31 Random but Guaranteed Tips on How To Be Better at Your Job
Being good or, rather, good-enough in working with patients or service users
requires intelligence. This isn’t the narrow, academic intelligence which has no bearing at all on whether you can be good-enough. It’s more a kind of cognitive dexterity. This means being able to think and behave in two, different and seemingly incompatible ways.
You must be yourself (i.e. spontaneous, human and humane) but also professional, in the sense of fulfilling your role as an implementer of policy, law, best clinical practice and so on. The better you integrate these two, the greater your job satisfaction.
You must also hear and fully take in what is being said (or not said) while at the same time organising it, testing it against your experience (clinical and otherwise) and working up a hypothesis. This is giving your undivided attention to two fields (the particular and the general) at the same time.
You must be neutral, but not indifferent or collusive. Being neutral in response to what you are told does not mean that you are condoning it or are unaffected by it. You may strongly disapprove of it but voicing disapproval belongs to a different profession or a different relationship. If you are not neutral, this is likely to trigger resistance or transference: that is, the revival of earlier relationships, usually that of parent-child.
Bearing these tips in mind, have a look at the list below and decide if they make any kind of sense at all.
• Don’t tell someone what they already know
This is a very common mistake. It is affects the confidence or faith that the person has in the professional, and will leave them feeling that they have not been understood.
• Always strive to understand
This should be the primary goal, though it may take a long time to reach it. It provides containment and without this there can’t be any therapeutic progress.
• Consciously make yourself see the ways in which a patient is vulnerable
If you can’t see the ways in which a patient is vulnerable, you are likely to be punitive or dismissive and ultimately of no help. Often, behaviours which attract a diagnosis of personality disorder are well-masked and determined attempts to conceal vulnerability.
• Find the right questions, don’t try to provide answers
Patients mostly know the answers, though they may not know they know the answers. What comes from within has a much greater chance of being durable than what is imposed or pushed in from outside
• Assume normality, not disorder or pathology
This is a state of mind which should become your first base. Most people are mostly normal though, for some, what is abnormal has a disproportionate effect on their lives.
• Provide normality – in all clinical contact (and clinical areas)
Normality is highly therapeutic reference point - for those of us who have not been deemed to be ill as well as for those who have.
• See the individual while at the same time recognising the type
This is difficult but essential. Professionals who tend mainly to see the type will have difficulty engaging and being effective. Those who see only the individual are likely to be over-involved and inconsistent.
• Ditch stereotypes – think in patterns
Stereotypes are fixed, finite and therefore crude. Humans can’t function without stereotypes because we need to organise material and information, and to locate what we find problematic somewhere else. We should try to leave them behind when we are at work but often we will be carrying them around: for example, there tends to be a stereotypical picture in mental health services of the kind of women who go on to commit suicide. Patterns are infinite and adaptive. Each time new information is added to a pattern, you just get a very slightly more complicated pattern. For example, if information D is added to pattern ABC ABC, you will have a pattern ABC ABCD, ABC ABCD and so on.
• When patients tell you something about relatives, all you know for a fact is that they have told you this: you don’t know that it is true. This does not mean you are disbelieving them but to accept narrative as truth is counter-therapeutic.
This is tricky but very important. Not believing someone (in the sense of accepting what they tell you as an objective fact), is not the same as disbelieving them. Jung said that one of the goals of treatment was to help the patient come out from under the shadow of the archetype. If we accept as true (it may of course be true but that is another matter) an account of an absent mother, a cruel father and so on, without a great deal of investigation, we run the risk of binding the patient into a fixed, disabling narrative. A further risk is that you both become marooned on an island of distorted, internalised images (or objects as psychoanalysts call them).
• Remember that in treating the patient we are also treating ourselves in the patient
If we are forgiving and compassionate towards ourselves, we are likely to be these things towards the patient. The risk is that, if we haven’t reached this stage developmentally, we will re-enact or repeat in our responses to patients the punitive, sadistic, controlling or uninterested behaviour of past others (usually parents) towards us.
• Examine yourself before you examine patients.
The order is as follows: first treat yourself, then the organisation, then the patient
• Remember that interventions from outside the circle of transference are much more likely to be effective than those from within
We tend to accept, say, the opinion of a surveyor we have enlisted to survey a house we want to buy. This is because, mostly, he or she will be outside the circle of muddled, messy relationships, derived from relationships we had in early life, which we have with those in our immediate circle. This explains why patients subject to the Mental Health Act tend to have a cleaner, perhaps more adult relationship to the law than they do to their consultant who may carry parental associations or resonances.
• Advice that you give will almost always be wrong
This is partly because of the tendency (see above) to advise the other as if the other was ourself. Give advice very sparingly and only when it is technical or factual. Find other approaches, such as: “in my experience…….”; “I’ve noticed that…..”; “you may find, if you do that, that x will happen”; “I can only generalise – you must decide”; “perhaps this isn’t the right time to be doing x…..” etc
• Abandon completely concepts such as insight, compliance and concordance. They set up an unproductive, uncollaborative dynamic
Often, what professionals call “lack of insight” is actually a disagreement about terminology or perspective: e.g. “I don’t have schizophrenia but the voices are a problem”; or “the medication is rubbish but it does stop me being erratic sometimes”.
• Abandon completely expressions such as “treatment resistant” or “treatment refractory”
Helpful treatment is there but it just hasn’t been found yet.
• Avoid the “depot mentality”
This is seeing the job or clinical task as forcing what we believe to be good (medication, ideas, answers, ways of seeing, services etc) into the (often resistant) patient
• Don’t over-refer
Stay with the patient, psychologically. Referring on too readily or at the wrong time may convey that you can’t cope with or tolerate what you are being told.
• Refer the patient, not the problem
This means that the patient’s relationship with the problem, his or her capacity and willingness to address it, and its place in his or her personal history must be understood first. Watch out for automatic thinking: e.g. “this person has a drinking problem, so I will advise him to go to an alcohol service”.
• Badly timed referrals waste time
Defensive referrals (“I’ll refer X to Y service to avoid criticism for not doing so”), or automatic referrals (“she has A problem so I must refer her to B service”) or referrals where the systemic/individual function of symptomatic behaviour is not understood (“J’s drinking is not good for him so he needs to work with K service”) consume a lot of unproductive time.
• Unsuccessful treatment (with medication or psychotherapy of whatever kind) may increase despair and feelings of being unhelpable
Despair (“no-one can help and I can never be different”) tends to be the end-stage for patients who commit suicide. Often they will have had a series of unsuccessful or temporarily successful stints of treatment. This may increase ideas of untreatability in the minds of both the patient and the professional.
• Despair is infectious. Part of your job is to assume and later tap the potential that everyone has.
This means that, as quickly as possible, you should develop a picture of a more fruitful way of being that the patient has this potential to move into
• The knowledge we have of patients is always superficial: we are on the distant margins, not at the centre. We should know that we don’t know.
As individuals in our non-working lives, we feel ourselves to be at the centre of things, looking outwards. It is risky to transfer this perspective into clinical work, because it tends to lead to “insider blindness”, that is, missing things which are obvious to those on the outside or margins.
• Take on board that the NHS is anti-family and this is institutionalised
As a professional, you will not be deliberately or knowingly anti-family but this is in the DNA of your organisation. Understand this and remind yourself that, while consulting relatives or significant others may be procedurally necessary (for the Mental Health Act, “carers’ needs assessments” and so on), it will almost always be clinically helpful.
• Remember that where risk is concerned the patient isn’t your only client
Relatives or the public may be as much your client as the patient is.
• Risk events should not be dismissed or discounted simply because they happened years ago
You may discount them because, for example, they happened when the patient was drinking heavily and no longer is, but not solely on the grounds that it was twenty years ago and it is unfair to hold distant offences or incidents against him or her.
• Don’t make the logical error assuming that depression which arises after or in the context of adverse life events is caused by them
There may be link, even a causative one, but don’t assume there is any link at all.
• Remember the importance of the subjective: i.e. the meaning or significance of events or circumstances to the patient
Objectively, a patient’s depression may be moderate but to him or her it may seem catastrophic. Or what may generally be seen as a protective factor – for example, getting a job, the involvement or support of parents etc – may not be protective at all to the patient.
• Avoid using lack of information, or problems in getting information, as a platform or reason for discharge or closure
All teams, systems, practices and individual professionals are risky or dangerous to an extent. A policy or culture of closing cases because of difficulty in getting hold of a patient or in engagement carries unacceptable and avoidable risk.
• Attend to the ways in which your practice is risky
It will be. All you can do is make it less risky over time.
• Help the patient to leave the room with one new thought
Mostly, sessions with patients cover old ground; or they cover ground which is new to us but very familiar to the patient. This interferes with engagement and prevents the growth of confidence in the professional.
• Learn to be neutral
Being neutral means there is less for the patient to be resistant to. Being neutral, for example about destructive drinking or unlawful behaviour, past or present, doesn’t mean that you are condoning or colluding with such behaviour, or that you would not be able to report it to the police or other agencies. But it enables you to say: “well, let’s look at this together” instead of being the parent figure on the inside of the circle of transference (see above).