Category Archives: Practice

Just who am I!?

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Humanistic and existentialist thinking might lead us to conclude that our sense of self is constructed from, among other things, being autonomous, being free thinking and being part of a community. More here!

But just what is ‘self’ and why does it matter to us as social workers?

I wonder what your idea of your own ‘self’ is? Given you’re reading this blog you may define yourself as ‘social worker’ or ‘professional’. And obviously that will only be part of the story. You may also be a father, mother, son, or daughter, friend. Some of those words I’d also use to define myself. So, what makes me different to you and how do I know that I am different to you?

Psychologist Ulric Neisser (in an article in Being Human: The Inside Story of What It Means to be One of Us, New Scientist, The Collection, Volume 2 Issue 3, Reed Business Information Ltd., England (2015) gives us a multifaceted description of self.

You have an ecological self. You understand that you have a place because you have a point of view. How others respond to your point of view shapes something about you. Do others acknowledge your point of view? Does this validate who you are? How do you feel when someone criticizes your point of view? You also have a sense of your physical being and that there are rules about access to your body by others. There are acceptable things and unacceptable things defined by culture, the life experiences you have had, and by the age you are. When we think about supporting adults with disabilities these lines often become blurred due to the nature of the support that needs to be offered. The line between acceptable and unacceptable intimacy around personal care sit in a different place and in delivering such care concerns around lack of dignity need to explored.

You know your image in a mirror and the sound of your voice. You understand that others are physically different to you. You understand that they have a role, a purpose and that they also can make decisions to interact with you or not. This is your interpersonal self. You understand you can, and do, use your body language to try and influence the action of others. You generate ideas about how it might be for others born out of your own experiences. But caution! You can never know – not really – what it’s like for the other person. Similar experiences are not the same experiences. Avoid, “I know how you feel”!

Your existence is temporal, lasting only for a period of time. Fleeting, in terms of the ‘big picture’, you might say! But you are not just what you are now – you are what you have been. What you are going to be, or want to be, shapes you. The awareness of your potential future, or your aspirations, have great bearing on who you are in the here and now. So, consider then how this must be for people who, because of lack of opportunity, lack of support, disability, or lack of social status have their sense of self eroded by feeling their options for the future may be limited in some way. This ‘temporal self’ links to your conceptual self. You have an idea of who you are based on your life story, your personal goals, motivation and values. So in practice, when, for example, we think about making best interest decisions under the Mental Capacity Act it’s essential that we have not just an understanding of the risks associated with the decision, or the pertinent facts that relate to the situation, but also an understanding of the person’s values that have, and are being, shaped by their story. What would have been ‘driving’ them if they had been making this decision for themselves? This must be factored in so that when making a decision for someone lacking capacity we maintain them at the heart of the decision and don’t draw conclusions from our own value base, or as a consequence of risks that may well be professionally or organisationally constructed.

So, existentialism underpins humanist ideas of self, about being free and autonomous but with responsibility. There is also a shared journey between us as social workers and the people we work with. There are some tensions created by the fact we work within often very inflexible, risk averse frameworks.

Reflective practice definitely has its place here in our existentialist view of the world. Developing insight, through reflection is required so we understand what we are doing and most importantly why. Are we working to the service users agenda, our own, or our agencies? At best, in reality, it may be a combination. At worst the service users voice may be silent or misheard. Theory, research and practice wisdom, as well as knowledge from service users all have their place here.

Our work needs to be holistic, incorporating all the elements and taking a ‘big picture’ view so we capture an understanding of the essence of the person – where they have been, where they are at, and crucially where they want to go. As social workers we can’t just deal with situations from an objective viewpoint but have to understand the subjective dimension. We can only discover that by exploring the person’s sense of who they are and what they value before any decisions are made.

Cicero, self, and Social Work

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Just what does the Roman philosopher, politician and orator Cicero have to do with social work in 2017!? What can the musings of someone from 107 – 44 BCE tell us about life in the 21st century? Well, Cicero’s philosophical writings on the nature of the person and existence have contributed to humanism and this in turn has contributed to ideas around person centered intervention! So there you go! Read on!

What exactly did Cicero have to say? He suggested that people’s sense of self, their sense of who they are, was created by being autonomous, and therefore making their own decisions, and by being free thinking, and therefore able to make their own mistakes! He said people were possessed of rights that define responsibility. This tells us that to be valued, and see themselves as valued, people need to be active participants in society defined by their rights and, as a consequence of those rights, they must take, as far as they can, responsibility for their actions (maybe we can explore this in relation to the Mental Capacity Act at some point…)

Cicero also suggested that the human community is the bond between people. People need to be connected to other people because our sense of self is not only defined by our inner dialogue but also by how people perceive us and we can see how people perceive us through how they interact with, and react to, us. These interactions give us definition and status.

But what are the two things that have often been denied to people who come to social work for some form of intervention? Yes! They are denied the right to make their own decisions and the ability to be part of the broader society. This could be for many reasons. The views of professionals and the misuse of power they hold taking decision making away from people. Or it could be the lack of access to information, knowledge and physical spaces that comes with having a disability. These things erode the ability of people to develop a positive view of ‘self’, denied autonomy, denied freedom, and denied access…. No wonder people kick against ‘the system’!

As social workers we can run the risk of ‘doing to’ people rather than ‘doing with’ especially when time is tight and the demands on us great. We must see people as individuals and part of a community in order to see the full picture and encourage individuals to make their own decisions and take risks. Maybe this needs risk to be redefined in our organisations to include the positive aspects of risk taking more strongly.

The threads from Cicero’s thinking are picked up in existential philosophy which emphasises the existence of the individual person as a free agent determining their own development through acts of will stressing their position as a self-determining agent. People form their ‘essence’ in the course of life resulting from their personal choices. Who you are results from the decisions you make.

There are some assumptions here though. This assumes people are allowed to make their own choices. At best often people are given choices from a very narrow range of options or people are not made aware of all the options that are available. Our job as social workers is to ensure people are fully informed so that they can fully engage. Sometimes people need support, as they are not psychologically in a position to make decisions, even when all of the facts are available. Some people may feel constrained by society’s view of them. Undervalued therefore not worthy of being permitted to make decisions. Disempowered by ‘the system’. This certainly was a theme in the House of Lords Select Committee report into the Mental Capacity Act

Social work clearly has a role here.

We need to support people to make their own decisions so they can own them and develop a sense of who they are and where they ‘fit’. We need to let people take responsibility for their own risks and the consequences when things go wrong without the fear of being held accountable for the capacitated decisions people make (this is a one for the managers and politicians to grapple with though as it often those people who are restricting good social work). Freedom to make your own decisions is both liberating and at times a heavy burden so that means working with people to acknowledge and accept risk and to go with it.

For many ‘existence’ is characterised by powerlessness and helplessness – decision making taken from them. This needs to change if we are to provide truly person centred social work. People need to shape their own lives with support so they can be true to the individual version of themselves they are and want to be. We are shaped by our experiences. We have to give people the opportunity to ‘experience’ so they develop into the best version of themselves that they want to be. Just in the same way we all do.

There is a tension here between the authority and duty that comes with the social work role and being involved in the, what is often, non directive work that is required to help people find their own way with support.  There is a need for people to be given real choice and control so that can move forward in the direction they want to.  What social work needs to do then is support people to engage as citizens, to give people back some power, to support people to grow and develop, maybe to provide opportunities for fulfilment, help people make their own decisions – promote choice. Most of this is not done in the services that are ultimately provided but in the foundation building face to face work we engage in. How we ‘social work’ in the time we are with people is what’s important. Much more important than what we then write about them or provide to them. Personalisation is in the face to face interactions we have and not necessarily just in the flexibility of services.

How delivering good practice is adding to the DoLS assessment backlog problem.

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Ongoing increase in outstanding assessments

The annual review of deprivation of liberty safeguards has revealed an on going increase in situations that still require attention through assessment. The safeguards ensure that those deprived of their liberty in a care home or hospital in England and Wales, who do not have the capacity to consent to being accommodated, have recourse to the law to challenge their deprivation.

Opening the flood gates

The law has been problematic since it’s inception with difficulties around definitions of deprivation and ‘best interests’, two concepts essential to getting the right decision in this area. The Cheshire West ruling opened the floodgates of people needing an assessment. So, when people were under continuous supervision and control and unable to leave, this deemed them to be deprived of their liberty, and an assessment to confirm this was in their best interest was required. The reality of this ruling was that it applied to most, if not all, people in a care home who lacked capacity to decide to live there. This created an immediate crisis of a backlog of assessment. The solution to train more social workers and to employ locum best interest assessors has clearly not resolved the problem and with a review of the legislation placed on hold until at least 2019 it’s difficult to see how the problem will be resolved.

The backlog

Estimates seemto suggest that it will take years to clear the backlog as obviously, as people enter care or hospital, they add to the numbers of those already deprived who require assessment. Uncompleted cases have now risen to, in excess of, 100,00 it is thought. 

Good practice ironically adds to the problem

The North East of England appears to have a disproportionate number of assessments to undertake. The reason for this is an interesting one. It appears that practitioners in the north east are happy to recommend a short review period and that local authorities are happy to accept this. The best interest assessor can recommend a period of anything up to one year before the deprivation is reviewed but in terms of best practice this should not be seen as the default time scale. Where someone thinks a situation may change, or where recommendations are made to make the deprivation less restrictive it is right and proper to review this in a timely fashion. Hence, a shortened time scale. The irony of this is that best practice is compounding the problemof the assessment back log and while we wouldn’t want to lose this it highlights the need for a new more efficient and effective system of managing the safeguards.

The risk of ‘desk top’

This is the third year in a row that the backlog has increased despite more practitioners being trained to undertake the required assessments. The risk of not transforming the law and process is that councils may resort to ‘short cut’ methods like ‘desk top’ assessments. Some already have. This will mean the safeguards will have very little if no potential for impact on the lives of vulnerable people. Through the process the best interest assessor gets to meet the person and talk to them and is tasked with finding out as much as they can about the person. This can result in recommendations that may reduce the restrictive nature of a deprivation with the potential of improving quality of life for someone. A ‘desk top’ exercise turns this person centred assessment into a bureaucratic exercise. Surely that can’t be right? 

Emotions and running away from wooly mammoths

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Universal_emotions7Emotions are a strong and powerful force. Sometimes our emotions get the better of us. Sometimes they lead us to lose focus and control and respond in ways, in hindsight, we wish we hadn’t.

When my teenage son was out for the night with his friends and I’d asked him to be back in for 10 o’ clock it was remarkable how I could go from being completely chilled and mellow at 9.59 to being an absolute fire ball of annoyance at 10.01. And how, when he walked through the door at 10.03 with a jaunty ‘Hello!’, I would react, dare I say, a little negatively. But in the cold analysis of this he was only 3 minutes late! And anyone can be 3 minutes late for all sorts of reasons. So, why the extreme reaction!?

Evolutionists would argue that our emotions, and the fast responses they give us, have proved useful throughout our history. When approached by a wooly mammoth we got scared and ran away! That’s a good reaction! So when confronted with my teenage son being late I feel fear for his safety, which in turn fuels anxiety, which in turn promotes one of three things – fight, flight, or freeze. Now, in the ‘late teenage son’ example none of these are particularly helpful as the situation doesn’t need a fast, automated, response but we have such responses easily available to us… so I pick fight!

Why do we pick the easy ‘in built’ response? Well, Daniel Kahneman in his excellent book ‘Thinking Fast and Slow’ explains that we have two systems at play in our brain. Our automated ‘quick response’ brain and our slower more ponderous brain. He explains in much more depth, and with much more eloquence, that we are generally lazy when it comes to thinking and when we have a quick response available to us we have a tendency to go for that response rather than having to engage our more thoughtful and slower brain. Because to engage that part of our brain is frankly hard work!

So, as Howe (2008) tells us despite our emotional reactions lacking subtlety they are emotionsquick and powerful and provide us with a range of possible immediate responses to situations we find ourselves in. Some of which are useful, especially when things like safety are being compromised, but some of which are less so when a better response would have been a more thought through one.

Howe (2008) lays out the positives of these rather automated responses. He states they are tried and tested solutions to the problems we all face. When lost, physically rather than metaphorically (!) we experience fear and that fear drives us to take stock quickly of the circumstances so we can be ‘found’ again. The emotion makes us focus on the task at hand quickly until it is dealt with, at which point, hopefully, the emotions will subside.

He also suggests that emotions help us explore situations quickly that are too important to leave to intellect alone. When out on a home visit and confronted by a large angry dog growling and snarling and approaching you you want something inside you to say ‘run’ rather than to stand there and think ‘well let’s consider my options’. ‘What will the person who loves their dog think of me?’ ‘How deep would the bite be, and therefore how much at risk am I really?’ ‘Will the owner intervene… oh I’m sure they will, I would?’ No! There’s not time! Run! And figure the rest out when you’re safe!

The core of an emotion, like in the example just given, is a readiness to act and to formulate plans. You need to give a sense of urgency to your actions with regard to the advancing dog so in a few moments you will plan what to do, as your emotions will demand it of you. You will not consider how this might impact future relationships, or what it will mean for the end date of the assessment, or whether you will need to inform the home support staff you commission! You will consider ‘how can I get to a position where I don’t feel terrified anymore!’ And that’s fine!

mammoth-2512585_960_720One of the problems with the modern world though is these in built, almost animal like, gut instinct responses, work for wooly mammoths and advancing dogs but don’t work so well for situations where the threat is not as obvious and the solution not as instant. You might feel anxious and scared when you look at your diary for the week, or you might feel fear and distress when you see you have a visit to a particularly challenging family – but you can’t run from these things. It’s unlikely you can use a ‘flight’ response given you’d like to get paid at the end of the month but you may feel like engaging in a ‘freeze’ response or a ‘fight’ one when your manager gives you another task. Neither of which in the long run are helpful.

The emotions you are feeling in such moments will ‘flavour’ your responses in other situations as they present themselves. Unless of course you manage the emotion in some way so that you can use your emotional responses to drive you positively rather than letting them have a negative impact.

Here’s a ‘low-level’ example. I was driving to work recently and there was a broken down car up ahead. I was already a little late and this was going to make me even later. I started to get anxious and angry because I left some prep till the last minute for a 9 o’clock lecture and now I wasn’t going to get to work until 8.30. This would mean the usual things I’d do on a morning would not get done. And if you know me you know I love my routine. I started feeling tense. So I engaged in some planning! I figured that when I got to work I wouldn’t even turn my computer on. I’d grab the printed copy of the slides, grab a coffee, and spend the small amount of time running through what I had. I used the negative way I was feeling to drive me to plan rather than just living in the angry, frustrated, moment. And it worked. I had a plan so felt myself relaxing and felt the negativity disappear. Now I know some of the issues we face in practice are bigger than this example but the idea still works.

This type of approach is not easy but it comes with practice and certainly relies on being self aware. You have to be able to know your emotions, know what triggers strong feelings in you and plan for how to deal with them rather than leaving your reactions to chance. This is born out of experience. In a sense ‘forged in the fire’ of practice. But you can start to develop an understanding of yourself by considering your strengths and weaknesses in relation to emotional responses. You can think about your values and what’s important to you ….and dare I suggest looking after yourself should be just as important as the service users you work with or the timescales you work to. Figuring all of this out will give you a sense of self regulation and an ability to control or redirect disruptive emotions to emerging circumstances.

Emotional intelligence is about managing your emotions but also about managing the emotions of others. I’m convinced as social workers you will have the skills to do this. In showing people empathy you will show you understand, as far as you ever can, how they are feeling and may be able to help them move in a desirable direction

The social work task is to work with people who are often in an emotional state. Just the presence of you as a social worker will bring some emotions ‘to the table’. It’s your job to create a safe space to explore those emotions. People’s idea of self, as we’ve seen elsewhere, is formed in the relationships they have and in their interactions with others. People with problems may have their sense of self undermined so need to return to a supportive relationship with someone to explore who they are. This is done by you engaging with them in a warm and sincere relationship.

You’ll need to make the person feel comfortable and this may take time. But you will also need to feel comfortable yourself. Not be distracted or rushing to get through the appointment. Being ‘in the moment’ with the person will show you are available to them, not just physically present, but also emotionally and psychologically present. This will develop an encouraging relationship and a safe environment where the service user can explore themselves and hopefully come up with their own solutions and way forward.

Howe (2008) says that once this relationship connection is made ‘the self of the service user can form and re-form. The social worker is like the sculptor who frees the sculpted form from the marble; the worker recognises the potential of the client and enables him or her to realise that potential’ (Howe, 2008, p.186)

Howe, D., (2008) The Emotionally Intelligent Social Worker
Kahneman, D., (2011) Thinking Fast and Slow

 

Stop talking, start listening!

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listen-picAs social workers and social work students we understand, I suspect, the importance of effective communication and spend a lot of time thinking about what we should say and how we should say it. We think about what signals we send through our tone of voice and our body language. But, do we give enough time to listening and thinking about how to listen?

Listening is a physical and cerebral act. We need to engage our ears and our brains. As we physically hear we should be working through what is being said, why it’s being said, and just what does it all mean. All the time thinking about direction for the conversation. Keep all of your plates spinning at once springs to mind! So our brains need to be engaged in the activity and we need to appear present, not distracted, while all of this is going on. Exposure to doing this is really the only way you learn. I work with students from time to time on communication and they tend to leap straight to problem solving before finding out enough. There’s an urgency to intervene, to offer a solution, when often people just want to be heard. Simple? Not really!

Listening attentively is part of demonstrating empathy (but not the whole story!) We are trying to understand what a person means by understanding their position. We are trying to understand how they feel – something I feel we often miss at the expense of trying to get to the facts (I think evidence based practice has kicked intuition into touch at times). We are trying to ‘feel’ with the other person what their experience of reality is and try to show our understanding by feeding some of it back to them to confirm or develop our understanding. You can also show this non verbally through your facial expressions and body language.

You can never fully understand how the person feels and what they are experiencing but you must try to get close. As I once read somewhere (and I wish I could find where – if you know tell me!) – empathy is walking in the other persons shoes but with your own socks on! 

As practitioners we can’t always rely purely on our empathetic listening – there’s a tension between empathy and actually generating a direction – we are not simply in conversation – we are in a conversation with a purpose. We need to think, while ‘in action’ how to help a person move forward or we risk reinforcing the persons position having had them ‘tell all’ and simply leave them there. That’s not good! We have to deal, as far as we can, with what we are told. All of this builds up a working alliance, understanding, and trust. ‘Here is someone who is listening and is trying to help’.

 

The tension at times can be that we also need to listen objectively with a certain level of detachment. I don’t like that word but I still think it’s the right word. You have to be there in the moment, in the persons shoes (but with your socks on!) but also outside of the moment to offer that objective view that is also required just as much as the subjective view – or how would we ever get anywhere?

We need to be cautious that our objective view is not fuelled by our own value base and therefore imposes, through any power we may have, or be perceived to have, our way forward. To do this then we need to practice in a certain way. We need to engage in a equal conversation. Avoid phrases, or imparting knowledge that shows a power imbalance. Don’t interrupt but rather wait patiently giving supportive non verbal cues. We need to seek to understand both thoughts and feelings from the other persons perspective guarding against ‘expectant listening where you hear what it is you want to hear filtering out the bits of the message that don’t fit with where you want to take a situation. Don’t filter out things you believe to be untrue or irrelevant but hear them and consider them fully. If someone is telling you something that is not the truth – then why? When working with people with some sort of impairment or disturbance of mind their response may seem irrelevant in terms of what you’ve just asked but may be very relevant in terms of something they are trying to tell you. In these circumstances and others explore what you hear both literally and for underlying messages.

Also, attend carefully to messages the person sends about themselves and how they view themselves. Stereotypes exist not only in our minds but also in the minds of the people who the stereotype is deemed to fit. The media is a powerful thing and people will be acutely aware of how people in their position are portrayed and may well buy into that portrayal. In the way we talk and present we tell others, and feedback to ourselves, just what we think about ourselves. You may well need to unpick stereotypes that are influencing people in how they think about themselves.

So communication is physical and cerebral. We need to engage in both empathetic and objective listening. Most of all, for me, we need to show that we are alongside people and not there to simply ‘do to them’. Talking and listening are both powerful tools!

Communication – The Impact of Context

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artfofconvCommunication is absolutely fundamental to social work practice. As well as communication taking place between individuals it also takes place within specific contexts. This is about environment but also the contextual framework in which the communication act takes place. Let’s have a look at a range of contextual factors

The Physical Context

This is firstly about the local environment in which the communication act is taking place. So , as social workers this may be in a range of settings. Primarily the majority of face to face communication is going to take place in people’s homes or in an office environment. The advantage of a person’s home is clearly that they are more likely to feel comfortable to an extent. It is their usual environment. Your presence is going to change the impact of that depending on how they perceive you. For example, do they perceive you as a threat to their autonomy, or do they perceive you as an ally. How you approach the initial stages of your dialogue will have an influence here (more on that in a later blog). The physical context can come with some obstacles. The environment may be noisy, other people may be close by which may not help in having personal conversation, it may be very warm or cold. All of these things will have an impact. Try to minimise noise. Ask politely for the television or the radio to be turned off. Suggest moving to the kitchen or returning at a different time for example. From time to time if service users were attending other locations, for example, a day centre, I would suggest meeting them there rather than at home. This may not be as comfortable for the individual in terms of it not being ‘their space’ but may have the benefit of being able to secure a private space for open conversation.

There are other sorts of ‘noise’ that may encroach on the physical context. The person may be unwell, or may have just taken medication that makes them drowsy. The may therefore not be as engaged. People may be hearing and responding to voices which will impact in their focus. The ‘noise’ that comes with the power they may perceive you as having may mean they don’t readily open up to you and only reveal limited information. (I intend to expand on this in a later blog).

Office visits, for me, should be avoided whenever possible. Obviously where risk to your personal safety is an issue then having a service user visit you where personal risk is managed is essential. But where there are safe alternatives office visits, I find, are often not productive. The power balance is shifted very much to you and the organisation and, I feel, people are less likely to relax and engage fully. There is also a lot to be said for seeing people in their own environment. Doing this will give you valuable information and you can use cues around the person to stimulate conversation. Asking about people in photographs was always a great opportunity for me, when working with older people, to find out more about their history and their family.

The Cultural Context

Cultural perceptions of power, position and authority also have an impact on how you communicate with people. I don’t know about you, but I communicate very differently when out for a drink with friends compared to when I’m work. We communicate differently in different settings based on what is expected of us culturally. For example, think of the hushed tones we often find ourselves speaking in when in a church, or the boisterous language used when in the pub. There is a language with goes with different cultural environments. There are colloquial turns of phrase that need to be understood and interpreted, and maybe unpicked, to make sure of understanding. If you are communicating with people in different locations they may expect different things from you or perceive you differently. In a care home, for example, someone may feel they have limited choice as to whether they speak to you or not so may readily agree when really they may not want to, while in their own home, they may well ask you to ‘come back later’. People may feel less empowered to make their own decisions when in the cultural context of the care home where they may feel their personal autonomy is eroded.

The Social-psychological Context

As I’ve already alluded there is a social and psychological status to us as individuals. As a social worker you have a real, and also a perceived, position in society and therefore in the minds of the people you may want to communicate with. Some of this may come with negative perceptions of you based on your position. We assume different roles with different gravity as practitioners. That of social worker, Best Interest Assessor (BIA), Approved Mental Health Practitioner (AMHP) to name a few. And all of them come with different levels of power. BIA’s and AMHP’s have considerable power while social workers may actually be perceived as having more power than they actually have. This can create a barrier if not managed effectively. So, the words you use to introduce yourself, and the manner in which you do so, may help to overcome some of this. Those initial few minutes (some would argue seconds!) are crucial in establishing a level of rapport.

The Temporal Context

This is the communication event’s position within a sequence of other events. “It’s not all about you”, as people are fond of telling me! The conversation you are about to have has been preceded by events for you and will be followed by events for you that you are already aware of. Don’t forget this is the same for the person you are talking to. They may have just had a great morning and be on top of the world or they may have had an anxious few hours waiting for your visit. They may have just received good or bad news, or just had a lovely, or fractious, visit from a family member. You will probably have no knowledge of this so how you initially approach your conversation should bear this in mind and should aim to establish emotionally and psychological how the person is and therefore how you may need to tailor the conversation to their requirements. Also, they will have things happening after your conversation, as will you. This may lead to someone wanting to prolong the conversation or cut it short and both of these things can have a direct impact on the quality of the interaction. No doubt you will have prepared for the conversation but will the other person? You will find you therefore can’t simply launch into your agenda at your pace but will have to effectively judge how to approach the other person.

So, be conscious of how you can best ‘shape’ the physical environment, be aware of any cultural norms that may be having an impact, and be mindful of the place the conversation is within yours, and the person’s, day.

coming soon
‘Noise’ and its impact on communication
The importance of conversational ‘openers’

 

Communication – the bedrock of practice

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comms

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:

Communication & Eye Contact

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pelican

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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memory

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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dementia

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]