Training Systems and
Psychological Services
​

Chief Operating Officer of LivesthroughFriends Rob Fountain and our new COO here at Studio 3, Claire Fennell, discuss the merits of having a COO to implement changes and allow ambitious ideas to become reality. LivesthroughFriends is a Community Interest Company (CIC), and in effect a social enterprise. As well as operating as a business providing commissioned advice and support to public bodies, we also have a driving social purpose: for people with disabilities, autism and mental health challenges to get to live their best life. We know from experience that current systems fail in this and let people down badly. We are vocal in calling this out and are champions for doing things differently in order to achieve much better outcomes. This social mission drives everything we do, maintaining an ambition to change the world for the better. Our Directors are a collective who bring insights and experience from a range of disciplines. They are united by the determination to fulfill our social mission. They each get involved in different pieces of work that are aimed at achieving our goals. Our shared vision and values unite us and guide what we do (as well as what we don’t/won’t do). It is, though, also vital that we organise and operate in a robust way. Good intentions only get you so far. We are delivering complex work, across the UK and internationally. We therefore need to make sure all the elements of work we are involved in are coordinated, our resources are deployed in the right places, and that we fulfill our promises. That’s when having a COO – or Chief Operating Officer – can help. Rob Fountain joined LtF as Chief Operating Officer in May 2022, LivesthroughFriends’ first employee. He leaves the organisation this year after 2 years of supporting the Directors in ensuring we are delivering on our ambitions. Day-to-day, that has involved some less revolutionary aspects – preparing proposals, assigning associates, reporting on progress. It has also been a hands-on role, working directly with individuals and their families to deliver bespoke planning or delivering training to providers on working towards a good life. Rob’s experience in social work, higher education, public sector consultancy and running charities was useful. He also reconnected with Bob Rhodes having met him initially back in 2003 whilst working for an advocacy organisation. Appointing a COO to oversee the running of our organisation has freed Bob (as the founder and President of LivesthroughFriends) up to focus on agitating and influencing for system change. After a period of growth and looking to the future, Studio 3 have also recently appointed a COO themselves to help drive the organisation forward. In October 2023, Claire Fennell joined Studio 3 as Chief Operating Officer to take over day-to-day operational management from their founding CEO, Professor Andy McDonnell, enabling Andy to give 100% focus and leadership on the development and promotion of non-restrictive practices and Low Arousal Approaches. Like Rob’s role at LtF, Claire will be ensuring that the clinical and training work undertaken across Studio 3 delivers on the vision and ethos of the company. With over 40 employees working across the UK and internationally, Claire’s day-to-day is primarily concerned with the coordination of operational and business support processes and functions, including finance and administration, so that the amazing teams at Studio 3 can get on with the skilled and important work they do. Claire brings a range of experiences from social care, rights-based charity and public sector services with children, adults and families, from early years onwards, including specialisms in autism, disability, looked after children’s advocacy. Claire is excited to get stuck in and work collaboratively with colleagues at Studio 3 and LivesthroughFriends this year! Written by Rob Fountain, COO of LivesthroughFriends and Claire Fennell, COO of Studio 3 To get in touch with Studio 3, contact us at 01225 334 111 or drop us an email at info@studio3.org.

This article is based on a real-life example of the ways in which the LivesthroughFriends team has worked alongside an independent commissioner to support an individual transitioning from a hospital setting to community-based supports. Some names and places have been changed to protect privacy. Liz Leach Murphy is a Director of LivesthroughFriends who has worked closely with commisioners and other professionals in her work transforming care and supporting individuals with complex needs. In conversation with one commissioner that she has worked closely with over the last 2 years, Liz reflects on some of the obstacles and challenges they have faced together. Liz and the commissioner John’s collaborative work is focused on supporting people to be discharged from institutional settings when they are either deemed ready for discharge, or where it is recognised that they are no longer receiving therapeutic input from the setting. Their work together proves to be valuable when working with people who have been given complex reputations or have found themselves in complex situations. Liz was keen to hear John’s perspective on the difference it makes when the LivesthroughFriends framework is brought into practice. For those readers who are not familiar with our framework, here it is: The Person Ask HOW you want to live? What’s the best we can envisage? Address behavioural issues from a very skilled Low Arousal perspective, focused upon supporting participation, inclusion and relationship building Everyone is different – bespoke works; the service ‘menu’ usually doesn’t The Economy and Social Capital Start with the ‘core economy’ - Supplement & Complement Organise and systematise to serve these aspirations Remember, it’s not (only) about the money! Attend to that where it adds value Strengthen/build reciprocal relationships and social capital for and with the person Contribute to, receive from, and build ‘community’ You BE TENACIOUS – there’s rarely a compromise that works! Show another way – It’s about LEADERSHIP Creativity Promote Effective and Creative Thinking, Possibilities & Problem-Solving It’s a Journey – not an episode John shared his appreciation of what LivesthroughFriends offers in terms of an approach that makes a difference, as well as expertise in autism and learning disability. This also included the invested time that the LivesthroughFriends team can give to the work, and their level of energy and passion in actively applying the principles set out in the framework. This is a stark comparison to the position of Care Coordinators, Social Workers and Mental Health nurses, who are often understaffed and therefore do not have the time to commit to ‘complex patients’ and situations. John spoke about how recognising how well-meaning colleagues with great intentions were offering to take on the input that LtF provide, however the colleagues do not have the same level of skill, experience and expertise in terms of autism, learning disability and mental health. Alongside this, it is impossible for colleagues to provide a cohesive approach that oversees the whole journey from planning for discharge to being back in the community simply due to the sheer number of people they are expected to work with, and their focus having to be on meeting statutory requirements. During the first engagement, LtF was first involved in working with two people who had exhausted the system approaches, and a dead end had been reached. LtF’s involvement changed the content of the conversation, getting right alongside the people, spending time with them, getting to know them, hearing what mattered to them and then steering the rest of the conversations, meetings and decision-making around this. One person in particular who had a multitude of labels and had challenged the system and those within it significantly seemed destined to be moved to a step-down specialised and secure placement, despite the fact they had made it clear that they just wanted to go home. LtF threw in a different position ‘of course we can get them home,’ and this became the focus of all conversations moving forward: within 9 months this person was home, with good support in place and a much better quality of life. John talked about the strength that has been brought from drawing on the networks the team working at LtF have developed over their years of practice, connecting with providers who bring an approach that would work well for the person, working one person at a time. This means completely circumnavigating the usual ‘approved providers’ tendering processes. The networks established at LtF also include specialised organisations, such as Studio 3, who bring expertise in Low Arousal Approaches, sensory assessments, transition plans and 360° plans. At present, current tendering processes lead to the work being granted to the lowest bidder, with some instances of the tender specification and framework being adapted to be able to select a predetermined chosen provider. It is not uncommon in these instances for the chosen provider to later approach the commissioning team to request further funding as ‘the person is more challenging to support than originally anticipated’ – leading to a provider with an ill-informed approach costing much more money. This is why LtF ensure that the support that is designed around the person is based on what the person wants and what would work best for them, leading to better lives and less costs in the long term. This involves bringing provider organisations into the arrangement based on solid recommendations, track record, and established relationships, not forgetting the values and principles the provider organisation functions from. This starts with how they recruit the team around the person, involving the person from the start, and how they embed a culture that values and protects the team. John stated that the difference between approaching this work with the input from LtF, compared to approaching the work without this input, as ‘night and day.’ This, not only in the sense of the difference it makes in how the person is supported to reach the life they want to lead in the community, but also in the experience of being involved in the work, bringing positivity and maintaining the focus on the person. It can be easy to otherwise get sidetracked by some of the systems and processes that simply get in the way. As a byproduct of following the LtF framework, the commissioners recognised that from a costing perspective, this approach and way of working made a lot of sense too. In some instances, the budget for ongoing support at home can end up being a quarter of the original health and social care spend. In addition, after reflecting on some of the MDT meetings that took place at the time, we collectively realised how the language used to refer to the person did not come from the value base we hope to see in this work. Consider how bad the person’s family would feel if they heard their family member and loved one talked about in that way? Through the work we did together, alongside the involvement of the ongoing support provider, we were able to influence this and change the culture, focus, and language within the meetings. The key to this is compassion; treating people respectfully, with the perspective that they can have a positive life ahead of them. This, alongside focusing on what is possible based on what the person wishes to achieve and how they want to live their life, rather than treating them as a recipient of set services and approaches. When talking about an individual Liz and John had worked with together, who has been within institutional settings for decades of his life, John laughed and said, ‘I did not expect after only being back in the community for less than two years that they would be being invited by members of the local community to join a social group.’ This demonstrates that relationships matter, and being in the community - present and valued - is what makes a difference, whilst also being supported by a sensitive and committed team of people. LtF brings this perspective to all areas in order to influence practice, starting with what matters; relationships, love, and a place to call home. This outlook is embedded in the LtF training and mentoring, which is provided to the teams supporting people who are re-establishing their life in community. John then went onto share the first time he visited an individual once they had moved out of hospital and into their own home - not a step down or specialised placement, a home on a street with a park, neighbours and great views. He reflected on how he had subconsciously expected the person to be sat around as he had been in hospital whilst their support did everything during the visit, including making the drinks. However, this was not the case. John was greeted by the person at the door, invited in and asked if they would like a drink. The person then proceeded to go to the kitchen and make drinks for everyone. Here he witnessed the power of standing back and letting people get on with their lives. This does not mean to say the person is ‘fighting fit’; everyone recognises that this person experiences daily mental challenges, but with thoughtful, positive and sensitive support he is able to get on with his life with a good future to look forward to. Within the conversation, John also recognised how the independence that associates and directors of LtF have is fundamental in building relationships with the person and their family. Where there has been significant failings in the past, this relationship is doubly important.  To be able to bring in a different perspective and ask the challenging questions within ward rounds and MDT meetings is essential. It starts with encouraging everyone involved to function from the perspective of the person first. On the other hand, when professionals work within a multiagency setting, there could be a temptation not to challenge so as not tarnish or derail working relationships, especially in highly volatile and complex situations. John summarised the conversation by stating, ‘We didn’t know what we didn't have until LtF got involved.’ Written by Liz Leach Murphy LivesthroughFriends Director To speak with a member of the LivesthroughFriends team about how they can work with you or an individual you support, visit www.livesthroughfriends.org.

Rob Fountain from LivesthroughFriends discusses their approach to finding imaginative solutions to supporting individuals in the community, and redefining complex care. LivesthroughFriends is a Community Interest Company (CIC) and not-for-profit social enterprise that helps people with complex reputations live better lives. We do this by developing bespoke support arrangements that are tailored to the individual’s needs and goals. In every local area there are individuals who expose the limitations of the placement model. These people have acquired complex reputations, and have often experienced multiple placement breakdowns with providers feeling they cannot meet the needs presented. These people often get stuck in institutional settings, without hope and with an ever-increasing ratio of staff put around them to control distressed behaviours. The outcome is a high-cost situation delivering a deeply unsatisfying life for the person. However, there is another way. We have learned from hard won experience how to transform these scenarios to provide good lives for institutionalised and traumatised people, often at lower cost to the public purse. Our experience-informed approach Start with Good Life Planning (rather than needs assessments) Build support around the person (don’t try and fit complexity into a placement) Anticipate turbulence and plan for it (don’t just cross your fingers and hope) We have learnt that it is essential to start with the person and the life they want to live, rather than focusing on their needs. This means that we look beyond containment to create a life of purpose, relationships, and contribution. Once a Good Life Plan has been created, we help to make it happen by finding suitable housing and identifying the best support provider. We also devise detailed transition plans and project manage the set up and preparations for the new arrangement. Does bespoke mean more expensive? Not at all.  Building a home and support team around the person, informed by a clinical picture of how to reduce the triggers of challenging behaviour, and proactively building a wider community network around someone, makes it possible to aim for reductions in the paid-for input over time. Not only does our approach improve lives, it can also offer a far more cost-effective way of doing so. How can we help? The LivesthroughFriends team are located throughout the UK and work ‘hands-on’ wherever we are engaged.  We have current work in England, Wales and Scotland. We welcome conversations with those in health and local authority roles who are feeling stuck with one or more people and would like to explore whether our approach might reveal another way. We are always happy to talk to families about pushing for a better life for their loved ones, and we are happy to be introduced to statutory bodies to explain what is possible when you apply some different thinking. To speak to a member of the LivesthroughFriends team about how they could help you or a person you care for, visit www.livesthroughfriends.org. Written by Rob Fountain COO at LivesthroughFriends

Professor Andrew McDonnell discusses Studio 3's framework for working with traumatised individuals using the Low Arousal Approach which, alongside the work of service brokerage organisation LivesthroughFriends, can enable them to live independent lives in the community. In my recent book, The Reflective Journey: A Practitioner's Guide to the Low Arousal Approach, I provide a number of anonymised examples of real-life practical work. The following case example of a young man called Adam (not his real name) gives a good understanding of how we place trauma-informed approaches at the heart of our work. The following extract tells his story: ‘The people we support may not necessarily be formally diagnosed, but they can still show a number of clear signs of trauma. Trauma can have an even greater impact on specific populations, although some of the evidence is limited. Mevissen and de Jongh (2011) point to evidence which suggests that people with intellectual disabilities are more likely to suffer from PTSD. Understanding the trauma process may sometimes involve a good understanding of a person’s life story. We can refer to people having ‘traumatic pasts’ in this context. For three years, I worked with a forty-four-year-old man named Adam who had a complex and traumatic history. This is his story: ‘Adam was supported by a staff team in a small community home. He had been labelled with a severe personality disorder, mood disorder and attachment issues. In his past, there had been several periods of hospitalisation, most of which were related to his difficulties coping on his own and a profound sense of loneliness. Adam’s current team found it difficult to emotionally cope with his ‘explosive rages’, which could be triggered by seemingly trivial things such as the post arriving with utility bills, or a reminder that a significant birthday was imminent. Adam could be arguing with you one minute and very quickly move on and appear quite calm. There were a number of past traumas which included being restrained by hospital staff and, on another occasion, being restrained by the police. Adam consistently made abuse allegations against others, often after he had been restrained. Eventually, Adam’s early life history was revealed to the team (the files had been sealed to respect his privacy). Adam had been sexually abused by a family member at age twelve. At fifteen, he was used as a child prostitute, with his Aunt acting as his agent. Adam had also witnessed extreme violence and experienced temporary homelessness on several occasions. As an adult, Adam rarely had contact from his own family and he would constantly tell people that he was lonely. Paradoxically, he also seemed to struggle to be around people for prolonged periods of time. His sleep was often disturbed. Though he never really spoke about why, he often woke up in the night, and some staff reported hearing him scream and shout “No!”’ Adam’s traumatic history was enough to explain the failure of many well-intentioned attempts to provide psychological interventions, ranging from CBT and dialectical behaviour therapy (DBT), to a number of attempts at various psychotherapies. The latter approach did have some success in terms of his own understanding of his behaviour. Adam consistently ‘burnt out’ staff teams, but things began to improve when they were given contextual and historical information about his life traumas. This helped individuals to understand his explosivity, as he was clearly experiencing what trauma victims describe as ‘flashbacks’. Sadly, Adam died of a very sudden heart attack. At the young age of forty-four, I believe that his death was caused by a combination of his difficulties in regulating his own arousal and the effects of long-term trauma.’ I have worked with many individuals with similar profiles to Adam. The people that we are often asked to asked to develop community-based supports for have often been exposed to highly institutionalised specialist care. A core part of the Low Arousal Approach to managing behaviours is to train and coach supporters to ‘see the person, not the behaviours.’ The many Studio 3 collaborations with LivesthroughFriends do involve individuals who are highly traumatised and view the world often as chaotic and frightening. Experience has taught myself and my colleagues that time, patience, compassion and empathy, and of course supports such as Low Arousal Approaches, can ultimately help to reduce the stress of the person and their supporters. Written by Professor Andrew McDonnell CEO and Clinical Psychologist at Studio 3

LivesthroughFriends Founder Bob Rhodes on the concept of 'rewilding care,' and allowing individuals to thrive in their natural communities rather than being institutionalised in hospital settings. “At Rewilding Britain, we define rewilding as the large-scale restoration of ecosystems to the point where nature is allowed to take care of itself. Rewilding seeks to reinstate natural processes and, where appropriate, missing species – allowing them to shape the landscape and the habitats within. It’s focused firmly on the future although we can learn from the past. Rewilding encourages a balance between people and the rest of nature so that we thrive together. It can provide opportunities for communities to diversify and create nature-based economies; for living systems to provide the ecological functions on which we all depend; and for people to reconnect with wild nature.” - (www.rewildingbritain.org.uk) A comparison struck me as I made my way home following the Citizen Network’s often exhilarating It’s Our Community event in Sheffield. I had spent a couple of days in the company of grassroots community organisations and peer support initiatives who exuberantly celebrated the impact that actively associating and taking personal agency had wrought in their lives. However, this was not a novelty to me – indeed I feel like I’ve witnessed that energy diminish over that past half-century. And I came away worried; not least because a significant number of the inspiring folk I had met expressed a simple faith that their example would change the system that they had not changed but rather disavowed. In workshops and conversations, myself and others had sought to get people to think about: How professionals and services – as is inevitable and ‘normal’ within a market environment where service systems need and trade upon our perceived deficiencies – promote themselves as the prime solution to our ‘needs’, accentuating our dependency, and diminishing our personal agency. The importance of nurturing both strong and resourceful citizens, families and communities, and local resources, enabling, skilled and complementary service systems. Hence, the fundamental importance of redefining the purposes and principles underpinning social services. The consequences of all-encompassing consumerism The ideological roots of the disintegrating system. In hindsight, it is clear that such discussions are not at the centre of everyday conversations in most grassroots community groups. Pinching the strapline of Compass’s bi-weekly seminars, this is too “Bloody Complicated”. Indeed, one forceful leader looked at me aghast and said, “Do you mean this is political?” As ever, people are preoccupied with getting by despite the system; rather than actively plotting revolution. John McKnight put it this way: “Consumer society begins at the moment when what was once the province or function of the family and community migrates to the marketplace… In adopting system life, people choose to yield sovereignty in exchange for the promise of predictability. Even families and communities turn over their sovereignty for the promise of a safe and predictable future.” - In The Abundant Community: Awakening the Power of Families and Neighbourhoods And he goes on to say: “Here is the rub: systems that are constructed for order cannot provide satisfaction in domains that require a unique and personal human solution. They are unable to provide the satisfaction that they promise because of their very nature.” In short, the ‘promise’ is worthless. So, on the train home, I mused upon keywords and straplines that we might use to generate conversations and facilitate conscientisation. It struck me that, no matter how overwhelming the evidence throughout decades, ‘global warming’ repeatedly failed to grab widespread attention. However, people have got behind ‘climate change’ – perhaps because we experience and to some extent understand the weather and its palpable changes. From there, it wasn’t much of a leap to think about how the public understanding of the parallel ecological disaster arising from humanity’s self- interest and ignorance has unfolded. It has not taken too long, even for the most industrialised agribusinesses, for folk to get the message that getting out of the way and permitting nature to do what it does naturally is a powerful remedial strategy. For example, Plantlife’s annual ‘No Mow May’ campaign; hedge planting; restoring wild flower meadows; natural pest control with lacewings, ladybirds, or parasitic wasps; and wild corners in our gardens are all strategies familiar to casual viewers of Countryfile or Gardeners’ World. While most may not have progressed to considering the wild reintroduction of large free-roaming ungulates such as bison or top predators such as lynx and wolves, there’s a general understanding of the good sense associated with enabling nature to ‘have agency’. For me, that rings a very loud bell. If we are to evolve a sustainable and truly caring society and effective and economic social services we - as was so clearly recognised by both Seebohm and Barclay Committees during the early years of Social Services Departments - must build upon the care that is naturally present in strong, resourceful and interdependent communities. In pursuit of this, the challenge for Government is to restore agency to citizens and to design societal systems and social services that have their primary purpose in resourcing, supporting, and where necessary supplementing the associative activities of families and communities. This, of course, cannot be a top-down activity, hence the imperative to find an ‘imagery’ that is generally understood through which inclusive, democratic change can evolve. I wonder if ‘Rewilding Care’ has resonance? When we talk to people about what really matters to them, the universal answer is loving and reciprocal relationships closely aligned with a strong sense of belonging. These attributes are not in the gift of services, but supplementary and complementary services can be designed to support families, friends and others to give their gifts. However, concurrently, there’s a job to do in both ordering society to enable citizens to invest in relationships and supporting people to reject passive consumerism and assert active citizenship. At some point, we all are likely to need care. Not to put too fine a point upon it, commissioned care institutionalises. Is that really what we want for ourselves or those we truly care about? Hilary Cottam is one of many social activists stunned by the silliness of marketised social care: “Relationships were allowed no place in the welfare state because they were thought at best not to matter and at worst to be a hindrance to social progress. But Beveridge realised he had made a mistake and now, when our human connections determine the social, emotional and economic outcomes of our lives, this omission matters more than ever. But in the intervening decades a reform process that has centred on management and control has further limited the possibility of human connection within existing systems. Today the welfare state concentrates on the efficient delivery of inputs and outcomes, trapping us in the cultures and mechanisms of transaction and limiting human connection.”― Hilary Cottam, Radical Help: How We Can Remake the Relationships Between Us and Revolutionise the Welfare State In chorus with Hilary Cottam, I would assert that, “our current systems whether financial, social, political, ecological, are actually beyond reform…” So, here’s a thought… By Rewilding Care, I define rewilding as the intentional, societal-scale nurturing of interdependence and reciprocity to the point where real agency is restored to citizens, families and communities. Rewilding seeks to reinstate the natural interdependent societal relationships that have served humanity so well over millennia as the basis for a sustainable and flourishing future. Rewilding recognises that collaborative relationships constitute the basis of care and that professionals and services (who also have useful specialist roles) are complementary and supplementary actors whose core role is to support and strengthen the agency of citizens and their various associations. Rewilding means valuing people for their gifts rather than emphasising and exploiting perceived deficiencies. Rewilding thrives on the apparent chaos of our unique lives and relationships. Rewilding Care builds upon the essence of humanity, and it works! Written by Bob Rhodes, Founder and President of LivesthroughFriends A version of this article appears on the LivesthroughFriends website, published June 2023

Founder of LivesthroughFriends, Bob Rhodes, discusses their framework for working to create bespoke care solutions in the community for people who are locked away in hospitals, and how the LivesthroughFriends team works collaboratively to get people their 'Good Lives.' When asked to explain the LivesthroughFriends ‘model,’ we usually reply that we don’t have one. In reality, we probably do. But we have learned the hard way that what we do is not ‘painting by numbers’. Over decades of not only doing, but studying; properly understanding what needs to be done – which is different for every person – and then exploring and exploiting every possibility for realising that vision without compromise; we’ve identified a way of approaching our work with individuals who are institutionalised, secluded, and excluded. We’ve gotten many things wrong as we’ve tried different approaches, but we have learnt and always taken responsibility for remedying our misjudgements. The main conclusion from this experiential learning has been that there is no single way to achieve a good life. There is no step-by-step guide, no ‘do this, then this’ playbook to follow: there is no model to spread and scale. Human lives are messy, complicated, complex and unique. Our engagement needs to be similarly fluid and flexible. However in order to be ‘loose’ there are a number of activities and principles that must be ‘tight’ and conscientiously adhered to. We look to share all this with those who commission us, such that adopting the LivesthroughFriends way of working is, in its most successful manifestation, an opportunity to acquire insight, knowledge and methods through experiencing new ways of thinking and practicing. So, while we won’t offer up a fixed model of working, we are happy to share the continually evolving list of practice and principle imperatives that provide a reference framework for our interventions. For clarity, when we use the term ‘our,’ we mean everyone with a role and influence in the life of a person – family and friends, service providers, commissioners, and MDT professionals. 1. Ask how people want to live: what’s the best we can envisage? Everything starts by getting alongside a person, those who love them, and professionals who really know them to paint a picture of the person’s best possible life; a direction of travel to which we all aspire. Fully engaging with the person to understand the particular life they want to live is grounded in the building of a trusting relationship. It is blatantly disingenuous to undertake this inquiry on the basis of a pre-ordained questionnaire. Impoverished and, in the case of the work LivesthroughFriends tackles, often traumatised experience does not provide a solid foundation for informed choices. In setting a vision for how life could be, we believe passionately that there is a need to be ambitious. Our job is to help the person to dream, imagine, and ideally experience the possibilities that might be realised which go beyond their lived experience, and to encourage those around them to be ambitious contributors to the venture. This is about starting at the opposite end to where traditional ‘needs assessments’ begin. It’s about centering all subsequent planning on creating a life worth living (not on allocating a narrow menu of services). 2. Start with the ‘core or relational economy’ – Supplement & Complement Rather than beginning with paid services, we advocate starting with the ‘core economy’ (the resources of family, neighbourhood; kith and kin) and how these can contribute to achieving the person’s good life. Engaging and bolstering this should come first as the core economy is a fundamental and ever-present part of life. The addition of paid-for services and support should then be designed to supplement and complement this – to fill the gaps that the core economy cannot provide, to fit alongside and not to replace. Too often, service inputs dominate and the core economy is ignored or stifled. This is an inevitable consequence of the commoditisation of services. Where Social Services are structured and organised to support strong and resourceful families and communities, Social Care promotes dependence, stimulates demand that it is ill-equipped to meet, and redirects valuable professional resources away from relationship-based work to administer counter-productive transactions. 3. Strengthen and build reciprocal relationships and social capital for and with the person The heart of the core economy is the engaged commitment of other people freely giving their love, care and support to fellow citizens. We all need relationships with others who can sustain us, nourish us, and allow us to fully experience being human. The fundamental hurdle faced by almost everyone we work with is the absence of naturally occurring relationships in their life – relationships that create opportunities for them to be reciprocal, contributing members of a community. Without a range of connections, a life will always be limited.  As such, we put the intentional development of relationships as a top priority in developing and implementing every plan for a Good Life, and provide opportunities for all involved to develop their knowledge and skills in this crucial area of practice. Our approach has been heavily influenced by our three-decade long relationship with PLAN – www.planinstitute.ca. This is why we are called LivesthroughFriends: because relationships are pivotal! 4. Promote Effective and Creative Thinking, Possibilities & Problem-Solving The lives of people with complex needs are rarely straightforward or easy. There will be challenges, barriers, and continual changes. For this reason, we champion the development of creative problem-solving within the support networks around a person. At the centre of problem-solving and creativity resides both a capacity for and commitment to generating a wealth of possible courses of action prior to prioritising the most promising, and a bias for reflective action. In our potential partners we look for adroitness in not just taking, but also making opportunities. The Go Make A Difference (Go MAD) approach developed by Andy Gilbert is one we find effective. Equipping supporters around vulnerable people with these skills, and encouraging them to invest time in imagining possibilities, prepares them to face these challenges with hope, resilience, and the tools to identify solutions. 5. Contribute to, receive from, and build ‘community’ A good life involves being a contributing citizen. We passionately believe that everybody has gifts – their intrinsic characteristics, strengths, abilities that enhance the world around them. Crucially, gifts have to be given. Those with complex lives are too often seen only as people with needs. When we focus on people’s gifts and how they are able to share those with the wider community, we transform lives. Our plans always consider how the person can contribute to the community they live in, as that is the path to connection, a sense of purpose and well-being. Experience tells us that inclusion and citizenship are everybody’s business. Hence, we ensure that education in strengths-based practice underpins induction and on-going training for support providers. 6. Address behavioural issues from a very skilled ‘Low Arousal’ perspective The challenging reputations that we encounter are essentially about the behaviours people exhibit. These behaviours dominate how the person is seen and energy gets directed solely on managing – or controlling – that behaviour. Often we are changing people’s perceptions of behaviour by developing a deeper understanding of a person’s life journey. We understand behaviours as being responses to how the person experiences the world. Stress, sensory overload, frustration and trauma can all trigger behaviours that lead to increases in seclusion, physical restraint, and other restrictions. Working with our clinical partners at Studio 3, we promote Low Arousal Approaches that are non-restrictive. Operating in this way with traumatised and complex individuals requires high levels of training and skilled supervision in order that practitioners gain and sustain the confidence and skills needed. Working in this way is fundamental to enabling the focus to remain on supporting participation, inclusion, and relationship building for the person. 7. Everyone is different – bespoke works; the service ‘menu’ usually doesn’t We don’t have confidence that placements and the menu of service solutions often put forward can always respond to the unique circumstances that the people we support bring. Many carry long lists of ‘placement breakdown’ as evidence that ‘off the shelf’ options do not attend to the right things. We design and implement bespoke options that are built around the person and their specific circumstances. 8. It’s a Journey – not an episode We are interested in people having a life. Some of the shifts and opportunities we can imagine for someone will take a long time to achieve. That is not a problem when you are thinking about someone’s lifetime, not just their next placement. When we implement a plan we anticipate periods of turbulence, and the need to modify and adapt plans. That is life – we need to respond accordingly; and our statutory partners need to be structured to sustain lifelong local, relationship-grounded, and professionally competent support that is focused on progressing the journey in the direction of a better life. 9. Remember, it’s not (only) about the money! Costs loiter like elephants in a room when talking about bespoke packages of support.  The question of “How much?” looms as an ultimate arbiter. We never start with the money; we start with what is needed – remembering that we’re looking for funded services to be supplementary and complementary. The focus should always be on value, not cost.  We encounter too many situations where people are in institutional settings at extortionate public cost, living an awful existence. The cost is high, the value is low. We need to look at the value that public money is getting: aiming for those with complex needs to become contributing members of their communities, rather than passive recipients of services is always a better value proposition. In reality, we can also point to bespoke packages of support that typically cost less than institutional alternatives. In general, support costs decrease the better and more included a person’s life becomes. Justifiable trust is required between commissioning organisations and support providers if resources are to be best applied. The current system rarely achieves this. 10. Show another way – It’s about LEADERSHIP We talk a lot about leadership. In particular, when identifying support providers to work with individuals, we know that success is dependent on excellent leadership. Leaders create the conditions for their teams to do the right thing: leaders beget leaders. They do this by showing how to behave, how to think creatively, how to turn values into actions, and how to take responsibility. When we are selecting providers, we are looking first and foremost for evidence of leadership and we invest in developing leadership in those we work with. 11. BE TENACIOUS – there’s rarely a compromise that works! Crucially, in this work, effective leaders demonstrate and exemplify tenacity! Helping someone with a ‘reputation’ to get a real life is not an easy undertaking, but the prize is worth the hard graft needed to secure it. We encounter lots of barriers – largely from systems and processes that struggle with the flexibility and creativity needed to be truly person-centred.  Refusing to give up, to seek to bring problem-solving thinking to get around obstacles, to keep the human being at the centre of a plan at front of things, and to take thought-out risks in a too punitive world – that is critical. 12. Organise and systematise to serve these aspirations Ultimately, we believe that systems need to change to reflect these lessons. Whether we work on individual cases or interventions involving a number of people, we constantly strive to influence local statutory systems to recognise that they could achieve better outcomes for people, more easily and efficiently, if they abandoned some of their unhelpful structures and procedures. However, we are very alive to the fact that, while we help to bring about much improved lives for the folk we are privileged to assist, our example is having negligible impact upon the national system that serves to unjustifiably incarcerate and traumatise some of the most vulnerable citizens in our society. Our framework helps keep our noses to the grindstone, whilst our practice keeps us connected and alert. It is shameful that those who prescribe the systems stay aloof from the day-to-day experiences of those the claim to help. Written by Bob Rhodes CEO of LivesthroughFriends To find out more about our work, or to discuss how we could work with you or a person you support to imaginatively reach bespoke solutions to complex care problems, please find out more about us by visiting our website www.livesthroughfriends.org.  You can also get in touch with us through Studio 3 by contacting their office at 01225 334 111, and by emailing info@studio3.org.

This article is the second in a series of discussions around physical interventions training in the crisis management industry, and Studio 3's approach to physical skills. In this article, Professor Andrew McDonnell discusses the importance of listening to the consumers of services, and people with lived experience of being restrained and secluded. Before I became a Clinical Psychologist, I worked in care settings, many of which were medicalised in nature. This was in the 1980s, when the battle for person-centred care was growing, particularly in NHS settings in the UK. When I became an assistant psychologist in a hospital for people with intellectual disabilities, I was very fortunate to be supervised by a psychologist called Rowena Kelleher, who encouraged myself and other assistants to spend time with and talk to clients. It was a profound experience listening to the life stories of individuals who in some cases had spent their entire adult lives in institutional settings. Many of these individuals have been victims of restraint, seclusion, and punitive sanctions of various kinds. I remember being amazed by the resilience of some of these individuals. A key lesson for me throughout my career has been that, unless we listen to our customers, our approach to managing crisis situations will be one-sided and inherently ineffective. Staff and carer belief in the effectiveness of physical interventions is inextricably linked to their own experiences and belief systems. We can become trapped in a style of thinking that overly justifies the use of restraint because, in our experience, ‘there is no alternative.’ It can be extremely difficult to get people to change their minds, and understand that there are alternatives; that restraint and seclusion should only be used as a last resort (Deveau & McDonnell, 2009). Most importantly of all, to keep people safe even in crisis situations requires calm and mindful responses. The human rights and consumer views research in general has always been present in our work. Whilst we wish to keep all people safe in crisis situations, the people that we are supporting (whom I will call consumers) have a voice, and sometimes this is not listened to enough by practitioners. Restraint and Seclusion: The Imbalance of Power Whilst professionals often convince themselves that crisis management strategies are part of the process of keeping people safe from harm, there is another dimension to their use which can involve a power dynamic, whereby individuals attempt to over-control people. In my experience, many staff and carers are blissfully unaware that they are reinforcing a narrative that can lead to individuals becoming more rather than less distressed. In the case of Winterbourne View (Panorama, 2011), there were numerous examples of staff who used coercive methods to control the behaviour of the consumers as if they were ‘naughty children’ who needed to be taught a lesson. There is by definition an imbalance of power in the application of restraint, seclusion, and other restrictive practices. Fortunately, my colleagues and I at Studio 3 now work within a sector that does have more checks and controls than in the past. However, with regards to the views of our consumers, it is my honest view that individuals require greater independent advocacy if they are to lead flourishing lives. Professionals, staff, and families all need to be part of the conversation to challenge the use of any restrictive intervention as routine practice. The Case for Social Validity In my early work, I was strongly influenced by a researcher called Montrose Wolf. This was one of the first people, particularly in the 70s and early 80s, who talked about what he called the ‘social validity’ of behavioural interventions (Wolf, 1978). In my book, ‘Managing Aggressive Behaviour in Care Settings: Understanding and Applying Low Arousal Approaches’ (2010), I identified that Wolf’s work could be applied to crisis management methods such as restraint and seclusion. This involves thinking about the social impact of methods on the person, the people around them, and society. Consumer satisfaction is a major component of this. Wolf, in his 1978 article, really emphasised this point: ‘It seems to me that by giving the same status to social validity that we now give to objective measurement and its reliability, we will bring the consumer – that is, society – into our science.’ Wolf clearly understood that society in general is also a consumer. I appreciate that sometimes when a restraint has been implemented with an individual in a crisis situation, there are two consumers, not one (staff and client). Both may be traumatised by the process, but I do not believe that this is a 50/50 transaction. The people we support are often vulnerable, highly stressed, and struggling to make sense of a chaotic world. They often live - sometimes temporarily, sometimes permanently - in places where they have little control over their lives. My colleagues and I believe passionately that the people in receipt of restraint should have a say in their care. Listening to People Alexis Quinn has previously been a consumer of services. In her book ‘Unbroken,’ she described her experiences in the mental health system, where she was restrained 96 times (2018; pp. 53-4): ‘Someone would push an alarm on their belt. This started the high-pitched doot-doot-doot-doot sound. At least four people, maybe six, would come. Three from the ward I was on, three from other units in the hospital. This was a standard procedure. The staff would immobilise me by taking over my movement in a standing, sitting or prone position, depending on where I was, what I was doing, and where was easiest for them. They would smash me onto the floor. One might hold my head down onto the floor. For the first two years it was always a face-down restraint. One would be on each arm, pressing them straight out like a starfish. They would lean in to my body. There was also one on each leg, and one just talking at me. This was how they controlled me, and by injection too – a chemical restraint.’ It is difficult to read this passage without feeling some distress. Too often, people justify such methods as the ‘only option.’ The reality is that, to change someone’s practices, people need to understand that restraint is not neutral. My colleague Rebecca Fish at the University of Lancaster has excessively researched the experiences of women who have been restrained or secluded. In 2017, she published an article with Professor Chris Hatton, interviewing 16 women with intellectual disabilities on locked wards. The following is an unedited sequence that is difficult to read (Fish & Hatton, 2017: p. 797): ‘Researcher: What happens when you get restrained? Louise: They just hold you down, and you can’t move. … Researcher: How does it feel? Louise: Horrible, hate it. It makes me more angry. Researcher: Does it not help you calm down? Louise: No.’ In the opinion of the author, this study should be compulsory reading for healthcare professionals. The authors recommended, and I would agree with them, that a gender-sensitive analysis of the alternatives to restraint is urgently needed. We cannot continue to justify such experiences which are traumatising to all parties concerned. Accounts such as these are not just a collection of interesting observations: they should be viewed as scientific data and used to inform practice. Active Campaigning and the Neurodiversity Movement I was once speaking to an eminent researcher who I will not name, who bitterly complained that research was becoming more difficult unless it contained a consumer’s account or lived experience perspective. His point was that there was no ‘pure academia’ any more. I think I surprised him when I said, ‘I agree there isn’t; and about bloody time.’ I pointed out that the growing neurodiversity movement in our work is not going to change, in fact it’s going to grow. We cannot – or more appropriately have no right – to try and put the genie back in the bottle. Coproduction and collaboration from neurotypical and neurodivergent individuals is the way forward. Restrictive interventions is an obvious area that requires collaboration. Increasingly over the years, I have become genuinely frustrated with the minimisation of the experiences of neurodiverse individuals around being restrained, restricted, and secluded. We need to continue to view individual accounts and experiences as data (McDonnell, 2022; pp. 108-9): ‘It is not anti-scientific to include data from a whole range of sources, including individuals with lived experience of restraint and seclusion. We must be aware of the limits of research when it comes to changing practice. Restraint, seclusion and other restrictive practices are unpleasant and traumatising for all people concerned. We cannot wait for laboratory studies and field trials to drive the agenda: we have a duty to address human rights injustices within the industry.’ Achieving consensus in these sensitive matters is a challenge for all of us, not just within the neurodiverse community. If we are serious about eliminating restraint and seclusion, we have to change the narrative. It is my view that, as society changes, the challenging of out-dated practices such as restraint and seclusion will become more commonplace. Professionals and providers of supports and services not only have to start listening to people’s accounts, no matter how emotional and unpleasant they are, but they must also channel their emotions into focusing on positive changes. I think the phrase that best fits this is, ‘less talk, more action.’ Listening to People with Lived Experience: Consumers as Trainers One of the most positive developments that I have witnessed in the crisis management industry is the increasing awareness that the views of our consumers about the use and abuse of restrictive practices has become increasingly more central. Alexis Quinn, who described her harrowing accounts of experiencing restraint in the mental health system in her book ‘Unbroken,’ is today a Manager for the Restraint Reduction Network. The evidence base highlighting the negative experiences of consumers in the healthcare system continues to grow. It is imperative that we listen to the views of consumers, and include them in the conversation in order to eradicate restraint and seclusion. Of course, the counter-argument remains that we have to keep people safe, and sometimes this means using methods on an emergency basis. Whilst I do accept that there are extreme situations where there is a need for emergency responses, I also believe passionately that people with lived experience should be more actively involved in crisis management training, and informing which methods are acceptable and which are not. My own organisation has made attempts to be as inclusive as possible. The more trainers who have walked the walk, the more impactful I believe our training will be. Consumers, Quality Assurance, and Coproduction Collaboration and coproduction have to be the way forward if we are to have meaningful dialogue in this field. If I am to declare my own bias, I have never viewed the views of consumers and staff about restraint as being equal. Often, the people we support are distressed and traumatised, and do not have people to advocate for them. To create a new way of thinking requires us to apply some weight to their account. I am more in favour of putting the opinions of consumers above those of staff when weighing up the need for restraint, seclusion and other restrictive practices. Increasingly, collaboration and coproduction is becoming part of our approach. I have recently been involved with my colleagues at the Anna Freud Centre and AT-Autism who have collaborated to develop a National Autism Training Programme (NATP) which will aim to train staff in understanding the principles of autism. The training delivered on this programme is balanced between individuals with lived experience and professionals. My colleagues and I are involved with this programme delivering training on the Low Arousal Approach to managing behaviours. Programmes such as these are, I believe, the future, and they move us away from the ‘professional versus other’ paradigm. Coproduction should also be part of training organisations’ quality assurance processes. When thinking about the application of physical interventions and their quality control, the Studio 3 organisation is highly supportive of the goals of the RRN. Increasingly, an approach to regulation is emerging which could arguably make the training of crisis management that includes physical interventions safer. Studio 3 Learning Principles When delivering training or supports, it is essential that supporters have to be exposed to consumer accounts of restraint, seclusion, and other restrictive practices. Consumers of services accounts and experiences must be considered as data. Involving consumers in the entire training and coaching process where true coproduction can occur should be at the core of training. Traumatic accounts of peoples’ negative learning will only change practice if they are followed up with collaborative action, which should include members of the neurodiverse community. Written by Professor Andrew McDonnell CEO Studio 3 To download this article as a PDF, visit www.studio3.org/practitioner-articles. References Deveau, R. & McDonnell, A. (2009). As the Last Resort: Reducing the Use of Restrictive Physical Interventions Using Organisational Approaches. British Journal of Learning Disabilities, 37(3), 172-177. Fish, R. & Hatton, C. (2017). ‘Gendered Experiences of Physical Restraint on Locked Wards for Women,’ Disability & Society, 32(6): 790–809. doi:10.1080/09687599.2017.1329711. McDonnell, A. (2022). Freedom from Restraint and Seclusion: The Studio 3 Approach. Peterborough: Studio 3 Publications. ---------(2010). Managing Aggressive Behaviour in Care Settings: Understanding and Applying Low Arousal Approaches. Oxford: Wiley-Blackwell. Panorama. (2011). ‘Undercover Care: The Abuse Exposed,’ Panorama – BBC One. Quinn, A. (2018). Unbroken: Learning to Live Beyond Diagnosis. London: Trigger Publishing. Wolf, M.M. (1978). Social Validity: The Case for Subjective Measurement or, How Applied Behavior Analysis is Finding its Heart. Journal of Applied Behavior Analysis, 11(2): 203-214.

Studio 3 reviews ‘Changing Perceptions: Deciphering the Language of Behaviour’ written by Graham Chatterley, an insight into some of the reasons behind the behaviours of children in mainstream and special education schools. Graham Chatterley is a teacher, school leader, trainer and consultant whose work in schools has led him to write this book about changing perceptions around behaviour management in schools. Behaviour is a tricky subject in any setting, but particularly in schools where distressed children are often misunderstood as being disruptive or misbehaved. Too often in education settings, children and young people are made to feel shame and fear over behaviour they have little control over. Graham here delves into the hidden world of some of the reasons behind challenging behaviours in schools, and why having a little more compassion, empathy and curiosity can pave the way towards positive behaviour change. This book is a positive guide, not only to changing behaviours, but to changing how we as educators, support staff, and families feel and think about behaviours. Key to this is seeing the child as being stressed and sometimes traumatised, unable to cope with the demands placed upon them within mainstream and specialist school settings. Meeting the child where they are, and avoiding punitive and consequence-based practices at all costs is what Graham advocates for and practices in his own career. ‘Changing Perceptions’ starts by outlining what the key features of a positive learning environment are, including positive relationships in the classroom with safe and trusted adults, SEMH education for staff and peers, and having a strong shared ethos throughout the school setting. Deciding what is important – obedience, or well-being? – and shaping learning around meeting those fundamental needs in order to achieve learning is the first step. This means being curious about the reasons behind challenging behaviour, and prioritising positive and compassionate relationships between educators and learners, where everyone feels supported to risk the failure that is inherent in any learning situation. ‘If I’d had a better understanding of child development, additional needs, self-esteem, emotional regulation and trauma, and if I had realised the importance of safety, trust, co-regulation, belonging and happiness, I would have started out as a better teacher.’ (p.2) Graham tells us that changing childrens’ experiences requires a ‘relentless consistency of response’ across the whole staff team, which is why changing perspectives is so important. This is a view also shared by our own Gareth D. Morewood, who champions ‘constant consistency’ in mainstream and specialist school settings in order to ensure inclusive practices for every pupil in a setting. Where punishments, sanctions, and consequence-based approaches are in practice and in a sense ingrained into a setting, it can be difficult to change people’s minds. We all have deeply held beliefs about behaviour, some of which we have carried with us from our own childhood experiences, and these can be stubborn to uproot. Graham’s persuasive prose and to-the-point messaging demonstrates that there is another path, and that in the long term, punishing ‘bad’ behaviour does more harm than good. ‘Having an understanding and empathetic approach will never cause emotional harm to a pupil.’ (p.13) Having unconditional positive regard for a pupil whom you might see as being disruptive and challenging may sound impossible, but with some reflection, curiosity, and compassion, you may discover that there is another explanation. Graham talks the reader through the arousal curve, and moments where we have a chance to predict, prevent, and successful de-escalate distressed behaviours. Where a crisis is already in motion, the most important thing is to remain calm and in control – or at least appear to be. As Graham says, fight fire with water. By being in control of your own emotions first, you model calmness and can help a young person to calm down themselves through co-regulation. This is not easy, but as Professor Andrew McDonnell says, it is something that can be taught, and has been successful on a number of Low Arousal Training courses for practitioners in a range of settings, including the LASER Approach for educators. ‘Going against your instincts, maintaining self-control in the most challenging environment and making a judgement that might upset colleagues all make focusing on putting out the fire difficult.’ (p.27) Co-regulation is so important in these moments. Punishment, Graham warns, will not change a behaviour: only a safe, trusting relationship will – a relationship we compromise when we introduce punitive consequences before a child has had a chance to regulate and reflect on the situation. ‘Punishment without repair doesn’t prepare children for life after school, and it compounds the shame children already feel. With enough repetition, ‘I have been bad’ becomes ‘I am bad.’’ (p.94) It is important not to assume that a child of any age has the ability to successfully both recognise their feelings of distress, and then to self-regulate in response to them. Kelly Mahler’s work on interoception sheds a light on the difficulties some individuals face in recognising physiological signs of hunger, pain, and fear within their own bodies (Mahler, 2018). Graham goes on to discuss some of the potential motivators behind behaviours of concern, including physiological, emotional, environmental and psychological factors that may cause distress and dysregulation in young people. Recognising the build-up towards these often unconscious fight or flight responses is essential, and is only possible when we recognise stress and trauma in a young person, rather than simply seeing a child who is ‘breaking the rules’ (p.51). Children fundamentally cannot learn when they are distressed, and so recognising when a child is within their window of tolerance – calm, engaged and ready to learn – and when they are not is key. When we know what to look for, we can help to increase this window, and avoid situations and feelings that push a learner out of this window. Graham here uses the ‘fizzy juice analogy’: when you see the warning signs, don’t open the lid. Graham provides a thought-provoking list of examples of things that can affect regulation and attention in schools, such as unstructured time, group work, and certain times of the day, such as after lunch. ‘We can’t possibly be expected to do this with every child in the school, but by changing the way we see our most challenging pupils – and seeing them as our most distressed pupils – we can hopefully attune to them better.’ (p.78) This book provides a guide to firstly reflecting on what might impact an individual at school, and how to write a simple plan to help that individual to cope when signs of distress creep in, as well as how to proactively avoid and manage stressful triggers. With helpful do’s and don’ts at the end of each chapter, the advice in the book is easy to apply in practice, and will help practitioners in a range of educational settings to reflect on their thinking around behaviour in an empathic and curious way. Graham’s personal reflections and perspectives gained from his teaching career and through supporting how own children with SEND needs lend a particular insight into his own journey, and how this has helped him to empathise with and learn from children with additional support needs. Graham also shares some case examples, which help to illustrate a sequential approach to creating safety, trust, regulation and belonging, thus changing behaviours and fostering courage and resilience. We would recommend this book to educational professionals who are supporting children and young people in mainstream or specialist educational settings, particularly those who may be supporting young people with SEMH needs who experience distress. Graham’s empathic and compassionate approach resonates with our own practice and beliefs here at Studio 3, and reflects what we would call a ‘Low Arousal Approach’ to creating calm, consistent environments for learners, where every member of a school community is informed about SEMH, and thinks differently about behaviour. ‘See the behaviour as an outcome rather than a choice’ p.115 'Changing Perceptions: Deciphering the Language of Behaviour' is available from Amazon or Crown House Publishing. Written by Rachel McDermott Studio 3 Information and Social Media Co-Ordinator

The following extract is from a recent practitioner article on the role of exercise in reducing stress, written by Assistant Psychologist Matt Cotterill. The full article can be accessed here. Providing care and support to people in the caring professions is often fraught with stressful interactions. The stress-induced cascade of hormonal and molecular responses can, if left unchecked, serve to disorientate you to the world, culminating in a negative view of future interactions and, more nefariously, the individual themselves. Over time, the feelings of helplessness and fatigue entrench themselves and burnout becomes imminent. The purpose of this article is to make a case for exercise as a means by which we can re-orientate ourselves to the world: that the biological processes initiated by exercise can fundamentally alter the cellular, neurological, and sensory landscape, leading to a more resilient individual able to cope with, and bounce back from, stressful episodes. A Stress Case Study Sarah has been working in a supported living service for 22 years, 15 of which have been with the same individual called David. David is a kind, personable soul who has an intellectual disability, and due to a life of hardship and abuse, suffers from complex PTSD. For Sarah, working with David can be a volatile experience given his traumatic past, which can rapidly manifest in the form of verbal and physical aggression. While Sarah’s 15 years of experience with David has, to some extent, desensitised her to his proclivity for aggression – it’s just “David being David” – underneath the façade, Sarah is struggling to cope. But like the fabled frog who, sitting in a pot of steadily heating water doesn’t realise it’s boiling before it’s too late, Sarah also didn’t realise the effect that working in an unpredictable environment was having on her mental and physical health. Until, that is, on a rainy Tuesday morning, when pulling up to David’s house she was met by a torrent of rage and, to her surprise and later to the surprise of her superiors, broke down in tears and decided she was done. That afternoon the GP signed her off work with stress. Stress is a term that, in contemporary use, refers to prolonged psychological strain. The term brings up images of hunched over office workers busily typing under a mountain of paperwork, or more extreme,  listening to babies crying for hours on end. Ultimately, it is agreed that stress is something to be avoided at all costs. Its original conception though, by Dr. Hans Selye in the mid-20th century, was to simply denote the physiological response to ‘noxious stimuli,’ namely temperature, toxins, and muscular exertion, free from any judgement of ‘good’ or ‘bad.’ Dr Selye found the that the application of such stimuli would set off a cascade of general physiological reactions that was largely proportional to the amount of stimulus used; little stimulus = little response; large stimulus = large response. Over the following decades, researchers tinkered with the types (psychological, physical, environmental), amounts, frequency, and duration of stimuli, which revealed that our response to stress is highly adaptive so long as the exposure to the stimulus was appropriately managed. Too much exposure would lead to ill health and eventually death, whereas frequent exposures to a small-medium stimulus, or exposure to a large stimulus with appropriate rest, would result in adaptation such that the exposure to similar amounts of stimuli the next time around would result in less of a response (i.e., the body was more resilient). With this understanding, Sarah’s eventual breakdown comes as less of surprise and more an inevitability. Using Dr Selye’s and his posthumous colleagues’ work, we can reasonably speculate about what was happening to Sarah physiologically over the 15 years of working in a ‘stressful’ environment: The initial exposure to aggressive behaviour would initiate what Dr. Selye would call an ‘alarm reaction,’ a reaction that sets off a cascade of ‘stress hormones’ coordinated by the hypothalamus, pituitary gland, and adrenal glands, to the resulting release of cortisol and adrenaline – both of which serve to mobilise the body to respond to the stressor by fighting or running away. The physiological symptoms of this cascade are an increase in heart and breathing rate, dampening of pain receptors, the production of sweat, and increased vigilance around the perceived sources of stress. The proceeding weeks and months of working with a complex and unpredictable individual such as David would do little to truly stem this stress response with each encounter. In fact, the rumination about past and future encounters with David could well have formed an insidious and continuous release of cortisol and adrenaline to the point where Sarah’s natural circadian rhythms become disorganised. For example,  more time spent wide awake at night while becoming increasingly tired during the mornings and day time, appetite begins to flatten out across the day, and Sarah may have to increasingly rely on external stimulants (coffee, redbull) to maintain productivity. A vicious cycle of too frequent and intense a stress response begetting too little recovery time, repeated daily, would mean Sarah was essentially bathing in stress hormones for much of her time. To buttress Sarah from the ill effects of the stress, her body would initiate what Selye would term the ‘resistance’ stage: a flooding of the body with immune and inflammatory cells that would attempt to reduce any cellular damage Sarah may be suffering. The tragic irony of long exposure to stress-inducing situations though is that the very defences your body uses to protect you initially, ultimately exacerbate the problem further as the frequent continuous influx of inflammatory cells becomes problematic, further compounding the damage that is already present. Years of continuously going through this cycle brings about the final stage of Selye’s model, ‘exhaustion,’ At this point, general physical and psychological/cognitive health begin to decline more rapidly. More trips to the GP, more time off sick, lack of energy for meaningful relationships and pursuits, more arguments at home, and a general sense of dread or resentment over the prospect of interacting with the perceived sources of stress - in this case, David. ‘Malignant alienation’ is a term often used to describe the feelings of disliking a client who you’ve been charged with supporting and has been discussed at length elsewhere (Naismith & O’Shea, 2022). From a physiological perspective, we can understand the forces driving such alienation when we consider the impact of the stress response on our perceptions of the world around us. For instance, let’s try and imagine what the world looks like for Sarah with each interaction with David. Before the initial meeting with David when Sarah reads his clinical profile, the warnings of aggression and unpredictability would stand out amongst the other descriptive statements, such is our evolutionary hard wiring to heavily attend to the negative and dangerous aspects of our environment. Understandably the feelings of nervousness and anxiety start to rise, and cortisol starts to seep into the system. That first drive up to David’s house does little to stem the flow, in fact a call from her supervisor saying he’ll be late but for Sarah to go on ahead and introduce herself sends her anxiety into a rapid climb. David, being the kindly and personable man he is, welcomes her in and sits with her to talk. With a sense of relief, Sarah starts to settle into the conversation but never truly relaxes, the thoughts of ‘unpredictable’ and ‘aggression’ simmering in the back of her head. Flickers of annoyance from David at misunderstood statements capture her in such a way that she begins to pay more and more attention to the words she’s using and how they may be interpreted. The result is that by the time Sarah gets back to her car, the 20-minute conversation feels like a 2-hour marathon, and she feels an understandable sense of relief and pride in surviving it. For the rest of the day, there’s a euphoric spring in her step that steadily gives way to a complete crash as bedtime rolls around. Of course, in the morning, those feelings of elation start to erode as the prospect of the first full shift with David begins to draw closer and the cycle begins again. This pattern continues over the months and years, with every iteration of the cycle begetting more cortisol, more vigilance over her interactions, such that the anxiety becomes increasingly entrenched. The first plate thrown, the first shout and punch, all serve to increase the space that the ‘idea of David’ takes up in Sarahs waking thoughts. The joy of Friday slips into increasing dread over the weekend as Monday morning draws closer. Days are counted down to Holidays and long weekends, but can never be fully enjoyed in the moment, because the thought that she’ll have to go back is always there. As the resistance and exhaustion phases start to truly settle in, social engagements and hobbies begin to ebb away: the prospect of doing something after a shift just seems too tiring, and every spare moment is needed to relax. This is the particularly insidious nature of stress and the moments that malignant alienation begin to emerge – as Sarah’s attention is increasingly taken up with thoughts of David, the ‘idea of David’ begins to mutate into something more terrible that leaves little room for anything else. A reciprocal narrowing of Sarah and her world begins with the ‘idea of David’ at the centre of it. Over time, the idea that this is in some way a controlled and personal attack, however false, seems increasingly justified. What power then does exercise have in helping mitigate this cycle of stress? When considered through the lens of Selye’s work, exercise is a stress like any other, prone to the same physiological highs and lows. But at its most fundamental level, exercise differs in the nature of its application; a directed and targeted source of stress that is phasic and multi-modal rather than chronic and singular. What does this mean? It means that unlike the forms of stress that we would consider more damaging, such as the psychological stress Sarah is suffering, which is sustained, corroding, and singularly focussed, exercise is a largely infrequent (relatively speaking), often high dose form of stress that comes in many forms and that we recognise as needing rest and recovery from. Continue reading... Written by Matt Cotterill Assistant Psychologist at WALK References Naismith, L. & O’Shea, M. (2022). Malignant Alienation: Overcoming Barriers to Professional Practice. Studio 3 Publications [Online]. Available from: https://www.studio3.org/practitioner-articles Selye, H. (1956). The Stress of Life. New York: McGraw-Hill.

The following is an extract from a practitioner article by practitioner Stephanie Bews-Pugh in which she reflects on her personal experiences of having a hidden disability. Introduction In this practitioner article, I reflect on my experience of having a hidden disability and how this informs my practice as an Assistant Psychologist (AP). Throughout I will use some illustrative examples, both from my personal life and from a clinical case study. The case study I describe is of a young woman named Emily who received a diagnosis of Autism in adulthood. Like many women on the Autism spectrum, Emily’s difficulties were often not noticed by others. Nonetheless, she experienced some very real challenges from living in a world not set up for her needs, and often felt misunderstood by people around her. In this article, I explore some of the similarities between this experience of late diagnosis and my experience of hidden disability. To gain a fuller understanding of my personal identity and of how this relates to my professional identity, I employed John Burnham's (2012) personal and social ‘GRRRAAACCEEESSS’ to write a reflexivity statement. The letters in this mnemonic stand for Gender, Race, Religion, Age, Ability, Appearance, Class, Ethnicity, Education, Sexuality, and Sexual orientation. Burnham and Nolte (2020) write that this serves to remind us of the multiple experiences that contribute to identity; the final S also stands for ‘Something else,’ to give space to other aspects not explicitly stated. My personal and social GRACES include identifying as a woman and as an ‘aspiring Clinical Psychologist.’ Burnham and Nolte (2020) point out that aspects of identity are often viewed by ourselves and by others as being either a resource or a restraint, in both our personal and professional lives. I am aware that some of my GRACES do confer power and privilege in society, and therefore could place me in a position of advantage over others; for example, being white and educated. However, this is not the whole picture. Burnham (2012) notes that GRACES may be seen or unseen, voiced or unvoiced. In my professional life, aspects of my identify that are less visible include that I have encountered many barriers to my chosen career path. To qualify as a Clinical Psychologist is a competitive process, requiring high levels of achievement in work, education and research before there is even a remote chance of gaining a place on a doctoral training programme. I completed my Undergraduate degree when my children were at nursery and primary school. Due to parental and financial commitments, it took many more years to return to university again to gain a Masters degree. Another less visible aspect is that I have a disability. I have a congenital eye condition and am partially sighted. However, as I have developed many compensatory coping strategies, my difficulties often go unnoticed by others. As such, this is a ‘hidden’ disability. While some of my less visible GRACES could be construed as ‘restraints,’ I personally view them as resources that can be drawn on to enrich my practice. My Personal Experiences Just prior to the 1981 Education Act, my parents succeeded in their fight to get me into the local mainstream primary school. Unaware of my parents’ efforts or of the wider political context, I quickly learned to hide any difficulties so that I could ‘fit in’ and be ‘normal.’ In those days, teachers wrote on a board at the front of the classroom, from which I was unable to decipher letters and numbers. When I was around 6 years old, I was given a large desk with an easel-like contraption to bring paper nearer to my eyes, a lamp, a monocular, and some support from a teaching assistant. My new desk was placed at the front of the classroom in the hope this would enable me to read from the board. None of this helped with what I wanted, which was to be like the other children. Unsurprisingly, I learned to read relatively late, eventually teaching myself over the summer holidays when I was 10 years old. To this day I am an avid reader of stories, and am also fiercely independent. As an adult I have gained skills and experience to voice my needs, for example by asking for adaptations at work. The Equality Act (2010) requires employers to make reasonable adjustments that prevent employees with disabilities being disadvantaged in the workplace. It is good practice for employers to assess the needs of disabled employees, to propose adjustments based on this assessment, to check proposed adjustments with the employee, and to implement agreed adjustments in a timely fashion (Equality and Human Rights Commission, 2011). Despite this, my experience of disclosing disability and of employers’ responses has been mixed; ranging from waiting a long time to be assessed, to waiting an even longer time for adjustments, to provisions that do not account for my actual needs. One manager expected me to work from a laptop with a 15” screen despite having been informed of my visual impairment, and persisted in ignoring requests for reasonable adjustments which I made in person and via email. Eventually, after escalating my request to my manager’s manager, the company bought me the largest monitor imaginable. This must have cost them a great deal, but as they had still not taken the time to talk to me to find out about my vision or what would help, it was not fit for purpose. This caused me to wonder if the barriers I was coming up against were due to the hidden nature of my disability; is it because my partial sight is not immediately apparent that others failed to see it as ‘real,’ or to appreciate the multiple ways it affects me? Such experiences of not being heard are isolating and disempowering, and have an eroding effect on personal resilience. Reflecting on my GRACES and experiences has made me realise that my disability was not always hidden. From talking to my parents, I know that as a young child I would get up close to things I wanted to see. By the time I was 8 or 9 years old, I can remember pretending to see more than I could. Bringing my psychological knowledge to this, it seems that from early childhood I learned to mask my difficulties, and that most of the time I continue to mask completely unconsciously. Having a ‘hidden disability’ then is in part my own making, in as much as learning to mask was a response to an environment that did not support my needs (despite the best efforts of teachers and my family). That my disability is not immediately apparent to others has its advantages. Perhaps I avoid some more overt forms of prejudice and discrimination. On the other hand, the hidden nature of my disability makes it more difficult to have my needs met. While the GRACES framework has given me another tool to make this visible and to voice my needs, letting go of my ‘coping’ mask and asking for help involves exposing my most vulnerable aspects - a risk that has not always paid off. Fortunately, I have also had some positive experiences of support in the workplace. For me, it has made a crucial difference when the person assessing my needs has listened and attempted to gain an understanding of my needs. It is helpful when I am given the opportunity to check the assessment and recommendations, and to give feedback. When these things are in place, they tend to lead to the provision of appropriate adjustments that are helpful. How My Personal Experiences Have Impacted My Work Each person’s experience of disability is individual: context, upbringing, nature of condition, age of onset, culture, time and place will all have an influence. However, I do believe that my personal experience of disability in an able world does give me an insight into some broader effects of living with disability, including social and psychological impacts. For example, many of the problems I have encountered have not been about my disability per se, but about systems that are not tailored to my level of ability, or to other people’s lack of understanding. Street signs, bus numbers, and boards at train stations are all tantalisingly just out of visual reach: I can see that they are there, but cannot see enough to get the information I need. This experience of being forced to navigate barriers and challenges erected by society is shared by many people with disabilities. For people with a hidden disability, these barriers are just as ‘real,’ but our struggle is often unseen. Whether hidden or visible, people with disabilities experience being ‘different.’ My experience of hidden disability has been particularly pertinent to my recent work with women with Autism Spectrum Condition (ASC). Historically, more boys than girls have been diagnosed with Autism, and it was widely believed that such conditions disproportionally effected males. However, recent research suggests a different reason for this: women and girls with Autism often remain undiagnosed due to a more ‘social’ presentation and a learned ability to ‘mask’ their difficulties (Elcheson et al., 2018; Stewart, 2012). Despite (or because of) such learned social skills, Autistic women describe feeling misunderstood by others and being forced to navigate a world that is not designed for them (Dugdale et al., 2021; Scottish Autism, 2021). Whether due to late diagnosis, or to the invisible nature of their difficulties, the needs of Autistic women and girls are often not recognised. This means that their needs often remain unmet in education, employment, social services, and healthcare. Drawing on my own experiences of support - not only in work, but in education and healthcare settings - I try to support people in ways that I personally have found helpful. This involves being person centred, listening, recognising strengths, and providing interventions in-line with needs and goals. A Practical Exploration of How This Influences My Practice: A Case Study Emily is a young woman who was referred to Studio 3 for help with her mental health. Previously, she had undergone multiple mental health assessments and received various treatments and interventions. Some of the core skills of Clinical Psychologists are assessment, formulation, intervention, and evaluation. This means working with individuals to assess their needs and strengths, hypothesising or suggesting possible causes for psychological distress, and offering appropriate help to reduce distress and increase wellbeing (British Psychological Society, 2013; Department of Clinical Psychology, 2001). To achieve this, we must pay attention to the personal accounts of the individuals we aim to support (Coles, 2010). In other words, we must listen first. In the remainder of this article, I will focus on how my personal experience of disability influences the way I endeavour to use core psychological skills when supporting clients. To illustrate, I present a clinical case study. This case study does not represent any one person, but is an amalgamation of several individuals I have worked with. All personal characteristics have been changed to protect their identities. Continue reading... Written by Stephanie Bews-Pugh Assistant Psychologist

Whether you are an individual looking to access clinical or training services for yourself, a family member looking to access our services for a person you support, or an organisation thinking about working with us, this is a helpful guide to what support we can offer and how to access it. At Studio 3 Training Systems and Clinical Services, we offer a range of supports, advice, and input from our experienced clinical and training teams. Whilst some people who come to us for training or counselling know exactly what they are looking for, others may be unsure specifically which service best suits their needs. That is why we operate a referral system, whereby we take details from individuals, supporters, or organisations about their situation and needs, and our clinical and training teams will then decide how we believe our services can best be of assistance in each individual scenario. If you are unsure how we can help you, an individual you support, or your organisation or service, submitting a referral is the best way to visualise the pathways of support available to you. Clinical Services If you are seeking clinical and psychological support, guidance, or intervention from the Studio 3 team, our team of clinicians will review your referral. If you have a specific type of support in mind, or are seeking guidance, our team of clinicians can work with you to determine the appropriate pathway of support for you or the person you are referring. Our approach to clinical services, such as diagnostic assessments and therapy, is outlined in our Neurodiversity Pathways Approach, a term we use to illustrate the many overlapping and distinct pathways of support available to individuals, families, and organisations. This can include therapeutic and psychological interventions, assessments (we conduct a wide range of assessments, including diagnostic assessments (e.g. ASD, ADHD), psychological assessments, service specifications, and ‘360° Assessments’), clinical consultations, and more. We would be happy to talk with you about the options available to you, which are outlined here in more detail. Training and Coaching We also provide training and coaching for individuals, services, schools, and families depending on need. We can also develop and provide bespoke training and coaching interventions for staff teams, organisations, families and services in order to build knowledge, skills, and resilience. Studio 3 Training Systems specialises in Low Arousal interventions and non-aversive practices. You can see what training we have available here, and our training team is happy to advise you if you would like to explore what training we could provide, or discuss bespoke training options. Making a Referral The first step is to contact us. When you make a referral, we will need information about who you are, who the person you’re referring is (you can also make a self-referral), and what area you’re based in so we can assign a clinician nearby and assess logistically how we would carry out the work. You will also need to summarise to the best of your ability what the presenting issues are and, if possible, what kind of input/support you’re looking for. A member of our referral team (clinical or training) will be in touch to either get more information, or confirm that your referral is being processed. ​ Sometimes we may need to do a remote consultation meeting. There will be no charge for this and the purpose will be to get more information in certain areas in order to proceed. This is more likely when there are questions of risk, an MDT is already involved, or we need to determine the scope of our involvement. The second step is where your referral will be processed. We have a referral review meeting every fortnight where the lead clinicians discuss and determine what potential pathways of support we could offer. Based on this, a proposal is put together and this will be sent back to the person making the referral for their review. The proposal will outline how to proceed, and will require the recipient to reply in confirmation or denial to the proposal. If accepted, appropriate contracting will be outlined and then work can start. If you have any questions about submitting a referral, you can see some of our FAQs here, or contact us directly to discuss your options. To submit a referral, visit www.studio3.org/submit-a-referral.

This article discusses the recent Supreme Judicial Court ruling allowing electric shock treatment to continue to be practiced at the Judge Rotenberg Center. The Judge Rotenberg Center in Massachusetts has been the subject of controversy since the 1970s. Throughout its history, it has been criticised for Human Rights abuses and aversive punishments for children, young people, and adults with autism spectrum condition (ASC), learning disabilities, and ‘problem’ behaviours. Today, it remains the only institution in the United States that applies electric shocks to correct undesirable behaviours using archaic graduated electronic decelerator (GED) devices strapped to students’ bodies. At Studio 3, we do not believe in any form of punishment for behaviours, and continue to campaign not only for the reduction but the eradication of restrictive practices. The fact that these devices are still being used on vulnerable individuals is a Human Rights violation, and cannot be tolerated within the caring profession where our role as educators and supporters is to better understand and protect individuals in our care, not to punish them or try to make them conform to neurotypical ideals of ‘good behaviour.’ This article will look briefly at the long history of abusive practices at the Judge Rotenberg Center, discuss the recent Supreme Judicial Court ruling allowing electric shock treatment to continue to be practiced, and question why such practices are allowed to persist in modern times. A Brief History The Judge Rotenberg Center began its life as the Behavior Research Institute, founded by Matthew Israel in 1971. A student of the father of Behavioural Psychology, B.F. Skinner, Israel believed in aversive ‘treatments’ for undesirable behaviours, which ranged from self-injurious behaviour to ‘non-compliance,’ such as not following commands. Since its inception, there have been many complaints and legal cases brought against the institution for abusive practices, and six students have died of preventable causes. Shocking footage emerged in 2012 as part of a legal case showing a pupil being restrained face-down on a restraint board for 7 hours and shocked 31 times. The institution has a long list of behaviours which are targeted by the electric shocks: in this instance, the restraint and subsequent shocks were administered because the pupil refused to take off his coat. In another instance, 7 staff members were fired following a prank call to the institution claiming to be from a member of staff informing those on-shift that 2 pupils needed to be shocked for ‘misbehaviour’ earlier in the day. Based on this, on-shift staff members woke 2 pupils from their sleep and shocked them up to 77 times whilst their arms and legs were restrained. This resulted in second degree burns for one individual. The school has since been condemned for violating the United Nations Convention Against Torture (Pilkington, 2018): “The use of electric shocks to control the behavior of children inflicts pain and suffering that at least rises to the level of cruel and degrading treatment and in some cases is definitely torture. That is prohibited by state, national and international law.” Present Day In March 2020, the use of electric shock devices was banned by the FDA to treat self-injurious or aggressive behaviour. This decision was appealed, and it was determined that the FDA could not ban the use of electric shocks where it had been approved for medical use. Therefore, in cases where electric shock treatment had already been allowed by a judge or healthcare professional, this practice was allowed to continue. In September 2023, the Supreme Judicial Court of Massachusetts ruled that the Judge Rotenberg Center can continue to use electric shock devices on its students after claims by JRC lawyers and parents of students at the school that it is a ‘lifesaving, court approved electric stimulation device treatment’ (Pierson, 2023). Despite campaigns against the use of the method since 1985, The Judge Rotenberg Center is the only institution where electric shock therapy is still sanctioned in the United States. In 2022, a task force set up by the Association for Behavior Analysis International (ABAI) sought to study the use of contingent electric skin shock (CESS) in order to inform a position statement about its use. As part of this report (Perone et al., 2022), the JRC was investigated due to being the only institution still practicing CESS. Their report found that, as of July 2022, there were 52 adults aged 26-59 authorised by law to receive electric shocks at JRC. These CESS treatment plans do not require the consent of the individual, and a student may wear multiple GED devices simultaneously, receiving shocks in different parts of their body without knowing where the pain will land. Treatment plans can be approved for up to 15-20 years, despite regulations stating that they should be reviewed yearly. They also found no evidence that treatment plans were faded over time; CESS application can last between 5 – 20 years, and in fact the intensity of the shocks and number of devices often has to be increased to maintain effectiveness. Aversive Punishments Aversive consequences for behavioural treatment are a controversial topic. Whilst these can range from denying an individual a preferred object to applying a physical punishment, they can be extremely harmful to the well-being of individuals. The use of punishment to modify a person’s behaviour is not something we agree with here at Studio 3. The philosophy of our practice hinges around understanding why a person may need to engage in a behaviour to self-regulate, or to communicate need to their supporters. Whilst there are some extreme cases where preventing self-injury or violence to staff or other vulnerable people is necessary, most ‘challenging’ behaviours are perceived as such due to a societal focus on other people’s behaviours. In addition, the argument that electric shock treatment results in behaviour change in the long term is a nebulous one. The Judge Rotenberg Center itself states that some individuals may require CESS treatment for up to 15-20 years, indicating that the shock treatment has no longevity for behaviour change. In many instances, the intensity of the shocks administered needs to be increased to maintain effectiveness (Perone et al., 2022). Some individuals are reported to have habituated to the GED-4, a device created by the JRC which delivers the most powerful electric shock available. There can also be a delay of up to 30 minutes between the behaviour and the application of CESS, which calls into question whether an individual can even comprehend why they are being punished in order to change their behaviours accordingly. Whilst the school claims that the electric shocks (which they describe as ‘contingent skin shock for severe problem behavior’ on their website) are used to prevent pupils from injuring themselves or others, and are only administered in extreme cases where the alternative would be dangerous restraint methods, many former pupils have spoken out against the school’s approaches. Jennifer Msumba, a former pupil, has spoken extensively about her treatment at the school, saying, ‘It felt like I was being punished for being born.’ The JRC claims to use ‘compliance’ as a ‘treatment goal,’ claiming that ‘students are given a variety of demands and tasks to perform throughout the day, are rewarded immediately when they comply, and lose privileges if they refuse.’ This punishment and reward system can result in loss of privileges when ‘problem behaviors’ are displayed (JRC, 2023). So-called problem behaviours can include: ‘Health Dangerous (includes self-abusive actions such as hitting self); Aggression; Destruction; Noncompliance (such as refusing to follow a learned direction); Major disruptive behaviors (such as screaming, stealing, touching others without permission); and Educationally and Socially-Interfering behaviors; Inappropriate Verbal Behaviors’ (JRC, 2023). Under these parameters, staff could administer punishments on the basis of non-compliance for a person engaging in any behaviour that they feel is undesirable. Indeed, the JRC states that, ‘If a particular student needs more than these seven standard categories, additional categories are created.’ Essentially, what this means is that staff can determine what is desirable or not, and have complete control over what behaviours should be rewarded, and which punished. This adheres to the medical model of disability, whereby autistic individuals and people with learning disabilities are forced to conform to neurotypical standards of behaviour. Behaviours like stimming, which may be necessary to self-regulate, can be punished under this regime, denying individuals essential coping mechanisms. The medicalised language used by the JRC attempts to justify the practice of electric shocks as a treatment procedure, sending problem behaviours into ‘remission.’ Our view at Studio 3 is that so-called ‘problem’ behaviours are actually a sign of extreme distress and trauma, and that there is no place for approaches which involve re-traumatising individuals and making them more distressed. The International Coalition Against Restraint and Seclusion (ICARS) recently stated that there is evidence of shocks being administered ‘not just for discouraging undesired behaviors but for the actions that precede the undesired behaviors’ (Lodestone, 2021). Evidence that CESS is being used not to mitigate risk of injury to students or staff, but to correct and change behaviours, confirms the concerns of autistic advocates and individuals across the globe – that this method is neither therapeutic nor ethical. Eliza Hunt, lead organiser of ‘Stop the Shock Coalition,’ has frequently spoken out against the practice of CESS as being disproportionate to the behaviours being punished (Ruhalter & Rath, 2023): ‘The JRC contends that they only use this for dangerous behaviors, but at the same time, they also say that certain actions like standing up is, for certain individuals, an indication that they’re going to be violent.’ It is inevitable that where restrictive practices are allowed to persist in aversive cultures, staff will inevitably fall into the ‘slippery slope to abuse,’ whereby restrictive practices become the first resort, not the last resort (McDonnell et al., 2014). Where restrictive and aversive practices are normalised, the degree of lasting harm and trauma they cause to individuals is minimised by staff. Whilst people may believe they have no other choice and that they are using restrictive practices as a ‘last resort,’ this is rarely the case in reality. Pain Compliance It is essential that practitioners and organisations in the caring industry speak out against aversive practices such as pain compliance, restraint, and seclusion. Many former pupils have confirmed that the electric shock devices are incredibly painful. The recent task force interviewed 4 pupils at the school who, as of July 2022, were receiving CESS. All four students stated that the electric shocks were painful to receive, and the majority said that they did not want to receive them. One resident, unsolicited and without prompting, asked the task force members to remove them from JRC. The inhumane practices at JRC have been widely spoken against by many individuals and organisations across the globe. The Autistic Self-Advocacy Network (ASAN) have been leaders in the ‘Stop the Shock’ campaign against JRC. A recent survey from NeuroClastic asked the public how they felt about the use of electric shock as a punishment for disabled adults (2023). The responses include: 'I think that it's abusive and torturous and should be banned at all costs.' 'Absolutely horrified and prepared to do anything in my power to make it stop.' 'It is grossly inhumane. Electroshock should not be used as a “therapy”, nor should any type of aversives.' The results of a recent ICARS poll on X (formerly Twitter) demonstrates that 96.8% of parents who voted would not like their child to be subject to any of the practices being used at JRC, not just CESS. We cannot stress enough the importance of listening to lived experiences in order to inform against abusive practices such as these. Dr Damian Milton has spoken extensively against aversive practices which seek to alter behaviours. In a Studio 3 web conference, Damian spoke about his opinions on aversive practices and punishments in the caring industry (Milton, 2020). In addition, Professor Andrew McDonnell, CEO of Studio 3, has spoken frequently about his views on punishment (McDonnell, 2018): ‘In my work I am often asked about the role of punishment to correct behaviours. There is no doubt that sanctions and negative consequences can have an impact on the behaviour of children and adults. But what do people learn in these circumstances? Our role is to encourage self-regulation rather than imposing external controls.’ It is clear that the focus on control and compliance at the JRC violates the Human Rights of the children and adults being supported, and is both inhumane and untherapeutic. Punishing stressed and traumatised individuals for engaging in behaviours that they need to engage in in order to self-regulate has no place in caring environments. Attempts to alter behaviour that is perceived to be disruptive, ‘bad,’ or not typical, merely forces conformity and asserts control over vulnerable people. It is our role as educators, supporters, and carers to understand why a person may need to engage in certain behaviours, and to constantly question our own beliefs around behaviour. Punitive systems such as these which use punishment/reward schemes and restrictive practices can not only re-traumatise individuals, but also create a lack of self-agency and independence that is essential for well-being. By inflicting physical and psychological pain, supporters destroy the ability to form safe and therapeutic relationships with individuals, which is the key to supporting individuals to lead thriving independent lives, supported by their community. Compassion and empathy are essential, which is why there is an urgent need for a unified approach from autistic advocates and professionals determined to enact change and permanently ban the application of aversive and out-dated treatments such as CESS. In 1979, Dr William Bronston said of JRC that the school used an ‘unrelenting pursuit of traumatic interventions’ against its most ‘powerless and undefended’ students (Summers, 2021). That this still rings true today, more than 50 years later, should be a wake-up call for organisations and individuals around the globe to ensure that these practices are not allowed to continue. References Judge Rotenberg Center. (2023). Behavioural Treatment. Judge Rotenberg Center [Online]. Available from: https://keyfeatures.judgercblog.org/behavioral-treatment/. Lodestone, A. (2021). Autistic Advocates and Behavior Therapy Industry Professionals Join Forces to #StopTheShock. International Coalition Against Restraint and Seclusion [Online]. Available from: https://againstrestraint.com/2021/08/26/autistic-advocates-and-behavior-therapy-industry-professionals-join-forces-to-stoptheshock/. McDonnell, A. (2018). Negotiate Don’t Punish. LinkedIn [Online]. Available from: https://www.linkedin.com/pulse/negotiate-dont-punish-andy-mcdonnell/?utm_source=share&utm_medium=member_ios&utm_campaign=share_via. McDonnell, A., Breen, E., Deveau, R., Goulding, E. & Smyth, J. (2014). How nurses and carers can avoid the slippery slope to abuse. Learning Disability Practice, 17(5): 36-39. doi: 10.7748/ldp.17.5.36.e1516. Milton, D. (2020) Applied Behavioural Analysis and the autistic community: time to listen. In: Are We Asking the Right Questions About Behaviour? Studio 3 Web Conference [Online]. Neuroclastic. (2023). Judge Rotenberg Center – Responses. Survey Monkey [Online]. Available from: https://www.surveymonkey.com/results/SM-2TSVC9G99/. Perone, M., Lerman, D., Peterson, S. & Williams, D.C. (2022). Report of the ABAI Task Force on Contingent Electric Skin Shock. ABAI International [Online]. Available from: https://autisticadvocacy.org/wp-content/uploads/2022/11/CESS-Task-Force-Report-09-28-22.pdf. Pierson, B. (2023). Massachusetts top court allows electric shock therapy for disabled patients. Reuters [Online]. Available from: https://www.reuters.com/legal/massachusetts-top-court-allows-electric-shock-therapy-disabled-patients-2023-09-07/. Pilkington, E. (2018). 'It's torture': critics step up bid to stop US school using electric shocks on children. The Guardian [Online]. Available from: https://www.theguardian.com/us-news/2018/nov/16/judge-rotenberg-center-massachusetts-electric-shocks. Ruhalter, K. & Rath, A. (2023). Electric shock therapy is still allowed in one Mass. treatment facility. Advocates say change is long overdue. GBH News [Online]. Available from: https://www.wgbh.org/news/local/2023-09-11/electric-shock-therapy-is-still-allowed-in-one-mass-treatment-facility-advocates-say-change-is-long-overdue. Summers, J. (2021). The Shocking School. Boston Review [Online]. Available from: https://www.bostonreview.net/articles/the-shocking-school/.