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Here we go again - Another Credit Crunch.
Well, we don't need a sophisticated scientific theory, or even a half baked clinical, or social theory, to know what the consequences of the latest news will be. We have been seeing Financial Crises in the Health and Social Services throughout the history of these services.
In the past we relied upon the good will of practitioners to keep the services going, in spite of relatively poor pay, poor physical, psychological & emotional conditions and often anti-social hours. Those days are largely gone. And so they should have. Well actually they are not gone, just moved on to another unfortunate bunch (Social Care Workers and Health Support Workers).
Practitioners will not put up with 'its your duty' blackmail arguments any longer and service managers are having to resort to the 'its our policy' leverage. confining professional practices to 'assessment', offer rationales for 'not' providing services and engage the services of a new cohort of 'vocational' workers (who are poorly paid and have atrocious conditions of service). This includes those overworked 'Family Carers'.
Vocational Dilution:
Unfortunately there are consequences for the 'Professionals'. The vocational commitment of the professions has generally diminished, both in terms of the the intake of vocational practitioners to the service and the opportunities to maintain a healthy vocational attitude. Patient & Client focus becomes almost impossible, 'system' focus rules.
The Bureaucratic nature of the Institutions has advanced down the hill and overwhelmed even the most committed professionals. I include myself in this. We are in a state of overwhelm and it is getting worse, year by year. The quasi-entrepreneurial methods of the large 'community' institutions (Health Trusts & Social Business Units) are failing to improve the situation.
There is no consensus of professional resistance to the reduction of professional independence. Fear of of institutional criticism now stultifies our attempt to express professional concerns. Bureaucracies are 'self protecting' and the expanding nature of 'micro management', by way of 'Prescriptive Policy', is stark evidence of this.
Most professionals that I meet still have a real commitment to the patent/client, but have an increasing proportion of time designated the administrative procedure, which are often duplicative. Any attempt to improve the time constraints, or reduce administrative requirements, is argued to be against policy. You have to go through the 'procedure', a process that just adds one more bureaucratic layer upon another.
The Computerised Institutions:
So, what have we established in our 'new' community institutions and what drives this ridiculous Heath-Robinson, steam powered engine? Well, firstly we saw the opportunity for people, without real commercial experience, to attempt to engage in competitive tendering, to provide the services that had previously been directly provided.
Like in the advancing hi-tech revolution, these competitive bids were made with the anticipation that economies of scale could be made and improved services offered, at relatively lower costs. Well we are not a constantly advancing, Hi Tech industry; We are inefficient, overworked 'people' industries. The approach does not work like that.
I should know, I have worked in health & social service sectors and as an Entrepreneur. (Ask my Bank Manager). More entrepreneurial practices engage, assess and manage risks and accept the need for constant, on-line review. Bureaucratic systems are risk averse, or risk phobic; at all levels within the organisation. Changes here often only equate to a cosmetic makeovers, after persistent, unforeseen failures.
Technology could be helpful, but is often incompetently used within bureaucratic administrations. A famous computer edict is 'Garbage in - Garbage out'. This not only applies to the computerised systems in use, but also to the processing competence of the organisation itself. The level and quality of the direct service is what counts. Efficiency is increased by 'lessening' bureaucracy, nor increasing it.
The main benefits of technology are in 'expert systems' and these are not being employed. These would take a lot of the drudgery out of the administration of services, reduce the risks of error and ensure adequate 'monitoring' of service user contacts & status, rather than simply facilitating early closure of cases, promoting; 'it is not our problem now' attitudes (until the next crisis).
Since the 1980's I have come across one pretentious in-house, 'health & social care', computer expert after another. Usually someone who managed to conquer the use of spreadsheets. The bureaucratic engagements of computer industry experts does not fare better. The institutional focus is on the data output stage, for the purpose of meeting bureaucratic management needs.
Sadly, even experts fail to understand that any competent 'database & information processing system' makes the best foundation for producing the reliable statistics required by bureaucracies. The statistical outcomes need to be the result of competent, professional, decision making tools. These 'attract & engage' committed and consistent, professional use and 'facilitate' service implementations.
Systematic Failures:
So, in such circumstances, there is underbidding for contracts and subsequent bureaucratic mismanagement of personnel, resources, systems and funding. This has left the newer incumbents of these institutions (assuming you sort out the incompetence) with inadequate resources to do a proper job and the development of quasi-professional attitudes, established within the wider, bureaucratic structure.
Of course, public confidence has to be maintained and the original contract has to be at least seen to be be met, or the there will be a takeover bid (probably at lower relative cost, per capita). Everyone carries on doing more administration, to justify the next funding bid review (if this revision is possible) to cover, or else hide, the previous period of service shortfalls and administrative overspends.
With the ever increasing demands on all services, this produces a further shortfall, even if the institution has become more effective, or administratively 'efficient'. The institution has to continue its secretive practices and maintain rule, else someone may let the cat out the bag. Actually the cat is out of the bag. The funds were inadequate for the job right from the beginning. Commercialisation is a cover up.
Like in the legitimate protection of commercial & industry secrets, professional staff are told to pass all public disclosures and media engagements past the Management. These are not commercial secrets, however. They are institutional incompetence's, service shortfalls and poor practices. These requirements to clear communications with the executive are effectively 'Gagging Orders'.
Policy & Mal-Practice:
The original purpose of policy and practice procedures, was to ensure consistent, good professional practices. This never really worked but the intentions were laudable and gave us a general framework, which guided us in the right direction. The limited purpose now is to protect the institution and its managers, from personal and institutional litigation, should the inevitable happen (as it does).
It doesn't offer this protection, however, it reduces the face to face service, impoverishes practitioner work satisfaction, adds to frustration and increases risks (all be that they are hidden). Practitioners can be effectively 'infantilised' & disempowered. Shortfalls, that professionals have ethical and legal duty to disclose, are massaged out. It appears on the service that all is well, but those referred in are often frustrated.
By pretending that there are 'nominally' adequate staff, resources & professional practice time available, and by writing thousands of pages of quite specific directives; it is possible to fall back on 'policy', any time there is a failure to meet obligations. You have to be a special kind of nerd to remember all the directives. It fools nobody, but we are required to pretend we have read, understood & engage on its basis.
Assessing for 'Exclusion':
Changing the criteria for who is eligible for services, by the arbitrary criteria of 'severity' of problem, also increases the risks to patients and clients. The trick is to ensure that the criteria are above the level of any significant problem. In other words, wait till there is an imminent crisis in the institution's terms, before engaging specialist services. Then you appear the professional saviour, of the problem that had been brewing.
If anything goes seriously wrong, Service Managers can pretend that everything was in place and that it was an individual practitioners 'failure' that produced the errors and shortfalls. Even where the shortfalls & failures of the institution are formally disclosed to Service Manager (if anyone dare), it is still possible to argue incompetence; 'because other practitioners appear to be managing' in their roles.
They are not (of course) they are scraping by as best they can and covering their backs, by following orders with a reduced service to client/patient. Or else they are stressing and working past normal time to make up the difference. Any number of effective methods are used to cover the shortfalls, rather than risk any criticism of 'failing'. The bureaucratic system is governed by fear & denial, from top to bottom.
Who can blame people just doing what is essential, cheating the statistics, passing on workloads to others, leaving a pending problem till it becomes unavoidable, missing appointment and still having to skip lunch. No surprise that we may make increased administrative mistakes and, heaven help us, even clinical errors. Getting tired, disillusioned and eventually going off sick, tired and broken.
The constant pressure to perform under unacceptably dishonest, disempowering, degrading & infantilising circumstances is intolerable and immoral. It provides the worst working environments and, most importantly, it provides the worst kinds of services. Services that are generally disempowering to clients, patients & family carers, some who are almost apologetic for bothering these services, or else angry.
Topsy Turyy Health & Social Care - Oppressive Caring:
Sadly, it is those who are able to maintain the strongest professional commitment and persist in the face of adversity, who put themselves at biggest health risk today. The healthy thing to do is resign oneself to the fact that we will never be able to do more than protect and contain, at the point of crisis. We are even advised to do this. Gone is the commitment to service and a true sense of vocation, that was once respected. Gone is 'enabling' professional supervision.
What would Florence Nightingale, or Lena Dominelli have done, if they were effectively told to 'put up and shut up' in this way. Silly me; I forgot, we are all expendable and replicable and should not have expectations beyond our calling; sorry, I mean; our pathetic, lowly position. The process we call 'regression to the mean' has set in once more. This is were we get a poor average service, from working within our mean institutions. Now, our institutions can seek for the 'lowest common denominators', in order to cheapen the services further.
Well, I have to admit that I have somewhat succumbed to this pressure and resign myself to sit back and critically reflect a little, not just upon myself, but on the institutions I have worked for. I have decided to write about these experiences. This is in the hope that the Institutions will be less able to hide their failings & mismanagements and the quite obvious reasons for them. More importantly, in the hope that we finally acknowledge that this social experiment did not work. A new perspective is required, with a youthful vocational spirit.
Our modern Health, Social Care and Community services do not have the true, social entrepreneurial spirit and lack the vision necessary to produce effective services that professionals can creatively enjoy providing. This would involve the proper management of risks, rather than suppression of them. This would require Assessment of Need for 'Inclusion', not 'exclusion'. Real change and growth is not possible without this. It is a quality of calculated risk that has to be shared between all involved, in the truest sense, including with our clients, patients and family carers. Early, empowering intervention is key.
An appropriate level of Professional autonomy is essential, along with a commensurate level of accountability and occasionally, culpability. This should be shared with managers and supervisors. We need to stop kidding ourselves. We can not continue to avoid individual responsibility and face the fact that our clients / patients engage in the real world of their choosing and that involves known risks. Such is life; attempts to suppress risks oppresses people. Who are we protecting?
Life involves risks, else should we continue to cajole and seek to incarcerate people against their known, historical and current wishes. Not to protect our clients & patients, but (as in the past) to protect ourselves professionally and institutionally. The institutional risks are greatest in the specialist areas of learning difficulties, mental health, dementia care, alcohol & drug dependencies and cases of serious brain trauma. For many people, we are the oppressive Nanny State.
These misunderstood 'mental capacity' issues can also affect our perceptions of the additional, marginal 'mental health' features, that may be apparent in the case of any physical, sensory, or social problem. The misunderstanding of risk and mental capacity actually increase the risks, as does the misunderstanding of transitory poor health, in combination with any recognised incapacity, or combination of presenting difficulties a person may have.
People are not their 'primary conditions', they are complex and variable, with differing expectations from childhood onwards. We must respect this. They have a right to 'react' to injustice. Our Ethical obligation is to respect this individuality and the person's known wishes, whatever the institutional fears of litigation. There needs to be real, equitable contracts between professional and service users.
How to become (and make things) 'Upright':
We need to make sure that patient / client expectation and prior experiences are known, before making important decisions that affect the remainder of their lives. Remain open to revision of assessments and changes of heart, acknowledging mistakes and misinformation. We need to be willing to try the least restrictive practice and revise our professional conclusions, almost by the minute.
We are obliged to take a truly 'no shame no blame' approach and ensure that everyone in the network of care feels supported and appreciated. This includes the service user, who even with the severest of problems, should be encouraged, informed and enabled to play the fullest part possible in their treatment, recovery, enablement, or retirement. This should not feel embarrassing, it is more than merely to do with words. We know when people are distressed, or happy!
We (or our professional predecessors) set up the expectations that all will be done for people in crisis. We can not expect to see this attitude and expectation change overnight. Family Carers have their wider family responsibilities. The challenges and demands of modern living usually means that they are not adequately available for providing 'care' and it is not always appropriate that they should.
A family carer who 'cares' under duress, in ways that are forced upon them, by the expectations of others, circumstances and a sense of induced responsibility, is no better a 'carer' than the professional who feels obliged to do the same, under these conditions. It should be a supported and rewarding experience, which is adequately funded and compensated for, properly supported by community resources.
A Carer assessment without support, is worse than useless. A referral to a low cost domiciliary, or residential service should be followed up with proper professional support and proper integration into the community, not just periodic reviews and a pat on the head, with a few criticisms. Passing the buck, with a few pennies and a all-inclusive institutional package, is not social inclusion, we are kidding ourselves.
These placements are not adequately funded to provide the the full level of professional and specialist support that can and should be provided. Community Services are the entitlement of all members of the community, wherever they live. A small institution cannot provide all the legitimate personal and social needs of the person. Institutions can become as isolated as they can be isolating. Care workers and clients are disempowered and neglected alike.
Opting out of this wider support is negligent, unless we pay for a much fuller level of service. The same is true of our own services. You can not do it on the cheap. Efficiency and economy is OK, in its way, but this is not a production line. The situations are not as predictable. People are not machines. Good support produces good motivation and greater independence, for longer. You get what you pay for in the end.
Seek for 'quality of life criteria'. Find them and you obtain a motivated individual who wants to continue to do their very best. Make the professional and the patient / client experience enjoyable, fulfilling & mutually respectful and you will get the best out of both sides. That is how efficiency and economic criteria can best be met, with greater persistence and having satisfactorily met the ethical requirements.
The Obligations of Social Inclusion, falls to US!
One final point. People who are 'disabled' in taking on employment are often keen to do something worth while with their time. Most people who have become low in self esteem value the opportunity to help themselves, often through 'helping others' in various ways. Most people who have been disempowered, by their experiences, can learn to represent themselves and others, in seeking improved community attitudes and services. Enabling this is all of our responsibilities.
Service User Volunteers are some of the best volunteers you could hope for. It can take some time to help them gain their confidence and appreciate their skills, but once discovered they are capable of providing a viable, Service User led, community resource. These are best obtained by resourcing their initiatives and and the active promotion of 'informed choice'. We need to utilise the anger and frustration of those who most 'feel' socially excluded.
In rural communities in particular, appropriate meeting locations, the means of communication and availability of transport, are essential to make these kinds of community projects happen. They are also the ideal basis for promoting service user conferences, largely lead and organised by themselves, but actively support by professionals on a 'consultative' basis. Social Inclusion is about promoting involvement at all levels and ways. It is not just a condescending 'committee' thing.
These positive initiatives have been tried and tested in the learning difficulties field, over 35 years ago. It is the ideal means of empowering people and obtaining the type of service that most benefits them. Similar projects were very productive in mental health, some 15 - 20 years ago. Most of the successful, user led projects are inner city centres and larger towns. The counties are unacceptably far behind.
It takes more effort to ensure projects develop and survive in rural areas, because of social dispersion and relative individual isolation. Rural counties are 20 - 30 years behind the times in these initiatives and so, they lack the experience in 'enabling and supporting' such projects. It is easy to loose the initiative and motivation, out of shear frustration from broken promises. Instead of making promises, we need to get on and DO. Social Inclusion need costs very little.
Organising 'Real' Community Based Services:
Best Practice and the most cost effective arrangement, for Community and Therapeutic Networking, is based upon the 'Core and Cluster' structure. This was originally developed in United States Learning Difficulties services. It was an initiative started, following a constitutional challenge to the poor Human Rights provided to people with learning difficulties, by the large professional institutions.
On the same basis, and for much the same reasons, this can also be argued (and has been shown) to be beneficial, in mental health recovery and support. It also has good potential in dementia care. The core and cluster arrangement is simply the setting up of small service user support networks within the general community, with 'care' inputs, consultative professional input and hands-off administrative support.
These support arrangements may be limited to specific types of client problems, but are more usefully 'generic' in character, perhaps with some 'assigned' specialist, 'on-call' support. Service User, volunteer representative should have the primary Organisational Roles. Where necessary (due to Mental Capacity) these are shadowed by other volunteers, who are supportive to the Service User's initiatives.
The 'Core' component is the social and administrative hub from which and within which, consultative support is made available and regular gatherings of the cluster members are organised. The ideal 'Core' location is a general community resource, like a community centre, town hall, possibly with an existing voluntary service playing host to the visitors; who can be the established 'network' members, or those needing temporary support, or just social company and activity.
By keeping most professional involvement at the administrative levels and performing a consultative, or advisory role, the project remains largely independent, self supporting groups, that are not cluttered by the usual bureaucratic restrictions and encumbrances. This proud independence is essential, even if there is some measure of apparent inefficiency. Trust is thereby established and, as a result, those who go into crisis are more likely to turn to professional help early.
Professionals and seconded expert volunteers, can help with setting up and registering charitable status, should this be wanted, or needed. They can also help the evolving User Group overcome any bureaucratic difficulties that can arise. Every effort should be made to avoid the establishment of a mini institution. This changes the whole character of the organisation and most of the benefits are then lost.
Whatever charitable status is decided (if any) the core group's formal constitution should clearly state that the purpose is to facilitate and maintain independent function of a self-help, service users & ex-service users and others with appropriate personal, or social needs, that may 'fit' and benefit from the services provided. This arrangement can include a provision for including 'seconded friends' of the group.
Ideally, the groups, and individuals within the groups, should have access to professional resources, should they need these in an emergency, or for specialist advice and guidance at the groups request. These groups and networks also make excellent 'reference groups' for Service Providers, wishing to get the views of the typical users of professional and community services.
One way of additionally supporting these projects is through the use of direct payments and grant arrangements. The professional time has a cost, as does the transport provision, but these can be reasonably managed as part of secondment arrangements, from a wider service. With and without charitable status, local commerce and voluntary agencies can and are often very willing, to provide support in kind; rooms to use, facilities and even personnel to act in support roles.
If the provision of a vehicle for the project is not possible, the use of local 'link' services and voluntary car drivers, can be a good option for small groups. Ideally, there can be the provision of a vehicle for the core & cluster groups use, with volunteer drivers recruited to run the statutory, or otherwise funded vehicles.
Perhaps this transport arrangement can be part of a more general, multiple purposes, community resource, thus getting the best advantage out of the transport provision (perhaps the most expensive initial component, especially in rural areas). Whatever the identified difficulties of members, the 'mobility' and 'accessibility' of resources is often a primary inhibition to true community based services.
The more that these groups can use existing community resources the better, as it tends to add to community education and encourages better quality and more inclusive social integration. It is also true that many people, with widely differing problems, often have very similar root to these problems, or very similar consequences. No disrespect intended, but; 'Society Disables and People make us sick'.
© Terry Couchman, July 2008
At Last - Genetic Evidence to substantially confirm two important predictions I have made.
These were based upon my own direct evidence and through Operational Research; while operating a Therapeutic Community, Undertaking Community Work, Therapeutic Social Work & Counselling, Social Work Advocacy, Mental Health practice, Commercial Operations, Social Care Consultancy and by helping establish local, Therapeutic 'Service User' Networks.
This direct 'talking treatments' type work and operational research, including longitudinal, family, group and institutional studies, was undertaken over more than a 40 year period (actually 54 years, including the work done in my childhood from the age of 6, as the earliest that I can remember and accurately, critically and reflectively recount).
Prediction 1: There will never be direct evidence of the predicted Schizophrenia Gene (or Bipolar genotype), but there may be a genetic association with creativity, genius and other potentially beneficial social adaptations, (Organic psychosis is otherwise accepted as a 'similar' manifestation, which can be due to genetic, organic, or any serious toxic agent).
Schizophrenic symptoms are predictable negative manifestations of socially & environmentally induced practical, cultural, psychological, or emotional trauma and the social inhibition (frustration) of a person's natural creative process & expression. It is often initially triggered by temporary 'toxic', or 'cultural' shock, then maintained by inappropriate social & clinical treatment, or actions (especially following a formal misdiagnosis of organic, rather than a functional, or reactive condition).
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See: www.psychminded.co.uk
Feature: Sept 5: Schizophrenia gene, where art thou? Molecular genetics has failed to reliably identify DNA for schizophrenia. So has the search been a complete damp squid? Adam James examines the evidence.
Terry Couchman suggests that we now get on and work with the real, underlying social causes." Wake up 'Mental Health'. More shocks to come. It is Social & Community Health we need to be looking at".
For some further Insight Click Here
Further Gene Studies
PsychMind Report
April 14,2008: "Unlikely" that key genes cause schizophrenia - according to most comprehensive genetic study of its kind. Reported in the American Journal of Psychiatry April 2008.
Terry Couchman has come across 2 more clients, classified as having Schizophrenia (out of 2 that have recently met with us in the Community Project), who have apparently overcome their condition, to the point where they have reduced, or come off their medication and now seek to to be re-assessed.
This is no cure, they identified the discrepancies for themselves and sought alternative help and advice. These are just further cases of misdiagnosed drug and trauma induced 'temporary' psychosis. One has been reclassified, the other is seeking this.
There is also, at last, an increasing trend to avoid classifications of Schizophrenia, an assumed genetically based condition. Sadly, the use of the term 'Personality Disorder', or to avoid a formal diagnosis all together, is rather neglectful. This resulting trend is a little worrying, as it is clear that these people have problems, it is just that they are socially induced, rather than manifestations of genetic inheritance.
We have to ask ourselves why institutional Psychiatry is so uncomfortable with the idea that the identified condition is proving to be a social ill rather than organic in its nature. I have my theories and they are available here. See: Current Features, Social Adaptation, Relativistic Psychology & Transformations
Prediction 2: ADHD and Dyslexia will become recognised and progressively evidenced, as misrepresentations of the observed evidence, by people currently unable to conceive in these 'alternative' intelligent ways of perceiving, conceiving and understanding. (Psycho-social Rule: It is possible to 'Explicate' up to one level of understanding below the level at which we Intuit).
This psychological / psycho-social feature is, in fact, an advanced form of integrated, largely 'intuitive', creative process of multi-channel, multi tasking, multi sensory observation, hypothesising, theorising, testing & generalising ideas. The child / Adult is only able to 'express their understanding at the highest level for which they have 'words / concepts'.
In leaping to this conclusion (in all but the most damaged cases) we are perpetuating the 'disablement' that is assume to be the consequence of a 'disorder' when, in fact, it is a manifestation of mal-treatment, whether drugs are used or not. We have self fulfilling prophesy, creating the 'reactive' behaviours that are used as evidence to support the mistaken assumptions. See: Current Features, Social Adaptation, Relativistic Psychology & Transformations
Radical Perspectives on 'Problem Children (and Adults)'
& ADD(S)/ADHD:
See: http://www.psychminded.co.uk/
October 1: Drugs should not be first-line treatment for ADHD, doctors told - and NICE says medication should not be prescribed at all to pre-school children with ADHD
See: Attention deficit hyperactivity disorder or hyperkinetic disorder (Including Dyslexia).
Well, no one said having kids, or teaching would be easy, just because they don't think and act like you doesn't mean they are stupid. In fact they may well be cleverer than you in many ways. Watch out for our alternative stories, where it could be you, or your society with the problem (it usually is).
Beware clinicians and experts looking for power, fame and fortune. Just as a taster, try this 'Pill': Get Attention 'Deficited' (and Get Real). Most of what is stated on this link is fundamentally true, but they want you to buy the books. I am not recommending that. All that information and more, is free on this website. Go to: ADHD Unplugged
© Terry Couchman, July 2008
Professionals and Managers are sometimes too arrogant and too quick to jump to identify problems as being 'within' individuals, rather than a manifestation of their own and others prejudiced perspectives and intellectually induced ignorance. Critical Self Reflection is essential, but so is Critical Perspective on Institutions and the Professions. We are not that advanced!
Psychminded Latest: