Tag Archives: cause and effect

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