‘RECOVERY’ AS THE FUNDAMENTAL AIM IN A/NZ
MENTAL HEALTH SYSTEM
“Recovery is a deeply personal, unique process
changing one’s attitude, values, feelings,
goals, skills, and/or roles. It is a way of living a
satisfying hopeful and contributing life.
Recovery involves the development of new
meaning and purpose in one’s life as one
grows beyond the catastrophic effects of
psychiatric disability.”
 (William Anthony, 1993: 12-13)
POSITIVE RISK MANAGEMENT IS NEEDED:
…decisions about risk management involve improving the service
user’s quality of life and plans for recovery, while remaining
aware of the safety needs of the service user, their carer and the
public… Over defensive practice is bad practice. Avoiding all
possible risks is not good for the service user or society in the
long term, and can be counterproductive, creating more
problems than it solves (UK DoH 2007, cited in Woods 2013:
808.)
COLLISION BETWEEN RECOVERY ORIENTATED
PRACTICE AND CORPORATE RISK MANAGEMENT
•
Corporate risk management designed to protect organisations and their
workers from error and blame.
•
This can lead to development of a ‘blame culture’, with ‘defensive
practice’.
•
Special significance given in such a culture to critical and adverse
incidents . They come to define in retrospect what constitutes
acceptable or unacceptable practice.
•
Workers come to rely on routinised procedures to protect themselves in
relation to idiosyncratic practice problems, instead of their experience
and judgement.
•
These routinised procedures often developed in relation to inquiries and
courts of review outcomes.
Sawyer and Green 2013
Tickle, et al 2012: 5
WE ATTRIBUTE BLAME NOT – OR NOT JUST – TO THE PERSON WHO
HAS COMMITTED AN ACT BUT TO THE AUTHORITY WHO SHOULD HAVE
FORSEEN AND PREVENTED IT. ONCE IT SEEMS POSSIBLE TO PREDICT
THE FUTURE THROUGH THE APPLICATION OF KNOWLEDGE, ONCE IT
SEEMS POSSIBLE TO TAKE ACTION IN THE PRESENT TO AVERT A
POTENTIAL UNWELCOME FUTURE, THEN FAILURE TO DO SO CANNOT
BE ASCRIBED TO CHANCE. EVEN A NON-DECISION IS A DECISION.
SOMEONE HAS DECIDED, SOMEONE COULD HAVE DECIDED
OTHERWISE, SOMEONE IS THEREFORE CULPABLE.
Rose 2005: 8-19
RISK CULTURES CREATED
Adverse incidents occur…
Coroner’s reports, HDC reports, litigation, media
outcry…
Policies to protect organisations from
institutional liability created (corporate risk
management)…
Defensive practice develops…
Freedom and autonomy lost to patients…
Iatrogenic risk: trauma, suicidality and loss…
TRAGIC OUTCOMES…
25% of people committing suicide (England and
Wales) have had recent contact with mental
health services.
160-200 mental health inpatients (England and
Wales) die by suicide annually.
About 50 homicides per year committed in
England and Wales by people who have had
recent contact with mental health services
Tickle, et al 2012: 3.
CLOSED DOWN ENVIRONMENTS
The tea and coffee making facilities in the patients’ lounge were
kept locked away. As a result, patients had to use the kitchen to
make tea and coffee, which wasn’t always open to them. When it
wasn’t open, they had to ask a staff member to make them a hot
drink. I asked why the tea and coffee making facilities in the
patients’ lounge were locked, and was told that the hot water was
a risk.
The courtyard off of the second patient’s lounge was kept locked.
Patients weren’t allowed to use it at all. I asked the reason for
this, and was told that it was a risk as patients might hang
themselves from a fence ligature.
When patients want to wash their coffee mugs, they have to ask a
staff member to open the locked cupboard under the kitchen
sink, which contains nothing except washing up liquid. I asked
why this was kept locked, and was told it was a risk.
The windows in the main part of the ward only open a few
millimetres. This means that it is impossible to generate a flow of
cool air on hot days.
SOME QUESTIONS
Is it possible to prevent all adverse incidents, if
somebody is determined to harm themselves?
How much control would be required to achieve
this?
What are the consequences for the patient’s
sense of emotional wellbeing, of being
subjected to this level of surveillance and
control?
What does ‘safety’ mean? Who is it for?
RECOVERY AS A SYNONYM FOR ‘LEARNING’
“Peer support is a very deep thing, you know.
And recovery and wellbeing’s a very deep
thing as well. You know you could say
recovery’s almost like a spiritual experience
but it’s certainly, I would say, a critical learning
experience. It’s an experience of true learning.
And if you look at learning environments and
recovery environments, they’re the same
thing.”
(Geoff, peer support manager, cited in Scott et al 2011a: 21).
A CULTURE OF FEAR…
Because I was waking very early during my time on the
ward in November 2013, my consultant charted early
morning walks for me, before the ward doors opened. I
went for one early walk, at 7 am, without incident. When
I tried to go the next morning, I was told that this wasn’t
allowed by ward policy, and I had to wait until the doors
opened at 8 am. When I asked the reason for this
prohibition, I was told that it was because early morning
walks were risky, since few people were out and about.
MORE QUESTIONS…
How does one balance the desire to support autonomy,
healthy activity and creativity, along with the need to
‘protect’ very unwell people?
How does litigation, and media reporting, around
adverse incidents drive defensive practice?
Is it easier to deal with one’s guilt feelings over not
preventing a suicide, or other blatantly harmful event,
or one’s feelings about ongoing repression of choice
and freedom?
How does the making of ‘ward policy’ allow the personal
divestment of such guilt feelings?
RISK CULTURES ARE DRIVEN BY FEAR…
…it seems, on balance, better to take some well
judged, carefully worked out risks than to lock
everybody up and throw away the key, that’s
crazy. (Angela, cited by Tickle, et al 2012:7).
…assessment is only as good as the minute and
day that you do that assessment, and the
assessor who’s doing it, and an hour later, 5
minutes later, things can change enormously.
(Trish, cited by Tickle, et al 2012: 7)
LACK OF TRUST LEADS TO ‘NOTHING TO DO’
During my March-May stay, there were no games on the open
shelves in the lounges where patients could access them. I
asked the reason for this, and was told that patients might
‘lose’ or ‘break’ the pieces. I was told that there were games
available to patients. I asked where these were, and was
shown a locked cupboard in the intensive care wing of the
ward. The cupboard was not labelled, and there was no
indication of what games were there, or indeed if games were
there at all. Most patients are not allowed on the intensive
care wing. During the two months I was on the ward, the only
game to come out of this cupboard was scrabble. This was
played extensively by patients. Most of the patients were
entirely unaware that there were any other games anywhere
on the ward.
YET MORE QUESTIONS…
How does a ‘culture of risk’ build on itself?
Can restrictions intended to prevent suicide or other
major events lead to restrictions focused on much
smaller ‘risks’? How and why does this happen?
How does development of a ‘culture of risk’ affect
therapeutic relationships?
HOW CAN A RISK CULTURE BE ‘TURNED
AROUND’?
“We work on relationship; I think that’s the thing that we do really well.
And when those relationships are working well, we’re checking in with
the people all the time and we’re seeing whether they’re eating,
drinking, doing all the normal things or not. And you know, if the person
stops eating and drinking and stuff like that, you might think, ‘What’s
going on with them?’, and you can check it out and see if they’re ok. It’s
that relationship, and we put a lot of intense hours into just chatting
with people… and it’s really great to get people reporting for themselves
and taking responsibility for themselves to say, “hey, I’m feeling a bit
unsafe”. You know, recognising it first themselves, before they do
anything.” (Maya, peer supporter in a crisis house; Scott, et al 2011a:
55).
AGENCY IS CENTRAL…
“It is important to understand that persons with a
disability do not ‘get rehabilitated’ in the sense that
cars ‘get’ tuned up or televisions ‘get repaired’.
Disabled persons are not passive recipients of
rehabilitation services. Rather they experience
themselves as recovering a new sense of self and of
purpose within and beyond the limits of the
disability. ... It is through the process of recovery that
disabled persons become active and courageous
participants in their own rehabilitation project.”
(Deegan 1988: 12).
“One team’s coming from a very risk averse medical
model approach. And we’re coming from an opportunity,
risk is opportunity and if you don’t take any risk you don’t
learn anything, sort of approach. And, but the safety’s
in… I guess safety’s not quite the right word. The
container is the relationship, really, the peer
relationship.” (Geoff, peer support manager of a crisis
house; cited in Scott, et all 2011a: 57).
SOME THEORETICAL QUESTIONS…
How and why are patients ‘governed’ in the
mental health system?
If selves are constructed through discourse,
what are the ‘selves’ that are available to
patients in a risk culture?
What sort of self can be constructed in a
recovery environment?
How can fear of suicide, self harm and harm to
others be addressed when constructing such
regimes of governance?
REFERENCES
Patricia Deegan (1988) ‘Recovery: the lived experience of rehabilitation’; Psychosocial
Rehabilitation Journal 11(4): 11-19.
William Anthony (1993) ‘Recovery from mental illness: the guiding vision of the mental health
service system in the 1990s.” Psychosocial Rehabilitation Journal. 16: 11-24.
Anne Scott, Carolyn Doughty and Hamuera Kahi (2011a) Peer Support Practice in Aotearoa
New Zealand. Available online on HDC website:
http://www.hdc.org.nz/media/199065/peer%20support%20practice%20in%20aotearoa
%20nz.pdf
Anna Tickle, Dora Brown and Mark Hayward (2012) ‘Can we risk recovery? A grounded theory
of clinical psychologists’ perceptions of risk and recovery-oriented mental health services’;
Psychology and Psychotherapy: Theory, Research and Practice.
Nikolas Rose (2005) ‘In search of certainty: risk management in a biological age’; Journal of
Public Mental Health 4(3): 14-22.
Woods, P. (2013) Risk assessment and management approaches on mental health
units. Journal of Psychiatric and Mental Health Nursing 20: 807-813.
Sawyer, A.M. and Green, D. (2013) Social inclusion and individualised service provision
in high risk community care: balancing regulation, judgment and discretion. Social
Policy and Society 12(2): 299-308.