A Positive Philosophy to Challenging Behaviour

By Jane Verity ©Dementia Care International

Challenging, physical and verbally aggressive behaviours have combined to become one of the three most common Occupational Health and Safety issues occurring within many facilities. However, these behaviours do not belong as an OHS issue.

When caring for people with dementia, we are not working with machinery but are caring for human beings. When they react with challenging behaviour, it is not because the ‘machines’ are faulty, it is because the way they are being treated is flawed.

People with dementia are incredibly vulnerable individuals with special and finely-tuned needs. They should not be expected to adjust their needs to routines and requirements; rather their care routines should be adjusted to meet their needs.

Understanding Challenging Behaviour

Challenging behaviour is a reaction to something that is not right for an individual person and generally occurs when the person has a need that is not being met. The need doesn’t have to be a physical one, but may be emotional or spiritual, such as the need for respect, love or happiness. Or the need might be something said or unsaid; something done or not done. Always remember to ask:

What is this person attempting to communicate?
What is the need that is not being fulfilled?

Challenging behaviours are not the exclusive domain of those who have dementia. If you were to take a moment and think like one of the people for whom you care, how would you respond to the following question?

‘How long would it be before I started to react to the control and supervision I experience here with behaviour that could be branded as challenging?’

You might not be able to express your hurt, concern or disapproval in words or fluent sentences. Does that mean you have to show your disapproval by lashing out?If you did react like this, you may be medicated because you’d become an OHS problem.

Knowing that challenging behaviour is a reaction to something that isn’t right or in other words, an unmet need the ‘challenging’ person may be indirectly attempting to say, ‘Please acknowledge me as a whole person and not only for my deficiencies and changed behaviour; for I am not in control of them. I cannot bear to constantly be reminded that I need help… that I am told when to go to the toilet; when to go to bed; when to eat and especially that I can’t go home.Being treated like has become my entire existence now, and it is absolutely soul destroying. I want to smile once more, laugh again and make light of it all. Please acknowledge me for all my beautiful human qualities, of which I still have plenty. The more you do this, the more these qualities will shine through and show the real me.’

Shifting Focus

People with dementia can be the greatest teachers in personal growth; if only their carers are prepared to learn from them. Instead of seeing them as the problem, reflect on what they reveal and take each opportunity to learn something new .

By trying to change others, more challenging behaviours are created and maintained. When we change ourselves, we also change everyone around us!

To prevent challenging behaviour, change focus from only looking at what’s wrong with the person physically, to compassionately searching beyond for what the person’s unfulfilled needs might be.

The story of Michelangelo illustrates this shift in thinking. When embarking on his new sculpture the angel, ‘David’, Michelangelo did not focus on the block of white marble in front of him. Instead, he saw within to the angel trapped inside. He then chiselled away to free the angel and his masterpiece was born.

To release the good in everyone, look for the good and ignore all that is not.

When challenging behaviour is experienced in our own families, colleagues, residents, or their relatives, we are the ones who define the behaviour as challenging. This is due to focusing solely on the problem, and seeign the situation only from one point of view. It is easy to see the block of marble and not the angel inside.

Challenging the Professional Distance

In his book Non-Violent Communication, American psychologist Dr. Marshall Rosenberg teaches the language of compassion – a powerful tool towards communicating when communication is difficult such as being angry or experiencing anger in another person.

Rosenberg defines compassion as the innate desire to enrich another person’s life and explains how modern day professional training systematically alienates carers from their compassion.

Carers are taught to ‘engage a professional distance’, to observe, evaluate, judge and label another person’s behaviour. This can result in cares losing touch with their innate human quality of compassion. It’s difficult to be both clinical and compassionate.

Here’s an everyday example. Howard is calling out, ‘Help! Help! Help!‘ Joanna checks on him and finds that he has no obvious physical needs and she concludes that there is no reason for his calling out. She then engages her professional distance and observes, evaluates and judges. From this perspective, she labels Howard’s behaviour as ‘attention seeking’.

This label is purely a one-sided, subjective observation. It does not take into consideration the ‘challenging’ person’s point of view. When behaviour is labelled as ‘attention seeking’, it has a very powerful effect and at a completely subconscious level, carers may begin to change their behaviour towards the person.

Group thinking begins to echo, ‘If we give this person an inch, he or she will take the proverbial mile, so we’d better hold back and not get too closely involved.’ So as a group, the care staff may begin to withdraw more and more from the person.

Language of Compassion

Step into the ‘challenging’ person’s shoes and compassionately discover why this person is reacting with challenging behaviour. Ask, ‘What deep, underlying need has not been fulfilled for the person to be calling out, ‘Help, help, help?’

There could be many reasons, such as the need for attention, security or companionship. However, behind even these needs lies the need for love. The key is to always go one step further, beyond obvious needs. Keep asking the question; ‘What is the real need behind this behaviour?’

Cause and Effect

When the true nature of compassion is misunderstood, when a person is calling out it may not be recognised that his or her underlying need is for love. What the person is doing is only perceived as an irritation and branded accordingly as challenging behaviour. The more the person calls out, the more carers withdraw. By withdrawing, the person intensifies their behaviour because no one has listened, understood or responded to the underlying need. In turn, they may out even louder, causing further withdrawal.

A typical response might be; ‘There goes Howard again with his attention seeking behaviour!’ Now we simply turn our backs on him and walk away. This type of situation can often escalate until, in desperation, the person ends up banging on the armrest or table – possibly even throwing him or herself onto the floor. This has nothing to do with the ‘machinery’ being faulty and nothing to do with any neurological changes; it has everything to do with the quality of the interaction.

Solution

Acknowledge the person’s need for love and then find ways to provide it. This suggestion often sparks the response, ‘We’ve already tried that and it doesn’t work. The more we give, the more they take; and we don’t have time to spend with just one person.’

In reality this comment is often absolutely true; however, there is a way to work with a need rather than against it. Whenever a person experiences something that hurts deeply, they need between seven and eleven positive experiences to compensate for that one hurtful event. If a best friend hurts another friend emotionally, they may be able to forgive the friend, but it will usually still take between seven and eleven positive experiences with this friend before trust is re-established.

It is exactly the same for the person with dementia who is calling out for love. He or she may have experienced many harmful, damaging and undermining experiences it may take more than one turnaround of staff reactions to fill that need. It will take many positive and genuine loving experiences to fill the unmet need.

Find one, two or three staff members who have no problem with the person, because they will be the only ones who can fill the well with love and respect. At the same time, free those staff members who find it impossible to be naturally loving towards the person from their current involvement with the person. It may be because those staff members are genuinely exhausted, have simply had enough or just don’t get on with the person.

Instead of thinking of challenging behaviour as something that needs managing – understand that challenging, angry and aggressive behaviour is all about cause and effect, and our failure to meet a person’s needs.

When you are with a person whom has been labelled as exhibiting challenging behaviour, ask yourself, ‘What do my actions create?’

‘Our actions create either suffering or happiness.’

Dalai Lama