Managing Demanding Behavior

Definition

Demanding behaviour can fall into two broad categories:

  1. Anxious and emotionally needy service users who require considerable attention from practitioners. This may take the form of extended appointments, unplanned contacts and/or frequent telephone calls.
  2. Service users presenting as very entitled. These are individuals who typically have high expectations of others, and may demand immediate or special consideration from services. Such individuals may sometimes require additional input from practitioners, or more commonly they may actually want less time, but place pressure on the practitioner to use that limited time exclusively to meet the expectations of the service user.

Demands involve resources. Resources often involve practitioner & agency time. However, it can also include money (eg, travel reimbursement, benefits), medication & physical healthcare, or ‘goods’ such as housing.

 

Who makes excessive demands and how

Anxious and emotionally needy behaviour is commonly associated with borderline personality disorder (see Borderline PD Top Tips ). However, Cluster C disorders – anxious, depressive and dependent individuals – might also be relevant. The service user may lurch from crisis to crisis (see also Managing Self Harm), and often draws several members of the team into managing the dilemma. Sometimes practitioners from a range of agencies might find themselves all trying to solve the same problem or working at cross purposes. The service user typically engages reception and admin staff in their problems, and in residential settings, may also spend hours talking over a crisis with the night staff.

Demanding behaviour which is entitled, is more likely to be associated with service users who have marked paranoid, narcissistic or antisocial traits. Their underlying motives may be different of course: for example, the antisocial service user will tend to be selfishly wanting to find a short cut to get his needs met; whereas the paranoid individual’s demands might be the result of suspiciousness regarding services’ intentions towards him. When these needs are not met, service users may respond with disproportionate outrage about the situation (making complaints, threats, or resisting engagement).

 

Why service users make excessive demands?

Reasons why service users make excessive demands can vary hugely. For example, when service users have had childhood experiences of abuse and neglect, they may carry with them intense anxieties about rejection and abandonment; making demands on agencies or practitioners may be a way of testing whether or not they are thought about or cared about. Breaking a boundary – eg, making sure the practitioner talks to you for longer than your allotted hour – might be the only way they can reduce their anxiety.

Entitled demands may arise from earlier experiences of being in care, and feeling that there were no adults around for whom you were a ‘special’ child; as an adult, such individuals feel that life is a jungle (a competitive environment with few rules) with winners and losers, and they put a lot of energy into making sure that they are one of the winners. For others who hide their feelings of inadequacy behind arrogance, they may prefer to focus on what is not being done for them by services so they don’t need to talk about what they may be struggling doing themselves.

Reasons for excessive demands may be multiple and complex. A summary of reasons are listed below:

  • Pushing limits to seek proof of caring from others
  • Pushing limits because nothing ever feels enough
  • Protecting themselves from feeling shamed or humiliated by focusing on the failures of others
  • Making ‘a lot of noise’ as the only way to get their needs met
  • Trying to feel like a ‘winner’, not a ‘loser’
  • Not feeling able to manage demands placed on them
  • Feeling unable to cope with intense distress
  • Fear that if they improve, or appear more independent, others will leave them

 

Impact on the practitioner

Service users who make excessive demands can have a substantial impact on the practitioner, often resulting in feelings of burnout. You might feel:

Frustration – each attempt to offer additional help fails to succeed, the service user holds you responsible and continues to make demands. S/he is like a sieve, you keep pouring water in, but it always empties out.

Deceived – you go the extra mile, worry about the service user over the weekend, you sort out services, only for the service user to reject your efforts, or to have enlisted the help of others.

Burnout – you are exhausted and no longer able to think about the service user’s needs. The lack of gratitude has finally got to you. You begin to feel unsympathetic about their concerns, believing that this is manipulative behaviour

In other difficult behaviour guides we have referred to the two R’s – rescue and reject – and to the two C’s – control and capitulate – which are common responses to difficult behaviour (further information on Control and Capitulation can be found under the managing suspiciousness and paranoia).

 

The practitioner’s stance   – do’s and don’ts

DO DON’T
Offer opportunities for the service user to leave texts or phone
messages if highly anxious
Respond to the phone
messages or texts outside of sessions except in exceptional circumstances
Explore the problem with the service user sooner rather than later Pretend it’s not happening
Set limits, be clear about what you can and can’t do Pretend you might be
able to help when it is clear you can’t
Give the service user a 5 minute warning about the end of the session Try to control the session by shutting it
down.
Get support from your colleagues, share the load Take it all on yourself,
and offer countless suggestions that you will have to coordinate
Acknowledge the frustrations and the service user’s feelings of being
‘hard done by’
Become more strict and
inflexible/judgemental in your approach to the service user
When entitlement flares up, this is a clue about hot topics for the
service user, and something to come back to.
Take their response
personally, even if it feels like that.
Expect that service users will be dismissive or complaining about you Attempt to defend your position, or ‘fight
back’ until you know them very well.
Aim for agreeableness but firmness, as the first step to build rapport. Disagree or highlight
the service user’s short fallings.
Consider offering slightly more frequent but shorter contact sessions
to distressed service users
Succumb to the impulse to offer more time
than the appointment was scheduled for.

 

Managing excessive demands

There are three steps to managing excessive demands, set out in the Figure below.

managing-aggressive-demands

Identify the service user’s history of excessive demands and the current pattern. Link up with the other practitioners and services involved in the service user’s care, so as to get a clear picture.

Analyse, preferably in collaboration with the service user, the triggers to the demanding behaviour. These can include:

  • thoughts (no one is helping me, the help I am getting isn’t working, I am owed something by society)
  • feelings (anxiety, panic, anger)
  • behaviour (multiple phone calls, complaints, requesting a change of worker)
  • relationships (a tendency to be rather bullying/dominating in relationships with staff, getting staff to ‘mother’ them)

Like other problem behaviours, a time line of events can be a helpful way to break down a problem. This is particularly the case with emotionally driven demanding behaviour because the time line might offer some clues for a management plan. Some triggers might have occurred years previously, but might have happened earlier in the day or a few days beforehand.

The time line below provides an opportunity to add in the consequences to the demanding behaviour. That is, the behaviour has a function or a meaning, and the consequences – like obtaining attention – are a clue to the underlying need in the service user.

 

Timeline

aggression-timeline

 

Intervene – the contract

Now you have a clearer idea of the problem, and the likely triggers, you need to work to develop a plan. For those service users who are emotionally driven in their demands, it will be best to try and develop a contract about needs and demands – rather like a sentence plan for probation officers, or a care plan for mental health practitioners but with a focus on the behaviour. See Managing Self Harm for tips about developing a crisis plan, which may also be relevant.

For those who are not emotionally engaged with the practitioner or services, but behaving in a demanding fashion, you may want to think about a plan or contract which is shared with other staff but may or may not be useful in working directly with the service user. Please download our example contract sheet if you are interested.

The best plans include a brief description of the problem and analysis of why it occurs, and state the aim of the plan. Your aim might be, for example:

  1. To increase the planned contacts with the service and decrease the unplanned contacts
  2. To achieve a better balance within the sessions between what the offender expects and what you need to address

Set limits- be honest – be honest about what you are able to do and not do. State the length and frequency of sessions, what kind of contact can be made between sessions, and what you will do with that ‘in-between’ communication.

Be consistent – but not rigid! Generally, sticking to the rules works.

Develop and review the contract – This is an agreement about what can and cannot be done. This outlines the work you will do in your key work sessions or supervision. Set a time period in which the contract will be reviewed. You may wish to change the nature of the work you do if you are able to reduce problems around excessive demands.

Achieve a balance – a contract should contain a reasonable balance between your goals and those of the service user.

Phrase the contract positively – express expectations and the boundaries in a positive fashion. There is evidence for this working better. For example, ‘I will meet with you every week for 40 minutes’ works better than focusing on the negative – ‘do not turn up at the office unless you have an appointment’.

Reward appropriate behaviour regularly – do not spread contact out too much, but try to make sure that the service user receives regular positive feedback whenever s/he manages to stick to the rules.

Address underlying reasons – Interventions should focus on understanding the underlying reason for the excessive demand. Focus on the interventions that will reduce the distress.

Limit practical interventions – Try to limit the number of practical interventions. Focus on the priority issue.

Consider additional services carefully – cut back the input from other services, particularly when the picture is rather chaotic.

Communicate regularly with all others involved – including your own team members. A professionals meeting provides an opportunity to explore and understand the demands more effectively.