Category Archives: mental health

Privileged glimpses 12: Don’t flap

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.

More haste – less speed.

There is a very real responsibility in social care work. The best workers are aware of that and strive to live up to it. They know that what they do matters and they take their work seriously.

Unfortunately though that sense of responsibility can become a problem in itself. The more seriously we take our duties the more likely we are to become stressed about them unless we also learn how to manage our own anxieties. Some of the most caring and compassionate people I know are also the ones most likely to turn into headless chickens the moment anything out of the ordinary happens.

The problem is that the more we flap the less effective we become. Our emotional over reaction is contagious too. If we lose our cool then our colleagues are more likely to do the same. Not only that, the people we care for are just as susceptible to displays of emotion themselves. Uncontrolled displays of anxiety from workers serve only to unsettle the environment even further. Instead of having one problem to deal with over anxious workers quickly find themselves stuck in the middle of a whirlpool of unrest and that just makes their work even more difficult. And they brought it upon themselves with their own lack of self control.

Perhaps more importantly it’s not fair on the people who rely upon us – the people in our care.

So the message here is simple. This ‘privileged glimpse’ really is bleedin’ obvious:

Don’t flap!

Privileged glimpses 11: Risk-free is impossible

life without riskThis 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.

 Risk free is impossible – managed risk is the way to go.

Individual v Organisational risk

There is much more to the notion of risk than meets the eye. Many care workers think that it is their job to prevent service-users from taking any risks at all but this is not possible. In fact, even if it was possible to prevent people from taking any risks it would not be the right thing to do.

Life without risk would be life without living. It is only through accepting a level of risk in our daily lives that we are able to do anything at all. In fact, even doing nothing is risky. The risk to mental health from boredom and unchanging routine is as great as the risk to our physical health from inaction and lack of stimulating activities.

All activity, from making a cup of tea to crossing the road or even going to the toilet must involve some degree of risk in order for the service-user to maintain or develop skills. There is always a risk of failure when learning to do new things and on occasion that failure can result in some form of harm.

The trick then is to help people to understand the individual risk they are proposing to take. If they cannot understand it (for example if their mental capacity is impaired) then the risk becomes an organisational risk. In that case the organisation that creates the risk/activity for them must manage that risk to bring it down to manageable proportions. This does not necessarily mean remove the risk – simply manage it.

Obviously some things carry more risk than others. An activity that involves crossing the road with supervision might be considerably safer than the decision to go sky-diving but the principle still holds. The task is to make the risk manageable.

Just imagine how empty your life would be without risk. If we need to take risks in order to have a fulfilling life is it not just as important for our service-users?

Just as nobody has the right to remove risk from your life so you do not have the right to remove all risk from the lives of your service-users.

Types of risk

However – you really do have an obligation to manage the risks taken by those service-users who do not understand the risks they take and sometimes to prevent the more extreme or unnecessary risks.

So we need to determine:

  1. Is it an individual or an organisational risk?
  2. Is the risk manageable?
  3. What are the ‘reasonable foreseeable’ outcomes?
  4. Do we need to prevent the person from taking this risk or can we support them in it?

You can follow the entire blog series as it develops here.

Privileged glimpses 10: Sympathy isn’t usually helpful

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.

I spoke with a colleague recently about a difficult situation she had to deal with at home. It doesn’t matter what the situation was. It’s enough to say that this lady considered that she was being treated unfairly and unreasonably by a family member. So far as I could tell (having heard only one side of the story) I’m inclined to agree.

The temptation was to sympathise with her. That often feels like the most human, most compassionate response to another person in distress. It’s how we show that we care, how we demonstrate understanding and, perhaps most importantly, it maintains rapport. When we sympathise with people we usually find ourselves ‘on their wavelength’ and that feels good.

Unfortunately though, however good it may feel sympathy is far from positive. In reality it’s usually very destructive. Here’s why….

When I sympathise with you I’m really telling you what you already want to hear. I’m reaffirming what you already think:

Sympathy empathy“Yes it is awful and you’re quite right to feel that bad about it.”

Sympathy locks us into the same emotions and beliefs as the other person and that’s not a good place to be. I can’t help you to move on and solve problems if I’m wearing the same emotional blinkers as you.

Of course, it is true that people really do have a right to feel bad when things don’t turn out as they would like them to. But it is also true that you don’t have to feel bad as well. You’re not obliged to join in.

If you resist the urge to sympathise you can keep a clear head without risking being drawn into the ‘doom and gloom’ thinking of the other person. This means that you will be free to explore other explanations and solutions. You can problem-solve and you can encourage others to do the same.

Sympathy acknowledges that people are right to feel bad and that traps them:

“Oh poor you. I’d feel awful if that happened to me.”

Empathy is a much, much more helpful proposition. Empathy acknowledges that people have a right to feel as badly as they want to but then it asks:

“But why would you want to?”

Empathy acknowledges and validates problems and emotions but then moves on to find solutions. Sympathy merely validates distress but offers no help to overcome it. In fact sympathy risks prolonging distress.

Don’t ‘do sympathy’.’ Do empathy’ instead.

 

Privileged glimpses 9: Lapse is different from relapse

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.

A good friend of mine began attending a well known self-help group for problem drinking a few years ago. I’m happy to say that he didn’t attend for very long, partly because he found himself far from convinced about the group’s ‘message’.

He’d been having a difficult time at work and briefly retreated into alcohol as a way of coping. It wasn’t the best tactic he could have chosen by any means and it did start to cause more problems than it solved. It was a response to stress and like many such coping strategies it made him feel better in the short term but only served to exacerbate his troubles in the long term. But it was still a coping mechanism, however self-defeating it may have been over time.

The self-help group he attended took a very simplistic, almost religiose stance. All alcohol was bad, or so they told him and even a single drink would automatically put him right back to square one. They wanted him to believe that he had a permanent, unresolvable problem that could be managed with total abstinence but never ‘cured’.

According to my friend, we’ll call him Tom, the other members of the group accepted this idea uncritically. Presumably that was because those who didn’t accept it left the organisation, as did Tom after a few months. But he did stay around long enough to notice something very interesting.

As the pressures at work lessened he found himself able to drink in moderation once again. He reverted back to previous levels of alcohol use – social and quite infrequent. He stopped getting drunk and found himself quite able to ‘take it or leave it’ as the occasion required. However the other members of the group, those who believed the ‘one drink and you’re back where you began’ mantra didn’t seem able to do that.

During Tom’s time in the group he witnessed a small number of others ‘fall off the wagon’. They too had intended to have only a couple of drinks but they seemingly were unable to do so.

Lapse isnt relapse

Tom realised that their belief prevented them from controlling their alcohol use. They thought that they must keep drinking after their first little tipple and so didn’t attempt to do otherwise. They defined a single drink as impossible to achieve and nobody tries very hard to do what they think is impossible.

It was a self-fulfilling prophecy

Had those people been able to acknowledge the possibility of ‘lapse’, a single event, they might have stopped at a single drink but since they believed only in relapse or abstinence they couldn’t.

So it’s important that those of us who work in mental health and/or addiction services understand that success in any endeavour (not just in overcoming substance related problems) depends upon both achievements and lapses into previous ways of coping. The lapses are a vital part of the process because, as we saw in a previous entry, it’s how we learn. It is neither necessary nor desirable to convince people that they’ve failed when all they’ve really done is stumble a little along their path to success.

Lapse is different from relapse

 

Privileged glimpses 8: Do as I do

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.

Do as I do – model behaviours we want to encourage in others

Mental health work involves many aspects of care including working to help people to manage their emotions, their thinking and their behaviour. It involves challenge and more often than not it involves problem solving and behavioural intervention.

Goals and objectives relating to developing both behavioural and emotional control are commonplace and much of what we do is centred around working toward them.

Do as I do

A very important part of this work is ‘modelling’. If we expect our service-users to make positive changes we need to demonstrate them in ourselves.

  • If the service-user has anger management problems they need to see us remaining calm.
  • If they have problems with paranoia they need to see us actively seek reasonable solutions in our own lives. Thinking the worst of the boss or seeing conspiracy among colleagues is not the best example to set.
  • Similairly if the service-user has difficulty sorting fact from fantasy it’s useful for them to see how we go about assessing evidence and making rational judgements. Let them know how we make sense of the world without jumping to conclusions and work on helping them to develop the same skills for themselves.

Most importantly if we want to encourage service-users to develop good support networks (a vital aspect of mental health maintenance) we need to show generosity of spirit in our own dealings with those around us.

The rule of thumb is very definitely ‘do as I do’ and not ‘do as I say’

 

 

 

Privileged glimpses 7: What people say

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.

Just a quick post today. This one is as obvious as it gets.

What people say may not be what people mean

There are many reasons why people in health and social care settings don’t say what they mean and it’s worth taking a little time to think before deciding whether or not to take what they say at face value.

Here are just a few possibilities to consider…

People may be too frightened or insecure to tell the truth. Or they may know that what they have to say will be unpopular. Many would argue that fear of exposure and a basically unpopular message explains why people are often less than honest about their true intentions. The truth may be too problematic (or the other person’s reaction too scary) to admit to honestly.

The service-user who is always satisfied with the care we give them may genuinely be happy with what we do but, realistically speaking, the person who never feels dissatisfied is pretty rare. That’s why inspectors such as those from the CQC sometimes worry when an organisation receives no complaints at all. Are the service-users too intimidated to say what they actually mean.

There is a power imbalance between nurse, carer and service-user and it’s easy for people to be intimidated by that imbalance – even if it’s unintended. If it is intended, if the nurse is a bully for example then it’s even more of a problem.

If nobody in your service ever complains it’s a good idea to ask yourself why. You may want to look beyond their words and understand the fear that prevents them from being honest.

The other possibility I want to consider here is the ‘challenging behaviour’ strategy of taking people at their word even if you don’t think they’re being honest.

Sometimes people will tell you things they don’t mean because they have a hidden agenda. In those cases you may want to consider acting as if they’re being honest with you even though you think they may not. This more or less guarantees that the solution you give them, although appropriate for the problem they stated will be unlikely to match the subtext. Stick to the stated problem until they tell you what they really mean.

This means that over time they learn that it’s better to be clear and to be honest.

Privileged glimpses 6: Don’t blame people for their disorders

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.

Don’t blame people with disorders for behaving like people with disorders

l_300_168_BFB62138-883B-4070-8F84-F868E3CC5219.jpegOne of the fundamental themes throughout almost all of my writing is the idea that there is no ‘us and them’ and that people are just people. We are all fallible and we are also all capable of improving ourselves. This means that it is never OK to assume that people with mental health problems can never overcome them. Those of us who work in mental health services have an obligation to work toward improved functioning and coping skills development. That obligation includes a duty to believe that the people we work with are capable of change given the right circumstances, opportunities and motivations.

Unfortunately there is a downside to this approach. Some mental health workers use the belief that ‘there is no us and them’ to justify unrealistic expectations of their service users. It is true that people can achieve great things regardless of diagnosis but it is also true that people with mental health problems are unlikely to function as well as those who are free of such problems in the short term. It takes time to overcome our difficulties and there is no value (or logic) in expecting people who have problems to act as though they had not.

And yet some mental health workers, of all grades and professions seem unable to separate potential coping skills from current achievement. They expect their service-users to behave as though they had already overcome their problems and then blame them when they do not. This is not only lazy thinking, it is evidence of severely limited understanding of mental disorders, the process of recovery and the role of mental health workers.

When we blame our service-users for behaving like service-users we recreate the same sort of invalidation that brought many of them into our care in the first place. Rather than assisting people to develop better coping strategies this attitude further damages service-users and serves to trap them in their existing circumstances and psychological difficulties. Our job is to help people to develop beyond their problems, not to judge them for having those problems in the first place.

Don’t blame people with mental disorders for behaving like people with mental disorders.

 

Privileged glimpses 5: Don’t expect perfection.

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.

Perfection

Don’t expect your service user to perform perfectly. You don’t so why should they?

As we saw in the last entry we all make mistakes and it takes time to learn a new skill. But that’s only half the story. Even with practice people rarely achieve perfection. It’s true that we might perform faultlessly some of the time but even the best of us gets things wrong on occasion. For most of us it’s a very regular occurrence no matter how much we’ve practiced. We all have ‘off days’ and we all make mistakes.

“Nobody’s perfect” as the saying goes.

But whilst it’s easy to excuse ourselves for the regular little errors that make up every day of our lives many workers in health and social care have difficulty extending the same understanding and forgiveness to service users. The next time you go into work take a random batch of care or support case files and look at the care plans inside. See how many of them have been discontinued as ‘unattainable’ after only one or two attempts. Notice also how many have stated goals set far too low because of an assumption that since the service user didn’t get it right every time they cannot be expected to attain meaningful goals.

Then apply the same logic to your own life.

Would you find your own support plans discontinued if the same stringent demands were applied to your….

  • Sobriety
  • Spending and budget management
  • Anger management
  • Compliance with medication regimes as ‘self-administrator of meds’
  • Smoking cessation (how many times did the ex smokers you know try and fail to stop before they succeeded?)

The fact that you screw up from time to time doesn’t make you a failure. It merely makes you human and fallible. We all make mistakes but that doesn’t mean we are incapable of doing well too.

Remember that there is no us and them. If we allow ourselves to be less than perfect then we must also allow the same freedom to be fallible for our service users.

Privileged glimpses 4: Coping skills develop slowly

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.

Proud of yourselfTake a moment to think of all the things that you’re most proud of in your life.

For some that might mean professional qualifications from NVQs or VQs to diplomas, degrees and even PhDs. Others will think of less formal achievements like charitable endeavours or learning to play a musical instrument. Perhaps you’re good at a particular sport or maybe you’re proud of overcoming your fear of heights and going on a parachute jump. It takes a particular form of courage to jump out of a perfectly good aeroplane several thousand feet above the ground. A friend of mine recently climbed Kilimanjaro. He’s rightfully proud of that.

What have you achieved?

The fact that you’re able to read this blog at all means that you’ve achieved something that most humans throughout history never managed to do. You have learned to read!

Whatever you’re thinking about the chances are that the things you’re most proud of didn’t come easily. They took effort. They took mistakes.

Thomas Eddison reputedly failed thousands of times before he successfully invented the light bulb. His attitude to these mistakes was interesting. He didn’t see them as failures. He saw them as learning opportunities. He saw them as milestones along the road to success.

Every time he built a bulb that wouldn’t light up he learned a little bit more about how not to make a light bulb. Inevitably all that knowledge, all that trial and error eventually led him to find the right way to generate light.

Eddison learned from his mistakes just as you have learned from yours. Writing the first assignment you submitted in that college course, your first fumbling attempts at making music, the first time you tried to hit a cricket ball or ride a horse you made mistakes. Over time you learned from these mistakes and you did better.

That’s as true for you as it is for your service users. They make mistakes too. And when those mistakes are handled correctly they learn from them – just like you do.

So the next time your service user gets something wrong or fails to meet expectations don’t assume they’re incapable. Help them to grow because of that mistake, not in spite of it. It’s a vital part of learning new skills and new ways of coping.

Privileged glimpses 3: People do the best they can with what they’ve got

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.

sweet shopImagine a small child in a very large sweetshop. The lights are off and it’s completely dark except for a single spotlight illuminating a tiny piece of shelving. On the shelf, visible in the little pool of light are three bars of chocolate. One bar is milk chocolate, another dark while the third is white chocolate. That is all the child can see.

The child has one simple instruction…

Take your pick…

Obviously the child will choose one of the three chocolate bars he can see. It doesn’t matter what other treats might be in the shop because he can’t see them – he doesn’t know that they are available options.

This little post isn’t really about chocolate bars and children in sweetshops though. It’s about social care service users and the options they have available.

The sweets in the shop represent coping strategies. They’re behaviours. Choices about what to do in different situations. And just like the child in the sweetshop service users (along with everybody else) only choose the options, the behaviours that they know about.

So if someone you work with makes poor choices that’s not necessarily because they don’t want to do better. It’s more likely because they either don’t know what else to do or because they don’t think that other options will work for them. Many people understand intellectually about good coping skills, socially acceptable behaviours but don’t believe that they will be given the opportunity to make different choices work for them. If they’re used to being treated with mistrust they won’t believe that the truth will work for them. If they’re used to being ignored they won’t believe that not drawing attention to themselves will meet their need for human contact. And they may well be right.

So, just like the child in the sweetshop they take the best option available to them.

They do the best they can with what they’ve got.