Challenging behaviour strategies aren’t necessarily complicated but they are powerful. It’s important then that we use them ethically. This video outlines some of the more basic points about ethics and philosophies of working with people who challenge us.
When assessing an individual’s mental capacity it is important that we confine ourselves to assessing that person’s ability to make this particular decision (or type of decision) at this time. This is what the Act means when it refers to ‘time and decision specific’ assessment.
At first glance this seems obvious and clearly reasonable. However on closer inspection it brings up a number of issues relating to ‘established practice’ that need to change. It also provides many workers from support workers to nurses, social workers and many others with a very real source of anxiety. Here’s why.
In the past capacity decisions tended to be made by certain professionals such as psychogeriatricians or psychologists. One typical approach would be to ask a doctor to come and assess a service-user’s capacity, not in relation to a specific issue but ‘globally’. This would be done using one of several techniques, the most common in UK being the Mini Mental State Examination (MMSE).
The MMSE is a reasonable tool to assess cognitive deficit and is helpful in diagnosing certain conditions such as dementia but it is not an assessment of capacity. Diagnosis is not the same as capacity. The fact that a person has a particular diagnosis does not tell us anything about their capacity to make particular decisions. The MMSE is not decision specific unless the care and treatment being offered relates to the service-user’s ability to count backwards from 100 in 7s or to name the current Prime Minister.
The MMSE does not inquire into preferences of diet, whether or not a person understand how to cross a road safely or what time they would like to go to bed. These are the sorts of questions that must actually be assessed on a day to day basis when we are making decisions about a person’s capacity.
The other major problem with ‘global’ assessments of capacity (apart from the fact that they do not asses capacity in the first place) is that they are not time specific. A psychogeriatrician’s assessment at the start of the month will have little bearing upon the service-user’s day to day decision-making capacity at the end of the month. So unless we can persuade the Dr to visit each service-user every mealtime to assess their capacity to choose between carrots and peas we have to use a different system.
Fortunately the Mental Capacity Act provides us with just such a system and, although unfamiliar to many it is very straightforward and in fact reflects what we’ve all been doing since early childhood anyway. You see assessing capacity is not difficult in itself so long as you understand it – and also understand what we are NOT expected to assess just as clearly as what we are expected to assess.
The Mental Capacity Act is clear….
“The decision maker is the person delivering the care or treatment”
This means that the support worker who decides that Albert needs a bath is responsible for assessing whether or not Albert has the capacity to consent to that bath. If he or she decides that Albert does not have the capacity to consent to that bath then the support worker is also responsible for deciding whether or not the bath would be in Albert’s best interests.
This may seem unfamiliar when it’s written down like that but actually that is precisely what has happened day in and day out in practice for decades in health and social care settings. Nobody calls the GP every time they think a resident in a care home might need their hair washed – they just decide. What the Mental Capacity Act does for us is it provides us with a way to show that our decisions make sense and gives us the legal backing to be free from prosecution for assault so long as we can justify our actions.
Part 5 of the Mental Capacity Act is subtitled ‘Protection from liability’ and deals with just this issue, ensuring that care workers can do what is necessary so long as they can show that the individual lacked capacity and that their actions were both proportionate and in their best interests. This is very empowering for care workers because it allows them the respect they deserve in making day to day decisions and provides them with legal protection at the same time.
Everything humans do is behavioural. There’s no justification for using the label to hide our own inadequacies or laziness.
Sometimes the only way to protect the therapeutic relationship is temporarily to behave as though you have no concern whatsoever for the other person’s point of view. This seems counter-intuitive and it most certainly doesn’t ‘feel’ good but how we feel is often far less important than what we do.
It’s important not to allow anyone to use our emotions against us in order to influence our therapeutic decision-making. That’s a form of emotional blackmail. It’s also a very common behaviour strategy that people use because it often works.
You probably won’t be able to stop someone using this sort of underhand strategy with others but you certainly can stop them using it on you. The trick is to show them that it won’t work and then invite them to bring something better to your therapeutic relationship instead.
A short video introduction to the principles of the mental capacity act 2005.
Who put us in charge?
If you’d like to arrange training for your staff please complete and send the contact form below.
Confidentiality can be a real headache for carers. Whether their loved one is being cared for by the NHS or by some other health or social care organisation they often have great difficulty in getting the information they need to care for their relative or friend as the vital part of the care team that they actually are. But does this really need to be the case?
It’s true, of course that people have the right to privacy, including those people who need care services – a fact that few carers would deny or seek to change. But patients and service-users don’t necessarily want to keep EVERYTHING private. Very often the problem arises, not because people have the right to confidentiality but because of the way that workers approach the issue when discussing confidentiality with them in the first place.
It’s important to be nuanced in matters of confidentiality. too often the question is asked…
“Do you want your family to know about your care?”
Really we ought to be far more specific. We need to differentiate more between the types of information we can disclose and that we should not. After all, there can’t be too many young men who would want their mothers to know all about their sex lives or other, equally personal details. Professional care workers need to be much more specific about the types of information to be disclosed and also about which family members or friends it will be disclosed to.
Most carers don’t want the intimate details of personal issues anyway. They do want to understand about medication regimes, care planning, symptoms and side effects, relapse profiles and plans and they need to know who to contact when things go wrong. This requires far more nuanced discussions than typically happen in over-stretched care services. So here’s my solution…
Click here to download a form that you can use to help workers determine just what information can be shared and with whom. It takes all the difficulty out of the equation for care workers by providing them with clear, unambiguous guidance about what they can and cannot disclose.
It is important that the form is completed collaboratively with a representative of the professional care team. The organisation working with the patient or service-user will have legal issues to consider and the worker may need to speak to their management about the form. Don’t ‘ambush’ them with the form. Let them know about it in advance. Ideally give them a copy to discuss with their management first. That way there should be no problems when you do sit down to complete it.
Complete this form at a time when the patient has the mental capacity to make the decision. Staff will not be able to abide by confidentiality decisions made when the patient lacks the capacity to decide.
Please feel free to get in touch, especially let me know of your experiences in using the form. It’d be great to hear from you.
Those of us who work in mental health services, be that for the NHS or in social care settings receive both payment and training for our efforts. However, there’s an army of unpaid, informal mental health carers who receive neither, despite the fact that without their contributions the whole system would collapse.
It’s estimated that informal carers save the NHS more than it actually spends each year and that situation doesn’t look like it’s going to get better any time soon.
The ‘Carers in mind’ project is my attempt to help redress the balance by providing information and training in practical ways for carers struggling everyday to hold their families together, often in truly desperate circumstances.
If you’re a carer involved in mental health please feel free to comment and let me know what you’d like me to cover. I can’t promise to fulfil every request but I’ll do my best.
Please leave a comment to let me know what you’d like me to cover as this series progresses or use the contact form below to get in touch privately.
Care workers need to learn from past experiences.
The best predictor of future behaviour is past behaviour.
But the people we work with can change too.
The whole point of much of our work is to help them to change.
How can we balance past behaviours and future potential?
How do we promote change without becoming naive and vulnerable?
Complete the contact form below to arrange training for your staff.
Back in 1963, researcher David L. Rosenhan masterminded an elaborate hoax. It was a scam designed to study the effects of labelling upon clinical practice and to determine whether psychiatric diagnosis is based upon professional skill or simple expectation and prejudice. It was a bold experiment with profound implications for clinical practice even now almost half a century later.
The idea was simple enough. Rosenhan persuaded a group of confederates to approach state hospitals in America and request a consultation. Each told the psychiatrist who assessed them that they had begun to hear a voice which said “Empty”, “Hollow” or “Thud”. That was enough to secure them a bed in the local psychiatric hospital. But that wasn’t all, bad though that low threshold for admission might be, in itself.
Once admitted on to the ward Rosenhan’s confederates ceased any pretence of voice-hearing. They behaved perfectly normally and showed no symptoms of mental disorder at all. At this point we might expect the staff running the ward to smell a rat but that’s not what happened. Whilst the fellow patients could tell very quickly that their fellow patients weren’t actually ill, the staff apparently could not.
Even perfectly ordinary activities such as writing was seen as pathological. Pacing up and down through boredom in this secure, low-stimulus environment was interpreted as a sign of illness. It seems that once the label of ‘mentally ill patient’ was applied everything the confederate did was interpreted by those lights.
The staff saw precisely what they expected to see.
This mirrors an earlier study by Rosenhan and his colleague, Jacobson who examined teachers’ attitudes to students who had arbitrarily been tagged either as ‘bright’ or ‘not bright’ by the researchers. The school, known as ‘Oak school’ to protect the identities of all concerned, also lived up to expectations of labelling theory. Not only did teachers interact with children in accordance with the labels they had been assigned, but the children also began to live up or down to the expectations of the teachers – even though their actual test scores had been ignored when they were randomly assigned ‘bright’ or ‘not bright’ status. Each child took on the behaviours and traits of the label, regardless of their actual abilities and achievements.
This is why it is so important that we understand labelling in our work with people who have mental disorders. Whatever we believe and expect is likely to come true.
If you want the people you work with to recover you need to start believing that they can, and you need to act upon that belief. Remember that recovery is built upon lots of little steps in the right direction and we can encourage that simply and effectively by doing relatively simple things, things like offering praise, acknowledgement, recognition and practical help, repeatedly and well.
That’s hardly rocket science, is it?
Complete the contact form below to arrange training for your staff.
What is schizophrenia? How do reasonable attempts to cope with symptoms like voice-hearing come to be thought of as symptoms of illness in themselves? Why is it so easy to get diagnosed with schizophrenia? More importantly, how can we use an understanding of the diagnostic process to aid recovery?
In this short video Stuart Sorensen introduces the basic idea behind the tripartite recovery model and shows how meaningful recovery is really all about coping. It’s not magical and it’s not complicated. Like most of mental health work in social care it’s about doing relatively simple things, repeatedly and well. Do the things that help people to feel valued and to cope with their experiences and you’re more than half way there.
Complete the contact form below to arrange training for your staff.