The Problems with “Best Practice”

Best Practice. How often do we hear that phrase? And what does it mean exactly?
I work with a lot of people with mental health issues, so inevitably I end up having to take short training sessions about a specific illness or problem. In each training session, “best practice” is discussed, but it is discussed in a way that makes it seem that there is only ONE way to respond to an incident – best practice.
This may be fine in mechanical situations, or situations in which the sequence of events is predictable, but I find “best practice” often ignores the human aspect of mental health and dealing with people.

All of that is a little vague so let’s look at some (very anecdotal) examples.
Let’s start with a person who suffers from anxiety, this person (Let’s say, John) is starting to get very anxious about something small – say, walking into a party to find his partner. John knows everyone at the party, but the thought of walking in alone is terrifying. Then, he thinks about how everyone will be looking at him (and judging him) as he looks for his partner. John’s breathing starts to quicken, he begins to sweat, and he starts to feel nauseous.

How do we deal with this? What is “best practice”?
According to John Hopkins Medicine supporting John would mean providing validation and expressing concern, without enabling the behaviour or forcing confrontation. I don’t have a problem with this…. seems like solid advice for most people. Forcing confrontation may increase the anxiety, and comments like, “It’s no big deal, you already know everyone in their,” may belittle John’s experience as his panic and anxiety are real.
However, what if forcing confrontation and belittling John’s experience are exactly what help him??? What then? What if the best way to help John get over his anxiety in that moment is telling him he is acting like a crazy person and it’s no big deal to go into that room and find his wife?

I gave the above example at my last training session and the facilitator said, NO! You NEVER, never, never, tell someone who is experiencing anxiety that they are acting crazy (or insane, or irrational)!
So I followed up with, but what if John has previously expressed that that is the best way to help him in the moment.
The facilitator told me that John was wrong.

I’m sorry… John isn’t wrong. John knows himself well, and expressed what he needs to help him.
I am John. I experience horrific anxiety about walking into rooms full of people by myself. To the point where if I think about it for too long, I’ll vomit. So usually I am the first person to show up at the restaurant or the party or the… whatever, in order to avoid the anxiety.
It’s not always possible to avoid though. So, on those occasions that I am late to something and I start to experience anxiety sitting in the car before going in I tell myself not to act like a crazy person. If it gets really bad and I can’t talk myself down, I will call my husband and he will tell me to stop acting like a baby and just go do the thing; that I will be fine and I am making a big deal out of nothing. He does this, because I have told him this is what helps me.
Why does it help me? Well, because I know my fear is irrational, the anxiety is real but it is based on an irrational fear, remembering that allows me to look at the situation objectively.

Example number two…Borderline Personality Disorder. This one is fun, if you have ever dealt with a person who has BPD it can be a roller coaster! I used to work with a lovely young girl who had the most severe case of BPD I had ever seen. She had almost no positive, prosocial coping skills. This resulted in many incidents of self-harm, suicide attempts, assault, and other violent outbursts.
There were many times that I would be with her during an “episode” and if a stranger off the street saw how I handled the situation I am sure there would have been some bad repercussions.
Experts say that when a person with BPD starts to escalate that you must remain calm in order to avoid escalating the situation further. Well… .staying calm did nothing buy escalate this young lady even further! So there was more than one occasion in which she started to escalate and I would just start yelling at her. Sometimes the conversation would carry on as normal, just at a very increased volume. Other times, I would yell random shit, like, “HEY! I CAN YELL FOR NO REASON TOO. I CAN BE CRAZY TOO!” Almost always, when I raised my voice like this she would come down, not to baseline, but down enough that we could have a productive conversation and get her to move on from whatever was upsetting her. Or sometimes, we would just yell the same thing back and for at each other (like, “You’re not listening to me!” “No, you’re not listening to me!”) until she forgot what she was upset about and started laughing.

I have worked with others who have BPD and this one girl is the only one I would deal with in the above manner. It was what worked for her. It wasn’t best practice, but it was effective. Yes, that strategy may be harmful to other people, but staying calm and even was harmful to this girl.

So “best practice” tell me why you are invalidating my experiences.
I understand that “best practice” is what generally works the the vast majority of people, however, there will always be people who require a different approach. If you have no information about the person you are dealing with, then yes, best practice is the best approach, but if you have some rapport use that rapport to read the individual and respond appropriately. Even if that looks awful to someone who doesn’t have the full context of the situation.
This message is what I feel is lacking in mental health training. Best practice is the best approach for the majority of people, however, there will always be people at the extremes on each side that need to be dealt with differently and people need to be encouraged to expand their repertoire to deal with these types of people.
I suppose there is always the chance that if you go outside of best practice your attempt can backfire and cause harm, and if you are a professional, that may result in disciplinary action. But what happens if you follow best practice and still cause harm. Nothing. This stops risk taking, but it also means that it can stop progress.
As someone who always seems to fall outside of what “best practice” encompasses, I implore you to try something new, if you think the situation calls for it.


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