Definitions of challenging behaviour that ignore context aren’t just wrong – they’re actually damaging and cause more problems than they solve.
Tag Archives: support worker
Online video training
“Very thorough and high quality…” Abi, Student nurse
Lifetime access for only £30.00
Do you work in mental health services?
Are you a support worker, student nurse or just an interested person who’d like to know how to make more sense of mental health and disorder?
Do you find it hard to see how all the different disorders and peoples’ approaches to them fit together?
Do you have difficulty getting other professionals to see things as you do?
Would you like to be more effective in working with the people you care for?
Then this online video course is for you.
People learn best when they have questions and they remember best when they have a ‘schema’, a ‘picture on the box’ to help make sense of what they’re taught. That’s what this training is all about. Over two and a half hours of video instruction alongside a range of information and exercises in the accompanying workbook help you to make sense of the seemingly overwhelming field of mental health and disorder.
And all for much less than the cost of a good night out.
You can have all this for less than you’d pay for a take-away meal for two. But unlike a take-away, the benefits of this training will last your entire career.
Click the link below to get full access to the course videos and workbook.
https://www.tamtalking.co.uk/p/onlive-video-training-the-picture-on-the-box/
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Webinar: Mental health recovery
What’s #recovery really about in #mentalhealth? For many it means so much more than a return to how we were. Join my one hour seminar to learn more.
https://tinyurl.com/recoversemi
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Beware the saviour fantasy
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
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MCA: Who decides?
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.
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Personality disorder and compassion
Sometimes a single day’s training makes all the difference. You can access such a training day here.
Watch a video on Personality Disorder below
Complete the contact form below to arrange training for your staff.
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Mental health care needn’t be complicated
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.
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The meaning of psychiatric diagnoses
One of the most common concerns among social care workers, at least those I meet is around diagnosis. There are so very many different psychiatric diagnoses, all with their own particular symptoms and they seem almost impossible to remember.
I can sympathise with that view – there really are a lot of diagnoses and the differences between them sometimes seem so very subtle that it’s hardly worth mentioning at all. However – that doesn’t need to be such a problem in social care.
Support workers aren’t diagnosticians and they don’t need to be able to fit everyone they work with into the particular boxes of psychiatric diagnosis. It’s enough to know what the service-user’s actual problems are without worrying about pigeon holing them. After all – there really is much more to life than diagnosis.
So here’s a breakdown of what really matters in psychiatric diagnosis.
The word ‘diagnosis’ comes from Greek. It’s made up of two words:
- Dia – through
- Gnosis – knowledge
Diagnosis means ‘through knowledge’ and yet we know much less than we’d like to for sure. In fact there are those who argue that diagnosis is little better than useless in mental health care and should be replaced by a different system known as ‘formulation’ instead. This is because whereas diagnosis seeks to place sufferers and their conditions into predefined ‘boxes’, formulation seeks to construct a new explanation for each individual regardless of the experiences of other people and the ‘boxes’ they may have occupied in the past.
Perhaps the biggest criticism of diagnosis in mental health care is based upon the established purpose of diagnosis. It is intended to:
- Predict outcome (prognosis);
- Inform treatment.
In the case of diseases like Alzheimer’s dementia or Parkinson’s disease diagnosis can (to a greater or lesser extent) fulfil both of these promises. In the case of ‘Schizophrenia’ or ‘Brief Psychotic Episode’ it seems far less effective and in the opinion of many far less plausible too.
It’s important to be clear about what this means in practice. There’s a set order (a syntax) to psychiatric diagnosis and it really only works in one direction. This is different from many other sorts of diagnosis, the diagnosis of physical illness for example. That’s because whereas physical illnesses tend to be diagnosed ‘through knowledge’ of measurable physical processes with very specific, known (or at least likely) and predictable specific effects, psychiatric diagnoses tend to be based upon ‘clinical judgement’ with little or no physical tests available to support them.
Psychiatrists don’t rely upon measurable evidence to support their diagnosis and so they can’t really say for sure that one symptom will follow another. For example…
The physical diagnosis of COPD (Chronic Obstructive Pulmonary Disease) is diagnosed using specific tests that show that a person’s lung function is impaired. The inevitable result of significantly impaired lung function is breathlessness when exercising. So, because of this measurable condition and the inevitability of breathlessness we can reasonably say…
“Of course John gets breathless – he has COPD”
We can say this because we have excellent evidence of impaired lung function and because we know what happens to respiration when people with COPD exert themselves. We have good, testable information about the causes ranging from oxygen saturation levels in the blood to peak flow measurements of respiration itself to name but two. We know exactly what we’re looking at in other words.
Psychiatric diagnosis is different. It isn’t usually based upon blood tests or sophisticated scans. Instead the psychiatrist takes a history, observes the current ‘presentation’ of the patient and then makes a diagnosis based upon how closely the person’s ‘symptoms’ match the descriptions in the psychiatric diagnostic manual.
This means that diagnosis only shows what ‘symptoms’ are already apparent – it can’t predict other symptoms that aren’t already there. This means that we can only say something like:
“John has a diagnosis of schizophrenia because he has visions.”
We cannot say:
“Of course John has visions. He has a diagnosis of schizophrenia.”
Not everyone diagnosed with schizophrenia has visions. So the symptoms might explain the diagnosis but the diagnosis can’t explain the symptoms. It’s just a name, a label and names don’t explain things – they simply classify them.
For example, on my office wall I have a large clock. I know it is a clock because it has the observable characteristics of a clock (hands that rotate, a numbered face and it ticks). However naming it as a ‘clock’ doesn’t tell me anything about how it works. I am no closer to understanding the intricate mechanisms of the various cogs and springs inside the clock just because I know what to call it.
Many psychiatric diagnoses are just like that. We don’t get any closer to understanding the workings of schizophrenia just because we can name it. That’s why we must be careful to let symptoms explain the diagnosis but not to delude ourselves into thinking that the diagnosis explains the symptom.
Generally speaking we can only go one way with psychiatric diagnosis. It doesn’t usually work well ‘in reverse’.
The symptoms explain the diagnosis
The diagnosis does not explain the symptoms
But diagnosis isn’t entirely useless. My own view is that it is too reductionist. Diagnostic psychiatry reduces people to component parts to be ‘fixed’ rather like a mechanic working on an engine. Diagnosis has its place although, like many other people working in mental health services, I’d welcome a more widespread use of psychological formulation alongside the ‘boxes’ of traditional psychiatric practice.
In the simplest terms mental disorder is really only a combination of three types of symptom:
- Anxiety – physical and psychological arousal
- Depression – physical and psychological de-arousal
- Psychosis – hallucinations, delusions and thought disorders
All mental disorders (except the dementias which also include memory and orientation problems) are made up of combinations of these three types of experience or people’s vulnerability to them.
Personality disorders are diagnoses based upon the way people usually think and behave and upon their susceptibility to anxiety, depression and psychosis. Remember that those personality disorders that are categorised by anger are really anxiety based. Both anger and anxiety (as we shall see later) are products of the same ‘freeze, flight or fight’ response. The only difference is in the way we think about the situation but in biomedical (physiological) terms the bodily processes are identical.
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 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.
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