Category Archives: Uncategorized

IDS champions mental health reform

We’re all familiar now with the unprecedented powers for change granted to Theresa May under the Great Repeal Act. This is the legal device that will allow her to make ad hoc ‘modifications’ to UK human and civil rights post-Brexit without any need to check with the electorate first. You may think that this is a pretty big responsibility for one person. So does she.

That’s why she’s delegated large areas of work to other senior MPs. One such delegation goes to former tory party leader, Ian Duncan Smith. He’s been given the mammoth task of rewriting mental health legislation now that European ideas of liberty and respect for privacy no longer apply here in UK.

IDS was nominated for this monumental task by human rights champions Michael Gove and Boris Johnson. They were impressed by the “outstanding compassion” Duncan-Smith demonstrated during his time at the Department of Work and Pensions.
“IDS is the only choice for such an important task.” Said a Westminster spokesman yesterday.

“Nobody is more committed to protecting the vulnerable than Ian.”

On learning of IDS’ appointment a group of around 1,500 mental health activists and protestors who had gathered in Parliament Square applauded. 

“That’s just fantastic!” Said organiser, Mark Davis before packing up his tent and joining the rest of the protestors heading for the tube. The activists had gathered to demand a suitable appointment was made. Upon hearing the news about IDS they declared their mission achieved and headed off to Soho for a celebratory pint in a well known Shaftesbury Avenue boozer.

Mr Duncan Smith himself has not been available for comment. He is believed to be burning the midnight oil planning how to extend funding and aftercare entitlements under Section 117 provisions.

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

Player 1 failed: Return to start of level 2016

Game culture seems to have taken over in a really, really big way in 2016. Corporate bosses and government politicians played the year for profit as though they were in Grand theft auto. They even employed the nations WMD to provide Call of Duty action in Syria.

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At home many hitherto ordinary people got into Assassins’ Creed mentality, even dressing up as medieval knights in search of victims.

Some of my generation’s best-loved personalities seem to have invented their own version of ‘Dead pool’ and shuffled off this mortal coil almost to order, so regularly did they drop, fly-like to their graves, leaving our world all the poorer for their passing.

The main theme of level 2016 was destruction. Democracy was hi-jacked by the deceit of the alt-right whose ‘post-truth’ lies really shouldn’t have fooled anyone… but they did. Social harmony, whilst not yet destroyed has certainly taken a few hits from the little-Englanders and nationalist contingent, many of whom seem to think that the 2016 game is really just a re-run of 1941.

We’ve seen death, destruction, Brexit brought us the twin ‘bonus’ points of economic suicide and the greatest threat to human rights in UK since 1948. We’ve suffered increased intolerance and racially and religiously motivated hate crimes together with anti-Muslim propaganda that almost equals the early medieval ‘blood libel’ against European Jews.

But never mind because it’s nearly Christmas and apparently that makes everything alright.

Can’t we return to start and have just one more try at level 2016?

Labelling & prejudice starts early

This video really got to me. Not because little kids can be prejudiced – we all know that children tend to have some very fixed, black and white opinions. That’s the only way that their little heads can make any sort of sense of the nuanced world around them. They make snap decisions based upon very limited information because they have to. We evolved to do that as adults but even more so as kids.

What really pissed me off is the consistency of colour prejudice across different races. Even the black kids were dismissive of blacks and saw whites as somehow better. What are we teaching our children (and by ‘our’ I mean all human children) about themselves and each other?

View this short video here

racism something very wrong children video

It’s true that as they grow these kids will become more subtle in their thinking. They’ll start to understand that the world is more complicated than that and they’ll develop their opinions accordingly. But the early lessons don’t go away – they stick around to influence adult opinions too.

What have we done to these children?

More importantly – are we prepared to change it?

It’s incumbent upon us all to challenge prejudice in all its forms, be that colour, race, nationality, religion, gender, whatever whenever we come across it. Let both adults and children know that it’s neither correct nor fair to judge others or ourselves upon irrelevancies like skin colour.

People are just people – let’s make sure we treat them accordingly!

Duty of care: A slug in a bottle

Donoghue vs StevensonIf there’s one thing that unites almost everyone concerned with health and social care services it’s the fear of being sued. Otherwise rational and courageous workers have been reduced to quivering wrecks at the mere suggestion of litigation or the slightest suggestion that they might have failed in or ‘neglected’ their duty of care.

Duty of care is such a preoccupation for workers that it crops up daily in conversation and in practice whenever we encounter ‘thorny’ issues relating to ‘health and safety’, ‘rights and responsibilities’, ‘freedom of choice’, ‘confidentiality’ and a host of other topics. What all of these conversations have in common is ‘duty of care’.

However not everyone who hears the term understands what it means or indeed where it comes from. This is a shame because as we all know knowledge is power and one way to know about something is to know a bit about its history and development.

Lord Atkin delivered a judgement in the House of Lords on August 26th 1932, thus ending a legal battle that had gone on for four years. The judgement became what is known in UK law as a ‘binding precedent’ because (with the exception of the new Supreme Court) no other UK court has the authority to overrule the principle that comes from it. This is the principle that most Duty of Care decisions are based upon.

What is this principle that was so important it still affects us today? We’ll get to that. First let me tell you the basic facts of the story.

May Donoghue was a shop worker in Paisley, near Glasgow who, one Saturday afternoon went with a friend to buy an ice cream float at Frankie Minghella’s café. As it turned out Mrs. Donoghue didn’t pay, her friend did – and this is significant.

Having finished most of her ice-cream float she discovered the partly decomposed carcass of a slug in the bottom of the bottle that had contained her drink. She was later treated for gastro-entiritis (presumably as a direct result of consuming some of the corpse).

Mrs. Donoghue’s next move was to sue the owner of the café. However the café owner, Mr. Minghella argued that his only duty of care was to the person who bought his goods and since Mrs. Donoghue had not paid herself there was no legal case to answer.

Not to be deterred Mrs. Donoghue turned her attention to Mr. David Stevenson whose company had manufactured and bottled the soft drink in question. The argument was that Mr. Stevenson had a duty of care to the people who used his products in the end – however far removed they may be from his own bottling and production plant.

Lord Atkin’s ruling was that Stevenson was responsible and stated in the ‘Obiter Dicta’ (legal jargon for ‘last words’ that explain the judgement) that we all have a legal responsibility not to injure our neighbour.

“You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour.”

The definition of ‘neighbour’ he used was this:

“persons so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions which are called in question.”

In other words we all have a legal duty, ‘a Duty of Care’ to consider the effects of our actions upon other people who may be affected. In health and social care this basic principle includes following the various rules and legal obligations that surround our work.

In practice it means that:

We all have a duty of care to the ultimate consumer

That’s the principle of this case: Donoghue v Stevenson 1932. However far removed we might be from the face to face ‘frontline’ of clinical practice we all have a duty of care to ensure that our practice is safe and reasonable.

 

The meaning of psychiatric diagnoses

One of the most common concerns among social care workers, at least those I meet is around diagnosis. There are so very many different psychiatric diagnoses, all with their own particular symptoms and they seem almost impossible to remember.

I can sympathise with that view – there really are a lot of diagnoses and the differences between them sometimes seem so very subtle that it’s hardly worth mentioning at all. However – that doesn’t need to be such a problem in social care.

Support workers aren’t diagnosticians and they don’t need to be able to fit everyone they work with into the particular boxes of psychiatric diagnosis. It’s enough to know what the service-user’s actual problems are without worrying about pigeon holing them. After all – there really is much more to life than diagnosis.

So here’s a breakdown of what really matters in psychiatric diagnosis.

Diagnosis meaning and purpose

The word ‘diagnosis’ comes from Greek. It’s made up of two words:

  1. Dia – through
  2. Gnosis – knowledge

Diagnosis means ‘through knowledge’ and yet we know much less than we’d like to for sure. In fact there are those who argue that diagnosis is little better than useless in mental health care and should be replaced by a different system known as ‘formulation’ instead. This is because whereas diagnosis seeks to place sufferers and their conditions into predefined ‘boxes’, formulation seeks to construct a new explanation for each individual regardless of the experiences of other people and the ‘boxes’ they may have occupied in the past.

Perhaps the biggest criticism of diagnosis in mental health care is based upon the established purpose of diagnosis. It is intended to:

  1. Predict outcome (prognosis);
  2. Inform treatment.

In the case of diseases like Alzheimer’s dementia or Parkinson’s disease diagnosis can (to a greater or lesser extent) fulfil both of these promises. In the case of ‘Schizophrenia’ or ‘Brief Psychotic Episode’ it seems far less effective and in the opinion of many far less plausible too.

It’s important to be clear about what this means in practice. There’s a set order (a syntax) to psychiatric diagnosis and it really only works in one direction. This is different from many other sorts of diagnosis, the diagnosis of physical illness for example. That’s because whereas physical illnesses tend to be diagnosed ‘through knowledge’ of measurable physical processes with very specific, known (or at least likely) and predictable specific effects, psychiatric diagnoses tend to be based upon ‘clinical judgement’ with little or no physical tests available to support them.

Psychiatrists don’t rely upon measurable evidence to support their diagnosis and so they can’t really say for sure that one symptom will follow another. For example…

The physical diagnosis of COPD (Chronic Obstructive Pulmonary Disease) is diagnosed using specific tests that show that a person’s lung function is impaired. The inevitable result of significantly impaired lung function is breathlessness when exercising. So, because of this measurable condition and the inevitability of breathlessness we can reasonably say…

“Of course John gets breathless – he has COPD”

We can say this because we have excellent evidence of impaired lung function and because we know what happens to respiration when people with COPD exert themselves. We have good, testable information about the causes ranging from oxygen saturation levels in the blood to peak flow measurements of respiration itself to name but two. We know exactly what we’re looking at in other words.

Psychiatric diagnosis is different. It isn’t usually based upon blood tests or sophisticated scans. Instead the psychiatrist takes a history, observes the current ‘presentation’ of the patient and then makes a diagnosis based upon how closely the person’s ‘symptoms’ match the descriptions in the psychiatric diagnostic manual.

This means that diagnosis only shows what ‘symptoms’ are already apparent – it can’t predict other symptoms that aren’t already there. This means that we can only say something like:

“John has a diagnosis of schizophrenia because he has visions.”

We cannot say:

“Of course John has visions. He has a diagnosis of schizophrenia.”

Not everyone diagnosed with schizophrenia has visions. So the symptoms might explain the diagnosis but the diagnosis can’t explain the symptoms. It’s just a name, a label and names don’t explain things – they simply classify them.

For example, on my office wall I have a large clock. I know it is a clock because it has the observable characteristics of a clock (hands that rotate, a numbered face and it ticks). However naming it as a ‘clock’ doesn’t tell me anything about how it works. I am no closer to understanding the intricate mechanisms of the various cogs and springs inside the clock just because I know what to call it.

Many psychiatric diagnoses are just like that. We don’t get any closer to understanding the workings of schizophrenia just because we can name it. That’s why we must be careful to let symptoms explain the diagnosis but not to delude ourselves into thinking that the diagnosis explains the symptom.

Syntax of psych diagnosis

Generally speaking we can only go one way with psychiatric diagnosis. It doesn’t usually work well ‘in reverse’.

The symptoms explain the diagnosis

The diagnosis does not explain the symptoms

But diagnosis isn’t entirely useless. My own view is that it is too reductionist. Diagnostic psychiatry reduces people to component parts to be ‘fixed’ rather like a mechanic working on an engine. Diagnosis has its place although, like many other people working in mental health services, I’d welcome a more widespread use of psychological formulation alongside the ‘boxes’ of traditional psychiatric practice.

5 types of mental disorder

In the simplest terms mental disorder is really only a combination of three types of symptom:

  • Anxiety – physical and psychological arousal
  • Depression – physical and psychological de-arousal
  • Psychosis – hallucinations, delusions and thought disorders

All mental disorders (except the dementias which also include memory and orientation problems) are made up of combinations of these three types of experience or people’s vulnerability to them.

Personality disorders are diagnoses based upon the way people usually think and behave and upon their susceptibility to anxiety, depression and psychosis. Remember that those personality disorders that are categorised by anger are really anxiety based. Both anger and anxiety (as we shall see later) are products of the same ‘freeze, flight or fight’ response. The only difference is in the way we think about the situation but in biomedical (physiological) terms the bodily processes are identical.

 

Privileged glimpses 24: The clinician’s illusion

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 clinician’s illusion sounds as though it would only apply to clinical, therapeutic situations but that’s not the case at all. This is one of the most widespread examples of faulty thinking and we are all susceptible to it. Essentially it’s one of several logical errors that are based upon the false idea that ‘my experience is all there is’.

There are very good reasons why human beings are so vulnerable to the clinician’s illusion. Many would argue that it’s inevitable because we base our judgements upon our experience of the world. In evolutionary terms that’s one of the main reasons why our species has survived at all. This is probably as ‘hard-wired’ into consciousness as any human trait could ever be. We all learn from experience.

Unfortunately that experience can be misleading as we shall see.

To make sense of the clinician’s illusion I want to tell you a little about my own experience as a mental health nurse on acute psychiatric wards. Then, having made the point we’ll widen the scope a little to show how the clinician’s illusion is both applicable to all of us. We’ll also show how our vulnerability to it is used by cynical persuaders from private citizens to politicians who manipulate our understanding to gain agreement or endorsement of their views.

When I worked on the wards my colleagues and used a familiar expression – a cliche if you will. It went like this:

“We don’t have much money but we do see life.”

It was, as much as anything a relatively light-hearted way to acknowledge amongst ourselves that sometimes we witnessed and were involved in situations that were distressing, unpleasant and occasionally harmful. What we saw on a fairly routine basis had the potential to cause very real psychological trauma in its own right and I have known many mental health nurses who have been unable to bear its weight. The use of clichés such as this is more than just a way to acknowledge that ‘shit happens’ – it’s also a way to demonstrate mutual awareness and support. Like the ‘gallows humour’ so often heard on ward nights out (and so often criticised by the uninitiated) it’s part of an arsenal of psychological defence mechanisms that nurses at the front line employ to keep themselves sane.

But there’s a major problem with this. It’s not true. Well – the not having much money part might be but not the rest. Acute nurses do not see life – at least they don’t see very much of life. They see the worst of life but not the best.

By definition patients in acute psychiatric wards are distressed and they are not coping well. If they were then they’d be somewhere else getting on with their lives. Acute nurses meet people at their most unwell – and only at their most unwell. And many of them return repeatedly to the wards as their mental health breaks down.

Our experience then, as ward based nurses was that everyone with a diagnosis of serious and enduring mental disorder comes back to us sooner or later. We see them come back every working day and that experience of working with relapsing patients is what we used to form our opinions. That’s why, when I was an acute nurse I didn’t believe in recovery from mental disorders such as schizophrenia. I had no experience of it. Everybody I met at work had relapsed (or I expected that they would one day based upon my past experience of other people).

But not everyone comes back.

According to the Royal College of Psychiatrists own figures only about a third of people diagnosed with schizophrenia experience lifelong deterioration and another third (give or take) get beyond their problems altogether. We didn’t see those people on the wards because they never needed us again. We only saw the people who did relapse.

Not everybody relapses

The clinician’s illusion is the illusion that comes from limited experience. Clinicians see ill people and so they come to believe that everybody is ill – or at least likely to become so.

The clinician’s illusion is what happens when we place too much weight upon our own limited experience and ignore the wider experience of others. It’s the fatal flaw that underlies the statement so beloved of many that..

“I speak as I find”

It’s laudable, of course to learn from our own experience but not to the exclusion of everything else. If we really want to make sense of the world we need to be prepared to look beyond our own experience and take account of the experiences of others.

Oscar Wilde once remarked that only a fool learns from his experience. The wise man learns from the experience of other people. Perhaps Wilde would have called the Clinician’s illusion the ‘fool’s illusion’ for precisely that reason.

But it’s not enough just to say ‘learn from everyone’. It’s necessary to have some means of judging the reported experiences of others too – otherwise we’re open to all sorts of abuses and misrepresentations. My own view is that ‘evidence is the thing’.

Don’t worry too much about anecdote – that can be misleading. Follow the evidence. Otherwise we end up making just as many mistakes.

For example there is a narrative in UK about people with disabilities and those who need to rely upon state benefits to survive. The narrative is that disabled people are workshy scroungers and that honest hard-working people should not be asked to support them. This narrative has proven to be very persuasive and many people (largely those who do not work with disabled people) believe it. Let’s look at why..

Ever since the ConDem government came into power back in 2010 UK citizens have repeatedly been told that benefits claimants are predominantly abusing the system. Government ministers have repeatedly made that claim and the real evidence about claimants and their circumstances has repeatedly been suppressed.

Right wing media articles repeatedly publish stories about people ‘swinging the lead’ and even ‘fly on the wall’ television shows present benefits cheats to the nation on a very regular basis. For the majority of people (who don’t regularly come into contact with severely disabled citizens) this constant procession of fraudsters becomes the only experience they have of disabled benefits claimants. And cynical politicians know this all too well.

So the clinician’s illusion (my experience is all there is) means that the population is easily swayed by arguments about benefits fraudsters because they believe that it’s a real problem when in fact official figures (the evidence from a range of experiences) show that only a tiny proportion of claimants are ‘swinging the lead’. But that’s not what our political leaders want us to believe. So that’s not what we are shown.

Unless we become alert to the notion of the clinician’s illusion in our own lives we will remain susceptible to persuasion by any Tom, Dick or Harry who wants to manipulate our opinions for their own cynical ends.

For example, if your only experience of someone you meet is what they tell you about themselves it pays to look a little deeper before you jump in and support their endeavours. You might just be being played.

I’ll end with another cliche.

“Self praise is no recommendation”

Privileged glimpses 20: Do we need help?

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 we need help?

Let’s look at two other ‘categories’ of challenging behaviour:

  • Behaviours that we can cope with;
  • Behaviours that are beyond our ability or authority.

Behaviours that we can cope with

These are behaviours that fall within our own skill set and area of expertise. For example a care home resident refusing to bathe from time to time. It is well within the authority of the staff to decide how best to handle it. However, if the refusal is accompanied by signs of depression or dementia for example then the larger multi-disciplinary team may well need to be involved.

For example, I remember working with a young drug-user who simply stopped going to bed. Instead he would sleep in the communal lounge on the settee. Speaking with him (not ‘to’ him, by the way) seemed to make him more determined to sleep in the lounge, even though the settee was too short and uncomfortable. So we decided simply to stop mentioning it.

We provided an alternative area for other service-users and ignored the fact that he was sleeping in the communal lounge altogether. We didn’t even mention it when he started to complain of back pain. We simply suggested that he might want to see his GP about pain relief. He didn’t make the appointment but he did stop sleeping on the settee.

The decision to stand back and wait for him to learn ‘the lesson of experience’ was ours to make and the situation was remarkably easy to resolve. Often ‘the path of least resistance’ really is the way to deal with things that are within our remit to solve.

Behaviours that are beyond our ability or authority to cope with

When I was a community psychiatric nurse I had a client who regularly called me reporting that she’d taken an overdose and asking for an ambulance. Actually I’ve had several clients who did that over the years.

The more I responded the more frequently she called. She didn’t always tell the truth (sometimes she had overdosed and sometimes she hadn’t) but I had no way to know in advance.

I wanted to stop responding to these situations because by reacting to the phone calls I was only making things worse. However, I needed the support of the multi-disciplinary team first. So I called a meeting involving all the relevant workers, the service-user herself and (with permission) her brother was also present

We decided upon a new care plan. Essentially we all agreed (including the service-user) that if she was able to call me she was also able to call an ambulance if that was what she needed. We therefore agreed that I would expect her to do precisely that in the future. If she called me reporting an overdose I would advise her to call an ambulance and remind her of our scheduled appointment time (which may be some time in the future).

The behaviour stopped working for her and she stopped. She called in these circumstances only twice more before changing tack and talking about her real problems instead. I’m not going to pretend that the problem she presented next was easy to resolve by any means but at least we got to focus upon the thing that mattered instead of a haze of challenging behaviours that served only to distract us both from the real work we had before us.

The point here is that although I ended up doing precisely what I thought was right I needed the backing of the multi-disciplinary team first. Their ‘blessing’ was important.

Sometimes we need others to get involved when we discuss what we need to do about a situation. There’s no problem with that – it’s just appropriate.

Incidentally this doesn’t mean that the decision not to respond to my overdosing service-user was a ‘team decision’. It was always my decision how to respond when I picked up the ‘phone (and I could have changed my mind had circumstances demanded it). Team meetings don’t take away our responsibility for our own decisions – if you’re ‘on the spot’ you decide what to do – but they do make those decisions easier to defend if we need to. My decision was safer because I had discussed the situation with the team and they had agreed with my strategy.

Had I not discussed the situation with the multi-disciplinary team and my client really had overdosed I’d have had a hard time explaining my actions to the ensuing inquiry. As it was – had she come to grief (she didn’t but she might have) I’d have been able to defend my decision precisely because of the involvement of the team.

Privileged glimpses 15: A duty of care myth

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.

Many people are confused about the exact nature of their Duty of Care toward the people they look after. To a large extent this is because they think that they are somehow accountable for the actions of other people (in this case the client or service-user).

This gives people the sense that they are:

Hanged if they do and Hanged if they don’t

In reality, you are responsible only for what you do – not for what your client does. If you do all that you can within the law to minimise risk, to help them to make decisions in their best interests and to help the client to cope more effectively then you have fulfilled your duty of care. This is true whatever the outcome might be.

  • You are not responsible for someone else’s behaviour.
  • You are responsible for your own behaviour in the situation in which you find yourself (including acting to keep others safe when necessary).
  • You are not expected to take away people’s rights to choose if they are able to.
  • Care workers are judged upon process – not upon outcome.

 

Do all that you reasonably can within the law.