Professionals' viewpoints

There are many reasons why an individual fails to participate, for example fear, rebellion, depression, withdrawal, incapacity and ambivalence, and these need clarification through careful assessment.

Regardless of his reasons, are Stephen's choices leading him towards recovery? If not, our responsibility is to ensure that he is engaged. His progression through the system will inevitably be determined by his engagement with all aspects of treatment. To collude with his passivity is to perpetuate detention.

A divided team cannot consistently support people who are themselves divided about the ‘choice’ to participate. To avoid splitting, leaders in the service need to make explicit for both staff and service users the guiding principles that underpin the ward's therapeutic programme. There needs to be a culture of expectation, purpose and hope.

Activity itself should not be optional, but which activity Stephen decides to pursue can be – a range of activities should be available that tune into his values and interests.

Healthcare professionals know that their intentions may be misunderstood by patients, because of their current condition, and where there is denial or lack of insight such misunderstanding can be protracted. Through psychologically informed reflection, staff should be helped to retain a compassionate perspective in the face of continued opposition, so that care does not become abusive.

Offering patients recovery coaching by ‘support, time and recovery’ (STaR or STR) workers (Department of Health, 2003) and involving service users in staff training would be a more ambitious option.

Service users' comments

‘If this were me I would want to be asked why I wanted to stay in bed. It could be down to fear of socialising or fear of other patients or even just simply because there may be nothing to get up for. No activities, no friends, no hope. One incentive to rise early that worked for me was an early-morning breakfast club.’ (J.W.)

‘Sometimes I would stay in bed in the hospital because I did not want to be alive, and getting up was an acknowledgment that I was and then I could not cope. I was also afraid of the other patients. I was just so scared.’ (E.H.)

‘When I've been on substantial sedative medication it has been very difficult to find the energy to get out of bed and I would want this acknowledged rather than being criticised or deemed lazy or unmotivated. Also, many people have different sleep preferences and what may be staying up late or getting up early will change with age, energy levels and quality of sleep.’ (E.H.)

‘I've often used my behaviour to protest about feelings of powerlessness, and staying in bed and disengaging could be an example of this. I was once advised by a nurse that by engaging and getting up on time I would recover more quickly and thus leave hospital earlier. This for me was a powerful incentive. Something I, and many others, do is to “fake it to make it” or “believe it to achieve it”, meaning that I'd behave as if I was better than I actually felt in order to have a section lifted and thus “escape”.’ (J.W.)

‘As this issue is creating a split, with people taking sides in the staff group, there may be a need for the whole group to meet and negotiate. There is a need to give and take, be explicit, take an educative approach and give reasons (procedural justice).’ (J.W.)

‘When they started to reduce my medication I did not feel the need to spend so much time in bed.’ (E.H.)

Professionals' viewpoints

An initial evaluation of risk and capacity can set the parameters for subsequent considerations of choice and responsibility.

The longer-term aim is to stimulate personal responsibility for owning necessary treatment. This could be through creating opportunities for informed experimentation while in a safe setting.

Some individuals pose such a high risk to the public that all consideration of personal preference is displaced by considerations of risk. Paradoxically, to insist on reliable acceptance of medication, for example by depot, is to support recovery. Defaulting and relapsing can result in a poorer prognosis and longer-term detention.

Depot antipsychotic medications can have an image problem linked to perceptions of passivity and imposition. If patients share this perception, healthcare professionals may dismiss the option of depot administration, without even making an adequate risk/benefit analysis of its usefulness or considering the possibility of re-presenting it to patients as a tool that can promote their recovery (Reference BarnesBarnes, 2005).

Clinicians who work with patients who pose significant risks are trusted to be cautious and aware of the potential of relapse and recidivism. However, rigorous risk assessments that evaluate historical factors in terms of the current context can be a basis for hope. These can be shared with service users and used in the co-authoring of risk strategies that may support new outcomes. But note that clinicians risk accusations of naivety if they do not balance such empathy for the patient's experience with sound risk management.

Service users' comments

‘If this were me I'd want some investigation into my past experiences of meds, whether they were effective and whether there were other factors involved such as a needle phobia or a fear of side-effects. This can be a complex relationship between my individual experience and the positive and negative effects of medication.’ (J.W.)

‘My fear of depots was that they would kill the voices. The voices were afraid (of annihilation) and I felt it too – the panic, and the onslaught of horrible stuff they would give me … I did want to have medication at this stage but needed to talk to somebody about my own realities and be heard in an unpatronising way and respected for how difficult it can be to talk about something nobody else will believe in.’ (E.H.)

‘I rejected treatment because I felt at the time “they want to bring you down to the common miserableness of everyday life”.’ (J.W.)

‘For me, support to realise that it's OK to be OK is important and could come from peers, staff and the example of others. It's all too common to feel like a “lab rat” being tested upon and done to. I have had fears both of dependency and of recovery, along with feeling that by accepting medication I am condemning myself to a life sentence.’ (E.H.)

‘When I feel that I've had input into a discussion on medication with a certain amount of choice negotiated over preparation and dose, then I feel more likely to agree to comply. If this can be achieved with minimal confrontation then I will feel less diminished by agreeing.’ (J.W.)

‘There is a dilemma here between “escape” and “recovery” and it's important to try to understand the complexity of a relationship that can swing from “leave me alone” to “hold me”. The overarching aim is to create a sense of mutual trust.’ (E.H.)

Professionals' viewpoints

This story, told from J.W.'s viewpoint, emphasises having to ‘earn’ leave and ‘plead’ for privileges. It touches on complex issues in the struggle of healthcare professionals to establish relationships in secure settings while also managing risk, i.e. how to balance their dual responsibilities to both an individual and society – particularly salient for patients still under the jurisdiction of the criminal justice system or Ministry of Justice – and how to ensure that all patients, convicted or not, are dealt with consistently on the basis of an accurate assessment of risk.

Appreciating the language used by all parties involved in the decision-making helps the decision-makers to recognise the underlying feelings and values implicit in requests such as J.W.'s. The challenge is to empathise with the individual, to appreciate what their request means to them, but to retain sufficient objectivity to weigh up the risks and benefits. This is the difficult art of balancing over- and under -identification with someone's wishes.

If it had not been possible to grant J.W.'s request, understanding the needs that led him to make it would allow the team to think of other, less risky, ways of helping him feel more connected with his life outside hospital and with his sources of support.

It is one of the more challenging personal/professional skills to be able to say no and remain compassionate in the face of anger, perhaps hatred, or the knowledge that others (staff and patients) think that one is unfeeling. It is about seeing the whole picture, and weighing up evidence, in the context of explicit values and principles. It is about seeing hope of recovery in the long term.

Sometimes health workers become inappropriately guilty or apologetic about their roles through a sense of guilt or fear arising from their own insecurity or inexperience, especially when they have to set limits and say no. In difficult confrontations, overwhelming or unrecognised emotions can distort decision-making – hence the need for team work and supervision.

If the risk that J.W. will abscond or set another fire is too great, allowing him ground leave may prejudice his future and undermine his recovery. Staff need to convey such messages with kindness and consistency, and be prepared for this to be appreciated only in retrospect, if at all.

Service users' comments

‘When I found myself in this position I felt that my consultant failed to understand the bond between me and my dog Gemma. She was old and I feared losing her before I was discharged. Fortunately the initial decision was overturned and I was overwhelmed to be with her on Christmas Day. What was important was that I was listened to and able to explain my reasons for something incredibly meaningful and special.’ (J.W.)

‘As well as having a strong need to be heard and not just acknowledged or paid lip service, I also believe that it's important to know where the individuals involved stand on the issue. If there's no way the consultant will let me see my dog, possibly because of the rules of a particular section, then it's vital to be told. This is easier to accept than being fobbed off. It's useful to know the “rules of engagement”, to quote a military phrase, and that the system will be consistent and fair. This situation can feel like a battle of wills at times.’ (J.W.)

‘I appreciated that the services were prepared to take a risk in the pursuit of recovery and I felt more encouraged to engage with my treatment regime as a result of having been granted this concession.’ (J.W.)

‘I would ask that you consider how personally significant issues such as this are a powerful way of reconnecting with who you are and your life outside treatment. They can give a sense that you can recover and have something to recover for.’ (J.W.)

‘I would ask that special issues such as this are dealt with sensitively. I'm not suggesting the rule book be thrown out but that a way of working innovatively is sought.’ (J.W.)

‘I remember my children coming to visit me in the hospital and at the time I was considered a danger to myself and my children. My children wanted to go outside on the grass to play, and luckily there was enough staff on duty for me to go out with them. Then my daughter fell down a manhole in the hospital grounds and she needed stitches in her leg. The hospital were very quick and helpful at arranging for me to be accompanied to the A&E with my daughter. She wanted her Mum with her at a time of great distress and this was allowed to happen. This helped me in my self-esteem around being a parent and was very important in aiding my recovery and bond to my children.’ (E.H.)

Professionals' viewpoints

Pete's story offers a powerful metaphor of extending experience by taking creative risks in a situation that looks dangerous but is safe and well supported. It encapsulates much about working with detained people in a recovery-based way.

Arrangements for leave are an essential component of treatment. Careful and collaboratively planned leave that is safe and successful can provide opportunities for people to feel that they are active participants and to own the process of acquiring the skills they will need to regain independence.

How such a decision is reached is likely to be as important as the decision itself – it should be through open discussion, weighing up risks and benefits in a fair and reasoned way, in the context of a supportive relationship.

As with anyone presenting with recurrent self-sabotaging behaviour, it is vital to try to understand why Pete absconded so frequently and to look for ways of developing a more secure attachment between him and the care team.

The story poses the interesting question of when it is justifiable to ‘break the rules’, when the benefits of greater spontaneity outweigh compromising an agreed care plan. In Pete's case, the nurse acted in the context of an established working relationship with the responsible medical officer who had ultimate responsibility for authorising his leave, and accurately anticipated what would be endorsed – in other circumstances the situation might need to be discussed and negotiated.

It is important to anticipate the broader issue of how this opportunism will be experienced by other detained patients on the same unit: it might influence their attitudes and expectations and affect the overall culture for both residents and staff. On this occasion there was a shared pleasure in Pete's achievements, but it could have led to divisiveness.

Service users' comments

‘This story highlights the need for staff to be flexible rather than giving the lame excuse/reason that due to staff shortages you can't leave. It also shows how escorted leave can have a dramatic effect on recovery. Personally, I have a long history of absconding and the only time I didn't feel the need to escape was on a ward where the door was left unlocked.’ (J.W.)

‘There is much value in being grounded in supporting someone's recovery and it's possible to find new ways of “connecting”. Finding out what this activity meant to Pete became obvious after his successful descent, and a new level of trust formed between staff and patient.’ (E.H.)

‘I want to promote “responsible risks” and I appreciate “the opportunity to fail”.’ (J.W.)

‘I don't – I would want someone to keep me safe – but I wouldn't say so at the time.’ (E.H.)