Caring for People with

Challenging Behaviors
Essential Skills and Successful
Strategies in Long-Term Care
SECOND EDITION
by
Stephen Weber Long, Ph.D.
Baltimore London Sydney
It is not unusual for people who receive close care, attention, and assistance to
behave in challenging, or diffcult, ways. In fact, up to 80% of long-term care
residents are described as having moderate to severe behavior problems. Such
problems are a primary reason for family members deciding to place a loved one
in a long-term care setting. Diffcult behaviors also happen in other care settings,
such as assisted living, and as part of professionally provided home-based care.
Many people who begin working in long-term care settings are surprised by
how often they see, experience, or hear about care recipients behaving in diffcult
ways. It is common for those who need care to resist what others try to do with or
for them by insulting or threatening others, yelling, shouting, or screaming. Al-
though less common, there are also instances when a care recipient hits, scratches,
kicks, or even bites. Challenging behaviors are frequently aimed at caregivers.
Family caregivers are sometimes not surprised by the diffcult behaviors of a
family member who is in need of care. They may describe the behaviors as just
the way he (or she) has always been. Sometimes, however, diffcult behaviors or
actions may be dramatic changes and are very upsetting to caregivers.
Caring for People with Challenging Behaviors: Essential Skills and Successful Strat-
egies in Long-Term Care is intended as a guide for professional and family caregiv-
ers. Its aim is to help reduce or eliminate many typical behavior challenges of care
recipients. In this book, the term challenging behavior refers to any behavior that
causes emotional or physical harm to either the person engaging in the behavior
Introduction
xiii
xiv Caring for People with Challenging Behaviors
or to someone else. From this point of view, hostile behavior aimed at someone
else is a challenging behavior. If a behavior hurts someone unintentionally, it is
still considered a challenging behavior. In addition, behaviors related to depres-
sion, anxiety, or fear can be considered challenging behaviors. This book details
techniques for successfully addressing such behaviors.
An environment that supports the use of these techniques can increase how
helpful they can be. In long-term care facilities and professionally provided home-
based care programs the effectiveness of these skills is strengthened when staff,
supervisors, physicians, and administrators, as well as family members, have a
common understanding of the skills and their importance. When family members
or signifcant others are primary caregivers in the home, the effectiveness of the
techniques will be increased if family members in general understand and support
their use. Whether you are an administrator, a supervisor, a professional hands-on
caregiver; whether you are a student or a veteran in the feld of long-term care;
whether you are caring for a spouse, a parent, a grandparent, or another signifcant
person in your life, this book is meant for you.
Dealing with challenging behaviors is often stressful to caregivers, and learn-
ing ways of reducing or eliminating stress is very important in empowering us to
provide successful care. Throughout this book you will fnd detailed descriptions
of methods of managing stress that many people fnd effective.
Caring for People with Challenging Behaviors can also assist mental health pro-
fessionals who provide consultation to families and administrators and staff of
long-term care settings and programs on how best to approach a diffcult situation
with a particular person being cared for. The principles and skills outlined in this
book also can be used to create workable treatment plans that address common
troubling behaviors.
This book can be a valuable part of training programs as well. It may be used
as a basis for in-service training of staff, supervisors, and administrators. It may
also be used as part of the overall training of those who are preparing to begin
work in long-term care settings or programs. In addition, it may be used in classes
or workshops for family caregivers.
Often when someone in need of care behaves in a troubling way, the be-
havior is related to an illness, such as Alzheimers disease. Challenging behaviors
are also sometimes related to other conditions that are more often thought of as
mental illnesses, such as depression or schizophrenia. Physical pain or discomfort
can also infuence a person to behave in diffcult ways. Sometimes a challeng-
ing behavior is related to lifelong attitudes, habits, or personality. The methods
described in this book are appropriate for use with individuals whose behavior is
affected by any of these infuences.
Whenever a mental or physical illness seems to be contributing to a care re-
cipients challenging behavior, it is important to seek the advice of appropriately
qualifed healthcare professionals. Even in cases when a mental or physical illness
is not clearly involved, it is important to consult with trained and experienced
healthcare or mental healthcare professionals if a challenging behavior is per-
sistent. Caring for People with Challenging Behaviors is not intended to replace the
Introduction xv
advice of physicians, nurse practitioners, social works, psychologists, or any ap-
propriately trained or experienced professionals. Yet, it is important that the skills
described in this book be a central part of treating the problem, regardless of cause.
They really are skills for all of those who help, whether day-to-day staff, medical
specialists, administrative staff, family members, or other signifcant people, in the
life of someone who requires care.
Chapter 1 discusses why people in need of care do the things they do. The
chapter looks at major infuences on behavior through specifc examples of how
physical functioning, thinking, feeling, the way some behavior seems to lead to
other behavior, and interactions with others can affect what someone does. Chap-
ter 1 ends with a discussion of coping with stress. It also describes the importance
of increasing the number of pleasant events that can be enjoyed each day as one
approach for caregivers to manage stress.
Chapter 2 offers examples of ways to encourage a care recipients positive
behaviors. The chapter is based primarily on three ideas: 1) the more a behavior
is reinforced, the more it will occur; 2) the more a positive behavior is reinforced,
the less often a diffcult behavior will happen; 3) a care recipients experience of
interactions with others can be the most important source of reinforcing positive
behaviors. This chapter describes the steps of active listening, a communication
skill for developing an empathic, emotional understanding. Such listening and
understanding reinforces many positive behaviors, as it encourages a care recipi-
ent to value his or her relationship with caregivers. Other ways of encouraging
positive behaviors are explored as well, such as allowing people who are depen-
dent on care to make choices and praising, complimenting, or acknowledging
positive behaviors. The chapter ends by discussing the stress management tech-
nique of progressive muscle relaxation.
Chapter 3 is about problem solving. It describes a way of looking at a situa-
tion, particularly interpersonal interactions (or relationship situations), to un-
derstand what might trigger or reinforce a challenging behavior. Knowledge of
possible triggers and reinforcers can be used to help the care recipient reduce or
eliminate the behavior. The chapter also describes a two-step process for helping
reduce frequent demanding or attention-seeking behaviors. Chapter 3 contains
several examples of how to use problem-solving steps to work with individuals to
help them eliminate or reduce challenging behaviors. Chapter 3 also explains the
importance of holding on, or containing, our reactions to diffcult behavior. Fi-
nally, mental imagery is explored as a stress management technique for caregivers.
The main point of Chapter 4 is to look more deeply at dealing with stress
related to the diffcult behavior of those to whom we provide close care, atten-
tion, and assistance. The chapter examines how our thinking and feeling can
be affected by those whose behavior is challenging and how our own thinking
habits can cause or add to our stress. This chapter is about exerting conscious in-
fuence on our own thoughts and feelings in order to feel less stressed by the chal-
lenging behavior of those who depend on our care. How we deal with such stress
directly infuences how effectively we address challenging behaviors. In addition,
Chapter 4 considers how our feelings about those whose behavior is diffcult and
xvi Caring for People with Challenging Behaviors
the things they do can help us in understanding and responding. The chapter
concludes by describing a breathing-focused technique for deepening relaxation
and stress management.
In Chapter 5 we look at the use of behavior (or behavioral) contracts and
advance directives, both of which may be used in addressing challenging behav-
iors. This chapter and its contents are completely new to the second edition.
The focus is on some limitations of the use of behavior contracts and on the
potential benefts of using advance directives for mental health, behavioral
health, and stress management issues related to challenging behaviors. Behavior
contracts and advance directives may be of most interest to those working in
long-term care facilities or programs. Family members of those who are long-term
care residents or clients, or of those who may become residents or clients, may
also fnd the discussion of behavior contracts and advance directives helpful.
Chapter 5 also describes steps for how caregivers can use forgiveness as a way of
managing stress reactions to the diffcult behavior of others. This part of the chap-
ter may be useful to every reader in some way.
Chapter 6 examines factors that can interfere with the effective use of the
techniques described in this book, including our own personal obstacles to effec-
tively using the techniques, the environment of a long-term care facility or pro-
gram, and societal attitudes toward aging and illness. The chapter provides ways of
addressing these different obstacles and encourages us to see ourselves, long-term
care settings and programs, and society as parts of a systemwhat we do affects
the other parts of the system and can promote positive change. Chapter 6 ends
by considering the importance of good relationships in managing stress and offers
ways to improve relationships.
Chapter 7 is a guide to treatment planning for addressing challenging be-
haviors. The chapter presents a fve-step treatment plan guide for individual
caregivers. Although the guide for individual caregivers is presented in a format
for professional caregivers, it can also be used by individual family caregivers at
home. Chapter 7 includes another fve-step treatment plan guide for professional
treatment teams. In addition, this chapter describes how to integrate educational
material based on Caring for People with Challenging Behaviors into the day-to-day
routine of a facility, an approach aimed at increasing and deepening all staff mem-
bers familiarity with effective techniques for addressing challenging behaviors.
The goal of this approach is also the prevention of many behavior problems, be-
cause prevention is the best possible treatment. Finally, Chapter 7 can be a useful
tool for mental health professionals called on for consultations in cases involving
the challenging behaviors of those in need of close care, attention, and assistance.