Case Study - I didn’t feel like myself, I felt out of control

The names of all those referred to in this case study have been changed to maintain their anonymity.

Steve is a male in his 30’s with a primary diagnosis of Autism and is detained on a hospital order with restrictions (S.37/41). Steve has been in secure services for 7 years and is currently in a low secure forensic unit.

Steve was one of the members attending a group trip to a nearby town. This was being organised and facilitated by staff member. Jackie is a middle-aged woman who has worked in forensic services for a long time and is an experienced member of staff. As Jackie was gathering the group ready to depart, Steve took £100 from his locker and his bank card to take with him. Jackie checked that he knew the plan regarding it being a group event and therefore he would not have opportunity to go for his own shopping. She also pointed out the potential risks regarding taking his card and all his cash out with him. Steve questioned if she was suggesting he would be "mugged", and was upset by this.

Jackie walked away and went back into the nursing office to talk to the nurse in charge to finalise leaving for the trip.

Steve came and knocked the door of the nursing office, he said to Jackie that she was making him paranoid about going on the trip and questioned why she was asking him about his money. Steve became angry and shared he felt Jackie was deliberately trying to wind him up and started swearing at her. Jackie advised Steve that if he continued to swear at her, his place on the trip would be reconsidered. She offered Steve the opportunity to discuss the situation with ward manager if he wished. Jackie then disengaged with Steve and continued about the business of preparing for the trip.

Steve sat down briefly before standing up and shouting at Jackie across the room which she did not respond to. He then suddenly went towards Jackie pushing and hitting her, striking her arm. He made various threats towards her, including derogatory comments regarding her family. He expressed a desire to see her 'beaten' as she was a woman, to keep her 'in line'. Other staff were required to intervene and he was restrained, all the while making threats towards Jackie. He subsequently was not taken on the group and due to his actions, further group leave was suspended.

In the days following the incident, Steve expressed no remorse or offered no apology for his actions. He openly shared that the staff member was at fault and deserved his actions towards her.

At following ward reviews, Steve was still very angry about the incident and towards the staff member involved. A member of staff tried to speak with him about the incident, but the review ended abruptly with Steve flipping items over on the table and walking out. The staff member felt that there needed to be some work undertaken to repair the harm caused and ensure all parties were safe before the unit could consider reinstating leave. A restorative approach was suggested.

Prior to speaking with either party, I reviewed our internal guidance manual and identified the relevant aspects of the guidance which I felt were most relevant to this incident. I gave careful consideration to the needs of the people involved, specifically Steve given what I knew about his communication needs being an adult with an Autistic Spectrum Condition (ASC).

Based on the information I had gathered, I created document which I could use to illustrate the processes I intended follow, this included:

  • The general structure of the restorative process and how it would work
  • The ground rules
  • Who might be involved
  • How I propose to do this - and how they can contribute to this
  • The script format and what aims may be achieved

I also selected the questions I felt most relevant to the circumstances from those suggested in our restorative justice manual for each individual (Steve and Jackie).

I met with Steve first to introduce the idea of participating in a restorative intervention. I explained the process and showed him the illustrate I had prepared so he could see what intervention could look like. Steve said he would be willing to engage with this and agreed to participate.

I had prepared several questions I asked Steve during the preparation meeting. These included:

  1. What happened and what was your role in the incident?
  2. What were you thinking at the time?
  3. How did you feel at the time?
  4. How have you felt since?
  5. Who was affected by your actions?
  6. How do you think Jackie was affected by what happened?
  7. How responsible were you for what happened?
  8. How could you repair the harm caused by the offence?
  9. Do you think you could say these things to Jackie yourself?
  10. If I arranged a safe meeting, would you attend and tell them what you told me?
  11. How much of what we have discussed today are you happy for me to share with Jackie?
  12. What do you think you would take from a meeting? If you wanted to apologise, what would you be apologising for?
  13. How would you react if… (The harmed person says... the harmed person does…?)

To help give some context to this meeting, I’m going to share the notes I took following this first session. With the exception of the names used, I have not adapted these for the purpose of this case study.

Steve described the incident - on face value there appears no factual difference to what has been reported. Steve denies trying to punch Jackie, he accepts that he swung at her but to knock the bottle she was holding out of her hand only.

Steve felt paranoid, and felt he could see patterns emerging in interactions regarding Jackie, he was unsure if he was 'right' or 'wrong' in what he was feeling and questioned what was a reality and what wasn’t. He described this feeling as 'not going away'.

Steve doesn’t know if Jackie was aware of how he had felt, he hadn’t shared it overtly. 'I became fixated on her comment that I may be mugged, I didn’t understand this, I felt like she was suggesting I was weak or not able to protect myself'.

'I needed to be reassured - I didn’t get that, I got told off'.

'I said some terrible things and I made it personal. I don’t know how Jackie felt, I need her to explain how she felt, how did it hurt her. I suspect that she is tough but I don’t know that. I felt I had to compensate because I couldn’t be physical - I don’t know if the words I used were true or not, I made assumptions, trying to find the thing that would hurt the most'.

'I didn’t feel like myself, I felt out of control and I could see I was out of control but didn’t know how to stop'.

'I need to apologise, I shouldn’t have reacted in that way, I take responsibility for that, I was so sure though that the pattern was being confirmed'.

'My behaviour was bad, but not as bad as what I have witnessed in [previous hospital], I saw some terrible things, patients bleeding, fighting, staff restraining other patients.’

Steve wished for there to be understanding on Jackie's part, and how her approach triggered the 'paranoid' thoughts he had been having.

Steve feels able to say these things to Jackie. He agreed that having a structure and a chance for all parties to have their say was important.  I noted that Steve demonstrated difficulty in allowing me to talk and adhering to the structure of the initial meeting.

Following that initial meeting I used our suitability consideration tool to weigh up the best course of action moving forward. I was concerned that Steve felt like he needed to be the one that was apologised to and the potential this could have on further victimising Jackie. I was also concerned that Steve had been speaking over me and that he had not enable us to take turns in exploring his views. Below are my notes that I took at the time:

Steve may find it difficult to sit and listen to Jackie's views. He may find it hard to maintain an acceptance of responsibility. Steve is likely to raise his voice, and may not find it easy to adhere to structure of intervention. Steve may feel he is as much victim as wrongdoer and seek to justify his response and lay blame at victim or others.

Although I had reservations, I decided to speak with Jackie about a restorative approach and, as with Steve, outline the basic format and ascertain her interest and willingness to participate in a restorative intervention. At our initial meeting, I decided I would not disclose any of the views that Steve had shared with me and only focus on what Jackie felt was important.

Jackie very much wanted to engage in a restorative process and although I didn’t have it mind to ask her the questions I had prepared straight away, the meeting felt safe enough to explore these questions with her at this time.

The questions I prepared to ask Jackie included:

  1. What were you thinking at the time?
  2. How did you feel at the time?
  3. How have you felt since?
  4. How else were you affected?
  5. What was the hardest thing for you?
  6. What would you say to the wrongdoer if they were here now?
  7. How do you think they would respond to that?
  8. Do you think they ought to know what you have told me?
  9. What would make things better for you personally?
  10. What do you think could stop this happening again?
  11. Do you think you could say these things to the wrongdoer yourself?
  12. If I arranged a safe meeting, would you attend and tell them what you told me?
  13. How much of what we have discussed today are you happy for me to share with the wrongdoer?
  14. What do you think you would take from a meeting?
  15. How would you react if… (The wrongdoer says... the wrongdoer does… your hopes aren’t met?)
  16. Is there anything else I need to know that we haven’t covered?

Below are the notes I made following my meeting with Jackie.

Not concerned about personal nature of attack - more concerned about the fact that she feels the attack came about because she is a woman. Concern is for women in general.  Saying and acting in that way will be a detriment to Steve for the future and getting discharged.

Jackie feels it was "not ok" for Steve to respond in the way that he did. The issue is broader than this one incident and is an issue of his behaviour towards women.

Jackie does not want female members of staff to be subject to what she experienced.

Jackie advises that the harder thing for her was not how she experienced the attack both physically and verbally, but the assumption by staff that she was hurt by it and they being offended on her behalf.

Jackie feels that there is a chance that this could happen again as a consequence of the "wider care impact". She gave example of Steve being 'allowed' to stay isolated in his room all the time. Jackie explained that 'if the only time he see's and interacts with me is in a group setting, where I have to give instructions and am responsible for the safety of all in attendance, and must have some element of control, then the potential for him misunderstanding and reacting again is high'.

Jackie would like to talk to Steve about why, in those types of interactions, she must act like that for the greater good of the group.

Jackie would welcome a conversation with Steve - and she understands that he may not find it easy to hear her view.

She would like to "unpick" the paranoia. She would like to try and explain that "my approach is my approach" when she is facilitating a group, and how they can both learn from this.

Jackie feels that a communication plan and bespoke support planning for Steve is important. Which may involve, in moments of difficult interaction or conflict, another staff member intervening to break the intensity between a specific person and Steve - but questions that if, like on an escorted outing, there is such a moment and there is no one else there to communicate differently how Steve can be supported effectively.

Following this meeting, I had an informal discussion with another colleague who has undertaken restorative practice training. We talked through my concerns and discussed whether there was a risk of further harm or revictimisation occurring and whether, given the information I had gathered, a positive outcome could be gained.

Ultimately, although both were asking for the other to reflect on their actions, there was also a shared theme of recognising that harm had been caused and wanting to make things right. Confident that risks could be safely managed, I arranged another meeting with both Steve and Jackie individually.

In both these meetings I shared the feedback the other had given. Specifically, with Steve it was important for him to be clear about what Jackie needed to say, and what she wanted to achieve from the meeting. Steve at times found this hard, raising his voice, struggling to engage in a back and forth conversation, speaking over me and not allowing time for me to respond to him before speaking again. As the meeting went on, Steve’s emotional response lessened and he was able to engage in reflection in regard to the outcomes Jackie wanted and the need for him to hear what Jackie had to say. Steve continued to express a view that he wanted to reconcile with Jackie.

We spent time going over the ground rules again, and Steve agreed that these were important and that he would adhere to them. He even stated that having a structure made the whole idea of the meeting easier for him.

When I spoke with Jackie, I made her aware of Steve's initial reaction. At the time, I thought this would be the point at which Jackie would say she did not wish to continue the process. I was surprised that Jackie found it encouraging that Steve had seemingly overcome his initial emotional response and was able to engage. Jackie concluded that if Steve was able to manage this, she felt comfortable in meeting with him face-to-face so he could hear what she had to say it in her own voice.

Following my second meetings with Steve and Jackie, I met again with a Restorative practice trained colleague to share my feedback, observations and reservations. As before, we both felt that Jackie and Steve wanted this and that we would proceed with a meeting.

To give you some insight into the face-to-face meeting between Jackie and Steve, I’ve included the notes I made after the meeting concluded.

Steve, Jackie, a restorative practice colleague and I met today to discuss the incident. This was to reflect on what happened, acknowledge the harm that Steve caused and to work together to find a resolution and repair the harm done.

The meeting was semi structured allowing time for Steve to share his views on what happened, what he was thinking at the time and taking responsibility for his actions. Steve was calm throughout the meeting, allowing Jackie time to share her experiences and views on what happened as well. Steve acknowledged that his words had been chosen to hurt, and he had not realised at the time the wider impact of his words regarding violence against woman could hurt others witness to the incident. He apologised for both of these. Steve listened and acknowledged that he had misremembered the incident believing he had only struck a bottle Jackie was holding when he had instead hit her on the arm. Steve explained that in the moment of anger, he was not fully aware of what he was doing, and now that he had been told, he accepted responsibility and apologised.

Steve described his paranoia regarding Jackie and what he saw as 'patterns' emerging in their interaction which fuelled a sense of him being deliberately omitted and treated differently to others on the ward, and on the day the manner of their interaction confirmed this pattern and was the reason for his violence. Jackie was able to explain that her actions were oblivious to this paranoia and explained why she may interact with Steve in the manner which angered him on the day. Steve advised that he understood this now but could not fully describe the paranoia itself. Steve explained that it helped him to understand why Jackie had spoken to him in certain ways and how he may have interpreted this differently, he felt it would aid him in understanding future interactions.

Jackie shared her view that if the only time they interact is on group leave or when she is having to be giving instruction or holding boundaries, then his perception of her was likely to be skewed negatively.  She encouraged Steve to be more engaged on the ward and involve himself in more activity thereby having a more interactive relationship with staff and communicating more effectively.

Actions were agreed upon to move forward; Steve agreed it would be helpful for him to share suspicions or paranoias emerging with staff early, even if he felt it may be something he was imagining to explore this with staff or to identify why these thoughts about individuals were in his thoughts. Steve and Jackie both agreed that a way in which to minimise 'flashpoints' in regard to using leave and/or times when there was a lot of hustle and bustle to be signed out would be to plan in advance with Steve what he wished to take (including money), the agenda for the trip, the limitations of the trip and to allow Steve to ask questions about it and prepare himself.

Both Jackie and Steve felt they had said all they wanted to say in the meeting and it was agreed to close.

Both parties have since shard that they found the restorative process beneficial. They continue to work together and we continue to utilise the agreed plans. Steve is now coming forward to share and engage more with the team, and the plan to discuss leave has been helpful for him. He has been on group trips since, and there have been no further issues of this nature.

This experience has given me slightly more confidence in considering, and using, restorative practice in future. I feel that the positive outcome for all parties in this case was a pleasant surprise.

I do believe that if we'd taken a poll before we attempted it, we would have got a resounding response that Steve would not have been able to engage well at all, or he wasn’t the right kind of 'fit' for an intervention like this (perhaps an unconscious bias related to people with autism).

So, the fact that he did, and that he has progressed so far since this, demonstrates not only the therapeutic value for both involved, but also how we can all learn from the experience even though the wider team were not directly involved in the confrontation.

Chris Jones

Social Worker

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