As promised, here are the answers to the initial questionnaire. Let me know how you did in the comments.
Picture on the box 2.2: Answers
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Author Archives: stuartsorensen
Picture on the box 2: Questionnaire
We’ll begin with a short questionnaire about all the things we haven’t talked about yet. This isn’t to be cruel, it’s to get you thinking… To get your head into gear
People learn best AFTER they’ve tried to come up with their own answers. So start here. Trust me, there’s much more information to come…
The picture on the box
Many years ago, back when Adam first met Eve and a good Saturday night out involved hunting dinosaurs on the High street, I enrolled as a student nurse. To say the course was bewildering at times would be an understatement. I found myself learning all sorts of disparate facts and principles but I had real trouble making sense of how they all might fit together. What I needed was an overview: a way to make sense of it all. I needed ‘the picture on the box’ to help me complete the jigsaw of mental health nurse training. Unfortunately no such overview existed. That’s why I’ve developed my own. This series of videos won’t make anyone an expert but it will give you the basic grounding you need to make sense of further learning.
Therapeutic risk-taking
Without risk life becomes meaningless. Our whole quality of life depends upon a balance between risk and reward. This is as true for our patients and service-users as it is for us.
Genuinely helpful care must involve positive, therapeutic risk-taking.
Meaningful activity and happiness
If you want to find happiness or even contentment do something that you define as more important than yourself.
Remember: Happiness comes from what we do, not from what we’ve got!
Rights and mental health
It is not the task of mental health workers to take away another person’s individuality.
Responding to self harm
Much of the stigma around self harm comes from the many myths and misconceptions that abound among professionals and the public alike about the reasons behind Self Harm. I remember as a student nurse in the early 1990s being fed these same myths by nursing and medical staff. The failure to see past our own perceived importance as professional ‘experts’ was rife and it led to some extremely damaging and cruel approaches to people who harm themselves.
Let’s look at some of the more common misconceptions. Perhaps one of the most common myths is to do with the notion of the ‘cry for help’. The idea is that by cutting or otherwise injuring themselves clients are trying to get some sort of assistance from services. If this is true then as professionals working in the field we need to ask ourselves some very difficult questions such as……
Do people really not know how to ask for help? If not – why not?
What sort of help can I offer them that is worth self-mutilation?
Am I really that special?
How good am I at noticing people’s distress if they need to resort to self-harm to get my attention?
What’s wrong with our access policies? How good are my listening skills?
How ‘accessible’ am I if people can’t just talk to me and ask for what they want?
What does this say about me as a professional and as a person?
Another myth is that self-harm is an attempt to manipulate or emotionally blackmail professionals.
Do we really believe ourselves to be so important that people will mutilate themselves just to influence our thoughts, feelings and behaviours?
Is self-harm really all about us as professionals or is it more to do with the personal needs of the client? Then there is the good old ‘attention seeking’ myth. It doesn’t take a genius to work out how inaccurate such an assumption is likely to be when we understand that the vast majority of self-harm is done secretly and in private.
Contrary to popular belief, deliberate self-harm is not usually an attempt to manipulate others. Nor is it usually a ‘cry for help’. Most people are quite able to ask for help without self-harming and the secrecy that often accompanies self-harm demonstrates that something else is going on.
Duty of care summary poster
Many people are confused about the exact nature of their Duty of Care toward the people they look after. To a large extent this is because they think that they are somehow accountable for the actions of other people (in this case the client or service-user). This makes people think they are:
Hanged if they do
and
Hanged if they don’t
In reality, you are responsible only for what you do, not for what your client does. If you do all that you LEGALLY can to minimise risk, to help them to make decisions in their best interests and to help them cope effectively then you have fulfilled your duty of care… whatever the outcome might be.
- You are not responsible for someone else’s behaviour.
- You are responsible for your own behaviour in the situation in which you find yourself (including acting to keep yourself and others safe when necessary).
- You are not expected to take away people’s legitimate rights to choose if they are able to.
- You won’t be prosecuted for not breaking the law.
- Care workers are judged upon process – not upon outcome.
However there really is a ‘do’ and there really is a ‘don’t’…
Do all that you reasonably can
Don’t break the law.
What’s a mental health support worker worth?
Given my background you might expect me to argue that senior, qualified professionals are the most important members of any multi disciplinary team. But you’d be wrong.
It’s true that I’d really like to be able to say that. After all – we all like to feel important, don’t we? But the truth is that such people are relatively low on the list of priorities and that’s how it should be.
To understand what I mean we’ll need to review a little of the research that has been developed over the last fifty years or so.
We’ll begin with High Expressed Emotion. This is a concept that has fallen out of fashion in recent years – not because it’s not accurate but because it’s not sufficiently trendy. This is a great shame because when care workers understand the concept of Expressed Emotion their clients are likely to fare far better than when they don’t. We’ll cover High Expressed Emotion in much more detail in later instalments but for now a basic overview is enough.
The idea was first introduced by George Brown in the late 1950s and onwards (Brown G. et al 1958) and then later refined (Brown & Rutter 1966) to mean three distinct types of behaviour:
Criticism
Hostility
Over-emotional involvement
The basic idea is that for people to avoid relapse – and in modern terms to recover from disorders such as schizophrenia it is important that expressed emotion is managed. At first this is managed by the care workers but over time the individual is helped to develop the skills they need to manage the amount of expressed emotion they are exposed to for themselves and also to deal constructively with it when it does occur. In short they develop the sorts of skills and environmental management techniques that most people use without thinking about it.
Brown’s original work was interested in the roles of families but the principles apply equally to any social group including care settings.
In many ways the idea of High Expressed Emotion is simply a way of restating the much older beliefs of William Tuke, an 18th century quaker who developed ‘Moral Treatment’, a method of working with the ‘insane’ that involved respect, value and meaningful contribution. Somewhat radically it also involved reasonable food and clean accommodation. Tuke founded the York Retreat in the 1790s with apparently remarkable success using little more than respect for the individual, good basic low tech care and an ethos of involvement and appreciation.
So we begin to see that the importance of good quality social interaction and supportive environments is not to be underestimated. Clearly the person best placed to influence the environment of the individual is the person who is there most of the time. That is not the therapist or the psychiatrist – nor is it likely to be the community psychiatric nurse or social worker. The person who has most influence over an individual’s social environment is the unqualified and often unsung support worker or care assistant. Their work, and their attitude to that work is one of the most crucial elements of the care process. Without them all the therapy in the world will fail because the service-user will be too distracted dealing with their real world difficulties to think about the sometimes difficult issues raised in therapy sessions.
One way that I explain this to unqualified workers in training sessions is this:
“Your stuff works without me. My stuff can never work without you. Now then – who do you think is most important?”
More recent research was conducted by the World Health Organisation in two consecutive studies over a period totalling 25 years. Collectively the studies are known as ISOS or ‘The International Study of Schizophrenia’. This study produced some remarkable results. In short it demonstrates that places where there is good social support, involvement and respect – where the individual is valued tend to have much higher recovery rates than the developed world where there is access to high-tech medications and talking therapies but a stigmatising culture. Once again – the emphasis is upon social situations rather than treatment. (Harrison G. et al 2001).
Similair findings are reported by the British Psychological Association in the ‘Recent Advances’ document from 2002. This describes a number of psychosocial approaches to psychotic and other mental disorders.
Key to the findings of the BPA is the concept of the self-fulfilling prophecy. This is the ‘give a dog a bad name…’ principle that seems to be mirrored throughout human existence. As a general rule people live up or down to the expectations others place upon them. If then, support workers do not expect their service-users to recover there seems little likelihood that they will.
This phenomenon was best identified some 40 years ago in the famous ‘Pygmalion in the classroom’ experiment at ‘Oak School’ by Jacobson & Rosenthal. Fortunately their original work has been reprinted and is available again. It is well worth a look (Rosenthal R. & Jacobson L. 2003).
When we bring all this information together it is obvious that the most important part of any multi-disciplinary team working with mentally disordered people is not one of the professionally qualified, highly skilled and lettered clinicians who sees the service-user rarely and briefly. The most important work is done by the unqualified support workers and care assistants who work day in, day out to develop good quality relationships with individuals, not patients and who have the power in many cases to influence the environment in which those people spend their time.
To ignore the value such care workers bring to the team is to miss the point entirely. We professionals are far less significant than we might think. A healthy acknowledgement of that simple truth may be a very good and appropriately humbling place to begin.