FSPHP Annual Meeting 2010 - Chicago, IL
Resources for the Distressed Physician
William Swiggart, MS, LPC/MHSP
Associate in Medicine
Co-Director
Vanderbilt Center for
Professional Health
Betsy White Williams, Ph.D., M.P.H.
Rush University Medical School
Professional Renewal Center
Reid Finlayson, MD
Assistant Professor of Psychiatry
Director
Vanderbilt Comprehensive
Assessment Program
Martha E. Brown, MD
Assoc. Dean Faculty Development
Associate Professor of Psychiatry
USF College of Medicine
William Swiggart, MS, LPC/MHSP
Associate in Medicine
Co-Director
Vanderbilt Center for Professional Health
www.mc.vanderbilt.edu/cph
Disruptive / Distressed
Physicians
When “a little chat” doesn't work
Mr. Bangsiding felt (and wrongly so) that a little
chat would be enough to stop Bob’s disruptive behavior.
4
2004 AAMC Council of Deans
“Physicians are often poorly socialized
and enter medical school with inadequate
social skills for practice.”
“There is a growing body of literature
documenting residency programs do not
prepare resident physicians adequately for
the practice of medicine.”
Why bother dealing with
disruptive behavior?
Reported Prevalence
State/Country
Alabama
Indiana
Kentucky
Tennessee
Wisconsin
Australia
England
Multiple References Available
Prevalence
12%
8%
1%
20%
0.4%
30%
30%
36%
6%
Source
Referrals
Referrals
Statewide
Referrals
Statewide
Referrals
Referrals
Referrals
Disciplinary
Failure to Address Disruptive
Conduct Leads To

Team members may adopt disruptive
person’s negative mood/anger (Dimberg &
Ohman, 1996)

Lessened trust among team members can
lead to lessened task performance (always
monitoring disruptive person)... effects
quality and pt safety (Lewicki & Bunker, 1995;
Wageman, 2000)
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and
dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
Disruptive Behavior Leads to
Communication Problems…Communication
Problems Lead To Adverse Events1

Communication breakdown factored in OR errors 50% of the
time2

Communication mishaps were associated with 30% of adverse
events in OBGYN3

Communication failures contributed to 91% of adverse events
involving residents4
Gerald B. Hickson, MD
James W. Pichert, PhD
Center for Patient & Professional Advocacy
Vanderbilt University School of Medicine
1. Dayton et al, J Qual & Patient Saf 2007; 33:34-44.
3. White et al, Obstet Gynecol 2005; 105(5 Pt1):1031-1038.
2. Gewande et al, Surgery 2003; 133: 614-621.
4. Lingard et al, Qual Saf Health Care 2004; 13: 330-334
Disruptive Behavior Creates
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fear
confusion or uncertainty
vengeance vs. those who
oppose/oppress them
hurt ego/pride
grief (denial, anger,
bargaining)
apathy
burnout
unhealthy peer pressures


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
ignorance (expectations,
behav. standards, rules,
protocols, chain of
command, standards of
care)
distrust of leaders
dropout: early retirement
or relocation
errors
disruptive behavior
begets disruptive
behavior
Vanderbilt University and Medical Center Policy #HR-027
Spectrum of Disruptive Behaviors
Aggressive
Anger Outbursts
Profane/Disrespectful
Language
Throwing Objects
Demeaning Behavior
Physical Aggression
Sexual Comments or
Harassment
Racial/Ethnic Jokes
Passive
Aggressive
Derogatory
comments about
institution,
hospital, group,
etc.
Refusing to do
tasks
Passive
Chronically late
Not responding
to call
Inappropriate or
inadequate chart
notes
Two systems interact
The internal system
The external system
Functional &
nurturing
Hospital/Clinic
Physician
Dysfunctional
Good skills
Poor skills
“The Perfect Storm”
Why are we so hesitant
to act?
13
©CPPA, 2008
The Balance Beam
Competing priorities
Not sure how lack
tools, training
Leaders “blink”
“Can’t change…”
Fear of antagonizing
Do nothing
Staff satisfaction
and retention
Reputation
Patient safety,
clinical outcomes
Liability, risk mgmt
costs
Do something
June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional
Advocacy; Hickson GB, Pichert JW. Disclosure and Apology. National Patient Safety Foundation Stand Up for Patient
Safety Resource Guide, 2008; Pichert JW, Hickson GB, Vincent C: “Communicating About Unexpected Outcomes and
Errors.” In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 2007
14
Why Might a Medical Professional
Behave in Ways that are
Disruptive?
1.
2.
3.
4.
Substance abuse, psych issues
Narcissism, perfectionism
Spillover of family/home problems
Poorly controlled anger/Snaps under heightened
stress, perhaps due to:
a. Poor clinical/administrative/systems support
b. Poor mgmt skills, dept out of control
c. Back biters create poor practice environments
15
©CPPA, 2008
Why Might a Medical Professional
Behave in Ways that are
Disruptive?
5. Well, it seems to work pretty well
6. No one addressed it earlier (why? See #5)
7. Family of origin issues—guilt and shame
8.
9.
16
©CPPA, 2008
Etiologies

1.
3.
Individual Factors
 Predisposing Psychological Factors1
 Alcohol and Drug Family History
 Trauma History
 Religious Fundamentalism
 Familial High Achievement
 Personality Traits2
 Narcissism
 Obsessive/Compulsive
 Physician Burnout3
 Clinical Skills Satisfactory or Above Average4
Valliant, 1972
Spickard and Gabbe, 2002
2.
4.
Gabbard, 1985
Papadakis, 2004, 2005
Etiologies

Institutional Factors1
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
Scapegoats
System Reinforces Behavior
Individual Pathology may over-shadow institutional
pathology
Williams and Williams, 2004
What controls behavior?
Thomas Krause, PhD
Presentation at the National Patient Safety Foundation Board of Governors Meeting June, 2007
19
©CPPA, 2008
Consequences



Consequences control behavior
Antecedents influence behavior only to the
extent that they predict consequences…
Timing, consistency and significance of
consequences affect their impact
Thomas Krause, PhD
Presentation at the National Patient Safety Foundation Board of Governors Meeting June, 2007
20
©CPPA, 2008
Consequences
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disharmony and poor morale1,
staff turnover2,
incomplete and dysfunctional communication1,
heightened financial risk and litigation3,
reduced self-esteem among staff1,
reduced public image of hospital1,
financial cost1,
unhealthy and dysfunctional work environment1, and
potentially poor quality of care1,2,3
1. Piper, 2000
2. Rosenstein, 2002
3. Hickson, 2002
Characteristics and Behavioral
Change in the First 39 Disruptive
Physicians
Samenow CP, Swiggart W, Blackford J, Fishel T, Dodd D, Neufeld R, Spickard A. A CME
Course Aimed at Addressing Disruptive Behavior. Physician Executive; 34 (1) Jan/Feb
2008: 32-40.
General Trends


At 3 months, significant improvements in 20 of
the 22 physicians
 Increased motivating behaviors and
motivating impact
 Decreased disruptive behaviors and disruptive
impact
Changes in behavior reported by “others”
Samenow CP, Swiggart W, Blackford J, Fishel T, Dodd D, Neufeld R, Spickard A. A CME Course Aimed
at Addressing Disruptive Behavior. Physician Executive; 34 (1) Jan/Feb 2008: 32-40.
23
Demographics

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Total Physicians Studied = 39
Mean Age: 49.7 (compare to CPH mean age 49)
Age Range: 27 - 64
Predominantly Male (84%) and Caucasian (87%)
49% Married, 10% Divorced, 26% Multiple, 10%
Single
Group Practice/Partnership (41%), Hospital Based
(21%), Solo (10%), Trainee (3%)
Samenow CP, Swiggart W, Blackford J, Fishel T, Dodd D, Neufeld R, Spickard A. A CME Course Aimed
at Addressing Disruptive Behavior. Physician Executive; 34 (1) Jan/Feb 2008: 32-40.
Specialty Types
Specialty Medicine
7 (18%)
Anesthesia
5 (13%)
General Med/Family
Practice
5 (13%)
Specialty Surgery
5 (13%)
Ob/Gyn
5 (13%)
General Surgery
4 (10%)
Emergency Med
2 (5%)
Dentist
1 (3%)
Other
5 (13%)
Samenow CP, Swiggart W, Blackford J, Fishel T, Dodd D, Neufeld R, Spickard A. A CME Course Aimed
at Addressing Disruptive Behavior. Physician Executive; 34 (1) Jan/Feb 2008: 32-40.
Infrastructure for Addressing
Unprofessional Behavior
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Leadership commitment
Model to guide graduated interventions
Supportive institutional policies
Surveillance tools to capture pt/staff allegations
Processes for reviewing allegations
Multi-level professional/leader training
Resources to help disruptive colleagues
Resources to help disrupted staff and patients
Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism:
Identifying, Measuring and Addressing Unprofessional Behaviors. Academic Medicine. November, 2007.
Potential Resources for Healthy
Coping
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Courses
Coaches,
counselors
Comprehensive
Evaluation
360° Evaluations
Risk Managers
Physician Wellness
Treatment Centers
 Office
of General
Counsel
 State BME
 Professional Societies
 QI Officers
 EAP
 Others
 State Physician Health
Program
27
Reid Finlayson, MD
Director, Vanderbilt Comprehensive Assessment Program
Associate Professor of Psychiatry
www.mc.vanderbilt.edu/root/vcap
“Disruptive”
Health Care Professionals
1)
2)
3)
Literature review
Fitness-for-duty evaluations
Future research
“More than 20% of caregivers have witnessed
actual harm come to patients as a result of
condescending, insulting or rude behavior by
professionals.”
SEVEN ZONES OF SILENCE:
Broken rules, Mistakes, Lack of support,
Incompetence, Poor teamwork, Disrespect,
Micromanagement
N=4530 RN=2846 MD=944
Rosenstein and O’Daniel, 2008
Rebecca Saxton et al 2009
Rebecca Saxton et al 2009
Comprehensive Evaluation



APA guidelines for Fitness for Duty Evaluations
Multidisciplinary: 1-5 days
 Medical
 Psychiatric evaluation
 Psychological testing
 Psychosocial including genogram
 Addiction screening
 Collateral information
Comprehensive report with recommendations
Disruptive Data, Axis I diagnosis
n = 118
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
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No Diagnosis
Dysthymic D/O
Adj. D/O
SIMD/PTSD/MDD
Substance Abuse/Dep
Int. Explosive D/O
Other (psychosis, cognitive d/o, bipolar)
52
16
13
17
16
4
12
Disruptive Data, Axis II diagnosis
n = 118


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Narcissistic Traits
Personality D/O, NOS
Compulsive Traits
Defer/None
Other traits
Other Pers. D/O
41
35
26
25
13
7
Disruptive Data: Axis III
n=118

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
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None – 29
Occular-3
ENT/allergy-9
CNS - brain lesions -7; seizures-1; migraine-3
Cardiac - CAD-2; HTN-19; arrhythmia-5; dyslipidemia-9
Diabetes – type I – 3; type II - 4
Hypothyroid - 7
Respiratory asthma/bronchitis- 6; sleep apnea- 5
GI - obesity -10; bariatric surgery-1; GERD or ulcer-12;
IBS-3; const-1; Liver-3
Cancers - 4
Arthritic back- 9; other joint-13
Case presentation – history (1)
Dr A is a 40 year old general surgeon referred for
evaluation following several angry outbursts in his
hospital’s OR. The most egregious (and final)
outburst involved his threatening to shoot one of his
OR staff. Although he reportedly immediately told
staff that he wasn’t serious about the threat, a
complaint was filed because he was commonly
known to have an extensive gun collection at his
home, and this staff member lived in the same
neighborhood.
Rebecca Saxton et al, 2009
Rebecca Saxton 2009
The Disruptive Physician: A Conceptual
Organization
Williams and Williams, 2008
Problematic Physicians
MMPI -2 Profile
Categories
60
40
Disrupt
Sexual
Other
20
0
Ds Ch Nl nV
PAI
80
60
40
20
0
Disrupt
Sexual
Other
D
I
AS N
A - Disruptive n=39
B – Sexual n=25
C – Other n=24
Category Analysis
MMPI-2: Ds=distress, Ch=character, Nl=normal, nV=invalid
PAI: D=distress, I-interpersonal, AS=antisocial, N=normal
*Roback, Howard et al, Canadian Journal of Psychiatry Vol 52, No 5, May 2007
Problematic Physicians

A (Disruptive)


Valid profiles, open, high interpersonal
dysfunction, admit and rationalize anger
B (Sexual) – FEWEST NORMAL PROFILES
- MOST CHARACTER PATHOLOGY
Impulsive, selfish, low empathy,
irresponsible
 Exaggerated positive light = Therapeutic
Challenge


C (Other)
*Roback, Howard et al, Canadian Journal of Psychiatry Vol 52, No 5, May 2007
Systems and Monitoring
Betsy White Williams, Ph.D., M.P.H.
Rush University Medical School
Professional Renewal Center
Background
• I have been asked to speak to:
– The relationship between disruption and systems;
– Monitoring and measurement of behavior.
• These may seem like unrelated issues, but in
my view they are very closely intertwined.
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
4747
Organization of the discussion
• I have taken the liberty of employing a few
illustrative quotations to provide an
organization for these thoughts.
• In the area of systems, this presentation
focuses on three:
– Social systems;
– Institutional systems; and,
– Personal systems.
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
48
Social Systems
• "All mankind is of one author, and is one
volume;....No man is an island, entire of
itself…, because I am involved in mankind; and
therefore never send to know for whom the
bell tolls; it tolls for thee.”
• John Donne: Meditation XVll
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
49
Institutional Systems
• "Every system is perfectly designed to get
the results it gets.”
• Batalden 2006, attributed variously,
perhaps W. Edward Deming
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
50
Personal Systems
• 'Cause, remember: no matter where you go...
there you are.’
• Buckaroo Banzai In the Fourth Dimension
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
51
Systems
• Systems nest like Russian dolls:
Social System
Institutional System
Personal
System
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
52
Disruptive Behavior – Personal Systems
• “… no matter where you go... there you are.’
• Can be based on a lack of social competence.
• Can be based on a lack of behavioral
regulation.
Poor social competence
Poor regulatory competence
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
53
• Can be aimed at diffuse
and ill defined goals.
• Can be aimed at specific
and well defined
outcomes.
Ill defined goal
Well defined objective
Disruptive Behavior – Personal Systems
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
54
Ill defined goal
Well defined objective
Disruptive Behavior – Personal Systems
Demanding
Manipulative
Frustrated
Angry
Poor social competence
Poor regulatory competence
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
55
Disruptive Behavior and Institutional
Functioning
• "Every system is perfectly designed to get the
results it gets.”
Social System
Institutional System
Demanding
Manipulative
Personal
System
Frustrated
Angry
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
56
Disruptive Behavior and Institutional
Functioning
• Disruptive behavior affects both the
– Connotative elements
• Emotional well being,
• Affiliation, as well as the
– Denotative elements of healthcare institutional
functioning, including
• Role clarity,
• Protocol implementation and duties, and,
• Communications.
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
57
Disruptive Behavior and Institutional
Functioning
• Emotional wellbeing is
negatively affected:
• Depression, and
• Anxiety
70. 00
Increased
control and
fatigue
65. 00
60. 00
T-Score
– A significant increase in
departments with
identified physicians in:
Mood Data
Increased
anxiety
55. 00
50. 00
45. 00
40. 00
35. 00
30. 00
T ensi on
Depr essi on
Physicians
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
A nxi et y
V i gor
Fat i gue
Conf usi on
Mood
Nurses/Techs
58
Disruptive Behavior and Institutional
Functioning
• Disruptive behavior
decreases staff’s sense of
affiliation with the
healthcare institution.
– A significant decrease in
staff’s reported sense of
affiliation;
– A comparison of staff in a
department with an
identified disruptive
member as compared to a
matched department in
the same institution.
Loyalty
Affilliation
Obligation
-1.00
-0.75
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
-0.50
-0.25
0.00
0.25
0.50
0.75
1.00
Index Comparison
59
Disruptive Behavior and Institutional
Functioning
• Disruptive behavior
decreases staff’s
understanding of their
role.
– A significant decrease in
staff’s reported
understanding of their
role;
– A comparison of staff in a
department with an
identified disruptive
member as compared to a
matched department in
the same institution.
Clear Tasks
Unnecessary Tasks
Clear Clients
Clear Goals
-1.00
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
-0.75
-0.50
-0.25
Index
0.00
0.25
0.50
0.75
1.00
Comparison
60
Disruptive Behavior and Institutional
Functioning
• Depending on the nature of the disruptive
behavior it can engender:
– Deviation from accepted institutional protocols;
and,
– Support staff providing services out-of-scope.
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
61
Disruptive Behavior and Institutional
Functioning
– Such decreases are typically
marked by a decrease
between the disruptive
physician and others;
– Other patterns include
decreased communications
between micro-systems or
even entire departments.
5
4.5
4
3.5
3
In
de
x
De
In pa
de rtm
x e
nt
De
pa
rtm
en I
t nd
ex
De
Inpar
de tm
x en
t
De
pa
rtm
en
t
In
de
x
De
In par
de tm
Dex en
t
pa
rtm
en
t
• Disruptive behavior’s
hallmark is a decrease in
communication:
TeamCohesionIndexPhysicianvs. Department
2.5
2
1.5
1
0.5
0
Frequency
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
Importance
Comfort
62
Disruptive Behavior and Institutional
Functioning
• The presence of the
system disruption
ultimately results in
breakdown:
–
–
–
–
Communications;
Affiliation;
Roles; and,
Protocols and duties.
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
63
Disruptive behavior – Social systems
• ”… never send to know for whom the bell tolls; it
tolls for thee.”
Social System
Institutional System
Demanding
Manipulative
Personal
System
Frustrated
Angry
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
64
Disruptive behavior – Social systems
• The disruptive physician is referred to
treatment, administrative procedure or both.
Social System
Institutional System
Board
Personal
System
PHP
Treater
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
65
Disruptive behavior – Social systems
• If the physician is returned to the institution
to practice, it is necessary to ensure that the
behavior does not recur,
– There is a significant level of recidivism,
– As high as 20% among “severe offenders” (Grant
and Alfred 2007)
• Prior behavioral issues are a significant risk
factor for later disruption (Papadakis and collegues,
see for example, Papadakis, Arnold et al. 2008)
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
66
Disruptive behavior – Social systems
• A monitoring system that is under
development measures these issues using a
360◦ survey.
• Early data show the survey to be well
tolerated and demonstrates face validity.
• The survey was developed to facilitate
integration with institutional systems.
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
67
Disruptive behavior – Social systems
• Preliminary results
suggest that disruptive
physicians may not
differ significantly from
normal physicians in
mean performance but
may differ significantly
in skew.
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
68
Disruptive behavior – Social systems
• It seems likely that over
time as the disruptive
behavior is extinguished
the pattern of data will
modify.
• Early results suggest the
proportion of extreme
reports falls and
moderate to good
reports increase.
B.W.WILLIAMS TO ACCOMPANY A TALK
DELIVERED AT THE FSPHP SPRING
MEETING 2010
69
A Quick Summary
Issue
Result
'Cause, remember: no matter where you
go... there you are.’
The disruptive physician carries the
behavioral consequences of their problem
to all systems in which they function.
"Every system is perfectly designed to
get the results it gets.”
A system in which a disruptive physician is
functioning is a system in which a
disruptive physician can function and
perhaps prosper.
"All mankind is of one author, and is one
volume;....No man is an island, entire of
itself…, because I am involved in mankind;
and therefore never send to know for
whom the bell tolls; it tolls for thee.”
The disruptive physician can be treated,
but if they are treated as an “island”, they
are likely to return to the behaviors that
had “worked” for them in the past.
BWWilliams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
70
Approaches To The Disruptive
Professional
Martha E. Brown, MD
Associate Dean for Faculty Development
Associate Professor of Psychiatry
USF College of Medicine
Remembering this is treatable is
hard



When the professional who is taking a
CME course on the issue, cusses out and
files complaints against your assistant and
the CME office
When the professional punches a hole in
your wall
When the professional is arrested for
hiring people to injury and kill those who
have made them mad
The Solution Many Consider


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
Could be the most cost saving
Certainly efficient
Saves time
Simple
Great fantasy
However, not real practical…
Institutional Barriers To Dealing
With The Problem

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
Medical Center and hospital leaders not
committed to addressing the problem daily and
want the PHP to do it all
Directives do not come from the top down
Lack of funding for implementation of an
internal program in the organization (selling
point is that programs can save the
organization $5.00 to $16.00 for every dollar
invested as well as decrease and prevent
malpractice suits)
Institutional Barriers To Dealing
With The Problem




Behaviors not extensively documented
Hospitals do not want to “anger” their top
producers
No one likes lawyers
Lack of in-depth policies in the hospital or
practice
HAVING LESS AUTHORITY
WITH DISRUPTION
But Others See You As The
Solution
DETERMINING YOUR
APPROACH





Do you want to monitor disruption?
What legal support do you have?
What is the level of your tolerance for
dealing with the behavior?
What is the tolerance level of your staff
for dealing with the behavior and do they
need additional training?
Determine if you can accept delayed
gratification
STARTING AT THE TOP




Talk with the referral source about what
policies they have in place
Ask what the hospital or medical group is
willing to do about the problem
Seek information from collateral sources
Assess the level of the problem



Inpatient evaluation
Outpatient evaluation
360 workplace evaluation
STARTING AT THE TOP



Can start with a comprehensive outpatient
evaluation with psychological testing
Many outpatient evaluations SHOULD lead
to a five to seven day inpatient evaluation
Determine what category the professional
falls within:



Needs long-term inpatient treatment and has a
treatable disorder or an Axis II Disorder
Determine can do well outpatient, can keep working,
needs information, therapy, monitoring, and/or CME
Needs to find a paper hat job
WHAT WE HAVE LEARNED


Medical student and resident training
cultivates many of the disruptive
behaviors as they learn from their
mentor’s behaviors
It is important that the Federation start to
work with medical schools to ensure
information on disruption is included in the
training programs
WHAT WE HAVE LEARNED


There is a need to develop standard,
model policies for hospitals
Information needs to be widely distributed
to hospitals and medical practices that this
is treatable, saves money, prevents
malpractice suits, and that early
intervention is best
WHAT WE HAVE LEARNED



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Monitoring contracts need to be flexible
360 evaluations are imperative for
monitoring and to see how the
professional is progressing
Not all can be helped or saved
Intensive small group CME with
monitoring works for many
Summary
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Disruptive behavior is a patient safety
issue
State PHPs can be an extremely valuable
resource for both physicians and
institutions
An objective, comprehensive assessment
is invaluable
It is important to understand the system’s
issues related to an individual’s behavior