Environmental fit - the way to deal with challenging behavior

Environmental adaptation adjusts the environment to those persons who are unable to adapt to it themselves. This concerns communication, immediate environment and other factors.

Before we start thinking about the concept of environmental adaptation, I need to include a digression that will make it easier to understand what I mean by adequate interaction with people with dementia. I mentioned earlier that in the context of dementia, a particular concern must be to discover, use, and strengthen resources rather than to focus on deficits. That many things fail in dementia is clear. But that is not the focus for me! Of course, we must know which deficits can occur so that we can provide meaningful assistance in moments of deficit. But the goal must always be to use and promote even the smallest resources. Discovering them will only succeed if we do not remain attached to the deficits and place the person instead of the diagnosis in the center of our thinking and acting.

If we set out on this path, we will discover that supposed deficits hold a treasure chest of resources. How so? Example:

Aggression such as hitting, yelling and spitting - to name just the most common - is thought to be part of the diagnostic characteristics of dementia. But what if we started asking different questions? If we assume that people in dementia also lose their learned communication skills, why do we still assume that they interact in familiar ways? When a person with dementia cannot find the words to express their feelings of displeasure and instead yells, spits, or hits, it is certainly distressing to family members or caregivers. However, the person with dementia has done nothing but express his or her own displeasure according to his or her capabilities. We may have previously missed that displeasure has arisen and therefore the reaction comes as a surprise, but it is not inappropriate; at least not if one sufficiently appreciates the circumstances! So why not evaluate the reaction as a resource; namely the resource to express feelings - just differently than we have learned it as "decent", because we are programmed differently.

As children with an increase in communication abilities, we have become accustomed to such reactions as crying. So why not let the persons with decreasing communication abilities - i.e. those suffering from dementia - have this original reaction? It is a means of being heard; thus, a resource. Recognizing and appreciating this is, among other things, environmental adaptation.

Environmental adaptation is my "secret tip" for anyone who is surrounded by people - whether professional or personal - who stand out because of behavior that we call conspicuous. We learn from the beginning of our lives that our behavior should be "adapted." We learn early on that non-conforming behavior is undesirable and that there are usually repressive consequences if we behave contrary to expectations. This is rarely questioned and often the achievement of certain behavioral norms is the goal of education. It is not a matter of who benefits if everyone behaves conformed, but to do so without constraints; simply for the sake of being conformed. Not standing out in a crowd is stylized into a virtue. This in turn leads to people who do not want to and/or cannot conform to the norm becoming all the more outsiders because we are not programmed for exceptions to rules.

Socially, this means that people are pushed out of the center of society if they do not want to - and/or cannot - submit to certain norms, especially norms of behavior. For those who do not want to, this does not seem to be a problem that they have chosen this path. But maybe it is not? What if these people look for the way out of the society, because this does not hold any place ready for them at all? If it does not correspond to their inner program to adapt, then the requirement "to adapt" will not be able to be fulfilled. And because we have no program for otherness, these "ricochets" either have to be adapted or they remain outsiders. In either case, they will be punished - whether actively or passively. After all, we know enough restrictive sanctioning tools with which children and young people as well as adults are "brought to heel."

Unfortunately, our social systems do not make room for everyone and allow everyone to participate in the community. Inclusion is correspondingly difficult. But not because teachers or caregivers, for example, are unwilling to do inclusion, but because they are not provided with enough professionals or the tools to do it.

What we need first and foremost, I think, is a different view of people's behavior; especially when we perceive it as maladaptive and challenging. We need to finally understand that it is not people's behavior that is wrong, but our reaction to it might be unfavorable if we feel we cannot solve the problems with "behaviorally sororigine" people. People behave perfectly adequately according to their capabilities and resources. They are using their resources to tell us that something is not right for them in the current situation and that they do not have the means and tools to solve it differently. Many - probably most - also do not possess the ability to learn tools (anymore). Others can, but at a high price because they have to compensate for their own impulses most of the time to make themselves "fit". This is a high price insofar as it ties up capacities and energy that would be more usefully employed elsewhere if we would let them be just as they are. And if we would listen to them and take a closer look!

An old lady whom I visited every morning as part of outpatient care could hardly be moved to get out of bed. According to her daughter, she was a late riser and was visited later by the caregivers; around 10 o'clock most of the time. During the induction, I experienced that the lady was more or less coerced out of bed and the nurse was quite annoyed in the process. Sentences were uttered such as, "Every morning this fuss." I was instructed to prepare breakfast in the meantime "so that it would go faster" and the lady was pushed into the bathroom so that she would "finally get ready."

We were pressed for time...

I was aware of that...

And yet, this situation with the colleague left a funny taste in my mouth. We talked about it afterwards and the colleague - whom I otherwise experienced as very sweet and patient - told me that she had been told by the relatives that the lady was "difficult". I asked to be allowed to try something the next morning and presented my idea. I was able to refute the counter-argument of "time" by suggesting a new approach. If this did not work out, we would reconsider. The next morning I quietly went into the lady's room and turned on a small light. I made coffee, prepared the bathroom and went to her with a cup of coffee with the words "To wake up, nice lady!". Afterwards, I made sure she was able to sit up well in bed. She enjoyed her coffee while I prepared breakfast so far, which we started right after the bath. When I went back in to see her, she looked much more awake and sorted. Washing and dressing went easily from the hand. She could do a lot of things on her own because she was more sorted and at breakfast she was in a good mood. She didn't have to be encouraged to eat as usual and so I was able to clean up, make the bed and do the other chores. By the way, we were ten minutes faster than usual and after a team meeting, everyone did as demonstrated that day. With minor exceptions - the form of the day makes for deviations - it always went very well.

Now before you read on: Please let the example sink in for a moment! I think you understand that the problem was not one. We just had to adjust the situation and then everything was fine.

The following is primarily about dealing with people who have neural or emotional limitations - or both. This applies to people with autism and AD(H)S as well as to people with depression, intellectual disabilities, dementia, and other limitations and illnesses. Environmental fit and how we view and deal with challenging behavior is also an issue when dealing with the seriously and chronically ill. Asking why a person does what he or she does is exciting and resolves some conflicts differently than if we approached human behavior in a judgmental way. Give it a try!

If you are a professional inpatient or outpatient nurse, the following thoughts will help you in documentation and team discussions to see crisis situations in a different light. You will install new approaches and become more flexible. If you are a caregiver, the same applies to the family.

Sometimes a new view clarifies your own approach decisively and makes you more creative. Exchange yourself gladly with your fellow men and learn from them and with them. This way of dealing with each other is learning in dialogue and we will not be finished with it for a lifetime: Because learning in dialogue means to approach people with open ears, eyes and feelings and to work together on creative as well as individual solutions!

Before we completely dedicate ourselves to the concept of environmental adaptation, there are some terms to clarify - or even just a term, as we will find out in the following section...

You know the following terms:

• Aggressive
• Restless
• Inaccessible
• Striking
• Stubborn

If you let the individual terms work on you, matching images will come up in your mind. Let's pick out a term from the set to take a closer look at it: With "aggressive," some see a person who yells and "builds up." Others, again, see an individual throwing objects. Still others may see a person lashing out, pushing, and threatening. Some come up with multiple descriptions of the term in general.

Thus, there is a different definition for each term. What we associate with these terms is highly individual and shaped by our own experiences as well as adventures. All terms are decidedly general or, conversely, imprecise. What exactly does it mean when I describe someone as aggressive? Is that enough to decode behavior? You guessed it: my explanation is definitely inadequate. "Aggressive" is a superficial description of behavior that does not deserve the name "description" at all. Rather, the terms are not descriptions, but subjective evaluations of behavior; evaluations that, on top of everything else, presume to allow no room for interpretation: Who behaves in such a way, behaves badly!

Now you will possibly object that - since it corresponds to the social guidelines - aggressive behavior is to be evaluated naturally as bad. I answer to this fact with: Yes and No.

First and foremost, it is difficult to put a value on behavior. Imagine for a moment that you would not evaluate the behavior in question as aggressive, but would first describe it in a value-neutral way: He or she hit, threw, yelled - whatever. That's a description. Described in a value-neutral way and as detailed as possible - with a consideration of what the situation was like in which the person behaved in this way - aggression may turn into something else. You may notice things that would have escaped your quick assessment as "aggressive." This can include many aspects and opens other ways than a mere evaluation of the behavior does.

This is why scientists, caregivers, and others besides myself refer to conspicuous behavior as "challenging behavior." The behavior challenges us: it challenges us to respond. If I first ask myself what exactly the other person is doing and then look at the situation as well as the other person's premises, I can next ask the question, "Why is a person doing what he or she is doing?"

With that, something has changed:

I don't have to take the behavior personally. If I assume that I have something to do with how the other person behaves, it is not personal. Maybe the situation triggered something in the other person? Or maybe the reaction is due to being overwhelmed? That's what we have to find out.

So: The behavior of the counterpart challenges you to look at the situation and to rethink your own behavior:

• If the behavior has something to do with me, what can I change? That is the question behind it!
• If the situation has triggered the behavior of the counterpart, what can I change about the situation next time? That is the other question behind it!
• If the behavior has a typical pattern for that person, then the third question is why do I think I could break the habit?

If someone has been ranting about everything and everyone all their life, always had an opinion and was always "grumpy", why do I think it should be different now of all times? Where do we get off wanting to educate? It would make more sense to intervene in a helpful way.

That's a very different approach. When I evaluate, I demand that the other person change his or her behavior. If I describe, on the other hand, I can..:

1. ...help the other person to look at the behavior and change it, if that is possible.
2. ...understand situations better and conclude what my counterpart needs so that he or she no longer needs this behavior.
3. ...think and act in a resource-oriented way.

Values are deficit orientation, questioning is resource orientation. It is about adopting a questioning attitude. The goal must be to ask why a person does what he or she does and what resources and possibilities are behind it. Of course, this becomes more difficult the more limited the possibilities of communication are, but it is rarely impossible. In case of doubt, all sources must be consulted that tell us something about the person in question. I will say something about this in the next chapter, when it also deals with validation and biography work.

So much for my basic reflections on challenging behavior.

Simply summarized, environmental adaptation means adapting the environment for someone so that he or she feels comfortable and safe.

For me - and some experts will want to contradict me here - environmental adaptation is basically the big heading over all measures that lead to a person who cannot find his or her way (anymore) in the world surrounding him or her feeling safe and comfortable. Feeling safe and comfortable are basic human needs that are there from the beginning and never stop.

You may wonder why this needs to be explained so explicitly. Because seriously, isn't that a given?

When we come into the world, we are nurtured and cared for, then grow up to discover our own world. For most people, it is natural to create the environment in such a way that the baby or toddler does not hurt himself or put himself in danger. This is a form of environmental fit. Over time, the safeguards are adapted to the child's age: As it becomes more mobile, one or two things need to be re-secured. Other things don't need securing because of the child's continued development. Some parents are more anxious, others less. And that's where it gets exciting: the disposition of the parents determines how much environmental adjustment they think is necessary and how much the child is expected or expected to do. You notice: The facts become more differentiated!

If parents are very cautious, then the child is programmed for danger. Accordingly, it will react more fearfully in certain situations than other children whose parents are more courageous. Then there are parents who hardly think about dangers and whose children learn early to manage on their own. We experience these children as daredevil, courageous and/or independent, but also, under certain circumstances, as difficult to steer and "resistant to parenting".

For the children with the more fearful parents, the parents' behavior means that they are not learning enough to be confident, to approach unknown situations with confidence, and to distinguish what is dangerous and what is not. This does not seem favorable because in that case the child discovers and develops few resources. For a child whose parents are rather unconcerned, this means that resources are demanded of them that they cannot actually have yet, according to their age. They do not learn healthy caution and are not adequately protected. Both have in common that their environmental fit is unfavorable. Their environment prevents them from developing and discovering their resources in an age-appropriate way. For some, the framework is set too narrowly; for others, it is set too broadly.

An environmental fit would mean that children learn to assess dangers in an age-appropriate way and to counter them adequately.

In a shared flat for people with dementia lived an elderly gentleman who had been a pub landlord all his life in a so-called "social hotspot"; a place where a pub landlord certainly does not throw around polite phrases and knows how to defend his skin. Unfortunately, that man was known for his - let's call it - problematic dealings with women.

This man stayed up late in the evening, cashed in the last beer around 1 a.m. and then went to bed, sleeping until at least 11 a.m. in the morning. That's how he was used to it and that's how it was done: environmental fit! Now, for various reasons, he had to take his medication in the morning and in the evening in a timed fashion. By 8 a.m. at the latest, it was time to go in to him in the morning, wake him up briefly, and get him to take his medication. I and my colleagues have been trained to be polite and careful with people. Accordingly, my first attempt was as follows: "Good morning, Mr. Meier (name fictitious)! I don't want to disturb you long at all, but you would have to take your medication for a moment."

What can I say? I was badly insulted, threatened with beatings (his behavior towards his wives was impressively proven here) and when I left the room in a hurry, his drinking glass flew behind me. Similar reactions had to be expected by all who dared to show up early at his room. Likewise, he could be very unpleasant in many other situations: He cursed, swore, hit and - yes, he was one of those people - liked to touch when a woman was well built.

First reaction in the team: indignation! How can he treat you like that? How dare he? What a macho man! That's disgusting! "Totally justified!", you will now think....

But we tried something else after we did a case review on him, where we learned and understood a lot more about him: We were simply too polite. After all, that got on the nerves of the guy in the shared flat all the time. How often did he ape us, because he simply couldn't do anything with all this "wishy-washy talk"! He was programmed differently. If you wanted something from him that bothered him, then the good man was annoyed and reacted to it with his habits.

So, it was up to me to start a new attempt: At 8 o'clock sharp, in with tablet and sweaty hands. Towards the bed, nudged once, loudly and clearly addressed: "Mr. Meier, open your eyes for a moment, you have to take your tablet, the doctor ordered!" Normal reaction from him with cursing and swearing. My response: "I don't care what you think, the tablet has to go in, the doc said, so zack now and done. Don't act like a girl! But my goodness, a guy like you will probably be able to cope if he has to take a pill for a moment!" Not particularly friendly, but energetic and loud... A grumbled "Give me the shit with which the quack earns his Porsche!" came back and the topic was through!

I see you now shaking your head in horror. Such a thing is not possible...

Well, you're right. Actually, it's not possible at all and if I would have talked to the ladies in the flat-sharing community like that, they would very likely have been struck by it. Also in general such behavior is unacceptable, especially since I brought an example at the beginning of this article, in which I acted exactly the opposite.

So why is this going on here?

It's environmental fit, even if that's hard to believe. The man has lived for decades in an environment where there was such a tone that ensured survival. If you don't have your wife/husband standing in a hot spot bar, you won't be there intact for long. Now the man had become demented and had been placed in an environment that was a clear contrast to his previous life. He was no longer strong and independent, at least outwardly. But in his self-image he was, and he could certainly stand his ground. His relationship with women was characterized throughout his life by the fact that he was "the man of the house," which he even enforced by force - except for his last wife. She was able to stand up to him and, according to his son, she was his great love. Moreover, in the milieu surrounding him, people spoke loudly and clearly.

We met him on every level with a behavior that did not correspond to his imprints and due to the dementia he was deprived of the possibility to abstract his behavior and adjust it to us. As a solution, we in the care team copied the behavior of his last wife, which the son had described to us. After all, she knew very well how to deal with him.

• So we talked louder and clearer.
• We left out polite phrases that had annoyed him so much.
• We changed the tone of speech and now and then cursed back or along with him!

We did the same in personal hygiene and other situations in order to adapt the environment - i.e. us - to his needs. The fact that we also deal with the topics of biography work, familiarity principle and validation is an important part of the environmental adaptation. The topics are so closely linked that their integration is inevitable: adapting the language has a lot to do with validation and biographical knowledge and thinking is a mandatory prerequisite for making environmental adaptation possible. Environmental fit has to do with previous habits.

Environmental fit can therefore mean that I adapt my behavior and reactions to what I am used to and thus make myself fit.

Another aspect of environmental adaptation is an adaptation of the surrounding world: everything must be adapted to the needs and abilities that the respective counterpart has. This means creating space and avoiding trip hazards when a person has limited movement or perception:

• A wheelchair user should be able to move without barriers and appropriate modifications are necessary? Then a stair lift is a possible solution.
• The person in question has limited vision? Then the installation of appropriate aids for the visually impaired is an option.

All this makes sense, unfortunately we still see too few corresponding measures implemented in public. It becomes especially difficult when we look at people with disabilities that do not relate to (purely) physical limitations:

A young woman who had severe mental and physical disabilities due to oxygen deprivation at birth and was thus limited in her independence because she needed assistance in everything she wanted and needed to do, lived in a facility for people with multiple disabilities. She was 20 years young and could only speak single words. Most of the time she communicated with sounds and gestures that were as difficult to interpret as her word language because everything about her was erratic and uncoordinated. However, she had a kind of computer with which she could communicate. It spoke aloud what she typed. The fact that she could type, and at a not inconsiderable rate, could have made me think from the beginning that she had a lot more resources and potential than we assumed. She had to prove that to us first, so that we would deal with her differently and according to her level of development. Here's what happened: she was always at home on the weekends, doing a wide variety of things.

• buying clothes
• Visiting the hairdresser
• Buying books
• And whatever else was going on....

We never questioned that the mother did the shopping with her and discussed things such as the new hairstyle. SO it was conveyed to us by the parents and there seemed to be a trusting and relaxed relationship - it seemed....

One Saturday morning I experienced that that young woman refused to get out of bed and kept writing, "Go away!" She would not get up and after we had all tried our luck and no coaxing, threatening, pleading or begging could get her to let us help her get up, we finally left her alone! We thought the mother would get it sorted out. So we limited ourselves to bringing her breakfast, helping her prepare food in bed, enforcing some hygiene, and then waiting to see what happened when the mother came to pick her up. Today was going to be about clothes and even furniture shopping....

The mother came, we were anxious and then came again clearly from the young woman: "Don't want! Don't go! Go away, go!" The mother came to us completely perplexed, we consulted and decided to suggest to the young woman that she could stay at the facility this weekend, especially since there was a movie night in the evening. The young woman agreed. As soon as the mother left, she asked us to help her get up and was happy the whole weekend. On the phone she told her mother that everything was fine.

From now on she did this "theater" every Saturday. For four weeks we didn't know what was going on. You may rightly object that we may not have asked the right person. It was like this. We talked to the mother about possible motivations. We accepted as a matter of course that the mother was naming her daughter's feelings on behalf of her. As if we could not understand that the mother sees and describes the feelings of her daughter only through a filter; through the filter of her own feelings and imagination! How should the mother know exactly how it looks in the daughter, since she is not in the daughter? Only the daughter herself is in it, and we asked her by mistake that noon while cooking! My colleague talked to me - attention! - about the young woman who was also present! She asked me if I had any ideas, to which I replied in the negative. Then suddenly there was a tug on my shirt and the young woman said quite forcefully, "Come on!" In her room, she had the computer say the following, "I don't want to shop with my mother anymore because she never asks me if I like what she picks out. She always buys kids' stuff, even though I'm already an adult!"

Well: we were then able to solve the problem with the mother, who simply had to learn that she is not allowed to decide and talk for the daughter, as well as that her daughter has a right to design her room, her environment, according to her wishes. Likewise, her choice of clothes.... The hairstyle! Because she was an adult! Of course!

What happened here?

An adult young woman is confronted with the fact that she is reduced to her handicaps by her carers - deficit-oriented thinking! - and she is not allowed to mature and develop. She is held in being a child. Her environment is not adapted to her changed needs. She is reduced to being disabled and needy and none of her resources are used. She can communicate, but no one uses that purposefully. Because of her limitations, she is no longer perceived as a personality. Her possibilities are underestimated and her potentials undermined.

Until she finds a very creative way to make herself heard!

Here, environmental adaptation - the immediate surrounding world, i.e. the room and the attitude of the caregivers - has to be adapted to changing needs and developments. In order to do this, however, we must seriously understand that we must always look for ways to make communication successful and to understand it. Then we can make the environment fit for those who cannot make a fit themselves.

Environmental adaptation means understanding where individuals cannot adapt themselves and their behavior to the conditions of their environment for a variety of reasons. Thus, one must ask why a person does what he or she does. Only in this way is it possible to find out how every source and every possibility as well as the resources of the person concerned can be used. From the understanding of the person, one's own actions must follow in order to adapt the environment and one's own behavior to the person's situation. In doing so, by far not everything works right away. That's why you and every other practicing person are dependent on trying things as well as methods, discarding or keeping them, trying them again and always talking to each other. You will clearly notice from the behavior of the person whether your way of adapting to the environment works or whether there is room for improvement. The only thing you can do wrong is to do nothing! Learn optimistically from failures and be sure to tell others about them. Others learn from them too!