Sleight of mouth in psychiatric settings - Part 2

[sunlit_music]

I've read an interesting article called "Sleight of Mouth patterns and Communication Patterns in Psychiatric Settings". You can read it here:

http://web.archive.org/web/20050802013551/http://www.23nlpeople.com/sleight_of_mouth_patterns.htm

The following text in italics is from the article. The normal blue text are my own comments on the article:

Now, let's look at the patterns from the reverse perspective. A patient who is asked to carry out a task X,Y or Z denies responsibility/capability by stating, "I haven't got a head." I have experienced a patient that maintained this line for several years. The standard response from the staff was a simpering effort of, "Well, that is just how you feel, why don't you go and sit down."

Because she was labeled as "ill", this statement was permitted as a statement of feeling and thus supported and inadvertently legitimized by the staff. Through experience, the staff had soon learned on arriving in the department that for themselves, this was the line of least resistance. Questioning this patient too closely could prove to be a very frustrating affair where invariably the patient would still get her own way.

Statement: "[I cannot do X,Y,Z because] I haven't got a head."

Pattern #2 - Consequence: "And what happens when you haven't got a head?"

Pattern #4 - Chunk Down: "So how can you talk without a head?" I think this is a good comment, as it clarifies and gently challenges what the client is saying
"
Pattern #6 - Counter-Example: "How is it that you are able to talk then?" This also gently challenges what the client is saying, which is appropriate.

Pattern #9 - Apply To Self: "So the head that you haven't got thinks that?"

Pattern #11 - Change Frame Size: "Oh right, so if we all used that excuse, nothing would ever get done." This sentence shouldn't be used, as it could aggravate clients. I've worked as a student social worker in a psychiatric hospital, and some clients could get physically or verbally abusive (and very distressed) if staff made rude comments like this. Many clients at the hospital I worked at were also less likely to obey instructions from staff who talked rudely like this. I've seen clients who refused to talk to staff who they thought were rude.

Pattern #12 - Meta-Frame: "You only say that because you like to confuse the staff about how you feel." How could Austin have known if the client is trying to confuse the staff? Not an appropriate question, IMHO. Plus it makes assumptions about the clients that may not be true. And plenty of psychiatric clients say bizarre things because of their mental illness, anyway!

Pattern #13 - Model of The World: "In my opinion, you are saying that as a metaphor for something else, are you not?" This question seems fine, except for the words "are you not". Using the words "are you not" assumes something that may not be true, and it is a leading question. Plus I've seen some psychiatric clients become easily offended (and refuse to talk/give vaguer answers) if someone uses leading questions (even when the leading questions are inoffensive).

Pattern #14 - Reality Strategy: "How do you know that not having a head stops you from doing X,Y,Z?" This is good, as it's a clarifying question (it gets the client to explain their views).

Now here is the bit I find disturbing, although most of the article was helpful:

This approach of "Frame setting" rather than "Frame responding" means that the operator can directionalise the transderivation of the client, rather than finding himself being directed into the psychotic reality of the client.

I (Andrew Austin) was called to see a patient held under a compulsory detention order who told me that he was a secret agent, placed there to evaluate the professionalism of the staff. He had been maintaining this apparent "delusion" for several weeks and no one, nor any drugs, had appeared to relieve it. My impression of this guy was that he didn't really believe it for one single second, but his ability to maintain the conversational postulates of it outdid that ability of the staff to argue with him.

My conversation with him went something like this:

Andrew: (Picks up telephone and starts dialing) "I'll check with the hospital administrator to ask for a pay rise for you." (Chunk Down, implied threat of consequence - the administrator sits on the appeal panel when a patient challenges the compulsory treatment order - I was due to represent this client in 2 days time).

John: "Don't do that."

Andrew: (stands up, speaking in mock aggression, southparks style) "Ok, I'll tell you what, if you are a secret agent, you get to kick me in the nuts, if you are just a dickhead I get to kick you in the nuts. Stand up." (Consequence)

John: (Looks anxious) "You can't kick a patient here."

Andrew: (Laughing) "No, but I can kick a secret agent, right? It's part of the risk you guys take." (reverse of reframe, double-bind, Consequence)

John: (Laughing) "Ok, ok, maybe I really am ill, I can't help it..."

Naturally, I immediately denied he was "ill" and we did another round, then another and another, until exhausted and exasperated he flopped down on his bed crying, "Enough, enough! You are insane!!"

Personally, I reckon that John (the patient) might have just confessed that he might not be a secret agent to avoid getting kicked. One senior psychiatric social worker has told me that very few people in psych wards *pretend* to be mentally ill. Because hardly anyone would want to be in a psych ward (well, not in Australia anyway).

Plus, upsetting a psychiatric patient by acting aggressive, and threatening physical violence is a *terrible* idea. Firstly, this is because nobody deserves to be abused (and threatening to kick someone *is* a form of abuse). Secondly, it tends to make a person's mental illness get worse (according to the psychiatric staff at my placement). Thirdly, acting aggressive and making threats can cause the psychiatric client to become physically violent or very distressed. I've witnessed normally peaceful clients become aggressive or violent if a psychiatric staff member was aggressive towards them. 

Questions? Comments? Please feel free to add on to or disagree with anything I've mentioned here.
 

 

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Comments

[rosehiptea.livejournal.com]

I agree with you, that those particular statements are problematic. And threatening to kick someone is never appropriate.

I think I told you this already, but when I was in the hospital a nurse held up a mirror and told me how ugly I looked when I was crying. Her "get tough" attitude made me feel worse, and I ended up having the med nurse give me an Ativan to calm me down.

Which isn't really relevant to this article, but maybe it speaks to the issue of not wanting to be confrontational.

[sunlit-music.livejournal.com]

when I was in the hospital a nurse held up a mirror and told me how ugly I looked when I was crying

The way that nurse treated you was absolutely horrible, and offensive. If I were in your shoes, I would have felt humiliated and furious. I'm so sorry to hear that you were treated like this.