This article was originally published inthe International Journal for Direct Support Providers (volume 12, issue 5), https://thefamilyhelpnetwork.ca/resources/international-journal-for-direct-support-professionals/
In a word, maybe. But not because you don’t have what it takes or because you don’t care about the work you do, or the people you serve. Of all the things you do every day at work; the problems you solve, the challenges you overcome, the relationships you build, when a behaviour that challenges shows up, it usually commands your immediate attention (and perhaps intervention). It often comes with a sense of urgency to eliminate it – a client may be doing something that is causing harm or putting others at risk – and your job is to fix it, right?
There’s a hidden problem in trying to solve “behaviour problems”, if you show up with an eliminative agenda (get rid of it, suppress it, solve it), you might be unwittingly choosing a path that limits not only your role but also how you engage the people you serve. Maybe it’s possible to do something different…
From a constructional view of behaviour, all behaviour makes sense - meaning all the things that we do (we as in you, me, the people we serve, and everyone else). ‘All behaviour’ encompasses behaviours that challenge (or whatever you call it: challenging behaviours,problem behaviours, maladaptive behaviours, dysfunctional behaviours, misbehaviours, etc.). All behaviour makes sense because these behaviours (responses/actions) have been ‘selected’ into a person’s repertoire given the contexts they occur in. From here, patterns of behaviour are built over time.If a particular behaviour didn’t serve a purpose (meet a need or want; access some reinforcer) then that behaviour would not continue to occur –there’d be no pattern; no pattern, no problem. So, from this view, no behaviour can be ‘maladaptive’, it’s quite the opposite actually – behaviours that challenge that keep occurring over time are in fact adaptive. That doesn’t mean that the behaviours that challenge aren’t costly or harmful – they likely are, otherwise, they wouldn’t be commanding your time and attention. If you have a client who is engaging in challenging behaviours, know that they have arrived there honestly – it’s not on purpose, it’s for a purpose – these responses have been selected based on the client’s unique history and circumstance. Our job is to make sense of this behaviour. Consider the following 4 client scenarios:
Client A seems to tell “tall tales” in everyday conversation, like they single handedly rescued a child who fell into the lions’ den at the zoo, or they survived for a week in the wilderness with nothing but a plastic spoon and the clothes on their back, or they won the lottery four times last year, but each time chose to anonymously donate the millions to various charities. In response, some staff just ignore the stories,some get irritated and tell the client to stop lying, and if the client tells the stories to friendly strangers in public, the strangers seem to just politely nod and look quizzically at the staff standing beside the client.
Client B can’t seem to keep their apartment clean; there is usually not a single clean dish and there’s garbage and clothes covering the floor. Staff have set up countless contracts, schedules, and incentive programs some of which seem to work for a little while but usually what ends up happening is after a few weeks one or two staff just bite the bullet and blitz clean the apartment while the client helps a little.
Client C will yell and swear at staff if they can’t immediately meet her demands. If asked to wait, she’ll call staff on the phone repeatedly seemingly just to hang up on them. Since staff can’t get aword in edgewise, usually someone ends up going by the client’s apartment to see if she’s ok and remind her that it’s not ok to yell, swear, and hang up on staff.
Client D has limited communication, but he can speak using a few words and gestures. He will bite his hand and hit the side of his head at the day program. The team has noticed that it most often happens when it gets too loud or when certain other clients get rowdy or too close. The team usually tries to keep the TV volume down and remind others to “use an indoor voice”. If the client bites or hits himself, they will quickly usher the client to another room to have tea and calm down for a few minutes.
For each client scenario, how can you make sense of the situation so that you arrive at the conclusion that this behaviour that challenges is 100% logical given the circumstance? To explore this, a different line of inquiry is needed than the usual starting point of “How bad? How much? How often?”. For every behaviour that challenges that we feel we need to intervene on, we need to first arrive at a place of “Yes, given this person’s context / circumstances, I can totally get why they are doing exactly what they are doing.”
As natural helpers and problem-solvers (in some ways, your career path chose you, didn’t it?) we tend to want to jump straight to ‘fix it’ mode – how can you eliminate, suppress, or get rid of this behaviour that challenges? This plays right into the usual starting questions (“How bad? How much? How often?”) which keeps laser focus on the “problem behaviours” while unfortunately eclipsing pretty much everything else about the client. What if we were to change tack on our starting questions, is it possible we’d end up in a different place than just eliminate, suppress, get rid of? Consider the following alternative starting questions:
See Box 1 for hypothetical responses to these questions for Client A. Once answers to these questions have been explored, we’ve actually established two very important things: (1) Where we are now (what the client is currently doing) and (2) Where we want to go (the goal state—the new skill/skill set). From here we can focus on the ‘how’ – how do we get from where we are now to where we want to go? This is all about the behaviour change procedures that focus on shaping new repertoires and tracking progress along the way. Notice how the “eliminate, suppress, get rid of…” is not along for the ride here. In this approach, behaviours that challenge that decrease as a result of the programming occurs more as a side effect than anything else.
Staff: “Well, it seems like the client gets a chance to talk to other people and they tell a story in which they come off as the hero or really skillful or special and caring to others in some way. So, I guess maybe they are trying to be seen as special or important by others.”
Staff: “Well, in the moment they seem to have someone listening to them but really in the long run, other people are probably weirded out or think of the client as a liar but yes, in that moment, they are leading an interesting and fantastical conversation and they’re connecting with someone.”
Staff: “The client talks to so called friends online but really since the pandemic, the client doesn’t have much contact with family, and the client doesn’t really have any lasting friendships in real life. The client spends most of their time at home and other than the staff team members who come in for program time once a day, the client doesn’t have anywhere to be – no job or day program or school and no other regular social events other than the occasional special event like a cookout, movies,or bowling. So, I guess feeling lonely or bored or being alone for most of the day kind of sets the stage for wanting to capture people’s attention and interest in these wild stories.”
Staff: “Well the client is actually really funny, and kind, and they can talk to anyone and carry on a conversation for a long time. They seem to get a lot of general knowledge about random things from the internet – some of it is questionable and is more in the realm of conspiracy theories but the client has actually shared random helpful life hacks particularly about ecofriendly cleaning products and alternatives. Now that I’m thinking of it, before the pandemic, the client used to volunteer at the seniors’ lodge, and they’d play cards and hang out with residents and serve and drink tea so that’s a skill –being patient and compassionate and having the gift of gab.”
Staff: “The client would have conversations with staff about regular stuff. The client would have the chance to chat up other people if they are willing, I guess it might be kind of boring only talking to staff about daily routine stuff. Maybe the client would do well getting a volunteer job again that involves talking to people.”
This line of questioning starts to shedlight on the costs and benefits of both the behaviour that challenges and possible alternatives. You may find that in the short run the behaviour that challenges may have some immediate benefits and costs or perhaps the costs come later in the long run. These are important patterns to observe because immediate contingencies are very powerful and in the moment often override possible harmful long-term consequences. You may find that after exploring these alternative starting questions, it is necessary to enlist the expertise of other healthcare professionals for example, for a client who is socially isolated or lonelyor who has a history of trauma it may be prudent to connect with a psychologist, social worker, or case manager to explore supports – not in the place of the work that you do, but rather to inform and bolster your programming.
We want to hear from the client too. If the client is willing and able, why wouldn’t we try to tap into their perspective and insights? As long as your questions are coming from a place of curiosity, compassion, and collaboration, you might receive unexpected and insightful responses. Instead of peppering a client with the usual questions about the ‘problem behaviour’, think of a client you’re working with right now and try to imagine what they would say if you were to ask them, “If we were successful in our work together, what would others see you doing?” or “If this (insert behaviour that challenges) was just not an issue anymore, what would you do more/less of? What would you do with your time?”
In a constructional approach, there are 5 domains of questions (Outcomes, Areas to Change and Not Change, Change History, Assets, and Consequences) that help clarify ‘where we are now’ and ‘where we want to go’ from the client’s unique perspective. The following list is a sample question from each domain:
See Box 2 for hypothetical responses from ClientA to these questions. It is possible that your client may be surprised by these questions, and it is very possible that you won’t get perfectly tidy answers leading you to a perfect and simple solution but the questions will help you get to know your client a little better and provide you with information to help you make sense of why your client is doing exactly what they are doing in the circumstances they are in. At the outset, we may have a sense of ‘where are we now?’ but without taking the time to unpack these questions with the client and with people close to them, like a rudderless boat, our programming will lackdirection and probably fail to ever pinpoint a meaningful and client-driven ‘where do we want to go?’. As you’ll see in the questions posed to the hypothetical Client A in Box 2, the client didn’t outright say, “Oh, yes, I’m aliar and I’d like to stop telling so many lies” so there is already some difference between what Client A’s caregivers are identifying as “the problem”and what Client A is telling you they want to work toward. This doesn’t mean that the opinions and observations of Client A’s caregivers are unimportant but imagine how different the conversation would go if the interviewer started with, “So, I understand that you have a problem with telling the truth…”. What important information can we learn from Client A about what’s important to them? This information is critical for providing direction on ‘where we do we want to go?’.
If you’re willing, I’m hoping to ask you a few questions so that we can figure out whatwe’re going to work toward.
Client A: “I don’t know. I want to be more independent; I would love to travel and go on adventures. I wish I had someone that I could goon adventures with. I want to do fun things and meet new and interesting people. I want more friends. I get irritated when some staff or my parents tell me I’m lying or tell me to quit day dreaming, I would love for them to stop doing that.”
Client A: “Well, I spend a lot of time on the internet, and I’ve learned a lot of stuff too. Most of the friends I have I met on social media, so I don’t want to lose these friendships because they are the only friends I have, and they get me.”
Client A: “Well, I’m not a kid anymore and if I want to travel and go on adventures, I need to make some money, so I need a job. I’ve basically been stuck in the same place doing the same old things for the last few years and that was ok during the pandemic because everyone was stuck, but now I see other people are out there and doing adventures and stuff and I’m not.”
Client A: “I think I’m a friendly person and I don’t judge anyone or treat them bad because of what other people say. If I saw someone who was lonely or alone, I would talk to them and be their friend. I’m good at talking, my mom jokes that I started talking late but once I started, I never stopped and it’s true!”
ClientA: “Well, sometimes if my brother is being irritating when I’m visiting my parents’ place or if staff are bugging on me to do some chore, if I just say whatever is on my mind and keep on it then they usually leave me alone. Mybrother will tell me I’m ‘crazy’, but I don’t care, I didn’t want to be around him anyways.”
This approach is not about simply “focusing on the positive”. There are some behaviours that challenge that are truly very serious and harmful – this isn’t about minimizing their impacts or ignoring them and hoping they won’t occur. The occurrence of a behaviour that challenges gives us important clues about the naturally occurring reinforcers that are maintaining it. Instead of taking away reinforcers, our goal is to help the client build repertoires to access these naturally occurring reinforcers in ways that are less costly and less harmful. There is something elegantly simple here because this approach doesn’t necessitate adding on external consequences or artificial reinforcers – everything you and your client need is already present in the current context. This approach helps expand your role beyond scanning for and managing behaviours that challenge and it reminds us that the people we serve are not simply a collection of problems to be solved—there’s a human there with a history and personally chosen values and goals. Our role can be about helping engineer environments that set the stage for the clients we serve to build repertoires to meet their goals. Once your client has arrived at the goal, the work then switches to how to keep it going – how can you ensure the context is supporting the new or alternate skill/skill set? Your role is still about providing support to the client, it just doesn’t have to be about eliminate, suppress, get rid of.
Human behaviour is complex and there is alot that we do not have access to – we can’t change people’s history, we can’t open up someone’s head and remove this particular behaviour that challenges, let alone convince someone to just do things the way we want. We do know that human behaviour is influenced by circumstance, and we do have access to current contexts, so this is a wonderful place to focus our attention and efforts to help the clients we serve to build repertoires that serve them well in the contexts they live in. We’ve just explored the starting point of a constructional approach… but there is a lot more to it. Planning change procedures takes careful work and there is also tracking over time to evaluate progress, but this doesn’t mean you can’t start something different right now. Even just slowing down, resisting the urge to swing the “let’s eliminate this behaviour problem” hammer, and making serious business of making sense of behaviours that challenge are small steps that are all travelling in the direction of a collaborative constructional approach.
Layng, T.V.J., Andronis, P.T., Codd, R.T.,& Abdel-Jalil, A. (2022). Nonlinear Contingency Analysis: Going BeyondCognition and Behavior in Clinical Practice. New York: Routledge.
Lesley is an Assistant Clinical Professor in the Psychiatry & Behavioural Neurosciences Department at McMaster University and a Board Certified Behavior Analyst (BCBA) who has worked in fields of children’s mental health, neonatal follow up, and intellectual and developmental disabilities across the lifespan. Lesley works at Surrey Place in Toronto and serves clients and caregivers in Northwestern Ontario. Her clinical interests include parent and teacher mediated interventions, goal setting in self-management, and infusing Acceptance and Commitment Training(ACT) into traditional functional behaviour assessment and intervention.
