Harm Minimisation: A Recovery Orientated Approach to Traditional Risk Assessment

1. Harm Minimisation: A Recovery Orientated Approach to Traditional Risk Assessment Alison Brabban & Sally Smith

2. Clinical Recovery Focused on diagnosing and treating illnesses. Focus on removing symptoms, getting back to normal or on ‘maintenance’.

3. Personal Recovery Recognition that mental health/wellbeing doesn’t always equate to removing symptoms. Personal recovery is not about “cure’’ or ‘getting back to normal’ – it’s about focusing on what matters to each person and improving wellbeing and quality of life. Recovery focuses on individual needs not diagnoses. The principles of wellbeing apply to all of humankind.

4. CHIME Factors Connectedness (Feeling connected to another person or persons) Hope Identity beyond that of a mental patient Meaning to life and to experiences Empowerment – choice and autonomy.

5. What Service Users Said They Wanted (and often hadn’t received!) To be listened to. To have experiences and feelings validated. To be seen as a person and not just as a set of symptoms. To be given hope. To be given choice.

7. What are human needs? Hope that things can improve. To be seen as a whole person with strengths, interests and something to contribute. Healthy relationships or feeling connected to something such as a pet or spiritual connection. • To feel safe • To feel in control of your own life. • Having meaningful activity or ways to spend your time • A home • Enough money to eat and keep warm. • Physical health • Emotional well-being

8. Key Aspects of a Recovery Focused Approach Understanding the needs of service users and carers. Coproduction (from care to service planning & delivery). Seeing people as human beings and understanding their distress in the context of their lives. Offering choices. Supporting self management. Focus on harm minimisation as opposed to risk.

9. Harm Minimisation

10. Risk Focused Services Idea that all SI’s can be prevented if practice is of a sufficiently high quality – leads to staff always worrying! Staff perceive it as their responsibility to prevent any Serious Incidents. Risk assessments and safety plans not produced collaboratively. Focus on short term risks Service users given little or no responsibility for making decisions and managing own personal risks and keeping safe Service users not given ‘the dignity or risk’ or opportunity to fail and learn from their mistakes

11. Moving from considering risk to considering harm Harm to self Harm to others Harm from others Harm from services/treatments (iatrogenic harms) including harm to recovery Need to consider both long and short term harms

12. Service User Perceptions of Harms • Not being listened to • Being invalidated • Being kept in hospital too long • Receiving too much medication • Bullying • Paternalism • Isolation • Side-effects from medication • Lack of support on discharge. • Being controlled or coerced • Loss of identity

13. When recovery is misapplied. Providing so much autonomy that it appears you don’t care. “It’s your choice.” (e.g. Watching someone who is very distressed leave the ward without a conversation about their safety). Too great a focus on strengths – invalidating the person’s distress. Using recovery to discharge people who still require support. Services defining what recovery should look like e.g. employment and coming off benefits rather than understanding what matters to the individual. Staff not having the skills and experience to do something other than C and R. Positive risk taking done by staff in isolation is another form of paternalism.

14. What should influence our decisions? Does the solution meet the person’s needs? Short term harms of each options? Long term harms of each option? Probability above harms will happen.

15. Key Messages This is complex: There is no simple solution Each situation needs to be considered individually. Harm min is not about taking unnecessary risks but if applied appropriately should promote better long term outcomes. Decisions about safety should be shared with the service user and where appropriate their family. All actions/interventions should be considered and have a clear rationale for their use.

16. What would you do? Emma is a young woman who has had an informal admission following a significant overdose after hearing that her parents are separating. Whilst on the ward she has informed staff that she has a blade in her possession. She says having it gives her a sense of security and is beneficial to her mental health. She hasn’t cut herself at all during this admission. What would you do about this situation?

17. What would you do? Hollie is 14 years old and has been admitted to an Eating Disorders Unit with a BMI of 13. It is suspected that she has been sexually abused and is trying to regain a sense of control in some part of her life. She has refused to eat or drink anything and has resisted NG feeding. Staff are now having to restrain her daily to introduce the NG tube. Both Hollie and some of the staff are suffering from PTSD as a result. What would you do about this situation?

18. Sally Smithsally.smith46@nhs.net Alison Brabbanalison.brabban@nhs.net