by Ni Holmes
Ni began his career in social work in 1982. After four years working as a Residential Social Worker followed by eleven as Social Worker (Intermediate Treatment) he took up a training role with a major focus on professional values and behaviour management. In 2004 he became internal Violence & Aggression Consultant to a Scottish local authority’s Social Work Service working at all levels from policy to practice and across the full spectrum of social work and care services and also providing support externally to partner agencies. In addition he is an occasional freelance trainer.
What is better than training?
Behaviour management has come a long way since I started my career as a residential social worker in the early 1980s. I was taught that what to do with an aggressive teenage girl was to lay her on the floor and hold her down, preferably with the aid of two colleagues. We considered this professional practice and sincerely believed that because the system was named as “therapeutic” it was actually good for these young people and that the techniques we were using were “safe holds”.
Some guidance is now available to us in Scotland in the form of “Holding Safely” (perhaps an unfortunate choice of title given my previous comment) written in 2001 and given an overhaul in 2013 (Davidson et al 2005). The other key standard is the British Institute for Learning Disabilities (BILD) Code of Practice (BILD 2014) and of the thirty-eight training providers registered under the BILD physical intervention accreditation scheme three have their base of operations in Scotland. All notionally follow a public health model of violence reduction and promote a whole organisation, systematic approach. There the similarity ends and in spite of the advances in the state of knowledge relating to behaviour management we continue to be unsure how best to tackle the issue of what and how to teach our care staff to ensure best practice when they are faced with violent or aggressive behaviour from the young people they look after. Consequently the Scottish Qualifications Authority Professional Development Award “Promoting Positive Behaviour” has performance criteria that would allow the award to be achieved by candidates who have been trained in a range of diverging approaches.
I shall present a case here that training is not the most important feature of an effective approach to behaviour management. The problem of workplace violence in the social work and care sector is one that is globally recognised (Polak 2010) but has had less attention in literature than the health care sector (Wassell 2009). In a recently published study the authors had to rely on some dated research in the absence of more recent data (Macdonald and Sirotich 2005). I shall draw on literature and research from a range of contexts that have relevance to the issue from other professional fields, in particular the health sector as there is synergy that can be gained from cross professional knowledge sharing.
This discussion will be concerned with violence defined as ‘incidents where persons are abused, threatened or assaulted in circumstances related to their work involving an explicit or implicit challenge to their safety, wellbeing or health’, this definition being adopted by the original National Occupational Standard for Managing Work Related Violence (ENTO 2002).
Both actual violence and the intent to cause physical or psychological injury have similar potential to inhibit the capacity of the target of violence or aggression to deliver the best standards of care. Therefore, adopting a definition of this kind is essential to a proactive approach that seeks to address the causes and contextual issues of violence within social care settings
The distinction between violence and aggression is complex and where the latter is used here it is intended to refer to an aroused emotional state that may drive violent behaviour. It is not the intent here to use violence and aggression to differentiate between physical and verbal behaviour respectively as the terms appear in some literature.
The term challenging behaviour is a technical description of a specific behavioural phenomenon unique to the person that displays it. This is widely misunderstood and misused as a euphemism or to refer to acts of defiance, being uncooperative or disobedience. This misuse of the term is heavily value laden and so the term will not be used here (see Chan et al 2011 for a useful discussion about this).
In developing a model of trauma informed care Sandra Bloom suggested that “It’s so simple really, the problem of violence: Hurt people hurt people.” (Bloom 2001) Delivering care that seeks to understand the root causes of violent behaviour in all its forms links together the safety and quality agendas. By seeking to effectively meet a service user’s needs, sometimes by addressing deep seated issues, it is possible to reduce the potential for violence to occur. Where the best quality service is delivered violence will not be required to serve the function of distracting or displacing the emotional impact of traumatic experiences in the past nor will it be necessary as a means of communicating distress.
A primary concern when examining short term issues that impact on violent behaviour must be the culture that exists within an organisation, referred to by Leadbetter and Budlong (2003) as “agency ethos”. Fisher (2003) argues that it is proven that residents will conform to the norms of staff behaviour and relationships, echoing the findings of early social experiments by Ashe and Zimbardo on group conformity. The implication of Milgram’s work on obedience is that there is a greater force to conform to culture if authority figures display the normative behaviour. Bandura’s Bobo Doll experiment demonstrates how children’s behaviour may reflect or even amplify what they observe in adults. It is therefore essential to explore the nature of the cultures that we create in places where we look after children and young people in order to avoid what has been described as the “corruption of care” (Wardhaugh & Wilding 1993) and the development of “toxic cultures” (Bowie 1998 cited by Paterson et al 2010). XXXX
It should be expected that the culture within a care setting would reflect a professional value base that fosters positive working relationships that enable the key social work objectives to be met (social inclusion, promoting independence, maximising choices and opportunities, etc.). However, where a culture is characterised by violent or aggressive behaviour these agendas will be compromised and measures to reduce violence from service users are likely to be confounded by the influence of staff in four key areas, covert abuse, acquiescence, counter aggression and inter-staff relationships.
Aggression and staff behaviour
The source of culture lies in the behaviour of staff at all levels within an agency. It is suggested that there are four key areas where the nature of an agency’s culture or ethos is defined and communicated to service users.
Although direct abuse of service users by staff should not occur within care settings the reality is that it does exist. The BBC Panorama investigation into practice at Winterbourne View was shocking but not entirely unexpected (BBC 2011). Within the context of childcare in Scotland widespread abuse of power was identified in the Frizzell inquiry into abuse at Kerlaw School (Frizzell 2009). More subtle forms of abuse are not easily observed but are less damaging because of the imbalance of power between service user and staff. Input to the Royal College of Psychiatrists National Audit of Violence in health and social care settings included these comments from service users:
“Staff wind me up by shouting at me and others instead of walking up to them and talking properly (we’re not dogs!).”
“Staff are very rarely violent towards service users. They instead use the power that they have to deliberately wind up or antagonise a patient.”
(Royal College of Psychiatrists 2005)
There can be no doubt that any form of violence toward service users is not acceptable whether or not it is deliberately intended as abuse or if it is simply thoughtless practice. Where covert abuse occurs it will blur service user perceptions of the boundaries between acceptable and unacceptable behaviour and will compound efforts to reduce service user violence.
In a similar way to direct abuse of service users by staff, acquiescence with service user violence will not communicate a message that violence is unacceptable because it gives tacit acceptance to the behaviour. In conditions where acquiescence occurs it is likely that violence by service users will continue to happen.
Historically there was a notion that violence against social work service staff was “part of the job” (Rowett 1986). This cannot be considered appropriate within a contemporary social work service (for example see Scottish Executive 2006). While there may be a fine line between understanding and accepting violent behaviour it is important to maintain this distinction. An understanding is important to any proactive approach to violence and essential to a trauma informed model of care. However this should not mean that violence should be seen as part of the job as the major agendas in social work are compromised by acquiescence (Department of Health 2001). It is in the interest of service users as well as staff to seek to reduce violence in care settings.
There is a complex distinction between understanding behaviour and accepting behaviour. Understanding behaviour should be the foundation to proactive approaches as this is essential to a process of behaviour change. An understanding approach must not be confused with acquiescence. There is similarly a complex distinction between not accepting behaviour and attitudes of intolerance whereby staff responses to violence lead to a cycle of retaliation and revenge. Critiques of the zero tolerance model adopted by health services in the 1990s have identified a rise in hostile or confrontational attitudes and behaviours among staff working under that approach (Paterson, et al., 2008). Concern with reflects an over-reaction to sometimes minor incidents leading to escalating patterns of behaviour. The imbalance of power and inherent injustice of counter-aggression in itself may constitute a different form of abuse to the covert abuse identified earlier.
Two significant specific ways that counter aggression can be demonstrated deserve specific consideration as both involve application of coercive power and may be experienced as aggressive or violent by service users (Fisher 2003).
By its nature punishment is intentionally aversive. Translation of the word “punishment” into “consequence” has been popular in child care in recent years but only thinly disguises the nature of this response to concerning behaviour. The intention in applying or threatening “consequences” may be “therapeutic” but from a service user’s perspective it may amount to the application of coercion. Consideration must be given to a service user’s capacity to understand the application of “consequences” beyond the feeling that staff are deliberately imposing a sanction that is intentionally hurtful.
The question as to whether or not restraint is justifiable is not the critical issue under consideration here but once again, in either justified or unjustified application of restraint the issue needs to be seen from a service user perspective. The application of coercive force in any form as a response to violence may result in the aggressor feeling like a victim (Morgan 2004, Commission for Social Care Inspection 2007)
The relationships between staff impact on culture to produce what has variously been referred to as “collective disturbance” (Bloom 2006) or the Stanton-Schwartz effect (Fisher 2003). According to Bloom conflict or tension in the form of collective disturbance often originates at a high level within organisational structure, revolving around friction between agency functions and institutional needs. She asserts that
If the managers and staff members were able to confront their own unspoken conflicts they could prevent, or at least terminate, a collective disturbance and in doing so reduce the level of violence within the therapeutic community.
Similar lessons should be applied to the detail of staff relations at horizontal levels within care agencies including those between staff at basic grade. Service users whose spoken language is inhibited or still developing may be more sensitive to “unspoken conflicts” than they are given credit for and may then adapt to conform to a culture of conflict that is evident to them in the way they perceive behaviour of staff toward one another.
Where conflict is evident in management relationships this is likely to communicate something about power to service users. Those seeking power (or to avoid powerlessness) may model their behaviour on what they observe in those relationships.
In addition to other considerations, within a model of trauma informed care it must be recognised that there is a likelihood of reinforcing past trauma where service users experience in care settings treatment that recollects past traumatising events.
The Leadership agenda
The major role in developing positive workplace culture that is not in any way characterised by violence and aggression lies with management (Colton 2004). This requires leadership that demonstrates a commitment to a set of core professional values and principles. This should be evident in provision of policies and procedures along with adequate resourcing to permit implementation of the values and principles in practice. Appropriate behaviour within relationships should be modelled not only in any direct dealings with service users but also with the elimination of hostility and confrontational approaches from management systems. Staff should be supported with good professional supervision and where necessary critically challenged in order to foster learning and development.
Inappropriate behaviour modelled in the form of aggressive management systems and processes is likely to be mirrored by the behaviour of staff toward colleagues or service users and ultimately reflected by behaviour among service users or between service users and staff.
Values in Practice
Central to all of this is a value base that must be evident in practice. Miller et al (2007) indicate that “Many incidents of violence arise from the individual feeling vulnerable, disregarded or ignored” (p33) echoing an earlier assertion by Kaplan and Wheeler (1983)that violence is often the result of a disequilibrium of power between worker and service user. A clear link is evident between the quality of service delivery and the safety of staff (Department of Health 2001), the foundation to both being a thorough commitment to professional practice. Inclusion of value base material throughout the training programme is essential. However, explicit and discrete training on values and principles of service delivery should not be overlooked as an effective tool for violence reduction. The acquisition, development and application of ethical values and principles must also be supported by workplace culture if any training in violence reduction is to deliver impact to its full potential.
Essentially, this value centred approach to service delivery implies the necessity for adopting an organisational approach to the public health model of violence reduction (Paterson et al 2005). Reductionist models of violence that seek to individualise the problem and in doing so pursue solutions based on training need to be replaced with a co-creationist understanding of the issues. (Paterson et al 2009). This understanding recognises the broader context of violence involving the interplay of a range of factors. This expands beyond the immediate circumstances of the behaviour to encompass the beliefs, values and skills which the individuals involved bring to any situation and critically the prevalent culture of the workplace. (Paterson et al 2005).
A culture needs to develop that places fundamental professional values back in a prominent position at the centre of service delivery, eliminating practices that undermine the value base. Effective leadership must promote the change imperative through commitment and action and must model values in practice.
What this really means.
Application of this approach in practice can be powerful. Finally I would like to share a practice illustration.
I was approached by a social worker who was concerned about the amount of times a young person was being restrained where he was being looked after by another agency. I identified in the incident reports frequent use of the term “safe hold” but a description of practice that appeared fundamentally unsafe. A discussion with the manager clarified that what was written was not an accurate reflection of practice. The staff group were highly trained in a reputable behaviour management system, well skilled and possessing among them a lot of experience. The problem was that they were using language that disguised the risks inherent to physical intervention and had developed a culture that did not give much thought to the use of restraint. The manager agreed that this was contrary to the values that the agency sought to uphold and took a lead on changing the behaviour of staff. They stopped using the term “safe hold”, not to be politically correct but to change their understanding of a particular practice. The number of restraints plummeted, the relationships improved and the young person began making progress in a culture where positive values had become more evident than restrictive practices.
Training in behaviour management often does not have the impact we would like to expect. In this instance it was demonstrated that injection from leadership of an attitude that reflected professional values fostered the development of a culture that had a greater impact than the quality training that had gone before.
Effective behaviour management founded on good relationships is undermined by a culture that has characteristics of aggression or violence but enhanced by a culture that demonstrates professional values in action.
BBC 2011 Panorama Undercover Care: The Abuse Exposed Broadcast 31st May 2011
Bloom, S., 2001. “Commentary: Reflections on the Desire for Revenge”. Journal of Emotional Abuse 2(4): pp.61-94
Bloom, S., 2006. Organizational Stress as a Barrier to Trauma-Sensitive Change and System Transformation [pdf] Philadelphia: CommunityWorks Available at: http://www.sanctuaryweb.com/PDFs_new/Bloom%20Organizational%20Stress%20as%20a%20Barrier%20to%20Trauma%20Chapter.pdf [Accessed 29th May 2014]
British Institute of Learning Disabilities, 2010 ‘BILD Code of Practice for minimising the use of restrictive physical interventions: planning, developing and delivering training’,. Kidderminster: BILD Publications
Chan, J., Arnold, S., Webber, L., Riches, V., Parmenter, T. and Stancliffe, R. (2012) “Is it time to drop the term ?Challenging Behaviour”?” Learning Disability Practice Vol 15 No 5 36-38
Colton D., 2004. Checklist for Assessing Your Organization’s Readiness for Reducing Seclusion and Restraint. [pdf] Staunton, VA: Commonwealth Center for Children and Adolescents Available at: http://www.ccca.dmhmrsas.virginia.gov/content/S&R%20Checklist%20-%202010.pdf [Accessed 29th May 2014]
Commission for Social Care Inspection 2007. Rights Risks and Restraints. Newcastle upon Tyne: Commission for Social Care Inspection
Davidson, J., McCullough, D., Steckley, L. and Warren T., eds. (2005) HOLDING SAFELY – A Guide for Residential Child Care Practitioners and Managers about Physically Restraining Children and Young People.
Department of Health, (2001). National Task Force on Violence against Social Care Staff: Report and Action Plan [pdf] London: Department of Health Available at: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4062820.pdf [Accessed 29th May 2014]
ENTO, 2002. National Occupational Standards for Managing Work Related Violence (First Edition); [cd rom] Bury St Edmunds: Arima Media Limited
Fisher, J. (2003) Curtailing the Use of Restraint in Psychiatric Settings. Journal of Humanistic Psychology, Vol. 43 No. 2, Spring 2003 69-95
Frizzell, E. 2009. Kerelaw Residential School and Secure Unit – Report of the Independent Inquiry [pdf] Available at http://www.scotland.gov.uk/Resource/Doc/271997/0081066.pdf [Accessed 29th May 2014]
Kaplan, S.; Wheeler, E.: (1983) Survival Skills for Working with Potentially Violent Clients. Social Casework, (64): 339–346
Leadbetter, D. & Budlong, M., 2003. Safe Practice in Physical Restraint: A Transatlantic Perspective. Residential Group Care Quarterly [online] Vol 3, No 3 Available at: www.cwla.org/programs/groupcare/rgcqwinter2003.pdf [Accessed 30th March 2009]
Macdonald, G., and Sirotich, F. 2005 Violence in the social work workplace. International Social Work 48(6): 772–781
Miller, G., Paterson, B., Benson, R. and Rogers, P. (2007) Violence reduction in mental health and criminal justice: recent and current developments. The Journal of Mental Health Workforce Development Volume 2 Issue 1 28-41
Morgan, R. (2004) Children’s Views on Restraint Commission for Social Care Inspection Newcastle upon Tyne
Paterson, B., Leadbetter, D. and Miller, G. (2005). Beyond Zero Tolerance: A Varied Approach to Workplace Violence. British Journal of Nursing, 2005,Vol 14, No 14
Paterson, B. Miller, G. Leadbetter, D. & Bowie, V., (2008). Zero Tolerance and Violence in Services for People with Mental Health Needs. Mental Health Practice Vol 11 No 8 26-31
Paterson, B., Ryan, D., & McComish, S. (2009). Research and best practice associated with the protection of staff from third party violence and aggression in the workplace – a literature review. NHS Scotland Available at http://www.healthscotland.com/uploads/documents/10148-LiteratureReview.pdf [Accessed 22nd March 2010]
Polak, D., 2010. Social work and violent clients: An international perspective International Social Work 53(2) 277–282
Rowett, C., (1986). Violence in Social Work. Cambridge: University of Cambridge
Royal College of Psychiatrists, 2005. The National Audit of Violence
(2003 – 2005) Final Report. [pdf] London: The Royal College of Psychiatrists. Available at http://www.rcpsych.ac.uk/PDF/Final%20Report%20shortened%20for%20website.pdf [Accessed 29th May 2014]
Scottish Executive (2006). Changing Lives Summary Report of the 21st Century Social Work Review. Edinburgh: Scottish Executive
Scottish Qualifications Authority The Professional Development Award (PDA) in Promoting Positive Behaviour http://www.sqa.org.uk/sqa/58008.html# [Accessed 29th May 2014]
Wassell, J. T. (2009). “Workplace violence intervention effectiveness: A systematic literature review.” Safety Science 47(8):1049-1055.
Wardhaugh, J & Wilding, P., 1993. Towards an Explanation of the Corruption of Care Critical Social Policy 13; 4