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From self-harm to self-belief

Lead occupational therapist Emily Gajewski 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.

Managing self-harm

Everything we do is geared around helping the women we work with to meet their needs. For instance, one way that their need for control over their own lives is addressed is by their being entrusted to manage their own self-harming behaviour. In previous units, if people self-harmed, anything sharp and therefore potentially dangerous was removed from them, which could be experienced by them as punitive and intrusive. They would be subjected to one-on-one observation by a staff member. So, effectively, a person in great distress might be left in a bare room, stripped of anything meaningful and being constantly observed by someone she might not know that well, who might not even converse with her. In terms of meeting needs, this is clearly counter-productive.

In the house, people are given back control. The whole multi-disciplinary team carries out a thorough risk assessment when someone first joins us, agrees a management plan, and reviews both regularly, so we are confident about giving the women a high degree of autonomy. Every woman has a locked box containing her medication (for which she has the key). Whether it contains one day’s supply or one month’s supply depends on how responsibly she uses that control. If someone expresses a wish to self-harm, we spend time with her, helping her to think about other ways of coping or distracting herself. However, if a resident ultimately chooses to go through with the self-harm, she has to take the responsibility for dressing her wound with the first aid kit, kept in each bedroom. If staff feel a visit to the accident and emergency department is advisable, the resident is encouraged to go and transport is provided. If the incident is judged serious or potentially life threatening, however, (for instance, very severe cutting or overdose), staff’s duty of care means making the decision for appropriate medical intervention. On rare occasions, this may mean the police have to be called to take the person to hospital.

Balancing attention needs

Focusing on the need for attention has been very helpful. As we know, attention needs must be met in balance but, as one of our clients observed, “My need for attention is huge and it doesn’t get met!” She has been able to learn, however, that attention received may be more satisfying if sought appropriately. For instance, women who feel starved of affection may yearn for simple physical contact, such as a hug, but in traditional institutional settings such contact is taboo. It is not so surprising, then, that, when the hug is not forthcoming, a woman may resort to acting violently in some way, to ensure the need for physical restraint – and, therefore, contact. We work in a different way. If a woman who is upset asks in an appropriate way to be cuddled or have her hand held, the staff member, if comfortable, will comply. The result has been that the need for such attention lessens and is asked for much more sparingly.

There is a major emphasis on fulfilling the need for emotional and social contact, as our aim at the house is to help women settle back into the community and to be a part of it. We encourage attendance at courses and social groups, so that women don’t need to depend upon our unit, once they have moved on, although they are always welcome to spend a night on the sofa if they have a crisis of confidence. Most of the women are excited to move on to supported housing (usually a housing association flat, where they are visited by a staff team who check they are shopping, cleaning and managing their bills) but it can also be frightening suddenly to be alone. (We have just been granted funding to set up our own supported housing, consisting of six supported flats, and this is going to give us a great opportunity to base this new service around meeting human givens needs from the outset!)

Moving on

To help our residents manage when they move on, we created a skills-based course, designed around the human givens. We call it a community living skills course, rather than a group, so that the focus is firmly on learning rather than ‘therapy’ and reinforces skills for those already attending college courses, or planning to, thus helping to meet needs for meaning, wider community involvement and achievement. The course lasted a pre-set number of weeks (10), so that women knew exactly what they were letting themselves in for (helping meet needs for security and control). It was held in the local community centre in town, to which the women travelled independently (helping meet the need for autonomy and feeling part of the wider community).

Attendance was voluntary, as we wanted participants to take responsibility for their own learning and to be motivated to learn (meeting the needs for control and status). To that end, too, they were asked what they wanted to learn on the course. The participants were encouraged to undertake to organise a social event to celebrate completion of the course.

We sent each participant a formal, introductory letter and a special ring binder, dividers and lined pad and pen, so that the material learned could be clearly organised and easily accessed long term. Most of the material was developed through brainstorming and group discussions, rather than being presented as a fait accompli (again to increase sense of control and status). We covered a variety of topics – from filling out forms, making official phone calls and shopping and cooking for one, to more emotionally challenging areas, such as assertiveness, raising confidence and self-esteem, meeting new people and responding to difficult or invasive questions, structuring time alone and self-management plans for times of crisis. 

Participants gained a lot, even if not everyone’s personal aims were achieved in full. Comments included, “I have been able to use assertiveness skills to arrange an important meeting with my daughter’s social worker in regards to her care”; “With staff support, I was able to use my self-management plan during a time of crisis”; “I was able to explain the scars on my arms to a young girl at church when she asked me what they were. I was able to tell the truth in a way that didn’t scare her” and “I thought it was like looking on the outside world and that helped a great deal for me, for when I leave here”.

Colleagues at our sister service, a medium-secure unit for six women, have also begun to embrace the human givens approach themselves and plan to write it into their own philosophy. I am currently working with them to introduce the concepts, which they believe will help them develop a very different, more effective style of forensic service, within constraints we do not have at the community-based house. For instance, we try, in consultation with our highly supportive consultant psychiatrist, to get people off their Mental Health Act ‘sections’ as quickly as possible – all as part of giving them back self-control. But, because some of the women at the medium secure unit have committed crimes and are on what are known as ‘Home Office sections’, their movements are restricted and they do not have the opportunity to integrate into the community and meet their needs for achievement and connection so easily. However, just identifying essential needs has given the team a clearer structure for successful work in their more restricting setting. For instance, the team are working hard to provide opportunities for the women to experience achievement through tasks, such as individually cooking a meal for the whole house. For some of the women there, it is the first time they have ever achieved anything that brings them both admiration and personal satisfaction. Residents are also being given control over their self-harming behaviour and, even though self-harm there is generally more severe, it is now reducing.

Overall, staff within the service have really appreciated the input from the human givens approach, as they feel it gives them clear guidelines about what they are aiming to achieve with clients, and how to get there, rather than feeling submerged in vague and amorphous ideas of ‘recovery’ and ‘hope’. We are also using the human givens as a template for supervision of staff, using it as a focus for discussion. One manager suggested it could be a way of identifying when things are not working as well as they could. For instance, if, after three supervision sessions, someone is still not getting sufficient sense of achievement or status from their work, they might need extra support. New workers undergo a thorough induction when they start with us but those who have never previously worked in mental health may have limited knowledge about the type of challenges our clients face and how best to help them. If their sense of control is revealed to be low, it may be a signal that they need to learn more about handling difficult behaviours. 

As a result of all this, we have all seen a huge difference in women who had felt themselves to be pretty much written off by other services. Comments from them include, “I can see I will move on from here”; “I get the attention I need, staff time and help with the things I need to do”; and “I’m starting to achieve new things all the time”. Women who had continually been involved in fracas, ending up shouting and lashing out in police stations and psychiatric hospitals, are now involved in training courses, voluntary and paid work, forming good relationships and becoming more socially skilled. Two women who have been with us since we opened are now moving on. One had been in institutional care, including prison, for almost 20 years. Now she has her own flat, and she is loving it.

The women we work with have very many difficulties to overcome, and working in such a setting can be quite a rollercoaster. I’ve lost count of the times I have left work on a Friday afternoon, with everything operating peacefully and have returned on a Monday morning to chaos and mayhem because, over the weekend, someone has become extremely distressed and seriously self-harmed or threatened violence or run away. At such times, having the human givens needs as a template to refer back to, to check we are on the right track and to keep us focused, is a welcome stress-reliever!

 

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)

 

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