New article - The Slippery Slope to Abuse. November 2013.

The impact of the panorama documentary 'Undercover care the abuse exposed': A personal perspective

Andrew McDonnell PhD. Clinical Psychologist
Director Studio3 Training Systems
No one shall be subjected to torture or to inhuman or degrading treatment or punishment. European Convention on Human Rights - June 2011

I should start by stating that the documentary aired on Monday 30th May was a truly disturbing experience for anyone who watched it. On a personal note it has had a positive impact on my colleagues at Studio3 Training Systems and of course it has had a profound impact on my own behaviour; we at Studio3 intend to redouble our efforts to make restraint a thing of the past. My heart goes out to the many families of people with intellectual disabilities and autism who will have been disturbed by what they witnessed. However, there are many organisations and individuals in the UK that should view this documentary as a wake up call. I would like to outline a personal view about how we at Studio3 manage the behaviours of people who present with challenging behaviours and I will use the experience of the documentary as a focal point.

What did we witness?

I am very aware that criminal proceeding are taking place and therefore specific comments are subject to sub judice rules. I will begin by summarising some key issues:

  • There were numerous incidents where physical restraint was being applied for what can only be described as minor reasons.
  • The shear variety of the physical restraints involved were staggering, these included the use of painful wristlocks, staff applying pressure to the neck area, bending fingers back, the use of a chair as a restraining device,
  • Service users appeared to be victims of physical and verbal assaults from staff.
  • Staff appeared to have developed a controlling culture where they appeared to believe that they had to 'get tough' with service users or they would lose control.
  • There were overt uses of punishment (physical assaults, throwing water on people) and with more subtlety, the denial of preferred objects to individuals.
  • Individuals were seen to be 'ringleaders' of the abuse appeared to be allowed to practice without challenge.
  • Managers appeared to collude with these practices.
  • Recording of 'incidents' appeared to be fabricated.
  • The above descriptions present only a limited summary of the many abusive practices which I defined as 'torture'. Certainly, from a human rights perspective we witnessed acts that were 'degrading and inhuman'.

An expert commentary

I was asked as an expert to view some of the undercover footage, it became very clear to me that what I was seeing was far worse than I expected. In over 25 years of working with people with intellectual disabilities the practices I witnessed were horrific. I consider myself to be an emotionally robust individual, but, I do not think that I will ever forget many of these scenes. My initial emotional response was one of shock and then disgust and finally this turned into anger. However, in many ways the documentary has reaffirmed my values and beliefs that how we manage distressed people is an acid test of our own humanity. I have always believed strongly that to understand challenging behaviours we must always reflect on our own values and attitudes. For me there are a number of key aspects to working with individual who may from time to time present with challenging behaviours.

There is a slippery slope of abuse

When I witnessed the level of intensity of abuse in the documentary I was reminded that abuse does not occur in a vacuum. People are often witnesses to very subtle controlling measures by their colleagues and over time they tend to acquiesce. Abuse does not occur overnight there is a slippery slope in terms of bad practice that leads to more and more restriction and abuse. In the documentary there were brave whistleblowers and I wholeheartedly praise them for their courage.

In addition there are levels of restrictions such as boundaries and rules which lead to a culture of control. These can involve locked doors, withdrawal of privileges, stopping of activities as a punishment; all in the name of behaviour management. I very often come across people who believe that individuals are presenting with challenging behaviours to control or manipulate people. The reality is that stressed individuals reach a point where they literally are not processing information around them. In many situations the service user wants to literally escape from the situation. But, research shows clearly that the more a person perceives a challenging behaviour as deliberate the more controlling and less caring they are likely to be towards that person. This in my experience leads to a whole chain of assumptions that end with controlling responses from staff or carers.

I am very concerned that people forget that there is a ?slippery slope?. Each time a person withdraws a drink or imposes more boundaries and restricts choice then another step has been taken down the slippery slope. Significant numbers of incidents of challenging behaviours are inadvertently triggered by carers. If a person does not understand this then they will never accept that their own behaviour is having a positive or negative impact.

The more the process continues the more people start to dehumanise people. There have numerous psychological studies which demonstrate that ordinary people may be able to commit barbaric acts and justify what they have done. The American psychologist Stanley Milgram (1974) managed to get ordinary members of the public to deliver electric shocks to people in a learning experiment. We can already think of examples from history ranging from the holocaust, to modern day massacres in the Congo and Bosnia. How is this relevant to the documentary? People were behaving in a barbaric manner to people with intellectual disabilities and autism. They talked about them like they were dangerous animals that needed controlling.

The opposite approach is to continue to see the person behind the behaviours. In my work I have always been impressed by carers who can see that a person who is being aggressive is often a victim of trauma. Some people are capable of 'humanising' people. That is, they see the person and not their behaviours. When we work with vulnerable people we must be vigilant for the first signs of dehumanising practices by carers. Good warning indicators include the use of devaluing language, treating individuals with disabilities and autism like children, using consequence based interventions. In the latter case one punishment can lead to another and then another; this was typical in the old behavioural psychology of the 1980's and it has no place in modern day practice.

Crowded Poor Quality Environments Maintain Challenging Behaviours

In the mid 1980's I was a newly qualified clinical psychologist, trained in behaviour analysis. In my early career I would often be asked to 'fix' behavioural difficulties and tried to ignore the fact that these individuals lived with individuals with similar difficulties. As an analogy, if you have a problem with your weight, will you learn to control your weight living with other people with similar problems? Putting it more bluntly do distressed people improve by living with others who are similarly distressed? Herding distressed people together can only exacerbate challenging behaviours. These types of services often turn into 'pressure' cookers. Incidentally, I should also state that I have witnessed the major improvements.

Stressed people can be traumatised by care environments

Significant numbers of individuals who are labelled as challenging are often victims of trauma. Placing them with similarly traumatised people seems illogical models and approaches to behaviour management skills need to account for the traumatised nature of the populations in their care.

It is firm belief that the common denominator of many people who present with challenging behaviours is stress. If an individual is viewed as being high susceptible to stress it changes our responses to them. The real question is how should we manage people who are stressed? In Studio3 we developed the low arousal approach to manage difficult behaviours (McDonnell 2010). Two key elements of the approach is to understand that a person is traumatised and to encourage people to be reflective about their own contribution to challenging behaviours. The central key is to create environments which reduce arousal and stress as this will allow the development of positive relationships between carers and service users. We have trained staff to manage crisis situations using a low arousal approach. The idea is incredibly simple always ask the question how would you approach and communicate with a person who is highly stressed and in a state of hyperarousal? Although, it would appear to be commonsense to avoid increasing arousal in these circumstances many carers (often inadvertently) seek out confrontation.

People are often restricted from things that give them pleasure and reduce their stress.

When we are distressed or unhappy we often attempt to distract ourselves with things that give us pleasure. This is primarily a coping response to stress. It has always amazed as a clinical psychologist how much of the negative impact of stress can be alleviated by practical coping responses. Many people with intellectual disabilities and or autism usually have limited access to these opportunities. I was working in a house for a number of people who had been resettled into the community from a local institution. It is no surprise that many of these individuals were labelled as very challenging. Years of control by often well intentioned carers had led to a situation that the few pleasures in their life (food and drink) were restricted. Given their extremely traumatic histories it was not surprising that food and drink were a major issue. I remember when one staff member complained that every time she 'unlocked' the kitchen door service users would almost charge past her. One young man even accessed a freezer and attempted to eat frozen meat. My approach was simple. Start to open the door gradually, let people learn that they do not have to grab food like they were on a military raid. I cannot comment fully on restrictions that might have ben in place at Winterbourne View but my guess is that there would have been many as that typify specialist places.

Reflection: Am I part of the problem?

Carers often were a cause of many episodes of challenging behaviour (mostly inadvertently). Most of my information came from these people. Often the most negatively vocal individuals had poor relationships with the service user in question. In many cases these people had real difficulties in taking the service user's perspective. It is my firm belief that we need to consider that sometimes 'staff are part of the problem'. This could be reframed very easily in a positive manner; if carers can be part of the problem they can also be part of the solution.

Physical interventions should never become acceptable in services

There are many policies which state that physical interventions should only be used as a last resort. The reality is that staff will sometimes use them as a first response. My own approach to this in developing the Studio3 approach was to teach as few interventions as possible, avoid techniques that deliberately inflict pain and set boundaries to what can be taught to staff. In my experience we have to provide methods that maintain dignity and respect. Better still we need to develop cultures that aim to eradicate the usage of restraint. My own organisation in 20 years has not taught hold down methods of any kind and we do not intend to start now. We encourage staff to practice very simple low key methods. I have never taught methods in 'matted areas' as care environments do not have these. Consider the statement which is the mantra of Studio3 trainers 'if you need to practice a technique safely on a matted area then by definition it will be very unsafe to apply in a care home'. In the documentary I witnessed physical techniques that had been 'bastardised' and martial art techniques that have no place in care settings. If a person is distressed and vulnerable why on earth would you inflict pain on that person, how is such a technique going to calm a situation?

Therefore, physical interventions should be limited and highly regulated in their use. We should accept there use in care settings as anything more than an admission of a failure of communication. I stress that this is not just some form of naive idealism. We have set very high standards in this area. In my view every time a method is used staff should ask a simple question 'How do I avoid doing that the next time?' and most importantly 'was it justified and /or could I have prevented its use?' In the vast majority of cases with careful analysis the use of physical interventions are preventable.

The last area I wish to address is the over justification of restraint by means of legal argument. In my career I hear only too often that we can all use reasonable force to defend ourselves and that force should be proportionate in any area of restraint. But, who determines what is reasonable? Moreover, what exactly is the so called 'proper use' of restraint? The justification of physical restraint is a psychological process of rationalisation. On a personal note I would rather allow a distressed individual to damage property than use that as an excuse to restrain a person with disabilities or autism. So we must make concerted efforts to never accept the use of physical interventions. Finally, people often use the concept of reasonable force to imply that carers are at a major risk of harm and therefore they have a right to defend themselves. I have always had a simple response to this. Working with vulnerable and distressed people is not the same situation as being mugged in a dark alley. If people cannot distinguish between these two situations then do not work in care settings.

Training with positive values and clear boundaries

Training staff to manage challenging behaviours has been my lifes work. For the record I do not believe that training on it's own will ever be enough, but, it is still important. Staff training is necessary but not sufficient for change to occur. The key issue for me is that training that imparts knowledge and skills alone is not suficient. Training in behaviour management should encourage people to reflect on their own practice. Training should also challenge attitudes and beliefs about behaviour and encourage carers to view service users as victims of stress and panic. It is also my strongest belief that training should impose clear boundaries on what is acceptable and unacceptable practice. My own organisation has sometimes been criticised for being very restrictive about what we teach. This is because we constantly challenge individuals through training and impose clear boundaries such as 'avoid the use of sanctions' or 'give people choices not boundaries' and in extremes do not use any kind of floor restraint holds.

My own organisation is called Studio3 Training Systems for a clear reason, namely, a training system implies an organisational approach. We try to create a low arousal message throughout the culture of the organisation so that the message is reinforced at all levels. We accept that this is a difficult and complex task. Sometimes my colleagues do get frustrated with the slow process of change in some organisations, but, I feel strongly that the documentary shows why these messages are so important.

Inspection of Services

On a final note what can we say about the regulation of services? I do not claim to be an expert on this subject but, it does seem to me that inspection should be an 'unannounced' process. It is difficult to always reveal abusive practices, but our system needs to be more robust. I think having more inspectors is not the answer on it's own. There needs to be a very transparent whistle blowing process to inspection services. I favour a small undercover group (this could include services users and carers) with advice from the police. This group could be regularly rotated. I believe that referrals to such a group would involve only a small sample of agencies but, it would send the message that it is not just the BBC that can work undercover.

My Conclusions

There are many places throughout the UK that offer good quality supports for people with disabilities and autism. It is imperative that we must not blame the whole care system for the systematic abuse we witnessed. Although, it is impossible to quantify the bad practice we observed at Winterbourne View cannot be an isolated event. I believe that we must make it extremely difficult for individuals such as these to operate in any care setting. There are so many things that need to change both at the coalface and organisationally to avoid the horror of Winterbourne View. At the moment there is righteous indignation and public outrage but, if we are to truly learn from this we need to think about simple steps to make a real difference. So here is my summary:

  1. Better quality environments for people who challenge let us stop clustering distressed people together. It is my view that commissioning services on an individualised support basis represents the best way forward.
  2. Make these environments enriching and fun. (I have a simple rule it is quite easy to witness service users laugh or show signs of happiness, this does not require fancy measurement!).
  3. We need to understand that many challenging behaviours are linked to the stress of individuals and the lack of purpose in their lives.
  4. We need to make staff more reflective about their own contribution to challenging behaviours, (this is the cornerstone of the low arousal approach) (McDonnell, 2010). If a person recognises that they are part of the problem then they can become part of the solution.
  5. Training in behaviour management needs to challenge the attitudes and beliefs of staff. Training should contain clear messages of what is unacceptable practice.
  6. Training organisations need to accept that they have a role in investigating the implementation of their training in the area of physical interventions. We believe that training organisations need to provide evidence that they have audited their training post delivery.
  7. There needs to be clear organisational messages about what is acceptable and unacceptable practice. Organisation need to publicly pledge to minimise the use of restraint and other restrictive practices and make data available to public scrutiny.
  8. All physical interventions usage should be considered as a failure of communication. If we are to eradicate such approaches we need restrict their use in training and in the workplace. I call for organisations to consider that every individual who attracts physical interventions on a monthly basis should have a clear restraint reduction plan.
  9. I would call upon organisations themselves to ban the use of specific physical interventions. These organisations should not wait for a governmental decree. I was involved with the Millfields charter which called for a ban on prone restraint (McDonnell, 2007). We at Studio3 would go much further and call for a ban on supine restraint as well.
  10. With regard to inspection, I would support increases in unannounced visits to services but, in my opinion this will not help reduce abuse. I believe that Inspection does require a covert investigation arm. I feel strongly that agencies themselves need to be publicly more proactive about reducing the use of restrictive practices and creating a culture of zero tolerance to abusive practice.

A positive note

I would like to end this on a positive note. I cannot claim to have truly invented the concept of a low arousal approach. In the past there have been many great innovators in this field. In my book 'Managing aggressive behaviour in care settings: Understanding and applying low arousal approaches' I illustrated this point by examining the work of the physician Jean Marc Gaspard Itard. In 1799 the so called 'wild boy' was discovered in Aveyron in Southern France. Victor was mute and attempts were made by to restore his speech and socialise the young man. Although Itard could not help him to speak Victor was reported to be more placid and capable of understanding some verbal communication and showing empathy. Victor lived with Itard and his housekeeper Madame Guérin until his death in Paris in 1828. The approach adopted to manage Victor contained strong elements of low arousal approaches. I would finish with Itard's observations about how to work with Victor He was acquainted with four circumstances only; to sleep, to eat, to do nothing, and to run about in the fields. To make him happy, then, after his own manner, it was necessary to put him to bed at the close of the day, to furnish him abundantly with food adapted to his taste, to bear with his indolence, and to accompany him in his walks, or rather in his races in the open air, and this whenever he pleased.' (p38).

With regard to Studio3, our philosophy of low arousal is not new, but its relevance to the modern practice of care is very high indeed. I was always taught that you get more out of people with kindness. Although it is a simple mantra it has always been my own guiding principle. I hope that we can learn from the trauma of the documentary and make a real difference to the lives of people with intellectual disabilities and or autism.