Acknowledging caregivers' vulnerability in the managment of challenging behaviours to reduce control measures in psychiatry

Background: The management of challenging behaviours in inpatient with intellectual disability and/or autism spectrum disorders can lead to an escalation of control measures. In these complex situations where patients have an intellectual disability/autism spectrum disorder accompanied by a psychiatric comorbidity, the experiences of caregivers related to the crisis management have rarely been studied.

Purpose: This study examined the moral experiences of caregivers related to challenging behaviours' management and alternatives to control measures.

Research design: Using Charles Taylor's hermeneutic framework, a 2-month focused ethnography with a participatory approach was used.

Participants and research context: Sixteen caregivers were interviewed in a Canadian mental health setting for adults with intellectual disability/autism spectrum disorder and psychiatric comorbidity.

Ethical considerations: The research was conducted in compliance with the Declaration of Helsinki and local Research Ethics Board approval. Written informed consent was collected systematically from participants.

Findings: By accounting for caregivers' moral experiences, this study sheds light on a neglected dimension of the care relationship: the vulnerability of the caregiver. We highlight the main barriers and facilitators to alternatives to control measures. First, a caregiver's vulnerability was characterised by the overall impact of challenging behaviours and the moral distress associated with the use of control measures and exclusion mechanisms of intellectual disability/autism spectrum disorder patients. Second, a strong ambiguity between care and control measures and a lack of inclusive approaches were identified as the two main barriers to challenging behaviour management. Third, the involvement, both professional and personal, of caregivers was deemed necessary to implement alternatives to control measures.

Discussion: A conflict of values opposes two conceptions of autonomy: a rational autonomy, which is counterproductive to the reduction of control measures, versus a relational autonomy based on shared vulnerability.

Conclusion: The recognition of caregiver's vulnerability is a benchmark to create alternative approaches, which defuse the logic of control and promote an ethics of care within which caregivers' self-concern can be understood as fostering mutual respect.