Tuesday, May 24, 2011

Explosive Behavior an Indicator of Not Having the Necessary Skills

I've been reading The Explosive Child: A new approach for understanding and parenting easily frustrated and chronically inflexible children by Ross W. Greene. The major premise of the book is that "kids do well if they can", and if they are not doing well, it is because they do not have the ability to do well in those situations. More specifically, he feels they often are lacking flexibility, frustration tolerance, and problem-solving skills. A lot of what he says rings true when it comes to my children, but also reminded me of a client I had as a new therapist.

I remember I was actually frightened when Jane (name changed) was first referred to me. There were all sorts of rumours about her extreme, aggressive behavior. I even went as far as to see if I could give someone else the referral, but no other therapist would take it. I read her chart - aggressive incident after aggressive incident. I had heard some staff refer to her as a "monster".

Yet there was very little information in her chart on who she was, and what her goals were. Despite years of institutionalization, I couldn't find any evidence of an occupational therapy interview. Jane had communication problems - she was hearing impaired, had poor speech. "OT" in the past had meant participating in "jobs" or "crafts" that were not individualized, but I believed in a much more individualized, goal-oriented approach. Where would I even start?

Well, I took the time to get to know her, which was one of the most rewarding experiences of my career. I found out that she desperately wanted to move out of the institution. I found out that she had been so institutionalized that she had no independent living skills. I also found out she was able to learn those skills.

An important thing I found out was about her communication skills. I found out that she did not understand many common words. After we had been working together for awhile, she would bring a list of words to every session to have me explain the meaning of them. Some of the words were very common, everyday words.

I never once had trouble with her being aggressive toward me. If Jane seemed to be escalating, I would pull out a pad of paper to help our conversation, and it worked every time. I found her to be a wonderfully warm and caring person. When she let you into her circle of trust, she was incredibly loyal.

As I watched her interactions with staff on the ward, I saw that often Jane would not understand what the staff were saying to her. Because she was not understanding, and the staff knew she was hearing impaired, the staff would raise their voices. Speaking louder does not help verbal comprehension, and she interpreted the raised voice as the staff member yelling at her. She would reciprocate by yelling. Staff would be intimidated, and often end up forcefully taking her to a seclusion room. She interpreted this as them physically assaulting her, and responded in kind. No wonder she desperately wanted to move out.

These situations were horrible for Jane, and she definitely would have done well if she could have. She was responding explosively because she did not have the communication skills the situation required.

The ward staff were well-intentioned and often do not have the same luxury to invest the time that an OT can in getting to know someone. I see their point of view - they were often frightened of these explosive outbursts, and had the added responsibility of ensuring no other people were hurt. However, what I found frustrating was that my notes and explanations of her communication difficulties (and recommendation to pull out a pad of paper) did not seem to make a difference.

As a follow-up, Jane basically won the lottery, because after years and years of institutionalization, she found a psychiatrist and treatment team that thought she deserved a shot at moving out. You would not believe how many other staff told us it would never work. She worked very hard and learned many of new skills, and moved to independent living. She had great community supports, and has lived in the community for many years now. Her explosive outbursts were greatly reduced in the community, and not physical in nature (no one was trying to restrain her). The last I heard from her, she had moved in with her boyfriend. Years after leaving, she was still counting how many days she had been out of hospital.

Here is the book:

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