Richard

Richard, an autistic 36-year-old, had lived in six different placements by the time he was in his late teens. From a special school to a residential service for young people and a special unit, all these placements had broken down.

At his last of these placements, Richard was restrained 180 times in a year. The 24 hour three-to-one staff support designed to protect him had become a trigger for his aggression. Overwhelmed by the constant staff presence, Richard bit, kicked and punched others, self-harming by hitting himself or headbanging the wall.

Richard needed a new approach, one that offered him control over his life and a quieter physical environment in which he could thrive. In 2003 his social worker contacted a support provider and asked if they could help. The provider:

• assessed Richard’s needs
• allocated a manager to work with him, his family and other professionals
• developed a plan to enable Richard to move into a home of his own.

Clinical staff involved with Richard were unconvinced that the provider could manage him in the community and were reluctant to discharge him. The provider worked with clinical staff and Richard’s family to develop trust, knowing that it had to demonstrate quickly that the proposed community support would work.

From the start the provider employed a Positive Behaviour Support approach. This involved examining Richard’s background and noting when his outbursts of aggression occurred. With this knowledge they created an environment to suit Richard and recruited support staff that matched his interests. A Positive Behaviour Support lead trained and coached Richard’s new team, and helped develop a bespoke support plan.

For example, this approach revealed that too much choice disturbed Richard because routine and ritual helped him feel secure. However, that was not to say that he needed a strict regime to function. Rather, that he required a flexible framework that he felt comfortable with. In response the provider introduced meal choices and activity planners. These involved presenting Richard with visual cues, such as examples of types of food and pictures illustrating activities. This enabled Richard to make choices without anxiety.

Seventeen years ago, Richard moved to his own home near his parents in the north of England. Initially he had three-to-one support 24 hours a day. This was delivered on the principle that only one member of staff worked with Richard at a time, to minimise sensory overload.

Integral to the success of the service was breaking the incident/restraint/incident cycle that had come to dominate Richard’s life. The provider recognised that Richard saw restraint as punishment, making him resist further. To break the cycle, the provider decided to halt restraint, even when it seemed risky to do so. Instead, if Richard’s behaviour escalated staff began using non-aversive techniques like reading aloud from his favourite book, from another room, if they sensed he needed space.

The risk paid off. Within a year of moving in Richard was no longer restrained, needed only two-to-one support, and his annual support costs fell from £350,000 to £250,000.

Since that first move in 2003, Richard has moved twice more – on both occasions at his own instigation. He now lives a few miles from his family, who he sees regularly. He continues to be supported by the same provider.

Once considered too high risk to use a public gym, Richard is now a regular at his local pool, sports centre and cinema. He likes cooking and, with minimal support, plans and prepares meals like spaghetti bolognese or a roast dinner. Richard has developed a love of music and is learning the piano. In a landmark moment two years ago, he played a lullaby for a 60-strong audience at a talent show organised by his support provider. Richard is planning a trip to Disneyland, Paris. He has been on a flight simulator to get used to the idea of flying. Planning for the future is, Richard’s parents say, just one example of how he has "regained his life".