This weeks #Otalk is on the topic of “When clients don’t get better” and will be hosted by Keir Harding (@Keirwales).
Here’s what Keir has to say….
“With patients who do not get better, or who even get worse in spite of long devoted care, major strain may arise. Those who attend the patient are then pleased neither with him (the patient) nor themselves and the quality of their concern for him alters accordingly, with consequences that can be severe for both patient and attendants” (Main 1957).
Our training tends to prepare us for people who will come to see us with a problem, take our advice, then go away and get better. The reality is that some people who are referred won’t turn up to appointments, some will ignore our advice, some won’t improve despite our best intentions and some will do things that seem to make their situation significantly worse. I have sat in offices cursing people for not turning up and making judgements in my head about whether they want to get better. On the other side of the scale I’ve worked with people who have repeatedly self-harmed in ways that are potentially lethal and made repeated suicide attempts. I often hear this described as ‘attention seeking’ or ‘sabotage’. These explanations are seductively simple. After reading in someone’s notes the other week that they were self-harming ‘due to their diagnosis’, I wanted to spend some time promoting a more nuanced way of thinking about the things people do that seem to cause harm. I wonder whether we all do something on the self-harm spectrum and whether there is an impact of people we are there to ‘make better’ apparently making themselves worse. To set the scene here is a paragraph ripped from my blog. It would also be worth checking out “The Dark Side of Occupation” (Twinley 2013) which you can get free if you’re in BAOT.
“Let’s start by saying that I self-harm. I self-harm regularly in a way that society tends to approve of. Most Saturdays I strap on my rugby boots and on a good day, for 80 minutes large, hairy men will charge at me while I try to knock them over. On other days I am punched, stamped on, scraped with studs, or just hurt. Over the years I have broken my nose, chipped my teeth, ripped the skin under my chin open, split my forehead and all last week, sported a big purple eye. I play rugby every week, not seeking pain but knowing full well that it is inherent in this activity. The pain and damage that it gives me is worth it in terms of the other benefits that I receive. Now obviously playing rugby isn’t the same as cutting lines in my thigh, but I’m arguing that that both activities are on a spectrum of things that damage you but come with some reward that makes it worthwhile.”
Suggested Talking points:
1 What do we do in our own lives that isn’t totally in our best interests?
2 How do we understand what our client’s do that seems to make things worse?
3 What is our role in working with these clients? Do we help them stop or do we facilitate harm?
4 What is the impact on us of our clients not getting better? (Or seemingly making things worse?)
5 How do we protect ourselves from making simple explanations to complex occupational problems? (Often in systems that will tend to reinforce that)
MAIN, T. F. (1957), THE AILMENT*. British Journal of Medical Psychology, 30: 129–145. doi:10.1111/j.2044-8341.1957.tb01193.x (Free online at http://www.ljaa.lv/download/dokumenti/the_ailment_by_t_main.pdf )
Twinley, R. (2013), The dark side of occupation: A concept for consideration. Aust Occup Ther J, 60: 301–303. doi:10.1111/1440-1630.12026
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