Personal narrative
My work as an occupational therapist began when I was a student in York. I qualified in 1985 and then began practising in Edinburgh. Throughout my career I have always worked in mental health settings in Scotland, first in a rehabilitation day unit for people with enduring and severe mental illness and in acute care both for people under and over 65 years. Latterly, I have practised in a range of secure units initially on an intensive psychiatric care unit and then in a medium secure forensic unit, but more about that later. I am a clinician and a manager and I believe strongly in the principles of developing an evidence-based, client centred-service enabling the potential and social inclusion of individuals.
Until recently I was the professional lead for occupational therapy in a primary care trust in Scotland, with approximately 140 occupational therapists employed in all aspects of service delivery in learning disabilities, rehabilitation and mental health services incorporating acute admissions, vocational rehabilitation and specialist services including child and adolescent mental health, substance misuse and homeless practice.
As both a practitioner and manager, I have always valued supervision in my professional life. This interest led me to explore supervision in occupational therapy in mental health for my BSc in Health Studies (Hunter, 1991) and then the implementation of a supervision package for all staff (Hunter & Blair, 1999). Currently I am completing a Master’s in Occupational Therapy and this has allowed me to examine the implementation of evidence-based practice in the allied health professions and the role of the manager. This work is in its early stages and will be reported in due course.
As a student I was fortunate to be taught by Linda Finlay, and I developed an interest in group and personal awareness and completed two group analytic courses over 3 consecutive years. Although these courses did not lead to formal qualifications, they provided a valuable learning experience of the importance of reflecting and listening, not just to what people say but how they say it. I have also had 10 years’ experience of being a facilitator in group analysis within a psychotherapy outpatient service using the principles of Foulkes (1964).
Over the last few years I have become a mother of two young sons who keep me busy in lots of ways and have given me the greatest learning curve of my life, as there are no textbooks that tell you how you will respond to being a working mother or the overwhelming feeling of pleasure when your children make small steps in their development.
I now work in a medium secure forensic psychiatry setting, the interface between mental health services and the criminal justice system. Clients may have acute or chronic mental health difficulties, personality disorder, problems with substance misuse or a combination of these. They may have committed or been charged with a criminal offence or their mental illness is unmanageable in normal prison contexts. In this chapter, when case examples are given, there will be mention of an index offence. The details of these have not been included to ensure the confidentiality of the clients, but readers need to be aware that a crucial factor of forensic service is that, when an offence has been committed, ‘for the most part these assaults are against victims they already know: wives, children, relatives, friends or neighbours’ (Higgens, 1995, p. 57). So when considering clients’ and professionals’ narratives, their sense of loss can be overwhelming.
As forensic mental health settings increase, this area of practice tests occupational therapists. The clients may have limited ‘occupational abilities, their choices and opportunities have often been eroded due to the effects of long-term institutionalisation’ (Cronin-Davies et al., 2004, p. 170). Furthermore, some individuals are affected by earlier experiences including the contexts in which they grew up and lived. Mountain (1998) reminds us that that the range of problems, people with a forensic history exhibit, is wide and complex.
Given this background, this chapter will explore the use of narrative as a means for creating meaningful occupational engagement in the forensic setting. Some of the narratives come from the team members I now supervise.
Introduction to forensic psychiatry in Scotland
Flood (1997) identified five settings for forensic services in the UK: maximum secure hospitals, medium secure hospitals, low secure hospitals, private secure hospitals and prisons. In Scotland, The State Hospital at Carstairs provides maximum secure services for Scottish and Northern Irish patients. The early special hospitals throughout the UK were isolated both geographically, to some extent, socially and professionally and their values and practices went largely unchallenged (Nolan, 2005).
The Butler Report (Home Office and Department of Health and Social Security, 1975) was influential in the establishment of regional secure units within the mental health sector, although not in Scotland. The Reed Report (Department of Health and Home Office, 1992) reviewed the current services available for mentally disordered offenders and stressed that local services were crucial. However, until 2001, in Scotland, forensic psychiatry was mainly practised in local intensive care units of psychiatric hospitals, in some out-patient facilities and by The State Hospital at Carstairs – no unit met the recognised medium secure standards as outlined by the Scottish Executive (2006).
A number of crucial reports influenced services in Scotland. The Scottish Office document ‘Health, social work and related services for mentally disordered offenders in Scotland’ (1999) provided guiding principles similar to the earlier Reed report proposing that ‘Health boards should investigate the need for a structured development of local facilities and services to provide for mentally disordered offenders from courts, prisons and returning from The State Hospital’ (p. 29). Despite this directive, there was no funding recommendations or allocations available.
However, one primary care trust in Scotland had an aspiration to re-provide hospital services, and in conjunction with a number of lead clinicians, proposed a new forensic medium secure unit gaining Scottish Office approval in May 1999. This unit serves a population of 1.5 million people, covering the geographical area of southeast Scotland. The unit is located within the grounds of the mental health hospital for the city of Edinburgh, the Royal Edinburgh Hospital; it has 50 forensic beds, 25 acute medium secure and 25 long-term medium secure beds. Clients are admitted from the courts, prisons and The State Hospital.
The new forensic unit is small, and the staff adopts approaches to their work that are similar to those in use by health care personnel elsewhere. However, the historical tension in forensic services between care and containment had also to be considered (Porter, 2002). Special reference was given to the different power dynamics in forensic mental health outlined by Nolan (2005, p.14), who states there is a ‘dominance of the biomedical model’ sustained ‘through its close alliance with the law, while psychology has sought to assert itself through the alliance with research and education’. Nolan (2005) suggests that team meetings and discussions cannot mask the lack of genuine parity among the staff groups. This is supported by Coffey and Jenkins (2002), who note that consultants have a statutory role of responsible medical officer and social workers have a statutory responsibility as social supervisors, unlike nurses and occupational therapists who may be excluded from key decision-making processes. In designing the building and the service, it was also necessary to acknowledge these factors and work with the reality of clinical practice and in partnership with everyone involved, including the team and clients who access the service.
As Head Occupational Therapist in the Intensive Psychiatric Care Unit (IPCU) the brief in 1999 was to develop and design an occupational therapy service for the first medium secure unit in Scotland, The Orchard Clinic. The design process was exciting but detailed with hours spent deliberating over items like the depth of the doors to the heights of the perimeter fence.
In the design process, consideration was given to the clients’ current and future needs and to the scope of occupational therapy within this environment. The design of the therapy facility concentrated on the environment, making good use of natural light, developing, as much as possible, a non-institutional setting, creating rooms that were spacious and would allow creativity and choice but at all times be secure. It was also important that the design, both of the building and philosophy of practice, could be integrated with the occupational therapists in the wider mental health service to ensure ease of access to services for the clients. After extensive consultation and hard work by the multi-disciplinary team, this unit admitted its first patients in January 2001. Two further medium secure units will open in Scotland, in 2007 for the West of Scotland and Glasgow and in 2011 for the North of Scotland.
Occupational therapy in forensic settings
Couldrick (2003, p. 13) suggests that forensic occupational therapy ‘can be seen not only as the treatment of people with mental health problems who offend but also as a means of addressing offending behaviour’. It is about acknowledging the important link between occupational behaviour and well-being.
Forensic services care for some of the most marginalised, vulnerable and difficult-to-treat individuals in society. Those admitted to forensic facilities may spend an average of 18 months as in-patients and, in some cases, in excess of 3 years. Such psychiatric clients take longer to rehabilitate for reasons of chronicity and legal status. Today, the concept of forensic care can still evoke negative feelings in people who are normally rational and fair minded (Nolan, 2005). Thomspen et al. (1999) highlighted that staff, too, can be repulsed by forensic patients and their behaviour. Lloyd (1995) highlights ‘the client group itself is not an easy group to work with’ (p. 210).
Case Study 6.1 Negative feelings
I work with Stephen who has never acknowledged his index offence or indeed his mental health illness. My role was initially to consider how he spent his day and what occupations would be meaningful for him in this setting. However, it became clear in working with him that he evoked negative feelings in some of the staff. He interacted with the majority of staff in a derogatory manner using sarcastic and discriminatory comments, creating many negative transference situations. It was apparent that he responded well to staff in a hierarchy position within the clinic. When I worked with Stephen, I was aware of his negative responses towards staff that could then result in undermining comments from some staff. It was therefore crucial to be aware of his limited insight into his mental illness and into his own negative communication.
This example highlights that it is essential for good staff support, time to reflect and a supervision structure to be available. Regardless of the apparent challenges of individual histories, and the obtrusive security measures in forensic settings, Crawford and Mee (1994) emphasised that the occupational therapy process is the same as in psychiatric settings elsewhere. Chacksfield (1997) agreed, but he highlighted additional aspects to be considered, including safer environment and security, level of knowledge of mental health legislation and patients’ knowledge of their rights. Flood (1997) stressed that other factors can also impact on occupational therapy. For example, activities can be limited because of the secure environment; access to resources or equipment maybe restricted and attendance at activities may be reliant on sufficient staff to provide adequate cover. Finally, patients’ motivation may be reduced because of their perception of being confined against their will.
That said, Cronin-Davies et al. (2004, p. 170) stated that it is important to ‘acknowledge that the nature of secure environments can limit patients’ access to a diverse range of occupations, which might be available to them in other settings’. The challenges that face occupational therapists working in forensic areas are twofold: the first is the ever-present risk posed by patients and second is the need to be resourceful and creative in facilitating occupational engagement relevant to these risks. Despite this challenge, the work is satisfying when the clients do leave the clinic and, with the right support, move to their own accommodation. Two colleagues from The Orchard Clinic published a short report ‘From Seedling to Service’ and wrote ‘ in our opinion, working with the clients is the highlight of the day, being able to offer them an activity that they are interested in, and will assist them with their recovery is extremely rewarding’ (Schofield and Spencely, 2006, p. 23).
Most occupational therapy intervention in a forensic setting is focused on enabling individuals to attain skills in daily living tasks, vocational and social skills, enabling them to be reintegrated, into the community. To achieve these goals, a key skill of the occupational therapist is the ability to engage and motivate patients by using a diversity of occupations tailored to meet their specific needs, skills and aspirations. While it is the ultimate aim of occupational therapy to enable individuals to experience occupational enrichment and achieve occupational functioning, it can be hugely challenging within secure environments, and so the occupational therapist’s skill is in devising creative and versatile treatment programmes with and for their clients.
Case Study 6.2 Being creative
During a peer review, a therapist presented a client (Jim), who, after completing an interest checklist, stated that he had a strong interest in learning Spanish. However, the occupational therapist’s role was to prepare him for discharge from the clinic and, in particular, budgeting skills. Jim, however, showed little interest in looking at budgeting. He had been in an institutional setting for many years and learning Spanish did not appear to relate to the clinic’s role of assisting him in the basic skills of living. However, with some thought and creativity, the therapist introduced the use of the computer to assist Jim to learn his Spanish and was then able to use this skill to look at budgeting on the computer. By listening to Jim’s interests to learn Spanish, the therapist gained his trust to focus on his improving his much-needed budgeting skills on a limited budget.
Related posts:
