1. Security, Risk and Recovery Bowman Low Secure Unit (LSU)
Michaela Burt - Clinical Manager
Dr Ian Hogbin - Forensic & Clinical Psychologist 1

2. Bowman LSU – who are we?

3. Challenges Managing risks
Moving people on within a given time frame and suitable move on facilities
Evolution of the unit
Standards
Keeping focused!
Stigma and discrimination

4. Hope
Control
Opportunity

5. Positive Risk Taking

6. Positive risk taking in practice
It’s not easy.
But we have a duty to our service users and if we don’t take positive risks, change is likely to much slower if it happens at all.
Positive Risk Taking can be defined as an approach to mental health care that promotes the taking of risks as a deliberate and planned strategy designed to enhance health, welfare and educational outcomes of the service users we care for.
The first thing to say about positive risk taking is that it can be difficult to do. Whilst it is easy to talk about positive risk taking, doing so in reality can be a challenge. There are considerable barriers that if left unchecked can prevent, or reduced the chances of professionals taking positive risks with the clients we work with. These barriers typically include things such as:
The fear of “what will happen if something goes wrong”, will there be negative professional or personal consequences, Could I get suspended, ridiculed, sued, struck off.
Self doubt can creep in – are we making a sensible decision? Are we doing the right thing in the right way?
Sometimes we might avoid, either consciously or unconsciously taking risks for an easy life because we don’t want to carry a sense of uncertainty that comes with taking risks.
there is no way in avoiding the the fact that if we take a positive risk there is a chance that harm could occur to patients, patient, public or the professional making the decision. If this wasn’t the case it wouldn’t be a risk.
Why should we both taking positive risks then? Well we are employed to help the service users we work with, we have a duty to them and positive risk taking can crate quite rapid positive change. In many cases, without positive risk taking change would be significantly slower if it happened at all.
So the real issue is how can we maximize the chance of professionals taking good, appropriate positive risks whilst minimizing the harm that can occur if things go wrong.
So with this in mind we have worked hard on Bowman ward to develop a culture that we thing promotes positive risk taking and tackles some of those barriers to effective risk management and decision making.
The first thing we try and do is to look at whether we are part of the problem –If left unchecked risk making decisions can have more to do with the personality, anxieties and mental state of the decisions maker that than that of the service users we work for. We need to develop awareness of whether our views are being influenced by subjective biases and social influence as opposed rational argument and reasoned evidence. We found we can do this in part by reflection but what worked even more effectively was appointing a devils advocate.
This is actually an effective group-think counter measure. Group think is a process that can occur within teams whereby increasingly poor decisions get made. Members of the team may not feel able to challenge each other due to fear of being made to feel stupid or the team as whole only see the problem within limited parameters. Appointing a devils advocate was a good way to prevent this from occurring. A different person was chosen at each meeting and their primary jobs was counter and consider alternative options to what was being said. This had the effect of developing better decision making and creating an environment in which it was safe to reasonably challenge each other.
The other thing we did was to consider and utilise the power of non-contingent rewards. Non-contingent rewards are positive rewards for patients for no reason at all. Whilst we all know the importance of being nice and caring we can get in to patterns of only rewarding patients for good behaviour. Sometimes the absence of bad behavior can be just as important but can go unrewarded. It can also be a powerful technique to break negative patterns of behaviour between staff and patients (e.g. seclusion).
Working in this way we were able to create a shift in culture in which the following points were emphasized in relation to positive risk. 6

7. Positive risk taking in practice
Are we a barrier to positive risk taking?
Appointing a devils advocate.
An example of this would be 7

8. Positive risk taking in practice
If a care plan goes wrong its not necessarily a failure.
Focusing on transitions.
Learn from those we care for.
The other think we did and still try and do is re-frame our thinking. We needed to appreciate that if something does go wrong it is not automatically a failure. There is no such thing as a perfect care plan.
So if for example a client manages to curb there aggressive behavior for 4 months in order to achieve a pre-agreed trip but then goes AWOL we should not immediately forget that they have gone a 3rd of a year without any incidents. That good be a highly important and clinically significant irrespective of the fact they fell at the final hurdle by going AWOL.
We also became increasingly aware that we needed to focus on Transition. Change is hard for all of us but we often forget to help users with the specific occupation and psychological effects that transition from hospital and the risk that can bring (i.e. institutionalisation, gate fever, self sabotage). In response to this Bowman ward developed and structured evidence based programme designed to help our service users understand and manage the psychological and occupational issues that typically arise when nearing discharge or transfer from psychiatric hospital.
The last thing we did and continue to promote is the mantra that we need to learn from those we care for. Our service users are experts in mental health through experience and they have insights regarding what we do and don’t well that we should embrace. Having ex service users in recovery come back and teach staff and support those currently receiving care has an invaluable positive impact that has intrinsic credibility in a way that can’t be achieved by may mental health professionals. And with this final point in mind Michaela is going to give a brief summary of how we have achieved this and many of the other principles through a live case example. 8

9. Dan’s Story - A Recovery Narrative9

10. Conclusions Positive risk taking isn’t easy.
You need a supportive team and the team needs to feel able to question the decision making process.
If a care plan does go wrong it is not necessarily a failure.
You need to give clients the chance to prove themselves.
So in the form of a summary and conclusion there are several things that we need to take into account when considering and working with risk, security and recovery.
Risk taking isn’t easy but can become easier through the development and promotion of a supportive team.
We need to give our service users a chance and if we don’t change will be much slower if it happens at all.
There is no such thing as a perfect care plan and if things do go wrong we should remember that it may not necessarily be failure. 10

11. Any Questions?
Thank you