Transcript The History of Low arousal approaches

The History of Low arousal
approaches
Andrew McDonnell,
PhD.
[email protected]
The Historical Context
In the intellectual disabilities field the
avoidance of punitive consequences has
been a guiding principle of non aversive
approaches especially so-called Positive
Behavioural Supports (Carr et al, 1999).
 Verbal aggression appears to be a more
common occurrence than physical
aggressions in care environments (Kiely &
Pankhurst, 1998).
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The Historical Context
People with disabilities have been identified as a vulnerable
group in terms of their exposure to restrictive practices (Chan et
al, 2011) and physical restraint (Baker & Allen 2008).
 Whilst a technology of behaviour support and behaviour change
was emerging. There was a paucity of data for behaviour
management strategies (McDonnell, 2010).
 In the early 1990’s I became increasingly interested in both the
academic rationale for training in the management of challenging
behaviours and the reduction of restrictive practices in care
environments.
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My Background
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I trained as a clinical psychologist in the UK
(1986 to 1988).
I worked both in institutional and community
settings.
I was trained in behavioural approaches.
I became interested in how staff were trained to
manage crisis situations.
I also witnessed on many occasions ‘strong
methods’ being used by care staff.
Bad Practice
The Term Low Arousal Approach
The term low arousal approach was first used
in 1994 (McDonnell, McEvoy & Dearden,
1994).
 The approach was then reformulated within a
cognitive behavioural framework (McDonnell,
2010; McDonnell, Waters & Jones, 2002).
 The work was developed originally in
institutional environments
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Key Areas of Interest
There were three areas of early development.
 The first was a specialist high staff ratio support service for adults
with intellectual disabilities and autism.
 The second area was a community service for people with
intellectual disabilities.
 The third area was a hospital for people with intellectual
disabilities and most notably a secure area for people with
severe challenging behaviours.
 All three of these work areas involved the author working with
people who presented with aggressive behaviours with varying
levels of resources.
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Punitive Practices
It was very noticeable that there was a great
need to manage behaviours in a dignified and
socially acceptable manner.
 The behaviour management approach was
developed as a response to observational
data that staff and carers often adopted
punitive approaches in verbally managing
aggressive behaviours.
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More Words of Caution
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“It is a mistake to think that once an
intervention is underway, you no longer need
to worry about serious outbursts and the
necessity for crisis management” (Carr et al.
1994, p.14).
Training Staff
Between 1987 and 1992 I carried out staff training
which what described as ‘non aversive behaviour
management’ (low arousal began to be used in 1992).
 The majority of this training contained physical
interventions with a simple behavioural rationale.
 The main emphasis was to show staff gentle physical
interventions.
 Even in these early day no restraint ‘hold downs were
taught and no techniques which involved the
deliberate use of pain.
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Training Staff
Based on these experiences and ongoing
reviews of the literature, the author published
a series of three brief articles for a practitioner
journal in Intellectual disabilities (McDonnell
Dearden & Richens, 1991a, 1991b, 1991c).
 The emphasis was on developing training
systems.
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Training staff
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McDonnell et al. (1991b) described three principles involved in the training
courses. They were:
First, practitioners should avoid violent situations. The best way to avoid
assault is to not be in the specific place. It is our experience that conflict can
often occur in situations that tend to be repeated. Avoiding these predictable
violent situations is a more practical option that managing them
Second, where physical restraint is required it should not use procedures
that involve painful locking of joints. The use of pain as means of coercion
can damage the relationship between carer and service user. There is also
the real possibility that a service user may consider retaliating in a similar
manner.
Third, staff should learn to use their body weight more effectively. These
methods biomechanically require less physical strength to use, but more
technical skill. Physical techniques that use bodyweight are more likely to be
universally applied by male and female staff.
The Development of Studio3
In 1992 the Studio3 organisation was initially
formed.
 The aim was to allow independently the
philosophy of low arousal to be developed.
 The name was chosen as it had no
connotations with violence.
 ‘It sounded like a hairdressing salon!’
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Social Validity
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Wolf (1978) argued that three dimensions
were important in understanding the concept
of social validity. First are goals or objectives
‘socially significant.’ That is, do they achieve
what society wants? Second, are procedures
or methods ‘socially appropriate’; literally do
the ends justify the means? Finally, are
consumers satisfied with the results?
The Case for Socially Valid Behavioural
Interventions
I conducted several studies that examined the
social validity of physical Interventions
(McDonnell et al, 1993. McDonnell et al,
2000, Cunningham et al, 2002)
 Methods of intervention should be both
effective and highly socially valid.
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The Views of Service Users
There is a growing literature examining the
views of service users.
 A survey of staff and service users in a
secure facility found real differences between
these groups. Staff reported the major
reasons for use of restraint was to prevent
harm. Service users tended to report that
restraint was used as a form of punishment
(Fish & Culshaw, 2005).
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Low Arousal Approaches: Early
Speculations
The early papers outlined five key principles.
 1. Stay calm. Or more correctly give the appearance
of being calm. Staff members need to control their
breathing and avoid sudden movements and
increases in the pitch of their voice. There is a
commonly used phrase ‘do not pour fuel on an open
fire’. In a conflict situation a staff member should be
appear calm and not increase arousal in a conflict
situation; especially when the service user they are
managing is hyperaroused.
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Low Arousal Approaches: Early
Speculations
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2. Avoid physical contact. Human touch can
have both calming and excitatory effects.
When a service user is hyperaroused it is
possible that physical contact may increase
this further. Touch should be intermittent.
Low Arousal Approaches: Early
Speculations
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3. Be aware of your own bodily reactions. It is
the experience of the author that staff
members in these situations are not aware
that their own body language often
communicates fear and distress. Individuals
may perspire or stare at a service user (also
physiologically arousing). Aggressive
postures such as folding arms should be
avoided.
Low Arousal Approaches: Early
Speculations
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4. Keep your distance. Everyday social
interactions tend to take place at a social
distance of three to six feet. Research has
demonstrated that close proximity to
individuals who are angry or aroused may
increase the likelihood of interpersonal
violence.
Low Arousal Approaches: Early
Speculations
 5.
Respond in a non-violent manner. This
is as much a moral as well as a pragmatic
approach. Essential to the approach is the
view that violent acts elicit violent
responses, thus creating behavioural
response chains that increase the
likelihood of violence.
Developing Low Arousal Approaches
There was a consistent emphasis on the role
of staff behaviour in the maintenance of
challenging behaviours.
 In 2002 the low arousal approach was
reformulated within a CBT framework.
 A key facet was an understanding of staff
attributions surrounding challenging
behaviours (including belief systems).
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Staff Perceptions
“peoples’ levels of motivation, affective states and
actions are based on what they believe, than in what
is objectively true” (Bandura, 1997, p21).
 Staff who work with aggressive service users face a
challenging and sometimes dangerous task. They all
come into their job with their own learning history of
managing aggressive behaviour and conflict
resolution McDonnell, 2010).
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A Service Example (Circa 2000)
We conducted a four year audit of a service
where staff were trained in low arousal
approaches.
 18 services users were monitored over this
period.
 All of these individuals were judged to present
with significant challenges.
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Organisational monitoring
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All incidents of PI were actively monitored by
staff.
Where multiple incidents occurred in a month a
review meeting to discuss PI reduction strategies
was held which involved a clinical psychologist.
Low arousal strategies were reviewed in these
meetings and written reactive plans were
produced.
Measures
 Staff
reported Management of aggression forms. These had
to be filled in after any use of PI in the service.
 Reliability of reports were established by getting staff to
separately rate a sample of the same incidents for a one
month period incidents
 (this produced reliabilities of over 96%).
 Service user support plans were audited for evidence of
‘low arousal approaches’.
Figure 1: The use of the ‘chair method’ of physical intervention used
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over four years
Figure 2: The use of the walking method over the four year period
Low arousal strategies
Key Main Findings
There appeared to be significant reductions in
PI usage across the service.
 There was a shift from more intrusive (chair
restraint) PI’s to less intrusive methods (walk
around method).
 The increased use of low arousal strategies is
a measure based on a ‘paper trail’ as
opposed to directly observable evidence.
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The Last 10 Years
A greater emphasis in the Studio3 system on
low arousal approaches.
 Training in the last several years has spread
to several European countries.
 There has been an increasing emphasis in
placing these approaches within a stress
management framework.
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The Last 10 Years (Research)
‘In summary, what do we know about the
effectiveness of physical interventions training?
At present, a worldwide training industry is
based primarily on anecdotal evidence and
fourteen studies only four of which show
reasonable design quality. An evidenced based
approach represents the only way forward.’
(McDonnell, 2008)