7 (More) Things I Want Mental Health Professionals to Know
Two years ago, I wrote an article about the 12 things I wanted mental health professionals to know. This was published just as I was starting my job in a CAMHS (Child and Adolescent Mental Health Services) inpatient unit, where I still work to this day. Over the past two years, I’ve gained insight into the ideal standards of care that I presented in the days where I only knew the inpatient system as a patient, with no clue what the reality of working on an inpatient unit was really like.
With two years of experience as a staff member, I have learned so much, both positive and negative, and I feel this is important to share. So, let’s start by reverting to my previous ideologies and facing the cold, hard, truth of the three out of 12 things I have discovered are not always feasible, but also how I’ve learned to manage these challenges.
1. Treat every person equally, with dignity and respect.
This is something we all strive to do, and on the dignity and respect front, is always fulfilled. However, as I mentioned in my first article, you will have favorites. Unfortunately, patients do recognize who you like better, and even worse, recognize when you don’t appear to like them. If they mention this, it can most often be resolved by having a 1:1 chat with them and talking through the difficulties in your therapeutic relationship, making it clear that you do not dislike them as a person, but may just have difficulties managing their behavior which causes frustration, or you just don’t know how to get through to them. Honesty is key here, and can repair a therapeutic relationship, and build one stronger than you thought possible.
4. Don’t take anything personally.
OK, at the end of the day, you’re already working in a high-stress environment, so when a patient says or does something that upsets you, sometimes you will take it personally. The best way to deal with this is to debrief with your colleagues. And, more often than not, if they recognize it, the patient will apologize for whatever they’ve said or done that’s upset you. If they don’t, you’re allowed to be upset, and if they ask if you’re upset/annoyed with them, you’re allowed to broach the situation with them and tell them that you’re unhappy about what they said/how they behaved, because as I will continue to say until I’m blue in the face, patients are people, and should be treated as such.
11. Your patients need to know you believe in them.
The brutal reality of this is that for some, you may not see them leaving the hospital and becoming productive members of society. This is rare, but it is a fact. However, this doesn’t mean you shouldn’t support them in creating goals and encourage them to use the skills they are being taught and to focus on their future and their recovery. When a team gives up on a patient, they are essentially creating a self-fulfilling prophecy, wherein that patient will most likely give up on themselves. No matter what you believe, you must still try your hardest to instill positive self-beliefs within them — this may not make a difference, but it also might. You never know.
Years after leaving the hospital, I have found out from staff members that few of them expected me to survive post-discharge, some of these being the ones who provided me with the most support and encouragement I had ever received. Towards the end of my therapy with CAMHS, my therapist told me that if she found out that I had ended my life, she would be devastated, but not surprised in the slightest.
Thankfully, these comments came at a time where I was relatively stable and had accepted the fact that I was alive and would stay that way, but it was still a shock. But if I had heard that at my lowest point, I don’t know if I’d have been able to get through it. Yes, I was told some pretty god damn disheartening things whilst I was an inpatient, but those words were of a different nature, said with spite and disdain, from people who made it evident they did not like me. I was so detached from myself and the world around me, and so consumed with rage, I took that despair and anger out on them, not myself. And then, I turned my anger into determination and proved those fuckers wrong.
I still stand by the nine other points made in “12 Things I Want Mental Health Professionals to Know,” and I try my hardest to overcome the challenges faced by the three aforementioned points. And, after two years on the dark side, I have learned more, or at least confirmed a fair few of my suspicions.
1. Don’t throw a pity party.
Let your patients be upset. Listen to them and remain non-judgmental. Whilst it is important to feel, acknowledge and express difficult emotions, dwelling on the problem for too long and letting them continue to ruminate on it, is not helpful. If they’re ready to hear solutions, offer suggestions to implement a practical plan to deal with the issue at hand. If it is a fear or worry that cannot be resolved with practicalities, validate their feelings and try to help them to come up with ways to manage these difficult feelings, for example by asking what skills they have been taught in therapy and encouraging them to use these, or by using self-soothing techniques, or by distracting themselves. If it is a problem that cannot simply be “fixed,” listen to them, support them and show them that you care. If the conversation starts going around in circles, try and distract them. Try to move the conversation in a different direction without invalidating their feelings. You should neither join in with or throw them a pity party. The kitchen won’t bring up a cake, and balloons are restricted items, so it would be a pretty crap party anyway. Try to offer practical or emotional support and help them to address the issue, rather than dwelling on it.
2. Patients are watching you as closely as you are watching them.
Now, this is something I knew as a patient but terrifies me as a staff member. Your job entails observing your patients to ensure any risk is minimized and they are kept safe. But, your patients are watching you too. They may not have an observation sheet or a referral, but they have a near-constant awareness of your competence, concentration and experience. It’s like a twisted version of “I spy.” No matter how calm things appear, always remain aware. Never let your guard down and don’t underestimate them. If you’re not sure about something, check with a nurse or on the system.
3. Listen to understand and learn.
When a patient opens up to you about anything, be it their past or the fact that they support puppy farms, don’t argue, blame or make them feel ashamed. It’s already hard enough for them to open up to someone, so don’t make them regret it by making them feel worse. Don’t assume you know how they are feeling, because you probably don’t. Don’t tell them you know how they feel, because even if you do, you cannot tell them why. Sometimes they may know that you have an understanding of how they are feeling in that moment; they may have seen scars on your arms, noticed that you have a heightened awareness or understanding of their situation or found your puppy farm website. But that understanding should remain unspoken, or, if they bring it up, your answer should be vague, non-committal and include something along the lines of, “You know that we cannot disclose personal information.” Puppy farms and arm decorations aside, you should also pay very close attention to what they are saying, as they may drop bits of information into a conversation because they don’t know how to, or don’t feel comfortable addressing the matter directly, they also may not think it is significant. They may also be testing you to see if you are really paying attention.
If whatever they may drop into said conversation is considered a safeguarding issue (e.g. bullying, abuse of any kind either perpetrated, experienced or witnessed by them, drug use, social media concerns etc), there are a number of essential things you must do. Firstly, you must tell them that you will have to pass this information on to the safeguarding team (the hospital social workers) and you should explain why this is and what this will entail. You should then ask if they are happy to continue talking about the matter but make it clear that even if they say no more, you will still have to raise the information as safeguarding.
Secondly, whilst you can gently see if they’re willing to disclose more — for example, by asking if there is anything else they want to share, you must not ask leading questions — for example, if they have said, “Grandpa did something bad and then my goldfish Timothy died,” asking, “Did your grandfather run over your Timothy with his car?” would not be an appropriate question. A more appropriate question would be, “Do you feel able to tell me what your grandpa did that was bad?” or “Can you tell me what exactly happened to Timothy?”
Finally, and most importantly, you must respect their boundaries. Do not pressure them into speaking about something they are not ready to as this will often do more harm than good. They will open up if and when they feel comfortable to do so. Safeguarding matters are usually far more serious than the demise of a goldfish, regardless of whether Grandpa played a role in this or not. Most things that are escalated to safeguarding are things that have made the young person feel unsafe, out of control, uncomfortable, pressured and scared. Do not add to this feeling by making it seem like they absolutely have to tell you what has happened. Make it clear that it is their choice to disclose or not disclose any information. Do not lie to them and tell them you will keep it a secret, and absolutely do not tell them you will keep it a secret and follow through on that promise. Be transparent from the moment you realize they are saying something that needs to be escalated and be honest.
5. Respect is a two-way street.
For the most part, patients will treat you as you treat them. And it is you, the healthcare worker, who must earn that initial respect — not the patient. Think about it this way; they have been removed from their home and family. They have been deprived of their liberty. They are surrounded by strangers and are intensely unwell. Why would they instantly trust, or respect you? You must earn their respect to earn their trust… treat them with dignity, be kind. Do little things like asking them if they prefer their door left open or shut during checks. When you check on them, ask if they need anything, ask how they are, ask if (during the day) would they prefer to be observed via the window panel (if you can clearly see them this way) and not disturbed, or if they would like you to open the door and ask how they are — they have very little choice or say in their lives at this moment, and from a personal perspective, something as small as that can make a huge difference. Greet them by name and ask them about their day every shift, without fail, even if the response is constantly the standard “I’m fine.” This is how you begin to earn their trust and respect. By showing that you are willing to identify, acknowledge and respect the few choices they initially have. I have found this is to be the beginnings of the therapeutic relationship between HCAs and patients. From the perspective of an ex-patient and a current staff member. By showing respect you earn trust, and with that trust, they may start to open up, they may listen to suggestions of coping mechanisms and try them, and maybe, if you show enough genuine faith in them, as someone they trust and respect, they may begin to believe you and start to have some faith in themselves.
6. Patients do care about staff.
If you are kind, genuine, caring and trustworthy, in all likelihood, your patients will care about you just as much as you care about them. They will sense when something is wrong, and they will be concerned — and will probably express that concern. Psychiatric patients are some of the most genuinely caring and empathetic people you will ever meet, but this can be masked by what they’re going through. I have had my knee kicked in once, and due to my not so subtle explosion of expletives, it was pretty obvious I’d been injured, but I had to stay for a few hours after to get the paperwork done. Once the patient who had done the kicking in of said knee had calmed down and realized what had happened, she was distraught.
I’ve also been on the ward after obviously crying (I’m an ugly crier and whilst my mascara is waterproof, my glitter is not) and have had patients ask what was wrong/if I was OK seeming genuinely concerned. Boundaries are no match for human nature. Obviously sharing your problems with patients and using them as a source of support is entirely inappropriate, but you cannot suppress peoples instincts. Many mental health patients wish to work in mental health or healthcare in the future. Their instinctive, caring nature, combined with the supportive and positive care they received in their past, will, in the future lead to change in the healthcare sector. It will improve clinical practice, patient care and increase positive outcomes. There is no better person to work in mental health than one that has survived their own mental health issues.
7. It’s OK to not be OK.
Something I have learnt in my journey as a healthcare assistant is that you don’t always have to pretend that you are OK. This doesn’t mean telling your patients that your cat got run over by a steamroller, then a colleague called you a fat hairy turnip in the WhatsApp group chat or that your boyfriend threw a whole salmon at you, so you had a shower, but when you got out, you fell over and wet yourself in your towel, and that’s why you are upset. Basically, you don’t tell them why you’re upset, but if, for example, you’ve just been crying, and it’s obvious that you have, and a patient asks if you’ve been crying, or if you’re OK, it’s OK to be honest — just be vague. You can say something along the lines of, “Yeah, I had a little cry, but I spoke to someone and I’m feeling a lot better now” or “I’m not having a great day, but I know it’ll pass.” This teaches them that in real life, people get upset but it is not the end of the world and that it is OK to admit that you are not OK. It’s not healthy to suppress our emotions, so why should we put on a constant façade of false happiness and act like we don’t know the meaning of a bad day? I’m not saying you should start sobbing in front of your patients and blowing your nose on their pillowcase, or that you should tell them about your piss-soaked towel from the aforementioned salmon incident — you should definitely avoid both of those things at all costs. But, every now and again, it’s OK to drop the “everything is brilliant and I’m always happy and when I shit glitter comes out even though I haven’t eaten glitter since I was 6 and also sometimes small woodland creatures help me with my housework and brush my hair whilst I sing about how perfect my life is” act.
I intend on spending many more years working in CAMHS and will undeniably learn so much more in the next year I spend as an HCA and even more once I start training to be a nurse. I hope that, throughout this time, with a combination of my personal and professional experiences, I can continue to share what I can about what I have seen and know to be best practice within CAMHS, and that this is no longer ideological standards, but becomes standard practice throughout the country.
Getty image via dickcraft