Professional Ethical Therapeutic Management of Aggression (PETMA?)

Subtitle:???

Some questions and considerations?in the?support of individuals?who?may present with behaviours that challenge?

?Summary:??

• Ethical considerations must be paramount before we consider supporting any individual?
• Interventions?should be based on?a recognition of stress and?a foundation of respect??
• A?holistic?and person-centred?approach to behaviour?management?is?essential?

Main Article:?

In?terms of?history?one?could?take a?short trip back in time to?the?late?1990’s?to?discover that the concept of ethical behaviour management was?a concern?in the provision of health and social care.?The?“Macintyre?Undercover”?documentary?(1999)?exposing abusive practices in Brompton Care Home?(UK)?was?the first time the author had seen this sort of?inappropriate?treatment?so publicly exposed.?Consequently?there was increased attention?paid?to the training and supports provided to staff teams?and services?in these contexts.?A “gap in the market” was spotted and subsequently?flooded?by?numerous training models?with widely varying degrees of?understanding,?competence and?consideration?for the individual?and their story.?This?generated the?phrase “The Behaviour Support Industry”?to describe?entities?that have arisen and?currently?operate in this?lucrative?area of health and social care.?Organisations?spend?literally?hundreds of thousands?of?euros?nationwide?ensuring?that their staff are?trained in behaviour?management?approaches.?Why???

• Is it because they have a statutory requirement to do so under?SI 367 of Health Act (2007)?(1)??“The person in charge shall ensure that staff receive training in the management of behaviour that is challenging including de-escalation and intervention techniques”.??
• Is it because they recently had a serious incident and need to manage risks or reduce insurance costs???
• Is it because they proactively desire a culture of understanding, respect and empathy????

Documentation entitled “behaviour management strategies”, crisis management plan”, etc. is often produced because of staff training that focuses?behaviour management?on the individual?receiving care?as the issue.?There is a key consideration that is overlooked in that approach?–?Who is the?client/customer/consumer??Crucially, we?need to re-direct (nice behaviour management term) our services?to?concentrate on?changing?OUR behaviour – as a person, as a team, as an organisation.?Models of support that focus on?the?“mediators” must be the preferred option?in order to avoid a consistent?theme in?which?individuals who?experience?behaviour interventions?are?often the wrong?“target”.?We must acknowledge that good practice involves?addressing the?practice of?“significant others”?rather than the individual?themselves.?We must focus on?the individual, their story?and where they fit in the?“system”.?As Paul Collins said?“The problem with pounding a square peg into a round hole is not that the hammering is hard work…. it’s?that you're destroying the peg”?(2).?People who may present with behaviours that challenge are simply?asking?services?to?listen, with our eyes and our ears?when they try to tell us things:?

1. “Somethings not right….I?need you to help me with it”?(Physiological)?
2. “I am not being understood”?or?“I’m not understanding”?(Communication)?
3. “This is not the place for me. It could be if….” (Environment)?
4. “I’d like to be supported by people that know me and want to support me and are being looked after?also?(Mediators)?

If?behaviour management?training?models?are?successfully?able to communicate these concepts to?services,?then the need?to?reactively?respond?to?behaviour?should be reduced?or as Albert Einstein put it – “A clever person solves a problem; a wise person avoids it”.?Realistically however there is likely?to always?be?a need for?ethical?reactive?strategies?particularly when there?may be acute or exceptional circumstances when?reactive?interventions may be required as part of the?supports?for an individual.?“Therapeutically we have a lot to help a lot of people but not enough to help all people”?(Prof. David Allen, BILD Conference – Reducing Restrictive Practices & Changing Cultures of Care, May 2009).?Whilst most organisations would like to eliminate the use of restrictive reactive?interventions,?they will often find that they are not?able?to discount the use of such?interventions?where they may be of benefit to the person who is affected by their behaviour,?or provide protection for that person or others.?

There are some key questions?services?need to consider before commissioning any?behaviour management model:?

• How do they ensure that?the model is focused on the Irish context??
• How are they assured that the content, strategies, theories, attitudes and cultures are the right fit???
• How do they assure themselves that any physical strategies that may be taught are ethically sound and will keep the individual, and their?carers, safe????????
• How are they assured that various populations are suitably supported (e.g.?children) and that there isn’t one generic model??
• Are?internal trainers?trained to a high level, vetted and audited regularly? Is the content and delivery consistent across trainers? Are they giving consistent advice? Is the content being diluted or distracted at any time??
• Is there an opportunity for?participants?to build both competence and confidence that the strategies?they are taught (including defusing/de-escalating/verbal/non-verbal strategies)?will work should they need them???
• How do they know they are getting value for money??

Currently there is only one?Irish model?that is?accredited?with the Restraint Reduction Network?(an essential benchmark for quality).?Uniquely for this?field?this model also retains accreditation as Guaranteed Irish.?This model is called Professional Ethical Therapeutic Management of Aggression (PETMA?) and is being provided by the?National Institute of Intellectual Disability Studies (https://niids.ie).??

What does it mean to be accredited by the Restraint Reduction network??

Restraint Reduction Network Training Standards – “have been developed and apply to all training that has a restrictive intervention component and will provide a national and international benchmark for training in supporting people who are distressed in education, health and social care settings. These Standards will ensure that training is directly related and proportional to the needs of populations and individual people and that training is delivered by competent and experienced training professionals who can evidence knowledge and skills that go far beyond the application of physical restraint or other restrictive interventions”.?(https://restraintreductionnetwork.org)?

Professional Ethical Therapeutic Management of Aggression (PETMA?) is a model of behaviour management training for staff in health and social care services who strive to support individuals in an ethical, respectful and person-centred manner.?By establishing itself as the first and only Irish behaviour management model to be accredited with the Restraint Reduction Network,?as well as?being?BILD?Certified,?PETMA??can?provide strong?reassurances?that?individuals?supported within the?PETMA??framework will be confidently, competently?and?most importantly, respectfully supported.??

What’s included in the?PETMA??framework??

PETMA??Instructor Certificate Course?offers a suite of 6 modules that cover a?wide?range of issues?to ensure that participants?are enabled to?support an individual within a holistic framework. This is an?NMBI Approved Category 1 Programme?with?35 CEU’s:?

Module 1: Foundation?PETMA??programme?

This module provides learners with a human rights-based approach to supporting people who may engage?in behaviours of concern from time to time. It will provide learners with the skills, competency, knowledge and attitudes to prevent, predict, assess, engage and manage risks associated with behaviours of concern. It provides learners with a range of highly useable practical skills and tools to develop positive support.?

Module 2: De-escalation Skills?

This module explores?in depth a range of best practice responses to support a person to come to a calmer state. Empathy, compassion respect, non-verbal, para-verbal communication strategies, preventative strategies and a good understanding of the?impact of trauma?informed care are the tools developed?in this module?

Module 3: Decision to use?Restrictive?Practice?

This module explores the Irish legal, regulatory, ethical and professional?issues relevant to supporting people whose behaviour may pose a risk to themselves or others. It prepares learners to develop a skill set which can be utilised?in practice to support the?implementation of?interventions?which provide an appropriate balance between safety and human rights approaches. In particular?it will examine the relationship between Positive Behaviour Support planning, risk assessment, least restrictive practice and physical?intervention risk reduction planning. This module will also, help learners to develop a greater understanding of debriefing and the use of data-driven?interventions?

Module 4: Disengagement Skills / Physical Intervention Skills?

PETMA??provides a suite of physical skills designed to manage the risks associated with actual or potential verbal or physically distressful behaviour. All techniques are designed to respect the?individual?in distress whilst meeting the needs of staff working?in care settings with vulnerable clients. The skills are graded to equip staff with an appropriate level of response using the least restrictive?intervention when the client’s behaviour?is at risk to either themselves or others.?

Module 5: Teaching and Assessing?

This module award?is to equip the learner with the knowledge, skill and competence to deliver, assess and evaluate the?PETMA??foundation programme.?

Module 6 Practicum –?PETMA??Certified Instructor?

This module will focus on learners developing a deep understanding of subject matter and apply the learning objectives of the different stages of training delivery and assessment. Learners will understand the critical role of workplace training as an ongoing process to ensure verbal, physical and restrictive?interventions are applied as part of a least restrictive practice and as ethically and safely as possible. Learners will be required to complete and submit a portfolio of evidence of their teaching capability,?to?be entered onto the BILD Certified Instructor list as a?PETMA??Certified Instructor. This portfolio will be developed during a 3-month probation period which occurs directly after the teaching component.?

Additionally?the NIIDS offers?PETMA??courses in a 2- or 4-day format which can focus on either child or adult specific interventions. These programmes are designed to provide learners with the basic professional, ethical and therapeutic competence, knowledge, skill and attitudes required to support children/adults when they become distressed, and facilitate them to a calmer state, whilst ensuring the safety of all concerned. These programmes aim to provide learners with the relevant skills in prevention, prediction and recognition of situations which are escalating and the ability to manage actual or potential verbal or physical distressful behaviour.??

Throughout the?PETMA??framework there is an emphasis on recognition of stress and distress?with?an acknowledgement that behaviours of concern are often a manifestation of these aspects of the person.?Assertions that ‘behaviours that challenge are manifestations of stress’?is often countered with ‘Sure how could “they” be stressed? Isn’t everything provided for “them”?’. The fact is, in a lot of cases, they are stressed because their access to a ‘good life’ is being impeded. The packages aren’t working for them. Maybe they’re not being heard. Maybe they’re lonely. Maybe they have limited choice. Maybe they’re unwell. Maybe there are many other reasons that would cause any of us to be greatly distressed.?We should acknowledge that?when?we?work with people who are highly stressed and traumatised, who are often frightened and scared,?we?should focus on making them feel safe and less stressed rather than “targeting behaviours. This is?a?focus of the?PETMA??Framework.?

All too often the?emphasis?is on supporting the person when they are in crisis. Using what we often term as?“Last Resort” Strategies?including how to restrain safely?or how to physically disengage safely. A large component of the?PETMA??philosophy is on supporting the person when they are not in crisis or as John F. Kennedy said?–?“repairing the roof while the sun is shining”.?PETMA??strongly emphasises the use of?1st Resort?Strategies?such as engaging, connecting, interacting, reinforcing, praising, communicating, involving, building a therapeutic relationship, making?positive behaviour more useful than behaviours that challenge, improving Quality of Life.?

PETMA?’s philosophy is?also?entirely in keeping with?Safeguarding Ireland & HIQA’s?2021?document entitled?Guidance on a Human Rights Based Approach in Health & Social Care Services?(3)?in?which it is recognised that?“health and social care staff encounter complex situations in practice, where many factors need to be?considered,?for example an individual’s will and preferences and their right?to autonomy versus the risk of harm from a particular decision.?In some?situations?there may be competing human rights, and?staff need to consider the applicability and weighting of each right?within that situation and their duty of care to ensure safety and?fairness for all people using services”.?

As a final consideration – please don’t be fooled into thinking that?ticking the box on?“staff training”?alone?is the solution.?It really isn’t.?“If the team providing support cannot get training (including hands-on training), or if the training they are receiving is not followed up with good Practice Leadership, then the difficulties they will face in trying to support individuals with more complex needs are likely to wear away at their ability to sustain their?performance”?(4).?Training does not vaccinate?human?services against issues.?In numerous abuse scandals that followed on from the Brompton Care Homes case the staff were trained. Health and social care provision?is?about people - not models, methodologies, packages etc.?therefore?training?delivery, trainers?delivering?and models?employed?are?critical elements to?get right.?The individuals in our care absolutely deserve the right person teaching the right things?to the right people. This, alongside considerate and compassionate practice, are?key pillars in?PETMA?’s approach to the?support of individuals who may present wibehaviours that challenge.??

?For details on our PETMA Courses in January 2022 visit www.niids.ie

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References:?

1. Health Act (2007)?
2. Not Even Wrong: Adventures in Autism?-?Paul Collins?(2004)?
3. Guidance on a Human Rights Based Approach in Health & Social Care Services?(2021)?
4. https://www.unitedresponse.org.uk/practice-leadership?

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