Thinking Outreach

Personality Disorders

2009-12-05T10:18:00.002Z

Recently Mark Easton, a journalist and the BBC's home editor, made a reasonable stab at an article on Personaility Disorders. The article has lots of little flaws but it is a large and detailed article that for a brief spell brought a wider audience into the discussions of what constitutes a disorder in something as nebulous a 'personality' and what we we do with those that do seem to be difficult ot manage, or worse, whose daily experiences and interactions with the world are actually distressing to them.

In this case however, probably more valuable than the article itself are the numerous comments made in response that you will find at the bottom of the page. The comments range from the ill-informed, to those with direct personal experience, to those who see 'the state' as conniving and manipulative actors in this field, and thankfully to a number of professionals that chip in to make it a fairly holistic and ultimately informative discussion.

One of the simplest and most informed points of view comes form a clinical psychologist who points out quite rightly:

Rather than ask "does this person have disorder X?", I believe we should instead be asking "should we offer this person help?"

In answering this last question we need to consider 6 things;

1. Level of current subjective distress and suffering.
2. Risk of future distress and suffering if not offered help.
3. Whether their capacity to make consequential decisions is impaired.
4. Whether they are at high risk of losing capacity to make consequential decisions if not offered help.
5. Available resources.
6. Whether we can help.

I find this invetory extremely helpful and will bear it in mind in my negotiations with mental health services who sometimes shy away from offering support to even their own recognised patients because their psychiatic problems are deemd to be psychological and intractable. On the Assertive Engagement Website I have an article on working with dual diagnosis, a rather simple top tips piece but similar to working with personality disorders I hold it as deeply important that no psychiatric worker, even at psychiatrist level should ever be able to say in your presence (not without a fight) that someone's problems are intractable and cannot be changed. There is sufficient evidence out there that improvements in quality of life will have a bottom-up effect on emotional processing, and reduction in daily distress. The goal is always to move someone from personality disordered thinking to personality 'style' thinking, recognising that core traits may never be changed but the damaging effect of those traits can, with work, be minimised. The answer to point six of this inventory is always yes and it is sometimes lone workers that have to fight for recognition of this in each individual case.

The article is at: Mark Easton Article on PD

Keep fighting the good fight.

Team Leading Presentaton

2009-08-31T11:18:00.002+01:00

Recently I had to give a five minute presentation on team leading. Five minutes is not a great deal of time and so the best I could do was list what I felt were the five key elements of leading a social care team. Here is the powerpoint presentation:

Team Leading Presentation

boredom, drink, and the green shoots of recovery

2009-06-11T22:31:00.004+01:00

A client of mine called Mark spoke very eloquently yesterday about giving up his drinking. He described the boredom that comes with giving up an addiction and I asked him what advice he would give to others going through what he was going through. He said the boredom was important, that people had latent characteristics, skills and strengths that they buried so deeply through perpetual substance use that only a period of sustained nothingness gave time for these characteristics re-emerge. He explained that after a while the emergent skills you have on a day to day basis become in and of themselves exhilarating as you watch them grow from inside you.

This was borne out only a few days earlier when I had been quite pushy with another client of mine who is still drinking to come and sit at an outdoor cafe with me and chat over a cup of tea. It was slow progress but after a while Steve was really enjoying himself (we talked a lot about football). Ironically, Mark walked by as we were chatting and Steve, a friend of his and ex-drinking buddy, shouted out to Mark: 'Look Mark! I'm drinking tea!' With a purity of joy that surpirsed even me. I understand now that Steve was exhilarated by the simplest skill of actually sitting and talking over a cuppa. What is a daily occurance for me was something he hadn't done for years and had believed himself now incapable.

I pushed Mark to come up with an analogy (a useful conversational gambit - lateral thinking and all that) and between us we decided that it was like having a garden patch over-run with weeds, wildly growing in every direction. When you finally take control, and clear out the weeds and you plant some seeds, you have, for a while, nothing to look at but a boring plot of earth, just some mud. It's easy to wish the weeds were back because at least they were lively. But with patience comes small shoots, pushing through the mud. And watching these small shoots grow is exhilarating. We decided the difference was that weeds are the product of external forces and these shoots, soon becoming plants in their own right are yours, the product of your own toil - and even when they are tiny they matter a great deal.

It's a nice analogy, and as per the mandate of this blog where I'm trying to note down the learning from the day to day encounters we have in this very special field we work in, I thought I'd share it. Soon I won't be working with Mark anymore and I thought I should give him a mention - he's said some excellent things.

Why is my client lying?

2009-01-29T22:28:00.007Z

A colleague and I carried out an evening street shift tonight, walking the streets looking for drinkers and beggars, descending upon them and immersing ourselves in their problems. We talked about the process of working in a field full of obfuscations, defences and at times out and out lies. One particular client communicated always through a filter of half-truths - everything they said existed only to create a particular effect in the listener. The effect is deeply odd. We mused on how workers should navigate this kind of communication.

For myself, I talk about what I call the 'neutral space' - the place in my head I put information I cannot fit into any valid emotional or cognitive category. To me it becomes neither true or not true. Instead I find myself thinking in terms of actionable and unactionable - can I do something with this information or not? Yet this is not the full truth because I can't just stand there passively when what the client is telling me is emotive - but nor can I respond with a fully congruent level of emotional confirmation when nothing quite seems to be true. There is a very real sense that my responses, even when accurate, are detached from the reality of my thinking. So what we have is a client telling a collection of half-truths and sometimes pure lies, and me responding with a certain fake (but accurately empathetic) sentiment. Our level of outer congruence is great but our sense of inner distrust (for both of us) is equally great - we are reaching out to eachother but our positions mean we must be guarded.

One might be inclined to demand the truth, pull out discrepancies and reflect them back but the half-truths are emotional camouflage and I am in no position to denude someone of their defences at 9 o clock at night on a street corner. That is not to say I would not challenge, but that I must tread carefully and can't challenge everything said. In this the outreach worker is less safe than a counsellor.

More usefully, I remember a lecture I listened to talking about 'core component communication', this is a development on Eric Berne's 'games people play'. In core component communication we are asked to look at the meta-message (as Alan and Barbara Pease would have us term it) behind each statement. Yes, they are lies, but why tell them? To achieve what?

No one is wholly truthful all the time because the described truth rarely captures the emotional content we feel. Often we exaggerate or underexaggerate towards the truth. The example I give in training is of waiting for someone on a street corner in the rain when they are five minutes late. It is the most awful five minutes ever and you count every single second of it painfully. When they finally arrive the actual truth of the situation doesn't fit your level of emotional content and so rather than say: 'I've waited five minutes for you!' You say: 'I've been here twenty minutes in this rain!' And even though it is a lie, it is more congruent with the emotion you wish to communicate and more cathartic (it feels better). This is an important point. So often I have met clients that have a £20 a day drug habit but are in crisis. £20 a day doesn't seem a lot so in trying to communicate their level of crisis, they say: 'I''m using £100 a day!' Or alternatively, someone is working really hard to keep their use down and maybe they've only used 4 times this week, yet telling me this doesn't quite seem to fit the emotional context so I'm told: 'I haven't used all week!' And so in the end whilst I can't really have a clue how much someone is or isn't using, based solely on self-disclosure, I can at least say that my client wants me to know they are doing quite well or doing very badly and it is that that becomes actionable not the actual facts.

As an example of this we recently had a rough sleeping client who would tell stories of being in the army, that were probably not true, and in times of distress would say things like: 'As a sniper i killed 97 people.' Now this is blatantly ridiculous, but a worker would have to find a way of making an emotionally congruent response. Why tell such a lie? Because esteem and the flow of power dynamic demanded it - he had nothing and was utterly disempowered but desired a degree of parity with the workers he 's talking to. So the best thing to to reflect was not the actual fact of the statement ('Good god! You've killed that many!') but to pick out the core component and reflect this instead: 'You're a man to be taken seriously.' This seemed to work and it forms a good general rule: don't get sucked into a lie, and don't just reject it - instead put it into your neutral space and try to work out what it represents and use that as your reflection, and your guide for how to take the engagement forward.

The beginning of the blog, bear with me.

2009-01-24T16:11:00.005Z

Welcome to the Thinking Outreach blog.

This blog is a counterpart to the Assertive Engagement Resource, a website resource dedicated to the skills employed by outreach workers, drug workers, prison workers and any other worker whose client group is often termed 'Hard to reach'.

There you can find weblinks, book reviews, listings and formal articles, here I aim talk about good practice in outreach in a much less formal sense. The idea is to use this blog to share ideas and observations well before they get honed into something that can be presented as an article, a good practice guideline or a presentation.

There are three core drivers to the aim of this blog:

1. I believe that the good practices of the workers I work alongside in a range of fields are too infrequently recorded, analysed and disseminated and yet by doing just this we can begin to build up a picture of what works and what doesn't in fields of working that sometimes are no more than only a few years old (my own field of Anti-Social Behaviour is so new expertise is very hard to come across).

2. The thoughtful application psychotherapeutic techniques, along with learning from social and cognitive psychology, can enhance our engagement with vulnerable and disenfranchised groups enormously and yet these techniques, and this learning, are often seen solely as the dominion of psychologists and counsellors who actually need work much less hard than outreach workers (and require fewer techniques) to secure meaningful outcomes. This blog (and the Assertive Engagement Resource) is an attempt to redress this balance slightly by trying to draw lessons from the ways that a client's responses to a worker's attempt at intervention can often be unpicked and understood through the same processes that more formally recognised workers use to analyse their practice.

3. A part of this blog will just be a cheeky polemic on subjects close to my heart such as homelessness and substance misuse. Mostly this will just be my opportunity to vent but more charitably you could look at these entries as being, at least in part, representative of the kinds of conversations that professionals in these fields are having, and the kinds of views we hold. I do not think that there is often a close attention paid to the views of workers who work on the front line of service provision - certainly we are under-represented in the media.

So welcome, I hope that some small part of this blog proves useful to you. And if not, at least interesting.