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Chapter 51 - Chapter 55 >>

Chapter 41 Communication Skills

This chapter begins by referring to communication as the sharing of thoughts, feelings, attitudes and ideas between people. It moves on to question different ways of conceptualising communication, or in other words different models of communication. In the early years of the twentieth century, the growing use of telegraphic means of communication was still restricted by the fact that, as when the ship at sea sent a Morse code message, the sender and receiver sent messages alternately. The early mechanical model of communication based on this sequence of ‘one-way’ messages was limited. Later, the social science basis for communication has broadened its conceptualisation. In the process, in psychology and developmental and social psychology in particular, there has been a huge amount of research into how people communicate. Psychological

Factors affecting communication between individuals include the relationship between inner motives and the words and gestures they inform. There have also been linguistic theories about how the structure of language defines how people relate and shapes communication. These approaches are very much associated with sociological ways of analysing how the social setting defines the structure of power in a professional/ patient encounter, for example, or ensures the interaction remains relatively formal where there is a hierarchy of power between the speakers. In a residential setting, of course, it is sometimes said that information, that is communication, is power.

The elements which comprise communication include details such as our choice of words, the speed of speech, tone and the non-verbal clues we give in our clothes, body movements and facial expression. The chapter moves on from these and considers the main ingredients of good communication. This relies on our knowledge and skills. In interviewing, we have to be aware of the range of formal and informal settings possible and how these affect the interview. It is important to plan the interview, to ensure that we engage with the person adequately and that our responses are appropriate. We need listening skills, or skills in ‘active listening’, interaction skills and assessment skills, where we are alert to all the different physical and verbal cues given by the person about their situation and, hopefully, pick these up, explore them as appropriate with the person and incorporate them into the assessment process and negotiate with the person how they are reflected in the outcomes.

 

Chapter 42 Cognitive Behavioural Work

The chapter begins by identifying the major features of Cognitive Behavioural Therapy (CBT).

This derives from well developed traditions of cognitive behavioural theory and research in psychology, which have roots in the linked but distinctly different areas of classical conditioning or operant conditioning. The chapter briefly refers to some of the theoretical ideas about CBT. Simply put, classical conditioning involves trying to bring about behaviour change by rewarding desired behaviour and discouraging or punishing undesirable behaviour. There are many psychologists and therapists working in the field of CBT. Among the leading psychologists, we mention a small number in the chapter. For example, Skinner used conditioning as a therapeutic technique to reinforce desired new behaviour, through rewarding it. Bandra used what he calls social learning as a form of modelling (copying) desired behaviour and goes beyond mere behaviour modification techniques.

CBT draws on the seemingly quite contrasting ideas of cognition and behaviour, which may be what gives it such power as a therapeutic approach. Cognition refers to our consciousness, thoughts, feelings and intentions, whilst behaviour refers to what we actually do. It offers the potential of empowering people to exert control over their problems, by linking their conscious thoughts and their behaviour. At the same time as empowering people, CBT has limitations in that it only focuses on visible behaviour. It assumes people can reason about and control what they do.

The chapter spends some time giving illustrations of how CBT works in practice. The therapy is based on a relationship between practitioner and ‘client’, developing a learning programme modifying thoughts and behaviour and relying on the ‘client’s’ desire to change. In this sense, learning is 'changed behaviour resulting from experience'

The main stages of CBT are as follows: assessment to establish suitability; initial formulation of the problem; continuous recording and challenging negative thoughts; various behavioural experiments; final formulation; more detailed clarification of the problem; termination; outcomes, asking person to score on severity measure; prevention of relapse (Blackburn and Twaddle 1996)

 

Chapter 43 Therapeutic Work

This chapter outlines the origins of the ideas which provide the basis for many therapies. Many of these have their roots in psychoanalytic theory. Psychoanalysis remains a rather specialist area of practice, too expensive for most people to afford, but it has led to a wealth of psychodynamic and psychotherapeutic theories and practices which are much more available to people. Many of these are called on by medical and healthcare practitioners in their own work. Family therapy forms a part of the resources offered by many hospitals and clinics. Psychotherapists, art therapists, music therapists and others often work on a sessional basis in the NHS. There are many centres where they practise independently throughout the country.

By no means all therapies draw on psychoanalytic theory. Different therapies use a diversity of frames of reference. Some are based on ideas rooted in Eastern rather than Western philosophies and tend to be grouped under Complementary Therapy, Complementary Medicine or Complementary Health. (See Appendix 3 of this book)

The chapter gives one indication of how the little-known field of photography therapy may be used very effectively by health and social care practitioners in work with people with disabilities.

 

Chapter 44 Systemic Work

Systemic work relates to systems theories, which tend to have been used since the second half of the twentieth century to inform management and practice in commercial and industrial organisations. In health and social care, systemic approaches can be used in many settings. They have applications at managerial levels as well as in what we are dealing with here – face to face work with carers and people who use services.

The chapter proceeds to identify key features of systemic work and uses illustrations from practice to show how the practitioner works with different systems to achieve change in the circumstances of the patient or service user.

Some space is devoted in this chapter to discussing the strengths and weaknesses of systemic approaches. Because these derive from systems theories, they share the general weaknesses of those perspectives in the social sciences and sociology in particular. These include the limitations of functionalist sociology, where they are rooted in particular, notably a tendency to: emphasise equilibrium and the status quo as the norm; work towards harmony and away from conflict; tend to operate most effectively where individuals relate to wider systems eg. relatives, neighbourhood, work, community, rather than where people live in physical and/or social isolation.

 

Chapter 45 Counselling and Advice-giving

In this chapter, we begin by examining the nature of counselling and advice-giving; explore three main approaches to counselling: psychodynamic, humanistic person-centred and cognitive behavioural; explore typical qualities and skills needed in a counsellor. We also have to decide when, and whether, it is appropriate to counsel a person and who is appropriately qualified to do it.

To begin with, we state that counselling is enabling people to reflect on their situation and empowering them to deal with it themselves, if they wish. So, much counselling (cognitive behavioural work is more structured and proactive) is reactive and reflective. On the other hand, advice-giving is more directive and involves giving guidance, giving information and 'helping' people via providing knowledge for them to use.

We go on to discuss in turn the three main approaches to counselling.

Psychodynamic counselling has roots in psychoanalysis. There are many different forms, but a core assumption of psychoanalytic work is that much of people's thoughts and being is unconscious and hidden and people's actions being shaped by their inner awareness, thoughts and feelings. There is an emphasis on the therapeutic benefits of interaction between the counsellor and the 'client'.

Humanistic person-centred counselling is based in philosophical ideas of existentialism and phenomenology. The 'client' is regarded as the expert in his or her own problems and the counsellor as reflector. One of the leading exponents of this approach to practice is Carl Rogers.

The third approach is cognitive behavioural counselling, rooted in behavioural psychology and cognitive learning. This is a relatively powerful method to use, when the goal is to change a particular, restricted area of behaviour.

Finally, we consider the qualities and skills needed in a counsellor. We distinguish between qualities – which are more inherent in us – and skills – which we can acquire through learning. Qualities include aspects such as sensitivity and self-awareness which some of us can develop, but others seem to find difficult to grasp. Skills include communication skills and listening skills.

 

Chapter 46 Emergency, Crisis and Task-centred Work

We begin this chapter by identifying features of emergency, crisis and task-centred work and specifying circumstances where they are appropriate. We are dealing in this chapter with very different ideas which are apparently quite close, but in reality are only linked by their short-term focus.

 

Emergency Work

One of the most debated areas of the NHS is the accident and emergency service. In this sense, an emergency is a change in a person's circumstances interrupting and threatening functioning and requiring immediate action. Responses include those through acute medical/health and social care services. By definition, this is short term work which may need aftercare passing on to further services. Emergency services are not the monopoly of the health service. Adult and children’s services do have emergency teams, or individual practitioners on call to provide out of hours services.

Crisis Work

Crisis work is not emergency work and relates to entirely different ideas. The ideas informing crisis work are psychodynamic rather than simply behavioural. A crisis is an unplanned event or situation, interrupting and threatening functioning. Treatment aims to interrupt the crisis and minimise or prevent harm. Treatment may include dealing with emotions and unconscious behaviour. However, this approach is not suitable for long term work with 'chronic' conditions.

Task-centred Work

A problem suitable for task-centred work can be broken down into small, easily managed tasks. The tasks can be achieved in the immediate future, for instance, working a day at a time. This makes the approach suitable for tackling visible difficulties.

 

Part VII Roles and Tasks in Multi-Professional Settings

With a few exceptions such as Chapter 28, the book so far focuses on the work of the health and social care practitioner alone. This has enabled us to get our heads round other aspects which present other challenges – contexts, knowledge and skills. In this Part of the book we introduce ideas about working in multi-professional teams. We go on to examine in Chapters 48 and 49 how these ideas are worked through in cases involving adults and children respectively. This is followed by a Resource File highlighting how to tackle suspicion or disclosure of child abuse. We come then in Chapter 50, to an example of multi-disciplinary teamwork viewed from an occupational therapy viewpoint. Finally, in Chapter 51 we examine a framework for decision making which applies across the entire field of health and social care.

 

Chapter 47 Working as Part of a Team

The chapter begins by exploring the meanings of words such as 'partnership' and 'team'. These are words which are widely used in the literature on organisations and management. In health and social care, partnership tends to apply not just to professionals working together but also to practitioners working with carers and people who use health and social care services.

The chapter refers briefly to the many problems of joint working and collaboration between professionals which health and social services agencies have tried to tackle over the years.

There are different organisational settings where practitioners support each other, including multiprofessional settings, community settings and institutional settings. Finally, the chapter considers the ingredients contributing to effective teamwork. Team effectiveness is affected by factors such as leadership style and the dynamics of the team. Leadership style can vary from autocratic through consultative to group-based.

 

Chapter 48 Multi-professional Work with Adults

This chapter draws on a range of ideas as it takes a focus on the ingredients of multi-professional work and works through the sequence of practice with adults. It recognises at the start that multi-professional work between different agencies requires several components to be in place: a high level of understanding of overlapping responsibilities; a willingness to share tasks; high trust between professionals; openness and good communications.

The chapter refers to ideas about the effective working of partnerships, which must be: run according to the law; run flexibly to meet people's needs; based on working agreements about roles, resources and leadership; based on effective working relationships.

The chapter then uses the framework of the stages of the work to generate a series of questions which need asking. It finds it helpful to add a preliminary stage, called ‘beginnings’ here, to summarise the information available at the start.

It should be noted that it is not just the service user’s needs which should be assessed. The carer’s needs should be assessed. The chapter refers to the relevant legislation, which includes: Carers (Recognition and Services) Act 1995 and Carers and Disabled Children Act 2000.

The remainder of the chapter is taken up with working through the sequence of planning, implementation and review/ evaluation.

 

Chapter 49 Multi-professional Work with Children and Families

This chapter focuses on the main stages of practice with children and families. It identifies in the process issues and complexities in multi-professional work and works through the main stages of the work. These are assessment, planning, implementation/ intervention and review/ evaluation. At the start, we have added a preliminary stage, under the heading of ‘beginning’. At this point, we cover the laws and procedures govern the work and confirm which approach to use to assessment. In this case, there is no debate. The source is the DoH Framework for the Assessment of Children

in Need and their Families 2000. This focuses on three dimensions of assessment: the child's developmental needs; the parenting capacity of the adults; family and environmental factors.

To start with, the assessment involves asking: Is there any information about previous agency contact? Are there any known risks? What are individual family members' views? How can we ensure family members participate throughout the work done with them?

When we move to the planning stage, we ask a number of questions: What are we trying to achieve in the plan? What are the views of family members about the plan? What supports are available? Where do the supports come from? What level of resources is entailed? What evidence backs up our plan?

At the implementation stage, we ask: How do we ensure there are no risks and family members are safe? What do we need to do, to support family members? Do we need or have legal backing for the implementation of the plan?

The final stage is review and evaluation. These are two separate but linked processes. Review is regular, on the way to the end, whilst evaluation is what we do at the end when we look back over the entire process. We ask: What were our aims? Which health and social care practitioners were involved? What did we carry out in the plan? What outcomes did we and individual family members notice? What, if anything would we do differently, if we could? What, if anything, would family members have us do differently? What are we, and each individual family member, happy with?

 

Chapter 50 Occupational Therapy: Multi-disciplinary Work

This chapter has two intertwined tasks: to introduce the basics of occupational therapy work and to explore the practice of multi-disciplinary practice involving an occupational therapist. The contribution of the occupational therapist (OT) is very relevant in this book because the OT has a very similar approach to the healthcare and the social care workers who are engaging in health and social care practice.

The chapter describes how the task of the OT has different strands: to optimise a person's performance in work, social, leisure and personal activities and to enable people to maintain or improve their ability to carry out purposeful and

meaningful activities. This involves working in a variety of health and social care settings in public and private sector and working with people of all ages, vulnerabilities, physical, mental impairments and disabilities.

The multi-disciplinary team (MDT) the two OTs writing this chapter refer to consists of the medical doctor, psychologist, support worker, physiotherapist, nurse, clerical officer and social worker, but in a sense these are only representatives of a much wider group.

The actual process of the work the OT does in the example that forms the core of this chapter is as follows: identifying strengths and deficits, by means of joint assessment through the MDT; formulating a plan with the individual; carrying out planned strategy and reviewing and evaluating the work done.