Monthly Archives: December 2016

Communication – the bedrock of practice

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Communication skills are the bedrock of social work practice in all situations – when working with service users or their carers, presenting a case in court or at panel, or liaising with other professionals. How you engage, listen, and deliver your message is of huge importance. Words are powerful and body language is powerful. So how you use your communication can make or break a situation, can escalate or deescalate conflict, and can certainly change, for better or worse, the outcome of your involvement with individuals.

Carl Jung says that “The meeting of two personalities is like the contact of two chemical substances; if there is any reaction, both are transformed”. In this quote we see the power of communication. How we communicate can be dependent on our personality, dependent on what we ‘bring to the table’ and how we use it. When two people meet something will inevitably occur and something or someone will change or be transformed. Even if you walk into a room and the other person there ignores you they have told you something in that action and that will impact on what you do next. What you do next will impact on their next response. In this situation the ignoring is a reaction in itself. We can’t help but communicate!

William James offers us this, “A man (sic) has as many social selves as there are distinct groups of persons about whose opinion he cares. He generally shows a different side of himself to each of these different groups”. My first practice educator when I was training told me after my first observed practice, as social workers we are actors on the stage. He wasn’t suggesting that we fake anything but was alluding to the point that in trying to build a professional relationship quickly with someone we need to be who they need us to be. We need to find some common ground through our communication to start to build a relationship, engender trust, and demonstrate empathy. As a simple example, I would sense the broadness of my accent shift depending on the accent of the person I was with. I felt this was reflecting and responding to who they are and showing that we, inevitably, have some similarities. In a sense this was a subconscious reaction on my part bourn out of trying to establish a human, emotional connection.

There is more to communication in social work practice than simply having a conversation. I remember reading the phrase somewhere that it is a ‘conversation with a purpose’. So, what is that purpose?

Well, firstly we should endeavour to make it a positive experience. Now, I’m not dismissing the fact here that some of the messages social workers need to deliver are difficult messages and some of those messages may not want to be heard by the people we are working with but still, we should approach all conversation looking for positive outcomes. We should demonstrate compassion for the situations people find themselves in and not appear punitive in our actions. Our role is to minimise, as far as is possible, the potential for conflict and hostility that may result from what needs to be said. Aside from difficult conversations we should use our ‘human touch’ skills to make people feel at ease, as far as you ever can, especially in the early stages of relationship building.

So, an important part of our communication is therefore to relate to the other person. To form and establish relationships where we can work with and, where appropriate, on behalf of, the individual. We should listen more than we speak. We should be aware of body language and what someone is communicating through that. The ‘music behind the words’ as Lishman would put it.

We also may find we need to use communication to influence, to put other options and to consider strategies for change. We may want to strengthen certain attitudes while asking people to consider the impact of others. At times we may need to challenge, sensitively, and in a spirit of cooperation. When challenging we need to ensure that we are not trying to move someone to change or think differently from our own personal value base but rather that we are working with an understanding of theirs. What do they value? What is important to them? What do they feel they need to change?

We must not fall in the trap of thinking that we only communicate to acquire knowledge of the person. We communicate to build a relationship, to create trust, and to demonstrate empathy. Get it wrong and these things aren’t achieved. Get it right and we can create movement and develop understanding.

The other facet to communication is that we learn about ourselves. We learn about what makes us ‘tick’, what challenges us, what makes us uncomfortable. We need to listen to ourselves while we are communicating, creating a feedback loop, reflecting in action, and modifying our style as we go to enable us to work effectively with the individual we are with.

Not easy…..

But essential….

[Stephen Mordue]

Recommended Books:

Cut the risk of dementia with a sauna

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In the news is research that says that taking regular saunas can reduce the risk of dementia. Research published in the journal Age and Ageing explores the conclusions of a 20 year study that says that the men who go for a sauna 2 or 3 times a week are less likely to get dementia. The study looked at over 2000 men who were aged 42 to 60 in the 1980’s and followed them over the next two decades. Men who went to the sauna 2 or 3 times per week were 22 per cent less likely to get dementia even when adjusted for other factors. For those who went 4 to 7 times per week it was found that 66 per cent were less likely to get dementia.

In a sense this comes as no surprise. Lifestyle factors have an impact on all health conditions. Keeping fit, eating well, keeping mentally active, have all been reported to have a beneficial impact. Our bodies need to be looked after and the brain is an organ just like others. What you put into your body or do to your body has an impact.

Previous research by the leader of this current study has shown that saunas can reduce blood pressure and have beneficial impact on heart health. As we know these conditions have an impact on the risk around vascular dementia it is understandable that improving these conditions and general health will lead to a reduction to that risk.

Let’s hit the sauna! And what better during the cold British winter. A treat that’s good for you!

Read more at Alzheimers UK
or in The Telegraph

[Stephen Mordue]

The ‘Two Minute’ Rule

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2min

Being productive either at work or at home is a crucial part of being organised and being organised is essential to a happy and content life I feel ……All your ducks in a row so that you just get on with your day.

I live by the ideas in David Allen’s book “Getting Things Done” and by far the most effective, easy to implement, approach is the two minute rule. Simply put…. If it’s going to take you less than two minutes to do it just do it… don’t even think about it… just get on with it. This little productivity hack gets so much done in my world!

I find it most effective in dealing with email. As Allen points out your inbox is a collecting tool not a storage tool so your email inbox should be empty! How many of us can say that! The problem is once they disappear off the bottom of the screen you may as well delete them as they risk being forgotten about! The two minute rule is so effective at getting through the morning grind of ‘getting in to empty’, as Allen puts it, that my inbox is routinely empty (or nearly empty at least). It’s amazing how many things only take a small amount of time but how easily they all mount up and then become onerous. And once those emails disappear off the bottom of the page they get forgotten about…. You know they do… and then they eat away at you as you wonder what’s further down the inbox list! The beauty of emptying your inbox daily and doing something with the things you find there (diary it, delete it, delegate it, or put it into your ‘trusted system’ (more on this soon)) is that you know that, if you don’t get back to your email for the rest of the day, there’s nothing in there you don’t know about that’s more than a few hours old! That’s a great feeling.

The two minute rule works just as well in other areas! At home the dishwasher gets dealt with while I’m making a cup of tea, the bin gets emptied as soon s it’s full, the recycling gets put out, the cooker top gets cleaned while the coffees on… and on it goes…. Things just get done… and you feel so much better and have more space to do the important stuff. Simple.

SO what do you do if it’s going to take more than two minutes!? What’s this ‘Trusted System’ idea. Ah! That’s for another day…. Or do read the book!

[Stephen Mordue]

Communication & Eye Contact

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I love the Pelican Originals, which were published by Penguin from the ’30s to the ’80’s. I’ve got myself a little collection that I’m building; I love the blue spines and the cover art, especially of the ’60’s ones, and now when you buy them in second hand book shops they have that ‘browned’ look of old books. Love it! But… that wasn’t what I came here to tell you about…..

We talk a lot in social work about communication. We understand the importance of words but also the importance of non verbal communication. And one of the important factors we discuss is eye contact. So, you know how important eye contact is in demonstrating that you are there with the person, and how it goes some way towards showing empathy. Well, there are some interesting things that sit behind all of that.

I’ve been reading (some of) The Psychology of Interpersonal Behaviour by Michael Argyle (1967), a Pelican Original! And he tells us some interesting things. He says that there is evidence that as early as four weeks old babies show more interest in the human face than in other objects. He feels that this fascination with the face is an innate reaction and further that in research by Coss (1965) it was found that patterns resembling eyes produce a greater emotional response from adults than other similar patterns (pg. 26,27). So, eye contact is important to us from an early age and  Argyle comments that, for babies, following with the eyes is the equivalent to physical (i.e. following by walking) following. A visual dependence for eye contact is formed.

When talking about eye movements (pg. 44) he particularly observes that eye movements play an important part in maintaining the flow of conversation. The speaker looks up to gain feedback (is the other person interested, attentive) and will make eye contact for longer to signal that it is time for the other person to speak. Eye contact, he says, increases the sense of intimacy.

So, he suggests there are different elements to eye contact (pg. 84-93). There is looking as seeking information, and there is looking as a signal or social technique (e.g. to initiate a reaction, to show emotion). Also, there is a motivational basis to looking. Looking may be rewarded with information, a smile maybe, affirmation that we are being listened to and valued. As he said, this basic motivation to seek such responses may well go back to being a baby. He states that being looked at is emotionally rewarding. In tests on rhesus monkeys brain stem activity increases when they are looked at by humans, he says. He points out, however, that long gazes can feel uncomfortable, even threatening, suggesting that if eye contact starts to feel like ‘being observed’ it can disturbing.

Interesting!?

“The Psychology of Interpersonal Behaviour”, by Michael Argyle, (1967 – the year I was born! – I know hard to believe!) is a Pelican Original, published by Penguin Books.

[Stephen Mordue]

Reconstructing Memory

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The advantage that memory gives us is the ability to predict the future. When confronted with a situation we can explore what we already know and act accordingly. If we do not know the specific situation we are presented with then we can make an approximation based on similar situations. Fernyhough (2012) seeks to overturn the ‘common sense’ view of memory as being, as he calls it, a DVD of our experience or specific snapshots of time, with a view that our autobiographical memories are reconstructed every time we remember them from a combination of semantic memory (memory of facts) and episodic memory (memory of events).

Each time we remember it is a reconstruction with the potential for flaws and embellishments. These memories then become our real lived experience of the ‘remembered’ event. This means that by supporting people to combine various strands of knowledge, memory finding may be supported. One significant aspect of remembering is emotion. We are more likely to remember the emotion of the event than the detail. This also has resonance from my own practice experience when discussing the events of the day at a day centre with a man with dementia. I found he could not recount what he had done but could remember the emotions he had felt. He was able to state that he had had a generally good day but something had upset him on the way home. It turned out that there had been an incident with the day centre transport, not involving him, that had been quite alarming. He remembered how he felt but not the events.

One important aspect in the reconstructing of memory, and therefore remembering, is environment. If people with dementia are reconstructing their memories it is important for them to have cues around them like photographs, the ornaments on their fireplace, or the view of their garden. Under such circumstances their capacity to remember may improve. They will ‘remember’ through exploration of their environment. We’ve all done this: you walk from one room to another and can’t remember what you were about to do so you return to the room where you had the thought and find you can remember by looking around for cues.

A practice example would be when people with dementia are in hospital their presentation becomes more confused and more disorientated but then when they return home these ‘symptoms’ improve. This has proved the case many times in my experience and I would argue you cannot adequately assess someone’s ability to be at home without them being at home. The value of a home visit while still an in-patient, or while in a reablement centre, is substantial in gaining a true picture of strengths and levels of independence. Convincing families and family carers of this can be understandably difficult, but anecdotal evidence shows the possibility of a successful return home under these circumstances to be significant.

In working with people with dementia there are also some opportunities we can utilise to help people remember. Fernyhough (2012) observes that remembering is a social process. It happens with other people and is often contextual. What you can remember may rely on cues, but also some of those cues can be the people you are remembering with. So, in the earlier example of the man attending the day centre if I were reviewing his attendance there I might want to do that at the day centre with staff, and possibly even other service users that he relates to, obviously considering the appropriateness of that in terms of service user choice and confidentiality, to help ‘scaffold’ his memories.

De Vries (2013) reports Normann et al (2006) found that when supporting people with dementia, close contact with family and caregivers improved lucidity. Even when not at the day centre, priming memory with facts, for example, “the place you go on the bus”, “where you see George”, may aid remembering.

So in undertaking interventions or assessment work with people with dementia we need to consider where we undertake the work we do, who we have present, and how we can assist the person with remembering in order to make sure they are fully represented in the interaction and more importantly that they are shaping the outcomes of our involvement themselves.

Fernyhough, C. (2012) Pieces of Light: The new science of memory. Profile Books:London
de Vries K (2013) Communicating with older people with dementia. Nursing Older People. 25, 4, 30-37. RCN Publishing Company

 

[Stephen Mordue]

Communication & Dementia

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Effective communication is paramount in working with a person with dementia where verbal communication may have declined (expressive ability) and where comprehension of language may be difficult (receptive ability). Communication cannot be left to chance but needs to be effectively thought through and managed from a theoretical and personal perspective. That is, what does theory tell me about how to communicate and how do I use myself as a tool in this exchange?

Communication in general relies on both verbal and non-verbal exchanges of information and is described as a sophisticated art (Junaid and Hegde, 2007) and noted as the heart of intervention (Lishman, 2009). Listening needs to be a physical, cerebral and emotional act if we are to ensure its effectiveness and if we are to demonstrate empathy within a practice situation. Lynch (2014) suggests that there is a distinct difference between listening and hearing – with hearing being the more important of the two. He suggests people can listen without necessarily hearing, but not vice versa. Hearing requires engagement and not just physical presence.

Your demonstration of your presence is particularly important when working with people with dementia to ensure they remain engaged with you in dialogue. They are more likely to remember how they felt during the exchange rather than the actual content, so your body language and attentiveness is of paramount importance.

Communication is a valuable ‘end’ in itself as it supports the individual’s sense of self; their personhood as Kitwood (1997) puts it. What gives people a sense of self is how others are with them and how they react to them. In maintaining our sense of self we need others to legitimise who we are in a social situation. But for the practitioner communication is also a means to an end in terms of information gathering with a view to assessment and support planning. What can appear to be simple conversation – chatting about their life, their family, likes, dislikes and aspirations – is rich in information for the social worker.

It is advisable when working with anyone, but particularly those with dementia, to ‘tap into’ this rich seam of information. This type of general conversation can form part of the assessment in itself as it helps you explore the person’s short- and long-term memory, their ability to articulate, their language skills, their ability to track conversation and return to earlier themes; all of which gives you valuable information in how to continue to communicate. You will need a constant cycle of reflection regarding the person’s communication skills and preferences during the interaction to ensure a successful exchange.

The use of silence should not be underestimated in any communication. For people with dementia it can give space to think and consider a response and as long as the silence does not become overbearing it can be a valuable tool. Silence can also communicate other things such as an individual’s annoyance with a question, or that it is not a question they want to answer at that time. Interpreting which questions are answered and which are not may enhance overall understanding of the interaction and indeed the person (Lynch 2014).

You will need to work at the pace, and on the subject matter, of the person’s choosing, at times gently responding to, and steering, the conversation. After all, this conversation has a purpose but needs to feel natural and not invasive, although invariably there will be some questions and subjects that simply need to be addressed at an appropriate time. When in conversation it is important to ‘listen to’ the emotion attached to words or phrases; the ‘music behind the words’ as Sutton (Lishman, 2009) puts it. This will give you an indication of the importance of some statements in relation to the individual’s view. For example when someone says ‘my son can only visit once a week as he is really busy’ you may be able to note in the intonation whether the person is comfortable with this and accepts it or is annoyed by it.

What practical things help? Small et al (2003) and Wilson et al (2012) give us some clear observations, and some debate, on how to approach communication with someone with dementia. Good practice would lead us to, eliminate environmental distractions and create an atmosphere where it is apparent time is available so that the person is not rushed. You should use short, simple sentences, which include only one question or point and use repetition and paraphrasing to ensure understanding before moving on. You should allow plenty of time to respond to each question and not to interrupt, finish or pre-empt answers; and encourage people to talk around a subject where they may be having difficulties with finding the word or recalling information.

There is also a suggestion that the use of pronouns can lead to problems so it is better to say, “Mary visits twice a week”, rather than, “she visits twice a week”. Being specific is helpful. There is some discussion around slowing down speech, but if speech is slowed too much the person may not be able to retain the information from the start of the sentence once the end of the sentence is reached. This point serves only to illustrate that the need to adjust your communication style within a theoretical practice framework is essential.

Other practical considerations to bear in mind include thinking about the time of day you talk to someone with dementia as there is a tendency for mental ability to fluctuate throughout the day and it often declines the later it gets. The impact of medication, particularly where it causes drowsiness, will also need to be considered.

Particularly for those in the later stages of dementia, but universally to a significant degree, is the importance of tone, volume, and pace of conversation where understanding of vocabulary is compromised. Where expressive language has declined for the individual, conversational communication remains important in terms of the person’s view of self and in developing your understanding of them. Where people can no longer communicate verbally, communicating continues to be a human urge and if denied it denies the person.

People will find ways to communicate at a fundamental level such as facial expression, gestures, and movement (Ellis and Astell, 2010). Specific information may need to be sourced from elsewhere, but the person with dementia needs to remain included in the whole process even where the level of factual, accurate information is limited. Continue to maintain eye contact with them and ask questions even if someone ultimately has to answer the question on their behalf. This element of human contact and inclusion signifies that the individual remains important within the overall exchange.

Communication remains key to both including the person and gathering information during every aspect of working with someone with dementia, from assessment to discussing personal budgets, from putting together a support plan and reviewing it, to safeguarding and assessing risk. Clarity is of the utmost importance. It is important to use non-ambiguous language, to break complex information down into smaller statements or questions, and to return to statements or questions to confirm understanding. You may want to think of other ways like leaflets or written notes of main points to help the person ‘remember’ what has been discussed. They may need a reference point to scaffold their memories.

References:
Ellis, M., & Astell, A. (2010). Communication and personhood in advanced dementia. Healthcare Counselling and Psychotherapy Journal, April, 32-35.
Junaid, O., & Hegde, S. (2007) Supportive psychotherapy in dementia, Psychiatric Treatment vol. 13, 17–23
Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First (Rethinking Ageing), Open Univerity Press
Lishman, J. (2009) Communication in Social Work, Palgave Macmillan
Lynch, R., (2014) Social Work Practice with Older People (A Positive Person-Centred Approach), Sage
Small, J, Gutman, G, Makela, S, & Hillhouse, B 2003, ‘Effectiveness of communication strategies used by caregivers of persons with Alzheimer’s disease during activities of daily living’, Journal Of Speech, Language & Hearing Research, 46, 2, pp. 353-367
Wilson, R., Rochon, E., Mihailidis, A., & Leonard, C. (2012) Examining Success of Communication Strategies Used by Formal Caregivers Assisting Individuals With Alzheimer’s Disease During an Activity of Daily Living Journal of Speech, Language, and Hearing Research, Vol. 55, 328-341

[Stephen Mordue]