Tuesday, 24 March 2015

What if "Restraint" was not an option?

by Freda Lacey

About this time last year the Minister of State for Care and Support, Norman Lamb, wrote about “Positive and safe: reducing the need for restrictive interventions” within health care. Mind’s report from the year before on “physical restraint in crisis” clearly outlined that the use of restraint was used to varying degrees and “face down” (or “prone” restraint as it’s sometimes called) was still being used despite the knowledge that it can cause serious harm and, in some situations, death.  The report made recommendations to the Government that the use of “face down” restraint should never be used in care and treatment settings.

The Mental Health Act Code of Practice, (currently being revised in Wales) devotes an entire chapter to “Managing behaviours that challenge,” and it clearly states that the least restrictive option(s) must be explored and restraint used only as a last resort.

The use of “restraint” and the “how”, when managing patients in hospitals, has been the topic of numerous blogs, reports, white papers, and news articles, particularly over the last few years. The Winterbourne Review spurred a great deal of investigation into the use of restraint, the Care Quality Commission specifically reporting on “Monitoring the Mental Health Act” in 2012/2013” and the use of restraint in hospitals. One of my favourite blogs is written by Mental Health Cop and he has his own views about restraint which may add texture to the topic. I am not going to write about how, when and where restraint is used in mental health settings, this has already been done by people far more knowledgeable than myself.

What I really want to highlight is how I’ve been affected by the topic of “restraint”. During my attendance at the Department of Health’s revision of the “English Mental Health Code of Practice” Expert Reference Group with Jan Rogers, I was privileged to sit in on several of the group meetings discussing changes to “the code”. The chapter called “Safe and therapeutic responses to disturbed behaviour” in the new Code of Practice made the experiences of restraint very real to me.

It was the first time where I listened to people’s direct experiences of being “restrained” in high, medium and acute wards whilst experiencing care under the Mental Health Act. I listened to family members speak of their experiences of witnessing their children’s restraint and the distress this has caused. People openly shared feelings of humiliation, trauma (some of this due to physical injuries they had sustained) and feelings of distrust in the people caring for them. They made direct links to the “way” they were physically restrained, sometimes stating they didn’t know “why” it had happened. I imagined how children or young adults may feel experiencing restraint and the trauma this may hold for them, particularly if abuse has been experienced. What is felt by people with a dementia, what comes up for them as a result of being restrained? As I listened, I wondered what would have happened had restraint never been an option. 

Interestingly around the same time, I caught sight of a national workshop on the management of violence in hospital settings. The workshop was pulled together by the “All Wales Senior Nurse Advisory Group for Mental Health” and their call to action really struck me. “The management of violence and aggression in mental health settings is a key issue for practitioners and educators. The Department of Health have recently consulted on restrictive practices in England along with the Mind publication in 2013; and we want to be at the forefront of planning developments and actions in Wales on behalf of our service users and our staff”. 

Having heard the recent stories from people who had experienced being restrained, I was curious to see and hear how staff approached the subject of restraint. The workshop was well attended by national ward management teams, general nursing staff, senior nurses and senior management.
One of the things that became apparent was that a good many staff felt the need to move away from restraining people and advocated “de-escalation” techniques, or “conflict resolution”. Basically, talking people down from a heightened sense of anger. I could see the difficulty experienced by staff when faced with a patient who is throwing punches and hurting them (one nurse spoke of being punched and having to be off work for some time) where the instinct is to restrain the patient so as to prevent being hurt. If restraint had to be used, then the workshop advocated using “supine” restraint or “face up” which is deemed less injurious and safer for the patient.

I volunteered to experience what it felt like to be restrained as in the afternoon we had a demonstration of using various methods of restraint for adults and older adults with dementia, (for example). Whilst the demonstrators were very careful with me (I was held down by two men and one woman), and pinned down so I couldn’t move and injure myself (and/or them), I was not trying very hard to be aggressive. I could imagine that if someone was very angry and aggressive that it may take some time of being held down and spoken with before the situation may diffuse. I was also startled at how quickly I went from standing to down on the floor and wondered if I was really emotional, angry and distressed, what effect the entire process might have on me. Also, if I were to be restrained by male nurses, how might this feel as a woman and similarly for men.

Hospitals are required to have policies on how to “manage” aggressive behaviour and in reading some policies from different areas I was struck by the following list of some of the things that staff should look out for as factors that may provoke disturbed or violent behaviour:       
  • boredom and lack of environmental stimulation;
  • lack of access to external space;
  • personal frustrations associated with being in a restricted environment;
  • difficulties in communication;
  • emotional distress, e.g. following bereavement;
  • antagonism, aggression or provocation on the part of others;
  • physical illness;
  • and an unsuitable mix of patients. 

It is worth noting that most of the above factors have been encountered by patients we see as part of the Powys Patients’ Council meetings and come up in patients’ feedback to us, so I wonder if these factors will always exist, to some degree, within in-patient units. If they do, then perhaps it’s not a matter of “may” provoke aggression, but that these are constantly having to be managed by staff in ways other than restraining patients.

One staff nurse mentioned that he worked within a high secure unit and that the staff never used restraint, that “conflict resolution” techniques were consistently used successfully. Here in Powys, ward management have mentioned that they don’t use restraint although staff are trained in Safe Physical Intervention Techniques or SPIT as it’s called. In fact, one of the staff on the ward here in Powys is the trainer for all Aneurin Bevan staff (including Gwent) in SPIT.

Another option for all psychiatric patients is to complete what is known as an “advance directive”, or here in Wales: “wishes known in advance” statement (we will be exploring this in more detail in a future blog post). This allows patients to state how they would like to be treated (or not treated) if they are detained by the Mental Health Act. They could quite clearly say that they don’t wish to be physically restrained and whilst an advance directive is not a legally binding document it would be good practice for hospital staff to respect the person’s wishes.

So, what’s the answer to restrain or not to restrain? It may be that while the Mental Health Act (and requisite Code of Practice) results in feelings of deprived liberty by people, there will always exist factors which may provoke people to behave aggressively. If this is the case, then ongoing debate and engagement on this topic will continue to be needed.

Finally, I’m curious to see if people may read something further into the paper outlined from the Department of Health mentioned at the very beginning of this blog post. It states, “This guidance forms a key part of the wider new Positive and Safe programme, which aims to end the unnecessary use of restrictive interventions across all health and adult social care." I wonder….

Tuesday, 17 March 2015

Reflections on volunteering at the Commonwealth and Olympic Games: what can sport teach us about life?

Anne enjoying volunteering at the Commonwealth Games!
Our latest guest post is by Anne Woods - Anne is a freelance writer, researcher and photographer living in Powys. Sport has been an important part of Anne's life pretty much since she could walk! She has represented her county in competitive gymnastics, taken part in equestrian events and played football for Brentford WFC: the highlight, winning a preliminary round match in the Women's FA Cup. She volunteers at several major sports events, including the British Grand Prix at Silverstone. She is currently playing for Hay St Mary's Ladies' Football Club, who train on Wednesday evenings in Hay-on-Wye. They welcome new players, aged 16 and upwards. Find out more on their Facebook page or via Twitter.

Last summer I was a Clyde-Sider, one of the small army of 15,000 volunteers at the Commonwealth Games. Whilst in Glasgow, I was lucky enough to have immediate access to some of the top athletes in the world and to watch them training and attempting to perform to the best of their ability in competition. What struck me as I watched them, is how much sport can teach us about ourselves and how we navigate through life, falling, picking ourselves up and trying again.

Sport encapsulates the full range of human emotion, providing a controlled and safe environment for the expression of frustration, disappointment, even fear; emotions that sometimes we seek to keep at bay and avoid in life. It occurred to me how useful it is to have an outlet for both positive and negative emotions, where feelings can be expressed in the moment without festering or escalating. With good coaching, sport offers a structure for learning how to manage and channel emotions positively: skills that we all find useful.

I was working in The Hydro, a cauldron of expectation and excitement as up to 10,000 spectators cheered on their heroes in the rhythmic and artistic gymnastics competitions. At first hand, I witnessed the anxiety that each athlete experiences and must learn to control to perform well under pressure. As a former gymnast myself, I know how important focus is to remain fully in control of acrobatic movements that have the potential for injury if not executed correctly. Balance and awareness, remaining alert and making minute corrections second by second can be the difference between a gold medal and falling off the beam in agony.

Sport is about the mind and body working in harmony, being in the 'zone', in the present, going with the flow, not over-thinking, not letting the nerves take over or being over-confident but allowing the muscles to do the movements they've trained to do over thousands of hours of often gruelling practice. The discipline of training itself teaches perseverance and determination and an acceptance that we might not be able to do things immediately but with practice we can get better.

Competition brings out the best of us and also the worst. What I remember most about my time as a gymnast is the perfectionism that blighted a good performance and made it not good enough, rather than a joyful expression of hours of practice and the feeling of achievement of pushing my body and mind to their limits. I saw evidence of gymnasts being very hard on themselves at the Games as they strove for perfection by contorting their bodies into shapes most people could only dream about. This is the element of sport that has the power to distort our image of what is good enough and replace enjoyment with disappointment and feelings of failure.

Scene from the opening ceremony. Humanity, equality and destiny are the
underpinning values of the Commonwealth Games Federation.
Image credit: Anne Woods
I was also lucky enough to volunteer at the Olympics in 2012. I was a Games Maker at Greenwich Park for the equestrian events. I will never forget watching the breathtaking performance of British rider, Charlotte Dujardin and her horse Valegro in the dressage - the "dancing" horses. At the very end of what had been an almost flawless routine, Valegro lost composure, and broke stride in an obvious error. I, along with thousands of others, gasped and held our breath. It didn't matter: they won the gold medal with a score of over 90%. What I learned from this and watching days of equestrian competition is that even the best in the world make mistakes. What distinguishes them is their ability to move on quickly and not let the mistake affect the rest of their performance.

The athletes who do best, in my opinion, are those who achieve the balance between pushing themselves to achieve, accepting their successes humbly and not taking their failures too seriously. Giving '110%' is important but not at the expense of self-compassion. Perfection is unattainable and there will always be something to be disappointed about if we look hard enough for it. Focussing more on what has gone right makes for a kinder and more enjoyable passage through life.

At the closing ceremony of the Commonwealth Games, Lord Smith of Kelvin made a speech. These words hit home, "no matter who you are or where you are, sport has the power to make you feel part of something bigger." Certainly, my experience of volunteering at big events bears this out. I would recommend that anyone gives it a go. Even if you don't think you like sport, if you like people, there will be something positive to take from it. The volunteering community tend to be caring, friendly and will go out of their way to help others. Spending time with people like that is a good way to restore your faith in humanity. Sometimes we all need to feel part of something bigger. I agree with Lord Smith. Sport has that power.

Wednesday, 4 March 2015

Comic Relief award of £110,605 for Powys project to develop Mental Health Networks

PAVO's mental health team celebrates news of the award
Back: Glynis Luke, Jane Cooke, Freda Lacey
Front: Jackie Newey
Shaping Our Services - "Together For Powys Mental Health" 
Local Participation Networks

Powys Association of Voluntary Organisations is pleased to announce that it has been awarded £110,605 from Comic Relief for a three year project, to be managed by the mental health team, to develop local mental health participation networks around Powys. The work is being funded under Comic Relief’s Fairer Society theme, which aims to: “empower and give a voice to marginalised groups of people, enabling them to challenge injustice and bring about positive changes for those who face discrimination and stigma”.

Freda Lacey, our team's Participation Officer, who worked on the funding bid to Comic Relief, told me more about the new project.

“Our county mental health participation network has made a positive difference to marginalised people’s lives since 2010. Using principles of collaboration and co-production, we have successfully challenged injustice and ensured that people excluded from decision-making processes have had their voice heard and been involved in shaping services both in Powys and nationally.

This county-wide work has identified the need to develop participation networks in local communities. Here people face local problems sometimes not appropriate for county discussion, they lack confidence to participate at this level, and are unable to access meetings centrally or to participate remotely. Statistics show that we only reach 10% of people in contact with services as the majority live in more rural areas.

Decisions about mental health services are being made nationally, but 90% of people in Powys currently do not know how to ensure their voice is heard at this level. This means that they cannot participate in decisions that affect their lives. In 2013 we recruited local individuals to participate on local/national mental health strategic decision boards. These individual representatives require local networks to be in place to listen and share with other people, from all ages, in contact with services, and those close to them, to ensure that they are reaching as many people as possible in local communities. This not only empowers grassroots community voice but also supports the individual representatives as carriers/channellers of that collective voice.
Freda (far left) at Comic Relief HQ in  London on February 5
meeting people from other award-winning projects
People will use their lived experience to make a positive difference, to their own lives and the lives of others. Their voices, lived experience, and skills will be used to help reduce the disadvantages, discrimination, social inequality and stigma faced by people experiencing mental distress and influence and improve services and opportunities available to “all of us” across Powys.

Participants in the project will increase their negotiating, listening and influencing skills and their understanding of public sector delivery, decision making and strategy. People in Powys, from children to older people, will know how to access local, county and national participation opportunities. They will know how to speak out and get their voice heard, and how to actively engage with those working in mental health services and help shape service delivery."

If you would like to find out more about mental health participation opportunities in Powys, please take a look at the Getting Involved pages on our website here.

You can find out more about the work of Comic Relief here, and Red Nose Day Friday 13 March 2015 here

Make your face funny for money!

Red Nose Day comes along every two years and combines two very British things: having a laugh and helping others. Be it at school, work or home, people across the land put on Red Noses and pull out all the stops to raise as much money as possible. Then, once everyone’s run out of fundraising juice, they tune into BBC One for some top entertainment from their favourite comedians and to donate even more cash! And why do they do it? To help poor and vulnerable people living incredibly tough lives both here in the UK and across Africa.

Update: The Participation Worker post related to this project is now being advertised. Closing date 7 April 2015. More info here.