Rotten Apples, on Poisoned Branches in Toxic Orchards

“It is a poor thing to enslave another.  I would suggest you find yourself a different line of business” 

The Sandman, Neil Gaiman

I wrote this last year after a BBC program exposed a number of abuses going on in a care home that I’m pretty sure would fit with the description Out of Sight, Out of Mind. It fits with a number of the themes I’ve been talking about in the #NoOOA ( No Out of Area) topic this week and here I am sharing it again. Yes there are bad staff, but there are serious systematic problems here….

Scrolling through my social media feeds I’m coming across a lot of vitriol for the “care” workers of the hospital exposed on Panorama.  There is anger, fury, sadness and disbelief.  This is often followed by a graphic depiction of what medieval tortures the person posting the comment would like to inflict.  This is an understandable response to witnessing people in power seemingly taking pleasure in inflicting pain and humiliation on those who are helpless.  It was sickening to watch, and they should face justice.  

It’s essential that our quest for justice does not stop there.   The destination turned out to be awful, but perhaps this is a journey that should never have been embarked upon?  After the Winterbourne scandal, Transforming Care emphasised the need for people to be supported in their communities.  The Rethink #InSightInMind campaign highlights how those with mental health problems are often put in locked rehab wards many miles from home.  Most are probably bored of me listing the enthusiasm of the NHS to send people diagnosed with personality disorder to long term locked rehab, which most could  agree is an utter inversion of what NICE would recommend. Despite all these voices arguing against the use of long term compulsory detention far away it continues to happen.  We need to ask ourselves why.

A common feature of those with complex needs (whether they be branded as learning difficulties, schizophrenia or personality disorder) is that they can worry those who feel responsible for them.  There is a two pronged fear around what might be done to you (E.g. assaults, allegations) and what you might be blamed for.  My MSc research and studies highlighted the impact of anxiety in organisations and how this can lead to a perversion of care.  I’ll use the example of someone diagnosed with personality disorder (not a real person but an amalgam of many I’ve met over my 20 years in mental health working in and researching this area).

“a pressure developed affecting all levels of staff, managerial through to clinical, to ‘manage risk’…but this soon slipped into ‘managing risk to themselves…this is understandable, since the consequences of a faulty risk assessment were and continue to be quite horrendous”  Independent Review of the Mental Health Act

There was a girl (it’s almost always a girl) who didn’t want to live.  She didn’t necessarily want to die, but she felt the world was an awful place.  After she had overdosed she felt unwell and went to A&E.  She ended up getting admitted to an acute ward.  On the ward she started to swallow things and to tie things around her neck.  Here, she never sought help and it was up to the staff on the ward to save her.  They watched her more and more.  They took everything dangerous away from her.  The things she did became even more dangerous.  She stopped being allowed any leave.  They took everything away from her. 

We sat in a meeting and talked.  Some people talked about how she was only doing this for attention.  Some people recognised that since others had taken over “keeping her safe” she had become significantly more dangerous to herself.  We could hear her saying loud and clear that she didn’t want to die, she just couldn’t cope with her living situation and the overdoses helped.  We thought really carefully and came up with some different accommodation options.  We thought about how we could provide therapy and support for her now and in the community.  We all agreed that the NICE guidelines for her diagnosis told us that collaborative working, minimal use of the mental health act and treatment in the community were the ideal response.  Then someone said “What if she kills herself?”.  The rest of the meeting was about how the organisation could protect itself from blame.  The solution that best met this objective was to send her to a private hospital for at least a year.  Some of the people in the room believed that private hospitals were specialist places with experts and exclusive therapies.  Some of the people in the room knew they were locked rehab wards with less therapy than was currently available in the community.  She would be locked there, for years, with people with difficulties vastly different to her own.

Clinicians had “failed to rescue the patient, were uneasy at their failure, and were inclined to blame others, especially relatives, but sometimes colleagues. They were clearly worried by the patient’s distress, and wanted to rid themselves of their responsibility, with professions of goodwill. Concern for the patient was emphasised; impatience or hatred never.” Tom Main 1957

She had to wait a long time to go to placement.  During this time she was never told that placement was the opposite of what was recommended to help her.  She kept being told it was the answer, that this would fix things.  Again some staff believed it.  Others not so much.  Different quotes were obtained from a variety of hospitals that all claimed they were special and could all provide intensive therapy.  It turned out one didn’t even have a psychologist.  3 different quotes were obtained.  One could say that the NHS made sure it got good value.  One could also say that the opportunity to provide substandard care was auctioned off to the lowest bidder. 

She went anyway.  Her years stay slipped into two, then three.  People visited but it felt more like the hospital told them what was needed rather than them holding the hospital to account.  Eventually a different hospital was suggested for her.  People talked again about how much more dangerous she had become since we had started keeping her safe.  People pointed out how her care was the opposite of what NICE recommended.  The answer was “What if she kills herself?” and she moved to another hospital. This one was further.  Despite the label above the hospital gate the staff there knew there was nothing special about them.  They knew they were working with those the NHS had given up on.  Why else would they be sent 100 miles away to a ward where none of the staff had any specialist training? After allegations were made against the staff she was eventually brought home to a greek chorus of “She will kill herself”.  She didn’t, but she had seen multiple people die in hospital with her.  Every inquest said they should have been watched closer.  None of them questioned why they were there in the first place. 

Due to the recent coverage it’s very easy to focus on those diagnosed with learning difficulties, but the reality is that a trip to the modern asylum is a danger for any person who elicits anxiety in those who feel responsible for them.

“The need to believe in the hoped for magical solution prompts denial of the inadequacy of the solution achieved, notably again in the poor quality of the institutions” Isabella Menzies Lyth

Last week I was at a study day where 30 people from across the country looked at ways of avoiding the above happening.  There are some trusts that do not use OOA placements and we studied what they did that made it possible. While the NHS is frightened the temptation is that we do not focus on the risk to our patients but instead the risk to ourselves.  When we are frightened it’s understandable that we do what we can to get the things that frighten us out of sight and out of mind.  When we stop thinking about people, unthinkable things happen to them.  Many people will watch Panorama and feel that it should never happen again.  It is happening today.

Keir works at Beam Consultancy helping organisations to avoid long term out of area hospitalisation via the provision of training, consultancy and intensive support.  contact@beamconsultancy.co.uk

Product Placement: Out of Sight and Out of Mind

This is jointly written by Keir Harding @keirwales and Hollie @Hoppypelican.  Please stay safe reading this.  It contains descriptions of self harm and restraint and allusions to abuse.

It’s taken a long time for us to put it together but we think its something that needs to be heard.

A story…

She places her hands against the cold window and peers through the grill into the twilit garden; the grill that traps her, obscures her view of the outside world and reinforces her cage.  The reds and pinks of dusk bleed across the manicured lawn; the progression of day to night being the only consistency amidst the chaos she lives within. Along the corridor someone is still screaming.  She knows the staff have tired of it because she hears the shouting and clattering of the ‘care’ starting.

She remembers arriving; the initial feelings of safety, respite and containment that disintegrated over the days and months.  It was substituted with anxiety and frustration.  Still she wasn’t allowed to leave the cage that exacerbated her distress and eroded her last shreds of hope and resilience.   For a time she’d wanted to die but somewhere lurking in her subconscious was a desire for something to be different.  Even when things were at their darkest; when she’d swallowed down the tablets and knocked back the vodka, even after she’d written the note something inside her wanted to keep her alive.  She phoned for an ambulance even though she felt sick and ashamed. She knew she was wasting resources and she knew she was undeserving, but it took so much to pick up that phone. Utterly overwhelmed by sadness, self-loathing and desperation she sobbed as she told them. Drowsy and nauseous and to a total stranger, she gave away her darkest thoughts.  By the time she’d finished she just wanted to be looked after.  She just wanted someone to care.

When she got to the ward the ‘care’ started.  She told them she wouldn’t try again but they took her shoe laces and belt off her, then her bra. They rifled though her belongings like a Primark sale bin and anything deemed a ‘risk’ was confiscated; no explanation. Every night for years she’d listened to music to keep the worst of the thoughts at bay, but now that she was being cared for her headphones were snatched away, no recommendation of how else to keep out those intrusive barbs.  She was told she’d been silly.  She was told that everything she’d done was just to get attention.  She was told that the bed she had should have been used for someone who needed it. She was told she wasn’t ill, that it was just ‘bad behaviour’. She cried as she tried to shrink into the corner of the room.  The warm, wet tears dropped onto the blanket she’d pulled over her head.  In her mind she shrunk down like Alice in Wonderland and cowered within the Airtex cocoon.  After 15 minutes the blanket was ripped away and she was told she was attention seeking again.  It didn’t feel much like care, but they ‘cared’ for her every 15 minutes until the end of the night. The unlocking door and flash of torch, a reminder 4 times an hour that they were there, ‘caring’, watching and depriving her of sleep, the thing she longed for most.

The day came slowly with a murky light turning the dark into grey.  She’d watched every minute tick by, as between the 15 minute door clanging of the care and the shrieks of the others who were living in some other reality, sleep hadn’t come near her.  The energy of the other patients and the sudden noises frightened her.  This was not being looked after.  This was not what the care was supposed to feel like. She noticed that the other people on the ward seemed to have a very different version of care to what she was receiving. Having gone through life feeling like a pariah, this augmented and reaffirmed everything she believed about herself being different and not belonging in the world.

Conscious of her drooping jeans and laceless shoes she shuffled to the office.  She knocked gently and saw someone in a uniform catch her eye and look away again. This happened often. She knocked once more and waited for someone to come to her.  After she’d waited a while someone came along with a clipboard to give her the 15 minute care.  She explained that she wanted to go home and was told she couldn’t.  She told them that she felt different now, that she didn’t want to die, that she just needed to sleep; she wasn’t getting that here.  They told her she couldn’t go home.  She turned to walk towards the doors. She pulled and yanked at the stupid handle that you have to claw onto, it rattled but didn’t yield. They shouted that she needed to stay.  The doctor needed to see her; they made it clear if she didn’t behave she’d be made to – detained and totally stripped of liberty and dignity.

She felt helpless, like she had so often before.  She felt like a puppet; those in authority directing her moving parts and holding the control, just like before.  She was told that she’d manipulated her way into hospital and was now wasting people’s time.   With her face calm and her heart screaming, she walked to the toilet and wailed a piercing scream that vibrated though her head but didn’t make a sound.  Once again it didn’t matter what she wanted, others would make her do things, once again she didn’t matter, she was worthless and nothing.  She rooted through what was left of her things, biting the little plastic buds off the end of a hair-grip and dragging it down her arm; it brought nothing. She frantically searched for something else and found a lip balm tin.  She didn’t remember taking the lid off and jamming it into the doorframe to bend it and create a point.  She only remembered the noise stopping when she pushed the shard of metal into her leg.  She only felt that the world was right when she treated herself like the piece of shit everyone else had, when she punished herself like she was told she deserved.  She only felt like she had some control again when the pain blotted out everything and the blood let the agony flow away.

Within 15 minutes the toilet door opened, someone shouted “For fuck’s sake” and an alarm started going off.  In the tiny space of the toilet, three men she didn’t know ran towards her.  Just like before, they pinned her arms.  As she thrashed about they pulled her to the floor; she was no longer in hospital, she was transported back to that terrified child again.  She was pushed down, face to the floor, arms held, the backs of knees knelt on. She couldn’t move, couldn’t breathe, and as she fought to escape she felt her trousers being pulled down.  She screamed as loudly now as she had then.  She knew how this would end.  Broken, hurt, degraded. This pain was different.  This time a needle penetrated her buttock and as they held forced her into the floor she felt the wave of numbness wash over her.  Before everything turned to watercolour she heard someone saying that they knew this would happen.

Reality started to creep back as her body thawed but the world around her still felt hazy, like her head was full of candyfloss but no where near as sweet; this was due to the benzos she’d been forced to swallow with a thimble full of water. Made to open her mouth dentist wide and stick her tongue out and up to make sure they’d gone down. She still wanted to leave.  And they still wouldn’t let her.  She explained that she’d be okay.  They told her that people that cut themselves aren’t okay. She told them she’d only done that because they wouldn’t let her leave.  They told her she had to stay until she wasn’t going to kill herself and could keep herself safe.  But she’d thought about suicide every day for the past 4 years.  She’d cut herself carefully, with her special blade every day for 4 years.  How was she going to stop this now?  How was she going to stop it here?

She didn’t stop.  The urge to cut and get some sense of control back became overwhelming.  Without having her blade with her she did what she could to get the same relief but it became harder to do. They watched her.  They followed her.  After she smashed apart the Perspex covered display board and cut with the shards they stayed within arm’s length.  After she ripped her pants apart and tied them around her neck in the toilet she had to piss with the door open; underwear confiscated and hospital paper pants instated.  Every time they did more to ‘care’ for her she had to do something more frantic, more dangerous and with more of a chance of killing her.  Every time she did this, they did more and more to make sure she couldn’t do anything to hurt herself.  Every time she did this, three of them would hold her down, just like the men had when she was young; like them she could feel that they hated her. Every time she cut herself, they reacted as if she was cutting into them.  They couldn’t go on like this…

And they didn’t.  They told her that her personality was disordered and that she needed specialist treatment.  That her reaction to the ‘care’ was inappropriate.  That she needed to go to a specialist unit where she would be treated to get better.  She did not want to go, but to them she was voiceless, she was going, and would probably be gone for a year. Ripped away from everything and anyone she ever knew.

She’s been here 2 years now.   Things aren’t much different.  She can’t cut with anything so she tries to tie things around her neck a lot more.  She never did that when she was at home.  She’s on more medicine which is supposed to help but instead makes her drowsy.  She bothers people less when she’s sleepy.  She’s not got the energy to exercise, which she wants to do because she’s 3 stone heavier than when she arrived.  The specialist treatment she was supposed to get has turned into seeing her nurse 1:1 for an hour once a week, something she got more often at home. These sessions are not tailored to her needs and she is jammed into boxes she does not fit in; square peg, round hole.  She wants to go home but they tell her she isn’t safe.  She needs to stay in the specialist placement.  It doesn’t feel special.  She doesn’t feel special.  She feels likes she’s been forgotten and in a sense she has.  If any of the staff that worked with her previously think of her, they feel relief when they remember cutting the cord from her neck.  They think of their relief when they remember that she’s gone, not their responsibility, not their risk to contain, not their problem.  They never think of the time she looked after herself by phoning an ambulance.  They never remember that the things most likely to kill her began after they started ‘caring’ for her.

__________________________________________________________________________________________

Between us we have worked in  and received mental health services for about 30 years now.  Sadly we have lost count of the number of people who have lived the exact same story we’ve described above.   People get stuck on an acute psychiatric ward and staff believe that the only answer is a specialist placement, even if no therapy or more intensive support has been tried in the community first.  Because “Specialist Unit” is not a protected title and doesn’t come with any accompanying standards, places become such a unit by changing the sign above their door.  People are then compelled to go to these non-specialist ‘specialist placements’ to receive little more than warehousing.  Unsurprisingly things don’t improve.  Unsurprisingly, the promised one year stretches into two or more.  Between a private provider who makes money from people being on their unit, and an NHS team who is afraid something dangerous will happen and they will end up in court, there is no incentive to bring people back home.  The cost to the NHS is extortionate.  The cost to people’s lives is immeasurable.

What Does an Occupational Therapist do in Mental Health?

I wrote this 2 years ago but this seems a good time to dig it out again…I get asked this question a lot.  It was asked more often when I actually had Occupational Therapist as part of my job title, but it’s still asked fairly regularly and often by people who are Occupational Therapists themselves.  As it’s OT week from today (November 6th), I’m going to spell out what my understanding of OT in mental health is and spend a bit of time talking about what I do.

Keir provides Training, Consultancy, Supervision and Therapy around people with complex mental health problems via BeamConsultancy.co.uk

To understand what OTs do in mental health, we need to have an understanding of what OTs do in general.  Whenever I tell people I’m an Occupational Therapist, unless they’ve seen one they generally assume I’m ‘something to do with backs’ or that I work in Human Resources. This normally leads to me disabusing them of these notions and beginning the following tirade…

We see humans as having an inherent need to act – to do things.  We can break down these actions (or occupations) into what we want to do, what we need to do and the skills we need to be able to do them.  While there will always be some overlap, an example might be that I WANT to play the guitar and I NEED to be able to go to the toilet. There are also a range of (physical, cognitive, emotional…) SKILLS that I need, to be able to manage both of these occupations.  A big factor that impacts on my ability to do these things is the ENVIRONMENT around me.  If my social environment doesn’t like the sound of bad guitar players, my progress will be hampered.  The environment will hinder my functioning.  If my toilet is upstairs and I can’t use my legs then again, the environment is not helping me to do what I need.

OTs help people to identify the things they want and need to do in their lives, identify areas where skills development is needed and assess how the environment helps or hinders people in achieving their goals.

In mental health the process is exactly the same.  I don’t think diagnosis is particularly important when we’re thinking about this, but I’m going to use it in some examples just so we have a shared understanding.

If an Occupational Therapist comes across someone with depression, the drive to do what they want and need to do will have plummeted.  They will tend to isolate themselves, thus missing out on the things that give them a sense of accomplishment (from what needs to be done) and a sense of pleasure (from what they want to do).  If we use ideas from CBT, the client loses the skill of being able to rationally weigh up their thoughts and overly identifies with negative thoughts about themselves, others and the future.   An Occupational Therapist might identify the priorities of what the client wants and needs to do and establish what gets in the way.  We can then support the client to use the energy and motivation that they have to perform the activities that will give the most reward.  We can help the client build skills in recognising and challenging negative thoughts.  We can adapt the environment so that there are more opportunities for achieving a sense of reward and accomplishment.  We can also support our colleagues by letting them know how their interventions affect the clients functioning. For example, after changes in medication, we can do something the client finds meaningful and observe changes in concentration, cognitive ability, body language, communication skills… all the things that don’t depend on symptoms, but whether the client is more or less able to do what they want and need to do.  This observation and assessment of changes in how the client is able to function can be useful to everyone involved.  I’d argue it’s more important than a descriptive account of what some has been doing.   The OT is able to describe what has increased or decreased that has allowed/prevented the person doing what they’d set out to do.

Taking Schizophrenia as another example, at times someone with this diagnosis is likely to have things going on in their mind that make focus and concentration pretty difficult.  Here we are again following the same process as above.   In this case the client’s life may well have started to deviate markedly from the lives of their peers.  They might leave school, become isolated and find themselves in situations and ways of being that result in them being ostracised by society. OTs would again look at what the client wants and needs to do and what gets in the way.  We might teach ways to drown out or cope with voices and how changes in the environment (smaller classroom sizes?, shopping at midnight?) to allow the client to do what they want and need to.  As the medication for schizophrenia can cause side effects some feel are worse that the condition itself, we would be closely looking at how other treatments affect function.  We might argue on behalf of the client that a small reduction in voices isn’t worth a 16 hour sleep cycle, impotence and an extra 4 stone.

You will tend to see Occupational Therapists doing activities with people.  This is because we think this is the best way to help people make changes.  People will engage more in an activity that they find meaningful than they will in some random task that isn’t part of their life (“I’d like you to meditate on this raisin???”). It might look like we are just doing things that are fun.  We might well be, but the purpose of the activity is to effect change in some way.  It might be the building of social skills, or exposure to something that is disproportionately feared. It might also be challenging a sense that nothing can be accomplished.  If we are doing our jobs properly, there is always a purpose.  I won’t go as far as to say that Occupational Therapy is never entertaining, but if we are only entertaining then something has gone seriously wrong with us and the system around us.

Some Frustrations with OT in Mental Health

But Can They Cook?

My colleagues are always asking if someone can cook.  We seem to get obsessed with it.  I see many OTs choosing to spend time teaching clients to make curry, going to the supermarket to buy healthy things and making sure they wash their hands enough times in the therapeutic kitchen.  Unless my client is desperate to be able to cook, I genuinely don’t care whether they can or not.  “Can they feed themselves?” is a much more pertinent question and we need to respect some of the choices our clients might make in this area, rather than enforcing some faux middle class dining etiquette upon them.  I once worked with one poor man who wasn’t going to be discharged until he could cook, when he knew full well he wouldn’t use the kitchen for anything other than making tea and toast once he got home.

I Think I’ll Ask a Nurse to Handle This

I’ve always hated other staff suggesting that critical incident decision making and complex risk management is somehow not my business.  I’ve loathed it when senior Occupational Therapists have said the same.  I’ve been in meetings where a Nurse has fed back about John’s suicidal urges, a Doctor has described his life threatening self-harm and the OT has said he came to the walking group and is eating his 5 a day.  I’ve always felt that when the challenges to mental health are so strong that people lose all boundaries, those are the times OTs should be most interested and involved.  That is when their functioning is most severely compromised. The idea that we wait until people are ‘well enough to come to group’ can make us seem (and possibly feel) useless.

The Primary Care Team in Secondary Mental Health Services

It fits with the above point, but I often saw the OTs getting dragged into (with full throated encouragement by their managers) short term pieces of work that barely gave time to form a relationship.  These seemed to set the clients up to fail.

“A 12 year history of anxiety?  6 weeks anxiety management for you.”

“Not left the house for a year? 12 weeks of graded exposure to solve that issue.”

So ridiculous.  I wanted to get in and help people with lifetime issues make changes over the long term.  I couldn’t articulate it at the time, but I spent hours modelling that someone could be non-judgemental and reliable, because this was the basis for everything else we might ever do together.  In more OT terms, I changed the client’s environment by modelling another way that people could ‘be’ around them.  To my Managers, it looked like it didn’t quite fit with the plan to provide some input for 6 weeks and move on.

When OTs work well, they don’t manage symptoms, they help people live.  Just like physical OTs, in Mental Health we identify and tackle what gets in the way of a life worth living.

Anyway, enough of what other OTs do.  Let’s talk about me.  For the past 8 years I’ve worked with people who have been taught that others are untrustworthy and who cope by self-harming to a degree that could well kill them. They tend to get given the label of Borderline Personality Disorder which is often very unhelpful to them and also to the staff that they work with.

In terms of the usual OT process, this can be a bit tricky.  As people are chronically suicidal and genuinely see death as a better option than living with their pain, much of what they want is simply to get by day by day.  In terms of what they want, it’s often mainly to escape from the pain. I think humans have an intrinsic need to connect with others and because the people I work with have had such a poor experience of other humans, attempts to connect can be fraught with danger.  They may have had to hurt themselves to feel they deserve help from others.  They may need to place themselves in danger so that others will show they care.  All the skills they have were designed to cope with a dangerous environment when they were defenceless children, so they don’t work anywhere near as well when the threats are significantly reduced. While they use the skills they have to manage every day as it comes, they can’t plan for the future (they feel there is no future) so they get stuck in their current situations.

My main intervention in work is trying to change the environment around people.  This often involves recognising that for them, restrictive environments like acute wards often result in decreased functioning and increased life threatening behaviour. Once we both understand why this occurs we can then help the organisation to react in a way that doesn’t replicate some of the punishing and coercive experiences the client has had in the past.  In English, this means I spot when hospital is unhelpful and try to get people out as soon as possible.  This generally results in a significantly higher quality of life for the client, as well as the organisation saving hundreds of thousands of pounds.  I will often spend time with clients to try to understand how self-harm fits into a framework of what they want and need to do.  Once it makes sense, we can help the organisation respond to that knowledge rather than to its own interpretation. For example, staff are cold towards someone ‘who self-harms to get attention’, but are warmer towards someone who experiences such crushing numbness then needs to feel pain just so that they can feel something.  I also train other staff to understand how past experiences are played out in current ways of coping, so that they react in a more thoughtful, caring way and in a way that promotes the client’s functioning.

My favourite way of offering therapy to people is via a therapeutic community.  You can hear me bang on about it here (pump up the volume or it’s a bit quiet)) but it basically gives people opportunity to practice relevant skills while being cared for and providing care to each other.  If you ever get the chance to experience working in this way you should snap it up.

So all the above is some of what OTs do in mental health.  Having said that, it might be what I think OTs should do in mental health.  And actually, having said that, some might look at me and wonder if I’m actually still being an OT.  I think I am.  I don’t see diagnosis and instead I look at how people are inhibited from what they want and need to do.  This is a useful mind-set to take into all aspects of health services, as it keeps us focusing on people as individuals rather than clusters and diagnoses.  OTs can bring much into debates about healthcare and because we are a relatively small group, we need to shout a bit louder about what we do and ensure that what we do is useful.

I hope that gives you an idea of what all the OTs in the Psychiatric inpatient Wards, Community Teams and all the specialisms in between are doing.  If might look like we’re just having fun.  And it should be fun.  But it’s also hard.  We work with people who don’t have the lives they want and we help them to get there.

Next time the OT emerges with a cake from the kitchen, remember that we were looking at all the physical, cognitive and interpersonal skills that went into its creation and in a sense we didn’t care whether the cake got made or not.  Seeing as it normally does get made, let’s blow out some candles on it now.  Happy OT Week, now go tell a colleague what we do.

Keir provides Training, Consultancy, Supervision and Therapy around people with complex mental health problems via BeamConsultancy.co.uk

Occupational Therapy: The Greatest Career in the World?

When I was sat in school at the age of 16 I didn’t really know what I wanted to do with my life.  I had a vague notion that I wanted to be of help to others but no real notion of what that might entail.  I pictured flying fighter planes, being a barrister, teaching and being a physiotherapist. A lackadaisical approach to education ruled out a few options but after much pondering, I eventually applied to university to do either physiotherapy or education.  In their wisdom the admission tutors took one look at my lack of academia and attendance and decided that higher education was not for me.  It was with much trepidation that I collected my A Level results knowing that I had no offers and while my peers were off to pack for uni, I was off home to go through clearing. 

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

Clearing is an interesting experience that I hope you never have to go through.  You find a list of all the institutions that have vacancies on different courses and get in touch to see if they will take you on.  You phone asking after one course e.g. Spanish and they offer you a different one like woodwork.  I was on the phone making or waiting for calls for the next 2 days and eventually I spoke to a guy called Chris Bailey in London.  Once we had ruled out physiotherapy (“not with those grades mate”) he asked me about Occupational Therapy.  It had the word therapy in it so I said I was interested.  He made me an offer to go and study Occupational Therapy at Brunel in London and as soon as I had accepted I went down to the library to find out what on earth Occupational Therapy was.  

Occupational Therapy is great.  You help people to do the things they want and need to do.  Sometimes you teach people things so that they can do what they want and need to do better.  Sometimes you change the environment around them so that it becomes easier to do them.  When you’re working with people, more often than not you are doing things together – frequently things that either you or they love.  You find that rather than stopping people from dying, you’re helping them to live. 

What surprised me was the breadth of occupational therapy.  I wanted to be like a physio when I turned up at uni and there was full scope for me to specialise in areas like hand therapy, people with amputations, traumatic injuries, blindness, stroke…any physical health problem that impacted on their ability to live the lives they wanted and needed to.  One of my placements was in social services and I went around giving out equipment, fitting handrails and even designing houses so that people could live in their own homes and care for themselves independently.  If this area of work had piqued my interest I could have spent my career working with people with physical health problems and making a profound difference to their lives.  

Two things happened.  Firstly I discovered that I found learning anatomy rather dull and there’s loads of it.  Secondly I went on my first mental health placement and fell in love with it.  I became fascinated by what went on in people’s minds that meant they were unable to do what they wanted and needed to.  Equally I was shocked when what they wanted and needed to do in the moment, was totally outside of anything I’d ever thought of.  After university I threw my green trousers away and never worked in physical health again.  

Occupational therapy is a recognised profession within the NHS.  This means you will find a job pretty much anywhere in the UK.  I knew I wanted to work in forensic mental health so I took the first job that wanted me and moved to Edinburgh.  I loved my first year in Scotland and took away some really important things from my first job that set me up well for the rest of my career. 

After a year my wife got the chance to study in London and off we went without any doubt that I was going to get employment.  While there I worked on hospital psychiatric wards running sports groups and making sure people were safe to go home.  I went onto the psychiatric intensive care unit (PICU) and spent a while working with severely ill people, trying to help them get to a place where they could go back to a normal ward.  

Once the PICU had seen through my incompetence I went off to work in community mental health before going on to the really exciting area of assertive outreach.  This is where people who normal services struggle to be helpful for, get a more interested and determined approach.  I used to love building relationships with people who rarely trusted anyone and whose experiences of mental health services were often around being forced to go into hospital.  I also used to love using my knowledge of their likes and habits to find people who hadn’t been seen for a while, scoping out their regular haunts, waiting around in the hope of making contact with them, anything that would give a chance encounter and an opportunity to avoid the next relapse.  There was a lot of talk about how important medication was but now I know it was all about the relationships.  

One of my ambitions was to go and work abroad.  At one point we decided to go and work for a year, then we wanted to to work for six months and we got to a point where we didn’t want to work at all.  In 2003 I packed in my job and my wife and I bought round the world tickets which ended up including 3 months in a Community Mental Health Team in Masterton, New Zealand.  While there we went to hot springs, climbed mountains and spent too long touring vineyards and sampling wine in an incredibly disproportionate ratio to the amount of wine that we bought.  Those were happy days. 

When I got back to the UK I was able to try a few different areas of mental health.  I’ve found an area that I love and I’ve managed to build a specialism in a non-traditional role.  Occupational therapy has so many opportunities to be forward thinking, creative and innovative and I’m aware of loads of OTs getting themselves into places we’ve never been before, crafting out opportunities to help people live the lives they want in multiple areas.  Housing, homeless, asylum seekers, charities, schools…all over the place OTs are finding a way in and showing they can bring value.  

Within the NHS its traditionally been hard for OTs to get into senior leadership roles but this is changing.  I’ve loved seeing OT ward managers and Heads of Therapies come along.  There’s a definite career path for those who want to make systemic change but growing scope for specialised clinicians. In our hospitals and universities OTs are researching so that we are more aware of what will be most helpful in the years to come. 

In my area of work, its still hard for OTs to get into senior positions but this helped me to start my own business.  I’d never have envisioned this 20 years ago but the core clinical skills I’ve developed over the years are valued in the private sector.  Working for myself means that I can target the areas that I prioritise but the NHS finds difficult to work on.  It’s immensely rewarding.

In OT you escape some of the worst parts of work that unfairly seem reserved for nurses.  You skip away from most of the tedious bureaucracy I see social workers drown under.  Occupational Therapy is the key to a great job and and the gateway to wherever you want to go.  

There are many different ways of being able to help people.  Occupational Therapy may not be the best one but because it’s OT week forgive me if I say it is.  You get to be a part of helping people do what they want to do most.  You get to help them by doing things that are fun, engaging and meaningful to you and those you help.  Work has got me going to the cinema, going out for dinner and, because it was a client’s life long ambition, running the London marathon.

This year I joined the board of a national body and I’m going to give a keynote speech at a national conference.  No one would have thought this possible from the socially anxious, awkward student that lazily turned up in Brunel 20 years ago.  No one would have thought that the bumbling, incompetent practitioner I was for a good part of my career would ever get to a point where he was seen as an authority on anything.  OT shaped me into someone who could avoid being judgemental and make sense out of why people did what they did.  It shaped me to confidently stand up for the rights of others.  It shaped me to push myself and others to do more, and I’ve loved the journey it has taken me on.  

The point of the above is that OT is a decent job.  You can spread out into multiple fields and change tack whenever you see fit.  It makes you highly employable, it gives you experiences you might never have otherwise, and it can help you travel the world.  It will let you help people without just talking to them, but by actively doing what’s important.  

The health service workforce is changing.  The influence of OTs is growing.  When you’re thinking about your career don’t just think about if you want to help people, think about how you want to help people.  I could very easily have missed my chance to be an OT as I knew so little about it when I was was younger.  Make better choices than I made.  Best career in the world. 

Huge thanks to Ruth Hawley, Elaine Rutherford, Dianne Lane and Hollie Berrigan for reading over this and offering their feedback (which I did not pay enough attention to)

Keir provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

The Nature and Degree of ‘Borderline Personality Disorder’: Is Detention Warranted?

In my current role I’m (un?)lucky enough to meet a number of people with a diagnosis of borderline personality disorder who are detained in private hospitals who wish to get out.  I’m going to share some of the common features of these encounters and then explore some thoughts about the value and legality of compulsory treatment for this group of people.  

While I don’t think very much of the science of borderline personality disorder, one of the values that the diagnosis brings is a set of diagnostic criteria and a wealth of evidence and theory about what it helpful and harmful.  I know that even the people who are most critical of our diagnostic system pragmatically know the value of of writing a diagnosis in a benefits claim or housing application.  This piece similarly makes use of what works rather than proposing a theory that might be more ethically sound.

The shared features of those I meet are:

• They have a diagnosis of BPD/EUPD

• They are at least 6 months into a placement to receive treatment for their ‘personality disorder’

• Their self harm is more dangerous now than when they arrived

• They have a history of traumatic events.

• They are regularly restrained is response to incidents that would pass almost without notice in the community. 

• They were told this was a specialist unit with specialist staff.

• The therapy on offer is different from what quality indicators would recommend.

• The medication prescribed is different from what quality indicators would recommend.

• Their ‘care’ deviates significantly from what is recommended.

• Nowhere is it documented that people are aware of this deviation.

• The clients themselves have no idea how far their ‘care’ has strayed from what is seen as quality provision.  

Because the young women (and it is always young women) are not aware of how far their treatment has moved from what NICE would recommend, they often feel that it is futile to challenge their detention.  They are told that their behaviour, which could easily be explained as an understandable reaction to being forcibly detained somewhere you don’t want to be, while sharing a living space with a bunch of erratic people you wouldn’t choose to live with - is a result of their disordered personalities.  They are told they can leave the environment, which people unanimously agree is the trigger for the majority of their self harm, once they have stopped self harming. 

One of the first questions a medic will be asked during a mental health tribunal is whether the ‘nature’ of the clients illness means that they are liable for detention under the mental health act.  “If the Tribunal is not satisfied that a patient is, at the time of the Tribunal, suffering from “mental disorder of a nature or degree which warrants detention in hospital” for either assessment or treatment, then they have to discharge the patient” (Masked AMPH).  This aspect of the tribunal is often fudged and I’ve heard some embarrassing tales of innate personality problems and intrinsic unreasonableness, but no-one articulates that every quality measure in the UK including NICE and The Confidential Enquiry into Suicide and Homicide for those with Mental Illness recommend that we avoid prolonged detention for those with this diagnosis.  With those in mind, it’s possible to argue that the nature of what is described as borderline personality disorder is such that detention for prolonged treatment should be actively avoided.  

Once the nature has been dealt with we can then talk about the degree of disorder.  Because it’s common to see that risks have increased proportionately to the amount of restriction people experience, we can then argue that the degree is influenced by the detention, rather than the detention being required because of the degree.  

Once this foundation has been laid, it becomes a relatively straightforward task to compare the care someone is receiving to what NICE recommend and question the value of detaining someone to receive treatment so at odds with what is seen as likely to be helpful.  The consistent defence of the detaining hospital is often along the lines of “but they might hurt or kill themselves” as if the NICE guidelines were written for people for whom self harm and suicidality were not part of the diagnostic criteria.  This “but what if?” reasoning can reflect reasonable cation, but I frequently hear it being used as a reason to continue detention when it could never have been used to instigate detention.  

As of July 2020, every tribunal panel that I’ve made this argument to has discharged the client from their detention.  These were not people who had been admitted for a brief crisis admission, they were all articulate young women who had been told that they had to receive therapy for a year or more and would be allowed to leave the hospital only after they they stopped doing the things they only did in hospital.  

I’ve got a piece coming out in the Lancet in August arguing that one of the reasons we use long term private placements to treat this client group (with poor outcomes and huge cost) is so that risky people can be risky elsewhere.  The placement acts as more of an insurance policy to the local area rather than something that is in the best interests of the client.  My experience is that when presented with the evidence above tribunal panels can see the veracity of this.  We need to stop compelling people to receive treatment that doesn’t bring a likelihood of recovery.  Following the line of argument above can help.

I hope the above is useful if you’re challenging your detention or representing someone in such circumstances.  If I can help get in touch,

Keir

Do we need any more bloody Mental Health Awareness? #MentalHealthAwarenessWeek

It is mental health awareness week and it’s a peculiar time to be focusing on mental health.  A lot of us have spent the past 2 months locked in our houses, theres a deadly virus romping up and down the country and 50,000 more people are dead than the average deaths for this time last year.  Anxious?  You’re supposed to be.  Lonely?  Why wouldn’t you be?  Sad that anyone you love over the age of 70 is suddenly more delicate than a paper doll in rain storm?  That makes sense.  

This mental health awareness week comes at a time when there are some very real challenges to our mental health and wellbeing.  Despite this, I’m seeing some very mixed reactions to the week circling on social media.  Perhaps the traditional reaction is that Mental Health Awareness is something that needs promoting.  Chances are the majority of us will experience mental health problems in our lives.  We should rid society of any shame in talking about them and feel free to ask for help.  This view recognises that mental health services are the poorer cousins to physical health services and that we need to invest more in the wellbeing of our population.  Celebrities will tell us that it’s TIME TO TALK and that MENTAL HEALTH MATTERS.   

There is another view.  It’s somewhat more pessimistic and suggests that there isn’t really anyone to talk to and that when you find the courage to tell someone you need help, they might well tell you that actually you’re wrong.  This view will see services as being understaffed with fragmented under resourced teams all fighting passionately and articulately not to work with you.  It sees mental health services being held back as a reward for only the most dangerous presentations meaning that to ‘deserve’ care you need to be doing something pretty damaging to yourself.  Should you win the lottery and make it into a service based on your level of dangerousness, you’ll be told about the long waiting list to access help.  Perversely, once you do get in, you might find it’s pretty hard to get out.  If you act in the way that wasn’t deemed important enough to get help in the community, on a ward, you might well find you’re being restrained, the doors are locked and you’re off to a private hospital in the country that you’d seen on Panorama the month before.  It makes sense that jolly messages to always keep the kettle on and make time to talk seem like excreting into the wind.

I’ve got a lot of sympathy for the second view.  My last years in the NHS saw provision to the people I’d opted to work with slowly decline and come to a juddering stop with the appearance of covid.  Services are not good enough.  They are too difficult to access and they do not have the resources to offer appropriate care and support to those who need them.  I wonder if mental health awareness week can be used for highlighting these issue?  The time to talk may have passed.  Perhaps it’s time to scream? While “I’m mad as hell and I’m not going to take it anymore” might be misconstrued, it’s vital that the public and politicians are aware of the reality of the help that we encourage people to seek.  I wonder why we don’t do this more during this time?

This Image is by Rachal Rowan Olive. If you like stuff like this its worth checking out her etsy shop

Perhaps a reason for our reticence is that it’s still too hard to share that you’re struggling.  To campaign for better services might mean that you’re tainted by some of stigma that remains around mental health problems.  This is where I maintain some sympathy for the traditional Mental Health Awareness messages.  If you’re a man, you need to reach the ripe old age of 45 before it’s more likely you’ll die of anything other than suicide.  The majority of men who choose this path won’t ask anyone for help.  They will experience unbearable feelings of shame, guilt and/or fear and because society has literally beaten the message “big boys don’t cry” into them, too many will feel that a way to avoid the shame that needing help brings is to remove themselves from life.  At the time in my life when I felt my social anxiety was so problematic I needed to get help for it I told no one other than my GP.  I swallowed hidden tablets with ropey side effects and crept to psychology appointments more stealthily than a grandmaster ninja.  On top of the problems that had led to me telling the GP I needed help, I carried the shame that I had failed as a proper man and human being, and a terror that this illicit relationship with a psychologist might be discovered.  I didn’t kill myself rather than seek help, but my goodness it crossed my mind.  

There was a time a few years after this that things were not going well.  There’s some British understatement in there but after some problem solving and decision making, it felt like not being around anymore was probably the way to go.  I talked about this with my best friend at the time and after a while, we found something else that might be a bit better.  My point in saying all this is that while changes in services, society and political ideology are required, we can do things as individuals to reduce the shame around finding things hard.  We can ensure that in our world, struggles with mental health are things that we know everyone experiences rather than being unique to the nutters who are nothing like us.  We can create an environment around those we care about where it is ok to talk, to share and to be accepted.  

The last time I wrote something similar to this it was suggested that I was being funded by some neoliberal think tank.  I’m still waiting for the cheque and while I’m quite vocal about the inadequacy of services, I firmly believe that individually we can make a difference.  At some point this week someone with good intentions will tell you that “We all have mental health”.  This is utter nonsense.  We all have mental health problems.  Sometimes to the extent that we feel uncomfortable , sometimes to the extent that we just don’t want to feel anything ever again.  If this can’t be talked about, if it can’t be shouted about, then it will be easy to prioritise other issues in society.  

Whether you’re critical, supportive or ambivalent, it is #MentalHealthAwarenessWeek  

THE best Occupational Therapy books for Mental Health OTs

The results are in, the votes have been counted and I am putting on a sparkly dress to announce the top 10 Occupational Therapy books that all Occupational Therapists MUST read.  

I wanted to put this list together because I knew I hadn’t read widely enough in my own area.  This has given me a few places to look so thank you to everyone who took part in the survey. I was really interested to see what was nominated and absolutely delighted to see what wasn’t.  We are going to do the top 9 in no order whatsoever and then the overall winner is at the bottom.  Enjoy.

First up is Diverse roles for Occupational Therapists edited by Jane Clewes and Rob Kirkwood.  I’m quite pleased this got through, not least because the chapter in it on ‘Personality Disorder’ is by me.  This book has a range of OTs in different mental health positions describing their roles and it’s a great resource for particular areas and for bringing innovation into places we haven’t been before.  Colleagues of mine wrote about PICUs, Prisons, and Eating Disorders - I’m pretty sure at one point we were the most academic OT corridor in the UK.  It’s probably due a sequel now with even more novel roles emerging.  Check it out for £32 or £15 on kindle. 

23 years old and still pulling in the votes, Groupwork In Occupational Therapy by Linda Findlay is the oldest book in the list, retailing on Amazon for £50!!!  Written primarily for occupational therapists, “this text explores the range of groupwork activities used within occupational therapy practice. Discussing theoretical aspects and practical approaches this book is an invaluable handbook to those working and studying occupational therapy.”

Occupational Therapies Without Borders: integrating justice with practice,

by Dikaios Sakellar and Nick Pollard is a book I hadn’t even heard of before.  Apparently this builds on the previous two volumes, offering a window onto occupational therapy practice, theory and ideas in different cultures and geographies. It emphasizes the importance of critically deconstructing and engaging with the broader context of occupation, particularly around how occupational injustices are shaped through political, economic and historical factors.

Centering on the wider social and political aspects of occupation and occupation-based practices, this textbook aims to inspire occupational therapy students and practitioners to include transformational elements into their practice. It also illustrates how occupational therapists from all over the world can affect positive changes by engaging with political and historical contexts.  It could probably do with a chapter on covid, but then I’m sure most books could at the moment….

4th on the list is An Occupational Perspective of Health by Ann Wilcock and Claire Hocking (£60!!!!).  Another book I hadn’t come across before, Amazon says “For nearly 20 years, An Occupational Perspective of Health has been a valuable text for health practitioners with an interest in the impact of what people do throughout their lives. Now available in an updated and much-anticipated Third Edition, this unique text continues the intention of the original publication: it encourages wide-ranging recognition of occupation as a major contributor to all people’s experience of health or illness. It also promotes understanding of how, throughout the world, “population health” as well as individual well-being is dependent on occupation.” which sounds like a useful message for us to articulate.

Coming in 5th (They’re not in order) is Creating Positive Futures: Solution Focused Recovery from Mental Distress by Lucie Duncan, Rayya Ghul and Sarah Mousley.  This is currently going for a much more modest £13 and you can let me know whether the Wilcock book is 4 times better.  With 5 stars on Amazon “this is a valuable resource for anybody working in the fields of mental health and disability, regardless of professional discipline, not only occupational therapists but psychiatrists, psychologists, social workers and nurses. "It shows a respectful, structured and realistically optimistic way of talking with troubled people so that their own strengths and resources are highlighted.This book introduces their Solution Focused Measure of Occupational Function. It is clearly written and almost jargon-free, and contains many useful case- examples and suggestions for generative questions.The authors have avoided it becoming too much of a therapy-by-numbers ‘cook-book’.  

Enabling Occupation II: Advancing an Occupational Therapy Vision for Health,well Being & Justice Through Occupation is on Amazon for £213!!!  For that money I’d expect it to assess my clients for me.  It’s not easy to find a synopsis for this book (if someone sends me one I’ll add it to the article) but what I have learned is: “As a practitioner, Section I provides you with the opportunity to reflect on the implications that embracing occupation as our core domain of concern has for your practice. The Section promotes an appreciation of the full breadth of human occupation and facilitates the adoption of an occupational perspective in viewing the world. With the Section you are encouraged to adopt an occupational perspective to guide your practice, be it as a clinician, educator, researcher, administrator, manager, or consultant. You will immerse yourself in language frameworks and models that will help to organize your thoughts and articulate your understanding of occupation and to explore the learnings that occupational science can shed on your understanding and appreciation of occupation” - £213 well spent. 

7th on the list is Foundations for Practice in Occupational Therapy by Edward AS Duncan.  Eddie was one of my first supervisors back in the days when I was young and knew nothing.  Now that I’m old and know less it’s good to see this scoring so well. “Now in its fifth edition, the internationally acclaimed Foundations for Practice in Occupational Therapy continues to provide a practical reference tool which is both an indispensable guide to undergraduates and a practical reference tool for clinicians in the application of models and theories to practice. Underlining the importance and clinical relevance of theory to practice, the text provides an excellent introduction to the theoretical basis of occupational therapy.”  A Snip at £31.

Client-Centred Practice in Occupational Therapy: A Guide to Implementation is 8th.  This is penned by Thelma Sumsion, one of my undergraduate lecturers who once chided me for napping during a talk.  “Directed primarily towards health care professionals outside of the United States, Client-Centered Practice in Occupational Therapy continues to be the only book that provides the reader with both the theoretical underpinnings of client-centred practice as well as guidance on the practical application of this approach.”  Who knows what authoritarian practices will take place in the USA without a book like this to guide them?  You can pick this up for £38. 

Nearly there…This book was one of the two that dominated the field.    Updated throughout with new research, the “5th Edition of Kielhofner's Model of Human Occupation (MOHO) offers a complete presentation of the most widely used model in occupational therapy today. In the new edition, author Renee Taylor preserves Dr. Kielhofner"s original voice and contributions while updating MOHO concepts and their uses in today's practice environment. Throughout the book, readers will see a client-centered approach used to explore what motivates each individual, how they select occupations and establish everyday routines, and how environment influences occupational behavior. The 5th Edition continues to deliver the latest in MOHO theory, research, and application to practice and adds much that is new, including new case studies that show how MOHO can address the real-life issues depicted and expanded resources that enhance teaching and learning.”  This probably influences my OT clinical reasoning more than any other profession specific book I’ve read.  £67 on amazon.

And the moment you have all been waiting for….will have to wait.  I asked people what book wasn’t shortlisted but should have been and I was told Recovery Through Activity by Sue Parkinson was the missing gem. 

It “is underpinned by the conceptual framework of the Model of Human Occupation and will provide an invaluable tool to practitioners and also create a platform for research.

Recovery Through Activity:

• enables service users to recognise the long-term benefits of occupational participation by exploring the value of a range of activities

• provides occupational therapists with a valuable tool to support the use of their core skills

• provides comprehensive evidence regarding the value of activity along with a wealth of resources to support implementation of an occupation focused intervention

• helps to refocus the practice of occupational therapy in mental health on occupation

• and supports occupational therapy practitioners to engage in their core skills and enhance the quality of service user care in mental health” 

All yours for £33.

Finally we have the winner.  With more votes than any other and 5x the votes of the lowest scoring finalist, Creek's Occupational Therapy and Mental Health edited by Wendy Bryant comes romping in first with a price tag of £44.  Another ‘go to’ book for me, this "seminal textbook for occupational therapy students and practitioners has retained the comprehensive detail of previous editions with significant updates, including the recovery approach informed by a social perspective. Emerging settings for practice are explored and many more service users have been involved as authors.  Occupational Therapy and Mental Health is essential reading for students and practitioners across all areas of health and/or social care, in statutory, private or third (voluntary) sectors, and in institutional and community-based settings”

If you want to read a non-OT mental health book, The Body Keeps The Score annihilated the competition.

And that is the result of the survey.  You also told me you’re interested in an OT TED style event so I might see if I can make that happen.  Go forth and read these books.  Very little is written about some of them so add to the reviews and tell people what you thought.  Before you smash out your money on hardcopies of these, it might be worth considering joining BAOT.  At least one of these is available as a free ebook to members.  If you hadn’t considered joining before (And why not???) this might be enough to tempt you.  If anyone wants to send me a copy of any of these I’m happy to review it.  Hope this was useful.  Happy reading.

Keir provides supervision and thinking space around mental health provision, particularly those viewed as being high risk.  He is contactable via www.beamconsultancy.co.uk and is active on twitter @keirwales and Facebook - Keir Harding OT