Tackling Our Culture of Cruelty

A recent Panorama investigation found systematic abuse of elderly residents going on in a UK care home.  Some of the most vulnerable people in our society were being ritually abused by their so-called carers:

On the top floor of a special hospital, locked away from their families and friends, a group of men and women are subjected to a regime of physical assaults, systematic brutality, and torture by the very people supposed to be caring for them.  The victims are some of the most vulnerable in society – the learning disabled, the autistic, and the suicidal.

Sadly, this may be merely the tip of the iceberg.  In this week’s Sunday Times Minette Marin wrote of the terrible neglect of nurses that she witnessed first hand.  Similarly, the MP Ann Clwyd has told of her husband’s inhumane treatment at the hands of the NHS and asked whether cruelty is now normal in the NHS.  Today I listened to a phone in programme where one man described a ward of vulnerable geriatrics and simply said:

“Nobody seemed to care”.

How does this happen?  Presumably no nurse goes into that profession for any other reason than to care for others?  So what happens?

Organisational culture is clearly a factor and a number of systemic problems contribute –  poor job control, lack of autonomy, lack of a proper leadership.  But at some level cruelty is an individual choice.  We create our cultures, then they create us.  So what can we do about that?

I think this is a problem of experiential avoidance.  I propose that nurses dealing with ‘difficult’ or elderly patients are brought into contact with their own fears and insecurities about becoming old, infirm, or mentally impaired.  These fears – being intolerable – can only be dealt with by distancing themselves from the patients and dissociating from them.  And we don’t have to go far back in history to see the terrible, shaping effects of dissociation on human behaviour.

So what can be done?  Plenty, and we could start by not dissociating ourselves from the nurses.  The problem is that the alternative – empathy – is not the simple panacea that most people assume.  It takes real effort and psychological skill.  It is not something we can just do, any more than we can suddenly start sticking to diets or going to the gym five times a week.

The key to empathy is reducing experiential avoidance.  And we know how to do that.  Firstly train people – help them – to gently reconnect with what they care about.  Then help them to defuse empathy & experiential avoidancefrom the difficult thoughts and emotions that will arise from taking valued action.  We know we can’t get rid of those fears and demons, but we can respond to them differently, and in so doing shift the context for our behaviour.

People often talk about practicing empathy and practicing compassion.  That’s good, because these things do take practice.  But in order to practice we need to understand what prevents us from practicing.

In most cases, it is our own demons.  And we have been running from them for too long.

warning, this is a harrowing clip:

We Can’t Get Rid Of Our Mental Junk – So What Do We Do Instead?

The Big Clear Out

People in my neighborhood are throwing out their junk. They are sorting out their stuff and leaving it on the side of the road. In a few days some lovely people from the council will come and take it all away. Wonderful!

Wouldn’t it be great if we could do that with the junk in our minds? If we could choose which of the rules about ourselves and the world that we carry around in our minds, no longer work for us and just get rid of them?

Sadly, behaviorism tells us that this isn’t possible. We can’t unlearn something (unless we are willing to suffer brain damage – which seems a little extreme!). We can only add to our learning.

Let me give you an example. When I was a medical student I learnt that it was a very bad thing to make a mistake. When I practiced medicine, this was usually a very good rule to follow. I think my patients were glad I took that approach!

However, I don’t practice medicine anymore. Although doing an excellent job is still very important to me and my clients, generally it isn’t a disaster if I make a mistake. In fact, trying too hard to avoid mistakes can impair my capacity to do a good job. I can end up being too much of a perfectionist.

I can’t unlearn the rule I learnt as a medical student. It will always be with me. But what I can do is learn some new ways of behaving so I have more options. And I can get better at recognising when an old rule like ‘I mustn’t make any mistakes’ isn’t appropriate and 80% is good enough.

What internal rules do you have that are no longer useful for you?

How Can We Build Others Motivation to Change their Behaviour?

At work, we often need to encourage others to change their behaviour. It might be the co-worker who repeatedly misses deadlines; the direct report who is irritable with stakeholders, or, our boss who isn’t delegating well to us.

Our instinct is to try asking (or telling!) the person to change. Explaining to them why we want them to change. If we are really good at ‘selling change’ then we might even explain to them the benefits of changing.

A therapeutic technique called Motivational Interviewing suggests a different approach.

William Miller came up with this approach when he discovered that some therapists do a much better job at helping their clients to change compared to others. He then studied the differences between the effective and ineffective therapists and found that the highly effective therapists:

  • Were good at empathic listening and were genuinely interested in understanding the client’s perspective
  • Coached their client’s to explore the pros and cons of change and helped them to make their own decision about whether they wanted to change
  • When the client resisted the idea of change, the effective therapists ‘rolled with that resistance’ rather than arguing with the client
  • Had a respectful stance
    • Honoring the client’s autonomy – the client gets to choose whether they change or not, and as adults, they take responsibility for the consequences of their choice
    • Viewing the client as the expert in their own life. They didn’t talk down to the client but took a collaborative approach where they worked together to figure out what to do next

Miller found that in the sessions that had the best outcomes, it was the clients who were describing the benefits of the change rather than the therapist.  The clients came to their own decision that they wanted to change. It was only at this point (when the client started to say ‘I want to change..’ or ‘I am going to change..’) that effective therapists started to help the person to make a plan for how they would go about changing.

I know that when I apply this to my own life, I am much more likely to commit to change if the other person takes this approach with me – but perhaps I am just a contrary Derbyshire lass!

The collaborative, respectful approach used in motivational interviewing fits well with the approach taken by a good ACT practitioner.

An ACT practitioner helps clients choose their own values rather than values that society or significant others might want the individual to adopt.

ACT practitioners have the stance that we are all dealing with our own difficulties – the ACT practitioner isn’t the expert who has it all sorted.

An ACT practitioner works to help the client see the reality of their situation and then make decisions taking this information into account.

Both ACT and Motivational Interviewing are empirically supported approaches shown to help people make important and often challenging changes in their lives (from giving up drugs to losing weight) and they seem to be saying similar things about the best stance for the practitioner to take.

Perhaps there is something for all of us to learn here?

Perhaps, next time we want some else to change their behaviour, it might be helpful to start by being genuinely interested in their viewpoint. What if we were really curious about understanding how the current approach both is and isn’t working for them? What if we respectfully explored whether the person sees any benefits in changing their behaviour? Perhaps we might discover that they are less likely to dig their heels in and resist us? They might even be more inclined to work collaboratively with us to create a better outcome that meets both of our needs.