Keynote speakers

People not places are violent, surely? But what if aspects of the environment create conditions where risk is increased and violence more readily ignited? In this presentation, I bring together evidence based insights from design, architecture and psychology, to create a system level appraisal of escalation, violence and seclusion use. This perspective I have termed ‘psycho-ecological’ to represent the theoretical and empirical synthesis of environments and people, to examine how environments ‘afford’ greater risk, through increasing anxiety, closing down relations between staff and patients and reducing a sense of agency and meaning. This theoretical aperture invites closer inspection on how to work collaboratively with experts by experience, architects and designers to create environments that are safer – both physically and psychologically.

The disproportionate use of force in mental health settings and beyond is a significant issue in the modern-day care of the most vulnerable individuals in society. A range of inequalities are evident and impact upon the quality of care that certain populations experience.

The disparities are extensive and include matters pertaining to ethnicity, age gender, and disorder. These clearly affect the experiences of those involved and need to be addressed.    In order to do this, we need not only to understand the extent and nature of the problem in terms of accurate reporting but also how to understand the challenges faced by all parties.  Clearly participatory action approaches such as experience based co-design can help drive the changes required going forward.

I will present the evidence base on the current position and highlight some research we have been working on to co-create new ways of working.   Some examples include the experiences of Black Afro-Caribbean men about being detained and research on those with learning disabilities and autism around restrictive interventions.  Both populations experience disproportionately in the use of force when engaging with mental health services.  It’s time to flip the narrative.

The Covid-19 pandemic has hit mental health care services unexpectedly in early 2020. Many services were shut down, inpatient capacities were reduced and services had to deal with outbreaks within their service user populations and staff. This Masterclass session will provide an overview on the impact of the pandemic on mental health issues in the general population and in mental health care service users. A particular focus will be made on critical incidents such as aggression and suicide attempts and how institutions have dealt with these issues under stressful circumstances.

The session will include a presentation and an interactive part with participants who are asked to share their personal and institutional experiences on how to deal with critical incidents during a pandemic and what can be learned for future infectious outbreaks.

The bulldozer and the ballet dancer are metaphors for opposite ends of nurses’ different caring approaches that can often be observed on acute psychiatric wards. The bulldozer is recognized by a rather low level of interest in getting to know, understand and support patients but is often active and fearless in acute violent and controlling situations. The ballet dancer on the other hand is frequently seen interacting with patients, almost like a form of art, imagining the patient’s situation and constantly trying every option to building rapport. The ballet dancer, however, is rarely seen involved in violent and controlling situations since it is frightening and may challenge his or her values and beliefs.

In this interactive and maybe slightly provocative masterclass, we will dig deeper into nurses’ different caring approaches and specifically discuss the impact on violence prevention and management from a realistic as well as idealistic perspective. Are both bulldozers and ballet dancers needed in acute psychiatry? Or a hybrid nurse with a little bit of both?

Reference:

Björkdahl, A., et al. (2010). The bulldozer and the ballet dancer: aspects of nurses’ caring approaches in acute psychiatric intensive care. J Psych Ment Health Nurs. 17:510-518.

We want a psychiatry where we help the patients towards a better and more tolerable life, and therefore it is important to listen to them.

We want to reduce violence, coercion and increase the possibility of recovery, but is it even possible if we don’t know the person it’s all about?

Based on her own experiences, Sidsel talks openly and honestly about her many years in psychiatry, what helped and what hindered recovery.

EDITION developed and evaluated an evidence-based intervention to enhance de-escalation in adult and forensic inpatient settings. Intervention development involved qualitative inquiry with multidisciplinary professionals, patients, carers, ward staff and violence reduction specialists, systematic reviews and co-design events informed by behaviour change and implementation science methodology. The EDITION intervention aimed to modify aspects of inpatient care experience that mimic aspects of patients’ interpersonal trauma histories. Components included:

1) de-escalation training;

2) collaborative prescribing and patient-centred ward rounds;

3) sensory modulation;

4) peer support to improve admission experience,

5) conflict formulation and restrictive intervention debriefing;

6) an intervention to enhance critical reflection on limit-setting practices, interpersonal boundaries and attitudes to staff vulnerability;

7) an intervention to enhance ward staff’s psychological safety and relationships with clinical leaders;

8) an intervention to involve service users in shift handovers and nursing documentation.

Ten wards in two NHS Mental Health Trusts trialled the intervention. Wards included male high secure wards (n=2), male and female medium secure wards (n=2), male and female low secure wards (n=2), mixed PICUs (n=2) and male and female acute wards (n=2). Data collection was feasible, the intervention was acceptable and significant pre-and-post reductions in both conflict and containment occurred.

There is universal acknowledgement that the prevention and recognition, and the safe, effective and therapeutic management of conflict occurrences poses a serious challenge within mental health settings. Such occurrences, and the utilisation of emergency restrictive interventions, are associated with potentially serious physical and psychological risks for all concerned.

Beyond the immediate risks, evidence suggests that the impact of such occurrences endures beyond the incident, can impoverish the therapeutic environment, and diminish the quality of the care experience for both recipient and provider. Furthermore, witnessing such occurrences is distressing to others, and costly to services.

Professional and regulatory guidance impose explicit imperatives for some form of ‘post incident review’ to ameliorate potential distress and restore/preserve therapeutic relationships, while coercive minimisation initiatives consistently include ‘debriefing’ as one critical component of overall strategies (Huckshorn 2005 Colton and Xiong 2010; MHCI 2014; UK NICE (2015) Duxbury et al 2019).

Despite these mandates, there remains some confusion as to the specific purpose and function of ‘debriefing’ and/or ‘post incident reviews’, and considerable variance in practice reflects the paucity of evidence as to what constitutes evidence-based best practice.

During this highly interactive masterclass participants will:

• Actively explore the function and purpose of post occurrence reviews for all stakeholders.
• Actively clarify and describe the specific needs of, and desired outcomes for, each stakeholder
• Actively appraise a tentative best practice model of post occurrence review, with particular emphasis on application to everyday practice, within mental health settings.

Each stage of the masterclass will involve active engagement among participants.

Learning Outcomes:

• Participants will have the opportunity to broaden their understanding of the role purpose and function of ‘post occurrence reviews’ with emphasis on both the challenges and opportunities.
• Participants will have the opportunity to consider a ‘practice’ model of ‘post occurrence reviews’ with emphasis on application within mental health settings.

References

• Colton, D. Xiong, H. (2010). Reducing seclusion and restraint: Questionnaire for organizational assessment. Journal of Psychiatric Practice, 16(5), pp.358-362.
• Duxbury, J., Thomson, G., Scholes, A., Jones, F., Baker, J., Downe, S., Greenwood, P., Price, O., Whittington, R. and McKeown, M., (2019). Staff experiences and understandings of the RE s TRAIN Yourself initiative to minimize the use of physical restraint on mental health wards. International Journal of Mental Health Nursing, 28(4), pp.845-856.
• Huckshorn, K. A. (2005) Six core strategies for reducing seclusion and restraint use: Draft example—Policy and procedure on debriefing for seclusion and restraint reduction projects. Alexandria, VA: US National Technical Assistance Center.
• Mental Health Commission Ireland (2014). Seclusion and Restraint Reduction Strategy. Dublin. Mental Health Commission Ireland.
• NICE (2015) NG10  Violence and aggression: short-term management in mental health, health and community settings. London. National Institute for Health and Care Excellence.

From an ethical perspective coercion is a problematic issue. The autonomy of the patient has become more important. On the other hand coercion provided effective means for preventing injury. There is clearly a tension between autonomy on the one hand and safety on the other. The focus is on whether or not seclusion is justified at a certain moment. Little attention is paid to everyday ethical issues in contact with patients and the dilemmas involved, which may in the end result in recourse to coercive measures. Moreover, the morality of care relationships and the mutual expectations and moral obligations of the patient, the professional and other stakeholders are not addressed. In this presentation an argument will be made for an ethics that goes beyond the focus on autonomy and security: an ethics of care! This different way of looking at coercion gave the opportunity to develop some best practices in the Netherlands.

In the last decades, significant efforts have been made, both at national and international levels, to reduce the use of coercion in mental health services. New international human rights instruments were created, innovative strategies and interventions were developed to reduce the use of coercion, many countries promoted important changes in their mental health legislations, policies and services to scale up rights of persons with mental disorders, and in some places the active participation of people with lived experience of severe mental health problems was strengthened.

In this presentation, we will discuss the results of these efforts, based on the available evidence. We will analyze, with special attention, the data that can help us understand the real impact of new mental health legislation and policies on reducing compulsory treatment and the use of other coercive measures in mental health care, and we will present some examples of initiatives and programs that have shown encouraging results both in high- and low-income countries.

Finally, after discussing the main challenges we are currently faced with in promoting more human rights and recovery-oriented services, we will share some thoughts on how research could contribute to respond to these challenges.