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’

White Christmas

White Christmas

The care home had given notice and were very clear on the telephone call that came through that in their opinion there was nothing more they could do. Betty was a problem. Wandering. Absent Without Leave. Absconding. Leaving other vulnerable people at risk whilst staff had to go find and recover her. She had been found in the launderette, in the local church and once in the local pub. All places of her old life. The life she had left behind when she had entered the care home. The duty logs carefully recorded and logged each successive incident of risk, using words which captured their increasing sense of frustration to describe Betty’s ‘behaviours’, which they had passed on to social services as they increased the number of telephone calls which they had made to check out how their referral was progressing through December.

By December 22nd things were reaching fever pitch and the Matron had got involved. As the Team Manager I handled a really difficult phone call with Matron insisting that I take action. I reminded her that this close to Christmas there were very few spaces in other care homes due to pressures from the hospital and given Betty had been with them so long could we not work together to help make things work? No. Was she sure the situation could not wait until the new year? Very sure. Matron was adamant that I needed to look into options for Betty as she was really very confused and more concerning, she rarely ‘did as she was told’. Betty was wondering all over the town after she had been told not to. Most alarming to Matron, last week Betty had ‘absconded’ and been found by staff wondering the streets of town looking for her late husband, Ronnie. When Betty had been told her husband had been dead for 10 years, she had become very distressed, crying, need a lot of calming down. Matron was concerned, upset even, she had Christmas to think about and this meant that she would be dealing with reduced staffing levels, a sickness bug and increasing number of relatives visiting the home. But it was really the staffing levels that concerned her. Two to one staffing was not cheap over Christmas, and whilst she would usually try to accommodate the increase if I would authorise an increase in fees to the home, it was unlikely that she could afford to commit that level of staffing to manage Betty and her behaviours.

On the afternoon of 24th December, two of us were the last ones in the building, running the Duty Social Work desk, when a panicked call came through from the home. Betty had gone missing during the night. She had been returned by police who had brought her back freezing cold and extremely confused. Matron was clear. The home was at their wits ends, Betty was a huge risk to herself, the GP agreed and the impact Betty was having on resources was leaving other vulnerable people at risk. Matron demanded that we arrange an emergency placement in a home which provided specialist support for people with dementia. Faced with the risk that Betty would end up in hospital if we did nothing, at risk of all sorts of harm from infection over the Christmas period, confused and alone, we rang Betty’s daughter in Tenerife and spoke to her about what may happen to Betty that afternoon. From the sunny shores of Tenerife ‘permission’ was granted to ‘move her somewhere nice’. DoLS sorted st the stroke of a pen. So a move that afternoon, Christmas Eve, was in the offing. All in time for Christmas.

Both of us went to the home, just in case we needed a driver and someone to chat to Betty. We knew we’d certainly need two to handle Matron. When we arrived at the home Betty was the first person we saw but neither of us recognised her. She watched us walk from the car down the snow-covered path to the home. Her gaze haunted, searching our faces as though looking for someone. We rang the door bell and waited to be let in by the matron, admiring the wreath on the front door, shivering from the cold.

The care worker who answered the door in her purple uniform had tinsel in her hair. She looked relieved when she saw us. “Oh, thank god you are here, follow me, Matron is expecting you”. We were ushered into the Matrons office before the door was slammed behind us before we had chance to say hello to Betty or anyone else. The Matron was ready for us “Do you want a cup of tea. We have mince pies, help yourself to Quality Streets”. “Thanks” we said and did as offered noting that the toffee ones were missing from the tin, presumably already eaten. Matron had her script and was not to be distracted or diverted “She is 89 but you probably know that. Been with us for about 5 years. Her daughter put her here for respite as she was at breaking point. We had to go back to Panel to make the decision permanent as she needed care. Was very underweight when she first arrived. We’ve sorted that out. She was self-funding for a year, her daughter sorted the finances. But once the money ran out and she moved onto your rates we had to move her as you wouldn’t match the amount we charge for the room she was in. She was no bother at first. Kept herself to herself. You could talk to her and that. Not now. All you hear is her talking about her husband Ronnie but as I say, it’s been ten years since he died. The photos are all over her room, they seemed devoted from what her daughter says…”. Matron paused to root round the Quality Streets. A moment of displeasure on her face as she realised that her favourites (the toffee??) weren’t there, then settling on a coffee cream. “The thing is, we cannot continue with her. It’s taking the girls all they can to stop her disappearing. I’m down to two staff from this afternoon. We just cannot keep her. Her meddies are there and I’ve spoken to the home where she’s going. It’s got a locked door, so you got that bit right. Is she going in your car? Could she go now? It’ll probably be for the best. I’ll get someone to fetch her”. My colleague and I exchanged glances, a mutual decision made, this is dreadful but let’s get this done, Betty needs to be somewhere where she is welcomed. We followed Matron bustling toward the lounge, rounding up a staff member who was tasked with gathering together Betty things. Within 10 minutes Betty’s whole life had been packed. 89 years reduced into fitting into a suitcase and a plastic bin bag.

Betty was compliant because in truth she didn’t know what she was complying with. Yes, she’d get in the car. It was the same colour as her daughter had. And Betty listened as we talked about driving her to the new home “My Pamela has got a car just like this. Do you know her?”. We asked Betty if she would consider a new place to live? Yes, she was ok with that too. “Until Pamela comes. She’s in Worksop. I’m going to live with Pamela”. Excitedly Betty climbed into the front seat and the one suitcase and half-filled black bin bag, a lifetime of experiences bundled in the boot. “Now then gentlemen. Just one thing. We need to pick up Ronnie on the way please”. We smiled and carried on and wished we were taking Betty back home to Ronnie.

The journey took about thirty minutes via two small market towns at the foot of the hills. Streets were quiet with the occasional shopper heading in and out of shops to grab a last-minute gift or jar of cranberry sauce. The radio in the car was playing in the background. And then, from no-where the radio DJ became the umpteenth that day to play White Christmas. Time stopped.

“Aww. This is a favourite of my Ronnies, is this one” Betty said. And started singing. Softly to herself.

Every traffic light we paused at Betty thought she saw Ronnie. She unbuckled her seatbelt as we stopped for a pedestrian crossing, she opened the door and leapt out shouting “He’s there! Ronnie love, I’m here, it’s me, it’s me Betty, get in”. A young man of about 20 pushing a pram and smoking a cigarette looked up with alarm and swerved to quickly get passed. Betty’s face fell, dejected. She looked confused and got back into the car. Moments later she turned to the social worker on the back seat and said, “That wasn’t Ronnie you know. He wouldn’t be pushing a pram nowadays and our Pamela wouldn’t fit in it, yer daft apeth.. And he never smoked”. Betty went back to singing. “Where the treetops glisten and children listen. To hear sleigh bells in the snow”. From my front drivers seat, in the rear view mirror I caught sight of my colleague in the back seat next to Betty, who was gently holding her hand, tears in his eyes.

The deal was concluded quickly enough. Within an hour Betty was literally signed, sealed and delivered. The new care home, a dementia specialist unit with lock doors a plenty, were very welcoming. She won’t be at risk here, we were reassured by the nurse, we have special key pads to keep residents safe. The nurse was most interested to hear about Ronnie and assured Betty, whilst leading her down a dimly lit corridor, that Ronnie would be there to see her soon. We said goodbye to Betty but by then she was already half way down the corridor towards the lounge. There was no transition for Betty, no endings, no time for her to adjust and realign to her new situation. Just a sharp new beginning in another room full of armchairs, forgotten lives and the unwatched television in the corner.

Dreaming of a White Christmas whilst living your last.

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.

Clouds in my Coffee

latte-art-kak-delat-risunki-na-kofe-foto-7

My favourite mornings start with a coffee. I’m a member of the coffee club at work. Gossiping with others over that first cup is a ritual that grounds the day. There’s something about the feeling of belonging that being part of the coffee club brings. I can’t imagine how it would feel to have that removed from me.

The gossip which goes with the first cup of the day often drifts into speculation about big ideas. Social work naturally draws people in who are interested in big ideas about people, community, society. So, it’s no surprise that the speculation over a morning cuppa at the moment is about the content of two big papers on social care which are due this summer:

There are big headlines coming out of the CQC led reviews. The focus on the person is uncompromising. If care and support isn’t person-centred – it isn’t high quality. And being person-centred mean upholding the 5 statutory principles of the Mental Capacity Act through every decision.

  1. The person has the right for it be assumed that they should be in control of whether they want support at all, and if they do how their support is arranged.
  2. All practicable steps must be taken to enable them to make the decision including reasonable adjustment to enable them to communicate how they want their support arranging.
  3. If they want to arrange their support in a way that doesn’t fit the views of professionals – the social workers job is to advocate for them and use the law to enable them to take risks, challenging where professionals and others argue that the risk is unwise and therefore questions the original assumption that the person has the capacity to be in control of how their support is arranged.
  4. Any decision taken on behalf of a person who does lack the capacity to make the specific decision must be taken in their best interest. Section 5 of the Mental Capacity Act provides a defence against liability if the statutory principles are applied. The bar is much lower than most professionals realise when it comes to capacity. The latest analysis shows a 95% increase in the number of requests for the Deprivation of Liberty Safeguards not granted. This includes people who have died since the request was made, but it also includes people who the MDT deemed lacked capacity to be involved in the decision whether to go home or whether to move to a care home, who have subsequently been found to have had the capacity to understand, retain, weigh up and communicate their view once a social worker trained to a higher standard of legal literacy as a Best Interest Assessor has met the person.
  5. Any decision taken must be the least restrictive. Rarely will 24-hour settings, such as a care home, a supported living house, a hospital be the least restrictive.

When it’s understood well, the Mental Capacity Act is the most powerful tool in the social work tool box. It defines a unique role for social workers of knowing legislation, understanding advocacy and the ability to interpret and enact keeping power and control with people. Person-centred enshrined in law.

Lizzie’s social worker is also a coffee drinker. When she met Lizzie, they shared their love of coffee. Over coffee Lizzie shared a secret, she had a lover. Her sons didn’t know. She didn’t want to upset them. She used to meet him in a coffee house. But now she was in a care home she wasn’t allowed to go out, she didn’t have her own phone, she couldn’t speak to him or see him. Lizzie couldn’t go home, her sons had sold her house. Her heart was slowly breaking. She just wanted her life to end so she could meet him again in heaven.

Lizzie’s social worker spoke to the nurse who had arranged for Lizzie to be moved into the care home when she’d been in hospital. She was very worried about the suggestion that Lizzie leave the care home to walk to the local coffee house, she wouldn’t be safe, she might get confused and lost.

But nothing is too difficult if you want to make it happen. The social worker was upset for Lizzie. They wanted her to be happy. The social worker made contact with her lover. He was alive and missed her deeply. He wanted her to live with him. A meeting was arranged between Lizzie and her lover in the coffee house.

Lizzie’s sons were furious. They thought he would steal her money. They wanted her to stay in the care home where they thought she was safe. The social worker used the MCA to uphold Lizzie’s right to make the decision about where she lived. She arranged a family meeting where Lizzie told her sons that her decision was to move to live with her lover. The sons wanted other professionals there. Lizzie was quiet upset listening to the nurse and her sons tell her why she needed to stay in the care home. But the social worker was brave and stayed clear that Lizzie had retained and understood what they were worried about and had weighed up the risks of staying in the care home over the risks of moving in with her lover. Lizzie clearly communicated that she wanted to move. The social worker made it happen.

There’s a hashtag at the moment #socialcarefuture where bloggers are speculating big ideas. It’s worth a look. But it seems to me that being drawn to big ideas misses the point. High quality care is person-centred. Being person-centred means being drawn to the small places – the coffee houses where real social care is happening.

Speculating about big ideas is the realm of professionals who are looking to find their place in people’s lives who may not want them there at all. A mature health and social care system is one that recognises and critically reflects on its need to exist at all. Our systems are remain stubbornly determined by historic models of investing in ill health. Debates about how to work within the system will do little more than incremental gains. Perhaps this is enough, it certainly worls for athletes. But if we are to achieve a genuine shift to upholding people’s right to live healthy, happy lives as active citizens free from unwanted state intervention it will require braver shifts from the system controlling resources to people being in control. It requires professionals to be open to challenging their professionally taken for granted assumptions that their involvement in people’s lives is helpful. Being a member of the health and social care coffee club is a comfortable place to be, but being a bystander in a coffee house, walking away from Lizzie as she gets on with her life is a far more person-centred place.

For the Valentines I never knew

Valentine

There’s a song by a band called the Wedding Present which like so many other songs is about falling in love.  It’s called A Million Miles.  It’s about that moment when you meet someone for the first time. The moment when your stomach spins. You can’t eat, you can’t sleep and yet despite this, as the song goes, you ‘can’t even remember the colour of her eyes’. The song connects with that first fleeting moment when a returned smile and a burst of shared laughter on the walk home together means everything. When your world is filled with subsequent endless telephone calls to each other (it was written in the mid 80s before text). It’s about that mad bit. The bit where the massive risk has paid off, even if it’s only momentarily.

I know it’s different for everybody but that song has always resonated with me because that’s how it feels when it happens. It’s a kind of prolonged Christmas Eve of anticipation. It’s mystifying, scary and the most exhilarating experience that you can have. Its the 1000-1 off-chance of a new human relationship that may lead to love and will involve lust and desire alongside, hopefully, some happiness on the journey. The risk you’ve taken was huge. The smile that might be unrequited, the humiliation of a misread signal, the shocking discomfort of a blind date from hell, the deeply personal hurt that comes from rejection if, as may be likely, a rejection is just around the corner. Yet despite that, despite all of that, we felt it was risk worth taking.

Love and falling in love. Seeing people fall in and out of love. Beginning and endings to relationships plays a huge part of our lives. I’ve completed two three year courses on issues around humanity and social care and I’ve completed countless additional training courses but I genuinely cannot recall ever being asked to write about love in any assignment that I competed. I have definitely never written the word love in an exam. I can’t remember a single lecture on love or certainly not one that didn’t medicalise it, or quickly move towards framing love in terms of ‘attachment’ or ‘obsession’. But love and relationships appear to be one clear thing that drives us. We don’t get to choose who we love or we can not prevent unrequited love. It is part of who we are, and can at times lead to terrible sadness. It is the essence of humanity. And yet, it is something that health and social care isn’t comfortable with.

As social workers you would think that our profession would be there when people needed help and support with love – it’s sort of in our job title. But in my career, I have found the most significant block in terms of our thinking about supporting people to experience the love, with all the risk it brings.  I can recall on one hand the number of conversations I have had with people where there has been a positive approach to helping someone with any aspect of having that ‘Wedding Present song’ feeling.

It is particularly stark when it comes to people with a learning disability. Instead of love, I hear about sex a lot. And sexually transmitted infections. And grooming. The words sex and relationships in social care are invariably linked to risk and danger and professional worry, rarely love. I worked with a young man some years ago who according to his allocated learning disabilities nurse had had sex with his boyfriend who also had a learning disability after an evening party at the day centre. Within the course of that day over 20 professionals were made aware of what had happened. We knew what had happened in forensic detail and more or less where it happened. The police were mentioned. No crime had taken place but someone thought something needed to be done. What about the risks? What about consent? What about protection? Everyone focused on the sex. No one of course said anything about love. Whilst I find the term ‘making love’ a bit toe-curling, it was safe to say that none of the people who got to hear the intimate details of whatever happened between that loving couple stopped for one moment to consider it to be anything other than a physical act. The couple are still together. They are still upsetting people by having sex. No-one is mentioning that they love each other and may get married. No one is talking about how their lives have been enhanced through love. They often skip their allocated day centre to spend the day together travelling on buses. The fact that as a couple they want to stay in each other’s company all day every day, seemed to worry and upset professionals rather than be celebrated. But surely that’s what love does, it puts everything else outside of that relationship into context. For them, love is the answer, not social care.

Social care, day centres, endless games of ten pin bowling, coffee and cake in Merry England for ten people and two carers – all makes sense when there’s nothing in your life other than people who are paid to care for you. Especially  so if you also do not have the comfort of love from your family. Add love into the mix and suddenly ‘outcomes’ and ‘achievable goals’ and ‘support plans’ find their context – in the bin. Love between two people makes sense of everything.  Leaving the question – why don’t we embrace the possibility of love for the people we support rather than reframing relationships in terms of worry, risk and danger; The pain from love is a risk that we are willing to take ourselves, and not infrequently do so. Yet by worrying about others feeling pain from those very risks we embrace for ourselves, we inadvertently ensure love remains always just outside of reach and relevance of those we support.

Perhaps, as professionals we find this so difficult as it calls into question our professionally taken for granted assumption that our interventions are wanted and helpful. If we properly understood love and humanity we would have to understand our place in a person’s life is somewhere much father down in the pecking order. Our rules, our say so, our plans for you suddenly lose gravitas when competing with forces like love. What always strikes me about Mark & Steven Neary’s powerful account about ‘Getting Steven Home’ is that via the Court of Protection the Local Authority seem to very late in the day to be forced into having to grudgingly accept the fact that there is a relationship between Mark and Steven which must be respected and upheld in law (Article 8) but never really seem to get close to understanding that it is the love between them that drives everything about their words, actions and motives. It’s as if love is quite literally an emotion beyond us. We’ve typed ‘love’ into our health and social care computers and it’s come back with an error message and then crashes.

So we tend to stick with what we know and what keeps us safe as professionals. We’ve sort of come up with a fudged thing in assessments which is about relationships. This means that we don’t really have to talk about love but we can talk about other people – significant others, next of kin, nearest relatives and relevant persons. And we’ve got a form and a process for every relationship. Some relationships (nearest relative and relevant person) even come with special powers. Whether nearest or relevant relationship is loving never really crosses our minds. Love becomes relationships. Relationships become processes. Processes get processed. Health and social care box ticked. Love don’t live here anymore. Not that it ever did.