Challenging behaviour

Psychologists are accustomed to thinking about "challenging behaviour" in terms of the mechanisms of reinforcement that contribute to sustaining it. I associate this view with the work of Eric Emerson - who wrote an excellent book on the topic. 

The Emersonian view is a perspective that focuses on the contingencies that reinforce behaviour. It gives rise to mechanistic interventions that adjust those contingencies: removal of the rewards that sustain a behaviour, easier routes to the outcome being sought, differential reinforcement of other behaviour (DRO). This sort of approach has been effective especially in Learning Disability settings, where people typically spend long periods of time living, and where staff are primarily concerned with supporting behaviour. There are also case reports of successful interventions in long term psychiatric hospitals. These are the sorts of settings where the consistency and commitment required to adjust environmental contingencies are in more plentiful supply. 

Recently I have been involved in delivering "challenging behaviour" training in the context of an acute general hospital. I use scare quotes because the whole concept of challenging behaviour (a concept clinical psychologists are fond of) begins to fray a bit around the edges when examined more closely. For one thing, some have pointed out that the terminology itself is likely to stigmatise and mislead; framing behaviours as inherent to the people who exhibit them. This kind of critique seems right to me: behaviours are of course a function of person and the situation they are in.  Too much terminological pendantry can seem to miss the point. I have heard it suggested that "challenging behaviour" should be replaced by "behaviour that challenges," as though the two terms weren't in fact extremely similar. The sort of flexibility that would help us think productively about behaviour is likely best served by a similar flexibility in our approach to terminology.

More significantly, professional approaches to challenging behaviour are substantially impacted by the role the professional occupies, and the sorts of permissions they feel they have. Even before you get into adjusting reinforcement contingencies and so on, there is a significant difficulty about helping people feel permitted to do the basics. That sounds a bit strange - what am I talking about? 

When a person in a hospital becomes upset and behaves in a way that is experienced as challenging, the optimal response is for the staff around them to make sense of the behaviour (as a communication of distress and so on) and to respond in a way that the distress is mitigated. So a person shouts and punches in fear. They aren't restrained, but instead are met with reassurance. They feel calmer and they shout and hit less. This sequence seems so obvious that I sometimes feel embarrassed to deliver the slides about it. People usually nod enthusiastically along. But its obviousness or otherwise isn't really at issue. For the most part - I increasingly feel - it's not that staff don't know how to behave, it's that they lack a subjective sense of permission to behave in this way.

Consider this story:

A young girl sits in the middle of a room in a psychiatric ward. She has removed all of her clothes and is rocking back and forth.

The hospital staff has invited a visiting doctor to look in on the patient. They talk about the girl, who was diagnosed with schizophrenia: for a long time now, she has done nothing but rock, and she has not spoken since being admitted many months ago. They ask the visitor’s opinion.

His response is wordless: he takes off all his clothes and steps into her room.

He sits down next to the girl and begins to rock in sync with her, two naked figures side by side.

This goes on for a while. This goes on for 5, 10, 15, 20 minutes.

And then she speaks to him. Her first words in nearly 200 days.

Later, the visitor will ask the staff, “Did it never occur to you to do that?

The visiting doctor in that story was RD Laing, and its hard to read it without entertaining the hope that you too would have the clinical nous to do something similarly dramatically empathic. Laing comes off as heroically insightful, drawing his colleague's attention to their failure to do the obvious.

But such an approach is far from obvious. Assuming this really happened as reported, Laing's colleagues must have had doubts about what he was doing. The same is true - I want to suggest - even for responses with much lower stakes. Who wants to risk spending time listening when you don't feel qualified to deal with a person's tears? Who wants to try and reason with an angry shouting patient when you worry it might be done better by a more senior member of staff?

To connect with someone emotionally in hospital - even in a less dramatic way than Laing - involves a degree of risk. There is the risk of becoming emotionally impacted, the risk of feeling engulfed, and there is the risk of doing something wrong or foolish. Laing was free of this latter risk. He was Laing - a great psychiatric guru. Even if the encounter hadn't gone so well (the patient might not have talked - might even have baulked at the idea of being approached by a naked doctor) he would still have been lauded as a psychiatric genius taking an empathic risk. In other words, Laing was permitted by the whole set up to do something that was actually very difficult, even if he said it was obvious.

When we teach about responding to "challenging behaviour" in terms of a technical approach to reinforcement or distress reduction, we risk overlooking systemic factors that have to do with the granting of permission to respond empathically. My impression is that people want to respond empathically and know in theory what that looks like. A difficulty arises in any given stressful situation when people think that they are not the right person for that job, that someone more senior or more qualified ought to be drawn on. We could improve institutional approaches to "challenging behaviour" by finding ways to grant this permission as extensively as possible.