Category Archives: challenging behaviour

Expectation

Care workers need to learn from past experiences.
The best predictor of future behaviour is past behaviour.
But the people we work with can change too.
The whole point of much of our work is to help them to change.
How can we balance past behaviours and future potential?
How do we promote change without becoming naive and vulnerable?

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An interview with Freya Smith

Freya Smith is a carer and youth worker. She’s fluent in British sign language and sees all of life as an opportunity for compassion and for helping those in need.
 
Click the link to see Freya interviewed about her experiences working with homeless children on the streets of Cardiff.
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Click the image to play the video
Freya’s enthusiasm is infectious. Her no-nonsense philosophy is practical and effective. To hear her speak about her work with some of the most disadvantaged children in the UK is to catch a small glimpse of what can be possible when we really engage with the task at hand.

Personality disorder and compassion

Sometimes a single day’s training makes all the difference. You can access such a training day here.

Personality disorder training meme MTCTWatch a video on Personality Disorder below

Complete the contact form below to arrange training for your staff.

Mental health training – a short sample

This abridged, edited audio (& video slideshow) is taken from the introductory session of a 2012 mental health training day in Glasgow. Although not all of the session is included it gives a flavour of the day, the topics to be considered, the training aims and the insights to be expected throughout the day.

You can find a longer version (26 minutes) by clicking below…

Training courses

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Should psychiatrists diagnose personality disorder?

Personality disorder is a controversial diagnosis. There are no blood tests or physical criteria confirming personality disorder. In fact there’s no real evidence to suggest that personality disorder is a medical condition at all. So why do psychiatrists diagnose personality disorder? More importantly… should they?

Here we consider the roots of personality disorder diagnoses from the Moral defective of a century ago to the 3 personality disorder clusters of today. We look at the way personality disorder is diagnosed through behaviours, emotions and enduring patterns of response to society and we consider the advantages of understanding a person’s personality traits. Knowledge is power.

The more we know the more likely we are to be able to help. But we must be careful. Too often the diagnosis of personality disorder is used as an excuse to write a person off as incurable, hopeless or even undeserving. That’s the legacy we’ve been left by our Edwardian and Victorian predecessors.

If we are to do right by the personality disordered patients of today and in the future we need to embrace the understanding this diagnosis can bring but reject the pejorative notions of undeservingness, incurability and hopelesness that all too often come along with it.

To arrange training for your staff please complete the contact form below…

Social and mental health care training

I’ve been getting a lot of new inquiries lately, which is wonderful. It seems that training budgets are becoming available to the small specialist trainers again without organisations having to rely upon the off-the-shelf generalists on their ‘pre-approved supplier lists’. There are many courses that only a specialist clinician can provide. Click below to download the Mind The Care brochure…

170429 Mind The Care brochure.

That’s great news for the little man like me. It means I can get to more organisations and train more staff from the perspective of the expert practitioner. Learning from someone who actually does the job is always better than listening to a training executive with a script.

So I thought I’d put a little post up for those organisations who haven’t experienced my training yet (and it is an experience), outlining my most popular courses and seminar topics and inviting them to get make contact. Just click here and I’ll be in touch to design the exact training or speaking programme you need to help you look after and get the best out of your care team.

Click here 170429 Mind The Care brochure to download Mind the care’s most recent brochure.

courses-meme

14 key points to manage self-harm

Self harm and suicide ladder memeDo you find it difficult to deal with people who self-harm. Are your staff at a loss to know how best to respond? Download our free PDF today.

self harm in social care 14 key points

While you’re about it – why not subscribe to the site too? That way you need never miss an article or an offer from Mind The Care. It’ll all be sent by Email straight to your inbox.

Go on – you know you want to!

 

 

Privileged glimpses 23: “It’s just behavioural”

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.

Privileged glimpses 22: The whole team approach

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 whole team approach

I have mentioned several times throughout this series of posts the importance of consistency throughout the whole team. There are several reasons for this:

  • Clear boundaries;
  • No ‘pedestals’ & staff safety;
  • Effective, consistent care;
  • If you can’t stop the person behaving poorly you can at least stop them doing it to you;
  • Corporate identity – “you’re all the same”.

As we consider these reasons we will also be outlining the argument that staff who are too ‘permissive’ when faced with genuinely unacceptable behaviour are actually counter-productive. They do their clients no favours.

It is my belief, however hard or unpopular it may be, that such workers should have no place in health and social care. The outcome of such poor boundaries can be tragic and yet it is all too common for workers to forego their responsibilities in practice.

Health and social care workers need to develop the strength of character necessary to maintain consistent boundaries. They need both peer and management support to do so. We ask a great deal from staff who are faced with challenging behaviour and we owe it to them to offer sufficient support as well.

It has become trendy to talk about social care settings as though they are democracies but this is a misrepresentation. It’s true that we should always have an eye on the rights of service-users but this doesn’t mean that organisations should abandon control of their systems. We need to maintain firm boundaries.

Firm Boundaries

Ask any parent what happens when adults who share responsibility for a child have different boundaries and rules. Ask any worker how they react when they have to work with two or more managers (perhaps on a rotating shift pattern) who have different approaches. Think about your own reaction to varying and conflicting sets of rules.

Now think about the different ways that your colleagues approach ‘problem behaviours’ at work. In every case you’ll find that different colleagues face different types of behaviours’ based upon their particular responses to them. It’s cause and effect.

If you do the same things, you get the same results.

If our job is to help people move beyond their behaviours’ and the need for our services then we must ensure that the experiences we give them are both appropriate and consistent. This means a whole team approach.

No ‘Pedestals’ and Staff Safety

A common problem with inconsistent care is the divided perception of workers it creates. Staff who don’t ‘toe the party line’ as it were typically appear to the service-users as more compassionate. They also tend to appear weak because they are easily manipulated but that’s not the issue for the moment. They appear compassionate.

By contrast other staff who do their jobs properly are seen to be less compassionate when compared with the weaker staff member. This can breed resentment toward the more professionally minded workers and even put them at risk of assault or malicious allegations. In the end neither staff member comes out well and the service user’s care becomes inconsistent too. Everybody loses when staff try to put themselves on a pedestal of compassion.

The other big problem is that if you climb on to a pedestal you also gave to keep it clean. If you acquire a reputation for being a ‘soft touch’ the negative or potentially explosive reaction you get when you do eventually stand firm will be far worse as a result.

Effective, Consistent Care

The point about effective and consistent care has already been made and does not need much restatement here. However it is, of course a major reason for ensuring a whole team approach.

If You Can’t Stop The Person Behaving Poorly, You Can At Least Stop Them Doing It To You

Health and social care workers are not supposed to be able to save the world. Some service users behave poorly for reasons that are way beyond our influence or control. For example we will not necessarily stop a grown man being violent if he learned to be so in the schoolyard 30 years earlier and has lived that way ever since.

However, clear and consistent boundaries will go a long way to ensuring that they behave differently toward you and your colleagues.

Contrary to popular belief people aren’t ‘just violent’ or ‘just rude’ or ‘just’ anything. Human behaviours’ are the result of complex equations involving costs and benefits, social norms, consequences and degrees of acceptability.

Think about the people you know who are offensive but hide their insults through humour. Did you ever ask yourself why they do that?

Usually this sort of behaviour (one of several forms of passive-aggression) is only there because outright aggression and hostility isn’t worth the price. Either the group norms forbid open hostility or the victim of their venom is just too scary. So they hide behind humour instead.

There’s a valuable lesson there. People tend not to behave in ways that are too dangerous to them. Clear boundaries will make it too dangerous for potential abusers to aim their abuses at you. That won’t stop them from behaving badly toward others but that’s not within your control. We have a legal system (or if appropriate a mental health act) for that.

‘Corporate’ Identity – “You’re All The Same.”

Every worker has experienced blame for the actions of a colleague. We’ve all found ourselves faced with an angry service user or relative because of some other worker’s actions. That’s because in the eyes of many of the people we work with we really are all the same. The wrongs they perceive from one of us might as well have been perpetrated by any of us.

So a good, firm team agrees standards of behaviour and everyone sticks to them. That way we all know what to do, what to expect and how to deal with the inevitable conflicts that our work involves.

Or you could make your work harder and less effective if you prefer.

Remember…….

If you do the same things, you get the same results

 

Privileged glimpses 21: Consequences, learned behaviour and boundaries

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.

Imagine yourself transported without warning to a completely dark space. You can hear nothing, there are no significant smells, you have no light to see by and there isn’t even a breeze. You have no idea where you are or how you came to be there. What will you do?

When I ask this question in training sessions people generally answer by telling me first how they might feel but that’s not the question. What will you actually do?

Most people say that they’d stretch out their arms and walk forward gingerly in one direction until they find something in their path. This will give them the beginnings of a sense of their environment. If they’re lucky they’ll find a wall – a boundary.

Once they have the boundary they will feel their way around the space until they either get a sense of the size of the place they occupy or maybe even find something really useful like a door.

The interesting thing is that most people report that this would go some way toward alleviating any anxiety they might feel. The more they can understand the limits of their environment the safer they feel. It doesn’t necessarily mean that they will be happy in their new surroundings (although if they find a light switch they might become so) but the more we understand our boundaries the more confident we feel.

This is generally recognised as the reason that children and adolescents rebel – they ‘push the boundaries’, not because they want to break them but because they want to understand them. This is why children from families with poorly defined boundaries are generally less happy and less confident than those who know their limits clearly and without variation.

In fact there is a very strong argument that in order to feel safe and protected by their parents or other caregivers young people need to know first and foremost that the carer can control them. After all if the parent can’t control the child then they can’t be any better at defending against threats either. In short – boundaries allow children to feel secure and also to feel confident enough to concentrate on the massive task of growing up that lies before them.

Clearly the task of health and social care workers is not generally to control the people they work with but none the less there are real similarities between the boundaries that children need and the limits and boundaries that adults need – whether they’re receiving care services or not. Think about the boundaries that are imposed upon you in your working life.

You have shift patterns to stick to and certain tasks to perform. There are shared values that health and social care workers must stick to and there are some very real limits to acceptable behaviour. The clearer these limits and expectations are the happier the workforce is. The same is true for people who receive our services.

If you don’t know what the boss expects you will try to find out. If that means pushing the limits a little to see what happens then so be it – at least you’ll know afterwards and it’s worth a minor rebuke to get the lie of the land. Think how difficult it would be to concentrate on your job if you were forever wondering how far you could go before you faced disciplinary action. We all need to know the boundaries.

If this is true for us it is equally true for the people we work with. How anxiety provoking would it be for a service-user to have to guess what was and was not acceptable? How confident would they be if they didn’t know what would and would not result in eviction from their home for example? How much time could they spend working on their problems if they first had to try to establish the boundaries of their situation?

Sometimes workers think that it is somehow cruel or unprofessional to lay down boundaries for their service-users. They see it as treating them like children without ever realising that all adults, including the workers themselves, need boundaries too. Whether those boundaries are formal or informal, civil or criminal, social or procedural we all need boundaries.

To deprive a person of boundaries is to leave them, clueless as to what sorts of behaviour would be acceptable or unacceptable. Now that’s really cruel.

So what do we mean by boundaries? Well first of all we mean clearly and consistently outlining what is acceptable and what is not. It also means respecting the person enough to understand that sometimes they will push those boundaries just to see how firm they are – this is no different from what we all did as children – and what we all continue to do as adults. We also need to understand that they are grown up enough to accept the consequences of their actions.

Actions have consequences and we do our service-users no favours

by pretending that they can behave inappropriately without facing them.

What they need is the security of knowing that the boundaries are firm enough to withstand the odd bit of testing and the awareness that we as workers are strong enough individually to apply them. If we fail to do this we lose respect. After all our service-users are just as capable of recognising weakness as we are. We also do something else….

When we fail to uphold a boundary we leave the other person with a dilemma. They won’t know where the limit really is – that means they will have to push harder until they find it. Their poor behaviour escalates, not simply because of their own ‘challengingness’ but equally because of our inconsistency. We leave the other person no choice but to push and push until eventually they go so far that we have to act and usually this means major consequences that could have been avoided much earlier if we’d only had the confidence to act sooner.

By contrast, if we uphold the behavioural boundaries we set – if we stick to the ideas we have set about acceptable standards of behaviour then the person can relax – they know what the rules are and so they can stop worrying about them. This means they can get on with the task of working on whatever problems they have.

We also demonstrate our own emotional strength and integrity – itself a vital component of effective therapeutic relationships.

So the next time you consider ignoring unacceptable behaviour because you ‘understand what they’re going through’ or simply because you lack the confidence to deal with it spare a thought for the behavioural effect of your decision.

People who avoid their responsibilities to obtain ‘an easy life’ rarely get it. On the contrary – that way chaos lies.

If you do the same things you get the same results

Maintaining the problem

Most people are surprised to learn that they maintain (and often actually create) the problems they face. Often people will work hard to resist this idea and that can be difficult to overcome but it’s worth the effort. Until people understand their own role in maintaining their difficulties they cannot really take responsibility for solving them. After all – if you don’t think you’re a part of the problem you won’t think that you need to change your behaviour to change it.

This is why it’s often useful to chart a person’s reactions to their difficulties with them. At each stage ask the person what they could have done differently and what might have changed for them if they had? The point here is not to blame the person or accuse them of creating their own problems – it’s simply to get them to tell us how they might react differently in the future and begin to find a way out of their problems instead of making them worse. So we ask what might be different instead of trying to tell someone what we think. It’s always much more effective if the client or service-user tells us the answer rather than the other way around.

This can form the basis of a support plan or other strategy that the person can use to change their situation for the better.