Academy of Consultation-Liaison Psychiatry How To Guide: Behavioral Plans
Anne Felde M.D., Residency Education Subcommittee
Vers. 04/15/2022
How to Create a Behavioral Plan in a Medical Setting
Conflict of Interest: The author had no conflict of interest to disclose
Learning Objectives:
1) Identify clinical situations in which behavioral plans are beneficial.
2) Identify drivers of patient behaviors in medical settings that disrupt care and behavioral
strategies to minimize these drivers.
3) Identify common behaviors in medical settings that occur with patients with personality
disorders and strategies for managing through behavioral plans.
4) List the necessary steps to develop and implement a behavioral plan.
Step 1: Recognize clinical situations in which a behavioral plan may be useful
• Agitated, aggressive, or verbally abusive patients.
• Family or visitors who interfere with patient care, are threatening, or excessively
demanding of staff.
• Patients who are excessively dependent and make frequent, often non-urgent, requests of
staff
• Patients who are willfully noncompliant with care (e.g., eloping from the medical unit)
• Patients with inappropriate boundaries with staff (e.g., sexual behaviors or comments,
splitting).
• Surreptitious behaviors such as substance use, self-harming behaviors, or manipulation of
medical equipment or wound dressings.
• Patients demonstrating problems in relating to the primary team or cooperating with care,
creating conflicts that arise out of disordered personality.
Step 2: Examine the problematic behaviors and identify the causes and functions (benefits
to the patient) of these behaviors in the medical setting
• Gather data. Interview the patient, staff, and family when appropriate and review the
medical record. Outpatient mental health providers and caregivers can provide important
context. Nursing staff may have observations about behaviors that are not documented in
the medical record. Information about behaviors should include:
o Timing, frequency, duration, and triggers of unwanted behaviors
o Interpersonal factors (e.g., particular staff who may be involved)
o Consequences to patient care or to staff of unwanted behaviors
o Descriptions of altered sensorium or cognitive problems witnessed
o Results of objective measures or screening tools that might be used to assess
cognition or behavior, such as substance withdrawal screening tools, CAM-ICU,
Agitated Behavior Scale, or Overt Behavior Scale
o Staff response to unwanted behaviors
• Consider the function for the patient (or family) of engaging in the disruptive behavior,
whether conscious or unconscious. Potential functions include:
Academy of Consultation-Liaison Psychiatry How To Guide: Behavioral Plans
Anne Felde M.D., Residency Education Subcommittee
Vers. 04/15/2022
o Attention-seeking
o Improve social connection.
o Increase stimulation in a boring environment or decrease stimulation in a
confusing environment.
o Calming (to reduce anxiety and arousal).
o Escape or avoid an interaction they don’t like.
o Autonomy or power struggle (to assert themselves when feeling powerless,
helpless, scared, confused, or belittled).
• Investigate possible contributors to the unwanted behavior:
o Patient factors:
▪ Cognitive impairment
▪ Psychiatric disorder
▪ Physical distress (discomfort or pain, exhaustion, hunger, constipation, etc.)
▪ Fear about medical condition and/or impact on wellbeing
▪ Adaptation to patient role
o Staff behaviors or characteristics that trigger or reinforce behaviors:
• Demographic characteristics (gender, race, ethnicity) to which patient
responds negatively.
• Frustration or irritation demonstrated with roughness in demeanor, voice, or
handling of patient.
• Use of medical jargon or speaking too quickly for patient to understand.
• Medical staff team surround the bedside, making patient feel overwhelmed or
confused.
o Environmental factors:
▪ Frequent turnover of team members or poor communication between team
members leading to poor knowledge of patient care
▪ Noise and stimulation of care setting
▪ Lack of privacy
▪ Rigidity of expectations for patient activities in care environment and limits
on behavioral freedoms.
Step 3: Evaluate for maladaptive personality traits or personality disorder disrupting care
• Care settings can be destabilizing since they require patients to cooperate with many
different care providers and adapt to the patient role even while experiencing physical
and emotional discomfort. Patients with personality disorders are likely to tolerate these
expectations poorly and this often leads to conflict.
• Personality disorders are divided into 3 clusters. Patients in each cluster show common
behavior patterns in medical settings. See Table 1 for examples of behaviors and
proposed staff responses.
• Check the medical and nursing staff’s emotional response to competence with caring for
a patient with a personality disorder
Academy of Consultation-Liaison Psychiatry How To Guide: Behavioral Plans
Anne Felde M.D., Residency Education Subcommittee
Vers. 04/15/2022
o Help the staff recognize that the behaviors are related to a personality disorder,
which is a psychiatric illness, and part of the patient’s longstanding defensive
strategy for managing a chaotic or frightening internal emotional state.
o Emotional responses may differ between staff and can include overinvolvement,
withdrawal, hostility, or anger.
o Validate team’s emotional responses and offer support without encouraging
acting on countertransference feelings. Recognize that such patients can be
deliberately provocative and that they expect to elicit a defensive response from
others. An empathic response from staff can de-escalate these patient behaviors.
Step 4: Identify strategies to intervene with the patient, staff, or environment to modify
drivers of problematic behaviors
• Develop interventions that specifically address the underlying driver or function of the
behavior. See Table 2 for details.
• Interventions should be:
o Practical: can be implemented by staff without requiring a high degree of
psychological sophistication and within the limitations of the environment and
staffing levels.
o Ethical: see https://www.practicalbioethics.org/files/guidelines/15-Difficult-
Relationshipsweb-2008.pdf for ethical guidance in interactions with patients who
have difficult behaviors in medical settings.
o Time-limited: expected to produce results within the time frame of the patient’s
need for care.
• The medical team, nursing staff and management should contribute to the behavioral plan.
Input from the patient may be solicited when they can recognize and reflect on the problem
behaviors, can offer input into drivers, and can accept help in modifying behaviors without
relying entirely on externalization. Outpatient and other staff affected by the problem
behaviors or familiar with the patient may also be solicited.
Table 1. Behavioral interventions and responses to patients with personality disorders
Personality
disorder
cluster
Types of behavior
Advised Staff Response
Psychiatric Consultant Role
Paranoid,
Schizoid, and
Schizotypal
Paranoid concerns,
mistrust of medical
team’s intentions,
refusal to accept
proposed
treatments.
Ignore behaviors that don’t interfere
with care.
Evaluate for capacity if there
are concerns about decision-
making.
Caring and concern best expressed by
conveying recommendations and
medical information supporting
treatment, rather than with an overly
warm or emotional style.
Overtly express respect for patient’s
autonomy, seek patient’s input in
problem solving.
Antisocial,
Borderline,
Histrionic,
Insulting staff,
splitting staff,
overreactions when
disagreements or
Reinforce desired behaviors and ignore
some negative ones.
Check team’s emotional
response. Help manage
countertransference and limit
acting on negative emotions.
If patient is threatening or insulting,
label the behavior (not the person) and
Academy of Consultation-Liaison Psychiatry How To Guide: Behavioral Plans
Anne Felde M.D., Residency Education Subcommittee
Vers. 04/15/2022
and
Narcissistic
limits set, refusal to
work with some
staff, help-rejecting
behaviors.
ask patient to stop. Thank patient and
offer to help if behavior is changed.
Offer support to team members.
Model neutral affect in
communication style and
empathic listening. Consider
which boundaries and rules are
primary and which can be
flexed. Help patient with skill
building.
Withdraw social contact if patient
escalates, specifying when staff
member will return. Re-engage when
patient is calm.
Avoidant,
Dependent, or
Obsessive-
Compulsive
Constant requests
for interactions and
help. Anxious
about their medical
condition but help-
rejecting.
Arrange regular, frequent schedule for
brief staff interaction that is not
dependent on patient asking for it.
Encourage patient to bundle their
requests. Increase social interaction
across nursing shifts.
Identify and treat co-occurring
anxiety symptoms. Help
patient identify coping
strategies for managing
uncertainty and fears.
Obsessive requests
for information and
clarification or
correction of minor
details. Focused on
details.
Set limits on number of requests for
interactions but identify planned daily
time when requests can be discussed.
Specify how much time will be spent
during interaction.
Can serve as liaison to team to
collect requests for information
or clarify medical information
to patient.
Table 2. Behavioral interventions to address problem behaviors
Driver of behavior
Sample interventions
Attention-seeking
Brief removal of patient from environment when behavior is exhibited.
Ignore unwanted behavior to withdraw reinforcement (negative attention).
Reinforce desired behavior with small rewards and attention.
Caregiver leaves briefly in response to abusive behavior to diminish reinforcement,
announces they will return in a few minutes when they expect patient to change the
abusive behavior. Provide specific example of behavior they expect to see.
Help patient identify alternative words to use that are socially appropriate
Stimulation or
anxiety
Address boredom, provide alternative activities, provide comforting objects to hold,
listen to music
Provide behavioral substitutes that are less disruptive (e.g., objects that can be rubbed or
touched, headphones for music) or settings that are more appropriate (e.g., for
masturbation, ensure a private location if possible).
Provide regular physical exercise.
Provide safety barriers or environmental changes to minimize risk to patients who
wander.
Escape or avoidance
Caregiver pauses the interaction patient is avoiding, but states that they will return in a
certain time to continue.
Distract agitated patient with pleasant reminders to allow resistance to pass before
reattempting.
Autonomy or power
struggle
Offer patient choices when feasible to complete the resisted activity (e.g., “Would you
like to have the dressing changed before lunch, or after lunch today?”)
Break up resisted tasks into smaller ones.
Confusion
Modify environment to decrease disorientation (labeling places, objects, patient’s room,
provider calendar, etc.)
Improve day-night cycling. Reset body clock, set bedtime at sundown, out of bed during
the day.
Academy of Consultation-Liaison Psychiatry How To Guide: Behavioral Plans
Anne Felde M.D., Residency Education Subcommittee
Vers. 04/15/2022
Step 5: Communicate and disseminate a behavioral plan
• Choose your audience and means of dissemination.
o A written behavioral plan in the medical record may be appropriate to ensure that
the plan is distributed to all pertinent staff and is implemented consistently.
o Verbally communicated behavioral plans are appropriate when the plan’s goal is
to manage staff emotional reactions when a written plan would potentially
stigmatize the patient.
o A written behavioral plan could be limited to recommended staff responses for
specific behaviors that do not carry an implied stigma; e.g., requests by patient to
go outside or a script for staff to use in response to patient using abusive language.
• A written behavioral plan should include the following elements:
o Description of behaviors that are causing problems, with pertinent descriptive
details (contributing circumstances, timing of events, etc. that may provide
context for implementation of behavioral plan).
o Brief discussion of factors felt to contribute to behaviors (if appropriate) to
provide rationale for behavioral interventions.
o Delineation of any rules or expectations of patient that staff feel patient is capable
of abiding by or understanding.
o Outline of recommended staff response options to various patient behaviors that
are disruptive or maladaptive.
o Expected patient behavioral goals after implementation. Include outcome
measures if possible.
o Plan for evaluation and modification of behavioral plan, with time frames set to
evaluate success of plan and anticipated behavioral changes.
o Discussion of the elements of the behavioral plan that are communicated to the
patient (if any) and who communicates this to patient.
Step 6: Evaluate the effectiveness of the behavioral intervention and modify the
intervention as needed
• Set a timeline for re-evaluating the intervention. Some unwanted behaviors may initially
increase after implementing behavior plan, but with time and consistency it will have
desired effect.
• Develop a plan to address barriers to implementation or modify behavioral plan to
accommodate barriers which cannot be changed.
• Set reasonable expectations about timelines for behavioral change in patients and
evaluate when expectations for patient behaviors may be unrealistic, e.g., patient’s
cognitive impairment may be more significant than presumed.
Academy of Consultation-Liaison Psychiatry How To Guide: Behavioral Plans
Anne Felde M.D., Residency Education Subcommittee
Vers. 04/15/2022
References:
1) Riddle M, Meeks T, Alvarez C, Dubovsky A. When personality is the problem:
Managing patients with difficult personalities on the acute care unit. J Hosp Med
2016 Dec;11(12):873-78. doi: 10.1002/jhm.2643. Epub 2016 Sep 9.
2) McConnell ES, Karel MJ. Improving management of behavioral and psychological
symptoms of dementia in acute care: Evidence and lessons learned from across the
care spectrum. Nurs Adm Q. Jul-Sep 2016;40(3):244-54. doi:
10.1097/NAQ.0000000000000167.
3) Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S,
Bernard GR, Inouye SK. Evaluation of delirium in critically ill patients: validation of
the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care
Med. Jul 2001;29(7):1370-9. doi: 10.1097/00003246-200107000-00012.
4) Kelly G. The Overt Behavior Scale. The Center for Outcome Measurement in Brain
Injury 2010. http://www.tbims.org/combi/obs/OBS%20%202008.pdf
5) Bogner J. The Agitated Behavior Scale. The Center for Outcome Measurement in
Brain Injury 2000. http://www.tbims.org/combi/abs/abs.pdf
6) LaBuda J, Axelrod BN, Windell J. Cognitive Behavioral Protocols for Medical
Settings: A Clinician’s Guide. England, UK: Routledge; 2018.
7) Center for Practical Bioethics (2000). Guidelines for providing ethical care in difficult
provider-patient relationships. https://www.practicalbioethics.org/files/guidelines/15-
Difficult-Relationshipsweb-2008.pdf.
