Tag Archives: nurse

The ‘family tree’ of mental health exercise

This is a simple exercise intended to be completed either individually or preferably by a group (up to around 16 people) in discussion. The idea is to help care workers to overcome the perception that mental health is difficult to understand by asking them to arrange these 21 cards as they think they should go. Click the link below to download the PDF…

Mental disorders family tree exercise

Give them the blanked out key to work from as though it’s a jigsaw with the key taking the place of the picture on the box. 

mh family tree diagnosis symptoms exercise training

Most groups are able to do this correctly without any help at all – just by process of elimination, the application of the things they already know and the clues they can glean from the key (length of blacked out words, number of items in each column etc). I’ve done this little exercise with countless groups and only rarely do they need any assistance. Those few groups that have needed help didn’t need much. 

The advantage of this exercise is that it works as a warm up, it gets participants talking early on and it boosts their confidence. It also provides the participants with a rough and ready mental schema to hang the rest of the day’s training on to. 

Follow it up with a discussion about the fact that, whilst mental health work might seem very complicated, at its most basic level it’s really just about these categories and symptom groups. There is, of course much more to learn but this little overview really is a damn good start!

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

The fight continues

I’ve neglected my blog over the past few weeks and months. It’s easy to be distracted by other things as life’s hectic pace continues unabated. But this week I’ve seen things, some positive and some not so good, that inevitably have brought my attention back to my roots and the reasons why I got into mental health care in the first place.

I didn’t always want to be a nurse. As a young man my dream was to act. I planned to tread the boards throughout the world to the delight of my adoring fans. Unfortunately for me the world had other ideas.

By my early twenties I found myself unemployed and homeless. I’d taken the advice of Thatcher’s government to ‘get on my bike’ in search of work. I didn’t have a bike so I hitchhiked instead, seeking my fortune in a country where working-class lads like me could never do well. There’d be no pot of gold at the end of Thatcher’s rainbow no matter how hard I searched.

Those weren’t the happiest times in my life but they may well have been the most instrumental. During those days I met some extremely troubled people. I became pretty ‘troubled’ myself for a while. I learned to let go of social prejudice as the most unlikely of my associates showed immense kindness whilst those my society had always taught me to respect displayed a callousness and indifference that seemed almost beyond belief. I made some good friends and I learned a lot about human frailty.

Lincoln YMCANo single incident made me decide to become a mental health nurse but there are a few ‘front-runners’. One or two of the people I met in hostels left a permanent impression upon me. Several of my old friends from those days are dead, long before their time because of a lifestyle that was more about drug-induced psychological ‘anaesthesia’ than anything else. And I saw a woman jump to her death from a multi-storey car park not far from my accommodation in Lincoln YMCA.

I was the first to reach her. She whimpered softly as I knelt beside her, shouting to the office workers in the building across the road to call an ambulance but it was no good. She died in Lincoln hospital a little while later. I felt helpless and I felt ashamed.

It seemed clear to me that my society had driven her to this drastic course of action. I didn’t know her story. I still don’t. Looking back I have no idea what led her to this tragic decision but at the time it all seemed so clear. Society was indifferent to suffering and I wanted to do something to change all that.

In those days I was misguided, I was overly-simplistic, I was unrealistically ideological and I had a ‘saviour fantasy’. I thought I could make everything alright for everyone I ever met just by being me. I was heading for burnout before my mental health career had even begun.

These days I have a more seasoned view of what I do. Twenty-one years as a qualified mental health nurse will do that for you. I’m only one man and I’m not all-powerful. I can’t change everything… but I can help.

The paternalism of my early career has gone now. I no longer see my role as the all-knowing saviour come to ‘bless’ the patient with my charitable assistance. Now I’m a fellow traveller trying to find individual answers to individual problems in a system that still likes to put people in boxes and pretend that’s enough. The pigeon-holing culture of psychiatric diagnosis still remains but things are getting better. I’d like to think that my generation of nurses have been instrumental in that. God knows – we’ve tried.

mh-recovery-nothing-mysticalToday, 20 years on, recovery is seen as a reality. Inter-agency working has become so ingrained that it’s often hard to know which worker has which training in the community teams I work with. Diagnosis is giving way to formulation. Generalised assumptions about faulty biology are giving way to more evidence-based ideas that are just as likely to include the effects of social inequality and cognitive style.

Society at large is slowly waking up to its own role both in creating and maintaining mental disorders through exclusion, prejudice and marginalisation of those who don’t fit the required stereotypes of ‘acceptable culture’. There’s still work to be done and the fight against stigma and dehumanising assumptions goes on, but I’m proud to say that I’ve been part of that struggle and will continue to be for a good few years yet.

20 years from now though, the newly qualified nurses of 2036 will look back at my generation of nurses, at the class of ’92 and throw their hands up in horror at the way we used to treat people. At least I hope they will.

If the nurses of the future don’t criticise the nurses of today then we won’t have done our work properly. Each generation should have reason to criticise the one that went before. I hope they’ll also understand though that had we not fought against the injustice of our own time they would still be perpetuating it in theirs.

The fight continues…

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

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 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.


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.

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 19: Behaviours that harm other people

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.

Sometimes the harm, or risk of harm, affects others and so we really must intervene. Service-users don’t have the right to hurt others, no matter how much they might learn from the experience.

If, for example you heard of an assault you must take reasonable steps to try to prevent it. If necessary and appropriate call the police or other outside agencies as needed. If an offence has occurred then always report it to the police. That’s part of learning from experience too.

Never fall into the trap of being too ‘understanding’ in these situations. Compassion is important but naivety is not. Shielding a person from consequence teaches them the wrong lesson – it teaches them that there are no consequences and that tends to encourage both more frequent and more serious challenging behaviour. Do you really want your service-users to believe that it’s OK to hit you or your clients? If you don’t then let them face the consequences of their actions while they’re still at the shouting stage.

We know that challenging behaviour, including violent behaviour, escalates if left unchecked. We know that some people are dangerous and that they tend to become increasingly violent so long as they continue to ‘get away with it’. So the obvious solution is to ‘nip violence in the bud’, thus preventing it from escalating.

If you work with people, be they mentally disordered or not, ask yourself this:

Do you ever excuse their hostility because you ‘understand’, because they’re ill, because they have anger ‘issues’ or they’ve been through such a lot of trauma in their early lives etc etc?

If so please understand that the more you excuse the behaviour the worse it will get. People learn through consequence – you did, from an early age. That’s why you’re able to hold down a job. You learned to behave appropriately in society by experiencing negative consequences when you transgressed. That’s why as parents we ‘ground’ our children for example – it teaches them ‘the rules’. We do people no favours by pretending that violence and aggression is acceptable.

When you or others are at risk intervene, do what is necessary to manage those risks but without focussing more than is needed on the behaviour itself and always encourage more appropriate alternatives.

Privileged glimpses 18: Behaviours that harm the individual

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.

Behaviours that harm the individual

For those of us who work in health and social care it can be very distressing and frustrating to see our service-users undermine their health, their social situation or their state of mind. At times like these there is a temptation to intervene and simply try to prevent the behaviour. Of course sometimes this is appropriate and necessary, for example if the service-user appears to be actively suicidal, but not always. Often there is a judgement to be made between potential damage or harm and the benefit of experience that will help the service-user to learn from their mistake. Everyone learns best from consequence and it’s not necessarily helpful to shield people from the consequences of their actions. The more we intervene and prevent people from making mistakes the less they grow and develop in our care.

This might seem like a simple point to make but it’s also a fundamental principle that goers to the very heart of health and social care work.

If we accept that our job is to help people to be all that they can be and in most cases to grow beyond the need for our help then we must also help them to learn how to cope without us. They need the skills and understanding necessary to survive in the ‘real world’. It’s our job to help them to develop these skills before they leave us. After all, there’s no point expecting them to survive outside our care if we haven’t helped them to prepare, to take a few (managed) risks, and to learn how to deal with disappointment too.

Part of that preparation, that development is to learn how to take responsibility, understanding that actions have consequences and that in the ‘real world’ we all have to face them. We do our service-users no favours by teaching them that they don’t need to face the consequences of their actions.

This is why, for example, a service-user who damages property should be given a bill. This is why the young person who sulks and refuses to come down for dinner should go hungry (provided that there’s no physical or psychiatric reason behind the refusal). People learn from the consequences of their actions and it is not the job of social care staff to prevent that learning process from happening.

So when the challenging behaviour is detrimental to the service-user themselves the first decision to be made is whether to intervene at all. If you do intervene it should be because the risk of harm to the individual is greater than the benefit of them learning from their experience. Often a debrief after a mistake is much more productive than intervening to avoid the mistake in the first place.

I’m assuming that, before we even begin to consider behaviours as challenging the normal process of discussion and ‘advice’ (always something to be cautious about) has been followed and the service-user has not responded to that.

This is why most of the time we focus very little of our attention on the challenging behaviour itself. Much more time and effort should go into the debrief and the process of encouraging behaviours we want to maintain rather than trying to discourage behaviours that we want to reduce. Generally speaking the more that we focus upon a behaviour the more it recurs anyway so only intervene if you have to.

Remember that our duty of care doesn’t ask us to prevent the development of coping skills and independence – only to assess and manage the risks associated with that growth so far as is reasonable and lawful.

Privileged glimpses 17: Challenging behaviour means …

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.

There are many different definitions of challenging behaviour. Some rely upon long lists of activities and behaviours that society sees as unacceptable. Others attempt to define the concept philosophically by referring to the works of ethical or moral authorities, sometimes dating back thousands of years. Throughout this series we shall use a fairly simple definition.

Challenging behaviour means

Challenging behaviour is a combination of two criteria:

  1. Behaviour that we don’t like;
  2. Behaviour that we think we need to respond to.

According to this definition both criteria must be met before we can say that the behaviour is challenging. For example, someone somewhere has been attacked within the last thirty seconds (a statistical certainty). I am not challenged by that because I am not in a position to respond to it. Therefore the behaviour is merely something I disapprove of but it is not actually challenging to me because there is nothing for me to do about it.

It’s important to get the sense of this definition clearly in mind before we go any further with this topic. Much of what people think of as challenging behaviour is not really challenging at all. We don’t have to respond in every case. Arguably, if we do respond and try to prevent people from doing things that they have a perfect right to do then the truly challenging behaviour is our own – not that of the service-user. Disagreeing with the care staff is not necessarily a challenging behaviour – it’s just a choice.

One of the most common problems among health and social care workers is the assumption that they have to ‘deal with’ behaviours that they do not personally agree with. This isn’t always true and by adopting a more flexible approach to the choices of service-users we can avoid many of the conflicts that make this work so difficult in practice.

Another important theme is the right of the worker (and others) to be free from abuse, assault or harassment. The law in UK, in particular the Health & Safety at Work Act (1974), is very clear on the responsibility we all have to keep ourselves safe and the need for proper assessment of risk. This is intended to ensure the safety of the service-user but also that of the worker and the person’s other carers or relatives. We’ll also consider ways to strike a realistic and reasonable balance between the needs of all concerned and the rights of all people to be safe and free from abuse.

Different types of challenging behaviour require different types of approaches. This is one of the most fundamental principles of challenging behaviour work and yet it is overlooked with alarming regularity. Just as with other challenges we come across in life, behavioural regimes and strategies are most effective when we take the trouble to understand the problem before we begin work on the solution.

In the broadest sense behaviours can be divided into two basic categories:

  • Behaviours that harm the individual;
  • Behaviours that harm other people.

Of course some behaviours will fall into both these categories so it’s not quite so simple as all that but this way of thinking does, at least provide us with a starting place. In the next post we’ll begin to look at these categories in turn.