Daan Hulsmans

146 Chapter 6 possibly due to prospect of this exhilarating moment, marked the start of a new phase with few challenging behaviors. However, the relation between transitions, instability and extraordinary events was not entirely clear-cut, as two desirable transition-points (day 147 and 286) occurred during stable periods and without any notable events. Figure 5 further shows that extraordinary events occurred during stability, but without a transition (e.g., starting her tattoo on day 350). Even an extraordinary event in combination with instability was no guarantee for a transition (e.g., on day 367 a fight in the family occurred during a highly unstable week without a transition). In summary, although instability seemed to increase the chance of transitions – especially in combination with an extraordinary event – our findings do not imply that instability and extraordinary events are incontrovertible warning signals that always explain meaningful change on the participant’s 560-day timeline. 4. Discussion and conclusions The current study provides a unique exploration of day-by-day aggressive and self-injurious patterns in one woman with a a mild intellectual disability and borderline personality disorder. Applying a three-step-approach inspired by complex systems theory, we aimed for an in-depth understanding of her challenging behaviors over the course of 560 days. Summarizing her daily life was the first step, revealing that a large set of internal and environmental factors relevant to her daily life. The clinician narrowed this large set down to 11 staff hypothesized risk- and protective factors: freedom restrictive measures, reliving trauma, hallucinating, experiencing pain, sickness, negative affect, familial tensions, positive interactions, receiving medical care, compliments or psychological therapy. Overall, freedom restricting measures were more likely to occur on the same day as challenging behaviors, which is not surprising. It is striking, however, that self-injury and/or aggression were more likely to occur the day after a coercive measure by staff, indicating that although these measures may be effective to suppress certain behaviors in the moment, they have detrimental effects on the longer run (Deveau & McGill, 2016; van Dorp et al., 2021). Furthermore, we found that on the day after a psychological therapy session (dialectical behavior therapy or psychomotor therapy) she was less likely to self-injure. These results imply that downscaling of freedom restricting measures and upscaling of psychological therapy (where possible) is warranted. All other bivariate associations between hypothesized risk- and protective factors with both challenging behaviors – explored phase-by-phase and day-by-day – were non-significant, indicating that challenging behaviors are not governed by

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