Psychosis recovery day 4.5: Therapeutic risk-taking

It is possible to assist people with social care needs (complex or otherwise) to develop the quality of their lives and to enhance their coping strategies. In large part this is achieved by assessing and encouraging risk-taking.

Without risk, life becomes empty. We develop as people by stretching ourselves and by gradually pushing the limits of what has come to be known as the ‘comfort zone’. But there is a balance to be struck, both in terms of ensuring that risks are reasonable and also in motivating clients to take therapeutic risks with a high likelihood of success.

This involves careful planning in order to ‘factor in’ the possibility of failure so that setbacks are seen not as disasters but as learning experiences – grist for the mill in refining plans to enable future success. This process is known as ‘risk debriefing’.

An understanding and appreciation of risk in relation to personal development is a vital element in the provision of social care in any setting. The process of person-centred planning must involve personal development and a striving for increased independence. This cannot happen without appropriate risk-taking.

So what are the elements of risk assessment?

According to the Health & Safety Executive there are 5 elements of good risk assessment and management and 5 principles that risk assessment is not

Risk management principles

  • Ensuring that workers and the public are properly protected
  • Providing overall benefit to society by balancing benefits and risks, with a focus on reducing real risks – both those which arise more often and those with serious consequences
  • Enabling innovation and learning, not stifling them
  • Ensuring that those who create risks manage them responsibly and understand that failure to manage real risks responsibly is likely to lead to robust action
  • Enabling individuals to understand that as well as the right to protection, they also have to exercise responsibility

Sensible risk management is not about:

  • Creating a totally risk free society
  • Generating useless paperwork mountains
  • Scaring people by exaggerating or publicising trivial risks
  • Stopping important recreational and learning activities for individuals where the risks are managed
  • Reducing protection of people from risks that cause real harm and suffering.

Task debriefing

We all learn by our mistakes. Everything that you have achieved has been the result of trial and error – often the most valuable and effective lessons are learned precisely because of our errors in judgement. This is as true for our service-users as it is for us. If we give up on our plans at the first hurdle then we are doomed to fail. If we give up on our service-users when they make mistakes we doom them to failure just as surely.

Autobiography in 5 chapters (Anonymous):

Chapter 1

I walk down the street. There’s a hole in the road. I fall in the hole. It’s deep and I can’t get out.

Chapter 2

I walk down the street. There’s a hole in the road. I see the hole but I fall in it anyway. It’s deep and dark and I can’t get out.

Chapter 3

I walk down the street. I have my ladder with me. There’s a hole in the road. I see the hole but I fall in it anyway. I use my ladder to get out.

Chapter 4

I walk down the street. I have my ladder with me. There’s a hole in the road. I see the hole and I walk around it.

Chapter 5

I walk down a different street.


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Psychosis recovery day 4.4: SMART Goal Setting






What effect does ‘SMART’ goal-setting have upon recovery from schizophrenia?

What are the advantages of SMART goal setting?

What are the disadvantages of SMART goal setting?

Goal hierarchy

By starting with the goal at the top and working backwards we can avoid the trap of SMART goal setting with it’s insistence on realistic outcomes.

The basic notion is that whatever a person wants to achieve – and however unrealistic that goal may seem to the worker we can break it down into smaller consecutive steps until we reach the subordinate goals that we can achieve.

If that person is ever going to achieve their ultimate goal then they will have left us and our service far behind and so we are not making false promises or peddling false hope. Rather we are openly working on the bits we can achieve with an acknowledgement that we can only go so far along the road with our clients. After that it will be up to them.

This strikes a balance between avoiding unreasonable/unrealistic promises and retaining motivation.

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Psychosis recovery day 4.3: What early signs of relapse might you identify?

Make a list of first signs. These can be around your initial:



























What would you include in your Relapse Plan??

Make two lists:

Relapse plan yes and no

How could you ‘capture’ the early warning signs?

Think about your goals

Short term

Medium term

Long term

Are you moving towards or away from something?

What do you want to achieve?

How can you help your partner to construct a plan to achieve that goal?

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Psychosis recovery day 4.2: Advance decisions – some legal stuff

An advance decision allows people to express their views clearly, before they lose capacity.

Advance decisions, which used to be called ‘advance directives’ or ‘living wills’ can currently be made under common law and the Mental Capacity Act puts them on a statutory footing. It also explains what is required in law for an advance decision to be valid and applicable and introduces new safeguards.

An advance decision is where a person aged 18 or over may set out what particular types of treatment they would not want to have and in what circumstances, should they lack the capacity to refuse consent to this treatment for themselves in the future. It can be about any treatment even if the refusal may result in the person’s death and if it is valid and applicable it must be followed. An advance decision does not need to be in writing, except for decisions relating to life-sustaining treatment but it is helpful if it is.

If a person has made an advance decision refusing a particular medical treatment, and that advance decision is valid and applicable, then the refusal has the same force as when a person with capacity refuses treatment.

The MCA introduces a number of rules people must follow when making an advance decision. If you are making a decision about treatment for someone who is unable to consent to it, you must be satisfied that the advance decision exists, is valid and applicable to the particular treatment in question. The following list gives a brief summary of some of the main requirements for advance decisions:

  • It must be valid. The person must not have withdrawn it, or overridden it by making an LPA that relates to the treatment in the advance decision or acted in a way that is clearly inconsistent with the advance decision;
  • It must be applicable to the treatment in question. It should refer to the treatment in question and the particular circumstances it refers to;
  • where people are detained under the Mental Health Act 1983 and can therefore be treated for mental disorder without their consent, they can also be given such treatment despite having an advance decision to refuse the treatment;
  • people cannot make an advance decision to ask for medical treatment – they can only say what types of treatment they would refuse;
  • people cannot make an advance decision to ask for their life to be ended.If you are satisfied that the decision is valid and applicable then you will have to abide by that decision. The MCA sets out additional formalities for advance decisions that refuse life-sustaining treatment. An advance decision to refuse life-sustaining treatment must fulfil the following additional requirements:
  • It must be in writing, which includes being written on the person’s behalf or recorded in their medical notes;
  • It must be signed by the maker in the presence of a witness who must also sign the document. It can also be signed on the maker’s behalf at their direction if they are unable to sign it for themselves.

It must be verified by a specific statement made by the maker, either included in the document or a separate statement, that says that the advance decision is to apply to the specified treatment even if life is at risk. If there is a separate statement this must also be signed and witnessed.

An Advance Decision is not an Advance Agreement. People making Advance Decisions do not need workers to agree – they need them to comply.

Advance Decisions and the Mental Health Act 2007

Three types of situation (people can be in several groups at the same time depending upon the issue in question)

legal status x 3If you help a service-user who has capacity to understand what they are writing/planning to create a relapse plan then parts or all of that plan may well count as an Advance Decision under the Mental Capacity Act 2005.

This means that whilst their decisions can be over-ruled in certain circumstances if the decision is covered by Part IV of the Mental Health Act their advance decisions to refuse treatments not covered by part IV will be legally binding.

Any part of the relapse plan that requests or demands a particular treatment or intervention will be treated as a ‘statement of preference’ under the Mental Capacity Act and will not be legally binding but decision-makers will need to consider what they have written under the Mental Capacity Act.

What would you include in your statement of beliefs and values?

It is important to me that (make a list)……..

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Psychosis recovery day 4.1: What is a relapse plan?

One of the biggest problems facing health and social care providers is knowing what to do to ensure that their response to people facing relapse of mental disorders is appropriate and truly individualised or ‘person centred’.

The ‘relapse plan’ is one way to work collaboratively with the service-user to ensure that what we do in the most difficult situations really is the right approach for that particular individual.

The relapse plan is actually a combination of two different things. First we have the relapse ‘profile’ or ‘signature’ which is a formal method of understanding the nature of relapse for each person. What the early warning signs are and what has or hasn’t worked in the past.

Then we construct the plan itself to ensure that what we actually do has the best chance of avoiding relapse.

The additional benefit of this is that it takes away the uncertainty for the service-user. They know how you will respond because they helped to design the plan and so they can feel confident that service-providers will not over react in the early stages. Consequently service-users feel much happier about reporting their difficulties early on and so preventing them from becoming worse.

Another benefit is that the construction of the plan is itself a process that encourages and develops improved insight for both the service-user and the workers, thus further preventing relapse in the future.

A good relapse plan is a vital aspect of structured recovery work and, although often overlooked, is indispensible if we are truly to help the service user to grow beyond our service and rebuild a ‘normal’ life outside of mental health services.

However relapse plans do require some thought, not least since the law has changed regarding issues such as the Advance Decision (formerly known as the advance directive) with the creation of the Mental Capacity Act (2005) which came into effect last year. It’s important that workers engaged in relapse profiling and planning understand at least the basics of the new legislation or they could find themselves facing real consequences. In short:

  1. Understand the legality of the Advance Decision;
  2. Be careful what you ask for – you might just get it.

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The Guide 5: The importance of physiology

Physiology is, in broad terms, the study of how the body works. It is different from anatomy which refers to the structure of the body. In this section we’ll consider how the way we use the body affects emotion just as emotion affects the way we use the body in return.

We know, for example that when people feel sad or miserable they tend to hold their bodies in particular ways. Muscles become more relaxed and breathing and posture change. When we’re sad we tend to look downwards or stare into space and over time our movements and even our thought processes slow down.

We also know that these physical changes produce chemical alterations. The neurotransmitters serotonin and noradrenaline, or rather the lack of them seem to be most closely associated with low mood and inactivity (so far as medical science can ascertain). Inactivity appears to reduce levels of both these neurotransmitters in the central nervous system. We also know that reduction of noradrenaline and serotonin appears to bring about a deepening of our misery in return.

The result is a ‘chicken and egg’ style cycle which, if unchecked can result in such extreme debilitation that people actually lose the ability to move or even to organise their thoughts. One depressed person I nursed described this as a feeling of ‘wading through treacle’ whereby everything seemed to require gargantuan effort and even speaking to others took an effort, not just of will power but of exhausting physical work as well.

This is why in clinical depression (when biological symptoms occur) it may be necessary to boost the levels of brain chemicals with antidepressants.

However there is much that people can do to stimulate their physiology naturally before they reach the stage of clinical depression. Prevention is better than cure and boosting levels of serotonin before the onset of depression is much easier than dealing with biological illness later on. So another of the principles we need to develop emotional management skills is that of early intervention.

A stitch in time saves nine.

If you want to avoid sinking into clinical (biological) depression then intervene at the first sign of sadness and take positive steps to boost your physiology. Get active, take exercise, go for a walk, do something – and do it ‘briskly’.

It’s also important not to sabotage serotonin by over use of other chemicals such as alcohol which destroys serotonin and also depletes the body’s supply of vitamin B. Develop a routine along the lines of Alfred the Great’s 8 hour ‘clock’. Divide the day into three equal parts devoted to work, rest and recreation.

Even if you don’t feel like doing fun things, act as if you do. That will affect your physiology and begin to boost serotonin, thus preventing a deepening of your problems long before you reach the stage of clinical depression. The increased activity also aids sleep. Sleep disorder is another problem associated with serotonin depletion so stick to the routine, force yourself to get up when the alarm goes off even though you may not want to and get active. You can have a day off when you’re feeling better. Let’s face it – if you stay in bed when you’re feeling down you’re not going to enjoy it anyway so you might as well do something positive instead.

Some people, I’m sure will object to the idea that serotonin levels can be affected by any means other than pharmacology. I absolutely understand that. However, in writing this series of posts I cannot avoid making this fundamental case for non-medical interventions, particularly when (at least so far) we’re only talking about a general sadness or perhaps mild clinical depression.

The belief that only medication can affect brain chemistry is a leap of faith that is not supported either by the scientific evidence or by the less formal experiences of those people who have mastered the skill.

I’m proposing the same belief in emotional management that prompts parents daily to encourage their children to go out and play when they’re upset. This is the same process of physiological change that makes exercise or even dog-walking so helpful.

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Course design 4: Know your audience

Knowing the client is important as we saw in the last episode. But beyond that it’s equally important to know the audience. After all it’s one thing to know that you’re delivering training for a Local Authority but that knowledge alone won’t help you decide whether to plan a course for senior social workers in child protection or home care service providers in elderly care services.

We need to know who the training is aimed at as well as who it’s delivered for.

There is no point introducing training on medication administration to workers who don’t deal with it. Similairly it’s not necessary to train psychiatrists in psychiatric diagnosis – they’re already well versed in that. It doesn’t matter how interested I might be in deliberate self harm (as it happens that really is a topic that fascinates me) – not everyone needs to know about endorphins, self harm as a coping strategy that releases emotional turmoil resulting from invalidation and trauma.

This is one of the many situations in training design and presentation when we need to be clear that our own individual opinions and preferences are much less relevant than the needs and philosophies of the client.

There is a limit to this, of course, and most of us have at one time or another withdrawn from training rather than become involved in something we disagree with but these are relatively rare extremes. More often than not disagreements between the interests and philosophies of the trainer and the client are much less significant than that.

In most cases all we need to do is remember that good trainers are able to ‘step aside’ and focus upon the topic at hand rather than their own personal opinions and bias.

So another of the keys to good and effective training is to know your audience.

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