Work in #socialcare &/or #mentalhealth is not an exercise in #HumanRights removal. The #law giveth, the law taketh away. #rights are not ours to withhold.
Tag Archives: rights
Challenging behaviour: Validating opinions and beliefs
When dealing with people whose behaviours are challenging it’s important to acknowledge that those behaviours may well be based upon some very deep-seated beliefs. Whilst we don’t need to agree with or even support beliefs that cause problems it is vital that we acknowledge the person’s right to hold them – even if we deny their assumed right to act upon them. It’s one thing to object to behaviours – it’s quite another to dismiss the person who holds those beliefs.
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A duty of care myth
Hanged if you do… hanged if you don’t!
Many people are confused about their duty of care. They think they’re somehow responsible for the actions of other people. This leads them to try and prevent people from doing things that they have a perfect right to do because it might be risky. In truth our duty of care is actually much simpler than most people imagine:
- Do all that you reasonably can;
- Don’t break the law;
- You are not responsible for the actions of other people;
- You are responsible for your own actions in the situation you’re in;
- Care workers are judged upon process, not outcome.
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Human rights in the UK?
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.
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.
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Privileged glimpses 25: Who put us in charge?
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?
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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.
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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.
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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 is a combination of two criteria:
- Behaviour that we don’t like;
- 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.
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Privileged glimpses 15: A duty of care myth
This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.
Many people are confused about the exact nature of their Duty of Care toward the people they look after. To a large extent this is because they think that they are somehow accountable for the actions of other people (in this case the client or service-user).
This gives people the sense that they are:
Hanged if they do and Hanged if they don’t
In reality, you are responsible only for what you do – not for what your client does. If you do all that you can within the law to minimise risk, to help them to make decisions in their best interests and to help the client to cope more effectively then you have fulfilled your duty of care. This is true whatever the outcome might be.
- You are not responsible for someone else’s behaviour.
- You are responsible for your own behaviour in the situation in which you find yourself (including acting to keep others safe when necessary).
- You are not expected to take away people’s rights to choose if they are able to.
- Care workers are judged upon process – not upon outcome.
Do all that you reasonably can within the law.
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Privileged glimpses 11: Risk-free is impossible
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.
Risk free is impossible – managed risk is the way to go.
Individual v Organisational risk
There is much more to the notion of risk than meets the eye. Many care workers think that it is their job to prevent service-users from taking any risks at all but this is not possible. In fact, even if it was possible to prevent people from taking any risks it would not be the right thing to do.
Life without risk would be life without living. It is only through accepting a level of risk in our daily lives that we are able to do anything at all. In fact, even doing nothing is risky. The risk to mental health from boredom and unchanging routine is as great as the risk to our physical health from inaction and lack of stimulating activities.
All activity, from making a cup of tea to crossing the road or even going to the toilet must involve some degree of risk in order for the service-user to maintain or develop skills. There is always a risk of failure when learning to do new things and on occasion that failure can result in some form of harm.
The trick then is to help people to understand the individual risk they are proposing to take. If they cannot understand it (for example if their mental capacity is impaired) then the risk becomes an organisational risk. In that case the organisation that creates the risk/activity for them must manage that risk to bring it down to manageable proportions. This does not necessarily mean remove the risk – simply manage it.
Obviously some things carry more risk than others. An activity that involves crossing the road with supervision might be considerably safer than the decision to go sky-diving but the principle still holds. The task is to make the risk manageable.
Just imagine how empty your life would be without risk. If we need to take risks in order to have a fulfilling life is it not just as important for our service-users?
Just as nobody has the right to remove risk from your life so you do not have the right to remove all risk from the lives of your service-users.
However – you really do have an obligation to manage the risks taken by those service-users who do not understand the risks they take and sometimes to prevent the more extreme or unnecessary risks.
So we need to determine:
- Is it an individual or an organisational risk?
- Is the risk manageable?
- What are the ‘reasonable foreseeable’ outcomes?
- Do we need to prevent the person from taking this risk or can we support them in it?
You can follow the entire blog series as it develops here.
Mind The Care Training 