This weekend, I’ve been reflecting a lot on kindness and the way it impacts on my job. On Friday, I had a conversation with someone I work with (in a different organisation) in which they demonstrated a level of kindness towards me that I was not expecting in the context of our previous conversations and professional relationship. It surprised me. They could have dealt with the situation in many different ways, as could I, but the kindness took me aback and I’ve been thinking about it ever since.
We hear a lot about the need for compassion in health and social care. There has been a ‘lack of compassion’. After the Francis Report publication, organisations within the NHS but on a broader level have been asking about whether there has been a deficit of compassion shown in services. I’m far from convinced of it. Cruelty happens. Neglect happens. Organisations develop toxic cultures. Does that mean there is a general lack of compassion by staff who do their jobs on a day to day basis? I don’t think so. I’m also confused by the language that is used.
I like to think I’m a kind, compassionate person. I try to be. I wonder though, what kindness/compassion is in the role that I have and have had and whether they are the same thing. Wikipedia tells me
English noun compassion, meaning to suffer together with, comes from Latin. Its prefix com- comes directly from com, an archaic version of the Latin preposition and affix cum (= with); the -passion segment is derived from passus, past participle of the deponent verb patois, patī, passus sum.
Whereas kindness is again, according to Wikipedia
a behavior marked by ethical characteristics, a pleasant disposition, and concern for others. It is known as a virtue, and recognized as a value in many cultures and religions (see ethics in religion). Research has shown that acts of kindness does not only benefit receivers of the kind act, but also the giver, as a result of the release of neurotransmitters responsible for feelings of contentment and relaxation when such acts are committed
Would we rather, on these definitions, that someone treat us with kindness or compassion? Personally, I’d go for the latter. I have no desire for someone else to feel my pain or suffer with or alongside me. When I was working with people on a daily basis, we used the rule of thumb about treating people as you would like to be treated or as you would like a member of your family to be treated. As a simple baseline, it’s a good start and it’s easy to understand but perhaps we need to look beyond the self and beyond the ‘compassion’ which is about putting yourself in other people’s shoes or imagining they are in your shoes, and thinking how we treat people to create a better, more caring, kinder society as a whole. Compassion, perhaps, is about the individual but kindness can be broadened out to a wider group of people that we might not ‘feel’ for.
If we are looking at the word, compassion and compassionate in terms of the care I delivered when I was in a social work role, I’d like to think that I regarded everyone I worked with respect and kindness. Was I always able to feel their difficulties and suffer with them? I hope not as it would have burnt me out far earlier but I think I did my job well and tried to remember that I was in the position of power that flitted in and out of the lives of others having significant influence on their wellbeing and making fundamental decisions which I never took lightly. However, I had bad days too. I remember one time when I was annoyed with someone whom I was working with. It was a family member of a man I was working with and they had acted in a way that I thought had not been helpful. I remember actively biting my tongue and being short with them. I returned to the office and had a long chat with my manager. I phoned them and apologised. I was not compassionate. I was not kind. I don’t think it made me a bad person but gives us an awareness that people who see themselves as compassionate (however that’s defined in the context) can act in ways that aren’t. Does that mean the system is broken or that the people in the systems are human and have good days and bad days? Of course, cruelty and neglect are not ‘bad day’ things but I have never come across anyone working in health and social care who has not considered themselves ‘compassionate’ or ‘kind’ but sometimes that isn’t necessarily what I have seen in their actions.
So telling people to ‘be more compassionate’ doesn’t work. Telling people to ‘think more’, doesn’t work because we all think, to a large extent that we are doing our best.
I’m far from convinced that organisations need to buy in external agencies to ‘teach compassion’. My gut feeling is that there is something of the snake oil salesman approach to those who peddle the ability to ‘teach’ organisations how to be compassionate. It’s not rocket science, as we like to say. I don’t think anyone (apart from the few who fall into the ‘cruel’ group for which no teaching will work) believe we are not kind or don’t want to be kind. We need space to develop kindness and in my view that comes through reflection. Just as I’ve spent a day or so, reflecting on a very simple act of kindness towards me, it has led me to think about how I can be kinder, in unexpected ways, to and with those people and organisations I work with. So one act towards me has had a ripple effect. Similarly others, if they have that space, can think about how they have been influenced by kindness and thought from others in professional and personal settings and how that can be passed on.
Are organisations needing to buy in external consultancy firms to do this? I hope not. My hope is that any organisation in this ‘trade’ has sufficient professional expertise to grow their own reflective practice. It’s far cheaper and more productive to ask your own staff what would help them than getting a consultancy in to tick the ‘done compassion training’ box and tell them. I’d have far more confidence in any organisation that sourced the space and time to embed reflective practice over one that bought in a firm and got 100% compliance with ‘compassion training’. The key is that kindness and thoughtfulness start at Board level. If staff feel engaged with an organisation and a part of it, they want to do their best – sometimes they do, even if they don’t feel connected but it’s better for everyone if we do.
Kindness needs to drip down. Focusing on value based recruitment for health care assistants is great. Blaming health care assistants for all the problems in organisations when a lack of compassion has been identified is not. Staff treat people how they are treated. I’ve worked in different organisations and seen that those that have the best cultures are the ones that have most visible and responsive leaderships. Then the rest will follow. Staff teams that are well-led will filter out the team members who are less thoughtful in their approaches. Those that are poorly led will embed poor practice and culture. It doesn’t need any fancy training sessions to ‘teach’ that. It just needs, in my opinion, thought and time to reflect.
I’m aware that I can sound like a broken record at times, but fundamentally, I think the gap that is perceived to exist in kindness and care can be solved through reflective practice. The problem comes with the space that is given for individual staff members and organisations to reflect and the value given to it within the world that is driven by cuts and outputs. To ignore the need for reflection and consideration though, leaves individual practitioners and organisations at a far higher risk of delivering care that is thoughtless. The wellbeing of staff knocks on directly to the wellbeing of patients or people who receiving services from an organisation. A stressed and anxious social worker will by less effective, less kind, perhaps, than one who feels that they are a part of an organisation that shares their values. I know it’s easier said than done. In my previous team, we took time to talk through cases with each other, even when we were at our busiest because it made us stop – and think – about what we were doing and the impact that it had. The skills we learn to reflect and reflect well and often are imperative to good and safe systems. Reflection should also allow space to challenge practices within organisations which are faulty or unkind. We need to look after ourselves as practitioners and we need to demand it from our employers if they do not provide it.
So back to the initial kindness that was shown towards me. It made me realise what a difference it can make especially when it comes from an unexpected source. In my theme of hope for the new year, I think that I’m going to try and be kinder, if I can, for as much as I can, to those I work with and around. While kindness cannot solve the financial difficulties the sector finds itself it, it might be able to make the work environment more pleasant and more caring for those who use the services proved but also for those who work within them, at all levels.
I watched Bedlam, a documentary based on the work done in the South London and Maudsley (SLaM) NHS Foundation Trust last week and this week. I was reassured by last weeks’ episode, titled “Anxiety” which followed some people who had obsessive compulsive disorder so I was looking forward to the episode broadcast last night titled “Crisis” which was based in an assessment ward (which they called a Triage ward) where, the programme makers told us, decisions were made about whether to admit over longer periods or discharged home.
The “story” aspect of the programme focussed particularly on four people – two men and two women who had found themselves in situations which had necessitated (or where they had chosen – in the case of informal patients) to be admitted to psychiatric inpatient wards. Fashionable documentary style is very much in the ‘story-telling’ vein. We like stories. We like stories with ‘happy’ endings and as the programme finished, they made sure we had the resolution we required but I was left uncomfortable by a number of aspects and details in the programme. Maybe I was more critical this week because it was an area I had more experience of but I didn’t walk away from the programme thinking it had necessarily reduced stigma and instilled a greater understanding of the mental health system as it is. Of course, that’s not the purpose of TV programmes at 9pm. The purpose was entertainment and perhaps that’s where some of my discomfort lies.
I saw a lot of the positive waves of support for the programme, helpfully tweeted out by NHS Maudsley through the programme. Interesting (but of course, unsurprising) that they didn’t deal with some of the criticisms. I know the issue of capacity to consent to filming has been raised and the programme makers have addressed it.
The producers state
One of the complex questions for filming on the ward was that of patients’ capacity to consent. We’d agreed a rigorous consent protocol with the Trust which included getting an initial steer from a lead consultant in charge of the patients’ care before even approaching an individual. At times we just got a patients’ consent to film them, we had to return to them at a later date to get consent to broadcast the material. We filmed with one lady, M, for a number of days while she was on the ward and then when she was discharged home we met her for lunch and she decided not to be involved further. Central to the filming was a respect for people’s right to privacy and we respected M’s decision.
Clearly they have covered themselves legally but some of the situations presented made me wonder how much thought had been given to the future impact of the broadcast on recovery in the long term and a full understanding of the implications of being filmed at your most unwell “in the public domain” for perpetuity – and the effect on yourself and your family of this. Of course, I’m sure these issues were covered but I was uncomfortable in the same way that I was with the ‘much lauded’ Protecting Our Children series. I’m not sure that seeing people at their most unwell or disturbed is ‘entertainment’ and now ‘educational’ it is. Do we need to ‘see’ crisis? Do we need to see a psychiatrist telling a patient he is going to use section 5 (2) of the Mental Health Act to demand that he remains on the ward when he has asked to leave? Are some things necessary to film and show on the television with real people to understand?
Perhaps I’m too sensitive because I’m thinking that for me, the thought of being filmed if I were to be restrained and forceably medicated by a team of staff is abhorrent personally. And thinking about the shots of someone being ‘persuaded’ to take their medication and forceably injected, I wonder how much it was necessary to see it. It reminded me of Panorama where the abuse at Winterbourne View was shown – not because there was abuse, clearly, but because I wondered at that point too, how much needed to do shown on camera and whether we were indulging voyeurism too much. Of course, legally, the Trust and TV production company had consent tied up but I can’t say it didn’t leave me with unease at the way we view entertainment and couch it in ‘education’ and ‘attention raising’ to make us feel better.
My other discomfort, and I’ve been criticised for raising this, was some of the racial undertones and stereotypes that I felt were perpetuated by the ‘storytelling’. Dominic, the white middle class man who would be someone who could be ‘identified with’ by many at home, was a ‘danger to himself’. Rupert, a black man, was presented as having been a ‘danger to others’. I felt distinctly uncomfortable not with the people telling their own stories in the context of the programme but with the narrative of the documentary makers that ran over it. The sequence with Dominic and Rupert singing together, seemed particularly focused on the viewer ‘empathising’ with Dominic – possibly at Rupert’s expense. Dominic was someone who was ‘like us’ – at least, until he got his ‘new’ diagnosis of having a personality disorder which immediately ‘othered’ him. Rupert was presented differently. Perhaps I am too sensitive to these things but having worked in mental health services in central London, it’s hard not to attune to race as an issue – particularly when we look at compulsory admissions.
Lots happens on admissions ward but in terms of staff, we only saw doctors and nurses. It’s a shame that there was a missed opportunity to see some of the multi-disciplinary work that happens on inpatient wards constantly especially as people move towards discharge but perhaps that’s an unfair criticism, after all, it isn’t an ‘entertaining’ as seeing people in distress. The ‘follow ups’ we got intimated that hospital admissions were successful. If that’s the case (and it isn’t always although obviously, we hope it is), I’d have liked to have seen some of the ‘why’ that we saw last week. Apart from seeing someone medicated, what other ‘tools’ are used to help prepare someone to move out of crisis. In my view, that’s an opportunity that was missed.
Early in the programme, I heard the documentary makers mention that patients who were ‘informal’ needed to see the doctor before they could leave the ward. This, I have to admit made me bristle. I hope it was a misunderstanding on the part of the documentary makers as it is veering dangerously close to ‘de facto detention’ on the part of the Trust. Someone asked me, during the programme to explain this better so I’ll give it a go. An ‘informal’ patient is a patient who chooses, willingly and with capacity understanding the implications of their actions, to admit themselves to a psychiatric ward. They are free to leave whenever they like. They are not under any compulsion to stay. If staff feel they are making a clinical decision that there is a need for someone to remain on the ward, or ‘see a doctor before they leave’ they have to ensure they have the legal authority to do so so as not to breach article 5 of the Human Rights Act – either by a detention under the Mental Health Act (known as ‘sectioning’) or by using immediate short term holding powers under section 5 of the Mental Health Act (5(2) is where a doctor can compel someone to stay on the ward until an assessment is carried out and 5(4) is where a nurse can do so for a much shorter period). Leave cannot by restricted for an informal patient. If they need to stay, or if their leave needs to be restricted there are legal processes which need to kick into place. Detaining someone is a massive infringement of human rights and needs to be considered carefully. It cannot be a flippant comment by a member of staff on a ward about ‘staying to see the doctor’.
So Bedlam this week, definitely not leaving me feeling that it was waving the flag for stigma busting. It’s a shame as the opportunity was there but the need for stories and entertainment were paramount. Personally, it compounded my view that fly-on-the-wall wouldn’t be my personal format of preference for gaining insights into worlds that might not be apparent to others. I am of the view, and I am aware I’m probably in a minority on this, who thinks that created drama without ‘real’ people on camera – at least during their moments of crisis – would be a better way to achieve this. Drama created by people who have understanding and experience, absolutely, but I’m not sure how much seeing the ‘real time’ distress and illness is a help to those who are experiencing it. Is that my inherent paternalist nature creeping out? Perhaps it is. Perhaps I overthink things and should let people get on with it but frankly, after last week, I was disappointed with last nights’ episode – as a rather sad epilogue, I am also thinking, thank goodness the Trust I worked in didn’t agree to TV cameras. Stories are good. Stories are necessary. But do we need every part of a story to understand? Do we need to see the needle being injected, the distress and confusion, do we need to see all that in ‘real time’ to understand? Maybe we do now. I accept I probably don’t hold the majority view on this, judging by the waves of praise for the Trust and the TV production company but it doesn’t shake off my general unease.
I didn’t think I’d come back again but I’m pondering it now. I have a new job and a new role. While I’m still a registered social worker, I’m no longer working in the local authority and am no longer a practising AMHP. It’s been quite a journey over the past two years.
While I’m pondering a return here, I have a low-key project I’ve just started running here. Feel free to join me and.. well.. watch this space.
Thanks again for all the support and patience. It’s meant and means a lot to me.