In this article, Professor Andrew McDonnell describes the evolution of Studio 3 Training Systems and Clinical Services, and the development of a non-aversive approach to crisis management now widely known as the Low Arousal Approach.
The ‘Low Arousal Approach’ in the context of managing behaviour was first introduced by myself in the early 1990s. In 1994, I published a chapter in a book about crisis management where I first used the term (McDonnell, McEvoy & Dearden, 1994), but the concept of arousal and its influence on behaviour was then not a new one.
Arousal refers to the physiological process by which individuals react to the environment around them, simulating a stress response by activating the autonomic nervous system. This can involve increased heart rate, changes in breathing, and increased alertness, which can in turn affect areas such as learning, attention, and information processing. In psychology, Yerkes and Dodson’s (1908) research showed that arousal and performance are linked in a bell-shaped curve, whereby a certain level of arousal was required for optimal performance in a series of tasks, but too much or too little arousal impeded performance. Physiological arousal can also be seen to have an unconscious impact on emotions, judgements, and behaviour, though even now, arousal mechanisms and how they influence individuals are still poorly understood. I remember having a conversation with the cognitive neuroscientist Elkhonon Goldberg around 20 years ago, who was one of the leading experts of the time. This conversation confirmed to me that arousal mechanisms were crucial to understanding and managing distressed behaviours (then referred to as ‘challenging behaviours’). My Own Low Arousal Journey I originally trained as a Clinical Psychologist at the University of Birmingham in the UK in the late 1980s. In these early days, I was particularly concerned with treating people in crisis situations in a humane manner. Eventually, the methods that I developed led to the formation of my organisation Studio 3, and to the growing network that now believe in and apply Low Arousal Approaches. What started out as a goal to train staff in alternatives to restraint and seclusion has now evolved into a philosophy and a way of thinking about, interacting with, and supporting individuals.
This brief article has emerged from many individuals asking me questions about the Low Arousal Approach and its origins. What follows is a personal and ultimately subjective account of the evolution of this approach. I want to stress that the Low Arousal Approach overlaps and interacts with many historical philosophies of non-confrontation and non-violence. It is also steeped in unashamedly humanistic values. For my own part as a practicing Clinical Psychologist advising supporters and families, it has certainly changed my practice. When I first qualified, I used to refer myself as a ‘radical behaviourist.’ These days, I would describe my clinical approach as eclectic. Recently, I published a practitioner article on the Studio 3 website describing my journey as a ‘recovering behaviourist’ (McDonnell, 2019b). Even in the early days, I became obsessed with trying to give people the skills to manage day-to-day crisis situations in a positive manner, and moved away from my teaching rooted in Behavioural Psychology. The following timeline seeks to demonstrate the evolution of the Low Arousal Approach from its humble origins in crisis management training, to its current status as a philosophy of practice in the present day.
Timeline of the Low Arousal Approach
1984-6: Pre-Low Arousal Throughout this period, I had not yet qualified as a Clinical Psychologist and needed to obtain experience: ‘I spent a year working in an institution for people with intellectual disabilities. Most of the people they asked me to support had highly traumatised histories. The wards (definitely not homes) were overcrowded, and in some ways it felt more like a prison. I worked with some amazingly caring staff, but there were others who were just disconnected from the people they supported. I learned to recognise a small minority of people who seemed to enjoy demonstrating their power. My first debates with staff involved giving people cups of tea ‘off the schedule.’ I witnessed physical restraints being applied to people and it became clear to me that the largest cause of ‘challenging behaviours’ were the people supporting these individuals. It took me a long time to realise that these extreme experiences were going to shape my entire career.’ – from The Reflective Journey (McDonnell, 2019a, pp. 6-7) During this time, I had my first exposure to using restraint, both as an observer and a participant. I was extremely uncomfortable that decent people could justify what would later be described as physical interventions. I was exposed to many different methods and techniques which I realised did not take into account the experiences of the people being cared for. My first exposure to training in crisis management occurred in 1984, where a nurse showed me some techniques in a two-hour session. At the time, I was also learning a martial art called Jiu Jitsu, which became a life-long passion. I began to realise that there was very little systematic training in this area, and that people weren’t being given sufficient tools to manage crises. In my book Managing Violence and Aggression in Care Settings (2010), I showed an example of one of the many methods that I was taught during this period: I still cannot believe that I originally participated in restraint without question. Like many junior staff, I accepted the authority of senior people who I rather naively thought knew more than me. It became clear to me very early on that methods of managing crises and the physical skills that were being taught were not proven to be effective or safe. During this period, I also began to question many of the behaviourally-based techniques that I had been taught - most notably, the use of aversive consequences to manage behaviours, including punishments and sanctions. I remember a nursing colleague explaining to me that people needed ‘firm handling and boundaries.’ I still smile to this day remembering what I said to them: ‘This is not some kind of boot camp, and we are not trying to break horses; these are human beings.’ At this time, simplistic reward-based systems such as ‘token economies’ where people had to earn ‘rewards’ were extensively used. By the time I started my training as a Clinical Psychologist, I was beginning to question what people really needed to support them in times of crisis. To me, it became increasingly obvious that people need caring and compassionate responses. Most importantly, I really started to worry about what was being taught to staff to manage crisis situations in terms of what we now call physical interventions (though I still call them restraints). 1986-90: Bad Kung-Fu During this period, I attended a number of training courses, mostly titled ‘managing violence.’ The themes were consistent across these courses, and the instructors were nearly always males with some kind of police, military, or martial arts background. I considered myself a mystery shopper, and was determined to see what customers were being taught. I learned that there was no clear rationale for de-escalating incidents. The courses predominantly consisted of people being taught a collection of physical methods which they would have little chance of remembering once they left the training room. I could also see that the physical skills taught were often taken from a variety of martial arts, none of which should be applied to individuals in care environments. The most established system in the UK at the time was called ‘Control and Restraint.’ The origin of this approach appeared to be the UK Prison Service. The training courses that I attended really shaped my thinking. Many of these courses used aversive holds and the locking of joints to deliberately inflict pain on individuals. I remember attending a training course with a leading UK managing violence trainer who spent most of the time sharing his experiences of managing violent situations in the military and nightclubs. I remember thinking, ‘What has this got to do with supporting the vulnerable people that I work with?’
As a trainee Clinical Psychologist, I fed back to my supervisors, most notably a colleague called Alan Richens. He suggested that I should try to develop an alternative training programme. Shortly afterwards, I ran a two-day training course in a hospital for people with intellectual disabilities called Monyhull in 1987 – a course which eventually became the origin of Studio 3 Training Systems. It was the first step in trying to create something different, and our message was clear - no-one should be restrained on the ground.
I have also been fortunate to be a practitioner of the martial art of Jiu Jitsu for most of my adult life. In the early development of the Low Arousal Approach to managing behaviours, I was always certain that my martial arts experience (at that time I had achieved a black belt) should be kept separate. I was concerned that people wouldn’t understand the importance of de-escalation if there was a focus on teaching people physical skills.
Around this time, I became passionate about the work of the amazing Gary LaVigna and Anne Donnellan. In 1986, they wrote a book called Progress Without Punishment. This book described a clear rationale for people who were behaviourally-orientated, and that the avoidance of aversive consequences could be achieved by building skills for individuals. Both of these people greatly influenced my own thinking. In latter days, I have discussed with both Gary and Anne that their book drove me to look even closer at crisis management. I noticed that they both did not address crisis management, preferring to focus on preventing behaviours. I now know with the benefit of hindsight that they were both uncomfortable with talking about crisis management strategies such as physical restraint. I decided that we needed to talk about both. 1990-2000: Developing Alternatives The 1990s were a period where I became focused on developing alternative crisis management training. My key focus was on avoiding harm to individuals. The original core 3-day training we developed had a 50% focus on managing physical situations. Even with trying to minimise the use of physical interventions, I believe now that we provided too many ‘physical tricks’ to the frontline staff that we were training.
From this, the Studio 3 organisation was formed in 1992 by a small group of us who had started the training and wanted to make sure that we could protect the construct. This was also a highly productive period for my own academic writing on the subject of crisis management. There was so little written in these days that I felt like I was starting from scratch. In 1991, I wrote three conceptual articles for the British Institute of Learning Disabilities (BILD) (McDonnell, Dearden & Richens 1991a; b; c).
The first article examined staff training in the management of violence and aggression in terms of organisational systems, outcomes, and policies and guidelines (McDonnell, Dearden & Richens, 1991a). This second article presented strategies for avoidance and escape in the management of potentially violent situations using non-violent methods (McDonnell, Dearden & Richens, 1991b), and the final article examined how to deal with physical violence by using a non-violent method of physical restraint (McDonnell, Dearden & Richens, 1991c). I wrote a similar article for the British Journal of Special Education which outlined the basic principles of what we now call the Low Arousal Approach in classroom settings to manage challenging behaviour amongst children with learning differences (McEvoy, McDonnell & Dearden, 1991)
This was conceptually the strongest academic period for me to develop the ideas and concepts of what I began to call the Low Arousal Approach to managing behaviours. During this time, I did not particularly separate defusion and de-escalation from teaching people alternative physical interventions. I believed then, and still do now, that crisis management training needs both elements. Of course, there can be no argument with the idea that de-escalation is better than intervention, and that prevention is better than crisis management. Unfortunately, these statements created a taboo area where people did not want to talk about difficult issues such as physical restraint, seclusion, and the use of punishments and sanctions. I decided to make it my mission to get individuals to start talking meaningfully about crisis management. I passionately believe that transparency is the only way forward. We can only change bad practice by acknowledging it and coming up with alternatives. One niche area of my own research was to examine what we now call today physical interventions. I became very interested in a concept that arose in behavioural psychology called social validity. This emerged from the work of Montrose Wolf, an American psychologist who argued that interventions of all kinds may have social implications (1978). I decided to use pictures to show 3 methods of restraint that I had found in the limited literature. In effect, one was a prone hold, another was a supine hold, and the third was a method of holding someone in a chair which I developed within the Studio 3 system. This was the subject of an academic paper (McDonnell, Sturmey & Dearden, 1993). Throughout this period I was a practicing Clinical Psychologist, mostly working with people with an intellectual disability and/or autism in the West Midlands in the UK. I became the psychologist for Monyhull Hospital, where I had the opportunity to try and change practices in what could best be described as an institutional setting. My colleagues and I made great strides in changing practices on a day-to-day basis. There are a series of published articles that directly relate to my work at Monyhull (on phasing out seclusion - McDonnell & Reeves, 1996; evaluating a 3-day training course - McDonnell, 1997; applying non-aversive approaches - McDonnell, Cleary, Reeves, Hardman & King, 1997; safety, effectiveness, and social acceptability of physical restraint methods - McDonnell, 1998; single case study in the application of a Low Arousal Approach - McDonnell, Reeves, Johnson & Lane, 1998). This collection of articles really reflected the development of my own interest in training, de-escalation strategies, and the ethics of physical restraint. At this time, I also wrote a conceptual article about the approaches that I was developing (McDonnell & Sturmey, 1993). This article outlined key aspects of a Low Arousal Approach in terms of reducing physiological arousal in an individual’s environment by reducing maintained eye contact, physical touch, and proximity of supporters. The first use of the term ‘Low Arousal Approach’ appeared in a book chapter in 1994 (McDonnell, McEvoy & Dearden, 1994). The Low Arousal Approach was initially defined as ‘attempts to alter staff behaviour by avoiding confrontational situations and seeking the least line of resistance’ (McDonnell, Reeves, Johnson & Lane, 1998: 164). This definition was then expanded for a chapter in a book written in 2002 to include four key components (McDonnell, Waters & Jones, 2002):
‘1) The reduction of potential points of conflict around an individual by decreasing staff demands and requests. 2) The adoption of verbal and non-verbal strategies that avoid potentially arousing triggers (direct eye contact, touch, avoidance of non-verbal behaviours that may lead to conflict, aggressive postures and stances). 3) The exploration of staff beliefs about the short-term management of challenging behaviours. 4) The provision of emotional support to staff working with challenging individuals.’ By the end of the 1990s, the Studio 3 organisation was training staff in the UK and the Irish Republic. We were becoming more confident about the effectiveness of our crisis management training, and conceptually the Low Arousal Approach to managing behaviours appeared to have some kind of ‘face validity.’ 2000-2010: Changing Mindsets This was a period of great productivity. Most notably, Studio 3 Training Systems began to go from strength to strength, extending across 14 countries. The concept of Low Arousal was reformulated to include cognitive, behavioural and social aspects, as described above (McDonnell, Waters & Jones 2002). A systemic review of the literature on the effectiveness of staff training in physical interventions was also undertaken, which revealed a poor evidence base for many of the approaches in practice at the time (McDonnell, 2009; McDonnell, 2010). Originally, a Low Arousal Approach had focused on non-verbal and verbal de-escalation strategies and a system of physically managing people without the need to use punitive physical techniques. The great change in emphasis occurred during this period where empathic understanding and reflective practice became central themes to the approach. Training courses would invariably involve a conversation around the role of supporters in crisis incidents. I remember telling a group of professionals around this time who were in a large audience that they were the largest cause of challenging behaviour on the planet. Around this time, I started to believe that good crisis management, where people were treated with dignity and respect, and of course allowed some kind of choice and control over their environments, was all that some people needed to thrive. I became more and more convinced that simplistic behavioural approaches were in many situations escalatory in nature. When a person is drowning, that is the worst time to teach them to swim, as my colleague David Pitonyak wonderfully says. 2010-Present: A Global Network of Low Arousal Practitioners There are many individuals that I have worked with who have expanded the construct of Low Arousal. In the UK, my colleagues Andrea Page and Linda Woodcock began to collaborate around adapting our training for families. Andrea eventually completed a PhD on the subject of clinical holding of young children in hospital, which was an incredible extension of our work. Both Linda and Andrea wrote a wonderful practitioner book for families called ‘Managing Family Meltdown’ (2010). Another individual who taught me about applying the Low Arousal Approach to different cultures is my colleague Bo Hejlskov Elven. Bo attended one of the first training courses in Denmark in 2004/5. Bo became a Studio 3 Trainer and I discovered that we had a mutual interest in empathic approaches to supporting people. Bo’s background was not in behavioural psychology, and he is a passionate advocate of non-confrontation. I know that Bo has also been influenced by people such as the American psychologist Ross Greene, whose views align with my own. To the present day, Bo is an influential thinker in what I would call the ‘Low Arousal movement.’ Bo has written many publications, but perhaps the one of most note for me is the book he wrote about Low Arousal Approaches, with the wonderful title ‘No Fighting, No Biting, No Screaming’ (2010). I published my first book the same year on the subject of ‘Managing Violence and Aggression in Care Settings’ (2010). The book was a ‘smorgasbord’ of ideas. One particular concept that I emphasised at the time was trauma-informed behaviour management. Much of the work about Low Arousal is and was undoubtedly informed by understanding that we are working with people who have been exposed to complex traumatic life events. My colleague Peter Vermeulen often describes individuals on the autism spectrum as trying to understand a world that is chaotic and confusing to them. Trauma-informed behaviour management means that behaviour management strategies, ranging from methods of control such as consequences and sanctions to the use of physical interventions, should focus on the traumatic impact of these methods. My understanding of arousal regulation also became more sophisticated. I published an article with my colleagues in 2014 that outlined the homeostatic model of arousal and behaviour (McDonnell et al., 2014). Arousal regulation requires people who are themselves ‘regulated.’ In recent years, I have become much more comfortable with constructs such as zones of regulation (Kuypers, 2011). There has also been significant overlap in terms of understanding arousal and arousal regulation with the excellent work of Stephen Porges into polyvagal theory. For me, the idea is quite simple: sometimes we are dealing with intense behaviours that go well beyond simple day-to-day contingencies. Mona Delahooke outlines many of these ideas in her excellent book, ‘Beyond Behaviours’ (2019). At the time of writing, there would appear to be a growing movement of Low Arousal practitioners across the world. Whilst their stance is often viewed as ‘anti-behavioural,’ the reality is that, whilst there are many useful tools and frameworks developed by behaviourally-trained individuals, the key to all behaviour change lies in developing positive and meaningful relationships with individuals. From my own point of view, my training in behavioural approaches gave me a framework to understand the world. My current belief is that Low Arousal Approaches are in effect strategies that can be applied to all people when they are experiencing arousal dysregulation. 2023 and Beyond It’s been quite a journey in the development of the Low Arousal Approach. A concept that originally focused on how to manage people in crisis situations when they are highly distressed has evolved into a philosophical approach. There are many potential areas that are worthy of exploration: I will attempt to highlight a select few. a) Furthering our understanding of arousal regulation and co-regulation is certainly an obvious area to develop.
b) Deepening our understanding of supporting individuals with complex traumas. I think it is worth noting that arousal regulation and trauma issues go well beyond simple DSM-V labels. c) Developing the idea that Low Arousal Approaches are essentially ‘transdiagnostic’ in nature. Managing distressed situations can occur across all care sectors, but applying principles of demand reduction, empathy, and compassion are guiding principles that work in all circumstances. d) A major area of development should involve a greater understanding of perceived control and how it relates to our responses. If we continue to perceive people in terms of their dangerousness, we cannot develop an empathic and compassionate approach. I am particularly reminded of the work of Gabor Mate in his work with traumatised individuals. e) It is increasingly self-evident that there are overlaps with approaches such as polyvagal theory (Porges, 2011). Low Arousal practitioners, be they care/support workers, family members, volunteers or professionals, need to develop formulations and understanding frameworks that go well beyond simple behavioural methodologies. By definition, Low Arousal Approaches do challenge people to think much more in the ‘here and now’ rather than the future (McDonnell, 2019) f) Understanding stress-based models and relating them to strategies that focus on developing a resilient work force, is a central part of the Low Arousal Approach. I would particularly like to thank my colleagues at the University of Northumbria for helping the Studio 3 organisation develop further our thinking about practical strategies for reducing staff or carer stress. In a recent study, my colleague Daniel Rippon (Rippon et al., 2020) identified what staff think is stressful. Most notably in this study, one of the largest categories was ‘other staff.’ This inevitably will need Low Arousal practitioners to focus more on how they develop meaningful relationships with the individuals they support, especially when it feels like they are being pushed away. My colleague David Pitonyak always argues that relationships are key. Developing relationships where people feel mutually safe and secure will be an important future direction. g) Eradicating the use of strategies such as restraint and seclusion (which I explore in more detail in my 2022 publication, ‘Freedom from Restraint and Seclusion: The Studio 3 Approach’). This also includes other forms of restraint, such as chemical restraint. My own Low Arousal journey has taught me that much can be achieved if we reflect on our own practice, and – most importantly – stop justifying methods with the old catchphrase ‘there is no alternative.’ There are always alternatives, they just require us to think outside of the box.
I cannot predict what the next 25 years will look like, but it is my hope and desire that other people will engage in the development of Low Arousal Approaches and continue to evolve the humanistic philosophy of the approach. Written by
Professor Andrew McDonnell
CEO and Clinical Psychologist, Studio 3 References: Delahooke, M. (2019). Beyond Behaviours: Using Brain Science and Compassion to Understand and Solve Children’s Behavioral Challenges. London: John Murray Press. Donnellan, A. M. & LaVigna, G. W. (1986) Alternatives to Punishment: Solving Behaviour Problems with Non-Aversive Strategies. New York: Irvington. Elvén, B. H. (2010). No Fighting, No Biting, No Screaming: How to Make Behaving Positively Possible for People with Autism and Other Developmental Disabilities. London: Jessica Kingsley Publishers. McDonnell, A. (2022). Freedom from Restraint and Seclusion: The Studio 3 Approach. Peterborough: Studio 3 Publications. ---------(2019a). The Reflective Journey: A Practitioner’s Guide to the Low Arousal Approach. Peterborough: Studio 3 Publications. ---------(2019b). The Recovering Behaviourist. Studio 3 Publications [Online]. Available from: https://www.studio3.org/practitioner-articles. ---------(2010). Managing Aggressive Behaviour in Care Settings: Understanding and Applying Low Arousal Approaches. Oxford: Wiley-Blackwell. ---------(2009). ‘Effectiveness of Staff Training in Physical Interventions’ in Allen, D. Ethical Approaches to Physical Interventions II. Avon: BILD Publications. ---------(1998). The physical restraint minefield: A professional’s guide. The British Journal of Therapy and Rehabilitation, 3, 45-48 ---------(1997). Training care staff to manage challenging behaviours: An evaluation of a three-day training course. British Journal of Developmental Disabilities. 43 (85), 156-162. McDonnell, A. A., Cleary, A., Reeves., Hardman, J. & King, S. (1997). What is a non-aversive approach? A bit of gentle preaching. Clinical Psychology Forum, no 106, 4-7. McDonnell, A. A., Dearden, R. L. & Richens, A. (1991a). Staff training in the management of violence and aggression: 1. Setting up a training system. Journal of the British Institute of Mental Handicap, 19 (2), 73-76. ---------(1991b). Staff training in the management of violence and aggression: 2. Avoidance and escape principles. Journal of the British Institute of Mental Handicap, 19 (3), 109-112. ---------(1991c). Staff training in the management of violence and aggression: 3. Physical restraint procedures. Journal of the British Institute of Mental Handicap, 19 (4), 151-154. McDonnell, A., McCreadie, M.†, Mills, R., Deveau, R., Anker, R., & Hayden, J. (2014). The Role of Physiological Arousal in the Management of Challenging Behaviours in Individuals with Autistic Spectrum Disorders. Research in Developmental Disabilities, 36, 311-322. McDonnell, A. A., McEvoy, J. & Dearden, R. (1994) Coping with violent situations in the caring environment. In T. Wykes (Ed.) Violence and healthcare professionals, London: Chapman Hall. McDonnell, A. A. & Reeves, S. (1996). The adoption of a non-seclusion policy on a locked ward for people with a learning disability. Nursing Times, 92, 43-44. McDonnell, A. A., Reeves, S., Johnson, A. & Lane, A. (1998). Managing challenging behaviours in an adult with learning disabilities: The use of a low arousal approach. Cognitive and Behavioural Psychotherapy. 26, 163-171. McDonnell, A. A. & Sturmey, P. (1993) Managing violent and aggressive behaviour: towards better practice. In R.S.P. Jones & C.B. Eayrs (Eds) Challenging behaviour and intellectual disability: A psychological perspective, Avon: Bild. McDonnell, A. A., Sturmey, P. & Dearden, R. (1993) The acceptability of physical restraint procedures. Behavioural and Cognitive Psychotherapy 21, 255-264. McDonnell, A. A. Waters, T. & Jones, D. (2002). Low arousal approaches in the management of challenging behaviours. In D. Allen (Ed) Ethical approaches to physical interventions: Responding to Challenging behaviours in people with Intellectual Disabilities. Plymouth: BILD, pp. 104 – 113. McEvoy, J., McDonnell, A. A., & Dearden, R. L. (1991). Challenging behaviour in the classroom. British Journal of Special Education, 18, 141-143.
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Rippon, D., McDonnell, A., Smith, M.A., McCreadie, M. & Wetherell, M.A. (2020). A grounded theory study on work related stress in professionals who provide health & social care for people who exhibit behaviours that challenge. doi:10.1371/journal.pone.0229706.
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Woodcock, L. & Page, A. (2010). Managing Family Meltdown: The Low Arousal Approach and Autism. London: Jessica Kingsley Publishers.
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