Connections between violence and health have been revealed in a number of ways, not least through the World Health Organisation’s recognition of violence as a public health problem. Anna Gillions asks what we can learn from reviewing approaches to violence from the health and social care sector.

In the health and social care sector, there are people whose behaviour is deemed challenging, violent or aggressive. Historically, such people were incarcerated in asylums, away from the public eye. With the advent of the 1990 Community Care Act the asylums were gradually closed, and services appeared in the community.

Around this time, there came a challenge to terminology. There was concern amongst practitioners and academics that labelling people as ‘violent and aggressive’ placed the blame securely with the individual, while research and practice were beginning to suggest that this wasn’t the case. The labelling also sat uncomfortably with the acknowledgement that many people being given this label were amongst the most marginalised in society, heaping multiple labels and prejudices – black, mentally ill, disabled, elderly, poor, violent, aggressive – onto people who were also disproportionately physically restrained and medicated.

Many amongst this population had also experienced adverse childhood experiences (ACEs) or abuse, and were at risk of being re-traumatised by restrictive or punitive responses. The term ‘challenging behaviour‘ was selected in an attempt to show that the behaviour was challenging to us – the carers and practitioners – and as such we had a shared responsibility. Training courses focused on helping practitioners to see behaviour as a form of communication and respond accordingly.

As the science progressed, applied behaviour analysis (ABA), a term originating in the late 1960s, was finding more widespread application, particularly in the United States. It has become extremely contentious, not because of the theory (simply the science of how we as humans develop and maintain behaviour) but because of its application in making people ‘’conform’‘ to societal expectations, and endorsing the use of punishment.

Quality of life as security

The preferred approach at time of writing is Positive Behavioural Support (PBS), which uses the science of ABA combined with a range of values. It recognises that every behaviour we perform serves a purpose, or function, for us. The main aim of PBS is to increase the quality of life for the person, as it has been identified repeatedly that as quality of life increases, so behaviours of concern decrease. Ultimately, it demonstrates that if you strip someone of everything they value, little sense of purpose or incentive to change remains, and with increasing exclusion, aggressive behaviour is increasingly likely.

A single example from social care is that of someone who had been held for 13 years in a secure facility following numerous placement breakdowns as a result of challenging behaviour. He was being restrained face down on the floor by five people, twice a week on average, and injected with intravenous sedatives to manage the risk of his behaviour. His bedroom was locked (he had to request access), and only contained a rubber mattress. After moving to a community facility with a PBS approach, no further injections were used, he was never held on the floor, and within two years was living in a flat with 1:1 support.

An additional model is that of trauma-informed practice (TIP), which focuses on a shift from ‘what’s wrong with you’ to ‘what happened to you’, also reflected in the Power Threat Meaning framework. Like PBS, it sees behaviours as the person’s best attempt to cope in the situation. While TIP began in health and social care, it is being increasingly recognised in relation to criminal justice. Overall, the combined approaches mean addressing basic needs (including physical and psychological safety and security), counteracting marginalisation and inequality, and working with people in a way that acknowledges their experience.

Cultures of punishment

Despite these advances, the general approach in practice, inevitably, continues to mirror that of mainstream society. The individual is often blamed, and the response tends to focus on sanctions, seclusion, restrictions and medical treatment. PBS and TIP have good outcomes but limited reach as they are still predominantly restricted to the field of intellectual disability and mental health, and there is recognition that broader cultural change (reflected in policy, governance and management) is needed in order to enable them to succeed in practice. 

By now, the parallels with security more generally should be apparent. When one explores risk factors for violence, marginalisation, inequality and ACEs are key themes throughout the literature. In UK society, we continue to have a culture of punishment and individualistic blaming and shaming, which further excludes and traumatises people, contributing to further risk factors for violence.

Research, and areas of good practice, very clearly identifies the impact of marginalisation on individual (and group) behaviour, and projects around the country work in alternative ways to reduce these risk factors. These include projects specifically focused on peacebuilding skills or restorative justice, projects for ex-offenders or those that build connections across disconnected communities, and many more that work to support community safety, parenting, poverty, housing and other related factors. While we continue to be informed by a wider culture of individualism, blaming and punishment, the reach of these projects will be limited.

The preventability of violence

The World Health Organisation (WHO) defines violence as a public health problem on the basis of its impact on physical and psychological health as well as associated healthcare costs. There is a further parallel between the WHO’s definition of health as going further than merely the ‘absence of disease’ towards a state of complete wellbeing, and our understanding of peace as going beyond the ‘absence of violence’ towards Johan Galtung’s vision of positive peace. This by necessity implies addressing the structural violence underlying the root causes of much other violence, intrinsically linking violence to social injustice and inequality, and making policies around healthcare and education as important (if not more so) as conflict resolution activity. Scholars such as Douglas Fry and Farida Anwar challenge what they see as an assumption that positive peace is unachievable, demonstrating studies of peaceful societies which suggest otherwise, and echoing WHO’s evidence-based claim that violence is preventable.

This parallel demonstrates the flaws in the current focus on a punitive, individualised and militarised focus on security as well as showing the need for an alternative vision of security as it applies to societies. The PBS and TIP principles around quality of life and acknowledging people’s experience mirror Rethinking Security’s principles of security as freedom, common rights, patient practice and shared responsibility. This can only be effectively implemented through cultural change at all levels, and through engagement with communities so that voices are heard and valued.

The views and opinions expressed in posts on the Rethinking Security blog are those of the authors and do not necessarily reflect the position of the network and its broader membership.

Image Credit: Bessi via Pixabay.