Harm Minimisation

What is harm minimisation?

Harm minimisation is a proactive and recovery-orientated approach to supporting people with mental health conditions. It looks at the practices and procedures an organisation has, and the longer term harms that they may cause to an individual, as well as the longer term consequences.  For example, if a person is admitted to hospital, even if only for a short period of time, what effect could being in hospital cause to that person’s employment and finances? This could be particularly relevant if they are self-employed or on a zero hours contract at work.

Harm minimisation practices consider all the other options to either avoid this person being admitted to hospital, to speed up the time spent in hospital. This could include negotiating with the person’s employer with the view to reduce the financial impact of being in hospital.

Harm minimisation is a collaborative approach involving everyone from mental health professionals, to family members, and the individual. It introduces ‘Safety Summaries’ which focus on positives rather than negative incidents. For example, the number of times where the individual has attended their appointments rather than the number of times a person has not attended.  Safety summaries explore a person’s resilience. They look at how they have coped in the past and what has helped them. This is so these things can be incorporated into future planning. 

Patient records systems hold historical information about a person which may no longer be relevant today. Focussing on what is current for the individual and re-evaluating care and support accordingly means this will be more relevant.  Explaining to the individual what the patient records system is and why information is stored is an important part of the safety summary. It enables individuals feel included, as well as explaining what a safety summary is.

The approach of harm minimisation looks at doing with people, rather than doing to people. It’s about having conversations about why we do what we do, and the impact of it. It also considers taking positive risks which are part of being engaged fully in life.

Having conversations and using shared decision making is an important part of harm minimisation. It establishes how a person feels and how they wish to be supported. Every person should be supported in making choices about their care and support where possible, and to engage in shared decision making.

Without having conversations, mental health services risk taking away a person’s choice and their sense of empowerment which could cause longer term harm.

Personal Experience

My experiences of positive risk taking on the wards were very different compared to my experiences within the community setting, both with very different outcomes. Positive risk taking on the wards was only mentioned to me when I felt that there was no action or response being taken at all. In this respect I felt isolated and very much ignored; I felt I had to step up my destructive behaviours to feel validated and for acknowledgement that my distress was real and occurring to me. I was told that they had to take more positive risks within my care but I didn’t feel this was discussed collaboratively to help further educate and make sense and meaning for me as a service user,  or to help me understand my risks. Risk management – or risks to me that I felt were valid – were not asked about or discussed as part of my care. The term ‘positive risk taking’ was loosely used, and at times I appeared reckless as my risky behaviour increased. This made me feel unsafe and as a consequence usually resulted in me being put on constant observation. Although this de-skilled me in some ways, I wanted that reassurance that I would be protected, and I therefore struggled with this at first.

My experiences of positive risk taking around the decision of whether to admit me after a suicide attempt was, on one occasion, very useful and supportive. Positive risk taking was discussed with me and a care plan agreement was made collaboratively with me, not just for me. This made me more willing to engage and look at how taking some positive risks in actual fact positively enhanced my quality of life, my decision making, and reduced my risky behaviour overall so that it didn’t need to escalate further, therefore reducing my risk of harm to myself and preventing further admissions. I think positive risk taking is about balancing those risks without being reckless and taking them to the extreme where everything is put down as positive risk taking. I do think however, risk is often evaded within conversations for fear of upsetting the service user or increasing risk further for the service user. Positive risk taking should, I believe, be encouraged so long as it is in collaboration with the service user; where possible, it is clearly explained what this means, and the value and support it can bring to my care. Positive risk taking can sometimes compound feelings of rejection, so I believe the feelings it stirs up are the responsibility a person perceives as theirs, and other people’s responsibilities should be discussed, with feelings and actions validated and acknowledged.

I struggle with the belief that positive risk taking may as a consequence lead to more deaths at first, because to me that is a person whose life it is and I think it needs clearly explaining that the intent is still to prevent deaths. The person is a human being not a statistic, and I think that that is very relevant in making the decision or positive steps towards positive risk taking. What certainly determines whether staff take positive risks is the fear of something going wrong, someone could be severely injured or die, or there is the fear of litigation investigations and blame for taking those risks. All these factors need discussion, both with the service user for their benefit, but also discussion, validation and acknowledgment for what that member of staff is feeling, their decision making collaboratively supported by their teams, the service users and their families, and within the Trust.

I think in the past we have concentrated on risks that are the most dramatic or severe. We haven’t explored the positive or therapeutic benefits to that individual, that risk can be positive instead of always being a negative experience and how it can enhance a person’s wellbeing and quality of life.