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