Part 39 of The Mental Health Workers' Guide considers learned behaviours and the role of boundaries in challenging behaviour work. It's not quite so straightforward as it may first appear though. Boundaries aren't always obvious and (as we shall see later) consequence isn't the same as punishment. Don't forget that you can download all the podcasts and video clips that accompany this series here.

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

If you have a mobile phone, a kindle, an iphone or ipad or any of a number of other electronic readers you can get the entire Mental Health Workers Guide from Kindle. If you don't have a kindle don't worry - just download the app (it's free) and turn your phone or PC into a Kindle reader.

Then nip on over to the Kindle store and get your copy of The Mental Health Workers' Guide in handy Ebook format.

You can buy it here

The ebook is the completed version of the developing blog series. It covers:

What’s a mental health worker worth?

The problem of specialisation

Three models of mental health and disorder

The biological (medical) model

The social model

Merging the two (stress and vulnerability)

The importance of physiology

The meaning of psychiatric diagnoses

Anxiety

The psychology of anxiety

Depression

The psychology of depression

Psychosis (introduction)

Hallucinations

Delusions part 1

Delusions part 2

Thought disorders

The dementias

Types of dementia – Alzheimer’s

Types of dementia – Vascular

Types of dementia – Lewy Body

Types of dementia – Parkinson’s

Types of dementia – Korsakoff’s

Types of dementia – Fronto-temporal

Types of dementia – Mixed

Orientation and memory

Delirium

The CAM scale

Working with the limbic system

Personality disorder

High Expressed Emotion

Sympathy is not usually helpful

More on the Stress & Vulnerability model of mental health and disorder

The invalidating environment

The Self-fulfilling prophecy

The meaning of recovery in mental health

The three types of recovery

Duty of care: A slug in a bottle

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

There is no ‘us and them’

People are just people

Coping skills develop slowly

Lapse is different from relapse

Don’t expect your service user to perform perfectly.

The word ‘support’ is meaningless in and of itself

“It’s just behavioural” (A workers’ excuse for lazy thinking)

Challenging behaviour means….

Behaviours that harm the individual

Behaviours that harm other people

Do we need help?

Consequence, learned behaviour and the need for boundaries

Maintaining the problem

The whole team approach

Firm Boundaries

No ‘Pedestals’ And Staff Safety

Effective, Consistent Care

‘Corporate’ Identity – “You’re All The Same.”

Expectations

Self Harm

Self-harm as a response to trauma

Responding to a person who harms themselves

Individual v Organisational risk (Risk-free is impossible. Manageable risk is the way to go)

Don’t flap (more haste – less speed)

The saviour fantasy

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

Unhelpful thinking

Ignoring the positive

Exaggerating the negative

Overgeneralisation

Catastrophisation

Arbitrary inference

Determinism

Selective abstraction

Global thinking

Dichotomous thinking

Magical thinking (the Wizard did it)

Personalisation

Socratic dialogue and ‘the razors’.

The sticks we use to beat ourselves

Who put us in charge?

Final words

In case you missed it...

I recently delivered training on mental health (the basics) to a group of support workers in Glasgow. Not only were these people a joy to work with they were also generous enough to let me record the training and then post the recordings on the internet. Thanks also to Frank, the organisation's training manager for consenting to these recordings 'going public'.

You can listen to the sessions (minus group exercises and some of the lengthier group discussions) from this page

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Part 16 of The Mental Health Workers' Guide looks at how to work with the limbic system in dementia care. Don't forget that you can download the video clips that accompany this series here.

Buy the entire series as an Ebook here

We have established already that anxiety is essentially a physical state with physical symptoms known as ‘arousal’. That’s what we call the symptoms of racing heart, rapid and shallow breathing, muscle tension, sweating, trembling and churning stomach. But there’s more to anxiety than just physical stuff. There are psychological symptoms and characteristics of anxiety too. That’s what today’s episode is all about.

The Mental Health Workers’ Guide part 5: Anxiety (1)

Buy the entire series as an Ebook here

You can view all the movies accompanying this series at 'The Guide' 

No matter who we are, what religion we follow or what culture we belong to we all have at least one thing in common. All of our ancestors, from the earliest single-celled life forms right through to our own parents survived. I’m not suggesting that nobody ever dies but it is an inescapable fact that all of our forebears, human or otherwise managed to remain alive long enough to breed.