This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.
The young woman sat hunched in her chair, not making eye contact with any of the half dozen or so people seated around the little room. It was hot, stiflingly so with so many bodies in such a small space. All eyes seemed to be upon her as a moon-faced man, dressed in an immaculate suit, began to speak.
“How do you feel this afternoon?”
The young woman didn’t answer as she picked imaginary lint from her blouse.
“Have you been taking the tablets?”
The man in the suit, a consultant psychiatrist, seemed to be addressing his patient but his attention had already shifted elsewhere. He had given up waiting for a response even before he’d finished speaking to her. Now, along with everyone else in the room (except the patient herself) he was looking at me, her primary nurse.
“Everything’s been given as prescribed.” I said. “No problem.”
The psychiatrist nodded and half-smiled his approval. My patient, all but forgotten now, stared at the floor in silence.
A few minutes more discussion between the various members of the team followed about the relative merits of antidepressants ensued. Then, again looking directly at me, the psychiatrist asked:
“Do you think you’re getting any better?”
I waited for her to answer, shifting my own gazer toward her in the hope that others would try to include her also. Perhaps this would help her to feel noticed again. Then the psychiatrist spoke again:
“Is she improving, Stuart?”
There was no response from the patient so I explained that she had indeed made progress, she was sleeping and eating normally and had begun interacting with other people on the ward too.
“No evidence of that here, is there?” The psychiatrist quipped, eliciting tiny, almost imperceptible smiles from one or two of the others in the little room.
I explained (again) that these team meetings were intimidating for her and that her presentation on the ward was far more relaxed. I explained again about the work we’d done on the ward and how she was able to talk about her problems with us and her depression was lifting every day. I also pointed out that she specifically asked that I explain this precisely because she lacks confidence in this setting.
“It’s just that she feels much more ‘on show’ during the ward round”.
The young woman raised her head a little and grunted her agreement, albeit rather timidly.
“So you can speak.” Said the psychiatrist. “You just choose not to speak to me.”
Once again the woman’s gaze dropped to the floor in front of her. She said nothing more in the ward round although she did begin sobbing quietly to herself upon learning that she would be discharged home that day.
After she left the room (it’s strange how readily people accept the decisions of psychiatrists and just go) I made the point that although she was improving she wasn’t well enough for discharge yet. I believed, the whole nursing team believed, that another week or so would make all the difference. I pointed out that her lack of confidence in the meeting was evidence that her former high self-esteem had not yet returned.
“That’s only behavioural.” Said the psychiatrist as he completed the discharge forms.
I’m always interested to know just what people mean when they describe a person’s actions as ‘behavioural’. Actually I’d be interested to know of any action that isn’t ‘behavioural’.
In the health and social care context (including psychiatry) what ‘behavioural’ usually means is that we feel powerless to change the behaviour or that we are at a loss to understand it. Actually the two meanings often go hand in hand as a little understanding does tend to point the way to the solution anyway.
It’s not difficult to understand why this young woman was so quiet (elective mutism we call it in the trade). It’s not difficult to see the solution either – a smaller group meeting, perhaps with only one or two people present and some attempt to engage with her as a person rather than as a set of symptoms would probably have worked wonders. It certainly helped in my one to one sessions with her on the ward.
However, such understanding would require a little thought, flexibility and even compassion. It’s much easier to write the situation off as ‘behavioural’, all the time pretending that the word actually means something clinical and isn’t just an excuse for our own lack of imagination.
A fundamental premise of this series and of care provision in general must be that everything we do is behavioural but that nothing is ‘just’ behavioural. If we want to be effective we need to stop hiding our own inadequacies behind this meaningless term and take the time to understand the individual instead.
Everything happens for a reason and effective work with people whose behaviours can be challenging must begin with that ‘cause and effect’ principle clearly understood.