4 August 2020

Staff say they’ve seen positive changes after implementing the recently published Power Threat Meaning (PTM) as a framework for understanding the development of patients’ mental health difficulties at Ferneley and Eastlake Wards in Harrow.

The framework, introduced by the British Psychological Society last year, suggests a shift in perspective on why people experience mental health difficulties.

Instead of asking people ‘what’s wrong with you?’ PTM suggests we should be asking people ‘what has happened to you?’  Within the framework, mental health difficulties /symptoms are seen as understandable responses to potentially difficult life experiences or adversity. “It’s really making a difference,” said Gail Burrell, Interim Deputy Director of the Unit. She said staff now better understand why patients may think, feel and behave the way that they do, and it’s led to a decrease in violence on the wards and the use of restrictive interventions such as restraints or rapid tranquilisation  

“Harrow is currently one of the lowest for use of rapid tranquilisation in the whole Trust. Obviously there are lots of factors, but what I would argue is, it’s because we’ve been teaching staff a different way of communicating with patients, and understanding patients.

“Staff in the organisation have been asking what have you been doing that’s different?  I would argue it’s this,” said Gail.

The stark contrast is visible. Two and half years ago when she first started in this post, Gail said Ferneley Ward had one of the highest incidents of violence across the Trust.

Gail and her staff are so convinced by this trauma informed approach (TIA), that they’ve moved to rapidly overhaul the way they work with inpatients on the ward, undertaking intense weekly training.  Gail and the other TIA leads in Harrow receive supervision with Dr Lucy Johnstone, one of the producers of the PTM framework, after securing funding.

“It’s changed the atmosphere,” said Gail.

In an attempt to further embed trauma informed approaches on the wards,  Tanya Paxton, (Borough Director) agreed a six month secondment for a clinical psychologist with skills in this specialist area to work full time on the wards and introduce this way of working to the Harrow crisis time.           

Dr Faye Nikopaschos, Clinical Psychologist at the Unit was appointed to the seconded post. Incidentally, she was the one who suggested the unit consider adopting the trauma informed approach.

“Taking a trauma informed approach using a framework such a PTM has enabled us to develop new and helpful understandings of people’s mental health difficulties.  This in turn supports us in the planning and delivery of a range of different interventions.” The team have a dedicated weekly meeting (called Team Formulation) where they use the PTM framework to develop an understanding of patients’ presenting difficulties and agree a plan for intervention.  Weekly intense intervention training using the PTMF is also now running on the ward, where staff are taught psychological strategies to help patients stabilise their symptoms in a more constructive way.  For example, teaching mindfulness, relaxation and distraction as alternative strategies to self-harm or aggression.

They’ve been using this approach for seven months now, and Faye and Gail are very positive about the impact.   

“Rather than just suggesting that everyone does mindfulness, or have some medication, we’re trying to understand why the person is feeling the way they do.  It may be that they are feeling unsafe so a helpful starting point could be supporting the patient to develop their skills in breathing and relaxation in order to calm and soothe their mind and body.

“We’re trying to understand mental health difficulties in the context of people’s experiences. So rather than thinking about symptoms as meaningless biological expressions of an illness, we’re seeing them or trying to understand them as meaningful behaviours that have developed in the context of a person’s whole life experiences.  For example, we may consider experiences that have left a person feeling unsafe in some way or threatened their sense of self. It might have been an assault, abuse or a wider systemic variant such as poverty or racism, sexism or inequality,” said Faye.

They surveyed staff who reported positive outcomes too.

“Staff who took part in our research interviews reported a better understanding of why people may present or behave in certain ways as well as feeling better able to manage patients’ distress.”

Gail chipped in, “The fact that we’re saying we want to support you and help you, provide you with training, we want you to own it, we want your feedback. All of that is having an  impact on the staff and on the patients.”

“The evidence shows that if there’s a happier workforce you have more positive outcomes for patients,” said Gail.

Faye is now in the process of getting formal feedback from patients. But the impact is already evident in things like increased engagement and access to psychological skills groups, which can often be low on acute wards where people come in very distressed and feel unmotivated to participate.

“In the last two weeks we’ve had over 100 attendances to our trauma-informed ward based psychology skills groups.” said Faye who has been running daily patient groups on the ward..

Gail is excited in looking towards the future. The rest of the Trust is keen to learn more about this ground breaking work they’ve been doing to see how it can be rolled out on other wards and potentially in Addictions and Offender Care.

And the writers of the PTM framework are closely watching to see their resource tested in practise.

“We’re kind of pioneers,” said Gail. “Although they (BPS) released the framework they hadn’t actually used it and on inpatients as well, so they’re very interested to hear how we’re using it,” she said.

What is the PTM Framework?

The PTM Framework replaces ‘What is wrong with you?’ with four key questions:

  • ‘What has happened to you?’ (How is Power operating in your life?)
  • ‘How did it affect you?’ (What kind of Threats does this pose?)
  • ‘What sense did you make of it?’ (What is the Meaning of these situations and experiences to you?)
  • ‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)