DESIGN IN MENTAL HEALTH 2022 KEYNOTES
and seclusion occurred, we subsequently supplemented this with some qualitative research.” The latter involved interviewing both service-users about their lived experience, and staff working in the acute ward, and thinking about aspects of the environment both groups found either problematic or soothing and calming.”
Study had to ‘stop’ half-way through The two speakers would, Paula Reavey said, be addressing the qualitative aspect, ‘bearing in mind the co-existence of the quantitative measurements the researchers took’. She said: “Starting this study during the pandemic wasn’t ideal, because we had to stop it half-way through, and therefore didn’t collect as much data as we would have wished. However, we have some preliminary data we can use to build a wider funding application, so we can roll out the study nationally to consider the issues concerned more broadly.” Interviews had been conducted with both staff and patients, and the researchers had also used ‘visual methods’. Prof. Reavey elaborated: “So, we invited patients to take photographs of the ward, to really bring into view the relationship between the space and the feelings invoked in it – because I think there’s a tendency on psychiatric wards to think about ‘the problem’ as being the patient. We wanted to ask, ‘What is going on for them?’, and ‘What elements of their diagnosis might mean they’re more aggressive or problematic?’ In fact, one of things we are keen to move away from is the idea that the service-user alone holds the key to understanding aggression. Our approach moved towards an understanding based on the relationship between the service- user and their environment.”
Changing thinking evident In psychology, Professor Reavey explained, there was now considerably more thought about how environments might invoke or encourage particular types of escalations of aggression. She said: “Also, via Stephen, and my participation and observations on wards, we discovered that there are particular environments that seem to foster a more aggressive reaction in both staff and service-users. That’s thus something also to consider.” Prof. Reavey explained that she and
Prof. Brown would ‘only talk about three themes here today’. “Because we’re thinking about this in terms of environments,” she told delegates, “I want to highlight how not all spaces on the ward are perceived equally, and how some are felt to be more conducive to de- escalation, while others seem to invoke a kind of tension between staff and service- users; indeed staff and service-users talk about ‘some unhelpful qualities’ of the environment.” She added: “We also want to focus on seclusion rooms acting as an antithesis of their purpose – which is to de-escalate and calm. In fact, though,
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Prof. Paula Reavey: “We invited patients to take photographs of the ward, to really bring into view the relationship between the space and the feelings invoked in it – because I think there’s a tendency on psychiatric wards to think about ‘the problem’ as being the patient. We wanted to ask, ‘What is going on for them?’ ”
many seem to invoke feelings of agitation. Thirdly, and really importantly, how does seclusion impact power dynamics, especially after it has been used?; we will be discussing that in terms of trust between service-users and staff.”
Issues to emerge from the data Moving to highlight some of the issues that had started to emerge from the data, Prof. Reavey said the first was the overall ‘quality’ of the environment, with ‘a real consensus’ that outdoor spaces, and the activities within them, needed to be ‘in beauty’ to evoke a meditative state as a means of de-escalating tensions between staff and service-users. She explained: “A lot of patients, as well as staff, said one of the optimal steps for a situation requiring de-escalation is to move outside, which necessitates an understanding of how the ward flows.” Many staff would indeed often talk about ‘the flow of stress’, and where there was no means of ‘escape’, this would be detrimental to both staff and service- user wellbeing. The Professor said: “So, this idea of flow and movement is really built into the quality of the environment itself, and often people would talk about there being outdoor spaces – which we all refer to these days as beneficial – but added that there were barriers to their use.”
Activity Moving to focus on ‘activity’, Prof. Reavey referred to what she described as ‘a really wonderful conference address’ earlier in the morning about how activities, and ‘sharing and relating’, can de-escalate many aggressive behaviours among people living with dementia. She said: “I think the principles are really apposite for this group too – both staff and service- users; this idea that when de-escalation is needed, it’s often because relations have broken down. Some of the service- users that we are talking to cite there being physical separation between staff and patients via a glass barrier, or a door, and how in fact bringing people together, relating, and having a kind of relational
activity space, provides the best setting for people to be able to calm and build a connection with others.” That, in itself, had proven a de-escalation technique, but had had to be built into the environment itself.
Not just ‘passive containers’ Prof. Reavey said the researchers were also keen to emphasise that environments are ‘not just passive containers of behaviour and emotions’; rather ‘they actively communicate to people, and suggest ways of being, behaving, and emoting’. In the research, a number of service-users had highlighted this as being really important. “For example,” Prof. Reavey said, “people talked about the slamming of the doors, the noise of the doors, and the shutting of the door when you’re put in seclusion, and the perception – for the service-user – that this communicates punishment, rather than calmness and isolation, and that, rather than preserving wellbeing, it was, in fact, a means of disrupting it. I think we need to consider how those spaces are built; they’re often very functional, very ugly. There’s often, for example, a little window where somebody puts their face in to check upon the person, to observe, and the service-user thus feels more ‘objectified’. Objectification, we know in psychology, is a means for people to feel very unsafe, and can escalate aggression. So, again, while acknowledging that isolation is sometimes a necessity, the environment communicates a particular relationship that we need to understand more about.”
Stopping ‘trouble-makers’ Other comments from service-users had suggested that seclusion was often used ‘to stop people causing trouble’, whereas, Prof Reavey argued, it was often the inadequacies of the mental health setting that made people agitated. She said: “I think a relational and an ecological model of the psychology behind this are needed to understand how the environment itself can afford a particular mode of service-
NOVEMBER 2022 | THE NETWORK
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