Therapeutic risk-taking: A justifiable choice

Uncovering Complexities in Reducing Aggression, Conflict and Restrictive Practices in Acute Mental Healthcare Settings: An Overview of Reviews

Aggression, conflict and restrictive practices present complexities in acute mental health services, as do implementing service changes to reduce them. Existing published literature needs to offer more high-level guidance on the effectiveness of these service changes and their associated implementation factors. As a result, an overview of systematic reviews was undertaken to identify (i) nonpharmacological interventions to reduce conflict, aggression and restrictive practices in acute mental health settings, and (ii) their effects across different clinical outcomes. A parallel re-extraction from primary studies was then utilised (iii) to identify factors influencing successful intervention implementation. Of 124 articles sourced from nine databases and registries, four reviews were retained for the final analysis, using the direction of effect and tabular and narrative summaries. These reviews included programmes or interventions focused on inpatient adolescent, adult and older adult populations. They reported on alternative containment strategies, risk assessments, Safewards, sensory rooms and equipment, Six Core Strategy-based interventions and staff training. The overview found that a combination of interventions intended to improve relationships and reduce interpersonal conflict may help reduce aggression, conflict and restrictive practices. At the same time, stand-alone staff training and sensory rooms and equipment may have mixed effects. The quality of the evidence linking these interventions to reductions in aggression, conflict and restrictive practices is limited. Successful implementation hinges on multiple factors: intervention characteristics, preparation and planning, evaluation and monitoring, outcome interpretation, stakeholder involvement/investment, staff-related factors and contextual factors. Any implementation initiative may benefit from using pragmatic and complexity-informed research methodologies, including integrating meaningful involvement with service users, peer workers and culturally diverse groups.

Ontological insecurity of inattentiveness: Conceptualizing how risk management practices impact on patient recovery when admitted to an acute psychiatric hospital

Risk management which assesses and mitigates risks such as suicide and violence is under scrutiny, particularly within psychiatric inpatient settings. Restrictive practices, which result from risk assessment, such as observations, physical restraint and ward seclusion can impact negatively on patient recovery, hindering abilities to develop a meaningful life that emphasizes purpose, hope and autonomy, despite experiencing mental distress. Yet, less is known about the impact from the patient's perspective when first admitted to hospital, a period which among other reasons may come with increasing risk management practices owing to the clinical uncertainties about patient risks. In this grounded theory study, we explore the impact on recovery, interviewing 15 adult participants with patient experiences of being in an acute hospital. The main theme of the study, termed a core category with a grounded theory, was identified as "ontological insecurity of inattentiveness". This highlighted a staff inattentiveness with involving patients with risk management and explaining the purposes of the practice, which raised insecurities about what was happening to the patients when admitted to hospital. Four subcategories support the core category; discounting the patients' experiences to gain a meaningful grasp of risk management, ambiguity about risk management rules, particularly the reasons around their use, forebodingness to the hospital environment and, management from afar, with patients feeling scrutinized from observations without a voice to offer different views. It is hoped these findings will add to the field of patient involvement in psychiatric inpatient settings, proposing attempts to raise understanding and inclusivity of risk management, starting when first admitted to hospital.

How do people conceptualize self-harm recovery and what helps in adolescence, young and middle adulthood? A qualitative meta-synthesis

OBJECTIVE

Self-harm can be understood as any behavior individuals use to harm themselves, irrespective of motive. Evidence has extensively examined the epidemiology and function of self-harm to the individual, but less is known about the subjective processes underpinning recovery. Such insights could inform therapeutic interventions to better support individuals. The present aim was to synthesize qualitative themes from eligible literature to identify how adolescents, young adults, and those in middle adulthood conceptualize self-harm recovery and the factors impacting this process.

METHODS

Eleven studies were identified from a systematic search of five electronic research databases: PsycINFO, Embase, Medline, Global Health, and CINAHL. Studies were critically appraised using an adapted Critical Appraisal Skills Program tool for qualitative research. A meta-synthesis was conducted using reflexive thematic analysis to generate themes across the included studies.

RESULTS

Themes depicted recovery as a multidimensional, nonlinear, and subjective process, characterized by a "push and pull" between states of (re-)engagement and cessation/reduction. Transition between these states was influenced by intrapersonal and interpersonal factors which were embedded in a wider milieu of the meaning of self-harm to the individual.

CONCLUSION

Contemporary ideas of symptom eradication as the only marker of complete recovery may hinder individuals in the long-term, presenting an obstacle both to quality of life and therapeutic progress. Movement away from self-harm recovery as a uniform or singular phenomenon could enhance person-centered care.

Injury, illness, and emotion: A review of the motivational continuum from trauma through recovery from an ecological perspective

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Occupational therapists and physiotherapists weighing up the dignity of risk for people living with a brain injury: grounded theory

PURPOSE

Following a brain injury survivors may have physical, or cognitive changes or behaviours which bring safety risks into play when engaging in activities. Therapists experience tensions in enabling the dignity of participation in the context of managing risk.

MATERIALS AND METHODS

Ten occupational therapists and seven physiotherapists participated in a grounded theory study utilising semi-structured in-depth interviews to explore the tensions between dignity and management of safety risks. Data were analysed using constant comparative method and a process of moving from open coding to categories to theory development.

RESULTS

The process of weighing up was central to the therapists' approach to supporting dignity while managing risk. Respecting dignity itself is placed at risk when preventing harm is weighted higher than living a full life. Therapists who use weighing up as a process that respects dignity place greater value on the principles of respecting autonomy and promotion of justice for people with a brain injury.

CONCLUSION

Rather than taking control and attempting to minimise risk therapists who privilege the perspective of the client, and provide opportunities for learning through failure or success, enable clients to live a full life.IMPLICATIONS FOR REHABILITATIONEnsuring that clients with brain injury are safe often requires therapists to exercise control and remove agency thus removing the rights of the client to the dignity of risk and living a full life.Providing opportunities within rehabilitation for clients to experience failure and success enables learning and thereby support dignity.Privileging the client perspective provides clients the dignity of living a normal life.

Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management

Suicide prevention in psychiatric practice has been dominated by efforts to predict risk of suicide in individual patients. However, traditional risk prediction measures have been shown repeatedly in studies from high income countries to be ineffective. Several factors might contribute to clinicians' preoccupation with risk prediction, which can have negative effects on patient care and also on clinicians where prediction is seen as failing. The model of therapeutic risk assessment, formulation, and management we outline in this article regards all patients with mental health problems as potentially at increased risk of suicide. It is aimed at reducing risk through use of a person-centred approach. We describe how a move towards therapeutic risk assessment, formulation, and risk management, including collaborative safety planning, could help clinicians develop a more tailored approach to managing risk for all patients, incorporating potentially therapeutic effects as well as helping to identify other risk reduction interventions. Such an approach could lead to enhanced patient safety and quality of care, which is more acceptable to patients.

Defensive practices in mental health nursing: Professionalism and poignant tensions

Mental health nursing is a skilled profession, well positioned to support patients towards recovery with evidence-based therapeutic interventions. However, the profession continues to be challenged by tensions surrounding the delivery of restrictive interventions and concerns over tendencies towards defensive practices. This paper examines the ambiguity this creates within the mental health nursing role. Organizational cultures that overvalue metrics and administrative tasks create barriers for therapeutic engagement while contributing to role confusion and stress within nursing. We need to address such structural constraints on nurses as mental health nurses' well-being is crucial to service delivery and the realization of therapeutic goals. From the UK perspective, authors argue that there is a need to examine service structures that foster compassionate and transformational leadership to enable mental health nurses to exercise the agency to practice therapeutically. Education and quality nursing research have a pivotal role to play in enabling this shift.

Mental health professionals' perceived barriers and enablers to shared decision-making in risk assessment and risk management: a qualitative systematic review

BACKGROUND

Risk assessment and risk management are fundamental processes in the delivery of safe and effective mental health care, yet studies have shown that service users are often not directly involved or are unaware that an assessment has taken place. Shared decision-making in mental health systems is supported by research and advocated in policy. This systematic review (PROSPERO: CRD42016050457) aimed to explore the perceived barriers and enablers to implementing shared decision-making in risk assessment and risk management from mental health professionals' perspectives.

METHODS

PRISMA guidelines were followed in the conduct and reporting of this review. Medline, CINAHL, EMBASE, PsycINFO, AMED and Internurse were systematically searched from inception to December 2019. Data were mapped directly into the Theoretical Domains Framework (TDF), a psychological framework that includes 14 domains relevant to behaviour change. Thematic synthesis was used to identify potential barriers and enablers within each domain. Data were then matched to the three components of the COM-B model: Capability, Opportunity, and Motivation.

RESULTS

Twenty studies met the eligibility criteria. The findings of this review indicate that shared decision-making is not a concept commonly used in mental health services when exploring processes of risk assessment and risk management. The key barriers identified were 'power and best interest' (social influences) and 'my professional role and responsibility' (social/professional role and identity). Key enablers were 'therapeutic relationship' (social influences) and 'value collaboration' (reinforcement). The salient barriers, enablers and linked TDF domains matched COM-B components 'opportunity' and 'motivation'.

CONCLUSION

The review highlights the need for further empirical research to better understand current practice and mental health professionals' experiences and attitudes towards shared decision-making in risk assessment and risk management.

Rethinking Risk Assessments in a Borderline Personality Disorder Unit: Patient and Staff Perspectives

Background

The present study was undertaken in a borderline personality disorder unit in Cambridge, UK. Our aim was to evaluate patient and staff perspectives on the current risk assessment procedure and to assemble opinions on a proposed change to this procedure.

Methodology

Structured interviews were conducted with patients and risk-assessing staff. Likert-scale and open questions were asked to gather both quantitative and qualitative data on both the preexisting risk assessment procedure and the proposed change to the procedure. The qualitative data was assembled into key themes.

Results

Patients and staff were moderately satisfied with the current risk assessment process, with patients scoring it an average of 2.75 out of 5 and staff scoring it 2.5 out of 5. Six key themes emerged as relevant to the process for both staff and patients: holistic approach, autonomy and freedom, responsibility, staff-patient relationship, time taken, and chance for reflection. One theme, “triggering negativity,” emerged among patients only, while a theme exploring ideas about risk emerged only among staff.

Conclusion

Our study highlights the need to introduce a new risk assessment procedure that grants patients more freedom and responsibility and encourages staff to individualize the process for each patient by taking a holistic approach. This would cultivate a ward environment that is less risk-averse and more recovery-oriented.

Exploring Therapeutic Risk in the Recovery Process of Adolescents at Risk of Self-harm: A Thematic Analysis of Support Staff Perceptions

Background and Objective:

The high prevalence of adolescent self-harm within mental health services presents considerable management concerns, exacerbated by a lack of clear evidence regarding therapeutically effective approaches. This shortfall perpetuates traditional risk-averse practice, despite likely inadequacies in mitigating self-harm through failing to address underlying psychological mechanisms. Therapeutic risk, defined as an approach whereby clinicians support individual risk-taking, may be an alternative that yields improved recovery outcomes. However, related research is adult-focused and provides limited detail on its features, practical delivery and impact on recovery. Consequently, the current study explored the experiences of professionals delivering a therapeutic risk ethos, including their conceptualisation of it and its impact on young people.

Methods:

Semi-structured interviews were conducted with seven mental health support workers employed by a residential healthcare provider, which promotes a therapeutic risk approach. The provider supported service users aged 15 - 20 experiencing complex psychopathology who, following inpatient discharge, presented a high risk of self-harm and suicidality. Interview data was thematically analysed.

Discussion and Conclusion:

Staff participants provided their understanding of a therapeutic risk approach, suggesting risk is viewed as positive and beneficial to recovery, alongside the promotion of service user freedom and flexible therapeutic risk management. The perceived therapeutic risk incorporates both permission and support, which facilitate the exploration of underlying feelings and alternative actions. Additionally, therapeutic risk promotes positive recovery outcomes due to empowered service users having increased control over their lives. They argued this can reduce psychological distress, encouraging the development of emotional regulation and adaptive coping strategies.

Threshold concepts: A portal into new ways of thinking and practising in psychiatry

Introduction: The theory of threshold concepts conjectures that there are areas in every educational curriculum that are challenging; however, mastering these areas transform the learner's view of the subject. In psychiatry, research into threshold concepts can inform educators so that they can better support students with mastering these challenging areas.Purpose: To identify threshold concepts, we conducted semi-structured interviews with six psychiatry educators and free-text surveys with medical students. To identify avenues for improving the curriculum, we discussed with educators, ways of improving understanding and looked at different approaches to learning.Materials and methods: From our analysis of all responses, we derived three threshold concepts: Therapeutic Risk-Taking, the Biopsychosocial Model, and the Concept of Diagnosis in psychiatry. The majority of students experienced difficulties grasping these concepts and applying them in their patient interactions.Results and conclusions: Hence, we propose focused teaching activities that can help students cross these thresholds: student Balint groups exploring therapeutic risk, student Balint groups exploring the role of a psychiatrist, exposure to psychological therapies/psychotherapy skills and explicit diagnostic reasoning. These activities can be integrated into the undergraduate curriculum to help medical students develop a better understanding and appreciation of psychiatry.

Staff Expectations of an Australian Integrated Model of Residential Rehabilitation for People With Severe and Persisting Mental Illness: A Pragmatic Grounded Theory Analysis

Mental health services increasingly involve peer support workers. Staff expectations of working in these services are important because they frame processes and cultures that develop within services, and influence work satisfaction, staff retention, and consumer experience. We examined staff expectations at two new community-based residential rehabilitation units trialing a staffing model where most staff are employed based on their lived experience of mental illness. Qualitative semi-structured interviews were conducted with ten peer support workers and five clinical staff on commencement at Community Care Units that opened in 2014 and 2015. Staff views covered individual motivations, emerging organizational practices and culture, and the nature and philosophy of recovery and recovery-oriented rehabilitation. Subtle differences were evident in staff understandings of recovery and recovery-oriented rehabilitation. Staff were mostly optimistic about the services' potential but expressed uncertainty about how the professions would work together and practicalities of the new roles. Concerns that staff foreshadowed are consistent with those reported in the literature and can be pre-emptively addressed. Future research on staff experiences will enhance understanding of how staff perceptions of recovery-oriented rehabilitation change over time, and of how these relate to consumer experiences and outcomes.

The construction of people with mental health problems as risk objects: Findings of a case study inquiry

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and management in mental health services are contested and perceived as problematic by both professionals and service users. There is substantial emphasis on risk as a core component of professional practice. However, recovery for people with mental health problems emphasizes self-determination which seems to conflict with risk management. A critique is emerging of risk assessment and management. However, there is a lack of empirical evidence which seeks to explore how professionals manage the conflicts between recovery orientated practice and risk management. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper reports on qualitative research which highlights people with mental health problems are objectified and frequently associated with the potential for harm. Risk dominates the work of mental health professionals and undermines individualized care. Service users are subject to increased surveillance and medication as a result. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Service users' subjective experiences need to be prioritized in mental health care by renewed focus on the relationship between professionals and service users. Mental health professionals should question the centrality of risk to their practice. ABSTRACT: Introduction The emergence of recovery, alongside significant focus on risk management, creates potential for conflicting influences in mental health care. Although evidence has critiqued risk assessment, there is a lack of research that seeks to explore how professionals make decisions within these apparently incompatible agendas. Aim To explore how practitioners, experience potential tensions arising from delivering recovery-orientated care and enforcing containment. Method This paper reports on a case study inquiry, using interviews with mental health professionals and observations in an acute ward and an assertive outreach team. Results Risk governed the practice of mental health professionals to such an extent it defined how service users were understood and treated. Service users were constructed as objects of risk, first by being objectified and secondly by creating a link between that object and harm. Discussion Hilgartner's (1992, Organizations, uncertainties and risk (pp. 39-53). Boulder, CO: Westview Press) theory of risk explains how risk dominates the identity of people with mental health problems at the cost of recovery. This results in increased monitoring, surveillance and medication to enact control. Implications for practice To undermine the dominance of risk, professionals should reconnect with the subjective experiences of people with mental health problems and challenge the acceptance of risk as central to their role.

Recovery-based Training in Mental Health: Effects on Staff Knowledge and Attitudes to Recovery

This longitudinal study describes the effects of recovery-based training on staff knowledge and attitudes to recovery. Mental health staff (n = 101) completed the study questionnaire (the Recovery Knowledge Inventory (RKI-20) and Recovery Attitudes' Questionnaire (RAQ-16)) before training and after six months. On the RKI, significant changes between pre- and post-training scores (p < 0.01) were found. On the RAQ, the scores showed significant changes in Factors 1 (p < 0.001) and 2 (p < 0.009). The results indicate a significant difference in confidence using a recovery model of care following training suggesting that recovery-based training positively affects staff knowledge and attitudes to recovery overall.