Do Staff need to be Taught Compassion?

Sometimes I need time for blog posts to 'percolate'. The reasons vary, from me recognising that I need to consider the possible impact of what I am putting out there on others, to needing time to formulate my thoughts and feelings on a subject. I wanted to write about compassion in Mental Health settings since an incident before Christmas, but hesitated because my initial response was purely an emotional response to the distress of a friend. Before putting my thoughts in the public domain I needed to allow time and perspective before putting my thoughts down in black and white.

My friend is a diagnosed Schizophrenic who battles against his labels and the medicalisation of him as a person, who is more than his often disputed diagnosis. A few weeks before Christmas he suffered a major 'meltdown' - in his words. The first I knew of it was when he phoned me from the ward and asked me to visit him. This article could deal with the ongoing battles he has with his mental health team regarding his view of his auditory and other hallucinations or of his need for ongoing medication, but more than that I needed to highlight the lack of compassion he told me about on his admission to the PICU.

Over a period of some time he had been struggling with the increasing belief that he was a psychopath and therefore a major threat to those around him. He was terrified because he was convinced by these beliefs. Instead of understanding how terrifying these beliefs must be to him and the fears that they created in him about the threat he posed to those around him, some staff started to tease him, laughing about him being a 'serial killer' and even using the term 'path' when talking to him. 'Alright, path', 'harmed anyone recently, path?'.

It is a single individual incident involving one person that I know. What has concerned me most is the basic lack of human understanding and compassion for an individual clearly in distress and need. By definition, to be admitted to inpatient care in this day and age, indicates that by all clinical standards, this person is in urgent need of help. In the world outside I would expect the usual level of ignorance about mental health in general and Schizophrenia in particular, but inside a specialist Mental Health unit, surely even a modicum of professional pride and self respect dictates a better response than taunting a mentally ill man?

I try to be balanced in my consideration of such troubling incidents. I have tried to find reasons for members of staff responding in this way:

1) Stress and pressure - under-staffing, ongoing constant change and cutbacks, bring a weariness and cynicism, probably unthinkable in the early days of most of these staffs' careers?
2) Lack of adequate training about the symptoms and perceptions of Mentally Ill people who are in crisis?

Unfortunately, neither of these reasons adequately provides any acceptable rationale for the appalling lack of empathy and understanding displayed. I know in my twitter feed I can be political in my responses to the current state of the NHS, but I do believe that there is an ideological and moral battle going on for all of our public services. When patients, services users and others in need, stop being people and become units and target statistics, then the raison d'etre of our social care and health services is under severe threat.

If a person ceases to be a person, but becomes an obstacle to completing paperwork, or sitting in an office 'getting through a shift', it stands to reason that it is only a small step to not being able to see why you should 'waste' any human compassion on 'them'. And there it is: 'Them' and 'us'. There has been a rhetoric in public life which has separated us into 'camps' of rival 'tribes' of the 'deserving' and 'undeserving'. We are not in this together - or at least that has been the effect of much of the discussion in public around Benefits and other cuts to services. So the ironic comment that 'my job would be ok if it weren't for the people I work with.', ends up being a default which in turn

informs our actions towards 'those' people.

What most of the political rhetoric forgets is that for most staff in public services; NHS, Education, Criminal Justice, they did not enter a 'career path' or to seek 'progression', but most felt a vocation. Vocation cannot be conjured up, nor can its root motive, compassion, be taught or trained. I may attend any number of Mental Health Awareness training events, with input from service user perspectives, but if I fail to see the people I work with as worthy of compassion, then there is no magic bullet which will allow me to tick this off in my professional development portfolio.

Pity cries and walks away, it looks down on those in need. Compassion enters into the experience of the person in need and seeks to understand its causes and, in time, the actions which can be taken together to meet that need.

Don't get me wrong, compassion in public services costs those for whom it is the primary motivation. I would argue that the heart of compassion in many staff is why the NHS is the envy of the world. Day in and day out, committed, compassionate staff come along side the vulnerable and most hurting people in our society. This kind of response to need cannot be trained or imitated. You know it when you see it. I know when staff working with me are seeking to understand the roots of my distress. I know when staff are motivated by more than a pay packet or are just going through the motions. I know when someone, despite the limits of the system, sticks with me until, together, we find a way through to recovery.

I have been on both sides of public service and I know that when I meet staff who recognise our shared humanity, then there is a strong foundation on which therapy and medication can be built. Rather than mock the beliefs of someone in the throes of psychosis, humanity asks, 'What would I want someone to do if it was me?' Relationship depends on trust, therapeutic relationships begin with a compassionate assessment of another human being and their needs - some of them shared by all people, even me. If you view the people you work with as 'them' rather than 'us', maybe it's time for a change of career, or a holiday?

Nanny McPhee and the Therapeutic Relationship

"When you need me, but don't want me, then I'll stay. When you want me, but don't need me, then, I'll have to go" Or words to that effect. It has only just struck me that this quote from Nanny McPhee sums up the crux of the therapeutic relationship. I am into the second month since full discharge and have been reflecting on the transition from needing the support of services through wanting it more than needing it, to finally realising I no longer need the levels of intervention I have previously required.

I recently had an interesting discussion with a friend of mine who is also a service user. He now works as an Expert by Experience and told me about a psychologist colleague who had been arguing with him about the nature of the therapeutic relationship. She believed that such relationships should not be considered as friendships. My friend and I both profoundly disagreed with her. Boundaries and professional distance are essential to ensure the efficacy and the emotional health of both the practitioner and service user, naturally, that's a given. However, there is an emotional bond, or at least there has to be in order for 'unconditional positive regard' to have any hope of developing. If there is not an emotional trust, based on some aspects of friendship, then the relationship may well work to an extent, but, certainly in working with Borderline Personality Disorder, at least, a level of warmth is essential in order to bring about progress. Otherwise how can I learn what a positive relationship established with effective boundaries, but also warmth and compassion, looks like?

I guess it depends what you consider 'friendship' to be. I recognise in my friends different needs and different gifts to me from each one. Some meet my basic social needs. Some are based on shared interests and enthusiasms. A handful are deeply rooted in genuine affection and deep emotional bonds. As someone with BPD much of the therapy I received was focused on my relationships with my therapists. DBT as a therapy model, recognises this and builds in these relationships and working through the ups and downs as they develop to its methods of working.

I find it interesting that when Nanny McPhee first arrives into the chaos and mayhem of the unkempt and undisciplined children, she appears hideously ugly to them. I'm not saying that all therapists are ugly! However, it is a truism when discussing therapy that 'things get worse before they get better'. Part of this process is the setting of boundaries, and the inevitable challenging of behaviours which are generating real distress and pain on the part of the service user. So, in a way there are times when I may find it hard to 'like' my therapist, and vice versa. Such is the stuff of developing relationships of any ilk. If the relationship is allowed to continue and works in addressing the key characteristics of my emotional issues, then my perception of my therapist is likely to become more positive. So with Nanny McPhee, her warts and whiskers disappear, as genuine affection replaces her challenging discipline and the children blossom under her care.

I don't think friendship as an element of the therapeutic relationship need be a threat to the professional. It is a natural part of genuine positive regard and compassionate practice.

'Stop Being so Silly' Said the A&E Consultant

TRIGGER WARNING: This blog describes a distressing incident and discusses suicidal feelings and feelings of frustration and helplessness.If you are affected by discussion of these subjects, don't read on

It was early on a Sunday Morning during the Queen's Jubilee Bank Holiday weekend. I had implemented my Crisis Plan following a week of sleepless nights and five days of constant vomiting, which gave way to dry retching. I was not physically ill, but vomiting spasms were one of my most obvious symptoms, during periods of emotional distress.

I was feeling suicidal and needed help - desperately. I phoned the Crisis Team, as per my Plan and after ten minutes was instructed to attend the local A&E and ask to see a member of the Team as they were on site in my local hospital. So, I did as instructed and reported to the A&E reception, where the Receptionist was helpful and clear that I had already spoken to the team and had been told to report to them. So far so good. Thankfully, for a holiday weekend at 4.00 a.m. the unit was relatively quiet, just three others along with me in the waiting room.

The Triage Nurse, again was efficient and reassuring, I had continued to retch violently and had soiled and wet myself by this stage and so was in obvious distress. She was empathic and quickly ascertained that I was already open to the local CMHT and therefore was responding correctly to my Crisis Plan. Again, no regrets, relief that the plan was working. Then it went dramatically wrong.

Enter, the A&E Consultant. Opening gambit: 'Why have you come to the Emergency Department tonight?' I told him I was diagnosed recently with BPD and was experiencing a sustained period of emotional distress. Again, a long explanation about the building distress, finally admitting that I was feeling suicidal had contacted the Crisis Team and they had told me to report to them via A&E, could I please speak to them. 'No, you must speak to me' - cue frustrated banging of head against wall. 'You must stop being so silly and speak to me'. 'What is all this nonsense about suicide?''You are being very difficult and I'm not prepared to refer you on'. I decided to try pleading, 'Please, I don't want to explain anymore, I need to speak to the team, I have already spoken to them on the phone and they told me to come here immediately. That was two hours ago.' He again told me that talking about suicide was 'silly' at which point I exploded: 'Get this bastard away from me, I don't want to talk to him anymore'. Again, banging my head against the wall.

He continued to refuse to refer me on until I had 'stopped this nonsense and calmed down.' Then, a Staff Nurse and HCA appeared, alerted by my shouting, and quickly removed the Consultant. For the first time since speaking to the Triage Nurse, someone asked me if there was anything they could do to help me. It was the HCA. I was able to tell her about my soiled clothes. She quickly arranged some scrubs for me to change into and offered me a cup of tea. Then she and the nurse put me on a trolley and tried to get me to put my head down.

Within thirty minutes of their intervention, a member of the Crisis Team appeared and assessed me. She prescribed a sedative to stop the vomiting spasms and arranged a home visit from the Home Resolution Team the next day. Admission was never an aim of mine, as it is noted in my Crisis Plan that this is counter-productive unless there is an imminent risk of harm to myself. Having removed the Consultant and feeling listened to, my risk of harm had reduced significantly.I was allowed to go home at 6.00 a.m. and had a visit from the Team at home by 10.00 a.m.

The team responsible for my care had helped, but there seemed to be such a disconnect between their response and the response of the Consultant.

Given that the Receptionist and Triage Nurse had noted the involvement of the MH team, why did this man not recognise the fact that my case had a solution in place? Why did he feel that it was okay to belittle my response? Why did he not notice my physical discomfort and embarrassment? Given that I was dealing with BPD symptoms and risk of suicide attached to this condition, why did he not carry out a more thorough assessment of my suicidal ideation?

I guess there are no answers as to why, only he may know that. What worked in soothing my distress and stopping my self harming behaviour from escalating, was common sense responses to a human being in need. In a word, compassion.

Can we Afford to lose our Compassion?

I was bent nearly double as I tried to make my body fit the small opening made for me by a police colleague in the broken down door of a derelict pub. The stench of human detritus slammed into me like a wall as I inched forward into the blackness beyond. All of a sudden, a wave of nausea swept over me as I reacted to first the smells and, then the sight of the evidence of human degradation all around me.

“Breathe through your mouth” my colleague advised me and soon I became accustomed to my surroundings.

We were looking for a vulnerable young man, one of my ‘cases’. We were concerned for his welfare. He was a proficient petty thief, heroin user and someone many considered to be on the human scrapheap at the age of nineteen. We didn’t find him, in that den, one of his favourite hangouts, just soiled mattresses, empty junk food wrappers and the tell-tale signs of recent drug use.

We moved in silence wandering from one darkened room to another. Then, as my colleague and I scrambled our way back out into the winter’s gloom, the daylight hit me like the brightest noonday sun. Such darkness and filth as it would have been difficult to imagine. Yet Matt and countless others inhabit this netherworld in every one of our towns and cities. It has become all that they know and all that they think they are worth.

On the way back to the office I pondered what had been lost from his young life. He had been a promising footballer at the age of 11, and among the foul mouthed cynicism of prisons and drug dens he maintained an air of respect for others. He was devoted to his mother, who, at the age of 40, had met the ‘wrong man’ who introduced Heroin to their home. First he introduced her, then he introduced her son, to the great emotional blanket that enveloped both their lives – stole all that they had, and then left. Nice.

If I were to meet Matt in the street with his ‘chav’ uniform of joggers, hoody and battered hi-tops, what would I feel – would it be compassion or contempt? Would I be prepared to scratch beneath the surface?
He remains for me, one for whom I have a ‘soft spot’ simply because I could see his potential beyond the ravages of his drug of choice. My concern is that in the current climate where government ministers brief about ‘strivers’ and ‘skivers’ there is no room for us to invest anything of value or meaning into a life like Matt’s.

At the time I was working with him (before Cameron and Osborne began dismantling the welfare society) we offered him a place on an intensive multi-agency programme (comprising Probation Service, NHS, Police and Drug Charity staff members) whose main aim was to find ways to divert this prolific offender away from his need for drugs and to provide a pathway and the means to fulfil his potential.

The funding for such schemes – which targeted the 5% of criminals locally who committed 50% of acquisitive crime? Gone – replaced by ‘payment by results’ contracts with private companies such as Serco and G4S. Although, we had a proven record of significantly reducing re-offending rates. There was a cost, in time: average time on the programme, three years; in resources: each local team committed a full time member of staff to the core team of four (the police committed two neighbourhood police officers), we had a budget for ‘rewards’ such as interview suits, work boots and, on one occasion, Artists’ materials.

The concept of a Society in which all children regardless of birth would have the same access to Health, Education and Shelter was born out of the deprivations of World War. The politicians of the day were determined that the orphans, widows and wounded of our nation would not be neglected. There is an economic argument for cutting back on where resources are allocated. From what I can observe of the current round of ‘austerity’ this seems to be focused not on ideology with humanity at its heart, but on profit and loss as solely measured in monetary terms. The problem for the current government is that societal change relies on a desire to bring all members up to the same level of value. No one member of society is ‘worth’ any more than another.

I contribute as I am able and if that is more than my neighbour is capable of giving, then please share my over capacity with them…. Idealistic? Maybe, but the likes of Clement Attlee didn’t think so, and it did work in its very British way for so long.
Surely, there is enough inventiveness in this country to find a way to balance the books whilst maintaining a compassionate society with the ideals of education, health and welfare for all people regardless of background, upbringing or beliefs?