The CQC and Embarrassing Toilet Incidents

So the Care Quality Commission (CQC) is once again left feeling like the bloke who leaves a giant stool in his in-laws loo just as the flush stops working. They’re not just flapping around in a panic with their trousers around their ankles. They’re tripping over, hitting their head on the bath and suffering the acute embarrassment of the in-laws calling the ambulance out. 

I’d seen the trailers for last night’s Panorama so knew what to expect. Fiona Phillips flashing her Jimmy Choo’s as the celebrity face of Alzheimer’s and doing a bit of crying. Sorry Fiona, perhaps a little harsh but I do have issues with slebs doing ‘issues’. That’s for another blog.

It was of course revolting television and very hard to watch, even when forewarned is forearmed. The online world is rampant with a thousand calls for action, more respect for elderly people, and Telegraph readers demanding instant dismissal of all care home staff not carrying a Surrey passport. 

But while it’s good and right to howl loudly from the rooftops, we also need to take a step back and ask how we as a society put a stop to this. It would be lovely to think that the extended family will take over when Grandad starts leaving the gas ring on and tries to make toast with a chocolate digestive.

But the nuclear family is long gone in this corner of the world, and those care industry shareholders won’t be giving up their yachts and racehorses anytime soon. So for now at least we’re left with bodies like the CQC and our Safeguarding Panels to protect vulnerable people from the living nightmares we seem to be seeing and reading about every other day.

Still emerging battered and bruised from the ashes of Winterborne View, the CQC now have their old friends Panorama to thank for yet another death by spycam. They didn’t emerge with a lot of credit last night. It would be all too easy to point the finger and join in with a bit of quango-bashing, but in fact I come to praise Caesar, not to stick a knife in his guts.

They have the unenviable task of inspecting just about anywhere in the country that has a roof, paid staff and vulnerable people sitting indoors. They deserve to be cut some slack for that at least, but what concerned me last night was the sheer panic in the face of what was bound to be another incendiary device going ‘BANG!’ in the face of a horrified public.

They declined to appear on camera with Fiona Phillips. Now Fi is hardly Jeremy Paxman in a designer two-piece so why the reluctance? Our national care inspectorate reduced at once to the status of dodgy car dealer chased around by that bald bloke in a parka who makes shows about dodgy car dealers. 

But perhaps with the benefit of past experience, their ‘Panorama Statement’ was robust, reasonable and said all that needed to be said. A media-trained representative could and should have offered that content to the Panorama cameras. More dignity, more transparency, and much less cowboy builder.  

And then there was their slightly embarrassing Twitter campaign emerging almost as soon as the credits were rolling. Their output of Tweets is normally so rare I’d forgotten I even follow them, but last night? A slightly embarrassing flurry of ‘It Wasn’t Me Guv’ postings, and a link to their most recent report on Ash Court

To paraphrase the report: “Ash Court is lovely. I’d send my Gran there.” It contained enough typos to suggest the authorship of a chimp with a bad caffeine habit. Unprofessional, but let’s put that down to the inspector’s report-writing fatigue and almost certain overwork. More importantly, why the apparent whitewash? Well there is that notorious tendency of care homes to get the decorators in as soon as they have a whiff of an ‘unannounced’ inspection, and would we really expect care staff to be stood in front of a clipboard-wielding inspector abusing a frail, elderly woman while chatting away in Spanish and watching Corrie? You can’t punish what you can’t see. 

I don’t write public statements for the CQC or for anyone else other than myself and my business. But I might have asked this of those who will invariably point the finger at the inspoectors: “Did anyone from the CQC actually abuse vulnerable people at Winterbourne View or Ash Court? No. Did anyone at CQC have anything to do with building 60-bed three-tier monstrosities which are more about battery farming than any semblance of residential care? No.”

Their management of the latest care industry furore was undoubtedly poor and unnecessarily defensive. They need to learn lessons. They almost certainly need more inspectors on the ground, and less twonks in suits. But there’s a whole heap of reasons why we’ll keep on hearing, reading and seeing these horrors, and the answers won’t come anytime soon. So for now we need a care inspectorate thrusting it’s face into dark corners shouting “Oi! You!” and not running around panicking over an obstinate plop.

If you can’t be bothered reading his profile, Connor Kinsella is Lead Trainer with JCK Training and writes about himself in the third-person. 

Print Friendly

What is Narcissism?

Most of us know that describing ourselves as ‘narcissistic’ isn’t a good thing to put on a job application, and definitely isn’t a selling point on But what does the term actually mean, and how does it manifest (in it’s most extreme flavours) as a psychiatric disorder?

Narcissus is a character from Greek mythology. He was the son of a God and Goddess and were he around today would no doubt be described by Beliebers and the like as as ‘totes buff’. But Narcissus was only too well aware of his own buffness and rejected numerous come-ons from lots of water nymphs and other mythological characters. Why? Because none of the boys, girls or hermaphrodites (this is Ancient Greece after all) who fancied him were deemed by Narcissus to be anywhere near good enough for him.

To cut a long story short, Narcissus caught sight of himself in a pool and fell in love with his own reflection. Which wouldn’t have been too bad if he hadn’t become so obsessed with his gorgeousness that he couldn’t prise himself away from his own image long enough to get a bite of whatever they ate in Ancient Greece, and eventually died of starvation.

You’re probably thinking of more modern analogues of this mythical tale, but we don’t need celebrities to recognise the clinical reality of being smitten by one’s own self-esteem. A person diagnosed with Narcissistic Personality Disorder (NPD) might be thought of as pathologically self-obsessed, vain and arrogant to the point that they really are very difficult people to warm to. They are, like their namesake, so ‘in love’ with themselves they reject the attentions of others as being little more than an irrelevance. But they may just tolerate people who can a) achieve objectives for themselves such as the confirmation of their wonderfulness, or b) are of such high status that they are actually seen as almost being good enough to be in the same room, and c) may provide the narcissist with material resources and family associations to confirm their exalted sense of self-worth.

This is often a person who, to anyone else but themselves, is actually a rather strange, unlikeable person who tells very tall tales to confirm their own inflated opinion of themselves – in fact, some of us sometimes refer to NPD as ‘Walter Mitty Syndrome’.

I once worked with a colleague who would tell anyone that would listen (a rapidly diminishing number, surprise surprise) about his previous exploits of derring-do as a member of the SAS. Now anyone who knew this chap would immediately know that this and his many other stories were patently ludicrous, but he not only told these obvious lies with great and even entertaining conviction but even seemed to actually believe them himself. This is very typically narcissistic. The last time I saw him he (a mental health nurse) was being arrested at work for a serious assault on his wife, and much to the relief of his former colleagues was never seen again.

In extreme circumstances, NPD erupts in crime or extreme violence, usually as a means of perpetuating a lie or a self-belief.  The Brian Blackwell case is an example of where narcissism becomes more than just irritating and unlikeable, but a potentially sinister and dangerous psychiatric disorder. The Theresa Riggi murders are another example about which I have previously blogged and edited for the #mhchat Narcissism Twitter debate. Fortunately most of will never meet a Brian Blackwell or Theresa Riggi, but may certainly know someone who spends an awfully long time staring at their reflection and being very (ahem) wonderful.
Print Friendly

We Need to Talk about Derek

Mrs Kinsella looked at me quizzically. “But you absolutely loathe Ricky Gervais” she observed, very accurately as always. For  Derek was to be (as the C4 PR people would have us believe) thirty minutes of Gervais taking the piss out of the learning disabled.

For a social care blogger this was vitriol central, especially for one who always suspected The Office DVD box set was mainly bought as a Christmas present for ‘smart’ people pretending to be huge fans but who, if the truth be told, would have rather unwrapped  a JML Nasal Hair Trimmer.

Tuning in to Derek last night was for me a little like watching non-league football. Guaranteed disappointment, guaranteed moaning, guaranteed catharsis. The difference being non-league football is usually funnier.

I watched the first 10 minutes with a set of blades and a knife sharpener, smugly tweeting ‘Verdict so far. About as funny as Ricky Gervais’. But I clung on. Only because I felt I had to and certainly not because the opening scenes (involving a dodgy haircut, comedy custard and a fall into a pond) were exactly rocking my world of laughter.

But by the time the titles were rolling I found myself deeply disappointed. I had to put my knives away. I actually bloody liked it. Had I finally ‘got’ something by Ricky Gervais?

And it made me ask two questions. First up. Just how often do we see either care of the elderly or the learning disabled feature in any sort of TV drama, let alone one created by a bloke who hosts Oscar ceremonies? Almost never, so a doffing of the hat for that alone.

And for the second big question. Was Gervais taking the piss? Well I for one didn’t think so.

It’s easy to understand why many would take offence, especially those of us with personal or professional ties to the subject. In an excellent interview with disability-rights campaigner Nicky Clarke, Gervais is guarded about whether or not Derek is meant to have a learning disability. But few who have worked or lived with a ‘Derek’ would have failed to pick up the cues.

To the uninitiated our anti-hero is a scruffy, greasy haired, socially awkward oddball. Surely he’s living in some sort of supported accommodation and working at Remploy (ahem) sticking labels on coffee jars? Well, no. He shares a flat with a friend, goes for post-work beers with a female colleague (the ‘Glasgow Kiss’ scene was deeply satisfying) and he works in an elderly care home. 

For me at least this was a sharply and well researched study of those of us who don’t spend hours being acerbic and witty on Twitter, who don’t give a monkey’s toss about the politics of anti-disablism, but who can be refreshingly honest (and funny) about the stuff many of us would rather not discuss. And while he might may not care a fig about the latest in SuperDry casual wear or snappy Hoxton haircuts, he does care deeply about other human beings. Give me a Derek over a MENSA membership any day.

Call me old fashioned but if a TV show looks like a comedy, sounds like a comedy and your PR people say it’s a comedy, then it should be a comedy. But putting that to one side, when Kerry Katona’s pubic topiary provides a cultural highlight I for one can only applaud original drama starring positive portrayals of the vulnerable, the awkward and the uncool. 
Print Friendly

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. 

Print Friendly

Deaf, Daft and Demented: Improving Attitudes to Elderly Care

The woman on the radio sounded distraught. She was calling a phone-in show from the hospital where her frail, elderly Dad was being treated. Treated perhaps, but not being cared for. The caller described a ward full of elderly, infirm patients marooned in their beds trying to reach water jugs across the Grand Canyon of space between them and an impossibly far away bedside cabinet. Others pressed the call button repeatedly for commodes or help with moving up in the bed. Nobody came. 

The presenter Shelagh Fogarty suggested a shortage of staff. Apparently not. The caller described a large group of ward staff lolling around the Nurses Station chatting about Facebook. The phone-in took place on the back of a recent RCN report calling for minimum staff levels on elderly care wards. The RCN survey was itself a response to a catalogue of horror stories surrounding the care of older people. In the same week a Which? Magazine ‘secretshopper’ sting highlighted (yet again) serious failings in domiciliary care. It makes sad if not unfamiliar reading. Missed medication. Missed food and drink. Soiled beds. That sort of thing.

So what are the reasons for this constant torrent of bad news? There are plenty of ‘big picture’ factors involved, and others more eloquent than I have written about some of them elsewhere with the precision of front-line experience. But let’s look at one specific and rather uncomfortable area from my own perspective as a trainer.

It’s one of those elephants in the room that doesn’t get much of a public airing, and goes something like this. 

Care of the elderly is far and away the least popular of the health and social care specialities, and attracts the sort of staff who might just as well be earning a Gold Star for assembling Big Macs.

For as flawed as the bigger picture may be, it is still individual care staff leaving patients to dessicate or care home residents to sit in their own faeces. Whenever I hear one of these reports I imagine myself visited by The Ghost of Christmas Yet to Come, aged by forty years and placed in a nursing home by a family who have ignored my Living Will request to be shot at the merest suggestion of double incontinence. I have a memory span of thirty seconds, and I’m muttering to myself, probably because nobody else will listen. My Inco Pad fills with the end result of my soft diet lunch. A couple of care assistants haul me into a wheelchair and whisk me off to the nearest shower hose, deep in conversation over Kate Middleton’s choice in shoes. 

So in this Dickensian nightmare I’m quite literally at the arse end of the care sector, but back in the real world does it really follow that elderly care attracts the bottom of the pile in terms of it’s staff?

Speaking as a trainer working with hundreds of care staff over the years, most certainly not. But I do often see a demoralised workforce working long hours for poor pay and even poorer conditions. With the best will in the world it’s not hard to see how patients or clients eventually come to be seen not as valued individuals but as names on a job sheet spiralling ever downward  toward ever-increasing neediness and ultimate death.

So what do we do? Do we throw more centralised funding at our local authorities and privatised care providers?  Even if such fanciful thoughts had the slimmest of chances of becoming reality, I suspect this would achieve little in terms of progress beyond a healthier shareholding for their employers.

What about better training for care staff? For as long as I’ve been in the business training has been a luxury expense in an industry long governed by the bottom line of the profit/loss equation. ‘Stack it High, Sell it Cheap’ used to be the mission statement for Tesco but is now the essential business model for elderly care, where training is often seen as a costly irrelevance to short term profit. But could more and better quality training really improve the care and attitudes toward our vulnerable elderly? 
A few years ago I collaborated with some local colleagues on designing and facilitating a BTEC Short Course Award: Caring for the Older Person with Mental Health Problems. It was a fairly simple programme consisting of three classroom-based modules focussed on Dementia, Depression and Challenging Behaviour. We worked with a varied collection of staff from both nursing home, residential and domiciliary settings. Some of our candidates were managers, while most were front-line carers. Almost all were terrified at the prospect of taking a test at the end of each day although Exam Phobia faded quickly once our candidates realised how much they already knew and what they were capable of.

We looked at how depression, so endemically common among older people in care and yet so seldom tackled, can be quite easily identified by care staff using the sort of rapport and person skills that comes inevitably when helping a resident put on their socks every morning.  We looked at magnified images of protein plaques and discussed how these lead to memory loss. We looked at how awareness of the sensory and cognitive deficits of dementia can help us communicate much more effectively and reduce distress. Not only did our candidates earn a recognised qualification but challenged, examined and re-evaluated  how they worked with older people. Now let’s not pretend this was Dead Poets Society but the fact I’m talking about this award it in the past tense irks me more than Robin Williams. And that’s a lot of irk.

We were able to deliver the award only with the help of a generous funding pot from the now defunct Business Link Dorset. Once the funding dried up, so did the course, and we certainly didn’t have the resources to evaluate the shop-floor efficacy of the training. But on anecdotal evidence at least, investment in a reasonably cheap and effective project yielded greatly improved levels of care and support inspired by more positive attitudes and a greatly enhanced sense of self-worth among our groups. With potentially business-ruining CQC reports easily available online and a traditionally high turnover of staff, you don’t really need a degree in health economics to work it out. It’s just good business to have better trained staff.

In the meantime we’ll continue to hear an unending tide of bad news stories and radio phone-ins about staff who have become demoralised and dispirited when they could, with a little time and effort, be taking a fresh look at the work they do as something which is as skilled and satisfying as any of the ‘sexier’ areas of the care and support industry.  

It could certainly beat flipping a burger.
Print Friendly

Coffee. Biscuits. Powerpoint: Does Social Care Training really do the business?

This article first appeared on The Guardian’s Social Care Network

With social care budgets trimmed to the bone, how do we make sure the little money still  available for staff training gives maximum ‘bang for buck’ and becomes more than just a tick-box exercise?

Dear Reader

If you’re reading this then there’s a reasonable chance you work in health and social care and that you’re a veteran of the training room. And by training I don’t mean a Degree or Diploma, nor the Fire Lecture or the Food Hygiene course that taught you how to boil an egg. I mean the sort of workshop type training typically delivered over a day or two, focussing on a particular subject or skill with the intention of making you better at your job and better able to deliver services to vulnerable people. 

I hope the course left you inspired and invigorated, filled with new skills and knowledge. But there’s also another significant possibility. That it was little more than a chance to catch up with a few bods you haven’t seen the last Clinical Supervision workshop. Not to mention of course the free coffee and a chocolate bourbon.

The course may have been terrible/boring/poorly facilitated/ inappropriate. Tick any which applies. Or it may have been thoroughly enjoyable and a great means of meeting new people and networking. 

But (and it’s rather a big ‘but’) answer this question; ‘Did that course actually change the way you do your job?’ If the answer is usually ‘Yes, and in a good way’ then great. But if it’s ‘No, it was rubbish’ or even ‘No. But it was quite interesting’ then perhaps we need to be thinking about ways and means of delivering training that is both value for money, and effective.

Ask any group of health and social care staff how to resolve a particular issue and the probability is that ’more training’ will loom very large in the responses, as they often do following independent inquiries. ‘More training’ so often seems to be the panacea to all the ills of health and social care work, but is there an evidence base to suggest throwing a few workshops at failures in adult protection is the path to practice redemption? No. At least not according to a PhD student Lindsey Pike.

Lindsey’s doctoral thesis asks the same sort of question I’ve asked you here. It explores the remarkably under-researched question of how training actually impacts practice at the front-line of care and support, specifically focussing on safeguarding adults training in one particular county. Her findings are telling.

To summarise, Lindsey’sw  work shows that lots of resources, effort and administration are being ploughed into costly training which doesn’t, at the end of the day, result in improvements in safeguarding skills on the shop-floor- unless training is embedded within a positive training culture and transfer climate. Transfer climate refers to “those situations and consequences in organisations that either inhibit or facilitate the use of what has been learned in training back on the job” (Burke & Hutchins, 2007, :282). A positive transfer climate would be one where delegates attend relevant, timely training, with a clear idea of what they need to gain from it, and support and opportunity to use their learning in practice.

I know that both myself and others from both the UK and further afield are starting to think about a move on from the ‘Coffee Biscuits Powerpoint’ model, which ticks the box on a manager’s To Do list but achieves little else in terms of making us better at our jobs or providing better services. So what’s the answer? I suggest that traditional classroom-based training can be worth so much more when combined with three key features. 

Firstly, tightly-knit integration of the one or two-day course with an organisation’s own policies and procedures, client groups and focus of attention.
Secondly, training could and should be followed up by some form of one-to-one or small group meeting to allow participants to ‘nail down’ whether the course made an impact on their practice. And who should be doing this follow-up? Well, preferably the trainer who delivered the course. But what if the trainer is now hundreds of miles away? Well there is of course Skype or one of the many e-learning packages out there. But there is an even better solution. 
Localised training delivered by local practitioners who’ve been ‘skilled-up’ by a competent, focussed ‘Train the Trainer’ package is, I think, a genuine and realistic alternative to the ‘expert from afar’ model. Delivering good training is a considerable skill, but not so much a considerable skill it can’t be learnt, especially when training skills are backed up by the sort of expertise and experience in health and social care so valued by course participants.

Connor Kinsella is an author and training consultant at JCK Training:

Connor would like to acknowledge the contribution of Lindsey Pike to this article. Lindsey is currently working with Research in Practice for Adults:

Print Friendly

‘Just a little scratch': Care, Compassion and the Health Care Professional

He was once much better accustomed to putting words to music, but a recent hospital experience and a little nudge from me brings you a short but telling little addition to the ‘dignity in care’ issue from Frank Kinsella, my Dad.

Christmas 2004. A small group of elderly cancer patients sit in a Waiting Room at a well-known London hospital.  One patient begins to sing ‘Silent Night’. Then another.  And another. In her wheelchair one obviously ill lady without the energy to sing raised her bowed head to reveal a smile of pleasure. And maybe hope.

Remarkable? Yes. But completely unexpected? No. Such was the atmosphere created in that particular hospital, from the point of reception to the moment of departure, that all things seemed possible. Hope was conveyed in ready smiles and familiar greetings.

March 2012, and onto another hospital for a blood test. The two electricians working in the long corridor were more than helpful in providing directions, even to the point of one of them descending from his long ladder to provide exact information. So far  so good. The tall young lady with the short old lady got into the lift. “Do you know which level we need for Phlebotomy?” they asked. Smiles all round and inconsequential but friendly chatter. A little further and still good. Another long corridor and there ahead was a welcome sign indicating that the friendly electricians directions were on the button. Unfortunately that was the end of either’ friendly’ or ‘welcome’.

The blood test department was filled to overflowing. The  many who stood were envious of the seated and made any recognition of the correct ‘procedure’ difficult at very least. Behind the mostly hidden desk the blondish head brusquely indicated the general direction of the equally difficult to see ticket machine, from which a number was required.  The desk was apparently for selected patients and perhaps the blondish head resented those without the gift of psychic perception who presented themselves at the desk.

The white uniforms called out the numbers and Number 38 was directed to a booth with a cursory wave of a disinterested  arm and no eye contact.  The conversation went something like this: (Smile) “Is the department always as busy as this?” Reply: (No eye contact) “Mornings.”  The blood was easily taken, the only cost a sense of civility and a feeling of well-being.

Thoughts turned inexorably to one particular nurse who trained at that hospital and worked there for many years. For much of that time she worked under the long shadow of Matron, for whom order, cleanliness and high standards were not a ‘mission statement’ but just how things should be done. But to both Matron and the nurses who worked under her long shadow attitude and compassion were at least as important as a clean trolley.  They would have been sadly disappointed at this blood test clinic. Disappointed that so little compassion was evident and relief from anxiety absent, not least for those with more serious illnesses.

Of course the department was busy every morning and perhaps the working conditions for the white uniforms were not perfect. Of course those who waited for their number to be called were sometimes a little confused, or difficult or even occasionally a little smelly.

The white uniforms were presumably healthy. They were without pain or cause for serious concern. It could be reasonably assumed that the only real pressure in their comparatively secure situation is choosing lunch or affording a night out in hard times. It could equally be assumed that those taking numbers from the machine did have real life or death concerns, but were regarded as just that. Numbers.

Those who trained there as nurses in a bygone era may take some consolation in the fact that the white uniforms are not nurses. Maybe the white uniforms are only trained in the mechanics of taking blood and hopefully the nurses are selected and trained in both the mechanics and the compassion. It’s said that a smile or a kind word can go a long way.  Sadly it seems that they don’t always travel the short distance from one hospital to another, and sadly the the Matron, the Nurse and the Christmas Carols are no longer with us. But they have left such loud echoes behind them.
Print Friendly

The Mad, Mad World of Psychiatric Diagnosis

Is it time to tear up the rule book and design a system of mental health diagnosis that is user-friendly, scientific and weighs less than a small fridge? Connor Kinsella thinks we’re long overdue.

You’ve dimmed the lights, lit the candles, chilled the wine, smoothed down the Egyptian Cotton and put Barry White on repeat shuffle. But your partner seems far more interested in catching up on this week’s hot new blog from You forlornly pick up the CD cover and whisper “Sorry Barry. Not tonight.”  But you see, it’s not you, it’s your partner. Or more precisely, their HSDD. Eh? Oh sorry, I meant to say Hypoactive Sexual Desire Disorder.
I’m not making this up. This is a genuine diagnostic label plucked from the weird and labyrinthine world of psychiatric classification, where the everyday and the humdrum of human behaviour becomes labelled and filed as a ‘disorder’ and not your partner’s lack of enthusiasm for scented candles and a set of clean sheets.
There are two classification systems in use throughout the world of mental health care. In the UK and Europe, clinicians generally refer to the ICD-10 Classification of Mental and Behavioural Disorders published by the World Health Organisation, but clinicians and researchers worldwide also refer heavily to the American Psychiatric Association’s DSM-IV system.
Both systems provide a means of reference to both practitioners and research scientists, and have made considerable progress in moving mental health diagnosis away from ‘a case of the vapours’ or ‘nervous exhaustion’ and toward a scientifically valid and standardised means of being able to tell a patient they suffer from Schizophrenia, Bipolar Disorder or Anorexia Nervosa. Diagnostic classification has also paved the way for researching mental health conditions which, unlike most physical illnesses, are invisible to the blood test or scanner.
As a nurse I’ve spent many valuable hours helping people understand their emotions, thoughts and behaviours within the context of a psychiatric diagnosis and the treatment that is being offered to them. People who are unwell are generally more than happy to know exactly what is wrong with them. They want to be able to put a name to their collection of signs and symptoms, even where those signs and symptoms are clouded (as is often the case with mental health) by more than a little subjectivity. Psychiatrists can and do get it wrong for all sorts of reasons, but our current evidence base is certainly strong enough to be able to offer a firm and often reassuring definition to most people suffering most of the common mental disorders.
The American Psychiatric Association has for some years been working on the latest version of the DSM franchise, a term not inappropriate by way of the rather large financial income the AMA receives from its publication. The robustly named DSM-IV Task Force has been taking hits from all directions while it’s exclusively medical membership (itself a bone of contention) have sat on the various sub-committees coming up with shiny new diagnoses such as Disruptive Mood Dysregulation Disorder, which as far as I can glean could just as well be described as ‘Stroppy Teenagers Being Stroppy Disorder’. There is also a proposal  for a new Apathy Syndrome (a possible explanation for X-Factor’s less than sparkling viewing figures these last few weeks?) and another little beauty aiming straight at the heart of anyone reading this. Yep, you guessed it. Internet Addiction Disorder.
The critics are not just critical but fully tooled up with an arsenal of brickbats with which to slap the DSM-V Task Force hard across the buttocks, a phrase destined to have this blogger labelled with Sado-Masochistic Smutty Reference Disorder or it’s nearest relative. The British Psychological Society and the American Psychological Association have both weighed in with extensive criticisms of the proposed DSM-V prior to it’s publication in the Spring of 2013. But there are many, many more missiles being aimed at the Task Force and, lets face it, it’s hardly a moving target.
With diagnostic toolkits so loaded with the potential to change peoples lives, deny or facilitate state benefits such as Disability Living Allowance or Incapacity Benefit, and the template by which researchers worldwide base what is a growing and increasingly useful body of good science, do we really want labels based on a single case report written by an obscure psychiatrist which has no basis in research evidence nor any form of genuine scientific validity?

Do we really need, as is proposed by the DSM-V Task Force, even lower thresholds for diagnoses such as the already controversial Attention Deficit Hyperactivity Disorder, a ‘condition’ which has already made huge profits for the pharmaceutical industry and is set to become even more profitable with the suggested lowering of the bar?
For the jobbing mental health professional it is safe to say that a large percentage of both ICD-10 and DSM-IV is already of little or no use to anyone other than the odd psych-nerd playing Mental Health Trivial Pursuit with their psych-nerd friends. What both professionals and those who come to them for help really need is a diagnostic system which actually reflects this salient fact. Psychiatric diagnosis really isn’t rocket science.

Medics worldwide may secretly fantasise about that ’House moment’ where they wander into the clinic eating a sandwich and looking as if they’ve just got out of bed, casually saving the patient’s life just as they flatline with an incredibly obscure diagnosis that nobody else has heard of.

But in real life I would challenge any mental health professional to come up with more than a dozen clearly delineated, well researched diagnostic labels used in day-to-day psychiatric practice. Hippocrates came up with a quite reasonable psychiatric classification while most of us were still throwing spears at mammoths, so how have we managed to come up with such a convoluted and often meaningless plate of spaghetti as DSM and ICD?

Our diagnostic systems are already unwieldy, unscientific and wildly over-inclusive. Revised models ought to be filtering out the nonsense and returning us to some semblance of science and common sense. But DSM-V is scaring the pants off far too many well qualified observers for the critiques to be merely a hobby horse of those still clinging to battered copies of The Divided Self

Psychiatric diagnoses are big labels applied to many, many people and are far too important to be based on bad science, personal ego and a book that is often of more use as a door-stop than a frame of reference.

Right. I’m off to my analyst via the scented candle shop. Wish me and Barry luck. 
Print Friendly

A Longer View of Winterbourne View

Thanks to a few sleepless nights of keyboard bashing and the odd complementary tweet from The Guardian’s @patrickjbutler his employers have kindly (and perhaps unwisely) invited me on to their new Social Care Comment site. Here’s my take on the aftermath of the Winterbourne View scandal.

There have been many initiatives, reports and government level strategies in recent years but few, perhaps none, have hammered at the ramparts of care for learning disabled adults with the force of BBC’s Panorama expose Undercover Care: The Abuse Exposed.
Broadcast on 31 May this year, Twitter exploded almost immediately in response to some of the most unwatchable scenes on television in many years. As the blogosphere and online communities followed not far behind in an eruption of public horror, it was clear that that the care of society’s most vulnerable people had hit a watershed. My own blog posts on the subject and the comments of many both on my own site and countless others made me realise I wasn’t alone in being unable to sleep that night and getting up out of bed to bash seven bells out of my laptop.
But the media bandwagon rolls on and even those most horrified by those scenes are once again tweeting about X-Factor or the bedroom antics of Premiership footballers. Those of us who work in social care might suspect that the status quo has resumed. The sadists within our ranks have resumed their water-boarding, and the senior executives of companies providing care can once again get back to a nice round of golf. So what, if anything, has changed in 133 days?
As a social care training provider my colleagues and I meet hundreds of support staff from local authorities, charities and other care providers up and down the country, and strange as it may seem in the few months since that edition of Panorama I’m left with a glass which is, if not quite half full, is certainly far from empty.
Firstly, we can look to the already well publicised structural changes that have taken place. Both Castlebeck and the Care Quality Commission (CQC) have not just been caught with their trousers down, but suffered the acute embarrassment of being caught in a very intimate moment by an elderly relative popping round for a surprise visit. “Coo-ee, the door was open and… oh dear!”
But my recent experience of running training for care staff perhaps tells us about more than the closure of poor quality homes and a rapid increase in CQC inspections. A public who once knew, saw or heard little about learning disabled people and assumed that it was still the NHS and local authorities providing for them now seems to have woken up to the fact that much of our social care system is now run at a very tidy profit by executives who think more of feeding a racehorse than meeting the needs of a young woman with autism.
Thanks to the Winterbourne View scandal and the subsequent demise of Southern Cross, we now seem now more capable of demanding the sort of excellent, small-scale services where individualised care is more than just an empty mission statement written on a dusty wall plaque. We might even argue that the average man or woman in the street is now much more aware that the care and support for their vulnerable relatives is worth a good deal more than a healthy bottom line, particularly when that comes at the price of shoddy management, poor staffing and a training culture which means little more than the annual fire lecture. 
But no television documentary is ever going to completely rid social care of the occasional rotten apple who, through a combination of individual inadequacy and limp supervision, will quickly go on to sour the rest of the fruit bowl. But we can hope that in the aftermath of Winterbourne View we can all blow the whistle and perhaps get those who could and should have been listening to realise that Panorama wasn’t just a one-off. We’re all watching now.  

Connor Kinsella is an author and training consultant at JCK Training 
Print Friendly

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.
Print Friendly

With Connor Kinsella: Lead Trainer, JCK Training