Safe spaces: scoping report

6. Principles and Practice

6.1. Time Space Compassion

Time Space Compassion (TSC) is an approach aimed at preventing suicide. The TSC introductory guide^[14] informs that 753 lives were lost to suicide in 2021 and, between 2011 and 2019, 77.3% of those who had died by suicide in Scotland had contact with at least one of nine healthcare services in the twelve months prior to their death. Research has found that by applying the principles of TSC to a suicidal crisis the outcomes can be vastly improved. The TSC approach is about working to address gaps and inconsistency in people’s experiences, with a view to improving practice. The introductory guide recognises the barriers which individuals face when accessing support, these include overcoming fear and experiences of rejection and discrimination, fear of being a burden, and low expectations of the support on offer. Safe spaces should therefore be underpinned by the T, S, C principles:

Time

Staff working in the safe spaces will promote a safe space where individuals feel listened to and heard. This helps individuals feel validated and enables them to feel safe, speaking freely about their situation and getting the help they need. During discussions staff will be clear about any offers of follow-up and be transparent and clear about expected timescales. The safe space should also offer continuity of care when an individual is in mental health crisis and distress, offering ways back into receiving planned support when and if another crisis arises. Recognition of a shared respect, where acknowledgment and valuing of the individuals and the mental health or wellbeing workers time helps build therapeutic relationships.

Space

The safe space will offer a physical space which is accessible, welcoming, and designed to meet the needs of people experiencing crisis who may have also experienced trauma. Staff can create emotional safe spaces for individuals to share and feel heard, however transparency will be needed when there is a duty to share or report any information which is considered concerning. It will be necessary that all staff stay up to date with national guidance and practice on safety planning, risk management, and good practice guidelines.

Compassion

The safe spaces will have an ethos of demonstrating kindness, respect, and sensitivity as well as the ability to offer or connect the person to the right support. Staff will have an awareness of how trauma and crisis can affect people’s behaviour, understanding that it can take time to build trust and a relationship. Staff will be skilled in achieving a balance between a compassionate response and maintaining appropriate professional boundaries.

6.2. Trauma Informed Approach

This trauma-informed practice toolkit^[15] has been developed as part of the National Trauma Training Programme to support all sectors of the workforce in planning and developing trauma informed services. Evidence of the full impact of trauma has been emerging now for several decades, establishing beyond doubt that its effects can be wide-ranging, substantial, long-lasting, and costly. Resulting from harmful experiences such as violence, neglect, war and abuse, trauma has no boundaries regarding age, gender, socio-economic status or ethnicity, and represents an almost universal experience across the countries of the world. The seminal Adverse Childhood Experiences (ACE) study^[16] suggests that childhood trauma is common: 30% per cent of the sample of over 17,000 people reported substance use in their household; 27% reported physical abuse; 25% reported sexual abuse; 13% reported emotional abuse; 17% reported emotional neglect; 9% reported physical neglect; and 14% reported seeing their mother treated violently. The toolkit outlines 5 key principles which have aligned to the role and functioning of the safe spaces:

Safety

Efforts are made throughout to ensure that staff and the people they serve feel physically and psychologically safe. Staff and clients should experience the setting and the interpersonal interactions taking place within the setting as safe, inviting, and not a risk to their physical or psychological safety.

Trustworthiness

This principle refers to the degree to which operations and decisions are conducted with transparency, with the goal of building and maintaining trust among clients and their family members, and among staff and others involved in the organisation.

Choice

Throughout the safe space, clients and staff are supported to make decisions and choices, and to set their own goals. The safe space recognises that giving people choice can help address power imbalances. Clients and staff therefore have meaningful choice and a voice in the decision-making process of the organisation and its service.

Collaboration

The Centre for Mental Health published a guide to developing integrated statutory and voluntary sector mental health services in 2022^[17] which outlines the key areas for successful integration, noting senior level commitment, piloting, sharing successes, and learning and partnership agreement. Learning can be taken from this when considering the implementation of safe spaces where collaboration should be embedded across the board, from service collaboration to clinician and individual participation; working together to achieve the same goal. Attempts are made to level the power differentials between different staff groups, and between staff and clients. This principle is often implemented through the formal or informal use of peer support and mutual self-help. There is recognition that healing takes place in the context of relationships and in the meaningful sharing of power and decision-making.

Empowerment

Efforts are made by the organisation to share power and to give clients and staff a strong voice in decision-making, at both individual and organisational levels. Each level of the organisation, including management, operations, service delivery, and staff training, is designed to be empowering for both staff and service users. Staff are empowered by mechanisms of organisational support, and clients are empowered by services that are person-centred and based on belief in the resilience of individuals and their ability to heal and recover from trauma.

6.3. Human Rights Approach

In 2015 the MWC published the Human Right in Mental Health Care in Scotland report^[18] which defines a human rights-based approach as a way of empowering people to know and claim their rights as well as increasing the ability and accountability of individuals, organisations, and professionals responsible for respecting, protecting, and fulfilling rights. The report called for a greater focus on a rights-based approach to be embed within mental health services.

The Mental Health and Wellbeing Strategy highlights the need for a human rights, whole system approach, and where appropriate, it takes into consideration recommendations of the Scottish Mental Health Law Review. It is shaped by the commitment to embed human rights across the mental health system in Scotland.

6.4. Risk Appetite Management

The MWC stated ‘life is never risk-free. Some degree of risk-taking is an essential part of good care’^[19]. ‘Changing Lives,’ the 21st Century Social Work Review^[20], recommended a change in organisational culture to promote personalisation. Central to this approach is greater user and carer empowerment and the management of positive risk taking. For partner agencies to be able to deliver more personalised services, they need to manage risk effectively and support creative approaches to managing risk which enable individuals to live as full a life as possible.

When thinking about the safe space, a culture of positive risk taking and collaborative working and planning could be promoted to mitigate any unnecessary or disproportionate barriers to access. A positive risk-taking culture will promote a calm and supportive environment which will support the aim of reducing acute distress and crisis. However, training, planning, and collaboration are necessary to ensure that alternative safe spaces operate effectively.

There is the risk that services create strict eligibility criteria to manage the level of risk, excluding those considered most high risk or challenging. A balance will therefore need to be achieved to ensure access is maximised while also ensuring appropriate safeguarding measures are in place. It is crucial to have awareness of the stigma and negative public perception of the risks associated with people experiencing mental health crisis and distress. It is known that the risks of unpredictable harmful behaviours towards others from those in crisis and/or distress are low but the risk to self is likely to present a greater risk.