Categories
challenging behaviour mental health social care

Privileged glimpses 8: Do as I do

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 as I do – model behaviours we want to encourage in others

Mental health work involves many aspects of care including working to help people to manage their emotions, their thinking and their behaviour. It involves challenge and more often than not it involves problem solving and behavioural intervention.

Goals and objectives relating to developing both behavioural and emotional control are commonplace and much of what we do is centred around working toward them.

Do as I do

A very important part of this work is ‘modelling’. If we expect our service-users to make positive changes we need to demonstrate them in ourselves.

  • If the service-user has anger management problems they need to see us remaining calm.
  • If they have problems with paranoia they need to see us actively seek reasonable solutions in our own lives. Thinking the worst of the boss or seeing conspiracy among colleagues is not the best example to set.
  • Similairly if the service-user has difficulty sorting fact from fantasy it’s useful for them to see how we go about assessing evidence and making rational judgements. Let them know how we make sense of the world without jumping to conclusions and work on helping them to develop the same skills for themselves.

Most importantly if we want to encourage service-users to develop good support networks (a vital aspect of mental health maintenance) we need to show generosity of spirit in our own dealings with those around us.

The rule of thumb is very definitely ‘do as I do’ and not ‘do as I say’

 

 

 

Categories
challenging behaviour law mental health social care

Privileged glimpses 7: What people say

This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

Just a quick post today. This one is as obvious as it gets.

What people say may not be what people mean

There are many reasons why people in health and social care settings don’t say what they mean and it’s worth taking a little time to think before deciding whether or not to take what they say at face value.

Here are just a few possibilities to consider…

People may be too frightened or insecure to tell the truth. Or they may know that what they have to say will be unpopular. Many would argue that fear of exposure and a basically unpopular message explains why people are often less than honest about their true intentions. The truth may be too problematic (or the other person’s reaction too scary) to admit to honestly.

The service-user who is always satisfied with the care we give them may genuinely be happy with what we do but, realistically speaking, the person who never feels dissatisfied is pretty rare. That’s why inspectors such as those from the CQC sometimes worry when an organisation receives no complaints at all. Are the service-users too intimidated to say what they actually mean.

There is a power imbalance between nurse, carer and service-user and it’s easy for people to be intimidated by that imbalance – even if it’s unintended. If it is intended, if the nurse is a bully for example then it’s even more of a problem.

If nobody in your service ever complains it’s a good idea to ask yourself why. You may want to look beyond their words and understand the fear that prevents them from being honest.

The other possibility I want to consider here is the ‘challenging behaviour’ strategy of taking people at their word even if you don’t think they’re being honest.

Sometimes people will tell you things they don’t mean because they have a hidden agenda. In those cases you may want to consider acting as if they’re being honest with you even though you think they may not. This more or less guarantees that the solution you give them, although appropriate for the problem they stated will be unlikely to match the subtext. Stick to the stated problem until they tell you what they really mean.

This means that over time they learn that it’s better to be clear and to be honest.

Categories
mental health social care

Privileged glimpses 6: Don’t blame people for their disorders

This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

Don’t blame people with disorders for behaving like people with disorders

l_300_168_BFB62138-883B-4070-8F84-F868E3CC5219.jpegOne of the fundamental themes throughout almost all of my writing is the idea that there is no ‘us and them’ and that people are just people. We are all fallible and we are also all capable of improving ourselves. This means that it is never OK to assume that people with mental health problems can never overcome them. Those of us who work in mental health services have an obligation to work toward improved functioning and coping skills development. That obligation includes a duty to believe that the people we work with are capable of change given the right circumstances, opportunities and motivations.

Unfortunately there is a downside to this approach. Some mental health workers use the belief that ‘there is no us and them’ to justify unrealistic expectations of their service users. It is true that people can achieve great things regardless of diagnosis but it is also true that people with mental health problems are unlikely to function as well as those who are free of such problems in the short term. It takes time to overcome our difficulties and there is no value (or logic) in expecting people who have problems to act as though they had not.

And yet some mental health workers, of all grades and professions seem unable to separate potential coping skills from current achievement. They expect their service-users to behave as though they had already overcome their problems and then blame them when they do not. This is not only lazy thinking, it is evidence of severely limited understanding of mental disorders, the process of recovery and the role of mental health workers.

When we blame our service-users for behaving like service-users we recreate the same sort of invalidation that brought many of them into our care in the first place. Rather than assisting people to develop better coping strategies this attitude further damages service-users and serves to trap them in their existing circumstances and psychological difficulties. Our job is to help people to develop beyond their problems, not to judge them for having those problems in the first place.

Don’t blame people with mental disorders for behaving like people with mental disorders.

 

Categories
mental health social care

Privileged glimpses 5: Don’t expect perfection.

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.

Perfection

Don’t expect your service user to perform perfectly. You don’t so why should they?

As we saw in the last entry we all make mistakes and it takes time to learn a new skill. But that’s only half the story. Even with practice people rarely achieve perfection. It’s true that we might perform faultlessly some of the time but even the best of us gets things wrong on occasion. For most of us it’s a very regular occurrence no matter how much we’ve practiced. We all have ‘off days’ and we all make mistakes.

“Nobody’s perfect” as the saying goes.

But whilst it’s easy to excuse ourselves for the regular little errors that make up every day of our lives many workers in health and social care have difficulty extending the same understanding and forgiveness to service users. The next time you go into work take a random batch of care or support case files and look at the care plans inside. See how many of them have been discontinued as ‘unattainable’ after only one or two attempts. Notice also how many have stated goals set far too low because of an assumption that since the service user didn’t get it right every time they cannot be expected to attain meaningful goals.

Then apply the same logic to your own life.

Would you find your own support plans discontinued if the same stringent demands were applied to your….

  • Sobriety
  • Spending and budget management
  • Anger management
  • Compliance with medication regimes as ‘self-administrator of meds’
  • Smoking cessation (how many times did the ex smokers you know try and fail to stop before they succeeded?)

The fact that you screw up from time to time doesn’t make you a failure. It merely makes you human and fallible. We all make mistakes but that doesn’t mean we are incapable of doing well too.

Remember that there is no us and them. If we allow ourselves to be less than perfect then we must also allow the same freedom to be fallible for our service users.

Categories
mental health social care

Privileged glimpses 4: Coping skills develop slowly

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.

Proud of yourselfTake a moment to think of all the things that you’re most proud of in your life.

For some that might mean professional qualifications from NVQs or VQs to diplomas, degrees and even PhDs. Others will think of less formal achievements like charitable endeavours or learning to play a musical instrument. Perhaps you’re good at a particular sport or maybe you’re proud of overcoming your fear of heights and going on a parachute jump. It takes a particular form of courage to jump out of a perfectly good aeroplane several thousand feet above the ground. A friend of mine recently climbed Kilimanjaro. He’s rightfully proud of that.

What have you achieved?

The fact that you’re able to read this blog at all means that you’ve achieved something that most humans throughout history never managed to do. You have learned to read!

Whatever you’re thinking about the chances are that the things you’re most proud of didn’t come easily. They took effort. They took mistakes.

Thomas Eddison reputedly failed thousands of times before he successfully invented the light bulb. His attitude to these mistakes was interesting. He didn’t see them as failures. He saw them as learning opportunities. He saw them as milestones along the road to success.

Every time he built a bulb that wouldn’t light up he learned a little bit more about how not to make a light bulb. Inevitably all that knowledge, all that trial and error eventually led him to find the right way to generate light.

Eddison learned from his mistakes just as you have learned from yours. Writing the first assignment you submitted in that college course, your first fumbling attempts at making music, the first time you tried to hit a cricket ball or ride a horse you made mistakes. Over time you learned from these mistakes and you did better.

That’s as true for you as it is for your service users. They make mistakes too. And when those mistakes are handled correctly they learn from them – just like you do.

So the next time your service user gets something wrong or fails to meet expectations don’t assume they’re incapable. Help them to grow because of that mistake, not in spite of it. It’s a vital part of learning new skills and new ways of coping.

Categories
mental health social care

Privileged glimpses 3: People do the best they can with what they’ve got

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.

sweet shopImagine a small child in a very large sweetshop. The lights are off and it’s completely dark except for a single spotlight illuminating a tiny piece of shelving. On the shelf, visible in the little pool of light are three bars of chocolate. One bar is milk chocolate, another dark while the third is white chocolate. That is all the child can see.

The child has one simple instruction…

Take your pick…

Obviously the child will choose one of the three chocolate bars he can see. It doesn’t matter what other treats might be in the shop because he can’t see them – he doesn’t know that they are available options.

This little post isn’t really about chocolate bars and children in sweetshops though. It’s about social care service users and the options they have available.

The sweets in the shop represent coping strategies. They’re behaviours. Choices about what to do in different situations. And just like the child in the sweetshop service users (along with everybody else) only choose the options, the behaviours that they know about.

So if someone you work with makes poor choices that’s not necessarily because they don’t want to do better. It’s more likely because they either don’t know what else to do or because they don’t think that other options will work for them. Many people understand intellectually about good coping skills, socially acceptable behaviours but don’t believe that they will be given the opportunity to make different choices work for them. If they’re used to being treated with mistrust they won’t believe that the truth will work for them. If they’re used to being ignored they won’t believe that not drawing attention to themselves will meet their need for human contact. And they may well be right.

So, just like the child in the sweetshop they take the best option available to them.

They do the best they can with what they’ve got.

Categories
mental health social care

Privileged glimpses 2: People are just 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.

Be uniqueFollowing on from the ‘no such thing as ‘us and them’ post I’d like to make a more general point about people. Nobody is special. There – I’ve said it. You are not indispensible at work and your boss, your colleagues, your friends and your favourite service user are all replaceable. Nobody is special because people are just people.

If you work in mental health or social care services you will be used to certain professionals behaving as though they are more important or somehow more worthy of respect than others. You may even be tempted to behave that way yourself. Many in my own profession of nursing seem as though they have been pre-programmed to emphasise their own importance way beyond all recognition.

Different professional groups have different responsibilities and different levels of education are important but they don’t make us special. I’m a nurse – a pretty well educated and experienced nurse at that but that doesn’t put me in a position to tell a newly qualified social worker with a basic professional education how to do their job. I’m not special and I don’t know everything.

Similairly whilst I’ll happily defer to a GP when dealing with complex physical problems I’m not about to take their word when planning a cognitive therapy strategy for someone with psychosis. I will listen to them though.

By the same token I may be responsible for planning and organising a shift and delegating care tasks to support workers but I’d better not forget that they are more likely to know the best way to hoist, bathe or feed a particular resident than I do because they know their own jobs.

Nobody is special.

Nobody is indispensable.

Nobody is irreplaceable.

People are just people.

 

Categories
mental health social care

Privileged Glimpses 1: There is no ‘us and them’

I am a manThis 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.

In spite of having had my own issues in the past I began my nurse training with a very superficial mindset. I believed, without even thinking about it, that there were essentially two types of people in the world. There were ‘the mentally healthy’ and then there were ‘the mentally unhealthy’.

As a student nurse I believed myself (very arrogantly, I might add) to be one of ‘the mentally healthy’. I thought that people were born to mental health or to mental ill health and that the work of mental health services was to protect ‘the mentally unhealthy’ from themselves either by medication or by more social methods.

I’m embarrassed to acknowledge that my training did little to challenge that idea. There were a couple of outstanding exceptions but in the main the discriminatory attitude went relatively unopposed. Fortunately things have moved on and continue to do so but the student nurse training of 20 years ago was very definitely saturated by an ‘us and them’ ideology.

Of course, nobody ever came out and said it quite so bluntly, so starkly as I just did but there were plenty of references to ‘chronic illness’ and ‘irrecoverable’ conditions to illustrate the point just as clearly. Nowhere was this more obvious than during placements on the wards where people were described as ‘revolving door’ or ‘long stay material’ as though their very essence was illness and nothing more. I’m ashamed to say that for my first few years after qualifying I bought into this mindset completely along with all its negative (and essentially false) assumptions about incurable psychotic illnesses and irredeemable personality disorders.

I was glad to be one of ‘us’.

Then an interesting thing happened. I moved away from my first job on an acute psychiatric ward serving a large, deprived inner city area to my home town and began to meet up with old friends – many of whom I hadn’t seen for years. Around half a dozen of us met up for a meal in a local pub one night – it was a way to reintroduce myself to my old mates. And we had a good time swapping stories of our schooldays and catching up on the events of the intervening years. That was when it first began to become clear to me that there really is no ‘us and them’.

Of the six of us sat around that pub table five were taking anti-depressants. Every single one of my old friends had been prescribed pills to make them feel better. But they were my old mates. They were my best friends. They definitely weren’t to be considered as ‘them’.

That was the beginning of a mental journey that led me to rethink my old assumptions about mental health and illness. I needed to work out what was different between my old school friends and me. It surely wasn’t simple biology as I’d been taught. They couldn’t all have ‘the depression gene’ (whatever that is).

Finally it dawned on me – Sally had had a point. The difference isn’t just biology, although that can have a part to play. Biology is not the complete answer. It’s not the complete answer by a very long way. Attitude, social situation, environment and general coping style are just as important – arguably very much more so. This matters.

Once we acknowledge the impact of social skills, environment, opportunity, coping methods and psychological style we begin to see that given the right life chances people can be far more than they might appear. Our own assumptions about ‘them’ keep people from overcoming their problems by limiting those opportunities. It’s truly amazing what people can do when we treat them like ‘us’.

There really is no such thing as ‘us and them’.

Categories
mental health social care

Privileged Glimpses (of the bleedin’ obvious)

About this series

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 of the ‘glimpses’ only become obvious once they are explained. Until then they appear ‘counter-intuitive’. To put that more simply they seem to make no sense at all to people not used to thinking in this way.

The real aim then is to help people to examine and in many cases change their basic approach to people who need their support.

As always I’d be grateful for feedback on the ‘privileged glimpses’, either by Email or though comments on the blog.

Contents

There is no ‘us and them’

People are just people

People do the best they can with what they’ve got

Coping skills develop slowly

Don’t expect your service user to perform perfectly. You don’t so why should they?

Don’t blame people with disorders for behaving like people with disorders

What people say may not be what they mean

Do as I do – model behaviours we want to encourage in others

Lapse and relapse – two different things

Sympathy is not usually helpful

Risk-free is impossible. Manageable risk is the way to go

Don’t flap

The saviour fantasy

You’re probably not an emergency service – don’t try to behave like one

Hanged if you do & hanged if you don’t – a duty of care myth

The word ‘support’ is meaningless in and of itself

Challenging behaviour means….

Learned behaviour

Unhelpful thinking

“It’s just behavioural” – a workers’ excuse for lazy thinking about service users’ needs.

Who put us in charge?

Categories
Uncategorized

Models of mental health and disorder

The world of mental health care can be confusing – especially for those new to the topic. Often the different theories and professional approaches seem to contradict each other. It’s almost as though different workers speak different languages,

That’s not quite true but they do often come from different theoretical perspectives. That’s why, for example, a social worker and a psychiatrist will give you two completely different explanations for the same person’s problems. They’ve been taught radically different ‘models’ that they use to understand mental health and disorder, its causes and its treatments.

This little table isn’t intended to cover all the different models in depth. Instead think of it as a very basic list of models that can guide you in understanding why people focus upon different things. There’s more to it, of course but it’s a start for newcomers trying to get to grips with the contradictions they come across in practice.

The Care Guy Models of mental health and disorder