Presentation on theme: "A Needs- Led Approach to Understanding Challenging Behaviour"— Presentation transcript:
1 A Needs- Led Approach to Understanding Challenging Behaviour
2 Challenging Behaviour “Any behaviour which causes significantdistress or danger to the person or others, orany expression of distress by the person.”M.Bird(2001)And the person does not respond to interventionsChallenging Behaviour is behaviour that isdifficult for us to deal with. It leaves us feelingangry and helpless. Sometimes we feel sadand hopeless too. But the behaviour is ourchallenge.Challenging behaviour is a phenomenon that presents carers with the greatest subjective burden. It is one of the most common reasons for specialist intervention, treatment with psychotropic medication and hospitalisation.
3 What is the person trying to tell us? Why in this way? Our challenge is to understand the message and engage with the need not being metWhat is the person trying to tell us?Why in this way?What needs are not being met?How can we meet this person’s needs?
4 Common feelings/assumptions about challenging behaviour It’s the dementia/stroke/LDThey’ve always been this wayThat’s disgustingThis is hopelessI am helpless to make a change hereThe fact that CB often fails to respond to interventions leaves us (professionals and family carers alike) with a number of negative feelings and assumptions.
5 All behaviour is understandable on some level Have you ever hit someone?Have you ever destroyed your own or someone else’s property?Have you ever urinated somewhere you shouldn’t?Have you ever refused to do something you’ve been asked to do?
6 Fundamental Attribution Error The tendency to be biased towardpositive explanations for our ownnegative actions (e.g. that it was not inour control, that we were acting out ofcharacter)andthe tendency to be biased towards morenegative explanations for the negativebehaviour of others
7 Why is it important to know about the fundamental attribution error? We should be aware of our own biases when we go in to work with CB. We tend to hold a biased view on why people behave the way they do.It is a human phenomenon. We can assume everybody makes this error at some time re CB (‘he knows he’s doing it’ v ‘I was drunk, I wasn’t in control’)The way we respond to a situation depends on how we understand the situation and how it makes us feelWhen we are working with relatives/ carers who have problems with CB, we can help them by reframing the behaviour (changing their attributions)
8 Unmet NeedsIt is increasingly recognised that challenging behaviour in dementia is often an attempt at communicating an ‘unmet need’. People with dementia and other mental health problems often lose the ability to communicate in ways that we find easy to understand. What we see as bizarre, sometimes frightening behaviour is that persons way of telling us what their needs are.
9 A needs led formulation based framework to make sense of behaviour Introducing the Newcastle (“Columbo”) Model to Understand Challenging BehaviourA needs led formulation based framework to make sense of behaviourand aProcess to apply new knowledgeThis model is used in nursing and residential homes and is tailored for challenging behaviour. It was developed by Ian James, consultant psychologist in Newcastle The Newcastle model is needs led to allow us to examine the behaviours in terms of the person’s needs. Challenging Behaviours are seen as a poorly communicated expression of need.The needs perspective changes the emphasis from problem to be managed to need to be met.A common framework within which to place assessment informationInvites connections between parts of assessmentCreates an individualised story to explain the problemTheory-drivenSuggests appropriate interventionsCollaborative & empowering for staff
10 Understanding Challenging Behaviour Behaviour that challenges is a poorly communicated expression of needAt some level, all behaviour can be understoodClinical experienceStokesNewcastle Model/ Columbo approachInfluences on the model:Title of model used interchangeably with Columbo Approach.Influenced by Stokes who advocates pinpointing the behaviour , what is exactly happening at the tome of the behaviour. He pulls apart what is actually happening and promotes the use of creative brainstorming to look at all possibilities of behaviours and potential interventions.Cohen –Mansfield unmet needsKitwood heavily influences the model regarding person centred care although Ian James refers to the model as being staff centred and patient focused. The model takes into account the background information to the person including life history , personality etc and has added in mental health also as an area to explore in the context to their behaviour. It also encourages staff to look beyond the behaviour bringing the person into view againClinical experience of he cb clinicianFacilitate, educate, work collabarively engage with other professionalsAlso value and respect the knowledge that the staff in the home have.Clinicians experience allow the model to grow and is very much a live model and user friendly. E.g adding pain and communicationKitwood - PCCCohen Mansfield’s unmet needs
11 Cohen-Mansfield’s Unmet Needs Model Behaviour as a means of fulfilling needsLifelong habits & personalityCurrent condition – physical, mentalBehaviour as a means of communicating needsUnmet needEnvironment – physical, psychologicalBehaviour as outcome of frustration (n.b. decreased inhibition)
12 Application of the Newcastle Model Using the Colombo approach to connect information & reach formulation of difficultiesIdentifying unmet needs of patient/ client from formulationDeveloping care strategies to meet needs & manage risk
13 Two sources of information help us understand challenging behaviour: Information about the personInformation about the behaviour
14 A framework to understand challenging behaviour Cognitive impairmentLife historyMental healthPersonalityPhysical healthSocial environmentMedicationTriggersBehaviourAppearanceVocalisation
15 Cohen-Mansfield’s unmet needs model Behaviour as a means of fulfilling needsLifelong habits & personalityCurrent condition – physical, mentalBehaviour as a means of communicating needsUnmet needEnvironment – physical, psychologicalBehaviour as outcome of frustration (n.b. decreased inhibition)
16 A process to develop an understanding of CB AssessmentStaffFamily & friendsFormulation presentationCare planning and monitoringcollaborativeinclusiverespectfulcurious
17 The BehaviourWhat is happening?With or to whom is it happening?Where is it happening?When is it happening?How does the client look?What is the client saying?What effect does their behaviour have?
18 The Behaviour Triggers When do you notice the behaviour happening? (what do you actually see them do?)Appearance(how do they look?)Vocalisations(what do they say?)feelingsthoughts
19 Thoughts Actions Feelings Where’s my mum? I need to get the kids! Why is she trying to take my clothes off?ThoughtsChallenging behaviourActionsFeelingsSearch for lost peopleTry to leave building,Fend off care staffAnxiety, fear, angerNEED TO FEEL SAFENEED FOR CONTROLNeed to feel safeNeed to have some control
20 Cognitive Model and Carers She’s doing that on purpose!He targets the frail ones!ThoughtsActionsFeelings‘Tell off/ reprimand’‘Remove from room’Keep away from her/ himAngry, annoyed
21 Cognitive Model and Carers She doesn’t understand what’s going on!He thinks that person is stealing from himThoughtsActionsFeelingsRe-orientate/ redirectChange environment etcSympathyCare
22 Process of delivering the model Engagement with carersAssessmentFormulation sessions with carersDeveloping strategies & care planning
23 Engagement with Carers Sales pitch - introductions, selling the model, clarity around mutual expectations, telling stories & citing successSpotting & addressing sabotage - intervention reframed as a treatment modality, assertive approach, feedback loops to referrersIdentifying risksAccommodating needs of the carersNormalising & empathic response to distress
24 Assessment Holistic assessment taking information from many sources: Contextual information:- GP records- Psychiatric notes- Families- Spending time in the care environment to gainunderstanding of their needs- Neuropsychological assessmentInformation about behaviour:- Charts completed by carers- ObservationsMay involve referrals to other agencies e.g. continence service, palliative care
25 Why Conduct Formulation Sessions ? Identifying the person and their experience as the main focusPulling the information together to develop a storyChallenging unhelpful stories about the personCreating discomfort with current position e.g. “she’s always been like that”Carers as experts AND carers as learners – information givingEngage carers in finding solutionsWhy Conduct Formulation Sessions ?Central to success of interventionsAvoids ‘Chinese Whispers’ & accusations of ‘ivory tower’ practitionersChanges staff perspective on personMove from problem to be solved to needs to be met
26 Developing Care Strategies Needs-ledDeveloped by carers, bespoke to care environment3-tier approach to care planningMeeting unmet needs (avoidance)Identify and address antecedent behaviour (proactive)Manage challenging behaviour (reactive)
27 Case Study 75 year old man with longstanding dementia. Challenging behaviour – exposing penis in publicPlacement under threatFamily concerns about the future
28 Behaviour Triggers Vocalisation “look at this” Appearance Social and physical environmentMoved into EMI residential care in Own en-suite room overlooking the river.Personalised with own belongings.Generally good relationships with other residents – prefers female company. Popular with staffRegular visits from family Active participant in activities.Life history:Born in 1930 in a local seaside town, one of 5 children – happy childhood, very close to his siblings; Ran own garage business; RAF during the war when he met his wife – two children –adored his family; always loved music and dancing – danced at every opportunity;Very proud of his appearance – always wore shirt, tie and jacket; A practical joker with an excellent sense of humour; Always a bit of a prude – disliked smutty jokes; ‘page 3’. ‘Victorian’ attitude towards sex and nudityPersonality:Usually gentle and easy going but could be irritable and bad tempered if something really annoyed himProud and self determinedVery sociable – always a good mixerA private man who respected the personal lives of others, and who expected respect in returnAlways ‘busy’ – activities important to him Disliked “gossips” and “busy bodies”.TriggersNo obviously apparent trigger but instances seem to increase when he is constipatedCognitive impairment:Memory problemsDisorientated in time and placeExpressive DysphasiaWord finding difficultiesVisual agnosiaDeficits in reasoning and problem solvingPhysical health:Generally fit and healthyLong standing skin problem on lower legOccasional incontinenceProne to constipationRequires assistance with personal care.Good diet – gaining weightBehaviourUnzips his trousers in public and exposes his penisMental health:Visual Hallucinations – seeing small worm like creatures ‘escaping’ through the ends of his fingersDelusions – believing he could conduct electricityMedication:Donepezil 10mg nocteQuetiapine 25mg nocteEurax cream applied dailyNEEDS:Vocalisation“look at this”AppearanceMatter of fact Unconcerned
29 Possible Explanations To meet a sexual needTrousers too tight – rubbing on him, causing discomfort or a sexual responseExpressing a need to urinateResponding to delusions/hallucinationsConstipatedHabit – some men seem to derive comfort from ‘fiddling’ with their bitsAgreed InterventionsDetermine whether this behaviour is sexual in nature or due to some other reason.Rule out the need to urinateStaff feel behaviour is more frequent when Alfie is constipated – to monitor bowel habitsAlfie to be allowed/supported to meet any sexual needs he may have in the privacy of his own room (to discuss with wife)Obtain bigger trousers for Alfie (to discuss with wife)When Alfie does expose his penis staff to ask him to “put it away” – he usually responds positively
30 OutcomesStaffs’ understanding increasedIncidences of exposing penis stopped altogetherFurther medication avoidedMove to EMI nursing avoided