Fixing clients’ bad behaviour… or supporting recovery??

The following is a summary of a presentation I did on Friday 27th March for the Australian College of Mental Nurses WA Branch Symposium at Bentley’s Technology Park.

When we view behaviour, we make qualitative assessments dependent on the lens through which we see it. Where we are on the continuum from a mental illness understanding to a recovery-oriented understanding gives us a particular perspective as to what we see, what meaning we make of it, the questions we ask and the responses we give.
For this presentation, I am excluding dangerous behaviours (which is the subject of a presentation in itself) and limiting the topic to behaviour that is “disturbing or upsetting to others”. I will be talking about this from four perspectives.
o Norms/ values
o Anger as a normal human emotion
o Status: power/ authority
o Personal experience

Norms & values
The line between whether behaviour is ‘bad’ or justifiable is not clear and depends greatly on context and the lens through which we are viewing it. Our willingness to meet the person where they are at and explore what their behaviour means is a reflection of a recovery orientation. Behaviour can be seen as a communication.
When looking through a lens that is more down the mental illness end of the continuum:
• The consumer’s perspective, certainly in acute settings, is often not seen as credible because of the nature of their psychiatric condition.
• Their ‘job’ as such in the mental health system is to comply.
• Having an alternate view of their illness that doesn’t align with that of their treating team will often be seen as evidence of their ‘lack of insight’.
This brings us to the pointy end of working in a system that is run on biological psychiatric principles, in an evolving climate of recovery orientation.

Anger as a normal human emotion
Anger in itself is a normal human emotion but that is not something that we are taught in our culture. Feeling angry isn’t the issue, it’s how people express it that is the point.
Often there is a lack of clarity on the distinction between anger and aggression. It is crucial to have clarity around organisational expectation, policy and process, to deal with the person as a person rather than reacting purely to the behaviour we are experiencing as problematic, remembering that they are generally in our care because their thinking is disrupted.

Status: power/ authority
A person’s status will also affect whether or not they collect a tag of ‘bad behaviour’.
Within a hierarchy comes both power and responsibility. The authority is always open to being taken too far, the power abused. It is common for the person holding the ‘upper’ position in the hierarchy to be given more latitude in their expressed emotion and behaviour before it is labelled ‘bad’.

Personal experience
A fourth aspect to consider is our own personal experiences:
• How much do we think about the impact that our own life experience has had on how personally reactive we are in different situations?
• If we are able to recognise that we have particular triggers that are making us more likely to experience a client’s behaviour as disturbing or upsetting, what do we do about it?
These are important questions as our unrecognised ‘stuff’ can not only get in the way of us developing therapeutic relationships with our clients but set us up for burnout. Further, it can bring about detachment to the point where we no longer feel empathy for those with whom we work. None of these options are healthy, in fact they all lead to bad outcomes for us as professionals, the consumers with whom we work and the organisations within which we work. In essence, I would posit that it is essential to process our own life experiences in order to be able to maximise our therapeutic use to clients.

So to summarise to this point then it could be said that much behaviour of a disturbing or upsetting type in itself isn’t bad; rather it is the context that it occurs within that is the point. We need to understand that our own perception of the behaviour is affected by a number of factors both internal and external to ourselves and take responsibility for these. These include where we are on the continuum between a mental illness and a recovery perspective; expectations, norms and values; other issues such as status, power and authority; and our own personal experience.

Review of the continuum ‘as written’ for mental health professionals:

Standards and Frameworks
• National Recovery-Oriented Mental Health Practice Framework 2013
• National Practice Standards for the Mental Health Workforce 2013
• Standards of Practice for Mental Health Nurses (ACMHN)

The federal government uses the lens of recovery as we see by the references above.
Our own Standards of Practice for Australian Mental Health Nurses 2010 emphasise the need for recovery-oriented practice ie Standard 2, which talks about collaborative partnerships.
These state that mental health nurses are to identify themselves as facilitators and supporters of individuals in their recovery journeys. Further we are expected to establish collaborative partnerships that facilitate and support people with mental health issues to participate in all aspects of their care.

In Standard 3, which talks about developing therapeutic relationship, mental health nurses are required to build on strengths, hold hope and enhance resilience to promote recovery. The rationale for this Standard identifies the recovery journey as a subjective experience that is defined by the individual. One of the Practice Outcomes for this Standard is that the Mental Health Nurse interprets and contributes to the health care/treatment plan with respect to the principles of recovery.

The knowledge identified as being required to achieve this includes:
o evidence based practice and the principles of recovery
o the therapeutic use of self in the recovery process.

From a skill perspective, the Mental Health Nurse is required by this Standard to use
o reflective practice to ensure conformity to evidence based practice and principles of recovery
o clinical supervision to externally evaluate their practice with regard to ensuring recovery-focused care.
And attitudinally the Mental Health Nurse is expected to
o appreciate, value and advocate for the principles of recovery
o appreciate the necessity of clinical supervision to support clinical practice

I know that for some of you I’m preaching to the converted, that not only are you members of the ACMHN and hence bound by these Standards but you live and breathe an orientation of recovery and are . However you no doubt struggle to work in a system that is not yet reflective of these principles.

However many, if not most, nurses who currently work in mental health do not have specialist qualifications in the area but rather are general registered nurses. For those nurses who are not accountable under the ACMHNs Standards, their accountability is via the Registered Nurse Competency Standards and Codes of Ethics and Practice of the Nursing & Midwifery Board of WA as cited below. A search for the word ‘recovery’ in the Standards document yields no results, which is not surprising given that it is a concept that is primarily located in mental health.
• Registered Nurse Competency Standards 2006
• Code of Ethics for Nurses 2008
• Code of Professional Conduct for Nurses 2008
Many nurses may not know much at all about recovery which is not surprising given that the nursing competency standards don’t even mention it. A more generic use of the word ‘recovery’ can be found in Value Statement 8 in the Code of Ethics that states that “Nurses value a socially, economically and ecologically sustainable environment promoting health and wellbeing”. This Statement includes the point that “Nurses are sensitive to, and informed about, the social and environmental factors that may contribute to a person’s ill health and that may play a part in their recovery.” This is a starting point for recovery-oriented education in a mental health context however needs unpacking and clinical application.
Further, recovery is barely mentioned in nursing training at either an undergrad level or in the standard postgrad mental health nursing program, and there is precious little clinically-oriented recovery training in the sector. This is not because people aren’t trying; it’s a big job. We all need to work on it together.

In summary, there are some challenges immediately evident here:
• Only a small proportion of nurses working in mental health in WA are members of the Australian College of Mental Health Nurses.
• Even for those who are members, or for those who accept that working in the capacity of a mental health nurse means that they should be working within these standards,
there is the challenge of not actually understanding what any of these references to recovery, “recovery journeys”, “principles of recovery” or “recovery-focused care” actually mean.

To say that recovery is not at the foreground of clinical training for nurses is significantly understating it!

We are all of course still working within the National Recovery-Oriented Mental Health Practice Framework, as well as the National Practice Standards for the Mental Health Workforce. But unfortunately these are not obligations but would seem, at this point in time, more aspirational. This is something that needs to be addressed as a matter of urgency in workplaces so that all the mental health workforce are in fact accountable to standards of practice in their employment that are centred on recovery principles.
For e.g., psychologists to practice they must be registered with the Australian Psychological Society (APS). Nurses, by contrast, have to be registered with the Nursing & Midwifery Board but, as already pointed out, standards of practice that specifically pertain to mental health nursing are not covered in this. This is where a specialist level of qualification to practice is necessary in order to give a more solid foundation for the creation and flourishing of recovery-oriented environments.

Summary
• We are all on a continuum from a ‘mental illness understanding’ to a ‘recovery understanding’ of ‘bad behaviour’.
• There is no doubt that what we perceive, experience, name, document and respond to as ‘bad behaviour’ in clients is significantly affected by our personal history and makeup and our immediate working environment, as well as the larger cultural context in which we are operating.
• Currently most mental health settings are primarily about managing behaviour in such a way as to minimise risk; unfortunately in practice this often means suppressing emotion and focusing on compliance to set codes of behaviour. This is our inheritance of a system geared towards managing mental illness.
• All the mental health workforce need to made accountable to standards of practice in their employment that are centred on recovery principles in order to give a more solid foundation for the creation and flourishing of recovery-oriented environments. Currently this is not the case; recovery would appear to more aspirational as a concept. There are significant gaps in understanding and teaching recovery-oriented practice – these show up in it not as yet being generally evident in practice.

What can you do in response to this?
1. Supervision groups
• I offer fortnightly supervision groups for those of you who are serious about meeting the ACMHN Standards of Practice.
• These give the opportunity to work through cases from a recovery perspective.
• A person with lived experience of psychiatric diagnosis will generally attend with me to ensure we are ‘hearing the voice of lived experience’.
• Where this is not possible, and with the group’s permission, I specifically seek out their input on current cases the group is discussing.
2. Recovery Training based on ACMHN Standards

• Trainings and workshops are provided to better equip mental health nurses to meet the requirements of the Australian College of Mental Health Nurses in relation to recovery.
• See relevant section of the website for more information.
3. Monthly recovery forum for mental health workers
Expressions of interest are now being taken for attendance at a monthly forum to network, share information and mutually support one another in our shared commitment to recovery-oriented practice.
4. Ask for support

• For more information, to give feedback, find more info, read my blog or contact me via this website.
• I am part of an international community of professionals who are asking these questions and am committed to being part of the solution.
• There are processes to be re-thought and practices redesigned as we continue in the orientation asked of us through national standards and frameworks; an orientation that is now best practice internationally.

References:

Australian College of Mental Health Nurses Inc (2010) Standards of Practice for Australian Mental Health Nurses 2010. ACMHN, Canberra.

A national framework for recovery-oriented mental health services: Guide for practitioners and providers 2013. Commonwealth of Australia.

Code of Ethics for Nurses in Australia 2008. The Nursing and Midwifery Board of Australia.

Code of Professional Conduct for Nurses in Australia 2008. The Nursing and Midwifery Board of Australia.

National Nursing Competency Standards for Registered and Enrolled Nurses The Nursing and Midwifery Board of Australia 2006. The Nursing and Midwifery Board of Australia.

National practice standards for the mental health workforce 2013. State of Victoria, Department of Health.

National Standards for Mental Health Services 2010. Commonwealth of Australia.

Mental health and the workplace – corporate event

Last week I had the privilege of speaking on the expert panel at a day organised by 55central to encourage employers to think about employing people with mental health challenges. The audience was primarily CEOs, other execs and HR people and the focus was very much on reducing stigma through increasing understanding.
The panel was diverse and engaging, made up of about ten experts ranging from Amanda Waegeli, who facilitated the day to Kevin Dunn, General Manager of 55central. Glenn Mitchell MC’d the day, sharing his own story of mental health challenge and his journey through this in terms of employment, family and learning to pace himself, take time out.

The response from the 100-odd participants was extremely positive, with many questions being asked of the panel around, in particular, responsibility for the health and well-being of the workforce. This led to much debate, with HR professionals being clear that this lay outside their domain, while other staff, including at the exec. level, considered it to be within their accountability as it is incorporated within the Occ. Health & Safety realm.

This became interesting as there was consistent collapse during the day of mental illness and mental health. As soon as we started speaking of who is responsible for mental well-being the conversation moved to whose responsibility mental illness is. This is despite there being solid precedent internationally in leading employers incorporating measures such as on-site gyms, yoga and childcare so as to maximise wellness in their employees. Supporting the well-being of employees is clearly in the interest of employers as it ultimately maximises productivity, reduces turnover and absenteeism and makes for a much happier workplace where people are wanting to come, to stay and contribute.

OHS has traditionally focused on physical safety but has to a large part overlooked the core role that mental safety plays. This is an area that Ros Bowyer Consulting is particularly focused on, using numerous measures by means of which the wellness of an organisation can be objectively assessed and an appropriate plan for addressing the areas of challenge formulated and enacted.

‘Madness’ as a sacred cow

Recently I proposed a title for a presentation in mainstream mental health circles that included the word ‘madness’.
I was asked to come up with a different word as it was felt that this term would not be acceptable to the audience, which would have been primarily mental health nurses.

This made me wonder. Certainly my title brought sharp focus to ‘madness’ and the use of this term in the community. My intention in using the word was to garner the attention of those who may not as yet have moved into the use of ‘recovery terminology’.

Part of my presentation was indeed to focus on this very issue. I find that when I use politically correct, recovery-oriented terminology in titles I often end up with an audience who are already au fait with the core concepts and hence the opportunity to introduce others to whom it may be less familiar is lost.

The title and body of my presentation in fact drew upon changes in language that have occurred in the consumer movement to reclaim the word ‘madness’ away from the medicalised understanding of the term that is currently dominant. Evidence of this dominance was provided by the negative response I received in this scenario.

Others are using the word ‘madness’ in contexts other than the derogatory, stimatising one to which we are most accustomed in conventional mental health circles. This includes such notable and highly regarded professionals as John Read (Director, Clinical Psychology, Psychology Dept, Uni of Auckland, NZ), Loren Mosher (Clinical Professor of Psychiatry, Uni of California) and Richard Bentall (Professor of Experimental Psychology, Manchester Uni, UK) who in fact co-edited a book entitled ‘Models of Madness’ in 2004.

For the past six years I have been immersed in the world of recovery, learning from and sharing with people with all sorts of distressing lived experience. Through my professional training and experience I have worked to translate this learning into training for mental health professionals to improve their understanding of the nature of mental illness and distress and what works and what doesn’t from the perspective of consumers.

I have learned that words such as ‘mad’ and ‘madness’ have indeed been reclaimed and are preferable to many consumers to terms such as ‘schizophrenia’ which are words they feel have been put upon them by psychiatry and which miss the nuancing of their individual experience.
I would hazard a guess that Read, Mosher & Bentall’s rationale for using the word in their 2004 title ‘Models of Madness’ was along similar lines of wanting to extend the sphere of influence of recovery into the mainstream.

Why is madness as a term so disturbing to many mental health professionals? What is it we think of when we hear the term? What does it point to? Are we really more inclined to feel comfortable with terms such as ‘schizophrenia’ in its place? Could this be because, despite ‘schizophrenia’ being as ill-defined as ‘madness’ and in great dispute internationally, this term comes out of the medical fraternity and is hence laden with greater significance, being hierarchically superior.

Food for thought, especially in this time of focus on lived experience, consumer engagement and person-centredness. Should we not be taking into account the opinions and wishes of the people with these experiences themselves?