Papercuts: restorative approaches and cumulative harm in mental health care


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?

Formal Approaches

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.

Grassroots Initiatives

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.

Proactive Approaches

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 conclusion

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.


References:

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:

What is restorative justice?

Principles of Restorative Practice

Restorative Justice and Restorative Practice

Restorative Justice in Everyday Life

Restorative Approaches in Schools in the UK

Time to Think: Using Restorative Questions


Copyright 2021 Zoe Layton. All rights reserved.

How working in customer service taught me how to support people in crisis

Customer service is often viewed as low-skilled work, but there is actually an art to doing it well.

I have had a number of customer service jobs, including working for various auto breakdown services, and a private pathology lab. I was often on the phone to distraught people: perhaps they’d had a smash on the M25, and they had 3 terrified children with them, or they were waiting for a breast cancer test result that was running late and were petrified the delay was due to bad news.

Those calls were much trickier than the average; however, through them I learned some fundamental principles that have continued to help me help others, including work with prisoners, rough sleepers, and those with mental illness, for many years since.

Whether you are dealing with a vulnerable person in crisis or a customer on the phone, these principles come in handy.

Here are 9 that I see as the most important:


1. What people define as a crisis is relative

A crisis can be an enduring situation where someone’s entire life is collapsing quite literally, or it can be a sudden, short-lived incident that causes acute stress but is able to be resolved within a day, or even a few hours.

What one person experiences as a crisis may not be the same as another.

Timing is also a consideration – someone might normally cope very well, but they might not have the emotional resources to cope at other times, depending on what else is happening for them.

All reasons for distress are valid and relevant because of the meaning they have for the person experiencing them.

It is best to avoid judging someone coming to you in crisis, even if their issue does not resonate with you, or it could be seen as minor or silly in comparison to others.

People need to feel like their problems are not just valid, but that the extent and gravity of their problems as they see them is acknowledged.

People, understandably, need to feel like they matter, and that their problems matter to you as much as they matter to them.

2. You can make a big difference in just one interaction

When someone is already stressed out, whether it is because they’ve dropped their phone down the loo, or they’ve found themselves suddenly homeless, the last thing they need is a difficult interaction when they reach out for help. This only makes people feel more stressed, angry, and frustrated with their situation.

We all know what a relief it can be to have a problem sorted out speedily and adeptly. The call handler is friendly, empathetic, and competent, immediately putting you at ease. They give you opportunities to ask questions, explain what you’re not sure of, and tell you what they will do to help. You come off the phone feeling lighter and less worried about your problem, now it is in someone else’s capable hands. Your stress levels decrease immediately.

Most of us have had experiences at both ends of this spectrum and can remember how differently we felt after each of them.

You can radically affect how stressed someone feels in quite a short space of time, depending on how you approach their issues and how you treat them.

You do not have to work in a call centre. The same principle works when supporting people in social or healthcare environments.

Make the most of those opportunities. Lessen their burden, instead of adding to it.

3. Anger is fear and a need to be heard

When someone in crisis appears angry, it is often fear in disguise.

Understanding this is key to being able to help someone whose stress comes across as anger.

If someone seems frustrated or angry, I stop talking and I listen. I let them do the talking.

After they get their initial rush of frustration out, most people begin to relax, especially if they aren’t coming up against resistance from you, and it is obvious that you are listening.

A calm, attentive reaction often takes people by surprise. They’ve most likely been expecting a battle, and you don’t let that happen.

You will notice their relief emerging as they begin to slow down, take some breaths & come to a calmer, more centred place. Sometimes people begin feel a bit embarrassed at their outburst, and they apologise. So many times, I have heard the words:

“I’m sorry, I know it’s not your fault – I’m just so stressed about it all and I don’t know what to do.”

At which point I say ‘it’s ok, I understand that this is very difficult for you/stressful for you’ or something similar.

People often just need to be heard and have their fears acknowledged. They need to be able to share the impact a situation is having upon them and have someone be a witness to that. They need to feel the emotions they are having are externally valid.

Anger is rarely about you as the helper: it is more about the person’s situation, and how afraid and out of control they feel because of it.

(N.B. I am not saying anyone should have to tolerate aggression. It is not okay for someone to be abusive. I have found that active listening, followed by focusing on joint problem-solving, is very effective in de-escalating anger. If it isn’t working, it is important to be assertive and possibly end the interaction if they are being aggressive towards you.)

4. People need allies

Someone in crisis who is reaching out for help longs to feel that they aren’t alone.

Being distressed and alone is something no one should have to experience.

Knowing that someone is helping to shoulder the weight of their problem (especially someone who has access to resources to help them fix it) can make a huge difference to how powerless someone feels.

It doesn’t mean that you should do all the work for them, or that you should step outside professional boundaries. Even simply ensuring the person has a positive and genuine interaction with you will help them feel less alone. Be a human.

Even if there’s little you are actually able to do for that person, just listening and acknowledging their frustrations is a wonderful way to be an ally.

5. Be reliable

This is one of the simplest, but also most powerful, of these principles.

I cannot stress enough how important it is to be reliable when you are working with someone in crisis.

It is likely that you represent a glimmer of hope for that person, so don’t just throw that away.

If you say you’ll do something, you must do it. If you forget easily, make a note, or put it in your calendar.

If you’re not able to do what you said you would, let them know. Get in touch and tell them that you’ll need a couple more days to find something out, or that you’re going to be trying something else instead.

Not doing something when you said you would (especially when someone is relying on you to help them), shows that person that they don’t really matter – even if that is not your intention.

Don’t just leave someone in limbo, wondering what’s happening. Call them. Get in touch and let them know.

It might feel easy to get lazy about these details, but don’t let that happen. It is that important.

If you can’t commit to an action or communication, it is probably best not to make or state those commitments in the first place.

6. Be honest

Don’t take the easy road and simply tell people what they want to hear, just to make your life easier. Honesty is everything – even if it means delivering less than satisfactory news.

People appreciate being told the truth.

Most people prefer news that isn’t what they want to hear to lies or vagueness given only to placate. This is otherwise known as ‘fobbing someone off’, and most of us know how that can feel.

7. Move people forward

A manager and trainer at Citizens’ Advice taught me this:

You may not be able to solve someone’s problems in one go, but you should aim to move them on a step further than when they came to you.

Openness, warmth, and a listening ear may be helpful in the moment, but you should also think about what you could give the person that they can take away with them.

It might be something tangible such as an information leaflet or a telephone number to call, but equally important are hope, the relief of a problem shared, the courage that comes from having an ally, or even some restored faith in humanity.

We can all think of times when we’ve walked away from an interaction feeling more hopeful, whether it was from a medical appointment or a call to the insurance company.

Think about how you want that person to feel when they put the phone down, or walk away from your office.

People feel better when they can see where they are going, or what steps to take next. It is like finally receiving a map to somewhere when you’ve been completely lost.

8. Everyone can benefit

We could probably all do with more customer service in our lives! You don’t have to be in an official ‘helper’ position.

I use these principles in my daily life to support others, even my partner, my parents, and my friends. I regularly ask myself:

“What can I do to help this person? How can we sort this situation out? Will letting them talk while I listen help? How can I help, in this moment, to take them from feeling stressed to feeling a bit better about things?”

9. Be human

I’m not suggesting by using customer service principles we should all become call-centre robots. Not at all. Good customer service is warm, supportive, and validating. Everyone is treated as an individual equally as important as the last, and everyone’s plight is as valid as the next.

Nurse, doctor, receptionist, call handler, or friend: any of us can make a difference to other people’s distress by thinking about how we interact with them, and what effect that might have on them. It doesn’t matter who you are or what position you hold, these principles apply to everyone.

It is about being a human being talking to another human being: the simplest things are often the most powerful!