How well we’re treated has a significant impact on whether public services are effective or not. That’s not news, but is does make you wonder why there isn’t more focus on making the human interactions that underpin all our services the best they can be. A recent study on the effectiveness of services for people with personality disorders illustrates very clearly why we should take this more seriously.
Professor Mary McMurran from Nottingham University was the second speaker at the British Psychological Society Scottish Scientific Meeting. Her research on Early Engagement in Therapy: Lessons from Research in Personality Disorder showed that non completion of treatment is a major problem in services for people with personality disorders. For many of us in the room, it was pretty obvious that the issues she raised apply to a whole range of services for a whole range of people.
Professor McMurran outlined the scale of non completion:
- A fifth of patients failed to complete their treatment
- The rate of non completion for people with personality disorders was even higher at over a quarter
- Non completion was associated with poorer clinical outcomes which in themselves were more costly
- Ten years after treatment, non completers cost £144K per person more than people who completed their course
- Non completion was associated with reduced service efficiency and demoralised staff and clients
- Levels of non completion varied a remarkable 37% to 80% across different services
Professor McMurran spoke with a wide range of experts – clinicians and service users – to identify what lay beneath these findings. Her study showed the critical importance of getting early contact and preparation right. This mean paying attention to:
1. The individual’s situation – their internal world, their motivation, their acceptance of having a problem, whether they have memory or concentration problems, all factors which can impact on their ability engage with and benefit from a programme. People have lives, there may have other events and priorities in their life. People’s ability to access the service, transport, timing, literacy, emotional literacy, whether they get support from friends and family all of these make a difference to success or failure. This is why we need person-centred services, why we need to be human. And
2. How services work – how they communicate and build relationships with the people who use them. The nature and quality of relationships mattered too.
To build a service that maximises the chances that your client/patient/user will get involved and enhances the chances that it works requires that we:
- Prepare to succeed. Ensure clients/patients are clear what the treatment is about and what they can expect; work to build a therapeutic relationship and negotiate treatment goals; and actively support people so they are empowered, confident and have the competencies required to make best use of the programme.
- Value, respect and welcome participants. A welcoming and pleasant reception and therapeutic environment; a warm and enthusiastic greeting; encouraging appointment letters and clear information about what happens next. Following up why people haven’t attended and looking at how barriers to attendance can be tackled together.
- Build a therapeutic, authentic, human relationship. Where client and therapist work together to convert the client’s problems into goals using goal-based motivational interviews, helping people chase positive outcomes – much more motivating than avoiding negative events.
- Stick with it. Renegotiate goals during treatment, persist when there are slips and slides, build a long term relationship of mutual trust all help promote success.
None of this should surprise us, these are the steps we take when we want to succeed in sport or almost any human activity, why should be it be different when people are making any life change? Why do we think our clients/patients respond any differently than we do ourselves? Is this yet another example of the ‘them and us’ thinking that pervades far too much of our public service thinking?
Over the last wee while I have had experiences that have made me feel unvalued, unwanted, not in control and somehow wanting:
- Several scary, almost rude, formal letters ordering me to attend for X or Y – even if accompanied by a friendly plain english booklet, the message about who’s in control was very clear.
- Staff who ignored me and Mum when we walked in for appointments and only acknowledged us when our number came up on the screen and it was our turn to be processed
- The assumption that me and Mum can attend any meeting anywhere, any time in places we’ve never heard of and that neither of us have anything else important to do
So many of us just put up with it and hide our responses. Mum’s Alzheimer’s means she can’t do that. Mum’s response to poor service is tangible. Her memory might not work but she can see through the false smiles and the averted gaze and the disinterested comment. Mum can pick up all the things that people try to hide and she will become anxious, sometimes downright frightened; she worries she’s a nuisance, concerned that people are in a hurry and she’s holding them back. She trembles, stumbles, gets anxious and upset, gets breathless and sick. Mum’s emotional intelligence is acute, maybe it’s compensating for her memory, and she responds accordingly. The whole experience is difficult all round and I know has led to her condition being seen as more serious than it is.
Compare and contrast with what it’s like when we’ve been warmly welcomed with a smile and a ‘hello’; where people checked we’re okay and not lost or needing a hand and taken time to reassure Mum. Mum is relaxed, she can follow what’s going on, she can follow instructions. One of my favourite times was taking Mum to the opticians in North Berwick. She loved answering the questions and getting them right, she was totally on the ball and never panicked once. All because of the way Mum was treated.
It makes a big different to me too. I love it when I go into Mum’s Care Home or our local Day Centre and I’m greeted like a friend, a part of the team, a member of our extended family by people who know and care about my Mum. I love it when the staff and volunteers ask how Mum is even thought she’s not been there for a while and are genuinely pleased she’s well. I feel I’m part of a circle of care and that those words actually mean something. This is what co-production, if you want another buzz word, feels like. It’s when Mum, me and Mum’s carers work together and she knows that. Mum loves it when we’re all friends and she sees us talking together, it makes her happy and safe, life is simple and makes sense.
If you’ve got Alzheimer’s life can be very confusing and upsetting when there’s lots of different people doing different things. In the Abbey, Mum doesn’t need to worry about roles, job titles or even names, we’re all people care for her, together. Believe me that makes life infinitely better for everyone and you know what? it doesn’t cost a penny. You know what? It’s good for everyone, Mum, the staff and me. Professor McMurran’s research suggest it is also likely to save us money.
So why doesn’t this happen everywhere? (a key challenge raised for us all by the Christie Commission). I don’t know anyone in the care system who doesn’t want to make the world a better place, so what’s going on? What is it about our systems that change decent, hardworking human beings (us) into ‘them’? No one benefits.
Of course if there were easy answers, the world would be a different place, but there are things we can all do that will change the world. It all starts with a smile, eye contact, a warm welcome. If we could greet every patient, every client, every carer with a warm welcoming smile we’d have made a really important start and we’d all feel much better for it. And who knows what exciting changes might come next.
Go on, make everyone’s day!
Take care and 🙂