Restorative Practice in a Forensic Mental Health Service: Case Study
Toni evoked a range of strong responses from the staff team over a period of several years on the ward. She was vulnerable, hard-working, good humoured, playful, spontaneously violent and also sometimes instrumentally violent. She was often the subject of staff reflective practice; at times with a proportion of the team wanting to expel her back to prison or a more secure environment and the remainder of the team holding hope and wanting to nurture her. She had suffered institutional deprivation as a child before being adopted. She had quasi-autistic traits, in that she struggled to mentalise and had difficulties in social communication and relationships. Her thinking was very concrete, so when she encountered novel or complex social situations arousing anxiety, she envisaged a palpable threat such as muggers or kidnappers and the prospect of attack. When emotionally aroused she lashed out. Other times there was an element of planning to her violence, but this always appeared to be in the context of a prolonged state of feeling unsafe and an overwhelming urge to gain a sense of control over her environment. When in this aroused state, Toni’s thoughts centred on not appearing ‘weak’ to others.
Toni engaged in individual and group treatment with curiosity and motivation. Her goal was to ‘be normal’. She perceived herself to be different from peers in a variety of areas including her violence. Initially she demonstrated very little reflection or remorse following violent acts. If challenged she defended her actions. Over time she progressed from this position, to expressing a desire to control her actions and to live without the need for violence. She reflected upon the impact of her actions upon others and expressed remorse for harm she caused. With support, she was able to give a rich account of how trust and human connection can be harmed and broken through violence.
There was cautious hope and optimism when Toni moved to a ward of lower security.
Unfortunately Toni’s progress had been fragile and the change of environment, relationships and routine all proved too much for her to tolerate without resorting initially to self-harm and then to violence. With hindsight and exploration with Toni, we realised that a fast progression of her community leave in an area she did not know contributed to her sense of being unsafe. Toni attempted to manage her feelings through self-harm but had not yet developed the relationships she needed to be able to talk about her fears. She was ashamed about not coping. She did not want to fail and be returned to the ward she had left. Ironically, as things progressed and she did become violent, there was then an element of her deliberately engineering her return to a place where she felt safe.
The restorative meeting between Toni and Sally, the nurse whom she assaulted, occurred 10 months later. They had not seen each other since as Toni was nursed in seclusion following the incident and then transferred back to the medium secure ward. Toni expressed remorse very quickly, and both Toni and Sally responded positively to the idea of a restorative intervention in the months following the assault. It was decided that the case would be facilitated by the ward psychologist who knew Toni well (and was a trained restorative facilitator) and an external facilitator whom it was hoped would bring a sense of neutrality but also gravitas to the piece of work, marking it as something separate from the other work that Toni had engaged in. Toni’s mental health fluctuated for some time following her return to the medium secure ward, necessitating the restorative work being put on hold for some months. Over this period we emailed Sally occasionally to let her know that we were holding her in mind and that we would progress the work when possible.
When we did go ahead we prepared over a period of weeks.
The internal and external restorative facilitators had several individual meetings with Toni and Sally. Sally described the incident and the impact it had had on her and her family members. She spoke in detail and considered ‘what had been the hardest thing’ about being assaulted and the consequences. She used the preparation sessions both to consider her professional boundaries and the level of self-disclosure she felt comfortable with. She hoped that the meeting would be beneficial for Toni and also hoped that they would be able to have a good future working relationship when Toni returned to the low secure ward. The preparation with Toni was aimed at building her emotional resilience to be able to hear about the impact of the assault. Given our knowledge of her difficulties in coping with change and the unknown we went over the plans in detail with her. This included who would be travelling with her, who would greet her, when she would first see Sally, the ground rules for the meeting, what the questions would be, how she should indicate a need for a break, where the break would take place and who would be with her, who would respond if we needed to press the alarm, what the consequences would be of not completing the meeting , who would be travelling back with her and who would be available to support her once back on the medium secure ward. In consultation with her treating team it was decided that the restorative intervention should take place at the low secure unit as this is where the assault occurred and Toni’s care pathway was to return there. Toni used the preparation meetings well. She was able to hazard a guess at some of the things that Sally might say to her and she asked questions such as should she greet Sally by shaking hands and could she give Sally a letter of apology that she had written. We did not want to micro-manage and stage every interaction in advance as some of the power of the intervention is in the immediacy of what occurs between the participants (Cook, Drennan & Callanan, 2015) so we answered Toni’s questions with possible courses of action. We suggested that she offer a handshake if that felt comfortable but also considered why Sally might not want to shake her hand initially and how she would cope with that. We suggested that she offer the apology letter at the end after the talking and again rehearsed the possibility that Sally might not want it and how Toni would manage this.
The conference itself progressed very smoothly with little deviation from the classic structure.
Toni and Sally shook hands and took their seats. After a brief introduction to the meeting Toni described how she had followed Sally down a corridor and thumped her in the head because she thought that Sally was going to remove laundry which she could use to ligature. She was able to describe the assault and her thoughts and feelings prior to, during and following the assault. Sally agreed that this is what had happened and said that she had anticipated that Toni was going to tie a ligature and was trying to protect Toni from this. She said that she felt she had started to build a good relationship with Toni and to understand her; hence she was able to anticipate Toni’s self-harm. Toni agreed that Sally was one of the few people whom she had started to build some rapport and trust with. Sally described the personal impact of the assault on herself and her family. She also described the impact upon her professional practice in terms of her heightened awareness on the ward particularly when going down the corridors. She also spoke of the impact of the assault on others on the ward (staff and patients). Toni listened attentively and apologised. In the second part of the meeting we looked towards the future and how the harm might be addressed. Toni expressed hope that she could work towards repairing the relationship and rebuild trust. She said she was aware that this would be slow process. She expressed hope that she would do things differently in the future and spoke of the skills she had learnt to better manage her emotions. Both Toni and Sally expressed hope that Toni would be able to successfully return to the ward and that she would not assault people again. Sally said that she hoped that Toni realised the impact of what she did; not just the physical hurt, also the emotional hurt. She expressed concern that Toni might assault her again and said she hoped that this would not happen. Sally accepted the apology letter that Toni offered her and said that she would read it later.
The emotional intensity of the conference felt relatively low throughout, and I began to wonder whether there had been enough honest interaction and immediacy to give the intervention therapeutic value. However, as we closed the meeting tears began to slide down Toni’s face. Sally said a tactful quick goodbye and left. She returned to working on the ward and the possibility of peer support which had been set up prior to the conference.
When we followed up with Sally by email and telephone she said she was very aware that Toni had started to cry and she had left quickly as she did not want to make the situation more difficult for Toni. Sally reported that she was pleased that she had taken part in the intervention and that it had met her expectations. She said ‘The meeting was incredibly useful for me and I feel others would benefit from it in the future also’. When we asked Toni for feedback she also reported being pleased that she had taken part in the intervention. She said it had fulfilled her goal of being able to apologise to Sally. She expressed relief and gratitude that her apology had been accepted and she had not felt judged. She said that she would definitely recommend the intervention to others and thought that the intervention would have a positive impact on her life. When asked what had the most impact on her, she said that hearing how her assault had changed Sally’s working practice both surprised and upset her. It seemed that Sally’s description of heightened vigilance to danger at work following the assault had resonated with Toni and had reminded her of her own sense of vulnerability in the world.
Sadly, although perhaps unsurprisingly, Toni was violent again within the ward environment, and eventually was transferred to a high security ward for a period, rather than the low security ward. She has since returned to the medium ward and it is hoped that the restorative work will remain a positive base which she can build upon as she continues to progress.
With thanks to Dr Andy Cook, Forensic Healthcare, Sussex Partnership NHS Foundation Trust, Hellingly, UK
Restorative practice in a forensic mental health service: three case studies
Author | Cook, A. (2019), The Journal of Forensic Psychiatry & Psychology, 30(5), 876-893