By Sonia Johnson, on 4 August 2014
A team led by UCL Psychiatry researchers has recently published the main findings from the NIHR-supported TAS 2 study, a mixed methods investigation of therapeutic relationships in crisis houses and on acute wards. Crisis houses are 24 hour staffed residential services in the community that aim to support people who would otherwise be at high risk of hospital admission through a crisis. A recent national survey of crisis care suggests about 35% of English catchment areas offer some access to a crisis house. Study findings included that therapeutic relationships are substantially stronger in crisis houses than in acute wards. This difference, together with greater support from peers and fewer negative events, may explain the recurrent finding of greater service user satisfaction in crisis houses than in acute wards.
Dr Angela Sweeney was employed as lead research worker on this study. She is a survivor researcher who has now moved to St George’s, University of London, where she is undertaking a five year NIHR Post-Doctoral Fellowship focused on understanding and improving assessment processes for talking therapies. The following is her personal view, drawing on her experiences of conducting the study, of the current state of therapeutic relationships in acute care, and of the fundamental changes she hopes can occur in future.
Are therapeutic relationships between staff and service users on psychiatric wards possible? My hope for engagement on equal terms
I was sitting in the nurses’ station of a psychiatric ward waiting to talk to a nurse about our ongoing research into therapeutic relationships. “I haven’t had my medication yet” a man said to staff at the nurses’ station. “You have”. No eye contact, curt response, minimal engagement. “I haven’t”. Pause. “I haven’t, can you check”. No response. Increasing frustration, rising anger. “Ask that nurse, she knows”. No response, no engagement. The man began shouting. ‘Don’t talk to me like that. Keep shouting and we’ll call the police’. More shouting, increasing anger. A nurse moved out of the nurses’ station and stood in front of the man. “Calm down or we’ll call the police”. The man drew back his fist, verbally and physically threatening to punch her. Eventually he backed down, walked off, still visibly angry. His medication was still not checked.
It would be easy to dismiss this scene as atypical or unrepresentative. But in interviews with staff and service users as part of our research into therapeutic relationships in psychiatric wards and crisis houses, we found that the basic building blocks of therapeutic relationships between staff and service users on psychiatric wards were often absent. Service users on wards felt that some staff didn’t demonstrate human qualities like warmth and kindness, appeared to be going through the motions of their job to receive a wage, often ignored them, and at worst, baited them to react before forcibly injecting them. Service users often learnt which staff would engage with them and which would ignore or provoke them. In interviews, some nurses, generally early in their careers, described the same situation. One particularly compassionate nurse felt exhausted by being the only staff member that service users made requests to knowing that she wouldn’t ignore them. She felt burnt out, had taken sick time, and was considering leaving to work in the community.
Should we blame staff for the opening scene above? If some staff members can retain their compassion, why not others? Staff typically enter the mental health system because they are compassionate and want to make a positive difference to people’s lives. Scenes like that above are a product of a psychiatric system which reduces people to symptoms of a biological illness, and that believes people need treatment and control, including sectioning, psychopharmacology, seclusion, restraint and forcible injection. One young black man in our study had been pinned down by numerous staff, had his trousers pulled down and been forcibly injected. He described this experience as “simulated rape”. How do service users engage with staff when they have the power to mimic abusers? How do staff truly engage with service users when they are seen as objects of treatment and control?
The answer is not to see staff as the problem (nor indeed service users). Instead, there are calls for psychiatric systems to become trauma-informed. This means assuming that people in the system have experienced trauma (such as poverty, childhood abuse, marginalisation, racism) and that this impacts on how they engage with others and their environment. For an individual staff member, this means considering, ‘how do I create a sense of safety, collaboration and choice for this person in this moment?’ Crucially, the system must support its employees through training, supervision and ongoing support – otherwise, just like the compassionate staff member mentioned above, burn out and high staff turnover will dominate.
My hope? That our research will join the growing clamour calling for an overhaul of psychiatric wards, and that this will eventually lead to staff and service users being free to engage in therapeutic relationships. For me, this can only happen when mechanisms of control – seclusion, restraint and forcible injection – are minimised and eventually abolished. When people are seen in their full contexts, rather than having their distress reduced to symptoms of an illness. And when our experiences of trauma are acknowledged and respected. This will enable staff and service users to engage with one another meaningfully, respectfully and on equal terms, meaning that scenes like the one I opened with become the exception rather than the norm.
Angela would like to thank Beth Filson, Jasna Russo and Sarah Clement for helpful conversations and comments regarding this blog.