Earlier this month, PHSA's BC Mental Health and Substance Use Services held a panel showcasing a new, best-in-class approach to patient, physician and staff safety. Introduced in Canada last year at the Forensic Psychiatric Hospital in Coquitlam, therapeutic and relational security is a patient-centred and recovery-oriented approach to health care. 

Patient aggression isn't uncommon in hospitals across the country: people with dementia, mental illnesses, substance use disorders, and histories of trauma can be more likely to lash out when they feel upset or unsafe. Patients at the Forensic Psychiatric Hospital often live with a combination of more than one of these challenges, making them especially vulnerable and prone to disruption.

Older, custodial approaches to care prioritized tools and practices such as the use of restraints and seclusion, which can make patients even more agitated. By contrast, therapeutic and relational security recognizes that the best way to prevent patient aggression is a safe environment that minimizes triggers.

At the panel, international and BC Mental Health and Substance Use Services experts discussed the approach, how it is transforming patient care at the Forensic Psychiatric Hospital, and the potential it has to improve staff safety across B.C. and the rest of the country. Speakers shared their perspectives with an audience that included senior leaders from Fraser Health, Interior Health, Island Health, Vancouver Coastal Health and Northern Health. Representatives from the Ministry of Health and Ministry of Mental Health and Addictions also attended. 

“I found the session very informative,” said Sandy DaSilva, who attended the panel. “Therapeutic and relational security is a process that would improve stigma and trauma experienced by the patients we serve. I believe this should be a process we champion and would be beneficial in all sectors of health care.” Da Silva is the director of facility standards and compliance in mental health and substance use at the Interior Health Authority.

“We’re excited about providing leadership in this space,” said Lynn Pelletier, the vice-president of BC Mental Health and Substance Use Services. She moderated the panel. “Many of the health authorities are dealing with similar issues, and this provides a more sophisticated and comprehensive approach to security than care providers have typically used. The curriculum we use, called See Think Act, highlights the dependency between providing purposeful, thoughtful and considerate care and achieving services that are safe for everyone. It has the potential to be extremely beneficial in reducing the need for force and preventing various incidents from happening.”

Instead of focusing only on procedural and physical security, including fences, locks, and other infrastructure, therapeutic and relational security prioritizes relationships between staff and patients, which are vital to creating a safe environment. Providing training to every staff member at every level in the organization encourages each person to take responsibility for the care they provide and, when necessary, speak up if they see warning signs in patients’ behaviour.

The approach takes advantage of the knowledge and understanding that staff, from food services to cleaning service workers, have of patients, including their past traumas, triggers and how they relate to others.

“Our most skilled staff, say, the psychiatrists, might spend an hour with a patient in a week,” said Peter Parnell, the director of access, transitions and forensic clinical risk at Forensic Psychiatric Hospital. “But others, including food staff and health care workers, are with them three or four hours a day and can also contribute to care and safety."

Parnell was among the speakers at the June 7 panel. He discussed his own experience with therapeutic and relational security, including how adopting the principles inform all of the hospital’s risk-management practices, including official tools such as risk assessment forms or in-the-moment practices for daily patient care, including for very high-risk and high-needs patients.

Parnell also explained why focusing too much on physical or procedural security at the expense of relational security can be a problem. “Sometimes what we think is safe and secure care is triggering for patients, and can lead to further issues,” he said.

"For example, the first thing people see of our hospital is a 10-foot fence. If you’ve lived here for eight years and all you see is that fence every day, it may well upset you, to the point where you get agitated. What we think is keeping us safe can sometimes exacerbate the issue. So, it’s about having that wider breadth of thinking—of looking at life-cycle and daily events, at who the patients are and how they’re affected by the daily routines.”

Other panel representatives from PHSA included Dr. Connie Coniglio, the chief operating officer for complex mental health and substance use services; Trevor Aarbo, Forensic Psychiatric Hospital's senior director of patient care services, Dr. George Wiehahn, the medical director of Forensic Psychiatric Services, and Dr. Tonia Nicholls, a primary investigator at BC Mental Heath and Substance Use Services' research institute as well as an associate professor at UBC. Elizabeth Allen, a relational security expert from the UK, also spoke. They discussed how therapeutic and relational security could be incorporated in other mental health and correctional settings. 

“We tended to look at in terms of high-security areas, but it’s relevant everywhere,” Parnell said.

Last year, PHSA brought Allen to Vancouver for the first time to train Forensic Psychiatric Hospital staff in the See Think Act curriculum, which she developed for Royal College of Psychiatrists Quality Network in the U.K. She’s since been back twice more, and will return for more training in the fall.

Her training sessions, along with other safety initiatives introduced at the hospital over the last year, “have significantly decreased the number of incidents we’re seeing at the hospital,” Pelletier said.

The other initiatives include hiring additional security and clinical staff, enhancing clinical leadership and scaling up trauma-informed care. A trauma-informed approach, which is in use across BC Mental Health and Substance Use Services, recognizes that clients have experienced histories of trauma and shapes care practices accordingly. 

One example of trauma-informed practice at the Forensic Psychiatric Hospital is a sensory/comfort room, introduced just this year. Designed to provide a comforting environment for patients who have experienced trauma, it is furnished with items that are physically comfortable and calming to the senses in order to provide a sanctuary from stress. It provides staff with an additional tool to proactively reduce the use of restraint and seclusion.

Another key safety initiative introduced this year is the creation of several new positions at the hospital—the first of their kind in Canada: Five clinical security liaison nurses, hired just last month, will mentor other staff, provide relational security supervision where needed, and act as a resource to help maintain safety for patients, physicians and staff. Their mandate also includes helping to educate the wider network of PHSA staff about therapeutic and relational security.

"We've known for some time that patient aggression is an issue in health care agencies across the country,” said Pelletier. “With PHSA leading the way, therapeutic and relational security is a promising solution that will not only keep everyone safer and more security but also help patients recover."