Challenging & complex behaviours: responsible thinking approach
Acquired brain injury can result in a wide
variety of challenging behaviours that can impact negatively on
partners, families, carers and the community.
Professionals have developed a wide range of responses including
rewards/punishments, medication, seclusion, modelling, feedback and
token economies. A disadvantage with some of these strategies may
be that people who have previouslybeen high functioning independent
adults may rebel against methods often associated with managing
children's behaviour. Another approach is one that encourages
THE RESPONSIBLE THINKING PROCESS (TM)
RTP is a set of questions, which when asked respectfully,
encourage the person to reflect on their own behaviour and help
them to make choices that will meet their goals without
compromising the needs or rights of others. The person with a brain
injury is encouraged in how to think through their goals and what
they are doing in relation to the rules of the setting. Adapting
the RTP for managing challenging difficult behaviours after an
Acquired Brain Injury recognises that the person may have
difficulty monitoring their own behaviour and that they may need
prompts (use of the RTP questions) to reflect on their behaviour
and to help make choices that are more socially acceptable and
ultimately meet their goals.
You can't make anyone do anything. In the end people always make
the ultimate decision on how they want to behave.
You can only control your own behaviour and create a supportive,
Do not tell others what to do. Instead, ask a question that
encourages them to reflect on their behaviour.
A good rapport. With a calm non-judgmental interaction is vital
when asking the RTP questions.
ARRIVING AT AN AGREEMENT
To assist with behaviour change motivational interviewing is
done to help the person check if their behaviour is at odds with
their goals. Then, a plan or agreement is made whereby expectations
are specified and person comes up with ideas about what would be
reasonable (logical consequences) should the plan be adhered to, or
The idea is to develop an agreement as to what will happen when
challenging behaviours are displayed, and what alternatives there
are available (see case study).
Once the agreement has been made the RTP questions are used as
the basis for encouraging the person to reflect on what they are
doing and to be responsible for choosing what they will do
IF THE PERSON IS STICKING TO THE
The person is asked "how have you been going with the agreement
we made?" and "Has it been helpful?" Responses to their comments
may include affirmations such as "Yes, I've noticed you are doing
WHEN THEY DON'T ADHERE TO THE
Once again the approach is through questions, beginning with
"How are you going with the agreement we made?" Further questions
will help the person explore what is happening, such as "What did
you decide would happen if you broke the agreement?" After careful
listening to the response they person is again encouraged to self
reflect by asking "Is that what you want to happen now?" "Okay,
what will you choose to do now?"
IF THEY CONTINUE AGAINST THE
The key here is to not back down. A typical response would be
"Okay, I can see you have chosen to go with ____(the agreed
consequences)." Again the focus in on questions such as "Do you
want to work with me on this agreement?" If the answer is no then
again their choice in the matter is confirmed. The best thing to do
then is follow through on the logical consequence agreed upon and
calmly remove yourself or the person from the situation, without
argument and say "When you are ready to work on this we can talk
about it again."
OPPORTUNITIES TO GAIN CONTROL
By just asking questions instead of telling someone what they
should be doing, you are encouraging them to be more responsible
for their own behaviour. By being neutral you will appear to have
no investment in which behaviours they choose to exhibit. Ideally
this creates an environment for them to gain more responsibility
and control over their actions.
David lives in a residential setting and enjoys spending time in
the unit's social lounge. However, over the past six months David
has learned that throwing objects around the room and yelling will
get attention from the residential staff and visiting family
members. He has learned to get what he wants (attention) with
certain behaviours (that others find difficult).
It is explained to David that the unit staff and fellow
residents find these behaviours difficult.
Negotiations with David seek a more appropriate way to gain
attention from staff. Meanwhile the staff and family are encouraged
to engage socially with David when he is demonstrating more
David is respectfully asked, "What will happen if you throw
things and yell at staff?" He is helped to arrive at some logical
consequences, such as "You guys will ignore me, or I will need to
leave". An agreement is arrived at which runs along the lines of
"So, we are all agreed that it is ok for you to spend more
time in the social lounge, but not when you throw things or
yell at staff".
Of course, David has spent six months with this behaviour and it
doesn't change overnight. But the staff are very consistent with
the agreement. They regularly check with David how he is going with
the agreement and if it has been helpful.
If he breaks the agreement staff use the RTP questions.
Staff: How are you going with the agreement we made?
David: Bugger it.
Staff: What did you decide would happen if you threw things at
David: That I couldn't stay in the social lounge.
Staff: Is that what you want to happen at the moment?
David: %^$# you all! (Throws a cushion at staff).
Staff: Okay I can see you are choosing not to stay in the lounge.
David is calmly escorted away. Later, staff reassure David and help
him problem solve any triggers so that he can be in the lounge so
long as he is adhering to the agreement.
Over the next few weeks staff report a substantial reduction in
yelling and items being thrown around the lounge as David begins to
understand he is responsible for his behaviour and that he can
choose actions with differing outcomes.