This article discusses the recent Supreme Judicial Court ruling allowing electric shock treatment to continue to be practiced at the Judge Rotenberg Center. The Judge Rotenberg Center in Massachusetts has been the subject of controversy since the 1970s. Throughout its history, it has been criticised for Human Rights abuses and aversive punishments for children, young people, and adults with autism spectrum condition (ASC), learning disabilities, and ‘problem’ behaviours. Today, it remains the only institution in the United States that applies electric shocks to correct undesirable behaviours using archaic graduated electronic decelerator (GED) devices strapped to students’ bodies. At Studio 3, we do not believe in any form of punishment for behaviours, and continue to campaign not only for the reduction but the eradication of restrictive practices. The fact that these devices are still being used on vulnerable individuals is a Human Rights violation, and cannot be tolerated within the caring profession where our role as educators and supporters is to better understand and protect individuals in our care, not to punish them or try to make them conform to neurotypical ideals of ‘good behaviour.’ This article will look briefly at the long history of abusive practices at the Judge Rotenberg Center, discuss the recent Supreme Judicial Court ruling allowing electric shock treatment to continue to be practiced, and question why such practices are allowed to persist in modern times. A Brief History The Judge Rotenberg Center began its life as the Behavior Research Institute, founded by Matthew Israel in 1971. A student of the father of Behavioural Psychology, B.F. Skinner, Israel believed in aversive ‘treatments’ for undesirable behaviours, which ranged from self-injurious behaviour to ‘non-compliance,’ such as not following commands. Since its inception, there have been many complaints and legal cases brought against the institution for abusive practices, and six students have died of preventable causes. Shocking footage emerged in 2012 as part of a legal case showing a pupil being restrained face-down on a restraint board for 7 hours and shocked 31 times. The institution has a long list of behaviours which are targeted by the electric shocks: in this instance, the restraint and subsequent shocks were administered because the pupil refused to take off his coat. In another instance, 7 staff members were fired following a prank call to the institution claiming to be from a member of staff informing those on-shift that 2 pupils needed to be shocked for ‘misbehaviour’ earlier in the day. Based on this, on-shift staff members woke 2 pupils from their sleep and shocked them up to 77 times whilst their arms and legs were restrained. This resulted in second degree burns for one individual. The school has since been condemned for violating the United Nations Convention Against Torture (Pilkington, 2018): “The use of electric shocks to control the behavior of children inflicts pain and suffering that at least rises to the level of cruel and degrading treatment and in some cases is definitely torture. That is prohibited by state, national and international law.” Present Day In March 2020, the use of electric shock devices was banned by the FDA to treat self-injurious or aggressive behaviour. This decision was appealed, and it was determined that the FDA could not ban the use of electric shocks where it had been approved for medical use. Therefore, in cases where electric shock treatment had already been allowed by a judge or healthcare professional, this practice was allowed to continue. In September 2023, the Supreme Judicial Court of Massachusetts ruled that the Judge Rotenberg Center can continue to use electric shock devices on its students after claims by JRC lawyers and parents of students at the school that it is a ‘lifesaving, court approved electric stimulation device treatment’ (Pierson, 2023). Despite campaigns against the use of the method since 1985, The Judge Rotenberg Center is the only institution where electric shock therapy is still sanctioned in the United States. In 2022, a task force set up by the Association for Behavior Analysis International (ABAI) sought to study the use of contingent electric skin shock (CESS) in order to inform a position statement about its use. As part of this report (Perone et al., 2022), the JRC was investigated due to being the only institution still practicing CESS. Their report found that, as of July 2022, there were 52 adults aged 26-59 authorised by law to receive electric shocks at JRC. These CESS treatment plans do not require the consent of the individual, and a student may wear multiple GED devices simultaneously, receiving shocks in different parts of their body without knowing where the pain will land. Treatment plans can be approved for up to 15-20 years, despite regulations stating that they should be reviewed yearly. They also found no evidence that treatment plans were faded over time; CESS application can last between 5 – 20 years, and in fact the intensity of the shocks and number of devices often has to be increased to maintain effectiveness. Aversive Punishments Aversive consequences for behavioural treatment are a controversial topic. Whilst these can range from denying an individual a preferred object to applying a physical punishment, they can be extremely harmful to the well-being of individuals. The use of punishment to modify a person’s behaviour is not something we agree with here at Studio 3. The philosophy of our practice hinges around understanding why a person may need to engage in a behaviour to self-regulate, or to communicate need to their supporters. Whilst there are some extreme cases where preventing self-injury or violence to staff or other vulnerable people is necessary, most ‘challenging’ behaviours are perceived as such due to a societal focus on other people’s behaviours. In addition, the argument that electric shock treatment results in behaviour change in the long term is a nebulous one. The Judge Rotenberg Center itself states that some individuals may require CESS treatment for up to 15-20 years, indicating that the shock treatment has no longevity for behaviour change. In many instances, the intensity of the shocks administered needs to be increased to maintain effectiveness (Perone et al., 2022). Some individuals are reported to have habituated to the GED-4, a device created by the JRC which delivers the most powerful electric shock available. There can also be a delay of up to 30 minutes between the behaviour and the application of CESS, which calls into question whether an individual can even comprehend why they are being punished in order to change their behaviours accordingly. Whilst the school claims that the electric shocks (which they describe as ‘contingent skin shock for severe problem behavior’ on their website) are used to prevent pupils from injuring themselves or others, and are only administered in extreme cases where the alternative would be dangerous restraint methods, many former pupils have spoken out against the school’s approaches. Jennifer Msumba, a former pupil, has spoken extensively about her treatment at the school, saying, ‘It felt like I was being punished for being born.’ The JRC claims to use ‘compliance’ as a ‘treatment goal,’ claiming that ‘students are given a variety of demands and tasks to perform throughout the day, are rewarded immediately when they comply, and lose privileges if they refuse.’ This punishment and reward system can result in loss of privileges when ‘problem behaviors’ are displayed (JRC, 2023). So-called problem behaviours can include: ‘Health Dangerous (includes self-abusive actions such as hitting self); Aggression; Destruction; Noncompliance (such as refusing to follow a learned direction); Major disruptive behaviors (such as screaming, stealing, touching others without permission); and Educationally and Socially-Interfering behaviors; Inappropriate Verbal Behaviors’ (JRC, 2023). Under these parameters, staff could administer punishments on the basis of non-compliance for a person engaging in any behaviour that they feel is undesirable. Indeed, the JRC states that, ‘If a particular student needs more than these seven standard categories, additional categories are created.’ Essentially, what this means is that staff can determine what is desirable or not, and have complete control over what behaviours should be rewarded, and which punished. This adheres to the medical model of disability, whereby autistic individuals and people with learning disabilities are forced to conform to neurotypical standards of behaviour. Behaviours like stimming, which may be necessary to self-regulate, can be punished under this regime, denying individuals essential coping mechanisms. The medicalised language used by the JRC attempts to justify the practice of electric shocks as a treatment procedure, sending problem behaviours into ‘remission.’ Our view at Studio 3 is that so-called ‘problem’ behaviours are actually a sign of extreme distress and trauma, and that there is no place for approaches which involve re-traumatising individuals and making them more distressed. The International Coalition Against Restraint and Seclusion (ICARS) recently stated that there is evidence of shocks being administered ‘not just for discouraging undesired behaviors but for the actions that precede the undesired behaviors’ (Lodestone, 2021). Evidence that CESS is being used not to mitigate risk of injury to students or staff, but to correct and change behaviours, confirms the concerns of autistic advocates and individuals across the globe – that this method is neither therapeutic nor ethical. Eliza Hunt, lead organiser of ‘Stop the Shock Coalition,’ has frequently spoken out against the practice of CESS as being disproportionate to the behaviours being punished (Ruhalter & Rath, 2023): ‘The JRC contends that they only use this for dangerous behaviors, but at the same time, they also say that certain actions like standing up is, for certain individuals, an indication that they’re going to be violent.’ It is inevitable that where restrictive practices are allowed to persist in aversive cultures, staff will inevitably fall into the ‘slippery slope to abuse,’ whereby restrictive practices become the first resort, not the last resort (McDonnell et al., 2014). Where restrictive and aversive practices are normalised, the degree of lasting harm and trauma they cause to individuals is minimised by staff. Whilst people may believe they have no other choice and that they are using restrictive practices as a ‘last resort,’ this is rarely the case in reality. Pain Compliance It is essential that practitioners and organisations in the caring industry speak out against aversive practices such as pain compliance, restraint, and seclusion. Many former pupils have confirmed that the electric shock devices are incredibly painful. The recent task force interviewed 4 pupils at the school who, as of July 2022, were receiving CESS. All four students stated that the electric shocks were painful to receive, and the majority said that they did not want to receive them. One resident, unsolicited and without prompting, asked the task force members to remove them from JRC. The inhumane practices at JRC have been widely spoken against by many individuals and organisations across the globe. The Autistic Self-Advocacy Network (ASAN) have been leaders in the ‘Stop the Shock’ campaign against JRC. A recent survey from NeuroClastic asked the public how they felt about the use of electric shock as a punishment for disabled adults (2023). The responses include: 'I think that it's abusive and torturous and should be banned at all costs.' 'Absolutely horrified and prepared to do anything in my power to make it stop.' 'It is grossly inhumane. Electroshock should not be used as a “therapy”, nor should any type of aversives.' The results of a recent ICARS poll on X (formerly Twitter) demonstrates that 96.8% of parents who voted would not like their child to be subject to any of the practices being used at JRC, not just CESS. We cannot stress enough the importance of listening to lived experiences in order to inform against abusive practices such as these. Dr Damian Milton has spoken extensively against aversive practices which seek to alter behaviours. In a Studio 3 web conference, Damian spoke about his opinions on aversive practices and punishments in the caring industry (Milton, 2020). In addition, Professor Andrew McDonnell, CEO of Studio 3, has spoken frequently about his views on punishment (McDonnell, 2018): ‘In my work I am often asked about the role of punishment to correct behaviours. There is no doubt that sanctions and negative consequences can have an impact on the behaviour of children and adults. But what do people learn in these circumstances? Our role is to encourage self-regulation rather than imposing external controls.’ It is clear that the focus on control and compliance at the JRC violates the Human Rights of the children and adults being supported, and is both inhumane and untherapeutic. Punishing stressed and traumatised individuals for engaging in behaviours that they need to engage in in order to self-regulate has no place in caring environments. Attempts to alter behaviour that is perceived to be disruptive, ‘bad,’ or not typical, merely forces conformity and asserts control over vulnerable people. It is our role as educators, supporters, and carers to understand why a person may need to engage in certain behaviours, and to constantly question our own beliefs around behaviour. Punitive systems such as these which use punishment/reward schemes and restrictive practices can not only re-traumatise individuals, but also create a lack of self-agency and independence that is essential for well-being. By inflicting physical and psychological pain, supporters destroy the ability to form safe and therapeutic relationships with individuals, which is the key to supporting individuals to lead thriving independent lives, supported by their community. Compassion and empathy are essential, which is why there is an urgent need for a unified approach from autistic advocates and professionals determined to enact change and permanently ban the application of aversive and out-dated treatments such as CESS. In 1979, Dr William Bronston said of JRC that the school used an ‘unrelenting pursuit of traumatic interventions’ against its most ‘powerless and undefended’ students (Summers, 2021). That this still rings true today, more than 50 years later, should be a wake-up call for organisations and individuals around the globe to ensure that these practices are not allowed to continue. References Judge Rotenberg Center. (2023). Behavioural Treatment. Judge Rotenberg Center [Online]. Available from: https://keyfeatures.judgercblog.org/behavioral-treatment/. Lodestone, A. (2021). Autistic Advocates and Behavior Therapy Industry Professionals Join Forces to #StopTheShock. International Coalition Against Restraint and Seclusion [Online]. Available from: https://againstrestraint.com/2021/08/26/autistic-advocates-and-behavior-therapy-industry-professionals-join-forces-to-stoptheshock/. McDonnell, A. (2018). Negotiate Don’t Punish. LinkedIn [Online]. Available from: https://www.linkedin.com/pulse/negotiate-dont-punish-andy-mcdonnell/?utm_source=share&utm_medium=member_ios&utm_campaign=share_via. McDonnell, A., Breen, E., Deveau, R., Goulding, E. & Smyth, J. (2014). How nurses and carers can avoid the slippery slope to abuse. Learning Disability Practice, 17(5): 36-39. doi: 10.7748/ldp.17.5.36.e1516. Milton, D. (2020) Applied Behavioural Analysis and the autistic community: time to listen. In: Are We Asking the Right Questions About Behaviour? Studio 3 Web Conference [Online]. Neuroclastic. (2023). Judge Rotenberg Center – Responses. Survey Monkey [Online]. Available from: https://www.surveymonkey.com/results/SM-2TSVC9G99/. Perone, M., Lerman, D., Peterson, S. & Williams, D.C. (2022). Report of the ABAI Task Force on Contingent Electric Skin Shock. ABAI International [Online]. Available from: https://autisticadvocacy.org/wp-content/uploads/2022/11/CESS-Task-Force-Report-09-28-22.pdf. Pierson, B. (2023). Massachusetts top court allows electric shock therapy for disabled patients. Reuters [Online]. Available from: https://www.reuters.com/legal/massachusetts-top-court-allows-electric-shock-therapy-disabled-patients-2023-09-07/. Pilkington, E. (2018). 'It's torture': critics step up bid to stop US school using electric shocks on children. The Guardian [Online]. Available from: https://www.theguardian.com/us-news/2018/nov/16/judge-rotenberg-center-massachusetts-electric-shocks. Ruhalter, K. & Rath, A. (2023). Electric shock therapy is still allowed in one Mass. treatment facility. Advocates say change is long overdue. GBH News [Online]. Available from: https://www.wgbh.org/news/local/2023-09-11/electric-shock-therapy-is-still-allowed-in-one-mass-treatment-facility-advocates-say-change-is-long-overdue. Summers, J. (2021). The Shocking School. Boston Review [Online]. Available from: https://www.bostonreview.net/articles/the-shocking-school/.

Studio 3 reviews ‘So, I’m Autistic: An Introduction to Autism for Young Adults and Late Teens’ (2023) by Sarah O’Brien. Sarah O’Brien is a 26-year-old autistic advocate and academic who works with autistic young people, helping them to thrive in life, and supporting them to live the lives they want to in a world that isn’t always accommodating. In this book, Sarah provides information, guidance and advice for newly diagnosed or questioning teens and young people. The focus of this book is on working out what autism is and what it means for you as an individual, debunking some myths, stereotypes and stigmas along the way. This book is a helpful guide to navigating all the ‘firsts’ of adulthood as an autistic person and finding your path. The first part of the book is about understanding autism from a strengths-based perspective, and recognising neurodivergence not as a deficit but as a difference. Sarah’s first-hand experience of struggling with her own autistic identity in early adulthood guides the narrative. ‘Unfortunately, I’ve struggled through many years to get to the point of knowing how to exist in a world not built for us.’ There are many myths and misunderstandings around what autism actually is, which this book attempts to demystify. A large part of this, as Sarah says, is centred around the use and misuse of language. Many of us will be familiar with autistic people being referred to as high or low functioning, by person-first language, or as ‘sufferers’ of autism. Sarah explains why she personally prefers identity-first language, and points out ways in which language can be empowering or disempowering for autistic people. For example, a person’s ability to function may vary on daily, even hourly basis, depending on the environment and the demands being placed upon them, therefore to categorise people as being high or low functioning is divisive and inaccurate. Sarah unpacks some of the residual ideas from medicalised models around disabilities and autism, and encourages readers to unlearn some of the deficit models that they are exposed to before, during, and after diagnosis. ‘With increasing input from autistic people, we are moving form language that stigmatized us and was shaped by others to language that we are shaping and deciding upon ourselves.’ Language is so important, and we must move away from medicalised language that places the deficit within the person. Instead, following a social model of disability, it is more helpful to discuss support needs in terms of the environment and the situation a person finds themselves in. ‘This places emphasis on the fact that the environment needs to change to support the autistic person rather than the autistic person needing to change to fit the environment or society. It removes the responsibility from the autistic person and makes the responsibility for inclusion collective.’ In this book, the author also attempts to debunk some myths and stereotypes around autism in order to negate some misunderstandings and misinformation. There is a strong emphasis on recognising the role of society at large and the immediate environment on neurodiverse presentations. For example, Sarah talks about how autistic meltdowns are often perceived as ‘tantrums’ by onlookers: ‘It’s important to understand that a meltdown is not a tantrum but is a reaction to a highly distressing situation or environment.’ In many ways, the world was not built to accommodate neurodiversity, and this can make the world an extremely chaotic and uncertain place for autistic people. This can mean that autistic people have to mask in order to survive in neurotypical spaces, which can be highly demanding on a person’s coping resources. This can be incredibly uncomfortable and draining for people, as Sarah describes: ‘There are still days on which I hide, and I squirrel away all the pieces of myself until I become a knotted mess of identity. I conceal the stims my hands wish to paint in the air as my body moves to a different tempo through space and anxiety. I feign confidence and comfort around big conversations that wade through the sludge of small talk. I hold my body in the vice of engaged postures and twist my body language to map, mirror, and reflect the faces looking back at me.’ The language used here demonstrates just how uncomfortable it can be to ‘twist’ one’s natural responses, and ‘conceal’ your true self. The onus should not be on autistic people to change to fit their environment, but on the community to recognise, understand, and support neurodiversity in all its forms. The second part of the book looks at thriving while autistic, including navigating co-occurring mental and physical health problems, and helpful advice for advocating for equal access to healthcare. This section discusses some of the ways that mental health conditions can present differently and co-occur alongside autism, which can make accessing diagnoses and treatment more difficult: ‘Autism shapes so much of our daily experience and perception of the world. When you add on different health conditions, that can make daily life more difficult to manage. Difficult, mainly because it means managing your sensory experiences, societal expectations, anxieties, and processing what is going on – all alongside physical health conditions which can make those systems harder.’ Whilst Sarah acknowledges that there are some ‘scary’ statistics about autism and physical and mental health, these are ‘generally a result of autistic communication differences not being understood or supported.’ This means that accessing reasonable adjustments within the healthcare system, as well as at work or at school, is incredibly important. Sarah provides a helpful guide to making sure your needs are understood and met appropriately. ‘The fault lies within an inflexible system that has not listened to or appreciated the needs we have.’ Making big decisions for your future as a young person can be extremely stressful. Sarah shares some thoughts and guidance around making big life changes, such as choosing whether to pursue further education, where to live, and advocating for yourself within these spaces. It is important to explore your own autonomy and independence, and surround yourself with people who empower you to choose your own path. ‘You don’t have to have all the answers when you start making decisions and you might make some wrong ones, but they are your choices for your life.’ The book also emphasises the importance of finding a supportive community, and coming together with people of shared interests. Sarah stresses that community does not have to be a physical place – online communities are just as valid, such as discord servers or communities such as SpectrumGaming. ‘Finding so much similarity, where I had been told for so long that I was weird and unlike so many other people, shook the very foundations of what I thought about myself.’ For many people, finding a community of like-minded people is the difference between feeling like an outsider in the world, and feeling like part of a wider support network. In conclusion, ‘So, I’m Autistic’ is a helpful guide for young people who are considering a diagnosis of autism or have been recently diagnosed. With a strengths-based focus throughout, this book provides information and advice to help young people who may be starting out on their neurodiversity journey. It shares thoughts about neurodiversity, and how society can adapt to best support autistic and otherwise disabled people, not the other way around. Sarah’s positive outlook and proactive advice provides an important perspective on navigating early adulthood whilst battling myths and stereotypes surrounding autism that can often be misleading and confusing. ‘So often the conceptualization of autism is not of autistic people thriving but of autistic trauma and distress. When we are allowed to define ourselves and create our community, we can reframe this away from trauma and towards success or even neutrality.’ ‘So, I’m Autistic: An Introduction to Autism for Young Adults and Late Teens’ by Sarah O’Brien is available on Amazon and from Jessica Kingsley Publishers. Written by Rachel McDermott Studio 3 Information and Social Media Coordinator

This article is the first in a series of discussions around physical interventions training in the crisis management industry, and Studio 3's approach to physical skills. In this article, Professor Andrew McDonnell discusses the issue of terminology. As a Clinical Psychologist and practitioner with expertise in crisis management for the last 35 years, my views on teaching physical intervention skills has radically changed. Many of the ideas myself and my colleagues at Studio 3 Training Systems share have been placed in the public domain in my recent book, ‘Freedom from Restraint and Seclusion: The Studio 3 Approach’ (McDonnell, 2022). In this series of articles, I want to focus more on my own personal reasons for continuing to campaign about the policies and practices in the crisis management training industry, and the teaching of physical intervention skills. Understanding the Studio 3 Approach to Physical Interventions – Part 1: Terminology The restraint industry or, more appropriately, the ‘restraint industrial complex’ (McDonnell, 2022), often obsesses about terminology. It is important that we understand that terminology can drive our thinking processes. In this article, I would like to focus on the use of terminology which, although well-intentioned, can sometimes make issues ‘fuzzy.’ Physical Interventions: A Rose by Another Name The use of the term ‘physical interventions’ has, particularly in the last two decades, become quite extensive. I have never liked it myself, even when I was a member of the working party on physical interventions chaired by BILD in the late 1990s. I remember the passionate arguments of people saying that words like ‘restraint’ and ‘seclusion’ were too negative. My concern at the time - and now - is that we were sanitising physical restraint. Don’t get me wrong, language does influence thought, and we have increasingly seen people correctly move away from negative terminology such as ‘mental deficiency’ and ‘aggressive behaviour.’ My concern is that calling something an intervention has too many positive connotations. In medicine, intervention is a synonym of treatment; when it comes to physically managing a vulnerable person, this is not the case. In the crisis management industry, there has undoubtedly been significant progress in the area of regulating training through bodies such as the Restraint Reduction Network (RRN). However, there has been relatively little progress in regulating the use and types of physical interventions. Our use of terminology also greatly influences these processes. In 2000, in the BILD publication ‘Ethical Approaches to Physical Interventions Vol. 2’ (Allen, 2009) described a protocol where experts could agree on the merits and demerits of particular physical methods. It was my hope at the time, although somewhat misguided, that this would be the next stage in regulation. This process involved colleagues of mine (Alan Martin, David Leadbetter, and Brodie Paterson) forming an expert panel to discuss specific methods that were randomly selected (Martin et al., 2009). In another article, I will discuss specific physical methods, but the important point to know is that even agreeing on names for techniques and holds was difficult. Restraint Terminology Most readers will be aware that in the Studio 3 system we don’t teach prone or supine holds; we never have done, and we never will. It is still the case in 2023 that individuals and organisations do not want to talk about the merits and demerits of particular methods. At present, there is a consensus that, when talking about physical restraint, prone, supine, and seated holds are generally agreed categories. Interestingly, in the Studio 3 system, we have a walking hold called the Walkaround Method that does not fit into these categories at all. It is our hope that, through this series of articles and through wider discussions, we can encourage greater transparency about the methods we teach here at Studio 3, and encourage other organisations to do the same. Whilst there is a general consensus about some terminology, it becomes problematic when talking about other, uncategorised techniques that involve people using physical interventions to escape from an individual or protect themselves. Most alarmingly, I have noticed that training organisations often adorn the word ‘restraint’ to make it sound better. Over the years I have heard prefixes such as ‘dignified’ and ‘peaceful,’ to name but a few. The reality is that immobilising someone against their will, be it on the ground or in a chair, is neither peaceful nor dignified. It is a traumatic process for all parties concerned. Negative Language: Breakaways When we talk about so-called ‘physical interventions,’ there is a category of methods for physically restraining or immobilising people. In addition, people are also taught skills to break free from grips, having their hair pulled, being strangled etc. When I first got involved in the industry in the 1980s, terminology for this was often colloquially referred to as ‘breakaways.’ From both a scientific and practical basis, this is a dreadful term which in my opinion should be banned. When people used to ask me as a Studio 3 trainer, ‘Do you teach breakaways?’ I would often feign dumbfounded ignorance to the terminology and remind them that, at the time, a breakaway was a commercially available chocolate biscuit. To this day, I still hear people use the term. I would prefer it if people used words like ‘physical disengagement.’ We have to change the language and the emphasis. Why do people teach these skills on training courses? The answer for me is very simple. When we are trying to help people become more confident, teaching simple physical strategies is almost like a team-building approach on most courses I have seen. Unfortunately, we have ample practitioner evidence that people start to forget these skills as soon as they leave the training room. These days, I prefer trainers to ‘break the ice’ by focusing more on people’s fears and concerns rather than on a few physical tricks that they may not remember. I often say, ‘People can only focus on learning one movement at a time.’ If we add together the number of methods taught on a training programme, and then add to that the number of different potential movements, this formula suggests that a short training course that teaches physical interventions across 1-2 days realistically should mean the teaching of maybe 2 physical interventions in an entire day. This allows time for positive practice and rehearsal, which is the key to remembering any physical movement. Even with this simple syllabus, people will inevitably forget when they leave the classroom. I remember attending a training course in the late 1980s where, in the space of two days, the ‘instructors’ taught 15 physical techniques. It is far better to teach only specific methods where there is a clear evidential need. If you are supporting an individual who, for complex reasons, pulls hair and has hurt individuals, then by all means teach key staff what to do in those circumstances. This is very different from teaching hundreds of thousands of people in healthcare and educational settings how to get out of having their hair pulled when they have very little chance of experiencing such a behaviour. The mantra I have always used and become more passionate about is, ‘Teach fewer physical skills, but teach them to a high level, as people are more likely to remember them.’ Negative Language: Strangulation Many training courses (including Studio 3) have a category of physical interventions that focus on protecting people from specific types of what can often be highly traumatising behaviours. In the learning disabilities field, the most common situations encountered by staff in my experience involve individuals having their hair pulled, being bitten and clients grabbing clothing. My colleagues and I try to discourage physical techniques being labelled in specific categories. One of the reasons for this is that it is relatively common to come across terminology that implies aggressive intent from the people we support. Some good examples of these include phrase differences. You might use the expression, ‘hair pulling procedure,’ which has different connotations to ‘defence against hair pulling.’ There are so many examples where the language used to describe physical intervention methods can shape your thinking. In the Studio 3 system, we stopped teaching a class of methods called ‘strangulation’ 25 years ago. There were a number of reasons for this: firstly, it was such a rare experience for a staff member to be ‘strangled’ that we believed the teaching of this was unnecessary; secondly, the fear of being strangled evokes strong emotional reactions in all of us; thirdly, we believed that we needed to simplify our approach. Today, we will teach a method defined as ‘airway protection’ in instances where there is a clearly defined need for certain staff supporting an individual who may squeeze or hug you so tightly that they may restrict your airway (though this is still comparatively rare). The important point is, airway protection is a good descriptor of the method, as it is explicitly clear what the purpose is without negative emotional connotations. Avoid Sanitising Terms The flipside of this is that we must be careful that we do not use a term purely because it sounds nicer or less emotive. There is a balance between being specific in our descriptions, whilst at the same time trying to avoid negative connotations. I genuinely believe that the use of the term ‘physical interventions’ has moved the discussion away from specific methods and techniques, and created more generalisation and ambiguity. We exist within a legal system where terms such as physical restraint and seclusion are used because of their specificity. I was recently asked to write a report (outside of the UK) where an organisation’s policy used the terms ‘physical intervention’ to cover all methods, including restraint and seclusion. It was interesting to me that in my role as an ‘expert’ I could not find any adequate descriptions of the methods used, particularly a three-person restraint hold. It may be time to agree that nebulous terms such as ‘physical interventions’ have outlived their sell-by date. I believe as practitioners that talking about specific restrictive practices such as physical restraint, seclusion, sanctions, and PRN medication is less vague and more helpful to debates and discussions. Studio 3 Best Practice Whilst my colleagues and I do not wish to put ourselves forward as the authority in this field, there are some practices that we have adopted as an organisation that may be useful for other training and care organisations to consider when thinking about terminology. Use terms that are specific, such as ‘physical restraint’ and ‘seclusion,’ rather than over using the term ‘physical interventions.’ All Studio 3 trainers and practitioners are encouraged to use the term ‘restraint’ and ‘seclusion’ if that is what we are talking about – otherwise we are sanitising the process. When describing physical methods, we need to think about how the terminology can be misconstrued, and imply that the people we are supporting are aggressive or violent in some way. Do not use terms such as ‘breakaway,’ as they have particular associations with the more traditional training that used to permeate in the 80s and 90s - most notably systems that went by the names ‘control and restraint’ If you are a trainer/practitioner within your own organisation, encourage for written procedures to be routinely reviewed, ensuring the language adopted is positive but descriptively accurate wherever possible. Accept that language does evolve, and that we must move away from terminology which focuses on simplistic distinctions, such as ‘victims’ and ‘perpetrators.’ Terms need to be clearly defined in organisational policies. The term ‘restrictive practices’ has become so overused in recent years that it lacks clarity and specificity. We may restrict someone’s liberty under a best interest principle, but there are some restrictive practices that are indefensible – these should not be categorised in the same way. In our case, at Studio 3 we do not support anything that could be construed as a punishment or a sanction. It is my colleagues’ and I’s hope that we can continue to shed light on our approach, much of which is specified in my own recent book (McDonnell, 2022). In this series of articles, we wish to present meaningful debates and arguments to training organisations and providers to encourage open dialogue about an area which is, by its very definition, difficult to talk about and even considered taboo. My next article will look at the ‘psuedo-martial arts’ underbelly of crisis management training, and how we must move away from the mindset that sees self-defence physical skills as appropriate in caring environments. Written by Professor Andrew McDonnell CEO Studio 3 Download this article as a PDF here: www.studio3.org/practitioner-articles References Allen, D. (2009). Ethical Approaches to Physical Interventions: Volume II - Changing the Agenda. Birmingham: British Institute of Learning Disabilities. Martin, A., McDonnell, A., Leadbetter, D. & Paterson, B. (2009). ‘Evaluating the Risks Associated with Physical Interventions’ in Allen, D. (Ed.) Ethical Approaches to Physical Interventions: Volume II – Changing the Agenda. Kidderminster: BILD Publications. McDonnell, A. (2022). Freedom from Restraint and Seclusion: The Studio 3 Approach. Peterborough: Studio 3 Publications.

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. Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation (Norton Series on Interpersonal Neurobiology). New York: W. W. Norton & Company. 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. Wolf, M. M. (1978). Social validity: the case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behaviour Analysis, 11(2):203-14. doi: 10.1901/jaba.1978.11-203. Woodcock, L. & Page, A. (2010). Managing Family Meltdown: The Low Arousal Approach and Autism. London: Jessica Kingsley Publishers. Yerkes, R. M. & Dodson, J. D. (1908). The Relation of Strength of Stimulus to Rapidity of Habit-Formation. Journal of Comparative Neurology and Psychology, 18, 459-482.

The following extract is from a recent practitioner article on autistic women and self-injury, and how to provide support with coping within a Low Arousal framework. The full article can be accessed here. Abstract Self-injury (SI) is a relatively common mental health concern. Despite the high prevalence of SI in the autistic community, this particular form of distressed behaviour appears to be widely misunderstood by services, especially if presented by women. In this article, the author aims to describe the Studio 3 approach to assessment of and intervention in SI, drawing from the professional experience of supporting autistic women and the application of the Low Arousal Approach. Introduction Self-injury (SI) is a form of behaviour of concern presented by people who have difficulties coping with distress (Taylor et al., 2018). The behaviour is sometimes characterised as an intentional attempt to cause harm to oneself to reduce emotional distress and dysregulation (Klonsky, Victor & Saffer, 2014). SI may take many forms, often as non-suicidal self-injury, such as cutting, scratching, burning, hitting and headbanging. An individual may engage in several forms of SI. Studies show that the prevalence of self-injury in the autistic community is high, and that it is a relatively common mental health concern (Maddox, Trubanova & White, 2017; Mosley et al., 2019; Licence et al., 2019), with some studies reporting up to 50% of autistic adults having a history of SI (Maddox, Trubanova & White, 2017). SI displayed by the autistic population may be repetitive and stereotypic in nature (Licence et al., 2019). A person displaying SI may not be in control or even aware of engaging in such behaviour. Literature highlights several factors associated with an increased risk for self-injury, such as differences in communication (Chiang, 2008) and intellectual disability (Richards et al., 2012). Additionally, co-morbid mental health difficulties, such as depression and anxiety, have been found to increase the risk of SI (Cassidy et al., 2014). Some studies have found that a later diagnosis of autism can increase suicidal ideation (Cassidy et al., 2014) although relatively little is understood about these mechanisms. Gender may also be linked to a higher incidence of SI. Maddox and colleagues (2017) found higher rates of SI for women. While other studies have not replicated these results (Licence et al., 2019; Mosley et al., 2019), in our clinical experience at Studio 3, we have noted an increased number of referrals regarding women who present with SI. Many of these individuals have received a late diagnosis or are undergoing a diagnostic assessment for autism via Studio 3. We have observed a pattern of autistic women with significant difficulties frequently attracting multiple diagnoses. This may be due to the fact that women tend to be diagnosed significantly later than males (Benevides et al., 2020). Oftentimes, other diagnostic labels are explored to explain the difficulties these women experience. Late and inaccurate diagnoses may delay access to autism-informed support and services. Consequently, autistic women are at higher risk of poorer mental health, trauma, and distress. There is an emerging understanding amongst practitioners that women tend to be labelled not with autism as a primary diagnosis, but other conditions such as emotionally unstable personality disorder (EUPD) and ADHD. In addition, particular behaviours may overshadow and mask autistic features. Most notably, there are consistent studies which show a strong association between eating disorders and undiagnosed autism. Despite self-injury being a significant difficulty, autistic individuals report that services struggle to support these individuals (Camm-Crosbie et al., 2018). SI in autism is an under-researched and poorly understood area of need (Cassidy & Rodgers, 2017). Furthermore, it has been highlighted that the experiences of autistic women need closer attention (Taylor & DaWalt, 2020). In this article, the author discusses their experiences of assessing and supporting autistic women who self-injure. The information presented reflects the author’s views based on their professional experience and practical application of the Low Arousal Approach (McDonnell, 2010). Assessment Like any other distressed behaviour, self-injury is multifaceted in nature (Duffy, 2009). Consequently, a comprehensive assessment is needed to establish the functions and maintenance factors of the behaviour. Traditional functional assessments of SI and other behaviours of concern tend to focus on reinforcement theories. These assume SI is maintained by gaining a reward or removing an unpleasant stimulus based on exhibited behaviour (Iwata et al., 1994). However, it is commonly agreed that whilst one reinforcer may be implicated in the onset of SI, maintenance of SI may be influenced by different and multiple factors. Analysing antecedents, behaviours, and consequences tends to help gain an understanding of triggers and reinforcements influencing occurrences of SI. However, in the author’s opinion, these assessments provide a superficial understanding of incidences of SI. As Low Arousal Practitioners, we tend to look ‘beyond the behaviour’ and focus on examining the relationship between occurrences of SI, heightened stress, and coping abilities (McDonnell et al., 2015). Stress and trauma are associated with self-injury. Understanding these mechanisms is essential to developing empathic and appropriate responses. Stress Stress is a natural response which informs us of the dangers in the environment and regulates alertness levels throughout the day. Stress is ever-present, and most people have developed a way of managing it. According to the transactional model of stress and coping (Lazarus & Folkman, 1984), difficulties coping with stress present when the stressor exceeds personal resources. This could be influenced by the interactions between an individual and their environment (Lazarus & Folkman, 1984, p. 19): “Psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her wellbeing.” Research has shown that autistic people generally have higher stress levels than neurotypical people. Autistic people often show elevated levels of the stress hormone cortisol in their nervous system, which is associated with higher levels of stress (Nason, 2014; Lopata et al., 2008). Additionally, when we consider the different experiences of autistic women, for example ‘masking’ (Hull, Petrides & Mandy 2020), we can better understand the stressful nature of the world around them. Social, sensory, interoceptive, and communication differences can make any environment overwhelming and stressful. When social and environmental demands exceed an individual’s ability to cope, their stress can sometimes manifest itself in distressed behaviours which can be challenging for supporters. In these instances, behaviours of concern can be viewed as ‘maladaptive coping strategies.’ From the perspective of the diathesis-stress model, we can understand how lived experiences as an autistic individual and stressors in the environment can intersect with pre-existing vulnerabilities (Broerman, 2020). Stress is, therefore, an essential factor to consider. We should closely observe any signs which suggest that an individual’s coping ability is impacted. SI, as previously mentioned, is a coping strategy, and although ‘maladaptive’ may be the only effective strategy the person has to regulate their distress. Consequently, an assessment should thoroughly examine potential stressors the person may experience, including: Environmental factors - Is the environment meeting the person’s needs; for example, from a sensory and information-processing perspective? Personal factors - Are the needs of this person being met? Consider their emotional, social, psychological, and physical well-being. Interpersonal and systemic factors - Are the support systems around the person managing or experiencing stress and dysregulation themselves? This is incredibly important, as SIB tends to be emotionally challenging to witness. Trauma Trauma is another significant factor to consider when assessing self-injury. Research involving the autistic community has shown higher rates of PTSD symptoms than the neurotypical population (Rumball, Happé & Grey, 2020; Rumball et al., 2021; Haruvi-Lamdan et al., 2020). These figures are not surprising considering the stressful nature of navigating the ‘neurotypical world’ and other vulnerabilities associated with autism (Rumball, Happé & Grey, 2020; Kerns et al., 2022). The autistic population is at higher risk of experiencing traumatic life events such as bullying and physical, emotional, and sexual abuse (Reuben, Stanzione & Singleton, 2021). We also meet women who may have been ‘traumatised by the system’ through a lack of autism-informed support. Such approaches may include frequent use of restrictive practices; for example, restraint and seclusion. Some of the individuals we support have difficulties coping and engaging with the services offered, partially due to a misunderstanding of their needs and how their autism manifests. Inevitably, this contributes to re-traumatising these women. Self-injury may be an attempt to manage trauma and cope with trauma triggers, thus it is essential to consider individuals’ history and any traumatic events they may have experienced. This may help to create an understanding of SI, particularly if the behaviour is present or intensifies around specific triggering events. Consider: Has the person experienced any traumatic experiences in early childhood [see Adverse Childhood Experiences (ACE’s) (Felliti et al., 1998)]? Has the person been subject to physical, emotional or sexual abuse? Have restrictive practices such as restraint, segregation, or seclusion been used to manage the person’s behaviour? Are there any environmental factors that may trigger trauma? Consider sensory stimuli such as smells, noises, or sight of staff congregating in one area (may trigger memories of physical restraint/abuse). Is the person grieving and struggling with bereavement or another form of loss? Body Sensations/Interoception It is not uncommon for people who self-harm to report that they often feel ‘numb.’ This is particularly true of individuals who routinely cut. Understanding our own body sensations, from our heart rate to sensations of pain, is critical to answering why some people use self-injury to block out or create bodily sensations. The ability to be aware of our own body sensations is known as interoception (Mahler, 2016 a). Interoception is a sense responsible for signalling internal needs such as hunger, thirst and emotions, including stress (Craig, 2002). The ability to interpret internal cues has significant implications for homeostatic processes and emotional regulation (Craig, 2015). Interoception is considered the first step to recognising an arising need. Thus, interoception has received increased attention in recent research on emotional regulation, trauma, and developmental disabilities. Studio 3 practitioners routinely work with individuals who confuse emotional and physical pain. It is interesting to note that the emotional and physical pain pathways in the brain do appear to be intertwined and interlinked. Given the sensory differences experienced by the autistic community, interoceptive awareness may vary considerably. For many individuals, this system can be either hyper or hyposensitive (Mahler, 2016a). In practice, this means that one may not feel the urge to act on a need, or may feel these cues at an intensified level. An insight into how one experiences and makes sense of their ‘internal world’ may significantly shape our understanding of self-injury’s manifestation and stress regulation, for instance: Is the person able to recognise signs of building stress and emotions? Is the person able to communicate this and look for support? Is the person easily overwhelmed by their sensory experiences? Can they recognise building stressors and know what to do when overwhelmed? Continue reading... Written by Karolina Morgalla Studio 3 Assistant Psychologist References Benevides, T. W., Shore, S. M., Palmer, K., Duncan, P., Plank, A., Andresen, M. L., ... & Coughlin, S. S. (2020). Listening to the autistic voice: Mental health priorities to guide research and practice in autism from a stakeholder-driven project. Autism, 24(4), 822-833. Broerman, R. (2020). Diathesis-stress model. Encyclopedia of personality and individual differences, 1107-1109. Camm-Crosbie, L., Bradley, L., Shaw, R., Baron-Cohen, S., & Cassidy, S. (2019[RM1] ). ‘People like me don’t get support’: Autistic adults’ experiences of support and treatment for mental health difficulties, self-injury and suicidality. Autism, 23(6), 1431-1441. Cassidy, S., Bradley, P., Robinson, J., Allison, C., McHugh, M., & Baron-Cohen, S. (2014). Suicidal ideation and suicide plans or attempts in adults with Asperger’s syndrome attending a specialist diagnostic clinic: a clinical cohort study. The Lancet Psychiatry, 1(2), 142-147. Cassidy, S., & Rodgers, J. (2017). Understanding and prevention of suicide in autism. The Lancet Psychiatry, 4(6), e11. Chiang, H. M. (2008). Expressive communication of children with autism: The use of challenging behaviour. Journal of Intellectual Disability Research, 52(11), 966-972. Craig, A. D. (2015). How Do You Feel? An Interoceptive Moment with Your Neurobiological Self. Princeton, NJ: Princeton University Press. doi: 10.1515/9781400852727. ---------- (2002). How do you feel? Interoception: the sense of the physiological condition of the body. Nature reviews neuroscience, 3(8), 655-666. Duffy, D. F. (2009). Self-injury. Psychiatry, 8(7), 237-240. doi: 10.1016/j.mppsy.2009.04.006. Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine. 14(4): 245-58. doi:10.1016/s0749-3797(98)00017-8. Haruvi-Lamdan, N., Horesh, D., Zohar, S., Kraus, M., & Golan, O. (2020). Autism spectrum disorder and post-traumatic stress disorder: An unexplored co-occurrence of conditions. Autism, 24(4), 884-898. Hull, L., Petrides, K. V., & Mandy, W. (2020). The female autism phenotype and camouflaging: A narrative review. Review Journal of Autism and Developmental Disorders, 7, 306-317. Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., Richman, G. S. (1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 197–209. (Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3–20, 1982) Kerns, C. M., Lankenau, S., Shattuck, P. T., Robins, D. L., Newschaffer, C. J., & Berkowitz, S. J. (2022). Exploring potential sources of childhood trauma: A qualitative study with autistic adults and caregivers. Autism, 26(8), 1987-1998. Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Non-suicidal self-injury: what we know, and what we need to know. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 59(11), 565–568. https://doi.org/10.1177/070674371405901101 Lazarus, R.S. & Folkman, S., 1984. Stress, appraisal, and coping. Springer publishing company. Licence, L., Oliver, C., Moss, J., & Richards, C. (2020). [RM2] Prevalence and risk-markers of self-harm in autistic children and adults. Journal of autism and developmental disorders, 50(10), 3561-3574. Lopata, C., Volker, M. A., Putnam, S. K., Thomeer, M. L., & Nida, R. E. (2008). Effect of social familiarity on salivary cortisol and self-reports of social anxiety and stress in children with high functioning autism spectrum disorders. Journal of Autism and Developmental Disorders, 38, 1866-1877. Maddox, B. B., Trubanova, A., & White, S. W. (2017). Untended wounds: Non-suicidal self-injury in adults with autism spectrum disorder. Autism, 21(4), 412-422. Mahler, K. J. (2018). The interoception curriculum: A step-by-step guide to developing mindful self-regulation. --------- (2016a). Interoception: The Eighth Sensory System: Practical Solutions for Improving Self-Regulation, Self-Awareness and Social Understanding of Individuals With Autism Spectrum and Related Disorders. AAPC Publishing. ---------- (2016b). Comprehensive Assessment for Interoceptive Awareness. Autism Asperger Publishing. McDonnell, A. (2019). Reflective Journey: A Practitioner’s Guide to the Low Arousal Approach. Petersborough: Studio 3 Publishing. ---------- (2010). Managing Aggressive Behaviour in Care Settings: Understanding and Applying Low Arousal Approaches. Chichester: John Wiley & Sons Ltd. McDonnell, A., McCreadie, M., Mills, R., Deveau, R., Anker, R. & Hayden, J., (2015). 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., Reeves, S., Johnson, A., & Lane, A. (1998). Managing challenging behaviour in an adult with learning disabilities: The use of Low Arousal approach. Behavioural and Cognitive Psychotherapy, 26(2), 163-171. Nason, B. (2014). The Autism Discussion Page on the core challenges of autism: A toolbox for helping children with autism feel safe, accepted, and competent. Jessica Kingsley Publishers. Reuben, K. E., Stanzione, C. M., & Singleton, J. L. (2021). Interpersonal trauma and post-traumatic stress in autistic adults. Autism in adulthood, 3(3), 247-256. Richards, C., Oliver, C., Nelson, L., & Moss, J. (2012). Self‐injurious behaviour in individuals with autism spectrum disorder and intellectual disability. Journal of Intellectual Disability Research, 56(5), 476-489. Rumball, F., Brook, L., Happé, F., & Karl, A. (2021). Heightened risk of posttraumatic stress disorder in adults with autism spectrum disorder: The role of cumulative trauma and memory deficits. Research in Developmental Disabilities, 110, 103848. Rumball, F., Happé, F., & Grey, N. (2020). Experience of trauma and PTSD symptoms in autistic adults: risk of PTSD development following DSM‐5 and non‐DSM‐5 traumatic life events. Autism Research, 13(12), 2122-2132. Taylor, J. L., & DaWalt, L. S. (2020). Working toward a better understanding of the life experiences of women on the autism spectrum. Autism. https://doi.org/10.1177/1362361320913754 Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., Shahmalak, U., & Dickson, J. M. (2018). A meta-analysis of the prevalence of different functions of non-suicidal self-injury. Journal of Affective Disorders, 227, 759-769.

Autism Understood is a website about what autism really is created for autistic young people by Spectrum Gaming, a registered charity and online community for autistic young people. When young people receive an autism diagnosis, many are not told what it is or what it means, so often they will go online to look for answers. Most of the information generated by internet search engines is outdated and can be harmful. Therefore, at Spectrum Gaming we have worked hard over the past year to create a new website called Autism Understood that offers young people meaningful and correct information about autism. On 3rd July 2023, the accessible, free resource went live, with content created by Spectrum Gaming's staff team, over 30 other autistic professionals and advocates, and all reviewed and edited by 54 autistic young people (aged 7 - 17 years). We’ve had an abundance of positive feedback from the public, not just from autistic young people and their families, but also many late-diagnosed adults who have also been finding the website helpful. “Such a fab resource. Many thanks for creating this. I know it is really going to help some of the youngsters I work with to understand and to accept themselves more positively.” One of our goals at Spectrum Gaming is to make sure as many autistic people as possible are able to accept their differences and live the happiest lives possible. We're so glad that Autism Understood is already managing to increase self-acceptance for the autistic people who have viewed it in the first month. Visit the new website here for information about what autism actually is, including spiky profiles and sensory differences. Written by Spectrum Gaming Admins

Professor Andrew McDonnell shares some things to look for when choosing a diagnostician to carry out an autism diagnosis. As a practitioner with over 30 years of diagnostic experience, it is notable that there has been a recent increase in the number of provider organisations that conduct autism diagnostic assessments. For families and individuals, it is difficult to be confronted by long-term waiting lists for diagnosis. In this article, I am going to share some personal views about what to look for when choosing a diagnostician. Private vs Public Diagnosis When I first qualified in the 1980s as a Clinical Psychologist, private diagnoses were a relative rarity. It was most common to receive a diagnosis of autism from either a Consultant Psychiatrist or a Clinical Psychologist with appropriate training. Relatively early in my career, I was fortunate to be influenced by Professor Lorna Wing, Dr Judith Gould, and many others who led the charge to understanding autism. Since this time, our knowledge base has dramatically expanded to the extent that even our understanding of the autism spectrum incorporates a complex range of conditions and experiences. I think it is important to reassure people that a high-quality diagnosis can be achieved, both publicly and privately. Quality of the Practitioner Psychiatrists and Clinical Psychologists are accountable to their professional bodies. It is always difficult to judge an individual practitioner as, despite their professional qualifications, it is often difficult to get a sense from a website what their approach to diagnosis entails. I would encourage anyone who is considering a diagnosis to clarify the approximate number of diagnoses the individual has conducted themselves. Like any market, can these practitioners provide testimonials or examples of individuals that they have diagnosed and the impact it has had on their life? On a personal note, when I advise families and individuals, I always encourage them to ask relevant key questions: 1) Does the person have experience of diagnosing both children and adults? 2) What experience do they have of diagnosing women on the autism spectrum? 3) Do they work as part of a team or as an individual? 4) What diagnostic tools (i.e., Autism Diagnostic Observation Schedule (ADOS), etc.) do they use? 5) Under what ethical circumstances would they not diagnose an individual? Recently, there has been an increase in online diagnoses. Whilst there may be merits to such diagnoses in terms of their rapidity, I personally have serious ethical concerns where diagnosis is this impersonal. When determining the quality of a diagnostician, I would strongly advise people to ask for an informal consultation so they can determine whether this individual shows some kind of connection to the individual. Developmental History The increasing use of screening tools with statistical cut off points is important. However, diagnostic tools like the ADOS should be viewed as a guide, and only one component of any diagnosis. A clear developmental history (my own preference is to use the autism diagnostic interview (ADI-R) to take a thorough history) is very important. Significant numbers of individuals show early developmental delays in social communication, and in some instances developmental milestones, such as walking and talking. Interestingly, I have also worked with individuals who have shown advances at an early developmental stage which are not picked up by screening tools. For example, a person that I diagnosed at 18 years old was reported as having no developmental issues as a child. In reality, at 2 years of age, the individual was showing developmental advances - using sentences way beyond what would be expected of someone his age. It is important to understand that developmental histories are critical. Good diagnosticians and diagnostic teams will take time to talk to family and individuals about their early childhood development. In fact, a thorough developmental history is essential. Use of Screening Tools Increasingly, the use of screening tools such as the AQ50 (Autism Quotient 50) and others are necessary, particularly in diagnostic clinics that deal with high volumes of people. Please remember that they are called screening ‘tools’ for a reason. Screening for other health conditions is not an exact science – they just provide a guide or an indicator. The best way to think about screening tools is that they are a starter to your meal, not the main course. Screening tools are excellent at finding individuals who show considerable features of conditions such as autism, in particular behavioural issues. They are less good at indicating individuals whose features are more subtle. It is important to understand that if you are just given a screening tool and a short interview with a practitioner, that cannot in essence be a good diagnosis. Sensory Issues Our understanding of sensory issues in autism has significantly developed over the last 20 years. Many people on the autistic spectrum (and other conditions as well) experience quite profound sensory processing issues. I should also stress that I work with individuals on the autism spectrum who have relatively few sensory processing issues. In terms of this article, a good diagnosis should have either reference to a sensory assessment, or the diagnostic team/diagnostician should also include a sensory-based assessment. Language We know that language greatly influences our thought processes. For individuals seeking a diagnosis, there are a myriad of terms on the internet and in social conversation that refer to autism or the autistic spectrum. It is more common these days to refer to individuals as ‘neurodivergent.’ The language that your diagnostician uses could be a good indicator of their approach to understanding autism. From my own perspective, my colleagues and I at Studio 3 have moved away from referring to phrases such as ‘autism spectrum disorder or deficits (ASD)’ as it presents negative connotations around the condition. The use of language both in written reports and in conversation with your diagnostician will give you clues about their stance. Reports I have personally experienced seeing diagnoses written in one-page letters to individuals with little explanation of the rationale and reasonings underlying the diagnosis. In my own personal view, this is bad practice. A person should be given a report with a clear opinion statement of why the individual has either received a diagnosis of autism, or been told that they do not meet the criteria. Most importantly, if a person’s diagnosis is confirmed, then the recommendations in any report should give the individual guidance on useful resources and some steps to help the individual process their diagnosis. With any written report, I feel it is very important that there is at least a 3-month follow-up session with that individual and/or their family to understand what they have processed from their diagnosis. Time Taken Good thorough assessments take time. I have examined the assessments conducted by my colleagues at Studio 3 over the last 3 years, and the minimum would appear to be a full working day spending time with the individual and talking to their supporters. In addition, this face-to-face time can increase from anything between 1-5 additional days depending on the complexity of the situation. To produce a meaningful report without using ‘cut and paste,’ which sadly seems to be prolific in the diagnostic industry, it takes Studio 3 staff 1 and sometimes 2 full days to produce a report. Seeking Second Opinions It is essential to understand that many individuals do not neatly fit in the diagnostic categories specified in the DSM-V. Whilst the vast majority of diagnoses are likely to be reasonably reliable, there are many situations where an individual may be told they are not on the spectrum, or even more unhelpfully that they are ‘borderline.’ If a person is uncomfortable with not receiving a diagnosis, in our modern society they can always seek a second opinion. In conclusion, I have attempted to provide a personal perspective on diagnosis individuals with autism. Whilst this is not an exhaustive list, my parting advice is to spend time and don’t rush into choosing a diagnostician too quickly. Scrutinise their websites, talk to them if you can, get an understanding of their philosophy to diagnosis and practice, and remember that whether diagnosis is in the private or public sector, you are a customer and not a patient. Written by Professor Andrew McDonnell Studio 3 CEO and Clinical Psychologist For more information about autism assessments from Studio 3 practitioners, visit https://www.studio3.org/autism-diagnostic-assessments

In this article, Studio 3 reviews Pete Wharmby’s 2022 publication, 'Untypical: How the World Isn’t Built for Autistic People and What We Should All Do About It.’ ‘Untypical’ by Pete Wharmby is a broad exploration of the multitude of ways in which the world has not been built with autistic people’s needs at the fore, and how confusing and strange this neurotypical bubble can be to navigate for neurodivergent people in general. Pete Wharmby is a former English teacher who received an autism diagnosis in his thirties, and who has since emersed himself in the world of autism advocacy. In this book, he shares some of his person experiences of navigating what Peter Vermeulen calls the ‘chaos’ of neurotypical society, including the need to mask, the struggles of education and employment where no adjustments are made for neurodivergence, ADHD and other intersectional neurodivergent identities, as well as an overwhelming lack of knowledge and understanding around autistic experience in many sectors. Pete’s witty and engaging narrative throughout is both insightful and passionate as he implores non-autistic readers to attempt to understand the experiences of autistic people in social, educational and employment environments, and how we as a society can make the world a less harmful place for neurodivergent communities. Pete discusses his life pre-diagnosis, and voices a feeling of Otherness that is reflected in many autistic experiences. He admits from the outset, ‘I’m a little… cross.’ Why is the world so hostile and harsh for autistic people? Why are neurotypical people the ‘normal’ ones when everything they do is nonsensical? From unspoken social rules to the horror of phone calls, there are a plethora of hoops for neurodivergent people to jump through before they can be accepted into the fold, which at times felt like an impossible task for Pete: ‘I was like a version of Mowgli from The Jungle Book, brought up out of my element, learning how to exist in one world with its terrible dangers while the world I truly belonged to was elsewhere, unknown to me. Unlike him, though, I had no mentor or guide in this journey, no Baloo or Bagheera to help me understand the laws of the jungle.’ Pete’s jungle analogy here is not a frivolous one – the world really is a dangerous place for autistic people. The pressure to fit in is so great that it can feel like life or death; pressure not, as Pete says, ‘to make us fit in at a party, but to make us fit in with humanity.’ When passing as non-autistic has consequences as severe as not being accepted for a job or being persecuted by figures of authority, it becomes a huge burden on autistic people to behave neurotypically. This is particularly relevant for autistic people with other minority identities, such as the Black autistic community, historically misunderstood and mistreated by organisations such as the police force, particularly in America. Autistic people in extreme distress have often been mistaken for violent offenders (such as Linden Cameron), making this not merely an issue of autistic people’s comfort, but their welfare: ‘It’s vital for people in authority to understand the limitations of autistic masking, and to be able to recognise the signs of autistic meltdown and autistic behaviour generally.’ Misunderstanding meltdowns, dysregulation and sensory sensitivity in autistic populations can have dangerous consequences, and it is vital that autistic people’s needs are recognised by society at large. This requires more understanding around what autism is and how it can impact people, particularly when they may be distressed. Trying to impose neurotypical rules in these moments will only serve to escalate the situation and cause further distress. As David Pitonyak says, ‘When a person is drowning, that is not the time to teach them how to swim.’ Pete goes on to discuss the multitude of ways in which autistic people must work so much harder than neurotypicals in order to simply get through the day, leading to huge amounts of stress which, without support, can become unmanageable. This is due to a multitude of factors, including constant pressure to mask, social difficulties, and increased sensory sensitivity: ‘The understanding that’s lacking is that autistic people are already, just by being alive in this world, close to their natural limit of stress – their ceiling of tolerance.’ This is compounded by the lack of equal access to healthcare, where the needs of autistic people are not being met or understood by healthcare professionals. Even making an appointment with a doctor is difficult, requiring the social and executive function skills to call and make an appointment, travel there, and arrive on time. Pete calls for mandatory training in learning disabilities and autism for healthcare professionals, such as the recently enacted Oliver McGowan Mandatory Training on Learning Disability and Autism introduced in the UK. Pete is one of the many late-diagnosed people who have received no post-diagnosis support in the UK, ‘having been sent on my way with a handful of mediocre pamphlets and a ‘good luck’ from the psychiatrist.’ Pete states that, had it not been for the support he received from the online autistic community, his own outcome may have been far worse. At the heart of this is a lack of understanding and awareness of autism itself, and how best to support autistic people. Without understanding, inefficient or non-existent accommodations are the only support available: ‘The problem here stems from a lack of understanding of what autism is: after all, how can you offer to help someone whose difficulties you don’t comprehend?’ In this book, Pete attempts to demystify some of the misperceptions around autism, and provides a comprehensive insight into issues such as executive dysfunction and the impact this can have on education, employment, finances and housing; autistic inertia; monotropism; stimming and its effectiveness as a coping strategy; how special interests can save lives (a sentiment echoed by the wonderful autism campaigner Dr Carly Jones); pathological demand avoidance (PDA); ADHD; depression; relationship and communication difficulties; trauma; sensory sensitivities; as well as how autism intersects with other marginalised identities (being Black, Queer, Trans and more). This book is a call to action for neurotypical people who want – and need, for the sake of their fellow humans – to understand autism better, and use that knowledge to do better in their personal interactions with the autistic people in their lives. It’s also about us as a society, as communities, coming together to make the world a more accessible and safe place for everyone. The voices of autistic people have been drowned out throughout history in many sectors, and there have been many ‘ham fisted attempts to ‘raise awareness’ by charities run by non-autistic people using language and images despised by the autistic community.’ Now is the time to listen to the authentic experiences of autistic people and elevate these into public consciousness in order to inform individuals, organisations, research and practice in our society. As Pete points out, ‘This is so frequently planted as a problem that lies squarely at the feet of the autistic person.’ ‘It’s too easy to think, in a defeatist, miserable way, that we’re the ones who keep messing up and that we’re the ones, therefore, who need to change.’ This cannot continue to be the case. The responsibility to make the world a better place for autistic people lies with all of us, and it starts with you individually taking accountability, and ensuring that outdated and damaging myths about autism are not perpetuated. Listen to the stories of people like Pete who are fighting to be heard. After all, as Pete says: ‘We autistics can shout about it until the proverbial cows come home, some of us can even write whole books about it, but nothing will change until the neurotypicals do.’ 'Untypical' by Pete Wharmby is available to purchase on Amazon. Written by Rachel McDermott Studio 3 Information and Social Media Co-ordinator

Many people are uncomfortable with aspects of mental health diagnoses. The idea of neurodiversity echoes more nuanced ideas around selfhood and a search for new ways to understand individual human difference. I felt it might be helpful to reflect on the utility of current classification systems in the field of mental health, and focus specifically on autism and ADHD. One difficulty with diagnosis is that there is risk that everything a person does is then understood through the lens of a particular diagnosis. This is known as ‘diagnostic overshadowing.’ A person with an intellectual disability (i.e., broadly speaking, a person who has an IQ < 70 who also has difficulties in day-to-day task management) might find that they are excluded from the social rituals of grief or loss, or perhaps that their behaviour is always framed as “challenging” when in fact the cause may be trauma, loss, or just the everyday struggles of living. Maslow’s quote, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail,” (Maslow, 1966) is linked to this idea of diagnostic overshadowing, or the idea that we might overlook other explanations for a person’s difficulties because we are so aligned to a primary diagnosis. Thus, surface interpretations of another person’s experiences emerge, such as; “Well of course John does that…he’s autistic you know…that’s what autistic people do…” Maslow’s words are therefore a cautionary warning for all of us. Here, I concede my own practitioner bias as I don’t feel it’s possible to be wholly neutral on this topic. As a practitioner working in the field of developmental disability, I do feel there is validity in a diagnosis of autism given that it is understood to be a neurodevelopmental condition and that it is usually helpful for a person to either know this or have others understand something of this. I see the developmental component as critical, suggesting biological validity that may not be relevant for diagnoses that may be merely descriptive of current human behaviour/state. What then ought we to do to ensure we don’t as clinicians engage in diagnostic overshadowing? At Studio 3, we tend to be consulted around more complex and sensitive situations, in that we are usually looking at cases where simple ‘off-the-shelf’ autism interventions have been unsuccessful or perhaps reported to have caused harm. This is often so with more behavioural interventions which might have led to demand avoidance behaviours or resistance (eg. Kupferstein, 2018). What we can do is to hold diagnosis lightly, and also look for the other variables in the life of a person that might overlap with developmental conditions. Adverse past experiences or stigmatisation, for example at school, offer a rich seam of distress for young adults who have a primary autism diagnosis. Here we are regularly working not only with autism: trauma is often very much in play. And so it is necessary as a practitioner to have some understanding of how autism presents a stress vulnerability model, especially for the future relational struggles of life. I have in mind a case recently where a child’s distress had historically been framed as psychotic or just “bad” behaviour, when a systemic overview of their past linked together difficulties of attachment, neglect, and undiagnosed autism. Absence of diagnosis had led to harmful interventions and unhelpful responses by society where difference was hidden from view. In this case we worked alongside psychiatry to offer a corrective diagnosis (autism), which allowed new explanations, treatment and support pathways. And of course, the reverse might be true for some people; it seems obviously unhelpful to be wrongly diagnosed with autism if in fact your relational and emotional development was affected by adverse early life experiences or other later difficulties. These are without doubt the most complex cases my colleagues and I wrestle with. The case of ADHD offers another emerging professional battleground I sense, where on the one hand we might understand a person to “have” ADHD and thus understand them from that perspective, or whether we can take a broader look at past struggles and current life situation and formulate a more complete sense of what might have led to the features associated with this “disorder.” At Studio 3, we talk regularly in clinical meetings about how we engage with the reality of attentional difficulties or hyperactivity on the one hand, whilst also taking account of other systemic or support variables, so that we don’t sleepwalk into medicalising all aspects of the human condition. Anxiety, trauma, depression, premature birth, and autism amongst others all present different and overlapping pathways so that it may be unwise to allow ADHD to become the new “overshadowing classification.” And thus, while Studio 3 offers diagnostic assessment for ADHD, we remain mindful of broader perspectives in the life of the person so that we can find solutions which best fit the context in which a person lives, and indeed their own strengths and weaknesses. Part of this challenge is for example to take care not to always see a child as the “identified patient,” and keep in mind that difficulties at school for example might be around perceived lack of safety in their world from their perspective. And so the question around diagnosis becomes; “Is it appropriate in this case and helpful for this client to offer a diagnosis of ADHD?” To summarise, our approach at Studio 3 is to explore and offer diagnosis when that is felt ethically necessary or helpful as a tool which leads to clarification of a person’s difficulty or needs. We are unashamedly person-centred in our perspective. The more precise tool psychologists use alongside diagnosis is what we call formulation. A formulation might draw upon diagnosis, but seeks to arrive at a unique understanding of a person’s struggle, and thus make meaning of individual psychological or behavioural difficulty. A formulation might draw upon past losses or adverse experiences, or how change in a person’s life has caused distress they cannot cope with. An autism diagnosis, for example, might therefore lie at the heart of the formulation, but would not itself define the problem or in itself guide interventions. Similarly, nor might a formulation lead to interventions that place responsibility with the person, as often it is the support system around the person where one can realistically effect change rather than through 1:1 therapy. It is possible, for example, to work with parents or a school in response to a child with anxiety, rather than placing the onus for change on the child who may have no real insight into their distress. This of course is how we all started out in life; caregivers helped us co-regulate, and so can relational and environmental systems around us as we grow up. And so it is often the case that a person might not be equipped to cope with the tasks of 1:1 therapy, but can heal if the family, school, caregivers and/or workplace make environmental and relational adjustments so as to create conditions in which they can cope. Most of our work at Studio 3 is about just this – supporting systems around a person to help the person themselves manage to cope. Dan Hughes (PACE; Hughes & Golding, 2012), Eli Lebowitz (SPACE; Lebowitz, Omer, Hermes & Scahill, 2014) and Professor Andrew McDonnell (Low Arousal Approach; McDonnell, 2010) offer examples of such systemic caregiver models that we can draw upon when working with families. At Studio 3, much of our work is to support parents or caregivers to feel confident and competent to lead interventions which bring systemic safety so that a person can cope. Diagnosis often offers an important clarification that allows new thinking and ways to support a person, but is just one part of a more complex attempt to connect general theory with real people and their needs. I hope Maslow would be satisfied that his thoughts are very much alive in what we do. Written by Dr. John McDermott Studio 3, Counselling Psychologist For more information about Studio 3's diagnostic and assessment services, visit www.studio3.org/clinical-services References Hughes, D., & Golding, K. S. (2012). Creating loving attachments: Parenting with PACE to nurture confidence and security in the troubled child. London: Jessica Kingsley Publishers. Kupferstein, H. (2018). Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis. Advances in Autism, 4(1), 19-29. Lebowitz, E. R., Omer, H., Hermes, H., & Scahill, L. (2014). Parent training for childhood anxiety disorders: the SPACE program. Cognitive and behavioral practice, 21(4), 456-469. Maslow, A. H. (1966). The psychology of science: A reconnaissance. New York: Harper & Row. McDonnell, A. A. (2010). Managing aggressive behaviour in care settings: Understanding and applying low arousal approaches. Oxford: Wiley-Blackwell.

Principal Trainer Paul Phillips discusses recent developments in Studio 3 Ireland Training over the past year, and congratulates new Studio 3 Trainers who have joined the team! Busy year so far for ‘Train the Trainer’ The cohort of Studio 3 trainers in Ireland has continued to grow rapidly over the past year, with a further 54 new recruits joining the ranks. In April 2022, 11 Trainers graduated; David Stalford, Chris Stewart, Rachel Gibson and Tim McGeown from Positive Futures; Sean Kelly and Mat Farland from Peacehaven Trust; Dan Shanahan (WIDA); Mike Walsh (Ability West); Manfred Davies (WALK);Cormac Noone (BEAM); and Keri Dickson (Studio 3). Then in May 2022, a further 12 HSE staff from the Northwest (Donegal and Sligo). So, a warm welcome to the following new trainers; Deirdre McGee, Deborah Smith, Evelyn O Kane, Kieran Gorman, Leonie Kerr, Laura Elliott, Michael Doherty, Fiachra McMahon, Evelyn McBride, Olivia Montgomery, Sarah Frazer and Naomi Nibbs. Next it was on to Dublin in Autumn ‘22, a course kindly hosted by Avista, Navan Road. On this occasion, 11 staff successfully completed the course: Mairead Walpole and Stephen Kavanagh from Avista Limerick; Kevin Hickey, Ceire Swan and Pauline Thompson from Avista, Dublin; Sean O Callaghan (Kingsriver, Kilkenny); Kathleen Barry Murphy (HSE Southside); PJ Ryan (Gateway, Sligo); Dylan Hallett (Studio 3, Kerry); Sarah Mulligan (WIDA) and Kate Steed (Kolbe School). In the Spring of this year, Mayo Community Living, Swinford, Co. Mayo, was the venue where an additional 11 trainers were became qualified. We were very pleased to have 4 participants from the Children’s Disability Network Team, Sligo, namely Emer Loftus, Louise Leech, Jean Hession and Peigi NicDhonncha. Best of luck to them as they will be reaching out to support schools and families in the region. The remaining successful candidates were Pat Mulrooney and Ellen Johnson from Ability West, Galway; Neil Toner, Martha Fleming, Trevor Renick and Stephen McDermott from Mayo Community Living; and Antoinette Weekes (Western Care). Just recently, in mid-June, nine staff completed a Dublin-based course hosted by Peamount Healthcare. Congrats to the following: Urszula Maksimowska, Ayotunde Odusanya and Mayra Orrillorojas from Southside Disability Services; Tracy Dunne and Philomena Keogh from Peamount Healthcare; Lucinda Ramsey and Kate Finnegan from St Margaret’s, Dublin; Kelly Savage, Daffodil/ARCS; and Sophia Keane, WIDA, Waterford. It is really pleasing that 50 plus new trainers have come on board and it is likely that another course will be filled in the autumn, located in the North West. If you are interested in becoming a Studio 3 Trained Trainer, more information is available from www.studio3.org/training-trainers, or watch the short video below: The Atlass Stress Management Programme After a sojourn in 2022, Atlass Stress Management training will make a return in the Autumn of this year. Preparations are being made to deliver a 5-day non-accredited course in Donegal in September/October. This course is already fully subscribed but further courses will be scheduled for 2024, both accredited and non-accredited. If you are interested in attending an Atlass course, please get in touch. For more information about Atlass training, visit: www.studio3.org/atlass Upcoming CPD Events in Ireland All qualified trainers in Ireland are now required to complete 2 days Continuing Professional Development (CPD) training per annum in order to maintain their licence to train (prior to this 1 day a year was sufficient). To help facilitate this, we are organising 2 x 2-day events later in the year, one in the North West/Donegal and one in the Dublin area. Event 1 October 5th - 6th 2023, Co. Donegal (Venue to be confirmed) Day 1: Physical Skills Refresher, Back Office and new training resources online Day 2: Topics to be confirmed Event 2 December 7th - 8th 2023, Dublin (Venue to be confirmed) Day 1: Physical Skills Refresher, Back Office and new training resources online Day 2: Impact of Trauma - Importance of Trauma-Informed Low Arousal Practice with Raymi Doyle These events will shortly be going up online on the back office for Studio 3 trainers to register to attend – please do so in good time to ensure a slot. Written by Paul Phillips, Principal Trainer

‘Speechless’ is the first book written by Irish author Fiacre Ryan, who shares his journey as an autistic man and non-verbal writer in this non-fiction memoir and poetry collection. Published in 2022, ‘Speechless’ is a striking collection of poems and reflections from Fiacre’s unique point of view as a non-verbal autistic man living in Ireland. Diagnosed with autism at the age of 3, and non-verbal for his entire life, Fiacre seeks to defy the odds stacked against him as an autistic author in this, his first book. Fiacre started writing at the age of 16 using Rapid Prompting Method (RPM), a tool used to help non-speaking children and adults communicate using a letterboard. Whilst his family had tried lots of methods to communicate with Fiacre, they had begun to lose hope. With RPM, Fiacre’s world opened up, shocking his family with his knowledge and understanding. Speaking in the RTE Documentary, ‘Speechless,’ aired in March 2022, Fiacre’s sister Becky says that by using the letterboard to communicate with Fiacre, ‘We’ve been able to know a new person.’ As the first non-verbal autistic student to sit (and pass – with flying colours) the Irish Leaving Certificate exams, Fiacre felt enormous pressure to fit in and prove his intelligence to his peers and to society at large. In his book, Fiacre reflects on feeling held back by other people’s perceptions of what he is capable of. He describes his efforts to pass his exams as an attempt to ‘verify’ himself in the eyes of society; that by proving his intelligence, he could prove his value, and show that he deserves the respect and understanding shown to his peers. ‘Needing some type of assistance does not make someone less of a person. Being different does not impact my label of human.’ Describing himself as an ‘accidental advocate,’ Fiacre’s story has resonated with many autistic people struggling to be afforded the same opportunities in education as their neurotypical peers. In his book, he speaks of being separated from other learners, and not being given the same opportunities to flourish and thrive: ‘I am so weary and bored doing stupid autism things at the unit. Others eat their lunch each day at the canteen but I am always at the unit, alone.’ Fiacre’s prose is heart breaking at times, and he seems to resent being autistic – not because it makes him less, but because of how society views him through that lens. He writes, ‘Yes I cry each day – autism wet tears. Stupid useless autistic waste. Yet I am awesome.’ Whilst Fiacre understands that he is of value and worth, society’s perceptions of his worth swarm around him uncomfortably as he fights to break free of the restrictions placed upon him. Advocating more understanding and acceptance for autistic learners, he asks the reader to find new ways of teaching which are tailored towards better understanding and supporting autistic people to unlock their potential. ‘Teach us appropriately and everyone can learn.’ He further points out that the focus on certain subjects and exam settings in education does not give autistic people the opportunity to showcase their intelligence: ‘Tests are neurotypical, and I am not typical. I am unable to speak, voiceless… Caution, and re-test in a different way, then see my autistic brain show my intelligence.’ Fiacre says that RPM has ‘enabled’ his intelligence to be recognised by others, but that it was always there: that it exists whether society recognises it or not. By sharing his personal reflections and journey as a young non-verbal autistic man traversing life, he tells us plainly not to assume that because someone is non-verbal, they have nothing to say. Whilst Fiacre’s communication abilities are beyond what his family had imagined, his writing skills are extraordinary in their own right. Evoking his inner world with a unique and masterful command of language and imagery, Fiacre’s poems in particular are emotive and arresting. Fiacre’s main source of inspiration is nature, a place where he feels calm and content, and his poems convey his personal experiences with a clarity and beauty that is thought-provoking. The following extract from his poem ‘Spring Walk’ is just one example from the book where Fiacre takes his own experiences and translates them, devastatingly, into a universal struggle to be understood and to survive in a world which can be chaotic and hostile: ‘Sticky catkin buds tell of life Secretly hiding every day, Waiting to reveal, hastening to leaf. Crocus bursts orange crush petals by a stump. Early daffodil ragged wind – torn, broken – Tries to hold up her head. Teased by each gust she stays, A promise of strength.’ Here Fiacre evokes the strong imagery of budding flowers struggling to bloom to convey his own struggle to flourish in the harsh and often challenging environments of school and social life. His poetry speaks with its own clarity and beauty, and Fiacre believes that writing has ‘tamed’ his busy thoughts, which felt like a ‘tsunami’ in his brain. ‘I paddle under the waves Treading deep bobbing anxiety, Wet tears, yet each day, surviving’ – from ‘Swan Eulogy’ In particular, the short piece of prose entitled ‘My Experience of Living with Autism’ provides an insight into Fiacre’s perception of the world when he is stressed and anxious, which can make life extremely chaotic at those times. Colleague and friend of Studio 3 Peter Vermeulen often says that the world can be a VUCA place for autistic people – volatile, uncertain, chaotic and ambiguous. Fiacre’s writing brings this experience to life in an evocative and powerful way. ‘Speechless’ is not only a memoir detailing Fiacre’s experiences of being autistic and trying to fit in to a world that does not accommodate or understand him; it is a declaration and celebration of difference. ‘It is too easy to exclude people who cannot speak up for themselves. We have a right to be treated with respect. Our opinions matter, our lives matter. No one has the right to silence our unheard voices.’ Fiacre’s message is clear: ‘Nothing is impossible if I get support and understanding.’ His message is one that has resonated strongly with many autistic people, and our hope is that by sharing his story further more people can be inspired and moved by his writing. We would particularly recommend this book to people working in schools, and to autistic people who sometimes feel like they cannot achieve their goals – believe, like Fiacre, that you can, with the right support and self-confidence. ‘I believe that there are no limits to what young people with a disability can achieve, we just need to believe in ourselves, and for others to believe in us.’ ‘Speechless’ is available to purchase on Amazon and through Merrion Press. There is also a documentary on Fiacre’s journey available to watch on RTE player: https://www.rte.ie/player/movie/speechless-s1-e1/264381992324 Written by Rachel McDermott Studio 3 Social Media and Information Co-ordinator

We are very pleased to introduce our newest member of the Studio 3 Ireland team, Raymi Doyle. Raymi has recently started a new full-time role with Studio 3 as a Research and Development Lead, Senior Psychotherapist & Neurodiversity Practitioner. Raymi is now part of our multi-skilled team in the design and delivery of trauma-informed, therapeutic, neurodivergent, and educational support services for a range of service users across the island of Ireland and the United Kingdom. He is passionate about being able to offer this level of support to those that live outside the geographical area and to those who may need a more bespoke support package tailored to their needs. Raymi has began translating his theory of neurotransception from his doctoral research into his clinical practice, as well as disseminating this across multiple other channels here at Studio 3. About Raymi Raymi Doyle is psychotherapist who has been providing therapeutic and educational services to both individuals and organisations in the fields of autism and trauma since 2005. After completing a psychology degree in the UK, he moved to the USA to complete a Masters in Counselling/Psychotherapy where he continued to develop his therapeutic and supervisory practice as lead clinician in a wraparound service for autistic children/young people, which provided therapeutic support services across a wide range of communities and cultures. He returned to Ireland as part of a team who managed a school for autistic children before moving back to Northern Ireland, where he began to see a real need for psychotherapeutic support for both clients who were autistic, as well as the staff providing support services. This led Raymi to open a private practice specialising in autism and trauma to meet the individual needs of clients, as well as providing clinical supervision to practitioners. Raymi also developing a bespoke training programme that was disseminated through multiple educational and therapeutic services. Raymi has also presented on various national conferences with both the BACP and Middlesex University, and been a guest reviewer for the British Journal of Guidance and Counselling for articles on Autism. He has recently completed and submitted his thesis for his Doctorate at Metanoia Institute where he is exploring “Bridging the Gap between the Autistic, the Therapist, and the Theoretical Perspective.” This developed into the theory of neurotransception, which was grounded in the data from examining the relational dynamics between therapists and clients where either or both parties identified as neurodivergent. Raymi is excited to have started a new full-time role with Studio 3 as the Research and Development Lead, Senior Psychotherapist & Neurodiversity Practitioner. He has integrated his clinical and supervisory practice within the Low Arousal framework, where Raymi recognises that both ethos complements each other. Raymi has found his background in trauma-informed care, along with his theory of neurotransception, fits comfortably within and complements the Low Arousal Approach, where there is a focus on developing relationships and making connections with clients/service users whether online, via telephone, face-to-face, or a hybrid of all. Raymi’s role involves being part of a multi-skilled team in the design and delivery of trauma-informed therapeutic, neurodivergent, and educational support services for a range of service users across the island of Ireland and the United Kingdom. This will range between face-to-face, online and hybrid support system models of therapeutic and neurodivergent support that will be client centred and family/system focused, promoting a Low Arousal relational approach. Raymi is passionate about being able to offer this level of support to those that live outside of the geographical area of practice, and to those who may need a more bespoke support package tailored to their individual needs. In the past few years, Raymi has been focused on growing an online therapeutic presence to provide that service. Raymi works with a wide range of associates at the regional, national, and international level who have specific experience in certain areas, and who can be brought in as a multifaceted team to ensure services are tailored to be effective, efficient and affordable to all. Raymi has also began taking a lead in developing a relational stepped debriefing support package that he has already piloted with a range of key staff providing support to service users, where he has been able to begin to integrate his research findings into this service. This is something that he is passionate about further developing and he would like to begin to offer this to all key staff in Studio 3 as well as the services that we work closely with in partnership. We are delighted to have Raymi on board with all of his expertise, kindness and compassion!