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Farewell Farmer George

Yes, I know. I’m a bit late. One hundred and ninety two years too late as it happens. Farmer George (AKA George III) died on this day in 1820 and I don’t imagine that many people will be mourning his loss after so many years. In truth, I’m not mourning either – but I am interested in his legacy.

George III was an unusual King and not only because of his love of agriculture and his love of Britain (both rather atypical for a Hanoverian monarch). He was also notable because of his ‘affliction’. Farmer George, also known as “Mad King George” or simply “The Mad One” probably suffered from porphyria.

Porphyria, somewhat unfortunately for the royal house, is an inherited affliction with many possible symptoms including a debilitating form of mental disorder typified by psychosis, grandiosity and mania among other things.  At one point George was reported to have spoken nonsensically and without pause for two and a half sleepless and apparently monotonous days. George’s granddaughter was Queen Victoria and through her there is a very clear link to the modern House of Windsor.

Porphyria is the result of an enzyme abnormality creating vulnerability to the condition. However, in keeping with the Stress & Vulnerability model (I had to mention it somewhere, didn’t I?) environmental factors tend also to be necessary to trigger symptoms.

In George’s case that trigger may well have been arsenic. In 2005 a sample of his hair was found to contain 300 times the toxic dose. Arsenic was an ingredient of ‘James’ Powders’, a medication that George was known to have used.

The troubled monarch suffered several episodes of ‘nerves’ throughout his reign but these became more and more severe and protracted until in 1811 the Regency of the country passed to his son, George, Prince of Wales via The Regency Act. George, Prince of Wales eventually ascended to the throne in his own right to become George IV, known to the people of the time as “the fat one”.

By the time George III died in 1820 he had also developed dementia, was blind, profoundly deaf and unable to walk. A rather ignoble end for anyone. And yet it is this very ignobility that his legacy springs from. Just as his son, George IV started a trend in clothing to accommodate his corpulent frame so George III’s afflictions arguably moved society a little further  along the journey toward tolerance and understanding.  George IV popularised the unbuttoned waistcoat. George III made it just a little more difficult to sweep mental disorder under the carpet. We’re not there yet but George’s status as monarch certainly prevented him from being written off as merely ‘mad’ or ‘undeserving’.

I wonder what legacy the next ‘mad monarch’ might leave.

Understanding the Mental Capacity Act

Do your staff understand the Mental Capacity Act?

It’s about more than just people diagnosed with mental disorders. The Mental Capacity Act protects anyone who has difficulty making decisions for whatever reason.

http://www.thecareguy.com/blog/read_44130/course-outline-understanding-the-mental-capacity-act.html

If you’re at all uncertain about assessing capacity, deciding upon best interests or how the MCA fits with other layers of Safeguarding legislation then this is the course for you.

I look forward to hearing from you.

The Care Guy

Dealing with deliberate self-harm

Working with people who hurt themselves can be a confusing and bewildering experience. It is often extremely frustrating and distressing for the staff who may well be at a loss to understand why their resident keeps on injuring themselves.

Traditional views about ‘manipulation’ or a ‘cry for help’ may bring some limited sense of explanation but they do little or nothing to help prevent future self-harm.

First of all bear in mind that you are not alone. A decent GP, Psychiatrist or community psychiatric nurse will be worth their weight in gold. As a team, complete a thorough risk assessment and agree how to manage future problems and when to seek outside or emergency help.

All that aside though, there is much that workers can do on their own.
A resident’s ability to manage is greatly enhanced by good support from their surroundings and social group (British Psychological Society 2000). In supported housing this means that the staff can influence significantly the resident’s coping skills.

Back in the 1950s George Brown began studying the effects of families and social groups on coping and mental health (Brown G. et al 1965? & Brown GW 1985). This research led to the concept of ‘High Expressed Emotion’.
A few decades later in the USA Marsha Linehan came up with the concept of the ‘Invalidating Environment’ (Linehan M. 1993, 1 & 2). Both these concepts show how types of interaction increase stress, reduce coping and lead to the conditions which encourage (among other things) deliberate self-harm:

High Expressed Emotion

Aggression and hostility
Criticism
Emotional over-involvement

The Invalidating Environment

1 Erratic, inappropriate responses from significant others to the individual’s thoughts, beliefs and emotions.
2 Oversimplifying the ease with which problems can be solved.
Blaming the individual for not solving difficulties with ease.
3 A chronic and classical ‘double bind’ scenario in which the individual cannot ‘win’ whatever he or she does.

Attention to the concepts of expressed emotion and the invalidating environment make a huge difference.

Not attention seeking – coping

Deliberate self harm is likely to represent a coping strategy. For many people it is the only effective strategy they know.

The sweet shop analogy

Often in training sessions I use the analogy of a small child in a sweet shop. They can have anything they want but there’s a problem. The lights are turned off and all they have is a small ‘pen’ torch – the kind with a very narrow beam that only illuminates a small area of the shop.
Whatever they can see in the torchlight they can have but it’s a very limited choice. Most of the sweets are effectively invisible.

Clearly the child will choose from very limited options – not because the other sweets aren’t available but because he doesn’t know about them.

In one sense this is what it’s like for people with limited coping skills. The other coping strategies are available to them but they don’t know about them or they don’t believe that they will work. The coping strategies are the sweets in the shop and your job is to turn the lights on.

What to do now

Don’t waste time attacking the only coping strategy the service-user knows. If you remove the only coping skill a person has then they may see no alternative but suicide. It is no coincidence that service-users who harm themselves are around 50 times more likely than the general population to kill themselves (Royal College of Psychiatrists leaflet: ‘Self Harm’).

Instead work on discovering and experimenting with other, less injurious methods of dealing with stress. It may well be that to begin with this will amount to nothing more than some slightly less injurious methods of self harming but this is a step in the right direction. Build upon what you can and remember that overt criticism of the service-user is likely to create a barrier between you that may never come down again.

References

British Psychological Society (2000) Recent Advances in Understanding Mental Illness and Psychotic Experiences British Psychological Society, Leicester

Brown G. et al (1962) Influence of family life on the course of schizophrenic illness British Journal of Preventative Social Medicine 16, pp.55-68

Brown G. W. (1985) The discovery of expressed emotion: induction or deduction in
Leff J. & Vaughn C) Expressed Emotion in Families Guildford Press, New York

Kroll J. (1988) The Challenge of the Borderline Patient Norton & Company, New York

Linehan M. (1993) 1 Cognitive Behavioural Treatment of Borderline Personality Disorder Guildford Press New York

Linehan M. (1993) 2 Skills Training Manual for Treating Borderline Personality Disorder Guildford Press New York

Psychiatrists (undated) Self Harm rcpsych.org.uk

Zubin J. & Spring B. (1977) Vulnerability – a new view of schizophrenia. Journal of Abnormal Psychology Vol.86, No.2, pp.103-124

Dementia care training updates

Over the next few weeks The Care Guy will be updating several ‘off the peg’ dementia care courses. This will include an overhaul of training programmes on ‘Dementia awareness’, ‘Person-centred dementia care’, ‘Communication in dementia care’, ‘Challenging behaviour in dementia’ & ‘The environment of dementia’.

If you have any particular needs around dementia care training please get in touch at info@thecareguy.com and I’ll try to help.

Also I’m planning a ‘Dementia Care Guide’ series and I’d be very interested to hear your ideas about what to include. Email me at info@thecareguy.com with your suggestions.

Many thanks,

Stuart Sorensen
(The Care Guy)
www.thecareguy.com

AMHP research on stress & burnout

This research isn’t anything to do with me but I thought I’d promote it anyway. Below is the outline ‘from the horse’s mouth’.

”Approved Mental Health Professionals practising in England needed to complete a survey about stress and burnout.

The survey aims to determine whether there is a difference in experiences of stress and burnout between the professional groups that perform the AMHP role. The study has been approved by King’s College London Psychiatry, Nursing and Midwifery Research Ethics Subcommittee (REC reference number PNM/11/12-23). It is the first survey of its kind since the AMHP role was introduced and with your help we hope it will yield some useful and valuable data.

It is important that AMHP’s from all professional backgrounds complete the study. However we would particularly like to encourage those from a non-social work background to take part as they are still relatively small in number. An information sheet containing further details about the study is displayed on the first page of the online questionnaire. If you would like to read more about and or complete the survey please click on the link below:

https://www.surveymonkey.com/s/stressandthestatutoryrole1

Thank you in advance for your time and support.

Janine Hudson
Approved Mental Health Professional
Student, MSC Mental Health Social Work with Children and Adults”

Expressions 24: Validation – don’t recreate the invalidating environment

Here’s a quote from Marsha Linehan…

“The environmental disorder is any set of circumstances that pervasively punish, traumatize, or neglect this emotional vulnerability specifically, or the individual’s emotional self generally, termed the invalidating environment. The model hypothesizes that BPD results from a transaction over time that can follow several different pathways, with the initial degree of disorder more on the biological side in some cases and more on the environmental side in others. The main point is that the final result, BPD, is due to a transaction where both the individual and the environment co-create each other over time with the individual becoming progressively more emotionally unregulated and the environment becoming progressively more invalidating.”

Linehan M (1997)

Marsha Linehan, is famous for her work on the subject of Borderline Personality disorder and the creation of Dialectical Behaviour Therapy, a blend of various principles from cognitive therapy and Zen Buddhism among others.

Linehan studies the various factors that contribute to the creation of Borderline Personality Disorder and looked both at the causes and the ways to overcome them. The result, Dialectical Behaviour Therapy (DBT) is one of the most evidence-based and verifiable approaches to the treatment of people diagnosed with Borderline Personality Disorder.

I’d like to spend a little time covering the very basic principles of what Linehan called the Invalidating Environment’.

“An emotionally invalidating environment is any environment in which a person’s emotional experiences are not responded to appropriately or are responded to inconsistently. For example, in an emotionally invalidating home environment, a child who becomes frustrated and cries may be told

“stop being such a baby.”

“In extreme examples, a child may be physically assaulted for expressing feelings.  ”

Kristalyn Salters-Pedneault, PhD 2008

Trauma does not necessarily need to be acute (sudden/intense). It can be chronic (long-lasting) and might be relatively undramatic. This is the case with the Invalidating environment that Marsha Linehan identified.

In essence the very basis of emotional development is destabilised by the environment itself – or rather by the people who share that environment with the developing child. And it doesn’t really matter what the response is so long as it demonstrates that the child is ‘in the wrong’ or that their feelings are somehow inappropriate.

In truth all people have a perfect right to feel whatever they feel in any given situation. That is our private emotional life and it’s entirely up to us how we run our emotions. It may be reasonable to help people to control their emotions better but the fact remains that they can choose what emotion to feel for themselves. They can feel whatever they like.

The only real question then might be:

But why would you want to?

By helping people to understand their choices we can help them to develop self control. By invalidating the choices they have already made and blaming them for feeling bad for example all we do is introduce doubt and confusion into their emotional world. After a while the child comes to believe that they can neither control nor even trust their emotions. This is one possible explanation for the recurrent emotional turmoil in adults with the diagnosis of Borderline Personality Disorder. They don’t trust their emotions enough to know what to feel and so they end up experiencing a jumbled emotional mass that they cannot fully understand.

It is not necessary for the child to be beaten or abused sexually for this to happen. All it takes is for the child to be exposed to consistent criticism or for their beliefs to be undermined without rational explanation. If the way the child is treated by caregivers is inconsistent or if they are placed in the stereotypical ‘double-bind’ situation in which whatever they do they will be wrong then we have an Invalidating Environment.

The antidote to this is to acknowledge the child’s feelings – be clear that they are perfectly entitled to feel what they do and then, whenever possible, ‘catch them doing it right’. Many households have fallen into the habit of catching the child doing things wrong and then either punishing or mistreating them as a result. This is one of the hallmarks of an Invalidating environment.

The validating environment is at least as likely (if not more so) to catch the child doing it right – especially in matters of emotional control. So the child who feels angry but then manages to control their aggression is praised for their control – not criticised for their anger. The angry emotion is acknowledged as valid even if it’s not the best or most effective emotion that the child could have chosen. It’s OK to explain that anger is not always an appropriate response in difficult situations (that’ helps the child to develop understanding) but not to say that the feeling itself isn’t valid.

There’s a time and a place for every emotion – even anger.

A validating environment catches the child ‘doing it right’.

I need to be absolutely clear here – the invalidating environment is not the ‘norm’. Almost all families have moments of invalidation during which people’s emotions and opinions are not considered. As a father and stepfather I am well aware of the limitations of ‘good enough’ parents and none of us are perfect. This is not a problem.

Invalidating environments are those in which criticism and invalidation are constant. It takes more than the occasional row with your mother to constitute an Invalidating environment. It takes more than the odd inattentive moment from your father. These are the normal experiences of the average childhood.

In the Invalidating Environment the child is seen as a problem ‘in themselves’. They are criticised for having problems and the ease with which those problems might be solved is also exaggerated. The child is then criticised for failing to solve the problem on their own and then, to add insult to injury, further blamed and criticised for feeling bad about their inability to overcome their difficulties.

The net result of all this is that the child grows up believing themselves to be useless and possible even ‘evil’ or ‘unworthy’. They experience guilt about every little mishap – even if it’s not their fault because they failed to prevent it (as usual) and they also come to believe that they cannot rely upon themselves to keep safe. So, no matter how toxic the environment they are in might be they are frightened of being rejected by those they are close to – of abandonment because they do not trust themselves to survive alone.

They can’t even decide what to feel unless someone else tells them. This, of course, means that adults with a history of Invalidating Environments as children often lurch from one abusive relationship after another because the control they experience lets them off the emotional hook. They can rely upon others to tell them what to feel. It also explains why it can be so hard for them to remain in more normal relationships where they are expected to run their own emotional life. After all – a caring partner will want to understand what the other person feels. This is a source of real confusion and often fear for the individual who has never learned to make sense of their emotions in the first place.

The poem below was written by an anonymous BPD sufferer. I include it because I think it has an eloquence that goes way beyond anything that I might write…

All my fault

 

It’s all your fault

That’s what they say to me

When anything goes wrong

No matter what it is

Or where I was

When it happened

They still tell me

It’s all my fault

 

It’s all your fault

It used to hurt me deeply

It would make me cry and

Cause my heart

To break in two

But still they

Insisted that

It’s all my fault

 

It’s all your fault

And now I believe them all

It’s imprinted on my brain

I don’t question why

I no longer ask how

I just know that

They speak the truth

It’s all my fault

Anonymous

References

Linehan M. (1997) Dialectical Behavior Therapy (DBT) for Borderline Personality Disorder

The Journal Vol. 8/Iss. 1

Kristalyn Salters-Pedneault, PhD 2008 http://bpd.about.com/od/glossary/g/invalid.htm

My new website: The Care Guy

Meet ‘The care guy’

http://www.thecareguy.com

I’ve spent the last couple of days working on this – I’m not exactly an expert when it comes to websites so everything took me twice as long as it should but I’m getting there.

Have a look and let me know what you think.

Clearly the point of this website is to tempt people to use my training services so I’d really apreciate feedback on whether or not you think it will achieve that. One thing I’m already aware of is that I need to rerecord most of the ‘The guide’ movies now that I’ve had a haircut and worked out how to get the lighting reasonable. That’ll be tomorrow’s job.

Let me know if you spot anything else that needs to change.

Thanks a lot.

Stuart

Expressions 23: Therapeutic optimism

I’d like to thank you for reading to this stuff – it’s been a real labour of love to produce and I really love the fact that so many people are taking the time to click on it. So as a token of my appreciation I’m going to give you a gift. In fact it’s already with you. By a process known as

 ‘magical financial transfer’

I’ve already placed a brand new, crisp £50 note in your pocket. Just put your hand in your pocket and you’ll find it there, waiting for you. Enjoy.

Now I may be wrong but my guess is that you didn’t even bother to check your pocket even though I told you that the money was there waiting for you. There is, of course a good reason for that. You knew that it wasn’t there. There’s no such thing as ‘magical financial transfer’ and you’d be deluded to think that there was. I do appreciate the fact that so many people listen to my stuff but that doesn’t mean I’m in any position to give you all fifty quid.

But there’s a really important principle here. It’s to do with expectation.

People don’t try to achieve things that they don’t believe in.

That’s why you didn’t even take the trouble to check your pocket – hardly an arduous task. You didn’t check because you didn’t believe.

That’s exactly the same for you and your relative. Nobody works very hard if they don’t believe in the goal. Mental health recovery can be difficult – it takes work and before people are prepared to do that work they must first believe that it’s possible.

That’s why therapeutic optimism is so important. We need to believe in the possibility of recovery for our relatives or we won’t work toward it – and neither will they.

The other side of this is the self-fulfilling prophecy that maintains illness and dependence. If we believe that people are beyond help we won’t try very hard to help them. Neither will they try very hard to change if all they get from us is negative assumptions about hopelessness. We prophecy enduring mental disorder and that prophecy itself changes what we do. The prophecy fulfils itself.

Fortunately self-fulfilling prophecy works both ways. If we prophecy positive things we have at least a fighting chance of achieving them as well. Of course there’s more to mental health recovery than just good intentions – it takes hard work and proper planning but belief is vital. Nothing will work unless we believe it can.

Make sure that your self-fulfilling prophecies are positive.

And remember the phrase:

Therapeutic optimism

It really is far more important than many people think.

Putting stuff right

The trouble with starting a new project from scratch is that it’s always going to be vulnerable to mistakes. That’s what happened with the new movie series, ‘The mental health support workers’ guide’. Basically – I messed up.

I got excited about the project and rushed to get the first dozen episodes up on line before I really had any idea how to make them work. I’m still very much a novice when it comes to making movie files but I am learning. Novice or not, I’ve cast a critical eye over the first 12 instalments of the guide and they have definitely been found wanting.

So I’m re-recording (in a couple of cases just re-editing) them to try and improve the quality.

I’d still be grateful for feedback as the new versions go on line. That’s a vital part of the ongoing improvement process that I hope will continue throughout the year as the series progresses.

You can review the movies and PDFs here

Below is a link to episode 1 (movie). However if you’re viewing this page from a smart phone you may not be able to view it. Not all hand held devices will allow it. If that’s the case the link here will take you to the original youtube channel which should play without difficulty.

Click below to view Episode 1: What’s a support worker worth?

Feel free to comment below with your criticism and (hopefully constructive) suggestions for improvement. Please help me to get this right.

Thanks,

Stuart