Studio III Research

Title: The Role of Clinical Psychology in the Physical Management of Challenging Behaviour.

Andrew McDonnell BSc, MSc

Clinical Psychologist,

South Birmingham Psychology Service, 208 Monyhull Hall Road, Kings Norton, Birmingham. B30 3QJ.

Peter Jones BSc,

Assistant Psychologist,

South Birmingham Psychology Service, 208 Monyhull Hall Road, Kings Norton, Birmingham. B30 3QJ.

Address For correspondence:

South Birmingham Psychology Service, 208 Monyhull Hall Road, Kings Norton, Birmingham. B30 3Q

Issues surrounding the physical management of challenging behaviour.

Psychologists who work in the field of learning disabilities are often expected to provide advice and support to staff and carers who work with people who present with challenges. A great deal of this process involves developing interventions and producing both proactive and reactive plans (Ball and Bush, 1997). However, it is concerning that research on the effectiveness of long term proactive behavioural interventions for people who present with challenges is at best equivocal (Emerson, 1995; Reiss and Havercamp, 1997). Short term reactive strategies have received comparatively little emphasis (McDonnell and Sturmey, 1993). Traditionally, psychologists appear to be involved more actively from both a clinical and empirical perspective in the development of behaviour change strategies. Given that challenging behaviours are often long term, it would seem appropriate that psychologists should concern themselves with the short term crisis management of challenging behaviours (Ball and Bush, 1997). Research on the short term management (especially physical management) of challenging behaviours is incredibly sparse and often anecdotal in nature (McDonnell and Sturmey, 1993). The remainder of this article will examine some of these issues and attempt to question what role clinical psychologists should have in such matters.

Legal and professional considerations.

Government recommendations and professional guidelines have promoted the use of physical restraint by staff as an acceptable method of managing

challenging behaviour (DHSS, 1988; Health and Safety Executive, 1989). It is concerning that there appears to be no nationally approved methods of restraint. Even more worrying is that there are very few restrictions on restraint procedures. When recommendations are made they tend to be a little vague. The Department of Health circular HD76 (11) makes the following recommendations:

"As a general principle clothing rather than limbs should be held to effect restraint and if limbs have to be grasped they should be held near a major joint in order to reduce the danger of fracture or dislocation. Every effect should be made to safeguard the patient’s vulnerable areas, for example, the neck, throat, chest or abdomen. A patient....should, when possible, not be gripped by the head, throat or fingers. A bear hug from behind to pinion the arms to the side is valuable and it is better to grip the legs together above the knee and around the calves rather than separately. If the patient is brought to the ground,...staff lie with their weight across his legs and trunk and thus immobilise him...when a patient is biting, the hair may have to be firmly held". There are clear legal grounds to justify restraint by staff as acceptable means to bring about the end of a violent incident, provided that they act in good faith and use reasonable force (Ashton and Ward, 1992). A recent working party which involved both the British Institute of Learning Disabilities, the National Autistic Society and a number of experts in the field, produced a policy document entitled "Physical Interventions: A policy Framework" (Harris, Allen, Cornick, Jefferson and Mills, 1996).

Unfortunately, this document contained no detailed advice on the nature and content of approved physical procedures. However, it is hoped that such a process may well occur in the future (Allen, 1998). Clinicians do appear to have a clear "duty of care" in providing safe and effective practices. Physical management strategies need to be addressed if they are deemed to be in the best interest of service users (Harris, 1996). Psychologists will appear to have a role in this process. It is the experience of the first author that psychologists do not always involve themselves in discussions about the appropriate use of physical management strategies.

Physical restraint.

Physical restraint has been a contentious issue for health care professionals. Physical restraint has been defined as "actions or procedures which are designed to limit or suppress movement or mobility" (Harris, 1996). It is the opinion of the authors that psychologists should look at the practice of physical restraint and examine whether these practices are safe, effective and socially acceptable. The remainder of this article will examine a number of key issues pertinent to the management of challenging behaviour. The physical management of challenging behaviours in health-care settings is most definitely a taboo area (McDonnell, McEvoy and Dearden, 1994; McDonnell and Sturmey, 1993). Throughout their daily duties, carers will be confronted with behaviour which may require some form of physical intervention. This is

especially true of both self-injurious behaviour and physical aggression, where there is a real threat of harm to the person or others.

Breakaway skills.

The term ‘breakaway skills’ (Gilbert, 1988; Stirling and McHugh, 1997) has been used to describe physical procedures which may be employed to escape another individual. Unfortunately, there appears to be no standard definition of this term. Indeed, the expression has been to a certain extent "Reified". Literally, people use the term as if they were talking about a clear set of skills. It has been argued that such skills should only be taught for high frequency behaviours. There also appears to be any number of qualitative differences in violence displayed by people with learning disabilities (McDonnell and Sturmey 1993). We should not assume that violence experienced by staff in a care setting is not qualitatively different from a pub brawl. Anecdotal evidence suggests that the vast majority of staff assaults tend to focus on people’s hands and arms. Attacks to the groin area appear to be a comparative rarity (McDonnell and Sturmey, 1993; McDonnell, Dearden and Richens, 1991b). McDonnell et al (1991b) suggested such a technique for removing someone’s grip:

" Open your fingers. This helps to relax the person’s grip. Rotate your hand in a slow, circular movement, rather like unscrewing the lid of a jar. Pull your hand through the gap between the person’s thumb and fingers...as you pull towards the gap, stepping back, using your weight to break the grip".

It is difficult to provide such procedures without appearing to be suggesting a set of "physical tricks". In some clinical circumstances, it is possible to construe that the teaching of such skills could lead to an increase in aggressive behaviour towards staff. We should be careful not to be blandly people with a "loaded gun". It is also equally possible to expect a reduction in aggressive encounters if such skills are taught within the context of a value base and clear clinical framework. It would be useful if such procedures were designed to be safe, effective and socially acceptable. The remainder of this article will examine physical restraint and breakaway skills in this context.

Safety.

When assessing the safety of a restraint procedure, safety should apply to both clients and carers. Procedures requiring the locking of joints should be avoided at all costs. It may be effective to place a person in a wrist-lock, but there are dangers of inflicting damage to an individual if procedures are carried out incorrectly or in an over-zealous manner. This is especially true if the major human joints are manipulated to abnormal or unusual positions. In situations where service providers are extremely aroused or frightened, there is a very real danger that the procedures may be conducted which may result in substantial risks or physical injury to themselves or their clients. Anders (1983) suggested throwing a blanket over an individual to distract the person.

The following procedure was then recommended :

"One of the staff members in front of the patient should reach down between the legs and secure posteriorly in a rotating movement. If four staff members are available for the takedown another should approach the patient from the side and secure the other leg. The arms are restrained by the other two staff members. All of these movements should be made simultaneously. Once the extremities have been secured the patient should be gently lowered to the floor in a face down position".

Effectiveness.

The problem in assessing the effectiveness of physical restraint procedures and also so-called breakaway skills is providing a clear definition of the term ‘effectiveness’. An excellent definition would be containing the behaviour without tissue damage to both carer and client. When restraining an individual, effectiveness should not only include the immobilisation of limbs. Procedures exist that are effective in immobilising limbs, but these methods could be construed as socially unacceptable. Preventative ambulatory devices (PADS) (Van Rybroek, Kulman, Maier and Kaye, 1987) have been recommended in the United States. Although these devices are effective, the social validity of techniques that advocate the use of shackles and handcuffs would appear to be a regressive step.

Social acceptability.

The social validation of therapeutic intervention procedures has become an increasing concern for professionals (Wolf, 1978). To date, very little research has been conducted on the treatment acceptability of restraint procedures. Research has shown that restraint procedures using a chair method were rated as more socially acceptable than using restraint methods on the floor (McDonnell and Sturmey, 1993). Obviously, there are a wide range of physical procedures that could be assessed in this manner. This type of research for evaluating procedures.

Emotional content.

Physical factors can engender very powerful emotions among all participants. In a study of the use of restraint among an adolescent population, it was found that strong emotional feelings, especially anger, were experienced whilst carrying out restraint procedures (Hunter, 1989). Powerful physical procedures, such as the manipulation of joints, rely on pain to immobilise an individual. This may engender feelings of helplessness among the people being restrained. Research tends to show that when we are unable to perceive control over a situation, then a state of learned helplessness can occur. In a follow-up study of 25 people with mild intellectual disabilities and challenging behaviours, 16 people reported the experience of being restrained. All of the participants reported negative feelings about the procedures (Murphy, Estein and Clare, 1996).

Psychological Issues.

Psychologists, when drawing up guidelines for service providers, need to bear in mind the safety, effectiveness and social acceptability of restraint procedures utilised by services. Our profession should not ‘bury it’s head in the sand’. Procedures that are ambiguous, difficult to replicate and demean the individuals that they are designed to be operated on, need to be addressed and removed. Moral and ethical issues have particular relevance to staff working in long-stay residential settings where one of the primary goals is to establish and maintain a helping and supportive relationship, based on trust, empathy, warmth and positive regard (Stirling and McHugh, 1997). Clients who find themselves as recipients of such techniques may equally feel dehumanised, vulnerable and angered (Aschen, 1995). Thus, procedures that destroy supportive relationships and have clients feeling dehumanised can hardly be considered ethical, reasonable or productive. A great deal of emphasis needs to be placed on behaviour management strategies. Psychologists must take a more active role in examining physical restraint procedures. One way in achieving this is by continuing research.

Staff training.

Care staff play an important role in the physical management of challenges. The dissemination of skills to care staff is essential. Staff behaviour has been shown to inadvertently contribute to the maintenance of challenging behaviour (Hastings and Remington, 1994). There is some evidence that staff training

could help reduce the incidences of challenges (Allen, McDonald, Dunn and Doyle, 1997). It would appear that clinical psychologists should be directly involved in the implementation of training programmes that promote the acquisition of skills and advocate the use of safe, effective and socially valid restraint strategies. Follow-up sessions would highlight whether these techniques were being employed correctly and efficiently. Although staff training can increase confidence, there is no guarantee that this is generalised to care settings (McDonnell, 1997).

Conclusion.

Government recommendations and professional guidelines have promoted the use of physical restraint as an acceptable method of managing challenging behaviour, but, as yet, there are no approved methods of restraint. Although the recent policy framework (Harris et al, 1996) has provided a limited framework, the criterion for selecting physical procedures are, at best, poorly understood. Acting in "good faith" highlights the ambiguity and lack of direction that surrounds this area. Psychologists would appear to have a strong role to play in the entire process. Psychologists should be involved in evaluating these practices and examining whether they are safe, effective and socially acceptable. Procedures must be developed that prevent individuals feeling de-humanised. We do need to understand in much more detail the psychological processes involved in the physical management of aggressive behaviours. Evaluatory studies would contribute to this, especially research

that attempts to place the physical management of challenging behaviours in a clear psychological framework.


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		Title: The Role of Clinical Psychology in the Physical Management of Challenging Behaviour. Andrew McDonnell BSc, MSc Clinical Psychologist, South Birmingham Psychology Service, 208 Monyhull Hall Road, Kings Norton, Birmingham. B30 3QJ. Peter Jones BSc, Assistant Psychologist, South Birmingham Psychology Service, 208 Monyhull Hall Road, Kings Norton, Birmingham. B30 3QJ. Address For correspondence: South Birmingham Psychology Service, 208 Monyhull Hall Road, Kings Norton, Birmingham. B30 3Q Issues surrounding the physical management of challenging behaviour. Psychologists who work in the field of learning disabilities are often expected to provide advice and support to staff and carers who work with people who present with challenges. A great deal of this process involves developing interventions and producing both proactive and reactive plans (Ball and Bush, 1997). However, it is concerning that research on the effectiveness of long term proactive behavioural interventions for people who present with challenges is at best equivocal (Emerson, 1995; Reiss and Havercamp, 1997). Short term reactive strategies have received comparatively little emphasis (McDonnell and Sturmey, 1993). Traditionally, psychologists appear to be involved more actively from both a clinical and empirical perspective in the development of behaviour change strategies. Given that challenging behaviours are often long term, it would seem appropriate that psychologists should concern themselves with the short term crisis management of challenging behaviours (Ball and Bush, 1997). Research on the short term management (especially physical management) of challenging behaviours is incredibly sparse and often anecdotal in nature (McDonnell and Sturmey, 1993). The remainder of this article will examine some of these issues and attempt to question what role clinical psychologists should have in such matters. Legal and professional considerations. Government recommendations and professional guidelines have promoted the use of physical restraint by staff as an acceptable method of managing challenging behaviour (DHSS, 1988; Health and Safety Executive, 1989). It is concerning that there appears to be no nationally approved methods of restraint. Even more worrying is that there are very few restrictions on restraint procedures. When recommendations are made they tend to be a little vague. The Department of Health circular HD76 (11) makes the following recommendations: "As a general principle clothing rather than limbs should be held to effect restraint and if limbs have to be grasped they should be held near a major joint in order to reduce the danger of fracture or dislocation. Every effect should be made to safeguard the patient’s vulnerable areas, for example, the neck, throat, chest or abdomen. A patient....should, when possible, not be gripped by the head, throat or fingers. A bear hug from behind to pinion the arms to the side is valuable and it is better to grip the legs together above the knee and around the calves rather than separately. If the patient is brought to the ground,...staff lie with their weight across his legs and trunk and thus immobilise him...when a patient is biting, the hair may have to be firmly held". There are clear legal grounds to justify restraint by staff as acceptable means to bring about the end of a violent incident, provided that they act in good faith and use reasonable force (Ashton and Ward, 1992). A recent working party which involved both the British Institute of Learning Disabilities, the National Autistic Society and a number of experts in the field, produced a policy document entitled "Physical Interventions: A policy Framework" (Harris, Allen, Cornick, Jefferson and Mills, 1996). Unfortunately, this document contained no detailed advice on the nature and content of approved physical procedures. However, it is hoped that such a process may well occur in the future (Allen, 1998). Clinicians do appear to have a clear "duty of care" in providing safe and effective practices. Physical management strategies need to be addressed if they are deemed to be in the best interest of service users (Harris, 1996). Psychologists will appear to have a role in this process. It is the experience of the first author that psychologists do not always involve themselves in discussions about the appropriate use of physical management strategies. Physical restraint. Physical restraint has been a contentious issue for health care professionals. Physical restraint has been defined as "actions or procedures which are designed to limit or suppress movement or mobility" (Harris, 1996). It is the opinion of the authors that psychologists should look at the practice of physical restraint and examine whether these practices are safe, effective and socially acceptable. The remainder of this article will examine a number of key issues pertinent to the management of challenging behaviour. The physical management of challenging behaviours in health-care settings is most definitely a taboo area (McDonnell, McEvoy and Dearden, 1994; McDonnell and Sturmey, 1993). Throughout their daily duties, carers will be confronted with behaviour which may require some form of physical intervention. This is especially true of both self-injurious behaviour and physical aggression, where there is a real threat of harm to the person or others. Breakaway skills. The term ‘breakaway skills’ (Gilbert, 1988; Stirling and McHugh, 1997) has been used to describe physical procedures which may be employed to escape another individual. Unfortunately, there appears to be no standard definition of this term. Indeed, the expression has been to a certain extent "Reified". Literally, people use the term as if they were talking about a clear set of skills. It has been argued that such skills should only be taught for high frequency behaviours. There also appears to be any number of qualitative differences in violence displayed by people with learning disabilities (McDonnell and Sturmey 1993). We should not assume that violence experienced by staff in a care setting is not qualitatively different from a pub brawl. Anecdotal evidence suggests that the vast majority of staff assaults tend to focus on people’s hands and arms. Attacks to the groin area appear to be a comparative rarity (McDonnell and Sturmey, 1993; McDonnell, Dearden and Richens, 1991b). McDonnell et al (1991b) suggested such a technique for removing someone’s grip: " Open your fingers. This helps to relax the person’s grip. Rotate your hand in a slow, circular movement, rather like unscrewing the lid of a jar. Pull your hand through the gap between the person’s thumb and fingers...as you pull towards the gap, stepping back, using your weight to break the grip". It is difficult to provide such procedures without appearing to be suggesting a set of "physical tricks". In some clinical circumstances, it is possible to construe that the teaching of such skills could lead to an increase in aggressive behaviour towards staff. We should be careful not to be blandly people with a "loaded gun". It is also equally possible to expect a reduction in aggressive encounters if such skills are taught within the context of a value base and clear clinical framework. It would be useful if such procedures were designed to be safe, effective and socially acceptable. The remainder of this article will examine physical restraint and breakaway skills in this context. Safety. When assessing the safety of a restraint procedure, safety should apply to both clients and carers. Procedures requiring the locking of joints should be avoided at all costs. It may be effective to place a person in a wrist-lock, but there are dangers of inflicting damage to an individual if procedures are carried out incorrectly or in an over-zealous manner. This is especially true if the major human joints are manipulated to abnormal or unusual positions. In situations where service providers are extremely aroused or frightened, there is a very real danger that the procedures may be conducted which may result in substantial risks or physical injury to themselves or their clients. Anders (1983) suggested throwing a blanket over an individual to distract the person. The following procedure was then recommended : "One of the staff members in front of the patient should reach down between the legs and secure posteriorly in a rotating movement. If four staff members are available for the takedown another should approach the patient from the side and secure the other leg. The arms are restrained by the other two staff members. All of these movements should be made simultaneously. Once the extremities have been secured the patient should be gently lowered to the floor in a face down position". Effectiveness. The problem in assessing the effectiveness of physical restraint procedures and also so-called breakaway skills is providing a clear definition of the term ‘effectiveness’. An excellent definition would be containing the behaviour without tissue damage to both carer and client. When restraining an individual, effectiveness should not only include the immobilisation of limbs. Procedures exist that are effective in immobilising limbs, but these methods could be construed as socially unacceptable. Preventative ambulatory devices (PADS) (Van Rybroek, Kulman, Maier and Kaye, 1987) have been recommended in the United States. Although these devices are effective, the social validity of techniques that advocate the use of shackles and handcuffs would appear to be a regressive step. Social acceptability. The social validation of therapeutic intervention procedures has become an increasing concern for professionals (Wolf, 1978). To date, very little research has been conducted on the treatment acceptability of restraint procedures. Research has shown that restraint procedures using a chair method were rated as more socially acceptable than using restraint methods on the floor (McDonnell and Sturmey, 1993). Obviously, there are a wide range of physical procedures that could be assessed in this manner. This type of research for evaluating procedures. Emotional content. Physical factors can engender very powerful emotions among all participants. In a study of the use of restraint among an adolescent population, it was found that strong emotional feelings, especially anger, were experienced whilst carrying out restraint procedures (Hunter, 1989). Powerful physical procedures, such as the manipulation of joints, rely on pain to immobilise an individual. This may engender feelings of helplessness among the people being restrained. Research tends to show that when we are unable to perceive control over a situation, then a state of learned helplessness can occur. In a follow-up study of 25 people with mild intellectual disabilities and challenging behaviours, 16 people reported the experience of being restrained. All of the participants reported negative feelings about the procedures (Murphy, Estein and Clare, 1996). Psychological Issues. Psychologists, when drawing up guidelines for service providers, need to bear in mind the safety, effectiveness and social acceptability of restraint procedures utilised by services. Our profession should not ‘bury it’s head in the sand’. Procedures that are ambiguous, difficult to replicate and demean the individuals that they are designed to be operated on, need to be addressed and removed. Moral and ethical issues have particular relevance to staff working in long-stay residential settings where one of the primary goals is to establish and maintain a helping and supportive relationship, based on trust, empathy, warmth and positive regard (Stirling and McHugh, 1997). Clients who find themselves as recipients of such techniques may equally feel dehumanised, vulnerable and angered (Aschen, 1995). Thus, procedures that destroy supportive relationships and have clients feeling dehumanised can hardly be considered ethical, reasonable or productive. A great deal of emphasis needs to be placed on behaviour management strategies. Psychologists must take a more active role in examining physical restraint procedures. One way in achieving this is by continuing research. Staff training. Care staff play an important role in the physical management of challenges. The dissemination of skills to care staff is essential. Staff behaviour has been shown to inadvertently contribute to the maintenance of challenging behaviour (Hastings and Remington, 1994). There is some evidence that staff training could help reduce the incidences of challenges (Allen, McDonald, Dunn and Doyle, 1997). It would appear that clinical psychologists should be directly involved in the implementation of training programmes that promote the acquisition of skills and advocate the use of safe, effective and socially valid restraint strategies. Follow-up sessions would highlight whether these techniques were being employed correctly and efficiently. Although staff training can increase confidence, there is no guarantee that this is generalised to care settings (McDonnell, 1997). Conclusion. Government recommendations and professional guidelines have promoted the use of physical restraint as an acceptable method of managing challenging behaviour, but, as yet, there are no approved methods of restraint. Although the recent policy framework (Harris et al, 1996) has provided a limited framework, the criterion for selecting physical procedures are, at best, poorly understood. Acting in "good faith" highlights the ambiguity and lack of direction that surrounds this area. Psychologists would appear to have a strong role to play in the entire process. Psychologists should be involved in evaluating these practices and examining whether they are safe, effective and socially acceptable. Procedures must be developed that prevent individuals feeling de-humanised. We do need to understand in much more detail the psychological processes involved in the physical management of aggressive behaviours. Evaluatory studies would contribute to this, especially research that attempts to place the physical management of challenging behaviours in a clear psychological framework.