In a previous post, we looked at why it is important for service providers to implement strategies that are aimed at reducing the use of restrictive practices.
One of the interventions identified was physical restraint. Physical restraint is the application of physical force to overcome an individual to enable the person applying the restraint to impose their will over the individual being restrained.
Physical restraint is particularly problematic when considered within the context of promoting therapeutic relationships and improving the wellbeing and quality of life of the individual being supported. Amongst other things it can result in physical injury, emotional distress, damage to relationships and be re-traumatising; evoking feelings of shame and despair. It also runs contrary to ethical, human rights-based approaches to supporting vulnerable adults and children. It’s imperative therefore that services identify and employ evidence-based strategies that are designed to reduce the frequency and duration of physical restraint (episodic severity, will be looked at in a separate paper). One such approach involves changing the criteria for release from restraint.
There is some evidence that changing the criteria for releasing individuals who are being restrained can help reduce the duration and in some cases the frequency of restraints. Through his research, James K. Luiselli and his colleagues have provided some interesting insights into this strategy.
Conventional thinking has been that physical restraint should be continued until the person being restrained exhibits a pre-set period of time of calm behaviour. An example of this would be release from restraint following a period of 60s of calm behaviour free from agitation. This is referred to as ‘behaviour-contingent release’ or BCR for short (Macdonough & Forehand, 1973). The logic is that this approach reduces the risk of restraint induced problem behaviours such as aggression, struggling and resistance being reinforced by the release. In effect, the calm behaviour produces the desired outcome (release from restraint) for the restrained person rather than the problem behaviour.
The problem with a BCR criteria is that it can result in long periods of restraint for people who are unable to quickly regain their composure and those for whom physical restraint is in and of itself reinforcing. All physical restraint carries a considerable risk of physical and emotional damage to both staff and the person being supported. These risks are increased during extended restraints and clearly undesirable.
An alternative criterion for release called ‘Fixed Time Release’ (FTR) attempts to address this problem.
Luiselli (2011) Defines FTR as
‘Fixed Time Release ’refers to terminating physical restraint when a predetermined duration of time elapses independent of the person’s behaviour during restraint’
The premise is that the total time spent in restraint will be minimised by removing a restraint following a fixed amount of time rather than waiting for a desirable behaviour to be exhibited. An early case study conducted by Mace et al (1986) bears this out. This study looked at the relative impact that BCR and FTR had on the use of ‘time – out’ with children who displayed challenging behaviour. It found that the use of the FTR approach resulted in children spending less being subjected to a highly restrictive intervention. This is a very desirable outcome from both ethical and practical considerations.
Subsequently, Luiselli et al (2004) conducted a pilot case study to compare the relative impact of BCR and TCR on physical restraint duration and frequency. The subject was a 17.5-year-old female student who had a Pervasive Developmental Disorder and exhibited aggressive behaviours. She was being subjected to frequent physical restraints.
Initially, staff would release her after she had been calm for 60 seconds (a BCR criterion). This resulted in restraints which averaged 5.6 minutes. Luiselli introduced an FTR criterion of 60 seconds, that is restraint must be terminated at 60 seconds. * The result of this intervention was that FTR reduced the duration of restraints to 3.1 minutes. What wasn’t anticipated was a very significant (and highly desirable) secondary outcome. The actual frequency of restraints also decreased from 3.2 per week under BCR to .67 per week under FTR. Luiselli concluded that ‘this may indicate a therapeutic advantage to terminating ‘Physical Restraint’ based on the passage of time, instead of a criterion linked to behaviour’
A further study by Luiselli et al in 2006 also produced very positive outcomes. This focused on 3 children with intellectual disabilities living at a community based residential school. The use of physical restraint as a consequence for aggression was in place for all 3 children. BCR was being used as the criterion for release. A shift to the TCR criterion was then introduced by the researchers. The results showed that the average duration of physical restraint each of the students were subjected to weekly decreased dramatically under FTR (see graph below). Whilst restraint wasn’t eliminated completely this constitutes a worthy and clinically significant outcome. Shorter cumulative restraint times are a great benefit to the person being held and also reduce the risk of injury to the person applying the restraint.
* For clinical reasons, if staff felt that they could not safely release the student at 60 seconds, they maintained holding until the behaviour contingent release (BCR) criterion was achieved but for 15 seconds rather than 60 seconds.
Average duration (minutes) of physical restraint per week with three students at a community-based residential school under conditions of behaviour-contingent release and fixed-time release.
Finally, Luiselli (2008) looked at Fixed Time Release ‘fading’ as a way of eliminating physical restraint completely rather than just reducing its duration. Fading involves progressively reducing the length of time of the fixed release time criterion. In a case study involving a 13-year-old boy, they found they were able to gradually reduce the fixed time-release contingency from 60 seconds to 7 seconds. On reaching the 7-second criterion physical restraint was successfully eliminated by having staff move behind the boy as if they were going to restrain him, touch him gently on the shoulder and ask him to sit down. When he did this staff momentarily stepped away for a few seconds, and then invited the boy to stand up again. This is a significant result.
Discussion
Whilst these studies produced some very positive outcomes for the application FTR caution should be exercised in attempting to draw definitive conclusions. As they followed a case study format it’s difficult to make generalisations about the intervention’s application to wider populations of service users. Further research would be really helpful in this respect.
However, the main findings suggest that the switch from behaviour contingent release to fixed time-release does seem to reduce the duration of physical restraint, and in some cases also reduces the frequency. Additionally, in one study, the strategy of ‘fixed term release fading’ eliminated the use of restraint completely.
From an ethical and practical point of view, this research suggests that where physical restraint is unavoidable the shift from BCR to TCR is a worthwhile intervention. Any (socially valid) intervention that reduces the duration of physical restraint is inherently worthy. Injuries to both staff and those being restrained are less likely and it’s much more consistent with a therapeutic, human rights-based approach.
The coincidental reduction in frequency is very positive. It may be that the reduction in the time being restrained has the residual effect of achieving quality of life and wellbeing gains. Less time spent being restrained = less distress for the individual, being in less distress should improve a person’s overall feelings of wellbeing and have a positive impact on the quality of life. Staff may be more encouraged to engage in meaningful activities which the person enjoys, further boosting happiness and quality of life. However further research is required to clearly identify what is bringing about this unanticipated effect.
FTR has real potential to add value to multi-element behaviour support plans. People for whom physical restraint is (initially) unavoidable could gain immediate benefit from a shift from BCR to TCR. It would at least reduce the duration of any unavoidable restraints during the period of assessment and initial implementation of the plan. This would help minimise restraint induced distress whilst the proactive elements of the plan begin to have an impact providing the basis for longer-term improvements to quality of life and wellbeing.
