MENTAL HANDICAP VOL. 12 SEPTEMBEP 1984

DIFFICULT AND DISRUPTIVE BEHAVIOUR: 1. Reconciling needs of clients and staff

Robert Cameron Michael Shackleton Bailey John Wallis

Of all the changes which have occurred in the field of mental handicap over the past decade or so, one of the most significant has been the movement away from the old “medical model” of handicap to the more recent “psycho-educational approach”. Applying psychology, especial ly the powerfu l tools of behavioural psychology, has enabled peop le w o r k i n g wi th m e n t a l l y handicapped children and adults to move away from a passive caring involvement to an active teachingrole. The result has been that many people with mental handicap have acquired useful life skills which enable them to do things for and by themselves which, even 10 years ago, might have elicited comments like “They could never learn skills like these because they are just too handicapped”.

As well as affecting the work of direct contact people like parents, teachers, care staff, and nurses, these changes are reflected in the service delivery of the supporting professionals (for example, p sycho log i s t s , soc ia l w o r k e r s , psychiatrists). In retrospect, it does seem as though the “bad old ’50s and ’60s” r ep resen ted a per iod when bo th established and emerging professional groups erected barriers around their professional skills. Thus, doctors declared themselves as the custodians of mental handicap diagnosis and service allocation, teachers and nurses believed that they had a monopoly on teaching and nursing skills, and social agency workers saw themselves single-handedly supporting families with a handicapped member. Looking back from the vantage point of 1984 it seems as though the caricature of professional groups at that time could best be described by two statements: “That’s mine!” and “Hands off!”.

As one of t he newly emerging professional groups, applied psychologists in health, social services, and education were, if anything, more guilty than other professional groups in hoarding and jealously guarding areas of expertise. Nowhere is this better exemplified than in the world of psychometric testing where

tests of ability, personality, and aptitude were carefully restricted to psychologists, who made sure that even the most simple test material could not even be obtained (let alone used) by other professional groups, such as teachers, nurses, and so on.

Hoarding professional skills may possibly increase the prestige and status of professional groups. In mental handicap, however, restrictive practices probably contributed to slow service development for the clients. Carefully guarded skills also encouraged the growth of a narrow, and often incestuous, field of knowledge (for example, see Woods (1980) for an amusing account of the heated debates on proposed minor changes to test materials). It also supported an “illness model” rather than an “educational model” of mental handicap. Most of all it acted as a barrier to sharing useful skills in applied psychology with other professional groups, especially direct contact professionals and parents.

Of all the changes which have taken place in the past two decades, the movement away from hoarding to selling (or giving away) professional skills is one which has been growing for some time and which continues to gather impetus. In fact, so eager are some professional groups to share expertise that their efforts could almost be caricatured by two new statements: “See this?” and “Want some?”.

The workshop movement The growth of training workshops for

direct contact personnel, especially parents, has been rapid. The pattern of parent training was developed in the USA in the ’60s. By the ’70s it was so well established that Berkowitz and Graziano (1972) were able to review the decade and conclude that there was “little doubt that behavioural techniques can be effectively applied to children’s problem behaviour through the training of their parents”. Parent workshops continue to increase in popularity and in the UK a great deal of the present work in parent training owes a

The authors of this paper are Applied Psychologists working in Hampshire, in an education authority, social services department, and health authority respectively.

considerable debt to the pioneering work carried out at the Hester Adrian Research Centre at the University of Manchester (see Cunningham and Jeffree, 1975).

Although parent training continues to be a growth industry, many professional groups have also found the powerful tools of behavioural psychology to be equally useful. As a result, workshops have been organised for health visitors (Sutton, 1981), community nurse therapists (Manchester, 1981), probation officers (Remington and Trussler , 1981), psychogeriatric nursing staff (Brookes and Brown, 1981), and with teachers in mainstream schools (Moss and Childs, 1981) and in special education (Cook, 1975).

The growth of in-service training has doubtless been encouraged by the r e c o m e n d a t i o n s of t h r e e ma jo r government reports; Court (1976) on child health services; Warnock (1978) on the education of handicapped children and young people; and Jay (1979) on mental handicap nursing and care. In-service training has attracted increased attention from those applied psychologists whose major objective is to help direct contact people to use psychology, rather than to retain a highly effective set of techniques for their personal use.

Despite their eagerness to share skills with direct contact people within their own agency, there has been very little attempt to develop inter-agency workshops. One notable exception is the highly successful Portage model (see Cameron, 1982). Mittler (1978) sums up the problem succinctly when, in discussing the recommendations of the Warnock Report, h e s h r e w d l y p o i n t s o u t t h a t “recommendations for improving staff skills are just as relevant for staff of all disciplines whether they are working with adults or children and whether they are employed by Health, Social Services, Education or voluntary agencies”. He goes on, “. . . a major obstacle standing in the way of effective staff training is that staff are trained in separate professional departments with l i t t le chance to experience the work of colleagues in other disciplines, despite paying lip service to notions of multidisciplinary teamwork”.

Although some of the problems which occur in institutions are likely to be

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MENTAL HANDICAP VOL. 12 SEPTEMBER 1984

idiosyncratic, there are many common problems which frequently occur in different settings. For example, when asked to list some of the problems faced in their everyday work, nurses in mental handicap, teachers in schools, care staff in children’s homes, and supeMsors in adult training centres, often raise similar problems. These direct contact staff f r equen t ly compla in t h a t a few patientdpupildresidentdstudents take up a disproportionate amount of staff time. Staff often say that no-one (especially the line manager) notices when things are going well, or helps them with problems when they arise.

In recognition of the fact that similar problems do occur in different settings, the Hampshire Standing Committee on Mental Handicap was set up in 1976 to encourage closer cooperation between applied psychologists in the county working in health, social services, education, and applied research with people who are mentally handicapped. The Committee, which is open to all applied psychologists in Hampshire, is described in a paper by Westmacott, Cameron, and Wallis (1981). One particularly successful outcome has been

the setting up of jointly run workshops and training programmes for parents, care staff, voluntary workers, teachers, nursing st&, and other direct contact personnel.

The remainder of this article describes one section of a study day on “difficult and disruptive behaviour” which has been designed for a mixed audience of teachers in special schools, nurses in mental handicap hospitals, staff in hospital units, and supervisors in adult training centres and hostels.

The study day The study day is organised so that all

direct contact staff working with people who are mentally handicapped in a defined geographical area can be offered an opportunity to attend. As well as highlighting the fact that the approach is applicable in different settings this form of organisation also helps to avoid the familiar problem of individual staff members going on courses and returning to their work place with new ideas, only to find that their colleagues are lukewarm or even hostile to change. Offering everyone training at the same time does pose problems. While schools may be able to close for a day, other establishments (such

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FIGURE 1. Needs - interventions grid

Using the grid 1. State problem in top left hand box as clearly as possible. 2. List in the first column- headed “Persons” - people who are or who might be involved in some way

with the problem: for example: client, relative, other clients, staff, unit manager, service management, etc.

3. Write against each of the above persons (that is, client, relative, etc.) what, in your view, their needs/ interests are in this situation (for example: client needs attention; family needs to get some sleep at night; staff need not to have to clear up broken glass; service manager needs to stop staff complaining about the client).

4. List possible interventions in boxes along the top (for example: give medication; lock doors; transfer to alternative placement; call in “expert”; refer problem to unit manager; change client management; modify environment; change behaviour of otehrs; discuss problem with client. etc.).

5 . Ask yourself, for each person, whether each intervention meets their needs and place a tick, cross, or question mark in the appropriate boxes.

Y = yes X = no ? = not sure (use sparingly)

as hostels or hospital wards) cannot. If necessary two parallel and identical study days, a week apart, can be organised in each geographical area so that haif the staff can attend one week and the other half the next.

The information is presented by a team of four psychologists drawn from the three main services. Other psychologists working in the area act as group leaders at the study day itself and later provide a follow-up service. Ideally each study day should have about 40 members (giving a total of 80 over the two days) though days with both smaller and larger numbers have been successful. Key elements in the presentation are teamwork and humour. Cartoons and video clips are used, and group work and audience participation is built in to the day.

The day is organised around three major topics:

(1) reconciling the needs of people with mental handicap with those of direct contact and support staff;

(2) a problem-centred approach; (3) anticipating and responding to

The first of these will now be discussed. The other two topics will be discussed in Part 2 of the article in the next issue of the journal.

Reconciling needs Direct contact staff are the people most

likely to have to respond to difficult, disruptive, or violent behaviour. Often their efforts are successful, if success is seen as the elimination of the problem for the staff . Violent or disruptive behaviour is not likely to be overlooked and a formidable stock of well tried remedies exists in the mental handicap dispensary. In social services settings (such as ATC’s or hostels) persistent violence often cannot be coped with and the “offender” usually ends up in the care of the Health Service. Not surprisingly, one of the major criteria for determining that the person is “Health Service dependency” is the neat phrase “severely behaviour disordered”.

The game of “pass the parcel” is a remedy not just confined to social services departments. Most education departments have well oiled mechanisms which ensure that persistently disruptive pupils are referred to educational psychologists, who may themselves pass on the problem by ananging a special school placement for the pupil. Other well tried remedies include medication, punishment, or segregation. The further down the line the parcel gets, the more likely it is that a physical intervention such as medication, constraint, or confinement will be adopted.

In the study day four main ideas are presented in the “reconciling needs” section. Firstly is the suggestion that each profession has a restricted range of interventions; staff who choose their

violence.

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MENTAL HANDICAP VOL. 12 SEPTEMBER 1984 .- _- ~ . __ -.

profession often find that they have also chosen the intervention. The second idea is that, if staff react to disruption or violence in an unplanned way, they may solve the problems so as to meet their own needs but are likely to choose an intervention which runs counter to the needs of the handicapped person. The third point is that direct contact staff often look to others to solve problems of violent or disruptive behaviour, when in reality they are the people who are best placed to analyse the problem and plan a suitable management strategy. The fourth idea is the constructive one. Participants learn to state the presenting problem clearly, list all the people in the situation who have needs, state what these needs are, and list possible methods of intervention.

To simplify these steps a prepared interventions grid (see Figure 1) is introduced. This simple table lists the needsherests of everyone involved and suggests possible interventions. In order to assess how far any one intervention meets the needs of each person involved each box is marked with a tick, a cross, or a question mark. In an ideal world it would be possible to find an intervention to meet the needs of the person who is handicapped and everyone else. In practice, very few interventions do this. The “rule of thumb” suggested in the study day is that interventions which meet the client’s needs and the needs of as many other people as possible are likely to be most

Although the process of using ticks, crosses, or question marks to evaluate needs against intervention is simple and unsophisticated, in practice it does appear to achieve four important objectives:

1. Everyone’s needs, from the clients to the staff to service managers, are considered.

2. Arguments about the efficacy or a c c e p t a b i l i t y of c e r t a i n interventions are largely avoided when they are not judged in isolation but in terms of people’s needs.

3. This approach seems remarkably effective in steering people towards interventions which meet clients’ needs as well as their own.

4. The approach does not violate the p r i n c i p l e of m i n i m a l intervention.

Concluding remarks It becomes clear from carrying out this

exercise that very simple, low technology interventions often hold great potential for meeting most people’s needs, especially clients’ needs. The needs-intervention grid also acts as a device against which strategies for changing and managing violent behaviour can be evaluated. Procedures for ill

lpropriate. will be discussed

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References Berkowitz, B. P . , Graziano, A. M. Training

parents as behaviour therapists: a review. Bebav. Res. & ner. , 1972; 10, 297-317.

Erookes, D. J . , Brown, C. A. A behavioural approach to psychiamc rehabilitntion. Nursing 7 h e s , 1981; February 26th, 367-370.

Cameron, R. J . W o r k Together: Portngein the U . K . Windsor: NFER-Nelson, 1982.

Cook, J . Easing behaviout problems. Special Education: F o d Trends, 1975; 2:1, 15-17.

Court, S. D. M. Fir for the Funur. R e p n ofthe ihmrnirtce on Child Health Service. (Gnnd. 6684). London: HMSO, 1976.

Cunningham, C. C., J e k , D. The organisation and structure of parent workshops. B d . Brit. l’sychol. Soc., 1975; 28, 40541 1.

Jay, P. Repon of Commirree of Enquiry inro M e n d Handicap NursiOg and Guc (Vol. 1). (Cmnd. 7468). London: HMSO, 1979.

Manchester, J . Child abuse and its revention: a behavioural approach. Nursing Fhes, 1981;

Mittler, P. Developing staff skills. A p , 1. Brit. Inst. Menr. Hand., 1978; 6:2, 10-12.

Moss, G . , Childs, J . In-service training for teachers in behaviourpl psychology; pmbluns of implementation. In Whelda11, K . The tkhaviourisr in tbe Ghssmorn. Birmingham: University of Bxmmghnm, 1981.

Remington, B., Trusler, P. Behaviourpl methods for the probation service? Probation Journal,

Sunon, C. The behavioural approach in health visiting. H d t h Visiror, 1981; 54,%97.

Warnock, H . M. Special Educational Needs: Repon of the commitree of Enquiry inro the Education ofHandicappcd CbiIdnm and Y o u l’eople. (Gnnd. 7212). London: HMSO, 1978.

Westmacon, E. V. S., Cameron, R. J . , Wall~s, J . M. Close encounters of a Hampshire kind: cooperation between psychologists. Bull. Brir. Psychol. Soc., 1981; 34, 420-421.

W d s , M. Mistake in the WISC-R. B d . Brit. Psychol. Soc., 1980; 33, 68.

77:15, 57-58.

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@ 1984 British Institute of Mental Handicap 97