talkwell 2nd edition

7/27/2019 TalkWell 2nd Edition

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Encouragingthe art of

conversation onmental health

wardsHeres the SECOND EDITION!

With new information,new ideas, same old jokes.


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Star WardsIf youre reading this (which you seem to be!), odds are you know more about

Star Wards than I do. Youre probably one of the thousands of heroic staff

working on mental health wards, faced daily with extraordinary pressures and

challenges and enjoying satisfactions and achievements. (You certainly cant be

in it for fabulous pay or convenient hours!)

I set up Star Wards to in some way reciprocate the amazing care I receive as a patient at St Anns inTottenham. Happily we now have about 600 wards in the country as cherished members and the ideaswe collect, generate and share are making lie on the wards considerably more ullling or patients andsta. A modern matron wrote to us that: Star Wards has been a breath o resh air and its success in ourwards has been overwhelming. Everyone in mental health knows about Star Wards [and] is so proudo the way we can make the changes irrespective o budgets and other demands on time. Star Wards hasbeen the vehicle to say we can do this and just get on with it.

TalkWell is a practical resource to support you in your antastic work, by ocusing on the continuous butcomplex and oten raught process o talking with patients. The skills required to communicate with uswhen we are at our most unwell and not always super-reasonable (!) tend to be under-rated. Yet they arethe ones most valued by patients and which deserve a lot more attention, training and support.

This is the 2nd edition o TalkWell. That reminds me o an antiquarian book I saw in a library o Yiddishliterature. The title, written in Yiddish, was Shakespeare - translated and improved. A great example o

Jewish humour and chutzpah, which roughly translates as cheek. We hope that you will nd the changesand additions to this edition are indeed improvements, and that youll orgive any chutzpah which isethnically hardwired into me and erupts all over the place.

The changes have been inspired and inormed by eedback rom sta who have been using TalkWell,especially the wonderul Patrick Cullen in Birmingham and Jo Spencer in Highgate, north London. Weare also very grateul to Len Bowers and colleagues at City University or the invaluable inormation andguidance in their publication Talking with Acutely Psychotic People. Details o this essential resource areon the inside back cover.

Many thanks to all o you or all your work with TalkWell and your eedback. Ive beenparticularly struck by the ollowing three pieces o advice:

Be yoursel! Thats what patients really1.appreciate

Find and connect with the patient2.behind the symptoms

Mentalising is an awkward3.name but an invaluableskill or improvingconversational skills

ThankstoChristianSinibaldiforlettingususe

hisphotofromT

heGuardian

Marion Janner Buddyandme

beingourselves

.


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Contents

TalkWell

What is TalkWell? ............................................................................................. 3

Introduction ..................................................................................................... 4

1. Why does being listened to feel so good? ................................................. 6

2. Listening skills .............................................................................................. 7

3. Structuring conversations ............................................................................. 9

4. Openers ...................................................................................................... 115. Staff concerns .............................................................................................. 12

6. Checking youve understood ...................................................................... 13

7. Silence.......................................................................................................... 14

8. Appreciating difference. ............................................................................... 15

9. Giving advice .............................................................................................. 17

10. Dealing with sensitive issues ................................................................... 18

11. Apologising ................................................................................................ 19

12. Humour ..................................................................................................... 20

13. Responding to personal or sexualised questions and comments .......... 22

14. Keeping it going ....................................................................................... 23

15 Body language ......................................................................................... 24

16. Voice ........................................................................................................... 26

17. Touch ......................................................................................................... 28

18. Wrapping up ............................................................................................. 30

19. Creative conversing ................................................................................... 31

20. Talking with images ................................................................................. 42

21. Ideas for conversational questions ........................................................ 44

22. Putting it together ................................................................................... 46

23. Using TV for TalkWell training..................................................................48

Notes ................................................................................................................ 54


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TalkWell

Copyright Bright 2nd edition 2010

But please eel to share, copy, quote, blog, tweet and particularly to put up poster-size pictures o Buddy all over the ward.


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3TalkWell

Who we areTalkWell is produced by Star Wards, a project which works with mental health trusts to enhanceinpatients daily experiences and treatment outcomes. We discover, celebrate, share, publicise andinspire excellence in inpatient care and there is plenty o that all round the country. Our memberscreate resources and adopt or adapt resources we produce, to stimulate and structure therapeutic andenjoyable daily programmes or inpatients. The ull range o wards are imaginatively and energeticallyintroducing Star Wards, including elderly, rehab, learning disability and secure wards.

For more inormation, visit: www.starwards.org.uk

* Or not... May have got a bit carr ied away there.

How to use this resourceAs with most training resources, this is written in the hope that trainers will start at page 1 and work

their way systematically through the inormation and exercises till the very last ull stop. But, since wererealists, we also know that some trainers wont have the time to do this! (For example, because youvegot a ew million other tasks in order to run your ward.) And youll be very aware which o your staneed extra help in which aspects o eectively talking with patients so will no doubt choose eatures andexercises accordingly.

The exercises are marked by a speech bubble. Like this...

The exercises are intended to be useul whether sta are working on these by themselves, in pairs orsmall groups, or in a more ormalised training session. The exercises are addressed to your sta directlyrather than to you as the trainer, so that you can simply photocopy and use them. There are all sor ts oresources to support TalkWell on the Star Wards website: www.starwards.org.uk And there are evenmore TalkWell treats on our YouTube channel: www.youtube.com/starwardschannel

What conversation starters have youound helpul?

become better listeners

enjoy and feel able to manage conversations about anything from

Coronation Street to coping with compulsions

have a greater awareness of whats happening in patients minds and their

own

have richer relationships with patients

become popular, charming and gorgeous and probably win the lottery. *

What is TalkWell?

TalkWell is a conversation training resource for mental health inpatientstaff. Its a lively and practical way to help your staff to:


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The importance o conversation oninpatient wards

Think o three o your closest riends. Or thinkabout a boss you respected, a sales assistant whowas particularly helpul, a health practitioner whoreally understood and responded to you. Whatqualities do these people have in common?

Its likely that you elt as though they were reallylistening to you, as though all their attention wasocused on you.

Just listening to someone really listening to them is one o the best gits you and your team can

give patients, and ward sta s skill at listening topatients can make a massive contribution to theirrecovery.

This training book introduces TalkWell acommunication system based on caringconversation, intended particularly or non-registered ward sta including healthcare assistants.Its inormed by the evidence o the recoverypower o conversation to help people with mentalillness. There is considerable research showinghow expressing themselves and being heard

in a particular way enables patients to accessthoughts, eelings and experiences and to gainnew perspectives on these. This then helps themto have a greater understanding o themselves,their situation, their illness, its treatment and therecovery process.

That makes TalkWell sound like hard work! Well, itcan be intense, but the magical thing is that even asimple, sociable conversation can have a prooundimpact on someone who is in a bad emotionalstate.

Why is this? Everything about humans has beendesigned or social interaction. In evolutionaryterms, what separates humans rom our apeancestors is our ability to use complex speech.(Well, that and opposable thumbs. And the abilityto enjoy Strictly Come Dancing.)

Conversation is the primary currency o socialcontact. I someone is experiencing a period oacute mental illness, most o their lie and dailypatterns are temporarily up-ended. So caring

conversations suddenly become exceptionallyimportant as a way o continuing to eelconnected with other people, never mind what

the subject o the conversation. And a veryimportant actor in recovery rom mental illness is

gaining a sense o hope, which most conversationsshould be able to bolster.

In some ways, theres no big deal to conversing.Conversations are as easy as having an ice-cream.(And with less calories.) But just as there arethose who can turn out a nice bowl o pasta, andthen theres Gordon Ramsay, similarly there areenormous skills in being a good conversationalist.And in particular, a great listener.

What is TalkWell?

TalkWell recognises that the two partners in acaring conversation have very dierent currentexperiences and needs.

The member o stas needs include:

building up a relationship with thepatient, so patients like and trust them,and are motivated to spend time talkingwith them

getting to know the patient as anindividual what their lie is normally like,

what they enjoy, what they nd dicult,etc.

reducing the gul created by the powerdierence between sta and patients

understanding what that personsexperience o mental illness is like andhow they cope with it

assessing their current emotional state,including what is helping or slowing theirrecovery and their level o risk

The patients needs include:

wanting someone to be interested inthem as an individual, not just as a patient

eeling able to trust a member o staso they can rely on them or emotionalsupport, inormation and company

simply wanting to have a bit o a natterto relieve what can oten eel like longand empty hours in hospital

Mentalising

TalkWell is under-pinned by an aspect opsychotherapy called mentalising, created byPro. Anthony Bateman and Pro. Peter Fonagy.Mentalising is a slightly odd name but dont let

Introduction


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that put you o! It reers to that essential lie skillo being aware o whats happening or happened

in our own minds and in other peoples minds.

Mentalising, or being mind-aware is aboutbeing in touch both with what were thinkingand eeling and what other people arethinking and eeling.

This is a simple and practical concept and oneyou and colleagues are already using hundreds otimes a day.

At times o considerable stress, the ability to beaware o what is in the patients mind is put undergreat pressure. Its hard to think straight, andeven harder to tune into what other people arethinking and eeling. But its at exactly these timesthat we need to be eectively mind-aware. Letstake a common and very tough example whena patient is highly agitated and gentle attempts toreassure and calm them have ailed, and theresa real risk they will hur t themselves, or someoneelse. A non-mentalising response would be to

ocus only on the practicalities noticing wherethe patient is, whos near them, what sta areavailable to help, etc. A mentalising stance wouldnot only take into account these importantconsiderations, but also help you to identiy whatyoure eeling (e.g., scared, angry, empathetic,calm...) and, crucially, what the patient is eeling. Bybeing aware o whats in the patients mind, youwill be in a much better position to see thingsrom their perspective, and work out how best toresolve the situation.

Laid-back social conversations are a happy parto ward lie. Its possible to have a conversationwithout either person being mind-aware, but itmight be a bit dull and unsatisactory! It would belike one o them chatting about the programmeon purple newts that they saw on TV last nightwhile the other waxes lyrical about their childseating habits. I theyre mentalising, theyll each be

conscious o what the other person is making otheir conversation and trying to connect up what

theyre both thinking about and eeling. Sticking withthe newts and kids example, this could become amore mind-aware conversation i the two peoplestarted making links, e.g., talking about their kidsinterest in reptiles, or purple newts eating habits!

Caring ConversationThe main principle o TalkWell is that allconversations on wards have a therapeutic value.They dont need to be about treatment, or illness:even casual conversations about sport or theweather can be therapeutic, in the sense that they

support the therapeutic alliance. The therapeuticalliance is the essential relationship between amental health proessional and a patient, or service-user. This is an important concept or all your stato eel condent (and enthusiastic!) about. Its beenound that whatever therapeutic approach is used(e.g., psychoanalysis, cognitive behavioral therapy),one o the strongest actors in determining howwell a patient responds is the strength o thetherapeutic alliance. In other words, its all aboutbuilding a good, trusting, respectul relationship with

each other.

You dont need to have read any o thebooks about mentalising to be able to put

TalkWell into practice. (But i you want to, themost relevant one isMentalizing in ClinicalPractice by Allen, Fonagy & Bateman).

To re-cap, TalkWell:

is inormed by research on theimportance o good communicationand conversation

is based on the importance omentalising or being mind-aware

is about the value o caringconversation on inpatient wards

can be used in casual oremotionally-rich conversations

relies on the skills your sta alreadyhave their ability to make peopleeel listened to and understood, tohold an interesting conversation,and perhaps most importantly, theirriendly and caring nature.


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Think o a time when youve eltvery vulnerable like being atthe dentist or a job interview.What has the other person saidwhich has helped you eel moresecure? Did they say anythingthat made you eel worse?

I did some on the hoo research and askedpeople, including mental health sta, what theyenjoyed about conversations. Some o the thingsthey said were:

Its like a gift. Something you can givesomeone, which will make them happy orat least less sad!

Pleasure

I usually learn something. It might besomething about the other person, or

something about myself. Sometimes itsabout something I knew nothing about

before, like why dogs do so much snifng!

It makes me feel good that I can helpa service-user work out for themselves

whats their next step in recovery, and allI need to do is listen carefully. I dont even

need to advise them!

This person is interesting, has coped withexceptionally difcult things and knows

things I dont because Im not her.

I like to feel appreciated and being a goodlistener makes me popular!

Patients can get to trust me if I listencarefully to them. This helps avoid thebuild up of tension and frustration which

could otherwise lead to aggression. Andif someone is behaving aggressively, its

particularly important to listen verycarefully to what theyre saying.

1. Why does being listened to eelso good?

What do you think is the

most enjoyable thing about aconversation?

I were being mind-aware, it is essential to listencareully to a patient to know whats going on intheir minds. This should produce the necessarytrust or the patient to care about whats going on

in your mind and other peoples.

Which people make you eel reallywell listened to?

What is it about the way they listenthat is so good?

What do patients get rombeing listened to?

They eel understood1.

They eel cared about and accepted2.

It helps to make sense o things that are3.happening or have happened to them

It connects them with someone else4.when theyre probably eeling veryisolated and perhaps abandonedbecause theyre in hospital

It helps patients trust sta so that they5.can:a. tell you about whats going on or

themb. learn rom youc. participate in care planning

It helps them release tension in a sae6.way

1.1

1.2

1.3


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Examples:Show it with your ace looking interested, concerned, etc..

Show it with your body sometimes nodding your head, leaningtowards the person, gently touching them on their arm

Show it with your voice by making those small yes, Im ollowingwhat youre saying noises like uh-huh, hmm, etc..

Show it by checking youve understood them, e.g. by saying CanI just check that Ive completely got what youre saying. Do youmean.?

Examples:Distractions in the room, e.g. other people, noise rom TV or radio,an uncomortable place to sit and chat

Distractions in your head, e.g. worrying about your kids, thinkingabout your next holiday, daydreaming, letting your mind wander

Feeling pressure o work and time

Making assumptions especially negative ones about what thepatient is like, and not hearing what they say which conficts withyour assumptions

Worrying about saying the wrong thing, especially i it might upsetor anger the patient

Rehearsing what youre going to say rather than listening to whatthe patient is saying

Hearing the patient talk about things that you cant believe arereally happening, e.g. that the TV is instructing them

Having a strong personal response to what the patient is sayingbecause o similar dicult or traumatic experiences youve had, e.g.a bereavement

Examples:Yes

Sure

Absolutely

I see

Gosh

Good grie

Im sorry

Oh?

Oh dear

Really?

Really!

Howinteresting

Good point

I agree

Yourekidding?

Amazing

2. Listening skills

List 3 things youcan do to showyoure listening tosomeone:

List three little

things you cansay to showyoure listening:

2.1

2.2

What sorts

o thingsmake ithard tolisten topeople?

2.3


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And now list 3 things that show yourenot listening properly to someone:

2.4

Examples:Yawning (!)

Looking at your watch (!!)

Keeping glancing at the TV or newspaper

Looking around the room rather than at the person

Saying things like Youre not making any sense. Perhaps we should talkagain when your medication is working.

Keeping interrupting the person, either by nishing their sentence(probably inaccurately!) or saying something else

Talking about yoursel or someone or something else, rather than

responding to what the patient is saying


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3. Structuring conversations

The Samaritans (surely the ultimate great listeners?) use a simple ramework to help structureconversations

Story

Feelings

Options

This gives people rstly the chance just to get through the acts what has happened. Theyre then ableto talk about how this has made them eel. And then, i there is an issue or dilemma theyre strugglingwith, they can think about what their choices are. This last process is very important. Samaritans dont giveadvice. They help people work out or themselves what the possible solutions are.

Nurse: How are things?

Patient: Not good. Its the whole jigsawthing.

Nurse:The what?

Patient:The jigsaw thing. You know.*

Nurse: Tell me about it.

Patient: I was doing a jigsaw with Brian.And then we got to the end and Brianhad the last piece!

Nurse: Really.

Patient:You see?

Nurse: Im not sure Ive quite understood.What actually happened?

Patient: Brian had the last piece. Hedobviously hidden it, while we were doingthe jigsaw, just so he could be the one toput it in.

*

Nurse: I see. So how do you eel aboutthat?

Patient: How would anyone eel. Angry.Annoyed. Betrayed.

Nurse: And how does Brian eel?

Patient: I dont know. I wouldnt pretend tounderstand the mind o a sneaky jigsaw-piece stealer.

*

Nurse: OK. Did you tell Brian how youwere eeling?

Patient: O course. I made my disgusttranparently clear. I threw the wholejigsaw onto the oor.

Nurse: Right. And you think he would haveunderstood that?

Patient: (Pause) No. Probably not. It mademe eel worse. Because he just carriedon as though nothing had happened. Andthen I thought that maybe he didnt hidethe piece ater all, and now I dont knowwhat to do.

*

Nurse: What do you think you could do to

help eel better?Patient: I dont know. I could ask him

about it, I suppose.

Nurse: Sounds a good idea.

Patient: I could apologise about throwing iton the oor.

Nurse: That makes sense.

Patient:What about i I suggest we doanother jigsaw together?

Nurse: That would be positive.

Patient:Then I could hide the last pieceinstead o him...

The ollowing sketch shows the three parts o the structure in action- story, eelings, options. You can either get two people to read it

straight through and then ask people to spot the dierent parts, orat the points marked * you could pause the sketch and ask peopleor suggestions. What might the nurse say? How should she/herespond? What would get the conversation moving?

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Heres an easy way to remember ways to ask open questions. Its comes rom Kipling.(The poet, not the cake maker):

I keep six honest serving-men

(They taught me all I knew);

Their names are What and Why and When

And How and Where and Who.

Another aspect to structuring conversations is helping the patient to ully express themselves. Whenpeople are acutely mentally ill, actors ranging rom medication side-eects to the persons levels osel-esteem can get in the way o them identiying and describing whats going on or them. A corecommunication skill is asking open rather than closed questions. Open questions are ones whichencourage the person to respond reely with their thoughts and eelings. A closed question classicallyproduces a one word answer, whether yes or no or a act Blue. Horse.

Questions starting with are or do tend to be closed questions because they generate just yes

or no answers.

Questions which start with what, where, which. who and when are open questions. These willgenerate more interesting, uller answers.

I youre looking to probe a little deeper, then you could try questions beginning with how. whyand in what way.

For example, Are you eeling better today? is a closed question. The patient doesnt have to answeranything more than yes or no. Or they might just deliver a grunt or a shrug o the shoulders. All youhave to do is change the question slightly. Turn it into How are you eeling today? and the patient hasthe opportunity to describe how they eel. Open questions, thereore, are much better at providinginormation. Open questions are an avenue leading somewhere; closed questions are a dead end.

Imagine youre having a conversation with a patient who is anxious abouttheir next ward round.

suggest 5 open questions and 5 closed questions you could ask.

suggest how the patient might respond to each o these questions

use these possible responses to illustrate the eects o asking:

open questionsclosed questions

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4. Openers

Examples:Hello. (Er, yes, I know thats rather obvious, but actually oten all patients need to getstarted is a hello and a warm smile.)

Hi. Do you mind i I join you?

Good morning. How did you sleep last night?

Good aternoon. How are you eeling?

Hi. Did you see that programme about [whatever] last night?

Gosh. Its getting cold! We havent had much o a summer! (The weather is probablythe most common, easiest, saest ways o starting a conversation.)

Hello. Do you eel like having a bit o a chat? What would you like to talk about?

Hello. Ive been thinking about...

Think up ways to start a conversation in each o these ve

dierent situations:

youre sitting in the lounge and a patient comes and sits next toyou

youre sitting in the lounge and a patient comes and sits at theother side o the room to you

you go past a patients bedroom and see that they are crying

a patient is highly agitated, pacing up and down the corridor

you need to give a patient some news which is likely to upset

them

What conversation starters have you ound helpul?

4.1

4.2


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It would be easy to chat if therewere activities going on in the ward

which we could talk about. Butthere often arent!

It can certainly be easier to have a conversationi the ward is very active, as you can always askpeople about what theyve been or are planningon doing that day. But patients are usually keen tochat and oten need little more encouragementthan simply eeling listened to, and will then bringup the things they want to talk about. Its great iyou can nd a topic that the patient knows moreabout than you do. This could be stock-car-racingor managing intrusive voices but will help them toeel expert - and be interesting or you!

Patients are too ill or too wrappedup in themselves to be able to havea conversation.

Very ew patients are too ill to want to have aconversation, even i its just a very short, riendlyone that makes them eel cared about. Andthose patients who seem very wrapped up inthemselves would probably benet rom beingable to share whatever theyre going over and

over in their heads. I none o the patients whoare around want to have a chat, simply by beingobviously available to listen gives out an importantmessages o patients being valued. (Patients arevery aware o the dierence between beingobserved and sta being nearby and keen totalk with them. This is closely related to the issuesabout silence outlined on p.14)

I might say the wrong thing andupset a patient.

I youre mainly listening rather than talking, youre

not likely to say anything wrong. And i yourelistening careully, you will have the sensitivity tosay only helpul or neutral things. At times we allsay things we regret! But i patients eel you listento them, respect them and genuinely want to helpthem, theyll usually be very understanding i youeel youve put your oot in it.

Its not what Im paid to do.

Many hospitals specically include listening topatients as one o the most important roles o

ward sta. There are very ew tasks which canbe done well without having listened to patients.

5. Sta concerns

For example, you can only know only know whateect medication is really having on a patient by

listening to what they say about this.Im OK starting up a conversationbut I worry that I then wont knowwhat to talk about and there willbe awkward silences.

Again, patients usually have stored up lots o thingsthey want to talk about given the chance. We alsogive some ideas about conversational topics in thesection starting on p.44.

Im told to observe patients so

surely this doesnt involve talkingto them?

Good point! But whats wrong is the termobservation. Its very unhelpul because it doessuggest simply watching patients. How is all thatbeing watched likely to make patients eel? Manywards are now using the term engagement ratherthan observation, including special engagementor patients who need a member o sta withthem all the time. Listening to patients is the mostimportant element o engagement.

If Im chatting with a patient, it willlook like Im not working.

On the contrary! It will look like youre reallygetting to know patients and that you are activelyhelping them not just cope with being in hospital,but progressing rom whatever stage o theirmental illness landed them there. Even i its justa simple social chat, this is a really valuable part obuilding up a relationship, and trust, with a patient.

If Im chatting with a patient, I

wont be on the look out for adifcultincidentthatmightbeabout to blow up.

All the research shows that the best way opreventing dicult incidents, including avoidingpatients going missing, is or sta to have goodrelationships with patients.

I suddenly there is trouble on the ward, you cansimply leap up and go to help. You can apologiselater to the patient you were talking to, who will

understand why you had to break o so abruptly.


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6. Checking youve understood

There are three main reasons why itsso important to check that youre really

understanding what the patient is saying:to make sure youre really understanding what1.the patient is saying!

to check what the patient has understood2.about about what youre saying

because it demonstrates that someone is3.listening.

Checking youve understood correctly what theother person is saying is a core mentalising skill,

as it recognises that we oten (or usually!) makeassumptions about what the other person means,and were oten wrong.

A more specic way o checking and validatingwhat the patient is saying is to refect back

what you think they are eeling. One o themost powerul benets patients can gain romconversations is the sense that their eelings havebeen recognised. The sorts o things you can sayare:

It sounds like you eel

I can see how upset/angry/anxious thatmakes you

You seem particularly upset/angry/anxious about that

Although you say it wasnt a big deal, you

sounded really upset when you talkedabout it.

What phrases do you use,or might you use in utureto refect back what thepatient seems to be eeling?

Useul questions or checkingunderstanding include:

Could you just go over thatonce more so that Ive denitelyunderstood you?

Please could you say a bit moreabout that so that Ive understood

you properly?I think what youre saying is...

When you said... did you mean that...?

I Ive understood you correctly.

I Ive got it right, youre saying

Let me check that Ive ollowed thatproperly. Youre saying that.

Thats really interesting. Can I justgo over what you said to make sureIve understood what you mean.Youre saying that...

So it seems that youre eeling...about...

Sorry. I dont know about Pleasecould you tell me more about that?

Sorry. What do you mean by...

Im sorr y, but I was distracted by theshouting over there. Please couldyou repeat that?

Please could you just explain a bitmore about...

It can also be helpul to repeat the last ew wordstheyve said, turning them into a question. (Ratherthan turning yoursel into a parrot.) For example,i a patient says: And then a rabbi scamperedinto the bushes, you could repeat but with aquestioning tone: A rabbi scampered into thebushes? The patient will then clariy that it wasa rabbit not a rabbi. (Mind you, i it was a rabbi,it would probably be an even more interestingconversation.)

6.2

What phrases do you use, ormight you use in uture to checkunderstanding?

6.1


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What do the ollowing have in common?

Relaxing in a hot bath

Going or a walk by yoursel

Sitting watching your child sleep

Staring at a sunset

Reading a book

Looking at a painting

They can all be enjoyed in complete silence. Silence doesnt = nothing happening. On the contrary, someo the most impor tant thinking and emotional progress can be made during pauses in conversation.

But rst we have to get past the anxieties that silence can stir up in us!

7. Silence

What do you think aresome o the benetso silence?

Sta can be worried that:

theyll be seen as disinterested in the patient or not listeningproperly

the patient will think theyre boring

the patient will eel under pressure to come up with somethingto say

it could look like theyre not working

Silence:

gives time or you and the patient to refect on whathas been said and what you both eel about this

allows the chance or some mind-awareness orboth o you to consider whats going on in yourown and the other persons mind, including whateelings may have been stirred up or each o you

is a lovely breather. Just like having a rest during awalk

shows youre not in a rush as a listener. This really

helps patients eel valued and able to take their timein getting to the issues which matter to them andwhich might be very dicult to say at rst

Why can silence eelscary?

These concerns are understandable. But the benets o silence during a conversation should outweigh theanxieties.

7.1

7.2


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8. Appreciating dierence

One o the most enriching, but also challenging, aspects o inpatient care is the very dierent lieexperiences o patients.

Examples:Jobs

Marriage, relationships, sexuality

Kids

Religion

Ethnicity

Country o origin

First language

Make a quick listo some o theways that patientsmay have dierentliestyles to eachother and to sta

Everyone is unique and special. Its vital that we dont eel that how we live or what we believe is the onlyor best way. Most other ways are simply dierent not the only or best way, but what is right or thatperson. (Some behaviours are wrong and not to be condoned, eg dipping sardines into the chocolateountain at a Bar Mitzvah party.)

We need to recognise that dierences in liestyle, belies, etc. can make us eel uncomortable oruncertain, in order that we can make sure that this discomort doesnt get in the way. Its another case owhere mentalising helps! We can be mind-aware by understanding that whats comortable is what wereamiliar with.

Weve invented the sta comments in the list below. Mark with a J whicho the ollowing are judgmental comments (i.e. ones where theyre saying

that they disagree with the person) and mark with an N ones which youthink are non-judgmental (i.e. they regard the persons views or behaviourin a neutral way.)

I see. Could you help me out by explaining a bit more about why youdid that?

Thats interesting.

Thats weird.

I havent met anyone beore who indulges in that sort o thing.

I havent met anyone beore who has had that experience.

You seem very upset by what happened.

No-one in their right mind would be upset by that!

I totally disagree.

Dont take this personally, but youll probably go to hell.

Do you have a religious belie about the choice you made?

Does your imam/rabbi/vicar/priest suggest anything that you ndhelpul?

No wonder she walked out on you.

How did you eel when she walked out on you?

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Native Americans have an old saying: Dont judge anyone til youve walked a mile in their moccasins. Thisis a great principle. Unless weve had an identical experience to someone else (and thats impossible!), we

cant truly know what its like or them. So we should never assume we know, or know best, what its likeor the other person or just what they should do. However dierent peoples experiences are, we canusually nd something in their lives, values or personalities that are similar. What tends to work well is tond common ground. It can be arming and reassuring i the other person knows youre trying genuinelyto relate to their experience, or example by saying something like: I cant possibly know what its like oryou to have been brought up in a very religious amily. But I can relate to you having parents with strongviews.

Finding common ground

This is one o the ew exercises in this book which, ideally, should be done in

a structured training session, as it can raise powerul eelings.

Ask people to get into pairs and to nd a slightly controversial topic whichneither o them has strong views on. (Its just an exercise and we dont wantto provoke a major sta incident!) Something like whether its better to buyorganic strawberries fown in rom Spain or non-organic strawberries grownlocally. Or who should have won X Factor/Pop Idol/Big Brother. (Footballmay be too contentious!)

Anyway. What then happens is:

the pairs then decide on two opposing views e.g. Gavin should have

won because No he shouldnt, because.. They dont need tobelieve what theyre putting orward just to be able to think o enoughreasons to back up their position. (Bear with us on this exercise! Itsactually very powerul and constructive!)

they agree who will take which position to advocate

each person spends up to 3 minutes making the case to their pair andthen they swap round

This is the important part! They then spend up to 10 minutes ndingcommon ground between their two positions i.e. points they can bothagree on.

The whole group then discuss how it elt doing the exercise and perhapsgive some examples o how theyve ound common ground in the pastwith people putting orward views very dierent to or even confictingwith their own.

You wont be surpr ised that theres a mentalising take on diversity! Because it stressesthe need to really ocus on each individual and what theyre experiencing, it keepsreminding us that we mustnt make assumptions but must nd out directly rom theother person. This is a par ticularly useul skill with people who have very dierent lieexperiences to our own, as the courteous curiosity that mind-awareness encourages is

invaluable in asking open, non-judgmental questions. And in being genuinely interestedin the answers.

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9. Giving advice

Sta can oten eel like the most helpul thing they can do is to give a patient advice, especially i theperson seems very stuck in their situation and/or it seems obvious what the patient should do. But

its usually more complicated than that! And whats a mentalising angle on advice? That its somewherebetween unhelpul and irrelevant because, as you hardly need us to remind you, its all about whats goingon in each others minds. Its not about working out what we think the other person should do, but likemost therapeutic approaches, is to support people to work out their own solutions.

In which o these situations might it be appropriate to oer advice?

A patient wants to stop taking their medication

A detained patient asks you not to tell anyone else, but they areplanning to slip out o the ward tomorrow and go home to see their dog

A patient asks you i they should orgive their wie or having an aair

A patient asks you what kind o pension they should invest in

A patient asks about how they can cope with being at a ward review,which they nd very intimidating

A patient says that they nd working makes them too tired to be a goodparent. They ask what youd do in their situation

A patient asks you what you think are the chances o a horse calledTemazepamwinning the 3.30 at Ascot.A patient says they eel uncomortable about claiming Disability LivingAllowance even though they are entitled to it. They ask or your adviceabout what to do.

In some o these scenarios its ar rom clear whether its reasonable to advise someone. In others, itmight be patronising or just unnecessarily unhelpul to withhold advice, eg i the issue is a simple one orone that youre expert in. But i advice is given, it should be ollowed up with an enquiring, open question i.e. not one which prompts just a yes/no answer (see p.10).

The ollowing are the sorts o actors sta need to consider beore doing what comes naturally,advising someone who is either asking or your opinion or who you eel you can really help bysuggesting to them what to do:

People dont necessarily want to be told by someone else what to do. It can make themeel less able to sort things out or themselves

The process o trying to work out what to do can be as valuable as the solution, or options,they come up with

Its very unusual to have enough inormation about the person and situation to be able togive advice that is as useul as the ideas the patient themselves can generate

It may be the wrong advice!

Usually its possible to guide the person through the options, so that they can make thedecision themselves without being infuenced by what you think is best

One o the reasons why the Samaritans take over 5 million phone calls a year is their reputation orlistening rather than advising. (The Citizens Advice Bureau, on the other hand.)

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What phrases do you use, or might you use in uture to ask aboutsensitive issues?

10. Dealing with sensitive issues

When you need to ask something which touches on sensitive or painul issues or the patient, suchas bereavement, there are all sor ts o things which can help:

10.1

I hope you dont mind me asking but

I it doesnt make you eel uncomortable, please could you justtell me a bit more about.

I this doesnt eel too personal, please could you explain.

Please eel ree not to answer this, but I was wonderingwhether.

It would help me understand better, but you might not want totell me about.


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11. Apologising

There will o course be times when you or your sta put your oot, both eet or all 4 limbs in it. As,by now, you are ultra-mind-aware, you usually wont need a patient to burst into tears to realise thatthey eel upset by something youve said or done. And no surprises with these suggestions or what

you can say:Sorry!

Im sorry.

Im so sorry

I apologise or that

Please orgive me or saying that.

Im really sorry. That came out all wrong

Im sorry. That was an inappropriate thing to say.

Im sorry that what I said made you eel bad.

Im sorr y. We seem to be misunderstanding each other. Lets try that bit o the conversation

again.Im sorry. I put that badly. What I should have said is...

Oops. That was a stupid thing to say! Im sorry about that.

Gosh. Did I really say that? That was dat. Im sorry. No wonder youre annoyed.

Im sorr y. I put that so badly that youre probably eeling...

Im sorry. That was a clumsy thing to say. How has it made you eel?

Aarrgghhh! Id be really annoyed i someone said something like that to me. Im sorry.

I was wrong to say.Im sorr y and hope that I didnt make you eel too bad.

Thinking about a time, at work or home, when you probably shouldhave said sorry but couldnt manage to:

Why do you think this was?

How might things have turned out dierently i you had said sorry?

Do you think you were being mind-aware, in particular about whatthe other person was thinking and eeling?

How do you eel whensomeone apologises toyou when theyve madea mistake?

What phrases do youuse, or might you use inuture to say sorry?

11.1

11.2 11.3

As Sir Elton so wisely said (and tuneully sang) Sorr y seems to be the hardest word. It can beridiculously dicult to apologise. Some o the reasons why everyone can sometimes nd it impossible to

squeeze out that word that rhymes with lorry include:We dont want to admit we were wrong. This usually underlies whatever else may be preventingus rom releasing that simple word which might instantly make the situation much better

We dont want to look, or eel, weak especially i we eel its important to be sent to be in astrong position o authority in relation to the other person

We might worry that the other person will take advantage o the situation,


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You and your colleagues will be very aware that using humour with patients can be wonderully helpulor woeully hurtul. The star ting point is cer tainly tricky there is so much intense suering on wards, and

not just because o gruelling ward rounds. But humour can also be created by the extent o the distressand can dissolve the pain o the moment. Theres lots o research showing that humour is benecial ormany reasons.

12. Humour

Laughter can:

reduce physical pain

strengthen the immune system

stimulate the cardiovascular system

sharpen thinking

provide dierent perspectives

counteract stress

be very bonding between people

and show that were sophisticated enough to appreciate obscure comedies.

Being aware o an individual patients humour preerences helps sta judge i, when, and how touse humour with that person. Were not suggesting that a nurse should excuse hersel in the middleo a conversation with a patient, and rush o to look at the patients notes beore making a gentlequip about the weather. But where they have a substantial relationship with a patient or humour hasemerged as an issue or the patient, it can help:

to know that the more an individual uses positive humour, the more theyre likely toappreciate a member o sta sometimes being humorous with them.

to understand the role humour plays in the patients lie, or example by nding out whatcomedy lms, programmes, people etc they enjoy.

to know about the persons ability to laugh at their situation

to see how the person reacts to other people humour

Using humour on mental health wardsThere are, o course, particular considerations or sta using humour with patients, including beingsensitive to each individuals experience o their illness. Among other variables o the appropriateness ohumour with an individual, the specics o their symptoms, sel-esteem and the impact o their illness ontheir lie are important to take into account.

Healthul not hurtul humourHomer Simpson says to the medic: My little girls stomach hurts. Do you have anything to stop her

complaining?

I Hippocrates were alive today hed be 2,379 years old. And not too pleased that people think he saysone thing and does the opposite. But at least hed be consoled that First do no harm, his mantra ordoctors, is still going strong. This principle is highly relevant to using humour with acutely distressedpatients. Stu thats unny can also be deeply wounding either inherently (e.g. teasing, insulting, humiliating)or stylistically (e.g. sarcasm used or experienced as a put-down). And, just as patients oten rely onhumour to help distance them rom painul thoughts, sta use humour to help them cope with patientspain and complexity. But this creates potentially harmul distance between the sta and patients.


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Happily, some rather serious and studious people have gone to the trouble o providing some goodtips, which were reproducing rather than working it out or ourselves:

wait until you have a good rapport with the patient beore using humour, so that thepatient trusts you and your intentions

humour aimed at ourselves is more likely to be healthul

humour aimed at others is more likely to be harmul

dont make light o or joke about the patients experiences unless they do so rst, andeven then be cautious

dont make light o or joke about one patients experiences to another patient. Ever.

try waiting until the patient says something that makes her laugh and respond and build onthis

be very careul with your body language and tone o voice when using humour, so that thepatient is clear that youre not mocking but supporting

steer clear o the classic Christmas or Passover amily meal confict-igniters: sex, ethnicityand politics

Those that are par ticularly un, and also appealing to visitors, include:

a unny noticeboard with car toons, jokes, fyers or local comedy events, etc.

starting ward meetings with a good joke or unny anecdote or hilarious TV clip

unny board and other games, e.g. Pictionary, Twister (single-sex playing!)

books joke books, humorous books, comics, novels,

comedy lms, TV and radio programmes, poetry, music, drama.

religious estivals tend to be rather serious, i not gloomy, but there are some which areparticular ly good un, such as the Jewish estival o Purim

comedy outings, e.g. lms, plays and, o course, comedy clubs

pets dogs in particular can be very unny, (as can meerkats and aye-ayes but these areeven less likely to slip under Inection Controls penetrating radar)

Practical ideas or unnier conversationsLike all aspects o conversation, whether on a ward or in an ice-cream actory, the more activities goingon, the more there is to laugh about. And the easier it is to nd sae things to laugh about, during andater the activities.

What are your humorous skills and gaps? Whateect on conversations with patients could thesehave?

Give an example o when youveseen or used humour sensitively andeectively in a stressul situation.

Give an example o when youveseen or used humour damagingly in a

stressul situation.

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How do you think mind-awarenesshelps when a patient asks you avery personal question?

Being asked personal questions, or other

questions that you dont eel comortableanswering, is yet another occasion when mind-awareness is very handy! It can be very dicult inthis situation to think beyond: Blimey! Thats muchtoo personal! Cant possibly answer that. Andthis could be accompanied by eeling anxious oreven angry. But i sta can stretch their mentalisingto include considering what the patient may bethinking and eeling, this should help. For example,the patient themselves may be very anxious,and realise that its an inappropriately personalquestion but eel so desperate to know about

someone elses experience that theyll r isk asking.(Or, sometimes patients are just chancing theirarm or being nosey!)

The most important thing about responding tothis sort o question, is, perhaps, not the wordssta use, but the tone o their voice and theexpression on their ace. I they smile and saysomething gently, or humorously, most patientswill understand and accept that the member osta cant answer the question.

13. Responding to personal orsexualised questions and comments

An invaluable ploy in situations where sta are askeda dicult question is to buy some time. A patientwill appreciate that sta are taking their questionseriously and courteously i something like this issaid: Hmm. Ill need to think about how best to

answer that. Can I get back to you on that one? Thiswill genuinely give the member o sta time to think

Its sometimes possible to politely ignorethe question and carry on the conversation.But better to say this sort o thing:

I can see why youre asking this, butwere here to talk about you notme. (The classic therapists answer.)

Im araid I cant really talk aboutthat

Thanks or being interested, but Idont think that knowing about my

experience will be any help to you.Im sorry, but thats a bit toopersonal or me to talk about.

Is there a particular reason whyyouve asked that?

Examples:Being aware o your own thoughtsand eelings, especially i theyre sostrong that they get in the way obeing properly in tune with thepatient

Working out what might be goingon in the patients mind e.g.:

What do you know about the-patients past experiences (e.g.having been abused or bereaved)that might explain more about thepurpose o the question?

Is there a more hidden, important,-underlying reason why theyreasking that question?

What is their body language-saying about how theyre eelingat this moment? Is it aggressive?Withdrawn? Distressed?

about how to respond, and also to consult you or

another colleague.Sta should be alert to the possibility o a patientscare plan identiying as a problem their askingo personalised or sexualised questions. In thiscase, its particularly important or everyone toollow what was agreed as the most appropriateapproach or response.

What phrases do you use,or might you use in utureto respond to personal oruncomortable questions?

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OK. The conversation is underway. The member o sta wants to help the patient eel able to say whatsreally on their mind. The ollowing should help.

Providing brie, noncommittal acknowledging responses, e.g., Uh-huh, I see.

Giving nonverbal acknowledgements, e.g., head nodding, acial expressions similar to the patients,open and relaxed body expression, good eye contact.

Being patient (er, being patient with the patient), taking things at the patients pace

Coping with or even savouring some silence

I a patient seems to be struggling to know what to say, try The Politicians Dream Conversation a monologue, or one-sided conversation. You chat away, about topics that you hope willinterest the patient, or at least not stress them. They might eventually join in and couldappreciate your attention and eorts to engage them.

Saying things like:Please could you tell me more about how you elt about this?

Thats really interesting. Would you like to tell me a bit more about that?

Just let me think about that or a moment.

What are/were the best things about that? What are/were the worst things about that?

And then what happened?

So then?

Do you mean that.?

Thats ascinating/intriguing/interesting.

14. Keeping it going

14.1 What phrases do you use, or mightyou use in uture to encourage theconversation along?


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Were usually pretty aware o what weve just said, or generally what our speech is like and what peoplemight make o what were saying. But its incredibly dicult to be aware o our body language. However,

its impossible to over-emphasise how important these are to patients, and how easy it is or sta tounintentionally upset, oend or anger patients by giving a strong message through acial expression, handgestures or even sitting position!

Its particularly impor tant or sta to be aware o body language when working with inpatients, as thepatients may respond much more to non-verbal signs. This is especially the case or people with additionalcommunication challenges (see creative conversing p.31) Patients ability to ollow what someone is sayingcan be impaired i, or example:

theyre very distressed or angry

theyre very out o touch with reality

English isnt their rst language

15. Body language

Examples o body languageLike most other aspects o communication, body language mainly develops rom observing and copyingthose around us. So it varies between countries, cultures, communities. The usual example given is eyecontact. In the dominant (i.e. white) culture in the UK, its polite to look at people when we talk to them.Not making eye contact can be regarded as a sign o shyness or o lack o interest, insincerity or evendeviousness! But in other countries, making direct eye contact can be interpreted as being over-amiliar oreven aggressive.

The sub-conscious body-language signal were perhaps most amiliar with is arms crossed against thechest. This usually can be interpreted as the person putting up a barrier between themselves and others,

maybe to give themselves a sense o protection rom the other person, or a bit like hugging themselves.

But hang on a second! As this is an exercise about body language, how will youknow how this seems to others? One useul way o checking out your bodylanguage is to practice looking at a mirror. (Once the bathroom door is locked, yourembarrassment should soon evaporate i you keep your voice down!) But thebest way o checking out both body language is to get direct eedback, rom anotherperson. Colleagues (including your manager) are probably the best people to dothis, but partners and riends can be surprisingly helpul!

15.1 Spend a ew minutes imagining youre having dierent sorts oconversations with a patient, e.g.:

Enjoying a hilarious conversation comparing cooking disastersyouve both had

Having a practical conversation about the patients programmeor the week

Struggling to keep your temper when a patient is saying rude andaggressive things and their body language and tone o voice is

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Questions about the photos

How would you describe their expression?

What are some other possible interpretations o their expression?

What is their body language saying?

What might they be thinking?

What might have happened just beore this photo was taken?

Write some captions or the photos bonus points or wit!

What would be the best and worst responses to each person in words andbody language?

Do you ever eel like this at work or home? What helps?

15.2

How would you interpret these body expressions? You might come up

with more than one possible explanation or some, even options thatare opposite to each other.

15.3

Shrugging shoulders

Raising eye-brows

Cracking knuckles

Clenched sts

Pointing

Yawnin

Frowning

Pointing nger atsomeones ace

Hand coveringmouth whenspeaking

Hand placed onheart

Slouching

Standing with legsapart, hands on hips

Hands open, palmsupwards

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Quiet Normal Loud

Welcoming a new patient

Talking about the TV when theres lots o noise in the room and its hardto hear

Responding to a very distressed patient

Calming a very angry patient

16. Voice

Our voices convey more than just inormation, opinions and quirky versions o our avourite songs. I wesound excited, or example, the person listening to us will be more interested in listening to us. Famous

sports commentators are able to convey the excitement o events, even when, i theyre honest, thingsare a little more routine. (Although Ive yet to hear anyone who can make bowls sound thr illing.)

On a ward, voices can have a postive or negative eect. A member o sta may be trying to conveyconcern and warmth, but i theyre speaking in a monotone with a detectibly sarcastic note in it, thepatient will pick up the negative message more strongly than the intended one. (And o course this willbe reinorced i theres contradictory body language.)

But looking at things more positively (!), voices can be a huge help in making patients eel better. Evenhearing a really painul message can be sotened i the member o sta is careul to use a gentle, caringtone o voice. In act, there are a surprising number o elements making up what ones voice sounds likewhich is why its so important or sta to be aware o how they sound to others.

Ask the group to identiy the dierent elements o the voice, in otherwords what they can do with their voice to make it sound dierent orto express dierent eelings?

How loudly or quietly sta speak also makes a strong impact. Which do youthink is the most helpul volume in these situations?

Watch a TV programme with thesound o, identiying what emotionsor messages the people seem to beexpressing through their body language.

Volume

Tone (e.g. warm, sarcastic,riendly, patronising)

Pitch (high, low, deep, squeaky)

Speed

Emphasis (stressing particularwords)

Accent

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Try saying these sentences in very dierent ways, e.g. compassionately,irritatedly, patronisingly, angrily:

Your mother phoned.

The doctor has said you cant have s17 leave.

Where did you get that t-shirt rom?

Why do you think youd be a good teacher?

Then say the same sentence, smiling while you say it. What dierencedoes it make when people smile while talking?

Practice consciously using a tone o voice which shows thesedierent eelings (one ater the other, not all at once!):

Kind

Worried

Very worried

Hysterically worried

Irritated

Furious

Calm

Amused

Dismissive

Powerul

Sarcastic

Trusting

Genuine

Superior

Lying

Condent

Arrogant

Proessional

Respectul

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How do you eel about physical contact with patients during conversations?

This is a touchy issue. Beyond touchy-eely, it touches on matters rom the everyday (the sort o distancerom others we eel comor table with), to the traumatic (eg peoples experience o abuse). It is also one

where there are huge dierences between cultures and communities including age and social groups.All this is urther complicated on mental health wards by:

Patients states o mind

The use o physical interventions to control very disturbed patients

The power imbalance between patients and sta

Sta ears about touch being misinterpreted by patients or others, sometimes with even ananxiety about legal action

The high percentage o patients, especially women, who have a history o physical and/or sexualabuse

Mixed sex sta and patient groups

On the one hand, in most cultures sae touch is a very acceptable, welcome part o social contactbetween people o the same gender and, to a lesser extent, between men and women. And or most UKcommunities, a gentle hand on hand or arm around the shoulder is more consoling than gentle words canbe. This is especially the case or women and patients with dementia.

But even this very conventional physical contact stops being ordinary when located on a mental healthward and sta have to be aware o the risks to patients as well as themselves o even the most casual,spontaneous and unintrusive touching. Wanting to make a physical connection with a patient is usuallymotivated by warm, human, caring eelings. But people var y greatly in how they interpret, eel aboutand respond to others touching them, especially in a hospital situation where theyre probably eelingvulnerable, anxious, rustrated, uncertain and other unsettling emotions.

There isnt the room in this training resource to properly cover this complex issue. But asking sta toconsider the ollowing questions should help them urther develop their awareness and skills in relationto touch.

17.Touch

17.1

Are you a person who tends toinclude physical touch when

talking with others?Can you think o a time whenyou had a strong responseto someone in a position otrust touching you during aconversation?What did you eel?

Can you think o a timewhen you were surprised by

how someone responded toyou touching them during aconversation?Describe why they might haveresponded in this way.

What sorts o actors can helpyou know how an individualpatient might respond to beingtouched during a conversation?


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18. Wrapping up

Psychotherapists are very experienced at ending sessions, bang on 50 minutes! (Theyre usually

more fexible about other conversations!) Sta can borrow these phrases:

We need to nish now

Im araid weve run out o time

Im sorry but thats all the time weve got today

This nishing up phrase can be ollowed with something like:

Thank you or being so rank with me

Thanks or chatting with me

Thanks. Ive enjoyed this conversation

Thanks or letting me get to know you better. I really admire [and then something like]:

the way you have coped with such a tough situation-how strong youve been through all this-

your sense o humour despite how sad youre eeling-

the way youve continued looking ater your kids so well when youve been going through-such a terrible time

Ending a conversation can eel as daunting as starting one. But there are some simple techniques orending conversations in a way that eels good or sta and or the patient.

EndingsI its been quite an intense or emotional conversation or the patient, its really important to end it in away that makes them eel OK. You know whats coming next. Its very impor tant to be mind-aware!What might the patient be thinking most about at this moment? What are they eeling? These three stepsalways help.

1. Checking how the patient eelsHow are you eeling now?

2. Acknowledging how the patient eels:

I the patient says they still eel upset/angry/rustrated:Im sorry that you still eel upset/angry/rustrated.

I the patient eels better than beore the conversation:

Well thats good. Im really pleased that you eel a bit better

3. Letting the patient know that there will be more opportunities to talk:Lets catch up again tomorrow/later this week

What phrases do you use, or might you usein uture to wrap up a conversation?

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I noticed that

Ive noticed that otherpeople really like theway youre so good at.

I admire you or

I really like the wayyou...

Im impressed with theway you.

I appreciate the actthat youre willing to...

Your partner/amily/riend must appreciatethe way you.

Congratulations. Thatmust have been veryhard or you.

That was brave/honest/kind/smart/generous to...

Youre so...

Im pleased that you.

Finish the sentence with an example o what you could say18.4

Praise and complimentsPerhaps the biggest conversational git you can give is to pay someone a compliment. Its such a simplething to do but makes the other person eel great.

How does being thankedmake you eel?

What phrases do you use, or might you use in uture when a patientthanks you?

What are the worst things we can saywhen someone thanks us? How couldthese make the other person eel?

It can take a bit o practice (perhaps with amily!) to notice things to compliment and to eel comortableabout saying this. Practising out loud, even i by yoursel, really helps you to say it out loud to someoneyoure complimenting.

What phrasesdo you use,or might youuse in utureto show youappreciatesomethingabout theother person?

Accepting thanksFunnily enough, being thanked oten makes us eel very awkward. We can react as i someone hasinsulted us rather than made the eor t, and channelled their generosity to say that they appreciate us.

Graciously accepting thanks has been compared to receiving a git. I someone gives us a pressie, wedont usually squirm, mumble, etc., but smile and say thanks! Similarly, when were being thanked weare being given a git o appreciation, and a ew simple words back are all thats needed, eg:

Its a pleasure

Im glad Ive been able to help

Thank you or saying that

Thanks. I appreciate that

Thats nice o you to say so

Im so pleased that you eel that way

What are some o the nicestcompliments youve been

given at work or at othertimes? How did they makeyou eel?

18.2

18.5

18.6 18.7

18.8

When youve made a real eort withsomething, at work or home, but no-oneactually compliments you, how does thatmake you eel?

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19. Creative conversing

Sta are aced each day with having particular ly complex conversations with patients, conversations whichcan be very emotionally and intellectually demanding. These conversations might be exacting because a

patient is in a very raught state or because they have additional communication disadvantages such asdementia or psychotic symptoms.

Conusion and misinterpretation are oten major eatures o these interactions. I youre eeling conused,its likely to be much more bewildering or the patient who has the double challenge o mental illness andan additional communication complication.

You know whats coming mentalising. Trying to see things rom the perspective o the patient andkeeping track o whats going on with your own thoughts and eelings. Yes, very demanding on top o allthe other pressures o your work, but also incredibly satisying when unexpected breakthroughs happen.And the need or a creative, patient-centred approach means that theres tons o scope or interesting,un, memorable experiences. A big reward or the respectul, tenacious interactions about issues that areimportant to the individual where youre eectively harnessing your own and the patients motivation.

Theres a abulous approach to communication with people who have proound and multiple learningdisabilities, called intensive interaction. Intensive interaction is about using everything that yourcommunication partner provides, and because its designed or people who use little or no speech, bodylanguage and behaviour are careully considered. A really valuable concept rom intensive interaction isabout taking the lead rom the other person, building on the communication methods, style, pace etc theyuse, enjoy and can comor tably manage. The greater the persons communication challenges are, the morethis approach helps. Its all about creative conversing applying the ull range o your personal qualities,imagination and artistic abilities.

1.The individualLike everyone else but even more so in this situation, and to state the obvious, patients withadditional communication problems are very individual in what they nd helpul

Its crucial to encourage the person to communicate in the ways that work best or them andwhich build on their strengths, interests and motivation.

Peoples health can aggravate or cause communication problems, especially issues o hearing,sight, medication, pain, atigue or even ill-tting dentures.

Allowing a generous amount o time or the patient to understand and respond to you reallyhelps

It can unor tunately happen that given all the pressures on a shit, especially with many patientswith multiple health and communication complications, sta can unintentionally say or do thingswhich make the patient eel belittled. Substantial communication impairment doesnt mean thepatient isnt very aware o peoples attitudes to them. (see p.19 on apologising)

Lie actors shared by a member o sta and a patient can help the patient eel morecomortable and condent about communicating eg age, gender, ethnicity


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2. YouYou too will have your own attitudes, eelings and belies, and these will inevitably infuence the

way you see and interpret the persons needs, choices and interests.Success is highly motivating or sta and patients! Finding eective (especially breakthrough!)ways o communicating with individuals enables them to be more responsive and sta toappreciate them more. So its worth investing time considering what is it about the personwhich makes you eel you want to respond and whats getting in the way.

Staying calm not only supports your sanity but also reassures the patient and helps keep theemotional temperature low(er). Trying not to take things personally is a crucial skill here.

When someone does or says something that seems weird or wrong, its important to think odierent possible interpretations or these. Theres a great 50:50 principle rom mentalisationbased therapy. Assume theres a 50:50 likelihood that whats being said is accurate, or meaningul,or a muddledly expressed version o what did happen.

The stronger your relationship with the patient, the easier and more satisying thecommunication.

Gentle humour can oten help a situation where theres misunderstanding. But humour canalso unintentionally add to the conusion and make the patient eel vulnerable or belittled. (seehumour eature on p.20)

3. PreparationLots o things can help prepare or conversations eg reading patients notes, talking to colleaguesand also, where appropriate, to patients riends or relatives

Sometimes it helps the patient be well-prepared or a particular conversation (and especially

a meeting) by giving them advance notice, as long as this doesnt build up their anxiety. Somepatients eel more comortable and communicative i they have a riend or even an advocatewith them

Alternatively, it can work well to gently br ing up a par ticular issue while youre doing an activitywith a patient such as going or a walk, helping them with their sel-care, or while making andsharing a cup o tea. (Preerably a cup each.)

Speech and language therapists are endangered species in mental health inpatient care, but theirabulous skills are wor th tracking down in other services, including the community. Psychologistsare also specialists in communication especially in relation to peoples behaviour and emotions.

4. PlacesAsking the patient where theyd eel most comor table chatting, eg in the oce, their bedroom,during a walk outside

Ensuring privacy, both or that patients sake and to protect other patients rom what couldbecome a distressing experience

Making sure that where the conversation is happening is as comortable as possible in relationto practicalities such as seating, heating, lighting, distractions (including any which exacerbatepsychotic symptoms). For example:

smaller spaces are more private and quieter and can make it easier or both sta and the-patient to ocus.

theres a surprising amount o background (and oten oreground!) noise on wards rom-

talking, shouting, TV, radio, trolleys, outdoor traccomortable urniture and attractive homely decorations are good or sel-esteem, motivation-and concentration


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5. TimeMaking sure youve got enough time, to build up to and have the conversation and i it distressed

the patient, to support them aterwardsProcessing inormation and ormulating a response can be strenuous or patients with additionalcommunication impairments. Encouraging them to take their time reduces the sense o pressureand makes it easier or them to express themselves

Working out, perhaps with the patient or someone who knows them well, whats the best timeo day or them in terms o:

concentration and mental clarity-

symptoms (mental and physical)-

energy levels-

planned activities (including visitors)-

6. Building upGetting the patients attention beore star ting the conversation; eyecontact is essential andtouching their hand i thats appropriate

Reassuring the patient by saying youre there to understand and to support them and askingthem what they would nd helpul

Starting with gentler topics, checking how theyre eeling, taking the conversation at a pacetheyre comortable with and can ollow, and being comortable with silences.

Going easy on introducing new inormation

Being honest! Including i services or sta have let the person down. (Chapter 11 on apologisingis likely to help with this!)

7. LanguageIts all a bit like being in a oreign country where you dont understand the language, so whateveryou nd, or would nd, helpul in this situation is also likely to help the patient, or example:

using gestures or demonstrating what you mean as well as saying it can be very helpul.-

speaking slowly, using simple words, short sentences, easy topics and repeating impor tant-points no ancy words, jargon, idioms, abbreviations or brain-tangling sentence structures

Avoiding analogies and metaphors which can be very conusing. For a patient withcommunication diculties, trying to understand some fowery language is like playing scrabblewith only blank tiles. No one wins and we dont know the score. (Thanks to Nick McMaster orthat memorable description!)

A handy, slightly surprising tip is to make your language a little more ormal than usual. You couldtry imagining youre speaking to an overseas dignitary you particularly respect, or a membero the royal amily i youre not a keen republican. This approach tends to result in clearerpronunciation, ewer idioms and o course the bonus o the patient eeling valued and respected.

Simple yes/no questions can help get the conversation underway

Using peoples names rather than reerring to them as he, she etc. With people who havesevere communication impairment, eg because o dementia, it can even help to reer to yourseland the patient by name instead o saying me, you etc.

It can be clearer, as well as gentler, to give positive rather than negative instructions, or examplesaying Please can you come to dinner? rather than Dont go into your room now.


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8. SpeechThe aim is speaking clearly and calmly especially at times when youre under the most

pressure and its hardest to achieve this!Friends, relatives and sta who know the patient well will be amiliar with the persons ownvocabulary, which may have developed rom local dialects, having English as a second language,memory loss and/or amily traditions.

Being aware o your accent and the patients. Someone who has spent their lie in Liverpool,Llanelli or Lagos may have diculty understanding what the queen is saying whereas she haslots o experience o understanding pronunciation dierences rom around the globe. (But sheis unlikely to become a member o the ward team.)

9. Creative

I you or the patient have repeated what youre trying to convey once or even twice and the

other still doesnt understand, its time to try a dierent route.

Happily, spoken words dont have the monopoly on communication and are oten the leasteective. Alternatives (see chapter 20) include:

signs and gestures-

pictures, photos, clip-art-

symbols (eg Widgit)-

written words-

objects where possible, this is the least ambiguous way o showing what were talking about-

websites-

10. ChoicesThe more that a person has direct experience o the choices, the sounder the outcome. Itsdicult or anyone to make choices in the abstract, but this is especially so i someone has anadditional communication complication. For example, with housing options, the best is whensomeone can actually stay in a potential new home. Followed by being able to visit it or talkto people who live (or work) there. Minimally, seeing pictures (or a video) o it with additionalinormation and being able to have their questions answered.

Its easier to star t with small choices beore moving on to bigger ones, and to deal with just onechoice at a time.


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11. UnderstandingThe starting point o course is nding out as much as possible about what the patient can

understand, rom specic vocabulary to length o sentences, as well as alternative methods ocommunication like pictures or symbols.

Its very tempting, especially on hectic shits, to pretend to understand what the patient is saying.Theres a balance between avoiding rustrating the person by acknowledging that despite yourbest eorts you cant understand what theyre communicating, and being honest and avoidingacting on an incorrect guess about what the person means or wants.

Additional complications arise when someone seems to understand but doesnt. It could be astraight misunderstanding, or they could be agreeing to prevent causing diculties. People mayunderstand less language than they seem to because there are a surprising number o cues ina given situation, eg the time o day and routines, or your tone o voice and acial expressions.Even asking i someone understands what youre saying is no guarantee as its tempting or

people to avoid embarrassment or urther conusion by simply saying they do understand.An invaluable saeguard is to check with the patient, or example to use their own words (orgestures or pictures) to express what they think youve said. And or particularly importantmatters, its best to check with people who know the person well to see i your understandingo their views ts in with the persons usual preerences and needs.

12. Body languageTheres that much-touted thing about 70% o communication being non-verbal. Body language isparticularly important with people who have major problems in communicating clearly using words.So body posture, gestures, acial expressions, and eye movements arent just a bit o a bonus, theyre

the essentials. A truly holistic approach is needed, using everything available. All your resourceulnessand creativity and acknowledging all the communication indications the patient gives you. For example,communication-impaired peoples actions or behaviour (like the rest o us!) are usually very signicant,not arbitrary. This is particularly impor tant, but dicult, to remember i the person is behaving in a verychallenging way.

In addition to the points in chapter 15, the ollowing may help in communicating with patients who haveadditional communication challenges, especially i things are particularly raught.

I possible, sitting down next to the person so that youre on the same level, and generallyavoiding them eeling threatened by you standing too close or seeming to tower over them.

Helping the person eel they have your ull attention and enough time or them by being as still

and calm as possible.As well as your body language conveying how you eel, a lot can be picked up rom the patientsbody language eg their acial expressions, body position and movements etc.


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13. Distressed patientsWhen they are with someone sympathetic and supportive, crying can be one o the most healing

experiences or patients. The act o cr ying releases tension and dilutes painul eelings and thoughts. Thiseect can be made even more benecial i theyre with someone who is accepting o them and the statethey are in.

For understandable reasons, sta can want to urge patients to stop crying, perhaps because it saddensthe member o sta or they eel crying prolongs the patients distress. Its certainly true that whensomeone is crying a lot its hard to have a conversation. But i the essence o conversing is aboutcommunicating rather than specically talking, then its clear just what powerul communication is goingon. The patient is conveying unambiguously how much emotional pain they are in. And the sta memberwho sits alongside them, gently and suppor tively, is conveying that they recognise this and care aboutthem. Two o the most dicult aspects o being with very distressed patients are coping with them cryingand balancing being optimistic with not belittling the genuine, oten overwhelming challenges theyre

acing.

The ollowing can help.Sta dont actually need to say anything. Patients nd it comor ting just to have someone sitting with1.them

Its denitely better to say nothing than to ask a patient to stop crying!2.

Patients really appreciate being given time to stop crying, at their own pace. Some may then want to3.talk about whats going on or them. Others may eel its been helpul enough just to have got it outtheir system and not want to talk at that stage.

Anything you can do which helps the patient eel better about themselves, their coping skills4.and their problem-solving abilities will be really benecial. For example, asking them i theyve

experienced something like this beore, what have they ound helpul? I theyre very stuck,becoming one stage removed can ree things up a bit, eg asking them what they might say to ariend in a similar situation.

Trying to avoid going o to get mountains o tissues or distracting the patient so they stop crying;5.going with the fow and being comortable with the tears without eeling that you are responsibleor making them stop. Sometimes sta may want the tears to stop because they eel uncomortableor awkward. But i the patient is comor table enough to cry in the company o someone else, thisshould be supported rather than suppressed.

What might a patient eel i you ask them to stop crying?

Examples:

its wrong, inappropriate or weak to cry

you dont recognise how serious the causes o their distress are

you eel embarrassed or awkward with someone who is crying

youve got old-ashioned views about what men are like!

you dont accept them as an individual, complete with vulnerabilities aswell as strengths

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What phrases do you use, or might you use in uture when a patient is crying?

Examples:

Take your time

Im sorry this is so painul or you

You let it all out. Its best to have a good old cry

Its OK. Have a tissue.

Its not surprising that you nd talking about this so distressing.

What would you nd helpul right now?

19.2

14. People with learning disabilitiesThe learning disabilities eld has produced some o the most creative and eective communicationapproaches eg intensive interaction, total communication and symbol systems. (As well as kids buggies,job coaches and Wol Wolensbergers searing analysis o the specics o how stigmatised people aresocially devalued.)

There arent any crucial considerations or approaches or communicating eectively with people withlearning disabilities beyond those outlined in

talkwell 2nd edition

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