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“We need decent people as well as decent laws”:

Beth Greenhill, Amanda Roberts and Rebecca Swarbrick, 2013. “We need decent people as well as decent laws”:. Reformulation, Summer, p.18,19,20,21,22,23,24,25.

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Using CAT to understand and create Human Rights Based, Ethical Service Cultures

Summary

In the context of 'Winterbourne View', scandals in health care provision for older adults and the recent Francis Report, the current article aims to outline CAT’s potential contribution to developing ethical organisational cultures in services. The authors reflect on research findings and clinical practice, outlining dominant reciprocal roles and contextual (Sequential Diagrammatic Reformulations (SDRs) to describe services in relation to human rights for people with learning disabilities. ‘Co-production’ and relational approaches to clinical risk are advocated as preventative exits from distancing, dehumanising and exhausting services. Whilst the focus here is on learning disability services, the article hopes to invite others to re- formulate organisational cultures and philosophies of service change within their own sphere.

Organisational Cultures in Healthcare and Human Rights Issues

Destructive organisational cultures are consistently highlighted as a key factor in poor quality or abusive health care. Whilst the staff who degraded and tortured the residents of Winterbourne View (Panorama, 2011) are perhaps the most notorious example of human rights abuses of people with learning diffi culties in healthcare, there are many others (Healthcare Commission, 2006; Mencap, 2007; 2012). Recent inquiries into scandals in care provided to older adults and in general health care settings (Francis, 2013) seem to confi rm a sense of services as alienated and alienating. Changing the systems that permit or perpetuate dehumanising ways of relating is a vital part of working within services for people with LD and dementia, whose very personhood is often questioned (Kittay & Carlson , 2010). This need to work systemically, whilst ‘holding the person in mind’ is widely recognised in LD and Older Adult services, and is perhaps refl ected in the emphasis on person-centred policy and practice (O’Brien & O’Brien, 2000; Kitwood, 1997).

Research exploring the factors which promote or impede the human rights of service users identifi es “organisational culture as key to rights protection and promotion” (p270, Owen et al, 2009; See also Sobsey, 1994; Hattonetal., 1999; Gillet & Stenfert-Kroese, 2003); moreover, “Culture eats strategy for breakfast, every day, every time” (cited in Davies, 2002). That is, formal human rights law and service user-focussed policy have less of an impact on care- related decision-making, upon “what staff do”, than the informal water- cooler or canteen culture. Practice is shaped more by staff’s knowledge, attitudes, beliefs and their emotional responses to the client, to the client’s rights and to the ‘client’s risks’ than by the strategic direction or vision of the organisation.

Reinders (2002) contends that ‘we need decent people as well as decent laws”; human rights need ‘translating’ from legalistic courtroom rulings into concrete, living practice. Reinders (p.4, 2002) also argues that to enable staff to remain connected to service users, to remain ‘decent people’, human rights require a “moral culture” in which relationships can flourish; in contrast to current, bureaucratic institutional cultures in health. Human rights are social codes, ways of understanding our obligations to each other and the state; they cannot be understood without thinking relationally.

CAT’s relational approach might enable an ‘un-picking’ of some of the social and interpersonal processes which make up organisational culture. In turn, this may help us understand why some vulnerable adults are abused, why good staff sometimes do bad things, and why the organisational context often colludes. CAT also potentially offers a framework for some relational exits and solutions.

Contextual CAT and Human Rights

Walsh (1996) and others have written about the importance of contextual reformulation in helping teams and organisations recognise damaging enactments in organisations and develop the organisational capacity to navigate them. CAT may also facilitate relational thinking with the aim of recognising and revising human rights abuses in staff teams. Refl ecting on research data, previous investigations into services and experiences of various statutory and other services, we felt that naming a number of enactments might invite a dialogue with other practitioners. The enactments are variously in relation to the service, the service user and to colleagues. The SDR’s developed below were developed by the authors partly in response to the CQC investigations following ‘Winterbourne View’ and partly as refl ections on the ‘Human Rights in Healthcare’ pilot project completed with the British Institute of Human Rights and Department of Health.

Whistle-blowing Procedure

Many of the recent examples of poor practice have been exposed by ‘whistle-blowers’ casting ‘fresh eyes’ over the practices of an organisation. The courage to act often comes at a price. In relation to the service, idealistic or curious new workers may authentically seek to challenge poor practice they observe, with the intention of reducing harm to service users and promoting person-centred practice. With notable exceptions, services often respond negatively to the criticism heard in raising poor practice, with the result that the ‘Whistle-blower’ either a) withdraws (emotionally or leaves the organisation) or colludes to ‘gain safety’ within the organisation or b) ‘fi ghts on’ but feels increasingly depleted and unsafe. There are several senses in which the whistle-blower may experience the position of being ‘betrayed or let down’. This may be ‘self-self’ in that the whistle blower constructs themselves as naïve, experiencing self-doubt and a betrayal of their own values; “What do I know?”, “I’m not getting this”. The whistle-blower may also feel betrayed or let down by their own self efficacy; “why can’t I change it?” ‘Self-other’ betrayals may arise from the perceived or actual unwillingness or inability of others to tackle the issue. In some instances, such as the ‘Ashworth Inquiry’ (Fallon, 1999), attacks may be ‘other-self’, either via physical intimidation, ‘out- grouping’ or by seeking to diminish the credibility of the whistle-blower.

Figure 1: Whistle-blowing Procedure A potential exit for this procedure is to hope for and try to model open, transparent, responsive, organisational learning. For example by inviting constructive criticism and reflection from students on placement or new staff members in relation to our own practice.

‘Digging our heels in’: The Paradoxical Psychological Reactance Procedure

Trying to introduce changes to organisational culture can also create interesting dynamics. People frequently resist change imposed on them and the effects of any new policy can be counter-productive via the process of ‘psychological reactance’ (Kinderman & Butler, 2006). People are not passive creatures who are impinged upon by their environment, we actively respond to our environments. We also actively consider our possible responses to new circumstances in terms of a wide range of factors and we therefore cannot assume that people will respond to new initiatives as intended. People particularly resist change imposed upon them when we feel that another person is trying to coerce us to do something or to change our opinions, leading to negative emotions or cognitions. In general, people prefer to retain autonomy over their thoughts and their action. This ‘reactance’ can put a brake on any proposed policy action with the danger that effects of any new policy can be counter- productive.

Figure 2: ‘Digging my Heels in’ - Psychological Reactance Procedure In relation to the service, the ‘champions’ of service change are positioned as standing ‘ in their Ivory tower’ or ‘on their soap box’ and as detached from the realities of the team or the ward. Other staff may experience a split reciprocal position of feeling either a) coerced, dragging and ‘digging in their heels’, passively and sullenly or b) experience the change as inherently critical and attacking, responding defensively to the perceived judgement.

Staff training is a frequent organisational response to the need for service change. Relational exits might focus how the new ideas being introduced in training sit with existing practice and on the theory of learning used in staff training (Kidd, 2012). A number of studies suggest training is probably necessary but not suffi cient to secure and sustain organisational change (Rose and Holmes, 1991), particularly when trying to make changes to service ethics (Redmanetal, 2012). The evidence suggests that, at a minimum, formal teaching of complex behaviours such as human rights and ethical approaches might explicitly address the cognitive scripts, the attitudes and belief systems, of the learner. The idea that pre-existing belief systems infl uence future interpretations and judgments means that the more these attitudes are engaged with in training, the more effective the intervention is likely to be. Implementation of new ethical decision-making frameworks or values may be more effective if they are presented as complementary to well- established value systems and not as new/novel.

The model of learning is also important. Training initiatives are often implicitly informed by ‘expert’ models of pedagogy, ‘the banking model’, where expertise is transferred to the empty vessel of the learner who is filled with knowledge like a piggy bank (Friere, 1970). In our experience, ‘dilemma based learning’ demonstrates the perspectives a new model may bring to bear, allowing participants in training to assess for themselves the potential utility of any new approach. On this model, staff and service users bring their own real-life dilemmas and trainers engage with them to try and resolve or suggest ways forward, applying, in this instance, human rights based thinking. An approach which positions all staff as potential allies and allows opportunities to co-operatively develop real-world knowledge alongside a peer with an overview of the area (Vygostky, 1978) is less likely to create friction and a desire to distance from a ‘lecturing expert’(see also Friere, 1970). This approach is also more likely to lead to service change.

Risk Aversion Procedure

Clinical risk is often the crucible of values in an organisation and it can be vital to have clear ethical decision- making processes in this area. Ideally, risk processes might balance risk with service user’s views (Sheldon, 2010) incorporate a relational approach (Shannon, 2009) and involve a stretch of the ethical frame (Kahneman, 2011) to incorporate elements which balance risk aversion with more positive models for risk assessment and management, for example human rights (Greenhill and Whitehead, 2010).

Practitioners at every level within services are involved in navigating the complex ethical dilemmas which arise from the pull of the ‘Duty of Care’ (Sellars, 2002) on the one hand and, on the other, the ‘Dignity of Risk’ (Perske, 1972). Historically, services have emphasised a paternalistic response to client need, which we might understand as being linked to a ‘Protecting-Protected’ reciprocal role in CAT terms. Here, practitioners are tasked with minimising risk and ensuring that no harm comes to the service user; often autonomy is compromised for dignity and ‘safety’. ‘Dignity of risk’ refers to the chances taken in a life which contains real, every-day choices. This might be described as an ‘Empowering- Empowered’ reciprocal role, which has real resonance with longstanding policy drivers towards Service User Inclusion (Department of Health, 2000; 2009). There are polarised messages to staff and service users from this ethical tug of war. Frequently, practitioners become paralysed and ‘stuck’ in response to pressure on the one hand from risk-averse organisations concerned that ‘nothing goes wrong’, and their own desire to support and nurture the client’s autonomy or at least to meet the policy invocations to do ‘nothing about us without us’ (Department of Health, 2001; 2010). This indecision may also give way to also emotional disconnection from service users, arising from the anxiety and fear attached to the paralysis.

Whittington and Logan (2010) describe how organisations taking a risk averse approach, create a negative experience for the service user, who then disengages from services. This makes it harder to develop accurate strategies to manage risk, in turn leading to increases in risky, negative events for the person and reinforcing organisational risk aversion. Community and Secure settings may differ in the extent to which physical and procedural aspects of risk management are relied upon. Although service users are not subject to same levels of scrutiny in the community, much of the care they receive has human rights implications with intrusions or restrictions often being justified on clinical grounds.

In CAT terms, a specific ‘snag’ procedure in relation to HR and risk might understand staff to respond to perceived threat and risk either from or around the service user with the aim of reducing the risk and the severity of any perceived challenge. Trying to take back their power and gain control, staff become dependent on procedural and physical methods of reducing risk, neglecting the key task of creating a safe, containing relationship to work through and negotiate concerns with the client. Staff are then perceived as being aversive and punitive and the service user responds in ‘threat mode’.

Figure 3: ‘Not on My Watch’ (Risk Aversion) Procedure A shift in organisational culture towards ‘relational risk’ which understands risk as part of relationships – not just as an attribute of someone else (Shannon, 2009) might offer an exit to this procedure. Such approaches to risk recognise that clinical risk doesn’t reside in the person; it is “inextricably connected to interpersonal relationships” (Hansson, 2000). Relational risk assessment and management is made possible through formulation based, collaborative approaches to risk (Shannon, 2009). CAT and other frameworks have potential to re-frame approaches to risk (Shannon, 2009) in terms of their interpersonal impact and there is an increasing interest in using interpersonal approaches (Wood & Blumenthal, 2011) and ‘Relational Security’ (Allen, 2010; Kennedy, 2002; Kinsley, 1998).

Concretely, exits might include having clear practical decision making tools within services to support culture change so that staff make ‘choices guided by values’ using ‘Value Congruence Theory’ (Casali & Day, 2010). This model focuses on responding to confl icts between the individual and the organisation, seeking to achieve congruence by ensuring that shared values are ever present in decision-making processes. On this model, decisions are thought to be the building blocks of organisational culture and decision-making engages people with learning disabilities, their staff and the composite organisational culture.

Work within local services has attempted to promote a relational approach to risk by inviting service users with learning disabilities to have a conversation with their staff about risk. Service users are also asked to rate the risks as they see them using a traffic-light system. The structured professional judgement approach asks service users to discuss the risks to themselves from others, from themselves to others, those which are self- self and those to property. The process is supported by a practical ‘human rights and risk’ toolkit where pictures and accessible language support the service user to talk about risk and plan how to tackle it together. The risk assessment tool (Lee et. al. 2008) also balances risk with the person’s human rights (Greenhill et. al. 2008; see also Hall & Duperouzel, 2011) and considers risks such as those from racism or homophobia which are often missing from risk assessments but are important to service users (Langan & Lindow, 2004).

Figure 4: Sample Item from the ‘Keeping Me Safe and Well’ Assessment in the Human Rights and Risk Toolkit 7) Physical abuse by others.

Promt questions:

• Does anyone hurt you?
• Does anyone hit/slap/punch you?
• Does anyone spit at you?

Human rights which may be engaged:

FREDA: fairness, respect, equality, dignity, autonomy

Is the person treated as an equal and with respect? e.g. if the person makes a complaint about physical abuse, is it investigated fully and taken seriously?

Article 2: Right to life – If the person is subjected to extreme physical abuse by others, this could result in a loss of their life. Strategies should be in place to prevent this from happening.

Article 3: Prohibition of torture, inhuman and degrading treatment- e.g. is there a policy of restraint around the person? Could this be seen as physical abuse? If another service user is abusing the person, is anything being done about this to prevent a compromise to his / her right? Is the person vulnerable and likely to be a victim of physical abuse when out on their own? If so, are care plans and support in place to try and prevent this? (e.g. having a carer with them).

Article 8: Right to respect for private and family life – Physical abuse will affect the person’s physical integrity and their psychological well being. Are strategies in place to reduce this abuse as much as possible?

Two additional procedures, an ‘emotional labour procedure’ and a ‘distancing procedure’ emerged from our reflections about trying to create human rights based organisational change.

Emotional Labour Procedure

Qualitative findings from our research suggested that some staff embraced the opportunities presented by the pilot human rights project to break down conventional roles in relation to service users (see also Covell & Howe, 2007). For other staff, there was a definite sense that new policies and procedures, even if welcomed, add to the amount of ‘emotional labour’ that any clinician has to manage: ‘it’s another weight but we get through it don’t we?’. The term ‘emotional labour’ was first defined by the sociologist Arlie Hochschild (1983) as the ‘management of feeling to create a publicly facial and bodily display’. Emotional labour was both implicit and explicit in the interview narratives. Emotional labour involves managing emotions so that they are consistent with organisational or occupational display rules, regardless of whether they are discrepant with internal feelings. If different value systems and attitudes exist and require management, emotional labour increases and the need to maintain the outward appearance becomes more difficult. Emotional labour is thought to be connected to stress, exhaustion and burn out.

Figure 5: ‘Bag of Bricks’ (Emotional Labour) Procedure Distancing Procedure.

Staff’s fears of change, of organisational blame, or even of ‘madness’ or learning disability in and of themselves, can create powerful drivers to maintain an emotional distance from service users (Hyde & Thomas 2002). These anxieties can be compounded by the relentless demands of systems which encourage and promote task-focussed, un- relational care. The lack of emotional support and supervision provided to direct care staff also pushes staff away from retaining an authentic emotional engagement with service users. Psychodynamic work looking at the functions of organisational boundaries, defence and anxieties in institutions (Menzies-Lyth, 1988; Hyde & Thomas, 2002; Hyde, 2006) is also pertinent in understanding how systems create and maintain barriers to developing ethical service cultures through prioritising the emotional safety of staff (Roberts et al., 2013).

Figure 6: “Holding People at Arm’s length” (Distancing) Procedure Human Rights discourses are explicitly predicated upon equality in the law, constructing both staff and service users as citizens. This can be quite theartening to staff wanting to maintain a sense of ‘safe professional distance’. Exits and solutions most obviously involve providing emotional support for staff, so they can keep on ‘being people’ in the jobs they do, but might also involve approaches which fundamentally change the relational dynamics between staff and service users, such as co-production (Boyle and Harris, 2009).

‘Co-production’ Procedure

Co-production involves taking a different, collaborative approach to creating service change. Rather than tokenistic approaches to consultation, the approach requires a much closer engagement with clients, which is thought to enhance empathy, reduce stigma and reduce the desire for social distance (Kinderman & Butler, 2006). Co-production involves staff risking their ‘position of expertise’ and participating in a genuine partnership. Staff and Service Users jointly decide on changes to service design and participate in delivery; the outcomes and processes unfold together often with more imaginative results than those which might emerge from ‘expert-patient’ or ‘provider-consumer’ dynamics .

Figure 7: Co-production Procedure Several initiatives within our service have taken a co-production approach. In particular, these have focussed on developing human rights knowledge with service users. The ‘FREDA’ principles of Fairness, Respect, Equality, Dignity and Autonomy both underpin and provide a way of making the Human Rights Act (1998) accessible to service users and staff. Staff and service users personifi ed the FREDA acronym by turning FREDA into a character (Roberts et al, 2012; 2013). By asking ‘what would FREDA say’ in response to human rights breaches and dilemmas, staff and service users could have a dialogue about rights which was meaningful. The Human Rights board game, ‘FREDA Challenge’, was co-produced by service users and staff, creating a focussed activity where all participants can have a joint conversation about rights. A human rights DVD and booklet have also been co-produced by other groups of service users and staff.

Conclusion

In our experience, creating ethical service cultures necessitates different ways of relating with service users. We have focussed on beginning to understand procedural responses to whistle-blowing, to clinical risk and to introducing change as a process which in itself produces strong dynamics in teams, services and organisations. Most people who work in health and social services came here to care and to connect. We hope that by naming some of the processes through which staff become dislocated, despairing and unable to engage, we might open up a conversation with other practitioners about how to develop more relationally informed services. Relational cultures are needed to ensure ‘decent people’ remain decent in services and, ultimately, that service users get access to ‘decent laws’, rights, and quality, ethical care.

Full Reference

Beth Greenhill, Amanda Roberts and Rebecca Swarbrick, 2013. “We need decent people as well as decent laws”:. Reformulation, Summer, p.18,19,20,21,22,23,24,25.

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