Learning how to use the Six Category framework, and use it effectively, will present different learning opportunities and challenges for the mental health nurse. Given the uniqueness of each client–nurse relationship, each interac- tion will require different communication skills and interventions, based on the purpose of the interaction, the context of the therapeutic encounter and the nurse’s level of competence. Learning to use the Six Category framework does not mean the mental health nurse is learning a particular method of counselling (Heron, 2001). Instead, he/she is acquiring a set of therapeutic interventions to develop and shape into his/her style and repertoire of inter- personal skills as a mental health nurse. Having the opportunity to use the different categories in clinical practice can increase mental health nurses’ con- fidence and efficacy. For some nurses, some of the interventions, particularly those within the authoritative group, may be familiar and therefore easier to use, whereas other interventions, for example catalytic and cathartic, may be new and, as with all new learning, will require time and ongoing practice.
Learning how to use these skills can best be achieved by observing your men- tor or other ward staff along with practising with friends or colleagues. For the mental health nurse, the challenge is to:
r be equally proficient in a wide range of interventions in each of the cat- egories
r know what category s/he is using and why at any given time
r be able to move skilfully from one type of intervention to any other as the developing situation and purpose of the interaction requires
r know when to lead and when to follow the client, in other words whether to be authoritative or facilitative.
Clinical scenario
The following scenarios illustrate an interaction whereby the mental health nurse moves from one category to another, as and when the situation and purpose of the interaction requires.
Example 1 – Interaction between nurse and client
Zoe, a second-year nurse was sitting in the day room playing Scrabble with Sarah.
Sarah is 21 years old and was admitted to the ward following an overdose. Both Zoe and Sarah enjoy playing Scrabble and competing with each other. It also provides an opportunity for Sarah to talk about various issues that were causing her concern, in particular her recent weight gain due to her current medication.
Sarah: ‘I hate taking these tablets.’
Zoe: ‘What do you hate about the tablets?’ [Catalytic]
Sarah: ‘They make you fat, I don’t want to put on weight.’
Zoe: ‘How much weight have you put on?’ [Catalytic]
Sarah: ‘I don’t know, I haven’t weighed myself, but my clothes are getting tight. I keep eating, I can’t stop.’
Zoe: ‘That must be so annoying for you. I know I hate having to watch my weight, it’s difficult.’ [Supportive]
Sarah: ‘Yes it is.’ [Starts to cry] ‘I am sorry.’
Zoe: ‘It’s OK to cry.’ [Cathartic] ‘One of the side effects of your antidepressants is an increased appetite.’ [Informative] ‘I will weigh you and that will give us a baseline.
I will get the dietician to see you tomorrow to discuss your diet. Your doctor will be here later this morning; I will tell him and ask him to talk to you about it.’
[Prescriptive]
Sarah: ‘Thanks Zoe.’
Example 2 – Interaction between nurse and family member At the day hospital, Lydia asks to speak to Harry, a third-year nurse, about her son Toby who is 22 and attends the day hospital twice a week. She is worried that he is not taking his medication as he has been verbally aggressive over the weekend. Harry invites Lydia to a quiet and private area of the day hospital, free from distractions, to listen to the person.
Harry: ‘Hi Lydia, how are you?’
Lydia: ‘Thanks for talking to me; I know you are short of staff and very busy.’
Harry: What’s the matter, you look worried?’ [Catalytic]
Lydia: ‘It’s Toby; he stayed with me at the weekend.’
Harry: ‘How did that go?’ [Catalytic]
Lydia: ‘He got angry. I don’t think he is taking his medication. He kept shouting at me.’
Harry: ‘OK, I am sorry to hear that.’ [Supportive] ‘Tell me what happened from the time he arrived at your house.’ [Prescriptive]
Lydia: ‘He was supposed to arrive at 6pm. He came two hours late so his dinner was ruined. I was really upset as I wanted us to eat together. He said he was with his mates.’
Harry: ‘So you were disappointed and upset.’ [Supportive] ‘What happened when he arrived?’ [Catalytic]
Lydia: ‘Oh I lost it. I started shouting at him, I said things I probably shouldn’t have but he’s always messing me about.’
Harry: ‘What happened then?’ [Catalytic]
Lydia: ‘He stormed into his bedroom and swore at me.’
Harry: ‘So it sounds as if the weekend started off with difficulty for both of you.’
[Supportive]
Lydia: ‘Yea, I suppose I didn’t make it easy, shouting at him. I know it’s hard for him.
He is afraid his mates will drop him because he has mental health problems and was in as he calls it “a lunny bin”.’
(continued)
Harry: ‘It’s difficult for him; unfortunately there is still a lot of stigma about mental health problems/illness.’ [Informative]
Lydia: ‘Yes, I know. I haven’t told my immediate family or my best friend about Toby’s admission to hospital.’
Harry: ‘Because?’ [Catalytic]
Lydia: ‘I am sure they would be supportive, but I am afraid they will look at Toby differently. I know it sounds crazy, but I am also afraid they will think it’s my fault.’
Harry: ‘It must be difficult for you, not being able to share your concerns with people who might be able to support you.’ [Supportive]
Practice exercise: analysis of an interaction
The aim of this activity is to help you to monitor, select and review your use of Heron’s six categories in clinical practice.
Think of a recent interaction that took place during your clinical placement.
r When you have chosen your interaction, reflect on and answer the following questions.
r You may wish to write brief notes about your thoughts, feelings, observations, questions in your reflective journal and use them to discuss with your mentor.
r It is important to note that some of the questions may not apply to your interaction, and, in such instances, we suggest that you adapt the question(s) accordingly.
r We are aware that the following questions are by no means exhaustive and you may wish to add further questions.
Question Answer
What was my primary intention of this interaction?
What intervention(s) did I use during this interaction?
Which intervention(s) were useful?
Which intervention(s) were less useful?
What intervention(s) did I use too much?
What intervention(s) did I use too little and for what reasons?
What other intervention(s) could I have used?
What did I like about my intervention?
What did I not like about my intervention(s)?
What factors influenced my intervention(s) and how?
What have I learnt from this interaction?
What intervention(s) do I need to develop?
Conclusion
This chapter has outlined the principles and practice of Heron’s Six Category helping framework. We believe that this communication framework provides
a flexible and user-friendly tool for all mental health nurses, and in particu- lar the novice mental health nurse, to develop their ongoing knowledge and interpersonal skills, which can be used in various clinical encounters. As with all skills-based learning, it is not enough to learn simply the specific inter- ventions; they must be applied in practice where real learning takes place.
In addition, learning how to use the six categories effectively and with con- fidence requires time, ongoing practice and, more importantly, a willingness to be open to inquiry and feedback about your therapeutic effectiveness in practice.
Reflective questions
1 Which of the authoritative categories do you find the most challenging and why?
2 Which of the facilitative categories do you find the most challenging and why?
3 Drawing on your clinical experience, which categories have you observed being used most in clinical practice? Give examples for each category.
4 Which two categories would you like to become more skilled in using within the next three months, and for what reasons?
6 Communicating across cultures
Britain is invariably described as one of the most ethnically diverse societies in the Western world. In the course of caring for members of society, nurses will come into contact with black and minority ethnic (BME) people with diverse cultures, beliefs and languages from around the world. Mental health nurses have an important role in delivering equality in mental health services through appropriate and effective culturally capable practice. This chapter will examine the concept of culture and its role in relation to mental health nurs- ing. We will also outline various approaches to build on nurses’ ability to become more culturally competent in communicating with a diverse multi- ethnic population.
Learning outcomes
By the end of this chapter, you should be better able to:
1 Describe the concept of culture
2 Demonstrate an understanding of the role of culture in relation to mental health nursing
3 Examine some of the issues and challenges for nurses when working with interpreters in mental health
4 Demonstrate communicating across cultures in clinical practice