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PROactive Management of Integrated
Services & Environments
Psychiatrist who breathed new life into mental healthcare
PROMISE (PROactive Management of Integrated Services and Environments) is a paradigm of coproducing an alternative discourse in Mental Health Care. A discourse that creates hope, agency and empowers patients to take the driving seat in moving towards life beyond illness. A discourse that empowers staff to re-innovate the wheel and continuously improve on the small changes that make a big difference. A discourse in which patients and professionals can empower each other to eliminate reliance on force across the entire recovery journey.
The text below comes from ‘The Story of a Mental Hospital: Fulbourn 1858-1983’ which was written by David H. Clark, the then Superintendent. Even going back to the 1700’s they had aspirations to create humane environments and by 1862 Fulbourn Asylum was being cited as an example of progressive practice, as this excerpt shows. It has been a long journey and an inspirational one, which is why we are striving to continue this work. Our ambition is to take it to a new level by establishing and promoting a world-wide alliance called PROMISE Global.
“In the Journal of Mental Science for 1862 is reprinted a lecture given in Cambridge by Dr J. Lockhart Robertson on 'The Progress of Psychological Medicine since the Sixteenth Century’.
“In order vividly to see the progress which medical science has made since Dr Caius' time let us look at one of our English county asylums of today. A very good specimen is the Cambridge Asylum at Fulbourn under the able administration of my friend Dr Lawrence.The first great fact observed is the entire absence of all means of mechanical restraint. Neither belt, strait-jacket, manacle, strong chair, or any other means whatever for restraining the patient, are to be found there”. ‘The Story of a Mental Hospital: Fulbourn 1858-1983’ by David H. Clark
There is a fundamental contradiction at the heart of mental health services between care and control, risk and recovery. Recovery is all about wellbeing, hope, agency and empowerment. The use of seclusion and physical restraint is viewed as a practice incompatible with the vision of recovery. For many people it actually implies treatment failure. Its therapeutic benefits have not been substantiated with controlled studies, so there is good reason to think about alternative ways to deal with unwanted or unhelpful behaviours.
*“It was like a rugby scrum……. They got on top of me and held my face to the floor……… with my arms behind my back. There was someone on every limb…..it stayed with me”.
Restraint can cause psychological harm and or physical harm. Mind (2013) reported almost 1000 injuries resulting from restraint between 2011 and 2012 across 34 trusts in England. In some extreme cases it has been known to result in the death of a patient, for example the death of David ‘Rocky’ Bennett in 1998. Patients find it traumatic and dehumanising and the impact is worse when the person has history of sexual abuse and or physical abuse. Patients also report feeling stressed fearful, angry frustrated and confused. Even witnessing another patient being restrained can be distressing at many levels, not least because some patients will be reminded of previous trauma.
*“It was horrific……… I had some bad experiences of being restrained face down with my face pushed into a pillow. I can’t begin to describe how scary it was, not being able to signal, communicate, breathe or speak.
Anything you do to try and communicate, they put more pressure on you. The more you try to signal the worse it is”.
Seeing people as assets, offering them choices, building on their strengths, mutuality and reciprocity are core recovery values. By contrast using restraint disempowers patients and sets staff and patients apart helping to create a ‘them and us’ culture.
Restraint often results in a therapeutic breakdown rather than being a therapeutic intervention. Inpatient care plays a vital role in setting people on their recovery journey, so retaining therapeutic optimism is important and not only that, the use of restraint can keep people in mental health services for longer.
It should also be said that many of the feelings experienced by patients are shared by staff who feel distressed, devalued, anxious, guilty and powerless. Having to use physical interventions, even as a last resort, is at odds with the core values of caring. They may struggle to resolve their inner conflicts and this can result in self-reproach. “It’s part of the job, but it spoils the job” (Bigwood and Crowe, 2008).
Within Cambridgeshire and Peterborough NHS Foundation Trust we have been on a journey which PROMISE collates and celebrates. We have been able to tap into the innovation that exists at the frontline by focusing on patient-centred care, healing environments and valuing staff. Our website offers insights into the journey by using examples to illustrate the ongoing work across these themes. The forthcoming framework/toolkit will provide the innovations so that all can benefit from the hurdles we overcame and the successes and challenges we had.
*Quotes from the Mind report (2013)
|Values, Vision, Mission|
|Preslude to PROMISE|
|Introduction to PPI|
|Reflections on PPI|
|Open Arts - Navigating Rocky Waters|
|Breaking The Chains|
|Power to Emower|
|Person Centred Care|
|3-3-3 Mulberry Wards|
|3-3-3 Oak Wards|
|Eating Disorder Ward|
|George Mackenzie House|
|Older Adult Wards|
|Learning Disability Wards|
|Reflective Space - No Audit|
|Recovery College East|
|Peer Support Worker|
|Shared Decision Making|
|Mind the Gap|
|Interfaces across Care|
|Road So Far|
|Global Mental Health|
|Breaking the Chains|
|Maintenance - Help or Hindrance|
|Enhanced Primary Care|
|Psychological Wellbeing Service|
|County Council Perspective|
|Caring for Carers|
|Crisis Care Concordat|
|Next Generation Psychiatry|
|New Age Nursing Prospectors|
|Making our services safer|
|Food and Mood|
|Space for Carers|
|Best at Basics|
|ARC: CPFT’s Interface|
|Research in CAMEO|
|PD Pathway Interfaces|
|Affective Disorders Care|