Reciprocal Roles and the 'Unspeakable Known': Exploring CAT within Services for People with Learning Disabilities

Lloyd, J. and Williams, B., 2003. Reciprocal Roles and the 'Unspeakable Known': Exploring CAT within Services for People with Learning Disabilities. Reformulation, Summer, pp.19-25.


Introduction

“The defensive or restraining reactions of carers, care staff and service agencies to people who show challenging behaviours may prove significantly more detrimental to their quality of life than the immediate physical consequences of the challenging
behaviours themselves.  These social responses may include abuse, inappropriate treatment, exclusion, deprivation and
systematic neglect.”
  (Emerson 2002, p3)

This article considers the contribution CAT ideas can make in addressing the interactional challenges Emerson describes to enable increased positive support for clients within a more mutually rewarding staff-client relationship. The authors are two clinical psychologists – Julie works with learning disabilities and Barbara is a CAT practitioner.  We first review the background to the problem as described in the LD literature.  We then go on to describe some relevant CAT concepts and discuss how the introduction of these in a workshop enabled staff to explore previously ‘taboo’ issues.

Presenting Problems

Challenging behaviour is usually defined as behaviours, “of such an intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour that is likely to seriously limit or deny access to and use of ordinary community facilities” (Emerson et al., 1994).   Reviewing 168 incidents of challenging behaviour in one month, Harris (1993)  found that 51% showed punching, slapping, pushing or pulling, 24% kicked, 21% pinched, and 20% scratched, amongst other behaviours.   These cold figures do not convey the stressful experience of working in this context.  Different organisational structures determine the resources available, professional roles and expectations and the amount of staff-support. This can mitigate the situation but staff often lack resources and are unsupported. The DOH ‘zero tolerance’ policy (for attacks on staff) does not seem to be applied to protect staff working in learning disabilities. Clients are seen as unable to understand the consequences of their behaviour and so unable to take responsibility for this.

Staff Reactions to Challenging Behaviours

In the lives of people with learning disabilities staff are central, providing the key to the quality of life they experience.  The effects on staff of challenging behaviours have been explored in terms of their feelings, stress levels and behavioural responses.  There are also studies on job satisfaction.
Emerson (2002) states that in response to aggressive behaviour from clients, half or more of the staff usually report such emotions as annoyance (in 57% of cases), despair (41%), sadness (40%), anger (39%), fear (27%), and disgust (16%).  The dominant message from these surveys is that staff are generally at least moderately stressed (Hatton and Emerson 1993, Rose 1991a).  Factors identified involve the ‘daily grind’, their difficulty in understanding the person’s behaviour, the unpredictability of the behaviour and the apparent absence of any effective way forward (Bromley & Emerson 1995).  In more clinical terms, the staff stresses identified included hopelessness, anxiety and PTSD.  Behavioural responses range from avoidance to reacting in kind.  There are issues about how staff manage their own feelings of aggression (Cottle, Kuipers, Murphy & Oakes 1995, Hatton, Brown, Caine & Emerson op cit, and Rose 1998).  Further reactions involve a lack of staff warmth, lack of attention, exclusion from community services and “a hardening of attitudes” (Hastings, Reed & Watts 1997).  Results from a typical survey on job satisfaction showed that staff working with people with challenging behaviour were significantly more anxious, felt less supported, had less job and role clarity and had lower job satisfaction than staff working in houses with no challenging behaviour (Jenkins, Rose & Lovell, 1997).

Staff Interventions and Their Repercussions

Staff use distraction, giving attention, verbal responses, restraining, and until recently, seclusion in the effort to reduce challenging behaviour.  These strategies may be successful in the immediate sense in bringing to an end an incident of challenging behaviour (Hastings & Remington, 1994, and Hastings 1996).  However, reactions are designed to curb the impact of challenging behaviours with the utmost speed and so are often ‘non reflective’ (Grant & Moores, 1977). Hastings and Remington’s (1994a) review of how staff react shows that, paradoxically, they are likely to encourage the emergence and continuation of these behaviours. In their view, staff responses offer a socially mediated form of reinforcement.  However, staff are aware that their emotional reactions affect their behaviour (Hastings 1995).  Tsiantis, Diareme and Kolaitis (2000) show that when residents become less aggressive and the fear of attack diminishes, staff worry less about their mental health, but then develop concern about their own levels of aggression.  Data has been collected to establish whether staff responses to challenging behaviours function to avoid their emotional intensity. For example, experienced staff may appear calm and detached to new staff first encountering such behaviours.  Showing pain, fear or disgust is often forbidden, which sometimes can lead to staff telling the visiting psychologist that there are ‘no problems here’. However, lacking opportunities for reflection, staff may copy the aggression they witness in their attempt to see themselves as tough and able to handle anything. 

Abuse by Staff

Such “interventions” might therefore amount to a form of reciprocal abuse.   Emerson (op. cit.) quotes Rusch, Hall & Griffen (1986), in an analysis of documented instances of abuse in a North American institution, identified challenging behaviours as the major predictor of who was likely to be abused.  This is explained as a function of high expressed emotion (Brown 1958, and Vaughn & Leff 1976). Staff experiencing generally elevated levels of anxiety may direct critical comments against service users and not themselves (Cottle, Kuipers, Murphy  & Oakes op cit.; Kiely & Pankhurst 1998, both cited by Emerson in his review retrieved 2002).  Researchers describe a ‘hardening of attitude’ in which staff increasingly blame the client and relationships worsen as the client gets a reputation.  Actions and opinions are continually interpreted or re-framed in negative ways in front of the silent resident.  This can constitute a subtle abuse that is not recognised as such by the staff concerned, as it becomes part of a degrading culture. 

Active Support Model

Mansell’s influential Active Support (Mansell, Hughes  &  McGill, 1994) model shows that services work best where staff are well trained and managed, providing active support to clients, with an emphasis on meaningful activity, relationships and the acquisition of new behaviours.  Staff work towards agreed and clearly specified outcomes for clients.  A deliberate and constructive approach involving role clarity, training, addressing attitudinal and organisational barriers needs to be taken that supports typical activities of everyday living (Porterfield, Blunden & Blewitt 1980: Cullen 1999: Felce 2002).

Dealing with challenging behaviour requires focusing on assisting individuals to be engaged in everyday leisure, personal and household activities.  This implies that in order to understand how to reinforce positively appropriate behaviours, staff need to develop greater discrimination over the purpose, quality and timing of their interaction with residents, making attention a possible motivating force, contingent upon engagement in activities.   Julie recently undertook a Functional Analysis of a client with Down’s Syndrome and challenging behaviour. This showed that when the home provided an adequate number of well-trained staff who were implementing Active Support in a naturalistic and warm manner, there were no incidents of challenging behaviour, in contrast with times when insufficient staff were available.

Problems Faced by the Consultant

Staff nonetheless often have difficulty in learning to implement Active Support or other interventions proposed by the psychologist. When approached by staff who have been unsuccessful in reducing challenging behaviour, there is often an immediate clash of expectations, recognised by most consultants (see fig. 1).  Staff may want the psychologist to take away challenging behaviour as if by magic. The psychologist develops guidelines with staff to address the problem, but the strategy involves staff members changing their own behaviour.  LD psychologists often bemoan the regularity with which guidelines inevitably fail with certain ‘heart sink’ staff and the psychologist is seen as useless.  Afterwards, nothing changes and the problems persist, so those staff ask for help again and a cycle develops where the client is repeatedly re-referred.  Further thinking is needed to understand what is going on, and perhaps it is here that a CAT framework can facilitate the necessary reflection.

CAT and Contextual Reformulation

The tools of CAT and, in particular, the use of SDR’s to facilitate change and improve staff morale has been described in working with BPD (Ryle 1997), CMHT’s (Dunn & Parry 1997), PICU’s (Kerr 2001) and surgical theatre staff (Walsh 1996).  We thought that contextual reformulations could be particularly applicable in LD where there is often marginalisation by society, including mainstream caring professions.  This relative isolation means that people in the field are exposed to a narrower range of relationships compared with others.  People with learning disability are therefore more likely to develop a narrower range of RRs (Crowley – talk at ‘Advancing Practice’ PLD Psychology Conference 2003) with a more intense pressure to reciprocate.  Workers may also be attracted to challenging behaviour because it fits in with the reciprocal roles they already know. This is broached by Appleby in the last issue of Reformulation.

From Julie’s knowledge of the LD literature and her own local observations, she plotted (fig. 1) some of the common interactional cycles seen in the field that repeatedly return staff to a position of low morale and unmanageable feelings. Barbara then converted this into a more generalised diagram (fig. 2) showing the reciprocal roles involved in generating these painful (“core”) feelings.  From Julie’s diagram, we can see a number of Traps whereby the belief that the situation is hopeless gives rise to RRP’s confirming this.

For example, hurt staff avoid residents who feel abandoned and issue hurtful challenges to get attention (punishing to punished).  Similarly, when staff avoid residents they may get bored and do not learn new skills.  Bored staff may then fly off the handle at small incidents which then escalate as it is exciting for all. (Exciting to excited → rejecting to rejected).
Another example is when humane staff want to avoid conflict

and try to be the resident’s friend.  They may “walk on egg shells”, viewing any abuse they might receive as a personal failure proving they are not good enough (Controlling to controlled).  They cannot place any demands on the resident who in turn lacks opportunity to learn new skills.  The frustrated resident’s challenging behaviour is then viewed as further evidence of the personal failure of the staff to provide perfect care.  (Perfectly caring to perfectly cared for → contemptuous to contemptible).

All this occurs within a context where everyone feels powerless – the clients because they have little control over their lives, the staff because they cannot cure the clients, the managers because they cannot give staff the resources they need and the psychologist because they cannot make it all better.

CAT Workshop

Discussing these concepts had proved useful to Julie and LD staff. She found that by talking about the roles invited by client behaviour, there were changes in staff attitudes and they made previously withheld resources available. Julie was then approached by Mencap to facilitate a support workshop to help staff cope with challenging behaviour.  In the past, these training workshops had seemed impersonal events about the application of strategies, methods and “interventions”.  It was as if there had been a conspiracy of silence with staff not being able to name and discuss their personal reactions within work settings.  On this occasion, Julie divided staff into small groups to describe typical chains of events in unresolved incidents, and staff reactions to these painful episodes.  Many feelings poured out (fig. 3), including ones staff recognised that they wished they did not have.  Feelings of hopelessness about how to reach and teach people with severe learning disabilities were described.  Shock, hurt and “hyped-up” frustration was acknowledged.  Staff admitted that they often pretended that nothing had happened after being attacked by residents.  They stated residents would be unaware of the hurt incurred and they did not want fellow staff to know they were upset, as they might not seem tough enough or able to cope.  Perhaps for the first time in a group, these feelings could be shared.

Staff wanted Julie to have all the right solutions, but she said that they could all think together about general approaches to reducing challenging behaviour in the long run, such as Active Support and Augmented Interaction.  They looked at Barbara’s diagram and held a lively discussion.   Staff were particularly keen to talk about boredom and excitement and how this cycle contrasted with the many things they liked about people with learning disabilities, such as not having to prove anything to them, feeling accepted by them and liking their honesty. They expressed positive feelings about the client group. However, it seemed that many of their motives for working in the field had rebounded on them, as they were still striving for acceptance and confused by others’ unpredictability – if not dissimulation.  Ideologically, in attempting to “create a better world” by revering a marginalised client group, they had ended up appeasing and acquiescing in intolerable behaviour (worshipful to ennobled).  In working with this less intelligent group they had perhaps expected to feel in charge and competent, escaping earlier feelings where they were condemned as stupid.  Sadly, they had still ended up feeling judged and inferior.

At the requested follow-up session, Julie returned with a diagram based on what staff had described during the group.  It included blaming to blamed, unhearing to unheard, unpredictable to lost / confused (fig. 4).

It was seen that there were many characteristic RRs that keep swapping round, with workers and clients occupying alternate poles at great speed.   As with BPD, coping with challenging behaviour splits staff, arousing anger, dismay, frustration and rejection in some staff and a crusading wish to rescue in others.   Through the workshop, staff found that CAT has useful ideas to clarify situations and through diagrams and drawings to say what often goes unsaid. It offers a map to track how both staff and clients change in ways that otherwise appear so inconsistent and contradictory.  Staff were positive about this and said that they valued the chance to talk about things that were not normally talked about, including ways out of endless circles.  Work centred on continuing to develop a ‘buddy’ system where staff can talk to each other about how they feel after they have been hurt following incidents of challenging behaviour.  

Concluding and Beginning

What does a CAT perspective have to offer to those working in challenging behaviour?   Some of the professional and social isolation of the learning disability world may be bridged through offering ideas about Reciprocal Roles.  CAT may explain some mechanisms through which staff actions help to maintain challenging behaviour and preclude staff from adopting Mansell’s active support model. Exploring the RR’s of people drawn to work in learning disabilities can help to reduce the compelling drive to reciprocate, through providing a language for discussing what is known but rarely said or reflected on -  or even acknowledged within the system. When staff feel more understood and supported, they can extend more support to their clients.   By using a CAT informed approach, staff can recognise that they do not have to be a perfect friend / carer, or the ‘brains for two people’. They are neither ideal caregivers nor completely useless- but they are “good enough”. In this way, some of the demons inherent in RR’s that recruit powerlessness may begin to be tamed?

These are some thoughts and initial hopes for a CAT approach.  We would like to hear from others working in the field to see if the diagrams seem relevant, and whether we can network in any way to assist our own reflection.
 
Emails:
Julie.Lloyd@shb-tr.nhs.uk
Barbara.Williams@wlmht.nhs.uk

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Full Reference

Lloyd, J. and Williams, B., 2003. Reciprocal Roles and the 'Unspeakable Known': Exploring CAT within Services for People with Learning Disabilities. Reformulation, Summer, pp.19-25.

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