Challenging Behaviour
Written by Emma Gudgeon, Louisa Shirley, Ian A James
Challenging Behaviour
‘Challenging Behaviour’ or ‘behaviour that challenges’
are terms used within older people’s services to describe behaviours presented
by clients that challenge those around them. These behaviours also tend to impact
on the availability of opportunity for the person who presents the challenge.
The challenge presented may be physical (like aggression or ‘wandering’)
or emotional (like name calling or repetitive demands for help), and may refer
to the capacity of the environment around the person to cope with the behaviour.
Challenging behaviour is often used interchangeably with BPSD (behavioural and
psychological symptoms of dementia) though this term suggests that challenging
behaviour is inextricably and causally linked to the disease process rather than
influenced by the emotional, social or psychological environment. There are varying
estimates of the prevalence of challenging behaviour. Roberts et al (2005), for
example, estimated that between 60 and 90% of people with dementia will present
with challenging behaviour at some point in the progression of the condition.
The NICE guidelines state that non-phamalogical interventions should be used
first before medication in cases of challenging behaviours (2006). The difficulty
with this guidance is that the evidence base for many of the non-phamalogical
interventions is limited, often relying on single case studies. Ian James and
colleagues (James, Douglas & Ballard, 2004; Douglas, James & Ballard,
2004) have identified two distinct groups of psychosocial interventions. The
first group, non-specific psychological interventions aim to improve the general
well being of the person with dementia. Non-specific interventions include reality
orientation and validation therapy. In the former, staff/ family carers are
advised to reorientate the person to their current surroundings and context.
For example, if the person is attempting to leave to get home to cook tea for
their husband and children, this approach would suggest that the person is gently
reminded that their husband died some time ago and their children are now grown
up and able to fend for themselves. Validation therapy (Fiel, 1993) suggests
that the content of the person’s thoughts, concerns and worries is of
less importance than the emotions they evoke. In validation therapy, it is suggested
that staff or family members respond primarily to the emotional message. A validating
response to the situation described above might be “ You’re worried
because you think they’ll be concerned about you.” The practical
and ethical dilemmas inherent in these approaches are highlighted in on-going
discussions around the use of lie-telling in dementia care settings (Wood-Mitchell,
MacKenzie, Cunningham & James, 2007; Wood-Mitchell, Waterworth, Stephenson,
& James, 2006). Recent research has suggested that lies can be defined as
any occasion when the person’s questions or concerns are not answered
factually and this would include the use of validating comments. Staff and family
members will often tell lies or avoid telling the truth in order to manage episodes
of challenging behaviour. For example, colluding with someone’s belief
that they are still working. Other non-specific approaches include reminiscence,
music and activity therapy, aromatherapy, pet-assisted therapy, and doll therapy.
The second group of interventions are more specific and aimed at changing the
challenging behaviour and/ or staff beliefs about and management of the difficult
behaviour. Behaviour Therapy aims to suppress or eliminate the challenging behaviour
through the principles of conditioning or learning theory where Needs Led Therapy
aims to understand all challenging behaviour as an expression of an unmet need.
One model used in the Needs Led approach in residential and nursing care settings
is the Newcastle Model (James et al, 2006). The Newcastle Model provides a framework
for understanding the cause of the person’s challenging behaviour and
a process by which interventions are delivered. The Newcastle model or ‘Columbo
Approach’ uses collaborative information gathering to provide the informational
content of a formulation session. Within this session, a group of staff are
invited to reconsider the challenging behaviour as an unmet need (e.g. Janes
& Shirley, 2008). The Newcastle Approach has been influenced specifically
by Kitwood’s work around person-centred care and Cohen Mansfield’s
systematic examination of challenging behaviour aimed at identifying the unmet
need being communicated by the person with dementia.
Clinical Psychology and Challenging Behaviour
Clinical psychologists are often asked to work with families and staff groups
who are experiencing problems managing challenging behaviour. Psychological
therapists working in this area use formulations to help understand the root
of the challenging behaviour. Often the cause of difficulties can be related
to something physical like pain or constipation, and psychologists rely heavily
on colleagues from other disciplines to work together in identifying the most
likely cause for the challenge. However, by the time people have been referred
through for input from psychology, the problem behaviour has often taken on
a life of its own and the person has come to be identified by the challenge
they present rather than by the person they are. The psychological therapist’s
(clinical psychologist or nurse supervised by a psychologist and using psychological
models) role is in facilitating a systematic examination of the challenging
behaviour and using a formulation approach to help staff/ families begin to
reframe challenging behaviour as a communication of unmet need (need for sustenance,
pain relief, love, occupation, boundaries etc).
A number of specialist teams are beginning to form around the country, and
these teams are not always led by psychologists and do not always use psychological
models. However, there are some clear advantages in including psychologists
in challenging behaviour services. Psychologists have a basic training in behavioural
analysis and schedules of behavioural reinforcement. Challenging behaviour is
often a complex phenomenon: a response to both visible and internal triggers.
Psychologists have a number of ways of understanding behaviour that does not
rely on observation of events and clear cause-effect relationships. For example,
we are able to use cognitive models to make links between situations, feelings,
thoughts and behaviour when these links are not always clear during a challenging
incident.
A number of teams have psychologists working into them, or are housed within
psychological services but are largely staffed by other professionals (usually
nurses). There are many advantages to non-psychologists taking on the role of
facilitator and trainer including credibility for and acceptance by care home
staff and practical knowledge of strategies to work with challenging behaviour
and experience of care environments.
It is hoped that this website will provide the beginnings of a forum where PSIGE
members who are working in this area are able to discuss issues around their
services and share their experiences of working with people who challenge. There
are currently a number of teams who are linking together in the North East of
England and in Northern Ireland and this has encouraged a healthy sharing of
information leading to service development initiatives, but also has enabled
new team members to benefit from experienced clinicians through joint supervision
session which can take place by phone or by teams occasionally getting together.
These teams have been involved in the provision of workshops and working groups
to begin to explore service development with other colleagues. We are keen to
develop more links like this.
References
Douglas, S., James, I., & Ballard, C. (2004). Non-pharmacological interventions
in dementia. Advances in Psychiatric Treatment. 10, 171-179.
Fiel, N. (1993) Validation Breakthrough: Simple Techniques for Communicating
with People with “Alzheimer type dementia”. Health professions Press
James, I.A., Douglas, S. & Ballard, C. (2004) Different forms of psychological
interventions in dementia: Palliative care in severe dementia series. Nursing
and Residential Care. 6(6), 288-291.
James, I.A, Stephens, M., Mackenzie, L. & Roe. P. (2006) Dealing with challenging
behaviour through an analysis of need: the Colombo approach. In M. Marshall
(ed) On the Move: Walking not Wandering. Hawker Press
National Institute for Clinical Excellence and Social Care Institute for Excellence
(2006). Dementia :Supporting people with dementia and their carers in health
and social care.
Roberts, P, H., Verhey, F.R.J., Byrne, E.J., Hurt, C (2005) Grouping for behavioural
and psychological symptoms in dementia: clinical and biological aspects. European
Psychiatry, 20490-496
Wood-Mitchell, A., Mackenzie, L., Cunningham, J. & James, I.A. (2007) Can
a lie ever be therapeutic. Journal of Dementia Care. 15(2), 24-28.
Wood-Mitchell, A., Waterworth, A., Stephenson, M. & James, I.A. (2006)
Lying to people with dementia: Sparking the debate. Journal of Dementia Care,
14(6), 30-31
Downloads
The above text can be downloaded as a word document using the link below
PSIGE website newsletter Challenging Behaviour document (39KB)
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