Our service is a hospital with men with mental health difficulties who have also had contact with the criminal justice service. Inpatient forensic services can often suffer from poor recruitment and retention, staff who lack training, limited access to therapies for patients as a consequence and therefore increased rates of stress and risk. Relational Discovery is a culture change and clinical model that make use of a relational psychological approach derived from cognitive analytical therapy (CAT) to develop for staff and patients alike an awareness that problems can develop, be maintained and change in the context of relationships. Relational discovery takes a non-pathologising stance by identifying that staff and patients are learning in their daily lives, in their work, their care pathway individually and together - essentially discovering information about themselves.
What We Did
Our service is a hospital with men with mental health difficulties who have also had contact with the criminal justice service. Inpatient forensic services can often suffer from poor recruitment and retention, staff who lack training, limited access to therapies for patients as a consequence and therefore increased rates of stress and risk. Relational Discovery is a culture change and clinical model that make use of a relational psychological approach derived from cognitive analytical therapy (CAT) to develop for staff and patients alike an awareness that problems can develop, be maintained and change in the context of relationships. Relational discovery takes a non-pathologising stance by identifying that staff and patients are learning in their daily lives, in their work, their care pathway individually and together – essentially discovering information about themselves.
Discovery extends recovery models – taking in to account new developments in the recovery arena. Taking a relational stance, Relational Discovery projects have included: 1. The development of an MDT focused forensic services induction for all new staff at Langdon in which many sessions are co-produced and co-presented. 2. Teaching and training for staff across the MDT in psychological models – DBT and CAT – to provide staff with tools to use day to day on the ward to manage distress, reduce risk and teach coping skills, and to provide an understanding of relational approaches that can be used in clinical practice, as well as providing training in specialist areas of forensic work to support excellence in practice and to income generate for the service by attracting staff outside of the service to attend – by this means the service is also exposed to persons from out of region who may wish to come to work at Langdon, 3. increasing staff skills and experience has enabled psychologists to develop group therapies for patients and to provide these groups working with nursing and OT colleagues. These therapeutic groups have made a significant difference to the understanding of self and others in patients at Langdon and aim to extend the therapeutic culture at Langdon. The aim is for patients to become co-presenters of groups with staff where possible and is something patients would wish to do.
Groups have run consistently at Langdon for the first time in 10 years. These groups have included Understanding Psychosis, A CBT emotions group, Building Blocks for Change, Substance Misuse group, Life in Balance, A DBT informed skills group, Supervision structures and feedback processes have been built in to groups to ensure sustainability. We feedback in presentations to the MDT about group progress – a presentation that is developed with and presented by a patient as well as group facilitators. 4. We have developed a collaborative risk process, teaching staff about risk assessment from induction, providing teaching for patients and including patients in risk assessments as a matter of routine. Risk assessment and collaborative risk assessment and management is applied to every patient at Langdon. 5. Reflective Practice is key to making a difference to our service and we are developing a model of reflective practice that builds on relational models that are used currently in forensic services, to support this we are providing training to staff on core concepts in forensic services that are discussed in reflective practice. The benefit of the reflective practice using a relational model using cognitive analytic mapping is for staff to be aware how both they and patients live and work in an environment and are both affected by similar processes and can make positive changes to ways of working and living together by altering ways of relating i.e. from criticizing to criticized TO valuing to valued.
These innovations in our service have brought together clinical colleagues to appreciate and work together more effectively, have provided patients with a more effective series of interventions and the opportunity to be involved in the development of and delivery of interventions, all of which improves confidence, recruitment and retention and wellbeing and reduced risk. We are currently introducing mindfulness across the service, moving from patient groups to staff meetings, aiming to have mindfulness as a standard part of the service and are introducing a relational approach to human resources and recruitment processes. The psychologically informed and developed Relational Discovery model has been praised as a model of good practice on both medium and low and open security wards by the forensic quality network in 2017 and presentations are being made at the Quality Network in June 2017 and at the International Forensic Mental Health conference in June 2017.
Relational Discovery is currently being embedded within Langdon Hospital and therefore partner organizations are limited. However, we work with colleagues from across the Trust in our induction and marketing, we work with colleagues from community substance misuse services Rise and charities Re-Solv to provide training for staff and patients on substance misuse. As an initiative that started in 2016 we have made good ground and intend to expand to community settings at the request of community occupational therapists and to prison services who value the Relational Discovery model and can see its applicability to a prison setting for the support of staff and inmates in that setting.
Staff and patient feedback across the service is gained by feedback sheets at induction,
Staff and patients take part in a survey of ward atmosphere called EssenCES that help us develop our service against known benchmarks in other services.
We involve patients in presenting at inductions every month, We involve patients in feeding back on therapeutic groups and in time delivering therapeutic groups and training.
Looking Back/Challenges Overcome
Having more time to plan service innovation and more administrative staff would have definitely helped. Having the patient team directly feeding in to the steering group would have been helpful and identifying patient champions earlier might have helped with embedding the model. Giving more talks and having posters and leaflets across site wold have been helpful for spreading the word and a concept that at first might not have been understood.
We have a planning group
We plan interventions and provide appropriate training and supervision
Training is repeated for new starters and revision courses update those already trained.
Materials are produced and made available on the hospital’s shared drive,
Results are measured to report on achievements
Commitment from the senior management team and funding has been agreed.
embedding the model and spreading it beyond secure services and to the community is taking place.
Evaluation (Peer or Academic)
The Quality Network has reviewed the Relational Discovery model and advised that it is a model of good practice.
Internally pre-post intervention measures have demonstrated that relationally informed therapy groups have made a difference as well as DBT, DBT, understanding psychosis and understanding substance misuse groups have made a difference in terms of awareness of mental health and the development
Pre-post therapy measures for patients
Pre-post training measures for staff
Have shown improvements in outcomes as well as anecdotal comments from staff working in the hospital who have indicated that the relationally designed interventions have had a significant impact on clients and staff within the service.
We do share work with others,
We publish information on our intranet for DPT to advise colleagues of our work
We report on work internally and to families and friends via the Langdon Newsletters and televisions on site.
We have shared work and ways of working by inviting colleagues to work with us from community and prison settings.
We have had DBT British Isles review our service (current).