Tag Archives: abuse

Stoicism: No surprises!

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“Begin the morning by saying to thyself, I shall meet with the busy-body, the ungrateful, arrogant, deceitful, devious, unsocial. All these things happen to them by reason of their ignorance of what is good and evil.”

Meditations (Marcus Aurelius) Book 2

I’ve used this quote before but it’s a good one so I’m returning to it. In these few words you’ll find the essence of what we mean by ‘No surprises’.

It doesn’t mean ‘No changes’ – that really would be dull.

Nor does it mean control everything so you know what’s coming – that would be both impossible and (even if it were possible) entirely counter-productive.

Rather it means that we can understand the nature of the world and of the people who inhabit it. Understand that people are fickle, that misfortune is a very regular occurrence and that we do not need to be surprised by the things we have foreknowledge of.

We may not know precisely who will treat us poorly today, tomorrow or indeed on any other day but we know that someone will – and that’s enough. We also know the ways in which we may be mistreated, at least in general terms and so we can prepare for them ‘thematically’.

We know that misfortune comes in themes. That there are groups of issues that share the same characteristics and we can prepare ourselves to deal with, to cope with these characteristic annoyances in advance.

Self-harm parents

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It’s unfair and inaccurate to pretend that all parents of people who harm themselves are to blame. There are parents who treat their children in horrendous ways and who really do cause long term mental health problems. But they are not the norm.
Most parents, although fallible like everyone else, are ‘good enough’.

Stoicism 4: My ponytail is ridiculous!

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Here we build upon two earlier principles. Epictetus made it clear that we can only control our own thoughts, feelings and behaviours – not those of other people.

Marcus Aurelius taught us the 2 point maxim for dealing with abusive people…
1. Be the best me that I can be;
2. Be grateful that I’m not them.

Here we add another perspective from Seneca. Anger is only possible when the world doesn’t meet our expectations. If we adjust our expectations to reality the petty insults of others won’t hurt us at all.

In this, fourth Stoicism video we begin to show how it’s possible to layer Stoic wisdom, one point upon another to create a robust system of thought and attitude that really does defend us against those who seek to hurt, upset, anger or distress us.

 

Stoicism for mental health 3: Abusive people

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Stoic philosophers Marcus Aurelius and Epictetus help us to cope with abusive, contemptuous, disrespectful and mean-spirited people by remembering the distinction between what is ours to control and what is theirs. When others treat us badly their actions say more about them and their lack of understanding than about us. In truth, their behaviour has no bearing at all upon us. It’s entirely about them.

Marcus Aurelius’ 2 point maxim helps us to deal graciously with these people without becoming upset or being tempted to sink to their level. They take responsibility for their poor actions – we have a different standard of behaviour to maintain.

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Human rights in the UK?

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Everyone should read and understand this. We need the Human Rights Act and the European Convention on Human Rights. Without them this vicious tory government realky will be able to treat us all like expendable cattle.

https://kittysjones.wordpress.com/2014/08/16/uk-becomes-the-first-country-to-face-a-un-inquiry-into-disability-rights-violations/

We are more than just working stock for the moneyed establishment.
Those who cannot work are more than just burdens – they are people.

Don’t be fooled. Human Rights laws are there for a reason. We cannot afford to lose our HR protections.

Privileged glimpses 25: Who put us in charge?

law, Mental Capacity Act, mental health, mental health act, social care, , , , , , , , , , , , , ,

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 first of the Mental Capacity Act’s underlying principles is:

An assumption of capacity

This means that we need to begin by assuming that everyone we meet is capable of making this particular decision at this particular time unless we have reason to suspect otherwise. In other words that person is ‘Most people’ in relation to the ‘three types of legal status’ table below:

Three types of legal status

Most people

Make their own decision

 Bournewood gap

Follow Mental Capacity Act 2005

 Mental Health Act

Follow Mental Health Act 1983/2007
People whose capacity to make the decision is not in doubt People who are not detained under the MHA but who lack the capacity to decide People who (because of a mental disorder) are deemed to present a risk to self, risk to other or are at risk through self-neglect.

This might seem very obvious and reasonable (in fact it is) but it doesn’t sit too well with common practice in a number of care environments. Let’s look at an example.

When I was still a young man I worked as a care assistant in a Learning disabilities residential home. Looking back I can see a number of problems with the way the home was run but at the time, having come into a system that was already established, I thought that this was how learning disabilities establishments were supposed to operate. I didn’t know any better.

One of the fundamental mistakes I used to make related to the residents’ ability to make choices. This mistake covered all sorts of decisions from what to watch on the TV to whether or not they wanted to come on group outings to the local swimming pool.

The house was set in its own grounds in a beautiful part of Lincolnshire and the lawn and garden were nothing short of stunning. The home employed a full time groundsman to keep everything in good order and he did an excellent job. Consequently, many of the residents used to enjoy spending time sitting under the trees in the grounds or walking around the landscaped garden.

However this wasn’t always possible. You see, along with all the other staff there, I would take it upon myself to stop residents at the door and expect them to explain to me why they were safe to go outside. If I wasn’t completely satisfied then I would prevent them from doing so – this wasn’t difficult because the doors were always locked and only the staff had keys. Only if I was happy for them to leave would I let them go outside.

The problem was that this was the wrong way around. I emphasised the word let in bold for good reason. You see it wasn’t up to me to let people do anything.

We use the word ‘let’ a great deal in health and social care but that implies an authority we do not usually have. I can only let a person do something if I have the legal power to prevent them – and usually I don’t.

It wasn’t up to me to let people go outside into their own garden. They went because they had a right to and unless I had good reason to interfere with that they didn’t need my permission at all.

A more recent illustration of this comes from the N. Cornwall Learning Disabilities Partnership NHS Trust inquiry that took place in 2006. There were 40 referrals to the POVA list (now the vetting and barring list) and many of them were to do with staff preventing people from using areas that they had a right to without good reason.

Whenever we are tempted to take control of other peoples’ choices it’s useful to begin by asking ourselves:

“Who put me in charge?”

Unless you can demonstrate that the individual lacks the capacity to make this particular decision at this particular time then nobody put you in charge. The person has a legal right to make their choices whether we like it or not.

Even if the person lacks capacity (in which case you may very well be ‘in charge’) you will still need to act in their best interests and that doesn’t automatically mean doing what is best for the staff or for the relatives.

People have the right to occupy their own space, to make decisions about when they get up or go to bed, to choose who they spend time with and whether or not to involve themselves in activities. They also have the right to disagree with us and to ignore the preferences of family members just as you have. Your relatives have no right to tell you what to do (assuming you’re an adult) and the same is true for your service-user with capacity.

Who put us in charge?

Privileged glimpses 23: “It’s just behavioural”

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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 21: Consequences, learned behaviour and boundaries

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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.

Privileged glimpses 7: What people say

challenging behaviour, law, mental health, social care, , , , , ,

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

mental health, social care, , , , , ,

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.