McDonnell, A.A (2010) Managing Aggressive Behaviour in Care Settings: Understanding and applying Low Arousal Approaches. Wiley Publications.
... The Low Arousal Approach (McDonnell, 2010(McDonnell, , 2019 was developed in the 1990s as a reactive behavior management approach to supporting people with behaviors of concern. The approach was originally defined as a collection of behavior management strategies which focus on the avoidance of 'confrontation' (McDonnell et al., 1994). ...
... In special schools in Denmark over a two-year period, a significant reduction in staff injuries was reported (Larsen, 2018). Training has also been shown to increase the confidence of staff in adult services supporting autistic individuals (McDonnell et al., 2008;McDonnell, 2010). A single case study applied the Low Arousal Approach to an individual family (Shinnick and McDonnell, 2003;Hewitt et al., 2015). ...
... The intervention consists of training in the Low Arousal Approach and, in some cases, individualized coaching tailored to specific family needs. Anecdotally, families and supporters often design their own training based on the availability of published material (Elvén, 2010;McDonnell, 2010;Woodcock and Page, 2010;McDonnell, 2019). The approach has also been adopted widely by people supporting difficult behavior for individuals who are autistic (McDonnell et al., 2018). ...
Background
Parents and carers supporting a family member presenting with behaviors of concern experience heightened stress. The Low Arousal Approach is a crisis management strategy which recognizes that stress, or physiological arousal, can be expressed through behaviors of concern. This approach aims to equip parents and carers to manage behaviors in a person-centered and non-confrontational way. There is a paucity of published research exploring the experiences of families applying this approach.
Methods
Seventeen parents who had received training in the Low Arousal Approach were interviewed to gain their perspectives on supporting their family members using this approach.
Results
Thematic analysis revealed themes relating to parental stress, which was related to external pressures, isolation, family stress, and challenges in their caring role. They described encountering negative narratives relating to self-criticism and negative judgments from others. Training in the Low Arousal Approach was related to being empowered through access to evidence, increased confidence, and increased ability to advocate for their family member’s needs. Low Arousal was described as a “lifestyle” that enabled increased coping for the family unit as a whole.
Discussion/conclusion
Findings indicate that it is vitally important to recognize the views of parents and carers, and these are equally as important as the views of professionals. We must understand parents’ and carers’ needs in order to provide adequate support.
... Staff training in crisis management that includes teaching of physical interventions is a common approach in care services (24). Training aims to equip front line staff to safely manage aggressive behaviour, and typically includes both theoretical and practical components, covering topics such as understanding causes of behaviours, recognizing early warning signs, de-escalation techniques and instruction in physical interventions such as physical restraints (25)(26)(27)(28). ...
... There have been a limited number of literature reviews that have focused on staff training in physical interventions and its impact (1,4,40). The literature is regarded as limited in nature with poorly designed studies (4,24,29). Given the importance of reducing restrictive practices, an understanding of the evidence-base for staff training in physical interventions is urgently required. ...
... There is also variation in regard to reporting of reliability and validity data. This reflects that there is a need of multiple outcome measures that have good construct validity in the area of behaviour management within care settings (24,38). ...
Background
Restrictive practices are used frequently by frontline staff in a variety of care contexts, including psychiatric hospitals, children’s services, and support services for older adults and individuals with intellectual and developmental disabilities. Physical restraint has been associated with emotional harm, physical injury to staff and consumers, and has even resulted in death of individuals in care environments. Various interventions have been implemented within care settings with the intention of reducing instances of restraint. One of the most common interventions is staff training that includes some physical intervention skills to support staff to manage crisis situations. Despite physical intervention training being used widely in care services, there is little evidence to support the effectiveness and application of physical interventions. This review will examine the literature regarding outcomes of staff training in physical interventions across care sectors.
Method
A systematic search was conducted following PRISMA guidelines using Cochrane Database, Medline EBSCO, Medline OVID, PsychINFO, and the Web of Science. Main search keywords were staff training, physical intervention, physical restraint. The MMAT was utilised to provide an analytical framework for the included studies.
Results and discussion
Seventeen articles have been included in this literature review. The included studies take place in a range of care settings and comprise a wide range of outcomes and designs. The training programmes examined vary widely in their duration, course content, teaching methods, and extent to which physical skills are taught. Studies were of relatively poor quality. Many descriptions of training programmes did not clearly operationalise the knowledge and skills taught to staff. As such, it is difficult to compare course content across the studies. Few papers described physical interventions in sufficient detail. This review demonstrates that, although staff training is a ‘first response’ to managing health and safety in care settings, there is very little evidence to suggest that staff training in physical intervention skills leads to meaningful outcomes.
... People with autistic spectrum disorders (ASD) can present behaviours that challenge and a recent survey of the behavioural intervention literature identified a diagnosis of autism as a risk marker for physical aggression (McClintock, Hall, & Oliver, 2003). A large number of behavioural intervention studies have tended to focus on long term interventions for physical aggression (Horner, Carr, Strain, Todd, & Reed, 2000) with short term management receiving less attention (McDonnell, 2010). This paper will examine the low arousal approach to managing challenging behaviours in people with ASD (McDonnell, Waters, & Jones, 2002). ...
... There are categories of physical interventions, the two most common are breakaway skills and physical restraint. Breakaway skills can be defined as ''physical strategies which assists a person to break free of an aggressor, where actual physical contact has taken place'' (McDonnell, 2010). Physical restraint has been defined as ''actions or procedures which are designed to suppress movement or mobility'' (Harris, 1996, p. 100). ...
... Fourth, restraint methods such as prone holds may be associated with fatalities (Allen, 2008). Some experts have called for a ban on all prone restraint holds in care (McDonnell, 2010); other academics refute the claims that these postures are strongly associated with sudden deaths (Paterson, 2006). Incorrect application of methods is associated with some childhood deaths in care in the United States (Nunno, Holden, & Tollar, 2006). ...
... The midwives described that when some women were initially tense or aggressive, they tried to create a calm atmosphere by means of body language. This is in line with the low arousal approach described by McDonnell [43], which is intended to help professionals create a caring environment that reduces stress and challenging behaviour by being aware of how nonverbal cues can promote de-escalating behaviour [43]. An important part of recovery from suffering is the hope that the future will be better [44]. ...
... The midwives described that when some women were initially tense or aggressive, they tried to create a calm atmosphere by means of body language. This is in line with the low arousal approach described by McDonnell [43], which is intended to help professionals create a caring environment that reduces stress and challenging behaviour by being aware of how nonverbal cues can promote de-escalating behaviour [43]. An important part of recovery from suffering is the hope that the future will be better [44]. ...
Objective
Fear of childbirth is a well-known problem affecting women’s wellbeing and health. The prevalence of intense fear varies across countries from 4.8 to 14.8%. During the past 25 years in Sweden women with intense fear of childbirth have been offered counselling at specialised clinics staffed by midwives. Although the counselling demonstrates positive results, the training, education, supervision and organisation differ between clinics. It is still unclear which approaches and practices are the most beneficial. The aim was to explore and describe the counselling of women with intense fear of childbirth from the viewpoint of midwives who provide counselling in specialised fear of childbirth clinics in one region of Sweden.
Methods
A qualitative study of 13 midwives using focus group interviews and inductive content analysis.
Results
The midwives’ counselling of women with intense fear of childbirth is described as ‘striving to create a safe place for exploring fear of childbirth’, comprising the following categories: Providing a reliable relationship; Investigating previous and present fears; and A strong dedication to the women.
Conclusion
Although there are no guidelines for the counselling the midwives described similar frameworks. Some approaches were general, while others were specific and related to the individual woman’s parity. The midwives achieved professional and personal development through counselling experiences. The findings add to the existing literature on counselling and can be used to inform the development of midwife-led interventions for women with intense fear of childbirth and previous traumatic births, as well as for the formal education of midwives.
... There has been considerable discussion of the mediating role of setting event variables such as stress and arousal (e.g., McDonnell, 2010), and in particular in individuals with autism spectrum disorders (Goodwin et al., 2006), on the three term contingency. Low arousal interventions designed to reduce the effects of stress and arousal can include removing or reducing or ameliorating the effect of antecedent stimuli such as demand, noise, complexity of language, proximity, refusal, disappointment, and surprise. ...
... The study illustrates that people can overcome severe challenging behaviours in ordinary community settings with the assistance of functional assessment and multi-element behavioural intervention. In particular, the study converges with existing evidence of the effectiveness of low arousal environments for people with autism and escape-motivated behaviour (McDonnell, 2010). If substantiated by further research, the study provides a counter argument to the treatment of people with autism and exceptionally severe behaviour in congregate settings or in settings with others who present with significant behavioural challenges. ...
Positive behaviour support emphasises the impact of contextual variables to enhance participation, choice, and quality of life. This study evaluates a sequence for implementing changes to key contextual variables for 4 individuals. Interventions were maintained and data collection continued over a 3-year period.
Functional assessments were conducted with 4 individuals with exceptionally severe challenging behaviours. Interventions were based on the multi-element model of behavioural support (LaVigna & Willis, 2005a). Dependent variables were behavioural ratings of (1) frequency, (2) episodic severity, (3) episodic management difficulty, and measures of (4) mental health status, and (5) quality of life. The intervention sequence was low arousal environment, rapport building, predictability, functionally equivalent skills teaching, and differential reinforcement strategies.
Substantial reductions in target behaviours were observed, along with incremental improvement in mental health scores and quality-of-life scores.
The study demonstrates the efficacy of positive behaviour support for people with exceptionally severe behaviour in individually designed services.
... Gross (1998) suggests that a strategy which he called emotional regulation (Gross, 2002) can be used early in this process of emotional labour. Emotional regulation can be understood as a strategy to manage and minimise problematic patient behaviours and conflicts (McDonnell, 2010), which according to Hammarström et al. (2022) is strongly correlated with how healthcare staff treat the forensic psychiatric patient. ...
Aim:
The aim of this review was to synthesise qualitative research into how nurses perceive and experience encountering patients in forensic inpatient care.
Review method:
This review followed the steps of meta-ethnography developed by Noblit and Hare.
Data sources:
Twelve studies, published from 2011 to 2021, were identified through a search of relevant databases in December 2021.
Findings:
The synthesis revealed three third-order and 10 second-order constructs during the translation of concepts in the studies. These are: Adopting the patient's perspective (liberation, comprehension and resistance), Action (security, trust, flexibility and predictability) and Activation (afraid or safe, involved or indifferent and boundaries). Further, a line of argument was developed which indicates that in forensic psychiatry inpatient care, nurses experience having to deal with internal and external resistance that affects their freedom of choice in the creation of a caring relationship.
Conclusion:
The encounter is experienced as a continuous process in which the foundation is laid for the encounter (approach), the encounter unfolds and develops (action) and the nurse experiences the encounter (activation). The process is intertwined with and takes place in a context where care is influenced by the duality of the task (task), the culture of care (context), the patient's expression (patient) and the nurse's own impression of the patient's expression (oneself).
Implications:
Professional communities should support initiatives that can strengthen nurses' self-awareness and provide opportunities for reflection on practice, which will both benefit the resilience of the nursing staff and the quality of care for patients in this setting.
... Left unaddressed, it can result in feelings of incompetence, uneasiness, stress, and fear of future incidents, negatively affecting teachers' performance and mental health [111,112]. Therefore, (self-)debriefing and discussing the incident with colleagues is recommended [113]. In addition to its emotional advantages, debriefing facilitates the exchange of good practices. ...
1) Background: Dealing with students’ maladaptive behaviour in the classroom, such as verbal aggressive behaviour, is challenging, particularly for novice teachers. They often encounter limited opportunities for training and practice in handling such incidents during their pre-service education, rendering them ill-equipped and uncertain when confronted with instances of verbal aggression during their initial teaching experiences. This article reports on the design and validation of a verbal aggression management competence model to guide and substantiate novice teachers’ immediate reactions. (2) Methods: The model’s construction and validation processes were informed by a dual-pronged approach, encompassing a literature analysis to explore theoretical concepts and semi-structured interviews involving 32 educational experts to validate its practical applicability. (3) Results: The design and validation processes resulted in a comprehensive competence model consisting of concrete steps to be taken during or immediately following an incident and overarching attitudes to be adopted throughout the incident managing process. (4) Conclusions: This study contributes a structured framework to empower novice teachers, offering tools to address verbal aggressive behaviour within the classroom environment. Furthermore, it highlights the potential of incorporating this model into teacher education programs, facilitating the competence development of future teachers, and fostering conducive learning environments.
... In this way we feel this experience has given us foundational skills necessary for clinical practice Challenges to telephone-based support A significant part of working on the crisis line involves de-escalating individuals who have reached crisis point. Having worked in mental health services previously, many of us have developed our own toolbox of strategies to de-escalate individuals who are experiencing acute levels of stress, which often relies on non-verbal communication and good rapport with the individual (McDonnell, 2010). However, when we first started working on the crisis line it struck us that the lack of face-to-face communication would curtail the effectiveness of some these techniques. ...
In this article, we reflect as a group on our experiences working on a mental health crisis line as members of the psychological workforce. These reflections came from supervisions, team meetings and informal, day to day conversations between practitioners.
... One example is the ATLASS training programme developed by Studio3 based within the 'low arousal approach' (first developed by McDonnell et al. 1994). According to McDonnell (2010), this approach contains four main elements: decreasing demands made of service users in order to reduce potential conflict, avoiding potential 'triggers' of unwanted stress, avoiding aggressive non-verbal behaviour by staff, and challenging staff beliefs about the 'management of challenging behaviour'. These elements clearly indicate the social situatedness of social interactions and the responsibility of all involved. ...
... One example is the ATLASS training programme developed by Studio3 based within the 'low arousal approach' (first developed by McDonnell et al. 1994). According to McDonnell (2010), this approach contains four main elements: decreasing demands made of service users in order to reduce potential conflict, avoiding potential 'triggers' of unwanted stress, avoiding aggressive non-verbal behaviour by staff, and challenging staff beliefs about the 'management of challenging behaviour'. These elements clearly indicate the social situatedness of social interactions and the responsibility of all involved. ...
... In this way we feel this experience has given us foundational skills necessary for clinical practice Challenges to telephone-based support A significant part of working on the crisis line involves de-escalating individuals who have reached crisis point. Having worked in mental health services previously, many of us have developed our own toolbox of strategies to de-escalate individuals who are experiencing acute levels of stress, which often relies on non-verbal communication and good rapport with the individual (McDonnell, 2010). However, when we first started working on the crisis line it struck us that the lack of face-to-face communication would curtail the effectiveness of some these techniques. ...
The research published in the clinical psychology forum evaluated a 6 week emotion regulation group in an outpatient group who present with varying diagnosis (incl autism, ADHD bipolar affective disorder). The results showed statistically significant improvements in emotional regulation and alexithymia and increased wellbeing overall. The research promotes the use of emotion regulation as a trans diagnostic intervention and has implications for those who experience alexithymia.
... In this way we feel this experience has given us foundational skills necessary for clinical practice Challenges to telephone-based support A significant part of working on the crisis line involves de-escalating individuals who have reached crisis point. Having worked in mental health services previously, many of us have developed our own toolbox of strategies to de-escalate individuals who are experiencing acute levels of stress, which often relies on non-verbal communication and good rapport with the individual (McDonnell, 2010). However, when we first started working on the crisis line it struck us that the lack of face-to-face communication would curtail the effectiveness of some these techniques. ...
This article describes the evaluation of a novel, single-session group intervention which was offered on an acute inpatient mental health unit. The intervention was based on the principles of Mentalisation Based Therapy. We called this intervention the inside out group.
In the group, attendees used their mentalising skills to discuss and decide on the course of action taken by characters in a fictional story. Hence we referred to the group as a ‘choose-your-own adventure’.
Our evaluation showed that attendees were less committed to critical, self-focused explanations for others’ actions after the intervention than they had been prior to the intervention. Our findings therefore suggest that Mentalisation Based Therapy principles can be successfully adapted to produce effective, short term talking treatments on acute inpatient mental health wards.
... Mental health professionals cited lack of knowledge, low competency and self-confidence as barriers when providing services and treatment to people with intellectual disabilities(Ee et al., 2021b(Ee et al., , 2021c. The current findings suggest that mental health professionals would benefit from being equipped with knowledge of behaviour management strategies that focus on avoidance of confrontation and reducing demands or requests so as to de-escalate conflict with the person with intellectual disabilities when they experience emotional distress(McDonnell, 2010).More efforts are also needed to include family caregivers when their relatives with intellectual disabilities are receiving inpatient mental health services. Family caregivers may feel exasperated and have high emotional distress that can lead to a breakdown in the relationship with their relative and discontinuation of their caregiver responsibilities. ...
Purpose
This study aims to explore the experiences of people with intellectual disabilities in Singapore receiving inpatient mental health treatment. To date, there has not been any research that examines the views and experiences of this population in Singapore. The research examines how the participants view their mental health problems and their experiences of the services they received.
Design/methodology/approach
A qualitative design was chosen to address the research question. Six adult men with intellectual disabilities were recruited from the tertiary hospital and interviewed. The transcripts of these interviews were analysed using interpretative phenomenological analysis.
Findings
Four super-ordinate themes were identified; awareness of mental health problems; yearn for a life outside the ward; interacting with other people and finding purpose.
Originality/value
The participants reported that they struggled with being segregated from their families and communities following an inpatient admission. They were able to report on the emotional difficulties that they experienced and hoped to find employment after their discharge from the hospital. They talked about reconstructing their self-identity and forming friendships to cope with their hospital stay. This research is one of its kind carried out in a non-western society and the findings are discussed in the light of how mental health professionals can best support people with intellectual disabilities during their inpatient treatment.
... Within this, low arousal techniques were used. Low arousal involves a range of behavioural management strategies that focus on the reduction of stress, fear and frustration and seek to prevent aggression and crisis situations (McDonnell, 2011). Punitive consequences for individuals can be avoided through the early identification and management of challenging behaviours. ...
The aim of this paper is to describe the development of the Phased Model of Adventure Therapy. Adventure therapy is the use of adventure experiences to engage clients on cognitive, affective and behavioural levels. Use of adventure therapy has been found to improve psychological wellbeing, self- esteem and behaviour in young people. A UK-based adventure therapy provider, the Creative Outdoors Group, provides care to young people who are currently looked after by the Local Authority and display complex emotional and/or behavioural needs. The Phased Model of Adventure Therapy has been developed in association with the Creative Outdoors Group to promote improvements in psychological and behavioural functioning. The model consists of several theoretical models applied alongside a regime of adventure or outdoor activities. This paper describes the theoretical underpinnings of the Model and how this was applied to an adventure therapy regime.
... Self-injurious behaviours exhibited by children with autism [11]; repetitive vocalisations in adults with an intellectual disability [12]; and impulsivity in people with a diagnosis of bipolar disorder [13], have also been identified as behavioural symptoms that could elicit challenging situations in the workplace for health/social care professionals. It has been posited that under stressful working conditions, healthcare professionals may also inadvertently trigger challenging incidences [14], particularly when care recipients concerned are experiencing impaired cognition [15]. However, it has been suggested that there are no significant direct relationships between work related stress and the type or frequency of behaviours that challenge [16]. ...
Providing direct health and social care services for people who exhibit behaviours that challenge can be a highly stressful occupation. Existing literature has suggested that there is a need to develop further theoretical understanding of how work related stress can be reduced in professions that consist of providing care for people who exhibit behaviours that challenge. The aim for this study was to use a Classic Grounded Theory approach to develop a theoretical framework to illustrate a common issue that could influence work related stress levels experienced when managing behaviours that challenge in health and social care settings. A series of focus groups and 1:1 semi-structured interviews were conducted to explore the articulated experiences of 47 health/social care professionals who provide care for people who exhibit behaviours that challenge. This led to the development of Therapeutic Engagement Stress Theory (TEST), which illustrates that the perceived capacity to therapeutically engage with people who exhibit behaviours that challenge is an issue that can influence the levels of stress experienced by health/social care professionals. TEST provides a framework that could be applied to identify specific factors that inhibit staff to successfully deliver caring interventions for people who exhibit behaviours that challenge, and also inform bespoke support mechanisms to reduce stress in health/social care professionals.
... Noen ganger kan utfordrende atferd hos autistiske personer med intellektuell funksjonsnedsettelse forstås som «fight-or-flight» responser: forsøk på å unngå smertefull sensorisk overbelastning. Følgelig, for å forebygge utfordrende atferd, bør første bud vaere å gjøre en naermere undersøkelse av forholdene i omgivelsene (Caldwell 2006, McDonnell 2010. ...
«Innenfra-beskrivelser» av å være autistisk i en verden der de fleste ikke er det, kan på samme tid informere og utfordre en faglig tilnærming til det som kan kalles «autistisk atferd». Denne artikkelen trekker på perspektivene i «nevrodiversitetsbevegelsen»: personer som selv har diagnoser på autistismespekteret, men som avviser at autisme er en forstyrrelse og i stedet velger å kjempe for sin rett til å være autistisk. Ved hjelp av et praktisk eksempel utforsker vi hvordan slike beskrivelser og perspektiver kan komme til anvendelse i tjenesteyting til autistiske tjenestebrukere. Vår konklusjon er at, uavhengig av om autisme forstås som en forskjell eller en forstyrrelse, kan tjenesteytere som yter tjenester til autistiske tjenestebrukere trenge å undersøke sine antakelser og faglige ståsteder nøye, dersom de skal unngå diskriminerende praksiser. ------ Artikkelen er publisert i oktobernummeret av Autisme i Dag (2019), og er en oversatt versjon av en fagfellevurdert fagartikkel: Owren, T. & Stenhammer, T. (2013). Neurodiversity – accepting autistic difference. Learning Disability Practice, May 2013, No 4.
... It is one thing to embrace the principles of the low arousal approaches, which are recognised behavioural interventions to manage BTC among people with LD, in this instance by Maureen's use of low expressed emotion, and her understanding that the employment of active intervention strategies when Cindy is highly agitated at night might be counterproductive (McDonnell, 2010). However, it is quite another to simultaneously ensure that one's adult child's behaviour is not causing physical or emotional harm to herself or others when following this approach. ...
The debilitating impact of trauma on people with learning disabilities is increasingly recognised in research. Sinason's influential psychoanalytic writing has drawn direct links between the presence of an opportunistic secondary handicap and pervasive exposure to trauma. Traumatic events often occur within families, implying that more than one family member may be exposed to the same traumatic stressor(s). Because adults with learning disabilities require additional support from caregivers to live socially valorised lives with optimal degrees of self-direction, in the context of home living, a parent's experience of severe trauma could have a deleterious impact on her caregiving capacity to meet her child with learning disabilities' support needs in an equitable manner. This paper contains a case study that describes how a mother's experience of earlier trauma, which resulted in complex post-traumatic stress, had a profound influence on her object-relations and object-relatedness with both of her children, including her daughter who had mild learning disabilities and severe behavioural difficulties. While the mother's own experience of trauma deserves attention in its' own right, her defences against traumatic recollection also affected her responsiveness to her daughter's high behavioural support needs.
... Die gezielte Förderung der eigenen Aggressionsregulation scheint v. a. ab einem emotionalen Entwicklungsalter von ca. 4 Jahren (SEO-4) sinnvoll, während bei einem niedrigeren Entwicklungsalter Deeskalationsschulungen der Betreuenden (z. B. Studio III) im Vordergrund stehen sollten [26]. Der Einsatz der gewählten Maßnahmen hängt somit vom emotionalen Entwicklungsstand ab. ...
Zusammenfassung
Anliegen Ursachenanalyse von Verhaltensstörungen bei Menschen mit Intelligenzminderung (IM).
Methode Der Zusammenhang und der Einfluss des kognitiven und emotionalen Entwicklungsstands auf Verhaltensstörungen wurde mit Korrelations- und Regressionsanalysen bei 262 Erwachsenen mit IM und psychischer Erkrankung bzw. schweren Verhaltensstörungen untersucht.
Ergebnis Trotz der hohen Korrelation von kognitivem und emotionalen Entwicklungsstand fanden sich bei jedem 2. Patienten kognitiv-emotionale Entwicklungsdiskrepanzen. Die Schwere der Verhaltensstörungen war assoziiert mit einem niedrigeren emotionalen Entwicklungstand, insbesondere im Bereich der „Aggressionsregulation“.
Schlussfolgerung In der Ursachenabklärung von Verhaltensstörungen sollte auch der emotionale Entwicklungsstand erhoben werden.
... These include: differential reinforcement [118,119], in which desired behaviours are shaped through reinforcement; token economies [120], in which desired behaviour is rewarded with tokens that can then be exchanged for other reinforcers (e.g., magazines, concerts, favorite food items); extinction procedures [121], in which the payoff (maintaining reinforcer) is removed for problem behaviours. With the substantial move away from interventions based on consequential punishment [122], these strategies rather emphasise reinforcing (rewarding) desired behaviours and withholding payoffs for problem behaviour. Furthermore, given the influence of the PBS movement (discussed following), there is an emphasis on actively integrating contingency strategies within more comprehensive plans that incorporate proactive, preventative, and teaching strategies [123]. ...
Purpose: (1) to provide insight into the family’s experience and support needs following acquired brain injury (ABI) specific to behavioural changes; (2) to provide an overview of empirically-based behaviour support approaches for individuals with ABI; and (3), to examine family involvement in implementing behavioural interventions.
Methods: Review of the literature.
Results: Family members experience significant distress resulting from neurobehavioural changes in relatives with ABI, and report unmet informational and practical support needs regarding this issue. The importance of utilising family expertise within the rehabilitation process is widely acknowledged, with the increasing involvement of family members being promoted. There is growing evidence supporting the use of positive behaviour support approaches for individuals with ABI in community settings, and evidence supporting the involvement of family within behavioural interventions.
Conclusions: This review suggests the need to develop alternative support models that shift the focus towards building competence in everyday support people rather than dependency on the service system. A bottom-up approach is recommended, with the aim of addressing unmet support needs and increasing the competence of family members in supporting behaviour change in individuals with ABI. Recommendations are provided in informing an optimal community-based neurobehavioural support model.
• Implications for Rehabilitation
• Positive behaviour support is recommended in supporting behavioural changes following brain injury, with family expertise utilised in this process.
• Evidence suggests that family members can be effectively trained in developing and implementing behaviour support strategies.
• Family involvement in behavioural interventions may address unmet support needs and increasing the competence of family members in supporting behavioural changes following brain injury.
... » Provision of emotional support to staff working with people who show behaviours of concern. Low arousal is reported to be a widely used intervention that can support people with ASC as part of the Structure, Positive approaches and expectations, Empathy, Low arousal and Links (SPELL) framework (Bradley andCaldwell 2013, National Autistic Society 2018), in clinical case work (Elvén 2010, McDonnell 2010 and in a small group (McClean and Grey 2012). ...
Testing the validity and reliability of a new measure of low arousal.
... Severe forms of aggression and selfinjurious behaviour among children with LDD are often caused by mental illness (e.g., Cooper et al., 2009), behavioural phenotypes of genetic disorders (e.g., Royal College of Psychiatrists, 2001), and neurological impairment that is either partially linked with the child's learning disability or the result of neurological events which had occurred after the onset of LDD (e.g., Selwyn, Wijedasa, & Meakings, 2014). Qualitative impairment in social interaction and problems with affect regulation could also erode a person with autism's ability to effectively manage meltdown and autism-related problem behaviours (McDonnell, 2010). Severe or frequent displays of behaviours that challenge may result in social exclusion when a person's access to community resources, such as residential and vocational services, is hindered (National Institute for Health and Care Excellence [NICE], 2015). ...
A significant minority of parents of children with learning and developmental disability experience elevated levels of parental stress, particularly when their children present with behaviours that challenge. A small but influential number of psychoanalytic authors have made significant contributions to the learning disability field of research, however, the psychological distress of parents whose children have behaviours that challenge has received scant attention. This paper posits that distressed parents of children with learning and developmental disability and behaviours that challenge often make use of primary defences, which are linked with their children’s behaviour, albeit in a reciprocal rather than causal manner.
... Programmet med dess utbildning och handlingsplaner är en psykologisk strategi för bemötande med syfte att förebygga och hantera aggressiva situationer, och det används främst inom vård-och skolsektorn. Ett lågaffektivt bemötande bygger på teorier om affektsmitta (McDonnell, 2010). Detta gäller speciellt personer med utvecklingsrelaterade funktionsnedsättningar som har svårare att särskilja egna och andras affekter samt den egna känsloregleringen än vad andra personer har. ...
För mer inforamtion, se: https://www.stat-inst.se/webbshop/12-2017-hantering-av-hot-och-vald-personalens-syn-pa-etik-bemotande-och-sakerhet-i-motet-med-ungdomar-pa-institutioner/
... The care of people with learning disabilities and an offending background is currently in transition, with inpatient beds in the process of significant reduction (25-40% of national specialist-commissioned beds) by 2018 as part of the overall initiative to reduce hospital provision (NHS England, 2015). This is coupled with an ongoing challenge to alter the way in which we approach physical interventions, with a paradigm shift perhaps taking place (McDonnell 2010) as alternative ways are sought to respond to service users with particularly complex needs. The first of these issues is a continuation of de-institutionalization, a global phenomenon emerging during the final decades of the twentieth century, and which affected many population groups but is frequently most associated with people with mental health issues and those with learning disabilities. ...
Journal editorial to accompany an article published in the same journal. This is the peer reviewed version of the following article: Lovell, A. (2017). Learning disability nursing in secure settings: Working with complexity. Journal of Psychiatric & Mental Health Nursing, 24(1), 1-3. DOI: 10.1111/jpm.12364, which has been published in final form at http://onlinelibrary.wiley.com/doi/10.1111/jpm.12364/full. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving
... Noen ganger kan utfordrende atferd hos autistiske personer med intellektuell funksjonsnedsettelse forstås som «fight-or-flight» responser: forsøk på å unngå smertefull sensorisk overbelastning. Følgelig, for å forebygge utfordrende atferd, bør første bud vaere å gjøre en naermere undersøkelse av forholdene i omgivelsene (Caldwell 2006, McDonnell 2010. ...
‘Insider’ descriptions of living with autism in a world where most people are not autistic may at the same time inform and challenge a professional approach to what can be termed as ‘autistic behaviour’. This article draws on the perspectives of the ‘neurodiversity’ movement, people who themselves have diagnoses on the autistic spectrum but reject that autism is a disorder, choosing instead to fight for their right to be autistic. The authors include a case study to explore how such descriptions and perspectives can be applied to services supporting an autistic service user. They conclude that, regardless of whether autism is seen as a difference or a disorder, care staff providing services to autistic service users may need to examine their assumptions carefully if they are to avoid discriminatory practices.
... As described in Hallett and Dickens (2015), two broad theoretical approaches are commonly used to understand the de-escalation process within mental health settings. The first views de-escalation as consisting of distinct phases such as pre-crisis intervention, management of crisis, and post-intervention (e.g., McDonnell, 2010). Each phase provides a unique opportunity to reduce the likelihood of escalation, to calm the agitated patient, or to process the crisis post-escalation. ...
De-escalation is a skill most commonly discussed in mental health settings, but occurs across professions in fields such as law enforcement, nursing, and customer service. While much of the literature describes what could be done to de-escalate someone, we know very little about what is actually being doing in practice. In this study, we survey 56 professionals with expertise in de-escalation about the strategies that they use to help people in distress. Using group concept mapping, multidimensional scaling and cluster analysis, we provide a description of similarities and differences in what mental health providers rate as most important as compared to those working in other professions. Findings suggest that across professions, communication, body language, listening and validation are considered highly important for effective de-escalation. Although both groups also emphasize environmental safety, safety was less of a primary concern for mental health professionals. Applications for these findings are discussed.
... Furthermore, some ASD behaviours may mimic psychotic episodes, leading to treatment with high-potential antipsychotics. Instead of drugs being prescribed for challenging behaviours in persons with ID, the ASD diagnosis will emphasise the need to adapt both the environment and the support (McDonnell 2011); this may help carers to understand their clients' needs better. Adaptations in the care of clients with challenging behaviours may protect carers from burnout or high-stress during caregiving (Hastings & Brown 2002). ...
Background:
Identification of Autism Spectrum Disorder (ASD) in persons with intellectual disability (ID) is challenging but essential to allow adequate treatment to be given. This study examines whether the combination of two ASD screening instruments specifically developed for persons with ID, namely, the Diagnostic Behavioral Assessment for ASD-Revised (DiBAS-R) and the Autism Checklist (ACL), improves diagnostic accuracy when used in combination compared to the application of the single instrument.
Method:
A clinical sample of adults with ID who are suspected of having ASD (N =148) was assessed using two ID specific screening scales (DiBAS-R and ACL). The diagnostic validity of the single instruments and of their combination was assessed.
Results:
While both instruments showed acceptable diagnostic validity when applied alone (DiBAS-R/ACL: sensitivity: 75%/91%; specificity: 75%/75%; overall agreement: 75%/83%), specificity increased when two positive screening results were used (88%), and sensitivity increased (95%) when at least one positive screening result was used.
Conclusions:
Different combinations of the ASD screening instruments DiBAS-R and ACL lead to improvements in sensitivity and specificity. The complementary use of the ACL in addition to the sole use of the DiBAS-R improves overall accuracy.
... 'It appears that restraint in children's wards is a widely used intervention, underpinned by unspoken assumptions, and is rarely documented in nursing notes.' (Coyne and Scott, 2014:26) Behavioursthatchallengemaymakeitdifficultfornurses to manage a person's quality of care.The intensity of such behaviours can put parents, carers and nurses at risk of injury (McDonnell, 2010).This study aimed to investigate further why this may be. Given that there is little in the wayofformaltraininginthisarea,theresearchersaimedto providea'snapshot'intowhatcurrentpracticeinvolves,how thisinformationisconveyedacrossateamandwhatfactors influencethis. ...
Nurses hold children to administer treatment, prevent treatment interference and undertake clinical assessments, which can sometimes be invasive, as part of their regular duties. Clinical holding ensures this treatment or assessment is carried out safely, however, it has been reported that there is little training available in this area. This article explores the prevalent clinical holding techniques used by nursing staff when caring for children with behaviours that challenge. As an initial insight into what the researchers hope will become a more in-depth 2-year study, this investigation looks to explore current practice when holding children and the factors influencing this. It is hoped that this will inform the development of a training package offered to nurses when caring for these children. Thirteen semi-structured interviews took place with a small group of nurses, which were given thematic analysis. The overarching themes influencing holding practice were the nursing role itself along with intrinsic and external factors.
... Agresia pacientov je popisovaná ako problém, s ktorým je konfrontovaný zdravotnícky personál na psychiatrických pracoviskách rôzneho charakteru (Jonker et al., 2008;Zelman et al., 2010). Faktory prispievajúce k agresii pacientov sú v literárnych zdrojoch rôzne kategorizované, reflektované a interpretované (McDonnell, 2010;Bjørkly, 2006). Duxbury (2002) na základe kvalitatívneho výskumu incidentov agresie pacientov voèi sestrám vysvet¾uje kauzálne faktory vzniku agresívneho správania v rámci interného, externého a situaèno-interakèného modelu. ...
Factors contributing to patient aggression are categorized differently. Duxbury presents the causal factors of aggressive behaviour in the context of internal, external and situational-interactional models. Aim of the pilot comparative study was to compare the views of healthcare staff and patients on the causes of patient aggression and the management strategies used in current mental healthcare practice. The research sample consisted of 55 healthcare professionals and 52 patients of selected mental healthcare facilities in Slovakia. Data collection was conducted by valid and reliable self-report instrument The Management of Aggression and Violence Attitude Scale (MAVAS). In the perception of the causes of patient aggression perspectives of staff and patients significantly (p <0.05) differed in the subscale of external factors of aggression-the staff tended to disagree more with the impact of these factors on the emergence of aggression, while the patients agreed more that aggression is contributed just by the environmental factors. In the case of aggression management perception, we also found significant differences (p <0.05) between staff and patients. Statistically significant differences identified in the attitudes of boths stakeholders to patient aggression highlights the need for a more analytical approach to the issue and the need to discuss the management of patient aggression in clinical practice.
... Many nursing or therapeutic interventions by their very nature act as aversive stimuli. Lengthy waits for patients to be examined, problematic interaction and communication between patients and healthcare professionals, tests and investigations which give rise to pain, fear, and anxiety (McDonnell, 2010) should also be taken into consideration. Nurses' experience of patient aggression in particular workplaces varies. ...
Aim: The aim of the study was to explore the experience of staff nurses from selected hospitals in all regions of Slovakia of inpatient aggression in their past year of practice. Design: A quantitative cross-sectional study. Methods: The sample consisted of 1,042 nurses with a mean number of years of work experience of 19.23 (SD 10.96) from medical, surgical, and psychiatric wards, and emergency and intensive care units. Data collection was conducted by the self-reference instrument, the Violence and Aggression of Patients Scale (VAPS). Results: Over the past year, 97.4% of nurses have been confronted with patient aggression. 96.8% of nurses have experienced verbal aggression and 83.3% physical aggression. Nurses working in psychiatric and intensive care wards have experienced the most frequent episodes of patient aggression. A statistically significant difference was confirmed in the prevalence of patient aggression towards nurses based on their pattern of shift work. Nurses working in multiple-shift operation reported a higher frequency of patient aggression compared with those working single-shifts. The relationship between age, years of work experience, and level of education, and experience of patient aggression was not proved to be significant. Conclusion: The study highlights nurses' experience of different forms of patient aggression and provides confirmation of the current relevance of this issue. The results may become the basis for a systematic evaluation of the causative factors and the management of aggression. The implementation of preventive strategies in clinical practice is crucial.
... For each phase, the authors describe the dominant emotion of the aggressor, make recommendations about the aim and focus of staff intervention, and the skills and tactics to employ. Similarly, McDonnell (2010) has proposed a low arousal model of de-escalation based on four principles: decreasing staff demands on patients, avoidance of potentially arousing triggers (e.g. direct eye contact), avoidance of potentially arousing non-verbal behaviour (e.g. an aggressive stance), and challenging clinician beliefs about the management of aggression. ...
De-escalation is an important tool for preventing aggression in inpatient settings but definitions vary and there is no clear practice guideline. We aimed to identify how clinical staff define and conceptualize de-escalation, which de-escalation interventions they would use in aggressive scenarios, and their beliefs about the efficacy of de-escalation interventions. A questionnaire survey (n = 72) was conducted using open and closed questions; additionally, clinical vignettes describing conflict events were presented for participants to describe their likely clinical response. Qualitative data were subject to thematic analysis. The major themes that de-escalation encompassed were communication, tactics, de-escalator qualities, assessment and risk, getting help, and containment measures. Different types of aggression were met with different interventions. Half of participants erroneously identified p.r.n. medication as a de-escalation intervention, and 15% wrongly stated that seclusion, restraint, and emergency i.m. medication could be de-escalation interventions. Those interventions seen as most effective were the most commonly used. Clinical staff's views about de-escalation, and their de-escalation practice, may differ from optimal practice. Use of containment measures and p.r.n. medication where de-escalation is more appropriate could have a negative impact; work is needed to promote understanding and use of appropriate de-escalation interventions based on a clear guideline.
© 2015 Australian College of Mental Health Nurses Inc.
... 'It appears that restraint in children's wards is a widely used intervention, underpinned by unspoken assumptions, and is rarely documented in nursing notes.' (Coyne and Scott, 2014:26) Behavioursthatchallengemaymakeitdifficultfornurses to manage a person's quality of care.The intensity of such behaviours can put parents, carers and nurses at risk of injury (McDonnell, 2010).This study aimed to investigate further why this may be. Given that there is little in the wayofformaltraininginthisarea,theresearchersaimedto providea'snapshot'intowhatcurrentpracticeinvolves,how thisinformationisconveyedacrossateamandwhatfactors influencethis. ...
Holding practices are employed to help a child or young person stay still during the administration of treatments, prevent treatment interference or to undertake an examination, which can sometimes be invasive. The aim of this study was to explore assumptions and practices of holding to develop theories about teaching practices following Grounded Theory methodology for undergraduate nursing students, university lecturers and clinical mentors. The practice of therapeutic holding is often covert and not considered to be part of the treatment per se, which has led to concealment and a reticence to discuss practices openly. This study identified that there is variance in the experiences and practices. Prominent themes that emerged were a lack of clarity and lack of training. It appears that therapeutic holding practices have moved from being viewed as 'uncontested' (practice is not disputed) to 'indifferent' (where there is denial about this practice). These findings have serious implications for current practice and future training.
... Research indicates that the main reason staff restrain people is to prevent physical aggression (McGill et al 2009, McDonnell 2010), yet Ryan et al (2007) found that two thirds of the incidents in which restraint was used in a US day school had been recorded as responses to non-compliance. Meanwhile, McGuirk (1998) has suggested that a minority of workers are responsible for the majority of restraints. ...
... The capacity to move may be highly functional for individuals with autism. Indeed, the stereotypic movement of some children with autism may help regulate their levels of arousal (McDonnell, 2010). Hence, the children who regulated their own stereotypic rocking (see above) took advantage of this aspect of ECHOES. ...
Individuals with autism spectrum disorders supposedly have an affinity with information and communication technology (ICT), making it an ideally suited media for this population. Virtual environments (VEs) – both two-dimensional and immersive – represent a particular kind of ICT that might be of special benefit. Specifically, this paper discusses the importance of psychological theory for VE designed for this population. I describe the contribution that different theories of autism (e.g., theory of mind, executive function, weak central coherence theory) have made and can make, as well as the potential of other non-autism-specific theories (e.g., embodied cognition). These technologies not only illuminate our understanding of autism, but they can also be used to develop new technologies for people without autism. So, as well as being an area of specialism, I argue that VE research in autism has extended – and will go onto – the boundaries of human–computer interaction more generally. This is because autism provides a unique window into human social communication and learning. Further, this field offers a chance for better inclusivity for individuals with autism within a digital society.
... In addition to positive behavioral support, there are other alternative therapeutic approaches to restraint use as highlighted by Sturmey (2009). Some of the alternative approaches included mindfulness and innovative organizational strategies (Sturmey, 2009) and the low-arousal approach to managing aggressive behaviors that focuses on identifying and de-escalating the behavior of concern before it escalates, for example (McDonnell, 2010). ...
Some service providers use restraints and seclusion with people with an intellectual disability, and policies that permit such practices usually state that their use is primarily to prevent the risk of self‐injury or risk to others. However, the use and effectiveness of restrictive practices have been questioned due to the negative impact on the service user and staff and may also be considered a contravention of the human rights of the service user. Consequently, policies are now trending toward limiting restraint use or on the prevention of or safe elimination of the use of restraint. In Ireland, new legislation has attempted to formalize the definitions of restraint and seclusion, as well as place restrictions on such practices. However, issues have been raised with respect to the implementation of the new policies, particularly in operationalizing a definition of restraint and applying it to widely heterogeneous clinical groups considering the autonomy that service providers have in devising their own service‐level policies. The authors use legislation from Ireland and Victoria, Australia, to illustrate restraint practices and the issues emanating from its use. The authors argue that a gap remains between our understanding of the place of implementing restrictive practices with respect to service provision and their actual applications by providers. They conclude that such discordance between policy and practice needs to be addressed by stronger regulation.
... However, more recently, methods that successfully manage setting events and immediate antecedents to behaviour have been advocated in the management of children and adults with ABI (see, for example, Ylvisaker, Turkstra, & Coelho, 2005;Ylvisaker et al., 2007). These approaches have attracted a range of descriptors, including 'nonaversive' (Giles, Wilson, & Dailey, 2009), 'errorless rehabilitation' (Ducharme & Harris, 2005) and 'low arousal' (McDonnell, 2010), although the term 'positive behaviour supports' (PBS) appears to be most widely cited (Johnston, Foxx, Jacobson, Green, & Mulick, 2006). All these approaches endeavour to increase the likelihood that individuals will engage in behaviours that enable them to succeed in their social contexts, and are applicable to many settings, including the community and people's own homes. ...
Symptoms of neurobehavioural disability acquired through brain injury, especially aggression, are associated with severe social handicap. Differences in terminology have resulted in varying estimates, but aggressive behaviour disorder appears to be characteristic of survivors at some point in their recovery journey. This paper provides a brief review regarding the prevalence, development and causes of aggression associated with acquired brain injury (ABI), and what can be done to help manage them. The advantages of using standardised measures conceptualised for ABI in the assessment and formulation of aggressive behaviour disorders are especially highlighted. A range of treatment methods and the evidence base relating to these are described. The contribution of pharmacological therapies, cognitive behavioural therapy and behavioural interventions are explored. It is argued that the strongest evidence base is associated with behaviour therapy, especially when carried out in the context of neurobehavioural rehabilitation, and two case studies are described to illustrate the clinical advantages of interventions derived from operant theory. Comparative lack of ABI experts trained in the management of post-acute behaviour disorders remains a limiting factor.
... A general trend can be recognised in the literature to utilise approaches that attempt to avoid eliciting frustration-related aggression and avoid the use of extinction procedures that elicit frustration. These approaches have been variously described as relational therapy (Giles & Manchester, 2006), non-aversive (Giles, Wager, Fong, & Waraich, 2005;Giles et al., 2009;Manchester, Hodgkinson, Pfaff, & Nguyen, 1997;Rothwell, LaVigna, & Willis, 1999), errorless rehabilitation (Ducharme & Harris, 2005), intensive positive behavioural supports (Gardner, Bird, Maguire, Carreiro, & Abenaim, 2003), and low arousal (McDonnell, 2010). Slifer and coworkers (1997) reported the successful use of the titration of environmental and interpersonal stimulation to reduce aggression in the acute rehabilitation of children and adolescents with TBI. ...
Research in psychiatric settings has found that staff attribute the majority of in-patient aggression to immediate environmental stressors. We sought to determine if staff working with persons with brain injury-related severe and chronic impairment make similar causal attributions. If immediate environmental stressors precipitate the majority of aggressive incidents in this client group, it is possible an increased focus on the management of factors that initiate client aggression may be helpful. The research was conducted in a low-demand treatment programme for individuals with chronic cognitive impairment due to acquired brain injury. Over a six-week period, 63 staff and a research assistant reported on 508 aggressive incidents. Staff views as to the causes of client aggression were elicited within 72 hours of observing an aggressive incident. Staff descriptions of causes were categorised using qualitative methods and analysed both qualitatively and quantitatively. Aggression towards staff was predominantly preceded by (a) actions that interrupted or redirected a client behaviour, (b) an activity demand, or (c) a physical intrusion. The majority of aggressive incidents appeared hostile/angry in nature and were not considered by staff to be pre-meditated. Common treatment approaches can be usefully augmented by a renewed focus on interventions aimed at reducing antecedents that provoke aggression. Possible approaches for achieving this are considered.
This paper intends to examine the development of conflictual interactions, how they might be resolved, and the socio-cultural norms involved, by adopting an analytical framework in an online gaming context. The current paper was inspired by Kádár and Haugh’s framework as it enables me to investigate both the macro and micro aspects of (im)politeness. The study’s aim is to further examine how impoliteness, language aggression and conflict are realised in two online gaming platforms, namely Fortnite and PUBG Mobile. Thus, I will explore discursively how these phenomena are subjective in a Tunisian Arabic setting and discuss how participants reach their subjective perception of conflict in ways that do not always correspond to the supposed intentions of the ostensible offender. The results indicate that conflict is subjective as it is evaluated in different ways by different gamers and could be a result of a conflictual intention. The findings also reveal that conflict may also be created/ escalated as a result of a non-conflictual intention. Thus, this paper contributes to understanding of conflict, how impoliteness can lead to conflict and the various aspects of impoliteness/the perception of impoliteness.
The aim of this study was to describe the phenomenon of “fleeing the encounter when facing resistance” as experienced by carers working in forensic inpatient care. Qualitative analysis, namely reflective lifeworld research, was used to analyze data from open-ended questions with nine carers from a Swedish regional forensic clinic. The data revealed three meaning constituents that describe the phenomenon: shielding oneself from coming to harm or harming the other, finding one’s emotional balance or being exposed, and offering the patient emotional space and finding patience. The carers described their approaches in the encounters with the patients as alternating between primitive instincts and expectant empathy in order to gain control and deal with the interaction for their own part, for that of the patient, and for that of their colleagues. The phenomenon of fleeing the encounter when facing resistance was intertwined with carers’ self-perception as professional carers. Negative encounters with patients evoked feelings of shame and self-blame. A carer is a key person tasked with shaping the care relationship, which requires an attitude on the part of the carer that recognizes not only the patient’s lifeworld but also their own.
Mental health is considered a priority today all over the world; in terms of treatment and especially prevention. Studies also show that, year after year, mental health problems are becoming the cause of problems at work, absenteeism, disability, which, in addition to mental health, also affect productivity at work. For the realization of this study, a qualitative approach has been considered, in order to better understand such a problem, which has not been addressed often in our country. 6 focus groups were conducted: three in the private sector and three in the public sector. Each of them had 8-11 participants. The composition, in terms of sociodemographic variables, was diverse. The study showed that, in institutions, leaders and managers do not yet have the proper awareness to take care of the mental health of employees. Employees state that they cannot complain if they have such problems, that they cannot be absent from work for this reason and that, in general, elements such as relations between employees, etc., are not taken into consideration. No significant difference was observed in the comparison between the private and public sectors. This study brings attention to the need to focus on mental health at work, so that policy makers, managers and employees themselves appreciate its importance. A number of aspects are recommended to be taken into consideration, including division of labor based on skills and opportunities, fostering effective cooperation between employees, working conditions, etc. Received: 05 May 2022 / Accepted: 17 May 2023 / Published: 20 May 2023
Menschen mit Intelligenzminderung (IM) und psychischer Störung stehen gemeinsam mit ihren Unterstützern im Mittelpunkt dieser Forschungsarbeit. Die Lebenswelt von Betroffenen ist aufgrund kognitiver, sprachlicher und emotionaler Entwicklungsstörungen sowie der damit einhergehenden Beeinträchtigungen adaptiven Verhaltens in der Regel durch zahlreiche Behinderungen und Barrieren gekennzeichnet. Das Risiko, im Laufe des Lebens eine psychische Störung zu entwickeln, ist im Vergleich zur Allgemeinbevölkerung um ein Drei- bis Vierfaches erhöht. Mindestens jeder fünfte Betroffene weist eine psychische Störung auf, die Häufigkeit bedeutsamer Verhaltensstörungen wird mit bis zu 40% angegeben. Insbesondere aggressive Verhaltensstörungen führen vermehrt zu stationären Einweisungen und erschweren die gleichberechtigte Teilhabe am Leben in der Gesellschaft. Die vorliegende Studie geht aus einem Praxisforschungsprojekt mit dem Titel ‚Systemtherapeutische Methoden in der psychiatrischen Akutversorgung von Menschen mit geistiger Behinderung‘ (SYMPA-GB) hervor. Das SYMPA-GB-Projekt setzte sich aus zwei Teilen zusammen: erstens einer mehrjährigen systemischen Weiterbildung, basierend auf dem empirisch bewährten, nachhaltig wirksamen Trainingsprogramm für allgemeinpsychiatrische Kontexte (SYMPA), zweitens einer multimethodischen Begleitforschung. Die der Dissertation zugrunde liegende Forschungsarbeit fokussierte auf Erwachsene mit IM, die in stationären Einrichtungen der Behindertenhilfe lebten und sich aufgrund stark herausfordernden Verhaltens bereits mehrmals oder längere Zeit in stationär-psychiatrischer Behandlung befanden. Das übergeordnete Ziel bestand in einer Analyse der Beziehungen und Kooperationen im Multi-Helfersystem (Familie, gesetzliche Betreuung, Heim, ambulante/stationäre Psychiatrie). Drei Fragestellungen waren forschungsleitend: Welche Spannungsfelder werden im Zusammenwirken der Beteiligten offensichtlich? Welches Handlungswissen dient dazu, aggressiv-eskalierende Interaktionen zu bewältigen oder zu vermeiden? Inwiefern entsprechen die eingesetzten Handlungsstrategien systemischen Theorien oder Praktiken? Für die Bearbeitung wurde ein qualitativer Forschungsansatz gewählt, die Annäherung an den Forschungsgegenstand erfolgte über Leitfaden-Interviews mit den Helfern sowie den Personen mit IM. Interviewfragen bezogen sich auf die zwischenzeitliche Entwicklung, die Beziehungen und Kooperationen im Helfernetz sowie das jeweilige Verhalten der Akteure im Kontext aggressiver Vorfälle. Innerhalb der 2,5-jährigen Erhebungsphase wurden mit jedem Interviewpartner bis zu vier Interviews geführt. Insgesamt nahmen 67 Personen an der Studie teil, davon 14 Personen mit IM unterschiedlichen Schweregrades. Ein zwischenzeitlicher Drop-Out war nicht zu verzeichnen. Der Datensatz bestand aus ca. 125 Stunden Textmaterial aus 188 Interviews. Dieses wurde via PC-gestützter qualitativer Inhaltsanalyse in ein Kategoriensystem überführt, welches sämtliche Strategien für ein gelingendes, möglichst konfliktarmes Miteinander von Personen mit IM und deren Helfern abbildet. Das Kategoriensystem erreichte eine sehr gute Inter-Raterreliabilität (Cohens K .91). Es wurden 30 interpersonelle Strategien ermittelt, die hinsichtlich Haltung, Kontakt, Kommunikation und Kontext generell zu einem gelingenden Miteinander von Personen mit IM und ihren Unterstützern beitragen. Weitere 13 Strategien konzentrieren sich auf kritische Situationen und spezifizieren, wie eine Eskalation vermieden, entschärft oder im Nachhinein aufgearbeitet wird. Die dargestellten Bedingtheiten, Kontroversen oder Ambivalenzen innerhalb oder zwischen einzelnen Strategien illustrieren mögliche Spannungsfelder in der Zusammenarbeit, so zum Beispiel das Pendeln zwischen der Entwicklung von Förderplänen und Zielvereinbarungen einerseits und der Akzeptanz von Barrieren und Grenzen in der Entwicklung andererseits. Ebenso bedeutsam ist ein Abwägen zwischen dem Nutzen, die Eltern in die Zusammenarbeit zu integrieren, und dem Auftrag, die Autonomie und Selbstbestimmung der Person mit einer Beeinträchtigungslage zu unterstützen. Einige Strategien lassen sich mit systemischen Denk- und Handlungsansätzen verknüpfen, dazu gehören die Akzeptanz subjektiver Wirklichkeiten und differierender System-Welten, die Sinnhaftigkeit von Problemverhalten, das Klären und Verhandeln von (gegenseitigen) Anliegen, die selbstreflexive Haltung im Hinblick auf Wechselwirkungen, die Fokussierung auf Ressourcen und Stärken von Betroffenen und Helfern sowie die Einstellung, zwischen allen Beteiligten für Transparenz, Mitbestimmung und einen wertschätzenden Austausch von Expertise zu sorgen. Die Strategien-Sammlung erhielt den Titel „SMILE: Systemisch-inspirierte Methoden für die Interaktion und Lösung von Eskalationsmustern.“ SMILE dient als Anregung für die inhaltliche und thematische Ausgestaltung systemisch ausgerichteter Weiterbildungsprogramme wie SYMPA-GB. Bedeutsame Themen sind z. B. der Ablösungs- und Verselbstständigungsprozess von Menschen mit IM, die Verteilung von Einfluss, Macht und Expertise im Multi-Helfersystem sowie die gleichberechtigte Teilhabe von Menschen mit IM an der fallbezogenen Zusammenarbeit. Das SMILE-Konzept stellt für den Bereich Intelligenzminderung – unabhängig von Schweregrad, Störungsbild oder Helferrolle – sowohl ein präventives Modell zur Beziehungsgestaltung als auch ein interventives Konzept zur Krisenbewältigung bereit, entwickelt aus der alltäglichen und kollektiven Handlungspraxis von Betroffenen sowie deren familiären wie beruflichen Helfern. Eine Stärke liegt in der detaillierten Darstellung nützlicher Handlungsstrategien für die Zusammenarbeit im Multi-Helfersystem an den Schnittstellen zwischen Familie, Heim und Psychiatrie. Grenzen ergeben sich durch die nicht-repräsentative Stichprobenauswahl, Verzerrungseffekte sind aufgrund der narrativen Zugangsweise nicht auszuschließen. Gleichzeitig unterstützt eine hohe Experten-, Konstrukt- und kommunikative Validität des Kategoriensystems die Gültigkeit der Befunde.
Research has shown that employees in special education settings are at high risk for work-related threats and violence. Previous research has not yet been able to identify the essential components of training programs that offer protection from work-related threats and violence. Therefore, the aim of this study was to explore how employees in special education schools deal with prevention of work-related threats and violence. Group interviews were conducted with 14 employees working at 5 special education schools. Results show that employees use a wide range of prevention strategies drawing on specific violence prevention techniques as well as professional pedagogical approaches. We propose that the prevention of threats and violence in special education schools can be understood as an integrated pedagogical practice operating on three interrelated levels.
Background
De-escalation is the recommended first-line response to potential violence and aggression in healthcare settings. Related scholarly activity has increased exponentially since the 1980s, but there is scant research about its efficacy and no guidance on what constitutes the gold standard for practice.
Objectives
To clarify the concept of de-escalation of violence and aggression as described within the healthcare literature.
Design
Concept analysis guided by Rodgers’ evolutionary approach.
Data sources
Multiple nursing and healthcare databases were searched using relevant terms.
Review methods
High quality and/or highly cited, or otherwise relevant published empirical or theoretical English language literature was included. Information about surrogate terms, antecedents, attributes, consequences, and the temporal, environmental, disciplinary, and theoretical contexts of use were extracted and synthesised. Information about the specific attributes of de-escalation were subject to thematic analysis. Proposed theories or models of de-escalation were assessed against quality criteria.
Results
N = 79 studies were included. Mental health settings were the most commonly reported environment in which de-escalation occurs, and nursing the disciplinary group most commonly discussed. Five theories of de-escalation were proposed; while each was adequate in some respects, all lacked empirical support. Based on our analysis the resulting theoretical definition of de-escalation in healthcare is “a collective term for a range of interwoven staff-delivered components comprising communication, self-regulation, assessment, actions, and safety maintenance which aims to extinguish or reduce patient aggression/agitation irrespective of its cause, and improve staff-patient relationships while eliminating or minimising coercion or restriction”.
Conclusions
While a number of theoretical models have been proposed, the lack of advances made in developing a robust evidence-base for the efficacy of de-escalation is striking and must, at least in part, be credited to the lack of a clear conceptualisation of the term. This concept analysis provides a framework for researchers to identify the theoretical model that they purport to use, the antecedents that their de-escalation intervention is targeting, its key attributes, and the key negative and positive consequences that are to be avoided or encouraged.
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