Part 1
There is (thankfully) a growing buzz across most sectors working with adults and children regarding the issue of reducing restraint and restrictive practices. This is particularly true in services that support people who may, at times, express ‘challenging’ behaviour (behaviours of concern/behavioural distress).
This raises some interesting questions; What do we mean by ‘restrictive practices’, why is it imperative to try and reduce them, and what might best practice in this area look like?
Just to be clear from the outset, we are not saying that restraint and restrictions are never appropriate. There are occasions when a restriction may indeed be necessary. Where this is the case, the restriction must be legally and ethically justifiable, in that person’s best interests, be the least restrictive alternative available, and be subject to frequent review. A plan to reduce the reliance on the strategy should also be in place; this should form part of a broader proactive behaviour support plan.
Definition of Restrictive Practices
According to Paley-Wakefield (2013), a restrictive practice is;
“…any practice that limits or controls an individual that reduces their freedom”
Overt examples of restrictive practices might include; physical restraint, chemical restraint, mechanical restraint, seclusion and psychological restraint. However, restrictive practices can be much more subtle. It may be that everybody has to go to bed and be up by a specific time, rules on when people can have their phones, doors are routinely locked, and the use of fixed menus and mealtimes. There may be an emphasis on group activities with little thought given to individual preferences. Staff may also perceive themselves as ‘domestics’ doing everything for the people they support rather than doing things with them. In summary, people have minimal choices and control over their lives, and few opportunities to engage in new experiences or acquire new skills.
These more subtle restrictions usually arise because of habit or blanket rules; over time, they become deeply embedded in practice. It may be an attempt to make life ‘easier’ (usually for the staff), but as we’ll see, it often has the opposite effect. It may also be that punitive approaches to challenging behaviour prevail over more positive approaches in such settings. Staff responses to challenging behaviour may include withholding or taking away preferred items or activities or making people do things they don’t like or find aversive. To be clear, there is no place for punishment-based (aversive or shame-inducing) approaches within proactive and therapeutic approaches to vulnerable children and adults.
What is the link between restraint, restrictive practices and ‘challenging’ behaviour?
There is a well-established body of research which indicates that settings that lean toward more restrictive approaches tend to create conditions which promote higher levels of ‘challenging’ behaviour. This is linked to the degradation in the quality of life, which results from the imposition of excessive, unnecessary or unreasonable restrictive practices. This is a simple equation, the more restrictive an environment becomes; the worse the quality of life becomes for those living in it. As the quality of life deteriorates so does behaviour because people are not having their needs properly met (this would be true for all of us of course).
Adding punishment-based strategies to this mix compounds the effect producing a very vicious cycle. People are denied the opportunity to do things they enjoy because of their perceived ‘challenging’ behaviour. However, this behaviour, or said more accurately ‘response’, is a direct result of the distress they experience through not having opportunities to do things that they enjoy and make them feel happy. Staff might accelerate this process by trying to impose further restrictions and greater control. It’s fair to suggest that under these circumstances, the response (behaviour) of the people being supported isn’t in any way abnormal. It’s a perfectly rational response to conditions which are abnormal and extremely stressful. To describe their responses to these conditions as ‘challenging behaviour’ is disingenuous. It would more accurately be described as behavioural distress.
Furthermore, dignity and respect should be at the heart of good care and effective treatment. The use of excessive or unnecessary restraint and restrictive practices is in opposition to a human rights-based approach and runs contrary to treating people with dignity and respect. (Sanders 2009).
Inevitably this dynamic also has a negative impact on staff /carer wellbeing. High levels of stress-related sickness, injuries to staff, and a high rate of staff turnover are often common in such settings. This, of course, exacerbates the whole toxic process. The environment is, therefore, an unpleasant place for both recipients of the service and those who work in it.
For the sake of everybody’s health and well-being, it is imperative that we try to minimise the use of restraint and restrictive practices. It’s an inherently ethical (and pragmatic) endeavour. Individualised person-centred thinking and action are at the heart of best practice. What could be more person-centred than trying to improve an individual’s quality of life and well-being by identifying and engaging them in things we know to make them happy?
#AimingForZero! #RestraintReduction
Related posts:
Physical Restraint Reduction and the potential benefits of a ‘Fixed Time Release’ (FTR) Strategy
Majority of Services – Still Only Delivering Skills-Based Training!
Succeeding in Sustained Reduction in the use of Restraint
Using Positive Behaviour Support (PBS) to reduce the use of restrictive practices
