Category Archives: Violence

Physical Restraint: The Story Behind the Stats

As Mind publishes survey data and calls for a ban on face-down restraint, The Stuff of Social Care looks at the issue from the point of view of those doing the restraining

It’s been a long time since I last took part in physical restraint, but for many years I did work in environments where the need to prevent harm was part and parcel of a nurse’s working day.

For the most part we relied on the first resort. Talking, listening, reasoning, observing. Using a rapport that may have been built up over a period of time, and developing skills that were fundamental to working with highly distressed, agitated people. For most of my nursing career I was lucky enough to work in well-staffed forensic units where staff and patients knew each other well, and where the very thought of an agency or locum nurse was unimaginable.

But at times the last resort was unavoidable. Most of the trained, professional staff I worked with would much rather not use physical restraint. Like me, they would loathe the idea of holding down another human being to inject them with powerful drugs. But when all else has failed, or extreme harm was imminent, or where leaving a severely psychotic man or woman unmedicated would almost certainly leave them more terrified, confused and at risk than they already were, then I for one would not lose any sleep restraining that individual.

By the time I had qualified as a nurse, physical restraint had gone from the often chaotic bundle of arms legs and torsos of my student days toward a set of techniques called Control and Restraint (C&R), a Home Office approved means of managing physical aggression. I along with my colleagues attended regular training in C&R. We turned up at sports halls in trackies and trainers spending hours and days learning and practising the management of physical aggression.

A major (and rather unpopular) part of the training involved role-playing ‘the patient’ and being subjected to the procedures oneself. C&R was based on a 3-person team immobilising the patient. It used a certain amount of discomfort and even short bursts of pain to contain violent people, a fact which we as the role player would be only too well aware. Some of the techniques we learnt involved immobilising the patient face-down on a floor or bed. The reasons for this were that a) the person on their back can fight back much more effectively than if they are face down, and b) saliva and teeth make very potent weapons when they belong to a person who really, really doesn’t like being held down on a floor by several nurses. A key part of the 3-person team was the ‘head’ man or woman, whose job was to ensure minimum discomfort for the person on the floor and protect their airway.

But apart from the actual physical techniques, a fundamental of the training was that physical restraint was absolutely a last resort once every other strategy had failed, or where danger was imminent.

There are those who believe that physical restraint of the mentally ill is little more than state-sponsored thuggery, or who wonder whether restraint is necessary at all. Well, physical restraint is a necessary part of mental health care at times. That’s an undeniable fact, but it’s easy to see why and how restraint gets such a bad press, and why bodies such as Mind need to spend time, money and effort surveying it’s use.

We need go little further than Winterbourne View to acknowledge the presence of thugs masquerading as care professionals. From the very first emergence of the lunatic asylum, the opportunity to get paid for wielding power, authority and physical dominance over others has always proved attractive to a certain type of psychopath.

But there are much deeper and wide-ranging reasons why physical restraint may be over-used or abused. Mental health care certainly needs a sensible, contextualised and much broader discussion about physical restraint per se, and the reasons behind it’s use and misuse. The ‘face down’ issue is perhaps something of a narrow lens, and when 22% of staff report not having had face-to-face training in the last 12 months, we need to ask why that is.

I have a few observations. Questions about restraint are far from being a solely modern phenomenon, but for those whose 7.5 hour shift seems incomplete without a dose of adrenalin-pumping action and a ‘good decking’, current conditions have never been better.

Beds are disappearing. Only the very sickest of the sick have access to hospital treatment. The most distressed and disturbed are funnelled into smaller and smaller pockets of in-patient chaos, often provided by companies with shareholders and profit margins to maintain and gladly filling the gaps left by the running down of NHS in-patient psychiatry.

I would hope that such critical care would be delivered by the sort of skilled, well trained staff I described earlier. This all too often isn’t the case. Many of our most severely ill patients are being cared for by agency and locum staff with bare minimum training, a lack of experience and often poor communication skills. Many will barely know the names of the people in their temporary care.

This is where the ‘jump on, grab a limb and for f*** sake make sure they’re still breathing’ model of managing potential and actual aggression is practised today much as it was in the dungeons of Bedlam.

Right at this moment, someone, somewhere is in a psychiatric unit posing potential or actual danger to themselves or others. People with mental disorders can and do become violent, and staff are needed to contain the violence and minimise that risk. Hopefully they are with staff who can reassure, listen and diffuse aggression with empathy and skill. They are trained to use restraint safely and appropriately, and to be able to make decisions as to when and how it is used.

Mind’s survey results suggest this is all too often not the case.

Homicide, Suicide and Mental Health: Time for a Rethink?

In the wake of yesterday’s ONS crime statistics revealing a major drop in homicide rates in England and Wales, has the ‘inquiry culture’ made any significant impact on mental health-related tragedies, and is it time for a rethink? 

If you’ve worked in front-line mental health at any time in the last two decades, there’s a small but not insignificant chance an independent inquiry has shone it’s torch at you, your colleagues and your collective role in a homicide.

Yesterday’s announcement suggests a downward trend in homicide rates, but before 2011-2012 there were between five and six hundred and fifty homicides recorded in England each year (National Confidential Inquiry, 2012). On average around ten per cent of these deaths will have been committed by a ‘psychiatric patient’, or to be more precise, by a perpetrator who has been in contact with mental health services within a year prior to the offence.

This relatively small contribution may come as a surprise to the more indignant ends of the media. And it is hardly a damming indictment of community care, especially as only a proportion of ‘psychiatric’ killings will have been committed as a direct result of psychiatric pathology such as command hallucinations or paranoid beliefs.  A mentally ill killer doesn’t necessarily kill for reasons that are different from anyone else.

Nonetheless, this is still fifty or sixty people a year dying at the hands of someone whose name is on the books of a mental health professional, and the question of preventability is one that must be asked.  And it does. Dozens of times a year.

Independent inquiries into mental illness related homicides were made mandatory in the wake of the Ritchie Report of 1994. In the light of criticism about their continued usefulness, not to mention the weighty invoices for an army of psychiatrists , barristers and other senior personnel who make up the panels, the ‘mandatoriness’ was slightly relaxed in 2005, but still we are seeing dozens of publications a year of inquiry reports which were once headline news but are now so common as to be barely noticed.
Homicide is not the only adverse event to trigger independent inquiries. Suicides, sudden unexpected deaths and safeguarding events can all be subject to scrutiny where circumstances dictate, generating what is now a vast library of reports, findings and recommendations. We are all aware of the benefit of hindsight, and there’s certainly no shortage of it here.
Lack of communication, inter-agency squabbling, non-adherence to the Care Programme Approach and poor or non-existent discharge procedures are all among the usual suspects to appear within the panel’s cross-hairs. We will also read frequent accounts of agencies such as the police, mental health professionals and social services treating each other as if they had a communicable disease. 

But other themes are also present in abundance. Professional disinterest. A ‘more than my jobs worth, guv’ attitude. Rigid bureaucracy and referral criteria trumping good clinical judgement. Oh, and we nearly forgot a lack of common sense and sheer incompetence.

We should all by now have learnt our lessons. We should have developed evidence-based, multi-agency training in prevention of violence and suicide. We should have developed collaborative approaches to working with crisis and risk involving everyone within a community who works with mental health: Community Mental Health Teams, the Police, Parmamedics and Support Workers. Everyone.

We should have developed collaborative, reflective approaches to analysis of adverse events and ‘near misses’ which involve service users and those so often excluded from deliberations, the families and carers. And we should have developed robust policies and procedures which mean risk work becomes a key clinical skill and not the ticking of a few boxes on a side of A4.
But while there is certainly evidence that care providers have followed recommendations at an organisational level, have eighteen years of automatic inquiries really made an impact at the sharp end of care and support? Are inquiry recommendations actually being followed and learnt from in day-to-day practice, or are the reports offering little more than a handsome hourly fee for their very expensive authors?

There is no evidence of any decline in the rate and frequency of homicides, suicides or other adverse events. Suicides are becoming less frequent among in-patients, but is this due to improved care on the wards or to the fact that trusts have followed previous advice from the NCI in removing ligature points such as curtain rails? And why has there been a rise in suicides among patients in ‘home care’? 

The faults highlighted by countless inquiries and repeated here are still happening day in and day out. I don’t need a literature review to know this – I’m a trainer. I see and hear the horror stories from staff all over the UK and from a wide variety of settings. So if these are the problems, where are the solutions?

I have two very simple, affordable suggestions for mental health care which may (if you’ll forgive the drama) save lives.

Firstly I would very strongly support the suggestion that we now abandon the independent inquiry system and hand responsibility for the scrutiny of adverse events to the National Confidential Inquiry. One centrally organised body using standardised methodologies to examine homicides, suicides and sudden unexpected deaths, feeding their work directly into a programme of training and research that directly links evidence with day-to-day reality.

Secondly, I think it’s time for a change in how front-line mental health services work with risk. We’ve seen painful evidence over many years of how the collective will, for a variety of reasons, make mistakes and allow tragedies to occur.

Perhaps it’s time for an individual response. A Risk Practitioner.  Or even, if you prefer the dramatic, a Troubleshooter.

An experienced individual who knows what can happen, has an intimate awareness of the inquiries and evidence base, can coach, micro-teach and work alongside front-line colleagues, and has the ability to link agencies, teams and individuals together  in a way that we seem patently unable to do when left to our own devices.

If this sounds rather fanciful, it’s been done. Unfortunately the very partisan forces that so often plague inter-agency working brought my particular project to a premature close, but as a Forensic CPN I once worked closely with an Assertive Outreach Team fulfilling pretty much the job description outlined above. There was of course a little more to it than that which might have benefitted from formal audit or research, but as proof of concept it worked extremely well.

The tragedy of psychiatric disaster is far more real and important than any number of statistics or findings or recommendations. If even only a few of these events is preventable, then surely we should be sitting up and taking notice of how to do the precenting. Maybe it really is time to try something new. 

This post was written as part of a Risk and Mental Health project currently in preparation by the author

The Occasional Tragedy of Mental Health

A Problem of Understanding
I used to work with people who had committed the most serious and often disturbing of crimes. All in all I spent twelve years in very close proximity to patients in secure psychiatric units. I played cards with killers, badminton with rapists and darts with men you had last seen played by an actor on Crimewatch.

I’ve been shopping with people who hadn’t seen a town centre for twenty years. I’ve handed out tissues to those still haunted by what they had done, and locked up patients in small secure rooms as the voices commanded them to kill anyone within range of a pool cue.

I’ve had the sort of conversations you could and should never forget with fellow human beings who have done unimaginable things. But one thing I have never done is to understand.

Not for want of trying or because I wasn’t clever enough. I ‘got’ the psychopathology of the psychopath. I ‘got’ the biochemistry of psychosis. I ‘got’ the medical model and the social model. But faced with someone who had tortured a child, blown off a neighbours head with a shotgun, or knocked nails into someone’s skull, I simply failed to truly understand.

Thirteen-year old Casey Kearney was walking through a park on her way to a friend’s. She was stabbed by a woman walking in the opposite direction. It wasn’t a frenzied attack, just one brief blow with a one of two kitchen knives purchased earlier that day by a woman called Hannah Bonser, who simply continued on her way before turning up at a local mental health resource to confess to what she called “a silly thing” and hand over her knives.

This was an appallingly random act of extreme violence. Bonser would have expended more time and energy stopping to ask her victim for the time. For any parent to imagine the deliberate killing of a child is not only incomprehensible, but entirely unimaginable for any more than the most fleeting of dark moments. But Casey Kearney’s family have had to deal with this reality since February 14 this year, and have no doubt tried and failed to make sense of the senseless.

Making Sense of the Senseless
Hannah Bonser was yesterday convicted of murder and sentenced to life imprisonment. She will serve an absolute minimum of twenty-two years before being able to seek parole. Those not involved with the case might have been surprised that Bonser did not receive a Mental Health Act hospital order and a conviction for Manslaughter rather than Murder.

After all, this was a bizarre and random killing committed by someone well-known to mental health services for some time before the event. Her legal defence argued she was suffering from Paranoid Schizophrenia at the time of the offence, and that her responsibility for the crime was therefore ‘diminished.’ The jury did not accept this argument.

But as with all homicides involving mental health service users, an independent inquiry will now take place in the aftermath of the trial. Like the dozens that have preceded it since the mid-1990s (when such inquiries became mandatory) the report will provide a public and detailed account of Bonser’s relationship with mental health services in the months and years prior to February 14th 2012.

As both a practitioner and trainer who has read with depressing regularity how tragedy has resulted from the failure of various services involved in mental health care over the years, I very much hope we will not be hearing from the usual suspects. Failures of communication, lack of information sharing, poorly motivated professionals, bureaucracy. All these and more have become depressingly familiar to readers of such reports, but seldom appear to change the way we work with potentially dangerous people.

What’s in a Diagnosis?
For some months prior to the killing, a close friend of Hannah Bonser had noted how her behaviour had become increasingly unusual. She claimed that her flat was possessed by demons. Her self-care deteriorated and she travelled down to London, where she slept rough and searched for a character called ‘Simon of Lambeth’. She was detained under the Mental Health Act before being transferred back to a Doncaster hospital, but was discharged shortly afterwards. Life appears to have become increasingly disjointed and chaotic. Shortly before Casey’s death, her killer had presented to mental health staff stating she was hearing voices commanding her to harm others.

Her legal defence was that her actions were driven by severe mental illness. It’s well beyond the scope of a short blog post to attempt to describe what we mean by this, but on current evidence we could state the following. That at the time of the offence her brain was showing signs of abnormal structural and biochemical functioning and was interacting with an environment which to Hannah Bonser would be a very, very different place to how most of you reading this would experience that environment. It may have been quite a terrifying place. Perhaps terrifying enough to randomly stab a complete stranger.

The prosecution argued that Bonser was not psychotic but suffered from a Personality Disorder. We know even less about the inner workings of PD than Schizophrenia, and argue about it a great deal more. This diagnosis would imply that the person is fully aware of one’s actions and knows exactly what they are doing, even when what they are doing is indescribably unpleasant.

The Sadness of Madness v Badness
The difference between severe mental illness and personality disorder is characterised by some as the ‘mad versus bad’ dichotomy. This is a very false dichotomy. In fact, it’s not a dichotomy at all.  The opposite of ‘mad’ is ‘sane’ and the opposite of bad is of course ‘good’. It’s an old and rather stale argument often used by lazy mental health professionals to characterise the difference between behaviours which are driven by ‘genuine’ and ‘proper’ mental illness on the one hand, and behaviours which are apparently ‘manipulative’ or ‘attention seeking’ on the other.

Being ‘Mad’ is beyond both the conscious control of the sufferer, and the moral judgement of others. It warrants our intervention, diagnosis and treatment, particularly with pharmacological means which offer a quick and relatively simple solution to ‘Mad.’

But ‘Bad’ is just, well, bad. If it isn’t ‘Mad’, isn’t a psychiatric problem, we needn’t offer an intervention. Personality Disorder is ‘Bad’ and this is what Hannah Bonser is now judged to be. She’ll go to prison not hospital.

The jury at Doncaster Crown Court accepted medical evidence suggesting Bonser suffered from a Personality Disorder. Essentially, she knew what she was doing.

The conception from both the public and aggrieved families is often that a ‘proper’ sentence is infinitely more acceptable than the apparently soft option of a psychiatric bed. Part of the argument around this case was that the stabbing of Casey Kearney was a calculated and manipulative act designed to achieve Bonser’s demands for hospital admission. To have received a Mental Health Act section might have been seen as a triumph for Bonser’s manipulation, and one could understand how that might be seen as unacceptable by many.

To Inquire or Not Inquire?
Nonetheless, an inquiry will now take place and the report will tell us something of how a family have lost a 13-year old girl who just happened to be in the wrong place at the wrong time. The court has already delivered it’s verdict on Hannah Bonser, but the inquiry will hopefully reveal a highly complex interaction between a twenty-six year old woman, her troubled background, her environment, her mental state, the services she turned to for help and the killing of Casey Kearney.

There are some who now call for the end of mandatory inquiries into each and every mental health related homicide. I wouldn’t disagree. It’s a hugely expensive procedure which, as we’ve already seen, throws up very similar conclusions time after time without seemingly making much difference.

But perhaps we should continue to study events such as these which, incredibly rare as they are, remain sufficiently horrific to merit the deepest scrutiny and may help us to at least try to prevent the preventable in future.

Talking Out of One’s Arse: The News Media and Armchair Psychology

Daniel Bartlam was yesterday sentenced to life imprisonment for killing his mother. Apparently inspired by screen violence in the guise of horror movies and TV soap storylines, he’s inevitably been dubbed the ‘Coronation Street Killer’ and provoked the now customary howl of online indignation. So far, so predictable. But along with the indignation has come a digital tidal wave of armchair diagnosis. The cod psychology inspired by this case features ‘inner worlds’, ‘trauma’,  the effect of pre-watershed television violence and, most alarmingly, the possibility of child abuse as a mitigating factor. But one feature all these armchair theories have in common is the almost complete lack of history, evidence or narrative around either Bartlam or the offence itself.

Shortly after the sentencing of Bartlam, The Guardian’s Comment is Free section ran an article titled Why Children Kill Parents. Accompanying the piece was the now familiar and rather haunting photograph of Daniel Bartlam. Philippa Perry, the writer of the piece, is a psychotherapist and author of a book called Couch Fiction.  She apparently specialises in work with adult survivors of childhood abuse. If she had any specific experience working with violent young people, or even ‘children who kill parents’, it didn’t appear on her author profile. At the time the piece was first published* her profile also mentioned that she was married to well-known artist Grayson Perry.

I was puzzled from the start. If The Guardian wanted a companion piece and online discussion around the Bartlam case why not find someone from the world of forensic child and adolescent psychology? And what was the relevance of the author’s marital status? This seemed the editorial equivalent of asking me to write a ‘pop-science’ piece on quantum mechanics because I use a mobile phone, or inviting Frank Lampard’s ex-girlfriend onto Strictly Come Dancing because well, she used to be Frank Lampard’s girlfriend.

To her credit the author made no attempt to ‘diagnose’ Bartlam, and presumably did her best to quickly bang out a few hundred words at the request of The Guardian’s CiF editor. She more or less stuck to her area of expertise which is helping adults who’ve been abused. But is that telling us anything about ‘Why Children Kill their Parents’? And more pertinently, did the author have anything to say about a case where there is absolutely no reported evidence of abuse as an explanatory factor?

No, of course not.

But what alarmed me even more than the article itself was the swarm of armchair psychologists, usually hiding behind silly avatars and even sillier acronyms, gathered online to spout thousands of words on everything from John Bowlby’s Attachment Theory to how the victim should never have bought her son an iMac. In keeping with the article itself, abuse was a constant theme from our cohort of keyboard shrinks despite no evidence whatsoever that this was in any way connected to the case.

At this moment in time nobody but those closely involved with the Bartlam case knows anything about this boy nor the circumstances of the offence beyond the bits and scraps reported by the news outlets.

For the online media (of which The Guardian is only one example) to be spreading and encouraging ill-informed or completely non-informed speculation as to how a 14-year old boy can become a hammer-wielding murderer is more than just pissing into a very strong wind. It is harming those personally involved in the case, harming our understanding of violent young people, and spreading even more ill-informed psychological rubbish than is already the case. 

And that’s a mighty big case.

*The Grayson Perry reference has now been removed from the author’s Guardian profile. 

Supporting People: Not

Many local authorities are now slashing and burning their way through vital community services, leaving highly vulnerable people without essential support. Thanks to Keith Cooper and the Guardian Housing Network for inspiring yet another sleepless polemic, mostly aimed at ‘Dave’  

It’s not often I start a post with a big, fat, steaming turd of a lie, but let’s do it anyway. I offer my apologies to all turds for the comparison. They really don’t deserve it:

“And I want to say to British people clearly and frankly this; if you are elderly, if you are frail, if you are poor, if you are needy, a Conservative government will always look after you” David Cameron: 4th May 2010

Courtesy of The Guardian

I remember watching with awe and amazement Cameron spouting this mantra over and over again on the pre-election campaign trail. He said it on the live TV debates. He said it on visits to Day Centres, usually with sleeves rolled up and gurning over a girl in a wheelchair. He said it bloody everywhere to anyone who would listen, and I remember thinking how remarkable it was that the leader of the Conservative Party was starting to sound like the hybrid spawn of Ghandi, Mother Theresa and that nice lady in Borehamwood who devotes her life to saving hedgehogs.

But ‘spending’ and ‘cuts’ were never far from the spiel either, Cameron’s point being that whatever they had to do to reverse the public sector overspend of the previous mob, it’s okay. Vulnerable people wouldn’t suffer. “A Conservative government will always look after you.”

The awful truth of what is happening to community care has been slapping me in the face like a wet fish ever since the grinning Dave and Nick garden party at No.10 way back in May last year. I earn a living running courses for social care staff up and down the UK, and I notice things. I notice how much less cheerful are the delegates who come to my courses. Is it my crap jokes? Have people really become homicidal at the mere sight of a Powerpoint slide? Well, probably yes, but this hasn’t been the reason for the pervasive gloom in my training rooms. 

The fact is, I’m working with large groups of people who are not only attending the last course they’ll ever get under the previous training budget, but more seriously are facing the prospect of reapplying for their own jobs, or being handed a P45 and a note of thanks ‘for all their valuable service’.

These aren’t the bureaucrats and middle-managers with incomprehensible titles and Mickey Mouse job descriptions. These are front-line, face-to-face support workers who do the often gutty work of helping people who really can’t get on in life without the help of that Warden, Carer or Support Worker who helps out with anything from benefit claims to suicide prevention. 
But sometimes something is so blindingly, dazzlingly obvious that it never really hits home until you see it in black and white. On paper or on a laptop screen, the effect is the same. And yesterday, thanks to The Guardians Housing Network, I read the confirmation of all that I’ve been hearing these last sixteen months:

Courtesy of The Guardian: Author Keith Cooper 22.8.11

Supporting People cuts leave housing sector unable to help most vulnerable

Now I can certainly help you understand why a 17-year old service user stubs out fag butts on his arm or help you devise a risk assessment and management strategy for your supported housing service, but mention ‘ring fencing’ or ‘local housing allowance’ and I’m likely to look at you as if you’re spouting the combined works of Stephen Hawking in Mandarin Chinese. But I do know a little about Supporting People, the programme of funding established specifically to provide community support for vulnerable people. 

People whose lives are shattered by mental illness, drugs, alcohol, homelessness or often a bit of each. Ex-offenders, people with learning disabilities or the frail elderly are also the very folk supported by Supporting People, usually with the invaluable provision of four walls and a roof, and a regular visit of one of those front-line, face-to-face support workers.

Supporting People (SP) is a fund distributed to local authorities to spend on housing and support provision for vulnerable people. The providers may be in-house local authority staff, but are more likely to be independent providers or charities who receive a portion of the local SP pot every year to help those who really can’t get by without support. The Guardian report highlights the massive re-allocation by some (not all) local authorities of SP budgets away from their original targets and into … well, I don’t know what, but it certainly isn’t going to be spent on providing sheltered accommodation and a warden for 80-year old Doris, or helping Gary get his life back on track after a 5-year jail term. 

David Cameron and Housing Minister Grant Shapps will undoubtedly argue that their government have barely touched SP funding (true), and it’s those nasty councils who’ve pulled the rug right from under the already unsteady feet of the vulnerable. But this sounds to me like Hitler blaming the Holocaust on a few SS officers who got a bit over enthused with the gas tap.

But back to my real world – the training room, where I spend coffee breaks and lunchtimes staring disbelievingly at yet another support worker telling me “Yes, Connor, this is a very useful course, but to be honest I’ll be stacking shelves in Tesco in six months so there won’t be much call for your insights on Dual Diagnosis.”

And I ask, rather fearfully, what will happen to the twenty or so clients on their caseload when they’ve chopped the staff allocation in half? “Don’t know. Haven’t a clue” is invariably the answer, but neither of us needs a crystal ball to imagine the misery, the mayhem, the reversal of fortunes and the undoing of what often amounts to years of hard work by a support worker who, whether at the end of a phone or the end of a sofa, is quite possibly turning lives around and staving off inevitable chaos. 

I often use a technique called Mind Mapping to help staff think about the work they’ve done, often for a particularly difficult or vulnerable client. There are inspiring success stories, the odd dismal failure, but more often the seemingly humdrum case of a service user encouraged to reduce their intake of White Lightning from four litres a day to two. 

I ask the support worker a simple question: “Where would this tenant be if it weren’t for your support and a roof over their head?” The answer is usually death, prison, homelessness or very long spells detained in a psychiatric unit.

With rapidly diminishing training budgets and fewer and fewer people left to do training with, I don’t expect to be asking these questions for very much longer, or to be talking job security over coffee and biscuits. But if I were, I’d expect the answers to feature less and less inspiration and more and more White Lightning.

Thanks for that, Dave.

Challenging Behaviour: How to Avoid Kicking the Cat

I ran a course yesterday for Residential Care Staff. The imaginatively titled Challenging Behaviour and Dementia course is always interesting in that it reminds me of some of the difficulties care staff have to face, even working with elderly clients. As always, the story of the course is that even little old Doris (85) can and does pack quite a punch when she wants to!

Now according to Google there’s an awful lot of people typing ‘challenging behaviour’ and ‘challenging behaviour definition’ into the little white box, which means if you’re here right now you’re a) writing up a college project or b) working with a bunch of service users/patients/clients who are posing difficulties of one form or another.

Now, I know how it works with students. You just want something quick and dirty to cut and paste into your Word Processor. Yep, been there. So if you just want a definition, here it is. In fact, here’s two!

Definition 1: ‘any behaviour which negatively effects both the ’perpetrator’ and those around them to a significant and/or frequent degree’ (Kinsella 2010)

Definition 2: Culturally abnormal behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities (Emerson 1995)

If that’s fulfilled your essay needs, glad to be of service. Bookmark this page and we may see you again ….

Otherwise, hang on in there.  We’re going to outline some of the key skills we need in dealing with the sort of challenging behaviour which can be problematic, highly unpopular, scary and generally pretty awful, often to the point where we really don’t want to go into work and face another shift. But challenging people with challenging behaviours are no less deserving of our efforts than anyone else, so let’s take a brief look at some of the stuff from the JCK Training Managing Challenging Behaviour course which I hope might be helpful and even save you that extra bottle of wine/shouting at the TV/shouting at family and those occasional feelings of wanting to put our heads through a wall. And of course, we want to avoid kicking the cat. Working with Challenging Behaviour is’nt easy.

The nature of challenging behaviours presented by an elderly care home resident may be very different from those presented by, for example, a young person with borderline personality disorder, but the way we are going to approach the behaviours does not change – we are going to try and replace instinctive, reactionary responses with a more systematic, model-based approach. But first we need a few basic assumptions.
  1. Any service user (or human being for that matter) has the potential to behave in ways which are anti-social, aggressive and likely to have a negative impact on themselves and others. In fact, think of the last time you phoned a call centre. After spending five minutes listening to Greensleeves (no, bloody Greensleeves) interspersed with the patronising grind of ‘your call is important to us but please hang another minute while we make another £4 billion out of your sorry arse’ before eventually getting to speak to a human being called Malcolm, you are probably going to feel like telling Malcolm to shove his headset somewhere dark and possibly a bit damp. See? We can all get a bit challenging sometimes.
  2. The service user is at the heart of our discussion, assessment, planning and evaluation. This may appear to be a statement of the obvious but once a challenging individual has become associated with aggression or worrying behaviour (or put less technically, ‘scared the crap out of us’) that person can easily become marginalised and begins to drift further and further from involvement in their own care. We shall try to avoid this as much as possible although it’s fair to say that some service users will never be able to participate in their own care. In which case a family member or nearest relative  will hopefully be only to glad to be involved. 
  3. It may seem at first glance that a person with severe cognitive impairment caused by dementia or a learning disability behaves in unpredictable, random ways, but all human behaviours occur for a reason and attempting to identify why challenging behaviour occurs is a key aspect of our project.
  4. We are not aiming to ‘cure’ the service user of their challenging behaviour. We are simply aiming to reduce the severity and frequency of the target behaviour so that life is better for the service user and people around them.
  5. Our final assumption is that the advice offered here can offer generic principles of good practice and a guide to using a structured approach. However, there are no magic wands. Local conditions, client characteristics, resources and restrictions will all govern how challenging behaviours are defined and recognised locally, and how we go about managing these behaviours.

The CAPEd (sic) Crusader
In our Challenging Behaviour course we introduce a framework for working with challenging behaviour. Like all frameworks or models we tried to come up with a sexy acronym to help you remember the various bits, but all we could come up with was CAPE

Yes, BANG, WHIZZ or KAPOW might have been more appropriate (and sexy) but the letters didn’t fit. So we have CAPE. So what does CAPE stand for?

  • Clarification
  • Assessment
  • Planning
  • Evaluation

Let’s take  look at these stages and what they mean for us.

We start by asking the question: What is the behaviour? This may at first sight appear a simple and straightforward task, but there are some common pitfalls especially when writing down or recording an incident in a service user’s notes or in untoward incident documentation.  We need to be careful here to actually describe the behaviour, not the emotion behind it. 

Writing ‘he got very angry’ in your notes is a description of how he feels, not of the behaviour itself. Right now we need to simply record what has actually ‘happened’. For those of a grammatical bent, we need ‘verbs’ not ‘adjectives’.
We also need to be aware of the possibility that an incident we are trying to describe may become the subject of further investigation, for example by the police or by a safeguarding vulnerable adults panel, so detail is good. Very good.

A key determining factor in where we go next is whether a behaviour meets a stated definition of challenging behaviour. We have defined challenging behaviour above but of course I’m here and you’re there. Local circumstances and environment will be key in determining what is significant or frequent enough to warrant further assessment and perhaps an action plan.  A person banging their head against a wall or shouting at a support worker will be seen in quite different ways in different environments, which in itself will demand quite different plans and interventions.

The first stage of our framework has asked the ‘What’ question. Our Assessment stage is where we attempt to look at the Who and Why and How questions, so perhaps we are going to get our hands a little ‘dirtier’ in this stage. But the effort expended will be well worth the effort as we attempt to address problem behaviours rather than simply accepting, putting up with or condemning them.

So where do we start? Hopefully with a clear and concise description of an incident or series of events based on our Clarification stage, but remember this is a structured, proactive approach to challenging behaviour and there are some key questions we may wish to ask:
  1. Is there Consensus within a staff team that what has been observed constitutes challenging behaviour according to an agreed definition or baseline?
  2. What is the Frequency of the behaviour? Are we looking at a standalone event or one of a series of incidents?
  3. What is the Impact of the behaviour? Ask the same question of the service user him or herself, and depending on location and circumstances, support staff such as yourselves, family members, neighbours or other.  Or couched in other words, who were the victims of the behaviour and how are they affected?
  4. If a there is a Victim as such including of course, the perpetrator(s), what are their characteristics? This is particularly important if there is a regular pattern to the challenging behaviour.
  5. Is there a Pattern of behaviour? In residential care for example, mealtimes are often a flashpoint for confrontation. Over a longer period of time, seasonal changes may be important or incidents may be seen to occur at a particular time of day.
  6. Is there a Precipitant for a person’s behaviour other than those we have already mentioned? Remember our starting position that behaviour almost never occurs purely at random regardless of the cognitive or functional abilities of the perpetrator. 
  7. Drugs and Alcohol. It may be a question of judgement whether or not we refer to substance use or misuse, but most of us are more than familiar with the association between intoxication and self-destructive or anti-social behaviour.  Our assessment may require more than a simple association between, for example, a client’s habit of drinking a four-pack of nuclear strength lager for brunch and his or her subsequent hostility on home visits, but it is always attempting to assess exactly how and why a substance affects the perpetrators behaviour as opposed to simply stating that ‘they get angry when drunk.’

The above is just a small selection of areas we might want to examine during our assessment, but our most useful tool is our own knowledge and rapport with the people with whom we work, and let us not forget that often the best informant of all is of course the person presenting the challenging behaviour. I often find when running courses that the most obvious question of all hasn’t been asked of the challenging individual: Why do you do it? This isnt always an easy question to ask depending on the individual and the circumstances, but can (if put skilfully and non-judgementally) yield surprising results. 

This is our ‘doing’ or ‘intervention’ stage. Whether we are referring to ‘Action  Plans’, Care Plans’, Support Plans’ or any other terminology which essentially means the same thing, most health and social care organisations have some form of written plan which clearly states what we are hoping to achieve and do with a service user.

We need clear consensus between ourselves as a staff member, our colleagues and collaborators from other agencies (such as professionals from Primary Care Trusts or Social Services or supported housing) as to how we describe challenging behaviours, our assessment and how we are going to respond. If and when appropriate, our planning should include as an essential of best practice a clear collaboration between ourselves and the service user.
Remember one of our initial assumption s from our very first page: we are not attempting to ’cure’ the perpetrator or change his or her personality, but simply reduce the frequency of challenging behaviours, the impact of those behaviours on others and themselves, or preferably both.
By now we have hopefully concluded that a consensual, structured, proactive approach to challenging behaviour is more likely to achieve our outcomes than staff response which is haphazard, reactive and fuelled by panic, fear or resignation. There is always the potential for staff who work regularly with challenging behaviours to become ‘over sensitised’ to verbal or physical aggression, self harm, destruction of property or any other of the challenging behaviours we have identified and set out to manage. 

Evaluation is a means of at least trying to ensure that we see worrying or dangerous behaviour for what it is, and whether we are are constantly evaluating informally over a cup of coffee with colleagues and service users, or more formally through meetings and reviews, our intention is to review the outcomes of our Plan in terms of impact, frequency and quality of life, add to our assessment and look toward the short and long term future which will hopefully mean a much better quality of life for service users, and a less worrying time for your cat. 
Emerson, E. (1995) Challenging Behaviour. Analysis and Intervention in People with Learning Difficulties Cambridge: Cambridge University Press.

Kinsella, C. (2010) Working with Challenging Behaviour JCK Training

Visit JCK Training for details of health and social care in-house courses, including Working with Challenging Behaviour

Jared Loughner and the Gabrielle Giffords Incident: Schizophrenia Unravelled

This is an image of Jared Lee Loughner taken shortly after his arrest for the attempted assassination of US Congresswoman Gabrielle Giffords, the killing of six others including a nine-year old girl and the shooting of twelve other victims.

Remind you of anyone? The shaved head, the staring eyes and that entirely inappropriate smirk. A movie director couldn’t come up with a more perfect casting for the role of the classic, crazed lunatic. Jack Nicholson may have had more hair but his character in The Shining is not a million miles away from the caricature of Loughner’s grinning, haunting image. But unlike Nicholson’s Jack Torrance, Loughner killed and maimed people for real. And this is one tragedy fuelled not by ghosts, but by a severe and devastating illness called Schizophrenia.

Yesterday Loughner was judged by an Arizona court to be ‘unfit to plead’. The UK mental health system is in many ways very different to that in most American states, but it’s a basic fundamental of most judiciaries that an accused cannot stand trial if they’re unable to understand the workings of a trial or to be able to communicate meaningfully with their legal defence. It is reported that Loughner has been ‘paranoid’ and distrustful toward his legal representatives, and his bizarre behaviour in court yesterday would certainly suggest someone who would struggle to co-operate with the rigours of any trial, let alone a case as high profile as this.

Medical reports submitted to the court reveal that Loughner has been diagnosed with a severe mental illness called Schizophrenia. He may be many thousands of miles away but Schizophrenia is Schizophrenia in whichever part of the world it manifests, generally at a rate of around one in a hundred of the population.

And other than the fact that he was able to buy weapons and ammunition as easily as we in the UK can pick up a pair of scissors, the history, the behaviour, the disturbed thoughts and the resulting tragedy are as familiar to us as the language we share. But it’s the stigma and misunderstanding surrounding conditions such as Schizophrenia which also struck me as being a common theme to both sides of the Atlantic. A quick summary of comments left on the Yahoo News website suggested that many Americans believe Loughner should be strapped to the nearest electric chair and plugged into the national grid. Asap. Crazy or otherwise.

If you’re already convinced there’s no such thing as a psychiatric defence even to a crime as horrific as Loughner’s, then you may as well click away now and take a look at Photoshopped cats dancing to Justin Bieber. 

But as a UK mental health trainer I’d like to take you on a brief tour around an illness which very, very occasionally leads to events like this, but more often results in despair, loneliness, shattered lives and in some cases death. Not of other people but of the Schizophrenic him or herself. If you’re willing to persevere, read on.  

What is Schizophrenia?
Schizophrenia is a severe, psychotic illness which affects approximately 1% of the population worldwide, including Jared Loughner. ‘Psychosis’ or ‘psychotic’ is one of those horribly misused words beloved of tabloid sub-editors as a shorthand for ‘dangerous’ or deranged’. To be psychotic is to be detached from reality, usually as a result of a mental illness, to the extent that the person becomes trapped in a mental world which is not only very real (and often terrifying) to them, but bizarre and incomprehensible to those of us on the outside not sharing this strange reality.

There are critics who object to the labelling of someone like Loughner as ‘Schizophrenic’. They would rather see mental illness as a complex collection of problems and expressions of distress as opposed to a neat little box of medical symptoms. While it’s certainly true that our key diagnostic ‘bibles’ such as DSM-IV and ICD-10 promote disorders such as Oppositional Defiant Disorder (aka moody teenager) or Hypoactive Sexual Desire Disorder (aka your partner doesn’t fancy a shag), the tendency for psychiatry to medicalise the tiniest tic of human behaviour does at times lead itself to ridicule and there are plenty of examples of the psychiatric ‘system’ treating the diagnosis rather than the person.  

Personally I have little problem with the term Schizophrenia. It’s a distinct form of mental illness clearly describing for hundreds (if not thousands) of years much of the disordered thought, conflicting emotions and perplexing behaviour of people like Jared Loughner.

What are the effects (or symptoms) of Schizophrenia?
Auditory hallucinations are perhaps the first common feature of Schizophrenia to be happily reeled off by the exam room student psychiatrist. The rest of us just refer to ‘hearing voices’.

Voices are neither ubiquitous nor necessary for a diagnosis of Schizophrenia. If you’re hearing the voice of your partner right now telling you to get off that bloody laptop and go do something a little more useful, this may be for real (in which case you’d better save the rest of this for later and do as he or she says!) or the sort of imaginary voice that many of us hear or live with without need for particular concern.

It is difficult to tell outwardly that a person is hearing voices. Unless they’re responding verbally to their voices or laughing/grimacing at what they can hear, or decide to actually tell someone about the voice(s) in their head the soundtrack of Schizophrenia is often a private conversation.

Interestingly, the word ‘hallucination’ may have become something of a misnomer. We are now aware that the brain’s audio pathways respond to ‘hallucinations’ in the same way it responds to sounds that are as real as the radio playing away in the background as I write this. So the voice of God, or Barack Obama or Satan may be a little more real to the Schizophrenia sufferer than the term ‘hallucination’ may suggest. 

Jared Loughner’s psychiatric notes were not released to the public so we have no way of knowing whether he heard voices. It is quite feasible that he was receiving what are known in the trade as ‘command hallucinations’ to do what he did. 

What is not in dispute is the very strange, erratic behaviour he was presenting to everyone that came across him in the years and months prior to the shooting of Gabrielle Giffords and the eighteen other targets of his rage. For some years following his premature departure from college he was reported as displaying an increasing preoccupation with politicians and their shortcomings. Now he definitely isn’t alone on this one. While this doesn’t warrant a psychiatric diagnosis on it’s own merit (imagine the waiting lists for a consult), the significant aspect here is the increasingly focused descent into an all-encompassing obsession, where all that mattered where his own particular objects of attention. As can be seen in what has become a macabre YouTube hit, Loughner became fixated on subjects such as ‘grammar’ and ‘currency’ and the descent of the American dream.

This sort of odd, incomprehensible behaviour is driven by what mental health professionals call thought disorder. Loughner’s strange, jumbled and rather macabre videos paint a picture of just the sort of thought disorder that will be familiar to anyone who has known or worked with a Schizophrenia sufferer. What is said, done (and in Loughner’s case) written may seem like a random collection of words and repetitive ideas, but in the mind of the Schizophrenic they make perfect sense. It’s the thought disorder and behaviour propelled by those thoughts which, often accompanied by voices, become the visible face of someone suffering a severe psychotic illness.

What causes Schizophrenia?
Neuroscience, genetic heredity and good old ‘nurture’ all appear to play an important role in the development of the illness, but long-term studies suggest that a genetic potential for the illness is by no means a guarantee that the symptoms will erupt into Schizophrenia.

When Schizophrenia does emerge, it does so usually in late adolescence or early adulthood. We have known for many years how the environment of a younger person who may already be susceptible to Schizophrenia can play a vital role in flicking the ‘On Switch’ for the effects of psychosis.

It is well reported that Loughner had quite a troubled childhood and was an enthusiastic teenage user of Cannabis and hallucinogenic substances such as Magic Mushrooms, although his use of drink and drugs came to an abrupt end some years before the murders, quite possibly as a response to the increasingly puritanical and quasi-religious ideas that were coming to dominate his thoughts, feelings and behaviour. It has been widely reported that drugs can ‘cause’ Schizophrenia, but this has yet to be proved and is almost certainly not the case. What is looking more likely is that heavy substance use does play a role in impacting an individual’s susceptibility to mental illness, particularly where the young brain has yet to physically mature.

How come he’s ‘mad’ but could drive a car, buy a gun, make videos and post them on YouTube?
If you’ve seen Loughner’s YouTube postings and read or seen the accounts of his descent into illness from people who knew him well, you may well wonder how someone this ill can possibly drive a car, buy ammunition from a Walmart, deal with a traffic cop who stopped him for jumping a red light, and know that a particular politician will be in a certain place at a certain time one Saturday morning. He also has the skills to upload his video contributions to the world wide web.

Well, Schizophrenia involves an unravelling of the personality (not a split personality) and a brain which almost certainly would look slightly malformed and peculiar to the expert eye armed with an MRI scanner. But it only takes a quick skim through Google or YouTube to see that mental illness has little effect on an individual’s ability to perform tasks such as using the internet, uploading a video or driving a car. 

In the UK, one of our most well-known serial killers drove an articulated lorry during a killing spree which led to the violent death of thirteen women. Peter Sutcliffe claimed to have killed his victims as a direct command from the voice of God and was diagnosed with Schizophrenia shortly after his conviction. He remains in a maximum security mental hospital many years later and will never be released. Severe mental illness is not necessarily a barrier to performing complex tasks.

In Conclusion
It may seem strange to a British mental health professional that someone so clearly unwell and tormented by psychosis has not yet been treated with, for example, anti-psychotic medication during the four months of his incarceration, but a severe and chronic shortage of in-patient psychiatric beds means we in the UK are in no position to moralise over this state of affairs.

It would appear from reports that Loughner will now be located at a secure psychiatric facility in an attempt to relieve enough of his symptoms to allow further attempts at a trial later in the year.

A mental illness such as that experienced by Jared Loughner is not to be wished on anyone. Our current drug and psychological treatments are far from perfect and will probably remain so for many years until psychologists and neuro-scientists are better able to advance the understanding of what causes the sort of cataclysmic events seen in Arizona this January. If it’s true that Loughner had a troubled childhood this would have corollaries with many mentally ill people who in turn become violent and just goes to show we cannot look purely at neurotransmitters and genes in explaining his extreme aggression.

It should also be stated very clearly that for every Jared Loughner there are hundreds if not thousands of people just as disordered, distressed and bewildered who will be far more likely to harm themselves either by violence or self-neglect than injure another human being.

This man suffers from a severe mental illness and may possibly have other underlying personality problems. He has planned and committed a crime which has ruined the lives of many, many people, but I hope this post has made you condemn a little less and understand a little more.