How to Effectively Deal with Inappropriate Behaviors: “The Rule of 9”

“I have been giving him the benefit of the doubt, but things have been worsening. Now I dread meeting with him, and I drag myself to work on the days I know he is scheduled to see me.”

Maria was teary when she articulated these words to Gaelle, one of her co-workers, who then responded: “I have been having similar issues with one of my clients. I am also unsure of what to do, and one week ago I had a bad dream about him. I have been scared ever since.”

Maria’s client, Ken, had started seeing her in the midst of a tumultuous relationship with his girlfriend. “I see you don’t have a ring, and you are very well dressed. Sometimes I wonder if you are as well dressed on the days I don’t come here to see you,” Ken asked Maria, on several occasions. He then added, “You are the type of woman I want and deserve, and I know you want me desperately.”

In a previous article entitled, Dealing Effectively with Inappropriate Behaviors: The Why, I explained that similar to Maria and Gaelle’s experience, our patients and clients may have displayed inappropriate behaviors towards us, and we may have dealt with them in such a way that may have either led to burnout or negative clinical outcomes or both.  I added that there is a method for effectively dealing with these situations, and in a subsequent article entitled, Dealing Effectively with Inappropriate Behaviors: 5 Steps, I outlined the steps to follow for effective management, while ensuring that everyone, clinicians, advocates and staff, our patients and clients, our agencies and system win, in the process.

In the first article, referenced above, we looked at why we all need to learn how to effectively deal with inappropriate behaviors, and in the second article, also referenced, we looked at the five steps to follow, in order to effectively deal with inappropriate behaviors.  In this third article, let us take one step back and look at the “Rule of 9” and how we can use it to effectively deal with inappropriate behaviors.

In previous articles and during SWEET seminars, we often talk about the problem-solving process; and we often describe that part of the process is to first formulate the problem and agree upon its definition.  We also explain that the next step is to seek to understand what is causing the problem in the first place.  No, we are not talking about the immediate cause, rather we are talking about the root cause, and for that we need to go through the process of a root cause analysis.

A root cause analysis may come across as a daunting task.  While it may be, we can adopt the “Rule of 9” to help simplify the process.  The principle of the “Rule of 9” is related to the neurocognitive concept that is explained as the fact that we often need to hear something at least 9 times before we finally really hear it.  This, in turn, can be adopted to mean that we need to ask, “why,” 9 times, in order to get to the root of any issue, when conducting a root cause analysis.  In practice, when applied well, this often leads to an “ah-ha!” moment.

To illustrate the “Rule of 9,” let us use the below scenario. It is a scenario based on a clinician that is seeking to fully understand the root cause of her client’s maladaptive behaviors, using the “Rule of 9.”

Scenario: “I see you don’t have a ring, and you are very well dressed. Sometimes I wonder if you are as well dressed on the days I don’t come here to see you,” Ken asked Maria, on several occasions. He then added, “You are the type of woman I want and deserve, and I know you want me desperately.”

The “Rule of 9” Applied (with possible answers):

1.     Why was Ken acting this way towards Maria?

There seems to be several contributing factors, including his family subculture, his religious beliefs, and his upbringing.

2.     Why is this contributing to his current inappropriate

        behavior?

His family subculture, religious beliefs, and upbringing seem to have taken precedence over considerably socially appropriate behaviors.

3.     Why did that (precedence) take place?

There has been a lack of social modeling of adaptive behaviors in this current context.

4.     Why did a lack of social modeling lead to this?

He may not have learned how to adjust his behaviors to different social contexts.

5.     Why may he have not learned how to adjust his behaviors to different social contexts?

The people whom he looks up to may not have told or taught him otherwise, or may not have told him enough times. Furthermore, he may not have been exposed enough to different social contexts to learn the importance of adjusting his behaviors.

6.     Why have those people around him not told him before?

People around him may have chosen to act out, or ignore him, or not tell him in the most effective way possible how to adjust his behaviors to different social contexts.

7.     Why have they been responding to him like this?

Those in his subculture may not necessarily perceive such a behavior as being problematic in a different social context; While those outside of his subculture may not know how to effectively deal with his behavior, and/or how to respond to it effectively.

8.     Why would they not know how to effectively deal with this behavior?

Dealing with such inappropriate behaviors requires a specific set of skills, and most individuals may not have learned such skills.

9.     Why have individuals not learned this before?

Let’s take clinicians for example. Many supervisors or teachers may not have learned these skills themselves, which makes it difficult for them to properly guide their supervisees, and the ripple effect never ceases.

As you have seen, the first question starts with trying to understand why Ken has been behaving the way he has been with Maria, and yet by the question 8, we have come to understand that Ken’s behavior, per se, may not have been the root of the issue after all.  Rather, the main issue seems to be how these behaviors that have been learned throughout his life have never been appropriately and effectively addressed.  This lends itself to the question of how prepared have we been in effectively dealing with inappropriate behaviors.  Continuing education, training, consultation, and proper supervision are some of the answers to this, but it does start with knowing what we do not know, knowing how to find the answer, and knowing how we learn best.

References:

1. Wilson, Paul F.; Dell, Larry D.; Anderson, Gaylord F. (1993). Root Cause Analysis: A Tool for Total Quality Management. Milwaukee, Wisconsin: ASQ Quality Press. pp. 8–17.

2. Taisha Ohno (1988). Toyota Production System: Beyond Large-Scale Production. Portland, Oregon: Productivity Press. p. 17.

3. Ferry, Ted S., Modern Accident Investigation and Analysis, sec- ond edition, John Wiley and Sons, 1988.

4. Occupational Safety and Health Administration Accident Investigation Course, Office of Training and Education, 1993.

5. Quality Basics-Root Cause Analysis for Beginners, James L. Rooney and Lee N. Vanden Heuvel, Quality Progress, July 2004, pp. 45–53.

6. Incident [Accident] Investigations, A Guide for Employers, A Systems Approach to Help Prevent Injuries and Illnesses, U.S. Department of Labor, Occupational Health and Safety Administration (OSHA), December 2015.