Do Anything You Wanna Do

Bwian

A guest blog by @briantheroomie

I have just found out the lead singer of Eddie and the Hot Rods has died. Heartbroken doesn’t even come close. There are gentle reminders everywhere that we are all living and breathing in world that can be cold and harsh. The poet Samuel Decker Thompson offers that “we are all just a car crash, a diagnosis, an unexpected phone call, a new found love or a broken heart away from becoming a completely different person” Today of all days I don’t want to be a different person. I certainly do not want any more news that leaves me hurt and wanting to cry. I am caught in the headlights, wide eyed and lost to pain, grief and the far reaching impact of a profound sadness.

The song ‘do anything you wanna do’ has been with me all my life, or it feels that way. As a teenager the words reverberated and were like a clarion call. Come with us and ‘be you’ seemed to be the central message. Don’t let ‘them’ tell you anything and make your own mind up. Barrie Masters (Eddie) sang in full roar and his words hit me like a sledgehammer. Eddie had all the charm, charisma and cheek of ‘the artful dodger’ as played by Jack Wild in the 1968 film version of Oliver Twist. On first seeing Eddie and the Hot Rods on ‘Top of the Pops’ I loved them and him with all of my heart.

Eddie had that ‘cheeky chappy’ persona about him. He epitomized independence and had a real working class swagger about him. Long before the Gallagher’s, Eddie rode in with fistful of arrogance and a stage presence to hang it all on. More than that though, he had that tune. It felt like it was written for me, just for me. It suggested rebellion was close to hand and I could be one of the main instigators. The central theme to the song was concerned with ‘self’.

Years later when introduced to the writing and thoughts of Carl Rodgers it seemed to me Eddie had been heavily influenced by psychological theory. That ‘do anything you wanna do’ embraced the notion of self-actualization was not in question to me. From that moment social work and rock and roll were inextricably linked and intertwined. I had fallen in love with music and here I was about to give my heart away all over again.

The Greek philosopher Plato observed that music is a kind of moral law and that “it gives soul to the universe’ and this in turn can allow us to fly from this earthly realm and imagine an existence where anything is possible. Baudelaire (1857) takes this one step further in stating “music fathoms the sky”. One might think all of this to be rather fanciful and too idealistic. However even Pythagoras maintained that there was a certain geometry to the noise strings make and that “there is music in the spacing of the spheres. 

Greicius (2017) argues the universe is alive with sound and that at its heart is a rhythm, as every night, our sky beats with the pulses of radio light waves, most of which go unseen. This would suggest we are surrounded by percussive back beats and these are an everyday part of the natural world. One could therefore assume there is a very real connection in terms of the effect this has on the human condition. Levitt (2019) asserts the spiral in a snail shell is mathematically equal to the spiral in the milky way. He further argues this ratio is the same in human DNA. Furthermore it is manifest in music that ‘transcends cultures all over the world.

It is difficult to find ‘rational logic’ in this statement but a huge part of me wants to believe  so to quote the famous 1960’s popular beat combo The Monkees “I’m a believer” 

When considering my own practice I would argue there is an inherent bias toward the arts within social work as much of what we see and observe is the basis for what we do next. Music seems to offer a unique way to both engage and give us insight of the lives of some people. Hannu (2107) argues that within some “social work practitioners experience, there is a wealth of evidence to support the idea that music can reach people in quite a profound way. This would sometimes negate the need for words. This might then be a manifestation of people telling their own stories without the need to provide elaborate personal detail in relation to what they might feel to be a very personal and painful narrative. In one sense the music itself becomes the voice, as for many of us the relationship with the sound or words is in itself an expression of our own inner being. 

Music as a tool can be widely used in the fields of both social work and health and social care. Sacks (2007) explore these themes further and asserts that music “can tap into “long-buried memories” and also help people move from their existing situation into a feeling of the familiar, thus making it an especially  “valuable tool in the treatment of aphasia, Parkinson’s disease, and dementia”

There is something in offering ‘art therapies’ alongside some of the more ‘talk’ based approaches to intervention. Art can offer the opportunity for a more expansive discussion as it allows for a broader understanding of the person within their own personal narrative. When one considers choice of music and the link with how people interact with the world and in what way they then position themselves when considering certain songs, the discussion could be freer flowing and provide an invaluable insight into another person’s life. 

From a right based perspective this approach sits well within an anti-oppressive discourse and intervention, in that it is important to recognize that  social workers see people that are being supported as having their own unique history. It also starts from a point of establishing a positive understanding of strengths, choice and independence. The dialogue regarding arts and music could equally give the worker an understanding into how people self-define when considering culture.

If one needed evidence of music as complimentary mechanism for relaying one’s personal narrative then Radio Four, Desert Island Disc’s is exemplary. Guests are invited on to the show and guided through an interview where ” they explain their choices and discuss key moments in their lives, people and events that have influenced and inspired them and brought them to where they are today” BBC (2019) This all starts to sound very familiar from a professional social work perspective. Life stories and personal testimonies are central in establishing identity as well as exploring processes for ‘positive change’. 

Christine Stevens (2009) examines the notion of ‘healing through music’ and claims that we are biologically wired to rhythm and we can’t hold still when a good beat is playing. Judging by some of my own recent public performances I would agree as I have a lifetime subscription to ‘Dad dancing magazine’ or would have if it existed. More importantly studies evidence that drumming and percussion can aid the immune system and there is a school of thought that would offer it can counter burn out. Stevens also argues that this approach to art based therapies can alleviate mood disturbances and give temporary respite from chronic pain.

When one considers the potency and impact of art it would seem sensible to view it as a tool to expand our limited understanding people’s lives. People’s loves, wants needs and desires can be writ large through the voice or music of another. Equally their fears and negative life experiences can be represented through this medium with little recourse for the person themselves to actually say anything.

When I starting typing this it was to remember Eddie and his Hot Rods I wasn’t really expecting to discuss art based therapies, right based practice and social work. However if music or art has relevance to the person we are supporting then why would we ignore what could us invaluable insight in to another human being. If Eddie is offering liberation through self-actualization and we can use this approach to support practice development then who am I to disagree, To quote the man himself “do anything you wanna do”

Now ain’t the Time for your Tears

Bumbles

It wasn’t the abuse at Whorlton Hall that made us cry. It was the footage of it. High definition images secretly filmed and brilliant audio technology that enabled us to hear the piercing screams right in the heart of our living rooms. Very 21st century. The abuse is significantly older. But really, what were we expecting?

We are the great and the good. All of us. Especially us in professional jobs in health and social care. We are the Mr Bumble & Mrs Corneys of our day. We know abuse goes on. Whorlton Hall is not new. Ely Hospital Inquiry, 1969. Normansfield Inquiry, 1978. Cornwall, 2006. Winterbourne View, 2012. Veilstone, 2017. Mendip House 2018. Whorlton Hall, 2019.

And we are in the thick of it, the administrators, greasing the wheels, occasional apologists for it, secret exponents of it, beneficiaries of it. All of us. Especially us. Because if we weren’t, we would stop it from happening again, and again and again.

Our Big Bed Time audit found that 7 out of 10 learning disabled people living in the modern version of workhouse, the group home (see Goffman’s definition of a total institution) were in bed by 8 o’clock on a evening. Not due to exhaustion of a week of activity but due to the banality of the unit’s staffing rota. How does totalitarianism start? Hannah Ardent will tell you, it starts with banality, boredom. The bored care workers, flicking through their mobile phones, rocking back on their chairs, rolling their eyes as they casually dished out abuse was when the cruelty on display led to calls on social media that this was beyond cruel, it was willful torture of one human being by another. It makes the days goes quicker. It makes the staff night out anecdotes funnier. It makes the flirting easier. Industrial organisational culture. The people on the receiving end just happen to be people. They could be sheets of metal or customers to cold call, or buses to drive. And really, even if the people are accepted as people they aren’t people like us. The very fact that they are living and breathing seems to be reward enough given the contempt they are held in. As Mr Bumble says of those in the poor house, “What have paupers to do with soul or spirit either? It’s quite enough that we let ’em have bodies”.

Our learning from the Bedtime Audit wasn’t what we thought. When we went out to ‘disrupt’ care providers, we naively thought we would be highlighting problems with providers. But, the truth is that we knew people were going to be in bed at 8pm on a Friday night before we even went out. It’s why we went out at 8pm. We knew what we’d find. I knew it when I was a social worker and I was involved in helping people move to those places. I knew it as a team manager encouraging social workers to help move people to those places. I knew it as a senior manager rubber-stamping the support plans in panel that enabled people to move into those places. I knew it as a strategist sitting down with with planners, commissioner and financiers that enabled design and build of the system which moves people into those places. We couldn’t pretend to be shocked when we knocked on doors at 8pm on a Friday night and found people in bed. The challenge is ours, those who broker and commission and support plan people into settings where their lives are no longer their own, where people who love them can no longer ensure their happiness and their safety. We are not only in on it, we are it. We know what we are exposing people to when we move learning disabled and autistic people into “secure hospitals”. And yet still we do so. We are the architects, the Bumbles and Corneys of this age.

So when we cried watching Panorama on that night of the 22nd May 2019, did we really cry in anguish and distress as we watched Panorama, as we would if the footage was of our own family and loved ones suffering? Is it honest to say that we could empathise with learning disabled people watching in fear or with parent’s like Sara and Mark who have lived horror of their child being abused whilst in state care? Or, in our more honest moments did we really cry out against Whorlton Hall because we were made to watch the impact on human beings of our Monday to Friday jobs. Did we see the outcomes from all our panels, assessments, funding conversations between NHS Specialist Commissioning with CCGs and LAs, our pink papers and tribunal reports, our contracts and invoicing, our posturing over risk being conflated with danger, our satisfaction at negotiating funding splits and our big talk. Did we really cry with embarrassment at having to face what it looks like when it’s exposed bare and beamed back into our living rooms after we’ve clocked off. Did we watch till the end in fascinated horror, or did we avoid/switch off, did we choose to not watch as it was outside of work hours and we didn’t want to bring work home with us? After all, once our work is done, the placement brokered and the person is in the transport and whisked away to the care home, residential school/college or specialist hospital unit, we rarely have to face the consequences. They become someone else’s issue. Passed along the conveyor belt of social care to the next stage in machine.

This time we were forced to bare witness to our truth and that makes us cry – we are human, the great and the good. As we listened to the cries from people who have been dehumanised, stripped of their right to be seen as a citizen, who has a right to be loved, a right to be protected in law and right to have their inherent dignity and freedom protected by the very State that arbitrarily detained them in Whorlton Hall. Are we really as outraged as we like to think we are, or is it faux outrage which will lead to nothing really changing as we find ourselves moving on, sliding into business as usual, calming reassuring ourselves that Whorlton Hall is a problem and that if we plan properly we can eventually wipe all those rogue providers away?

So can it be different? Can we turn this around? Given that we have centuries of history that indicates the failure of the great and the good the solutions aren’t likely to come from us. We’ve no track record on sorting things for people with disabilities. However in realising this, in realising that we are an integral part of the problem we can actually aid the solution. The solution is with people with learning disabilities and those who love them, not those who are paid to process them like us. People who are rightly angry about what they saw when they watched Panorama.

Instead of leaping into action with another round of committees, reports, programme plans, we could choose to stand in solidarity with self advocates, advocates, families, the thousands of genuinely outraged people. Having spectacularly failed to transform care, the state must evidence some humility and respectfully accept that history is against it, it cannot deliver change, but those with love in their hearts can. And for those who argue it won’t be quick, I would respond with reminding them that Ely Hospital was 1969, 50 years ago. The great and good have had 50 years.

So let’s kick it off with a quick and easy win and devolve power to the genuinely outraged whose tears are genuine, driven by love. Instead of the great and the good doing the planning, integrating everything under us, let’s get on with trusting learning disabled people and their families to be the people doing the doing.

  • Imagine if for every £1 spent detaining people in ATUs, a matched £1 was put into a pot managed by learning disabled people and their families who were charged with getting the person home from the ATU.
  • What if all the ATUs, regardless of who runs them (private or public) were opened up to a group of local learning disabled people and their families who went in every day to monitor progress in closing the ATU down and reported into the group holding the funds?
  • What if every bed emptied was closed so it could never be used again and the capital receipt from sale of the former hospital was also pooled into the fund for learning disabled and autistic people and their families to invest in advocacy to safeguard justice for their peers in the future?

Anyway, panel will start again on Tuesday. We all have our jobs to do.

‘And you who philosophise disgrace

And criticise all fears

Take the rag away from your face

Now ain’t the time for your tears’

Telling us what we want to hear

A guest blog by @DickyBiscuit

In this blog post, I will consider a particular phrase I’ve come across, which is used sometimes by a minority of professionals in assessment records.  When used however, it has huge implications for the person being assessed as it assumes the status of evidence which demonstrates or proves that a person lacks the requisite capacity to make a certain decision, and therefore may be subjected to whatever the professional and others think is in the person’s best interests. I am considering the use of the phrase, “She will tell you what you want to hear” or “He will tell you what he thinks you want to hear.”

This is worthy of analysis; the person is telling the assessor what the assessor wants to hear, rather than what they actually believe, and that, therefore, is evidence of incapacity? What degree of proof must be provided to support such a claim? Certainly, I have read that phrase many times in capacity assessment forms but have never seen it supported by any evidence, the statement just sits there on the report, a value judgement against the person. It is a peculiar thing to read, because the person is at once vulnerable and needing to be cared for, and at the same time devious and trying to pull the wool over the assessor’s eyes.

So, is there a legal test referred to in case law and professional agreement captured in guidance which shows that if indeed the person is telling professionals what they want to hear, that this is appropriate to use as evidence of incapacity?

Well the short answer is – no.

Maybe instead it is mentioned in the legislation itself? Section 1(4) of the Mental Capacity Act says;

A person is not to be treated as unable to make a decision merely because he makes an unwise decision.

Further, at section 2(1);

…a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.

And at section 2(3);

A lack of capacity cannot be established merely by reference to —

(a) a person’s age or appearance, or

(b) a condition of his, or an aspect of his behaviour, which might lead others to make unjustified assumptions about his capacity.

And finally at section 3(1);

…a person is unable to make a decision for himself if he is unable —

(a) to understand the information relevant to the decision,

(b) to retain that information,

(c) to use or weigh that information as part of the process of making the decision, or

(d) to communicate his decision (whether by talking, using sign language or any other means).

I don’t see anything in there about a person telling others what they want to hear being legal grounds to asses they lack capacity.

One might also consider that a person telling professionals what the professional wants to hear that would require the person to have the skills of Derren Brown? And logically, if a person can work out what the assessor wants to hear, and can then tell the assessor what they want to hear in order to secure a particular outcome, then surely that would evidence a very high degree of cognitive functioning, thus making a claim that the person lacks capacity look increasingly silly?

Forgive my cynicism. We must consider; do people tell professionals what they want to hear? I would suggest the evidence is strongly that they do, because we all do it from time to time.

Here’s an example. Nearly 30 years ago, I went to see my then GP for a routine appointment. He asked if I smoked and I admitted that yes, I would smoke about fifteen Marlboro Lights a day. I loved ciggies. I can still hear the incredulity rising in his voice as he leaned across the desk, almost pleading with me, “Mr Biscuit, do you realise the lunacy of what you are doing to yourself?”

I was unhappy as I left the surgery. I did not want to be called a ‘lunatic’ so six months later when I went back, I lied and told him I had quit. He was very pleased with me. I don’t think he gave me a Chupa Chups lolly for being such a good boy, but I enjoyed the visit more than I had the previous one. I told the doctor what he wanted to hear, he didn’t criticise me as a consequence, and so I lit a celebratory fag as soon as I had left the surgery.

You take my point. I was telling the GP what he wanted to hear because I did not want to admit to having the breaking strain of a KitKat when it came to quitting smoking, or to have him lose his patience with me. I knew smoking was bad for me, of course I did, but still I smoked.

So how many of us tell GPs the truth when they ask us how much we drink, how much exercise we do? Or when the dentist asks, “Do you brush twice a day and floss and use mouthwash?” Yes of course! Every day!

We tell people what they want to hear all the time. It’s called lying.

The people having their mental capacity assessed will tell the assessor what he or she wants to hear but probably for different reasons, and crucially it is not evidence of incapacity.

I believe it is about power. Since starting the social work degree course at university in 1998, I repeatedly heard inspiring things about social workers giving power back to ‘service users’ – and then there would inevitably be a comment about how the power was never ours to give back and we would all agree.

But in practice this plainly is not always true. The person telling the social worker or psychiatrist what they want to hear, may be doing so, as I did with the GP, because they don’t want to appear daft or lacking in will power. But more likely, the person is afraid that if they admit to doing something risky (like not living in a care home or going to the pub on their own) then the assessor will stop them from doing it.

And why should the person not lie to their social worker? Who are health and social care workers to question people as if they are children and we their parents?

So this, more than any other reason, is I believe why people lie to professionals. It is not because of their mental impairment, it is because of the power imbalance between the assessor and the assessed, and the likely outcome of that imbalance (e.g. the person is that evening prevented from going to the pub by the professional who knocks off at five and goes to the pub).

There is the phenomenon of those who, as 39 Essex Chambers describe in their excellent guidance in assessing capacity, “can talk the talk, but not walk the walk, especially if they have had numerous prior capacity assessments.”

39 Essex Chambers refer to people with brain injuries who might say one thing but do another. It may be the case that a person will tell the assessor that yes, going out alone at night to the pub (for example) might make them vulnerable to attack by bad people and that they won’t do it, only to later go to the pub. The assessor then leaps on this as evidence of incapacity.

As the 39 Essex Chambers guidance suggests, we should put that repeated mismatch to the person. That detail – that the person says they won’t but the assessor can prove they have done more than once and will do again – is relevant information. That relevant information should be put to the person, and as the law says, it must be provided in a way that will enable him or her to understand it.

But assessors must still show the causative nexus – that it is the person’s mental impairment that causes the person to not be able to understand, retain or use or weigh that relevant information and not some other reason, such as the person being afraid to admit the truth about what they want to do or intend to do (and how sad is it that most of these decisions are just the things that the rest of us do without being hindered or having to explain our behaviour or seek permission?)

In other words, assessors must show that if they think the person is telling them what they want to hear, the assessor must provide evidence of what they have done to make the person confident that they are not going to use what they say against them, that the assessor has taken all necessary steps to enable the person to make the decision – even if it is an unwise one. Assessors should try to gain some trust between themselves and the person, and sometimes, as I have done in the past, that might mean recognising that the assessor is not necessarily the best person to do the assessment if that relationship is not conducive to effective communication.

References;

The Mental Capacity Act 2005

https://www.legislation.gov.uk/ukpga/2005/9/contents

39 Essex Chambers, A Brief Guide to Carrying Out Capacity Assessments, March 2019

https://1f2ca7mxjow42e65q49871m1-wpengine.netdna-ssl.com/wp-content/uploads/2017/11/Mental-Capacity-Guidance-Note-Capacity-Assessment-March-2019.pdf

The only way is ethics

Ethics

Conflict between the lived experience of practicing as a social worker for a social work employer and trying to fit in to the bigger organisation with your social work values is possibly a big source of stress for social workers. Social workers are employed by lots of different types of employer. Housing associations, community health trusts, charities, inspectorates and regulators, hospitals including private treatment centres. Each with different priorities, accountability and ways of working. You won’t know what the cultural norms are until you start.

Social work is a global profession, with a shared, global definition. Through embracing the power of collectivist action, social workers can positively influence employers and reshape organisational culture to fit with social work values. Social work’s mission, as described in the British Association of Social Workers code of ethical practice, is to uphold respect for the inherent dignity, equality and worth of all people. Social workers can live this mission by encouraging their employers to recognise positive obligations to base practice around the United Nations Declaration of Human Rights (1948). Social workers who are encouraged by employers to promote social justice, through upholding the natural rights of the individual, and through taking positive action to strengthen families and communities will give back far more than the basic job description requires.

Social workers are natural agitators for positive change, whose values have public service running through them like words in a the middle of a stick of rock. And the Courts are encouraging social workers to remember and reclaim their unique contribution to public service:

“The Local Authority is a servant, not a master… vulnerable adults… do not seek to be ‘controlled’ by the State, … ‘working together’ involves something more, much more, than merely requiring carers to agree with a local authority’s decision even if, let alone because, it is backed by professional opinion” (Munby, 2011).

The contentious point for social workers is that you can only be a servant not a master if your employers supports you to be able practice in a way which enables you to spend time with people, taking all practicable steps to find out what they want from you and why. Working for a social work employer with a relational and rights-based ethos makes it much easier to live the values of an ethical practitioner than being in a highly ridged care management environment where your core function is to broker packages and move the person on to the next setting as quickly as possible.

Rights-based employers encourage what O’Donnell et al. (2008) termed as being a form of ethical activism. Ethical activism is a more radical approach to social work, with social workers positioned as being more than allies working within a network of support around people, but rather assuming the role of accomplice in subverting the status quo enough to disrupt and effect positive change.

You will know if you are working for a social work employer whose cultural norms support rights-based, ethical activism if you find yourself in the middle of ethical deliberations with people, their families and/or carers and other professionals on a regular basis. Usually over a cup of tea, reflecting on how the week is going, ethically activist social work employers have a culture where every day brings a new debate about the ethics of any given intervention or approach, always centred on upholding the rights of the person social workers are supporting. Ethically activist social workers respect autonomy as the first principle to uphold in practice (Gillon 2003), upholding people’s wishes and feelings through tackling oppressive power dynamics which push for unnecessarily disproportionate, restrictive interventions.

An example of the type of disproportionate, restrictive practice ethical practice avoids, can be observed in the ruling on the Wye Valley NHS Trust v Mr B (2015), which was about a 73-year-old gentleman with a long history of mental health needs and poorly controlled diabetes. Following the death of his partner, Mr B lived on his own. He developed a leg ulcer, which did not heal over time, leading to a hospital admission in 2014. During a long stay in hospital, Mr B resisted treatment for his diabetes and his ulcer which led to his leg becoming seriously infected. In 2015, the NHS trust who were caring for Mr B applied to the Court of Protection asserting that Mr B needed to have his leg amputated to save his life but lacked the capacity to make the decision, so they wanted Court authorisation to proceed. The evidence presented to the court made it clear that Mr B was likely to die within days from the infection if not action was taken, however if his leg was amputated, he had a positive life expectancy in excess of three years. Most people just remember it as the Wye Valley case, forgetting Mr B, the appellant. However, Justice Peter Jackson did not make such a crude error. Entirely centred on Mr B, and his views, the ruling upheld that whilst Mr B lacked capacity, this did not negate his known wishes, feelings, beliefs and values. In paragraph 11 of the ruling Peter Jackson noted that:

“This is not an academic issue, but a necessary protection for the rights of people with disabilities. As the Act and the European Convention make clear, a conclusion that a person lacks decision-making capacity is not an ‘off-switch’ for his rights and freedoms. To state the obvious, the wishes and feelings, beliefs and values of people with a mental disability are as important to them as they are to anyone else and may even be more important. It would therefore be wrong in principle to apply any automatic discount to their point of view.”

Given these considerations, the Judge ruled that it was not in Mr B’s best interests to undergo an enforced amputation and ruled against the NHS Trust. This is what makes the Wye Valley case ruling so important for social workers, this emphasis on the person’s wishes and feelings when constructing a best interest decision. It is a simple message; the person’s views are central. Ethically activist social work practice centres on respect of autonomy.

Gillon, R. (2003). Ethics needs Principles – four can encompass the rest – and respect for autonomy should be “first among equals”, British Medical Journal, Vol. 29, No. 5. https://jme.bmj.com/content/29/5/307

Munby, L. J. (2011). Safeguarding and Dignity: When is Safeguarding Abuse’. Keynote Address by Lord Justice Munby to the Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust’s Approved Mental Health Professional and Social Care Conference.

O’Donnell, P., Farrar, A., BrintzenhofeSzoc, K., Conrad, A. P., Danis, M., Grady, C., Taylor, C. and Ulrich, C. M. (2008). Predictors of Ethical Stress, Moral Action and Job Satisfaction in Health Care Social Workers, Social Work Health Care, Vol. 46 No. 3, pp. 29–51.