Originally published here.

In the recent NHS Executive survey of various parts of thehealth service in the UK, it was estimated that, on average,seven violent incidents occurred for every 1000 staff mem- bers employed in NHS Trusts each year. Nurses were themost common targets, and mental health and intellectualdisability services were the riskiest areas (NHSE 1998).In intellectual disability services, when faced with vio-lent assaults, staff may have to resort to physical interven-tions with service users, usually in order to preventchildren or adults from harming themselves (or others)through their self-injurious behaviour or aggression.

Harris (1996) noted that such procedures were normally justified as ‘in the best interests’ of the service users.Nevertheless, it is known that both staff and serviceusers are at risk when physical interventions areemployed. In relation to staff, Hill & Spreat (1987), forexample, reported that over a period of 1year, there were256 restraint-related injuries to 465 staff in a residentialfacility for people with intellectual disabilities in the USA.Moreover, it has been demonstrated that injuries to ser-vice users are particularly common when the restraint is‘unplanned’ (Spreat et al. 1986). Indeed, some serviceusers have died as a result of such procedures beinginappropriately applied (Department of Health & SocialSecurity 1985; Community Care 1997).

In addition, somecases have come to light where physical interventions orrestraint appear to have been used in an abusive manner(such as in a recent BBC documentary on some group homes in Kent, MacIntyre Undercover, 16 November,1999).Nevertheless, the policy framework for the use of phy-sical interventions has been slow to develop in the UK,with staff in mental health and intellectual disability ser-vices developing‘ management of violence’policies as best They could, in a rather haphazard way.

From the mid-1980s onwards, many NHS staff (and some local authority staff)in mental health and intellectual disability services wereoffered training in ‘Control and Restraint’ (C&R). C&R is amethod of physical intervention, which was originallydeveloped in the prison service and which was adoptedin the NHS, partly as a result of the recommendations of the 1985 Ritchie report (Wright 1999). In intellectual dis-ability services, a number of other methods of manage-ment of violence have been developed since the advent of C&R, including Strategies for Crisis Intervention and Pre-vention (SCIP), Non-Aversive Psychological and PhysicalInterventions (NAPPI), Protection of Rights in Care Envir-onments (PRICE) and Studio III, as well as newer versionsof C&R (British Institute of Learning Disabilities 2002). Allof thesemethodshavelinked trainingcourses, which have been marketed to the day and residential services thatmight employ them.

Service providers, however, haveshown a growing concern about both the lack of a nationalframework for such physical interventions and the con-siderable arguments they see between proponents of thedifferent methods.As a result, with funding by the Department of Health,the British Institute ofLearning Disabilities (BILD) and theNational Autistic Society (NAS) drew up a policy frame-workfortheuseofphysicalinterventionswithpeoplewithintellectual disabilities (Harris et al. 1996). They defined physical interventions and provided guidance on the law,values, prevention of violence, best interests, risk assess-ment, minimizing risks, managers’ and employers’responsibilities and staff training. Subsequently, BILDand NAS were interested in establishing the extent towhich their policy document was affecting practice inservices and they requested an independent evaluationof the impact of the policy document.This study was conducted in this context with fundsprovided by the Department of Health. The aims were toinvestigate the extent and types of training in physicalinterventions amongst staff working with children andadults with intellectual disabilities, and to examine staffs’views of the BILD and NAS Policy Framework document.The study involved three groups of participants (see below). Some of the results for group 1 have already beenpublished in a brief report (Murphy et al. 2001) but thoseare included here where comparisons across the groupsare of interest. Results for groups 2 and 3 have notappeared elsewhere.

The results of this study need to be viewed with somecaution: the resources available meant that the studyinvolved postal questionnaires. While the response ratewas better than normal for postal questionnaires (whichtypically attain a 20–30% response rate, Hayes 2000);nevertheless, it is not possible to know the extent to whichthose who responded were representative of the totalgroup. However, these data are presented as an initialsnapshot of the extent of staff training in physical inter-ventions in a sample of intellectual disability services, andof staff opinions of a policy framework for physical inter-ventions. Such studies are extremely rare.It appeared that the staff who responded to the ques-tionnaire were relatively experienced and well qualified,particularly in groups 1 and 3.

It is likely therefore that, if anything, the results overstate the degree of training inphysicalinterventionsthatistypicalintheirorganizations.Nevertheless, it does seem from these results that by nomeans all staff in intellectual disability services are trainedin the simple physical interventions of breakaway and de-escalation skills. Nor do all staff have any specific traininginaparticularmethodor‘brand’ofphysicalinterventions,even when they work in a specialist assessment andtreatment service, where it is known that physical inter-ventions are likely to be commonly employed because of the frequency of challenging behaviour (Emerson et al.2000; Adams & Allen 2001).

There appear to be a large number of different types of physical interventions training available. There seem to beat leastthreevarietiesthatarebasedonC&R (interestinglythe proponents of the various types of C&R were oftenannoyed that their particular ‘brand’ had not been suffi-ciently prominent or differentiated in the survey). Thesevarieties of C&R and SCIP appear to be ‘market leaders’ inintellectual disability services and it seems that C&R isparticularlypopularinNHSandspecialistassessmentandtreatment services. However, whether this is because C&Ris actually more effective or whether this is merely histor-ical accident is not known.It seems that about one-third of organizations (across allthree groups in this study) do not have written policies forthe use of physical interventions.

This is particularly wor-rying in the case of specialist assessment and treatmentservices(ofwhom20%donothavewrittenpolicies),as it is highly likely that they are using physical interventions fairly regularly. No attempt was made in this study to ask participants about the contents of their policy documents,to see what they could remember of them, as the methodology was not suitable for this purpose. It is interesting to note, however, that where researchers in other studies have asked staff about the content of policy documentsconcerning abuse, remarkably few staff could providemuch detail on the content (Brown et al. 1994), suggesting that even when policies are drawn up, they are sometimes destined to remain on a shelf gathering dust. Overall, staff who had read the BILD/NAS Policy Fra-mework document very much welcomed it. They mostly rated it as highly readable and very useful. In general,They seemed to want more guidance on a number of areas and often voiced concerns about the plethora of methods of physical interventions available and the lack of informa-tion and research into their relative efficacy. Worryingly,though,very large numbers of participants in groups 2 and 3 seemed to be unaware of the existence of the policy framework document (less than one-sixth of group 2 and a little over one-third of group 3 had read or even partly read the document). Of course,this would be imaterial if there were numerous other guides around but, at the time of thesurvey, there were very few (apart from one by Lyon 1994on the use of physical interventions with children).Since the BILD/NAS framework was published, a num- ber of other related publications have appeared, includingthe Royal College of Nursing (1999, 2000) and the RoyalCollege of Psychiatrists (1998) guides on physical inter-ventions; the Mental Health Act revised codes of practice(DepartmentofHealthandTheWelshOffice1999)andthe1997 Education Act (care and control), section 550A, cir-cular 10/98, which gave guidance for LEAs on the use of physical interventions. In addition, the DfEE and theDepartments of Health and Social Services are activelydrafting codes of practice for physical interventions. None of these government guides, however, tackles the issue of whether particular methods or ‘brands’ of intervention are preferable to others, even though there are often Strong views amongst practitioners on such matters [for example, on the use of prone restraint and the likelihood of pain, particularly in C&R (Stirling 2001)]. Ideally, physical interventions should only be used within a framework of planned programmes of positive behavioural support, as Allen et al. (1997) and Stirling (2001) have commented. However, it is well known that behavioural support programmes employing such frame-works (Donnellan et al. 1988; Carr et al 1994) are by nomeans universally available in services in the UK (Emerson et al. 2000). It is likely that poor practice and, at times,abusive practice will continue to occur for some time, as itseems that we still have a long way to go in improvingpractice in the use of physical interventions.

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