Doing Well, Staying Well,
What is RISE?
As an organisation we are dedicated to providing person-centred, responsive and evidence-based care.
Within Iris Care Group services, it is important that people receive support that is specific to their needs. Our service users typically have very complex needs. Many have spent long periods of time in hospitals; many have also been recalled to hospital on numerous occasions and have found it hard to stay in the community. This is why it is very important that they all have access to appropriate support, using the highest quality mental health support, provided by all our team.
We have called our support framework for service users with mental health conditions RISE. It represents our goal to help people with complex mental health needs to develop the skills needed to succeed in their current placements and prevent them from returning to hospital even when they have ongoing challenges.
We have used evidence of what works in mental health to inform the creation of the RISE Monthly Planner and subsequent work sheets. They have been designed in a manner that is accessible to service users and staff.
RISE also provides guidance for staff on the approaches they should adopt when supporting service users in moments of distress or anxiety.
The Mental Health (Wales) Measure 2010
The Mental Health (Wales) Measure is a law to ensure people with mental health difficulties have support that is delivered specifically to their needs.
This Measure focuses on:
• Ensuring that people are involved in the planning and delievery of their care to the fullest extent
• Equality, dignity and diversity
• Clear communication
• Targetted and effective care plans
• Choice
• Access to services
• Information
The RISE Monthly Planner has been created to ensure we are complying with the Mental Health (Wales) Measure, and with the requirements of the NHS Wales Social Care Framework.
The planner is a structured framework that supports mental health service users to identify and plan how to work towards specific goals that will aid their recovery. It will clearly monitor an individual’s progress towards their goal and highlight to both the service user and others when goals have been achieved.
Using RISE
The flow chart below outlines the process that will need to be undertaken for the RISE monthly planner. Staff should offer service users support with completing the ReQol, setting goals, and review progress towards these goals throughout the month. This progress is presented and discussed in MDTs and at CPA/CTP meetings.
• Service user completes baseline ReQol, with staff support if required.
• Service user completes the ‘’About me’’ section in the Rise Monthly Planner.
• Staff should encourage service users to set personal goals in each section of the Rise Monthly Planner.
• Make sure the goals are written in a ‘SMART’ format so they are: specific, measurable, achievable, relevant and time bound.
• Staff should support the service user to achieve their goals. The weekly table can be used to keep track of their progress towards achieving the goal.
• Identify recovery worksheets that can be used to assist recovery.
• Staff should review the weekly tables to help identify the progress service users have made towards their goals.
• Complete a review of the service users’ goals for MDT.
• Staff support the service user to review Rise work book.
• Readminister ReQol.
• Update service user’s goals and provide them with encouragement
Recovering Quality of Life Measure (ReQol)
The ReQol is a patient-reported outcome measure that aims to capture changes in a service user’s mental health. Traditionally mental health outcomes have tended to be focused on symptoms, however the ReQol measures outcomes of recovery in regard to the service user’s quality of life.
The ReQol looks at themes that include:
• Hope
• Autonomy
• Self-perception
• Belonging
• Wellbeing, activities and physical health.
The measure can be used with all mental health populations including common mental health difficulties and psychotic disorders.
Such measures are important as they help identify areas where the service user would benefit from receiving support and input, which then helps to inform the service user’s goal setting. It is important to see the ReQol as a way of helping organise information about the service user’s own goals and areas of particular need. It is not just a number or a score – noting the answers that people give is really important as it links how they respond on the ReQol to specific goals.
The ReQol can also be used as evidence to demonstrate to commissioners and service users that the support we provide is encouraging the service user’s recovery: helping them progress towards the next step, which might be living in a more independent setting.
Completing the ReQol
For each of the items on the measure, service users should tick the one box that best describes their thoughts, feelings and activities over the past week.
They rate their opinion on each of the 10 questions from ‘none of the time’ to ‘most or all of the time’. Each question has a scoring measure and, once completed, staff add up the scores for each question to get an overall index score.
There are six positively worded questions (Q2, 4, 5, 7, 8, 10) and these are scored 0 to 4.
Last week None of the time Only occasionally Sometimes Often Most of all of the time I felt able to trust others
Missing data
There are four negatively worded questions (Q1, 3, 6, 9) they are reversed scored from 4 to 0.
Last week None of the time Only occasionally Sometimes Often Most of all of the time
I found it difficult to get started with everyday tasks 4 3 2 1 0
If a service user has left a question blank you can use the mean value of the other questions as the response. To calculate the mean, add the other 9 items together and divided by 9.
If more than one question has been left blank an overall score cannot be calculated.
If a service user ticks two boxes for one item, choose the lowest score.
The minimum overall score is 0 and the maximum is 40. A score of 0 indicates the poorest quality of life, and a score of 40 indicates the highest possible quality of life.
Goal setting
Setting goals helps provide focus for both service users and staff on the purpose of the placement, underpins recovery momentum and supports the development of healthy adaptive behaviours.
Goal setting can provide a sense of self-mastery and motivate service users to continue achieving progression.
Within the “Recovery Goals” section of the RISE
Monthly Planner service users are asked to set four goals that are based on different areas that the ReQol measures. The four goal-setting areas are:
- Activities that bring me a sense of achievement (Activity)
- Building my friendships and relationships (Belonging and Relationships)
- Making my own decisions (Choice, Control, Autonomy)
- Looking After my Health and Wellbeing (Physical Health)
To increase the chance of goals being achieved it is important that they are written in a ‘SMART’ manner. This means they are: specific, measurable, achievable, relevant and time-bound.
Specific.
A specific goal will answer these questions:
• What does the service user want to achieve?
• Why do they want to achieve it? The specific reasons, purpose or benefits of accomplishing the goals.
• Who needs to be involved to achieve the goal?
• Where will the goal be accomplished?
• What restrictions or limits are important to consider?
Measurable.
A measurable goal will allow us to answer ‘yes’ to these questions:
• Is it clear how we are measuring the achievement of the goal?
• Is the goal written in a way that will allow us to know when the goal has been completed?
Relevant.
A relevant goal will be able to answer ‘yes’ to the following questions:
• Is the goal connected with the service user’s own priorities?
• Is it the right time to be working towards this goal?
Achievable.
An achievable goal will be able to answer ‘yes’ to this question:
• Can the goal be reasonably accomplished?
Time-bound.
A time-bound goal will be able to answer ‘yes’ to the following question:
• Is it clear when the goal should be achieved by?
Example of transforming a goal in to a SMART goal
Staff member: What goal would you like to work towards for ‘’Looking after my health and wellbeing’’?
Service user:
I would like to do more exercise.
Staff member:
Ok, how many hours of exercise would you like to do per week?
Service user: 1 hour.
Staff member: What kind of exercise do you enjoy?
Service user:
Going for long walks and bike rides.
Staff member:
Okay so each week you need to exercise twice for 30 minutes or once for 1 hour. You would then meet your month’s goal of exercising for 4 hours per month. Does this seem achievable for you?
Service user: Yes, it does.
Goal to be written as: Exercise for 1 hour per week.
The table in the monthly planner can be used to record the progress a service user has made toward their goal. The example on the right shows how this might be recorded in the planner.
The ‘How am I doing?’ section in the Rise Monthly Planner then provides an overview of each goal. The service users are required to state whether their goal has been met, if it is still relevant and, if it is, what support staff can provide to assist in the goal being met the following month.
The section also provides a reflection element which assists the service user to identify what has worked well for them and what needs to be altered to continue their progress.
It is important that this is completed every month as we can learn from what is working well, and we are showing the service users that their goals and achievements are important to us.
Exercise for one hour per week
Progress towards my goal this week has been…. Great, I have exercised for 1 hour 30 minutes in total. It has helped me to have staff prompts, and to do two different types of exercise.
Progress towards my goal this week has been…. Okay, I went for a 30 minute walk this week. I am going to try and do something different next week to make it more fun.
Progress towards my goal this week has been…. Very good, I tried a new Zumba class which I really enjoyed.
minute Zumba class
Progress towards my goal this week has been…. OK, I enjoyed my Zumba class this week. I didn’t plan any other exercise for the week, so next week I am going to do this.
Progress towards my goal this week has been….
Very positive. I visited some new places with staff this week which helped to keep it more interesting.
Progress towards my goal this week has been…. Good, I exercised every other day this week. I found it useful to have one day of rest in between.
SECTION 5
Supporting Resources
Recovery Worksheets
The flow chart of worksheets below directs staff to the most appropriate worksheets they can use with service users to help them manage psychological distress, work towards goals, and aid their recovery.
The purpose of the worksheets is to make 1-1 talktimes focused on supporting the service users. Having structured worksheets ensures talk-times make use of psychologically-informed work that supports the service users, it also ensures that, when service users are distressed, conversations do not make them worse. We know that without structure therapeutic support can either have very little effect or can make people feel worse. It is, therefore, very important that all scheduled 1-1s make use of these materials and refer to the Recovery Support Plan. Materials, along with the plan itself, need to be brought to all scheduled 1-1s.
It’s essential that staff check with service users and form an opinion on how helpful (or not) using these materials is. This must be discussed during handover and can then be documented in the Recovery Support Plans.
Each worksheet has been given a safety-rated star to inform staff whether they are appropriate to use with the service user.
A green star next to the worksheet means that it can be used even if staff haven’t known the service user for long as the content of the worksheet is less emotionally intense and doesn’t require the service user to discuss personal information. These sheets can be completed without staff support if the service user wishes.
An amber star means the worksheet is suitable to use if you know the service user well, although you should ask a senior member of staff beforehand. Service users may need some support completing these worksheets.
A red star means this worksheet should only be used when confirmed by the registered manager or clinician, as the content of the sheet may require the service user to discuss/think about personal information and potentially triggering topics. These sheets require staff support to complete.
Problem/need
Does the person need help managing emotions?
Anxiety, panic and stress - Section 1
Low mood
- Section 2
Behavioural activation
- Section 3
Coping with trauma
- Section 4
Previous DBT skills
- Section 7
Self-harm
- Section 8
Anger & aggression
- Section 9
Hearing voices
- Section 11
Bereavement
- Section 16
Does the person need help changing some of their behaviours or lifestyle?
Healthy eating and behaviour - Section 5
Motivation
- Section 6
Sleep disturbances
- Section 10
Substance use
- Section 15
Shame, low self-esteem and self-attacking behaviours
- Section 17
Coping with self-harm urges and thoughts of harming myself
- Section 18
Does the person need to learn about their diagnosis or prepare to move on?
Relationships and conflict - Section 12
Moving on - Section 13
My diagnosis - Section 14
The ‘’my therapy worksheet checklist’’ has been created for service users to keep a record of worksheets they have used and plan to use. An example of part of this checklist “Hearing voices” is displayed below. Each service user must have a completed checklist. This must be part of the Recovery Support Plan – included as an appendix at the end. All staff must be aware of the existence of this document.
Hearing voices
Worksheet
Myth busters
Contract between me and my voices
Getting space
Defending myself
Postponing orders
Voice commands and anger
Anticipating voices
Staff to use with familiar service users
Staff to use with service users they know very well
Prescribed by clinician
The work sheets I am going to use on my own
The work sheets staff will use with me in my 1-1s
Providing support when service users are in distress
Staff have a vital role to play in helping service users manage the times when they are very anxious or distressed. The best way for staff to support service users in these circumstances is to adopt an approach that combines empathy, validation, and redirection.
Empathy
Our service users, often due to a history of trauma, may think that people do not care about them and are not interested in listening to their difficulties, even if staff make a lot of effort in telling them that they want to help. It is important that staff members are mindful of this.
There are three main components to empathy: Active listening, identifying the emotional states of the person and reflection.
Active listening is an important skill to use when demonstrating empathy. How well we listen can have an impact on the quality of relationships with service users. The way we, as staff members, listen to service users has a big impact on the conversation and how service users feel and behave.
To improve active listening skills, we must make a conscious effort to hear the words the person is saying and, most importantly, hear the whole message that is being communicated.
To do this we must pay attention carefully to the conversation, ensuring we do not get distracted by the wider environment or lose focus.
To understand the importance of active listening reflect on an incident of being engaged in a conversation with someone when you have wondered whether the person was actually listening to you and what you were saying. At the time you might have wondered whether you were actually being heard, and whether there was any point in continuing what you were saying. You may have become angry and felt ignored and undervalued. This is something you want to avoid when engaging with service users.
To demonstrate you are actively listening you can follow these steps:
1. Pay attention
• Give the service user your full attention
• Put aside distracting thoughts
• Look at the service user directly
• Ignore environmental distractions
• Be aware of the service user’s body language
• It is always helpful to tell the person how much time you have for the conversation before you sit down and, if you are interrupted, it is really important to apologise and to tell them when you will be able to return. Always return to a conversation if you have promised to do so.
• Ask relevant questions
• Occasionally summarise what the service user has said e.g. “so it sounds like you had a bad morning and now you are feeling like you don’t want to go out”.
4. Avoid judgements
• Avoid interrupting with counter arguments even if you know what the person is saying is factually incorrect. It is not about facts and you will never win an argument of this kind – in fact interrupting and arguing against the person is more likely to cause a severe incident when someone is very emotionally distressed.
• Ensure the service user has been given the opportunity to finish what they are saying
2. Show that you are listening
• Use your body language (lean towards the person, avoid crossing your arms as this creates a sense of a barrier)
• Nod occasionally
• Use appropriate facial expressions (avoid extreme displays of facial emotion as this can make the person think that what they are telling you is harming you or making you feel bad)
• Keep your body posture open, for example keep your arms uncrossed. This is more encouraging for service users.
5. Respond appropriately
• State your opinions respectfully
• Avoid belittling and minimising what the service user has said, for example by saying ‘I’m sure it will be OK, and you are worrying over nothing’.
The second component of empathy is making sure that we are accurately identifying the emotional states of the person when we are talking to them. For service users, emotions can be often feared as much as the experience that has caused them. Many service users are terrified of certain emotions, and will do almost anything to avoid experiencing them. There is a clear link between these kinds of extreme emotions and trauma.
3. Provide feedback
• Repeat what the service user has said to demonstrate that you are listening and have understood e.g. Use terms like ‘it sounds like you have said…’ or ‘what I am hearing….’
For the service users we care for unmanaged emotion can result in the service user responding to their feelings without thinking. This can lead to episodes of self-harm, physical aggression, and other risk behaviours.
Therefore, supporting service users to understand the emotions they are experiencing is really important. Developing the service user’s awareness of what has triggered this emotion can lead to the development of their understanding of how to manage it. This is key to all mental health treatments and is particularly important for people with the kind of complex trauma problems many of our service users experience.
The third component of providing empathy is using reflection. There are different strategies we can use to reflect: these include repeating back what the service user has said or summarising the conversation in your own words.
The purpose of summarising and reflecting is to demonstrate to the service user that you understand what they have said. You can then clarify with the service user that your interpretation is valid.
Validation
Service users can often feel scared, humiliated, frustrated and out of control. Validation from staff means positively communicating to the service user that their behaviour, in this context, is understandable.
Showing that we understand is important. Throughout their life service users may have been ignored, neglected or told their feelings are not important. Validating their feelings acknowledges that their thoughts and feelings have developed due to past experiences.
An example of a validation statement might be: “I appreciate you are feeling upset, and this is understandable because you have been through a lot”.
Negative comments that invalidate might include “get a grip” or “you’re an adult now, and you need to act like one”. These type of comments just reinforce their previous experiences of neglect, being ignored and feeling insignificant.
Redirection
Having established empathy with a service user and provided validation the next step is redirection. Redirection means refocusing the service user’s behaviour, attention or thought process. This may be encouraging a service user to become involved in an activity (such as a structured worksheet, or a distracting activity of some kind) or leading the conversation on to a neutral topic.
This is important; dwelling unnecessarily on difficult emotional states without focusing on a coping strategy or a distraction can often make things worse.
Just talking about things is not always helpful - we also need to provide guidance on how an individual can move forward. This is why it is really important to follow the Recovery Support Plan as this will tell you how to approach the person when you are supporting them while distressed.
If we use redirection too early then there are dangers that we will have done this before the person has felt validated. This could increase the service user’s distress. It is important staff are mindful of the service user’s presentation and have spent enough time talking about how they are feeling before redirecting to a coping activity.
