A Matter of Life or Death

Imagine you are somehow called upon to save someone’s life and you only have one second to respond. What might you do with that second?

There is an aspect of my work, as a mental health nurse, which involves responding to crises in which there are concerns around people’s safety.

The way I approach a conversation with a client under these circumstances is largely unchanged from how I would at any other time, but the context of it being ‘a crisis’ makes a difference.

I would like to make it clear that what follows is not a description of pure Solution Focused Practice, but my application of Solution Focused Practice being used as appropriately as possible, within the current framework of an eclectic services culture and protocol.

So what constitutes a ‘crisis’?

It could be that I’ve received some prior information that the client has been directed to me because something they’ve said or done has worried someone.

It could be that the client has contacted the service in distress asking to speak with someone as soon as possible.

Or it might be that during a pre-arranged meeting something coming up in conversation has triggered me to start worrying, which might typically be something like an apparent absolute lack of a sense of future, or any significant connections to anyone else, no matter how much I persist in asking about these things.

The difference this makes is that I notice another type of listening becoming more prominent in my awareness, alongside my usual habitual scanning for language which can be used to form questions aligned with the client’s preferred future.

It is a type of listening which is to do primarily with establishing their safety, and recognising a formal, standard ‘risk assessment’ protocol.

The usual questions I would ask at the start of a conversation with a client are along the lines of “what are your best hopes from our talking?” or “what’s been better?” (when the client is returning having been seen before).

Occasionally such questions may seem less congruent in this context, in which case I might instead ask “what’s happened?” or make a statement such as “I understand you’ve asked to talk with someone urgently”, or “I’ve been told you might appreciate some time to talk”.

Having done so, I generally find I receive an account of facing adversity and a confirmation of feeling unable to cope, in which case a statement of acknowledgement; something like “how awful”, “that’s difficult”, or even just “wow” or “phew” or just a long exhalation of breath, followed by a pause, then “so now that you’re here, what are your best hopes from our talking?/ what would you consider to be a good direction to be going in?/ what would you like to happen after our talking?” naturally flows in the conversation, and acts like a kind of ‘reboot’. Another option is to go for something like “so how have you managed to get through?/ find sufficient hope that you can turn this around to ask for help to do so?”

This process can be summarised as:

1.       Acknowledge the crisis

2.       Pause

3.       Acknowledge the hope

4.       Establish the client’s choice of direction out of the crisis.

With a more interpretive type of listening central in my awareness, I might ask myself “what did they mean by that?” or “what are they implying they might do after leaving my office?”.

I generally find that just calmly acknowledging these thoughts whilst continuing with the conversation in the usual solution focused way (rather than asking such questions of the client directly) leads to a resolution in which I hear answers which reassure me that they are heading towards safety.

By doing this the conversation can, from the clients perspective, continue to consist of questions and answers which are directly relevant to their hopes, as described in their own words, free from interference from any agenda of mine or the services as far as possible.

Occasionally reassurance is less forthcoming, in which case I might say something like “I’d like to take a slight detour in our conversation here to ask some different questions which are more for the purpose of assessment, because I’m wondering about your safety, then we can return to what we’ve been talking about”.

A core concept in Mental Health Nursing which relates to responding in a crisis is that of ‘de-escalation’, a core component of which is often described in terms of talking with someone in a concise, direct, accepting and respectful manner so as to circumvent conflict and find a mutually acceptable way forwards. A solution focused attitude, tools and skills are very conducive to the application of this concept, so I continue to use them as much as I can while I gather the necessary assessment information.

Having returned from the detour, the natural flow of the conversation leads back into a detailed description of the clients preferred future, which is where their future safety, as a natural aspect of that preferred future, is co-constructed, beginning with the next small step they can take. I believe this is probably the most powerful ‘risk management’ strategy at my disposal, largely because the client’s innate agency (their capacity to act) is recognised and respected.

Incidentally, it stands to reason that this would also apply even when nobody is aware of a ‘crisis’, such as in the case of a client choosing not to disclose the full extent of their plight or ‘open up’ to anyone they are in contact with.

Solution Focused Practice, by its very nature can be seen to build safety.

Given that it’s fair to assume that the client can find a way to do whatever they desire after leaving my office, then having effectively rehearsed a possible future in which they have found a way to be safe and secure again, I believe increases the likelihood of such a future becoming their reality, and sooner than it might have done otherwise.

In very rare cases (approximately 1 in 1000 or so in my experience), effectively I can only be sufficiently reassured that someone is heading towards increasing safety by abandoning the conversation and taking steps for them to be admitted to hospital.

Even under those circumstances, I find opportunities to maintain my solution focused attitude, including an active respect towards the client and belief in their capacity to turn themselves around, which can make a useful difference for them.

This applies even when their liberty is drastically restricted to counter the possibility of them acting on a self-destructive impulse.

Whatever happens, there’s a chance ahead that they’ll recall the choice of action they had previously rehearsed during our conversation and the difference it made in that moment.

Typically, the difference might have been increased hope for a better future, which may encourage them to take them a step closer towards safety, ensuring their immediate survival and providing the opportunity to eventually arrive in that better future.

To recap, when I have concerns about safety, perhaps because of the context, or my instinctive response to what I’m hearing, I notice the emphasis in my listening changes in line with a ‘safety first’ priority in a way which includes more consideration of meaning, and questions evolve from an unusually protective more than empowering stance.

This shift in emphasis is a necessary exception, which reverts as soon as future safety is described reassuringly by the client.

The key to managing this effectively as a professional is second to second adaptability.

Having experienced countless conversations in which safety is a consideration, my conclusion is that we all seem to possess an extraordinarily powerful survival instinct that steers us towards safety even whilst confidence in this happening wavers.

Tragically, it isn’t always powerful enough in itself to save someone’s life, which is where we all come in for each other.

In theory, all suicide is preventable. It can certainly appear that way when individual cases are viewed with the benefit of hindsight.

In practice, in reality, no human endeavour ever has a 100% success rate, and whilst free will exists in our society, people will always find a way to do whatever they most want to do.

Our best bet of reducing instances of people ending their own lives through hopelessness is to therefore collectively do everything we possibly can to amplify the hopes of everyone for a future that is good for every human being in existence, especially those feeling most alone and unable to see a future, so that what everyone most wants to do, in the first instance, is continue to live and to love.

I hope that with greater awareness of the difference it can make to acknowledge, ask about hopes, use the other person’s exact words in conversation, and maintain respect and unshakeable belief in them, more lives might be saved.

This might be through professionals using their honed knowledge, skills, experience and adaptability whenever someone in crisis is fortuitous enough to meet with them, or it might be through anyone, professional or lay person, coming into contact with someone in crisis (knowingly or otherwise), relying on their love and instincts to acknowledge and amplify hope through conversation, then direct people they are still worried about towards professionals.

There are no guarantees. Everyone could be doing everything they possibly can and it still might not be enough to avert tragedy in some cases.

But it might.

 

I would like to thank Evan George of BRIEF for his answers to my questions on this subject, which supplied a lot of the words I found particularly useful in writing this post.

There are many books and articles covering this subject. One book which I have found particularly inspirational is Heather Fiske’s Hope in Action: Solution-Focused Conversations About Suicide.

 

This is our beginning coming to an end

adult background ball shaped blur

A and B enter room and sit down.

A “I feel so much better already!”
B “how did you manage to do that?”
A “what?”
B “to feel so much better already?”
A “no I just mean that coming here and talking to you really helps. Makes me feel better”
B “and your part in that?”
A “oh, err… talking to you. I get things off my chest. Talking to anyone actually, well not anyone, you know, talking to the right people”
B “how do you know they’re the right people?”
A “they listen”
B “you talk, they listen, you feel better, it helps”
A “exactly!”
B “what else have you been doing over the last couple of weeks that really helps you feel better?”
A “huh, well… It hasn’t been all better, it’s still been difficult… but what I’ve been doing… Well what we talked about, I’ve started the day like that most days. Oh and I got some work done”
B “cool! What else?”
A “well I’ve been walking in the park. I love being in nature, you know? That really helps sometimes”
B “nice. What else do you do that really helps?”
A “well, spending time with my friends… I’ve been thinking differently. When I get a group chat message about going out somewhere, I’m not just going like it’s to everyone they don’t really want me there”
B “and instead?”
A “I’m thinking they might, why not! I can always leave early, why don’t I give it a go, you know? Just thinking like that… That’s helping me feel better too”
B “and what is doing all of these things, helping you feel better, leading to?”
A “leading to? Oh yeah ok, it’s just like a weight is lifted off my chest, you know?”
B “what do you replace the weight with?”
A “I don’t… Oh ok, maybe I do… Hmm… It’s a lightness, acceptance”
B “and the difference this lightness, acceptance makes?”
A “… I believe I can do this. I have self-belief”
B “what else?”
A “I’m not hating myself anymore. I think I’m ok. More than ok! I’m cool!… I can’t believe how far I’ve come actually! I’ve still got a long way to go, but I can do it, I know I can”
B “can you do it without coming here and talking with me?”
A “…yeah… You know what? I think I can yeah… Thank you”
B “thank you too. It’s been a pleasure”
A “ok, well I have things to do now. Thanks again”
B “I better get out of your way then! You take care. See you around, or not!”
A “hopefully not to be honest! In a good way I mean! You know!”
B “absolutely! I hope not too! You know where we are, you’re always welcome, either way it’s cool. You’re cool in fact! You have a great day”
A “you too! Bye!”

A Resilient Generation

 

People around my age often ask me why I think it is that more young people than ever seem to have ‘mental health problems’, self harm, talk about not being able to cope, seek help.

This is often accompanied by one of, or both, the following questions:

“Is it because there’s so much pressure on them?”

“How can we help them to be more resilient?”

The first question is probably impossible to answer. It assumes that what seems to be is a fact, then picks out one possible causative variable which would be extremely difficult to quantify.

The second is easy. We can ask them how they are being so resilient.

When I listen to young people telling me about the ways in which they’ve been untitledjudged, examined, dictated to, criticised, compared to others, scoffed at, ignored and rejected, I’m struck by how resilient they must be to survive it and cling on to even the tiniest sliver of hope that things can get better, in order to seek help from anyone who might be able to come up with anything at all that might be of use to them in their struggle.

It seems to me that this is a generation who are literally being tested to breaking point, and are somehow managing to keep going, even to find some joy, some connection with others and to celebrate life at times.

The natural question to ask them, then, is “how are you doing this?”

I think young people can tell us a lot about resilience. They can describe it in great detail. Especially those who we consider to have ‘mental health problems’, who self harm, who talk about not being able to cope sometimes. And asking them the question, so that they can hear their own answer, is the best way I know to help that resilience grow.

Letting Go

blue and red dress religious man illustrationI’ve met Jesus many times.

Each time he had a different face, sometimes he was short, sometimes tall. His skin tone varied and he talked with different accents. I think he may have been female at least once.

On one occasion I was present when he met himself. Happily, they both got along fine!

That’s the thing about being a mental health nurse. You get to meet Jesus every now and then.

Each time this happens, there’s an old cultural pressure to humour him whilst theorising about why he’s saying what he’s saying, to attempt to understand what’s really going on for him, and to form a plan of action about how to get him back to reality.

A common conversation amongst mental health nurses is about what would happen if the actual Jesus really did show up in hospital! How would we know? How would he be treated? What miracles might he perform that could be recognised as such and therefore lead to us questioning our disbelief?

The thing is, why does it matter? Why not simply accept his reality and treat him with the respect and honour deserving of a deity incarnate? What difference does it make?

In actual fact, in amongst the humouring, theorising, planning and acting, this has generally been what I and my colleagues have eventually settled on doing whenever meeting Jesus anyway, for as long as he’s asked us to, then when he inevitably changes we’ve adapted our language accordingly.

I think next time I meet Jesus I’ll notice a difference in myself.

I’ve increasingly let go of my need to know why he might be saying what he’s saying, to disbelieve, to theorize, to think about how to get him back to ‘reality’, to understand anything, and to conform to the old cultural pressure.

I’ve replaced these habits with an unshakeable belief in everyone’s capacity to achieve whatever they hope for, and a deep love and respect for everyone I’m honoured to meet, in harmony with a new emerging culture.

The conversation I’ll have might not be hugely different, but I have a hunch that it’ll be more direct and consistently useful, because I’ll be putting aside the barriers and maintaining the catalysts for inevitable change and adaptation.

The result may well seem miraculous!