6 Broad skills for mental health nursing
Introduction
This chapter aims to examine the techniques and skills in mental health nursing that lend themselves to working across any area and with any diagnosis. The following discussion considers the skills of communication, facilitating a group, solution-focused working and health promotion. The opportunity to develop these skills should be available in any placement area and will often provide the basis for meeting a substantial amount of your learning outcomes.
Communication skills in mental health settings
This section will explore an intentioned, purposeful and effective approach to communication as it can be used by mental health nurses in different clinical settings. The application of this skill by nursing students will also be examined and discussed.
The first premise made in this section, as inferred above, is that there is something special about the skill of communication as used by effective nurses (Crawford et al 2006). This skill may sometimes be quite different from those used in non-work or social situations. This specialness is rooted in the nurse's ‘intention’ (Heron 2001) which originates in what the nurse is trying to achieve as part of care management.
Consider a community psychiatric nurse (CPN) calling at a service user's home for the first time to make an initial contact and assessment. The CPN will have a range of clear intentions. Some of these intentions will be clearly planned and obvious to an observer. Others may be reactive to the immediate situation, more subtle, not so easily detected and may even be such an integrated part of the nurse's professional personality that they are not aware of performing them until asked to reflect on what they are doing. For example, the skilled CPN is able to often process through a sufficiently comprehensive assessment of a service user, almost as if an everyday conversation is taking place (Bonham 2004). There is no sense of a ‘cross-examination’ or intrusive questioning. Areas of the service user's experience are examined and assessed with the minimum discomfort for the service user. At the same time, the nurse may sometimes be experiencing, at a deeper level, feelings or emotions which in a social context may be difficult (Bonham 2004). The experienced effective nurse develops the ability to manage these tensions by, for example, clinical supervision. Ask one of your mentors to give you illustrations of this.
Review the list of intentions below with one of your mentors. Discuss which they routinely have, which they rarely have and which ones they have that are not listed.
During interactions with service users, the CPN intends to:
Create a climate of trust and approachability.
Enable conversation to occur as naturally as possible.
Keep the focus of the conversation with the service user.
Explore issues being experienced by the service user.
Listen intently to the language and delivery used by the service user.
Support, validate and reassure the service user as appropriate.
Do the above with any significant others who may be involved.
Include any coworker (for example, you as a student).
Limit questions that are asked to those which have a clear purpose.
Encourage questions to be asked by the service user.
Involve the service user in any plan of treatment.
Be aware of timing, in terms of the needs of the service user, and other professional caseload demands.
Clarify any issues which are unclear to the CPN, the service user or any other involved party, before finishing the visit.
Leave the service user at least no more distressed, or anxious, than when the visit started, and possibly less so – if at all possible.
Summarise any action or plan arising as a result of the visit.
Confirm that the service user understands any action or plan.
Confirm that the service user understands what is happening next, in terms of any input from the CPN or any other care professional who may be involved.
Finish the visit at an appropriate point, and in a congruently positive way, if at all possible.
The CPNs you work with may have more intentions, or a few less, than in the examples below, but you will see that the below sequence suggests a thoughtful, deliberate, intentional and strategic approach. This is very different from social interaction with friends, family, neighbours and so on, which is often more spontaneous, less considered and less goal or outcome orientated. The effective mental health nurse will therefore be constantly ‘at work’ within clinical areas. Some of this work may appear to be ordinary everyday conversation (Burnard 2003).
Consider this example. A mental health nurse is sitting with a service user in a secure rehabilitation unit. The nurse is wearing a uniform and has a highly visible personal alarm. Yet, to an outside observer, it looks as if the nurse and service user are at ease with each other. They could almost be friends having coffee together.
Consider though … this is not a social relationship. One person is a service user and one person is a professional receiving a salary. This is a professional being friendly, not a professional being a friend (Murray et al 1997, Jackson & Stevenson 1998). Just like the CPN above, the mental health nurse, in this quite different clinical environment, has a range of clear intentions which could be as follows:
• Be approachable (if you don't have this, how can you be effective?).
• Use social connectors such as a cup of tea, a newspaper, TV programmes, sport, plans for the day, and so on.
• Be aware of time constraints such as shift changes and meal times.
• Be aware of personal limitations – tiredness, other service users arranged to be seen during the shift, care plans to update, liaison with other professionals.
• Assess. How is the service user at this moment? Different from earlier today, yesterday, last week? If so, in what way?
• Edit. What is going to be added to the care plan as a result of this assessment?
• Be aware of anything that needs to be communicated to other colleagues – the service user is becoming increasingly agitated, the service user is more settled, etc.
• Create, sustain or finish a professional relationship.
• Maintain continuity – in terms of being clear to the service user that you will be back on duty tomorrow/next week/not at all.
Again it is clear that the nurse in this setting has some similar intentions, but some different intentions, from the CPN in the earlier example. Intention is, therefore, a function of the complexities of the clinical setting, the desired outcomes of the service user and for the service user, combined with the personality and desired outcomes of the nurse. This is perhaps why, despite having carried out what appear to be little more than a series of social interactions (but in a clinical setting), most effective mental health nurses find the work demanding and tiring, but also often very satisfying.
If the above range of intentions is examined more closely, they can be separated into identifiable skills. Most of these can be found in the body of literature on therapeutic interventions, communication skills, counselling and so on. This confirms the existence of a robust evidence base for the skills and attributes. These can be considered and discussed in the classroom, then practised in placement. As confidence and proficiency increase (this is a slow process for most people, by the way), the skills can be combined and blended into each other. They will become less conscious and more a part of your natural professional personality (Benner 1984).
Intention as separate communication skills and attributes ‘Clusters’
Much of the literature on ‘beginner’ communication skills separates verbal from non-verbal skills. That separation will be apparent in the descriptions below, but you will also see how the two can be skilfully combined to form an effective, integrated whole. The following descriptors are the qualities you will see demonstrated by effective mental health nurses (and other mental health professionals) you will meet. They are not the raw communication skills you will see listed in most other texts. For instance, skills such as use of eye contact, touch, body positioning, voice tone and so on are discussed in the beginner literature. These areas will be discussed in classroom sessions during your time as a student nurse. Once you have considered basic separate skills, however, it is essential to refocus on the purpose of them and learn how to integrate them together.
Discuss with your mentors how basic skills can be used to start to achieve the following more meaningful communication skills and attributes:
Approachable
This is where it all starts (Bonham 2004). As a professional mental health nurse you are, in effect, being paid to be approachable. Other mental health professionals can use unapproachability to maintain distance between themselves and service users. It is a primary function of the mental health nurse to close that distance, professionally and skilfully. Not all service users wish to engage with mental health professionals, or even be friendly. If you are not sure what the individual components of approachability are, think about the colleagues you have met on placement. If you are just starting your career as a nurse, think of people you know who have this quality. What is it that seems to give them approachability? You'll find that the answer to this often lies in what they do, as much as in what they say. (Also consider – do you want to be approachable all the time?)
Consider with your mentor, or other students on your course, the skills cluster required to achieve approachability. Some components are the following:
Suitably engaging eye contact (Egan 2002).
A friendly or open demeanour (Bonham 2004).
Professionally available body language.
Manipulation of the environment, such as an open office door, or the deliberate positioning of oneself within the service user group rather than the professional group.
Choice of clothing that suggests equality rather than superiority or striking difference, together with clarity of boundaries, i.e. the clarity has to be meaningful for the service user.
Identify with your mentor how you might demonstrate approachability and the opportunities which you might have to reflect and gain feedback on your approach.
Honest
This personal characteristic is a good example of the difference between professionally outcome-driven strategic communication as a skill, and social communication. In social situations you are at liberty to be deceitful, avoiding or open and direct to the point of brutality. You can ‘call a spade a spade’.
In professional situations it is essential, for the safety and care of service users and your own professional credibility, that you are more considered and careful about what you say and how you say it. This pre-editing of your natural spontaneity can sometimes feel like avoidance or professional economy with the truth. The mental health nurse will often be in the situation of knowing more about certain issues than the service user. Often information is withheld from the service user as it is deemed to be ‘… in their best interests’ (Nursing and Midwifery Council 2008). This view needs very careful consideration and must be the result of a multiprofessional consensus whenever realistically possible. Reflect with other students and your mentors on how to best manage these situations.
Encouraging clarity
This is a skill rather than a personal characteristic. As above, its use can be very different in professional situations compared to social situations.
In the first example no effort is made to explore the nature of the word ‘hate’, the nature of the situation and the reasons for this view. In the second example the nurse has a strategy or intention to clarify. It may not be achieved immediately, during the next exchange, but the nurse is making a professional effort to tentatively (Bonham 2004) find out more, as part of a longer term assessing or monitoring, perhaps. It is important to note here that the above phrase ‘What do you mean, you hate it?’ can have many different impacts depending on how the words are delivered by the nurse. Try rehearsing some of these with another student and experiment with tone of voice, eye contact and general demeanour, to see the effect on the other person.
Consistent
Again, this aspect of communication can be very different in professional mental healthcare settings as compared with social situations. It does not mean ‘sticking to your guns’ regardless of changing circumstances around the care of the service user. The term means to be considered in your behaviour and attitude. These are two personality traits by which your effectiveness may be measured by service users and colleagues.
Both nurses in the examples above will be assessing, planning, implementing and evaluating the care they give (Norman & Ryrie 2009) as part of a consensus team approach. Even the CPN, who is more autonomous in terms of needing to make decisions about the care given, has to refer back to a team for support. That team will continue to give consistent, planned and agreed care. The original direction of this care may have come from the early meetings between the service user and the CPN. The team supports the carrying through of this care. So, to be consistent, the nurse must be empathic (Rogers 1951) to service users and colleagues, assertive with both, an effective listener to what is said and what is not said by both, sensitive to cultures and environments, a lateral thinker (de Bono 2009) and be open-minded to the ideas of others.
Transparent
Some other terms that can be linked to this are honesty, congruence, genuineness and authenticity (Rogers 1951). Like many of the attributes discussed in this section, transparency is not just something that is used in your interactions with service users. Some examples of transparent practice are the following:
• Fully including service users in all aspects of the management of their care, even the unpleasant or difficult ones, such as restricting their movements or unwanted adjustments to medication.
• Giving service users access to information written about them.
Just a little experience as a mental health nurse will tell you that the above examples of practice can sometimes be very difficult to carry through, and may actually have a negative effect on nurse–service user relationships. It can be difficult to judge an appropriate level of transparency when taking into account the immediate needs of a service user and the consequences of accessing or denying those needs. Transparency is something that is aspired to, but not always achieved.
Optimistic
Your work as a mental health nurse means that you are a professional optimist (Bonham 2004). In your personal life you may be pathologically pessimistic. In your professional life there is always hope for the service user you are working with. Looking at the caring role of the nurse at a very basic and pragmatic level, if you cannot visualise any hope for the service user you are working with then perhaps it is in the service user's best interests to minimise therapeutic contact with them. This might mean asking a colleague to take over the care of the person, referral to a more suitable care agency, arranging clinical supervision to reflect with another how hope might be found or a team consensus may be to no longer engage with that person. An example of this is the person who continually self-harms despite, and regardless of, a range of therapeutic interventions by different concerned professionals. There may come a point when the input starts to become counterproductive. It may be more caring to withdraw support in a planned way, to try to foster independence, rather than dependence. This is in line with contemporary ‘recovery’ approaches (Repper & Perkins 2003) (see Ch. 3).
Ordinary
This is sometimes seen as a rather strange attribute for a mental health nurse – the ability to be ordinary or to possess ordinariness. It could be argued that this is a re-presentation of Rogers' core condition of congruence (or genuineness, honesty, authenticity). It is not. Ordinariness is a separate entity. To a large extent, within healthcare literature, clear references to ordinariness are few. The term is used in passing as the focus of the text is foregrounding something else. Occasionally it features in its own right as an attribute that some nurses have (Burnard 2003, Bonham 2004), and that is appreciated by service users. This does not just apply to mental health settings. Oblique reference to ordinariness can be found across the complete spectrum of health care (Dunniece & Slevin 2000, Blomqvist & Edberg 2002, Giske & Artinian 2007, Hopkins & Niemic 2007). To paraphrase these ideas, the nurse who has this therapeutic attribute can use their ordinariness to consolidate any stage of the therapeutic relationship. It can manifest itself in the following ways:
Knowledgeable
Even students who are at or near the end of their nursing course express the idea that they don't know enough to work effectively. Becoming deeply knowledgeable can only ever be a gradual process. Clinical experiences can accelerate and deepen knowledge in relatively narrow or specialised areas. For example, a mentor or a tutor with a particular interest or enthusiasm can help develop a focused knowledge within students. Thus, the nurse can become knowledgeable in the specific characteristics of the narcissistic personality disorder, but not know where the pharmacy is. Service users and colleagues usually do not expect even experienced staff to know everything. The key piece of knowledge for the student or newly qualified nurse is how to find out where the pharmacy is, what ward visiting hours are, when the consultant holds review meetings and so on, and then actually do it.
Reliable
Many student mental health nurses would probably consider this attribute as insignificant. Many mental health service users would probably think in a similar way. The time when reliability becomes most noticed by mental health nurses is when it is absent in a colleague. The time it is most noticed by the service user is when it is absent in a professional.
The nurse who is regularly absent from work, who is late for the start of a shift, who is missing from team meetings, can quickly become a liability to a team and may even become destructive to any sense of teamwork. The nurse who is often late for appointments with service users, or who has to regularly rearrange or miss meetings, quickly becomes the unwitting saboteur of any therapeutic relationship. The student nurse who often phones in sick, does not phone in at all or has unplanned extra ‘study days’ becomes, in effect, an addition to the caseload of the mentor. Reliability is viewed as a ‘given’ in the range of essential mental health nurse attributes. Its absence is very noticeable and not appreciated.
Thoughtful
This could be remembering the names of people’s significant others, of both service users and colleagues, or remembering meaningful dates and anniversaries. It could also mean being aware of colleagues who are having difficult lives outside of the work environment and facilitating adjustment to this if needed.
Confident
Most mental health nurses acquire this with accruing experience, accumulating knowledge and the passage of time. They start to feel more a part of a team or a culture. This really starts to happen once you become a qualified nurse and can settle into becoming part of a team, rather than a transient supernumerary person passing through. Queries can be answered without reference to a senior or more experienced colleague. Difficult situations can be managed by leading rather than following. This process can be constructively accelerated by using clinical supervision, self-reflection, peer reflection and so on.
Empathic
The often quoted understanding of the quality of being empathic, or demonstrating empathy, is to have the ability to ‘… get inside the service user's world and experience their thoughts and feelings in that world …’ (Clarke & Walsh 2009). It is definitely not about having had the same experience as someone else. It is more about having the ability, or at least willingness, to try to get a sense of what the other person is experiencing now, has experienced in the past or may experience in the future. An essential characteristic of being empathic is the verbalisation of this sense. It is no use to the service user if you are thinking to yourself as they describe their problems: ‘That must have been pretty difficult for them.’
An example of how the service user could be included would be:
Notice that in ‘Service user response 1’ the nurse has been effectively empathic. She has focused on the difficulty of the situation by thinking about how she might have felt in a similar situation to the service user. In this instance the service user responds by confirming that the nurse's thoughts are appropriate (or near enough). This shows the service user that the nurse has been listening and is, at that moment, ‘tuned in’ to the service user. The nurse's verbal response is a clear example of ‘active listening’, i.e. there is a clear active response by the nurse. Notice the carefully questioning tone of the nurse's intervention. She is being appropriately tentative, and not overconfident. This is a sustaining attitude to have, in terms of keeping a therapeutic relationship productive.
In ‘Service user response 2’ it looks at first as if the nurse has got it wrong. You will note, though, that the service user gives a new piece of information to the nurse. The story has changed direction, but the nurse's initially misdirected attempt to empathise is the catalyst for this.
In ‘Service user response 3’, again, it looks as if the empathic intention has missed the mark. If you examine the service user's response, however, you can see that again it contains ideas from which the therapeutic dialogue can be usefully developed further. As long as you are thoughtful and careful, your attempts at empathy may not always be accurate, but they will more often than not be useful in terms of advancing the therapeutic process.
Assertive
This is not about always getting your own way. It is important to realise that the job you are training to do will involve you in conflict of some form at some time. The effective nurse will learn when to avoid conflict and when to become involved in it. The conflict may be with any other person you encounter during your working day. It can be with service users, psychiatrists, social workers … anyone. Conflict will be caused by issues from the differing views of what is in the service users’ ‘best interests’ through to the territorial behaviours of healthcare professionals. The nurse can be the unwitting catalyst of this conflict trying to advocate for a service user, for example. Or she may find herself acting as the mediator between a social worker and a relative of the service user.
The effectively assertive nurse will be able to listen to a range of views with a relatively detached degree of objectivity (Bonham 2004). They will have the skills to paraphrase and summarise the views of themselves and others (Bonham 2004). They will be aware of body language – both controlling their own and reading that of others.
Accepting
This is an ability rather than a skill. The term may be seen, in other texts, as ‘non-judgemental’, possessing ‘unconditional positive regard’ (Rogers 1951). It means that the effective mental health nurse can meet with and interact with any person that she meets professionally, and leave her own values, attitudes and beliefs outside the assessment and treatment of the service user's issues. The evidence of this can be seen in a consistent, considered and measured approach to all service users, regardless of the history they bring with them.
Use of language
The confusion caused by misunderstanding language and consequential inappropriate or poor treatment has a long history in all forms of nursing and especially mental health nursing where culture and nuance of language are pivotal in assessing and treating accurately.
Think about the countless ways in which these few words can be delivered to you as a student nurse by people of different:
What might be the implications of this and how might you ensure that you ascertain the right meaning for that individual?
The meaning of each of the above statements will differ according to who is saying it and the manner in which they express it, be that speaking, whispering, shouting, writing or texting. It is part of your job as a mental health nurse to be consistently reliable and accurate in your understanding of what people mean, and transfer some or all of that information verbally and/or in writing to your professional colleagues appropriately while at the same time taking into account issues such as confidentiality, privacy and dignity. The student nurse whose first language is not English may need extra support from their tutorial staff and clinical mentors.
Pitch
This is the skill of being able to account for or compensate for the diversity in communication, language and intellectual abilities that mental healthcare management will present to you. Consider how you alter your ‘pitch’ to communicate effectively with a terrified Iranian asylum seeker who has been admitted to your ward as compared to the pitch you use with the teenage son of a woman suffering with psychotic symptoms who you visit in her own home.
Non-verbal presentation of the above
Eye contact
There is no such thing as ‘good’ eye contact. The effective nurse uses appropriate eye contact depending on the situation presenting. Sometimes this can mean very little eye contact, or even no eye contact. Discuss with your mentors how this could be true.
Demeanour
Positive, approachable, relaxed, respectful, at ease with oneself – these are ideal components of a therapeutic demeanour.
Touch
This is a very potent means of communicating quickly and deeply with someone, but its use needs a considered approach. To use touch spontaneously can have a mixed result. Its effect can be welcomed by the person being touched. It can be very comforting. On the other hand, it can be received as offensive and distancing. It is to be used with great care.
Levels
Consider how you might best communicate with a confused and frightened female service user of 85 years old, as compared with a 9-year-old male service user. Should you be using your body language to help you work more effectively? If a child is playing on the floor it might be most effective, in terms of connecting with them, to sit in the floor at the same level. There is no clear rule for this kind of situation. It is clear, though, that consideration of issues like this makes a great difference to communication channels.
Proximity
Similarly, how near should you position yourself to service users? Should you be across the room, or close enough to touch them? Your proximity will make a considerable impact on the effectiveness of your interaction. Variables such as the clinical setting and relationship with the service user will help decide the optimum positioning you should take to maximise your effectiveness. Discuss how proxemics are considered in clinical practice with your mentors.
Tone of voice
A hard tone of voice may be distancing. A soft tone may be patronising. The tone is one of the key factors that govern how a spoken message is received.
Gesture
Do you ‘windmill’ your hands around or keep them in your pocket when talking with others as a professional? As above, it is useful to reflect on this with other students and mentors, specifically how hand movement can sometimes help, or sometimes distract, from the effectiveness of a professional interaction.
Self-awareness
Why it matters
Self-awareness is important because, as part of your job, it is essential that you maximise the effectiveness of your communication with others. This is particularly important in the field of mental health nursing as so much of the job is communication, using voice, body language, telephone and writing. In all these media you present a version of yourself that gives others an impression of what you are like as a person, and what your intentions are as a professional. It is important, therefore, that you manage the image that you present. Poor or inaccurate awareness of yourself means that this can be a very hit-and-miss process.
Impact on others
Even as a student nurse you have the potential to significantly alter a person's experience as a patient. Remember what it is like for you to be waiting in a room in a strange environment with people who work there coming and going without acknowledging you, or letting you know what is happening. It can make a huge difference to a person's experience by taking the trouble to just let them know that: ‘The doctor has been delayed on another call … she'll be about another 30 minutes. I'll let her know that you've arrived’.
The way that these few words are delivered by you are highly significant in terms of the effect they can have on the recipient. Say the above sentence with different tones of voice, or with a smile then a frown. Imagine the different impact you can have with these changes.
How you gain it
You look for it – in the reactions of others towards you. How do others react to you? Are they calmer, more agitated, indifferent? You acquire it by copying the good practices of the other professionals around you, and by not repeating or colluding in the poorer practices you might see. As a student you are in the perfect position to ask for feedback from your mentors and supervisors as part of your professional development.
Social self-awareness and professional self-awareness
These two aspects of you are different. As mentioned above, the most significant difference is that you are being paid to be effective and efficient at being a nurse. When you are on duty you represent the organisation that pays you. Your customers (patients/clients/service users/residents/other professionals/general public) are entitled to a professional, respectful, efficient service from you as a mental health nurse. This is regardless of the stage of training or career you are at, or the clinical setting.
Off duty, people will still have expectations of you because of the traditions of the job you are training for. In some respects, then, the need to be aware of self carries on after you leave your area of work.
One way of enhancing your self-awareness is to critically question yourself on assumptions or decisions you have made. For example, when people ask you why you wanted to become a nurse you may respond with something like ‘I enjoy working with people’. If you ask yourself this question again you may have a different response which you wouldn't necessarily want to share with others but that you are aware influenced your decision. For example, you may have a family member who experiences mental health problems which has led you to be interested in helping others. Take some time to ask yourself this question and reflect upon how this might influence the way you practise as a nurse.
Solution-focused brief therapy
Solution-focused work has its origins within psychological approaches. It emerged in the 1970s, influenced by the work of key psychologists at the time. It was in the 1980s that it developed as a more defined therapeutic approach through the work of de Shazer and colleagues (de Shazer 1985, de Shazer et al 1986). The main premise of solution-focused therapy is that therapeutic gains (which are defined by the person using the service) can be achieved by concentrating on what the individual can do and what they want to achieve. Focusing entirely on problems and difficulties of the past are therefore seen as inhibiting the creation of positive changes for the future. Solution-focused work is a form of therapy where individuals can undertake specialist training. It is also designed as a ‘brief’ intervention so the number of sessions between an individual and therapist are minimal. However, it is a therapeutic technique which can be incorporated into the interpersonal work of a mental health nurse, particularly as it shares its underlying principles with the strengths model and recovery approach. There is an increasing amount of literature which examines its potential for nursing practice (McAllister 2007, Wand 2010).
The underpinning philosophy of solution-focused therapy is based on the view that the service users are the experts and that they are able to define their own solutions and set their own goals (Ferraz & Wellman 2009). Potentially this is quite a shift away from the traditional manner in which health professionals work. We are used to identifying and assessing problems and offering our expertise on a solution to this problem. Indeed, when first using solution-focused techniques it can feel quite alien. Yet, recognising the expertise offered by service users is important. Solution-focused techniques also offer a very practical application of the principles of the strengths model and recovery approach.
Questions which are solution orientated are employed to identify what the person perceives is working in their lives rather than what isn't. This enables the service user and the worker to focus on how solutions are developed and constructed, therefore creating positive change (Hanton 2009).
Solution-focused questions to elicit goals might include:
• What are you hoping to get from us working together?
It is important to recognise that the solution that the person proposes might not reflect the problem that professionals have identified that needs working on. For instance, someone might identify that they would know the work has been successful because they are being a supportive sister or they have started Karaoke again. These roles and interests may have become invisible within the difficulties and problems that their contact with health services has brought focus on. Accepting this difference in perceived priorities is part of the nurse recognising the expertise and experience that the individual brings, which is so significant within a solution-focused approach.
Such a form of enquiry also asks the individual to think about their preferred future and positive coping resources. This provides an opportunity to explore in depth how they might want their future to look different, moving beyond the problems they are currently facing (Ferraz & Wellman 2009, Hanton 2009). One of the main ways that this is addressed is by asking the ‘miracle question’. Framing this question may feel a little odd initially, for both the service user and the worker, particularly as it is so different from how we usually approach problems. It would be fine to acknowledge this at the start.
Miracle question
Imagine if you were to go to sleep tonight and you woke up tomorrow morning and a miracle had occurred. This miracle was that all the problems that were concerning you have been solved. However, because it took place while you were asleep you didn't know that the miracle had happened. What is the first thing that you would notice in the morning that would tell you the miracle has happened (de Shazer 1988)?
Using the miracle question provides an opening for a miracle and solution-focused conversation to take place (Wand 2010). This entails involving the individual in visualising and imagining the changes that the miracle would create in depth. Therefore, the miracle question may be followed by further questions such as:
• How would your husband/mother/partner know that the miracle has occurred?
• What is the first thing that they would notice?
• What will you be doing differently when the miracle happens?
• What is it that will be different when you are smiling more/talking to your brother/feeling happier?
This miracle dialogue can then be followed with asking the individual whether they have noticed any small part of the miracle taking place, exploring, therefore, their current achievements and resources as part of this process. Scaling questions are a really useful tool employed within the solution-focused approach. These can help break down what may seem overwhelming and out of reach into smaller, more manageable, chunks.
• On a scale of 1 to 10, with 1 being the absolute worst it can ever be and 10 being you are on top of things, where are you today ?
• Ok … you are a 2 today. What stops you being a 1?
Wand (2010) also provides some useful examples of how these kinds of questions may be used for someone who may be feeling suicidal. Solution-focused interventions consider that there are always exceptions, so look at times when the problem didn't occur or times when it wasn't as bad as the person expected. Exploring these exceptions is important, particularly when it can be difficult for the individual to identify positives, resources and coping. This enables them to consider a situation more optimistically.
The example below puts together the techniques examined here to provide an insight into how a solution-focused conversation may be conducted, picking up the conversation after the miracle question has been asked:
Nurse–service user interaction
Nurse:
As you can see, one of the important aspects of using a solution-focused technique is adopting the language that is used by the individual. It also entails accepting possibilities. You'll notice that the words used by the nurse assume that these changes will be made and reached (e.g. what will it look like when you reach 4?).
This section has provided an overview of a solution-focused approach and introduced some tools that could be incorporated into practice with individuals within a variety of mental health practice settings.
Facilitating groups
Facilitating a group for therapeutic purposes can be a really valuable way to offer support. Groups developed with this aim are common within mental health services and can be facilitated by many different workers. Self-help and peer support groups can also be particularly powerful. Examples of this might include those developed and run by the Hearing Voices Network to offer support for people who hear voices.
Facilitating a group offers a number of benefits which include the following:
• The expertise and experience of others in the group.
• Giving and receiving peer support.
• Learning from one another, sharing experiences.
• Cohesiveness – being part of a close group.
• Sharing a sense of ‘we are all in this together’.
• Cost-effectiveness and resources – providing support/interventions/education to a number of people at one time.
However, there are also some difficulties and limitations associated with facilitating a group:
• Relations within groups can be complex and difficult dynamics might arise, which can be stressful to experience and manage.
• Not all groups make full use of their members effectively – some people may dominate or not participate fully.
Groups are naturally occurring within society and have been described as important for the functioning of humanity. They can offer social and psychological benefits in terms of identify, self-esteem and wellbeing (Barker 2003). Setting up and running a group can therefore be a useful way to provide and enable support for people experiencing mental distress. There are various areas where running a group may be particularly helpful, but common groups facilitated by mental health nurses include anxiety management, recovery and ‘hearing voices’ groups.
Setting up a group
Before starting a group, it is important to consider an aim for the group. This helps to give an outline of its purpose. It provides an opportunity to think about potential outcomes for group members, although this is something that could also be done in collaboration with group members during the early stages of a group forming. Recognising the purpose of a group and the reason for setting it up helps to provide structure and answer some key questions that need to be considered when establishing a group, such as:
• What is an optimum or appropriate group size?
• Will membership change and can people join at different stages?
Some groups grow more organically and their purpose might change as the group evolves. They may have a more informal structure such as a social or art group. However, it is useful to identify these aims in planning a group to help all those who attend get the most out of it as well as helping to identify any potential challenges or problems.
Some groups can benefit from structure. This entails more planning and will involve considering the aim or plan for each week. For instance, a ‘hearing voices’ group may be focused around understanding and interpretation of voices one week, and another around sharing ways that people cope with voices. The facilitators could plan key questions that they may ask members to encourage discussion, or exercises they might do to provide information in an interesting way.
Running a group
It can help to have some basic guidelines to help manage relationships within a group, set clear expectations from the start and establish boundaries. This, again, is best achieved in collaboration with the whole group at the start of the group forming. These might include the following issues:
• Respect and listening – ensuring all have an opportunity to contribute.
• Confidentiality – what is kept in the group and what can be or has to be shared outside the group.
• Arrangements – such as punctuality, plans for meeting location if group is social, what people will bring (if needed).
The facilitator's role
The role of the group facilitator will vary depending on the nature of the group. Some groups will involve providing education which may require the facilitator to take on a more directive role at points during the process. There are a number of core features that define the role of a facilitator and contribute to a cohesive and effective group.
A facilitator does not lead a group through telling; they should guide rather than direct a group. This might involve the following:
• Not answering all questions themselves but returning this to the group for discussion.
• Enabling participation of all group members; at times asking some to listen and allow others to contribute alongside inviting quieter members to have their say.
• Stepping back and encouraging groups to make decisions for themselves.
• Reminding members of the aims and guidelines agreed at the start of the group if necessary.
Through these mechanisms, a facilitator can help create a safe and welcoming space in which people can be open and the group can come together.
Ending a group
The end of the group is as important as the preceding stages. Plans need to be made about how a group is to finish (for groups that are ongoing, remember changes in members or functions might represent the ending of one group and the beginning of another). This will entail agreeing an expected timeline and processing any outstanding issues through discussion as a group. Such a process is aimed at ensuring that there are not any unresolved conflicts relating to the group that members are left with. Chapter 7 deals with the ending of therapeutic relationships which will help provide some tips for how this may be approached. On a practical note, finishing would include summarising what the group has achieved and helping members make action plans about how they will take this forward.
Tuckman (1965) provides a model to outline the lifecycle of a group which can aid in reflecting on the group process (see Table 6.1). This reflects the stages that a group is likely to go through and may help you understand changes in the functioning of a group that you may be facilitating or a part of (such as the group you are a part of for the theoretical component of your course).
Table 6.1 Lifecycle of a group
| Stage | Characteristics |
|---|---|
| Forming | Entails examining what the group is supposed to be doing and how the group works Members will try to create a good impression of themselves They are more likely to seek direction and help from the facilitators |
| Storming | Conflicts and disagreements within the group are common This can create challenges to power and boundaries These might be shown through not coming to the group or arriving late |
| Norming | The group feels more comfortable with each other and group rules/norms are clearly established |
| Performing | The group functions as a whole, they work together well and are productive |
| Mourning | The group comes to an end so adjustments need to be made to loss and change |
Group dynamics
A psychodynamic perspective on groups suggests that interpersonal relations are formed and people learn about themselves in relation to others through the group process. Relating to others within a group situation creates the potential for tension and dynamics to result at times from the way the individuals in the group relate to one another. Group dynamics refers to the way a group functions. Dynamics can be affected by a number of aspects which include the following:
• The individual characteristics of the members.
• The group qualities in terms of values, communication, size, how cohesive the group is.
• The task – how stressful it is, norms and consequences.
• Structures such as roles that people adopt within the group and power relations.
Agreeing guidelines at the start of the group process which can be revisited can be helpful in managing some dynamics. Exploring dynamics within your own supervision (ensuring agreed confidentiality is maintained) is important for a facilitator to help manage relations and help promote optimum functioning within the group.
This section has provided an insight into some of the key areas to think about when planning, implementing and ending a therapeutic group. Chapter 8 focuses on interpersonal skills and may aid in helping to put some of these skills into practice.
Health promotion
Mental health promotion became a key element of the mental health nurses’ role with the publication of the National Service Framework for Mental Health (Department of Health 1999). This document emphasised the roles and responsibilities of mental health practitioners in this area of practice and stated that health and social services should:
1. Promote mental health for all, working with individuals and communities.
2. Combat discrimination against individuals and groups with mental health problems and promote their social inclusion.
This can involve a range of activities focused on how individuals, families, organisations and communities think and feel and the factors which influence this individually and collectively. It also acknowledges the impact that mental wellbeing has on overall health and the cohesiveness of communities. This involves looking at the impact of the social environment on health and addressing the link between disease patterns and the way in which society is organised.
The examples in Tables 6.2 and 6.3 illustrate how your practice can enhance mental health and tackle some of the factors which challenge mental health. These are informed by Albee and Ryan Finn's (1993) 10 elements of mental health promotion and demotion. This model identifies that impact can be made at the micro (individual), meso (community) and macro (policy and legislation) levels. In order to promote mental health, interventions should be focused on enhancing the areas of environmental quality, self-esteem, emotional processing, self-management skills and social participation or, alternatively, minimising the impact of environment deprivation, emotional abuse, emotional negligence, stress and social exclusion.
Table 6.2 Promoting the physical health of people with mental health problems
| Level | Example |
|---|---|
| Micro | Julia has high blood pressure and is overweight. The mental health practitioner works with her to give her information on the impact of her weight on her physical health and explores how her appearance influences her confidence and self-esteem. She identifies that a key barrier for her in addressing the problem is the way she is treated at the local swimming pool. She feels that staff are rude to her and discourage her from using the pool because they think she is crazy and will hurt other people |
| Meso | The mental health practitioner makes an appointment with the manager of the swimming pool to consider ways of addressing this problem. When Julia and the mental health practitioner meet with him they are surprised at his attitude towards people with mental health problems and recognise that this is informed by a lack of accurate information and concern about how to respond to people if they get distressed while using the facilities. The mental health practitioner offers to run a series of sessions with the swimming pool staff to give them information and look at how they might support a person in distress. Julia offers to share her experiences with the staff and talk about what she finds helpful in supporting her to access community services |
| Macro | The mental health practitioner writes to the council to inform them of the intervention and discuss how this could be rolled out across the area |
Table 6.3 Maintaining employment
| Level | Example |
|---|---|
| Micro | The mental health practitioner is working with Darren who has a diagnosis of obsessional compulsive disorder (OCD). At work, Darren washes his hands up to 40 times a day. He is aware that his colleagues have recognised his problems and suspects that they ridicule him behind his back. His manager has issued him with a formal warning as a result of the impact that his handwashing is having on his quality of work. He feels isolated, stressed and is seriously considering quitting his job. The mental health practitioner works with Darren to first explore the impact of his environment on his mental wellbeing and identify that his handwashing is exacerbated by his colleagues’ attitudes. The mental health practitioner considers alternative ways of coping with his anxiety at work and approaches to addressing his colleagues’ attitude towards him. He also supports Darren to inform his manager of his mental health problem and challenge his formal warning |
| Meso | The mental health practitioner is told by Darren that his manager was not interested to hear about his problems and maintains that if he can't do the job then he needs to be penalised irrelevant of the circumstances. With Darren's permission, the practitioner contacts the manager to discuss with him the Disability Discrimination Act (1995). The manager is not aware that the Act includes people with mental health problems and has assumed it only applied to people with physical disabilities. He tells the mental health practitioner that he will retract Darren's formal warning and also inform other line managers in the company to ensure that they do not make a similar mistake |
| Macro | The mental health practitioner writes a letter to a national newspaper reporting on the concern about the potential for large companies to fail to understand and apply the Disability Discrimination Act (1995). The letter is published and they receive a number of responses thanking them for drawing attention to this problem and telling them about similar experiences |
1. Identify the factors which promote or demote mental health.
2. Identify the interventions put in place by the mental health practitioner at each of the levels.
3. In your placement area, think about activities which you have observed, or been involved in, which promote an individual's mental health. Consider how you might apply this at a meso or macro level.
The examples above demonstrate how the individual practitioner can influence perceptions of mental health problems at all levels through simple interventions which educate, inform and challenge stigma and discrimination. It may feel at times that negative attitudes towards people with mental health problems is entrenched, however evidence supports the impact of interventions such as these and emphasises the importance of mental health practitioners taking an active stance towards this social issue.
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