here are a few concerns:

I have never thought of my life in terms of “recovery”. I have talked to service users who say the same. I hope the enthusiasm for collecting and using “recovery narratives” will not come to mean everyone with a mental illness diagnosis will have to squeeze themselves into that framework for their life stories to have value.

There are contradictions within the Recovery “business”. One tension that strikes me in particular is between saying the recovery journey is unique and individual and then promoting key stages of recovery and posting 10 or 12 or 23 recovery outcomes on a website.

We already have Recovery as a vision, an orientation, a set of values, an approach, a programme, a plan. Perhaps we will end up with a Recovery kit. I think some of these are more desirable than others. I certainly feel we should not assume they are all the same thing and consider carefully how far we want to go with Recovery.

Since the 1980s, mental health care has become much more focused and managerial. Enthusiasm for written plans which predates Recovery in this country is one example of this. Planning is often helpful but can be inflexible and is not an end in itself. It may freeze some people up rather than energise them. I am concerned we do not reach a point where you can only be “a good service user” if you have a Wellness Recovery Action Plan in your portfolio.

Pat Deegan, an important influence on Recovery, has written: “Once recovery becomes systematised, you’ve got it wrong. Once it is reduced to a set of principles, it is wrong. It is a unique and individualised process.” That was in 1999. I wonder what she thinks about the way Recovery has developed since then? l I wonder what she thinks about the way Recovery has developed since then?

This article was found on the Social Perspectives Network site.

A little more about Peter Campbell:

The pleasure madmen know

Joe Bidder profiles survivor poet and activist Peter Campbell and gives a potted history of the movement, through his achievements.

There is a pleasure madmen know is the opening line of the first poem in Peter Campbell's first poetry collection entitled Brown Linoleum Green Lawns but this phrase is not an idiosyncrasy or merely a clever literary sleight of hand with a line taken from John Dryden. Campbell is a mental health system survivor, writer and poet who has devoted his life and considerable talents to the pursuit of survivors' rights and justice. He is proud of his identity. “I am a survivor but I don't feel that this is an impairment”, he says.
In 2006 Melvyn Bragg presented Peter Campbell with the MIND Diamond Champion Award for the person who has done most for users of mental health services in England and Wales in the last 20 years. It is noteworthy that this award was made based on a survey of survivor/user opinion. It wasn't until the end of a 60 minute interview that I was able to extract this from him: a fact which would surprise no-one who knows him well. Shy, self effacing and highly intelligent, Peter Campbell has spent 25 years battling with the government and the mental health system for survivors' rights.
Raised in the Scottish Highlands, Campbell's early years were spent confronting mental distress. Long stays in hospital, which curtailed his academic career at Cambridge, also prevented him from maintaining continuous paid employment. Consequently, in 1980, he changed his life and began an involvement with mental health activism coupled with poetry and performance which has lasted until the present day. By the 1990s he was able to construct a professional life as a freelance writer, consultant and trainer.
In the 1980s he participated in CAPO (Campaign Against Psychiatric Oppression), was a member of Camden Mental Health Consortium, a co-founder of Survivors Speak Out in 1986 and a co-founder of Survivors' Poetry in 1991. He is a gifted poet and performer, writes extensively on mental health issues, and trains psychiatrists, psychologists, nurses and other health professionals.
All his adult life Peter has been a mental health system survivor, cumulatively spending many years in asylums. He expresses deep anger, rooted in feelings of helplessness and the incompetence, indifference and callousness frequently displayed by psychiatrists and other health workers but has been able to convert his anger into constructive action.
Until 2004 he never considered himself a disabled person because he doesn't consider a mental health problem to be an impairment. Campbell readily concurs that society discriminates against people with mental health problems but for himself he refuses to accept that he has a mental illness and debates whether there is such a thing as mental illness.
Since 2004 Peter Campbell has become progressively deaf and uses a hearing aid, lip reading and induction loops (when they are available and in working order!) and now regards himself as a disabled person. “My deafness is a real impairment and I find immense difficulties making adjustments”, he says, then adds reflectively, “I don't feel part of the deaf community, and accept that there is an enormous chasm between those born deaf and those who acquire deafness in middle age”.

This artilce appears on the Disability on line website

See also From Little Acorns– The mental health service
User movement