With this issue we begin our ‘Dear Áine’ column, which we hope readers–both frontline staff and families–will find informative and practical. If you would like to send ‘Auntie’ Áine a question for a future issue, please write or email her at Frontline, PO Box 69, Bray, Co. Wicklow; email: firstname.lastname@example.org.
Challenging ethical behaviour
I work in a day unit for people with severe disabilities and challenging behaviour. One client has started to spit at staff when he cannot do what he wants. At a recent case conference it was decided that we try squirting water in his face, because nothing else seemed to work. I don’t feel comfortable about this–I have talked to the unit head, but he says we need to try this measure for at least a few weeks to see if it will work.
Is there anything else I can do, apart from refusing to take part in the programme? I don’t want to cause any conflict in the team–I have worked here for a long time. But I want to know what is best to do and how to follow the correct procedure.
It is exciting to hear from somebody with an ethical issue. It is ironic that a person who sprays one with water is responded to by being sprayed with water himself! What do we hope the person will learn? He has, however, learned a very powerful way to register what he wants or does not want. Lots of people exhibit behaviour such as you describe, and in dealing with it good practice should include the person’s life in general, the way his needs have been identified and are being met, and the quality of his life, i.e. what range of choices does he have? What about the quality of his relationships, and has he an effective way of communicating choices, needs etc.? Next you need to look at why the challenging behaviour is occurring. From your letter you seem to know why this person is spitting. Can you determine whether this is really the cause of the behaviour?
If his quality of life is satisfactory, his needs are being met and you are correct in your assumption as to why he is spitting, and yet the behaviour persists, then one needs to consider a range of positive targeted interventions. These may include teaching him how to dissent and disagree without spitting, by designing an IPP (individual programme plan) that heavily reinforces everything except spitting, and encouraging staff to actively respond to every attempt he makes to register dissent by more appropriate alternatives.
If none of these measures work, you may need to enlist the help of your psychologist. There is a debate around punishment and one school of thought will not accept any aversive therapy. Others consider the least restrictive alternative. You might consider reading the Psychological Society of Ireland’s policy document Responding to behaviour that challenges (Dublin, 1998) Another option would be to suggest to the Unit Head that you research the area to see what other options are available. You might also mention that squirting water at a client will give the service a very bad name and staff will be seen as nasty people who do nasty things. You might talk to your colleagues and see if they have other suggestions.
Were you at the case conference when the decision was made to try the water squirting? If you were, but did not voice your concern then, you may be obliged to carry through the decision. You may have had your dissent noted in the conference minutes but agreed to support the decision of the team. You could try to organise another case conference to review the decision, but to do that successfully you need to attend that meeting armed with research which will support alternative approaches. You may decide to become a conscientious objector who will inform the team of your view at the meeting and decide not to participate in the programme.
If all else fails you may need to consider changing your place of employment. Best of luck with your decision.
How can I encourage my adult son to improve his personal hygiene? He works outside and gets very dirty hands. Suggestions that he wash more thoroughly, or take more frequent showers, lead to stubborn resistance–shades of the old mother-child mealtime battles. My son simply does not share my concern about filthy hands and body odour. And I don’t wish continually to be drawn into no-win power conflicts. Any ideas?
I note from your letter that there may be two separate issues here. It could be a hand washing pre-meal problem or it may be a more general hygiene/showering issue. I wonder if you have any ideas as to why your son has one or other or both difficulties for example, is he afraid of getting scalded or does he need help with washing and yet resent getting that assistance?
Before I can help you I would need to have a good idea as to why you think he may have the problem. Refusal to shower may be due to: fear of hot water, fear of soap in his eyes, the bathroom may be cold and uncomfortable and therefore showering may be an unpleasant experience. What about your standards? Are they too high or does your son think they are? What about his peers? How often do they wash? Do they all wash hands before eating?
Is the real issue one of establishing independence? Is the issue an anti-parent stance? Once you have a good idea as to the cause then it should be possible to plan a strategy around that issue.
In one service where the young men had poor hygiene, it was tackled by installing showering facilities and the men automatically showered daily. Any chance you could suggest such a strategy to you son’s employers?