The Guide 13: Delusions part 1

As I think back over my training as a psychiatric nurse I am struck as much by the things we weren’t taught as by the things we were. Information that now seems absolutely vital for mental health nurses to know never even warranted a mention whilst hour upon hour was devoted to the almost religious doctrines of psychiatric classification. We’ve already discussed the limits of classification in the section on diagnosis and I won’t repeat the argument here.

One omission was the relationship between hallucinations, illusions and delusions. Had this been made clear even once during our three years of pre-registration training my fellow students and I might have had a fighting chance of dealing with psychosis. So might our patients.

Instead the three primary signs of psychosis (hallucinations, delusions and thought disorders) were always presented separately as though they had not and never could have any relationship to each other. I hope to show that they not only can be related but that they almost inevitably must be in any problematic psychosis.

I’m specifying ‘problematic’ because, let’s face it, hallucinations without accompanying delusions or cognitive difficulties aren’t going to cause any problems anyway. There are many people who experience hallucinations without having any problems but they’re not my patients and they’re probably not your service-users either.

To make the relationship clear I need to start by talking briefly about hallucinations and also ‘illusions’.

As we have already seen an hallucination is a sensory experience that is not actually caused by an external stimulus. To put it more simply the smell you smell isn’t real, the vision you see isn’t actually the result of light hitting your retina and no sound waves move through the air around you to produce the voice you hear. Hallucinations really are your senses playing tricks on you.

Illusions are different. They are misinterpretations of sensory evidence but they are based upon real external events. When we imagine a face in the shadows it’s not an hallucination because there really is a shadow. We’ve just misinterpreted what we see. However that doesn’t mean that illusions don’t matter – they very clearly do.

So how does this relate to delusions?

The standard medical definition of a delusion is

“A fixed, false belief, not amenable to reason”

A delusion is more than just a vague idea or a half-considered opinion. It’s entrenched and hard to shift. Modern therapeutic protocols have shown that it is possible to reason around (and through) delusions but that doesn’t mean that it isn’t difficult. That’s precisely why delusions are so problematic – because they are so strong.

Ask yourself a question ….

If a person lives in terror because of a delusional belief that the Mafia plans to murder them does it really make a difference to their quality of life if the belief is based upon an illusion (they mistook a stranger for a hit man) or an hallucination (they heard the voice of a Mafia boss ordering the ‘hit’)?

The terror is the same in either case and the delusion will be equally hard to shift.

Here’s another question….

When mental health professionals distinguish between hallucinations and illusions can they always be sure? If I wasn’t there and didn’t see the face at the window can I really distinguish between:

  • Hallucination;
  • Illusion;
  • Actual face of a real stalker?

The experience is the same whatever the cause. The person is still frightened and their belief is identical.

Why does this matter?

We can see that in both cases (illusion or hallucination) people’s beliefs spring from their perception. For example…

For example, antipsychotic medication sometimes (less often these days) creates problems with involuntary movement. People experiencing these side effects sometimes develop ‘delusions of automatism’ where they believe that their bodies are being controlled by others. It could be argued that this ‘delusion’ might be dealt with very easily by making sure that the person concerned knew the true, chemical cause of their problem. Then they wouldn’t need to find alternative explanations.

This point will become important later when we discuss ‘evidence’ and ‘explanation finding’ with people experiencing delusions.

A young man who sees images of demons in the embers of a camp fire will be no less terrified than if he heard Satan’s voice promising to steal his soul.

A woman I once worked with experienced ‘hallucinations’ of a spiritual monk walking around her flat. She interpreted this as a bad omen foretelling disaster for herself or for her family. She was terrified. As it turned out this ‘hallucination’ was actually an ‘illusion’ caused by shadows in her flat and a slight visual problem that needed ophthalmic treatment. Yet it was diagnosed as an hallucination simply because nobody had bothered to investigate other possibilities. These are all firm, distressing delusions based upon the evidence of the senses. The key is interpretation. This is also the key to dealing with them.

If we can help people to reinterpret their sensory experiences then we can help them to deal with many forms of delusions – but not with all of them. Not all delusions come from misinterpretation of sensory evidence but an awful lot of them do. Enough to warrant proper understanding of the link before workers are ‘let loose’ on delusional people.

In the future we’ll consider ways to help people overcome their delusions and distress. We’ll look at the power of attribution and the meaning of recovery. We’ll get into ‘delusional mood’ and ‘selective abstraction’ as well as the principles of real world experimentation. But they’re for later in the series.

Next we’ll cover delusions that seem not to be based upon sensory evidence but rather upon a form of ‘sequential reasoning’ or even ‘wishful thinking’. These delusions may not be pleasant but they do tend to serve a purpose and often that’s as much about self-preservation as it is about anything else.

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Course design 13: Take the time to tell the tale

The following is the text of an article I first wrote for ‘Local government Lawyer’ magazine. You can find it online here:

“Lessons in law      

Thursday, 23 June 2011

The right approach to training in health and social care law can make a world of difference, writes Stuart Sorensen.

The abuse of vulnerable adults at Winterbourne View Hospital was extreme, dramatic and horrific. That’s presumably why Panorama chose to investigate it and why it has received so much attention from both press and public. Many bloggers have jumped on the scandal to make a point, some moral and some procedural. I have done as much myself. Several of us have taken the opportunity to write about specific legal issues from the Mental Capacity Act and the Deprivation of Liberty Safeguards to the Mental Health Act and the European Convention on Human Rights. It’s always helpful to have a topical ‘angle’ to focus upon when discussing law.

Unfortunately though this sort of blogging often becomes an exercise in futility. Those people who are interested in matters of law will most likely already be familiar with the principles discussed, or at least know how to find out about them. Those who are not, who simply want to know more about the human drama unfolding as a result of the programme will simply ignore the legal stuff in favour of more lurid pieces. For many the very thought of trying to understand legal concepts conjures up images of dusty textbooks and overly complicated jargon that might as well be written in a foreign language. There’s a perception of inaccessibility that discourages many people from even trying to understand. That’s where I come in.

I’m not a lawyer – I’m a nurse. A mental health nurse to be exact. I’m also a trainer. Oh yes – and I’m a bit of a geek with a passion for law. Well, everybody needs a hobby.

So it’s not too surprising that I regularly find myself training nurses, care workers, social workers, doctors and even police officers on health and social care law related issues. I must have trained tens of thousands of people over the years on topics such as the Mental Capacity Act, the Deprivation of Liberty Safeguards, the Safeguarding Vulnerable Groups Act and its Scottish equivalents the Protection of Vulnerable Groups (Scotland) Act and the Adult Support and Protection (Scotland) Act. Does that make me an international trainer? I doubt it but a nurse can dream.

During these sessions one theme is almost constant. People come into the training expecting to be bored. They also expect to be confused by a topic that they will not be able to relate to and that has little or nothing to do with their everyday experience. Not the best starting place for a jobbing trainer like me.

The problem is that many legal trainers have never taken the time to understand how health and social care workers learn. We’re different from lawyers – at least I think we are. There are many ways to think about learning styles and personality types and generalisations can be misleading but here goes anyway. In my experience health and social care staff from support workers to social workers tend to be more or less ‘top down’ learners. If the training was a jigsaw they’d like to see the picture on the box before they even start to look at the individual pieces.

Introducing care professionals to the minutiae of doctrine has its place but not until they understand the broad picture – the background and purpose of the particular act and how it relates to their work on a day to day basis. These people are not lawyers, they don’t generally think like lawyers and very often they don’t even start with the basic point that the law can help and protect them.

There is a culture of resentment in health and social care, especially regarding mental capacity, rights and safeguarding legislation. It’s not because people would prefer to be abusive – it’s because they don’t understand the law well enough to realise how positive it can be. So we begin with the basics, the purpose, the background and the scope. And we do it through story. This allows us to pull out the basic principles that we will rely upon and return to throughout the rest of the training. It sets up a basic foundation, the ‘picture on the box’ and gives participants the confidence to engage without fear of looking ‘stupid’.

Care workers tend to be ‘hands on’ people. We don’t usually ‘do’ abstract nearly so well as we ‘do’ tangible. That’s not to suggest that we’re not capable, far from it. But tangible is the ‘default’. As a rule we work with people and we get involved in the narrative of their lives. That’s what we do. It’s also how we learn.

So for Safeguarding we begin with Soham and with Miss X. For the Mental Capacity Act we tell the Bournewood story and from this month DoLS training will start with Hillingdon and the ‘Neary case’. By using narrative right from the start we draw people into a world that they’re already familiar with. By asking questions throughout the stories we begin to relate legal constructs to everyday scenarios:

What should the social worker have done?

How should the care worker react?

Is this good practice? If not, why not?

Before they realise it the participants have gone from work to law without a hiccup. This is the value of narrative. From stories and case studies to participants’ own experiences and even newspaper headlines, stories work. Stories are memorable, stories are accessible and stories help people to ‘grock’, to assimilate the true meaning of the law.

That may seem obvious. Indeed it is obvious but it’s also depressingly uncommon. I genuinely have lost count of the number of people who’ve told me how much easier to understand they found social care law after narrative based training. I won’t bore readers with their reports of previous, ‘chapter and verse’ style training but I’m sure you can imagine.

So if you’re a lawyer, a trainer or a social worker with the responsibility for delivering health and social care law training to care workers remember the rule of ‘T’:

Take The Time To Tell The Tale

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Course design 12: Write handout titles and trainers notes first – then write handouts and activities

From this point on the course should be fairly straightforward to put together. You have a plan to follow and you know how to make your training inclusive and engaging. Now all you need to do is write the materials.

This is the point when I leave my low tech index cards behind and go to my word processor. I type up the list of topics in the order already identified and then copy and paste it immediately below. I now have two copies of the same list.

The first copy stays on the first page for reference.

The second copy is reformatted in bold and each entry becomes the heading for a separate handout or exercise. The links to the various, pre-identified themes become the first of the preparatory notes for each handout or exercise.

But that’s all you do with these handouts for now.

Next you write the trainers’ notes (even if nobody else will deliver it). These are the notes accompanying each handout that clearly define what each handout will aim to achieve and what anecdotes you will tell. These notes are also the place where exercises are identified and where you can list the particular learning points and questions you want to introduce to the group at each stage.

Only then, when you’ve identified all these ingredients should you write the actual handouts that you are going to use.

By the time you’ve finished the trainers notes and handouts you should have a single document (part pack) that anyone could use to deliver your training provided they understand the topic. This doesn’t mean that others necessarily will gain access to your materials – simply that the very process of creating trainers notes alongside the course materials themselves keeps you on track and helps ensure that the original training plan is reflected in the finished product.

You can never overestimate the value of a good set of trainers’ notes – even if you never look at them again.

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The Guide 12: Hallucinations

Psychosis dos and dontsHallucinations may occur in any sensory modality (e.g., auditory, visual, olfactory, gustatory, and tactile), ‘modality’ just means ‘sense’ but auditory hallucinations are by far the most common. Hallucinations are positive symptoms because they represent something more than the norm. They are an additional experience that most other people don’t share. Think of the ‘plus’ sign you first learned in school. That is also the symbol for positive. Positive symptoms are additions to the norm.

Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, that are perceived as different from the person’s own thoughts. This idea is important and we’ll pick up on it later.

Perceived as different from the person’s own thoughts

True hallucinations are different from what most people understand as thoughts. The voice in your head, the internal chatter of thoughts you experience all day long is not an hallucination. Hallucinatory voices are experienced as though they come from a source outside of you. You hear them through your ears – or at least that’s how it seems.

The voices might represent several different entities or just one. They may be nice or nasty and they may talk directly to you or simply talk amongst themselves. Some people hear voices that tell them what to do – these are called command hallucinations.

Interestingly voices often seem to mirror a person’s moods just as your thoughts mirror yours. If you’re feeling happy the voices will tell you positive things. If you’re feeling sad or insecure the voices will tell you how useless you are or how pointless it is trying to achieve anything. This is what we mean when we talk about ‘mood congruent’ hallucinations. The voices match the mood.

Many people are in no doubt that, however they may seem, hallucinations are their own thoughts. This is extremely significant because it gives them ‘ownership’ of their hallucinations and therefore ‘control’ over them. After all everyone has thoughts they don’t feel particularly proud of or that they wouldn’t be comfortable sharing with others. When considered in this light hallucinations become no more of a problem than any other thought process and equally open to control (admittedly with a bit of training and practice).

For me one of the most interesting aspects of hallucinations is the way that society interprets them. For example daytime television in UK is full of ‘psychic mediums’ who claim to hear voices from beyond the grave. And on the whole society accepts this as somehow more plausible than the experience of the teenager who hears the voice of his late grandparent. We see one of these people as ‘gifted’ and the other as ‘insane’. But is there really any difference? It seems to me that mediums, channelers, voice-hearing priests and the patient in your local acute ward who talks to the aliens all occupy one of three possible categories:

  1. They are psychotic;
  2. They are genuinely in touch with something outside of normal understanding;
  3. They are lying.

Of course, different people will have different opinions based upon their particular preferences and bias but that’s not really the point. If we call any one of these experiences psychotic we must also acknowledge that there is just as much (or as little) evidence to say the same about the rest. This is equally true if we decide that they are deceitful or even that they truly are ‘gifted’.

There’s an interesting cultural (and even subcultural) perspective here. For example, some African cultures are much more likely to accept voice hearing in a religious context than more traditional Western churchgoers might.

With all these cultural influences to take into consideration it becomes extremely difficult to say what is and what is not a hallucination in any ‘medical’ sense when so many people claim otherwise. I know an ordained priest who has told me on more than one occasion about her conversations both with God and Satan (the latter being a less than welcome intruder into her life). She is adamant that these conversations happened – or at least she was the last time we discussed it. I have a rather different perspective on the whole affair but then……..

Who cares what I might think?

However, if you are interested in what I think then keep reading and I’ll tell you.

I think that my opinion should be less important to the person experiencing hallucinations than their own ability to deal with them. If they choose to believe in conversations with some ill-defined spirit and that helps them to cope then so be it.

Who cares what I might think?

After all if TV mediums can find a place in the world then so can anyone else. What interests me is not imposing my own interpretation of someone’s experiences but in helping them to function with whatever explanation they choose. To that end I might talk with them about their interpretation but it remains their interpretation that matters, not mine. After all, many of the chief religious and political figures across the world achieved their status precisely because of experiences such as these.

However let’s not get too carried away ‘normalising’ psychosis and hallucinations. It’s true that many people cope very well but others do not. The majority of voice-hearers we see in social care settings are very likely to be in the distressed camp – otherwise we probably wouldn’t be working with them. These people are not the much feted psychic mediums and spiritual healers of the world. They are the struggling individuals who have not found a way to integrate their experiences into society’s acceptable mainstream and we would do them a great disservice by pretending otherwise.

Distressed voice-hearers may well need our help and it’s up to us to try so far as we are able to provide that help as part of the larger multi-disciplinary team.

Treatments and interventions for hallucinations vary. The traditional medical approach is to try to remove them altogether using medication. Unfortunately, although medication can work extremely well for some people, it isn’t always effective. Sometimes all antipsychotic medications do is dampen down a person’s thinking and energy levels until they lose all quality of life. For others the medications cause severe side effects that are extremely difficult to cope with and in some cases are irreversible.

Yet medication has its place and can work wonders. It’s always worth considering antipsychotics but if they don’t ‘do the trick’ – if they don’t solve the problem that doesn’t mean that there are no other options.

As we have seen, many people function extremely well with their hallucinations – sometimes because of their hallucinations. As we shall see later some people achieve great things precisely because they hear voices or see visions. These people have a lot to teach us about how to help the people in our care.

Many people argue that it’s not the fact that you hear voices or see visions that is the problem. It’s the way you think about those voices and visions that matters. Marius Romme and Sondra Escher founded the ‘Hearing Voices’ network decades ago to help people learn how to understand and deal with their voices constructively. There are many techniques that can be used with genuinely remarkable results. We’ll consider some of these as the series progresses.

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Course design 11: Planning

So far we’ve considered a few of the elements that need to be considered when putting together a training course. But that’s all we’ve done.

It’s one thing to understand that we need to identify the ‘jigsaw pieces’ and the themes that will bind them together but it’s another thing to know how best to do it.

It’s one thing to know that we need to incorporate a range of exercises, case studies and anecdotes alongside ‘information giving’ but it’s another to know how best to do it.

It’s one thing to know that people have different ‘modalities’ to take into account but it’s another to know how best to do it.

There are many ways to plan a course and every trainer is different so if you have your own system that works for you then please continue to use it. The system I’m about to outline is the one that works for me but realistically, so long as you have a method that works for you it doesn’t really matter what system you use. But this is how I do it.

First I do a little research to update myself. My field is so fast moving that even subjects that I was absolutely up to date with 6 months ago may well need updating today. So I check for recent developments that I might need to incorporate.

This can be anything from recent research to new theories – even political debates around service provision may need to be included (depending upon the client and the trainees).

Then I define the points that I need to make. I do this in one of two ways:

  1. Mind map the whole topic;
  2. Write everything that may be necessary to include on a separate index card with references as necessary.

Then I arrange that information into a logical sequence (this is the beauty of index cards – they’re easy to shuffle around.

Once I’ve done that I check my original notes to ensure that I’m still on track with the client’s requirements.

Is this still the content they were looking for?

Is it at the right level of complexity?

Is everything relevant?

Once I’m satisfied that I’ve got the right content in the right order I make a quick note of the order in which to present the information logically.

Finally I rearrange the index cards into themes which can be used to give the course structure and consistency. Don’t underestimate the importance of this stage. These themes are vital to the success of the training that you will deliver.

In the end I will have a list of subtopics (and handouts) in the order that I intend to present them and a note alongside each that serves to remind me of the themes that each relates to. This is exactly the sort of list we identified in part 8 when we discussed training on deliberate self-harm:

“The themes I’d use for this particular jigsaw are….

  1. Deliberate self harm is a coping strategy.
  2. We’re all the same.
  3. Care workers are not the focus of people’s problems – it’s not about us.

The ‘jigsaw pieces’ most commonly included in a one day self harm awareness day are:

  • Self harm is not about us (theme 3);
  • Self harm isn’t suicide – but people who harm themselves are at higher risk of suicide (theme 3);
  • Self harm is about coping (theme 1);
  • Most self harm is done in private and kept secret (theme 3);
  • When coping fails people behave in more and more extreme ways (theme 2);
  • We all use particular coping strategies to feel better when distressed (theme 2);
  • The most effective coping strategies change brain/body chemistry (endorphins) (themes 1, 2 & 3);
  • Deliberate self harm stimulates endorphins (themes 1 & 3);
  • People generally use the best coping strategies they know (theme 2);
  • Our job is to enhance coping strategies – not to remove the only effective coping strategy a person has. (themes 1 & 3);
  • Developing alternative coping strategies (themes 1,2 and 3);
  • Looking after ourselves (theme 2).

The jigsaw pieces follow a logical pattern and the use of themes allows participants to see how it all hang together. This is important if the participants are to create a ‘schema’ which will be the focus of tomorrow’s instalment.

This list and the thematic notes alongside it form the backbone of the finished course. In the next instalment we’ll consider some of the tips and tricks that help us to make sense of the many strands that will need to be pulled together to construct a really effective training session.

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The Guide 11: Psychosis (introduction)

If there is one word in psychiatry guaranteed to create misunderstanding and even fear among lay people its psychosis. This is partly because of the media’s insistence on confusing psychosis with psychopathy and partly because it’s so unlike most people’s experiences – or at least it appears to be.

Add to this strangeness the various diagnoses that crop up in discussions of psychosis, many of which are equally misunderstood and you have a recipe for confusion that is hard to underestimate. The word psychosis is just a term we use to describe certain experiences or symptoms. Psychotic symptoms come in three broad groups which are:

  • Hallucinations
  • Delusions
  • Thought disorders

Psychosis chart

Different diagnoses are made based upon which of these three symptom groups are present, how long they have been an issue for the person and what other types of symptom might also be present.

Perhaps the most well-known of the psychotic diagnoses is schizophrenia but there are many others. You may also have heard of other psychotic disorders such as bipolar affective disorder, drug induced psychosis, psychotic depression, puerperal (post natal) psychosis and delirium.

None of these diagnoses automatically means ‘axe wielding murderer’ – that’s just the myth that certain newspapers use to boost their sales. They take relatively rare tragedies and blow them out of all proportion to generate headlines such as

“Schizophrenic kills baby in crazed psychotic rampage”

What they don’t report are the much more common experiences of people diagnosed with psychotic disorders. After all a headline like

“Psychotic woman sits staring at the

wall for 15 hours each day”

Probably wouldn’t sell many newspapers.

Over the next few chapters we’ll consider the true meanings of hallucinations, delusions and thought disorders.

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Course design 10: Learning styles

Different people learn and process information in different ways. One way to think about these differences is to imagine that you were training a group of people who spoke different languages and so needed some sort of translation to make sense of the information and skills you present.

Of course we’re not really talking about formal language. We do occasionally need to rely upon translators in training (I often work with interpreters skilled in British Sign Language for example). But even when working with people who have no hearing or other sensory impairments and whose native language is English there is a real issue with ‘translation’ of a different sort.

It is possible to become so wrapped up in issues of learning style that inexperienced trainers become effectively paralysed when trying to determine the best ways to put their message across to a group of people, all of whom have their own preferred learning style and cognitive processing methods. The deeper we look into learning styles the more complicated it becomes and the variables become increasingly subtle. Fortunately though we don’t need to be experts in the fine detail of learning theory to design and deliver a good course. We do, however need to understand the broad principles. I like to boil learning theories down to three broad areas. These are:

Convincer strategy;

Sensory modality;

‘Top down’ or ‘bottom up’.

Convincer strategy

Different people are convinced by different types of evidence:

  • Some people need to be told;
  • Some people need to be told several times;
  • Some people need to work things out for themselves;
  • Some people need to experience learning points in action (case studies and exercises are useful here);
  • Some people need to know that others are of the same opinion;
  • Some people need to know that others whom they respect think this way;
  • Some people need to know ‘why’ something works;
  • Some people need to know ‘how’ something works;
  • Some people need to hear stories that illustrate the point so that they can imagine the issue at work in the real world.

For this reason we need to ensure that there is a mix of exercises and case studies as well as trainer presentation, group discussion and lots of Socratic questions designed to help people work out their own answers. It’s also useful to have a selection of stories and anecdotes (including those involving respected figures).

One of the more common mistakes new trainers make is to fill their training days with their own preferred type of exercise or activity without realising that there will be a mix of training styles in the room before them. For example my own preferred learning style is to think things through ‘in my head’. I don’t need direct experience so much as cognitive understanding but if I confined my training only to theory and ‘lecture’ I’d fail most of my trainees.

Similairly a day full of case studies with no room for discussion or more abstract theory would be inappropriate for people like me.

Sensory modality

We have five senses and they matter. It is only through our senses that we make sense of the world around us. The five sense of

  • Touch;
  • Taste;
  • Hearing;
  • Smell;
  • Sight

Are the interface between us and the rest of the world. They are our personal computer keyboard, if you will.

The problems begin when we realise that different people have different ‘preferred’ senses. Some people (most people in my experience) are very adept at processing visual information. That’s one reason why I use a lot of visual imagery in training. Flipcharts allow us to respond to questions with pictures or basic charts that can save huge amounts of time clarifying points of contention.

The visual sense is so important that Piaget, the renowned educational psychologist came up with the training dictum…

“I hear I forget,

I see I remember,

I do, I understand.”

Visual memory is an excellent standby and it’s always useful to bring in visual imagery. Even when relating stories and anecdotes paint pictures with words. It’s important.

But visual learning isn’t the only type of learning that matters.

Some people need words whilst others need more ‘experiential’ ways to process information. Of course it may be difficult (depending upon the topic) to involve taste and smell but role play can be a half decent substitute for the experiential aspects of touch. This mirrors the point we made earlier about case studies and experience.

There is just one rider I’d place on this.

Most trainees enjoy role play once they begin but almost all people expect that they will not. So use role play sparingly. It’s odd.

The experience of role play is generally positive but the memory of it (and certainly the anticipation) is often much more negative.

Very often though we can involve the elements of role play by setting up small group case studies without ever needing to get over the resistance that most trainees have to the technique.

The only time when I would definitely use role play would be when I’m training people on particular therapeutic or inter-personal techniques. Otherwise I use other methods rather than risk alienating the participants.

‘Top down’ or ‘bottom up’

The final aspect of learning theory I want to introduce here is ‘top down’ or ‘bottom up’.

I used the analogy of a jigsaw puzzle in earlier instalments and I want to return to that analogy now.

If the training course is a jigsaw then ‘top down’ learners prefer to see the picture on the box before they start to put the jigsaw pieces into place.

Bottom up learners are rarer in my own field of health and social care but are better represented in some other fields. It’s very well worth taking time to get a feel for the predominant style in your profession.

In my training sessions I always make a point of providing an overview very early on. A common way to do this is with an introductory exercise that serves not only as a warm up but also introduces the main themes of the training (as discussed earlier).

I often use an ‘introductory quiz’ to do this because the subsequent debrief allows me to provide that broad ‘picture on the box’ straight away before spending the rest of the training day ‘filling in the gaps’ with the remaining jigsaw pieces.

However you choose to do this make sure that your initial activities take account of ‘top down’ and ‘bottom up’ learning styles.

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