Mildness transforms the difficult

Press, 27 July 1988, Page 17

Mildness transforms the difficult

New control for behaviour of the mind-impaired

By

There was no mistaking which of the Kingslea Centre’s buildings at Burwood was being used to help intellectually handicapped people with severe problems of behaviour.

Angry shrieks were ringing out from a little building signposted Rene Pedder House. The door had to be unlocked to gain admittance, and down the hall could be seen the source of the pandemonium — a large, furious, screaming 14-year-old girl who was being restrained from punching and kicking everyone within reach. “You’d better come back another day,” advised Rebekah McCullough, supervisor of the New Zealand Society for the Intellectually Handicapped’s national behaviour support centre.

A few weeks later, all was quiet. Other children were in residence, being helped by the unit’s “gentle teaching” method, and the aggressive teenager had gone home, a changed person. “When she was given lots of opportunity for reward, it only took a few days and she could go back home,” said Mrs McCullough. “She is intellectually handicapped and was very aggresive. She was definitely in control — she would throw things at you, hit, kick, punch and scream.

“We set up situations that would normally be problems for her, and I taught through them, showing her that I wouldn’t change, giving her rewards, and showing her that I valued her for herself.” In institutions that care for the intellectually handicapped, and under the I.H.C.’s previous system, the girl would have been treated differently. Attempts would have been made to control her behaviour by the use of “aversives” — sanctions such as being sent to her room until she improved, being deprived of home visits with her family until she changed her ways, physical restraints, controlling chemicals, even harsh words.

Affection

and praise

But the “gentle teaching” technique which the I.H.C. has now adopted rejects all such aversives. It uses no punishments, only social rewards — affection and praise — and is achieving extraordinary transformations in the intellectually handicapped whose severe behavioural problems bring them to the crisis

GARRY ARTHUR

intervention unit at Kingslea. It is a subtle technique that calls for considerable patience and understanding. .Rebekah McCullough says she conveyed to the disturbed teenager what she wanted her to learn through her own posture, the quality of her touch, and the tone of her voice. “In this way I try to show: ‘l’m a warm person who wants to help you — and I want something in return!’”

The “gentle teaching” approach has been developed over the last 10 or 12 years by Dr John McGee of the University of Nebraska’s medical centre and the Nebraska Psychiatric Institute.

In observing a lot of mentally retarded people, he found that they had failed to “bond” with other human beings. They were being dealt with on the basis, of demands — "do this” or “don’t do that” — and consequently their own behaviour was geared mainly to drawing people to them, or driving them away. “He realised that skills could be taught to them,” says Rick Anderson, a psychologist who has spent five years studying and using Dr McGee’s methods. “They could be taught to value the presence of others, and to accept and share rewards. That was the missing component — humanness. It had not been realised that it was a teachable skill.”

Dr McGee took the traditional methods of behaviour modification and began to use them in a human framework, developing the same relationships with his retarded patients as with people in ordinary life. Three years ago, Dr McGee visited New Zealand, and Rebekah McCullough, who was then an I.H.C. regional adviser, was sent to Nebraska to study his methods. “When I came back, I recommended it to the 1.H.C., which was struggling with ways of dealing with difficult behaviour, and keeping these people in their families,” she says. I.H.C. accepted the recommendation; and she and two others were sent back to Nebraska to study the “gentle teaching” approach. Rick Anderson, who was their tutor in Omaha, was hired to return to New Zealand and help set up a national “gentle teaching” programme. At their Kingslea headquarters they are training other therapists in the method, and also working with specific patients and their families and care-givers. Rick Anderson says the method frequently calls for mutual change, in both the patient and those caring for the patient. The technique involves teach-

ing the intellectually handicaped how to develop relationships with people. “What they learned in the past was to get attention,” says Mrs McCullough, “but by doing inappropriate, self-destruc-tive things.” Rick Anderson says the traditional approach was to see the behaviour of the intellectually handicapped as maladaptive, whereas Dr McGee saw it as appropriate behaviour, but in the wrong context. The behaviour had been appropriate at the time and place that it originated.

No harsh

tone of voice

“This treatment is based on a philosophy of valuing people,” says Mr Anderson, “so we use no aversive treatments — for example no harsh tone of voice, no token economies, no time out, no chemical or mechanical restraints.”

At Kingslea the team also offers short-term residential respite and training for up to four persons with severe behavioural problems at a time. A lot more work is done at I.H.C. branches throughout the country, and in people’s homes. “Here is a last resort,” says Mrs McCullough. “They come here if they want to break a pattern and give people a chance to start afresh.”

Experience has utterly convinced Rick Anderson that the “gentle teaching” method works. “In the United States I’ve never seen these methods fail if there’s a commitment to follow through,” he says. “And we’ve served people from 38 states and other countries, people from

three years old to 60, people who have been at home or institutionalised, and people with dual mental health and related problems.”

Mrs McCullough says people have to be prepared to make the commitment. “It’s one of the best things I’ve ever seen, because we’re dealing with people who are very difficult, and you don’t have to treat them in inhumane ways. Now we’re saying to parents: you don’t have to just wipe noses; you can teach them something.” Rick Anderson has worked in the conventional ways of dealing with such people in the past, and is glad not to have to use aversive methods to modify behaviour.

“We’re saying, if you value someone, and these are human beings, there are things you don’t do to human beings.” He says I.H.C.’s national office is committed to no longer using aversives such as harsh words, physical removal to another room (time out), earning tokens that can be traded for privileges like visits to parents, controlling drugs, or physical restraints such as straitjackets and locked helmets.

Neither will it now use punishments such as vapour sprays (lemon juice, smelling salts, ammonia etc) sprayed in the faces of recalcitrant patients. Cattle prods have not been used in New Zealand on the intellectually handicapped, but Rick Anderson says they are used in the United States, and this extreme form of aversive is of course also rejected by Dr McGee’s “gentle teaching” philosophy.

Mr Anderson concedes that such aversives do change people. “You can build a good product,” he says, “but you don’t have a very good human being at the end of it. Another strong indictment of using aversives is that it changes you. It gives you a double standard; you say it’s O.K.

to do it to them because they are different — and you lose your humanity.”

He gives an example of a case where a “care-giver” was equipped with a spray of the mouthwash Listerine as an aversive; it was noticed that he had reached a point where he was just sitting and waiting for the moment when the patient’s behaviour would justify shooting him with the spray. The I.H.C. psychologists say that a lot of the people they get at the centre have had aversives, and it has not worked. What does work, they say, is simply teaching them a different behaviour. Videos of people treated by the “gentle teaching” method at Kingslea show extraordinary improvement. An autistic boy of 12 is seen entangled in a chair, exhibiting severe signs of “selfrestraint.” He could not be made to do anything at all, but would always imprison himself in a tangle of arms and legs wound through the furniture. If any demands were put on him, he would start to hit himself and could injure himself severely. “Gentle teaching” began with the staff looking for any sign of participation at all, and rewarding that. “We changed the focus from the behaviour that we didn’t want him to do, and on to doing something else. The only rewards were social — affection and praise. We studied what we were doing and its effect on him, and changed where necessary. “We got him to the point where he was more available. The staff and his parents made a big commitment, and we sent staff to his group home to follow up and give support.”

The end of the video shows the boy sitting at a table in the schoolroom, doing a jig-saw puzzle. It is a remarkable transformation. “He used to spend the whole time tied up in a piece of furniture,” says Rebekah McCul-

lough. “People would come up and cram a piece of toast in his mouth. Now his mother can play with him — she’s very happy. She was able to take him home.-

“He’s going somewhere now,” she says. “I don’t think there’s any limit — he can have a full and happy life. This sort of thing is really life-saving. He’ll probably spend the rest of his life in a supportive situation, but he can be taught to relate to people.” In some cases, the changes in behaviour begin almost immediately. One eight-year-old boy who was “totally self-involved,” and exhibited the distressing behaviour of continually hitting himself on the side of the head, began to change within the first 45 minutes of “gentle teaching.” . “Given the opportunity, he would run around and trash the room,” recalls Rick Anderson. “We tried to turn what he was doing into something constructive.” After 12 weeks, the boy was able to spend part of his time at home, and he became the star pupil in his class at a special school, even learning to read. “That’s the sort of thing that sustains you when other cases are taking longer,” says Mr Anderson. “It’s Very gratifying.”

Different

feeling in home

Another positive aspect of that boy’s case, say the psychologists, is that there is now a different feeling in his group home. “The staff have changed the way they are looking at the patients. Instead of just giving basic care, they are looking at what they can do.”

Quite a few of these seen at the unit are doing self-damaging things like head-banging. One girl had worn a hole under her chin by continually gouging it with her thumb. Instead of restraining a person to stop such self-abusive behaviour, the therapists position themselves to deflect it, while encouraging any other behaviour that seems more positive.

Even rewards in the form of sweets, food or drink are rejected by the “gentle teaching” system. Love and praise are used instead. Rick Anderson sees this as rewarding to both the subject and the teacher.

“I’d say that every teacher and every person in the child’s life would want to be more important than, say, potato chips,” he says. He has no doubt that “gentle teaching” is the answer. “It’s the best thing I’ve ever seen, and I’ve been in this business for 18 years.” Although the gentle teaching method has been adopted wholeheartedly by 1.H.C., it has not yet found its way into institutions caring for the intellectually handicapped. Mr Anderson says it has been made available, however, to psychopaedic hospitals. “Having it adopted by institutions will be part of our evolution.” If they can demonstrate in New Zealand that “gentle teaching” can work in institutions, they feel that they will then be able to export it to the rest of the world.