Words that blame

The language of social care is filled with words that blame people seeking and drawing on support. Our so called ‘strengths-based’ practice drips with deficit-based terms that stigmatise people as problems. Our ‘person-centred’ approaches are infused with phrases that marginalise.

In this blog post I’ll explore ten widely used blaming words and phrases, then in part two, I’ll consider what this says about our practice, and how we can shift the narrative and move beyond blame.

1. Hard to reach

Labelling individuals and groups as ‘hard to reach’ implies people are deliberately avoiding contact, keeping their distance, staying away. It places the blame entirely with them. But how hard are we really trying before we slap on that label as a convenient excuse?

Hard to reach? Or easy to ignore?

And couldn’t the ‘hard to reach’ label be just as easily applied to us? Our lack of accessible information and reasonable adjustments. Our jargon and acronyms. Our eligibility criteria. Our thresholds. Our risk assessments. Our waiting lists. Our 9-5, Mon-Fri opening hours. Our city centre offices with security guards on the doors.

We blame individuals and groups for being hard to reach, from behind our impenetrable walls.

2. Refuses to engage

We use the term ‘refuse’ a lot. Refused an assessment. Refuses services. Refusing treatment.

Refuse suggests defiance, stubbornness. Blaming, again.

What about ‘chose not to’? ‘Decided against’?

What about some acknowledgement of informed decision-making by the person? Of agency? Of control? What about some evidence of a conversation? Of capacity to decide? Weighing up options? Advocacy? Choice?

Was there any?

And what of the classic ‘refuses to engage’? We condemn people for not responding or participating. Not getting involved. But hang on, who exactly should be engaging here? We’re public servants – here to serve, not to get people to serve us. We should be focusing on what matters to people, instead of blaming people for not doing the things that matter to us.

“Again look at the question: ‘how do we get people to engage?’ With respect you don’t get ppl to engage. You listen to what they care about enough to act on, and then support them to work with others to do what they care deeply about. It’s not about getting ppl to do what we want.”

Cormac Russell [1]

3. Frequent flyers

We blame people for not responding, for not doing what we ask, for not being where we want them to be. And we blame people for being too present. For ringing up too often. For coming back too regularly. For asking too much. ‘Frequent flyers’. ‘Revolving door customers’. ‘High intensity users’.

Behind these derogatory labels are human beings with hopes and fears and worries and aspirations and fluctuating needs for care and support. Are we really listening? Are we really meeting people’s needs and supporting them to get on with living their lives? The fact they’re coming back again and again suggests not. So, who exactly is to blame here?

4. Carer breakdown

Our statutory guidance requires that we offer an assessment “where it appears that a carer may have needs for support (whether currently or in the future)”. That our assessment establishes “not only the carer’s needs for support, but also the sustainability of the caring role itself”. That we determine “whether the carer is, and will continue to be, able and willing to care for the adult needing care” [2].

Yet when someone is no longer able or willing to continue in their caring role, we’re quick to apply the ‘breakdown’ label.

Indeed, the language relating to unpaid carers is dripping with blame. We’re either blaming carers for ‘struggling to cope’ and ‘breaking down’ or blaming the person they care for and about by using phrases like ‘the burden of caring’ and ‘respite’ – which means ‘a pause or rest from something difficult or unpleasant’ [3].

‘Carer breakdown’ (carers aren’t cars!), or carers who are exhausted worried isolated ignored lonely confused angry grieving frustrated abandoned desperate scared just trying to do their best for the people they love – or don’t love – and facing so many too many hoops to jump through, forms to fill in, boxes to tick, phone calls to make, battles to fight.

‘Carer breakdown’, or carers we’ve failed to identify and listen to and support?

5. Bed blockers

‘Bed blockers’. Such a hideous, dehumanising term applied to people who are ‘medically optimised’ and no longer meet the ‘criteria to reside’ but can’t be discharged from hospital for any number of reasons – usually nothing to do with the needs and wishes of the person, and everything to do with failures in communication and coordination in the wider ‘system’.

This is the language of widgets and processes and targets and flow, not of compassion and humanity.

6. Challenging behaviour

The ‘challenging behaviour’ label is, well – challenging.

The phrase labels the person’s behaviour as problematic, as something that must be controlled or managed so the person behaves more ‘appropriately’. But who defines what is ‘appropriate’?

“Somebody has decided that my behaviour, or the person’s behaviour, needs to be modified. Needs to be improved, mainstreamed, made less extreme. So, there’s a power differential right there, isn’t there? And the person’s agency to behave in the ways that are most comfortable for them is taken away”.

Alexis Quinn [4]

‘Problems’ require solutions, and too often having identified ‘challenging behaviour’, our response is to increase medication or restriction or restraint. Separation. Seclusion. The classic medical model of treating and fixing rather than understanding what’s happened to – and what’s happening around – the person.

All behaviour is a form of communication. If I suggest your behaviour is ‘challenging’, I’m either failing to understand – or deliberately ignoring – what you’re communicating, and why. Maybe you’re scared? Excited? Frustrated? In pain? Angry? Bored? Lonely? Hungry? Sad? Maybe something has happened or there’s something going on around you that’s causing you to lash out or to retreat? Maybe it’s my behaviour that’s challenging you?

Even when we do acknowledge the communication element of a person’s behaviour, we still manage to twist this to blame the person, whose ‘challenging behaviour’ is attributed to their difficulty in communicating what they’d like or need – not our failure to meet their communication needs, and in turn their human rights, and our legal duties.

And no, ‘behaviour that challenges’ or ‘behaviours of concern’ aren’t any better, because they’re still loading blame onto the person. And while referring to ‘distressed behaviour’ (hopefully) shifts the focus to understanding the reason for the distress and (hopefully) prompts some wider changes to relieve it, it’s still a label. And anyway, maybe the person isn’t communicating distress at all.

“I can remember meeting an Afro-Caribbean man having treatment on a mental health ward. He told me that one day he was starting to feel better, so he started singing loudly in the corridor. For him this was an expression of joy. But in reserved Britain, staff interpreted this as unusual behaviour and upped his medication.”

Claudia Hammond [5]

7. Non-compliant

Compliant means obedient. Submissive. Biddable. It means you do what you’re told. You do what is expected of you, what somebody else thinks you should be doing. So, if we label you as ‘non-compliant’, we’re effectively saying you’re not doing what we want you to do. Because we know best. Obviously.

8. Complex

Complex cases. Complex individuals. Complex health conditions. Complex lives.

Real lives are complex. Messy. Rainbow coloured crayon scribbles on crinkled and torn pages. Stuff happens – or doesn’t. Too much. Not enough. Stops. Starts. Loops back. Dead ends. Creeping, miniscule shifts. Rapid, devastating changes. Balancing. Juggling. Waving. Falling. Drowning.

Real lives don’t fit the straight lines of our ‘system’, the black and white boxes on our forms. Our processes and pathways require a single label at the start. One ‘primary support reason’. One ‘service user group’. Go.

Too many labels = too many boxes ticked = too many pathways = too many professionals = too many conversations = too many options = too much time = not enough time = not enough options = ‘complex’.

And then often, ‘too complex’.

Of course, ‘complex needs’ is the classic. We’ve even built complexity into the term ‘complex needs’, as the multiple references in the Care Act statutory guidance illustrate. “Multiple and complex needs”. “Highly specialised and complex needs”. “Less complex needs”. “More complex needs”. “Particularly complex needs”. “Higher or more complex needs”. “Complex ongoing healthcare needs”. “The most complex needs”. “Multiple complex needs”. “Complex SEN and care needs”. “Complex health and care needs”. “Complex care needs”. [6]

The guidance contains several case studies, including ‘Isabelle’ who ‘is 15 years old with complex needs’ and Maureen who “is 72 years old.. with complex care needs’. We don’t find out what their needs are, just that they are ‘complex’.

Like ‘challenging’ and ‘vulnerable’, ‘complex’ is a meaningless term – used repeatedly to convey – well, what exactly? Yes, people’s lives may be complicated, but people’s basic needs are simple. Somewhere to call home and to belong. Someone to love, and to be loved in return. Something to do. Something to look forward to.

Stop using labels as excuses.

9. Difficult

“What starts as a note stating I cried in an appointment, becomes a letter that details a “difficult appointment”, which takes flight as a descriptor of me as a “difficult person”, which ultimately leads to a doctor I only just met describing me as “difficult – as expected.”

Wren [7]

Tricky discussions. Feedback we find hard to hear. People experiencing tough times. Difficult conversations and difficult situations quickly morph into just plain ‘difficult’… and yes, it’s pretty much a catch all term for all the other blaming words and phrases listed here too.

Difficult case. Difficult service user. Difficult customer. Difficult patient. Difficult family.

Labels stick.

10. Vulnerable

And finally, the v-word. Although I’ve already written at length about the term ‘vulnerable’, it’s worthy of a mention here – partly because it’s so ubiquitous, but mainly because it points the finger squarely at the person as the problem and stops any consideration of the external factors that make people vulnerable. And in turn this prevents any focus on – or attempts to change – the situations or circumstances that create vulnerability.

During the pandemic we’ve seen a further sinister step. Not just blaming people for being vulnerable, but in turn blaming ‘the vulnerable’ for ‘restrictive’ (protective!) measures, with tweets like “quarantine the vulnerable – let the rest of us live our lives” and “vulnerable people can just stay inside! Why should the rest of us wear masks??!!” and newspaper headlines including “Boris Johnson speaks of ‘heavy heart’ as Christmas is sacrificed to protect the vulnerable.” [8]

Such a divisive and dangerous narrative.

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These blaming terms demonstrate and perpetuate the ‘them and us’ divide that pervades our practice.

We know that connection and relationships must be at the beating heart of our better, brighter social care future. And we also know that blame destroys trust, stifles curiosity and sabotages relationships.

So how do we shift this narrative?

How do we move beyond blame?

Part two: Beyond blame

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References

[1] Again look at the question… Cormac Russell, Twitter, 16 April 2022

[2] Care and support statutory guidance, Department of Health and Social Care, Updated 27 January 2022

[3] Respite, Cambridge dictionary

[4] The problem with behaviour support, Alexis Quinn, Rightful Lives, You Tube, 14 April 2022

[5] D for diagnosis: Ever changing labels, Claudia Hammond, BBC Radio 4, Wed 22 Jan 2020

[6] Care and support statutory guidance, Department of Health and Social Care, Updated 27 January 2022

[7] Mental Health Clinical Notes: The Curse of the Paper-Self, Wren, Psychiatry is driving me mad, 22 August 2021

[8] Boris Johnson speaks of ‘heavy heart’ as Christmas is sacrificed to protect the vulnerable, Daily Telegraph, 19 December 2020