Positive Approaches Journal, Volume 8, Issue 1

Volume 8 ► Issue 1 ► 2019

Revisiting the Fourfold Positive Approaches Paradigm: Environment, Communication, Assessment,
and Hanging in There.

Beth I. Barol

Abstract

This article briefly reviews some of the advances in knowledge and treatment over the past 20 years for individuals with Intellectual Disability who have challenging behaviors. Revisiting the Positive Approaches Paradigm of “Environment, Communication, Assessment, and Hanging in There” the author explores the importance of continuing to focus on the compassionate education and training of the direct supporters to bring advances into the lives of people most in need of trauma-informed person-centered supports. She offers the Biographical Timeline process as one approach that can help transform the helping relationships, coordinate available resources and supports, and thereby assure positive outcomes.

Twenty-two years ago, the PA Positive Approaches Journal was launched with the intent to advocate for practices that would support people with behaviors that got in the way of living a fulfilling life. The journal was focused on sharing the successes and lessons learned in enacting the Positive Approaches fourfold paradigm: Environment, Communication, Assessment, and Hanging in There. Drawing on our original Positive Approaches article, the four elements of the paradigm are excerpted as follows¹:

Scenario 1

Eric was an 18-year-old young man who had very challenging behaviors. He would consistently hurt himself and lash out at others. A few weeks before his biographical timeline he had bitten one of his thumbs so severely that the doctors had to amputate it. After that, he was made to wear mitts on both hands most of the time. He was locked in his bedroom room day and night, because he was so violent towards staff, particularly women, often punching them in their faces if they were in his vicinity. His school refused to let him return to class due to his aggressive behavior. He was not verbal but had a creative sign language repertoire that he invented to communicate. Staff would often refuse to respond to his signs, insisting that he use the “correct” signs to communicate. His staff indicated that they were afraid of him and that they hated working with him. At the point of the timeline, he did not have any therapeutic program or a diagnosis other than “ID”. He was placed on antipsychotic medications for sedation, but according to the staff the medication was not effective.

The staff completed a record review prior to the biographical timeline meeting and the adoptive father also attended the meeting in order to fill in the knowledge gap about Eric’s early life. The story that unfolded was one of abandonment, and abuse and pain. He was dropped off at a hospital when he was one-day-old by a mother that was presumed to abuse alcohol. He never saw her again. He was then placed in a ward that was severely overcrowded, and afforded no individual attention, touch or comfort. He lived in a crib in that ward for the first year of his life. At this point we stopped the narrative and invited the staff to talk about early development and the possible ramification of this experience, neurologically and socially, supplementing the staff’s knowledge with mini lectures on development, trauma, and so on. The staff was moved by his experience and was able to compassionately talk about what he needed as a baby to have a better chance in life.

As the day continued, the staff saw that each stage of this child’s early life, before his eventual adoption by a caring family, was full of abuse and neglect. They were able to identify the effects of his traumatic experiences on his body, his responses to others, and his communication. They articulated how they now saw that their well-meaning, initial interventions were not tailored to his needs and his challenging behaviors increased as a result. As his fear-driven behavior issues escalated, the staff’s punitive responses escalated in return. It had never occurred to them that someone as scary as Eric could be afraid and just trying to survive.

After examining Eric’s life for a day and a half, the entire group listed the many painful emotional and physical wounds, issues, and missed opportunities in his life. They then moved into a brainstorming session where they excitedly postulated what it might take for him to heal and grow in the future, given their understanding of development and trauma. They then developed a very creative approach to his daily living. Several men volunteered to be his mentors observing what he enjoyed doing and introducing him to crafts and activities, including painting, pottery and gardening. They decided to learn his signs and work with him to add pictures to enhance their communication. They also decided to focus on developing trust and realized that it was their responsibility to become present and predictable. They decided to find out which affective styles worked with him and to pitch their responses to the affective mode that best met his needs. Their primary focus was going to be soothing, calming, and helping his body de-escalate from years of trauma. Later they shared their findings with the psychiatrist, who was in turn able to make an informed diagnosis and prescribe medication to address Eric’s anxiety rather than resorting to sedation medications.

Six months later, the staff was jubilant about the progress that they and Eric had made. No longer confined to his bedroom, Eric was spending time skateboarding and riding a bicycle, he was eating meals with his house mates, he was no longer aggressing against women on staff and even liked one or two. He was going outside and painting with one of the direct supporters (now social therapist) who was an artist. They discovered that he found pushing a heavy wheelbarrow in the garden to be a calming activity and so they included this in his daily routine. They all reveled in being creative and enjoyed working with Eric.

Scenario 2

Joey was a nice man. He was very social and loved being with people. While he couldn’t read or write, and he had trouble with articulation, he loved to talk with people. He was caring and would ask how the other person was doing, showing empathy in his responses.  He would often say that he was upset. He would express being “scared” and worried though he was not always able to explain why. He would not want to be alone. There were other times when Joey was in his own world, he would shut himself in his room, he would yell, cry, and destroy his possessions. Sometimes he would wet himself. Sometimes he would wander off and get lost. Sometimes he would get cut while destroying a piece of equipment. He would often try to cover up what he had done with excuses, other times, he would just look blankly and say that he didn’t know what had happened.

Joey was often considered to be very competent. He was allowed to go out on his own all day. During those times, he would take public transportation independently, hang out in stores or the mall, and drink soda all day. Sometimes he would not come home when expected, having unexplainably have gotten lost, or forgotten where he lived. Once found, he usually had a distant, vague expression and affect, and would take a few minutes to hours to return to his usually friendly self. All change was unnerving for Joey. Staff change in particular was unnerving, he was afraid that he might again be victimized and neglected by new caregivers. He was afraid to say something that might anger staff, afraid that an angry person might abandon him, or abuse him, or send him away. It seemed to him that not answering accurately about what happened was the safest option.

The direct care staff didn’t know what to make of this. They were worried for him and afraid for their jobs when he did this. Despite being deemed to be able to spend time unsupervised, staff became strict and scolding when he didn’t behave in a manner that met their expectations. They would respond as if he had personally let them down when he would become upset, destroy property, hurt himself, yell or cry. They wanted to control his challenging behaviors. They wanted to force him to own up to his behavior with the idea that this would make him stop the behavior. “What did you do?” “Did you do that?”, they would ask using accusing voice tones. Their relationships spiraled downhill.  Staff started to question if Joey should be hospitalized for self-harm.

The direct support staff did not know anything about Joey’s past, even though it was known to the agency directors. Perhaps they felt that the direct support staff did not need to know about the years of trauma and abandonment he had experienced from infancy forward, the multiple losses of loved ones, or his nagging fear that if things changed, he might end up back in an institution (an experience in his childhood that he hated and feared). Perhaps they thought, like many people in our field thought, that the past was not relevant to the present behaviors and intervention strategies. When the staff learned about elements of his life story and the array of traumatic experiences, they showed more empathy towards him, however they did not have appropriate training for trauma-informed care.

Joey then transferred to another agency with a different culture, and which also trained their staff on trauma-informed care and how to be social therapists. When they were given information about Joey’s history, they had the necessary tools to create an effective plan. Trained as social therapists, staff were able to recognize triggers and worked proactively to meet Joey’s need for warmth, predictability, and reassurance. They created opportunities to build his self-esteem and engage in meaningful activities. This informed approach had an immediate impact on Joey. He became clearer, more articulate, and much more relaxed. He enjoyed being with his social therapists, engaging in meaningful activities and practicing mindfulness in his daily life. He was also supported in making friends, something for which he had been searching for years.

As we saw in the two scenarios, staff may be left on their own without education, training or supervisory support, and yet we expected them to be able to effectively help the individuals they are supporting. Furthermore, many culturally normative child-rearing practices are counterproductive and unhelpful to the people who are overcoming trauma. Untrained staff may respond to challenging behaviors with the same harshness they may have experienced from their own caregivers and teachers to make them toe the line. They will often say “see, I turned out alright”, and credit the harsh treatment with their success. We need to consciously help staff see another way to get positive results without resorting to violent communication.^13,14

Our staff training therefore needs to start with the basics of human interaction, non-violent communication styles, and affirmative relating, including bonding, attachment and rich communication. Direct supporters need to be taught the fundamentals of trauma and how it effects the body, the cognitions, and the emotions. They need to be able to brainstorm, with clinical support and guidance, and have the means to apply what they are now being exposed to regarding trauma and its treatment, to the daily, even hour by hour needs of the person they are endeavoring to support. They need to be able to talk about the style of interactions they want to pursue, drilling down to tones of voice for example, and the relevant activities that would further the person’s wishes and desires.  They also need to explore together the helpful versus harmful use of power in their relationships with the individuals they support.

The well-trained social therapists understand that the health of the body directly affects the mental health of the individuals they support. They continuously seek the means to ensure that the healthy lifestyles recommended to all of us, to maintain health and to heal from so many physical and emotional issues are part of daily life: that people they support live in a healthy environment, eat a diet that supports their health, exercise daily, and have a good night’s sleep. They become versed in a variety of techniques that can sooth the autonomic nervous system and relieve stress, such as art, music, mindfulness, and yoga, and help incorporate them into daily life.

Summary

References