Problematic and Risk Behaviours in Psychosis

A Shared Formulation Approach

Alan Meaden, David Hacker

• Publisher: Routledge
• Year: 2010
• eBook ISBN: 9781136851322
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

In spite of improved access to psychosocial interventions, many people with psychosis continue to experience persistent problems which act as significant barriers to their recovery. This book investigates risk and problem behaviours in psychosis, including staff and service factors that can impede the delivery of effective care.

Problematic and Risk Behaviours in Psychosis provides a new approach for assessment, formulation and intervention within such problem behaviours in a team context. Of particular interest will be:

• an outline of the SAFE (Shared Assessment, Formulation and Education) approach
• an integrative model for understanding risk and problematic behaviour
• shared risk assessment and management processes
• approaches to reducing team and carer barriers to effective care
• the use of CBT in day-to-day interactions with clients
• a set of formulation-driven strategies for managing problematic behaviours
• case studies and vignettes providing guidance and highlighting the benefits of the approach.

This book will have particular appeal to professionals working in specialist community, hospital-based and residential services who often struggle to help those with the most complex mental health problems who are hardest to reach. It is also an excellent resource for those engaged in training in psychological therapies, risk assessment and management.

Part 1
The SAFE approach

Theory, models and processes

Chapter 1
Problematic behaviour in psychosis: a barrier to social inclusion and recovery

Definitions, prevalence and consequences

INTRODUCTION

Psychosocial interventions (e.g. behavioural family therapy, relapse prevention, psychoeducation and cognitive-behaviour therapy) for psychosis have received increasing attention and support for adoption into routine practice in recent years. Cognitive-behaviour therapy (CBT) for psychosis, for example, is now part of standard evidence-based practice, both in research and clinical arenas and latterly in government guidelines in the United Kingdom (National Institute for Clinical Excellence, 2002; National Institute for Health and Clinical Excellence, 2009). The focus of these interventions has often been on the reduction of symptoms and distress or the prevention of psychotic relapse. A large number of randomised controlled trials have, however, failed to show consistent evidence of sustained clinical outcomes (Jones et al., 2002; Wykes et al., 2007; Lynch et al., 2010). The reality is that many people’s psychotic symptoms and associated beliefs remain treatment resistant even to CBT and they continue to be cared for in long-term settings, by Multidisciplinary Teams (MDTs) where the emphasis is often on minimising risk. Perhaps surprisingly, much less attention has typically been paid to the multidisciplinary treatment and management of these clients who exhibit problematic or risk behaviours. This is in spite of the fact that behaviours such as aggression are a common issue in psychiatric inpatient treatment (Daffern et al., 2004, 2007) and in the community (Swanson et al., 1990; Monahan et al., 2001). Individuals with psychotic disorders such as schizophrenia are also at greater risk of suicide (Pompili et al., 2007) and self-neglect (ReThink, 2004). Furthermore, such behaviours may severely limit the individual’s independence and freedom, significantly reducing their opportunities for community living and decreasing their quality of life. In this book we outline an innovative approach to the assessment and management of problematic and risk behaviours in psychosis. We term this the Shared Assessment, Formulation and Education (SAFE) approach. Our primary focus is on achieving integrated MDT working, aimed at eliciting changes in the client’s problematic or risk behaviours, whilst concurrently promoting a reduction in distress. It is a collaborative process that values all perspectives and serves to normalise problematic behaviours, making them understandable through the use of shared formulation processes. SAFE aims to also increase staff¹ and carer empathy and promote shared effective care for managing such behaviours. Ultimately, our goal is to maximise the individual’s independence by reducing barriers to living an ordinary life that problematic and risk behaviours can create and thereby enabling opportunities for recovery.

THE NATURE OF THE PROBLEM: DEFINITIONS AND CLASSIFICATION

A key source of empirical literature regarding what we have termed ‘problematic behaviour’ is to be found in the literature on challenging behaviour, based on research conducted in the field of intellectual or learning disability. Emerson’s (1995, as cited in Emerson, 2001, p. 3) definition of challenging behaviour is now widely accepted in this field and is one we have adopted to guide our development of SAFE: ‘culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities’. Challenging behaviour is therefore inherently defined by its impact. The definition encompasses both risk behaviours that are life threatening or likely to cause significant physical harm to self or others, and those that may cause distress or discomfort to self and others. The scope of this definition also extends to behaviours that result in the social exclusion of the individual concerned by either preventing the use of community facilities or alienating the person from potential social supports or relationships. Whilst the social, physical and psychological impact is a crucial and defining element, the appearance or type of the behaviour (the behavioural topography) may also be important. In our experience, MDT members may hold very different beliefs about behaviours based on their apparent characteristics rather than their function (we discuss this in more depth in Chapters 2 and 8). In one of the few texts to make reference to challenging behaviours in psychosis, Hogg and Hall (1992) identified those which they considered to be commonly reported in people with schizophrenia. These included:

• aggression (physical assaults on other people, damage to property, self-injury);

• antisocial behaviour (shouting or screaming, swearing, spitting, recurrent and uncontrolled vomiting, smearing of faeces, stealing);

• sexually inappropriate behaviour (nakedness in public, exposure of genitals, masturbation in public, sexual harassment/assault);

• bizarre behaviour (stereotypic behaviour such as rocking or odd speech, using nonsense or jumbled-up words, unusual gait or hand movements, altered routine such as sleep reversal, unrestrained eating and drinking, including dangerous substances).

This list identifies many of the behaviours we encounter clinically and which prove problematic for the person or for others. It does not, however, encompass self-neglect or other behaviours that may make the person vulnerable in the community to either exploitation or abuse (e.g. wearing unusual clothes, talking back to voices out loud, walking alone at night in a dangerous area).

As a first step in beginning to understand and work with problematic behaviours, we offer a broad classification encompassing three dimensions:

• behavioural excesses versus behavioural deficits;

• high versus low risk;

• self versus other (the direction of the risk).

An individual with psychosis may display behaviours that are not typically exhibited within the cultural or social norm (depending on where they live) or age group to which they belongs (e.g. wearing excessive clothing in the summer, swearing loudly in public); we term these ‘behavioural excesses’. Alternatively, the individual may fail to display culturally or age-appropriate behaviours that are the norm for their peers. They may, for example, fail to attend to hygiene or personal safety, fail to engage in conversation when addressed or fail to display a normal range of emotional expressions; these we term ‘behavioural deficits’. Clearly, there is some overlap between these definitions and those symptoms used as criteria to define psychiatric disorders (such as those employed by the American Psychiatric Association, 2000). However, to some degree these symptoms relate to observable behaviours that are a result of more complex underlying processes. Behavioural deficits are a particular case in point. They may on the surface present as negative symptoms of schizophrenia (e.g. staying in bed all day). However, they may occur in response to positive symptoms (e.g. a voice telling the person that if they get up they will be punished). Our focus therefore is less on psychiatric diagnosis (although this is useful in defining some aspects of treatment and prognosis) and more on being clear about the behaviour exhibited, its function and its psychosocial impact.

A further dimension to defining problematic behaviour is whether the deficit or excess represents a high or low risk to self or others. Those with psychosis may exhibit behaviours that are clearly frustrating for those who care for them such as making excessive demands (e.g. asking for cigarettes or extra visits) or making inappropriate demands (e.g. banging on windows or making abusive phone calls). Such behaviours are clearly ‘excesses’ but do not necessarily pose a high risk. Other behaviours such as assaults on others or staff may pose a high risk of harm as well as being behavioural excesses. Similarly, behavioural deficits may present a relatively low risk (e.g. refusal to speak to certain team members or to tidy one’s living space) whilst others (e.g. refusal to maintain an adequate diet, refusal to take prescription medication for physical health conditions) may pose a significant but perhaps slightly longer-term risk to the person or their dependants. Finally, the direction of the behaviour in question (self versus other) is also a defining feature. For example, aggressive behaviours directed at staff may elicit more anger and resentment in the team than aggression directed at self, which may evoke sympathy and a greater helping response (Dagnan and Cairns, 2005). The interaction of these dimensions may be important: staff may respond with sympathy to apparently high-risk attempts at suicide (e.g. hanging) whilst lower-risk self-directed behaviours (e.g. scratching or cutting superficially) may be viewed as attempts at manipulation and hence regarded with more anger or dismissiveness. Clearly, the type of behaviour may predispose staff to make particular attributions about its purpose and subsequently alter their inclination to offer help; we discuss the role of staff attributions and beliefs further in Chapter 8.

THE SCALE OF THE PROBLEM: FREQUENCY AND PREVALENCE

Violence and aggression in inpatient settings

Violence and threatening behaviour are relatively common problems in inpatient psychiatric settings and may be the initial precipitant for admission. Binder and McNeil (1988), for example, found that 26 per cent of acute inpatients had been assaultative in the previous six months and 36 per cent had caused fear in others. Monahan (1992) reviewed 11 studies and found a median rate of 15 per cent of patients² committing a violent assault prior to admission (range 10 to 40 per cent). Of course, these groups may not be representative of people with psychosis as a whole, since these studies tended to examine the history of violence in those already admitted to hospital, which may represent a particular high-risk group. It may also be the case that procedures that are involved in the lead-up to admission themselves precipitate violent incidents (e.g. use of the police). During the stay itself, rates continue to be high. Daffern et al. (2007), for example, found that during one year, over 45 per cent of patients were aggressive on at least one occasion. Other similar studies indicate an overall rate of inpatient violence of between 10 and 40 per cent, with a median rate of 25 per cent (Monahan, 1992). It is notable that a small minority of patients tend to be responsible for a large proportion of incidents (Blumenthal and Lavender, 2000). In the United Kingdom, Commander ...

Table of contents

• Contents
• Figures
• Tables
• Abbreviations
• Preface
• Acknowledgements
• Introduction
• Part 1 The SAFE approach
• Part 2 Assessment
• Part 3 Interventions in SAFE
• Part 4 Implementation issues
• Appendix 1 Challenging Behaviour Checklist for Psychosis (CBC-P)
• Appendix 2 Recovery Goal Planning Interview
• Appendix 3 Personal, Social, Developmental and Psychiatric History Assessment
• Appendix 4 Challenging Behaviour Record Sheet for Psychosis (CBRS-P)
• Appendix 5 Idiosyncratic Behaviour Monitoring Checklist for Psychosis (IBMC-P)
• Appendix 6 Early Warning Signs of Risk (EWS-R) Checklist
• References
• Index