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Permissive language gives back control

At a recent BSCAH webinar, I mentioned an incident I’d experienced whilst working as a prison nurse, which happened several years ago. I used this as a case study as part of a presentation I delivered to fellow members of the Northern Branch a few years ago in York, but it was suggested that it could be of interest to the wider membership.

At the time, I was a “Recovery Nurse”, working on the Drugs and Alcohol Recovery Service inpatient unit in a local prison for young offenders, vis, men aged between 18 and 21 years of age. We were charged with looking after newly admitted prisoners who were actively withdrawing from alcohol and/or opiates. We had four cells, and they were frequently empty. Within the prison, there was also an inpatient unit, colloquially referred to as “Healthcare”, which typically catered for prisoners with acute mental health problems, and was often used for managing crises that individual prisoners were experiencing. 

One way in which prisoners’ risk to self was managed is through the ACCT process, (Assessment, Care in Custody and Teamwork). If a prisoner was perceived to be at risk (eg suicide, self harm etc), any member of staff could implement an ACCT, which involved a multi disciplinary meeting with the prisoner involved, to discuss what measures could be taken to mitigate against any such risks to self.

At the time in question, we had no prisoners/patients in DARS, and our unit was being used by healthcare. I had heard that there was a young man (lets call him Jason) in the segregation block (The “Seg”), who had been refusing food for the last couple of days. As well as this, despite being put on an ACCT, he was non communicative, and had not been observed to drink or move from his position, laid face down on the floor of his cell in the seg. A variety of staff had tried to establish a dialogue with him, to no avail, including officers, the duty chaplain and healthcare nurses. Some officers are specially trained in (eg) hostage negotiations, but I’m not sure whether they had tried. My healthcare nurse colleague, Katy, had tried to take basic physical obs, but he would signal his non consent by withdrawing his arm if she tried to put a blood pressure cuff on his arm. 

It was decided to move him to healthcare, which had to be done under physical restraint. NB, physical restraint was done using approved control and restraint (C&R) techniques, and planned interventions such as this were video recorded in case of any issues arising. My first sight of him was as he was led by a group of officers, and placed in a cell in the DARS unit. He immediately resumed his position, placing himself face down on the floor of his cell. 

A cavalcade of prison staff, including senior officers and prison governors made themselves at home in our office, ignoring me  to discuss amongst themselves in hushed tones what could be done next. Katy went into the cell, officers at the door, to try to take Jason’s BP. He roughly withdrew his arm. She talked gently to him, saying how worried everyone was that he wasn’t eating or drinking. The prison team decided that he should be watched every 15 minutes.I said to Katy “can I try something?” She said “what are you going to do?” “Talk to him” I said. 

I entered the cell. I assessed my position. I was sat on the bed. Being stood up may have been a bit authoritative. He was on the floor, face down, limbs splayed out, face to the side. I was between him and the door. There were two burly officers at the door, which was open, the lock being in the locked position so it couldn’t be accidentally closed and locked.

I started to speak, along the following lines. “As you lie there I wonder where your mind wanders because you may be curious as to why I’m here/hear what I’m saying because I know that there are ways in which you may tell us what it is that you may want. Of course, as you know, we are worried that you have stopped drinking, but I know that as you listen to me you are able to do as you will because there is a part of you that knows more about you do than you do yourself that is able to communicate. Perhaps now, and maybe later you’ll be able to have a refreshing drink of water and tell us what it is that you want to happen. But don’t get up and tellus until you are ready. I’m sure you will find time to think this over, but instead of me just rambling on to you, I’m just going to leave you in peace…” 

Note: the italicised phrases denote inserted suggestions, often also referred to as embedded suggestions. The general gist was permissive language, which is my favoured approach in most situations, but particularly in this context in which Jason had probably been subject to a more authoritative approach by the prison authorities. The final sentence uses a superficially negative suggestion “don’t get up…” to exploit his presumed tendency to buck against authority, and I clearly remember using this tack as my parting shot.

I exited the cell backwards. i said to Katy, with more cockiness than I was feeling “My guess is that he’ll be up and about this evening”, by which time I’d be off duty and my efforts would have been forgotten apart from my entry in the notes. It was in fact, within 5 minutes he was up and about, drinking a cup of water, and asking for something to eat. Katy said “what did you say to him???” I said I’d used hypnotic language patterns. The management team did not acknowledge me, I think they did not know how to respond, or what had happened. they vacated the area. 

I cannot, of course, categorically claim that it was my intervention that resulted in Jason suddenly coming to his senses. He may have just been pissed off lying on the floor not eating or drinking, or he may have merely wanted to be out of the seg. On the other hand, as was observed by one of the BSCAH members at York, he was already in a self induced trance state, all I had to do was to utilise it.

Jim Moorhouse