Recent articles by Christopher Stirling and Albert McHugh explore Natural Therapeutic Holding, an alternative to the use of control and restraint in managing aggression in people with learning disabilities. For a number of years there has been a move away from the use of control and restraint as a method of managing aggression, towards the use of non-aversive methods, e.g. gentle teaching, positive programming, humanistic approaches or teaching positive proactive alternative behaviours to aggression.
In view of concerns relating to control and restraint, Stirling and McHugh developed the natural therapeutic holding approach. The approach is described as non-aversive and non-punishing, where clients are held by carers to limit harm to themselves and others. Touch is used to communicate positive regard, serving the purpose of limiting violence, enhancing communication and developing the bonding process. Trust may develop where alternative coping strategies can be taught. It offers emotional support to clients through reinforced contact, during which the client learns to communicate feelings in positive ways. The carer assesses the client’s needs to determine the function of the aggressive behaviour and to find alternative coping strategies. This results in ‘setting clear therapeutic goals with the client as a means of managing the violence and focuses on the issue of bonding and development of positive interactions’. This approach can be combined with other approaches to help to find and implement alternatives to aggressive behaviour.
The process of holding
The process of holding is described in five stages:
Confrontation — When clients become aggressive they are challenged to redirect aggression back to a state of calm. The carer initiates holding. Clients who have gone through this process before may eventually initiate the holding activity.
Rejection — During this stage clients may be expressing anger towards the carer who judges whether or not to release and give control back to the client.
De-escalation — As the anger abates, control is returned to the client through a process of verbal and physical de-escalation where the client is encouraged to express feelings.
Resolution — When all anger has been expressed and a state of natural calm has returned, physical and emotional contact is maintained, in readiness for the next stage.
Exploration — During this stage, causes and alternative strategies are investigated.
Practical project and case study
Staff of the North Staffordshire Housing Consortium were trained to apply both control and restraint and natural therapeutic holding. In 1995, 84 aggressive incidents were reported in seven homes. Twenty-eight incidents required some physical restraint. Of the 28 incidents, 23 involved natural therapeutic holding and five involved control and restraint. In two of the homes, staff chose no longer to use control and restraint, opting instead for natural therapeutic holding. It was found that incidents were resolved in less time using natural therapeutic holding, with an average time of 13 minutes, as opposed to 55 minutes for control and restraint.
A report is given of a 42-year-old man whose aggression could last two or three days. His behaviour was being managed with control and restraint methods and medication. A violence risk assessment was carried out to develop an individual intervention strategy with the hypothesis that three factors contributed to his aggression:
- difficulty expressing feelings ® not understood by carers ® frustrated ® aggressive;
- often sexual frustration;
- difficulty coping with change.
These issues formed the discussion during the holding sessions. He began working on a sex education programme, interpersonal skills training, relaxation training and developing his self-advocacy skills. Over twelve months, he began to respond positively to the holding sessions. The confrontation and rejection stages decreased from an average of 45 minutes to 5 minutes, with overall aggression lasting hours now rather than days. Over time, he began to initiate the sessions and proceeded through the stages. Staff also had greater confidence in dealing with his behaviour and the severity of aggression was decreasing. He was learning better coping strategies. All medication was reduced and all ‘as required’ medication was discontinued.
The above articles give an insight into an alternative method of managing aggressive behaviour while also emphasising the need for more research with regard to natural therapeutic holding.