LEARNING DISABILITY PRACTICE April 2009 | Volume 12 | Number 3
Feature
27
goal, given his unpredictable behaviour. the hospital
liaison nurse, Michele, had already worked hard
to prepare the day surgery team and had devised
a comprehensive risk assessment and care plan.
Michele's work had used a tried and tested care
pathway for dental treatment. the only problem
was that tom was refusing to engage with us. Other
patients had looked at pictorial information and had
visited the hospital ward before admission to allay
their fears. We were all acutely aware that as time
was passing tom's behaviour was steadily becoming
more violent. How could we prepare him for the
extractions if he refused to engage with us?
As a team we could not agree on how to support
tom, but after several months, the answer came to
us. We had become too `problem-focused', rather
than person and solution-focused, so we needed a
paradigm shift. O'Hanlon (1999) states that being
solution-focused encourages people to stop
over-analysing the nature of the problem and to
focus on finding solutions and actions to attain
desired goals. this does not mean that the problem
is ignored, but the focus remains on present and
future actions to realise client goals (de shazer
et al 2007).
this new perspective enabled us to see that tom
had provided us with the solution; in that he knew
what was best for him. He knew that his rotten
teeth were causing him pain and needed extracting.
He had indicated that talking about the procedures
involved would cause him too much anxiety and
might provoke a violent response from him. from
tom's point of view he was protecting himself
against anxiety by refusing to engage with us over
the details of having his teeth out. this is not an
uncommon response in people who have a fear of
hospitals and medical/surgical procedures.
Solution-focused approach
One of the basic principles of solution-focused work
is that the client knows best, even if we do not fully
understand or agree with the course of action to
be taken (de shazer et al 2007). solution-focused
work identifies what clients want � their goals � and
matches those goals to existing and developing skills
and resources (Macdonald 2007). tom knew his goal
and trusted us to guide him through the process
of having his teeth extracted. We also had at our
disposal an expert and innovative clinical team being
advised by Michele.
solution-focused work lets the client take the
lead, although the practitioner may `tap on a
person's shoulder' to point out possible alternative
actions or avenues to explore (de shazer et al
2007). tom trusted me sufficiently to listen to the
suggestions and choices i gave him. His motivation
to have his teeth extracted was a positive incentive
and made us both take risks to achieve the desired
outcome. Within this paradigm the therapist does
not make interpretations or take an authoritarian or
directive stance; nor does he or she challenge, cajole
or push the client. the relationship is one of `expert
to expert', and a core belief is that most people will
have or develop the skill, wisdom and experience to
effect the desired change (de shazer et al 2007).
the day before tom's visit to day surgery the
practitioners involved in his care discussed how we
were going to manage the risks. the dominant risk
was tom's challenging behaviour. With Michele's help
we were able to give clinical staff instructions on what
to do if tom became `challenging'. Using examples,
we reminded staff how to approach and talk to
tom � for example, use his name first and gain his
attention before speaking; use simple sentences; allow
tom time to assimilate what is being said to him; be
relaxed, yet assertive; and treat him with dignity and
respect at all times. the anaesthetist was advised to
introduce himself and then keep communication to a
minimum, given tom's fear of needles.
Day of surgery
On the day of tom's admission we arrived in the
pre-allocated parking bay to be greeted by the
nurse assigned to his care. the team had decided
that, given the possibility of verbal and physical
In the case study, the
patient, who could become
aggressive when anxious,
was helped to manage his
fear of the surgery and
eventually had a positive
experience
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