Workshop Choice Session 1
Would you recommend your forensic service to
a relative of your own?
Incorporating Forensic Service Users’ Reflections
on Recovery
Darren Lumbard & Estelle Moore
London Directorate and Centralised Groupwork Broadmoor
Hospital, WLMHT
Embedding Recovery Principles into Secure Services;
Progress & Challenges, Easthampstead Park: 8th July 2010
Working with principles which support recovery
Some of our assumptions
• recovery is about leading a meaningful life, as defined by the
person themselves
• recovery represents a movement away from a focus on pathology,
illness and symptoms to health, strength and wellness
• recovery encourages development of skills in self care and self
management in whatever way works for the service user
“Teaching recovery without the heart is an intellectual
exercise, another wall to run into for a patient, at all
levels of the system be the person working as a cleaner
or consultant. The heart is king, there is no faking it’s
healing capacity”
Former high security patient, (2007)
Our invitation today:
Make use of your heart – view your service/work through eyes
of a person who cares profoundly about it
A Carer’s Perspective
“For us it was extremely traumatic. There was no warning, no build up. It was all very
unexpected and sudden.”
“I didn’t really have much idea bout the mental health system, but like most people I
didn’t really think of Broadmoor as a hospital.”
“I was still very frightened for him and for myself, not knowing what was going to
happen, but when I started hearing terms like medical records, it felt like I was on
familiar ground – it was something I could understand.”
“I miss him terribly and it’s very important to keep in contact. It is hard to have
someone taken away from you and, although it sounds silly, I almost feel jealous of
nurses who help him with everyday things because I feel that’s my role.”
InTouch A Carer’s Life
Carers’ Perspectives
“I know that many people won’t experience ‘high secure’ services first hand, but any
parents and carers who are on a journey with a loved one with a mental illness should
try to remember to take heart and try not to feel overwhelmed …Most people are
more understanding than you think they will be”
“When I visited Broadmoor for the first time, what struck me most weren’t the high
walls, but all the friendly and understanding staff, from security to social workers …
They performed their duties with professionalism, good cheer and humanity.”
“It’s all about communication – keep talking and keep listening. Find out about the
people who can help you and use them. Learn as much as you can about the hospital
and keep building communications. Remember that the staff are just ordinary people
coming to work and the other carers are mums and dads just like you. It could
happen to anyone.”
Published in June 2010: Mother of a son admitted to Broadmoor for the first time, InTouch
Local newspaper article June 2010: National Carers Week
Recovery and ‘high security’
There are four such hospitals in the UK
High security is about containment via locks, fences, walls, exclusion from
community
Mean duration of admission used to be 8 years; less now
Detention involves a temporary suspension of personal responsibility
Recovery from offending: what does this mean?
How can perpetrators of offences take positive, safe actions in their lives which
do not place others at risk?
What promotes ‘recovery’ in all domains in high security?
A scenario to consider:
Corbin is a young man aged 26 who has an antisocial personality
disorder, and has experienced psychotic symptoms periodically,
with a major relapse preceding his index offence (his strangulation
of a fellow hostel dweller), and in prison.
On the ward Corbin stays in bed whenever possible. Staff find his
dismissal of interventions, ranging from 1:1s to groupwork difficult
to ‘manage’. Some staff think his room should be “locked off” in
the morning (to get him up); others think he should be allowed to
choose not to engage. The team are split about how to proceed.
What are the options here and how could they move forward?
What might a relative’s perspective be?
“If Corbin were my brother, I would want the staff
to ask why he wants to stay in bed…”
Generating a perspective on recovery from service
users
Focus Groups (Wilkinson, 2008)
The focus group is designed to be a flexible method of data
collection, during which peoples’ understanding and views can
be elicited
We facilitated 3 such groups with patients from across the
hospital: admission, mid-stay and ‘long-stay’ (and interviewed
some ‘refusers’)
Focus Group Questions
• What do you imagine the patients might have said
about their understanding of ‘recovery’?
• What do you think they might have said about high
security that makes ‘recovery’ more
difficult/complicated/less possible for them?
What is recovery?
Service users with a diagnosis of mental illness
said:
“It’s about getting back to normal”
“It’s a journey, its about learning to walk again”
“About alleviating or diluting symptoms”
“It’s becoming like your average Joe”
“It’s not the same thing as discharge or release…
It means being healthy in yourself, not being prisoner in you own
mind”.
What is recovery?
Service users with ‘personality disorder’ said:
“Its about discovery… if its about PD which has an impact on
yourself and others, then you need to change that, learn from
your experiences”
In the words of one ex-patient:
“Recovery is not medical… it is based on finding what heals you
and that can be as diverse as fishing psychotherapy, work,
family, a spiritual practice or simply unemployment. Drugs only
offer so much. This has been understood at well-equipped
secure hospitals for decades”.
What about high security makes recovery less
possible for patients?
The impact of stigma?
“You tend to lose self-respect in a place like this”
The experience of hospital detention?
“You can’t underestimate how much the system can penetrate you”
“living in a gold fish bowl”
“every move you make, everything you say, the way you walk, the way you talk, you see them
analysing things all the time”
The role of medication?
“It can hinder you”… “It can also help”
The gravity of the offences
“you don’t come here for no reason”
(Where else can this conversation be had?: “Opening up chapters like your index offence can slow
down recovery”…)
Some realities for high security as an environment
(Moore et al 2010)
Coming to terms with detention:
• “it’s hard to relax or be yourself when you are always being
watched, analysed”
• “being detained in high security is the lowest point….”
• “there’s a whole level of rejection about being here. You say,
I’ve been in Broadmoor and people back up, leave you alone,
don’t talk to you, like it’s a dirty word, an X on your back or
something”
• “For a time you have to surrender your autonomy, and trust that
the system will give it back to you in better shape”
Would you really recommend your service?
What do you think you would most want from staff for your
own relative if detention was necessary for them?
Ideas about the fundamentals for secure recovery?
• Trustworthiness?
• Boundaried professionalism ?
• ‘Firm but fair’?
• Appropriate concern?
• Absence of force?
The quality of alliances with staff : user perspectives
A ‘human face’ to a potentially objectifying setting (Cook et al, 2005)
Our ex-patient said:
“When I was in hospital I was fortunate or fated to find someone who provided
that level of care” [previous reference to compassion and kindness]. Through
her close support over 3 years I was able to leave the hospital and come out of the
devastation of my psyche that resulted from my childhood, the illness and the
violence I committed, and from being in an environment which I experienced
as horrendous. Caring is simple, it is not necessarily easy”.
What is the impact of the absence of (healthy)
alliances?
“There are people on my ward, nursing staff even at team leader level, you don’t see them
interact, there is not time, and you are expecting someone to know you, and you are also
expected to have trust in somebody when you have problems and difficulties… I’ve barely
had a conversation with people in the five months that I’ve been here”.
“High case loads for (staff) impact on the time allocated to understanding patient needs.
As a result they prescribe everything in their arsenal to the problems, but miss the
underlying issues”.
Therapeutic practice with those with a history of violating interpersonal boundaries can
place significant demands on staff: selection, training, supervision, reflection and
management support are vital frameworks to help staff stay on target.
Practice in support of recovery
Ask yourself… Did I?
• actively listen
• help to identify and prioritise the person’s goals for recovery (not only
‘professional’ goals)?
• in so doing, did I demonstrate a belief in the person’s existing strengths and
resources in relation to the pursuit of these goals?
• identify examples from my own lived experience, or that of other service
users, which inspires and validates their hopes?
• identify a range of resources (friends, contact, organisations), relevant to
achievement of their goals?
• encourage the persons’ self-management of their mental health problems?
• convey an attitude of respect for the person and a desire for partnership in
working together, acknowledge the possibility of set backs, but maintaining
hope and positive expectations?
Sainsbury Centre for Mental Health (2008)
From their 10 top tips for recovery-oriented practice
“Recovery is the service user’s own
achievement” (Turner, 2009)
“It is not the worker’s responsibility to do
something to the person experiencing distress to
bring about change. Instead, the professional
can enable change by creating the right
conditions in which it can take place”
We would like our forensic service to:
Resources/References
Bentall, R. (2009). Doctoring the mind: Why Psychiatric Treatments Fail
Cook, N.R., Phillips, B.N. & Sadler, D (2005). The tidal model as experienced by patients and nurses in a regional forensic unit.
Journal of Psychiatric & Mental Health Nursing, 12: 536-540
Davies, J., Howells, K. & Jones, L. (2007) Evaluating innovative treatments in forensic mental health. A role for single-case methodology?
Journal of Forensic Psychiatry & Psychology, 18: 353 – 367.
Drennan, G. & Alred, D. (Eds) (2010). Recovery in Secure Services. Willan Publishers
Moore, E., Lunbard, D., Carthy, J. Ayres, J., one former patient and 19 hospital residents (2010) Giving Voice to Recovery: high secure
hospital service user perspectives. Recovery in Secure Services (in press) Drennan, G. & Alred, D. (Eds)
O’Hagan, M. (2003). Force in mental health services: International user/survivor perspectives. World federation for mental health
Biannial Congress, Melbourne, Australia.
Roberts, G.,Dorkins, E., Wooldridge, J. & Hewis,E. (2008). Detained – what’s my choice? Part 1: Discussion. Advances in Psychiatric
Treatment, 14: 172-180
Sainsbury’s Centre for Mental Health (2008). Implementing Recovery. A new framework for organisational change www.scentre.org.uk
Turner, J. (2009). On recovery. Openmind 155: 10-11
Wilkinson, S. (2008). Focus groups. Chapter 9, PP 186-206. In J.A. Smith (Ed), Qualitative Psychology: A Practical Guide to Research
Methods II Edition, Sage: London.
Photos courtesy of MIND
We can be contacted via: Darren.Lumbard@wlmht.nhs.uk; estelle.moore@wlmht.nhs.uk; 01344 754583/754492/754143