Community Residential Services Research Articles

Trust, respect, and training: Principles of care for service professionals supporting adults with intellectual disabilities in community residential programs.

Background: Adults with intellectual disabilities in community residential programs receive services from direct support professionals (DSPs) intended to facilitate community engagement. As part of a rate study for Washington State's Developmental Disabilities Administration on community residential services, adults in these programs were asked to provide their perspective on the quality and effectiveness of their care.Method: Twenty-five adults with intellectual disabilities were interviewed focusing on daily activities, staffing, and living situations. Interview transcripts were coded and analyzed for dominant themes.Results: Participants emphasized the desire for trustworthy, caring, and respectful DSPs; DSPs trained in behavioral management techniques made participants feel safe and supported. Nearly all participants called for greater staffing stability.Conclusions: People living in community residential programs are profoundly impacted by the stress and uncertainty of DSPs facing limited resources and high staff turnover. Stable, consistent support makes it easier for participants to engage in community integration.

Impact of the workforce allocation on the technical performance of mental health services: the collective case of Helsinki-Uusimaa (Finland)

BackgroundLong-term mental health (MH) policies in Finland aimed at investing in community care and promoting reforms have led to a reduction in the number of psychiatric hospital beds. However, most resources are still allocated to hospital and community residential services due to various social, economic and political factors. Despite previous research focussing on the number and cost of these services, no study has evaluated the emerging patterns of use, their technical performance and the relationship with the workforce structure.ObjectiveThe purpose of this study was to observe the patterns of use and their technical performance (efficiency) of the main types of care of MH services in the Helsinki-Uusimaa region (Finland), and to analyse the potential relationship between technical performance and the corresponding workforce structure.MethodsThe sample included acute hospital residential care, non-hospital residential care and outpatient care services. The analysis was conducted using regression analysis, Monte Carlo simulation, fuzzy inference and data envelopment analysis.ResultsThe analysis showed a statistically significant linear relationship between the number of service users and the length of stay, number of beds in non-hospital residential care and number of contacts in outpatient care services. The three service types displayed a similar pattern of technical performance, with high relative technical efficiency on average and a low probability of being efficient. The most efficient acute hospital and outpatient care services integrated multidisciplinary teams, while psychiatrists and nurses characterized non-hospital residential care.ConclusionsThe results indicated that the number of resources and utilization variables were linearly related to the number of users and that the relative technical efficiency of the services was similar across all types. This suggests homogenous MH management with small variations based on workforce allocation. Therefore, the distribution of workforce capacity should be considered in the development of effective policies and interventions in the southern Finnish MH system.

Exploring a volunteer community residential care facility for new mothers

Background:All women deserve a “dwelling space” during their postnatal period after the birth of their infant. This “space” provides her an opportunity to be cared for, to be replenished, to rest and to reflect on herself being a new mother before returning home. We explored a volunteer community residential service set up to help new mothers to document their experiences and determine if the outcomes matched their expectations. Methods: Semi-structured interviews were offered to all women who had utilised this service since its inception. The questionnaire explored their motivations to seek such as service and to learn of their experiences. The interviews were audio recorded, transcribed and a thematic analysis employed. Results: Over the last 8 years, 12 women, 4 twice, availed themselves of this service, two being first-time mothers. Reasons given by mothers for utilising this service included recovery from the trauma of childbirth both past and present, physical and emotional, and delaying assuming responsibilities at home. All the women had welcomed the “dwelling space”, being mothered, feeling replenished and having time to meaningfully relate to their newborn infant.The ambience of the accommodation and the care they received were above their expectations. All would recommend other new mothers to avail themselves of this service

Psychologically Informed Environments

Since the ‘enabling environment working group’ was first set up by the Royal College of Psychiatrists in 2008, the psychologically informed environments (PIE) model has been successfully adopted in a variety of settings such as HM Prison Service, hospital wards, day units, schools, supported accommodation (for the homeless or those with Personality Disorder), voluntary groups and faith communities. However, previously there was no PIE model used in Intellectual Disability and Autism services. This paper will describe the implementation ofa psychologically informed environment for 12 community residential services supporting people with Autism and Intellectual Disabilities, and provide provisional data exploring the impact of a PIE. Recommendations for ways of improving provisions with autism services using a PIE approach are made.

Staged residential post-acute rehabilitation for adults following acquired brain injury: A comparison of functional gains rated on the UK Functional Assessment Measure (UK FIM+FAM) and the Mayo-Portland Adaptability Inventory (MPAI-4)

ABSTRACTObjective: To compare the UK Functional Assessment Measure (UK FIM+FAM) and Mayo-Portland Adaptability Inventory (MPAI-4) as measures of functional change in patients with brain injury receiving a staged residential post-acute community-based rehabilitation programme. Research design: Longitudinal cohort study of consecutive admissions (N = 42) over 3 years.Methods: Patients were assessed at admission and discharge/annual review. We examined groups according to stage of independence on admission: Maximum support (stages 1 and 2: N = 17); moderate/maximum self-care/household support (stage 3: N = 15); minimal self-care and moderate household/community support (stages 4–6: N = 10).Results: Median (IQR) age: 50 (37–56) years. Male:female ratio: (71%:29%). Aetiology: stroke (50%), traumatic (36%) and other brain injuries (14%). Both tools demonstrated significant gains in overall scores and all subscales (p < 0.01). However, the UK FIM+FAM provides more detailed evaluation of personal activities of daily living and mobility, which were most relevant in clients admitted in graduation stages 1 and 2 of the programme, whereas the MPAI-4 was more sensitive to changes in adjustment and participation for clients admitted in the later stages (4–6).Conclusions: The UK FIM+FAM and MPAI-4 provide complementary evaluation across functional tasks ranging from self-care to participation. This study supports their use for longitudinal outcome evaluation in community residential rehabilitation services that take patients at different stages of recovery.

What motivates direct support providers to do the work they do?

Background Direct support providers (DSPs) in community residential services are often central figures in the lives of service recipients. There is little research to date focusing on what motivates these employees to remain in the field despite stressful work conditions.Methods An exploratory descriptive analysis of qualitative data obtained from semistructured interviews with 19 community residential DSPs in Ontario, Canada, was conducted. Data were analysed for modes of entry into the field and reasons for remaining.Results DSPs are motivated to remain in the sector because of the people supported, the nature of the work and the work environment, practical reasons like job security, and personal ambitions and reward. Most staff are motivated in multiple domains.Conclusion Future research can use these findings to further explore DSP work motivations and relationships to job performance and turnover. For researchers and human resource practitioners, adapting existing models and measures of organisational commitment may be a useful strategy for studying and utilising knowledge of DSP motivations.

Medicaid for Adults With Disabilities

You have accessThe ASHA LeaderBottom Line1 Nov 2011Medicaid for Adults With Disabilities Laurie Alban Havens, andMA, CCC-SLP Janey McCartyMEd, CCC-SLP Laurie Alban Havens Google Scholar More articles by this author , MA, CCC-SLP and Janey McCarty Google Scholar More articles by this author , MEd, CCC-SLP https://doi.org/10.1044/leader.BML1.16142011.3 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In http://www.asha.org/Publications/leader/2011/111122/Bottom-Line--Medicaid-for-Adults-With-Disabilities.htm Medicaid provides services for eligible children who have a developmental disability, covering services such as personal care, transportation, diagnostic evaluation, and intervention. They are provided under the Early and Periodic Screening and Diagnostic Treatment provision of the Social Security Act. However, when the individual turns 21 years old, those mandated services become optional. Because Medicaid is state-administered, these optional services vary from state to state. Coverage of speech-language and other services provided to Medicaid-eligible adults with developmental disabilities, therefore, depends on the policy of the client’s state (contact information is available at the Centers for Medicare and Medicaid’s website [PDF]). Some general information, however, applies to all Medicaid programs. Definition According to the U.S. Department of Health and Human Services, developmental disabilities are severe, life-long disabilities attributable to mental and/or physical impairments that manifest themselves before the age of 22 years and are likely to continue indefinitely. They result in substantial limitations in a number of areas, including receptive and expressive language, mobility, learning, and self-care. According to information from the Centers for Disease Control and Prevention, individuals with developmental disabilities (including Down syndrome and autism spectrum disorders) compose 13.87% of the U.S. population. Services Medicaid services available to adults with developmental disabilities might include a day habilitation program with training and supported employment; adult day care; or support services that may include nursing, behavior services, physical therapy, occupational therapy, speech-language pathology services, transportation, and crisis services. Service settings include individual homes, community residential sites, and day programs. Individuals may live in an intermediate care facility for persons with developmental disabilities, previously (and in some states still) called an intermediate care facility for persons with mental retardation. Home-based Services Medicaid rules can require people with disabilities to live in institutions to receive services. However, under the Social Security Act, states may request waivers of certain of these requirements to develop community-based alternatives to placing Medicaid-eligible individuals in hospitals, nursing facilities, or other institutions. States may develop a variety of services under a home- and community-based service (HCBS) waiver program. Many of the state waiver programs arose as a result of the Olmstead decision, in which the Supreme Court ruled that Title II of the Americans With Disabilities Act prohibits unnecessary institutionalization of persons with disabilities. Waivers allow services to be brought to recipients, rather than forcing them to be institutionalized. The number of services that can be provided is not limited. The programs may provide a combination of medical services, such as dental and skilled nursing services, and non-medical services, such as respite care and environmental modifications. Forty-eight states and the District of Columbia offer HCBS waiver services through 287 active programs. Arizona operates a similar program under a different section of the act. Maryland’s Waiver for Individuals with Developmental Disabilities, for example, covers case management services, community residential services, community supported living arrangements, respite care services, behavioral support services, and adult day habilitation including supported employment. Other states may offer services limited in duration and/or intensity to Medicaid-eligible adults with developmental disabilities. According to data compiled by the Kaiser Commission on Medicaid and the Uninsured in 2008, Medicaid services vary in coverage for speech-language pathology and audiology services: 35 states provide coverage at some level and 16 provide no coverage. In contrast, Kaiser data indicate that all states provide some level of home health care services. However, some states specifically exclude therapies in their home health coverage. For example, Alabama, Florida, Oklahoma, and the District of Columbia exclude speech-language pathology as a home health benefit. Some states (e.g., Georgia and Louisiana) require prior approval for therapy services, and many (e.g., Indiana and South Carolina) cap the number of therapy visits allowed per year. State Information Medicaid is a federally mandated program, but much of the design and implementation of the program is determined at the state level. Therefore, it is always necessary to check with the state Medicaid office to determine available services and eligibility. Despite budget cuts, funding options are still available for speech-language and audiology services. Author Notes director of private health plans and Medicaid advocacy, can be reached at [email protected]. private health plans advisor, can be reached at [email protected]. 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Residential Services for People With Intellectual or Developmental Disabilities at the 20th Anniversary of the Americans With Disabilities Act, the 10th Anniversary of Olmstead, and in the Year of Community Living

In June 2009, President Barack Obama launched the “Year of Community Living” for persons with disabilities (While House, 2009). The Year of Community Living was positioned to begin on the 10th anniversary of the Supreme Court's Olmstead decision (in June 1999) and to end on the 20th anniversary of the Americans With Disabilities Act (ADA; in July 1990). In doing so, the president committed his administration to enforcing the Supreme Court's recognition that the ADA established a right to receive needed services and support in the most integrated setting feasible and to work toward “maximizing the choices and opportunities for individuals to receive long-term services and supports in the community” (White House, 2009). As the Year of Community Living acknowledges the rights of individuals with intellectual and developmental disabilities to share in community life, it also brings attention to past progress to that end. To examine the progress of the nation and the individual states in overcoming the discrimination that the ADA, the Olmstead decision, and the Year of Community Living have recognized as inherent to institutionalization, we present data on the most recent 20-year period on people living in community and institutional residential settings for intellectual and developmental disabilities (defined here as places other than homes shared with family members in which people receive residential services and supports). That period, between June 1988 and June 2008, might well be called the “generation of community living,” as it brought greater net increases in community residential services and accompanying decreases in institutional services than any other 20-year period in U.S. history.Between 1988 and 2008, the number of people with intellectual and developmental disabilities living in residential settings with 6 or fewer residents increased from 78,173 to 321,025 (311%; see Table 1 and Figure 1). This growth was evident in every state, with every state but one reporting more than a 100% increase in persons living in settings of 6 or fewer residents. In June 1988, persons living in places of 6 or fewer residents made up 29% of all residents. In June 2008, they were 73% of all residents. Although data were not available for 1988, in the 1998 to 2008 decade, persons living in places of 3 or fewer residents increased by an estimated 76,437 people (60%), so that by June 2008 they made up about 47% of all residential services recipients with intellectual and developmental disabilities. The increase of residents in places of 6 or fewer residents was very similar between 1988 and 1998 (126,398) and between 1998 and 2008 (116,454). During this time, the number of people living in institutional settings of 16 or more residents decreased rapidly. There were 137,610 people with intellectual and developmental disabilities in institutional settings in June 1988. That number decreased to 89,349 in June 1998, a decrease of 48,261, and then to 59,312 in June 2008, a decrease of 30,037 institutionalized persons. The proportion of residential service recipients with intellectual and developmental disabilities living in facilities with 16 or more residents went from a majority (51%) in 1988 to 14% in 2008.The number of people with intellectual and developmental disabilities living in settings of 7 to 15 persons changed relatively little during the 1988 to 2008 period: 51,899 people in 1988; 54,474 people in 1998; and 56,529 people in 2008. However, because of overall growth in the number of residential service recipients, the proportion of all residential service recipients in settings of 7 to 15 people decreased from 19% in 1988 to 13% in 2008.The total number of people who received residential services increased from 267,682 in 1988 to 436,866 in 2008, a 57% increase. This compares with a total U.S. population growth of 26% during the period. The number of people receiving residential services grew by 80,711 persons (30%) between 1988 and 1998, from 267,682 to 348,393 persons, and by 88,473 persons (25%) between 1998 and 2008, from 348,393 to 436,866 persons.(Sources: Lakin, K.C., Larson, S.A., Salmi, P., &amp; Scott, N. (2009). Residential services for persons with developmental disabilities: Status and trends through 2008. Minneapolis: University of Minnesota, Research and Training Center on Community Living; White House (2009). President Obama commemorates anniversary of Olmstead (available from http://www.whitehouse.gov/the_press_office/President-Obama-Commemorates-Anniversary-of-Olmstead-and-Announces-New-Initiatives-to-Assist-Americans-with-Disabilities.)Preparation of this report was supported by a grant from the Administration on Developmental Disabilities (Grant 90D0217/01) of the U.S. Department of Health and Human Services and a cooperative agreement with supplemental support from the National Institute on Disabilities and Rehabilitation Research, U.S. Department of Education (Agreement H133B080005-09).

Changes in the Number of People With Intellectual and Developmental Disabilities Living in U.S. Nursing Facilities Between 1988 and 2007

Changes in the Number of People With Intellectual and Developmental Disabilities Living in U.S. Nursing Facilities Between 1988 and 2007

Deinstitutionalization in Two States: The Impact of Advocacy, Policy, and other Social Forces on Services for People with Developmental Disabilities

This paper presents a comparative case study of diverse approaches to deinstitutionalization of developmental disabilities residential services in two Midwestern states. During the 1970s and 1980s, the convergence of leadership by advocates, legislators, and bureaucrats led to Michigan's rapid transformation from an institutional to a community-based system, which was further facilitated by a political culture open to innovation. In contrast, during the same period in Illinois, fragmented leadership by advocates of community services, and the power held by unions, parents of institutionalized children, and private service providers worked for retention of institutions and against development of community residential services. Illinois' political culture, state governmental structure and bureaucracy also actively impeded innovation and further hindered the development of community homes. Implications for today's advocates are drawn from a comparative historical review.

Trust and managerialism: exploring discourses of care

This paper reports a study that explored the relationship between trust and managerialism through an analysis of professional discourse. Managerialism is a distinct set of discourses and practices related to managerial effectiveness, flexibility and consumer responsiveness that have come to characterize debates over the provision of health and welfare services across the developed world. At the same time, trust has attracted increasing academic and political interest. Managerial discourses are critical of healthcare professions and the way they operate. Professional opinions are challenged as representing the interests of professions rather than service users; as a consequence trust is contested. However, where practitioners are both professionals and managers, the boundaries between these discourses become blurred. Moreover, paradoxical development occurs where increasing autonomy for practitioners is accompanied by a strengthening of managerial controls over their activity. Discourse analysis was used to explore the text from two genres, academic literature and interviews (n = 17), in the context of community residential services for people with learning disabilities. The study was conducted in 2001. Two broad themes were identified, each with a number of sub-themes. The first focuses on the relationship between managerialism and trust located around the management of expectations. The second, 'the politics of care', explores the way professional and managerial discourse articulate to produce complementary and contradictory positions. The colonization of professional activity by managerial discourse has produced a context where professional activity is defined by a series of managerial imperatives; trust, which was once the product of intimate social activity is now shaped through techniques based on distrust such as audits and quality monitoring. Nevertheless, the persistence of tensions between trust and managerialism suggest an ongoing struggle for professional autonomy in the face of increasing managerial controls.

Impersonal trust and professional authority: exploring the dynamics

The aim of the study was to explore the relationship between impersonal trust, governmentality and professional activity through an analysis of professional discourse. This study emerged from an earlier paper that described a four-dimensional model based on Luhmann's definition of trust as "reducing complexity and managing expectations". Linking trust with the Foucauldian notion of governmentality develops this further. Governmentality raises the question of how professional authority is constituted through the practice of nurses and other health and welfare professionals. Discourse analysis was used to explore the text from two genres--academic literature and interview material (n = 17)--in the context of community residential services for people with learning disabilities. Findings. The study provided evidence to support claims that trust is produced through impersonal systems. Trust is contested in a dynamic process where there are gains and losses. Professionals in organisations actively promote trust, often through systems of distrust. The study also built on the four-dimensional model of impersonal trust--trust, mistrust, abuse and hope--and re-conceptualized the trust-hope dimension. There are theoretical links between governmentality and trust. Similarly, in order to understand trust nurses need to understand the dynamic nature of the systems in which they operate. The proposition that trust could frustrate hope adds an element of controversy to the discussion of hope in the nursing literature.

Parents Cede Custody in Futile Attempt to Obtain MH Care

Parents Cede Custody in Futile Attempt to Obtain MH Care

Living with support in a home in the community: predictors of behavioral development and household and community activity.

The purpose of this article was to review studies of behavioral development and household and community activity among adults with mental retardation living in community residential services and to distill knowledge about the factors that influence outcome. Research points to behavioral development occurring across the full spectrum of disability but influenced by mental retardation syndrome and the acquisition of pivotal skills. However, engagement in household and community activities has been found to be strongly related to individual adaptive behavior. People with more severe mental retardation are vulnerable to leading lives characterized by underoccupation and lack of community involvement. Moving from institutional to community-based residential services may be accompanied by significant increases in adaptive behavior, but a plateau effect on subsequent development has also been reported. There is substantial evidence to suggest that key aspects of effective teaching technology may be absent in community-based residential environments. Community settings support greater engagement in household and community activities than institutions. Ordinary housing stock and normative architecture and standards of material enrichment are to be preferred. The use of normative housing constrains group living to relatively small scale, but there is little evidence that smaller size within this range is to be preferred to larger size. There is little evidence to suggest that higher staff-to-resident ratios lead to uniformly better outcomes, but staff orientation, working methods, and performance are important influences. Little is known about what precise characteristics of community location give rise to greater community integration. MRDD Research Reviews 7:75-83, 2001.

Challenging behaviour in community services

The implementation of community care in the UK has led to the requirement that services should be able to meet the needs of adults with intellectual disability (ID) and additional needs in terms of challenging behaviour. However, the extent to which people with challenging behaviour are present in the community and the extent to which community services can support them effectively still requires significant research. The present study examines the prevalence of challenging behaviour amongst adults with ID residing in three London boroughs and the issues which arise from service delivery to this client group. All service providers and general practitioners in the area were contacted and asked to identify any individuals with ID and challenging behaviour. All responses were screened, and then key staff were interviewed for information on a range of demographic factors and on the Checklist of Challenging Behaviour. The reliability of the instrument was also assessed. Four hundred and forty-eight individuals were identified from a total borough population of 670 000. There was consistency in the types of behaviour which were frequently identified across the three boroughs. There were significant levels of self-injury as well as a range of behaviours of the 'hard to engage' type. Most individuals had more then one challenging behaviour and some individuals with seriously aggressive behaviour used local community services. Twenty-five per cent of the sample lived at home with their families and 50% were in community residential services. The boroughs differed in their ability to manage those with challenging behaviour in that one borough had many more people placed out-of-borough. Significant numbers of individuals with challenging behaviour were living in the community. The range and number of behaviours suggest that staff need to be very skilled in supporting such individuals, and that effective planning and support are essential if people with challenging behaviour are to be maintained in community settings.

Stress and residential staff who work with people who have an intellectual disability: a factor analytic study.

The present study describes the development of a questionnaire, and the subsequent collection of data, to gather information on the demands and supports which influence stress (as measured by anxiety and depression scales) in direct care staff who work with people with intellectual disability. The results from the questionnaire were also used to explore the relationships between the factors derived from the questionnaire and to consider how these may be influential in building organizational models. The questionnaire was specifically constructed to measure the demands and supports experienced by direct care staff. The participants included 216 staff working in community residential services for people with intellectual disability. These individuals included staff working for two British health trusts and similar staff working for one local authority. The questionnaire consisted of 33 demands items and 23 supports items. Separate factor analyses were conducted on the demands and supports scales. Analyses of the reliability and validity of the resulting factors were conducted. Stepwise multiple regressions were conducted to further explore the relationship of factors with the measures of anxiety and depression. Four factors were extracted from the demands scale and three factors from the support scale. There was some concern over levels of reliability and validity for individual factors; however, the reliability of the main scales appeared to be satisfactory. All but one support factor correlated significantly with levels of anxiety and depression. The factors explained a modest amount of the variance in the regressions. While there are some concerns about the psychometric properties of the questionnaire, it is argued that the scales and factors can be used to confirm and further understanding of the relationship between groups of demands, supports and stress in staff. The usefulness of the questionnaire as a means of diagnosing specific sources of demand and support is considered. It is suggested that the questionnaire could form the basis for assessment and subsequent intervention in houses where staff are reporting relatively high levels of anxiety and depression.

Community residential services would require expansion of 72% to serve everyone in community settings.

Community residential services would require expansion of 72% to serve everyone in community settings.

Bringing staff on board: creating an outcomes project tied to continuous quality improvement in an adult community residential service

This article describes the establishment of the ServiceNet, Inc. Residential Division Outcomes Project. Combining the need to respond to the emerging managed care funding environment and the commitment to having direct care staff engage in activities aimed at continuous quality improvement, the ServiceNet, Inc. Residential Division initiated a model for assessing the outcomes of the clinical curriculum. The article describes an outcomes model designed to bring the staff of a community mental health program into the measurement process. It describes how an outcomes program helped staff enhance the treatment they provide by improving quality of care.

Mental Health and Challenging Behaviour Services

Changes have occurred in the pattern of services for people with learning disabilities and mental illness and/or challenging behaviour over recent years, with the development of a variety of service models across the UK. In SE London, residential services are based predominantly on a supported housing model and the strong philosophical premise that people should not be excluded from a community residential service because they have complex physical, behavioural or mental health needs. Local services, therefore, are supporting individuals with a wide range of need. This paper describes the development of specialist mental health and challenging needs services in support of this model. The issues raised are outlined, together with a list for action and priorities to overcome the difficulties encountered, including the maintenance of an effective infrastructure.

Natural therapeutic holding: a non-aversive alternative to the use of control and restraint in the management of violence for people with learning disabilities.

For at least the last 10 years, control and restraint (C&R) has gained increased popularity amongst nurses as a safe, professional and legal means to manage violence in health care settings. However, during this period there has been an increased momentum to find non-aversive management strategies for people with learning disabilities and there has been frequent debate on the abolition of practices which do not achieve this. More recently, the main criticisms of C&R have been the professional and ethical objections that the techniques used inflict some degree of pain or discomfort to the client, and the fact that it remains a reactive strategy with no theoretical framework for professional practice. On this basis, alternatives should be sought which seek to address these issues. This paper outlines the development of natural therapeutic holding, an approach which is non-aversive and which provides a theoretical structure for professionals to base their practice on in order to develop clear therapeutic goals for the client. Initial findings within a small community residential service for people with learning disabilities indicate that natural therapeutic holding was a preferred method of intervention strategy by staff, proving as effective as C&R in the management of violent incidents, with interventions being much shorter in duration and non-aversive in nature.