How it began for me
A couple of years ago I was asked as an ex-patient to be involved in a participation project with mental health staff called ‘Reducing Restrictive Interventions’.
We split into separate groups (one of staff and one of service users), each with a facilitator, to brainstorm. One member of staff misunderstood the instructions and joined our group. None of us said anything, assuming there was an unspoken reason for her joining. She wasn’t meant to be there, but it turned out to be a really helpful mistake!
We talked about restrictive practices on the ward and their effect, from small things like not being allowed to congregate and chat in the corridor, to more difficult things such as restraint and seclusion. The staff member listened intently to what we said and acknowledged our experiences, saying it was very helpful to hear. She then tentatively told us about how imposing restrictions upon us sometimes made her feel, and we listened in return.
It hadn’t been planned. Out of nowhere a safe space materialised where testimony was heard and acknowledged on both sides. For that 20-minute slot, we were no longer staff and service users – we were human beings, equal to one other, listening and acknowledging with empathy and compassion.
The whole group agreed that it had been an enlightening experience, including the member of staff. I thought about how incredibly helpful it would be to have opportunities like this occur more often. It wasn’t until I recently came across a piece written in in the British Medical Journal by Dr Sarah Markham, that I realised what had emerged that day was the kind of space and situation that restorative practice (also restorative justice/approaches) works to create.
What is restorative practice?
Restorative practice can take many different forms, and for more comprehensive explanations, please see the links at the end of this piece.
The way I understand it is as a coming together of people who have been involved in a conflict, difficult experience, or trauma, in order to share the impact it has had upon them.
It can be used to repair specific relationships or harms that have occurred, or it can be a more general expression of thoughts, feelings, and needs in a mediated safe space where everyone is listened to without interruption or judgement. The idea is to create empathy, enable mutual understanding, and to then work towards a satisfactory resolution for the benefit of all.
Restorative practice and approaches are already used in various forms in a number of sectors, such as criminal justice, community mediation, and in schools.
Why might we need restorative approaches in mental health?
Restorative approaches could help by:
- Reducing the impact and level of trauma felt by those using or working in mental health services.
- Improving staff/patient relationships.
- Improving mental health outcomes and quality of life for all.
Despite it being a contentious issue that not all like to accept, harm occurs regularly within mental health services and on psychiatric wards.
Many are harmed by the most obvious major practices, such as Mental Health Act detention, coercion, restraint, forced seclusion and sedation (which is another article in itself!) but harm also occurs in smaller, more insidious ways.
These include verbal abuse, gaslighting, neglect, withholding care, not telling the truth, making decisions without the patient, breaking trust, not listening, ignoring, being dismissive, and acting without care or compassion.
When cumulative, these ‘little’ hurts can become more painful than the bigger harms. They are thousands of papercuts that never heal.
It is these cumulative harms that I would like to focus on in this article, because it is these that I feel are most unacceptable because they are the most avoidable, and could be most easily tackled by restorative approaches.
Of course, mental health staff are also harmed by what they experience at work. This could be directly through violence and abuse from unwell patients, high-stress work environments, or by being implicit in restrictive and coercive interventions or practices that they do not feel comfortable with.
Staff themselves are not subject to those coercive and restrictive practices, and they implicitly have more power than a service user even at the lower end of their pay grades, but they are certainly still vulnerable to stress and trauma.
Psychiatric wards are trauma machines: harm is cycled and passed from person to person in an enclosed space within the rigid, heavily bureaucratic, emotionless system that is NHS mental health services – a model unfit to deal with the complexity that is humanity and human emotion, let alone that of mental distress.
Relationships between staff and service users are often strained. Each views the other as an oppositional unit which they should be wary of and therefore protect themselves from. This creates huge rifts that undermine the therapeutic benefit of services.
Mistrust stops people reaching out for help in the future. If someone does so and is met with a dispassionate, unkind response, they will think twice about doing so again. This increases loneliness, fear, and risk of self-harm or suicide.
A lack of trust also adds to service users’ issues with healthy relationships in general: feeling suspicious or afraid of others can lead to further isolation from peers and greater society and worsening of the original mental illness.
Of course, there will always be those who find their interactions with mental health services supportive and helpful. This must be acknowledged, and I am happy that those people certainly do exist.
Where trauma is felt, however, patients are often dealt an extra burden to recover from in addition to the illness or condition that brought them to services in the first place.
In this way, mental health services can actually perpetuate mental illness and distress.
In particular, those deemed to have a personality disorder (a contentious label at the best of times) or complex needs, have often been on long journeys through services, experiencing exclusion, gross misunderstanding of needs, verbal abuse, threats, coercion, prejudice, not being believed, and a stark lack of compassion.
All of this mirrors and reinforces trauma already experienced in personal lives outside of mental health services.
Like a snowball rolling down a mountain, trauma and pain and their associated difficulties stick to the original, core problem, making people so heavy with pain that they become formidable, dangerous, and impossible to treat in the eyes of those who helped make them this way.
Those who have spent years in services can find it impossible to detangle the trauma that existed originally, from that gained since.
It doesn’t make sense to be healing and hurting people at the same time, particularly if you want them to thrive and get free of the revolving door of repeated discharge and re-admission.
Are restorative approaches feasible in mental health?
In a dreamworld, everyone who has been cruel and neglectful to me in a healthcare setting would come and sit with me and we’d use restorative approaches to work it through. We’d have conversations about how it affected me, and they would listen. I would ask the ‘why?’ questions I’ve always wanted to ask and listen to them in return, hopefully they’d apologise or at least reflect, and we’d repair things and find a way through that felt better.
This is an unlikely situation for service users.
There is rarely a single ‘perpetrator’. We often hurt from many actions from many different people, that have chipped away at us sometimes over decades of damaging interactions with mental health services, when we were already at our lowest and most vulnerable: those papercuts.
We have no chance of facing all of those who hurt us. Would they even remember the nasty comment they made years ago? Would they remember a single situation even months ago, during yet another busy, understaffed double shift?
(Most likely not but, rest assured, we definitely do.)
They might not even see what they did as wrong or negligent, or may not want to admit it.
One of the underpinning principles of restorative practice is that it must be voluntary – everyone has to consent to join in and so there needs to be a willingness to engage.
Services and staff may feel that restorative practice will involve some admittance of mistakes or of neglect and abuse, and it is unlikely they will be happy (or able) to do that.
Due to this, I feel that more formal restorative approaches like those used in criminal justice, with an obvious victim and offender, are most likely not feasible in mental health services.
Spandler and McKeown (2017) suggest that grassroots truth and reconciliation initiatives might indeed be what is needed, particularly in the absence of the interest or enthusiasm of services and psychiatry.
They describe instances of grassroots and service user led mental health organisations in the USA that have made use of community-based models and healing circles to hear testimony from those harmed, whether staff or patient, and also to hear from those who did not feel harmed – all viewpoints being equally welcome and compassionately acknowledged.
Perhaps something like this could be helpful.
I know from the experience I described earlier that if you can turn a room of service users and staff into a room of human beings, even for a short while, amazing things can happen.
There would need to be a level playing field offered, and a space of safety for all to be able to speak and listen, wearing no official ‘hat’ of service user or staff member.
There would need to be no repercussions for sharing, and it would need to take place in a neutral space, so not in a hospital meeting room.
There already exist initiatives amongst service user only communities where testimony is heard in safe and non-judgemental spaces, providing those who have been hurt a forum in which to express pain and anger, and for that to be acknowledged.
I am currently involved in project ‘For The Record’ with the grassroots service user group #MadCovid, where experiences are shared via closed-group presentations of writing and creative pieces on the theme of iatrogenic harm.
Supporting each other in this way is helpful, and for some it is the only forum in which they feel safe enough to truly express their feelings. However, it is no surprise for us to hear the trauma of our fellow service users. We know it only too well.
There is absolutely a place for this work, but for true restoration I feel that those with other viewpoints, perspectives, and experiences need to be included and need to listen, or we risk remaining in a well-meaning echo-chamber, with no real movement towards remedying the situation.
I like to think that there are staff and patients who would genuinely want to take part in informal initiatives that aim for better understanding for those on all sides.
Service-user led initiatives may not be impartial enough for this specific task. We need projects formed by both ‘people who work as staff’ (a distinction from ‘staff’, which is their official capacity whilst at work) and service users, and/or by allies who are completely impartial.
As it would be a voluntary activity engaged in outside of work time, that could be off-putting to staff who already work long hours, but if touted as an exercise that could enrich them personally, rather than a work-related box-ticking exercise, it could perhaps be more attractive. There will always be those who are not at all interested, but I believe there will always be those who are.
Meetings or circles should be trumpeted as positive, welcoming, healing spaces that are not about apportioning blame. The idea is to enrich understanding and empathy on all sides, which could go some way to better relationships within services and hopefully to change opinions and behaviour towards those previously seen as an oppositional group.
They would need to be closely guided by restorative principles, impartially managed, and only joined by those distinctly wanting to work towards restorative ends.
An important question at this point is: do we need to come together with specific people who were involved in our own individual experiences, or is hearing testimony from anyone, even people we don’t know, still helpful? In an informal meeting like this there would be no guarantees about who might attend.
As I said earlier, we may wish for the opportunity to face those who wronged us, so we can ask specific questions, understand particular instances, maybe even share apologies, but the chances of this are low.
Hearing from others who have been in similar situations (on either side) might not give us that, but it could still help expand empathy for and understanding of each other, break down oppositional barriers, and help us see each other as human beings, all with capacity to hurt and be hurt.
Will restorative approaches actually make any difference in terms of harm?
Despite me advocating for restorative practices, there is a voice of cynicism deep inside me, one which most long-term service users will know well. It says that nothing will ever be enough to make up for the pain that has been inflicted.
I’m trying not to listen to that voice, because I want to be more hopeful than that, but I acknowledge that there are many who have been hurt so badly that these drops in the ocean will seem nowhere near good enough, and I fully respect that.
There will be many people who won’t like these ideas. They won’t want to relive their traumas or remember certain times of their lives. Some understandably won’t feel able to be vulnerable around the ‘opposite team’ who has caused them so much harm. Many will be afraid of repercussions and further victimisation.
We need to acknowledge and be mindful of this.
I do think, however, that proactive restorative approaches could go some way to lessen the cumulative harm that occurs within mental health services.
If we deal with each papercut as it occurs, we can help to stop it building up into trauma.
I remember a difficult interaction that occurred once between myself and a professional within services. She made a mistake that broke trust and at the time it really upset me. Trust of healthcare staff was already something I found difficult.
When we were next in touch, she set aside a good 15 minutes of our appointment to talk about it. She apologised and completely owned the mistake. She didn’t make excuses and she listened to me explain why it hurt me so much. We talked through it. She did not rush me or minimise my emotions or reaction.
The fact that she had the courage and integrity to initiate this conversation made a huge impression on me.
It may seem obvious that someone would do this, but it is not common.
She was so demonstrably honest and compassionate that we quickly repaired the relationship and the hurt I felt disappeared. I also apologised to her for how I had reacted when it happened, and we were both able to agree to move on.
Just a single restorative interaction like this can give a service user hope and a renewed faith in services in general. It creates a welcome contradiction against the idea that ‘all staff are bad’, or ‘I need to protect myself from staff’.
The more examples we are shown of compassion and kindness, the more that serves to challenge ingrained views of staff and services as a homogenous group of unkind, uncaring people.
This experience helped me believe it is possible to have the restoration we seek with those who have directly hurt us if it happens as soon as possible after the incident.
Apologies are probably best left to occur in organic and spontaneous ways in order to protect their sincerity, however proactive restorative approaches could be part of a new way of working. Examples include improved communication styles and time set aside for restorative and reflective catch-ups with service users, as the need arises.
Restorative approaches in schools often include the use of restorative communication. Staff and pupils are encouraged to make ‘affective statements’, where they communicate to each other how they have been affected by the actions of the other, both positively and negatively. They also use ‘affective questions’ to explore things that have happened and how they could be best resolved as they arise, avoiding the use of blame or accusation.
Time is taken out to have restorative talks, as needed, which could just be a couple of minutes or longer if needed.
Something like this might be really helpful if it was embedded within mental health services, for both staff and service users to make use of.
It might be viewed as more work for already under-resourced staff teams, but I genuinely think it would be worth it in terms of improved relationships and outcomes for all involved.
It could also help improve communication skills, assertiveness, and skills for dealing with confrontation on both sides.
I acknowledge that issues of mental capacity, distress, and illness are factors to consider that aren’t as relevant in the school environment, but ways in which proactive restorative approaches could improve the mental health environment are definitely worth exploring further.
In believe that informal restorative approaches, utilised as we go, may be the best format for mitigating cumulative harm within mental health services. These have certainly made the most difference to me personally.
In addition, there could be grassroots initiatives that bring people who work as staff and people who are service users together voluntarily and on equal grounds, in order to learn more about each other’s experiences.
Restorative approaches may seem too meagre to make a dent in the impact of harm caused by mental health services. There is no doubt that social action aimed at general reform of mental health services and legislation is desperately needed in addition to any restorative work.
Bloom & Farragher (2010) call for organisations to be “trauma-informed systems” run to be more like living organisms, “capable of all the same emotions, processes, learning, disease and change that any other organism experiences”, instead of cold machines.
I think restorative approaches, especially proactive communicative ones, should be a key part of that vision.
I don’t have all the answers, but I know that ignoring the fact that trauma occurs within our services isn’t working and is a ticking mental health timebomb.
I also know that the interactions I have had with staff on a human level have made the biggest impact on my ability to heal and have faith in people, more than any psychology session or medication ever has.
Those interactions have expanded my own capacity for empathy with those who care for me and have most of all allowed me to feel hope that things can change.
I do think it is important to bring restorative approaches to mental health services, even if the efforts at first seem small. More opportunities, spaces, and interactions like those I have described – informal, voluntary, human – would contradict negative experiences, foster better relationships between staff and service users, and make small but solid steps towards repairing harm.
To achieve this, big work desperately needs to be done, but I personally believe enough small, reticent stones cast out in hope could cause enough ripples to rock the boat.
Bloom, S. and Farragher, B. (2010), Destroying Sanctuary: The Crisis in Human Service Delivery Systems, Oxford University Press, New York, NY.
Markham, S. (2018), “Dealing with iatrogenic harm in mental health”, British Medical Journal Blogs website, available at: https://blogs.bmj.com/bmj/2018/12/04/sarah-markham-dealing-with-iatrogenic-harm-in-mental-health/ (accessed 26 Mar 2021).
Spandler, H. and Mckeown, M. (2017), “Exploring the Case for Truth and Reconciliation in Mental Health Services”, Mental Health Review Journal, Vol. 22 No 2., available at: https://www.researchgate.net/publication/316848109_Exploring_the_case_for_truth_and_reconciliation_in_mental_health_services/ (accessed 26 Mar 2021).
Links for further reading:
Copyright 2021 Zoe Layton. All rights reserved.