Techniques for Community Support Behavioral Management

Managing behavior problems requires skill and clinical judgment. Many people, from school pupils with temper problems to psychiatric patients returning home after an inpatient admission, are so volatile that they require skilled community support for their behavior difficulties. The most tried and tested techniques for increasing self-control and ensuring relapse prevention come from cognitive behavioral therapy. A person's mental state will determine the pace of change. A psychoanalytic approach to evaluation can help.

Containment

• Maintain a calmly receptive attitude throughout. This may not sound like a behavioral intervention at all--but it's the most important one. Mental states and behavior influence one another profoundly, and ignoring the "emotional climate" can scupper all subsequent work. Behavioral problems always mean emotional problems, taking hold of people through a variety of routes--genetic predisposition, a traumatic history of loss or abuse, or a neglectful or chaotic upbringing which prevented them from learning to regulate their emotions in the first place. You have to listen attentively and calmly before you can try more active interventions; volatile people often need to vent disturbing feelings before they can take anything in. A receptive listener helps absorb the distress and establish an atmosphere of safety. Psychoanalyst Wilfred Bion described this as emotional "containment"--an essential part of all therapeutic endeavors.

Negotiation

• Once you've established a background of receptive calm and safety, you can negotiate a target behavior to manage. Don't try to impose one--but, equally, don't allow too much flexibility: choosing a wholly irrelevant behavior adds up to avoidance. If this happens, focus on the patient's "resistance"--what does she fear might happen if she selects a more relevant target? Change can be scary, and people derive a certain secret satisfaction from their symptoms (e.g., by driving their partners and friends around the bend or by securing a lot of attention). It's usually best to begin modestly. Encouraging people simply to notice changes to their bodily state when they're getting angry, for instance, enables them to practice "time out" (i.e., actively exiting the conflict situation before "losing it," and calming down safely before returning).

The Internal Saboteur and Positive Self-Talk

• Maintain a calmly encouraging attitude. Resistance, fear and failure can radically sabotage change. Failing to complete an agreed strategy isn't evidence of hopelessness, unworthiness or stupidity. It may simply mean that the chosen task was too ambitious and requires simplification or downscaling. Self-condemnation hobbles progress, keeping the status quo alive and well. To make sense of excessive self-reproaches, psychoanalyst Harry Guntrip developed the concept of the "internal saboteur," a mental structure which actively resists change and attacks hope. This concept helps challenge negative tendencies by re-describing them as the work of the internal saboteur, the enemy of change and happiness. It also encourages a spirit of competitive determination by facilitating "positive self-talk"--a heartening inner voice which helps overcome fear. Practice positive self-talk before each new target behavior for optimal results.