This material was presented in the 25th European Congress of Psychiatry which was organised by the European Psychiatry Association in Florence, Italy from 1-4th April 2017. I had access to the material as I attended the full Congress. Please note that this material remains the intellectual property of the European Psychiatry Association and its authors and any citation should include a full reference to it. For more information on the EPA and how to become a member, please visit: http://www.europsy.net/

1. Can Positive Community Practice
Models Help Prevent Abuse?
European Psychiatric Association Symposium:
Psychiatric Care in Europe for People with
Intellectual Disabilities: How to Prevent Abusive
Practices

2. Can Positive Community Practice
Models Help Prevent Abuse?
Dr Ian Hall
Consultant Psychiatrist and Lead Clinician, East London NHS Foundation Trust
Associate Dean, Royal College of Psychiatrists
Dr Niall O’Kane
Specialty Registrar in Psychiatry of Intellectual Disability, Camden and Islington
NHS Foundation Trust

3. Overview
• Historical background
• Abuse in institutions
• Community service models
• Abuse in community settings
– Case examples
• Preventing abuse in the community
• Concluding points

4. Historical background
• Learning disability services can be seen in
terms of three periods
– Rise of institutions
– Fall of institutions
– Balancing of community services, residential care
and inpatient services

5. Historical background

6. Historical background

10. Types of abuse reported in Community
Settings
• Physical abuse
– Restrictive practices
• Financial exploitation
• Sexual abuse
• Neglect

11. Paternalism v Autonomy
What is abuse?

12. Deprivation of Liberty
• Deprivation of Liberty can only be lawful if
there is a proper procedure in law
• Daniel was deprived of his liberty in a care
home using the DOLS procedures under the
English Mental Capacity Act
• An independent expert found he did have
capacity to decide residence and care

13. Staying indoors
• Jason is 18 and has a severe learning disability
and autism.
• He has not attended school for the last 2 years,
after one day the bus took a different route.
Now he doesn’t go out of the house.
• His family employ 2 workers though direct
payments who are family friends
• Psychology have been asked to help but the 2
workers are not engaging in the PBS plan

14. A wife’s duty?
• Amina got married to Foaz a few years go, after
their parents introduced them. She has three
young children
• Foaz helps Amina with looking after the children
and manages the family’s bills. She often asks his
advice and support.
• Foaz likes to have sex with her a couple of times
a week. Amina doesn’t really like this but goes
along with it as Foaz is good in other ways

15. Challenging behaviour
• Kwame, a 19 year old man with a severe
learning disability and autism, is presenting
with increasing challenging behaviour over the
past few months. He has been destroying
furniture, repeatedly flushing the toilet, and
pulling light fittings off the wall.
• You see him with one of his care workers who
asks you to prescribe him risperidone

18. Admitted to Hospital

20. Why did Martin die?

24. How can we prevent abuse?

25. How can we prevent abuse?
• Safeguarding procedures
• Legislation
– Criminal
– Civil/mental capacity
• Integrated working
– Health and social services
• Maximising communication
• Promoting access to health

26. How can we prevent abuse?
• Personalised services
• Positive Behavioural Support
• Teaching and training
• Advocacy
• Regular review
• Implementing clinical guidelines
• Positive risk taking

27. How can we prevent abuse?
• Open culture: duty of candour and
whistleblowing
• More effective inspection of services (by
councils/ID services/independent regulators)
• Ensuring more local community based
services

29. Can Positive Community Practice
Models Help Prevent Abuse?

31. Can Positive Community Practice
Models Help Prevent Abuse?
• Community based services have improved the
lives of people with intellectual disability
• Need to balance individual's rights with
protecting from harm
• Identifying abuse: systemic and cultural issues
• Prevention of abuse requires a broader and
more evidence-based response

32. References and further information
Building the right support: A national plan to develop community services and
close inpatient facilities for people with a learning disability and/or autism
who display behaviour that challenges, including those with a mental
health condition; ADASS & NHS England, October 2015. Available at:
https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-
plan-oct15.pdf. Last accessed 26 March 2017
Department of Health (DoH) (2008) Michael J. Healthcare for All – Report of
the independent Inquiry into Access to Healthcare for people with
Intellectual Disabilities, July, HMSO, London.
MENCAP (2007), Death by Indifference, MENCAP, London, available at:
www.mencap.org.uk/campaigns/take-action
Marsland D., Oakes P., Bright N. (2015). It can still happen here: systemic risk
factors that may contribute to the continued abuse of people with
intellectual disabilities TIZARD LEARNING DISABILITY REVIEW j VOL. 20 NO.
3 pp. 134-146, Emerald Group Publishing Limited

33. References and further information
Marsland D., Oakes P., Bright N. (2015). It can still happen here: systemic risk
factors that may contribute to the continued abuse of people with
intellectual disabilities TIZARD LEARNING DISABILITY REVIEW j VOL. 20 NO.
3 pp. 134-146, Emerald Group Publishing Limited
National Institute for Health and Care Excellence. Challenging behaviour and
learning disabilities: prevention and interventions for people with learning
disabilities whose behaviour challenges. NICE, 2015
National Institute for Health and Care Excellence. NG54 Mental health
problems in people with learning disabilities: prevention, assessment and
management. NICE 2016
Sheehan, R., Hassiotis, A., Walters, K., Osborn, D., Strydom, A., & Horsfall, L.
(2015). Mental illness, challenging behaviour, and psychotropic drug
prescribing in people with intellectual disability: UK population based
cohort study. BMJ, 351, h4326