False allegations and therapy

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lingua_franca
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False allegations and therapy

Post by lingua_franca » Fri May 06, 2016 12:41 am

Recently I have been working with someone who has been In hospital for a while and is very invested in her status as one of the longest-standing patients. She seems to have constructed her identity around illness and being in need of care. She has fabricated numerous stories of sexual and physical abuse, and while the team is sure that she has experienced such trauma at some point in her life, it's now impossible to unpick the truth. She has also fabricated stories about other things.

One of the goals set by the MDT is for her to feel acknowledged and 'seen' without having to resort to extreme behaviours or to constantly produce fresh stories of traumatic experiences. However, this goal was passed on to the HCAs without us being given much guidance on how we're supposed to implement it. I was wondering if anyone here had faced similar issues in a support role and had suggestions. I'd also like article recommendations on therapeutic work with clients who make false allegations, as I haven't found much so far.
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miriam
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Re: False allegations and therapy

Post by miriam » Fri May 06, 2016 1:21 am

I'm a bit uncomfortable with them labelling a client as making "false allegations" and "fabricating stories". It seems to me like a lot of people who have been through awful things need to test out the response, and to explore whether they will be believed. Some of them find it hard to make coherent sense of their experiences of trauma and/or have experienced other people changing the "truth" over time in way that makes it harder for them to be certain what has happened or how people will react. And others have learnt to express their needs indirectly, in ways that have been more successful in generating care. This means they might say confusing things, or might make partial disclosures or redirected allegations but aren't able to confide the whole story. They then end up with labels that undermine their future disclosures. People find it hard to retain sympathy when people have dysfunctional ways of expressing their needs, or seem to be telling lies. Yet all of those things are reactions to trauma, and not conscious choices done with the intent to be manipulative.

That said, I like the idea of helping a client to feel heard and valued without the need to make dramas to pull people in. Part of that is about being aware of the processes and naming them, rather than being sucked into it. I think Ryle's books on CAT are very helpful in that regard. But I'd be trying to notice things in the here and now - about her appearance, mood, behaviour, etc - and finding small things to do together, to show you care about her. Whether that is painting each other's nails or doing crosswords together, talking about the weather or what is on telly, or doing some form of relaxation or mindfulness doesn't really matter.
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lingua_franca
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Re: False allegations and therapy

Post by lingua_franca » Fri May 06, 2016 1:44 am

I hesitated about using those terms and I see what you mean. To be clear, the disclosures don't just concern her past - she has made recent allegations about staff that we know beyond a shadow of a doubt couldn't have happened. There is concrete evidence that they didn't, and this has happened in multiple placements, so she is never left on her own with just one person. We do understand that this is in the context of past trauma, which is why we avoid terms like lying. I understand this as a way of seeking care and an attempt to make sure she can have contact with the adults she likes while minimising contact with those she doesn't, but simply interpreting her behaviour in an empathetic light doesn't seem to help - she wants to be believed totally, in every detail. I can understand why she might feel like that, and while I'm happy to affirm her feelings, I can't start telling her that I agree with her conviction that So-and-so should be sacked. We try to redirect her when she starts saying things like this, but it's not always effective.

Regarding her past, the disclosures are tangled up and inchoate, consistent with what you describe, but she has also said things that were later demonstrated to be false. She told me and some other fairly new staff that she had a twin sister who had died very recently in a car crash, and then we discovered she has no siblings, let alone a twin. (I have changed details in this anecdote to avoid making her recognisable, but you get the idea - it was something that objectively never happened, as opposed to a distorted version of something that did.) I wouldn't say I'm struggling to retain sympathy for her as such, because she is obviously in a lot of pain to be saying these sorts of things, but I'm baffled at how to respond to it and frustrated at the loop we as a team seem to be stuck in with her.
"Suppose a tree fell down, Pooh, when we were underneath it?"
"Suppose it didn't," said Pooh, after careful thought.
Piglet was comforted by this.
- A.A. Milne.

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miriam
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Re: False allegations and therapy

Post by miriam » Fri May 06, 2016 3:01 am

I wasn't intending to imply any criticism of you or your terminology, Lingua, just a thought about labels on wards really. It sounds like some group formulation and reflective practise would be really helpful for all the staff around this case. Is there a CP or similar who can provide this?

Two tangential thoughts, perhaps relevant:

1) I had a client many years ago with some neurodevelopmental difficulties who had been sexually abused by her father. He had told her that it had never happened, that he was sorry (and that if he was sorry that undid what had happened) and that nobody would believe her if she told, and that being found not guilty by a court would prove that it never happened. She needed to do a lot of exploring of the difference between lies and the truth, and a lot of testing how people would respond, and it was a theme she revisited repeatedly in our sessions - often enacting court room scenes with toys in which the victim told or didn't tell, the perpetrator denied or admitted, the judge found guilty or not guilty, and other people believed the disclosure or didn't. Sadly, at the point she disclosed she was over 18, and the police didn't come straight away, so she went home to her parents, never made the allegations and withdrew from therapy. Disclosing is hard and often takes a lot of rehearsals.

2) When I used to work in residential care homes for older people with dementia, we would often have disoriented residents who would wander around looking for a long-past pet or loved one. Some staff would try to reorient them as to their current situation but it didn't alleviate their distress. The need was for reassurance that they were safe, and belonged, and once that was met the distress would reduce. I wonder if you need to find a way to say "it's okay, I'm here, we can worry about the kitten another time" but in the context of your client's situation? That has been looked into, but I can understand that you are distressed and I care about that, so let's do something together to take care of you...."
Miriam

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Geishawife
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Re: False allegations and therapy

Post by Geishawife » Fri May 06, 2016 8:07 am

Have you ever seen any of Naomi Feil's work on Validation Therapy? Admittedly, it was developed for people with dementia rather than younger people, but from what you've said I think it's an approach that could work. The approach suggests that when a person with dementia is making statements such as "what time is mum coming home?", although mum died 20 years ago, the statement is expressing need or distress and it is that that needs validating. Hence the reply wouldn't be "mum's dead" but would recognise what mum represents and explore that - "tell me a bit about mum and your relationship with her". That's oversimplifying things a bit, but I would strongly recommend you check out her work. Good luck! That sounds like a difficult situation.

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Re: False allegations and therapy

Post by BlueCat » Fri May 06, 2016 10:47 am

I guess I would be thinking about what need these statements are serving, and how they are helping this woman to have those needs met. Is it to feel special, or important, is it to initiate conversation, or secure interaction from staff? Is it to try to cause people to care, or see her as vulnerable? Is it a way of saying "I don't like it when that person interacts with me?". Is it that she's testing out responses prior to disclosing something? Could be any of these, all of these at different times, none of these?

I wonder if it would be helpful to think about each individual instance, rather than find an overarching theory that would answer/explain all the instances? I'm assuming that this woman's experiences have led her to find it difficult to seek care/interaction/support in a straightforward way and the explanation for her repeatedly making statements not based in fact is likely to be similarly not straightforward.

In terms of intervention, I would be basing that on the formulation developed by the team around these types of statements. Do ou have access to a psychologist on the ward?
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Re: False allegations and therapy

Post by reefflex » Fri May 06, 2016 11:24 am

Some thoughts:

- are you able to talk with the person about the allegation being found to be untrue? - do they acknowledge this subsequently, are they able to think about how they came to make the allegation?

- Could you work with them to carry out functional analysis/chain analysis of each allegation made, as for any behaviour? As bluecat says, try to look at instance by instance, so that both you and they can test out your theories about the reinforcement schedule. By your current formulation, non-contingent positive regard may meet the need that the behaviour functions to achieve, and so by providing this consistently you essentially set up a differential reinforcement of alternative behaviour (non allegation making) schedule.

- if as a team you are going to implement anything, you need good stable baseline data and then accurate measurement of the behaviour to look for change - otherwise you will have no idea if your new interventions are proving effective.

- Are there other behaviours aside from allegation making, that maybe go alongside, appear as precursors, perhaps could be early warning signs? if they are more frequent, then also recording accurately these early warning signs may give you a more detailed picture of the impact of your interventions, particularly if allegation-making is a low frequency behaviour.

- The problem of course in any healthcare setting is twofold - first, consistency. Second and connected, differing beliefs amongst the staff about functions and meanings of behaviour, leading to differing responses. If your formulation is right, then both of these issues need to be addressed, otherwise the risk is you instead set up a variable reinforcement schedule, which could actually increase the frequency of the allegation behaviour. Team formulation and consistency of team response are bound together.

- alternatively, do they continue to hold the idea of having been recently abused despite being presented with evidence to the contrary, and if so at what strength? is there any room for disputation, do they feel differently about it at different times? if so, have you considered that the memory/belief could be specific to a mood state or a schema mode?

- A third possibility - are you sure the client is not experiencing these events exactly as if they were true? For example, could they be having fragmented/sensory/dissociative flashbacks to previous trauma, that because of their "nowness", they are interpreting as new memories of recent abuse? Are you sure they are not experiencing any psychotic phenomenon of abuse that feels real to them?

- I worked with a client once who had made numerous allegations about staff, again labelled as seeking attention, when talked it through with them in detail they could explain the function as wanting to raise concern/disclose about someone who historically had actually hurt them, but they were too scared to name as they were still around. When this was done, the allegations stopped.

So what I'm saying is, don't assume a function until you can test it and show it quasi-experimentally.

lingua_franca
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Re: False allegations and therapy

Post by lingua_franca » Fri May 06, 2016 6:47 pm

These responses are very helpful, thank you. I'd never heard of validation therapy before but I'll definitely look into it. BlueCat, I think you're right that there is no one overarching explanation for why she says these things, but that makes her behaviour all the more challenging to understand and respond to.

Reflective group supervision is provided once a week, technically. It's led by a psychodynamic therapist. This was my first main exposure to psychodynamic ways of working, and I do benefit from it - when I'm able to go! On average I get to that group once every six weeks, as I'm usually doing observations when it's happening. I keep requesting shifts for the day when it takes place to increase my chances of participating. I wish the provision were less patchy, as it's really needed. Sometimes it feels that the ward is diagnosis-led rather than formulation-led, if that makes sense. When I've tried to talk with the nurses about how best to respond to the clients' difficulties, I've been directed to basic information on the conditions they're diagnosed with (NHS leaflets and NICE guidelines, etc.), which isn't that useful to me when I'm interacting with patients.
"Suppose a tree fell down, Pooh, when we were underneath it?"
"Suppose it didn't," said Pooh, after careful thought.
Piglet was comforted by this.
- A.A. Milne.

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Re: False allegations and therapy

Post by Ruthie » Sun May 08, 2016 11:29 pm

It seems to me that a major issue here is that support workers have been given a psychological formulation and told that this should drive the way they provide care without adequate guidance as to how this should be implemented in a practical way. This really needs to go back to the psychologist who has developed the care plan so they understand that the team aren't confident in implementing it and need more specific guidance. I don't think it's for us as a forum to be providing further suggestions as to how this should be done.

I think this is a great question for supervision, not so much for a web forum.

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lingua_franca
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Re: False allegations and therapy

Post by lingua_franca » Mon May 09, 2016 2:44 am

My supervisor is an RMN. I hesitate to say this as I don't want to be seen as running down nurses, and she's lovely, but from a formulation point of view my supervisions aren't that helpful. They normally focus on practical things, which are useful in their own way but not enough. I ask questions about why a patient might be acting a certain way, and I just get reminded of their diagnosis and told "that's how people with XYZ condition often present". The therapists on the ward respond differently and I benefit from the group supervision when I get the chance to go, but the chance isn't often there.

I am a bit disappointed by my individual supervision, as in my interview I was given to understand that it would be more psychologically informed. I don't feel able to request supervision by a CP or a therapist, because none of the other support staff get that, and I'm not some special snowflake who should have it when no one else does. Right now my strategy is to keep requesting shifts that fall on group supervision day to increase my chances of being allowed to go, but beyond that, it would be hard to change the nature and frequency of the supervision I receive. I see that a web forum may not be a good place for this either, though - I know that I can't seek specific guidance for a client no one here has met, and specifics are what I need more than general tips.
"Suppose a tree fell down, Pooh, when we were underneath it?"
"Suppose it didn't," said Pooh, after careful thought.
Piglet was comforted by this.
- A.A. Milne.

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Re: False allegations and therapy

Post by alexh » Mon May 09, 2016 11:52 am

How about group supervision or reflective practice from a psychologist for all the snowflakes.

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Re: False allegations and therapy

Post by workingmama » Mon May 09, 2016 3:32 pm

lingua_franca wrote: I don't feel able to request supervision by a CP or a therapist, because none of the other support staff get that, and I'm not some special snowflake who should have it when no one else does.
I am totally a special snowflake, and it doesn't diminish my specialness that I know that there are other special snowflakes too. Go be snowflakey, and ask away. Shy bairns get nowt!
Fail, fail again, fail better.

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Re: False allegations and therapy

Post by Loula » Mon May 09, 2016 5:20 pm

As a CP on a ward who facilitates group supervision I would have no problems with a HCA approaching me to ask for more/an alternative. I'm not saying that I'd necessarily be able to commit to offering individual supervision, but I'd definitely be interested that there was someone who wanted to attend but wasn't able to and take that to the management to see if we had options eg there was a better time to offer it/ a more equitable way.

In terms of your original question, definitely agree with Ruthie that the forum for it is supervision. It sounds like there's some really complex issues and you have been given lots of suggestions around formulating and therapeutic models which might be helpful for you, but just be mindful that you're not finding yourself dabbling in approaches in an unsupervised way.

In tricky situations where you're feeling stuck I often find it helpful to go back to the good old therapeutic basics of being present, attentive, non-judgemental, genuine, listen etc. If an entire MDT does that, it's a great starting place for more formal thinking and interventions. Don't underestimate them.

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Re: False allegations and therapy

Post by maven » Mon May 09, 2016 10:46 pm

And it isn't necessarily the job of your individual supervision. It is the job of the person who gave that formulation and advice to ensure the staff are able to implement it. Seeking advice here is about meeting your needs, not about the needs of the service or the patient. Providing feedback that staff don't know how to implement the advice day to day is something that needs to be raised for the benefit of the whole service, not just you as an individual HCA.
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The fool thinks himself to be wise, but the wise man knows himself to be a fool - Shakespeare

lingua_franca
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Re: False allegations and therapy

Post by lingua_franca » Wed May 11, 2016 3:34 pm

Thanks, everyone. The group supervision was today, facilitated by the therapist who provided this guidance. All the HCAs were on observations and couldn't go, so the therapist just left. I looked at my notes and realised that it's been over two months since I last made it to this group, which was described in my new starter pack as something that we would all be able to access frequently. I've spoken to some other HCAs about it and it seems that only one or two of us really mind missing the opportunity. I've sent the therapist an email explaining that personally I don't feel that I am receiving the amount of psychologically informed supervision that this role requires. I'll see what she suggests. Perhaps as there isn't much interest from the other HCAs I will be able to get some individual supervision without taking too much of her time (although I think the lack of interest is indicative of a vicious cycle that we need to change - people haven't been introduced to more psychological ways of working, so they're less likely to be interested in them!).
"Suppose a tree fell down, Pooh, when we were underneath it?"
"Suppose it didn't," said Pooh, after careful thought.
Piglet was comforted by this.
- A.A. Milne.

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