Elysian hopes shattered

 

...the opposite of Udine's Ward 9

 Last week I went somewhere with a colleague that I described as grim, appalling, and devoid of human life to him. I’m not often shocked at what mental health facilities are like – I’ve have been to, and sometimes worked on, everything from elysian communities where tea and scones are served every day at 4pm, to dingy dungeons not far short of torture chambers – and all between. Just as relevant is the spectrum between a social architecture which is compassionate and playful (but also challenging and supportive), versus the places that feel like a dehumanised, arid wasteland with lonely and angry souls trading skunk or spice, and fighting each other.

 I won’t name who I went to see today, or where it was, but its physical architecture was modern, bright and clean - although it was all made out of hygienic plastic furniture, shiny walls and floors, and with ‘mental health’ windows and light fittings (Perspex and indestructible). Not a ligature point in sight, of course. So maybe on that scale we could give it four or five out of ten – certainly no dungeon, but no hygge either.

 But the social architecture Is what rattled me – everybody was friendly and polite of course, so I suppose it doesn’t get a zero or one out of ten for social architecture. But the level of unspoken restriction, of overpowering social control, and ‘that is how it is done here’ was utterly pervasive. Most people unaccustomed to different types of mental health facilities would probably expect no different – but to me, it’s atmosphere, ambience and ‘smell’ was tangibly and visibly toxic, and essentially anti-therapeutic. It was made tangible when we were told on arrival that we could not visit the person we had come quite a long way to say ‘hello’ to, because they were disturbed and needed to be sorted out. Just what that entailed was never quite explained – except for the very flexible ‘disturbance’ euphemism, and the apparent need for two or more staff to be in their room. We were shown a list of forbidden contraband that was not allowed past the front office, so surrendered our phones; I also noticed that it included Pringles tubes and Blu Tac – need to cover all bases! The list was also on a nearby noticeboard which asserted Zero Tolerance in a very large font, and some NHS ‘Relational Security’ graphics (originally devised for the secure and prison estate, including the DSPD units in the 2000s) which, in both presentation and starkness of the communication, were about as alien to the foundation concept of ‘relational practice’ as is possible to be.

Some of the forbidden contraband

To try to get a more objective measure of this malignant alienation I was feeling, here is my quick reckoning against two published documents, and one which is work in progress:

ENABLING ENVIRONMENTS:     (related Comparison to the criteria for each standard, as detailed on EE website: http://tinyurl.com/EEsatRCPsych )                        

BELONGING                            Not seen | not happening | not likely | no

BOUNDARIES                          Opaque | possibly inconsistent | no visible review system

COMMUNICATION                  Unlikely | no opportunity | not so

DEVELOPMENT                       Absolutely not | forbidden | no | absolutely not

INVOLVEMENT                       Does not happen | stated as policy but no evidence of it happening | no

SAFETY                                    not so | unlikely | possibly | not happening

STRUCTURE                            slightly | no evidence of review | often prevented

EMPOWERMENT                    absolutely not | not so | no way | no, nor do family members

LEADERSHIP                            possibly, but likely to be administrative only | very unlikely | unsure | not so | possibly, not seen

OPENNESS                              not really | absolutely not | not likely

 

 3          RRELATIONAL PRACTICE MANIFESTO:  (commentary on a few selected quotes from the manifesto)      

·         An enabling and facilitating attitude
This was not in evidence at all; if anything, the staff attitude was professionally distanced and dispassionate.·             

·         An understanding of the inner and outer lives of individuals in their social field.
Very practical and superficial understanding of residents’ ‘outer lives’.
No acknowledgement at all of need to understand ‘inner life’ beyond overt psychopathological symptoms.
It is unlikely that the staff would know about, or be trained to include, this consideration.·             

·         If staff hold all the power, this keeps users dependent on services and does not give them the opportunity to take control of their lives or have a say in their care.
In the house seen, the power is clearly held elsewhere – from the evidence of our eyes, by the company policy and the visiting consultant psychiatrist. There is a strong sense that on-site staff have no discretion whatsoever in implementing decisions, and residents have to accept what they are told without any opportunity to discuss or challenge it effectively.·             

·         When human connections are lost, we see the breakdown of communities and relationships, and people struggle to find hope for the future.
It felt that people here were disconnected, there was very little sense of community – or hope for anything to be able to change.          

·         Make time to reflect on your current practices together
Reflective supervision would require all members of the multidisciplinary team to come together to discuss their feelings about the work; it is extremely unlikely that anything like it happens here.

Repurposed graphics from DH's PD programme, 2005

HOMESTEAD CLINICAL MODEL    (directly comparing models, based on the stated ideals draft for Homestead)

 
Our model is informed by a radical therapeutic approach with a long and venerable history, underpinned by understanding and using relationships.

                 The model at the place visited was primarily based on a biomedical psychiatry approach with minimal and secondary psychosocial factors seen

This includes all relationships between staff and residents, staff and staff, residents and residents - and all between-group relations.
                Nothing was seen to indicate that relationships were actively used as part of the treatment. Compare to www.cht.org.uk  

Residents recover through relationships and reconnecting with themselves, each other, the wider community and the natural world.
                Residents who feel cut off and isolated remain cut off and isolated, as they ‘are unwilling to engage’. There is no contact with the local community (which has rich resources, including nature). A small garden area is probably pleasant and well-used in Summer.

 
All members of the communities are heard and treated with respect whatever their role, gender, age, sexuality, ethnicity, religious belief or physical characteristics.
                It is unclear whether any residents feel heard (communication is almost entirely in the opposite direction), but there was no indication of this being any different with diversity issues.

 
Use of medication is by informed choice. The most up-to-date techniques of deprescribing and tapering will be used for withdrawal wherever appropriate.
                There is no informed choice of medication; its prescription and administration is not able to be questioned without causing disagreement. Withdrawal does not appear to be on the agenda.

 
We support people to find meaning in their difficult experiences, learning how to live well, and reclaim their future.
                No exploratory conversations are held to find explanation, understanding or meaning in psychotic’ symptoms. Living is the bare minimum – hygiene, order and cleanliness are well-attended to, but few would consider this to be ‘living well’ – or have anything to do with one’s future.

 
No coercive interventions are made.
                Although we saw no verbally aggressive or unduly forceful action, it is clear that dissent from what is suggested is only possible through distant and bureaucratic processes. The pervasive ethos is of gentle but pervasive social control, with its consequent lack of freedom.

 
All aspects of the services are co-produced: programme design, policies, leadership and management.
                This does not seem to happen at all.
 

It is anticipated that breakdown of relationships requiring detention under the Mental Health Act will be very uncommon. When it is unavoidable, harm will be ameliorated by the preventative establishment of good working relationships with statutory services.
                Here, the MHA is the main tool to allow insistence of conformity and prevention of any non-compliance. Relationships with statutory services were seen to exist, and discharge to them was possible – and appeared to be common practice when behaviour could not be contained (eg to forensic units)