Raj Gnanaiah

1. MindTheGap The importance of staff attitudes, beliefs & perspectives in managing challenging behaviour RajGnanaiah CPsycholAFBPsS BA, BSc (Hons), MSc, Post MSc CharteredPsychologist IntensiveSupportTeamManager Complex Interaction: Bristol 2013

2. Key Messages: 1. Most post scandal reports focus on regulation, inspection, quality or an organization’s culture, inadequate training, instead of looking at the processes involved in the management of Challenging behaviour (CB). 2. It is the attitudes, beliefs and perceptions leading up to CB malpractice that are often not investigated. 3. Training is often seen as a solution to problems and the need to modify staff attitudes, beliefs and perception about CBare being ignored. 4. Inevitably, beliefs and attitudes of others will directly effect the decisions made forthe service users. Some Gaps in our Practices here!

3. Overview: 1. Effects of staff attitudes, beliefs and perception on challenging behaviour (CB). 2. What is the research evidence? 3. Does training modify staff attitudes, beliefs and perception, if so what is the research evidence? 4. Best practices for training. Recommendations: 1. Use of psychometric tools before and after CB training to examine staff competencies. 2. Staff training must encourage reflective practice to asses any blind spots linked to their own attitudes, beliefs and perceptions.

4. Whatareattitudes? Definition: … “a settled way of thinking or feeling about something a ,or a position of the body indicating a particular mental state” Oxford Dictionary Staff who understand their own motives for working with people who challenge services, are less likely to to be cynical and pessimistic about providing support. Unacceptable behaviour is often determined by the staff’s own personal standards and values which are open to interpretation. Behaviour occurs as a result of interaction with people.

5. What are beliefs & values? Definition: “…one’s principles or standard, one’s judgment of what is valuable in life” Oxford Dictionary Our values are a kind of learned beliefi.e. whatis important to us. We learn them from our culture, family upbringing, religion, education, social environment and experiences. We tend to make close associations with like minded people and the opposite is true when there is a mismatch. Our values are evidenced by our attitudes. We use our beliefs to interpret other’s behaviour. Therefore it has an impact on how we see and define behaviour in general. “Belief gets in the way of learning.” ― Robert A. Heinlein

6. What is perception? Definition: “…a way of seeing or understanding things” We all see the world around us very differently. Perception is as a result of complex interaction with internal and external factors. We generally accept our perception as a true representation of reality although sometimes this may not be true. “Man is always inclined to be intolerant towards the thing, or person, he hasn't taken the time adequately to understand” Robert R. Brown

7. Not everything is what it seems! • Image missing

8. Staff response to CB Wiener Model: (1980, 1993) Staff response to the CB depended upon the degree of control that a service user had over it For example: Hasting & Remmington (1994) Staff exhibited negative emotions and became less helpful when they attributed the CB to be within the service user’s control and.. …became more sympathetic and helpful, if they attributed the CB to be outside the service user’s control. Implications: Staff responses are based on their interpretation of CB.(Dagnan, Trower and Smith, 1998; Hill and Dagnan, 2002; Stanley and Standon, 2000; McGuinness and Dagnan, 2001)

9. Further research evidence Heyman et al (1998) studied - How staff construct their perception of Challenging behaviour. Staff response: Staff rarely cited their behaviour, or the action of the service, for causing the CB Staff communicated their interpretation of CB and its potential risk to other staff, thus creating self fulfilling prophecies and making the situation even worse.

10. Interactive causes of CB Snow et al: 2007: argued staff response to CB may be mediated by their beliefs and perceptions and emotional response. For example: To determine socially acceptable behaviour. Weigel et al. (2006) : if there is a low expressed emotion used by staff when talking about CB, then they are more likely to perceive the cause of the CB as external to the service user and not in control of the service user. The opposite is true when it is high expressed emotions. Staff response when interviewed: “I can run around at home and slam doors and kick things, and that is all right. But if someone with learning difficulties does that it is, “Oh my god, they are expressing all these challenging behaviours”.” (Heyman et al., 1998, pp. 170) Jahoda and Wanless, 2005: reported that if staff were unable to talk about their perceptions of the behaviour, they became increasingly resentful of the service users.

11. Impact of CB on staff attitudes, beliefs and perceptions Oliver (1995): reported when staff rewarded service users to stop self-harm, they were in fact reinforcing the maintenance of the behaviour. (Mutual reinforcement) Hasting (2002): proposed that CB elicits negative emotional reactions of staff which impacts on their well being (stress & burnout), which influences the service in turn. Hasting also found a robust relationship between CB, staff emotional reaction and staff behaviour. Other related variables were: Staff beliefs, staff psychological resources and organizational culture.

12. Staff perception of CB Hasting (1997): Staff are more concerned about reducing the challenging behaviour than understanding it. Johoda & Wanless(2005): Staff hold more than one perspective about a person’s behaviour. Bromley & Emerson (1995): Staff indicated having a complex nature of relationship with the service user and inconsistencies in their interactions. Staff believed that they had very little control over the causes of CB. Markham and Trower (2003): reported a link between the diagnostic label given to a service user and how staff interacted with them.

13. Staff level of experience and CB Hastings, Remington, and Hopper (1995): Study - Explored different beliefs to determine the causes of CB amongst experienced and inexperienced staff: Experienced staff attributed the role of biological factors to determine CB, whereas inexperienced staff attributed emotional and environmental factors. Hastings, Reed, and Watts (1997): found significant differences between staff groups. However, Wanlessand Jahoda(2002): found younger staff negatively evaluating the service user’s who exhibited physical and verbal aggression to a greater degree than the older staff. In contrast – Elgie and Hastings (2002) found no relation between experience/ training variables.

14. Relationship between staff views, emotional reaction and willingness to help Wanless and Jahoda (2002) : negative appraisal of service users were associated with strong negative emotions of the staff. Dagnan et al. (1998): and Rose and Rose (2005): staff’s negative emotions were correlatedwith lower of optimism in changing CB. …and concluded correlation between lower level of optimismand less willingness to help. Dagnan and Cairns (2005): intention to help was positively correlated with responsibility of change and sympathy Rose and Rose: stated that reduced staff optimism was related to global attributions of CB

15. Does training modify staff attitudes,perception, and beliefs? The present CB management training has little effect on staff attributions. Gallivan. A. 2011: reported that one day staff training delivering principles of Positive Behavioural Support had a significant change in staff attitude towards CB.(A.B.O.U. T). (Grey et al. 2007): provides general oberservation from the last 10-15 yearsthatsome part of the trainingdoesincludehowstafffeelaboutchallengingbehaviour. However, its effectiveness is still unclear There is no research evidence to link organizational training culture and staff gaining CB competencies. ‘Typical training approach’ is not sufficient to address staff beliefs about CB

16. Best Practice Staff training and supportshouldtakeintoaccountthe cognitive (thoughts) and emotionalresponsesof staffto the challengingbehaviour. (e.g.,Kushlick et al., 1997). Regular refresher training to update previously held beliefs, in line with the changing needs of the servicer users. An example: Gallivan. A. (2011) A.B.O.U.T Challenging Behaviour One day training A : Attitude B: Behaviour O: Observation U: Understanding Requires refresher T: Techniques

17. In Real Life Options My primary role as an Intensive Support Team Manager is to examine staff interaction with service users whose behaviour challenge services. We take a holistic approach to training. Training to suit services. The Intensive Support Team (IST) takes a lead in making things happen: IST consists of a Speech and Language therapist, a Psychologist, a Dietician, and two Learning and Developmental Officersincluding external specialist training providers. We deliver : Positive Behavioral Support, Active Support with the clear emphasis on modifying staff beliefs, attitudes and perceptions. Communication training for enhancing staff’s understanding of service users’ behaviour. Dietetic input: Improving food and mood of the service users.

18. Conclusion Modifying staff perception about CB should result in positive interactions and offer a good quality of life for the service users, thus addressing the gap in the practice. Campbell and Hogg’s (2008): findings suggest that the more training staff have, the more effective it is at challenging their previous understanding of behaviour. (Refresher - ongoing) Consistent approach to CB is crucial: Using an evidence based model such as Positive Behavioral Support rather than depending upon experience. The importance of a supportive managerial culture where staff are able to freely express their views about challenging behaviour and find an alternative way of working. Use psychometric tools to screen ‘best fit’ staff to work within CB services. A mechanism to support staff when they are facing stress and feeling disorientated.

19. “Just because we don't understand doesn't mean that the explanation doesn't exist.” Madeleine L Engle Thanks for listening