To Risk Or Not To Risk?

To Risk Or Not To Risk?

At Care in Mind, we work within a least restrictive model, with an emphasis on therapeutic risk management.

The dilemma of risking or restricting risk comes down weighing up long-term benefits with present day risks. So, why do we believe in long-term benefits and managing risk therapeutically and with the least restraint?

When a young person spends lots of time in a hospital, it can lead to a heavy reliance on others to protect them. Additionally, it can be easy for them to unlearn, or become fearful of, various normal areas of life, such as making a cup of tea or using metal cutlery. Essentially, it can significantly hinder their ability to learn the value in responsibility and independence. This is especially true of young people who may have been in and out of hospital during their early teenage years.

As well as a loss of independence and reliance on others, heavy restrictions can cause young people to feel out of control. Losing this control may lead them to take increased risks as time goes on, thus they find themselves in a dangerous cycle of risky behaviour.

Of course, it is understandable that restrictive care has become the norm, as what is a natural reaction to someone hurting themselves? It is to take away that risk and stop them. However, at Care in Mind, we have intensive training in place for our residential staff so that this reaction can be challenged. Instead of restrictive care, we focus on assertive care and train our staff to support young people in keeping themselves safe. Our least restrictive model is very much based on the principles of Therapeutic Risk Management.

The Five Principles of Therapeutic Risk Managament
The Principles Of Therapeutic Risk Management

There are five principles of Therapeutic Risk Management and they each underlie our Therapeutic Risk model, which is paramount to successful risk management in a least restrictive manner.

The first principle is focused on collaboration, therapeutic rcaelationships and informed decision making on the young person’s part. Care in Mind young people are put at the forefront of their own care and work alongside our comprehensive MDT to ensure they receive care that is most helpful for them. Much of those relies on an open and honest relationship between staff and young people, which gives them the confidence to trust those who care for them.

The second principle is about creating a strength based, person-centred approach to recovery. This is done utilising the “Managing Mental Health Ladder” and the “Mental Health Recovery Star” (Recovery Star™ (4th Edition) – Triangle ( The ladder is all about progressing how you manage your mental health issues. To assess how young people progress and to ensure we focus on the necessary areas of recovery, we utilise the “Mental Health Recovery Star”. These will be filled out on a regular basis throughout the young person’s time within the homes to document how they are doing.

The third principle is about effective team-working and building risk-sharing partnerships. This is about the way we always care for young people being understood and consistent, including when liaising with Emergency Services, Social Care and Safeguarding teams. Maintaining a stable level of least restrictive care is vital in minimising the risk of further setbacks into a risky cycle of behaviour.

The Mental Health Recovery Star & The Managing Mental Health Ladder

The fourth principle is providing a safe culture for both residential staff and the young people. A significant part of this is through reflective practice and a no blame culture. We try to take every opportunity to learn from where we may have gone wrong and improve upon our practice, both individually and as an organisation. Rather than having one way of doing things and strictly enforcing that, we encourage staff to bring forward any innovative ideas they may have.

The fifth and final principle is about providing least restrictive interventions. Rather than removing risks, using physical restraint, or conducting observations on people, we utilise less invasive ways to care for our young people.

Naturally, a least restrictive environment is not suited to every individual and their mental health journey. In cases where young people are actively suicidal, have a means to end their own life or lack capacity, we may not necessarily recommend a least restrictive model of care. It all comes down to assessing potential risks and weighing up the potential benefits for each unique individual.

For some young people, a least restrictive environment and therapeutically managed risks can allow them to gain the necessary independence to thrive once they leave residential care. It can help break the cycle of readmission and give them the self-belief that they can take responsibility for their own safety.

Therefore, we choose to risk (where appropriate), because it can help the young person learn to live their most safe, satisfying, and meaningful life.

What is Dissociation?

Our brain has various methods for coping with trauma and stress, one of these methods is dissociation.

When someone dissociates, their thoughts, feelings, behaviours, how they see their environment, memory, how present they are, and how they view the world disconnects. Their mind no longer works in harmony, and instead becomes separated. There are many theories of dissociation, but one is the idea that dissociation is a continuum, and that symptoms can range from mild to severe. In fact, for many of us, it may be a surprise to realise that we often mildly dissociate in our day-to-day life.

Dissociation for some may mean ‘zoning out’ or ‘daydreaming’ – it may present itself as missing your exit on the motorway or losing track of time during in a dull meeting. However, for someone who has experienced trauma, dissociation can show itself in a more pronounced way. It may impact their memory, sense of who they are, and how they perceive the world.

Severe dissociation may occur in many ways, such as forgetting past experiences, depersonalisation (feeling detached from yourself), or unusual experiences such as seeing/hearing things other people cannot. It may also cause vivid and realistic flashbacks to past trauma, whereby you feel like you’re ‘reliving’ a past experience. This can be a very frightening experience for the individual.

Dissociation is not a necessarily a bad thing though; it actually provides the individual with a psychological escape. It allows those who have experienced trauma to go about their normal daily living whilst coping with emotional distress. For some, many aspects of dissociating is a comforting, positive experience but it can also be a frightening reminder of upsetting experiences, causing your brain to jump into ‘panic mode’.

Caring for someone with dissociation, whether in a personal or professional capacity, may feel daunting. However, with understanding, you learn that they have simply found their own way to survive. Sometimes individuals get stuck an unhealthy habit to survive, which challenges their ability to recover from whatever they were trying to survive in the first place. Therefore, paying attention to dissociation is an important part of recovery.

At Care in Mind, we use evidence-based methods for helping our young people in the most effective way. One of these methods is a three-step technique, based on regulating, relating, and reasoning. This can especially help during a flashback.

For regulation, the purpose is to help the individual to manage their response to the flashback. This may be done through encouraging grounding techniques. A comforting smell, relaxing song or hot drink may help assist someone in their grounding. It is also helpful to remind the individual that they are safe, and that the flashback will pass. Additionally, it is also important to promote self-care and soothing methods at this stage.

The second step, relating, is about connecting to the individual by being sensitive to their needs. We do this primarily through validation, which is a key element of our model of care. Validation is all about recognising someone’s feelings and allowing them to feel heard. However, it goes beyond words – it’s also about seeing and hearing the young person and connecting with them and their distress. For more help on validating statements and behaviour, click here.

Finally, it is important to help the individual reflect on what just happened. It is at this point that, together, you can both reflect on what happened and what may help going forward. It can be useful to make a note of triggers and consider why your brain had the response that it did. At Care in Mind, it would be the young person’s assigned therapy session where they may do further reflecting on the incident, and thus find methods to avoid future episodes.

Dissociation is a normal and understandable coping response but if you find that it is causing you distress, please seek support. There are also ways in which you can care yourself. The mental health charity, Mind, has several helpful suggestions and information about coping with dissociation.

The content of this blog post is a summary of a recent webinar facilitated by Dr Lena Marden and Dr Christy Laganis, Clinical Psychologists at Care in Mind.

Safewards for Safehomes

We began implementing “Safewards for Safehomes” at Care in Mind in 2015, to support our ethos of least restrictive practice and working therapeutically to manage risk.

Our team worked alongside Professor Len Bowers of Safewards to adapt the ward-based model for our community setting. Working closely with Professor Bowers, we have been able to stay true to the original Safewards model. To our knowledge, we remain one of the only residential providers implementing the model within a community setting.

Safewards is an evidence-based model that is designed to reduce conflict and containment, traditionally on ward environments. This is achieved through ten key interventions that serve to improve the relationship between staff and young people thereby reducing conflict and containment. You can find out more about the model and interventions on the Safewards website.

We have found that the implementation of Safewards for Safehomes within our residential services has had an overwhelmingly positive impact. The model allows for a more therapeutic relationship between staff and young people. In fact, in many ways, it allows the young people in our care to see the staff as more human. It also complements other elements of our model of care, including the Boundary Seesaw model (Hamilton 2010). Staff and young people can enjoy a healthy, supportive relationship with clear boundaries in place to promote a safe, consistent environment.

Analysis of incident data shows us that the implementation of Safewards has had a significant impact on conflict reduction in homes. The clear structure of the model and the range of interventions provide a positive framework for our staff, which guides them through managing conflict. This allows them to react in the most helpful way, creating a more supportive environment. Young people are also encouraged through the model to develop responsibility for their actions and conduct.

The use of language has been key for us in applying the model to a community setting. For example, words like ‘ward’ or ‘patient’ don’t translate to our residential environment. Each of our homes is 4 or 5-bedded, so there are fewer discharges than a busy ward environment, which means fewer “Discharge Messages”. Therefore, we use “Positive Messages” instead. These might include song lyrics or quotes chosen by young people, as well as messages left by individuals who have left the service.

Each of our homes puts their own creative stamp on the interventions:

Some of the challenges we’ve encountered include consistency and ensuring the model is thoroughly understood. This is targeted through a strong focus on training, and the identification of Safewards Champions in each service and department. We also now implement Safewards for Safehomes workshops for our young people. Our Best Practice Facilitator, Dominique Hooper, has corporate responsibility for embedding Safewards. She supports our teams to think creatively about how the interventions can be applied in challenging situations.

Our ideas for further building on the ten key interventions include:

  • Music and mood: thinking about the effects of music on mood and how we can use music to self-soothe or lower arousal and agitation
  • Physical activity: considering the impact of being more physically active on our well-being

Overall, the process of embedding Safewards into our model of care at Care in Mind has been phenomenally positive. Implementation has been no mean feat, and the continuous development and improvement of the project is ever evolving. We have seen the benefits to the wellbeing of our staff and young people, as well as the dynamics between them. We find that it promotes kindness, respect, empathy and validation, all of which are core principles within our organisation.

For more information on Safewards, the ten key interventions and lots of other ideas you can visit the Safewards website or join the international Safewards community on Facebook.