We live in a developing world of rapid communication, self-publishing and social media where we’re constantly made aware of what’s trending, what’s cool, what we should all be interested in and doing. Regrettably this has extended in recent years to therapies, with various treatments getting extensive media coverage, online promotion and in many cases becoming huge business. In the past decade CBT has held the dubious honour of being the #toptherapy but in more recent years Mindfullness has definitely taken the crown.
Now don’t get be wrong, Mindfullness has helped hundreds of thousands of people and I don’t paticularly object to it if it leads to good outcomes for people. At it’s core Mindfullness is “a mental state achieved by focusing one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, and bodily sensations”. Nothing particular sinister there. It’s got reasonably good (but not great) evidence for its use in treating, depression, anxiety and other mood disorders and that does make logical sense on a superficial level.
What does trouble me is how it is being held up as a veritable panacaea for all ailments, an easy first line option that is thrown at people at the first signs of any mental distress. Like all trends it is in danger of becoming overused, misused and obscuring alternatives. It’s Pokemon, it’s a chubby 46 year old with a man-bun and scruffy beard, it’s those bloody adult colouring books. For my OT friends out there, it’s like ONLY EVER USING MOHOST! (Seriously dudes, there are other assessment tools).
Whenever a therapy becomes popular you also get the phenomenon of an ever increasing pool of therapists. That’s great in terms of access for patients, but within that pool a certain number will be awesome, most will be average and some will be rubbish. I’d argue that a larger proportion of those will be people jumping on the bandwagon, thinking “Yeah, I could do a bit of that and make a few £££s” than the incredible therapists who first implemented the approach and the few who followed afterwards and creatively developed the idea. I can see how the therapy pool could easily be contaminated by OTs, RMNs, Psychologists, etc. who have just attended a half day Mindfullness course and are now using it as a core tool in their practice.
I suppose part of what irritates me is that I think you could make an argument for mindfullness running contrary to OT philosophies. It is fundamentally an inward looking and temporary approach. It’s about focusing on sensory experiences in the here and now. That’s quite pleasant for a time, but what does it solve? Where is the meaning? When it’s over we still have to deal with the things in life (or the lifestyle) that caused us to feel stressed, depressed, anxious etc. OT is about doing, about being actively engaged in the world and the infinite number of occupations we could be engaging in.
I also have mixed personal experiences of mindfullness. On the more pleasant side I’ve had some quite pleasant drives home incorporating a mindful philosophy – experiencing the wind cooling me down when it’s a warm day, noticing the pleasant green countryside, feeling the sensations of my body shifting as the car corners the winding roads. All quite enjoyable and relaxing. On the other hand, when I’ve practiced mindfullness more formally before going to bed it’s made me feel quite low in mood actually, with a growing sense of everything feeling a bit pointless. Also, I defy anyone to sit in a quiet room with a really loud clock just fucking ticking away like it owns the place and maintain an observational, non-judgemental approach. A more sensible extension of that thought – what about patients experiencing chronic pain and physical illness? – I imagine maintaining a noticing, non-judgemental approach to that with a traditional mindfullness method would be incredibly challenging.
To be fair, I have to recognise what my influences are here. I tend to dislike stuff that is trendy and cool without much further critical thought. I’m definitely about rock and hip hop rather than top 40, but in my defence I think there’s something in that. It’s about wanting things to not be too easy, it’s about seeking depth and content, discovering something awesome that others may have overlooked. I suppose my thinking runs along the lines of “Are you saying X is great because it actually is great, or because everyone else is saying it’s great.”. I think Mindfulness is in danger of becoming the latter. There just doesn’t seem to be that much to it and certainly not enough to treat people who are seriously unwell. Sometimes getting better is necessarily a real grind. Through that grind you develop skills, self awareness, knowledge and insight into your difficulties, emotional resilience, a sense of accomplishment from overcoming whatever challenge you were facing, a renewed sense of agency in your life etc. etc. etc. Mindfullness by contrast is light, easy and in some cases has strong short term benefits. I can see why patients go for it and why it is popular with the people commisioning healthcare and making referrals. Bosh, problem solved on the cheap. Excellent! But is it? There’s research emerging that he gains from both CBT and Mindfullness tend to be lost quicker than more traditional therapies. Unfortunately this wouldn’t be given too much thought by people paying for services who tend to function on a year by year basis rather than playing the long game and helping people develop the functional abilities they need to stay healthy.
I love this quote from Emma Barnett who writes for the Telegraph, “Anyone attempting a quick fix, like I was (admittedly I was only giving it five minutes in the dark before bedtime) has missed the bigger, scarier point: why are so many of us living lives we feel unable to cope with? How is it that we are so unhappy with our lots that we will willingly sit cringing in a room with our colleagues while remembering to breathe? ” I guess this is the heart of what I’m trying to get at.
In summary, my view is that Mindfullness is a useful addition to the toolbox of a mental health professional, but in no way should it be replacing the more in depth interventions provided by OTs, Nurses and Psychologists. GPs should be referring people for treatment with us, not DIY websites and superficial classes run by someone probably called Daisy who thinks everything is lovely.
If I could change one thing about mental health (beyond the obvious of just chucking a big bag of money at it) it would be to eliminate all incidents of outcome bias in decision making forever. For those of you unfamiliar with the concept of outcome bias, it is a flaw in reasoning where the decision maker assumes that because a positive outcome resulted from the decision, that the reasoning by which he arrived at the decision is therefore correct. The reverse can also be true – because a negative outcome resulted from the decision, the decider assumes that the decision itself was a poor one.
Some silly examples for further clarity:
Scenario A – I am playing Blackjack where the goal is to get as close to a score of 21 as possible and any score over 21 results in the player losing. I draw 20 on my first two cards. Logic would dictate that I stand on 20 because the odds of drawing an ace are far lower than drawing all the other numbers (2 – 10). However on this occasion for whatever reason I decide to take another card and amazingly I manage to beat the odds and draw an ace. In the next hand I get 20 again and decide to draw another card because last time I did that and I won.
Scenario B – This time I’m playing basketball. I’m feeling like Lebron so I decide to stand 40 feet from the hoop, turn my back to it and shoot it over my shoulder with my non-dominant hand. The gods of basketball smile on me and it happens to go in, nothing but net, swish! I then decide to take ever other shot in the game that way because that time it went in.
Scenario C – I’m now in a restaurant. The chef feels like being experimental and puts four times the normal amount of salt into my dish. Lucky for him I happen to have a rare condition that means I like a really salty dinner and send him back a tip with my compliments. He then decides that this is the way he will cook from now on because he got that positive response from me.
Clearly in these situations I am now going to lose a lot of money on blackjack, I’m going to almost certainly miss every attempt at the basket and the chef in the restaurant is going to have a room full of unhappy customers. Just because it worked out well in each of these scenarios doesn’t mean the decision was a logical one to make.
Ok, so we’ve got the basic premise down and you’re probably thinking of your own absurd examples. Unfortunately outcome bias does seem to rear its ugly head in mental healthcare and sometimes has some pretty serious consequences. So lets take a look at some more tangible real life examples.
Example 1 – A new patient is referred to your low security rehab unit. He immediately strikes you as someone your unit isn’t typically accustomed to accepting. His risk profile is really high, he was recently restrained by several police officers for using improvised weapons and his current team feel that he is highly likely to continue to use violence to intimidate staff and achieve what he wants. However a year ago the management decided to take on another difficult, aggressive patient and it worked out just fine. This patient took to the unit well, responded to a change in medication and built good relationships with the therapy staff. So you should take this newly referred patient right? It worked out fine before. NO! That patient could just as easily have assaulted someone on his first day. What should influence the decision are the factors that relate to the person and the environment they are potentially coming to. Is he likely to be aggressive? – all the signs point to yes. Is your unit equipped, trained and staffed well enough to cope with that level of risk? If the answer is no then the unit should not accept the patient because the factors being considered point to you not being able to successfully manage the patient. The fact that the management took a gamble the first time and it happened to work out ok does not have any influence on whether it will be ok this time.
In this example they did end up admitting the patient and within less than a week he had seriously assaulted one of my colleagues and only a 999 call to the police was able to resolve the situation.
Example 2 – A patient currently living in the community has been frequently calling the local mental health team stating that she isn’t coping at home and needs more support. She is very distressed and has made several threats to take her own life. The community mental health visit her a few times but decide she doesn’t need hospital admission or any further intervention and refer her to her GP. They don’t hear from her for a while and everything seems to be going well. No issues there. She was appropriately assessed and at the time was not felt to need further treatment in the eyes of the people who saw her. However six months later her mental state declines seriously, she calls the CMHT and threatens to kill herself again. The team do not view her as a priority because she was alright without any significant intervention the first time and she is therefore only seen at the end of the day, by which time it is unfortunately too late. This isn’t pure outcome bias in the debating/philosophical sense, but clearly the outcome of a previous decision heavily influenced what the team did the second time around, with an awful consequence. Of course what should have happened is that each contact with the patient should have been considered on its own merit and the suicidal statement responded to far more promptly.
Example 3 – A patient had been on the rehab unit for two months and was felt to be stable enough to be granted some unescorted leave. However regrettably that patient went out the same day and did some cocaine resulting in a significant deterioration in mental state. The unit therefore made a blanket policy that no newly admitted patient can have unescorted leave because of this negative outcome in this patients case. However at the time the decision made perfect logical sense. He had engaged very well with both the Clinical Psychologist on site and the community addictions group, had given 3 clean urine drug screens each week since admission and had been clean for six months in his previous placement, had been compliant with medication, there were no signs that he was a threat to himself or others, and he had repeatedly demonstrated a positive attitude towards abstaining from substance misuse. The decision at the time was a reasonable one based on the best available evidence. The decision to create a blanket policy of no leave until the patient has been on site for six months is a good example of negative outcome bias but also flew in the face of all those important things like individualised/person centred care, evidence based practice and so on.
The intention of this blog post isn’t to be all doom and gloom or even to be overly critical of the people involved in the examples I’ve given but this is stuff that we need to be getting right for the sake of our patients. I understand why it happens. There’s a basic (if flawed) logic in thinking that if something worked before that if we do the same things again we’ll get the same positive result, or at least avoid a negative one. However the people we work with and the nature of what we do has so many complex, intricate and inter-related factors that it will be extremely rare for two situations to be exactly the same. Experience is a great teacher but we need to make sure we arrive at each decision we make by analysing all the information we have on its own merit, not letting outcomes from previous superficially similar cases unduly influence what we do. If in doubt ask yourself one question – Does my decision make pure logical sense on its own? If not and you feel yourself being drawn into doing “what worked before” then it could be time to go back and re-evaluate what you’re doing.
If you work in mental health (MH) services long enough you’ll eventually come into contact with the Police in one way or another. The context of their activities varies depending on the situation and client group you’re working with, but some typical situations they become involved with are:
- Picking up people with no prior mental health history who have become unwell to the extent they are a threat to themselves or others.
- Assisting staff on mental health wards when an existing patient becomes acutely unwell and is attacking others/property to the extent that they are unable to make effective use of physical interventions themselves.
- Finding patients who have absconded whilst under a section of the Mental Health Act and returning them to an appropriate location.
- Dealing with alleged assaults (patient vs staff, patient vs. patient and staff vs. patient).
Regrettably my experience of MH service and police interaction has not always been great. Initially this was from a pretty one sided perspective. I was angry that I’d been badly assaulted by a patient we all believed to be mentally stable and have full capacity and they refused to act on this. However as my thoughts on this have matured I have come to realise that this isn’t necessarily the fault of the police officers involved or even the wider Police service. On one hand I have observed significant problems on numerous occasions with the way MH services report issues and manage the behaviour of their service users (or not as the case may be!). On the other hand I have been involved in situations where the police were not especially helpful due to a lack of knowledge on mental health. As a result I have come up with ten points that will help the two services work together more effectively, 5 for the healthcare folks out there, 5 for the boys in blue, just to keep it nice and balanced.
Tips for the Mental Health Services
- Don’t be the staff who cries wolf. If we get the police out every time a patient sneezes at us aggressively or calls us a bad word then unfortunately the police are unlikely to come to our aid quickly when the $%£ really hits the fan. Manage the things you can manage without external intervention. At times patients will get angry, swear at and even threaten us. I am not saying this is ok by any means but we need to be resilient and reinforce behavioural boundaries ourselves. Of course serious threats by patients with violent histories should be taken seriously, but this is a far cry from the patient who is acutely psychotic and is talking about dropping nuclear bombs on the nursing office.
- Build good links with local police services. Get Police Community Support Officers (PCSOs) involved in your ward’s community meetings once every few months, connect with the local station if you’re having issues with drugs in the unit etc. The police can be a positive, pro-active element as well as reacting to emergency situations.
- Share knowledge. The police can’t be expected to know every aspect of every mental health disorder any more than we can be expected to know every law that might relate to our service user. Talk things through with them to ensure that both sides can make use of the other’s expertise.
- When you need to get the police involved make sure you have all the appropriate information available for them when they arrive. They will need to know why you have called them rather than dealing with it in house, the significant events that have taken place, who is involved, the mental state, communication needs and capacity of the people involved and what outcome you expect them to help you achieve. Unfortunately I’ve been in a few situations where the Police have turned up and the staff involved have been really unclear about what has happened, the timeline of events and so on. It’s embarrassing and unprofessional, as well as being really unhelpful for all involved.
- Don’t try to be the Police. Despite point 1, know your limitations. Physical intervention/restraint/de-escalation training will work to a point depending on the nature of your service, resources available and your relationship with the individual, but there may come a point where violent situations escalate to the point where police intervention is necessary. Don’t be the senior staff member who sees an acutely unwell, 6’4″ muscular patient with an extensive forensic history wielding a knife who says to two tiny HCAs in their 50s “Come on, you’ve had your PMVA training, in you go”. Equally you are not on CSI, The Bill, NCIS, (insert other police drama here). Record the salient points, people involved and timeline of the events that happen, preserve any obvious evidence (eg. leave patient room and clothing alone in event of rape allegation, keep any weapons used in an assault etc.) then let the police do whatever investigation you need to do. It is not our place to be conducting full scale investigations and going all Jack Bauer on the people in our care – “TELL ME WHAT YOU DID WITH THE OLANZAPINE DAMMIT!”.
Tips for Police Services
- Develop training for officers on mental health law and mental health needs. Some work on this has been done. This document is a good start http://www.acpo.police.uk/documents/edhr/2013/201312-edhr-police-mental-health.pdf and there is a lot of great stuff here as well: www.mentalhealthcop.wordpress.com but I believe it needs to be part of regular mandatory training for anyone who may come into contact with people with mental health needs.
- Treat 999/911/111 calls about mental health seriously and respond to them as any other emergency. This happens when the person involved is displaying dangerous behaviour towards themselves or others in the community, but unfortunately sometimes this is not the case if the patient is already in a mental health unit. Bar a few regrettable exceptions, if a mental health ward is calling for assistance it will be a significant event that is going on that requires a prompt response. At times I have experienced the view from police services that mental health units are a “place of safety” and the situation is therefore not an emergency. While this is usually the case, there are limits as to what can be managed in any given situation. Staff and patients in mental health units are members of the public with an equal right to protection when needed.
- There is a difference between a patient that is acutely unwell, experiencing active symptoms of mental illness and lacking capacity acting in an aggressive, dangerous or otherwise criminal manner and a patient who is lucid, mentally stable who then makes a wilful choice to hurt someone or commit a crime (often referred to as the “Mad or bad” conundrum). In situations where a crime has been committed there is a risk that the wrong assumptions can be made either way by both the mental health and police services. I am reliably informed that police who attend in the event of such situations are independent investigators of fact who present evidence to the prosecution service. These are the people that decide whether this is pursued, not the attending officers or the responsible clinician.
- Assess the situation and take sensible action that takes account of the patient’s risks and needs. I have seen little old ladies with dementia who have slapped a care assistant in a moment of confusion and fear cuffed up and hauled down the station, as well as a 25 year old lad battering a psychologist with an improvised weapon and threatening to attack others who the police deemed to warrant no further action. Clearly neither were an appropriate response under the circumstances.
- Get to know the MH services in your local “patch”. A medium secure unit for individuals with serious forensic histories is going to need a different response to an open residential service for young people with learning disabilities. Take the time to arrange a visit, meet with the staff and possibly the patients if appropriate and maybe even discuss opportunities for reciprocal training and professional development.
In this period of austerity and cuts to public services I cam imagine that both sides might be reading some of this and thinking “Leave it out mate, when are we going to get the time to build up these relationships when we’re struggling to maintain the basics of our roles”. I would suggest that this IS a basic aspect of our roles if we work in either service. There are problems with how people with mental illnesses, mental health services and police forces interact and it is only by making the effort to do something different that things will change for the better for the vulnerable people we all have a duty to safeguard.
I have been developing a system of assessing the independent living skills of services users and would welcome some feedback on what I have come up with for an initial assessment. The final version will be prettier, but the core idea behind it should be clear. The assessment would be completed by the patient with the support of ideally an OT and a Nurse. It was initially developed with adults with mental health needs in mind but could reasonably be applied to a wider audience.
If significant needs are identified in the initial assessment, then there are more in depth assessments that focus on each of the major skill areas identified (cooking, shopping, finance, personal care and travel). Alternatively care/treatment plans could be developed from this assessment directly.
Thoughts welcome from anyone working in healthcare, or those interested in supporting people with mental health needs.
I’ve been thinking a lot for the past few weeks about the mask we put on everytime we go to work. You know the mask I mean. The one that says “Hi, I’m the OT! Come and do cool things. It’ll be good for you!” like some sort of chirpy holiday rep. For many of us the mask holds tons of positive significance. We’re proud of what we do and rightfully so. We like being an OT and that’s fine.
It also holds value from a practical standpoint. It signifies professional identity and to some extent, without us saying a word it conveys something about the interactions we expect to have. It lets people know what we are there for as well as what behaviour is acceptable and what topics of conversation will be allowed – meaningful activity? Hell yeah! Scoring with that hot girl from the bar last night? No, no, no!”.
However the mask has also got a side that isn’t so easy to reconcile ourselves with and that has been the main focus of ponderings this week.
I enjoy my work 99% of the time. That being said there are plenty of times I wake up and think that I really can’t be arsed with work today. I’m not ashamed to admit that. When it’s 6AM, freezing cold outside and I have a 90 minute drive ahead of me to work with some very challenging service users who probably don’t want engage in treatment I don’t think that’s unreasonable. I’m human. Yet I still have to put on the therapy mask and be the guy who is enthusiastic and motivates people to do what they need to do to get better. Sometimes its really f%&ing hard to do so. We might have all kinds of personal stuff going on. We might be tired, or sick or just simply not in the mood for it, but still we put on the OT mask and for 8 hours per day our own energy levels and emotional state take a back seat to those of our clients. This is necessarily the case. If we started going in to work and having conversations with our mental health service users about the messy argument we had with our partners things would get out of hand pretty quickly. The boundaries are there for a reason. We can’t be burdening vulnerable people with our own emotional baggage. They have enough to be dealing with already and may even end up using that kind of stuff against us maliciously in an agitated moment.
I guess that’s what’s so hard about it. By putting on the OT mask we necessarily have to deny parts of ourselves to be effective professionals. Often the real core, human, feeling parts of who we are. Big parts of our own lives and role identities which ironically we are all about promoting within our patients.
That being said I think there is definitely room for re-evaluating where those boundaries lie. I think over their career each professional finds where their own line in the sand is when it comes to patient interactions. One of the best RMNs I have worked with was also the type of person to walk very close to that line. If we imagine a 1-10 scale where 1 is robotically safe and impersonal and 10 is jail time for extreme inappropriateness, this guy generally operated at a 7.2 most of the time. His patients loved him for it. He built rapport in an instant, put staff and colleagues at ease but made the tough calls and drew the line when he needed to. This very human approach, where the mask was allowed to slip so to speak, produced incredible outcomes for patients who were never expected to do too well.
One of my biggest irritations is the kind of professional that operates more towards the 1 end of the scale. Maybe even a 0.7. You know the type I mean. The kind who may as well be screaming “I’m the professional, you’re the sick person. Step back” with their attitude, demeanour and choice of outfit. They’re probably called something like Jennifer and insist on being called Jennifer by everyone, definitely not Jenny or Jen. The Jennys you work with are fun, laid back…may even let you get away with a cheeky, well intentioned flirt at the end of a tough shift. Jennifer is mean. But I digress!
I think there’s room to be a little more like 7.2 guy (let’s call him Pete) and a little less like Jennifer. It’s not rocket science – people respond better to people. Specifically people they can relate to and who they feel understand them, or if they don’t fully understand can at least empathise. I think it’s ok to drop your guard at times in a trusting therapeutic relationship. I recently had a great 1:1 with a patient where I disclosed that I struggled with a really tough time when I was around 19 – 20 and had felt depressed and suffered with really low self esteem. For whatever reason this really helped the person I was talking with. I think a part of it was he saw someone who had been low and made it out the other side and gone on to do alright. It doesn’t really matter. The point is that in this scenario an action that was perhaps a little closer to that ethical line than many would deem acceptable (and perhaps even regard as taking a few steps beyond it) was the most effective way to reach the service user. Some of the best “interventions” I’ve done in a mental health setting are just casually getting people talking about whatever shit telly was on the night before.
Another personal favourite was celebrating with a 24 year old patient when we were out in town who (in a feat of great self restraint) came to me and said “I’d love to bang that blonde over there” because three months ago he would have gone over and said that to her face in a really sexually aggressive and intimidating way. Little steps right?! Pete says “Well done mate! See talking about these kind of things with lads your own age or people you trust is pretty much ok”. Jennifer says “How dare you speak that way about a person?! Get back to the ward! Your leave is cancelled!”, completely missing the point that chatting about girls is a perfectly valid, age appropriate and meaningful occupation that she should be helping the man channel in the right way i.e. making it clear when it is socially acceptable, when it is not and promoting an appropriate level of respect for women.
So I guess what I am saying is that I accept that the Therapist Mask is necessary for the protection of ourselves as professionals and for our service users, but what we need to be doing is allowing our humanity to be in the driving seat in our interactions with patients. We are people before we are therapists. We got into this profession because we care and want to help. Welcome and go with those impulses to connect with people on that real, human level. You’ll feel if its getting too close to that line I’ve been on about and will correct yourself as necessary. Building those beautiful therapeutic relationships may even help you keep putting on the buzzing, enthusiastic OT mask on one cold January morning when you really can’t be bothered to get people excited about your cooking skills group. I didn’t always agree with Pete and on rare occasions he took it a step too far in my view, but I’d rather be a Pete any day of the week than a Jennifer.
Have a great weekend,
P.S. Where would you place yourself on that 1-10 scale right now? Personally I think I started my career at a 7 and have probably scaled it back a little to a 6 these days. Let me know in the comments below on our facebook page https://www.facebook.com/OTZebra?ref=aymt_homepage_panel
I’ve been mulling over various articles on gender and race privilege over the last few days. Everything from the major news events like the white on black police brutality in the US and subjugation of women in certain nations to the relatively trivial like the Azealia Banks/Iggy Azalea beef where Banks is…
“… particularly upset that Iggy Azalea was nominated for Best Rap Album at the Grammys. “The Grammys are supposed to be awards for artistic excellence… Iggy Azalea’s not excellent,” Banks said. “When they give these Grammys out, all it says to white kids is, ‘You’re great. You’re amazing. You can do whatever you put your mind to.’ And it says to black kids, ‘You don’t have s***. You don’t own s***, not even the s*** you created yourself.’ And it makes me upset.” “At the very f***ing least, y’all owe me the right to my identity. That’s all we’re holding on to in hip-hop and rap.” (Telegraph)
I guess it struck a chord with me because I am white male who has advanced quicker than might be expected in the profession of Occupational Therapy. It got me wondering to what extent gender and racial privileges exist within our profession. Now I’m a decent Occupational Therapist, I’m not being self-deprecating here and hopefully not indulging too much in the social media trend of humble-bragging, but I am the first to admit that I have probably got promotions and been successful at interviews at the expense of colleagues who I know are almost certainly more motivated, dynamic, intelligent and just generally better at the job than me.
Did the fact that I’m a guy play a part in this? If so was it because there’s an ulterior motive in OT to encourage more men into what remains a female dominated profession? Is it because I have traits that are often viewed as more classically male like; ambition, self-promotion, competitiveness and these serve me well as I’ve BS’d my way through standard face to face interviews that are themselves a male created HR system.
Did I get promoted to my current role partially because I’m white and the position is in a Nigerian, Ghanain and Jamaican dominated area of London, and the staff are 95% of BME groups in a kind of positive discrimination way?
I’m not sure. I think maybe there’s been an element of both at play that has elevated me beyond my level of competency. That doesn’t sit especially well with me and I’m not sure what to do with it. I’d love to think that everything I have achieved is on merit but I’m not blind to the fact that there may have been other forces at play. Am I the OT equivalent of Iggy Azalea in the rap game? She’s alright, she’s competent… she’s certainly no Dre, 50 Cent, Lil Kim or Mary J and yet is supposedly selling tons off the back of being more marketable because people evidently want to buy hip hop tracks put out by a white girl. It’s an uncomfortable comparison.
One of my friends shared this article with me http://whatever.scalzi.com/2012/05/15/straight-white-male-the-lowest-difficulty-setting-there-is/ . The salient point is that if life were a video game and we were picking settings at the start, then straight, white, able bodied male is the easiest setting. I don’t dispute that at all and I think it would be hard to do so. What I struggle with is that when my parents booted up this “Life” video game I got no choice in the fact that they selected easy mode or that the game developers made my character class unbalanced and OP (overpowered in relation to other choices for you non gamers). How am I supposed to react to that? Should I just chuck the Longsword of Swift Professional Advancement +5 in the bin and impose a set of self developed restrictions as some hardcore gamers do? That seems a bizarre and self-destructive way for an individual to live in the wider society that created these morally unappealing imbalances. Is it hypocritical to be passionate about challenging injustices when I have thrived, at least partially because of other ones? I think I’m leading myself into a very twisty ethical maze that I am ill equipped to navigate so I will draw this post to a close.
I would be genuinely interested to hear if others have similar experiences of race/gender privilege in the OT profession, whether you’ve felt an advantage or disadvantage. Or maybe I’m talking nonsense and our profession is above such things (I suspect it isn’t). Regardless I’d like to hear your thoughts.
I wrote in bits of the last post about not getting sucked into generic practice and embracing your true OT colours. This time I want to take it in the opposite direction.
I was reflecting on the major tasks I completed last week and I was actually quite proud of the work I’d done with patients at the mental health hospital I work at. Here’s a summary:
- Monday – Met with the staff team of a residential service who are considering accepting one of our patients but are a bit nervous and needed some reassurance about how best to manage her mental health needs.
- Tuesday – Mostly sat in ward round and CPA meetings. Gave the occasional bit of feedback about engagement in OT, but the biggest issues we discussed were around leave and behaviours.
- Wednesday – Took a patient to spend the day at a potential new placement. He was super nervous about moving on because he’s been in the system for years and was also worried about being able to resist the temptation to use street drugs. I helped reassure him and reminded him of the strategies he has used to stay clean.
- Thursday – Worked at home putting together CPA reports and typing up supervision logs.
- Friday – Probably the most OT-like day. Did some computer literacy stuff with a patient who wants to increase her skills. However the biggest amount of time was spent planning training for the care assistants on autism.
Was it the most profession specific, occupationally focused week? No. Did I help people? Definitely. I was probably functioning more as a generic care-coordinator/ward manager than an OT, but the work I did mattered. I helped two patients have hope for the first time that they might be able to live more independently in the community, I offered general clinical reasoning in our MDT meeting and came up with risk management strategies that will allow several patients to spend Christmas with their families, and I planned training that will reduce the distress caused to patients by staff who (through no fault of their own and purely due to inexperience) sometimes don’t always interact with autistic patients in the most helpful of ways. I’m not saying this to be all “Look at me, I win at healthcare”, I’m just coming to terms with the fact that sometimes it’s ok and even the most productive thing to do to embrace the “Healthcare Professional” role, rather than the “Occupational Therapist” role.
A few years ago I’d have kicked off at having to complete such tasks and getting away from my training to such a significant extent. I was influenced by OT practice educators who continuously harped on about keeping my OT world-view and even the occasional lecturer who arrogantly asserted the primacy of OT above other healthcare professions (“RMNs? Psychologists? Eww!”) I’ve also come across so many narrow minded OTs who think that if they step one little toe outside of their OT box that the world will end. OTs like that usually end up being viewed as inflexible and naive to the functioning of modern healthcare environments, as well as not effectively meeting the needs of their patients.
What I have come to realise is that Occupational Therapy is simply one lens through which you can conceptualise a patient’s needs. Sometimes its an amazing lens that helps us really hone in on what matters to people and helps us enable them to construct the lifestyle they want. Sometimes a more psychologically oriented approach that focuses on behaviour and motivation makes the most difference. Sometimes a patient is simply trying to batter the staff because they haven’t taken their meds in four days. Sometimes a very basic, caring, human approach that is aligned to no specific profession is the way forward – “Come on bruv, let’s sit down and talk it through”.
Of course everyone on an MDT brings unique skills and these should be celebrated and fully utilised. However as my skills have developed and my perceptions have changed I now find patient outcomes are often best when we just take the professional ego out of the equation, look at what people’s core needs are and assign the right person or people to work with them. Is it a lack of occupational balance and limited roles, is it medication compliance issues, is it unresolved childhood abuse history, is it sexually inappropriate behaviour, is it a lack of ADL skills, is it housing or placement issues etc. etc. etc. Some of those I’m gonna step up and say “Yeah, OT got this.” Some of those I’m gonna take step back and say “Alright RMN Dave, do your thing” and some of those I’m gonna say “Alright Psychology Bob I’m not getting anywhere with person X on issue Y, can you give me some ideas on how we can do something different to make this work.”
When presented with the options of flogging the dead horse of a clinically reasoned, complex, high level OT intervention that has proven ineffective or doing something more generic that actually helps someone, which is the more ethically correct choice? For me the answer is clear.
To finish off, as I grew into adulthood and had to start making education and careers choices, all I knew at the time was that I was interested in how people think and why they do things, and that I wanted to help people. If the OT based skills I learned allow me to do that – brilliant. If I can more effectively help someone because I just happen to know a bunch of stuff about mental health, or because I relate to someone well because we play the same video games, or because I can figure out a way for them to live safely in the community – then that is absolutely fine as well.
So Occupational Therapy is pretty weird right? We work in all sorts of different fields; everything from kids with physical disabilities to end of life care for older adults with schizophrenia. Our training and the core principles of what we do, while revolutionary, thought provoking, philosophical and seemingly infinite in their scope can by their very nature leave graduates and experienced professionals alike a bit puzzled about where we fit in with everyone else and what we should be doing once we’re out in the big wide world.
The same is even more true for the non-OTs out there. A lot of people aren’t too sure what we’re all about. To begin the metaphor, they are looking around the great big African plains of healthcare, education etc. and thinking “Ok, we’re on the savannah, everything is in nice neutral earthy colours, pale greens, browns, dusty yellows and that. Oh look, here are some animals that fit in perfectly with their surroundings – an awesome, powerful sandy Lion, some brilliantly camouflaged Meerkats dashing about all over the place, a cheetah stalking in the long dry grass with its patterned fur perfectly breaking up its profile. This is all fine. This is nice. This fits in perfectly with my world view and concept of how things should be… wait a minute, hold the phone. What the f%^$ is that weird stripey black and white thing over there?! Well I’m not too sure about that! Is this allowed? It doesn’t look like it fits in with any of the other animals, on the face of it it doesn’t look like it’s particularly well suited to its environment… this makes no sense!”
If as an OT you take nothing else away from this blog post, let it be this – IT IS OK TO BE THAT ZEBRA.
Sure, at first people are a bit confused and may resist our input because we don’t fit in with traditional models of healthcare, vocational support or education. We’re not the obvious choice of Doctor, Nurse, or Teacher (Lion, Meerkat etc.), but that’s fine. I say let’s not stress ourselves out about that. The world will catch up eventually. In fact I say let’s take it to another level. Don’t feel shame and embarrassment about being that Zebra, revel in it! Here are some ways Occupational Therapists can channel their professional spirit animal and not only be more comfortable in their own skin but also be more effective practitioners:
- Zebras, more than almost any other animal stand out in their environment. Embrace that! People will from time to time think your perspective or proposed action is weird. “What do you mean you want to take that patient with extreme social anxiety and borderline agoraphobia to the beach where there are tons of people and way too much going on?!” Be prepared to stand strong and defend your proposal with whatever perfectly valid clinical reasoning made you come up with it. Maybe going to the beach has massive positive significance and meaning for this individual. Maybe you plan to get the family involved as a social support in a way that acts as a protective factor against the social anxiety. Maybe you’re at the stage where that person needs to take the first step and reengaging with a summer occupation that they used to value soooo much and desperately wish they could still do is a highly motivating factor. Whatever the reasons might be, Zebra it out in your MDT meetings, stand up for this seemingly wacky idea and help people see it from your perspective.
- Zebra’s work best when they work as a community. One of the real reasons Zebra’s apparently rubbish camouflage works is because the bold, contrasting stripes make it difficult for predators to pick out individuals in groups. Beginning to stretch the analogy somewhat here, but do the same. Learn from other OTs. Learn from your supervisor, learn from your OT assistant, learn from established practice and what the wider OT community is doing.
- Having said that, individual Zebra are well known for doing things that seem bizarre to the rest of their herd. One of the great things about OT is that it attracts people who think outside the box and can see different ways of doing things. So OT Zebra A might turn to OT Zebra B and say “Why on earth is OT Zebra C rolling around in the dust for no reason? This guy is few lions short of a pride” but ultimately OT Zebra C has the last laugh because he’s just used the dust to protect himself from pests and parasites. Pretty soon OTZ A and B are following suit and celebrating OTZ C’s emergent practice as an inspired bit of thinking.
- You’re a Zebra, not a Lion, Snake or Meerkat. You’re not built for chasing antelope around and chomping down on them, or climbing up trees or digging little tunnel networks. Don’t get sucked into generic practices or worse still the professional roles of other people you work with. We are trained as OTs and that is what we should be doing. If we start getting away from that at best we’re not utilising our training and skills effectively, at worst we’re taking on stuff we’re not equipped to do and potentially being a danger to our service users. In physical health settings it’s often the blurring of the line between OT and Physio, in mental health settings between OT and Psychology. Be a Zebra – run about with your mates, eat grass and stuff – hunting and tunnel networks aren’t for you.
- Zebra’s aren’t worried about being Zebra’s and justifying their existence. One of the biggest difficulties I’ve come across (and had myself at times) is having confidence in my contribution as a professional. What do I bring to the table? How do I know it works? Pretty standard for OTs to feel this way at times. Medical staff work towards the correct diagnosis and treatment and if it works people get better. With Teachers if they do a decent job students learn and get decent exam results. Our results will almost always be less tangible. That’s not to say we can’t demonstrate good outcomes however. Now I’m going to keep it real, there’s a lot of really naff OT “evidence” out there that has been born out of desperation to justify our place in the world. You know what I’m talking about, the kind of article that has a sample size of four and a half people (and one of those people was the author’s dog). Any OT Blog or text book will give you the standard advice about demonstrating value – know your service type, it’s core aims and how you will demonstrate that these are being achieved. For me, working in a mental health rehabilitation hospital, it’s generally about two major things; A) patients being more active throughout the day and reengaging with the stuff that was important to them and B) developing or reestablishing the skills they will need to live independently. Both of these are pretty straight forward to quantify using recognised outcome measures like COPM, MOHOST, ILSA-R and so on.Yawn – I’m boring myself already writing about all that. What I want people to take away from this post is Zebra attitude. Once you’ve got your outcome measures sorted, quit worrying about whether people respect you or think your work is important. Know that it is. Walk around your facility knowing that you make a difference for people. All the time we’re exuding uncertainty and trying to justify ourselves through research with titles that may as well scream “OT is good for people! Really it is! Please believe me! Pleeeeease!” then we’re only perpetuating our own sense of professional inadequacy and projecting that onto the other professionals we work with. IT IS NO LONGER A QUESTION. We’re not in the 70’s anymore people. OT is recognised. OT works for people. It’s enshrined in legislation and guidance as being a core role that most MDTs should have. So make like the Zebra – stand out on the savannah tall and proud with a attitude that says “I’m here, I’m black, white and stripey, deal with it”.
So there you go. Not only are Zebras awesome, if you’re an OT you can base your work on their unique look and distinctive behaviour. Who knew?! I’d love to hear what people think about this idea. Did you totally get what I was on about and you’re now ready to Zebra about in the workplace? Do you think I’m talking absolute nonsense? Do you connect more with another animal? I have no objection to OT-Dolphins, OT-Hippos. This is not a speciesist blog. Whatever works for you. Although let’s hold off on the OT-Cat, the internet is already run by cats these days. Enough is enough yeah?