Lead occupational therapist Emily Lindsey-Clark describes how the human givens approach has provided a practical focus for working with women struggling to cope with everyday life.

WHEN, at a conference on recovery attended by nearly 200 mental health professionals, Angela Western stood up to speak, she was a little nervous, as any presenter always is. However, Angela is not a professional and had never addressed a professional audience before. But what she had to say held them spellbound. She told them about her experience of self-harm and the impact on her life of the unhelpful attitudes taken by mental health and other health professionals during the many long years she had spent in and out of hospital. Now in her 50s and long ago ‘written off’ as suffering from borderline personality disorder, she spoke of how she now felt, for the first time, more in control, more confident, a sense of status, a desire for meaningful achievement and an awareness, at last, that she is not defined by self-harm.

It is no coincidence that she spoke in terms which represent powerful human givens ideas, for the human givens approach provides the framework for our work at a community-based, residential rehabilitation unit for women in Sussex with complex mental health needs, one of whom is Angela. (For the purpose of confidentiality, the unit will be referred to as ‘the house’ in this article.) Although we know it as a rehabilitation unit, to anyone else it is just an ordinary house in an ordinary street (designated for post office purposes by its number and the street name). However, we are able to house women (six at any one time) who might otherwise have been held in hospital under a section of the Mental Health Act, and offer 24-hour nursing care and a rehabilitation programme involving a multi-disciplinary team.

We work with women who have struggled with living independently and with managing relationships and their emotions. They often use self-harm as a way of coping; many have suffered severe trauma or abuse in the past and can be abusive or violent towards others. Currently, the age range is from 22 to 56. Although we don’t work with diagnoses ourselves, the majority of the women have been labelled with borderline personality disorder and have experienced many, many years of institutional care.

Our service was set up two and a half years ago, in line with two key government guidance documents.1,2 It is based on a non-medical approach of hope and recovery, with the emphasis on building good relationships with clients and encouraging self-responsibility, rather than relying on physical security and restriction. The recovery and empowerment approach challenges negative views, previously held by mental health staff and society at large, about the prospects of those affected by mental ill health3 and personality disorder, and emphasises that such people can and do recover and live satisfying lives, by learning to manage their difficulties. The individuals who recover, it has been shown, tend to be those who have people who support and believe in them, and the essential components of recovery are client empowerment, reintegration into the community and a normalised life environment.

So our service aspires to enable people to take back responsibility for their own lives, to make their own decisions and to develop self-efficacy. It draws on a variety of theories including attachment theory and transactional analysis, as well as the human givens. It is highly hands on. During the day, there are around five members of the multi-disciplinary team present – always a nurse and two support workers, plus two occupational therapy staff and an assistant psychologist. Others involved include a psychiatrist, consultant forensic psychologist and management team. At night, one nurse and one support worker are on duty.

We are all strongly committed to what we are trying to do. And yet, we all also found it difficult to explain what exactly we were about, when talking or presenting to staff in other services, or even to the women themselves. The notion of recovery, laudable as it is, doesn’t explain what it is that we actually do or how we arrive at it. What is it that makes a person able to feel empowered and live a normal life in a normal setting? I was already studying the human givens approach and it was when I started thinking about how we could bring it into the service that everything clicked into place.

A helpful framework

I soon spoke to our service managers about framing (and explaining) what we do in terms of meeting needs. Unlike some other models, which are seen as the province of particular health disciplines, the human givens idea of innate needs and resources resonated across the board because it is simple and concrete. Everyone was keen to work with it. We realised, however, that we would need to use it therapeutically in some way other than one-to-one therapy. The women we work with have commonly spent so many years in institutions where they have not felt listened to or genuinely cared for by staff that they find it extremely hard to trust anyone. Most are highly sceptical of one-to-one therapy and are unwilling even to be helped to relax, as that itself takes trust. So we tried to be more creative in how we integrated the human givens ideas into our daily work.

In some teaching sessions, I discussed with my team colleagues the basics about essential emotional needs, such as those for security, control, emotional and social connection, attention, achievement, status, friendship and fun, and meaning and purpose, and then we brainstormed how we would work with these. We came up with the idea of explaining, in the welcome pack we give to professionals and clients, that our goals are to help women who join us to meet these needs. We also decided to adapt our recovery plans to incorporate them.

What we call the recovery plan is traditionally known as the care programming approach (CPA) plan, in which a detailed plan is created to ensure that all professionals and agencies involved know what is being done in any individual case. They review the programme regularly, so that people at high risk of self-harm or harming others don’t slip through the net. The plan is based around a standard form, which has to be completed by the client and team involved in their care and covers areas such as housing needs, mental and physical health and social needs. However, these plans are often written by health professionals without consultation with the client.

We had already varied this by asking the women to imagine a preferred future and come up with their own goals, based on working towards this future. Once we had decided to incorporate the general principles of the human givens approach into our plans, we asked the women at the house to tell us what they considered basic human needs to be, and drew up a list together. (The idea was to put them in control of this new way of viewing things, rather than imposing yet another new theory or therapy model on to them). Their list, unsurprisingly, turned out to match very closely with the human givens list of emotional needs, outlined above: for instance, “having contact with my family and friends”, “getting a job/going to college”, “feeling like I matter”, “feeling like I’m in control of my life, not the staff” and “doing fun stuff that makes me feel good”.

We then explained basic emotional needs, as defined within human givens thinking, and presented each person with a laminated sheet, which had these needs listed vertically on the left. Next, we asked them to review their own recovery plans and decide which needs they thought were being addressed by their current goals, and also where the gaps were. We made this active, asking the women to snip out their goals from their recovery plans and stick each alongside the need they thought it would meet. The completed sheets made it instantly clear, for each person, which important needs were not even being addressed. For instance, the need for status was largely unaddressed (a few women felt that they counted in the house, but none felt that they mattered much to anyone outside of it).

We typed up new plans using this format (with needs running vertically and the corresponding goals running horizontally), ticked the needs that were already met and, at each six-weekly review meeting, we now routinely check progress towards the others. In effect, we have used the list of needs as a template to shape the recovery plans around, so that we can be sure we are working together to set goals to address them all and thus provide maximum opportunity for our clients to get them met. One woman had resisted looking for work, so this had not featured as one of her goals. When we reviewed her plan, it was immediately clear that her needs for ‘achievement’ and ‘status’ were unmet and she realised, for the first time, that she did need to do something to enable her to meet them. She chose to visit Workability, an organisation that helps people with emotional difficulties get back into work, because she could now see that an essential need would remain unmet until she took action. The effect on her has been highly positive: having a role as a student has boosted her self-esteem immeasurably.

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© Human Givens Publishing Limited and Emily Lindsay Clark (2009)

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An Idea in Practice... using the human givens approach

EMILY LINDSAY CLARK is an Occupational Therapy Clinical Specialist currently working in a Community Mental Health Team within the NHS. She has over ten years’ extensive experience of helping people in a wide range of settings, ranging from psychiatric Intensive Care Units to supporting people in their own homes. For the past four years she has worked with a multi-disciplinary team developing a Specialised Women’s Mental Health Service. The service was based on the results of a research project that fed into the Department of Health’s implementation guidance for Women’s Mental Health services and has achieved excellent results working with women with complex needs. It was recently independently reviewed by the Health Care Commission, who commented on its “impressive” quality of work – especially in its pioneering approach to positive risk management of self-harming behaviours. Within this service Emily led on developing Occupational Therapy and a drop-in service as well as integrating human givens ideas into the philosophy. Emily has published articles on clinical guidance in a variety of journals and contributed a major chapter on her speciality in the book An Idea in Practice (2007).

> More information can be found in the following books, both by Joe Griffin and Ivan Tyrrell

Dreaming Reality: How dreaming keeps us sane or can drive us mad

Human Givens: A new approach to emotional health and clear thinking

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