“I need to make a decision. I have been working for the past eight months with him, but there has been no progress.” Maria explained this to Jena, the new clinical supervisor, only one week on the job. Maria was referring to Ken, already introduced in a previous article entitled, Dealing Effectively with Inappropriate Behaviors: The Why.
Jena heard the story, and, though in disbelief, she took some time to respond to Maria, “We have to do something right now.”
I promised we would delve into the How of effectively dealing with inappropriate behaviors, and in this article I am going to provide you with a foundation on which to build. Similar to the way Jena responded to Maria, we, too, can do something right now.
Below are the five first steps you can take to effectively deal with inappropriate behaviors:
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Naming the behavior
Many of the patients and clients you work with are likely to have a trauma history, or symptoms of ADHD, anxiety, or learning disabilities. They may also have some form of developmental disability, undiagnosed or misdiagnosed from childhood. Mood, psychotic, or substance use disorders may also be present.
Common to the above conditions, it can be challenging when naming, conceptualizing, or operationalizing a particular inappropriate behavior.
Jena decided to meet with Ken initially, and he explained to her, with Maria present, that each time he sees a woman, all he sees is “A potential for a romantic relationship; boys and girls are never just friends. There is no such thing unless the boy is a sissy.” Ken’s father had actually reinforced these words to Ken so often enough that they have now become internalized. Ken now carries this deep belief in the way he sees the world and the women around him. Ken’s babysitter also sexually abused him when he was eight years old, which led to the dismissal of the sitter, someone for whom he had already developed a strong and caring relationship. A strong and caring relationship, followed by sexual abuse, followed by sudden disappearance, has had a lasting effect on the mind of an eight–year-old boy.
Jena explained to Ken that his father’s belief that “boys and girls could never be just friends,” was a belief that could get him into trouble, because it might lead him to always objectifying women, leading in turn to sexual harassment. “Objectifying women and sexual harassment” were not generally new words to Ken, but words he was hearing for the first time in this specific context. Jena was helping Ken with naming the behavior.
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Pointing out the inappropriateness
Naming the behavior sets the stage to point out its inappropriateness. Some patients and clients may have difficulty naming the behavior, and others may not be fully aware of its inappropriateness.
“If you keep believing that boys and girls can never just be friends, you will end up misperceiving many of your relationships with women, which will likely lead to either statements or actions that are inappropriate and may make them feel uncomfortable,” Jena explained this to Ken, who responded: “I had never seen it that way. I would never want to be inappropriate.” Maria found the words, “Ken, when you tell me, I was wearing no rings; that I may be dressing well only on the days you are scheduled to see me; and that you know I want you desperately; these were all inappropriate statements, and they made me feel uncomfortable.” Ken lowered his head and couldn’t apologize enough before asking, “Will you continue to see me? Am I in trouble?”
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Exploring it
“Will you continue to see me; am I in trouble?” This was a good opportunity for Jena to explore Ken’s pervasive behavior that had been distressing to Maria. They did just that and during this exploration phase, they learned about the extensive physical abuse Ken suffered because of his father. He often wondered whether he was in trouble; he worked hard to please his father, doing what he was told, avoiding further trouble, and pleasing him at all costs. However, none of that spared him from further emotional and physical abuse from his father, who struggled with alcoholism and was often intoxicated when home.
This need to please, partly explained why Ken remained in an abusive relationship with Monique; and his need to do exactly as his father dictated, partly explained his ongoing internalized belief that “boys and girls can never just be friends.”
“You can be your own parent now, Ken. You no longer need to believe what your father did or said when you were a child, nor do you have to do what he has taught you to,” said Jena. Teary for the first time in eight months, Ken asked: “How do I do that?”
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Addressing it
You have named the behavior, pointed out its inappropriateness, and you have explored it. It is now time to take the next step – addressing it.
Ken asked what he could do. Other patients and clients might not, but you ought to ask, “Do you now understand this is an inappropriate behavior that may get you in trouble? Do you want to work on it? What do you think you should do about it?” Part of this is intended to involve your patient and client in the endeavor, as described in two previous articles on Tips to Help Engage your Patient and Client.
Partly, this approach is also designed to establish their commitment and help them see themselves as part of the solution instead of the problem. Jena asked Ken these same three questions to which he responded, “I had never seen this as a problem before. I had not even thought it might get me in trouble. I feel ashamed; I want to do something, and I will work with Maria on this; just let me know what to do.” While Ken’s response was far from a guarantee, it was, at least, a first step towards doing something to address his behavior, once it had been named, pointed out as inappropriate, and explored.
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Taking actions
Maria had already been too traumatized to continue working with Ken. It was too late and the situation had already deteriorated. Jena supported her and they both agreed they would give Ken an opportunity to work on his behavior but with a different clinician, Caitlin, who after proper briefing and debriefing with Maria, agreed to work with Ken, under Jena’s close supervision. Caitlin and Ken agreed on a specific set of goals, objectives, and timeline. A lot surfaced, progress was ongoing, but Ken had his challenges and moments of inappropriateness with Caitlin as well. Caitlin’s threshold might have been higher than Maria’s; she also knew exactly why Ken was in treatment with her, and she explained to him that while he was making progress, there was a need for him to learn about consequences. His next inappropriate behavior would warrant a behavioral contract.
Part of taking action may warrant switching clinicians or staff professional, but may also include a behavioral contract, containing clearly expected behaviors, the statements and actions that are deemed inappropriate, and what the patient or client should expect with the violation of any agreements. Enforcement is also key in any behavioral contracts.
“I need to make a decision.” Maria told Jena, who did assist, helping her help Ken name the behavior, point out its inappropriateness, explore and address the situation and also take action. Caitlin did have to start a behavioral contract with Ken, which Ken has been able to adhere to. A concrete intervention can be a powerful tool to help your patients and clients change some of their inappropriate behaviors.
In this series of two articles, you have learned the why of learning how to deal effectively with inappropriate behaviors; and five steps you can take to empower yourself. You can use these tools as a start, and you can seek further training on this, as you continue to empower yourself, help you patients and clients and your co-workers and agencies. It is always an honor for me to be part of this journey with you, and I look forward to the next opportunity. Meanwhile, kindly share your stories, experiences, and feel free to share these resources with your colleagues. Helping to empower your colleagues also helps empower you in the process. Until later.
References:
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Fombonne E. Epidemiology of pervasive developmental disorders. Pediatric Research. 2009;65:591–598.
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Kennedy C. H. Research on social relationships. In: Emerson E, Hatton C, Paramenter T, Thompson T, editors. International handbook of applied research in intellectual disabilities. London, UK: Wiley; 2004. pp. 297–310. In. (Eds.) pp.
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Klin A, McPartland J, Volkmar F. R. Asperger syndrome. In: Volkmar F. R, Paul R, Klin A, Cohen D, editors. Handbook of autism and pervasive developmental disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (3rd ed. Hoboken, NJ: Wiley; 2005. pp. 88–125. In. (Eds.) pp.
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Rehfeldt R. A, Chambers M. R. Functional analysis and treatment of verbal perseverations displayed by an adult with autism. Journal of Applied Behavior Analysis.