This excerpt from a recent practitioner article looks at some of the issues residential services can face, including toxic working environments, safeguarding violations and abusive practices, and attempts to discuss the wider implications of poor practice for care services across the UK.
Introduction
At Studio 3 Clinical Services and Training Systems, we have worked with a wide range of residential services for autistic adults and young people, as well as those with other conditions and learning differences who may exhibit behaviours of concern. Many of these services have requested our support as they have experienced significant difficulties in managing behaviours that challenge. What we have found when working with such services is that there are often systemic barriers preventing the care provided from being therapeutic. At Studio 3, we employ the Low Arousal Approach which is a person-centred, non-confrontational method of managing behaviour. In this approach, there is a foremost focus on ‘reducing demands that are sources of stress for the individual and enabling individuals to deploy coping mechanisms that support effective self-regulation’ (McDonnell, McCreadie & Dickinson, 2019; p. 454). At Studio 3, we actively campaign against the use of restraint and seclusion and help settings to reduce restrictive practices in order to support individuals using the least aversive approach.
In many settings where elements such as staff training, supervision, regulations, and clear plans are not effectively established by management and staff on the ground, a culture of coercion and control can grow and be very difficult to reverse. On an extreme level, examples such as the abuse scandal at Winterbourne View, as exposed by BBC’s Panorama in 2011, demonstrate what can happen when staff training is neglected and restrictive practices are allowed to flourish. When supporting autistic individuals who may also have an intellectual disability and/or experienced traumatic events, person-centred trauma-informed care is paramount. As staff members and practitioners in these environments, we have an opportunity to make meaningful changes in the lives of the people we support. However, many factors need to be in place to enable supporters to provide the best possible care.
BBC’s Disclosure Locked in the Hospital documentary, which aired on 16th August 2022, unveiled some of the issues we are witnessing in the care sector today, 11 years on from the Winterbourne View exposé. In one example from this documentary, a mother went to visit her son in a high-security psychiatric hospital. After he became very emotional and upset, his mother reported seeing staff pile into his room, take him to the ground and inject him, chemically restraining him. This is not a therapeutic or mindful way to manage stress or stress-related behaviours; it is an overuse of restraint as a means of social control.
In many cases, individuals in crisis are not given the opportunity and space to regulate their emotions themselves. Restrictive environments of coercion and control can grow when the right support and guidance are not in place, particularly behind closed doors and in gated communities. In this article, we will look at some of the issues residential services can face, including toxic working environments, safeguarding violations and abusive practices, and attempt to discuss the wider implications of poor practice for care services across the UK.
Safeguarding Violations
Training
The role of a support worker involves supporting individuals to reach their goals and live with purpose and dignity. In residential services supporting individuals who exhibit distressed behaviour, to keep everyone safe, support workers are required to complete basic training. In many settings, physical intervention (restraint) training is part of this basic training. These restrictive practices are designed to be used when individuals in crisis are at risk of causing harm to themselves or others. At Studio 3, we believe in teaching physical interventions only on an individualised basis and after a Training Needs Analysis has been carried out. Sometimes physical skills are needed to keep people safe, and when this is the case, physical methods should be taught to a high standard and with clear guidelines around their use.
Though there is a vast range of care settings across the UK where restrictive practices are a part of daily life, many of these settings have staff teams who have not received sufficient, if any, restraint training. Inevitably, occasions arise where some of these staff members find themselves in situations where the use of some form of restraint is unavoidable. This can result in staff resorting to using their own unofficial and unsanctioned restraint techniques in environments where staff training is not closely monitored and prioritised. The use of such techniques greatly increases the risk of injury and harm to both support workers and the individuals involved. In many cases, even those who have received training in physical interventions are taught such a vast range of physical methods in such a short period that they forget these skills as soon as they leave the classroom (McDonnell, 2022).
Staff who are not provided with sufficient de-escalation strategies to avoid a crisis in the first place or taught physical restraint techniques when necessary are left unsupported and defenceless. If staff members do engage in any form of physical restraint while untrained, they will often also be, or feel, unsupported by management. The avoidance and fear that lack of sufficient training can spark in staff members will inevitably be felt by the people they are supporting, as fear can be spread through emotional contagion. In the example to follow, we observe the aftermath of a group of untrained staff who were forced to physically intervene in a potentially life-threatening altercation without guidance:
One member of staff was targeted and attacked by a person they were supporting. Several other staff members watched this occur and did not help; as is common in crisis situations, they froze. They froze because they were scared, not only of getting hurt themselves but scared, too, of allegations of intervening incorrectly. When one staff member eventually did intervene, they used unsanctioned physical methods as they had not received the appropriate training. Unfortunately, this staff member got injured in the process. It was only after this event that the staff members involved received the physical training they had missed.
This is an example of reactive rather than proactive training that failed to safeguard employees and those they support. For optimal care to be provided, staff need to be trained and supported to provide the standard of care required to safely and confidently support individuals in crisis.
According to Karasek and Theorell’s (1990) Job-Demand-Control-Support model, when staff experience high demands at work, have a low sense of control in their role and do not receive appropriate support, their well-being suffers and they experience stress. In short, the demands of work outweigh the staff’s inner resources to manage them. If staff do not have the resources they need to manage stressful situations and their stress and arousal levels are continually rising without awareness or support, there is a greater risk of their emotions influencing their behaviours. In environments where staff are permitted to use restraint techniques, this can be especially dangerous. What is being described here is a toxic cycle of ‘care,’ where staff are not able to support others to regulate their arousal levels if they are not in control of their own. In response, the arousal levels of the individuals they support will rise in tandem due to emotional contagion, increasing instances of distressed behaviour. This behaviour then affects staff’s stress and arousal levels, creating a toxic cycle. Reacting emotively when restraining vulnerable people, especially with untrained staff, can result in avoidable fatal outcomes. This is not therapeutic care. This is harmful and reckless care. In toxic environments such as this, how can we expect the individuals being supported to feel safe or at home?
Avoid Gathering Staff in a Crisis
In most settings where there is a restrictive culture and restraint is often applied, staff are encouraged to call for assistance if restraint is required, usually through alarm systems. When people are running toward someone in crisis to use restraint techniques, fear and anxiety will rise for those in the environment. This example of ‘staff behaviour’ is all too common in care settings where restrictive practices are taught and may increase the frequency of and duration of crises occurring. Staff must acknowledge that therapeutic support starts with them, and this is at the core of Low Arousal. Generally, it is less often that staff training focuses on attempting to deescalate and avoid situations where restraint may be needed. At Studio 3, we see many care environments that fit this description and recommend that such services avail of our Low Arousal training. Our de-escalation and crisis management training is informed by Low Arousal Approaches and focuses on non-aversive strategies to reduce stress and tension at the moment, as well as prevent crises from occurring. Continue reading...
Written by John Moriarty