Maintaining the problem

The Mental Health Workers' Guide part 40

Part 40 of The Mental Health Workers' Guide makes the simple point that if we keep on doing what wer're doing we'll keep on experiencing the same consequences. If you do the same things you get the same results. Don't forget that you can download all the podcasts and video clips that accompany this series here.

If you do the same things - you get the same results

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

The Mental Health Workers' Guide part 38

Part 38 of The Mental Health Workers' Guide is the second of two posts dividing challenging behaviours into categories tht we need to understand before we can decide what to do (or not do) about them. Don't forget that you can download all the podcasts and video clips that accompany this series here.

The Guide 38: Do we need help?

Let’s look at two other ‘categories’ of challenging behaviour:

• Behaviours that we can cope with;
• Behaviours that are beyond our ability or authority.

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The Mental Health Workers' Guide part 37

Part 37 of The Mental Health Workers' Guide is the first of two posts dividing challenging behaviours into categories tht we need to understand before we can decide what to do (or not do) about them. Don't forget that you can download all the podcasts and video clips that accompany this series here.

The Guide 37: Different types of challenging behaviour

The Mental Health Workers' Guide part 36

Part 36 of The Mental Health Workers' Guide presents a simple working definition of challenging behaviour that is more than just a collection of lists. It's an easy to understand, two point system that is far more use to workers 'on the ground' than the endless moralising we often come across in health and social care. Don't forget that you can download all the podcasts and video clips that accompany this series here.

Challenging behaviour means....

There are many different definitions of challenging behaviour. Some rely upon long lists of activities and behaviours that society sees as unacceptable. Others attempt to define the concept philosophically by referring to the works of ethical or moral authorities, sometimes dating back thousands of years. Throughout this series we shall use a fairly simple definition.

Challenging behaviour is a combination of two criteria:

1.     Behaviour that we don’t like;

2.     Behaviour that we think we need to respond to.

According to this definition both criteria must be met before we can say that the behaviour is challenging. For example, someone somewhere has been attacked within the last thirty seconds (a statistical certainty). I am not challenged by that because I am not in a position to respond to it. Therefore the behaviour is merely something I disapprove of but it is not actually challenging to me because there is nothing for me to do about it.

It’s important to get the sense of this definition clearly in mind before we go any further with this topic. Much of what people think of as challenging behaviour is not really challenging at all. We don’t have to respond in every case. Arguably, if we do respond and try to prevent people from doing things that they have a perfect right to do then the truly challenging behaviour is our own – not that of the service-user. Disagreeing with the care staff is not necessarily a challenging behaviour – it’s just a choice.

One of the most common problems among health and social care workers is the assumption that they have to ‘deal with’ behaviours that they do not personally agree with. This isn’t always true and by adopting a more flexible approach to the choices of service-users we can avoid many of the conflicts that make this work so difficult in practice.

Another important theme throughout will be the rights of the worker to be free from abuse, assault or harassment. The law in UK, in particular the Health & Safety at Work Act (1974), is very clear on the responsibility we all have to keep ourselves safe and the need for proper assessment of risk in order to ensure the safety of the service-user but also that of the worker and the person’s other carers or relatives. We’ll also consider ways to strike a realistic and reasonable balance between the needs of all concerned and the rights of all people to be safe and free from abuse.