Monthly Archives: February 2014

How smiles can change the world

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 🙂




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February 25, 2014 · 3:56 pm

Growing through trauma : living with dementia

On Friday I was fortunate enough to hear Professor Stephen Joseph talk about Post Traumatic Growth  at the AGM of the Scottish Branch of the British Psychological Society. Professor Joseph outlined how people can grow  from, not just survive, disasters. As I sat and thought about his talk, it made me realise that in many ways I see a diagnosis of dementia as a disaster. Given the family history of dementias of different kinds, it may well be something I too have to live with, and it fills me with fear.  What does it take to see beyond a diagnosis like that to a quality life ahead?

Disasters needn’t just be about earthquakes or plane crashes, our own personal disasters bring profound loss , unexpectedly changing our lives forever.  Most of us in the UK don’t expect to lose a child or have a serious health condition or an accident. Most of us are fortunate enough to live lives where we don’t expect to be the victims of crime, never mind being repeat victims. Traumatic events can turn our worlds and our assumptions about how things work upside down.

Professor Joseph’s research  showed that people can do more than just survive disasters. Even after extremely traumatic experiences, we can experience growth.  His study showed that 3 years after the Herald of Free Enterprise disaster,  whilst 46 per cent said that their life view had changed for the worse, 43 per cent of survivors said their view of life had changed for the better since the experience. Psychological growth has been found after other types of disasters too. Using a range of tools, Professor Joseph found that post disaster, some people reported growth in their self perception, their life perspective and their relationships.  Survivors spoke of appreciating their relationships, valuing being alive, appreciating every day and its simple pleasures. This isn’t about happiness or some people having a ‘glass half full’ cheery optimistic personality, nor is it about pulling themselves together. Psychological growth after trauma is something much more profound. It’s about psychological well being; a greater sense of autonomy and mastery, personal growth, positive relationships, self acceptance and having a purpose or meaning for life.

Professor Joseph said that psychological growth is the outcome of our struggle to find a meaning for what has happened,  a deeply human attribute.  Disasters smash apart our carefully constructed assumptions and expectations of life  that we’ve built over years of experience and learning.  It’s no wonder we are stressed, confused, angry, frightened at the void left behind after a disaster.

The logic behind Post Traumatic Growth connects with one of psychology’s most powerful and well known theoretical understandings of what it means to be human – Maslow’s hierarchy of needs. Maslow lists a range of needs starting from basic survival – to reaching the highest levels of human functioning. We  humans are intrinsically motivated to make sense of our worlds and need to fill the disaster-shaped void.  Client centred, person centred, humanistic, positive approaches to psychology all work from the basis that people are intrinsically motivated towards growth, to greater functioning, mastery and autonomy.  Daniel Pink in his research on what motivates us at work lists very similar factors – what drives us in our work is a sense of competence, autonomy  and relatedness. When these 3 needs are satisfied people are motivated, productive and happy at work.

Talking therapies like counselling help people re build their psychological worlds and create new meanings and this can promote psychological growth. There is a cognitive and an emotional component to growth. Professor Joseph found that emotional expression can be the bridge between distress and post traumatic growth. People need to express and make sense of their emotional responses to events. And we need to pay attention to our thoughts too, not simply hope it will all go away. What helps is deliberate rumination – consciously choosing to think about what’s happened actively and constructively rather than avoiding thoughts which become intrusive, uncontrollable and frightening. Psychological interventions, good quality therapeutic interventions, can help build new ways of thinking and rebuild our sense of autonomy and belonging.

I know that my fear of dementia comes partly through the experience of caring for my parents. The most traumatic experiences I’ve had over recent years have been caring for my parents with Parkinson’s and Alzheimer’s disease. A series of events, crises and slow gradual changes turned the parent/daughter relationship on its head; the gradual disappearance of the parents I knew; the end of a career and caring related health problems all took their toll. But as a carer you get through because you have to, it’s only when it’s over that you look round and see what the maelstrom has done to your life. I realised that I’d come out of the other end quite fearful that I too will get dementia and that the spectre of a tragic old age was robbing me of the life to come. I needed some re construction work to avoid living with an impending sense of doom.  Could I use Prof Joseph’s research to help me see the world differently now?

I drew a few lessons for me. I need to:

  • Face up to the possibilities that dementia and other older years ‘disasters’ might happen; plan and prepare as much as possible to minimise the impact on me and loved ones. Not push unwanted scary thoughts into the background.  I’ve started talking about it – a bit.
  • Find new and constructive ways of thinking about life with dementia. It’s so easy to focus on the losses dementia brings not on the reality of what life with dementia can be like. But there are increasing numbers of people living happy and fulfilled lives with dementia.  And whilst I have lost my ‘old Mum’, my current Mum is a delight to be with. My Dad had awful care, his journey with dementia was truly a nightmare. Life can be good with dementia – but the setting has to be right.
  • Express and recognise emotions , don’t try and ignore them.  When I was the main carer for Mum and Dad, I couldn’t face my feelings, they would have overwhelmed me, and indeed they did at times. But when Mum was in safely in the Abbey I had a deluge of emotional reactions built over the last decade. Everything caught up with me. I need to let the emotions through.

The more time I spend with Mum the more I value and appreciate the life and love we share. As we sit and sing together, laugh at one of her funny sayings or a childhood memory she shares with her sisters; as we hold each other’s hand and know we love each other; gradually dementia seems less scary, less of a disaster. Mum is not the person she was, but she is full of life and full of character;  she is happy, she has friends,  her life has meaning.  All because she is in a safe and caring environment where she is treated with respect and encouraged to get the most out of life.

Working to make the world a better place for people with dementia to live, focussing on what people can do all make a future diagnoses of dementia less of a disaster for all of us. No one would want to get dementia, but none of us knows what lies ahead. As we get older it gets harder to assume that we’re immune to the vagaries of the ageing process but there are ways of helping folk find meaning and even happiness after dementia. It takes time but I think it will be do able.

Take care



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Doing things differently

Insanity: doing the same thing over and over again and expecting different results. Albert Einstein

I was at the Strive (our East Lothian Third Sector Interface) conference this week; it was all about doing things differently. A great day and it really got me thinking for the umpteenth squared time: why is it so hard to change? Even when we really, really want to change the world and make great things happen and we get the logic and sense of it all, even with all that, why is it so hard? We talk a lot, read a lot, go on training courses, draw, sing, get creative and then revert to old habits, often with a hearty shove from the cultural, electronic, process ridden worlds we inhabit – nudge applies to paid people not just us punters! Even when we get a clear list of simple and easy things to start doing now, laminate and stick it in front of our screens; changing ourselves is not as easy as we’d like to think.

But doing things differently is exactly what we need to do to reform public services.

Twenty  years ago (gulp!) I evaluated an innovative restorative justice pilot run by SACRO. It provided mediation for victims and offenders in lower tariff offences . Working with economists we showed that not only did victims, offenders, Fiscals, almost everyone I spoke to think it was great, but it was cost effective and gave better outcomes (yes they did exist in those days).  Despite saying how much they valued the project, Fiscals struggled to remember that this was an option and referrals were low. Despite a rigorous evaluation, decision makers didn’t fund it beyond the pilot stage. Just one of very many similar great, transformational ideas that didn’t happen.

There have been hundreds of research reports that have highlighted what stops us doing things differently. Research shows that in the public sector the key thing is that we feel empowered to change – skilled, authorised, knowledgeable and motivated.  I had to ask myself what’s stopped me in the past?

Before I left my job at the end of the year, with the heady scent of freedom in my nostrils, I started to do things differently. Why not? I had nothing to lose, what were ‘they’ going to do? Sack me? I started small, under the radar, safe. I started to share things. Obviously nothing I wasn’t supposed to, I just re set my default to share. A piece of published research I’d read; a draft of a presentation I was doing on assets sent to people who know much more than me.  The world didn’t end, sharing helped to build connections and relationships and got things moving. I read an article in the Psychologist about how to use conversations to support change. I shared and that helped me find my way to expertise in NES on dialogue.   I joined the dialogue community of practice – a growing body of practitioners in a key skill.

When I left the Government I really had to start doing things differently.  Making things happen in the community is all about making contacts, sharing visions and joining and creating networks. It’s about cups of tea, new friends and introductions,. It’s about finding your place and space in a complex world.  Talking and listening are what you have to do when you’ve no power or money, no role or job spec. All you’re left with are relationships, negotiation and influence, the ability to communicate with other human beings.

My mission is to make life great for older people, especially people with dementia like my Mum.  One of the discussions at the moment is about setting up Dementia Friendly Towns in East Lothian. The first questions is who else round here is up for it? Who’s out there with the vision, passion and the time and energy to make things happen? Where do I find people with common cause? Who can I work with?  Who wants to work with me? Everywhere I go, almost everyone I talk to wants to get involved and do something, the energy is amazing and heart warming; it’s personal and crosses professional and personal boundaries.  How do I draw this out, support and focus it to make things happen? I talk, I share, I listen, we co create.

There’s the same buzz at the Social Enterprise in East Lothian (SEEL) events.  Busy business people, whether they run social or private enterprises don’t waste time.  The SEEL events are  busy, buzzing and totally inspirational. People go because they see the value of  hearing what others are doing, sharing great ideas and supporting each other.  Networking is great for social and community business, formal meetings are often seen as a waste of time. When it’s your time and not your organisation’s, meetings look very different. 

As the Christie Commission reminded us, none of this is new. Our great public services are here already, our new ways of doing things are all around us, despite everything. Our challenge is to make new ways of doing things happen everywhere, make them our new norm. The importance of building relationships and quality conversations between service providers and patients/clients/service users is recognised and supported through things like Talking Points, Caring Conversations and Appreciative Inquiry. Without these ways of interacting, co-production can’t happen. People are already starting to apply these ‘new’ ways of talking to how policy makers and decision makers talk, going beyond just using them in the critical relationship with service users and communities.

But there’s a way to go! Conversations with communities need developed. Public servants, and that includes people in Third Sector bodies paid to deliver public services on their behalf, have to get better at having serious and meaningful conversations with communities. Not just because communities need to be engaged and involved if public services are to survive and thrive, but because if we don’t, our public servants won’t do things differently enough. I’ve got a bigger rant on that to come…

I’ve recently been seeing a personal trainer to help me run better.  I know that to do this I have to change how I run, muscle by muscle, joint by joint.  Some muscles have to stop working, others have to start. Sometimes I don’t even know I have a muscle there, so I focus on that area until eventually  something starts to twitch. It’s similar to Yoga practice and similar mind/body disciplines. To make this my new normal, I have to embed the change in my physical muscle and sinew memory through repetition.

It’s more or less the same whatever change we want to make from losing weight to stopping smoking, Changing our work habits is just the same.  Take a look at how initiatives like the Entrepreneurial Spark, Early Years Collaborative and the Improvement method in health see change and compare with what a sports coach or personal trainer would say.

  • Remember that if this was easy, you’s be doing it already
  • Define your goal and focus with the intent and attention of Mo Farah and the mindfulness of the Dalai Lama (feel free to swap heroes there!)
  • Experiment like Einstein – look at what’s worked for others, make things up, read books, share ideas, be creative, dream
  • #GODO like the Entrepreneurial Sparks – start doing things differently and see what happens, observe what works when you push your boundaries, stop doing what doesn’t work
  • Start small so mistakes are easily dealt with and so you can manage risk 
  • Keep learning, keep learning, keep learning

Dan, my coach,  says that he does things differently as a matter of course. He carries his bags in a different hand. He starts his run on a different leg. He says the discipline of doing things differently requires the focus and practice we’d apply to any other human endeavour we want to achieve. It’s quite fun to try and of course we know that the longest journey starts with the first step.

Now which foot do I usually lead off with?

Have a great week. Be different.


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