Valuing People with a Learning Disability

Kate

Water torture

A woman with a learning disability who lived in supported care had been forced out of bed following a verbal confrontation with her support staff. This confrontation escalated to the point at which the staff restrained her in an illegal manner. This woman was then forced into the shower fully clothed, after which she was made to stand outside, where the temperature was near to freezing. She lay on the floor shivering uncontrollably. When she was allowed inside, she appeared to be in the early stages of hypothermia.

(BBC 3)

This incident was reported in 2011 on a Panorama programme entitled ‘Undercover Care: The Abuse Exposed’, broadcast on 31 May 2011. The woman involved had allegedly been subjected to assault and mistreatment.

This book asks the question, ‘What do we mean by valuing people with a learning disability?’ The ‘Water torture’ story appears to be a clear example of de-valuing people with a learning disability. It is probably safe to assume that, for most people, ‘valuing’ means the exact opposite to the behaviour described in this story. The programme narrative suggested that one particular man was the instigator and perpetrator of this mistreatment. Other members of the support staff were described as being scared of him and were reported to have gone along with what was happening. It would be possible to see this as just one example of mistreatment, which in no way reflects the standards within that service or the wider life experience of people with learning disabilities. This incident could be seen as an anomaly (or one-off incident) arising from the actions of one rogue member of the ‘care’ staff.

Castlebeck is the service provider at the centre of this exposé and their website contains a clear statement about the service they intend to provide:

The aim is to enable people to define and achieve the kind of life and relationships that work for them with the outcome being the quality of life for that individual…

Their website also has statements about the support plans they offer:

Person-centred plans help us discover and encourage the individual’s wants, wishes, dreams, ambitions and so on and make sure that ‘clinical’ plans don’t take up his or her whole time. Person-centred plans address the need for us to listen to people and their expectations and make sure we also monitor their progress in terms of quality of life.

We aim to focus on what progress means for the individual and will produce a plan that states exactly how we will support each person, the standards and outcomes to be achieved and who will deliver each aspect of the plan. This will also identify the resources we need to provide for each person’s needs.

These statements probably describe what most of us involved with services to people with a learning disability would recognise as clear intentions to ‘value’ those with a learning disability. Yet in the ‘Water torture’ story above, there is a huge gulf between stated intentions and the alleged reality. At one end of a ‘valuing’ spectrum, there is the intention to listen and work towards an individual’s dreams. At the other end of the spectrum, we have allegations of systematic abuse and even torture. What has happened here?

Was the abuse described in the Panorama programme an anomaly? Or was it an example of something altogether darker and more pervasive? It certainly did not appear to be an example of things getting temporarily out of hand, as the programme reported systematic abuse over a long period at this home. It told a story of the staff team apparently colluding in this mistreatment, of managers being reported as ‘turning a blind eye’, of the care organisation responsible allegedly ignoring a whistleblower, of the inspectors evidently finding nothing wrong (despite also apparently being contacted by the whistleblower), and of the devastated parents of the victim stating on the programme that they had not believed her when she told them of her mistreatment. It appears that the individual said to have instigated this mistreatment was not the only one who devalued this woman. Perhaps the other staff, the managers, the care organisation, the commissioners, the inspectors and her carers could all be viewed as ‘guilty’.

We might also question the attitudes of policy makers who are at present cutting public resources for disabled people, and then we might ask about all the people who voted in a government with a mandate to make these cuts. The list of ‘culprits’ is damning and wide-ranging. It includes ‘care’ staff, parents, the ‘care’ organisation, the inspectorate, the electorate and the government. This specific abuse took place in a wider context, which allowed it to continue. At an individual level, those of us who are practitioners can probably all recall times when we ‘turned a blind eye’ to sub-standard treatment – albeit far less abusive than that reported in the ‘Water torture’ example. How might we have appeared if there had been undercover filming of those things to which we turned a blind eye?

A report from the Equality and Human Rights Commission (EHRC 2011, p. 26) indicates that abuse of people with disabilities is widespread and not confined to supported living:

In March 2002, a 30-year-old woman with learning disabilities was admitted to Borders General Hospital in Scotland with multiple injuries as a result of sustained physical and sexual assaults. The abuse had been carried out at home and was perpetrated by three men, one of whom was her carer. The woman had made allegations against one of the perpetrators as a child but agencies decided her mother could protect her. When her mother died, he was allowed to become her carer, making her sleep on a carpet in the hall at his home. He began taking the woman’s benefit money, deprived her of food and liquid and made her sit in the dark for long periods. Together with two friends he forced her to strip, shaved her head, sexually assaulted her and repeatedly stamped on her face and body. They also threw the woman over a fence, handcuffed her to a door and set fire to her clothing.

Added to the list of ‘culprits’ we now have support agencies that apparently allowed this woman to be ‘cared for’ by someone she had already made allegations against.

Not all abuse is as shocking as that described in the vignettes above. Here is an example that some readers may recognise as a fairly typical encounter.

Behave

An adult with a learning disability wanted to go to the shops to buy a DVD. He needed staff support to negotiate traffic safely. He had been promised that he could do this activity the day before but it had not happened. As he feared being let down again, he asked the support staff several times whether he would be able to get the DVD after lunch. The staff replied, ‘If you don’t stop fussing you won’t be going at all, so behave.’

This is clearly not severe abuse but it is still abuse. The Equality and Human Rights Commission report (EHRC 2011, p. 5) made the following point:

The really serious cases catch the headlines. But what about the constant drip, drip, nag, nag of the so-called ‘low-level’ harassment that many disabled people face on a daily basis? It ruins their lives. They don’t have the confidence to go out. It undermines their ability to be part of society. It makes them behave differently.

The man in ‘Behave’ had the right to visit his local town to buy a DVD. The staff member assumed an authority he did not actually have, to deny him that right. In this particular case, there was no apparent misdemeanour. The staff member was abusing power on a whim.

The same report (EHRC 2011, p. 163) goes on to describe systematic and widespread abuse and harassment of many people with a disability. It concludes:

Our inquiry learnt much from both its investigation into 10 cases and the evidence that disability-related harassment is a widespread problem which has a significant impact on the day-to-day lives of disabled people. We found that the extent of harassment remains largely hidden, its seriousness rarely acknowledged, its link to the victim’s disability not investigated…

The same thing is happening in all these stories and the Equality and Human Rights Commission report suggests it is widespread. Through several layers of society, from government through local organisations to individuals, there has been a collective ‘devaluing’. At best it illustrates casual and unconscious disregard, but at worst we can see callous, conscious, systematic and sustained abuse. It would appear that the woman in ‘Water torture’ was not valued at any level. Yet these events all took place in a world in which the ‘mission statement’ from the service provider and government policy quite clearly defined what they consider to be ‘valuing’ treatment of people with a learning disability.

Several recent reports have highlighted similar issues.

• A joint investigation into the provision of services for people with learning disabilities at Cornwall Partnership NHS Trust (Healthcare Commission 2006, p. 5) highlighted abuse in care services in Cornwall and concluded:

Some individuals, as the trust has acknowledged, have suffered abuse including physical, emotional and environmental abuse. The trust’s own investigations at Budock Hospital have shown that some people using its services have had to endure years of abusive practices and some have suffered real injury as a result.

• An investigation into the service for people with learning disabilities provided by Sutton and Merton Primary Care Trust (Healthcare Commission 2007, p. 3) commented:

The investigation team examined 15 serious incidents that occurred in the learning disability service between December 2002 and November 2005. These were incidents of sexual and physical abuse including one incident when a woman with learning disabilities was raped.

• ‘Death By Indifference’ (Mencap 2007, p. 5) reported on the way people with a learning disability are often excluded from access to healthcare, quoting Allan (the father of Mark, who died in August 2003 of bronchopneumonia):

We believe that Mark died unnecessarily. Throughout his life, we encountered medical professionals who had no idea how to deal with people with a learning disability or what it is like to be a parent of someone with a learning disability – to know their suffering, to see their distress. If only they would listen...

• An independent inquiry (DOH 2008, p. 18), known as ‘The Michaels Report’, looked into the lack of healthcare for people with a learning disability and described the following example:

I work with a client with learning disabilities who has a cataract and challenging behaviour. The GP refuses to treat on the basis that ‘He can see out of his other eye’.

The examples discussed so far are relatively recent cases of significant devaluing of people with a learning disability. However, there is a long history of similar shocking exposés of abuse. Many of these cases have resulted in reports that have gone on to underpin policy change. For example, in the 1960s the conditions in long-stay hospitals for people with a learning disability were brought to public attention by a series of press reports of serious mistreatment. The News of the World exposed conditions in Ely Hospital in Wales in 1968. The Ely Report led to the Howe Report (1969), which in turn led to the White Paper ‘Better Services for the Mentally Handicapped’ (DHSS 1971).

The Seebohm Report (Home Office 1968) had led to the setting up of locally controlled, politically accountable social services. The building of the new hostels was based on the guidelines contained within ‘Local Authority Building Note no. 2’ (DHSS 1973). In 1974 the Secretary of State, Barbara Castle, set up the National Development Group and the National Development Team. She also commissioned the Jay Committee Report (1979), which suggested that hospital care was inappropriate for most people with a learning disability. In 1971 the Campaign for the Mentally Handicapped (CMH) was established to campaign for the rights of people with a learning disability in general and the closure of the long-stay hospitals in particular.

What do we mean by ‘valuing’?

The discussion so far has largely focused on the abuse that people with a learning disability frequently experience. In other words, the focus has been on de-valuing. There are problems in using words such as ‘valuing’ and ‘devaluing’ to aid understanding of the day-today experiences of people with a learning disability. These terms are in common currency in the world of learning disability. Of course the term ‘valuing’ appears in the titles of the most significant recent government directives, ‘Valuing People’ (DOH 2001) and ‘Valuing People Now’ (DOH 2009).

The word ‘value’ actually has two main meanings:

1. ‘To assess or estimate the worth, merit or desirability of…’

2. ‘To have a high regard for, especially in respect of worth, usefulness, merit etc.’ (Collins 1994).

The first definition is a verb and implies neither negative nor positive outcome. In other words, a consequence of ‘assessing or estimating the worth’ of something could be to ascribe either negative or positive value. In this sense of the word it would be possible, for example, to ‘value’ a person and come to the conclusion that they were worthless. The second dictionary definition is closer to what is probably intended when the word is used in learning disability services: ‘to have high regard for.’ However, simply to ‘have high regard’ is a passive state, in which one has already decided the worth of something. It will therefore be argued later in this book that the first definition offers an important consideration. To ‘assess or estimate’ suggests an active state in which one uses mental effort to reach a conclusion. The cognitive processes by which one reaches a conclusion underpin Chapters 4 to 6, and the external forces that impact on these processes are considered in Chapters 7 to 9.

‘Valuing People Now’ (DOH 2009, p. 10) sets out a vision for the life experiences deemed most desirable for people with a learning disability:

The vision remains as set out in Valuing People in 2001: that all people with a learning disability are people first with the right to lead their lives like any others, with the same opportunities and responsibilities, and to be treated with the same dignity and respect. They and their families and carers are entitled to the same aspirations and life chances as other citizens.

This appears to be a reasonable definition of valuing people with a learning disability, and most people who work in services supporting people with a learning disability would probably agree with it. Many would probably see the ideas expressed in this statement as the very basis of their job, possibly even the axiomatic basis of all services.

Any self-respecting support service for people with a learning disability will claim that it ‘values’ the people it supports, and many mission statements will make that claim explicit. A recent publication includes a chapter entitled ‘Values Based Support’ (Richardson 2011). This publication (Atherton & Crickmore 2011) includes a section entitled ‘Implementing Values Based Support’, which comprises seven chapters.

In everyday discourse in support services certain abstract words become reified – to reify is ‘to consider an abstract idea or concept real or concrete’ (Collins 1994). Terms such as ‘community’, ‘care’, ‘empowerment’, ‘choice’ and ‘valuing’ are taken out of common language and given assumed concrete meanings. These terms are all considered desirable aims at present and so services (itself a reified term) will describe what they do as being ‘valuing’. The following quotation from the ‘Valuing People’ White Paper (DOH 2001, p. 1) makes a link between ‘valuing’ and ‘doing’:

What’s also a real cause for concern and anxiety is that many parents of learning disabled children face difficulties in finding the right care, health services, education and leisure opportunities for their sons and daughters. At best, they can feel obstacles are constantly put in their way by society. At worst, they can feel abandoned by the rest of us.

We have to change this situation if we are to achieve our goal of a modern society in which everyone is valued and has the chance to play their full part.

Richardson (2011, p. 57) suggests that dignity is ‘the fundamental value from which all other values follow’. He considers it essential that services to people with a learning disability should be values based. It could, however, be argued that all services are ‘values based’, whether or nor not they are predicated on dignity. Using the first dictionary definition outlined on p. 5 (‘to assess or estimate the worth, merit or desirability of…’), it can be seen that it is possible to value people with a learning disability in a negative way, to come to the conclusion that they are worthless. A ‘service’ based on this value would still be ‘values based’, and this is more than a pedantic point. ‘Values based’ is sometimes seen as the opposite to, for example, ‘based on financial concerns’. However, ‘financial concerns’ can also be seen as ‘values based’. ‘Valuing People’ (DOH 2001, p. 1) makes an interesting reference to ensuring ‘value for money from public investment in learning disability services’.

We could argue that ‘value for money’ is equally a value. We might argue that this is a ‘morally lower’ value than ‘dignity’ but it is a value nonetheless. Indeed, some neo-conservatives might argue that it is a higher value. Taking this idea of ‘value’ as ‘value for money’ one step further, we might argue that the following example is also a ‘values led service’, however abhorrent that ‘value’.

Nazi nurse

In Nazi Germany it was legal to end the life of a person with a learning disability. One nurse described (Ebbinghaus 1987, p. 239, cited in Benedict & Kuhla 1999) how she actively administered a lethal dose of the drug used to take life:

When giving the dissolved medicine, I proceeded with a lot of compassion. I had told patients that they would have to take a cure. Of course I could tell these fairy tales only to those patients who were still in their right minds to the extent that they could understand it. I took them lovingly and stroked them when I gave the medicine. If, for example, a patient did not empty the entire cup because it was too bitter, I talked to her nicely, telling her that she had already drunk so much that she should drink the rest, otherwise her cure couldn’t be finished. Some could be convinced to empty the cup completely… They were not to be tortured more than necessary…

In Nazi Germany, decisions on whether people’s existence could be justified were based upon their productivity or past service to the nation. The nurse in this vignette was administering a lethal dose of medication to those deemed unworthy of life because of their negative impact on the economy. The ‘value’ upon which this practice was based is an extension of the economic notion of ‘value for money’.

As described above, ‘Valuing People’ (DOH 2001) suggests that ‘valuing’ can be effectively demonstrated by actions, particularly the actions of giving people access to resources and removing obstacles. The following vignette suggests a separation between ‘thinking’ and ‘doing’ in valuing.

Hidden feelings

A learning disability nurse supports a man who is sectioned under the Mental Health Act. He has been convicted of sexual crimes against very small children. The nurse feels revulsion at this man’s crimes and finds it very difficult to work with him in a non-judgemental way. In unguarded moments she thinks of him as a ‘monster’. However, she has worked hard to put her feelings to the back of her mind and offer a ‘professional’ front to this man. She believes that she is good at this and the man considers her to be a friend.

This man’s offences disgust the nurse but her actions are positive. This nurse appears to devalue the man in her thoughts but value him in her action. Does she therefore ‘value’ this man or not?

A further problem is that we can think more than one thing at once.

The cleaner (1)

A lecturer visited a student nurse on placement at a day centre. They found a quiet room in order to discuss the placement in private. A woman dressed in an overall and carrying polish and duster entered the room and started cleaning with her back to them. The lecturer felt frustrated at the disturbance to the meeting but thought that they were in the way. He apologised and said they would move so that the cleaner could get on. The woman turned to the lecturer and he then realised she had a learning disability. His instant feeling was one of, ‘It doesn’t matter, as she is not a real cleaner’. He was able to over-ride this initial feeling and he and the student excused themselves and left her to do her work. The lecturer later discovered that the woman was employed by Social Services to do the cleaning.

The lecturer had an immediate thought that the woman was not a ‘real cleaner’ and so could be seen to be devaluing her. However, he then realised what he had thought. In a conscious re-appraisal, he became aware that he had initially devalued her but was able (he hoped) to adjust his behaviour and ‘value’ her by leaving her to get on with the task. Within a very short space of time, perhaps one second, the lecturer had experienced a devaluing thought and then one that was more valuing. We might ask which was the ‘truest’ measure of the extent to which he valued the woman with a learning disability.

Another nurse who worked with a sex offender also had two very different thoughts about him, as described in the next story.

Revulsion

A nursing manager worked with a man detained under the Mental Health Act. The man’s offences were against children and were sexual in nature. The manager said that her staff showed a positive attitude to this man, seeming to like him as a person. He sometimes punched and kicked staff if told he could not walk past the local school (a requirement of his detention under the Mental Health Act). Despite such attacks, the staff remained positive towards him. This manager shared the team view and was very fond of the man. However, she said that if she thought of this man when she was at home with her young children she felt a sense of revulsion and anger towards him. She never felt this at work.

In this case, the nurse experienced valuing and devaluing thoughts about the same person according to where she was and, significantly, what role she was fulfilling. As a nurse, she believed that she valued the man, but at times when she was performing the role of a mother she very strongly devalued him. Again, we might ask whether this nurse values the man and which is the truer measure of her feelings?

The following story came from a care-planning meeting for a man with a learning disability. Those of you who work in services supporting people with a learning disability have probably had similar discussions.

The pie man

A man with a learning disability lives in supported accommodation. He loves chips and pies and hates vegetables, fruit and salad. He is gaining weight and his GP has advised that his health is at significant risk. He dislikes low-fat alternatives and is very clear about what he wants to eat. He is able to tell you that if he continues eating this food he will ‘have a heart attack’.

This man needs staff to support him when shopping, as he cannot manage his money. If the staff put pressure on him to buy healthy options he will reluctantly agree, as he has learnt that a good way to keep out of trouble is to agree with staff. However, once home, he will become distressed at mealtimes.

This is a story of everyday practice. It describes a typical decision that might be made in care planning for someone with a learning disability. Among other things,