SHADES OF GREY Working with clients with emotional issues

1. SHADES OF GREY Working with clients with emotional issues

2. Aims of the session: To help you to: • Be clear about safeguarding and the boundaries of the Skin Camouflage Practitioner role. • Learn and understand more about clients with emotional or mental health problems, especially those who self-harm • Feel more confident and aware when dealing with these clients • Please note, the focus of the session is to help you manage the emotional side of things, rather than the practical (although we will discuss this briefly too)

3. SAFEGUARDING Flow Diagram ABUSE TO CHILD ABUSE TO ADULT SUICIDE OR SELF-HARM (ANYONE) SERIOUS/IMMEDIATE RISK OF DEATH OR SEVERE HARM YOU ARE CONCERNED OR Head of Client Service Deputy Head of Client Service Changing Faces Practitioner Call 999 for an ambulance Inform Safeguarding Staff Stay with client Get support Record on Incident Report Form

4. SAFEGUARDINGWhat does it mean for you? • If you are worried about possible abuse, self-harm or suicidal behaviour towards or by anyone you encounter while undertaking your activities for Changing Faces, it is NOT your responsibility to decide what action should be taken or to breach confidentiality, unless the client is at risk of death or severe harm that may lead to death. • IT IS your responsibility to inform Safeguarding Staff: 1) the Head of Client Service (or if not available) 2) the Deputy Head of Client Service (or if not available) 3) a Changing Faces Practitioner (CFP) who will decide what action, if any, needs to be taken • If in any doubt, err on the side of caution – contact a member of Safeguarding Staff to discuss your concerns

5. WHAT ABOUT THESHADESOFGREY?

6. VERY DISTRESSEDANGRY DEMANDINGDEPRESSED VERY UPSET WON’T STOP CRYING UNUSUAL BEHAVIOUR NOT TALKING PASSIVE SHARING DIFFICULT FEELINGS MENTAL HEALTH PROBLEMS SELF-HARMSUICIDAL

7. Why is it hard for you? Shocked… surprised… unprepared… at a loss… doing wrong thing… feeling responsible… want to help… solve problem… can’t help… blame self… out your of depth… upsetting… hard not to react… feel sorry for them… don’t understand… confused… not make sense… want to tell them to stop… hard to talk to or engage… being manipulated… drawn in… out of control of situation… can’t please someone… can’t see problem… not know what they want… feeling sad… pity… angry… annoyed… critical… worried… intimidated… anxious… challenged…

8. We all have mental health Good<-----------------------------------------> Poor mental health scale • Our mental health changes – we move up and down the scale • Good mental health enables us to grow, learn, enjoy life, study, work, have relationships, cope with the stresses and strains of life • Poor mental health makes it harder for us to deal with everyday living and the challenges life throws at us • We feel less mentally ‘well’ when our thinking, mood, or behaviour, is disturbed and out of keeping with our cultural beliefs and norms • Mental health becomes a ‘problem’ when it causes ongoing: • Distress or turmoil • Inability to function day-to-day • Impacts on relationships, work, studies or social activities • Affects on our ability to live life in a fulfilling way

9. Labelling, stigma and language • Those with mental health issues are basically people with more severe emotional difficulties to cope with • Do not label people, mentally diagnose or assume you understand • Remember the client is a person first, not an illness or behaviour • People often experience stigma, discrimination, isolation, social exclusion, rejection, lack of access to work, £££, support, housing • The media often makes links between violence and mental distress – the reality is that people with mental health issues are much more likely to be suicidal than to harm another person Be aware of the language used about people: • The term ‘mental’ is often used in a negative or abusive way • Derogatory language, eg: “psychos”, “schizos” and “nutters” leads to stigma, fear, rejection and isolation

10. Types of mental health problems Depression disorders: clinical (ie: for no apparent reason) or reactive (ie: to an event or loss) depression, post-natal depression Psychotic disorders: schizophrenia, bipolar disorder (manic depression), post-natal psychosis Anxiety disorders: anxiety, panic attacks, phobias, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), body dysmorphic disorder Personality disorders: borderline personality disorder, anti-social personality disorder, paranoid personality disorder Eating disorders: anorexia bulimia or nervosa Dementia: Alzheimer’s disease, vascular dementia Other / related issues: drug or alcohol abuse, homelessness, learning difficulties, autism / Asperger’s See handout on protected section of the website for more information

11. Body dysmorphic disorder (BDD) • People with BDD are obsessed by slight defects in appearance, thinking they are hideous or ugly (often others can barely see it) • It causes much distress and significantly impacts on daily life: • Anxiety, poor body image, depression, ashamed, suicidal • Ritual checking of their appearance or grooming; often feeling by trapped doing this • Avoiding bright lights, mirrors or social interaction • Seeking treatments (surgery, dermatology, etc) • Possibly, Skin Cam may help at first, but this effect is unlikely to be long-term. • It is also likely the client says they are unhappy with the cover, insisting the defect is still visible. • Use the skills described later. Definitely encourage referral to Client Services for specialist appearance-related support

12. Symptoms people may present to you… Distressed… despairing… crying… pessimistic… withdrawn… tired… uninterested… down… restless… agitated… guilty… irritable… unconfident… low self-esteem... memory problems… lack of concentration… confused…. jumbled… sensitive… blocking suggestions… unhappy with results… distorted perception of reality (hallucinating, deluded, paranoid, manic)… mood swings… worried… anxious… afraid (fight, freeze or flight)… shaking… sweating… feeling faint… chest pains… hyperventilation… palpitations… tingling or numbness… feeling a lack of control… stressed… tense… angry… suspicious… obsessive… repetitive actions… difficulties dealing with change… challenging… defensive… manipulative… untrusting… suicidal thoughts… self-harm…

13. How to respond to clients • Listen to your client - show understanding: • Remember – you don’t have to have ‘something’ to say • You can acknowledge, rather than comment (see skills later) • Be respectful - you don’t truly know about or understand their life • Stay calm and even – don’t recoil or show your feelings • Be friendly, approachable, kind and gentle: • This may be a rare time they have contact with someone. • Chat first – ask the client what you can do for them • Manage their expectations – gently explain what you may and may not be able to achieve • Show empathy (understanding) as opposed to sympathy (pity) • Refer them on to the Support Service to help them manage the emotional impact of their appearance

14. The don’ts • Don’t react, judge or criticise. Even if someone is being difficult, don’t dismiss them as mad or manipulative • Don’t direct or tell the client what to do, think or feel. • Avoid SMOG! - should, must, ought to, got to…ie: “You should stop doing that.”, “You ought to go to your GP.” • Don’t ask questions, quiz them, ask why or comment • Don’t be too friendly or overstep the boundaries of your role • Don’t act like their friend, parent, relative, etc or give advice • Do not impose your own beliefs or attitudes on them • Don’t respond to challenges or rise to demands • Don’t ignore their feelings • Don’t expect to solve their problems or make things better • Don’t expect the client to be pleased (they might not be - but it’s probably not down to you)

15. Keep your boundaries • Be professional and remember your role (and it’s ok to gently remind your client too if you need to) • Accept they may need more support than it’s in your role to give • Do not share your own experiences or say you know how they feel • Don’t get over-involved in a long discussion about their life or mental health – don’t offer your opinion, comment or advise them • However, it’s very important not to ignore people with emotional difficulties – acknowledging and giving them a short amount of time to talk will feel heard and understood • Do not feel you need to suggest anything helpful, practical, or come up with solutions – you are not there as a therapist • If you feel they require additional emotional support, refer them to Client Services, their GP or relevant organisations (see list) • Get support afterwards if you need to

16. Active listening and responding • Leave silence – you don’t have to fill it • Speak clearly - keep a calm tone and speak at an even pace – do not mirror their tone if they are upset or angry • Be aware of you body language – try to be relaxed, smile, be open, make eye contact • Acknowledge them, using sounds, eg: mm, uh huh, yes, ok, etc • Or phrases like, “That sounds difficult.” or “You sound worried.” • Reflecting back by paraphrasing or summarising what someone has said – this is useful for responding without commenting • Focus on feelings rather than responding to the illness, behaviour or their beliefs • Check in with your caller - use open questions – how, when, where, what… for example, “How does that feel if I touch it”, or “How are you feeling now?”

17. Challenging situations The following happen with a client in a session. What’s your gut reaction? What’s the worst thing you could do or say? A person starts crying, becomes very stressed and starts gulping for breaths of air… A client says, crossly, “It’s not going to help… What makes you think you think you can help me… you seem pretty useless. I don’t even know why I bothered coming!” A client, who has been withdrawn throughout, whispers, “I’m scared. I’m nothing. I’m so scared… Help me…” A client says, “It’s so hideous, ugly, I can’t bear it!! Get rid of it!” A client says, “Can you keep a secret… I keep thinking about dying… don’t tell anyone, will you…”

18. Self-awareness • Staying aware of your thoughts and feelings is very important. • People with emotional issues often present strong feelings, which can cause strong reactions in us – this may influence how we act. • Clients may not behave in a way that you expect, understand or relate to – this is their experience. Don’t judge or react. • Others may present issues you do relate to or feel strongly about. • Check in with yourself and reflect on your thoughts and feelings • Remember your active listening and responding skills. Don’t get too drawn in or over-involved – it won’t help the client… or you. • Draw a mental “line” between yourself and the client - if you are being drawn in, take a deep breath and a mental “step back”

19. What is self-harm? Deliberately causing harm to oneself, by physical injury, by putting oneself in dangerous situations and /or self-neglect. There is no ‘typical' person who self-harms – affects people across the range of age, gender, class, sexuality, ethnicity and of different employment status, etc. Common forms that self-harm can take include: • Cutting, burning, biting • Head banging and hitting • Picking and scratching • Overdosing, self-poisoning or substance abuse • Neglecting oneself or taking personal risks • Pulling out hair • Eating disorders Source: Self Harm Network 2009

20. What situations causepeople to self-harm? There is no real answer to this. Everyone is different. However, some of the more common reasons behind self-harm are: • childhood abuse • sexual assault • bullying • stress • low self esteem • family breakdown • dysfunctional relationships • mental ill health • financial worries Source: Self Harm Network 2009

21. Why do people self-harm? A release of tension, frustration and distress: "I think it’s somewhat of a release… you’ve not really dealt with your feelings properly… that’s possibly the only way you can see at the time." To feel and regain control: “When things were happening to me that I had no control over I started hurting myself… something that I could control, I could do as much or as little damage as I wanted." To punish: "I have to take things out on myself, to drive the bad feelings away, punish myself for what I let happen to me…" To feel, to ground oneself: “When I feel numb or… disconnect from reality I need to feel pain to bring me back to the here and now… the pain makes me realise that I am really here." A way to express: "It's a way of expressing negative feelings about myself… as someone who finds it difficult to put things into words, it can at times be the only way of expressing how I am feeling.” Source: Self Harm Network 2009 – quotes from real people

22. Is self-harm attempted suicide? • Rarely. People suffering emotional distress may feel suicidal, but self-harm is a coping mechanism – it’s predominantly to prevent suicide rather than being a suicide attempt. Is it is attention seeking? • It’s often seen as a cry for help, to gain attention or manipulation. • However, usually it is very private and hidden behaviour. • People will take great care in hiding their injuries and scars through shame, embarrassment or fear. • Many treat wounds at home rather than seeking medical help. • Individuals who do let people know about their self-harm may have no other way to communicate how they are feeling. This may be a cry for help. If someone goes to these extremes, it is clear that they are in distress. Source: Self Harm Network 2009

23. Self-harm in Skin Camouflage 1) Those who no longer self-harm - who want cover for old scars 2) Those who are still self harming – who have old and fresh scars People may: • Be unable communicate, withdrawn, passive, down – remember, self-harm may be the only way they can show their pain / upset • Have been okay (generally not been self-harming), but have recently gone through a rough time – so self harm to cope • See this as a big step – and feel anxious, scared, concerned or unsure – you may be the first person they’ve shown their scars to • Feel ashamed, embarrassed, exposed and worried about showing something so personal and private that is usually hidden • Be hyper-sensitive to emotion, criticism or judgement • Have certain things that trigger their self-harm – this will be particular to each person, eg: shut in a room = lack of control

24. Responding to people who self-harm All the same techniques still apply: listen & acknowledge, have respect, don’t judge or try to solve problems, warmth, hide feelings, empathy, be calm, don’t comment/advise/direct, keep boundaries • If you can, think about how you may feel or respond beforehand – if necessary, discuss any concerns with the Head of Client Service • Don’t quiz or question them about scars – take the lead from the client – if they want to say anything, they will • Ask for permission before looking and touching – self-harm scars can be very sensitive - check in with your client (ie: is it ok? it doesn’t hurt?) – explain clearly what you are doing • Be very factual / non-judgemental about scars – comment on them only with relevance to the work • Make the room feel safe – so they feel unobserved and able to go at any time (you & clients should always have access to the door) • Be patient – it may all take a bit longer

25. Practical points • Don’t assume you know what the clients wants – ask them • Scars can be ultra sensitive. Check in with the client if it’s ok, hurts, feels uncomfortable, strange… • Make sure the client knows you are going to look or touch. • Explain you’ll need to touch them to colour match and cover • Depending on the site and number of scars, an overall cover may be easier for the client than doing each individual one • Manage expectations. Self harm scars can be difficult to cover • You may not feel you have done a good job, but don’t take it to heart. You can only do your best. • Consider colour matching on another area of skin if sensitive. • Don’t try out lots of colours (tempting if hard to colour match) • Don’t cover raw scars. Choose a healed area to colour match. • Using mattifier / powder may be better on shiny healed scars.

26. Risk assessment Sometimes, alarm bells may ring or you are concerned about risk, eg: • Fresh self-injury – ie: in last few days or worrying looking • Client seems delusional, very confused or behaving very erratically • Through the whole session, client shows high levels of distress, agitation, or is very withdrawn, or shows signs of severe neglect • Treat the client as usual (on non-broken skin) • Gently explore the risk, ie: How does the person seem today? Do they seem at risk of harming themselves today? What support networks do they have? This can be done by acknowledging that you have noticed, eg: • “I’m sorry, I’m not able to cover broken skin. Are you getting any help for those?” or “Is anyone supporting you with this?” • “You seem a bit down / confused / worried about things today. Have you spoken to anyone about it?”

27. If you are still worried… • Be honest (where possible and prudent) – tell them you are concerned and need to follow procedures • Tell them that you are a volunteer and therefore you need to tell a senior person within the organisation after the appointment • Be clear about confidentiality (ie: it remains within CF unless there is a situation of high risk). Reassure them that the information will only be shared with the people who need to know. • In the case of those under 18 years (under 16 years in Scotland), SCP’s should err on the side of caution – if there is any concern at all, it should be raised, even if a slight worry. • Contact a member of Safeguarding Staff as soon as possible after the appointment.

28. Consider the following scenarios There are three different scenarios overleaf – try to consider these types of areas in the context of the previous discussions in this presentation: • Identify the different feelings that are presented by the client (and anyone else present) as you go through the appointment. • What does all this make you feel and think? • What would you say and do? You may find it’s worth noting down your answers to help you think more clearly

29. Scenario 1 Johnnie is twenty nine and has been referred by a dermatologist. He shows you a small scar (barely detectable) on his left cheek, right near his ear. He says he wants it to be covered up. He says he’s seen lots of specialists, but no-one can do anything. He seems desperate. He’s says this is his last option. As the appointment goes on, he is clearly distressed by this scar, vehemently telling you it is hideous and ugly. He is convinced this is the reason he hasn’t got a girlfriend - and why he can’t hold down a job - people would stare at him. He has grown his hair longer to cover it up. But, he says he has to check it all the time, to make sure the hair is over it – sometimes he might check this hundreds of times a day. He still lives at home with his mum, who doesn’t understand at all and thinks he is making a fuss over nothing. Tears come into his eyes – he seems very unhappy. You cover the scar well – and feel you have done a good job. However, Johnnie, when he sees the results, bursts into tears and says he can still see it.

30. Scenario 2 Keira is 18 and has been referred to Skin Camouflage by her GP. Her mother has come with her. Keira’smother does most of the talking. Keira is quiet and withdrawn – and not very engaged with the process. You ask her to show you the area she wants covered. It is a warm day, but she is wearing tights and long sleeves. After a while, Keira is able to show you; it turns out she has scars caused by cigarette burns on both her legs. Keira’s mother tells you that this is from self-harm she did to herself at the age of fourteen. Keira nods and looks sheepish. You start to cover the scars, explaining that while you could minimise the discolouration of the skin you would not be able to restore the texture. Keiraseems more engaged and seems fairly pleased with the result, but her mother has high expectations – and starts to say it should be better. Keira suddenly becomes cross… and, rather than saying anything, rolls up her right sleeve to reveal more recent (but healed) burns and other scars from cutting. Her mother obviously did not know these other scars were there and seems very shocked.

31. Scenario 3 Alice is in her sixties. She has been referred by her psychiatrist. She speaks quietly and seems subdued. A volunteer from a woman’s day centre she goes to has come with her, but Alice asks if it’s okay for her to wait outside. She shows you her scarring – and you are shocked by the extent of it. It starts at the top of her right arm, goes all down her arm and her chest and on to her breast. It is very red, lumpy and uneven. You explain that you can’t even out the skin, but you do something with the colour. During the appointment, Alice explains she has schizophrenia. Although it’s managed well now, she used to be very ill. Eventually, she says she is so scarred because she set fire to herself when she was 20 – she was in prison; she was trying to kill herself. She wanted to die because she had killed her 18 month old daughter in a bedsit and she couldn’t bear to live with it anymore. The prison staff found her and put the fire out. At the end of the appointment, Alice smiles and seems very pleased with the results at first. Then, her face turns sad again… she says she doesn’t deserve to feel better about anything – not after what she did.

32. THE END Please let us know if you have any thoughts or comments on this presentation by emailing samc@changingfaces.org.uk Thank you very much for reading