When Care is a Battleground

When care is a battle of wills we can become so obsessed by interventions that we lose sight of what really matters – the person’s journey.

Nobody ever needed a therapist

There, I said it. That’s not to say that no one ever benefited from therapy, far from it. But therapy is not a need. It’s an intervention. 

Needs, problems, outcomes and interventions often get mixed up together, as though they are different words for the same thing. 

 

Needs are Not Interventions

“If I am depressed, what is my need?”

I asked this of a group of social care professionals at a recent training event. Their responses were a mixture of:

 – “Counselling”

– “Something to make you feel better”

– “Some kind of therapy”

– “Antidepressants”

In this case, my need was defined as an intervention. But needs are not interventions. Needs are desired states.

If I am depressed, my need is not to receive therapy, or medication. My need – my desired state – is to be happier and more content.

Therefore, the intervention should be Anything That Helps Achieve The Desired State. That could be playing music, having some friends or even fire-juggling.

Sounds kinda obvious. But this kind of intervention=need formula is extremely common and creates an awful lot of problems. Problems that risk turning care into a battleground. 

 

Trapped in the Problem

When a need is expressed as an intervention, we focus on the problem in the hope that doing so will propel us away from that problem. 

Only it doesn’t. Focusing on a problem doesn’t move us away from the problem. It traps us in it. 

Ergo, we end up with care plans that look like this:

Joey is always getting into fights. He needs anger management

Ellie self harms. She needs therapy

Rose is becoming anorexic. She needs dietary supplements. 

Interventions as Needs

This framing of intervention-as-need leaps straight from problem to plan. It bypasses any consideration of why there is a problem. There is no desired state. 

What need is being met by Joey’s fighting, by Ellie’s self harm or Rosie’s diet restriction?

Until we understand this, and understand it from the individual’s perspective, we have no chance of coming up with a solution that could help. 

 

Whose Need is it Anyway

Hiding behind this need=intervention is another need. It is the need of the professionals to feel useful – to feel like they can do something.

This usually goes something like, “how do we stop…”, for example:

“How to we get Joey to stop fighting?”

“How do we stop Ellie from self harming?” 

“How can we make Rose eat?”

The way these questions are asked predetermines that the answer will be a service intervention. And the interventions are controlled, funded and delivered by the very people making the decisions. If that’s not a cabal, then what is?

The professionals have taken over. They have shouldered the burden of responsibility for the individual’s problems and they are going to sort it out.

But it is not their problem to own. It is the individuals problem. The professionals have a responsibility to that individual, not for that individual.

 

War zone

Care then becomes a battleground for control of the interventions. 

Joey doesn’t want to go to anger management. Ellie thinks therapists are useless. Rose won’t eat her nutritional supplements. 

Now what? 

Do we up the ante? Put pressure on them, coerce them? “Persuade” them that it’s in their best interests?

Do we have lengthy care planning meetings, without them, where we all sit exasperated at their lack of engagement?

Here are a small selection of genuine examples of professionals expressing their need to have control over the individual and the situation, and framing their need in terms of the care recipient’s expected behaviour.

“What she needs is to come to her appointments on time”

“She needs to stop lying and trust people”

“What he needs is a good kick up the ass”

“She needs to take her therapy more seriously”

“He needs to be more motivated to engage”

They are frustrated that they are not being complied with or respected. They are losing in the battleground of care and they don’t know how best to proceed. 

In short, these needs can all be paraphrased as “I need them to obey me”

When their interventions don’t go the way they want, the care team get ever more controlling, without ever questioning whether they are, in fact, exacerbating the problem

The end result is that Joey ends up in a secure facility, Ellie is subjected to room searches, rules, and sanctions, and Rose has a naso-gastric tube stuck down her throat. 

 

Professional Target Practice

The person on the receiving end of care is often blamed for their “failure to engage” or lack of “motivation to change”, despite that the interventions on offer are doing nothing to address their actual needs.

So they lose faith in their care team and the gap between carer providers and cared recipient becomes wider. 

Herein lies part of the problem – the perception that there is a thing called “care” and that there are “care providers” and “care recipients” – be they called patients, clients, users, customers or whatever.

The care recipient just ends up being a dartboard for professionals to lob interventions at – hoping that one of them will hit the bullseye and stick. 

Professional Dartboard

And when none of them hit the target, the professionals blame the dartboard.

 

From Battleground to Treaty Negotiation

So how do we get out? I think the first step has to be abandoning the formulation of needs as interventions that are provided and received.

Instead, we should work towards a version of need that is aspirational, as defined by the individual themselves.

No more setting targets for other people to achieve with their lives. It’s their life. The role of a “care” team is to enable that person to live their own life, not the life we think they should have.

I’m avoiding the word recovery, because I think it is toxic in this context. Recovery has become a byword for a Service-Approved State of Wellbeing. 

Services have their own definitions of wellbeing in order to design, fund and deliver a new raft of interventions and assessment tools aimed at shoehorning people into that definition. And that is the antithesis of aspirational work. 

The only way to truly put the individual at the centre of their own aspiration is to ask them what they want. This sounds so self-evidently obvious that it shouldn’t even need mentioning. But clearly, it still does. 

I mentioned this to a group of social workers in a training session and was met with abject horror. 

“But they will ask for things we can’t deliver”, “we can’t raise people’s expectations by asking them what they want”, “do you know how short on resources we are?” – like people are going to ask for diamonds or something.

This is about actively listening to a person’s story and finding out, from them, how things could be different. It’s about establishing a desired state. A need.

 

Needs as Aspirations

Many people these days are familiar with Maslow’s hierarchy of need – for shelter, food, love, safety, belonging, purpose. 

I’m not a huge fan of Maslow’s hierarchy. I don’t think the hierarchy holds up to real world scrutiny – we often see acts of great compassion in war zones, we see love and belonging in the the midst of a famine. But that’s besides the point. Maslow’s definition of need as aspirations is universally known in health and social care.

Yet how often are these needs actually employed in care plans? 

Maslows Needs

Simply changing the question from “what’s the problem?” To “what would it be like if this problem wasn’t there?” Can open up so many avenues of potential. 

Rarely is it said that Ellie’s self harm is her way of meeting her need to be relaxed and free from distress. 

If it was, then maybe the response to her self harm would change. Instead of room searches, rules, sanction and therapists, we might be open to other approaches. 

Ellies Needs

Need-Based Roadmap

We can make an enormous change to this power dynamic by using a simple, needs-based roadmap.  What we call it, doesn’t matter – roadmap, flightplan, blueprint, adventure – whatever resonates with that person.

The purpose of a roadmap, as opposed to a care plan, is that it focuses on mapping out their journey, instead of planning our care. Their aspirations – their destination – is at the centre.

By working on the individual’s aspirations, we are no longer imposing our will on them by trying to control interventions. Instead we are invited onto their journey towards those aspirations.

For sure, it can be a bumpy old ride with a few terrifying moments along the way, but we’re now co-pilots, not captains. This can be unfamiliar territory for professionals. We relinquish control of the wheel and look at how we can help with navigation, advice, support, backup.

This framework consists of four stages of very simple questions.

Building a Roadmap

1 What happened to you?

The questions here are completely different to an assessment, where we ask what we want to know. This is about asking what they want to tell. This is not “What is wrong with you?” or “What’s the problem?”

It is “What’s the story?”, “What is occurring?”,  “What is going on for you?” “How did you get here?”

We focus on the person’s lived experience, rather than asking pre-formatted assessment questions. And we just let them speak. If need be, we can use life maps, genograms or other tools to assist the person to tell their story. But it’s their story – their journey to this point. Our job is simply to listen, understand and to acknowledge, not to interpret or assess.

2 What do you need?

This is establishing the desired state, a destination. This can be difficult for people, especially if they have been stuck in their problem for many years. They may not believe that a desired state is possible for them. If so, then maybe baby-steps are worth looking at. 

If someone rates their quality of life as 2/10, then ask what it would be like if it was 3/10, not 10/10. We don’t have to go the whole hog in one giant leap. The roadmap doesn’t have to have the entire journey on it. Just the next stop along the way.

The desired state is often the polar opposite of the problem and can be described as such “well, I wouldn’t be so stressed out all the time”

In which case, we can ask, “and if you weren’t so stressed out, how would you be?” Try to frame the desired state positively, like Maslow’s needs – “I’d be calm and relaxed”

3 What could we do to help? 

Knowing the destination opens up a whole raft of possible activities (not necessarily interventions) that might help the person get there.

Actions on a Roadmap

Our job is to facilitate the person to access these things, especially if they do not feel they have the capacity, skills, confidence or resources to do it alone.

It’s far better for us to be invited onto someone’s journey and for them to feel that they have the say over the destination. We can advise on possible routes to take, but we don’t go and grab hold of the wheel and scream “where the hell are you going?”

Once we have collaboratively developed a range of options, we can collaboratively appraise them and prioritise. Are there quick wins? Something that might help the person gain a sense that change can be achieved, even if it’s only small? Is there a logical sequence of “when we have… then we will…”?

4 What will we do to help? 

Finally, we get to planning. The default position of a lot of care planning, as described above, is to leap straight from problem to plan, bypassing anything meaningful that the individual might have to contribute on the matter.

But now we are working for them on their agenda, towards their destination. They need confidence in us and to see that we are taking them seriously.

So, who is doing what? By when? Where are the resources coming from? Who is responsible for what?

This is the stuff we’re good at. Professionals have access to institutions, resources, tools, people; we can open doors, make phone calls, referrals, pull strings. We under-estimate how much more power we have than the people we serve. So let’s use it positively.

And then we give it all some time and go back to Question 1 and ask “now what is the story? What happened?” And we do it all again, mapping the next stage of the journey.

 

Moving away from the care-planning model of “care provider” and “care recipient” and towards a roadmap model of “pilot” and “co-pilot”, completely changes the dynamics of care.

It is collaborative, creative, and dynamic. It’s a journey that we are all on together and professionals can find it pretty scary because we are not in control. 

But in truth, we never were anyway.