背景:攻击性和自我伤害等具有挑战性的行为对住院护理的客户和工作人员来说是危险的。这些行为没有得到很好的理解,因此经常被标记为“复杂”。然而,这种所谓的复杂性在个人层面上的含义仍然模糊。本案例研究采用了三步混合方法分析策略,受到复杂系统理论的启发。首先,我们解释了她日常生活中相关因素的整体总结。第二,我们通过确定稳定阶段来描述她具有挑战性的行为轨迹.第三,她的环境中的不稳定性和异常事件被评估为不同阶段之间的潜在变化诱导机制.
方法:一个女人,住在一个住宅设施,诊断为轻度智力障碍和边缘性人格障碍,表现出攻击性和自我伤害事件的慢性模式。她每天使用生态瞬时评估对560天的挑战行为进行自我评估。
结论:对看护者记录的定性总结揭示了许多与她日常生活相关的内部和环境因素。她的临床医生将这些范围缩小到11名员工假设的风险和保护因素,比如重温创伤,经历疼痛,接受医疗护理或赞美。强制性措施增加了第二天挑战行为的机会,而心理治疗会减少第二天自我伤害的机会。这11个因素与自我报告的挑战性行为之间的大多数同期和滞后关联是不显著的,表明挑战性行为不受单一因果关系的支配,谈到它的复杂性。尽管存在这种复杂性,但事件的时间顺序还是存在模式。在560天中,分别发生了13%和50%的攻击和自我伤害。在此时间表上,确定了11个不同的稳定阶段,这些阶段在四个独特状态之间交替:高水平的侵略和自我伤害,平均侵略和自我伤害,低攻击性和自我伤害,低攻击性和高自伤。十个阶段之间的过渡中有八个是由她的环境中的非凡事件触发的,或者在她的自我评价波动加剧之前,或者这两者的组合。理想的模式出现更频繁,不太容易延展,表明当她经历糟糕的时候,记住未来会有更好的时代是充满希望和现实的。
BACKGROUND: Challenging behaviors like aggression and self-injury are dangerous for clients and staff in residential care. These behaviors are not well understood and therefore often labeled as \"complex\". Yet it remains vague what this supposed complexity entails at the individual level. This
case-study used a three-step mixed-methods analytical strategy, inspired by complex systems theory. First, we construed a holistic summary of relevant factors in her daily life. Second, we described her challenging behavioral trajectory by identifying stable phases. Third, instability and extraordinary events in her environment were evaluated as potential change-inducing mechanisms between different phases.
METHODS: A woman, living at a residential facility, diagnosed with mild intellectual disability and borderline personality disorder, who shows a chronic pattern of aggressive and self-injurious incidents. She used ecological momentary assessments to self-rate challenging behaviors daily for 560 days.
CONCLUSIONS: A qualitative summary of caretaker records revealed many internal and environmental factors relevant to her daily life. Her clinician narrowed these down to 11 staff hypothesized risk- and protective factors, such as reliving trauma, experiencing pain, receiving medical care or compliments. Coercive measures increased the chance of challenging behavior the day after and psychological therapy sessions decreased the chance of self-injury the day after. The majority of contemporaneous and lagged associations between these 11 factors and self-reported challenging behaviors were non-significant, indicating that challenging behaviors are not governed by mono-causal if-then relations, speaking to its complex nature. Despite this complexity there were patterns in the temporal ordering of incidents. Aggression and self-injury occurred on respectively 13% and 50% of the 560 days. On this timeline 11 distinct stable phases were identified that alternated between four unique states: high levels of aggression and self-injury, average aggression and self-injury, low aggression and self-injury, and low aggression with high self-injury. Eight out of ten transitions between phases were triggered by extraordinary events in her environment, or preceded by increased fluctuations in her self-ratings, or a combination of these two. Desirable patterns emerged more often and were less easily malleable, indicating that when she experiences bad times, keeping in mind that better times lie ahead is hopeful and realistic.