When working in the care industry whether that is with the elderly, mental health or children it becomes apparent that you as an individual become empowered by virtue of being primary care for that specific individual hence being an influential figure in any individual’s life recovery and rehabilitation. Due to this factor we have had many horrific incidents which have involved individuals in a position of power and whom have abused this trust and disregarded legislation, policy and procedure to continually systematically abuse service users in a vulnerable position. It is no secret that this has happened and still continues today within places of care. This is the purpose of the new legislative law updated and reviewed to combat and eliminate such barbaric behaviours displayed by so called supportive staff members in supposedly places of secure safe environments.
The purpose of legislative law is to filter new and reform existing legislation through to the relevant policies and procedures within specific places of work. So to summarise the purpose of legislation in terms of managing difficult behaviours is that it functions to safe guard the vulnerability of service users in places of care which predominantly gets feed down through governing bodies to the policies and procedures file within the office within your place of work. It can be looked upon as a code of good practice with regards how to deal with vulnerable adults whom display challenging behaviours within places of care.
When working within such an environment it is almost expected to receive challenging behaviour due to the different backgrounds and diagnosis the service users have so it would not be acceptable to react within such a way as you would when away from the unit due to the very essence of the clientele we deal with. This is not to say we are not in a vulnerable position to so we are legally permitted to utilise restraint techniques which is in the form of an in depth restraint course which covers floor, escorting and seated restraints for the safety of the service user, other service users and also the safety of your fellow support staff within the workplace. This form of restraint is always the last line of defence it is paramount to utilise the different approaches available to return the service user to his baseline without putting hands on a client.
The reason for such care institutions is specifically to rehabilitate and educate service users in the acquisition of knowledge regarding them to facilitate them to utilise coping strategies in the effort of recovery and rehabilitation rather than punitive based techniques. There are a massive variety of different approaches and methods when attempting to change an individual’s behaviour. We will target only a specific few that are more prevalent within today’s industry. The methods and approaches will include motivational interviewing, cognitive behavioural therapy, solution-focused therapy and adult learning methods these will be the approaches and methods that I will expand upon throughout the chapter. CBT is a form of talking therapy that combines cognitive therapy and behaviour therapy. It focuses on how you think about the things going on in your life, your thoughts, images, beliefs and attitudes (your cognitive processes), and how this impacts on the way you behave and deal with emotional problems.
It then looks at how you can change any negative patterns of thinking or behaviour that may be causing you difficulties. In turn, this can change the way you feel. CBT tends to be short, taking six weeks to six months. You will usually attend a session once a week, each session lasting either 50 minutes or an hour. Together with the therapist you will explore what your problems are and develop a plan for tackling them. You will learn a set of principles that you can apply whenever you need to. You may find them useful long after you have left therapy. CBT may focus on what is going on in the present rather than the past. However, the therapy may also look at your past and how your past experiences impact on how you interpret the world now. The concept of motivational interviewing evolved from experience in the treatment of problem drinkers, and was first described by Miller (1983) in an article published in Behavioral Psychotherapy.
These fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures. Motivational interviewing is a semi-directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it’s more focused and goal-directed. Motivational Interviewing is a method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior. The examination and resolution of ambivalence is a central purpose, and the counselor is intentionally directive in pursuing this goal. Motivational interviewing recognizes and accepts the fact that clients who need to make changes in their lives approach counseling at different levels of readiness to change their behavior. During counseling, some patient may have thought about it but not taken steps to change it while some especially those voluntarily seeking counseling, may be actively trying to change their behavior and may have been doing so unsuccessfully for years.
In order for a therapist to be successful at motivational interviewing, four basic skills should first be established. These skills include: the ability to ask open ended questions, the ability to provide affirmations, the capacity for reflective listening, and the ability to periodically provide summary statements to the client. Motivational interviewing is non-judgmental, non-confrontational and non-adversarial. The approach attempts to increase the client’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Alternately, therapists help clients envision a better future, and become increasingly motivated to achieve it. Either way, the strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change.
Motivational interviewing focuses on the present, and entails working with a client to access motivation to change a particular behavior, that is not consistent with a client’s personal value or goal. Warmth, genuine empathy, and unconditional positive regard are necessary to foster therapeutic gain (Rogers, 1961) within motivational interviewing. Another central concept is that ambivalence about decisions is resolved by conscious or unconscious weighing of pros and cons of change vs. not changing (Ajzen, 1980). It is critical to meet patients/clients where they are (Prochaska, 1983), and to not force a client towards change when they have not expressed a desire to do so. Motivational interviewing is considered to be both client-centered and semi-directive. It departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than non-directively explore themselves.
Solution focused brief therapy (SFBT), often referred to as simply ‘solution focused therapy’ or ‘brief therapy’, is a type of talking therapy that is based upon social constructionist philosophy. It focuses on what clients want to achieve through therapy rather than on the problems that made them seek help. The approach does not focus on the past, but instead, focuses on the present and future. The therapist or counselor uses respectful curiosity to invite the client to envision their preferred future and then therapist and client start attending to any moves towards it whether these are small increments or large changes. To support this, questions are asked about the client’s story, strengths and resources, and about exceptions to the problem. Solution focused therapists believe that change is constant. By helping people identify the things that they wish to have changed in their life and also to attend to those things that are currently happening that they wish to continue to have happen, SFBT therapists help their clients to construct a concrete vision of a preferred future for themselves.
The SFBT therapist then helps the client to identify times in their current life that are closer to this future, and examines what is different on these occasions. By bringing these small successes to their awareness, and helping them to repeat these successful things they do when the problem is not there or less severe, the therapists helps the client move towards the preferred future they have identified. Adult learning theory is part of being an effective educator involves understanding how adults learn best. Andragogy (adult learning) is a theory that holds a set of assumptions about how adults learn. Andragogy emphasises the value of the process of learning.
It uses approaches to learning that are problem-based and collaborative rather than didactic, and also emphasises more equality between the teacher and learner. Andragogy as a study of adult learning originated in Europe in 1950’s and was then pioneered as a theory and model of adult learning from the 1970’s by Malcolm Knowles an American practitioner and theorist of adult education, who defined andragogy as “the art and science of helping adults learn”. Knowles identified the six principles of adult learning outlined below.
Adults are internally motivated and self-directed
Adults bring life experiences and knowledge to learning experiences Adults are goal oriented
Adults are relevancy oriented
Adults are practical
Adult learners like to be respected
When we discuss behaviours it is imperative to understand why these behaviours are being displayed and it is often something which appears very minor to care staff but it can be interpreted as a big dilemma to the individual in question. When understanding the reasons for behaviours there can be many reasons for them but here is a few more common examples, culture, gender, beliefs, personality, illness, medication side effects, family, personal occasions etc. These are all contributing factors as to why individuals will display certain behaviours. Within the unit it has been noticed that a specific factor i.e. family contact can have a huge effect on a certain individual in our care.
Due to the fact that this individual has very minimal contact with his family (personal choice) when this individual does eventually get to speak with his close family it can conjure up many different feelings within and can cause indirect behaviours within the unit. Feelings such as abandonment, not loved, singled out, why? These contributing factors will mix together and inevitably have to be released e.g. become withdrawn, aggressive, depressed (low). Now the staff team have highlighted this concern and a concise care plan has been put into place and agreed by the individual it can be monitored and dealt with more effectively in the requisition for this individual to eventually become more comfortable when discussing and contact the family. 2 (2.2)
When we discuss the influence of the environment and behaviour of other individuals we are basically referring to the place in which these individuals reside e.g. the psychiatric hospital or the community home etc. These environments can play an enormously important role in the behaviours of individuals whom are observing they can be easily influenced by others actions and will tend to mimic or act up to the situation or incident. It depends on the individuals in question but what can happen in a unit which is occupied by more than one service user is that individuals will observe (audience effect) and will either react in three different ways. The individual will either adopt and mimic the behaviour being displayed thus causing a major incident or the individual will remove themselves or will confront that individual or group of individuals having an incident thus again causing problems for the unit. 3 (3.1)
When working in an area such as mental health it is imperative from the beginning to ensure you adopt a professional relationship and maintain this as long as you remain in the care system. It has been said to me that a good rule to follow is that of firm, fair but fun but not forgetting that there are constant boundaries that should be followed throughout your working career and not to be crossed. The working relationship is so important within mental health due to the fact specific clients will have blurred boundaries or have no boundaries at all so it is imperative as support staff the clearly and quickly introduce clear concise boundaries for service users.
The working relationship has to remain purely professional for a number of reasons but mainly for the safety of the service users and that they do not miss interpret signals given by support staff and un intentionally cross the boundaries. If the professional working relationship is followed it can create a healthy relationship between support staff and service user and the avoidance of blurred boundaries. This is not to say that service users will not try and test the boundaries of specific staff members as this is commonplace within the area of mental health but as professional support worker it needs to meet with a firm approach and dealt with in a professional manner.