It’s easy to become emotionally disturbed when faced with a service-user, patient or client who self harms. Workers feel bad for the patient and bad about themselves for not being able to prevent it.
Unfortunately this emotional response – an element of High Expressed Emotion (HEE) known as Emotional over-involvement can make things worse. Try this instead.
Lifetime access for only £30.00
Here’s the introductory video for the first of several video training courses with accompanying PDF workbooks and exercises. This one’s an overview of mental health and disorder for workers and carers called ‘The picture on the box’.
I also plan to develop video courses on…
Anxiety
Depression
Psychosis
Self Harm
Personality disorder
Mental capacity act
Risk appreciation in health and social care
And my own self-help method called ‘The No Surprises method’.
Apart from ‘The picture on the box’, if there’s anything that you (or your wider contacts, come to that) would prefer me to work on sooner rather than later please let me know, even if it’s not listed. I can cover a whole lot more mental health and/or social care topics that I haven’t yet planned out.
Go on, get in touch. You know you want to
Self-harm can be confusing and bewildering for both staff and service-users. Ideas about ‘manipulation’ or a ‘cry for help’ do little or nothing to help prevent future self-harm. This interactive webinar explores some alternative notions and examines ways that support workers can make a difference in a genuinely difficult situation.
There is a great deal that support workers and others can do to help people who harm themselves. The trick is to be able to see past the behaviour and to understand the person who cuts themselves, takes overdoses or otherwise injures themselves.
In the past this sort of behaviour has been written off as attention-seeking or as an attempt to manipulate workers and yet most self-harm happens in secret and never comes to the attention of the staff. It’s really not about us. Something else is going on and the tired old notion that it is merely ‘behavioural’ is both meaningless and irrelevant in a modern context of deliberate self-harm.
This interactive webinar covers:
Definitions of self-harm
A cry for help?
Is it all just attention-seeking?
Self-harm and suicide – are they linked?
Pain, the brain and self-soothing behaviours
The emotional purpose of self-harm
Helping people to ‘get past’ self-harm
Managing the risks
Dos and Don’ts
Click here to reserve your place on this interactive webinar
Please note – this is an educational seminar. It is not a group therapy session and we cannot make time for individual or group counselling or other intervention here,
Newcomers to care, especially mental health care often believe that they not only can but actually will ‘save the world’. They genuinely expect that their winning personality, supported only by a nice smile, a cup of tea and a chocolate digestive will solve every psychological problem there is. They’re the saviours and their naivety puts everyone at risk.
Most of us grow out of such expectations early on in our careers. We may have begun wanting to save the world but now we just want the world to go away and leave us alone. We’ve had the naivety of inexperience kicked, beaten or otherwise drummed out of us in no uncertain terms and we’ve learned that we can only do so much in our little corner of the system. We knuckle down, get good at our particular task or set of tasks and keep that original, positive spark of enthusiasm alive with realistic expectations and the ability to take delight in smaller successes.
But some people never grow out of their saviour fantasy. They never overcome the innocence that may well have led them into the job but that also makes them beat themselves up every day because they haven’t yet fixed everything. They may not show it often but these overgrown saviours are racked with guilt because of the impossible task they set themselves. If you’re one of these saviours please read on…
It’s pension day and Mary, a kindly octogenarian toddles out of her local post office clutching a wad of notes in her gloved hand. She never did manage to catch up with all that modern internet banking nonsense and has always been a little suspicious of computers managing her affairs. ‘That’s what cheque books and cash are for’, she reasons. Her handbag hangs nonchalantly from her elbow as she fishes in the apparently inexhaustible, portable cavern for her purse.
Suddenly – two young thugs come dashing toward her. One snatches the cash, knocking Mary to the ground as he does so. The second stamps on her head for good measure, causing bright red blood to stream from her ear onto the pavement.
You run to her, screaming at passers-by to call an ambulance as you cradle the unconscious old lady in your arms. You feel helpless and angry as she breathes her last, still held tight in your embrace. You’re angry but you’re not guilty. You tried to help, after all. You never caused this and at least you had a go, unlike the rest of society who seem only able to cross the road and look the other way.
Mental health care’s like that. We didn’t cause the problems our patients have developed. Often it took them years to become this ill. That’s not your fault and you’re not to blame. At least you’re trying to help!
Beware the saviour fantasy
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.
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.
Socrates was an ancient Greek philosopher. He used questions to help people reach new insights or knowledge. Each question moved them a little closer to solving their problems. The technique takes a bit of practice but it’s not rocket science.
Socratic questions follow a fairly simple pattern and just a handful of rules (see the infographic below)
It’s very simple in theory but it does take practice to perfect.
It’s always better for a person to see the truth for themselves than to be told what to believe by someone else. Socratic technique helps people to draw their own conclusions.
Occam’s razor
William of Occam was a monk who lived in the 14th Century. He suggested that:
If one thing is true then other things should also be true.
For example, if it is true that the man next door sings louder than the sound of a jet aircraft taking off then it should also be true that we can hear him from our sitting room. If this second statement (that we can hear him) is false then the first statement (louder than a jet) must also be false. The razor ‘cuts away’ errors in thinking to help us understand the truth of the situation.
Another way to use Occam’s Razor is to consider the simplest explanation. The simplest answer isn’t always the right one but Occam’s razor does give us a neat way to approach problems.
For example, if one theory suggests that water pushes a water wheel and another suggests that the water wheel is actually pulled around by unseen ghostly hands then the simplest explanation is that the force of water is what makes the wheel move. Both theories have the same outcome – the wheel turns – but one involves a whole new set of circumstances (ghosts obsessed with mechanics) whereas the other provides a perfectly adequate explanation on its own. If we go with the ghostly hands explanation we must also explain where the ghosts come from and why on earth they’d be interested in water wheels.
Ockham’s razor would dismiss ghostly hands and lead us to the far simpler explanation that the force of the river turns the wheel. Only if the simplest theory turns out to be wrong should we start to think about ghosts with a water fetish!
Hanlon’s razor
The other ‘Razor’ rule, ‘Hanlon’s razor’ is similar. It’s a way of keeping perspective when things don’t turn out as we’d like them to. It’s used to ‘cut away’ knee-jerk assumptions about other peoples’ motives. Hanlon’s razor says…
Don’t assume malice when incompetence will do
To put it another way – the fact that my actions hurt you could just as easily be the result of my stupidity than a desire to cause you pain. I might not have meant you any harm. Realistically most people don’t go around dreaming up ways to hurt others – they have too much to do just sorting out their own problems. There are exceptions to that but malice isn’t the norm. Indifference and incompetence are usually far more likely.
By combining Socratic technique with the basic principles of Occam’s and Hanlon’s razors we have a perfect blueprint for therapeutic conversations. And all we need to do is ask the right questions.
It’s much more effective to ask questions than to tell another person what to think. Let them come to their own conclusions. That way they just might believe them.
I used to think that mental health care would be really complicated. So I looked for complicated theories to underpin everything I did. For many years I studied and tried hard to negotiate my way through the complex world of mental disorder. And because I looked for complicated answers, complicated answers were all I found. That was a great mistake.
The more I studied, the more I realised that good quality mental health care doesn’t need to be complicated. It may not always be easy to deliver but that doesn’t mean it should be hard to understand. Often the simplest solutons are the most effective.
Eventually I realised that there are some straightforward, basic principles that we need to follow. Everything else flows from there. These are the simple ideas that make the difference between good care and bad, between illness and recovery.
If only someone had distilled those principles for me when I first began. My early career would have been so much easier and more effective. But nobody did that in those days. That’s a great shame.
So I’ve done it myself. I’ve boiled down the basic ideas into usable, teachable concepts that every care worker can quickly understand and apply. These are the fundamental principles that underpin every Mind The Care Training course and seminar. Subscribe to this page and come back often to find out more.
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.
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.
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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