Recent images of the abuse of vulnerable people shown on television will have shocked many and awakened traumatic memories for some of those who have used services. For people whose loved ones are being cared for, they may have caused great anxiety. People are rightly asking how could this happen again? After previous inquiries into Staffordshire and Winterbourne and all the recommendations and changes made, why can’t we stop this happening? Answering these questions means thinking about what makes abuse more likely to happen and what can be done to prevent it.

The focus of discussion here will be on acute mental health inpatient care, but such issues affect many services for vulnerable adults and children.

We know abuse is more likely to happen when:

• There are significant inequalities of power between two or more groups.[1]
• ‘Labelling’, that is calling someone ‘learning disabled’, mentally ill, or ‘personality disordered’ leads one group to be seen as different or ‘other’ meaning they may be treated very differently.[2]
• The emotions of staff involved in providing care, which will sometimes include fear, anger and frustration are not acknowledged and thought about in a supported way, and instead influence how they interact with vulnerable people.[3]
• The service allows restraint and seclusion to be used as a last resort in response to what may be emergency situations but does not adequately monitor how they are used and support ongoing learning about when they are used.[4]
• The culture is ‘closed’ with a lack of visible, open leadership, and poor connections between managers, staff, people using the service and carers or loved ones.[5]
• People’s traumatic experience of coercion in inpatient services may worsen their distress and lead to a cycle of fear and despair which results in yet more coercion.[6]
• The culture lacks openness to learning from mistakes, fails to listen to the experience of staff, service users, carers and loved ones, and fails to promote co-production.

Over time a corrupted or closed culture develops in which abusive behaviour by staff becomes seen as ‘just the way things are done around here’. New staff may feel under pressure to behave in the same way to fit in.

Almost all care services have power structures which place service users and direct care staff at the bottom of the hierarchy. Both groups may lack status, power and control over significant aspects of their lives. Both groups may be stigmatised. Service users in an acute inpatient mental health service is disempowered by diagnostic labels attached to them, the medical model they derive from, care under the Mental Health Act, and by the service accommodating them[7]. The service user is likely to be struggling with significant, overwhelming emotional distress, impacting on their ability to manage their feelings, which may be linked with a history of neglect, abuse and trauma.  In this context, staff often experience verbal or physical aggression, linked to the level of distress service users are experiencing. It can be hard to make sense of this, and it has a significant emotional impact on staff providing care, potentially leading to compassion fatigue and burn out. The result may be a disempowered and frustrated worker who struggles to understand their experience, and to maintain emotional and behavioural regulation, and who continues to be expected to care for the service user. In such a dynamic the risk of misunderstanding and conflict should be expected.

If we are to prevent further scandals, we need to ensure that all staff are supported to understand the psychological, social and cultural aspects of mental distress both in those who are supported by the service and in themselves. It is essential that practitioners are provided with regular opportunities to reflect on the emotional impact of the work and make sense of their experience of working with service users and how the ways they cope make sense given their life experiences.

There is an urgent need for training to help teams understand individuals in a more holistic way. Formulation-based models provide a structure which can support this; however, systems need to change so a more holistic and culturally informed way of listening to the person’s experience and needs is embedded. It takes time to develop a therapeutic relationship with a person in acute mental health crisis so they feel safe enough to develop a shared understanding where different perspectives can be valued and integrated to support ideas of how to help them move forwards. Unfortunately, too often inpatient care systems are focused on throughput, risk assessment and management, and rapid discharge due to acute pressures. This culture goes against a trauma informed approach as it does not provide inpatients and staff with the psychological safety to develop and co-produce a shared understanding of difficulties and to agree on ways forward.[8]  People feel psychologically safe is when they feel included and able speak, challenge, to learn, and collaborate without fear[9].

Practising differently requires fundamental changes in how we educate practitioners and in the makeup of the multidisciplinary teams which support individuals in acute crisis. Teams need to be more evenly balanced, with increases in psychology, occupational therapy, art therapy, speech and language therapy, exercise therapy, social work, physiotherapy, and other therapeutic models. Such roles need to be within the leadership of the team, for example as multiprofessional Approved Clinicians to support multidisciplinary clinical leadership and a balance of models of understanding mental distress.

People will sometimes fail to reflect the values of trauma informed practice and the need to protect human rights. Preventing abuse means being sensitive to how the influence of individuals can impact significantly on a group[10] ^[11]. One person can influence how situations are understood and responded to, establishing norms within that group and making it hard for others outside of the ‘group’ to challenge bad practice. Whilst such ‘bad apples’ exist, we must though also be aware that sub-groups within a team, regardless of official status may come to hold significant power in setting the culture. It is therefore vital all individuals within a system uphold the values of the organisation in practice, and all are supported to challenge the individual, team and service when behaviour is not in keeping with those values. This supports ongoing, active, open learning, addressing issues as they arise with individuals and teams and helping to monitor the culture.

Listening to people’s lived experience of services is vital in ensuring high quality care. Co-production: reviewing and developing services alongside people with lived experience is a valuable way to support care quality in mental health systems, however, in practice it is embedded to a variable level, and in a multitude of ways[12]. Peer supporters enable lived experience to be heard, can help to challenge teams in the language they use and the way they make sense of situations. They provide a valuable role in supporting service users to feel heard, and in enabling healing connections. It is also crucial that a person’s network (be that family, friends, carers, community teams or professionals) is included in decisions about service-user. The network is invaluable in helping the team to understand that person and to think about what is in their best interests and how best to support them. They are also essential in supporting with and advising on recovery or discharge planning. The Panorama documentary highlighted how disconnected care can become from a person’s network, and how those around a person can be left feeling powerless to influence or challenge things.

If we fail as a society and as professionals to ensure that these systems can and do embody the values of human worth, mutual respect, listening and shared learning and minimise power differences, the system will become corrupted and there will be no sense of psychological safety within it. While individual workers must be accountable for their actions, if we do not understand such scandals as complex systems failures, we will learn nothing, and history will repeat itself.

References

[1] Paterson B., McIntosh I.,Wilkinson D., McComish S. and Smith I.  Corrupted cultures in mental health inpatient settings. Is restraint reduction the answer? Journal of Psychiatric and Mental Health Nursing.  20(3):228-35.  2013

[2] Martin J.P. & Evans D. (1984) Hospitals in Trouble. Basil Blackwell, Oxford.

[3] Campling P. (2004) A psychoanalytical understanding of what goes wrong: the importance of projection. In: From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services (eds Campling, P., Davies, S. & Farquharson, G.), pp. 32–44. London.

[4] Whittington R., Baskind E. & Paterson B. (2006) Coercive measures in the management of imminent violence: restraint, seclusion and enhanced observation. In: Violence in Psychiatry; Causes Consequences and Control (eds Richter, D. & Whittington, R.), pp. 145–169. Springhouse, New York

[5] Care Quality Commission (2020) Identifying and responding to closed cultures Guidance for CQC staff. Manchester. Care Quality Commission.

[6] Bloom S.L. (2010) Organizational stress as a barrier to trauma-informed service delivery. In: Public Health Perspective of Women’s Mental Health (eds Becker, M. & Levin, B.), pp. 295–311. Springer, New York.

[7] Ebrahim, S. & Wilkinson, L. eds. (2021) Psychological services within the Acute Adult Mental Health Care Pathway Guidelines for service providers, policy makers and decision makers. ACP-UK. https://acpuk.org.uk/new-guidance-on-psychological-services-within-the-acute-adult-mental-health-care-pathway/

[8] Office of Health Improvement and Disparities (2022) Working Definition of Trauma Informed Practice. https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice#working-definition-of-trauma-informed-practice. Accessed 08.011.22

[9] Hunt, D.F., Bailey, J., Lennox, B.R. et al. (2021). Enhancing psychological safety in mental health services. Int J Ment Health Syst 15, 33

[10] Campling, P Davies S and  Farquharson G, (Eds) (2004) From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services, London. Blackwell

[11] Zimbardo P (2007) The Lucifer Effect: Understanding why  good people turn evil . New York. Random House

[12] Norton, M. J. (2022) Coproduction and mental health service provision: a protocol for a scoping review. BMJ Open;12:e058428. doi:10.1136/ bmjopen-2021-058428