Introduction to Understanding Challenging Behaviour, Personal Safety & De-escalation Strategies CITRUS team.

Introduction to Understanding Challenging Behaviour, Personal

Safety & De-escalation Strategies

CITRUS team

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ObjectivesTo give participants opportunity to examine the events that create challenging situations

To understand how the actions of others may impact on a persons behaviour

To examine possible reasons for challenging behaviours to occur

To identify appropriate responses to challenging incidents

To understand how or why a person may need to challenge their support/environment

To introduce the Agency procedure regarding supporting people who challenge

To examine the role that communication plays in supporting people who challenge and factors that affect behaviour

To ensure participants are aware of the need for accurate recording of behaviour and incidents

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Group discussion

Do all staff need breakaway or physical intervention training?

IS THE USE OF PI LAWFUL?

Activity 1(pg 4)

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C.I.T.R.U.S

Creative

Intervention

Techniques

in Response

to Untoward

Situations.

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Group exercise

Is restraint an acceptable approach to difficult or risky situations

Always

Only as part of a care plan

Only as a last resort

NeverActivity 2 (pg 4)

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CITRUS referral

Assessment based on evidence of incidents

Evidence includes:-

Risk assessmentsSupport plansABC chartsIncident reportsHealth assessmentsCare planBest interest meetings – consentClinical governance

Group work

Read the article and consider

the following See booklet

Activity 2a (pg 4)

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Levels of intervention

De-escalation of challenging behaviour

Breakaway

Physical intervention

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Third

Second

First

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First level

Primary PreventionAddressing the root causes before

they happened

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Second level

Secondary Prevention

Reactive responses, de-escalation techniques

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Third level

Tertiary Prevention

Physical interventions, post incident reviews & debriefs

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Definitions Of Physical Intervention

By definition, a physical intervention involves direct contact between member of staff and a service-user BILD 2002

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Definitions Of Physical Intervention

“Physical intervention implies the restriction of a person’s movement which is maintained against resistanceIt is, therefore, qualitatively different from other forms of physical contact such as:

manual promptingphysical guidancesupport which might be used in teaching or therapy”

Harris et al, 1996, p6

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Definitions Of Physical Intervention

“In it’s broadest sense: restraint is taking place when the planned or unplanned, conscious or unconscious actions of care staff prevent a resident or patient from doing what he or she wishes to do and as a result is placing limits on his or her freedom”

Lyon and Pimor 2004

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DEFINITION OF PHYSICAL INTERVENTION

There are two broad categories of Physical Intervention (PI):

Direct physical contact between a member of staff and a service user, eg, holding a person’s arms and legs to stop them attacking someone

The use of barriers, such as locked doors, to limit freedom of movementeg, placing door catches or bolts beyond the reach of service users.

By definition, a physical intervention involves direct contact between member of staff and a service BILD 2002

“Physical intervention implies the restriction of a person’s movement which is maintained against resistance. It is, therefore, qualitatively different from other forms of physical contact such as manual prompting, physical guidance or simply support which might be used in teaching or therapy” Harris et al, 1996

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What is proactive

Describes what you are doing on a day to day basis to help minimise the likelihood of someone displaying challenging behaviour

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Proactive interventions

PRIMARY PREVENTIONMinimise triggersChanging the environmentRoutine and structureBoundariesTeaching replacement skillsInteraction styles

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What is reactive

How we respond to a person displaying challenging behaviour

A plan should be in place for this

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Reactive Interventions

De escalation – redirection, distraction stance

Not responding to identified behaviours

Withdrawal

Breakaway techniques

Physical intervention techniques

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Basic need

Is the person at risk of doing harm / injury to themselves or others?

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scenarios

ChrisKirstyAmandaZetta

How would you respond to this situation?What are your responsibilities?What could be the legal outcomesHow is the person’s needs evaluated?Activity 3 (pg 6,7,8)

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Group discussion

What was the action?What could you be chargedwith?Which defense(s) could youuse?

Activity 3a (pg 9)

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Scenario

Chris

Heightened moodverbally abusivethrowing things

“ stay in your bedroom and don’t come out until I tell you”

FALSE IMPRISONMENT

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SCENARIO

Amanda

attacks a male member of staff

unable to break away

use of physical intervention (standing hold)

BATTERY

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SCENARIO

Kirsty has become physically aggressive.

You tell Kirsty in the heat of the moment

“I’m going to restrain you if you don’t stop it!”

ASSAULT

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SCENARIO

Zetta

restraint and holding

Battery and False imprisonment

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False Imprisonment

Seclusion

Confinement in a roomTying someone to a chairPreventing (by any means) a person leaving a room or building

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Shaking a fist

Throwing an object

The threatened use of a restraining device

Assault

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Battery

Touching

Holding

Pushing

Putting in bed

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DEFENCES

There are a number of defences which may be put forward to justify the actions of carers implementing physical interventions which could otherwise be viewed as unlawful under the civil or criminal law

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REASONABLE DEPENDS UPON:

The scale of the threat

The other options available

Feasibility of options

Likelihood of success

Ability to give consent

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Defences

Statutory Justification

Prevention of a Breach of the Peace Duty of carePrivate Defence

Consent

Necessity

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Policies and Procedures

Breakaway and Physical Intervention

Health and Safety

Challenging Behaviour

Supporting Staff involved in incidents

Incident reporting

Medication

Risk assessment and management

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Further Reading

C.I.T.R.U.S model

Human Rights Act 1998

Management of Health and Safety at work regulations 1992

BILD code of conduct and checklist for use of Physical Intervention

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Break

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Group discussion

From time to time we all present behaviours that ‘challenge’ people around us.

List something that irritates you?

How does it make you feel?

What do you do to help you deal with it?

What else can effect how you feel and re - act

Activity 4 (pg 13)

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Group discussion

Define challenging behaviour

Activity 5a (pg 14)

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Blunden and Allen (1987) have said:

“The term challenging behaviour is used to emphasise the fact that the issue is a challenge to those who provide services, and to the rest of society, not just a problem carried around by the individual. The challenge is ours to provide effective ways of helping people to behave and express themselves in ways which are acceptable to Society”.

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Emerson et al (1987/1995) suggests the following as a definition of severely challenging behaviour:

“Severely challenging behaviour refers to behaviour of such an intensity, frequency or duration that the physical safety of a person or others is likely to be placed in serious jeopardy or behaviour which is likely to seriously damage or delay access to and use of ordinary community facilities”.

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Group discussion

What causes challenging behaviour?

Activity 5b (pg 14)

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Causes of challenging behaviour

Communication difficultiesBoredomHealth issues – pain, illnessMental health disordersEpilepsyNot being listened toInconsistent approachNo routineEnvironment ie. AutismLearned behavioursAnxietySeeking interactionLack of choicePersonality clashes

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Group discussion

Now we have defined challenging behaviour, take time in your groups to give examples you have either faced, may face or think could be challenging behaviour?

Activity 5c (pg 15)

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Challenging behaviours

PicaExcessive drinkingRepetitive behavioursSelf stimulating behaviours (rocking spinning etc)Physical aggressionInappropriate sexual behaviourRefusal to engage/participateExcess demandingThrowing thingsIntentional incontinencespittingPutting fingers or objects in body orifices

Throwing or Smearing faecesStripping off in publicVerbal abuse/ aggressionSelf injuryExcessive noiseIsolation/withdrawalSelf induced vomitingRipping/damaging clothesDamage to propertyDiscrimination/ swearing or abuse

This list is not exhaustive

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Recap

Ordinary behaviours / inappropriate setting.

Serious adverse consequences

Personal judgement

You need to be clear about why you think a behaviour is challenging.

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Recap

Challenging behaviours are often extreme versions of quite ordinary behaviour. They challenge because they happen more often, last longer, or have greater intensity than other behaviours.

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Recap

Services have a responsibility to respond positively and professionally to challenging behaviours.

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Fight or Flight

In relation to conflict situations we have an in built safety mechanism commonly called ‘fight or flight’ response. It enables us to

quickly evaluate a potentially threatening situation and then take whatever action is necessary to stay safe.

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Fight or Flight

Our behaviour in any pressure situation is linked to how we feel at the time, tired, fatigued etc, our attitudes beliefs and prejudices, genetic background, past experiences, family, up bringing and cultural background as well as present circumstances, all influence the way a situation is evaluated and thus responded to.

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Group discussion

In your groups please indicate on the body chart, what happens when adrenaline flows?

Activity 6 (pg 16)

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Thinking Patterns

Total fixated on the source.

Recollection of negative experiences.

Over generalisation.

Jumping to conclusions.

Disqualifying all positive aspects of the situation.

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Group discussion

What is Anger?

In your groups take 10 minutes to come up with a definition for Anger.

Activity 7 (pg 17)

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What is Anger?

It is an emotion triggered by feelings such as:

Frustration

Injustice

Humiliation

Threat

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What is Anger?

Although we believe anger to be an immediate response it is in fact a secondary response

Therefore we choose anger as a response to a perceived threat

This in time makes it the preferred choice of response which is then stored away in our subconscious

In fact, the more we use anger the more we will continue to use it as a response to a perceived threat.

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Aggressive Incident Model

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Situation.

A situation arises that may provoke feelings within the person. For example, a driver cuts in front of you on the motorway, or someone you know walks past without acknowledging you

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Appraisal.

The situation can be appraised either positively or negatively.

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Anger.

If a situation is appraised positively, anger is usually averted. However, if appraised negatively, the situation may lead to anger.

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Inhibitors.

Inhibitors are internal and external factors which prevent anger from leading to aggression.

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Aggressive Incident Model

Aggression. If inhibitors are not present, or are not strong enough, then aggression is a likely occurrence.

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Aggressive Incident Model

The use of the Aggressive Incident Model allows planning

- avoid the particular situations which may lead to anxiety or agitation

- teaching skills appraise positively or acquire inhibitors

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Emotional Arousal / Assault Cycle

Based on information gathered by Paul Smith, As a model it provides general advice.Based upon assumptions that indicators don’t occur ‘out of the blue’.

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Emotional Arousal / Assault Cycle

Represents a time frame of an aggressive incident which is made up of five stages

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Emotional Arousal / Assault Cycle (Based on Kaplan and Wheeler 1983)

Trigger

Phase

(A)

Escalation

Phase

(B) Crisis

Phase

(C)

Recovery

Phase

(D)

Post-Crisis

Depression

Phase

(E)

Baseline Behaviour

Aggressive / Challenging / Violent Behaviour

(PotentialAdditionalAssaults)

Approximately 90 mins to fully recover.

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Baseline:

The Assault Cycle is based on the premise that everyone has a baseline or ‘everyday’ set of behaviours, which are normally non aggressive.

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Emotional Arousal / Assault Cycle (Based on Kaplan and Wheeler 1983)

Baseline Behaviour

Aggressive / Challenging / Violent Behaviour

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Trigger:

The trigger phase is signified by the first movement away from how the service user usually behaves.

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Emotional Arousal / Assault Cycle (Based on Kaplan and Wheeler 1983)

Trigger

Phase

(A)

Baseline Behaviour

Aggressive / Challenging / Violent Behaviour

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Escalation:

Behaviour deviates more and more from baseline behaviour. Service users can become focused on a particular issue or person.

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Emotional Arousal / Assault Cycle (Based on Kaplan and Wheeler 1983)

Trigger

Phase

(A)

Escalation

Phase

(B)

Baseline Behaviour

Aggressive / Challenging / Violent Behaviour

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Crisis:

The service user becomes increasingly physically, emotionally and psychologically aroused. Control over aggressive impulses decreases and direct aggression is a possibility.

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Emotional Arousal / Assault Cycle (Based on Kaplan and Wheeler 1983)

Trigger

Phase

(A)

Escalation

Phase

(B) Crisis

Phase

(C)

Baseline Behaviour

Aggressive / Challenging / Violent Behaviour

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Recovery:

The service user slowly returns to their own baseline behaviour. The service user’s heightened state of physical and psychological arousal can remain a threat for up to ninety minutes due to the level of adrenaline in the bloodstream.

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Emotional Arousal / Assault Cycle (Based on Kaplan and Wheeler 1983)

Trigger

Phase

(A)

Escalation

Phase

(B) Crisis

Phase

(C)

Recovery

Phase

(D)

Baseline Behaviour

Aggressive / Challenging / Violent Behaviour

(PotentialAdditionalAssaults)

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Post-crisis depression:

The service user dips below baseline.

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Emotional Arousal / Assault Cycle (Based on Kaplan and Wheeler 1983)

Trigger

Phase

(A)

Escalation

Phase

(B) Crisis

Phase

(C)

Recovery

Phase

(D)

Post-Crisis

Depression

Phase

(E)

Baseline Behaviour

Aggressive / Challenging / Violent Behaviour

(PotentialAdditionalAssaults)

Approximately 90 mins to fully recover.

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Group work

Complete an emotional arousal cycle on an identified behaviour

Activity 8 (pg 18)

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Emotional Arousal / Assault Cycle (Based on Kaplan and Wheeler 1983)

Baseline Behaviour

Aggressive / Challenging / Violent Behaviour

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Group discussion

List factors within verbal and non verbal communication that influence behaviour

Activity 9a (pg 19)

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Group discussion

What barriers do people with a learning disability face when communicating

Activity 9b (pg 20)

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Group work

Communication

How can we help / develop our service users to express their feelings appropriately

Activity 9c (pg 20)

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Principles of de-escalation

Don’t deny its happening

Don’t challenge

Don’t insult

Be calm listen and negotiate

Provide a face saving exit

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Groupdiscussion

Activity 10

In your groups come up with 10De-escalation techniques.

Activity 11

List 5 benefits of using de-escalation techniques?

Activity 12

List what might happen if we don’t respond effectively to challenging behaviours?

- to services- to service users

(pg 21 and 22)

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De-escalation Techniques

The following de-escalation strategies could

be useful when trying to calm a potentially threatening situation.

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De-escalation Techniques

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De-escalation Techniques

Accent, pitch, tone and volume of voice.

Eye Contact.

Facial Expressions. Posture.

Allow the person space time.

Show that you understand.

Do not be confrontational.

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De-escalation Techniques

Avoid provocative phrases, De-personalise the issue. EmpathiseEmpower the client. Token ConcessionUse the word ‘we instead of you’Make a Friendly gesturePhysical Intervention

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Group discussion

Responding to an aggressive incident

•What is your role in managing challenging situations?

•Identify what paperwork must you fill in, in?

•Who will you report this to?

Activity 13 (pg 23)

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When attending practical training

•Don’t wear jewellery (Piercings removed or covered with a plaster)•Wear flat covered shoes i.e. trainers•Comfortable clothing•Be medically fit to be trained•Arrive on time 9.30am to start

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The end

Evaluation Sheets