Studio III Research

ISSUES SURROUNDING INTRUSIVE INTERVENTIONS FOR PEOPLE WITH A LEARNING DISABILITY: HOW DO WE OBTAIN PEOPLES CONSENT?

Andrew McDonnell,

Clinical Psychologist,

Director,

Studio3 Training Systems.

www.studio3.org

Kilarney, November 2003.

Introduction

· Choice and control are sometimes opposite ends of a spectrum.

· People who present with aggressive behaviours often end up being controlled by systems.

· Aggressive behaviours can lead to the employment of intrusive interventions such as physical restraint (McDonnell & Sturmey, 1993).

· Intrusive interventions often involve the controlling of consequences.

‘Nearly all of us recognize the importance

of diet and exercise and only a relative minority actually behave in a manner consistent with its importance…. Fewer people would surrender control to someone else to make people healthier’.

(Michael Smull, 2002)

· How do we manage crisis situations and provide a balance between choice and control?

· The following brief practical case example will examine these areas in more detail.

CASE EXAMPLE 1

Background

Michael is a young man labelled with learning disabilities and a ‘personality disorder’. Previously, he had lived independently in the community however a decline in his behaviour led to his being placed in a hospital eventually he was ‘resettled’ to a supported living scheme with ‘1 to 1’ staffing supports.

Risk Analysis

There were real concerns that Michael would physically assault staff and members of the public. There were also concerns that Michael would use a lawyer if employed intrusive interventions (he had done so in the past).

Negotiation

We agreed that care staff should not negotiate the behaviour management rules with Michael. A low arousal approach was adopted (McDonnell, Waters & Jones, 2002) This involved the reduction of boundaries and rules. Simple rules were developed by negotiating with Michael. The most important rule surrounded what staff should do if Michael became physically aggressive. Michael felt that:

‘he did not want to be restrained in his own house’

We adopted a simple approach.

1) Staff would withdraw from his house if he became physically aggressive. This allowed a ‘cooling off’ period.

2) It was agreed that if he emerged onto the street and threatened members of the public the police would be summoned.

3) Separate debriefing sessions were organized for Michael and his staff.

4) There was a ‘crisis on call’ system for staff.

Outcomes

There were several important outcomes of this scheme:

1) Michael averaged at least one incident per week where staff would have to withdraw from the house.

2) These incidents did reduce over a six month period.

3) There were no incidents that required the calling of the police to the house. (Michael could apparently cope with very few rules but, he did stick to the rule to stay in his house when he was angry.

4) Staff turnover was a problem. We found that some staff could not cope with the level of control given to Michael.

5) There was no doubt that this ‘complicated’ man had significantly improved his quality of life by returning to a community environment.

6) At 9 months into the scheme we negotiated a brief admission to a local service to allow time for the staff team to ‘regroup’. Sadly, Michael died of a heart attack.

Issues

In this case consent was clearly sought from Michael. He had the skills to advocate and negotiate about what he wanted. There are many people with severe learning disabilities who would not be consulted about intrusive interventions such as physical restraint.

It was extremely difficult to negotiate with Michael and there were many times throughout the scheme that we questioned what we were doing. Quite literally, it felt like

‘We were giving in and he was walking all over us’

When employing low arousal approaches these feeling are not uncommon.

The alternative would have been to adopt a more rule governed and intrusive approach which would undoubtedly have led to his incarceration and staff physical assaults.

References

McDonnell, A.A., Waters, T, & Jones, D. (2002). Low arousal approaches in the management of challenging behaviours. In Allen D (Ed) Ethical approaches to physical interventions. Kidderminster: BILD.

Smull, M. (2002). Responding to behavioural crises by supporting people in the lives they want. In Hanson, R.H, Wieseler, N, Lakin, K.C. & Braddock, D. (eds). Crisis: Prevention and response in the community. (pp225-241). Washington, AAMR.


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		ISSUES SURROUNDING INTRUSIVE INTERVENTIONS FOR PEOPLE WITH A LEARNING DISABILITY: HOW DO WE OBTAIN PEOPLES CONSENT? Andrew McDonnell, Clinical Psychologist, Director, Studio3 Training Systems. www.studio3.org Kilarney, November 2003. Introduction · Choice and control are sometimes opposite ends of a spectrum. · People who present with aggressive behaviours often end up being controlled by systems. · Aggressive behaviours can lead to the employment of intrusive interventions such as physical restraint (McDonnell & Sturmey, 1993). · Intrusive interventions often involve the controlling of consequences. ‘Nearly all of us recognize the importance of diet and exercise and only a relative minority actually behave in a manner consistent with its importance…. Fewer people would surrender control to someone else to make people healthier’. (Michael Smull, 2002) · How do we manage crisis situations and provide a balance between choice and control? · The following brief practical case example will examine these areas in more detail. CASE EXAMPLE 1 Background Michael is a young man labelled with learning disabilities and a ‘personality disorder’. Previously, he had lived independently in the community however a decline in his behaviour led to his being placed in a hospital eventually he was ‘resettled’ to a supported living scheme with ‘1 to 1’ staffing supports. Risk Analysis There were real concerns that Michael would physically assault staff and members of the public. There were also concerns that Michael would use a lawyer if employed intrusive interventions (he had done so in the past). Negotiation We agreed that care staff should not negotiate the behaviour management rules with Michael. A low arousal approach was adopted (McDonnell, Waters & Jones, 2002) This involved the reduction of boundaries and rules. Simple rules were developed by negotiating with Michael. The most important rule surrounded what staff should do if Michael became physically aggressive. Michael felt that: ‘he did not want to be restrained in his own house’ We adopted a simple approach. 1) Staff would withdraw from his house if he became physically aggressive. This allowed a ‘cooling off’ period. 2) It was agreed that if he emerged onto the street and threatened members of the public the police would be summoned. 3) Separate debriefing sessions were organized for Michael and his staff. 4) There was a ‘crisis on call’ system for staff. Outcomes There were several important outcomes of this scheme: 1) Michael averaged at least one incident per week where staff would have to withdraw from the house. 2) These incidents did reduce over a six month period. 3) There were no incidents that required the calling of the police to the house. (Michael could apparently cope with very few rules but, he did stick to the rule to stay in his house when he was angry. 4) Staff turnover was a problem. We found that some staff could not cope with the level of control given to Michael. 5) There was no doubt that this ‘complicated’ man had significantly improved his quality of life by returning to a community environment. 6) At 9 months into the scheme we negotiated a brief admission to a local service to allow time for the staff team to ‘regroup’. Sadly, Michael died of a heart attack. Issues In this case consent was clearly sought from Michael. He had the skills to advocate and negotiate about what he wanted. There are many people with severe learning disabilities who would not be consulted about intrusive interventions such as physical restraint. It was extremely difficult to negotiate with Michael and there were many times throughout the scheme that we questioned what we were doing. Quite literally, it felt like ‘We were giving in and he was walking all over us’ When employing low arousal approaches these feeling are not uncommon. The alternative would have been to adopt a more rule governed and intrusive approach which would undoubtedly have led to his incarceration and staff physical assaults. References McDonnell, A.A., Waters, T, & Jones, D. (2002). Low arousal approaches in the management of challenging behaviours. In Allen D (Ed) Ethical approaches to physical interventions. Kidderminster: BILD. Smull, M. (2002). Responding to behavioural crises by supporting people in the lives they want. In Hanson, R.H, Wieseler, N, Lakin, K.C. & Braddock, D. (eds). Crisis: Prevention and response in the community. (pp225-241). Washington, AAMR.