Introduction to
Understanding Challenging Behaviour,
Personal Safety & De-escalation Strategies
CITRUS team
Objectives
To 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
2
Group discussion
Do all staff need breakaway or
physical intervention training?
IS THE USE OF PI LAWFUL?
Activity 1(pg 4)
3
C.I.T.R.U.S
Creative
Intervention
Techniques
in Response
to Untoward
Situations.
4
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
Never
Activity 2 (pg 4)
5
CITRUS referral
Assessment based on evidence of incidents
Evidence includes:Risk assessments
Support plans
ABC charts
Incident reports
Health assessments
Care plan
Best interest meetings – consent
Clinical governance
6
Group work
Read the article and consider
the following
See booklet
Activity 2a (pg 4)
8
Levels of intervention
De-escalation of challenging
behaviour
Breakaway
Physical intervention
9
Third
Second
First
10
First level
Primary Prevention
Addressing the root causes before
they happened
11
Second level
Secondary Prevention
Reactive responses, de-escalation
techniques
12
Third level
Tertiary Prevention
Physical interventions, post incident
reviews & debriefs
13
Definitions Of Physical Intervention
By definition, a physical intervention
involves direct contact between
member of staff and a service-user
BILD 2002
14
Definitions Of Physical Intervention
“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
support which might be used in teaching or
therapy”
Harris et al, 1996, p6
15
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
16
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 movement
eg,
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
17
What is proactive
Describes what you are doing on a
day to day basis to help minimise
the likelihood of someone displaying
challenging behaviour
18
Proactive interventions
PRIMARY PREVENTION
Minimise triggers
Changing the environment
Routine and structure
Boundaries
Teaching replacement skills
Interaction styles
19
What is reactive
How we respond to a person
displaying challenging behaviour
A plan should be in place for this
20
Reactive Interventions
De escalation – redirection,
distraction stance
Not responding to identified
behaviours
Withdrawal
Breakaway techniques
Physical intervention techniques
21
Basic need
Is the person at risk of doing
harm / injury to themselves or
others?
22
scenarios
Chris
Kirsty
Amanda
Zetta
How would you respond to this situation?
What are your responsibilities?
What could be the legal outcomes
How is the person’s needs evaluated?
Activity 3 (pg 6,7,8)
23
Group discussion
What was the action?
What could you be charged
with?
Which defense(s) could you
use?
Activity 3a (pg 9)
24
Scenario
Chris
Heightened mood
verbally abusive
throwing things
“ stay in your bedroom and don’t
come out until I tell you”
FALSE IMPRISONMENT
25
SCENARIO
Amanda
attacks a male member of staff
unable to break away
use of physical intervention (standing
hold)
BATTERY
26
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
27
SCENARIO
Zetta
restraint and holding
Battery and False imprisonment
28
False Imprisonment
Seclusion
Confinement in a room
Tying someone to a chair
Preventing (by any means) a person
leaving a room or building
29
Assault
Shaking a fist
Throwing an object
The threatened use of a restraining
device
30
Battery
Touching
Holding
Pushing
Putting in bed
31
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
32
REASONABLE DEPENDS UPON:
The scale of the threat
The other options available
Feasibility of options
Likelihood of success
Ability to give consent
33
Defences
Statutory Justification
Prevention of a Breach of the
Peace Duty of care
Private Defence
Consent
Necessity
34
Policies and Procedures
Breakaway and Physical Intervention
Health and Safety
Challenging Behaviour
Supporting Staff involved in incidents
Incident reporting
Medication
Risk assessment and management
35
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
36
Break
37
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)
38
Group discussion
Define challenging behaviour
Activity 5a (pg 14)
39
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”.
40
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”.
41
Group discussion
What causes challenging behaviour?
Activity 5b (pg 14)
42
Causes of challenging behaviour
Communication difficulties
Boredom
Health issues – pain, illness
Mental health disorders
Epilepsy
Not being listened to
Inconsistent approach
No routine
Environment ie. Autism
Learned behaviours
Anxiety
Seeking interaction
Lack of choice
Personality clashes
43
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)
44
Challenging behaviours
Pica
Excessive drinking
Repetitive behaviours
Self stimulating behaviours
(rocking spinning etc)
Physical aggression
Inappropriate sexual
behaviour
Refusal to
engage/participate
Excess demanding
Throwing things
Intentional incontinence
spitting
Putting fingers or objects in
body orifices
Throwing or Smearing
faeces
Stripping off in public
Verbal abuse/ aggression
Self injury
Excessive noise
Isolation/withdrawal
Self induced vomiting
Ripping/damaging clothes
Damage to property
Discrimination/ swearing or
abuse
This list is not exhaustive
45
Recap
Ordinary behaviours / inappropriate
setting.
Serious adverse consequences
Personal judgement
You need to be clear about why you
think a behaviour is challenging.
46
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.
47
Recap
Services have a responsibility to
respond positively and
professionally to challenging
behaviours.
48
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.
49
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.
50
Group discussion
In your groups please indicate on the
body chart, what happens when
adrenaline flows?
Activity 6 (pg 16)
51
52
53
Thinking Patterns
Total fixated on the source.
Recollection of negative experiences.
Over generalisation.
Jumping to conclusions.
Disqualifying all positive aspects of the
situation.
54
Group discussion
What is Anger?
In your groups take 10 minutes to
come up with a definition for Anger.
Activity 7 (pg 17)
55
What is Anger?
It is an emotion triggered by feelings
such as:
Frustration
Injustice
Humiliation
Threat
56
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.
57
Aggressive Incident Model
58
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
59
Appraisal.
The situation can be
appraised either
positively or negatively.
60
Anger.
If a situation is appraised
positively, anger is usually
averted. However, if
appraised negatively, the
situation may lead to anger.
61
Inhibitors.
Inhibitors are internal and
external factors which
prevent anger from leading
to aggression.
62
Aggressive Incident Model
Aggression. If inhibitors are not
present, or are not strong enough,
then aggression is a likely
occurrence.
63
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
64
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’.
65
Emotional Arousal / Assault Cycle
Represents a time frame
of an aggressive incident
which is made up of five
stages
66
Emotional Arousal / Assault Cycle (Based on
Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
Escalation
Trigger
Phase
Phase
(B)
(A)
(Potential
Additional
Assaults)
Crisis
Post-Crisis
Depression
Phase
Phase
(C)
(E)
Recovery
Phase
(D)
Approximately 90
mins to fully
recover.
67
Baseline Behaviour
Baseline:
The Assault Cycle is based
on the premise that
everyone has a baseline or
‘everyday’ set of behaviours,
which are normally non
aggressive.
68
Emotional Arousal / Assault Cycle (Based on
Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
69
Baseline Behaviour
Trigger:
The trigger phase is signified
by the first movement away
from how the service user
usually behaves.
70
Emotional Arousal / Assault Cycle (Based on
Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
Trigger
Phase
(A)
71
Baseline Behaviour
Escalation:
Behaviour deviates more
and more from baseline
behaviour. Service users
can become focused on
a particular issue or
person.
72
Emotional Arousal / Assault Cycle (Based on
Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
Escalation
Trigger
Phase
Phase
(B)
(A)
73
Baseline Behaviour
Crisis:
The service user becomes
increasingly physically,
emotionally and
psychologically aroused.
Control over aggressive
impulses decreases and
direct aggression is a
possibility.
74
Emotional Arousal / Assault Cycle (Based on
Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
Escalation
Trigger
Phase
Phase
(B)
(A)
Crisis
Phase
(C)
75
Baseline Behaviour
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.
76
Emotional Arousal / Assault Cycle (Based on
Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
Escalation
Trigger
Phase
Phase
(B)
(A)
(Potential
Additional
Assaults)
Crisis
Phase
(C)
Recovery
Phase
(D)
77
Baseline Behaviour
Post-crisis depression:
The service user dips
below baseline.
78
Emotional Arousal / Assault Cycle (Based on
Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
Escalation
Trigger
Phase
Phase
(B)
(A)
(Potential
Additional
Assaults)
Crisis
Post-Crisis
Depression
Phase
Phase
(C)
(E)
Recovery
Phase
(D)
Approximately 90
mins to fully
recover.
79
Baseline Behaviour
Group work
Complete an emotional
arousal cycle on an
identified behaviour
Activity 8 (pg 18)
80
Emotional Arousal / Assault Cycle (Based on
Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
81
Baseline Behaviour
Group discussion
List factors within verbal and non
verbal communication that influence
behaviour
Activity 9a (pg 19)
82
Group discussion
What barriers do people with a
learning disability face when
communicating
Activity 9b (pg 20)
83
Group work
Communication
How can we help / develop our
service users to express their
feelings appropriately
Activity 9c (pg 20)
84
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
85
Groupdiscussion
Activity 10
In your groups come up with 10
De-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)
86
De-escalation Techniques
The following de-escalation strategies
could
be useful when trying to calm a potentially
threatening situation.
87
De-escalation
Techniques
88
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.
89
De-escalation Techniques
Avoid provocative phrases,
De-personalise the issue.
Empathise
Empower the client.
Token Concession
Use the word ‘we instead of you’
Make a Friendly gesture
Physical Intervention
90
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)
91
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
92
The end
Evaluation
Sheets
93