Q1 Explain what is meant by the terms 'behaviour that challenges' and 'positive behaviour'. (1.1)
a) Behaviour that challenges
Behaviour that challenges is a form of behaviour that is inappropriate or socially unacceptable. It should not be seen as a label, but merely a means of getting attention for tangible needs like food or drink, or to escape an unpleasant or difficult situation. These behaviours can be viewed in a Holistic way, thinking that challenging behaviours in another context can contribute to the dignity and quality of life of the person in another context.
Challenging behaviour can be monitored by a Behaviour Support Plan (BPS) to watch for signs that the behaviour may escalate. In an amber phase behaviours like, anxiety, agitation, body language and change in vocalisations may indicate that behaviour may escalate to a red reactive phase. Behavioural escalation is prevented and a return to a green calm phase is achieved. There must be support in place to keep the person in the calm green phase. If behaviour escalates to red then low arousal situations, or distraction or redirection like a guided walk to change the environment is used to de escalate to a blue phase befor returning to green. The blue or calming down phase has to be watched as behaviour may escalate quickly to red phase, to an incident of challenging behaviour.
categories of challenging behaviour include, passive aggressive such as maintaining a silence, disobeying orders, and an obstructive attitude. There is also stereotyped challenging behaviour with its examples of pacing or repetitive actions and repetitive speech. Self harm is another category including scratching and cutting, hair pulling etc. Direct aggressive includes punching, spitting, pulling hair and walking off amongst others. Finally there is non-person directed aggression with its challenging behaviours of stealing, damage to property, sexually inappropriate behaviour and withdrawal as examples.
b) Positive behaviour
Positive behavior includes actions such as setting boundaries so that acceptable behavour is adhered to, and respecting someones human rights. Humour is another example of positive behaviour in that it provides an opportunity for de escalation. Generally an attitude of viewing behaviour that challenges as a means to communicate needs is seen as positive behaviour.



Q2 Identify examples of verbal, non-verbal and physical behaviour that may be perceived as challenging. (1.2)
a) Verbal behaviour
Examples of verbal behaviour that challenges, are shouting and swearing, or inappropriate language.
b) Non-verbal behaviour
Examples of non-verbal behaviour are maintaining a silence, obstructive attitude, screaming and refusing to follow orders.
c) Physical behaviour
Examples of physical behaviour include, punching, scratching, hair pulling and walking off.



Q3 Describe the difference between conflict and behaviour that challenges. (1.3)
Conflict occurs when there is a clash of interests over some need that has to be met. To resolve conflict we need to find common ground for an agreement. Everyone should have there opinions heard and there should be a review at a fixed time in the future. Conflict differs from challenging behaviour in that conflict may result in an incidence of challenging behaviour happening. If there is conflict, a person may not be able to communicate a need and the the resulting challenging behaviour will communicate that. During conflict behaviour may escalate to challenging behaviour.



Q4 Describe the difference between aggression and assertive behaviour. (1.4)
Aggression can lead to violence, hostility, isolation and resentments. Assertive behaviour is a more socially acceptable way of communicating needs or resolving conflict over those needs.
Aggression can evoke defiance whereas assertive behaviour can ensure that everyone's opinion is heard.
Aggression can lead to behaviour that challenges. Anxiety over a need can lead to behavioural escalation through aggression. By understanding the opinions and needs of the person and carer through assertive communication the aggressive behaviour can be de escalated . Assertive behaviour allows effective control over a situation or incident of challenging behaviour and prevents any unnecessary distress and injury to the person and harm to the carers.



Q5 Describe how behaviour can be interpreted as a form of expression. (2.1)
Behaviour that seeks to get the attention of other people is a way of expression oneself to communicate a need that has to be met. Quoting section 2: Reasons why people present with behaviour that is perceived as challenging, Maslow's hierarchy of needs "A carer can establish a baseline for an individual's needs so that behaviour can be closely monitored to correctly interpret if that person is trying to express." Someone with a learning difficulty may not be able to communicate their needs directly but behaviour such as rubbing a jaw or an ear is an example of an individual trying to express that they may have a toothache or an ear ache. Another example is the case of sensory impairment where if an individual has diorientation, they may not be able to communicate their disorientation and so they are left feeling frustrated. Also with sensory impairment, a person may result to self injury. The reason for this is that an individual may touch his or her eyes or ears to obtain a level of arousal that matches their needs. This behaviour if interpreted correctly shows that it is a form of expression to communicate a need, which in the last example of sensory impairment indicates that the individual is bored with his or her environment. Reward driven causes for behaviour can be seeking attention from a favourite member of staff. This can be interpreted as reward driven behaviour where an an individual is rewarded by the attention they receive and is therefore a form of expression.



Q6 Describe how behaviour may be a symptom of something else. (2.2)
Behavour can be symptomatic of health or medical issues and the pain that results from them. An example is Lesch-Nyan Syndrome which results from a hormonal imbalance in the brain that produces uric acid causing dystonia. With this condition there is difficulty with the regulation of emotions. They may bite their lips, tongue and inside of their mouth which indicates they are in pain. The resulting distress, or the behaviour that challenges, is the behaviour that is symptomatic of an underlying cause. Another example is medication which can have a variety of symptoms, such as dizziness, nausea, body pains, rash and increased confusion, to name a few. People on medication have to be monitored for signs that they are experiencing difficulty as this may lead to behaviour that challenges. Angelman Syndrome is another example where an individual cannot communicate they are in pain. Challenging behaviour can result from gastrointestinal efflux, Otitis media which is an inner ear infection and skin irritation. The behaviour of rubbing or banging an ear, if interpreted correctly their behaviour suggests that an individual may have an inner ear infection.



Q7 Give examples of possible reasons for behaviour that challenges. (2.3)
There are a number of reasons for behaviour that challenges, one being reward driven behaviour where it can be seen that a reward of attention reinforces the attention seeking behaviour. Skinner showed with his Skinner box and his experiments on operant conditioning, that if a rat was rewarded for a particular action the action or behaviour was strengthened resulting in the behaviour being repeated more often. Similarly with people, if an individual has learnt that they can get a reward by attention seeking, they will repeat this behaviour to get what they want, which in this case is just the attention they seek. If the environment is boring for an individual, they will seek arousal in the form of stereotyped behaviour like repeated pacing so that the level of arousal and the challenging behaviour satisfies their needs. Overcrowding can provoke behaviour that challenges as the person may feel overwhelmed or distressed and seek to escape the unpleasant situation. Similarly, other people is an example such as an individual not liking someone because of a previous encounter, or they do not like the way that the person interacts. Forgetfulness may lead to behaviour that challenges as say someone with dementia who may forget words or not understand instructions leading to the situation where they do not follow orders and may put themselves at risk. Learned behaviour is another reason for behaviour that challenges. In this example an individual my have copied an action that somebody has used in the past to get attention. This involves observation and mimicking. Transition such as changing school or accomodation, or divorce may lead behaviour that challenges. There are also medical conditions such as psychosis where the person is quick to anger even when unprovoked, and also personality disorder where a person does not understand the consequences of their behaviour which can lead to this kind of behaviour. Depression is another example which can lead to withdrawal and isolation resulting in the individual becoming withdrawn, and isolated, which in turn leaves the person feeling unapproachable with little hope.
Quoting Section 2 Reasons why people present with behaviours that are perceived as challenging, and the paragraph on levels of behaviour - recent onset, " In recent onset behaviour there may be a possibility that there is a change in the environment and someone with dementia may struggle to understand what this change means to them". Also refering to dementia, a certain time may be a trigger for behaviour that challenges, as once what was a manageable regular routine before they became ill, on onset of the dementia may leave an individual experiencing difficulty leading to behaviour that challenges.
Another reason for behaviour that challenges can be ignorance of cultural needs as this may leave someone feeling disrespected and may have further implications for the family of the individual.



Q8 Describe how attitudes and lack of understanding can impact individuals. (3.1)
Attitudes can impact individuals when they are associated with stereotypes which is an inaccurate label for the behaviour that an individual presenting with behaviour that challenges exhibits. It may lead to an individual being ignored resulting in low self-esteem. A carer may think that someone is aggressive because they have a label of behaviour that challenges, but these are preconceived ideas about behaviour. As a consequence a person may be avoided or, his / her behaviour might be misinterpreted resulting in a possible escalation to behaviour that challenges. Attitudes can lead to an onset of mental illness which can lead to stress, anxiety and depression. The mental illness can impact on the behaviour that challenges as it can se up a difficult cycle. How psychology works published by DK states that anxiety can lead to a kind of behaviour that reinforces the anxiety as a cycle that is hard to break. Feeling left out can can be a consequence of being left of an excursion for example where someone may have an idea that the individuals behaviour is too challenging , and ignoring an individual may produce lower self esteem. Both of these examples illustrate how labelling allows people to wrongfully expect what they think challenging behaviour is based on stereotypes which allows for discrimination, so they may not receive the quality or type of care they need.



Q9 Explain the impact and effects of the behaviour that challenges on the individual. (3.2)
The impact of behaviour that challenges can be long term or short term. Examples of short term impact include relief where after an incident of behaviour that challenges, an individual may experience relief after expressing frustration. Carers may wish to provide support for the individual to express this frustration in a more postive way. A second short term impact is physical injury. A carer should provide immediate support for injury at the earliest safe opportunity, or ask someone for help. If it is a serious injury the emergency services should be called. Voluntary segregation may result as a consequence of behaviour that challenges, where an individual may feel remorse or guilt. If anindividual has been shouted at he may experience shame.
There are also four categories of ways that behaviour that challenges imapcts on the individual, the first being emotional. After an incident of behaviour that challenges carers may offer emotional reassurance to the individual who is distressed. The second category of impact on the individual is physical impacts such as bites, head injuries, bruises etc. The third category is psychological and the fourth is social.



Q10 Explain the impact and effects of the behaviour that challenges on others. (3.3)
The impact of the behaviour that challenges on other people is varied. Family members may feel that people are judgemental about the adequacy of care they give to the individual and they may feel guitly as a consequence of this. If there is hurt to another person by the individual's behaviour that challenges, the family members may feel sadness. If an individual has an episode of behaviour that challenges in a public place, the family may feel embarrasment. The same holds true for friends and colleagues if there is an episode in a public place. Careres may find their role demanding when dealing with this kind of behaviour and may leave their job. There may also be professional burnout from their job. Carers may find that they have low self-esteem and lower confidence as they are unable to reduce the number of incidents of behaviour that challenges. Staff may isolate and become depressed due to constant exposure to behaviour that challenges. In the work place there may be anger and resentments if the individual with behaviour that challenges gets time out or his / her own space.



Q11 Describe how the behaviour may potentially impact the individual’s own and others’ feelings and attitudes in the short-term and long-term. (3.4)
The individuals feelings may be impacted by feelings of relief after they have expressed their frustration and it may be necessary to find a more postive way of expressing needs after an incident of behaviour that challenges. An individual may have low esteem from episodes of behaviour that challenges and may be in fear of of the immediate consequences of their behaviour. Another short term impact is physical injury, and also voluntary segregation where they may feel guilt after an incident. Concerning long-term inpacts for the individual there is alcohol and drug abuse to manage behaviour or symptoms where there is inadequate care over a period of time. Also, if their is a decline in the overall well-being an individual he or she may become vulnerable and more prone to abuse. ln the case of physical restraint an individual may feel disrespected and humiliated and may go on to develop depression.
With regard to other's feelings there are also short-term such as frustration from not being able to prevent an incident of behaviour that challenges from occuring. Following from an incident of this behaviour assertive decision making may be employed to prevent another episode from happening. There may be shock and fear if the the incident of behaviour that challenges is particularly distressing, and there may be physical injury to the carer, staff, family, colleagues etc. If the behaviour that challenges occurs in a public place there may be some embarassment.
Long-term impacts to other's include isolation where for example, a carer may be involved with an individual over a long period of time to the exclusion of all other activities which may lead to depression. Proffessional burnout may result from continued exposure to behaviour that challenges.



Q1 Identify triggers for behaviour that challenges. (1.1)
There are a number of triggers for behaviour that challenges including environmental ones such as too light or dark, or too noisy and also an overcrowded place and too many objects. In the case of overcrowding an individual may find the presence of too many people overwhelming and become distressed. Another trigger is excessive demands such as being told not to do somehing. This could also be a problem in a reactive red stage of behavioural escalation where there is an incident of behaviour that challenges, and placing demands on an individual will trigger behavioural escalation. Somebody being given food they do not like can be a trigger, and also having an unmet need such as hunger, thirst or a toilet etc. Unwanted attention can be a trigger and I would like to mention that there is a disability equality, and anti-harrassment organisation as part of Bristol city council.
Mental illness can be a trigger as can side effects of medication for which there should be observation for warning signs that behaviour that challenges is about to take place. Generally a set of circumstances which produces heightened anxiety levels is called a setting event which is likely to include triggers, for example at meal times individuals with dementia may be unable to understand a change in the time for a routine. Similarly an autistic individual may find a change in routine distressing triggering an episode of behaviour that challenges. Last but not least, pain is a trigger also.



Q2 Explain the importance of identifying patterns of behaviour and triggers to behaviour that challenges. You should refer to at least two types of behaviour within your answer. (1.2)
It is important to identify patterns of behaviour and triggers to behaviour that challenges so that coping strategies can be developed to reduce or eliminate these unhelpful behaviours. Once a trigger is known Objective observation is used to document these behaviours and is used in a behaviour support plan to support an individual to use more appropriate behaviour. There are different categories of behaviour which are ritualistic, attention seeking, routine, avoidance, learned and new. It is important to identify which types or patterns of behaviour are being presented with as there is "a communication function as carried by that behaviour", quote from Personal Communication Passports by Sally Millar published by Call Scotland. Knowing which communication funtion is being used is important to de escaate the behaviour. In the case of Learned behaviour an individual learns that a particular behaviour is met by a desired response, or reward from a carer, family etc. A second category of behaviour which is ritualistic, examples of whichare repetitive behaviour or speech whichis used to produce consistency in a situation to try and take back control in a situation where an individual feels distressed. Avoidance is a category where an individual tries to avoid what he or she thinks is a threatening or unpleasant environment such as a doctor or a dentist etc.
Identifying patterns of behaviour can prevent labelling, for example if a schizophrenic is stereotyped as morose he or she might assume or live up to that behaviour. A consequence of this is the individual may be labelled by carers, staff or family as morose and the lack of objectivity could result in unmet needs and behaviour that challenges.



Q3a Describe why it is important to support individuals to recognise their limitations and take avoidance actions. (1.3)
It is necessary to start with a definition of limitations. A person's limitations have been reached when the individual is no longer able to cope with a situation. It is important to support an individual to recognise their limitations so that coping strategies can be put into place to help manage that person's behaviour and reduce or eliminate behaviour that challenges. When a person has reached their limitations their behaviour starts to change and the deterioration in behaviour can impact negatively on the individual and others. Supporting the individual to recognise their limiations will help in identifying the warning signs examples of which include rapid breathing, shaking, arguing, clenched fists or jaw to name a few. A behaviour support plan will describe what coping strategies and avoidance actions to take to de escalate the behaviour appropriately. If the individual does not recognise their limitations and take avoidance actions then the behaviour may escalate to throwing or smashing objects, damaging property and physical assault and so on.



Q3b Explain how to recognise changes in individuals that may indicate that their behaviour might escalate. (1.3)
Everyone who interacts with the individual should be aware of triggers or potential triggers that can lead to behavioural escalation. Carers should interact with an individual and his or her family and friends to observe why an individual behaves in a certain way. This may mean reading the behaviour support plan of an individual to become aware of what situations can cause changes in the individual. The situation that leads to behavioural escalation is called a trigger because it triggers behavioural escalation leading to behaviour that challenges. From my own testimony I can identify three triggers of my own that have led to behaviour that challenges. The first trigger was being bullied and experiencing name calling at school. The result of this was humiliation and a spoiled self-concept or identity which led to the ritualistic behaviour of asking for particular types of fashionable clothing and a racing bicylce from my parents so I would be comparable to other pupils. This placed demands on my parents where money was hard to find. The second trigger which I will discuss is having to attend a GP. I have been detained under the mental health act before for my schizophrenia and as a result I have a non-trusting, fearful relationship with my GP. Any difficulties with my health and I avoid my GP resulting in defiance and indignation which I interpret as behaviour that challenges. Instead of a GP I will go to an acupuncturist or a counsellor instead. The purpose of the defiance is to try and assert my authority over a situation over which I feel I have little or no control and I feel powerless. My third example arises when there is the trigger within a routine such as mealtimes. As one of the symptoms of my schizophrenia is personal neglect I find any additional pressure of a routine demanding and distressing and so I employ avoidance such as a coffee and a cigarette to forget about my responsibilities.
Patterns of behaviour such as these are recorded by objective observation using writing, or audio or video recording. Techniques for recording patterns of behaviour are anecdotal which involves writing down behaviour as a story , timed at set intervals, events such as mealtimes, and finally targetting specific individuals which the person interacts with to trigger behaviour that challenges. The example I gave concerning bullying and name calling at school does include target individuals with which I interacted with to trigger behaviour that challenges. Also my GP is a target individual that triggers my behavioural escalation. Being aware of such patterns of behaviour and targetting observations a carer will be able to recognise when an individual's behaviour is going to escalate.



Q4 Describe strategies that could be used to support positive behaviour. (2.1)
There are a number of strategies that can be put in place to support positive behaviour, the first of which is a consistent approach to managing behaviour that challenges. With a consistent approach a behaviour support is needed so that there is no confusion or ambiguity concerning an individual's needs. If there is any confusion concerning strategies between staff, family and professionals this will cause frustration and produce a mixed and confused message the the individual being supported. Another strategy is praise and reward. If an individual is rewarded it will positively reinforce the positive behaviour, strengthening it so it is more likely to be repeated. The rewards must take place before an incident of behaviour that challenges others the individual will receive a mixed message. Patience and compassion are also important as this will encourage the individual to be open and communicate their needs before their behaviour will escalate. Carers, staff, family, colleagues and professionals should provide a postive role model for positive behaviour as this will mean it may be more likely to be adopted by an individual. A preferred method of communication can mean acceptance for the individual being managed. An example of a preferred method of communication is the Picture Exchange Communication System (PECS) which is base on the principle of applied behavioural analysis (ABA). With PECS an individual gives a symbol for an object and then receives the object. Finally there should be no punishment as someone with a learning disability or profound learning difficulty as with Autism may not be understand what is being said to them, and this can lead to behavioural escalation.



Q5 Describe the advantages of pro-active strategies in supporting positive behaviour. (2.2)
Proactive strategies have the advantage that when they are in place they provide a consistent approach to care. The result of this is that an individual will know what is expected of them and have an insight into the consequences of his or her behaviour which will promote confidence, self-esteem and trust. The proactive strategies will support an individual to meet their needs in a number of positive and meaningful ways. A pro-active strategy with a behaviour support plan can identify triggers and reduce the number of incidents of behaviour that challenges. A behaviour support plan is an an example of focused support which focuses just on the needs of the individual. It can include distraction techniques, communication passports, meaningful activities and individual relaxation and calming techniques. In keeping with a person-centred approach a behaviour support plan makes no assumptions or generalisations about the needs of the individual, if a distraction technique works for an individual with Aspergers, then it will not be assumed that it works for all people with Aspergers. The consequence of this is that a behaviour support plan wil outine needs that are tailored particularly to that individual and will have the advantage that there will a clearer idea of what works for that individual. I myself have been making enquiries conerning the use of a database I have written to implement a disability flash card for special needs considerations in the event of a crisis or behavioural escalation for a number of suscribers. Each disability record on the database would be person-centred and tailored specifically to that individual's needs. I have come up against an obstacle with the database at present as it is a non - NHS database and would need to be encrypted to the standard set by a GDPR (general data protection regulations) officer. The link to my website is https://hellodatabases.webs.com/more-c
Pro-active observation can have the advantage of identifying triggers and reducing the opportunities for behavioural escalation. An awareness of policies and proceedures is pro-active and can have information concerning what triggers mean and what a distraction technique can do to reduce behaviour that challenges .
Another advantage of pro-active strategies is that they allow for teaching the individual new skills. This could be an individual relaxtion technique. This advantage could be particularly important with individuals with a learning disability or someone with the profound learning difficulties of autism as they can lack critical skills such as feeding for example, and certain social skills. New skills increases self-esteem and can cause a reduction in behaviour that challenges.
With the reduction of behaviour that challenges, an advantage is that there can be an associated increase in collaboration between care staff, and an increase in satisfaction for family and friends.



Q6 Explain the impact of reactive strategies in supporting positive behaviour. (2.3)
a) Positive reactive strategies
A positive reactive strategy that impacts an individuals behaviour is the use of a distraction technique such as providing an alternative activity, talking about a different subject matter other than the current one which precipitated the anxiety or escalating behaviour. Similarly, removing someone from the environment or another person that is a target individual that triggers the behaviour, also a distraction technique, will reduce the anxiety and allow the behaviour to de escalate. The impact of these strategies is a desired result of behavioural de escalation and also the effective management of behaviour that challenges.
b) Negative reactive strategies
An example of a negative reactive strategies that can impact on the individual is the inappropriate use of medication. Medication in this context is used to keep the individual drowsy or quiet to reduce behaviour that challenges. From my experience as a psychiatric patient with schizophrenia I have concluded that it is cost effective to prescribe a tablet like Stelazine that cost a penny rather than address the issues or triggers that produce behavioural escalation. The impact of this for me has been humiliation leading to the manifestation of behaviour that challenges in the forms of outbursts of anger, defiance, feeling rejected or not being heard, and subsequently isolation. Isolation can also come about from the humiliation of being inappropriately physically restrained and verbal abuse.
The organisation culture can have a negative impact on the standard of care. In a care institution people can assume that everything is normal ad will go along with what is happening. I would call this "pluralistic ignorance" (REF: Think like a psychologist, Chapter 14 'why didn't anybody help?', paragraph 'how bullies get away with it', page 114) where each person asumes that what the other carers are doing is correct, but this negligent attitude permeates through the whole organisation and becomes systemic. An example of this reduction in care was evident at the Winterbourne View Hospital near Bristol. There had been may complaints and many opportunities to address the fall in standard in care and abuse of patients, but the culture of go along to get along prevented positive action.
The impact of negative reactive strategies in supporting positive behaviour on family and friends is a lowering of confidence and trust in the care of the individual.



Q7 Explain strategies to support individuals to manage their behaviour. (2.4)
Strategies that are used to support individuals to manage their own behaviour are important as they assist an individual to be more independant which results in an overall increase in wellbeing and reduces the susceptibility to mental illnesses.
For strategies to support an individual to work, there must be good communication. An individual may have a communication difficulty from a head wound, dementia, sensory impairment, just to name a few examples. If communication is to work, an individual must understand what is being said and what is happening. There are a few points to observe to ensure that what has been said by the carers has been understood by the individual, firstly make sure if what has been said has been understood, and if not to act on it. Conversely, it is noted if the individual has understood. The final two points to remember are that the individual must have their preferred method of communication such as a personal communication passport, or picture exchange communication system, and secondly the individual must have time to process what has been said or indicated to them.
A strategy for supporting an individual to manage thier behaviour is the reward system. A reward will positively reinforce the positive behaviour with the result that this behaviour will be strengthened and more likely to be repeated. Again there are criteria to observe such as being consistent in the rewarding process and making sure that the individual understands what he or she is being rewarded for. Also small as well as big successes must be rewarded and others must be aware of the rewards for the purpose of celebrating, which I imagine would mean aligning with the team spirit of the organisation (REF: Sports psychology, celebrate win or lose).
One form of reward system is called 'Work towards' where an individual works towards a reward of their own choice, and they are aware of the process which can be in a visual representation. I remember in my primary school I worked towards receiving the visual reward of a coloured star for each piece of homework that I did.
Another strategy for supporting an individual to manage their behaviour is to understand the reasons or causes for the individual's behaviour that challenges. Once a cause or trigger has been established, a person can be encouraged to use self-coping strategies to manage their own behaviour. This results in more independence and a subsequent increase in self-esteem which is rewarding and positively reinforces the behaviour which then motivates them more in the direction of independance. Examples of self-coping strategies are applying an individual relaxation technique to themselves, removing themselves from a difficult environment, and assuming an alternative activity.



Q8 Describe how behaviour plans and support plans are used to support positive behaviour. (2.5)
A behaviour support plan is a document produced by a person-centred approach to record information concerning the management of an individual's behaviour. Important details can be kept on a behaviour support plan such as information concering an individuals personal communication passport which specifies the individual's preferred method of communication. The type of information also included is the kind of behaviour that the individual is showing at the time of behavioural escalation, such as what time and how long the episode of behaviour lasts. These criteria, as well as documenting triggers which can include setting events such as a room that is too noisy for example, are points to recognise as an indication when an individuals behaviour is about to escalate to an episode of behaviour that challenges. Once this behaviour has been recognised coping strategies can be employed to manage / de escalate it. A list of pro-active strategies will be mentioned in a behaviour support plan such as establishing boundaries or teaching critical skills, or noting that in a pro-active stage it would be a good time to support positive behaviour by reinforcing it. As well as pro-active strategies to support postive behaviour, reactive strategies will also be listed. In the case of reactive strategies these should never be used as punishment and there must be fewer reactive strategies than pro-active ones. A support plan will contain information on how to support an individual after there has been an incident of behaviour that challenges which will involve seeing if the individual has experienced physical harm and acting on it if there has been an injury.
The individual, professionals and family and friends will be involved in putting together a behaviour support plan and everyone will have access to the information it contains to ensure consistency in supporting positive behaviour. Everyone must be in agreement during the process of drafting a behaviour support plan, also to ensure consistency in care. Finally there must be a formal review if there is an increase in behaviour that challenges where previously that had been a reduction. A person - centred tool for seeing what is not working anymore is called the working / not working tool. It examines issues from different perspectives such as the individual's perspective and those of the careres and family and friends etc, By understanding what is working and what is not working from different view points a common ground can be found to move forward in supporting the positive behaviour of the individual.
The working / not working tool can reveal if what is important to the individual is present in his or her life, and as to wether the individual feels they are being supported in a positive way.



Q9 Explain the importance of person-centred approaches to establishing support strategies. (2.6)
A person-centred approach to establishing support strategies is essential as it focuses on the needs of an individual as a unique person. The individual will be involved in the process of establishing support strategies so that the support will be meaningful to them. Employing human rights is one aspect in setablishing support so that the individual does not experience discrimination, and also if the rights are in accordance with a legislative process, they will provide a base line for the individual, carers, family and friends to follow. A person centred approach will leave the individual feeling that they have been listened to which is important to reduce behaviour that challenges. Using myself as an example, I have had thirty four years experience as a psychiatric patient with schizophrenia and most of the time I have been told I am projecting, or that I am paranoid. The result of this is that I have felt I have not been heard. Rather then being a person-centred approach, I have felt assumptions have been made about my person and I am not an individual but a label possessing a lot of generalisations. This has led to an increase in frustration, anxiety and depression.
Another important aspect of using person-centred approaches to establish support strategies is the resulting increase in confidence and self-esteem. If the individual is involved in the process of establishing support he or she will no what is expected of them and they will be able to make predictions about their own behaviour and the increase in confidence will enable them to try new things to improve the quality of their life where before it caused distress. I see this process of change as an underlying factor in challenging discrimination. As well as trying new things, obtaining new skills is a desired goal of person-centred approaches. Some individuals lack critical skills such as not interupting when someone is speaking and queueing. Acquiring new skills enables the individual to be more socially adept.
Person-centred can mean empowerment for the individual. This is where an individual can take control of his or her own life and also can be responsible for employing self-support strategies devised to meet their own individual needs. This is in keeping with the human right that everyone has the right to liberty and security of person. Finally, another important criterion for person-centred approaches is the opportunity to employ sel-support strategies which means that the individual can be more pro-active in managing their behaviour that challenges.
As well as have a postive impact on the individual, person-centred approaches can leave family and friends feeling respected, and happy that the individual is being cared for appropriately, and in a way that is meaningful to them. Also, person-centred approaches allow the skills of carers and staff to be employed in managing behaviour that challenges.



Q10 Describe how support networks for the individual can help promote positive behaviour. (2.7)
Support networks networks can help promote positive behaviour by ensuring that there is collaboration between all parts of the support network to provide a consistent approach to care by making sure all parties adhere to the support plan and that the support strategies are still effective. For collaboration to workt there must be clear and open lines of communication which involves not forgetting or witholding information which could be included in the support plan. The resulting consistent approach to care can produce increased confidence and self-esteem levels which can cause a reduction in behaviour that challenges.
Objective observation is used to see if the support strategies are still effective and if they are not this will come under scrutiny in a robust review. During a review a person-centred tool is used to see if an invidual's positive behaviour is supported is called the working not working tool and this will be implemented in a review process so that an individual's needs are met in supporting and promoting positive behaviour. Regular meetings with support networks and the individual will give the opportunity to discuss and identify issues which can then be parked to support positive behaviour. Also in support of promoting positive behaviour if there are new policies and procedures, meetings can take place within support networks so that carers skills are updated to ensure consistency. This will establish a new baseline for carers, family and friends to work from to promote positive behaviour.



Q11 Summarise the legislative framework that applies to individuals who present with behaviour that challenges. You should refer to the following in your answer: (3.1)
a) Rights
The equality act of 2010 is part of the legislative framework that protects the right of the individual in relation to care. It ensures that the individual receives equal and fair treatment regardless of protected characteristics such as disability, race, sex, sexual orientation, religion or belief, age and so on. This act ensures that the health service provides equal care and that all individual's needs are met.
Another aspect of rights within the legislative framework is the care act of 2014 in which the local authorities have an obligation or duty to promote the wellbeing of the individual. Within this framework the individual is encouraged to be as independant as possible and to be part of the community. As part of the wellbeing examples could include ensuring that the individual does not experience neglect or abuse in the community or is involved in making a contribution to society. A purpose of the rights can be to to give a fair and transparent process for making a complaint. If an individual feels that they have not be heard, then after the British courts there can be a second hearing in the European court in Strassbourg.
b) Safeguarding
Safegaurding can apply in the context of deprivation of libery where an individual has to be detained in a hospital, or residential home. If an individual is considered to lack the capacity to make a decision concerning consent or refusal to being detained, the rights of the individual have to be considered and therefore an assessment must first be carried out. This wil provide information as to the the capacity of the individual in making any informed decisions. The issue regarding the an individual's competence to make decisions is covered by the 2005 capacity act.
Safegaurding aslo applies to the safegaurding of vulnerable groups. This is acheived by a disclosure barring service where a potential carer or professional is vetted for suitability for working with people that experience behaviour that challenges. The police computers are used to see if that person has any convictions or any other unsuitable history.
c) Deprivation of liberty
The mental health act of 1983 is the part of the legislative framework that deals with the detainment in hospital of up to one year for an individual. If an individual experiencing behaviour that challenges also has a mental illness, they may need to be detained if their behaviour presents a risk to them or others.
There was an amendment to the mental health act in 2007 which ensures that the individual who has been sectioned has access to an advocate. Another feature of the amendments is the implementing of new appropriate medical tests treatment to see if an individual is capable of making his or her own decisions and thus protecting their rights. It is the social services that finally have the say as to of an individual should be detained or not. The process of detaining an individual will also be a process involving a professional such as a psychiatrist, a GP and a relative.



Q12a Describe agreed ways of working to protect an individual who presents with behaviour that challenges. (3.2)
There are a number of agreed ways of working to protect an individual who presents with behaviour that challlenges. A behaviour support plan is an example and a key part of protecting an individual. The individual is involved the process and so are all the other people involved in the creating of a plan. As Everone is involved there will be an agreement on final content of the plan. A review of the behaviour support plan can take place at set intervals or six months. A person-centred tool called 'working not working' to be used during the review. This tools expects honesty and examines an individual's needs from all perspectives. The idea of this tool is to find what is still working and then use this common, or agreed ground to move forward.
A behaviour support plan will mention pro-active strategies which are a proactive in keeping the individual calm. The strategies used will be agreed on with the individual and carers, professionals and family and friends. When proactive strategies have failed the next line of defence or plan are reactive strategies which are employed once an incident of behaviour that challenges has occurred. Praise or reward will positively reinforce the positive behaviour and strengthen it so that it is more likely to be repeated. Another example of an agreed way is objective observation which is used to identify triggers. There is no function attributed to an individuals behaviour, as with objective observation just patterns of behaviour are observed and recorded. Identifying triggers will reduce the opportunities for behaviour that challenges. Another agreed way of working to protect the individual is to support them to manage their reactions and emotions in a safe and more appropriate way.



Q12b Give examples of appropriate and inappropriate use of restraint. (3.2)
An example of an appropriate use restraint is physical restraint where part or the whole of a person's body is restrained to subdue the movement of an individual where there is a risk of harm to themselves or others. This type of restraint may also be used to carry an invidual from one place to another. Physical intervention is also an example of appropriate use of restraint where an individual is held in a chair or on a bed. Mechanical restraint which can be appropriate and can include handcuffs while transporting an individual from one location to another. Handcuffs are more likely to be used on individual that has a severe mental illness. My final example of appropriate use of restraint is chemical restraint which can take the form of sedatives or anti-psychotic drugs to subdue an individual's behaviour which may be administered by injection for a more rapid restraint. I myself have been on anti-psychotic Modicate injections during the time of a crisis and the onset of a mental illness. I now take Olanzapine anti-psychotic drug orally. It may be worth mentioning here though that if an individual is on medication they should be observed for any side effects which may lead to behaviour that challenges.
An example of an inappropriate use of restraint is maipulation of the environment where obstacles are placed for example in front of a chair to stop the individual from getting up, aslo blocking a route to prevent an individual going from one place to another. Similarly, stair gates also an inappropriate use of restraint and should never be used.
Being in complete isolation is an inappropriate use of restraint as it can be used as a form of punishment but must not be confused with the distraction technique of 'time out' for a difficult or unpleasant situation.
Finally door locks are an example of inappropriate use of restraint as if there is a fire or some other emergency, the individual may not be able to unlock the door. For safety reasons this practice is against health and safety regulations.



Q13 Describe how to monitor interventions and safeguard individuals. (3.3)
Monitoring interventions is performed by record keeping and there are a number of approaches or guidlines for this. Keeping a record of what interventions are currently being used, as in a care plan, provides a baseline from which carers can work so that any future reviews will reflect the need of the individual. Interventions should be monitored in a way where the rights of the individual are balanced with an intervention and the individuals rights are not infringed, with the least intrusive and restrictive strategies being used first. Objective observation is a technique that is used to monitor interventions and it records the current strategies for supporting an individuals bositive behaviour and any new triggers that have been identified so that subsequent strategies employed can result in a reduction of behaviour that challenges. During objective observation there are established ways of recording a persons behaviour and strategies to be used, firstly written notes. These have the advantages of being spontaneous and simple to use but the disadvantage is that information may be forgotten when writing down a narrative. Secondly audio recording to monitor interventions can be used, and it has the avantage that you will also have audio cues to monitor, and finally video recording which has the advantage of recording both audio and visual information.
There are a few rules or guidelines as to the type of observations to make during the monitoring of interventions such as the date and time and type of restraint used and the reason for the restaint which is also called the rationale. Also documented are any injuries that may have resulted from employing an intervention.
Records have to kept up to date so that the individuals rights are not impeded and also ensuring that there needs are met and they are safegaurded from harm. Poor record keeping can result from a number of factors one of which is that careres do not understand what is meant by constraint and so do not know what to record for monitoring interventions. Also carerers may not be able to balance the rights of the individual with the type of intervention being used.


 Q1 Identify a range of communication methods. (1.1)
There a number of communication methods used to support individuals in expressing their needs. If an individual has a difficulty with vocal communication then writing can be a preferred method of communication. As well as writing there is a category of communication methods entitled Augmentative Alternative Communication which includes objects used to indicate an individuals needs. This has an advantage that an object like a toothbrush adds a context such as an individual wanting to brush their teeth. As well as objects being used in this category, both symbols and photographs are also used. An advantage with a photograph is the additional information it contains as to who, what and when is involved as depicted in the photo.
BSL or British Sign Language is another method of communication. This is used by people with a hearing difficulty to communicate their needs. With this method gestures and facial expression are used within an individuals' signing space to send a messgage. Makaton, another method uses symbols to convey a message but is not intended to replace speech but to augment it where individuals may have a communication difficulty. The communication method Picture Exchange Communication System (PECS) contains portable albums of pictures which allows individuals independance, and an ability to quickly communicate their needs and therefore reduce the opportunities for behaviour that challenges. Autism is an example of a communication difficulty that may use PECS.
A category of communication methods called human aids contains interpreters, translators and advocates. An interpreteter interprets between two individuals using the spoken word, or in the case of BSL gestures, whereas a translator translates using the written word. Advocates will objectively represent an individual but must not amend or manipulate the message recieved from that individual to reflect their own beliefs.
Another category of communication methods is called technological aids such hearing aids which amplify sound for individuals with a hearing difficulty. Also, mobile phones fall into this category as individuals who experience deafness or who have a difficulty with vocal communication can send text messages or emails quickly to meet their needs. Finally I will mention the communication method BROCA which contains a compilation of words which can be strung together to form speech.



Q2 Explain the importance of non-verbal communication. (1.2)
A lot of messages that we receive are dependant on non-verbal communication. Being able to read or interpret non-verbal communication means there is more information available and resulting in better chance of an individual having their needs met which will help in the reduction of behaviour that challenges. Misinterpreting non-verbal communication can cause confusion and increase the opportunities for behaviour that challenges. An example of this refers to cultural differences such as the thumbs up or hands out gesture which means nazo in Greek and is considered offensive. Also I will cite raising eyebrows in Japan which is considered as non-acceptable and being another example of cultural differences. Just as strategies for managing behaviour that challenges, and preferred interaction style etc, cultural differences should be mentioned in a behaviour support plan to be referenced by everbody involved in the care of an individual.
Gestures can give an indication of how an individual is feeling such as if the individual is gesticulating in a strong fashion, this may indicate the individual has strong feelings about what is being discussed, or the situation they are in. They can be quickly interpreted creating opportunities for the reduction of behaviour that challenges. As well as gestures there are facial expressions. A facial expression allows someone to read an individuals mood such as if the individual has a stern appearance they may not wish to be approached. Posture can also be read to see how an individual is feeling. An example of posture included in the book Manwatching by Desmond Morris is crossing ones legs. If someone sits with their legs crossed away from you this may indicate they are feeling defensive, similarly someone with their arms crossed in front of them may also suggest defensiveness. Finally proximity can provide information about an individual such as someone standing at distance may indicate defenciveness or feeling threatened. My own example of proximity is someone standing inside my own personal space, or what I would call my safe zone. If someone was to stand just inches from me without declaring the intent to give a hug with their arms open, I would interpret this as possibly hostile, or if anything was to happen I would be caught off gaurd without the room or ability to evade a physical attack. This would make me feel anxious or unsafe.



Q3 Describe barriers to communication. (1.3)
A barrier to communication for an individual arises whenthere is an unmet need. An individual may have multiple barriers to communication from multiple needs. I myself have several communication difficulties resulting from my illness of schizophrenia which to me feels like expressive disorder (REF: How psychology works - Chapter on communication disorders, pages 96-97). This is an example of mental illness being a barrier to communication where I feel am unable to communicate my thoughts. I also have autistic spectrum condition (Aspergers) which means I find it difficult to respond to other people's feelings which in turn presents a communication difficulty. Familiarity with a range of mental illness may facilitate an empathetic response to an individual. There are a number of other potential causes of communication barriers the first of which I will describe is sensory impairment. Impaired vision or hearing may present a communication barrier which can lead to aggressive behaviour, or behaviour that challenges. Triggers in the environment such as noise, light, and temperature levels and overcrowding all of which can produce frustration to all involved during an interaction. Cultural differences such as language and body language may present barriers to communication. With the language factor, there may expressions or phrases belonging in a language called idioms which do not have an equivalent in the individuals own language. Also with body language, a gesture in one culture may mean something totally different in another culture. In both cases these differences may result in confusion and may leave the individual feeling disrespected. Making assumptions such as assuming that an individual's needs are already known may cause the care worker to stop listening which is not in keeping with person-centred practice. When the care worker stops listening this may cause the individual distress as they may already have an issue with communication and a need that is unmet. Language differences, local dialect, and slang can present a barrier to communication as the individial may not understand what is being said and will as a result will receive confused messages. Similarly, technical terms may not be understood so the communication should be kept jargon free. Another barrier to communication can be the use of drink and drugs which alter perception and distort reality or facts. This can result in confused messages being sent and received and may result in frustration and behaviour that challenges. Finally personality may be a factor in barriers to communication. An example of this is shyness where a person may be feel vulnerable, threatened or frightened. From my own experience I have identified another personality trait of my own which is being obsessive. If I feel that I have a point to make such as with medicine, or getting my point across to a GP, my obsession and need for therapeutic match and recognition may then result in an obstructive attitude which might pre-empt a diagnosis from the doctor.



Q4 Describe ways to overcome barriers to communication. (1.4)
It is important to overcome barriers to communication to facilitate the meeting of an individual's needs and so prevent them from escalating. There are a number of approaches to the problem of communication barriers, the first of which I will describe is the use of a preferred method of communication or interaction style which could be the use of the Picture Exchange Communication System (PECS), Makaton, an interpreter such as with the use of British Sign Language (BSL), or an advocate to mediate in the process of meeting an individuals needs. The forming of relationships is an another example of overcoming barriers to communication, in this instance to increase feelings of well-being. This could also have a positive impact with regard to belongingness which is one of the levels in Maslow's hierarchy of needs and could potentially fulfill an unmet need and hence prevent behavioural escalation. Training staff in matters of mental illness awareness, cultural differences will ensure their are no mixed messages or communications, and increased confusion resulting in a decrease in the number of opportunities for behaviour that challenges. Self-awarenes or self-reflection by carers will ensure that they have an appropriate atititude and so they will not appear ignorant or indifferent towards an individual and as a result reduce the occurence of triggers to behaviour that challenges. Inividuals that are service users of health and social care may be vulnerable and communicating in a way that makes the individual feel valued and safe will be important, particularly long term service users who may be vulnerable and prone to abuse. Changes to the enviornment such as changes to light, noise or temperature levels will eliminate barriers to communication, and when this is not possible a change to a different environment can be implemented. Observation of an individuals behaviour to watch for signs of a trigger will help to prevent behavioural escalation and overcome barriers to communication, for example, if observation reveals signs that a person is becoming agitated, this will be and indication that there is a communication barrier and that the individual's behaviour is about to escalate.
One of my own examples regarding overcoming barriers to communication is the taking of a personal or full medical history by a General Practitioner (GP) or consultant. As a result once they have familiarised themselves with your past or history they would be able to make predictions concerning the individual's behaviour and offer positive support to avoid behaviour that challenges. I find myself disillusioned when I see a GP or a consultant psychiatrist for my schizophrenia and they just look at the computer monitor to see how I am feeling without taking a history to see how I have coped since the last attendance. Gone are the days of the house visits and the doctors bedside manners. This brings me to the second example of this scenario of taking a medical history which involves a profile of emotions. As well as being able to make predictions about behaviour, if the doctor was to take interest in an individual's activities since the last appointment by way of of a history, he or she would not be in a position of making assumptions concerning the individual's behaviour or illnesses. As a consequence the doctor would not have an obstructive or negligent attitude toward the individual and would have a more empathetic approach instead of browsing a monitor. To this I think the old addage 'a problem shared is a problem halved' would be appropriate. I myself write Open Source software for the Windows operating system you are likely to read this on. As it is free it represents a more user friendly approach to computing and is at the leading edge of technology. It is at the intersection of technology and social justice as opposed to GP's and consultant psychiatrist's commercialised and private power enterprises with computers in their surgeries and consulting rooms. One of my websites can be found at the following web link https://tarkastatistics.webs.com/



Q5 Give examples of how communication can be adapted to meet the needs and preferences of each individual. (1.5)
There are a number of communication methods available that are adapted to meet the needs and preferences of the individual. The first one I wil mention is British Sign Language (BSL) which is used for individuals with hearing impairment. Similarly, Makaton is an adapted communication method for individuals who have some vocal ability but also have a learning disability. It contains a set of symbols which are used to communicate a need. Similarly the Picture Exchange System (PECS) contains an album of pictures which is portable and thus offers a degree of independance. An example of PECS could be a picture of a door which would indicate a need to leave the room. Augmentative and Adaptive Communication (AAC) will contain pictures, objects which have the added advantage for providing a context, and symbols.
There are some general guidelines or rules for conversation so that conversation can be adapted to effectively meet the needs of the individual. An appropriate time for communication is an example of this where a time is selected when an individual is most receptive to communication. To illustrate this point, it would be a poor time when an individual has taken medication and it affects them in such a way to make them drowsy. I can reference this to my own medication Olanzapine, an anti-psychotic drug for my schizophrenia which states on the packet 'May cause drowsiness. If affected do not drive or operate machinery'. Another example of adapting communication to meet the needs of an individual is allowing enough time for the individual to understand the message and process the information. Again I can qoute my schizophrenia as an example with its associated learning difficulty requiring a greater span of time than normal to interpret a message correctly and put the information to use. Also important is for a carer to take the time to ensure that the individual has understood the message communicated to them. Key to this is not asking the question 'Do you understand?' where an individual may reply yes when they dont. From my own experience reasons for reply yes when I do not understand may be because of feeling intimidated, not knowing how to assert myself, being frightened of the consequences of saying no, or just being totally disillusioned by the the whole process and saying yes to get some closure on the matter. As well as saying yes when when the message is not understood is the expression 'at least there is...' which implies making assumptions about the individual and as a consequence is not very person-centred. Communication can also be adapted to the needs and preferences of the individual by the messages simple by not not using technical jargon or slang. If technical terms and jargon are used the individual will receive a confused message and consequently their needs may not be met leading escalation and behaviour that is perceived as challenging. Appropriate eye contact is also important but not straring. I think that the rules SOLERB which I learnt from the the Petroc online course 'Introduction to counselling and helping skills'. S is for sitting opposite, O is for open posture or body language, L is learning forward and slightly at an angle, E is effective eye contact but not staring, R is relaxed and B is for slow and steady breathing.
Being consistent in communication with an individual is important as not being able to communicate with some oeople and not othes can lead irritability and anxiety.
An important criterion for adapting communication to the meet the needs and preferences of the individual is being person-centred in the approach to communication. THis ensures the at the needs are met in a way that are unique to that individual. Person- centred means that an individual is supported in a way that helps them to be as independant as possible and experience social inclusion. While I was living in Bristol I was a disability advisor for a year with Bristol City Councils Disability Equality and Social Inclusion Team training under Anne Boothe which focused on social inclusion and independant living. Even the free sandwiches and coffees I would call social inclusion.



Q6 Explain the effects that communication can have on others. (1.6)
Communication can have an adverse or negative effect on an individual unless the carer has self-awareness regarding his behaviour and how it impacts on the individual. If the carer is able to observe his own behaviour he can become aware if it presents a trigger to the individual resulting in behaviour that challenges. There are a number of points to bear in mind while communication with the individual, firstly standing too close or within the individual's personal space or life space wich may appear threatening if they are vulnerable. Similarly pointing, especially to the face of an individual may be a trigger. Inappropriate body posture which is a form of non-verbal communication may have a negative effect on others. Speaking too loudly is another factor as too much noise can be a trigger such as the case with someone with Aspergers syndrome. An appropriate expression for what an individual has spoken is important so that a confused message is not received leading to behavioural escalation. Allowing enough time to understand what has been said is necessary to prevent a negative effect on an individual such as conditions that present with a communication difficulty, for example schizophrenia. Another way of preventing behaviour that challenges is using a preferred method of communication, or interaction style to provide an open and clear channel of communication so that messages are understood. An example of my own to illustrate these points is with my Schizophrenia and Aspergers syndrome which means I communicate more effectively on my own using social media as a preferred method communication such as my Twitter account. I also like to use my email account. Both allow me space and time to reflect and process information enabling me to communicate without the distractions and overwhelming presence of the public. As well as the aforementioned points that should be observed, it is important to give all of your attention to the individual and not to be preoccupied with another task while communicating, and also active listening is also important.
There are a number of a ways a carer or health professional can develop self-awarenes so that they are aware of the the impact of their behaviour on an individual, and also became aware if it is a trigger to behaviour that challenges in any way. One way is to be observed by someone and to ask for feedback as to how come across to another person. A second method is to be aware of the response or reaction from an individual during communication and if it is negative review the method of approach for a more favourable outcome. A third way of reducing behaviour that challenges from the effect of communication is for staff to attend courses on self-awareness or mediation skills. An example of mine I will give is to use meditation like Tai Chi to still the mind and to tap into inner resources to become more self-aware of my behaviour and feelings and any personal triggers that I may have, and to try to be peaceful enough to be aware of my own boundaries and limitations as well as other people's. I have recently been thinking that I would like to teach Tai Chi to disabled people.



Q7 Explain the importance of positive reinforcement. (2.1)
Postive reinforcement is important as it can be used establish a link between positive behaviour and a reward. Positive reinforcement can strengthen postive behaviour so it is more likely to be repeated. This is an example of shaping behaviour so that it is a more appropriate way of an individual expressing their needs in a more unique, meaningful and important way to that individual. It is important to implement positive reinforcement immediately after positive behaviour as a reward after any subsequent negative behaviour will suggest to the individual that they are being rewarded for negative behaviour. This is an example of a confused message which may lead to behaviour that challenges. So that a mixed or ambiguous message does not occur it is important to add a context. therefore positive reinforcement must be used consistently to strengthen the link or association between the reinnforcer and the positive behaviour. The aforementioned word of 'association' refers to idea of associative memory which makes connections between ideas and actions. When praise is being given as positive reinforcement for positive behaviour a context can be added by adding a context within the praise, for example, rather than just saying 'thank you', rephrasing the praise to say 'thank you for passing me that cup' may be more appropriate. In the context of effort there may not be complete success in terms of accomplishing postive behaviour , but even so the link between positive behaviour and reward may still be strengthened. One of the advantages of rewarding effort is that there will inreased effort as the individual will try harder after being rewarded.
Praise which is one form of positive reinforcement can take the form of social reinforcement which can be used by care workers to positively reinforce appropriate behaviour. Positive reinforcement in the form of praise can increase an individuals self-esteem. Positive reinforcement can also reduce the number of episodes of behaviour that challenges,. Another desired result is an increase in critical skills such as taking turns, for example not interrupting during conversation, and also manners such as saying please and thank you. Critical skills can take the form of natural reinforcement where an individual through learning manners can extend their circle of friends which in turn reinforces their positive behaviour. Another form of positive reinforcement is the form of token reinforcers. My example of this are the tokens of coloured stars which I placed on a card for completing assignments of homework at primary school. As a confession I used to go to the store cupboard where the answer books were kept to complete more assignments for extra stars. Hopefully you reading this and less guilty feelings for me will reinforce the idea of me being more honest in the future. Another kind of reinforcer is a tangible reinforcer. Tangible means physical and therefore a tangible reinforcer is a physical reward such as money or trips and so on for positive behaviour. Again my example goes back to school, this time secondary school where I received myy first bicycle for good accomplishments at school work.
For positive reinforcement to work effectively it is important to think of the context in which behaviours occurs so that obervation for patterns of behaviour can take place and predictions can then be made concerning the individuals behaviour. Positive reinforcement can then be applied within the context of such behaviours. The context for the behaviour of an individual can be either a social or a physical one. The social context is determined by environmental factors such as temperature, lighting, overcrowding, overstimulation, boredom, isolation and a lack of understanding of cultural beliefs. Physical factors can include pain, side effects of medication, sensory impairment, medical interventions such as giving blood, hunger and thirst, lack of sleep, and needing to use the toilet. I can cross reference these factors or needs with Maslow's hierarchy of needs where if the needs are not met then the individual will not be able to actualise within a social framework. By supporting the individual with positive reinforcement in the right context this will help the individual to meet their needs and to actualise and feel safe.



Q8 Describe how to avoid confrontation with someone who is emotionally agitated. (2.2)
It is important to use means and methods to cope with someone who is agitated to prevent behavioural escalation to behaviour that challenges and confrontation. One line of defence is the use of a distraction technique to prevent confrontation from happening. A distraction technique can take the form of offering a preferred alternative activity or talking about something different, or the use of a preferred interaction style to facilitate better communication to de- escalate the situation. In the cae of a preferred activity I find some classical music works as in the case of old addage 'music soothes the savage breast'. Another technique is an avoidance technique which comprises of observing an individual's behaviour as outlined in a Behaviour Support Plan to watch for changes in behaviour that may indicate that the individual is becoming agitated and that their behaviour might escalate to confrontation. Also, watching for triggers that may trigger behavioural escalation leading to confrontation is also an avoidance technique. De-escalation strategies may also help to avoid confrontation, for example an individual relaxation technique, or asking an individual to stop what they are doing, or removing them from the trigger by using a guided walk away from the current environment. In the case of a guided walk if I find myself distracted and unable to focus which leads to me feeling frustrated I change my environment by leaving my living room where the noise level is loud outside my window and going up into my attic bedroom which is higher up and therefore more detached and less noisy. As well as a change of environment, changing the conditions within the environment can also be important. An example of this is the way I de-escalate is by changing my mood by a process of remotivating. This is mentioned in Desmond Morris's book Manwatching and entails 'flipping into a different frame of mind' (REF: Dr Graham Roothe, consultant psychiatrist at the Bristol Royal Infirmary) by putting on a dimmer light or softer light. Generally, noise, light and temperature levels and overcrowding are important factors which can be triggers to behaviour that challenges and monitoring them can prevent confrontation. Using assertiveness to maintain effective control over a situation and being firm with an individual may help to avoid confrontation, and if a carer is unable to maitain control then the involvement of other people may be necessary to prevent harm happening to the individual or others. Another way to avoid confrontation with someone who is agitated is to give them more space and time. This can be acheived by removing them from the situation and also allowing them to use breathing exercises or to go for a walk. With regards to the latter point of going for a walk I can illustrate this with my own experience and confirm that it does de-escalate things when you are in distress. For example, today I experienced a relapse of more neuralgia in my eyes, temples and around the front of my head. Going for meal and a walk and shopping around in the charity shops and others occupied my mind and distracted me from how I was feeling. As I accomplished simple tasks I became more confident and the pain gradually subsided. The next way to avoid confrontation that I will discuss is if a care worker is agitated this may lead to behaviour that challenges by the individual. A calm approach is necessary and self-reflection on the part of the care worker to ensure that their behaviour is not ignorant or indifferent to the needs of the individual. I have read in one of R.D. Laing's books, 'Self and others' I think, that an individual may resolve their defences to see that the environment is not as threatening as they might think it is, a kind of desensitization. I have written a post on this about how to retreive oneself and regain mental composure under such circumstances. The link to the post
on my blog is http://reflectandretrieve.blogspot.com/2018/09/steps-to-straight-thinking.html
gives a number of steps to attempt to acheive this. I believe a disarming attitude or behaviour on the part of the carer can facilitate this. Finally identifying the cause or trigger for an individual's agitation can prevent their behaviour from deteriorating and de-escalate so that confrontation does not take place. Again I can give myy own example of missing time from drink and drugs which meant that few people were aware of the cause of my distress / agitation which meant that my condition has escalated over a number of occasions.



Q9 Describe how using knowledge of the individual can help to manage behaviour that challenges. (2.3)
Knowledge of the individual as implemented in a person-centred care plan means that behavioural management strategies can be put in place as a contigency plan in the event of triggers being missed. If family, friends and carers are involved in the production of such a person-centred care plan such as a behaviour support plan they will be able to identify patterns of behaviour that will indicate that the individual's behaviour is about to escalate resulting in negative behaviour. Here knowledge of the individual's needs are important so that such needs are met in a way that is unique to the individual and there is an awareness of any triggers and evironmental stressors. Also, if there is knowledge of the individual the care will be consistent such that positive reinforcement in one situation will be used in another same situation resulting in no mixed messages being given and therefore resulting in no frustration and a reduction in the incidents of behaviour that challenges. As having not been a carer I cannot give any examples of my own in this context, but coming from the other side of the story as a patient I can give my own example of a lack of knowledege and therefore an inconsistent approach by my general practitioner producing confusion and a feeling of being out of control. This led to defiance and a search for identification elsewhere to assert control over a situation where I felt frustrated and rejected. On this occasion visiting a doctor with regards to my schizophrenia I was anticipating a degree of commeraderie as I had a B.Sc. in microbiology with a substantial amount of medical content such as differential diagnosis in bacteriology, virology, mycotic illnesses and some research on antibiotics for my thesis. Not only was this not the case he took another person's word for granted instead of my own, and made assumptions about me based on a stereotype or label. Expecting him to have knowledge of me as an individual from a medical history and my person from previous encounters proved not to be the case. The following section under the mental health act produced an attitude of defiance and feeling of being humiliated. A knowledge of the individual should mean that an individual will be treated with dignity with the least restrictive intervention put in place. Again I can illustrate this with my own example of seeing a psychiatrist to whom I confessed concerning some character defects which had made my life unmanageable, and confessing some issues for which I was experiencing some guilt leading to behaviour that challenges. Here the psychiatrist seemed a bit defensive which was understandable and told me she could call the police but instead she listened and did not betray my trust allowing me to reduce the incidents of guilt trips and restoring some of my confidence. In this situation more professional, comprehensive and disarming knowledge of the individual specific to my condition of mental illness from a specialist (psychiatrist) point of view meant I was able to make predictions which was good for my self-esteem and confidence.



Q10 Explain how to maintain the dignity of individuals when responding to incidents of behaviour that challenges. (2.4)
There are a number of ways to respond to incidents of behaviourthat challenges to maintain the didnity of the individual. Firstly the carer remaining calm will provide a model for the individua to copy to de-escalate the behaviour. Another approach is to allow the individual feel valued by the carer accepting them for who they are as a person rather than being viewed in terms of their behaviour or a condition. With regards to the latter condition if the individual feels valued this will increase their feelings of self-esteem and self-worth and hence their dignity. Another example of maintaining the dignity of an individual during an episode of behaviour that challenges is not to react to the situation by de-escalating it, but to respond by attempting to find a cause or trigger for the behaviour such as distress from pain, or agitation from being in an overwhelming environment where sensory overload may occur requiring them to return home, or my own example of reacting to sirens from the street outside needing me to relocate in the attic upstairs. A criterion for maintaining dignity may also be no raised tones or shouting as this can escalate behaviour, and also a non-aggressive posture including gestures, particularly such as pointing to the face which may appear threatening to the individual. Concerning a non-aggressive posture I find as a physically disabled person, also with paranoia issues from schizophrenia, and post traumatic stress disorder from a stab wound and also difficulty with interpreting non-verbal communication with my Aspergers, that physical proximity of other people is in an important factor in making me feel comfortable and dignified in their presence of. I find a distance of two to three feet from other people is reassuring. Another way to maintain the dignity of an individual during an incident of behaviour that challenges is to address the individual appropriately. From my experience I have found name calling ,or a nick name, has resulted in my experiences at school and memories of it becoming a blur or a white noise that can escalate and can have repercussion in terms of alienation and also an impoverished self-concept even much later in life. Allowing an individual to retain control in a situation by allowing them to accept responsiblity for that situation will provide them with dignity as this will result in increased confidence so that they will be better able to find their own strategies to deal with similar situations in the future. My own example of this is having been formally discharged from psychiatry after thirty four years as a mental health patient. At first I felted cheated of support and a recovery but now I am nurturing my confidence and abilities which I have learned during those years as a reflexive knowledge and am now coping without the need of have to depend or lean on the external disciplines of psychitatry or General Paractitioners. Another aspect to maintaing the dignity of the individual is for care professionals to adopt an empathetic approach and support as if the individual feels that someone understands them this will encourage them to use more positive strategies to meet their needs. Lastly, an important factor in maintaing the dignity of an individual through episodes of behavior that challenges is a non-judgemental attitude which is important as this is a person-centred approach which allows an individuals needs to be met in a way that is unique, prsonalised, meaningful and important to them. If a person has a judgemental attitude to an individual it will be an obstructive attitude which will prevent the individual from fulfilling their needs and consequently not maintain their dignity.



Q11 Give examples of different techniques that are used to defuse behaviour that challenges. (2.5)
There are a number of different techniques used to defuse behaviour that challenges and the first example I shall describe falls under the category of diversion techniques. A diversion technique will take the individual away from the situation that is leading to behavioural escalation. An example of this is a distraction technique such as stopping the individual from doing something from which they are experiencing frustration. This can be accomplished by offering a preferred alternative activity, employing the use of humour, or a guided walk to a different environment. My own example of a diversion or distraction technique for when I feel frustrated is a coffee and a radio channel with my favourite channel BBC Radio four. Another example of a technique for defusing behaviour that challenges is prevention where vigilance for potential triggers in the environment is used to prevent behaviour that challenges from occuring and to ensure that positive behaviour is maintained. Seeking assistance from someone who knows the individual better can also be used to defuse a situation as I imagine they would be more familiar with the individual's patterns of behaviour and potential triggers and which distraction techniques work best. With regards to the carers role in defusing behavioural escalation is their acknowlewdgement of the their own abilities and competencies which help them and will also be a transferable skill in helping other carers. Concerning the individual a person-centred approach is important with the best intersests of that individual as the focus. With person-centred care strategies that both individual and the carer have agreed on are used as may be noted in a behaviour support plan for the benefit of both parties. Also in the behaviour support plan may be documentation of best practices to be used such as the best distraction technique. Another example of mine is the best practice of talking informaly about subjects of my own interests as a medical history with a psychiatrist of mine Dr. Kerry Jonsson of Riverside here in Barnstaple. If I find an issue resistant to insight she will allow me to gravitate towards a subject I wish to know more about. An instance of this is discussing a possible model for my schizophrenia where mutations for post-synaptic receptors of dopamine receptors in the brain mean they are more sticky thus leaving the pathway continualy switched on which is termed constitutive, resulting in the hallucinations. When all the available resources have been exhausted a carer may need to seek assistance from somebody else. If a physical intervention is needed when seeking help this must be carried out by someone that is trained and the legality and legislation must be in accordance with the deprivation of liberty act and also the mental capacity act of 2005 and there must be observation at intervals for signs of medical and physical distress, The carer keeping calm is also a technique for defusing behaviour that challenges as keeping calm will enable them to think effectively whereas panick will impair their ability to think. In the case of panick I am reminded of what a psychiatrist of mine Dr. Graham Roothe of the Bristol Royal Infirmary told me, ' you are worried about your troubles and your attention is withdrawn from the environment'. I am convinced the latter applies to panick. Also, if the carer is panicking this probably will not inspire confidence on the part of the individual and may cause their behaviour to escalate.
Crisis mahagement is technique used to defuse an incident of behaviour that challenges. A crisis occurs when things are at breaking point or there is an incident of behaviour that challenges. During a crisis ideas are taken from the behaviour support plan to meet the needs of the crisis. The ideas, or best practices will be the same as the aforementioned techniques such as a distraction technique using a preferred activity, prevention by eliminating the triggers before the episode happens, seeking assistance, support, remaining calm and a person-centred approach to the individual to meet their needs in a more appropriate way that is unique, meaningful and important to them.



Q12 Review how your own actions can defuse or exacerbate an individual's behaviour. (2.6)
There are a number of carer's actions that defuse or de-escalate an individuals behaviour. Firstly is the use of strategies that are noted in the individual's behaviour support plan such as in the amber stage of behavioural escalation where humour or a preferred activity is employed to de-escate. A distraction technique can also be used for this purpose which will also be noted as a best practice in a behaviour support plan. Maintaining the dignity of the individual is an important factor and the opposite of actions that humiliate the individual will excascerbate and not defuse the behaviour. Appropriate behaviour is also important in the defusing of behavior whereas the use of inappropriate behaviour such as shouting, or gestures such as pointing to the face will exacerbate it. A person-centred approach towards the individual where there needs are met in a way that is important and meaningful to them tailors the approach of care to defuse behaviour. Another approach is for the carer to remain calm which can provide a model for positive behaviour for the individual especially if this behaviour is reinforced with a reward, but the opposite situation of the carer panicking may exacerbate the behaviour especially as it will not allow the individual to experience confidence and not provide an opportunity for them to make predictions about their behaviour. A preventative strategy can be used to prevent any opportunities for triggers to occur and thus will defuse behaviour, or actually removing the individual from the source of the trigger such as in a guided walk will also defuse the behaviour. As for other factors which may exacerbate behaviour incude the use of inappropriate restraint, not seeking assistance during a time of crisis, and also the use of techniques that the individual is not trained for. There is a method that can be used called sel-reflection that can be used to improve a carers techniques which can then be used as best practice and noted in the individual's behaviour support plan and shared with all others involved in care for purposes of positive behaviour support and defusing behaviour. There are three approaches to this which include a learning a journal where an incident is noted as soon as it happens, secondly asking for feedback after observation, and thirdly asking for feedback after a period of formal supervision to make note of any amendments that can be made. These amendments will then be implemented during the next occurrence of a similar situation to improve the effectiveness of strategies in defusing behaviour.
To be an effective refelector to improve strategies to defuse behaviour a technique called 'Kolb's cycle of experiential learning' (Ref: Wikipedia) can be used. This involves four stages the first of which is concrete experience where an individual experiences the situation. The second stage is reflective observation where the carer will reflect on the experience in personal terms. Thirdly, abstract conceptualization will occur where a carer forms new ideas or modifies previous ones based on the experience. Finall during the fourth stage which is experimentation, the carer will put the new ideas into practice during the next occurrence of a similar situation, the results of which will feed into the next cycle of learning or reflection to improve the effectiveness of strategies in defusing behaviour.



Q13 Describe referral services available to provide support for individuals. (3.1)
Referral services to provide support for individuals are usually made by a General Practitioner using a letter of referral outlining a medical history and any other points of interest worthy of note. Referral to an NHS serivice may include a number of specialist services such as a psychiatrist. A psychiatrist will will deal with long-term and severe mental illnesses by providing behaviour support strategies. My example of a referral to psychiatry is my attending psychiatric out-patients at the Bristol Royal Infirmary to see a Dr. Glen Roberts where behaviour support took the form of counselling on interpersonal behaviour to obviate difficulties in relationships with other people. Counselling is another avenue of support that can be made avialable to the individual by referral, where they can be heard in a non-judgemental environment concerning issues such as anger and offered help in learning to park these issues. With counselling triggers to behaviour that challenges can be identified and the anger that ensues, and aslo help to deal with what has happened after an episode of such behaviour. The next referral service I shall describe is a behaviour therapist where an individual receives help in identifying self-destructive and unhealthy behaviours. Also identified are negative patterns of behaviour. With this referral service in mind I will give my next own personal example. I was referred to Dr. Anabelle Denney of the Cognitivive Behavioural Therapy service of Riversvale, Litchdon street here in Barnstaple. I was presenting with a self-critical attitude of admonishing myself for having taken things for granted when I was a teenager and being selfish for wanting fashion accessories at school such as flared trousers and platform shoes when my dad was working in factories for a low wage. The therapist suggested that although my dad had needs that were probably unmet, I also had an entitlement to my own needs at the time and should take up an attitude of self-compassion to myself. For me the result was a trade-off between being less critical of myself and an attitude of humility to other people who supported me and who had a more difficult time, had not made the mistakes I had and had accomplished more in their lifetime. Another referral serice that I will mention is an occupational therapist which will support an individual to perform tasks to assist them in being independant and to improve their quality of life. Here I will qoute my own example of asking to see an OT (Occupational Therapist) while I was sectioned under the mental health act at North Devon Hospital. I asked the OT to take a history of my interests and strengths to help motivate me and give me conviction in establishing a precedent where I could relate my complete history and ambitions to a psychiatrist to gain closure and park issues relating to obstacles to my progress.


Q14 Discuss limitations and accountabilities when supporting individuals exhibiting behaviour that is perceived as challenging. (3.2)
When supporting individuals exhibiting behaviour that is perceived as challenging a carer is responsible to the extent of how well they are trained and what are their limitations of their abilities to apply interventions in a situation. A carer must be trained for a range of strategies so that effective strategies can be put in place to support an individual. Being trained for physical intervention involves more than training for physical restraint, it involves being equiped to use a number of techniques. Training and limitations include points such as risk assessment of a situation prior to applying a restrictive intrervention. A risk assessment will also be included with regard to any medical considerations such as any medical distress that may arise from a physical intervention. A carer must also be trained how to tactically defend themselves in the case of a physical attack and how to free themselves from grabbing and holding. The safe applications of techniques must be thought of as well as the legal and moral implications. To support an individual with behaviour that challenges there must be an awareness of the legal accountabilities involved when using an intervention.
A legal requirement is that the least restrictive intervention is used first, for example if someone consents to use a medical intervention to make them safe, it would be inappropriate to use a physical intervention as the individual would not be prepared for this and may actually have the opposite of the desired effect by escalating their behaviour. If there is a risk of harm to the individual or others and the individual has not consented to an intervention then the mental capacity act of 2005 has to be considered to see if a restrictive intervention is in the best interest of the individual. Also, if an individual has to be detained against their will in a hospital, another legal accountability is the mental health act of of 20007 which again is concerned with the issue of whether the restriction in the best interest of the individal or not. The human rights act of 1998 is another legal accountability that will have to be considered. An example of human rights is the human rights charter UN2811 article one that states everyone has the right to security and liberty of person as well as the right to self-determination.
With regards to implementing a restriction there are a number of limitations that must be taken into consideration, the first of which I will discuss is ethical considerations. Again this will decide if an intervention is in the best interesets of an individual and if anything happens to an individual from omission of such an action would this mean a breach of duty of care on the part of the carer. A limitation also presents itself with environmental factors such as being in a limited space and does this present a risk of harm to the individual or others. If there is a space where there is a crowd containing a large number of vulnerable individuals it must involve a process that does not traumatise these individuals. There are cultural factors as well which must involve a person-centred approach by not making assumptions about the individual and assessing what the cultural norms for the individual are. Although not a carer I can give my own example of this where in my mother's country Cyprus, it is customary to give and receive gifts when visting or departing from homes of family or friends. This is the norm in this cultural context. In this country sending a gift of a book called 'A catcher in the rye' by J.D. Salinger to a rich person was misinterpreted and led to me being detained withount consent in a hospital. This led to escalation of my behaviour fueling the paranoia component of my schizophrenia by thinking that disinformation had been given to a doctor and psychiatrist for the purpose of some sort of sport.



Q15 Explain how to record and report incidents of behaviour that is challenging. (3.3)
a) How to record the behaviour
To record incidents of behaviour that is challenging a number of points of information must be included. Firstly the type of behaviour must be defined. Some behaviours may be defined as a cluster of behaviours, for example a temper tantrum which may include screaming, spitting and self-injurous behaviours and so on. Other behaviours may be a progressive sequence of behaviours which escalate. These behaviour must be described or defined as a sequence. I can give my own example of a progressive sequence such as when I experience rejection or a rebuttal. As I am thin skinned I take criticism that is not constructive too seriously and and first reaction is to rant to myself and then adopt a ritualistic pattern of speech by talking about the same thing to other people repeatedly which as ritualistic behaviour is an example of behaviour that challenges. If I cannot resolve the issue or get some closure then I can make a cause out of the issue. The next thing to record is the results that the behaviour acheives, or in other words, its consequences . Triggers must also be recorded, where a trigger is defined as a signal that takes place before the behaviour that challenges and results in an increased want, suggests a threat, or indicates that there is an available reward. Triggers may also take the form of personal triggers of which an example is the wrong type of non-verbal communication on the part of a carer. The environment in which the behaviour takes place should also be recorded. Finally it is important to record the identification of a lack of any critical skills which leads to an incident of behaviour that challenges. The STAR approach is an approach to record any such incident. It stands for Settings, Triggers, Actions, and Results. The first part settings is the context in which the behaviour takes placeand is determined by an individual's motivation to work and and acheive results. The setting may be of an external type or an internal one. The categories of external settings to record fall into four groups, the first of which I will mention is life events which can include things such as loss and change. The next external setting which can be recorded is the social climate, an example of which is conflict. Thirdly there is current activities to be recorded which can include the type and level of stimulation and a desired or preferred activity. The final category to mention is the physical climate where things like light, noise and temperature levels may be important. The internal type of a setting can include things such as an anxiety state, a communication difficulty, sadness and depression, and an inability to occupy self, to name a few. For my example of an internal setting I will describe an inability to occupy self. I can take this to mean an inability to concentrate on a task due to distractions, but I will add to this by saying that I can personally find it difficult to occupy my mental internal lifespace and focus on my own thought processes or thoughts (REF: Ruth, learning supervisor for Petroc's online course 'Behaviour that challenges') because of an inability to detach (REF: Dr. Graham Roothe, psychiatrist at the Bristol Royal Infirmary) from the environment. The trigger part of the STAR approach is used to record any triggers which were present before the incident of behaviour that is challenging took place. Actions will record what the behaviour or actions were and the ensuing consequences. Finally the results is used to include the results or consequences of the behaviour that took place. STAR can be used to arrive at a conclusion of best practices of effective strategies that can be recorded in a care plan for all people who interact with the individual to use.
Another approach to recording an incident of behaviour that challenges is the ABC approach. The A stands for antecedant which describes what happened before the behaviour took place. The B is a description of the behaviour, and C represents the consequences of that behaviour. The final part of the ABC approach will involve an interpretation based on a conclusion of what happened and what effective strategies can be put in place to prevent the behaviour that challenges from occuring.
b) How to report the behaviour
With regard to reporting incidents of behaviour that challenges, even minor incidents should be reported. The rational for this is that several minor incidents may lead up to a major incident later on, and if the earlier incidents have been reported staff will be better prepared to deal with it. Generaly , according to the Health and Saftety Exececutive any minory injuries sustained in a health and social care setting, including those resulting from incidents of behaviour that challenges are considered to be part of the job. Every setting should have an accident or incident book to log any incidents that have taken place, alternatively note taking in the form of a diary can be used so that other members of staff can read about any incidents. If an incident of behaviour that challenges results in a serious injury then it is a legal requirement to report it in line with the Reporting Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) of 2013. For the purpose of reporting an incident a Violent Incident Report form is used. This will include personal details of the person injured and the person reporting the incident. Also included are the location and the type of incident such as verbal abuse or threat , physical attack or near miss. The type of action taken will also be added to the form, for example, wether first aid was needed or an ambulance, and were the police or security involved, and if the incident was injury related. The types of injury that would be mentioned are a traumatic amputation after an accident or an amputation after surgery, a traumatic scalping or peeling of the skin from the head, burns, permanent loss or reduction of vision in one or both eyes, fractured or crushed bones, brain damage from a head injury or crushed internal organs. Loss of consciousness would also be reported where there is no vocal or physical response due to a head injury or an asphyxiation.
It may be not be possible to report a specific injury at a certain time on occasions when the extent of an injury has not been determined, for example a leg wound might be being treated but may need to be amputated later on.
As I have nor been in paid work in a health or social care setting I have not reported an incident of behaviour that challenges, but on on particular occasion I was in distress with my Aspergers Syndrom from noise from what appeared a disturbance, or heightened activity from the road. I reported the incident to the local police station here in Barnstaple. After some time the suspicious activity seemed to escalate and become an increasing distraction while attempting to study for this course. As a result I phoned the Health Safety Executive at night and the reply I was given was that only incidents with multiple casualties were dealt which, I assumed that this meant at that time of the day. Desperate to get a reprieve from my sensory overload I I reframed what the reply was by saying although there were no multiple casualties, there may be a collective trauma or distress shared by a group of people. I did actually feel calmer after being listened to.

Q1 Explain how reflection on an incident can assist in managing future behaviour. (1.1)

Reflection on an incident can assist in managing future behaviour by arriving at an insight as to how a practice can be improved to further de escalate behaviour during a future incident of behaviour that challenges. There are a number of models for cyclical processes to improve the understanding of a situation and how to improve a practice. A cyclical process repeats things over and over again in the same order to formulate a conclusion based on the events that have taken place. The conclusion will be the starting point for the next cycle of events that take place. The first cyclical model I will describe was proposed by Graham Gibbs 1998. The first part of the cycle involves a description of the events that have taken place which in managing behaviour might include the patterns of behaviour that occurred and the triggers that led to the opportunity for an incident of behaviour that challenges, and also the methods used to de escalate the behaviour such as a distraction technique of a preferred activity, or a guided walk. The second part of the cycle will include the feelings that were involved in the situations. Thirdly there is an evaluation of the situation such what was good or bad about the situation, or in other words the positives and negatives that took place.
The next part of the cycle is a conclusion about how the behaviour was managed and would mention what could have been managed better about the incident of behaviour that challenges. Finaly, the last stage of the process is the action plan which decides what new approaches are to be included to better manage an incident of behaviour.
The second cyclical process I will describe which illustrates how reflection on an incident will assist in managing future behaviour is the one postulated by Rolfe et termed the What?, So What?, Now What? model. This is a more simple model than the one described by Gibbs, and to my mind less can be more as the addage 'keep it simple' comes to mind. Rolfe et al's model for reflection is outlined as follows with the 'What' part of the model being the first stage. In the 'What' stage, during reflection, a carer might ask 'what was the problem'?, 'why was I stuck'?, 'what where the feelings involved during the incident'?. The second stage being the 'So What' part includes what does the incident of behaviour that challenges mean for my model of care for the individual'?, 'what were the broader issues arising from the incident'? to name a few questions that may occur. Finally, the 'Now What' stage might include reflections on 'What can I learn or infer from the situation', 'What are the broader issues that need to be considered'? , 'how do I stop being stuck'? which will throw light on how to assist in managing incidents of future behaviour.
A third model of a reflective process to make a carer an effefctive reflector is Kolb's cycle of experiential learning. During this cycle the first part includes the experience referred to as concrete learning which would mean a 'hands on' experience of an incident of behaviour that challenges. The second part of the Kolb's cycle involves conceptualisation based on the how carers relate to the experience in personal terms. Next, the third part of the process is termed reflection where new ideas are thought of as to what can be put into place to better improve the management of behaviour. The new ideas are then implented in the next occurence of an experience which becomes the first part of a new cycle. Hence, by a cyclical process practices are reviewed and and new ideas for a best practice are adopted which can be included in a behaviour suport plan for all involved in the care of an individual to share.
The first of my two examples I will describe concering how reflection on an incident can assist in managing future behaviour involves confessing a character defect to psychiatrist Dr. Kerry Jonsson at Riverside, Litchdon street here in Barnstaple. The process involved reflecting on an incident where a defect of character has brought me into conflict with other people. I discussed being obsessed with my own profile which I told her was a symptom of a serial killer. After affirming to her that I was not of that category of person I discovered from books (REF: textbook Abnormal psychology) and this course that this cognitive revelry, or internal mind games, was a form of self-stimulation, which is behaviour that challenges. It is typical of my Autistic Spesctrum Condition (ASC), or what is called Aspergers. As a result of this I have recently been more willing to resolve my defences and be more open and trusting with people rather than live in my own head and withdraw my feelings from people which is also seen as behaviour that challenges, thus managing my behaviour. My second example is of a rudimentary trial and error nature which can be consuming in time and resources. I have learnt to sound out areas of future study after years of attempting study subjects from intuition or hunches. These unrealistic targets or goals have led to failure and feelings of inadequacy which in turn led to an internal setting event of distress from an unmet need of self-esteem. The self-esteem issue has led to a feeling of being overwhelmed by feelings of inferiority and, once leading to withdrawing my feelings as a form of behaviour that challenges. By reflectin and doing some research first, and not going into a subject cold, I have partially succeeded in managing my behaviour.



Q2 Describe your own reactions to behaviour that challenges. (1.2)
It is imortant to be an effective reflector to become aware of your limitations when dealing with an incident of behaviour that challenges. If a carer is aware of their limitations they will not become involved in a situation they are not trained for and therefore will not be unprepared for the consequences of behaviour that challenges. Being unprepared can result in someone being hurt emotionally or physically. There are a numbere of different emotions that are natural reactions to behaviour that challenges, examples being guilt about not doing enough to prevent behaviour from escalating by not intervening enough, and also feelings of failure from allowing an episode to occur in the first place. There are other reactions ranging from fear resulting from observing someone who is out of control and not behaving as they normally do, to shock as when someone who is very mild mannered experiences a sudden change of dispostion and becomes aggressive very quickly as with the case of dementia. Anger may ensue if an invidual is insulting towards a carer which could involve spitting, or if the individual physically assaults the carerer. Other reactions can have the characteristic emotions of disbelief which occurs when a carer finds it hard to accept how an individual can adopt self-injurous behaviour during an incident of behaviour that challenges, and satisfaction when a carer feels that they have de-escalated the behaviour and therefore managed it successfuly to acheive a positive outcome for an individual communicating a need in a positive way.
After an incident of behaviour that challenges a carer may wish for support from a number of sources such a union representative, a GP, a counsellor or a colleague to name a few. There is also post-incident debriefing which is a form of support.
Although I am not in the caring profession at present, I do try to be mindful (Dr Annabel Denney, Riversvale psychology unit, Litchdon street, Barnstaple, and my referral to a mindfullness group) of my relationships with other people and try to be as supportive as possible. Where I find I have a shortfall in skills in relating to other people, I have found a talking therapy in the form of Cognitive Behavioural Therapy (CBT and Dr Annabel Denney, Riversvale psychology unit, Litchdon street, Barnstaple) supportive in finding a lifespace that is not judgemental to other people and helps me to find a new direction or lifepath where my feelings feel more supported (dealing with my post traumatic stress disorder and schizophrenia in the form of a writing therapy. A link to my blog of my writing for writing therapy is http://cbtandschizophrenia.blogspot.com/ ) .
I have learnt to try and be non-judgemental towards myself and my reactions to situations with amongst other things the contents of this course, including this topic, by realising that emotions are natural reactions to the environment and that sometimes we need to override these emotions to either obtain or retain control over a situation for a desired outcome.



Q3 Explain the consequences of your own actions when involved in incidents of behaviour that challenges. (1.3)
With regards to the consequences of the carers actions when dealing with an incident of behaviour that challenges, any action will have consequences so it is important that the consequences should have a positive impact leading to a de escalation of the behaviour. It is also important that the carer should be able to manage their feelings and respond in a way that leads to behavioural de escalation quickly.
There are a number of poor responses that can happen on the part of a care workly which will not de escalate an incident of behaviour that challenges but will in fact have the opposite effect of escalating the behaviour. The first of such poor responses I will explain is laughing in response to a situation. Laughing may result in the individual who's behaviour is escalating feeling humiliated and angry. Laughing may also have an affect on the individual's self-esteem which could have a negative impact on their behaviour in the long term. I can give an example based on my own personal experience of this. While attending a design for living class for my peer group designed to educate pupils about sex, drugs and alcohol, a practical joke got out of hand and some of the other pupils started laughing. The result was at first I felt humiliated and then angry and I my self-esteem was affected in such a way that I felt I had been reduced as a person. The consequences of this was devastating. The incident impacted on my behaviour which in turn had a long term impact on my future, I took up weight training and body building which then escalated to wanting to be different by buying motorbikes, and then taking up a very masculine approach to martial arts. I have tried to psychoanalyse this behavioural escalation and sequence of events which started with the humiliation leading to a complex, or behavioural issue. The humiliation led to a feeling of denial towards my peers and any personal development. The weight training and its 'no pain, no gain' philosophy then introduced a displacement activity component to my behaviour, and finally a lack of preparation for my final 'A' level examinations through being distracted by weight training and being preoccupied with my self-image led to repression. This denial, displacement and then repression model is outlined, if I remember correctly, in David Stafford-Clarkes book called 'What Freud really said' and is a model for a psychosis. I think I validated this model by taking a quick peek at the doctor Mithchell's computer at the Montpelier Health Centre in Bristol when he was called from his room. It stated that I had an organic psychosis and an inorganic psychosis, the former psychosis possibly being a consequence of the laughter and humiliation, and the latter psychosis probably being down to drugs which resulted from the behavioural escalation.
Another poor response is to retaliate towards an individual during an incident of behaviour that challenges as this response will cause the behaviour to escalate. Retaliationcould have legal consequences with regards to the care worker and it may be that that carer is the source of the escalation so it may be better to walk away from the situation and give the individual an opportunity for a prescribed intervention of a time out. As well as retaliation aruing is not a good response as if the individual is in a state of emotional distress, arguing may well exacerbate the distress. Also, shouting at an individual will not elicit a positive response particularly with an individual that has sensory issues. The last poor response I will mention is walking away. With this example walking away can be seen as a breach of duty of care as it may put the individual and others at risk.
Generally any other response that causes the individual's behaviour to escalate to an incident of behaviour that challenges is not desirable. The situation which leads to behavioural escalation of an individual will be unique for each for individual. A distraction technique of humour to de escalate for one individual may not work for another. Similarly, if a distraction technique of humour works for an individual during an incident of behaviour that challenges, it should not be assumed that it will work for the next incident. Conversely, if humour does not work during an incident, it must not be assumed that it will not work for another incident later.
When thinking of the consequences of a care workers actions when involved in an incident of behaviour that challenges it is important to think in terms of the risks involved. Risk reduction is an important factor and it should be considered before the care worker becomes involved in a situation that they are not appropriately trained trained for where they may put the carer, the individuall or others at risk. There are a number of areas of behaviour that challenges that are a focus of risk reduction, including risk of physical harm and emotional harm to the individual, the risk of uncessary physical restraint of the individual, the risk to the care worker of a legal action such as a formal complaint, unecessary distress to the individual, and finall the risk of loss of dignity and respect to the individual. An example of loss an dignity to the individual I will give is myself being sectioned under the mental health act. There was a person who I imagined was from the social services who I had not met before and who looked a bit officious, and two police officers. I thought I had been labelled as a criminal and made to feel guilty rather than as a person who was mentally ill and who had experienced difficulties. I am aware though of the possibility that they might of known something about my past conduct and the situation might have got out of control. This point brings me to effective reflection or self-awareness where the care worker effectively recognises that they are losing control of the situation and it will be time to ask for assistance or use some other appropriate means within the care setting such as using a password. Asking for assistance should not be seen as a weakness but instead it should be seen as the carer knowing their limitations and behaving in an appropriate and professional way to ask for assistance to de escalate the incident of behaviour tthat challenges. In this way there has not been a breach of duty of care on the part of the care worker.



Q4 Explain how to support individuals to understand their behaviour in terms of: (1.4)
a) Events and feelings leading up to it
After an incident of behaviour that challenges a review will take place in the form of a post-incident debriefing to help individuals to understand their behaviour in terms of the events and feelings leading up to the incident. The review will take place as soon as possible after the incident of behaviour that challenges so that the events and feelings are still clear in everybody's minds. The individual will be asked if anything caused them distress or frustration which led the incident of behaviour that challenges to identify if there are any new triggers that might lead to new new behaviours. It may be useful to also ask the individual if any particular person, including a member of staff, is a target individual that may be a trigger for behavioural escalation. Asking the individual about specific feelings prior to the incident and what these mean may help the individual to better understand their behaviour.
After a review, discussion by everyone including the indivual concerning what went well during the incident, or where there could be improvement could be noted and included as a best practice in the behaviour support plan of the individual for everyone to use. These positive changes will help the individual to better understand their behaviour and support them to avoid incidents in the future.
During the review process it is important that the individual's preferred method of communication is used so that no information is missed or misunderstood.
For my own personal example of a review the closest thing to it that I can remember is after over thirty years as a psychiatric patient I read in a New Scientist magazine that Cognitive Behavioural Therapy was a more compassionate way of treating my illness of schizophrenia. After a referral to Riversvale here in Barnstaple I reviewed my feelings and had a chance to disconfirm some of my beliefs and experiences that had accumulated over the decades so that I had a less 'blacker than though attitude' (REF: Challenges in Psychology by Richard Gross) that reduced some of the morbidity of my situation. This prevented a trigger of self-justication that may have led to confrontation and conflict with other people. Although this was not a complete success it did lead the therapist to conclude that other parties also had needs that possibly had not been met. From this I inferred that I was not responsible for some of the maladies in the world which for which I had held myself accountable which alleviated some of my feelings of guilt removing a trigger to drink alcohol and use cannabis. The use of both drugs eventually stopped. To conclude, guilt is an internal setting event which presents a trigger to relapse into old patterns, and best practice is to review and talk through the issues that produce guilt so that old, unhelpful behaviours do not reoccur.
b) Their actions
An individual can be supported to understand their behaviour in terms of their actions by giving them enough time to say how they reacted to a situation and how this made them feel. This is particularly important when an individual has a communication difficulty. By giving an individual enough time to speak there will be an opportunity for feelings to surface (REF: Psychiatrist DR. Graham Roothe of the Bristol Royal Infirmary Psychiatric outpatients department) so that reactions will not surface at a later date and possibly prevent reagitation.
This process of encouraging an individual to speak openly about what happens when they present with behaviour that challenges will support them to to develop insight into their own behaviour. This is a process for the individual of becoming self-aware and may offer opportunities for the individual to develop coping strategies or avoidance strategies. An example of an avoidance strategy is a distraction technique which is a subtle form of avoidance but if used to excess may cause the individual to become self-focused (REF: a web page on the internet about avoidance strategies).
My own example of undertanding my behaviour in terms of my actions is of confessing a series or, a pattern or cluster of disdemeanors involving hoax phone calls. When I realised that my psychiatrist Dr. Kerry Jonsson of Riverside, Litchdon street here in Barnstaple was not going to use punative treatment it presented an opportunity to allow feelings of guilt and anger to surface. As I had confessed my guilt it broke the cycle of guilt and then anger and indignitation so that I did not make a cause out of an issue and thus preventing the reation from surfacing again. There have been no more such incidents using phone calls.
c) The consequences of their behaviour
It is important to support individual's to understand their behaviour in terms of the consequences of their behaviour. With regards to the behaviour the individual must not be punished or rewarded, the consequences must be appropriate. I will reference this with material from the book 'Problem Behaviour and People with Severe Learning Disabilities, the STAR approach' by Ewa Zakowska and John Clements. A strategy mentioned in this book is a process of unlearning their behaviour. In this strategy the first step involves demonstrating that the negative behaviour, or behaviour that challenges, does not acheive a positive result. This means that the negative behaviour must not be rewarded, or in other words postively reinforced so that the individual presenting with behaviour that challenges does not receive mixed messages, or experience increased confusion. Increased confusion may in turn be a turn be a trigger for another incident of the behaviour. From an earlier part of the course it is noted that it is important for care workers and family to be consistent in their approach to the individual's behaviour by everybody being aware of the conent of the behaviour support plan for that individual, and also to review events after an incident of behaviour that challenges in the form of post-incident debriefing. The second step in supporting the individual to understanding their behaviour in terms of its consequence is to explain that their behaviour in a particular context is unacceptable. Simply put, it must be understood that the behaviour that challenges is an unacceptable goal to reach an acceptable result, for example shouting at someone in a class room lesson to be quiet when they are studying.
The concept of unlearning behaviour by understanding its consequences is an interest of mine concerning my own past incidents of what used to be called problem or anti-social behaviour and any subsequent relapses that may ensue. I will mention a Hamlyn book entitled 'Psychology' by William Barnes-Gutteridge. In this book is mentioned the concept, or generalised idea, of becoming unhooked. For me this means unhooking from environmental triggers, or conditioning factors or influences. To unhook I believe that an individual must understand the feelings or motives that led to an incident of behaviour that challenges, and the consequences of that behaviour so that as William Barnes-Gutteridge mentions, the behaviour, or as I see it, the focus of the behaviour, the operant, becomes a repondent. This would mean that unhooking results in free will or volition and the person is able to respond to a situation instead of reacting. I have partially acheived this by reflecting on a model for the classical complex of compulsive behaviour outlined in Sargent's book 'Teach Yourself Psychology'. Sargent was from Maudsley hospital in London (REF: John Chandler, a friend who did a history degree at Norwich university). The example is of a girl who has strict parents and is not allowed to discuss sex. Her peer group or acquaintances on the other hand boast of sex and stealing. As she has nobody to turn to concerning the environmental trigger or pressure of sex, she develops a compulsion to steal as an outlet for that pressure, and possibly to win affection from other peers. This model for compulsive or impulsive behaviour allowed me to establish parallels in my own behaviour by self-reflecting and meditating with the help of the external discipline and affective support of psychiattrists and family which provided a safe environment. This allowed me to develop insight into my behaviour whereas before it had been resistent to insight and my behabehaviour was escalating. Seeing the family tree of my emotions allowed to to understand the implications and consequences of my behaviour, and also possibly make predictions about it.



Q5 Describe the range of support services available to those involved in episodes of behaviour that is challenging. (2.1)
There are a range of support services within the work place and externally for care workers who experience emotional pressure when dealing with incidents of behaviour that is challenging. Due to this emotional pressure and the nature of their role, care professionals may experience professional burnout. Professional burnout can be defined as emotional and physical exhaustion wich leaves the care professional doubting their competence and the value of their professional contributions.
As well as the support services available in the work place there are external support services. A reason for wanting an external support service is that due to the stigma of mental illness and stress, a care professional may wish to keep their issues private from others.
The first support service I will describe is called effective debriefing which involves identifying what went well during an incident of behaviour that challenges and reassuring thae care worker that they did well and the way they reacted was the correct approach. Effective debriefing may aslo identify areas that need development. A second form of a support service is appraisal which allows an a carer to discuss openly issues that are causing stress in the workplace and will help to identify stressors , and also any areas where there is a need for improvement. During this process a carer may be signposted to another form assistance such as a counsellor. Appraisal is the same as effective debriefing with the exceptions that it occurs between an employer and a carer and concerns the general role of the career.
A third support service is the use of supervision and montoring in which a supervisor may identify signals that a carer is not coping, and also areas which have development needs. A supervisor may aslo signpost a carerer to an additional form of assistance such as a counsellor.
A fourth form of support is keeping training up to date is as this will give a care professional the confidence that they are performing their duties to the best of their abilitities which will be good for feelings of acheivemt and self-esteem, both of which are good for coping with stress. The fifth support support service I will mention is discussion with colleagues which involves a carer coming to terms with stress by discovering that they are not the only carer that experiences difficulties due to the demanding nature of their role in manageing incidents of behaviour that challenges. Finally, the sixth support service I will describe is the carers union representative who will intervene objectively and discuss issues that are causing stress in the work place, and where needed can signpost the carer to an additional form of support such as a counsellor.
As well as support services there are other care professionals that the carer can turn to such as as a GP. A GP can make make an intial diagnosis concerning a mental or a physical illness and can prescribe medication to improve a carer's mood which the carer may or may not wish too take. The GP can also make a referral to another form of assistance such as a counsellor. A counsellor will provide a non-judgemental and empathetic environment in which to listen to the carer. The counsellor will not give advice on an issue but may provide support to identify unhelpful behaviours and beliefs and help the carer to find a way forward. My own example of counselling involves attending a rehabilitation centre callled Broadway Lodge at Oldmixon road in Weston-Super-Mare for my use of drink and drugs. After my inital assessment I had given up all hope of finding any progress, but I was invited back and the feedback and counselling that I was given was being told that I rejected people before I gave them a chance to reject me. In other words I had an obstructive attitude. This led me to go on and and adopt a different approach of a twelve step program towards my mentall illness of schizophrenia. My step three of 'handing my life over to the care of a higher power' entitled 'letting go of control' can be found at the web link http://reflectandretrieve.blogspot.com/
Another form of support is of the type termed self-help groups. In such a group the carer will realise that they are not the only carer experiencing difficulties in their role and he or she will find comfort and support in this fact.
Finally other therapies can be mentioned such as Cognitive Behavioural Therapy, or CBT. CBT helps to identify cycles of stress that lead to negative patterns of behaviour, and resolve the problem by breaking it down into smaller chunks. In my own example of CBT I managed to break a cycle of guilt and anger leading to drink and drugs, which in turn led to more guilt and anger. By breaking my life history down into manageable chunks and offloading it onto paper I was able to write about the most intense part of my lifestory which created a channel for negative feelings instead of harbouring resentments and using alcohol and drugs. The testimony that I wrote can be found on the web link http://cbtandschizophrenia.blogspot.com/



Q6 Describe support systems available to maintain own well-being. (2.2)
A support system for maintaining well-being is a system to enable people to lead a more positive or productive life wether or not they are experiencing difficulties. Identifying positive approaches such as support systems are important for maintaining well-being where being involved with incidents of behaviour that is perceived as challenging may lead to episodes of work place stress. The support system used will depend very much on the person involved and what they find helpful.
One support system is the use of self-help techniques. A self- help approach is anything that the person does for themselves to reduce or manage levels of stress. Examples of this include being with friends, having a hobby, taking physical exercise, and prioritising goals and dealing with worries. My own example of dealing with worries makes a reference to Dr. Graham Roothe of the Bristol Royal Infirmary who discussed with me in psychiatric out-patients the subject of worry management. This involved making yourself worry intentionaly for a certain time each day to 'get it out of your system', as the saying goes. Another approach is to use a stress diary. A stress diary will help you to identify the sources of short-term stress as well as the level of pressure at which you perform best, and finally identify stratagies to reduce or eliminate the sources of stress. Such coping strategies to reduce stress include firstly, acceptance strategies which help you to manage when you have no control over the source of stress. The second strategy is an emotional one which helps to maintain emotional strength during moments of stress. Finally, the third strategy is a psychological approach which helps you to take control of your life and improve the situations where stress is present.
The second support system I will discuss is the use of relaxation techniques, such as breathing exercises, pilates, yoga and mindfulness. My example of a relaxation technique is the use of mindfulness after I was referred to a mindfulness group by Dr. A. Denney of Riverside psychological services at Litchdon street here in Barnstaple. In one exercise I let my thoughts come and go freely, not clinging to the good ones, and not pushing away the bad ones. This is a process of non-attachment where I do not hold on to issues which produce stress. In Dr. Patricia Collard's book 'The little book of Mindfulness', she outlines an exercise where a person regularly gives attention to the five senses and places focus on 'the here and now'. I assume that living in the past may bring depression, and focusing on the future may produce anxiety, bot focusing on the present is a relatively less stressfull situation.
A third support system is talking to someone who relates to the persons situation. Talking to someone who understands your difficulties will help that person to feel less isolated and may provide the reassurance that the difficulties they are experiencing from working in difficult situations, where there are incidents of behaviour that challengest, is actually normal.
Finally I will mention self-reflection as a support sytem to maintain well-being. With self-reflection the sources of stress are identified and wether these sources are directly related to working in conditions where incidents of behaviour that is perceived as challenging are prevalent. Identifying sources of stress by self-reflection will better enable a care professional to find coping strategies to reduce the levels of stress.



Q7 Explain the importance of accessing appropriate support systems. (2.3)
a) What is stress?
To explain the importance of accessing appropriate support systems and what is stress, I will first give a definition of stress. Stress can be defined as a perceived difficulty of a situation and the perceived ability to deal with that difficulty. The discrepanccy, or difference between the two raises the question of the ability to cope with the situation. It is important to access appropriate support systems to deal with this stress as consistently negative responses to stress can lead to further issues which can in turn impair someone's performance in the workplace. There are a number of issues that produce stress in the work place which have to be addressed such as bullying and harrassment, feelings of inadequacy and unprofessionalism, lack of control in the workplace, poor management, setting unrealistic targets and having unrealistic expectations, and having unrealistic demands placed upon the person. Also included in the list of issues that produce stress are not being appreciated for doing a job and a poor working environment.
It is important to access support systems for stress as the aforementioned issues in the workplace can lead to a number of symptoms. There are physical symptoms as well as emotional and psychological ones, the combination of which can make it difficult to deal with stress. Psychological and emotional symptoms can include memory problems, difficulty making decisions, irritability, increased frutration, feeling overwhelmed andconstant worrying, poor levels of concentration, overeating and undereating, and decreased motivation. Other symptoms of stress can include, poor sleep including sleeping for too long, constipation or diorrhea, constant fatigue, difficulty with breathing, indigestion, unidentifiable physical pain, constipation and diorrhea, and feeling nauseated.
I can can elaborate on the last two quoted examples of symptoms of diorrhea and nausea by relating to my experience of being a psychiatric patient of a general practioner (GP) Dr. Tim Mitchell of the Montpelier Health Centre in Bristol who diagnosed me as having an irritable bowel. This produced vomiting which I am convinced was down to stress of unecessary pressure. I feel that the additional stress encurred was from having slipped through the safety net of support in some way resulting in unmet needs. As a consequence of the unmet needs the additional stress progressed to the symptom of an irritable bowel. Another personal example of mine of stress is headaches. I suffered from headaches, which again I assume were the result of encurring additional stress from having slipped through the safety net of support. The Bristol Royal Infirmary Triage, or casualty, told me that a headache was a concern if it was a different kind of headache. By speculatively extrapolating I believe a different type of headache can result as a further issue of unresolved stress. My stress levels even led to the further issue of what I believed to be neuralgia which I read as a child from 'The home doctor' bought from a jumble sale in the 1970's, was supposed to be the worst pain known to man. I feel that my examples of not being allowed to resolve issues that cause stress, by slipping through a safety net, illustrates that appropriate support systens, in my case psychiatrists and other healthcare professionals, is important to stop the progress of stress and further issues from developing. To illustrate this point further, the stress of managing this issue has led to the further issue of my increased heart rate and high blood pressure which are two more symptoms of stress. There are other issues which are consequences of stress that have to be resolved by appropriate support systems, such as an increased time off work, susceptibility to physical illnesses, decreased job satisfaction, increased risk of accidents and risks to other people, and also anxiety and depression, as well as other mental illnesses.
Stress can lead to the natural response of fight or flight which can be a good thing as it will give our attention focus when we are in a survival situation, but when it is unecessary it can cause agitation and agression which can have a negative impact on our relationships and spoil our reputiaton. As well as the fight component, the flight component can cause the person involved to isolate. This instinct can cause the situation to escalate as the person realises the stressors are not going and they still have to face the problem. Here I believe a support system is important to deal with the issue of isolation. A third issue is called freeze where the mobilised energy from experiencing a perceived threat gets lock into our nervous system. This can produce a holding of breath and shallow breathing with an occasional deep response of breathing while the nervous catches up on its oxygen intake.
b) Describe positive coping strategies
Accessing appropriate support systems to deal with stress in the context of positive coping strategies includes a number of possible approaches. One approach is through the examples of yoga or pilates which offer well-being by combining exercise and relaxation. With yoga and pilates the feel-good factor of serotonin is released. My own example of yoga is doing Tai Chi short form which I learned at Petroc college here in Barnstaple. Tai Chi is Chinese yoga which stills the mind and hence offers an opportunity to relax. One of the form's moves is called 'repulse monkey' which involves stepping back three times and pushing away from you each time with alternate arms and hands in front as if you are repulsing a monkey. Repulse monkey is thought to mean stilling the monkey mind, or the 'chattering imagination' (REF: Dr Graham Roothe, psychiatric out patients of the Bristol Royal Infirmary) and bringing peace and relaxation. A healthy lifestyle consisting of a good diet and moderate physical exercise is another positive coping strategy . Like pilates and yoga physical exercise can also produces feel-good hormones, and also provide an opportunity to clear the mind. Mindfulness as a positive coping strategy works by preventing the mind from dwelling on the past and not overworking by thinking what might have happened. It also teaches self-acceptance by not worring about the future. Another positive coping strategy is helping people such as with volunteering. This can produce pride and feeling of achievement as well as increased self-esteem which help to combat stress. My own example of helping by volunteering is with a hospice shop locally here in Barnstaple where I put price tags on books and stocked the shelves with the newly donated priced books. I felt a moment of pride and achievement when someone called me the book manager. As well as being active sleeping well is also vitally important as good sleep enables someone to keep motivated in all areas of their life. A lack of sleep may cause fatigue and irritability and lead to physical ill health. A positive coping strategy that must not thought of as an individual being weak is recognising when they need help as this means that help can be sought to address the issues that lead to stress. An alternative approach to seeking help is taking time away or what is called me time wich offers the opportunity to do the things that a person enjoys the most. If the person involved takes time away at a set time each day or week this can have a positive effect on their well-being. Keeping a positive frame of mind is also a positive coping strategy. This involves someone focusing on the positive aspects of their life and the things for which they are grateful for so that they can come to the realisation that things are not as bad as they seem. In a survival situation the Special Air Services (SAS) have a catch phrase of 'Positive Mental Attitude' which is important to stay alive where survival training is necessary. Indulging in a hobby is a positive coping strategy as it might provide a distraction from stress and prevent someone from aimlessly sitting and focusing on all the negative aspects of their life. If there are any negative aspects, or difficulties in a person's life, being connected is important where being sociable and having social skills enables that person to build and maintain positive relationships so that if they are experiencing difficulties they have someone to turn to.
The best way to deal with stress is to identify the things that can be changed and changing them, and identifying the things that cannot be changed and accepting them. This latter method of dealing with stress brings to mind the serenity prayer which I heard at a mindfulness group at Riversvale psychological services on Litchdon street here in Barnstaple. The prayer goes 'God grant me the serenity to accept the things I cannot change, courage to change the things I can, and the wisdom to know the difference'.
c) Describe negative coping strategies
It is important to access appropriate support systems to deal with stress using positive coping strategies, but not all people use positive strategis. Some people use negative strategies which can result in the stress becoming worse and leading to further issues. Continual use of negative coping strategies can lead to isolation as the person involved cannot cope with letting other people know how much they are struggling and may have a fear of being labeled as mental by people who do not understand mental illness. Isolation is itself a negative coping strategy. I will describe my own example of isolation where I isolate to shield myself from environmental triggers and target individuals that produce stress leading to behavioural escalation and further distress.
As well as isolation there are other negative coping strategies which include, smoking, using illegal substances, excessive use of alcohol, excessive use of caffeine, shouting at people, self-harm, and spending too much. I will again give another of my own examples, this time referring to the negative strategy of spending too much. I have Post Traumatic Stress Disorder (PTSD) from a punture wound I received from an assailant outside of a night club. PTSD is a fear reaction involving isolation and trying to keep a lot of the world in abeyance. This is acheived by 'comfort spending' (REF: BBC Radio Devon concerning a rehabilitation project for solders who have left the army and find it difficult to integrate into society and also experience difficulty adapting to it). With comfort spending I compulsively spend on books and DVDS, now owning hundreds of each, in an attempt to maintain a self image and to detach from a perceived threat.