10 Working with people who hear voices or express unusual beliefs
Introduction
This chapter will describe a number of interventions which may be helpful when working with people who hear voices or express unusual beliefs. These experiences are often termed hallucinations and delusions and are viewed as symptoms of psychosis. People who have these experiences may be given a diagnosis of schizophrenia or mania. The interventions described here can also be useful when working with people with a range of other mental health problems and will add to your tool box of possible approaches to consider when you are planning care.
The approaches are underpinned by the Stress Vulnerability Model which is described in Chapter 3 and often come under the umbrella term of psychosocial interventions. They attempt to enable service users to develop their personal and environmental protective factors, minimise the influence of vulnerabilities or reduce current stresses. This is with the overall aim of supporting the service user to develop self-management strategies and promote a sense of personal control over their mental health. It is important to recognise that these interventions are not the starting point for therapeutic work. They are sometimes seen as a quick practical solution to a person's problems. This approach overlooks the importance of engagement, assessment and developing a shared understanding with the service user (Mills 2006).
Before you begin to work with people who are experiencing psychosis it is essential to consider how their experiences might influence your approach. You may discover that the person finds it difficult to concentrate for long periods of time, keep appointments or complete tasks in between sessions. Some people do not feel motivated to take an active role in their care and are not used to being asked for their input and views. There is a possibility that a person's strange thoughts or voices might become prominent during a session, particularly if it is a new and potentially threatening situation. This will often mean a more flexible or creative approach is needed, which takes into consideration these possible obstacles and adjustments should be made in response.
Responding to people who express unusual beliefs
Students often describe knowing how to respond to people who express usual beliefs or strange thoughts extremely challenging. There are conflicting ideas about the best way to respond and it is likely that you will observe a number of different approaches in practice.
Client experiencing an unusual belief
You meet James at his home with your mentor. He tells you that the cracks in his wall are there to allow his neighbours to spy on him and report back to the government on his whereabouts and actions. James is extremely distressed by this and is asking you and your mentor to do something about it.
Possible responses that your mentor could give:
1. Your mentor tells James that the cracks are not there for his neighbours to spy on him and that his belief is a symptom of his mental illness. Therefore you and your mentor won't take any further action.
2. Your mentor doesn't mention the cracks in the wall but recognises that James is upset and offers him comfort and support with his distress. She manages to distract James from his thoughts and he stops asking her to take action.
3. Your mentor talks with James about what makes him think that the cracks are there for his neighbours to spy on him, and explores the ideas which are underpinning his belief. They talk about this for some time and James seems to start to doubt his belief slightly. However, he would still prefer for you and your mentor to arrange for the cracks to be filled in. Your mentor tells James that she appreciates his view and concerns but sees the cracks in the wall as a normal occurrence and so doesn't feel that it is necessary to have them filled in.
Response 1 could be underpinned by the practitioner's view that unusual beliefs should be challenged and failure to do so can result in the practitioner colluding with the service user and further confirming their belief. This approach can have a negative effect on the therapeutic relationship as the service user may not feel that you are making an effort to understand his distress. It also reinforces the idea that the practitioner is the expert and that their version of the truth is more valid than the service user's. This implies an unequal position and contradicts a collaborative approach to working.
In response 2 the mentor is adopting a more humanistic approach by focusing on the emotion arising from the belief rather than the belief itself. This can be helpful in the short term to alleviate the person's immediate distress and may strengthen the therapeutic relationship as the service user finds the mentor supportive and understanding. However, the distress is likely to return when the person refocuses on the belief as it has not been explored or addressed.
Response 3 is informed by a more collaborative approach. The mentor acknowledges the service user's belief and suspends her own judgement of its accuracy until they have had an in-depth conversation about it. This offers the mentor the opportunity to encourage the service user to look for evidence, which supports or conflicts with their belief, in an attempt to encourage the service user to question their belief, which may reduce their conviction in it. It also enables the exploration of the meaning of the belief to the person and how this is influenced by their previous life experiences. This process will often need repeating and it may take some time to have an impact. It is therefore appropriate to be honest with the service user about your perception of their belief. This communicates genuineness and allows the service user to see that while you are open to discussing their view, you do not agree with it and therefore are not confirming it in any way.
Response 3 is based upon the following assumptions about the most effective way of responding to a person's unusual beliefs, which is informed by the Stress Vulnerability Model (Zubin & Spring 1977):
• Unusual beliefs are best understood in the context of the person's past experiences, their current perceptions of themselves and their perception of the world around them.
• They are on a continuum with normal psychological functioning and are an extreme form of something that we all experience. For example, many people hold suspicious beliefs despite having no evidence to support them. These beliefs influence their thoughts, actions or response to specific situations.
• The development of unusual beliefs can be a coping strategy which helps the person to deal with underpinning distressing experiences.
• The experience of unusual beliefs and the person's conviction in them can fluctuate and often increase during periods of stress (Gamble & Brennan 2000).
Assessment of voices and unusual beliefs
The in-depth assessment of unusual beliefs and voices is essential when considering the best way to help the person to cope with them. It can also help service users to make sense of their experiences and find their own meaning or explanation for them. There are a number of specific assessment tools which can guide you through this process, however they will commonly focus on the following areas:
For the assessment of voices:
• The characteristics of the voice, e.g. identity, gender, age.
• The person's explanation of how the voice is heard, e.g. telepathy, thought insertion from TV or radiowaves.
• What it means to the person to hear voices, e.g. they are gifted, having a spiritual experience or going mad.
• Whether the voice commands them to take a specific action and, if so, how easy they find it to resist the command.
For the assessment of unusual beliefs:
• The central theme of the belief, e.g. persecution, monitoring, fear of others.
• The rules and assumptions within the belief, e.g. everyone hates me, people are watching me, people are dangerous.
• The specific situations where the belief causes problems, e.g. going out in public, speaking to people in shops, maintaining contact with family and friends.
• How much conviction the person has in the belief.
General assessment of voices or unusual beliefs:
(Adapted from Mills 2006)
Once a thorough assessment has been completed it is also important to check that you have a shared understanding of the service user's experience. This can be achieved by feeding back your ideas in small parts and explaining some of the connections you are making. At each point it is important to ask for the person's views on your interpretation, invite them to give their perspective and to identify points which they feel have been missed. This will allow for the picture to slowly build and ensure you have established a shared understanding of the person's experiences on which you can base further interventions.
Coping skills enhancement
When working with someone to develop their coping strategies, there are three areas which should be taken into account:
1. Coping strategies to enhance – these are ways of coping which the person already finds helpful but that they do not always use.
2. Coping strategies to reduce – these are ways of coping which the person already uses but that have harmful effects or lead to longer term distress.
3. Coping strategies to introduce – these are coping strategies which you and the service user agree may be helpful to try out in light of what you have learnt about their current effective ways of coping.
The first step is to look at the person's current ways of coping. This reinforces the message that they already have resources which they have developed and focuses on their existing strengths. It can be helpful to ask the person to think of a recent time when they have felt distressed by their voices or beliefs and ask them to identify what they did, what they thought about and how it impacted on how they felt. This will allow you to recognise the style of coping that the person finds most helpful which can often be classified into:
Table 10.1 gives some examples of each.
Table 10.1 Examples of coping strategies
| Behavioural | Cognitive | Sensory |
|---|---|---|
| Talking to others Exercise Completing tasks around the house Reading Playing an instrument Taking extra medication Talking to the voice or telling it to go away |
Ignoring the thought/voice by thinking about something else Thinking about things which tell you the voice or belief is not true Repeating phrases in your head which you find soothing or reassuring |
Aromatherapy Eating Listening to music Having a bath Relaxation/breathing exercises |
Once you have identified these helpful coping strategies, you can suggest ways of increasing their effectiveness by encouraging the person to use them sooner and more frequently. You may also be able to suggest other ways of coping which may have the similar effect that the person is looking for. For example:
• Distraction – a way of thinking or behaving which removes focus on the voice/belief.
• Interaction with the voice – a way of responding to the voice which reduces its intensity.
• Testing out the belief – a way of looking for evidence to reduce conviction in the belief.
• Relaxation – a way of reducing the distress caused by the voice/belief.
• Accessing additional support – a pathway to a person or a group able to offer reassurance, a different perspective or a listening ear.
There may also be coping strategies, however, that the person finds helpful in the short term but that can have negative consequences in the longer term or lead to behaviour which is potentially harmful to the person's wellbeing. These would be coping strategies which you would be aiming to reduce. Consider the following case histories.
1. Ellen finds smoking cannabis enables her to relax and block out distressing thoughts. However, there is potential for this coping strategy to become uncontrolled leading to drug dependence, exacerbation of voices or thoughts, financial problems, reduced motivation and increased isolation.
2. Sean finds talking to his voices is the only way to quieten them. He usually does this in public by pretending to talk on his mobile phone. However, when he is at home, at times he becomes very angry with what they say and shouts and swears at them loudly. His neighbours have put a complaint in to the council about the noise and he has been given a formal warning.
3. Li believes that his ex work colleagues are involved in planning a terrorist attack in the city centre. He relieves his anxiety about this belief by phoning the police to report them. The police assure him that they are investigating his suspicions and monitoring the situation, however Li continues to ring daily to receive updates. The police are becoming less tolerant and some refuse to take his call which causes him increased distress and worry.
4. Geeta hears a voice which she recognises as a girl who bullied her at school. The voice tells her to cut her arms and gets increasingly louder if she doesn't follow through with this command. She experiences immediate relief from the voice once she has cut herself but feels ashamed of the visible cuts and embarrassed when colleagues at work see them.
These ways of coping may be the only way the person is able to feel in control of their distress and therefore they may be reluctant to consider alternatives. It may take time for them to agree to work with you on trying out other ways and it will be important to provide high levels of support to enable the person to feel safe to do so. Quite often a less harmful version of the same coping method can be identified which will maximise the beneficial effects and reduce the potentially damaging ones.
For the examples given above, identify the following:
1. What is the effective part of the coping strategy that is being used and why?
2. An alternative coping strategy for Geeta in example 4 might be to flick an elastic band on her wrist or use an ice cube. This would enable her to respond to her voice without experiencing the shame and embarrassment she feels from how others respond to her cuts. What do think could be alternative coping strategies for examples 1, 2 and 3?
3. How would you encourage the people in these examples to consider these alternative coping strategies?
Testing unusual beliefs
People who experience unusual beliefs often have some common thinking styles which lead to a higher level of conviction in the belief and attempts to control the distressing emotions which arise from it by engaging in protective behaviours. Examples of these thinking styles include:
• Looking out for signs which confirm the belief and ignoring evidence which does not support it.
• Being preoccupied with the belief and continuously looking for evidence which confirms its truth.
• Misinterpreting coincidences or everyday experiences as evidence to support the belief.
• Jumping to conclusions quickly based on small amounts of evidence.
Stage 1
When encouraging the person to test the belief, it is important to take into consideration their thinking style and help them to recognise when it is influencing their thoughts and responses. This may involve starting with a belief that they have had in the past which they have later realised was wrong, or identifying a time when they have jumped to the wrong conclusion. You may also wish to give an example of a belief that you have held in the past but have now revised in light of your experiences and the views of others. This starts the process off in a way which is non-threatening and reiterates the message that these thinking styles are common and something that we all experience to some degree.
Stage 2
The next stage of testing the belief is to encourage the person to identify the evidence they have which supports it and the evidence against it. You can then help them to assess the quality of this evidence by taking into account the potential misconceptions arising from the thinking styles you have already discussed. For example:
Nurse:
What makes you think that the cracks in the wall are there for your neighbours to spy on you? (Identifying the evidence for.)
James:
Well I've seen them look at me a certain way which tells me that they have been watching me. Anyway it's all over the news about CCTV and surveillance. This is just another way of the government keeping an eye on me.
Nurse:
Are there any other reasons why there may be cracks in your wall? (Identifying the evidence against.)
Nurse:
We have talked about how it is easy to jump to conclusions, especially when we are feeling a little self-conscious or anxious. Do you think that you could be reading a little more into the way your neighbours are looking at you? (Recognising thinking styles.)
Nurse:
That must be tough to see. Perhaps they are looking at you in a funny way, but that may be for different reasons to your idea about the cracks? (Validating the perception while introducing doubt.)
Stage 3
Now you have introduced doubt in the belief, you can support the person to look for further evidence to test its accuracy. This will involve working together to find a simple way of testing the belief which is safe for the person. The test should be thoroughly considered and take into account the person's predictions about the outcome of the test, any concerns they have about undertaking the test and how alternative outcomes to the ones they predict may influence their belief. In James's situation, the test might involve him going to his neighbour to ask to borrow some coffee. James may predict that the neighbour will respond to him in a negative way or refuse to lend him some coffee. If this is the case, it would confirm that there are some problems with their relationship which could be resolved. If not, it would add more doubt to James's conviction in the belief. Once the test has been carried out, time should be spent discussing the outcome and its meaning to the service user.
This approach can also be used to help a person gain control of their voices by testing the power the voice has over their actions or the validity of what the voice is saying to them. For example, if the voice is commanding them to carry out an action, what happens if they do not follow through with the action? Or if the voice is telling them they are insignificant and unlikeable, what evidence is there against this?
The key to this approach is to enable the person to lead the process in order to feel safe within it. It may involve the person changing a behaviour which they have used to protect themselves for many years or challenging thoughts which are an integral part of their belief system. This process may take time as change will require the person to place themselves in an uncomfortable position. It is important to consider with your mentor how you will contribute to this intervention and how it fits with the person's wider care plan.
Motivational interviewing
This approach is often used when working with people who have a substance misuse problem, however can be a useful framework when working with people to make any change to their behaviour. It is underpinned by Prochaska and DiClemente's (1986) transtheoretical model of change which focuses on the service user's motivation or readiness to change. They define four stages, however it is acknowledged that people will often move back and forth between stages:
1. Precontemplation – no recognition of the problem and therefore see no reason to change.
2. Contemplation – recognition and thinking of the problem leading to an openness to exploring the possibility of change.
3. Determination and action – preparing to make and making changes.
Motivational interviewing aims to enable the service user to identify the discrepancy between their current behaviour and any goals or hopes they have for their future. It recognises that people who abuse substances are often ambivalent or in two minds about their wish to engage in the behaviour and their commitment to restrain from the behaviour. Motivational interviewing techniques attempt to elicit and encourage the person's commitment to change by identifying factors which trigger the behaviour and exploring the consequences of engaging in the behaviour (Miller & Rollnick 1991).
Adopting this approach will require you to take a proactive and neutral position, often playing the role of the devil's advocate. Lecturing or attempting to advise the service user is thought to lead to further resistance to change and defensiveness. Therefore it is advisable to start with a behaviour that the person wants to change and emphasise their responsibility within the change process.
At each stage of the model, specific approaches or interventions may be relevant and Table 10.2 summarises these.
Table 10.2 Interventions to support change
| Precontemplation | Engagement and building of a therapeutic alliance which enables the service user to recognise the value of being involved with the service and establish their trust in the practitioner Gathering information on the person's readiness to change and the level of ambivalence they are expressing |
| Contemplation | Utilising the trusting relationship to explore the motivators for change Identifying the costs and benefits of change and costs and benefits of staying the same which are unique to that person Giving information on effects of their behaviour and reflect back aspects of their lifestyle which they appear to find problematic Negotiating short-term and realistic goals which are congruent with the person's readiness to change, e.g. reduction in the frequency or severity of the behaviour, avoidance of situations where behaviour is triggered, utilisation of an alternative behaviour which has a similar effect |
| Action | Setting longer term goals which will enable sustainable behaviour change, e.g. making permanent changes to lifestyle which remove trigger factors, using prescribed medication to allow for reduction or removal of a substance by managing withdrawal effects, engaging with self-help groups for peer support and encouragement Adopting alternative coping skills which replace the behaviour or enable the service user to cope with short-term distress arising from the behaviour change Planning for achievement of positive goals for the future which are dependent on the successful behaviour change |
| Maintenance | Relapse prevention involving the identification of potential triggers which may lead to previous behaviours, coping skills, sources of support and contingency plans (see section in this chapter) Recognising achievements made and building on successes |
Working with families
Involving families and informal carers in the care of service users has been highly advocated by research and policy (Department of Health (DH) 1999, Gamble & Brennan 2000, DH 2006, Mental Health Foundation 2010). The assessment of carers' needs is also a required element of the Care Programme Approach. This section aims to outline the skills and challenges of working with families.
This type of intervention should be distinguished from family therapy or family work. These are more specialist interventions which require specific qualifications and are often learnt and mastered under expert supervision.
Research suggests that the family can be highly facilitative in the recovery process due to the following reasons:
• They hold a deep knowledge of those they are in the relationship with, including their past history and developmental progress.
However, families often report feeling that their personal needs are neglected by mental health services and their views and opinions are dismissed. The complex area of confidentiality is repeatedly recognised as a constraint to working with families. This is because the mental health practitioner has a duty to maintain the service user's confidentiality unless there are concerns regarding safety. Families can feel that confidentiality is used as an excuse to justify poor communication or reluctance to share information. It is important to explain the limitations of confidentiality to the family and to establish with the service user what information they are comfortable with being shared. This should be clearly documented to ensure that all members of the team respect the service user's wishes.
Despite this constraining factor, it is important to acknowledge the potential effects of learning that a loved one has a mental health problem and the consequent impact this will have on their future relationship. This might include the following feelings:
• Scared of the service user's behaviour and the implications of them receiving a psychiatric diagnosis.
• Sad or hopeless about how the mental health problems may impact on their life or influence their future.
• Guilty about the role they may have played in the development of the mental health problem.
• Angry with mental health services or in disagreement with their judgements.
• Bewildered, particularly if the person has no previous experience of mental health problems or services.
• Powerless to improve the situation.
• Isolated as a result of stigma experienced from communities, friends and other family members.
• Overprotective of the service user and highly focused on getting their needs met by services.
The consequence of this may be the development of their own mental health problems or a fractious beginning to relationships with mental health practitioners. These feelings will also potentially have an impact on the service user's relationship with the family member. The relationship is in danger of breaking down as the service user may feel blamed for the family's problems, a burden or a disappointment. Additionally, the service user may believe that they are held back by family members who doubt their potential in light of their mental health problems or who are reluctant to allow them to take risks. This type of reaction has been described as high expressed emotion and is characterised by critical comments and hostility towards service users or overinvolvement in their lives. Consider the following scenarios.
Overinvolvement
You are on placement with a nurse practitioner in a GP's surgery. You have been seeing Mary for a number of sessions due to her tearfulness and hopelessness. Her husband, Bob, insists on bringing her to the sessions and waits for her to finish, often coming in at the end of the session to ask if she is getting better. At the last session Bob tells you he is seriously considering giving up work to look after his wife full time.
Critical comments and hostility
You are on placement at a residential rehabilitation unit. You answer the phone to Peter's sister who is complaining about her brother's personal hygiene. She is angry with staff for not assisting him to wash, dress and shave before his visit home. She tells you that she has sent him back to the unit and told him that he smells disgusting and is an embarrassment to the family.
Critical comments and hostility
You are on placement with a community mental health team. Your mentor is a community psychiatric nurse working with John, a 54-year-old man who lives at home with his elderly mother. When you visit his mother, she answers the door and immediately complains about her son.
‘You just ask him what he's been up to this week.’
‘I don't know how I can carry on putting up with him.’
‘He's useless and does nothing to help.’
The aim of working with families and informal carers is to address these types of reactions by supporting the family to express warmth towards the person who is experiencing mental health problems and develop positive coping strategies. This is known as low expressed emotion and is conducive to recovery.
1. In your experience and observations of mental health practice, how have families or informal carers:
2. For the examples you have identified, what evidence was there of high or low expressed emotion?
3. Discuss these examples with your mentor and identify how you might help to address the negative impact of high expressed emotion on the individual.
In order to help sustain relationships with families and carers, mental health practitioners can provide support and education. They may also open lines of communication between the service user and the family members to develop coping strategies, identify and solve problems. This is with the overall aim of maintaining or improving the relationships which the service user values. The structure and focus of the intervention will depend on the service user's and family's needs. An informal approach to giving support and information will be appropriate in many circumstances (Askey et al 2007). However, in situations where there is evidence of high expressed emotion or problems which are significantly affecting the service user's wellbeing, the following stages can provide the basis for facilitating this type of intervention. It is advisable that you work with your mentor to identify this need and discuss the contribution you can make to the intervention.
Stage 1: engaging families
• Consider with the service user who should be involved.
• Agree with the service user what information they are comfortable with being shared and discussed within interactions with family members.
• Offer positive, pleasant and consistent contact to family members.
• Show appropriate care and concern for the family situation.
• Speak to family members individually to gain their individual perspective on the situation and assess their level of understanding in relation to mental health problems.
Stage 2: setting the scene
• Find a convenient time and place to meet.
• Identify and agree upon the general purpose of the meetings. For example:
• Collaboratively set ground rules which will guide the group discussion. These might include the following:
Stage 3: identifying and addressing areas of concern (a problem-solving approach)
• Start by specifying in detail what the problem is.
• Identify everyone's view of the problem, particularly that of the service user.
• Enable people to state how the problem makes them feel.
• Elicit possible solutions from everyone.
• Look at the pros and cons of each possible solution.
• Compromise and agree on a desirable solution.
• Identify clearly the action that needs to be taken, a timeline for when it should be achieved and the responsibilities of the people contributing in order for it to be achieved.
Facilitating these types of interactions can be challenging for the mental health practitioner and it may be advisable to broach complex family situations in pairs to enable the effective management of potential dynamics or strong emotional reactions. It is important to focus upon the service user's voice within interaction in order to ensure that they are not used as a forum for further criticism or blame. This may require the mental health practitioner to take a more assertive approach at times depending on the personalities involved. The following are a number of hints and tips which can help when facilitating this type of discussion:
• Avoid jargon – this may exclude people from contributing to the discussion as they may not understand.
• Acknowledge expertise – recognise that the service user and family have understanding and information which is valuable to the process as a result of their lived experiences.
• Acknowledge loss – recognise how the person's experience of mental health problems has impacted on their lives and the adjustments which have had to be made as a result of this.
• Focus on strengths – identify positive elements of the relationship which are valued, recognise coping strategies which are already in place and goals for the future.
• Start with small problems which can be easily achieved to enable early success and establish a commitment to the process.
• Address critical comments directly and explore how they make the recipient feel.
• Attempt to identify what is underpinning the critical comment by considering the emotions which may be fuelling it, e.g. fear, guilt, frustration.
• Role model understanding and acceptance within the group.
• Be conscious of alliances you are making with individuals as this may influence your facilitation approach.
Relapse prevention
Relapse prevention refers to a set of interventions which aim to identify the early signs of relapse and act upon them to avoid the breakdown of mental health or minimise the negative impact of crisis on the individual's life (Birchwood et al 1989, van Meijel et al 2002a,b). It is a collaborative process where service users are viewed as the experts of their experience through the acknowledgment of personal strategies, skills and resources for self-management.
There are a number of relapse prevention tools, however they will commonly include the following:
1. Engagement and education –the Stress Vulnerability Model can be used to aid this process and the leaky bucket analogy described in Chapter 3 can be a helpful analogy.
2. Developing a relapse signature – identifying early warning signs of relapse.
3. Developing a relapse drill – agreeing and recording in advance the nature and timing of actions which should be followed if early warning signs are present.
4. Monitoring of the early warning signs and rehearsal of the relapse drill.
The Wellness Recovery Action Plan (WRAP) is a simple self-help system which facilitates the identification of personal resources and encourages people who experience mental distress to use these personal resources to stay well and help themselves during difficult periods. It is an example of a relapse prevention tool and was developed by Mary Ellen Copland who maintains that people with mental health issues can have hope, control over their lives, develop self-directed wellness plans and recover by working toward meeting their own life dreams and goals. These strategies and skills are being used worldwide both by individuals independently of support from mental health services and as part of approaches utilised within mental health services to promote recovery. You can hear Mary Ellen speak about the approach at http://www.mentalhealthrecovery.com and access the tools and supporting self-help resources that she has developed in collaboration with others who have experienced mental health problems.
The aim of WRAP is to give the person more control over their problems. The WRAP can become a practical support for recovery which can be referred to daily, as a reminder and guide, and also turned to at times of difficulty. It is designed as an aid for helping people to learn about themselves, what helps and what doesn't, and how to get progressively more in control of their life and experience of mental health issues. It also includes instructions on developing a crisis plan as a means of guiding others on how best to make decisions for the person during times when problems and symptoms have made it difficult for the person to do this for themselves.
A WRAP includes the following:
Developing a wellness toolbox:
This involves the person asking themselves questions which help them to identify their personal resources, the values that underpin their beliefs and their hopes and goals for their future.
Evolving a daily maintenance plan:
This will include a baseline description of how the person feels when they are well. This is important because this will differ for every individual. It is therefore essential not to judge a person's presentation on what you define as being well as the person may never have those feelings or describe themselves in that way. For example, some people may appear to be speaking quickly, finding it difficult to concentrate or sit still. This may be normal for them or part of their character and can be described as their premorbid personality. For some people, these ways of communicating are a sign that their mental health is deteriorating and are also known as early warning signs or prodromal symptoms.
Student reminders
It will be difficult for you to judge if a person's thoughts, feelings or behaviours are ‘normal’ for them when you first meet. Many students are surprised at how people can hold strange beliefs or behave in odd ways and still live very contented lives.
• Where a person has a WRAP or a relapse prevention plan, it can be helpful to read this before you meet the person as this will allow you to gain some awareness of how they describe themselves when they are feeling well.
• If this is not available, you may wish to ask your mentor for this information.
• Following your contact with the person, talk with your mentor about your observations of the person's thoughts, feelings and behaviour and how this compares with your preconceptions of what it means to be mentally well.
The daily maintenance plan will also include the things that the person does every day to help maintain and sustain their wellbeing and the things which they may have to do that they might find difficult. An example could be opening post or making a phone call. Additionally the tool encourages people to think about the things that help them but that they are less likely to do when they are finding their mental health is negatively affecting them. For example, some people find contact with others helpful, however tend to withdraw or isolate themselves when feeling unwell. This can give you an insight into how you can encourage the person to do the things that help during difficult periods or provide support to enable them to maintain contact with others, even when this feels overwhelming.
Understanding triggers and what can be done about them
This section of the WRAP is about identifying the events or circumstances that are likely to trigger unhelpful or distressing thoughts or behaviours. The person identifies how they can avoid the trigger or looks at how they will cope with it if it does arise. It often helps to look back at previous periods of crisis and to think about what precipitated the difficulties and what the person or others did which was helpful or unhelpful during that time.
Identifying early warning signs (relapse drill)
Early warning signs are the subtle changes in thoughts, feelings and behaviours which can indicate to the person or others that action needs to be taken to prevent the difficulties getting worse. For example, some people might have increasing feelings of low motivation and appear more reluctant to care for themselves. Others may start to spend lots of money and not worry about the consequences in a way which is out of character. In some cases, people can become easily agitated or fearful for their safety which may result in unusual behaviour.
It is important that the person and those around them are able to recognise these changes and identify what action can be taken to help. This may include increased support from family, friends or mental health services, reducing unnecessary stress, engaging in activities which help to relieve stress and reviewing medication.
You can facilitate the identification of early warning signs in the following ways:
1. Time line – this is a detailed account of the person's account of the events and experiences leading up to previous relapses. It enables the identification of factors that had an impact on the onset of relapse in the past.
2. Card sort exercise – the service user identifies early warning signs using cards which state common signs of relapse. They then arrange them into early, middle and late signs of relapse or signs which are constant during periods of stress.
3. Review information from both exercises with close family/friends to identify gaps that the service user finds difficult to remember.
These signs can be monitored both directly and indirectly. To directly monitor the signs, the person may score the degree to which they are experiencing the sign on a scale of 1 to 10. To indirectly monitor the signs, the service user, family and mental health practitioner can be aware if circumstances or life changes which have led to relapse in the past reoccur, in order to closely monitor their impact.
Signs that things are breaking down
This section asks the person to identify how they think, feel and behave when the situation has become very distressing, difficult to manage or dangerous. Often this is an extremely unpleasant experience for the person and they may need others to enable them to stop things getting worse, particularly if the person feels unable to identify or articulate their own needs at this time. It is therefore essential to agree in advance how the person would like to be supported during these times and the things that help reduce their distress. For example, some people find that particular environments are comforting and provide a level of security while others find similar environments frightening and stressful. There are certain medications which people may have found helpful in the past during periods of distress and others that they have found ineffective or that have negative side effects.
Crisis planning (relapse drill)
The crisis plan draws together all of this information to enable the person to communicate their views, wants and needs during periods of crisis. It should include the names and contacts of people who they would like to support their care during periods of crisis and those who they would not like involved. It should detail the interventions, treatments and care setting you find helpful, those which should be avoided and their reasons for this. Finally the crisis plan should identify when it should be deactivated and the person is able to take back personal control of their care by being included in decisions.
Postcrisis planning
The postcrisis plan emphasises that crisis is not a failure and does not mean that recovery is not possible for the person. It prompts the person to reflect on the experience and learn more about themselves in order to review the WRAP and identify what worked and what didn't.
It may be helpful to summarise this information for the service user, family and people involved in their care to access quickly. An example is given in Table 10.3.
Table 10.3 Example of summarised relapse prevention plan
While there is evidence to support the value of relapse prevention, it can be challenging in some circumstances. For example, when identifying early warning signs, the service user may not agree with the perceptions of family members or mental health practitioners. This is because many people experience difficulty with structuring their own reality leading up to relapse. This is sometimes referred to as lack of insight and has the potential to cause friction if the memory of past relapse remains distressing for those involved. Taking a collaborative approach to relapse prevention can alleviate these issues. This may involve agreeing to disagree on some areas in order to ensure that each person's perspective has been considered.
Also some people cope with their mental health problem by ‘sealing over’. This means they wish to forget previous crisis periods and are therefore unlikely to want to consider past experiences and the possibility of future relapse. It will be important in these circumstances to work at a pace that they are comfortable with. This might involve using approaches such as the card sort exercise which depersonalises the experience initially.
Finally the service user may experience feelings of guilt or hopelessness if they are proactive and engaged in relapse prevention strategies but relapse still occurs. In order to alleviate this issue, the mental health practitioner should emphasise that, while the person has control over their mental health and future relapse, it should not be considered as a failure and there is still value in limiting the negative impact that relapse has on a person's life.
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