Physical restraint in disability services

Current practices, contemporary concerns, and future directions

Physical restraint in disability services: Current practices, contemporary concerns, and future directions
A report commissioned by the Office of the Senior Practitioner, Department of Human Services, Victoria, Australia. Prepared by Dr Keith R. McVilly, Senior Lecturer in Disability Studies, RMIT University School of Health Sciences (Division of Disability Studies).
March 2009

Contacts Office of the Senior Practitioner Department of Human Services Level 7, 50 Lonsdale Street Melbourne Victoria 3000 Telephone: +61 (0) 3 9096 8427 Fax: +61 (0) 3 9096 8017 Email: seniorpractitioner@dhs.vic.gov.au Web: www.dhs.vic.gov.au/ds/osp

If you would like to receive this publication in an accessible format, please phone 03 9096 8427 using the National Relay Service 13 36 77 if required, or email seniorpractitioner@dhs.vic.gov.au This document is also available in PDF format on the Internet at www.dhs.vic.gov.au/ds/osp

2009 Department of Human Services, Victoria All rights reserved. No part of this report may be reprinted or reproduced or utilised in any form or by any electronic, mechanical or other means now known or here after invented, including photocopying and recording, or in any information storage or retrieval system without written permission from the publisher, except in accordance with the provisions of the Copyright Act, 1968. Suggested citation: McVilly, K. (2008). Physical restraint in disability services: current practices; contemporary concerns and future directions. A report commissioned by the Office of the Senior Practitioner, Department of Human Services, Victoria, Australia. Indemnity: The information provided in this text, together with the views expressed and any endorsements made with respect to policies, procedures, practices or matters pertaining to legal or medical issues are made in good faith. They do not necessarily reflect the views or the official policy of The Department of Human Services (DHS), nor do they necessarily reflect the views of individual contributors. DHS does not in any way indemnify persons or organisations implementing policies, procedures or practices detailed in this text. This work is copyright. Apart from fair dealing for the purposes of private study, research, criticism or review as permitted under the Copyright Act 1968; any process without written permission may reproduce no part. Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne. Also available online at: www.dhs.vic.gov.au/ds/osp

Contents
1. Summary 1 6 6 6 2. Recommendations 1. Defining Restraint 2. Response Cost 3. Seclusion 6 7 7 7

4. Locking of Facilities

5. Working with People with Disability, their Families and Advocates

6. Working with the Sector to Bring about Climate Conducive to Systemic Change 7. Staff Education 7 8 10

8. Regulating the Use of Restraint and Seclusion 9. Monitoring the Use of Restraint and Seclusion 10. Research 10 12

3. Background to the Review

4. Historical Developments in the Non-Restraints Movement 5. Current Rates of Restraint and Seclusion 18

17

6. Contemporary Directions in the USA, the UK and New Zealand 6.1 United States of America 6.2 United Kingdom 6.3 New Zealand 24 22 20

20

7. Legislation Governing the Use of Restraint and Seclusion in Australia 7.1 Victoria (VIC) 27 28

27

7.2 Australian Capital Territory (ACT) 7.3 New South Wales (NSW) 7.4 Northern Territory (NT) 7.5 Queensland (Qld) 7.6 South Australia (SA) 7.7 Tasmania (Tas) 32 33 30 31 29 29

7.8 West Australia (WA)

8. Factors Influencing the Use of Restraint and Seclusion and Barriers to Implementing a Minimal Restraint or Restraint-Free Service Environment 34 8.1 Policy 34 34

8.2 Physical Environment 8.3 Staffing 35 36

8.4 Client Issues

8.5 Barriers to Implementing a Minimal Restraint or Restraint-Free Service Environment

37

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9. Promoting a Minimal Restraint or a Restraint-Free Service Environment by Means of Organisational Policy and Staff Educational Frameworks 40 9.1 Policy Frameworks 40 46 46

9.2 Staff Educational Frameworks

(a) Predict Assess Respond Training (b) The Mandt System 47

(c) Nonviolent Crises Intervention (d) Therapeutic Options (e) Control and Restraint 47 48

47

(f) Therapeutic Crisis Intervention

48 48

(g) Strategies for Crisis Intervention and Prevention (h) Person Focused Training (i) Studio III 49 48

9.3 Other Systemic Intervention Strategies and Staff Development Programmes (a) Multi-element systemic intervention, including Active Support (b) Counter-intuitive intervention strategies (c) Room-based interventions (d) Sensory interventions (e) Low arousal techniques (f) Intensive Interaction (g) Mindfulness techniques 53 54 54 52 53 52 51 49

49

9.4 The Support of People with Persistent Self-Injurious Behaviours References 57

1. Summary
This report was commissioned by the Senior Practitioner, during the first year of the newly created Office of the Senior Practitioner. It is intended to contribute to the development of evidence-based policy and practice in support of people with disability whose behaviours of concern have historically given rise to the use of support practices involving restraint and seclusion. The project brief asked a number of questions: what constitutes restraint and seclusion; how are these practices viewed and regulated in other jurisdictions, across Australia and overseas; what is the evidence, if any, for their efficacy; and what are the alternatives? The report focuses primarily on issues concerning physical and mechanical restraint, and seclusion. A separate report specifically focusing on the use of chemical restraint is in preparation. The current agenda to develop the quality of services available to Victorians with disability, and by implication their quality of life, can be seen as part of a long-standing programme of reform internationally, most recently giving rise to the United Nations Convention on the Rights of Persons with Disabilities (December, 2006). In Victoria, this programme of reform dates back to (and prior to) the adoption of the Intellectually Disabled Persons Services Act 1986. Since that time, successive governments have sort to be both proactive in their development of services and responsive to situations as they have arisen. The recommendations in this report build upon and extend many of the recommendations of the Victorian Law Reform Commission report of 2003. Furthermore, this current report has been prepared taking into account the new provisions of the Disability Act 2006 and the recently enacted Victorian Charter of Human Rights and Responsibilities Act 2006, together with a range of research, practice and policy literature from Australia and overseas. The use of restraint and seclusion include issues that span consideration of ethics, human rights, legal rights, education, health care, clinical practice, industrial relations, human resource management, architecture, design and engineering. These considerations encompass the interests of people with disability and their families, those providing support services and the community at large. This report recommends that the shared and competing interests of these groups be taken into account, but that the ultimate arbiter of the appropriate course of action to be taken in any given instance be the provisions of Victorian Charter of Human Rights and Responsibilities Act 2006 which, among other things, provides that all Victorians are guaranteed in law that they will not be treated or punished in a cruel, inhuman or degrading way (Section 10). In seeking to address the many issues associated with the use of restraint and seclusion, the current report provides an historical context for the use of restraint and seclusion. It details a movement within human services, dating back to the 18th Century, to minimise or even eliminate the use of restraint and seclusion in services supporting people with disability. When reviewing the historical evidence, it becomes apparent that we have had the knowledge, technology and social inclination available for at least the past 200 years to minimise, and in a range of circumstances eliminate, the use of restraint and seclusion. Furthermore, this report highlights the known risks and adverse consequences associated with the continued use of restraint and seclusion, including risks of serious injury and death to people subject to restraint and seclusion, and the risk of physical and psychological injury to staff and others enacting these procedures. Data concerning prevalence of the use of restraint and seclusion in Victoria, nationally and internationally vary. Recent data reported by the now disbanded Intellectual Disability Review Panel (IDRP) indicate that in Victoria during 2005/06, on average, 28% of residents in accommodation services were subject to restraint and/or seclusion and 23% of clients in respite services were subject to restraint and/or seclusion (Intellectual Disability Review Panel, 2006). These figures are in contrast to estimates for the UK, which indicate between 7% and 17% of adults with disability are subject to restraint (Emerson, 2002). This current report recommends that existing efforts by the Senior Practitioner, in collaboration with the Department of Human Services, to establish systems for on-line reporting and monitoring of such incidents be identified and resourced as a priority activity (including the development and publication of a comprehensive data dictionary to inform data entry and analysis) and that these systems be used for both systemic monitoring and a means of supporting services to analyze data concerning the people they support. Furthermore, the report recommends the establishment of a longitudinal research framework that will allow for benchmarking against data from other jurisdictions and the use of these data to educate service providers concerning their practices and their efforts to improve these practices. Policies, procedures and lessons learned from efforts to reduce or eliminate restraint and seclusion in other jurisdictions across Australia, New Zealand, the United Kingdom and in the United States of America are reported. In Victoria, the

Physical Restraint in Disability Services 1

provisions of the Disability Act 2006 and the recently enacted Charter of Human Rights and Responsibilities Act 2006 represent progressive benchmarks against which other Australian jurisdictions could be measured. At the time of preparing the current report, Standards New Zealand was preparing to issue a revised Restraint Minimisation and Safe Practice Standard, to replace guidelines issued in 2001. In the United Kingdom there have been significant resources applied to researching and developing safe practices in the use of physical restraint and the UK departments of Health and Education have issued a consensus policy position that restrictive physical intervention should be seen as one part of a broader strategy to address the needs of children and adults whose behaviour poses a serious challenge to services (Department of Health, 2002, p. 2). Similarly, the US National Association of State Mental Health Program Directors (NASMHPD) has continued to affirm, since 1999, a call for the reduction and, ultimately, the elimination of the use of restraint and seclusion (National Association of State Mental Health Program Directors, 2007). The position of the NASMHPD is that restraint practices, including the use of chemical restraints, are safety interventions of last resort and should never be used for the purposes of discipline, coercion, or staff convenience, or as a replacement for adequate levels of staff or active treatment or education. Most recently, the Pennsylvania Department of Public Welfares Office of Mental Retardation has adopted the position that, the elimination of restraints is a key factor in ensuring that individuals experience a quality of life that is consistent with the Everyday Lives philosophy (Department of Public Welfare, 2006, p. 2). The current report documents a range of factors reported in the literature to influence the use of restraint and seclusion and which can act as a barrier to progressing a minimal restraint or restraint free service environment. These issues include a lack of clarity in legislation and policy concerning what constitutes restraint and seclusion. Consequently, the current report provides working definitions of what constitutes restraint and seclusion, including differentiating between various forms of restraint:

Social restraint
The use of verbal interactions (which might reasonably be construed by the person to whom they are directed as intimidating or potentially abusive) and/or threats of social or other tangible sanctions (e.g., response cost programmes), which rely on eliciting fear to moderate a persons behaviour (in contrast to planned interactions or formal programmes designed to educate the person about the natural consequences of their actions and to assist them to make reasoned decisions or choices about appropriate behaviour).

Manual restraint
The use of a hands-on technique in a reflexive way to guide or redirect a person away from potential harm/injury, consistent with what could reasonably be considered the exercise of a duty of care towards the person (e.g., momentary contact to guide or redirect a person, lasting for no more than approximately 30 seconds);

Physical restraint
The sustained or prolonged use of any part of a persons body to prevent, restrict, or subdue movement of the body or part of a body of another person (e.g., lasting more than 30 seconds; not a reflexive manual restraint);

Mechanical restraint
The use of any device to prevent, restrict or subdue movement of a persons body for the primary purpose of behavioural control, but excluding the use of an authorised mechanical restraint recommend by a medical practitioner or therapist for use at identified times and places for therapeutic purposes (i.e., explicitly to enhance health and wellbeing) and an authorised mechanical restraint recommend by a medical practitioner or therapist to support a person participate in identified activities of daily living (e.g., at meal times), or to enable a person to be transported safely according to law;

Chemical restraint
The use of a chemical substance to control or subdue a persons behaviour (be it regularly administered or prescribed as required PRN), but which excludes any drug prescribed by a registered medical practitioner for the sole purpose

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of treating a diagnosed physical illness or condition, or by a psychiatrist for the sole purpose of treating a diagnosed mental illness. Also excluded from the definition of chemical restraint would be any drug prescribed to control a persons behaviour so that a person can undergo a medical examination or related diagnostic procedure or receive treatment for a physical illness or condition, but only where the specific date, time and place of the treatment, examination or identified diagnostic procedure has been authorised by the treating physician. Strategies utilising response cost techniques, time out procedures and the locking of facilities are also addressed in the report. The way in which the use of restraint and seclusion is moderated by the environment in which support is provided, staffing characteristics, and client specific issues are documented. It is evident from the research, practice and policy literature that progressing a restraint minimisation or indeed a restraint free service environment requires a multielement approach. This multi-element approach would necessarily incorporate policy development, systemic monitoring and on-going research activities, staff education and investment in both physical and human infrastructure. The report includes examples of policy and procedural efforts in other jurisdictions designed to promote a minimal or restraint free service environment. These efforts include those in both childrens (educational) and adult services, in the USA and the UK. Given similarities in the support needs of persons from other vulnerable populations, research relating to the support of people with mental illness, the frail aged and prisoners are also considered. A number of staff educational programmes are described and their relative merits presented and critiqued. The report notes the lack of reliable evidence as to the effectiveness of many of these programmes. Consequently, no single programme is recommended for use. Rather it is recommended that a number of programmes be piloted and a formal research framework be established to evaluate them. Inclusion and exclusion criteria for curriculum content are proposed. These criteria incorporate the recommendation that programmes not include strategies such as: the use of prone (face down) restraint; hobble (hog) tying; physical or mechanical restraint that inhibits the respiratory and/or digestive system; physical or mechanical restraint that involves compliance through the infliction of pain, hyperextension of joints, and pressure on the chest or joints; takedown techniques in which the individual is not supported and/or that allows for free fall as the individual goes to the floor. Similarly, caution is expressed with respect to the safety of procedures such as basket holds. In addition to structured staff education programmes, a range of systemic and clinical interventions are presented for consideration. These include counter-intuitive strategies, room-based and sensory interventions, low arousal techniques, and mindfulness techniques. Overall, the research and practice-based literature repeatedly returns to the importance of adopting and implementing a non-aversive, Positive Behaviour Support (PBS) framework, as described by Carr and colleagues (Carr & Horner, 2007; Carr et al., 1999). The PBS approach includes two main areas of concern: (1) strategies to address deficient environmental conditions (e.g., physical access; staffing issues, including staff training; activity schedules; engagement techniques; choice making opportunities); and (2) strategies to address deficient behavioural repertoires of the person (e.g., communication; self-management; activities of daily living; and social skills). A major tool of the PBS approach is that of functional analysis, and subsequently the development of strategies designed to better meet peoples physiological, psychological, educational and sociological needs. However, when implementing a non-aversive approach, Weiss and Knoster (2008) caution that clinicians and staff using such strategies not automatically assume that they are necessarily positive, and that staff need to continue to reflect on their practices in order to ensure clients receive best, evidence-based practice. It is evident from the literature that it is necessary, but not sufficient to simply teach staff PBS techniques. Staff also require education and formation in the application of professional ethics and the use of reflective practices (e.g., ASSID, 2007; McVilly & Parmenter, 2006). The current report highlights the need for particular attention to be paid to the use of restraint as it is applied in the ongoing support of, and in intervention strategies for, persons with severe and persistent self-injurious behaviours. These behaviours are estimated to present in 4% to 14% of persons with intellectual disability, increasing in their prevalence as the degree of disability increases (Oliver, 2008). They are noted to negatively affect the physical and psychological

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health and wellbeing of both persons with disability and those providing support. Theses stereotypical and self-injurious behaviours commonly present as behavioural phenotypes associated with a range of identified syndromes and in persons with Autism Spectrum disorders. The emerging literature indicates that for these particular individuals some of the more traditional PBS style approaches to assessment and intervention might be insufficient. Consequently, a more bio-behavioural approach to assessment and intervention design could be required. The report recommends further research is conducted in this area, to inform policy development and clinical practice in support of persons with severe and persistent self-injurious behaviours. Overall, the report recommends that, consistent with the provisions of the Disability Services Act 2006, the Charter of Human Rights and Responsibilities Act 2006, and international conventions to which Australia is a signatory, the Senior Practitioner, working with the Department of Human Services, funded agencies, researchers and other specialists, people with disability and their advocates, actively pursues a range of policy, procedural and educational measures to ensure that citizens of Victoria with disability are not treated or punished in a cruel, inhuman or degrading way, particularly as a consequence of the misguided or inappropriate use of restraint and /or seclusion. Furthermore, that citizens of Victoria with disability are assured of their right to be free from restraint and seclusion, in any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff, family members or others providing support, and that educational, procedural, policy and legal remedies be advanced to protect this right and that, in the public interest, breaches of these rights be publicised, but with the identity of the person with disability reserved. Here is should be noted that, based on experiences in the United States of America, and given the trend in Australia towards the enshrinement of rights in legislation (e.g., Victorian Charter of Human Rights and Responsibilities Act 2006), it is highly likely that litigation will become an increasingly important factor contributing to the impetus for systemic change in services for people with disability. This report also recommends that organisational policy of government provided and non-government, funded services explicitly reflect (and communicates to managers, supervisors and staff) that priority be given to the reduction and minimisation of the use of practices involving restraint and/or seclusion and that data collection procedures be established to focus attention on and enable public and transparent evaluation of the implementation of that policy position. The current report concurs with the findings of Justice Carter QC (2006): That is not to say that appropriate restrictive practices cannot be justified in appropriate cases in the proper care and support of a small minority of persons with intellectual disability. The case studies include some where appropriate restrictive practices can be justified. But justification, the consequences of which will necessarily impact on the fundamental human rights of the affected persons, is to be found and will be supportable only in the proper case and subject to the proper criteria and only in a small minority of cases (p.147). Furthermore, the report proposes that the development of practice in Victoria, with respect to the use of restraint and seclusion in services for people with disability, be informed by the policy position established in 2006 by the Pennsylvania Department of Public Welfares Office of Mental Retardation: The elimination of restraints is a key factor in ensuring that individuals experience a quality of life that is consistent with the Everyday Lives philosophy. The values inherent in Everyday Lives and Positive Approaches suggest that restraints and restrictive procedures can be drastically reduced and many times eliminated by focusing on what the individual is trying to communicate, how we help to guide the individuals efforts in moving towards positive outcomes, and by ensuring that each individual is properly diagnosed and receiving quality supports. The use of restraints as a behavioral intervention continues to be a concern both in Pennsylvania and nationally due to the risk of serious injury and death, emotional harm and trauma, and the disruption of relationships with family members, peers, and staff. Except in case of emergency, OMR is dedicated to the need for ongoing reduction and the eventual elimination of all restraints and restrictive procedures (Department of Public Welfare, 2006, p. 2).

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This review of the literature establishes that contemporary worlds best practice in support of people with disability who exhibit behaviours of concern (i.e., challenging behaviours) is informed and directed by ethical, clinical and legal imperatives to at least minimise, and in many circumstances eliminate the use of restraint and seclusion. This focus on a policy of restraint minimisation, or even the establishment of a restraint free service environment, does not of course deny the periodic necessity for staff to exercise their duty of care to protect a client from imminent danger, through their use of minimal force. Rather it focuses attention on the need to conceptualise and regulate the use of restraint as an exceptional circumstance, requiring a high level of ethical, clinical and legal justification, rather than as a regularly used or commonly accepted practice. To successfully achieve this level of practice, action needs to be taken both systemically and at the point at which individuals receive support. Failure to so act will place individuals (both people with disability and those who provide their support) at an unacceptable level of risk, physically, psychologically, legally and ethically. Based on the current review of research, practice and policy-based literature, a series of recommendations are made. The recommendations are organised into 10 areas for consideration: defining restraint; response cost; seclusion; locking facilities; working with people with disability, their families and advocates; working with the sector to bring about a climate conducive to systemic change; staff education; regulating the use of restraint and seclusion; monitoring the use of restraint and seclusion; and research.

Physical Restraint in Disability Services 5

2. Recommendations
1. Defining Restraint
That for the purposes of education, together with the monitoring and the regulation of support practices in Victoria, restraint is recognized to include, and is understood in terms of: Social restraint The use of verbal interactions (which might reasonably be construed by the person to whom they are directed as intimidating or potentially abusive) and/or threats of social or other tangible sanctions (e.g., response cost programmes), which rely on eliciting fear to moderate a persons behaviour (in contrast to planned interactions or formal programmes designed to educate the person about the natural consequences of their actions and to assist them to make reasoned decisions or choices about appropriate behaviour). Manual restraint The use of a hands-on technique in a reflexive way to guide or redirect a person away from potential harm/injury, consistent with what could reasonably be considered the exercise of a duty of care towards the person (e.g., momentary contact to guide or redirect a person, lasting for no more than approximately 30 seconds); Physical restraint - the sustained or prolonged use of any part of a persons body to prevent, restrict, or subdue movement of the body or part of a body of another person (e.g., lasting more than 30 seconds; not a reflexive manual restraint); Mechanical restraint The use of any device to prevent, restrict or subdue movement of a persons body for the primary purpose of behavioural control, but excluding the use of an authorised mechanical restraint recommend by a medical practitioner or therapist for use at identified times and places for therapeutic purposes (i.e., explicitly to enhance health and wellbeing) and an authorised mechanical restraint recommend by a medical practitioner or therapist to support a person participate in identified activities of daily living (e.g., at meal times), or to enable a person to be transported safely according to law; Chemical restraint The use of a chemical substance to control or subdue a persons behaviour (be it regularly administered or prescribed as required PRN), but which excludes any drug prescribed by a registered medical practitioner for the sole purpose of treating a diagnosed physical illness or condition, or by a psychiatrist for the sole purpose of treating a diagnosed mental illness. Also excluded from the definition of chemical restraint would be any drug prescribed to control a persons behaviour so that a person can undergo a medical examination or related diagnostic procedure or receive treatment for a physical illness or condition, but only where the specific date, time and place of the treatment, examination or identified diagnostic procedure has been authorised by the treating physician.

2. Response Cost
2a. That behaviour support and modification programmes involving response cost strategies (i.e., the withdrawal of an identified positive reinforcer contingent on the occurrence of a defined behaviour) be considered a form of restraint for the purposes of reporting to the Senior Practitioner. While such programmes might be permissible under limited circumstances, and as a short-term intervention (usually involving formal authorisation by a Psychologist, and only ever as part of a comprehensive intervention and support programme), the Senior Practitioner reserves the right to review such programmes.

3. Seclusion
3a. That for the purposes of education, together with the monitoring and the regulation of support practices in Victoria, seclusion be understood in terms of the confinement of a person alone at any hour of the day or night in a room, the door(s) and window(s) of which cannot be opened by the person from the inside; or the confinement of a person alone at any hour of the day or night in a room in which the door(s) or window(s) are locked from the outside or their opening is prevented by any other means, such as a person holding the door shut; or where exit from a place is prevented by the presence of another person. 3b. That with respect to programmes and strategies that have the potential to resemble seclusion, such as time out, following a behavioural incident, no person with disability be left on their own or unobserved. Furthermore,

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that such procedures only be used as a means of de-escalating a persons behaviours (i.e., they are designed and implemented to reduced anxiety) not as a means of coercion, discipline, convenience, or retaliation. Importantly, that these procedures cease immediately the person has regained self-control or sufficient composure to continue with their usual routine or a suitable alternative activity.

4. Locking of Facilities
4a. That circumstances involving a locked door policy or procedure be considered a situation of restraint that must be reported to the Senior Practitioner, and subject to regular review. That a locked door policy or procedure be understood to include the regular locking of external doors and windows while clients and staff are inside a building, which restricts the entrance and exit of clients; and/or the regular locking of doors and windows, which confines a client to a particular part of a building or premises. However, the locking of a facility during the hours of darkness, for the purposes of security, should not be considered restraint. 4b. That with respect to locking of accommodation and other facilities where people with disability receive support, a persons freedom of movement should only be restricted where this is necessary to prevent the person from harming him or herself (for example by wandering on to a busy road) or from causing serious harm to another person. Where such a procedure is instigated as a consequence of the services current inability to provide a less restrictive means of support or supervision, a longer-term strategy to address, for example, staffing levels or other forms of minimally intrusive surveillance, should accompany any report on the use of a locked door policy. 4c. That both government operated and funded NGO services (via Authorised Programme Officers) provide a monthly report to the Senior Practitioner concerning their practices in relation to limiting residents or clients access to and exit from premises; and that this report include details of which facilities are locked, how they are locked, for what periods of time they are locked, why they have been locked and what programme or review measures are in place to evaluate and/or change these circumstances to a less restrictive environment.

5. Working with People with Disability, their Families and Advocates

5a. That the Senior Practitioner work with self-advocacy organisations and family groups to raise awareness of issues relating to the use of restraint and seclusion and to provide information that will better enable these groups to informally monitor and, as might be appropriate, formally report on or appeal circumstances about which they have concern. 5b. That the Senior Practitioner investigate options to include relevant information and monitoring procedures concerning the use of restraint and seclusion in the soon to be enacted Autism State Plan for Victoria.

6. Working with the Sector to Bring about Climate Conducive to Systemic Change
6a. That consideration be given to the Senior Practitioner hosting a conference focusing on international best practice in support of people with behaviours of concern that give rise to the use of restraint or seclusion. Such an event could be hosted in co-operation with specialist sector-based organisation such as the Australasian Society for the Study of Intellectual Disability, the Australasian Association of Doctors in Developmental Disability Medicine and/or the International Association for the Scientific Study of Intellectual Disability Mental Health Special Interest Research Group, or the Profound and Multiple Disability Special Interest Research Group.

7. Staff Education
7a. That the damaging long-term psychological effects of social restraint are recognised and that for the purposes of developing educational curriculum and organisational policy those providing support services are made aware of the potential harm they can inflict by using unjustifiably harsh or intimidating verbal interactions and threats of social or tangible sanctions when responding to or seeking to modify the behaviours of concern used by people with disability in an attempt to communicate their justifiable or reasonable needs.

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7b. That the Senior Practitioner, in collaboration with appropriate medical authorities with specialist expertise in the field of developmental disability medicine, publish practice guidelines highlighting the dangers of asphyxia and cardiac complications associated with the use of physical restraint, and in particular the use of hobble tying, the prone position, basket holds and mechanical restraint (including the use of clothing). Furthermore, that these guidelines include recommendations for minimum medical supports to be available in the planning for the use of any such restraints, the implementation of any such strategy and in the formal review of each instance of any such restraint strategy. 7c. That all staff employed to support persons with disability (including staff in direct support positions, supervisory positions, management and those providing health and allied health consultancy) be provided with mandatory education (accreditation) concerning restraint and seclusion. Furthermore, that a strategy be developed to monitor and ensure re-accreditations at regular intervals (e.g., at the time of renewing mandatory First Aid certificates). 7d. That an education and accreditation programme be developed for persons designated as Authorised Programme Officers (APOs), as defined by the Disability Act 2006. This could include their completion of on-line induction modules and their longer-term enrolment in units of study accredited as part of a degree-level (Higher Education) course. Programmes would need to include education in professional ethics, legal obligations and clinical skills. 7e. That mandatory education programmes focus staff attention on the techniques of Positive Behaviour Support (PBS) and verbal and environmental de-escalation techniques. They should provide guidance on what constitutes a duty of care, and highlight the dangers (physical, psychological and legal) inherent in the use of restraint or seclusion. 7f. That mandatory training programmes not include instruction in techniques that are explicitly designed to cause physical or psychological distress or which rely significantly on techniques based on martial arts. However, consideration could be given to the inclusion of break-away techniques where these are specifically identified as relevant to the support of particular clients and where they have been developed by the instructor based on the individual clinical and support profile of an identified client. For these reasons, prior to developing the programme, the instructor should be required to consult with, at minimum, both the persons medical practitioner and psychologist and document this information as part of a formal report individualised to each client whose support is to be informed by their course/training programme. 7g. That strategies be developed to enable training programmes to include personal accounts of persons with disability concerning their experience of restraint and seclusion. Such strategies could include people with disability directly contributing to training programmes, recordings of interviews with people with disability being used in training or, at minimum, written accounts being used as part of a staff discussion. 7h. That incident review and data analysis be incorporated into team practices, following individual incidents and at regular team meetings, and that teams be provided with education in how to implement such evidence-based processes into their clinical practice.

8. Regulating the Use of Restraint and Seclusion

8a. That, consistent with the recently enacted Victorian Charter of Human Rights and Responsibilities Act 2006, no citizen of Victoria with disability be subject to restraint or seclusion by a service provider without authorisation and regular review (at least quarterly) of that authorisation. 8b. That, consistent with the recently enacted Disability Act 2006, restraint and seclusion only be used in emergency situations if needed to ensure physical safety of the person or others immediately involved, and if less restrictive interventions have already been tried and have proven ineffective. 8c. That restraint and seclusion not ordinarily be approved as part of a behaviour support, therapy or educational programme, except where the explicit goal of the programme is to teach the person a self-restraint technique

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and that the form of restraint proposed is consistent with that which it is proposed the person will themselves learn to use. 8d. That clinical recommendations concerning procedures (including the use of social, manual, physical, mechanical and chemical restraints) for supporting a person who is known to exhibit behaviours of concern, that are of a danger to themselves or others, include: (1) strategies to avoid or minimise the likelihood of incidents occurring; (2) a hierarchy of responses, beginning with the least restrictive option; (3) details of clinical/behavioral indicators to assist staff move through the hierarchy of responses in an appropriate way; and (4) a detailed description of what staff are expected to do for each strategy. 8e. That a de-briefing protocol for both the person subject to restraint and those implementing the restraint be included in all clinical programmes where it is foreseen that circumstances could involve the use of social, manual, physical, mechanical or chemical restraint. 8f. That unless otherwise justified by clinical recommendations and authorised by the Secretary of the Department of Human Services, restraint and seclusion are not used to routinely control the behaviour of a person with disability, and nor should such strategies ever be authorised or used to prevent a person behaving offensively, for example by verbally abusing staff, where there is no risk of harm to themselves or others. 8g. That any application for the use of restraint or seclusion be accompanied by a detailed plan outlining the availability of medical support prior to, at the time of and following the use of the proposed procedure. Consideration should be given to the need to have available staff with training in advanced resuscitation skills and the use of defibrillation equipment. Note the availability of staff trained only in first aid is not considered sufficient. 8h. That where authorised, the particular form of restraint or seclusion used is the least restrictive means of preventing the person from physically harming himself or herself or any other person or destroying property, and that this criteria be established by any application for authorisation to include details of alternative strategies and justification as to why they cannot be implemented. 8i. That if used, restraint or seclusion be terminated at the earliest possible time and that any subsequent incident report include justification for the period for which the restraint or seclusion was applied to prevent the person from harming him or herself or causing serious harm to another person. And that the incident report include details of the medical observations conducted during and in the follow-up to the procedure. 8j. That prior to the authorisation of restraint or seclusion practices, the person have established a current individual service plan, a current positive behaviour support plan and a current medical profile/health care plan that includes findings from a full physical examination and both biochemistry and other investigations as recommended by the examining physician. 8k. That prior to the authorisation of restraint or seclusion practices, the person or their Guardian be consulted and their consent obtained. Where the person is unable to give informed consent and they do not have a legal Guardian, given the serious nature of the procedures proposed, an application for the appointment of a Guardian be made at least for the duration of the period for which the particular practices are proposed to be authorised. 8l. That all instances of restraint or seclusion be documented, reported and formally reviewed at multiple levels: on a clients individual file; on a centeralised organisational record maintained by each government or funded service; and on a database maintained at a systemic level by the Senior Practitioner (whose office should be notified within 48 hours of any instance of restraint or seclusion in either a government operated or funded service). However, instances of Social Restraint or Manual Restraint (as defined above), need only be documented at the level of a persons individual service file and on the organisations centralised register. Note the organisations centralised register should be available for periodic review or audit, at the request of the Senior Practitioner.

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8m. With respect to physical restraint, given the known risk of harm to persons with disability and of known risk of death, the following recommendations are made: Prone (face down) or hobble (hog) tying restraint is not used. No physical or mechanical restraint that inhibits the respiratory and/or digestive system is used. No physical or mechanical restraint that involves compliance through the infliction of pain, hyperextension of joints, and pressure on the chest or joints is used. No use of takedown techniques in which the individual is not supported and/or that allows for free fall as the individual goes to the floor. An individuals physical condition is evaluated throughout the restraint in order to minimise the potential of individual harm or injury. Physical restraint does not exceed 30 minutes within any two-hour time period An individual is immediately released from physical restraint when they no longer present a danger to self or others. Support staff monitor the individual for signs of distress throughout the restraint process and for a period of time (up to two hours) following the application of a restraint. That observations conducted and recorded include vital clinical indicators such as pulse, respiration and temperature.

9. Monitoring the Use of Restraint and Seclusion

9a. That the Senior Practitioner continue efforts to develop and enhance a system for on-line reporting of behavioural incidents involving physical, mechanical or chemical intervention, including the development of a comprehensive data dictionary to inform the input and analysis of data . Furthermore, that the reporting mechanism also capture data concerning the use of response cost techniques, time out procedures and the locking of facilities. 9b. That the monitoring and review of the implementation of policy and procedures pertaining to the use of restraint and seclusion include documenting instances of injury and death to persons subject to restraint or seclusion and that, in the public interest, de-identified details should be made publicly available. 9c. That the monitoring and review of the implementation of policy and procedures pertaining to the use of restraint and seclusion include documenting instances of injury and death to staff implementing restraint or seclusion procedures and that, in the public interest, de-identified details should be made publicly available. 9d. That, as one strategy designed to promote awareness and educate service providers concerning the serious nature of issues relating to the use of restraint and/or seclusion, the Senior Practitioner report publicly on a quarterly basis concerning the instances of restraint and seclusion.

10. Research
10a. That an analysis of current (and historical) records pertaining to restraint and seclusion of Victorians with disability be undertaken, to inform strategic planning and long-term evaluation of measures taken to reduce the use of restraint and seclusion, and that this analysis include a review of coronial and other public records which document adverse outcomes to the use of restraint and seclusion. Furthermore that the analysis of data from Victoria be benchmarked against that of other related jurisdictions across Australia, New Zealand and internationally, where these data are available. 10b. That the outcome of an analysis of current (and historical) records pertaining to restraint and seclusion of Victorians with disability, including coronial and other public records which document adverse outcomes to the use of restraint be published for the information of service providers. Furthermore, that measures be

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taken to have this information incorporated into training programmes for new and existing disability support staff, together with educational programmes for Authorised programme Officers, together with health and allied health practitioners responsible for the design and supervision of support strategies/programmes. 10c. That an evaluation of currently available physical intervention programmes be conducted, and that the evaluation consider, among other issues, the safety of clients, the safety of staff and the effectiveness of such programmes in the context of enhancing the longer term quality of life of the persons being supported. It is envisaged that the formulation of such an evaluation would necessarily involve professional researchers in the university sector. 10d. That research be conducted into appropriate strategies to use in the support of persons exhibiting persistent self-injurious behaviours, particularly where these behaviours are thought to represent a behavioural phenotype associated with a particular syndrome or an Autism Spectrum disorder.

Physical Restraint in Disability Services 11

3. Background to the Review

The recently enacted Charter of Human Rights and Responsibilities Act 2006 makes explicit that all citizens of Victoria are guaranteed in law that they will not be treated or punished in a cruel, inhuman or degrading way (Section 10). In addition, for people with disability, the Disability Act 2006 includes detailed provisions concerning limitations on service providers concerning the use of restraint and seclusion (Part 7). Furthermore, the Disability Act 2006 includes the creation of a new offence whereby a disability service provider (a term defined to include both service provider agencies and individuals acting on behalf of those agencies), who applies restraint or seclusion to a person with a disability, except as provided for in sections 140 or 147 of the Act, is guilty of an offence (Section 149). These provisions are consistent with a number of internationally accepted conventions including the recently enacted United Nations Convention on the Rights of Persons with Disabilities (December, 2006) which includes the requirement of states to protect the physical and mental integrity of persons with disabilities, just as for everyone else (Article 17), to guarantee freedom from torture and from cruel, inhuman or degrading treatment or punishment (Article 15) and to enact laws and administrative measures to guarantee freedom from exploitation, violence and abuse (Article 16). The current agenda to enhance disability services in Victoria must therefore be understood in terms of both international developments and local legislative reform. This current agenda for reform can be seen as part of a long-standing programme of reform in Victoria, dating back to (and prior to) the adoption of the Intellectually Disabled Persons Services Act 1986. Since that time, successive governments have sort to be both proactive in their development of services (e.g., Victorian Law Reform Commission, 2003, "People with intellectual disabilities at risk") and responsive to situations as they have developed. In March 2000, the Intellectual Disability Review Panel (IDRP) reported to the parliament of Victoria on the circumstances of 23 people with intellectual disability who had been subject to restraint or seclusion without any formal authorisation (Intellectual Disability Review Panel, 2000). The IDRP noted that 97% of reports (out of a total of 658 instances of restraint or seclusion reported to the IDRP) had involved chemical restraint, that there appeared to be a low instance of reporting of physical restraint, and 37% of reports to the IDRP were incorrectly completed. In November 2000, the Auditor General for Victoria reported to parliament findings of an investigation that indicated weaknesses in the operation of safeguards related to the monitoring of restraint and seclusion and a lack of clarity among service providers with respect to accepted procedures and reporting requirements. More recently, it is reported that in Victoria during 2005/06, on average, 28% of residents in accommodation services were subject to restraint and/or seclusion and 23% of clients in respite services were subject to restraint and/or seclusion (Intellectual Disability Review Panel, 2006). It was with a commitment to addressing situations such as these that the current review of best-practice and evidence-based practice in the use of restraint and seclusion, nationally and internationally, was commissioned. Restraint and seclusion practices are commonly justified on the basis of necessary situational management and in the interests of protecting both the person and others from harm. Various studies have reported that, approximately, between 30% to 40% of adults with intellectual disability display challenging or aggressive behaviours that are of significant clinical concern to those who provide their support (Emerson, 2001; Emerson, 2002; Hill & Bruininks, 1984; Jacobson, 1982a, b; Lundstrom, Saveman, Eisemann, & Astrom, 2007; Qureshi & Alborz, 1992; Sigafoos, Elkins, Kerr, & Attwood, 1994) and that between 10% and 20% of these people are reported to exhibit behaviours considered aggressive or violent (Jacobson, 1982a, b; Saloviita, 2002; Sigafoos, Elkins, Kerr, & Attwood, 1994). Crocker et al. (2006), in a prevalence study involving a population of 3165 adult Canadians with intellectual disability, reported in a 12 month period the incidence of aggressive behaviours to be 37.6% verbal abuse, 24.4% self-injurious, 24.4% aggressive towards others, 24% property damage and 9.8% of behavioural incidents reported as sexually aggressive. The authors further report that 4.9% of behaviours gave rise to an actual injury to another person. Emmerson, et al. (2000) report that in response to behaviours of concern staff typically respond with the use of physical restraint (44%), sedation (35%) and/or seclusion (20%). However, the use of restrictive practices such as restraint and seclusion are now subject to heightened scrutiny; in terms of the legality of their implementation, their clinical effectiveness and the ethics of their continued use in a contemporary service delivery system. It is widely agreed that these practices have a negative effect on the health, wellbeing and quality of life of people with disability (Sigafoos, Arthur, & O'Reilly, 2003; Singh, Lloyd, & Kendall, 1990). Furthermore, these practices present serious clinical, legal and

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ethical/moral dilemmas for both service providers and those responsible for managing the service delivery system (McVilly, 2002). They can also give rise to serious adverse consequences, including death (Miles & Irvine, 1992; Paterson et al., 2003). Morrison (1997) reported a total of 131 deaths attributed to restraints applied by means of protective clothing which were reported to the US Federal Drug Administration Agency between 1987 and 1996. These data were available because the clothing items were considered medial devices and consequently reporting the adverse events associated with their use were mandated. However, data pertaining to adverse events, injury and death arising from the use of other forms of physical restraints and related practices is reported by researchers as being inherently difficult to obtain, with the most accessible data being that provided in the public media (Lucardie & Sobsey, 2005; Nunno, Holden, & Tollar, 2006). In 1998, The Hartford Courant published a series of articles detailing the many deaths of adults and children resulting from the improper use of restraint in US mental health facilities (Weiss, 1998). This series of articles provided details of 142 deaths across the USA, between 1988 and 1998, with a quarter of those deaths being children. Subsequent research conducted by the Center for Risk Analysis at Harvards School of Public Health, and published in the Hartford Courant, estimated that in the USA, between 50 and 150 deaths were occurring each year which were directly attributable to the use of restraint and seclusion. Nunno, Holden and Tollar (2006) attempted to obtain data from US agencies concerning restraint related deaths. However, these data were not readily available. Subsequently, they document 45 fatalities reported in the US print media across 22 states between 1993 and 2003. A quarter of these deaths occurred in large residential services and nearly 20% in community-based homes. There were three such deaths reported in special schools. Physical restraint (and in particular the use of the prone position) was implicated in 38 of the 45 fatalities. Asphyxia and cardiac complications arising from the use of restraint were the most commonly reported cause of death. The authors also note that where the staff rationale for applying restraint were available, they did not satisfy the criteria that the person was at immediate risk to themselves or their actions were placing others at immediate risk. Most situations were reported to involve noncompliance with instruction or a programmed activity, though some instances involved fights with other clients and running away. Paterson et al. (2003) in a review of restraint related deaths in the UK health system, similar to the reported experience of researchers in the USA, noted the lack of official records together with data reporting and record keeping practices that did not readily allow for analysis. The UK authors also noted a lack of attention to restraint related fatalities in the peer-reviewed literature. The authors reported that the open media was the most readily available source of data, though acknowledging limitations in reliability of these data. They identified 12 restraint related deaths in the UK health system reported by the print media between 1995 and 2001, of which four were people with learning disability. Their analysis suggests that death associated with the use of restraint was generally caused by cardiac failure and asphyxia. The restraint procedures involved in these instances included the use of prone restraints, hobble (hog) tying, basket holds and the use of mechanical restraints such as clothing. Issues relating to the use of such procedures and the implications for policy and staff training will be discussed later in the current report. In Australia, similarly, data is not readily available. The Victorian Law Reform Commission, for their 2003 report on people with intellectual disability at risk, was unable to obtain reliable information on rates or injury or death arising as a consequence of restraint, nor were they able to obtain the numbers of people subjected to practices such as restraint and seclusion, or who lived in facilities where they could not enter and leave without permission because doors are kept locked (Victorian Law Reform Commission, 2003). The most recent Australian public enquiry focusing on the needs of persons with disability subject to restraint and seclusion has been that conducted in Queensland by Justice Carter QC (2006). The Carter Report includes documentation concerning 312 people with complex and challenging behaviour identified as currently receiving supported either directly provided by or funded in the non-government sector by Disability Services Queensland (DSQ), and whose challenging behaviour was either being managed by the use of restrictive practices or was at risk of

Physical Restraint in Disability Services 13

requiring restrictive practices. However, the Carter report does not report figures indicating rates of injury or death as a consequence of the use of restraint or seclusion. Subsequently, in preparing the current report, searches were made in the Australian media for relevant data, between January 1997 and December 2007. Multiple specialist search engines were used (e.g., the Australian Public Affairs Information Service, Find Articles and Factivia Database) and various combinations of the search terms disability, restraint, injury and death. Out of 140 articles retrieved, there were seven of immediate relevance. These articles typically documented systemic problems, involving multiple adults in each instance, persons living in supported accommodation, who had been subject to abuse or assault giving rise to serious injury and/or death. Many of these incidents were directly attributed to the (mis)use of restraint or seclusion. Consequently, these situations had given rise to a public enquiry by a either a government department or statutory authority (New South Wales x 1; Queensland x 4; South Australia x 1; and Victoria x 2). Any review of the use of restraint and seclusion of persons with a disability must also take into account the rights, safety and wellbeing of those providing support (Duperouzel & Fish, 2007; Lundstrom, Saveman, Eisemann, & Astrom, 2007). With this in mind, in Victoria the provisions of the Occupational Health & Safety Act 2004 and related regulations need to be noted, including the legal imperative for employees and employers to work together to ensure a safe working environment and safe systems of work (OH&S Act, 2004, Part 3). While in some instances it has been argued that creating a safe working environment requires that staff be trained in restraint techniques, it is also noted that the use of restraint can contribute to both physical and psychological injury to staff, as well as to their clients (Fenton & Sailas, 2000). A policy and practice environment that fosters the use of restraint and seclusion might therefore be considered to contribute to unsafe work practices and unsafe systems of work, especially where the staff are not provided with instruction in and sufficient resources to implement more appropriate alternative practices. This current review will provide an overview of historical, legislative, policy and procedural considerations relating specifically to the use of restraint and seclusion as they effect people with disability and those who provide their support in jurisdictions outside of Victoria. The review will make reference to current trends in the development and application of procedures in the related areas of mental health and aged care. It is anticipated that the review will inform the development of guidelines by the Office of the Senior Practitioner (OSP), the role of which was created under the Disability Act 2006 (Part 3, Division 5) for the purpose of, among other tasks, the development of guidelines and standards with respect to restrictive interventions and compulsory treatment (Section 24). The primary objective of the review is to provide material to inform the development of a comprehensive definition of physical restraint in the context of its application to addressing behaviours that present as a challenge to people with disability and those who provide their support (referred to in this review as behaviours of concern). Since commencing this review, the OSP has commissioned a parallel review which is examining issues relevant to the use of chemical restraint. For that reason, the current review will only make reference to such issues as might be necessary to contextualise information presented concerning physical restraint. To focus the review, three questions are posed: How is Physical Restraint currently defined in research and practice? How is Physical Restraint currently regulated in terms of legislation and/or policies interstate and internationally? Is it possible to minimise or eliminate the use of restraints and if so how might this be achieved in Victoria? Here it should be noted that physical restraint is only one form of intervention commonly referred to in Australian jurisdictions as a restrictive practice. The Victorian Law Reform Commission (2003) included in their definition of restrictive practices: mechanical restraint of a person for behavioural control purposes, for example using straps to restrain a person who is behaving aggressively;

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 physical restraint of a person for behavioural control purposes, for example holding a person down; seclusion of the person, for example locking a person in an area apart from others; locking doors to prevent a person leaving a facility or an area within the facility; and prescribing medication to control a persons behaviour. In the provision of support services these practices include, but are not limited to: Physical restraint or containment; Restricted access (e.g., to places, possessions or preferred activities, etc); Exclusionary time-out or seclusion; Response cost (e.g., removal of possessions or limiting rights as a consequence to specific behaviours); Overcorrection; and On-going chemical sedation or PRN medication intended to modify behaviour. Restrictive practices are distinct from other forms of intervention in that, when permitted, can only be implemented with the explicit consent of the person subject to the practice, or the consent of a legally appointed Guardian. Furthermore, it is usually a requirement that they be enacted only as part of a formally established behaviour intervention and support programme, which includes comprehensive guidelines concerning implementation, monitoring and review of all such practices. Restrictive practices are distinct from prohibited practices which are interventions or strategies that cannot be legally used under any circumstances (e.g., NSW Guardianship Act, 1987) because they: Are degrading or demeaning; Involve intimidation or aversive practices; Involve denial of access to basic supports or prevent the person fulfilling their basic needs; e.g., preventing access to food, personal possessions, contact with significant others or their usual routine and/or their preferred means of communication; Involve wrongful imprisonment, including unauthorised modification of equipment essential to their mobility; Give rise to assault or abuse, or any other action causing physical pain or serious psychological distress; and Involve the unauthorised use of medication. It is important that criteria such as those described above (from the Victorian Law Reform Commission and the NSW Guardianship Act) be included in educational programmes for all staff providing services to people with disability (e.g., direct support staff, health/allied-health staff and management). Furthermore, these criteria should be used in the development of practice guidelines and standards against which documented programmes and clinical/support practices are reviewed and audited. At the outset of the current review it is worth noting that, internationally, the necessity and legitimacy of including restraint as part of a persons programme of support in disability services is being questioned. There are jurisdictions where policy and procedures governing restraint, traditionally regulated in the context of a restricted practice, are moving towards the elimination of restraint (e.g., Department of Public Welfare, 2006; Smith et al., 2005) at least relegating the use of such procedures as only part of a broader array of strategies and then only as a strategy of last resort. Importantly, there is a growing body of evidence to support the position that practices involving restraint and seclusion should not be considered as elements of either an educational or therapeutic programme, and where used they should be reserved as an option of last resort to provide short-term protection to the focus person or others immediately in danger as a consequence of the focus persons actions (e.g., Department of Health, 2002; National Association of State Mental Health Program Directors, 2007).

Physical Restraint in Disability Services 15

In Australia, the most recent and wide-ranging inquiry into the support needs of people with disability who use behaviours of concern concludes, among other things, that: It is only in the development of that plan [a positive behaviour support plan] that justification will be found for the use of a restrictive practice. Restrictive practice is not an end in itself. It will be permissible only if necessary for the proper care and support of the person with the objective of the plan being the overall well being and welfare of the person. The objective of that Plan has to be to eliminate the need for the restrictive practice in the life of the person; so too its use, pursuant to a least restrictive alternative policy, will only be available as part of a well developed Positive Behaviour Support Plan after comprehensive assessment of the needs of the person and their relevance to the disturbed behaviour which is of concern (Carter, 2006, p. 152).

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4. Historical Developments in the Non-Restraints Movement

Concerns about the appropriateness and necessity of using physical and others forms of externally imposed restraint are not recent phenomena in human services. LeBel (2006) reports the earliest recorded efforts to replace the use of restraint and seclusion in human services were those initiated in England by William Tuke, in about 1792. Tukes facility, The Retreat at York distinguished itself from other institutions of the day by substituting coercive practices with teaching self-control techniques and the therapeutic use of meaningful and productive work. The work of Tuke fueled and informed the non-restraint movement in the United Kingdom. Contemporary with Tukes reforms, French physician Philippe Pinel in 1793 ordered patients at the Bictre hospital and the Salptrire hospital, to be released from their chains. After William Tuke, Edward Parker Charlesworth, Robert Gardiner Hill and John Conolly followed in this movement of reform. Edward Parker Charlesworth and Robert Hill worked in a small asylum at Lincoln, of approximately 100 patients. They are credited with developing a social mode of treatment where by mechanical restraint and coercion were made unnecessary by 1838. Similarly John Conolly is recorded as having eliminated the use of mechanical restraint at his 1,000 bed facility at Hanwell, in 1839. Conollys success was attributed to an environment that emphasised the importance of individualised treatment, exercise, spirituality and physical comforts: good food, bathing regularly, environmental cleanliness and occupation. Central to Conollys work was the concept of supporting the persons recovery through involvement in structured leisure and every-day self-care tasks, rather than the traditional focus on simple long-term care and containment. Here it should be noted that some of Conollys philosophy is reflected in more contemporary systems such as Active Support (Felce, Lowe, & Jones, 2002; Mansell, Elliot, Beadle-Brown, Ashman, & Macdonald, 2002; Stancliffe, Harman, Toogood, & McVilly, 2007), currently being implemented in the United Kingdom, Australia and, more recently, in the United States of America. Active Support will later be discussed as one example of a multi-element systemic intervention with the potential to enhance peoples engagement in meaningful activity, decrease their behaviours of concern and as a consequence staff reliance on restraint and restrictive practices. Ferleger (2007) reports that in the United States, restraint remained a common place part of treatment until, in Massachusetts in 1911, Dr. Vernon Briggs successfully pursued restraint legislation designed to eliminate the patient abuse he had witnessed in hospitals for the insane. In support of the legislation, Dr Briggs noted that at Northampton and Danvers State Hospitals little if any restraint had been used for ten years or more. He attributed the lack of necessity for physical or mechanical restraint in these institutions to the effective use of occupational therapy. Consequently, a feature of the new Massachusetts laws were a requirement that nurses, attendants and patients all be provided tuition in arts, crafts and various occupationally related skills. Physical interventions such as restraint and seclusion have however, endured in the systems and cultures of services supporting vulnerable individuals such as prisoners, those with mental illness and intellectual disability. This is despite the known dangers to both people receiving support and those providing their support. For example, the phenomenon of the insane ear has been well documented in the medical literature since the early part of the twentieth century (Murray & Turner, 1990). This condition was documented to take the form of a significant enlargement of the left ear of patients with schizophrenia, and commonly co-existing with fractured ribs. Its etiology was debated, until it was acknowledged that this condition arose as a direct consequence of staff management strategies. In more recent times, physical intervention involving restraint in particular has reemerged as one means by which the service system has sort to address issues concerning occupational health and safety for staff. Training staff in various methods of control and restraint has been adopted by the service system as an acceptable means of managing risk of violence in the workplace. However, there is little if any research evidence to suggest that such strategies are effective, only claims made by those responsible for dissemination (selling) the various training programmes (Leadbetter, 2002). These issues will be further addressed later in the current review.

Physical Restraint in Disability Services 17

5. Current Rates of Restraint and Seclusion

Generally, the literature reports three accepted ways of measuring the rates of restraint and seclusion (Fisher, 1994): measuring the proportion of people admitted to a facility over a defined time period who were secluded during admission; measuring the proportion of people resident in a facility who were secluded over a defined time period; and measuring the number of hours of restraint or seclusion per person or per episode. Comparing the results of different studies is therefore problematic. Furthermore, studies of the rates of restraint and seclusion of adults with intellectual disability are few (Jones, Allen, Moore, Phillips, & Lowe, 2007) and, as noted earlier in this report, publicly available data from government agencies not easily sourced. However, in Victoria the public record reports that during 2005/06, on average, 28% of residents in accommodation services were subject to restraint and/or seclusion and 23% of clients in respite services were subject to restraint and/or seclusion (Intellectual Disability Review Panel, 2006). Garrison (1984) commented that seclusion rates were higher for those with diagnoses of mental retardation, developmental disability and neurological impairment, and Millstein and Cotton (1990) found that children with specific learning disabilities were more likely to be secluded. Individuals with dual disability could be at high risk for seclusion and restraint, especially when presenting with co-existing behaviours involving self-injury (e.g., biting, pinching, head banging). Emerson et al. (2001), in a review of studies conducted between 1994 and 2000 reported that 5% of children with intellectual disability and self-injurious behaviour were usually subject to restraint or seclusion and that for adults these figures ranged from 7% to 17%. Emerson further notes that 10% to 15% of adults with ID demonstrate behaviours of concern and over 50% of these are subject to restraint & seclusion. Reflecting on broader data, Emerson concluded that the rate of mechanical restraint in UK disability services had not decreased in the past 20 years, despite a shift in service provision from large congregate care to small-scale, community based facilities. Sailas and Fenton (2000) in a systematic review of the literature, conducted as a study under the guidelines for the Cochrane Collaboration, reported that the use of seclusion varies widely across institutions (e.g., from 0 to 66%; Brown 1992). The review also noted there are reports of patients treated effectively with no use or very little use of restraint and seclusion in many psychiatric settings. Importantly, Sailas and Fenton concluded that the lack of high quality data on both the prevalence and effectiveness of restraint and seclusion needs to be addressed in order to make sound evidence-based decisions concerning their use in clinical and support settings. However, Fenton also noted that there exists important qualitative evidence to indicate that the continued use of restraint and seclusion results in substantial deleterious physical and, more often, psychological effects on patients and staff (p.8). In a follow-up Cochran review concerning the evaluation of alternatives to restraint, seclusion and pharmacological management strategies, Muralidharan and Fenton (2006) reported that no studies met inclusion requirements for a controlled study of sufficient quality on which to make an evidence-based recommendation for clinical practice. The authors concluded that the current alternative approaches are not supported by evidence from well controlled studies. However, they conceded that in practice it is difficult to ethically justify the use of the gold-standard, randomised controlled trials in this field of research. Livingstone (2007) in a review of seclusion practices mainly in mental health services found that, internationally, there are relatively few studies of seclusion rates. Those identified came mostly from the United States and from Britain. It was reported by Livingston that the available evidence indicated that seclusion is used less in European countries, including the United Kingdom, than in North America. However, the criteria for seclusion and the methods of measurement across studies are noted to vary, making comparisons difficult. Mattson and Sacks (1978) described seclusion in a private voluntary psychiatric ward of a New York general hospital, finding that 7.2% of patients required seclusion over the study period. In a study of 450 consecutive admissions at an adult and adolescent New York municipal hospital, Plutchik, Karasu, Conte, Siegel, and Jerrett (1978) reported that 26% of patients were secluded at some stage. Schwab and Lahmeyer (1979) undertook a prospective trial over 6 months in a single unit of a US university hospital, finding that 36.6% of admissions required seclusion at some stage. During the 1980s, Soloff and Turner (1981) conducted an 8-month prospective study of 39 secluded patients and 159 controls on two acute treatment units of a Pittsburgh university hospital, finding that 10.5% of admissions required

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seclusion on at least one occasion. Oldham, Russakoff, and Prusnofsky (1983) looked at 313 voluntary and involuntary sequentially admitted patients to a New York state hospital. The authors reported that 18% of patients were secluded at some stage. Thompson (1986) found that 2.6% - 3.3% of the patients admitted to hospitals in the Newcastle area of England over a period of three years were secluded at some stage of their admission. The catchments area was 426,000 persons, the total number of admissions was 7404, and the total number of seclusions was 213. Hammill, McEvoy, Koral, and Schneider (1989) in a study of 100 voluntary and involuntary sequential admissions to an adult schizophrenia unit in Pittsburgh found that 26% were subject to seclusion during their hospitalisation. Way and Banks (1990) reported that in a single group of 23 state psychiatric hospitals, all operating the same policies and procedures, considerable variation in the rates of seclusion and restraint were found, ranging from 0.4 to 9.4% of patients. Some differences between hospitals could be explained by patient characteristics and there was a significant effect for size of facility, with the instance of restraint higher in larger institutions. In Ireland, it has been reported that in 2000, 2942 episodes of seclusion were administered to 559 patients (2.7% of admissions) (Inspector of Mental Hospitals, 2001). The figures included patients in intensive care units as well as in acute units, but also included child, adolescent and aged psychiatry seclusion incidences. El-Badri and Mellsop (2002) found a seclusion rate of 16% in a general adult unit in New Zealand. Freuh et al. (2005) conducted a study of 142 randomly selected adult psychiatric patients recruited through a day hospital program in South Carolina, of which 59% were found to have experience of being secluded. In Australia, data submitted (voluntarily) to The Australian Council on Healthcare Standards (ACHS) indicated rates of seclusion in health services to be 9.93% of patients admitted to public hospitals and 1.68% of admissions to private hospitals. In Victoria, data submitted from 14 health service providers in 1999 indicated an overall seclusion rate of 14.85% of admissions, and from 13 providers in 2000, indicated an overall seclusion rate of 14.4% of admissions. These data compare with data reported by the Chief Psychiatrists Quality Assurance Committee (Harte & Burgess, 2003), which found that 13.1% of admissions into public mental health services in Victoria in 1999-2000 included a seclusion episode at some stage. Livingstone (2007) cautions that it is possible rates for the other states may be underrepresented in the ACHS figures as data collection was more complete within Victoria, and a higher rate of Victorian hospitals submitted voluntary data. In 2003, the Victorian Law Reform Commission noted in their report that in the period covering April 2002 restraint or seclusion measures were applied to 1285 people using Department of Human Services (DHS) services. However, the commission commented that this figure was likely to be an underestimated and that they were unable to obtain what they believed constituted accurate figures pertaining to the rate of restrain or seclusion. Figures for the health system in Victoria need to be contrasted with those reported in Victoria by the IDRP for 2005/06 indicating that 28% of residents in disability accommodation services were subject to restraint and/or seclusion and 23% of clients in disability respite services were subject to restraint and/or seclusion (Intellectual Disability Review Panel, 2006). The Carter Report (2006), conducted in Queensland by Justice Carter QC, includes documentation concerning 312 people with complex and challenging behaviour identified as currently receiving supported accommodation either directly provided by Disability Services Queensland (DSQ) or funded in the non-government sector by DSQ, and whose challenging behaviour was either being managed by the use of restrictive practices or was at risk of requiring restrictive practices. A sub-total of 132 of these people were supported in government operated services, representing 2.3% of all persons directly supported by DSQ. There were a further 180 individuals, representing 1.3% of the total number of persons supported in the funded, non-government service sector. Justice Carter notes that while these figures represent a comparatively small number of individuals, their legal circumstances and the costs associated with their support should be of major concern to the community.

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6. Contemporary Directions in the USA, the UK and New Zealand

There follows an overview of legislation, policy and service development in the United States of America, the United Kingdom and New Zealand. These three jurisdictions have similar legal frameworks to those of Australias states and territories, and both historical and contemporary service development issues across these jurisdictions display many parallels with developments in Australia.

6.1 United States of America

In more recent years, litigation in the United States of America has been a major impetus for changes in policy and clinical practice involving the use of restraint and seclusion. Courts in various jurisdictions have recognised that, initially, people with mental illnesses and, more recently, those with developmental disability, have the right to be free from the improper use of restraint and seclusion. In 1982 the U.S. Supreme Court decreed that the use of restraint is a drastic deprivation of personal liberty, holding that the right to be free from undue bodily restraint is the core of the liberty interest protected by the Due Process Clause from arbitrary governmental action (Youngberg v. Romeo, 457 U.S. 307, 316 [1982]). Consequently, health services across the USA found it necessary to review their policies and procedures. Similarly, in Australia, it is highly likely that litigation will become an increasingly important factor contributing to the impetus for systemic change, particularly given the trend towards the enshrinement of rights in legislation (e.g., Victorian Charter of Human Rights and Responsibilities Act 2006) In 1985 the American Psychiatric Association commissioned a report on the use of seclusion and restraint. The research included a survey of state mental health directors. The Task Force noted significant variations in regulations between institutions and across jurisdictions. The report found that most state regulations in the USA did not define seclusion or restraint, and only four specified the person responsible for ending seclusion and restraint episodes. At least eight states permitted the use of seclusion and restraint to prevent substantial property damage alone, two states permitted the use of these interventions to prevent disruption of the treatment environment, and four states allowed their use as part of a regular treatment plan. The Task Force concluded that there was an urgent need to develop and implement national guidelines concerning seclusion and restraint practices (APA Task Force on Psychiatric Uses of Seclusion and Restraint, 1985). The urgent need for reform was brought to the attention of the wider community in a series of articles published in 1998 by the Hartford Courant (Weiss, 1998). These articles documented 142 deaths across the USA, between 1988 and 1998, with a quarter of those deaths being children. Subsequent research conducted by the Center for Risk Analysis at Harvards School of Public Health and published in the Hartford Courant estimated that between 50 and 150 deaths were occurring each year attributable to the use of restraint and seclusion. In 1999, the Centers for Medicare and Medicaid Services (CMS) published an Interim Final Rule governing the use of restraint and seclusion in hospitals, including psychiatric hospitals (Health Care Financing Adminstration, 1999). This ruling was further amended in 2001 (Health Care Financing Adminstration, 2001). It adopts a regulatory framework that distinguishes restraints used for behavior management from other kinds of restraints used in hospitals and provides the following principles: The patient has the right to be free from restraint and seclusion, in any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 42 C.F.R. 482.13(f)(1) (1999). Restraint and seclusion can only be used in emergency situations if needed to ensure physical safety and if less restrictive interventions have been determined to be ineffective. 42 C.F.R. 482.13(f)(2) (1999). For the purposes of the Medicare and Medicaid regulations, restraint is understood to mean: Any manual method, or any physical or mechanical device, material, or equipment attached or adjacent to the patients body that he or she cannot easily remove, that restricts freedom of movement or normal access to ones body; and A drug used to control behavior or to restrict the patients freedom of movement that is not a standard treatment for the patients medical or psychiatric condition.

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The regulations define seclusion broadly to mean the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving. 42 C.F.R. 482.13(f)(1) (1999). Also in 1999, the US National Association of State Mental Health Program Directors (NASMHPD) adopted a formal position statement calling for the reduction and, ultimately, the elimination of the use of restraint and seclusion. This position statement was affirmed and strengthened in July of 2007 (NASMHPD, 2007). The position statement provides that these practices, which include chemical restraints, are safety interventions of last resort and should never be used for the purposes of discipline, coercion, or staff convenience, or as a replacement for adequate levels of staff or active treatment. More recently, NASMHPDs National Technical Assistance Center (NASMHPD-NTAC) has created a staff training curriculum with the explicit intention of training staff in order to reduce the use of restraint and seclusion. Elements of this curriculum will be discussed later in the current report. In 2002, the California Service Employees International Union (SEIU), the largest labour organisation of public mental health workers in the USA, and the California Network of Mental Health Clients adopted a joint position that the US mental health system needed to undergo a fundamental change in its culture. Of particular concern in the joint statement was the use of restraint and seclusion, stressing the need for de-escalation training, individual crisis plans and peer support for staff. In a similar vein, in 2003, the US Federal Substance Abuse and Mental Health Services Administration (SAMHSA) issued a National Call to Action concerning restraint and seclusion (National Association of Consumer/Survivor Mental Health Administrators for the Substance Abuse and Mental Health Services Administration, 2005). SAMHSA indicated its commitment to work with state governments, local communities, consumers, families, service providers and staff to eliminate the use of restraint and seclusion. Most US states now have laws, regulations, or policies explicitly governing the use of restraint and seclusion that reflect the minimum standards provided in the Federal regulations (Haimowitz, Urff, & Huckshorn, 2006). The basic tenets of these standards are reflected in the Behavioral Health Standards of the Joint Commission on the Accreditation of Healthcare Organisations (JCAHO; www.jointcommission.org) and in policy statements adopted by major professional organisations for health and allied health professionals in the USA. These organisations include: the Child Welfare League of America; the American Academy of Child and Adolescent Psychiatry; the American Association of Community Psychiatrists; the National Alliance for the Mentally Ill; the National Mental Health Association and The Bazelon Center for Mental Health Law. The American Association on Intellectual and Developmental Disability (AAIDD formally AAMR) and the Arc, in 2002, have adopted a joint policy position (AAIDD & Arc, 2002). Concerning behaviour intervention programmes for people with intellectual disability, they must not withhold essential food and drink, cause physical and/or psychological pain, use drugs as restraints, or produce humiliation or discomfort. The American Psychiatric Association, the American Psychiatric Nurses Association, and the National Association of Psychiatric Health Systems (2003) jointly undertook a review of US national policy on the use of restraint and seclusion. The final report concludes, what is clear in all of these standards is a national intent to see that restraint and seclusion are used appropriately, as infrequently as possible, and only when less restrictive methods are considered and are not feasible (p.4). In 2004 the Alliance to Prevent Restraint, Aversive Interventions, and Seclusion (APRAIS) was formed by a number of major educational, advocacy and research organisations in the USA. Member organisations now include: Autism National Committee, Bazelon Center for Mental Health Law, National Association of Councils on Developmental Disabilities, National Disability Rights Network, National Down Syndrome Congress, National Down Syndrome Society, The Arc of the United States, The Association for Persons with Severe Handicaps, The Family Alliance to Stop Abuse and Neglect, and The RespectABILITY Law Center. APRAIS members are working to identify the laws, regulations, and policy loopholes that permit the use of aversive interventions, non-emergency restraints and seclusion. The stated objectives of APRAIS are (www.aprais.org): To seek the elimination of the use of seclusion, aversive interventions, and restraint to respond to or control the behavior of children and youth;

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 To prohibit the incorporation of these practices into the education, habilitation, or other service delivery plans provided to children and youth with disabilities; To promote nationwide consistency in the protections, monitoring, and reporting that will keep children and youth safe from restraint, seclusion, and aversive interventions, ensuring that children enjoy equal rights and protections across all settings in which they receive education, health services, mental health services, correctional services, residential or foster care, and all other services; To educate our constituencies, providers, policy makers, and the public at large to understand that restraint is not treatment but represents failure to provide appropriate services and supports, that there is no evidence to justify the use of seclusion and aversive interventions under any circumstances, and that tolerance of restraint, seclusion, and aversive interventions causes serious physical and psychological harm, results in the dehumanisation of all involved, prevents the development of respectful and supportive relationships between children and adults, and leads to the segregation and exclusion of children from their communities. The Association for Persons with Severe Handicaps (TASH) adopts the position, we are against seclusion and aversive interventions under any circumstances and we are against the unnecessary use of restraint (Weiss, 2005, p. 44). With respect to moving towards a definition of acceptable conditions for the use of appropriate restraint, TASH consider permissible interventions that have a specific medical function, such as to enable a person to undergo a procedure or to recover form a procedure, and where brief physical intervention is necessary to support a person regain control over their own circumstances in order to prevent harm to the person or others. In 2006, the Pennsylvania Department of Public Welfares Office of Mental Retardation adopted the position that: The elimination of restraints is a key factor in ensuring that individuals experience a quality of life that is consistent with the Everyday Lives philosophy. The values inherent in Everyday Lives and Positive Approaches suggest that restraints and restrictive procedures can be drastically reduced and many times eliminated by focusing on what the individual is trying to communicate, how we help to guide the individuals efforts in moving towards positive outcomes, and by ensuring that each individual is properly diagnosed and receiving quality supports. The use of restraints as a behavioral intervention continues to be a concern both in Pennsylvania and nationally due to the risk of serious injury and death, emotional harm and trauma, and the disruption of relationships with family members, peers, and staff. Except in case of emergency, OMR is dedicated to the need for ongoing reduction and the eventual elimination of all restraints and restrictive procedures (Department of Public Welfare, 2006, p. 2). The policy position in Pennsylvania was reached following the review of a 10-year state-wide pilot programme designed to reduce the use of seclusion and mechanical restraint. Data spanning the period from 1990 to 2000 indicated that the rate of seclusion in the state had been effectively decreased from 4.2 to 0.3 episodes per 1,000 patient days. Furthermore, the average duration of seclusion decreased from 10.8 to 1.3 hours. The rate of restraint decreased from 3.5 to 1.2 episodes per 1,000 patient-days. The average duration of restraint decreased from 11.9 to 1.9 hours. Furthermore, there was no increase in the rate of staff injury across this same period (Smith et al., 2005). The current US National Core Indicators, used to assess quality in the delivery of services to adults with developmental disability across the United States of America, include assessment of the use of restraint in Domain 3, which addresses issues relating to safety and personal security, health and wellness, and protection of and respect for individual rights. It adopts as a measurable standard of practice that the system makes limited use of restraints or other restrictive practices (NASDDS, 2007). Attainment of this standard is measured against two criteria: (1) the incidence restraints reported in the past year, by type of restraint and by living arrangement; and (2) the incidence of serious injuries resulting from the use of restraints.

6.2 United Kingdom

In the United Kingdom research suggests that the most commonly used forms of restrictive practices to manage people with intellectual/learning disability who display behaviours of concern have been found to be; psychotropic medication

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(49%), physical restraint (44%), sedation generally (35%), and seclusion (23%) (Emerson et al., 2001). In recent years however, there has arisen a renewed focus on the non-restraints movement, especially following the implementation of the Valuing People white paper in 2001. In 2002, the UK Department of Health (in co-operation wit the Department of Education) issued its Guidance for Restrictive Physical Interventions: How to provide safe services for people with Learning Disabilities and Autistic Spectrum Disorder. The purpose of the guidelines was sated to be: to ensure that restrictive physical interventions (which employ force) are used as infrequently as possible, that they are used in the best interests of the service user, and that when they are used, everything possible is done to prevent injury and maintain the persons sense of dignity. Restrictive physical intervention should be seen as one part of a broader strategy to address the needs of children and adults whose behaviour poses a serious challenge to services (Department of Health, 2002, p. 2). The UK guidelines go on to emphasise: The inappropriate use of restrictive physical intervention may give rise to criminal charges, action under civil law or prosecution under health and safety legislation. As a general rule, restrictive physical interventions should only be used when other strategies (which do not employ force) have been tried and found to be unsuccessful or, in an emergency, when the risks of not employing a restrictive intervention are outweighed by the risks of using force (p.3). The Mental Welfare Commission for Scotland (MWCS) issued revised guidelines on the use of restraint in 2006 . The guidelines outline what the commission assert to be general principles that apply to the use of restraint in any care setting. The guidelines define restraint in a broad context and in so doing seek to identify situations of restraint that might be a daily occurrence in care environments but otherwise go without recognition or review: restraint is taking place when the planned or unplanned, conscious or unconscious actions of care staff prevent a resident or patient from doing what he or she wishes to do and as a result is placing limits on his or her freedom (Mental Welfare Commission for Scotland, 2006, p. 2). The MWCS guidelines consider the use of verbal control as a form of restraint. While acknowledging that such control can be considered the least restrictive of restraints, it notes that such control, especially where it could involve intimidation should be reviewed on a regular basis as would any other more obvious (e.g., physical) form of restraint. The MWCS guidelines also explore the concept of restraint by default. These forms of restraint are noted to include the use of a range of devices commonly justified as therapeutic (e.g., splints), the failure to provide access to appropriate equipment (e.g., a walking aid), the failure to maintain equipment (e.g., regularly charging an electric wheelchair or communication device) or interference with equipment (e.g., disengaging the drive shaft on a wheelchair or applying the breaks where the person cannot disengage them independently). The Royal College of Psychiatrists in providing guidance to clinicians defines seclusion as the supervised confinement of a patient alone in a room, the essence being the involuntary isolation of the patient (1995, p. 4). However, the guidelines note that the policy of both the UK Department of Health and the Welsh Office narrow the definition to those occasions when, as a clinical procedure, it is used to protect others from significant harm. The Colleges guidance goes on to include within the definition of seclusion those occasions when a door is open or unlocked as well as when the patient is locked in his room overnight. The guidelines discuss the use of restraint as a range of procedures spanning the use of medication, garments, together with the use clinicians make of the physical and social environment in which the person resides. The Royal College of Psychiatrists guidelines recommend that restraint should be subject to the formal framework of 'control and restraint' techniques which require supervised training and monitoring. The nature and place of restraint requires further scrutiny. Furthermore, seclusion is to be considered an emergency measure to be used only where there is a significant risk of harm to the patient or others. The guidelines recommend that seclusion in particular should be used as infrequently as possible and only for as long as it takes for the patient to return to a calmer frame of mind. The Royal College of Psychiatrists guidelines express the view that although it has been proposed that seclusion be phased

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out altogether, there remains some occasions when the alternatives are inadequate or more unpleasant. Furthermore, its removal would carry the risk that the practice would continue but under another name. The Royal College of Psychiatrists asserts that continued recognition of seclusion as a procedure has the advantage that its use is controlled, recorded and externally monitored. The British Psychological Society (BPS) has published a new set of Clinical Practice Guidelines (Ball, Bush, & Emerson, 2004). These guidelines specifically address psychological and behavioural interventions for people with learning disabilities (i.e., Intellectual Disabilities) and severe challenging behaviour. The guidelines caution that both informal and formally constituted behaviour intervention plans could be contra to both civil and criminal law if the procedures or strategies adopted constitute assault (where a person is in fear of attack) and/or battery (where a person is subject to unlawful touching, holding or pushing). Furthermore, the guidelines caution against strategies that could limit a persons freedom of movement, including the use of seclusion and time out procedures, and in so doing constitute the criminal offence of false imprisonment. The BPS clinical practice guidelines (Ball, Bush & Emerson, 2004) acknowledge that the law recognises occasions when actions which may be illegal might be justified if there is an overriding need to prevent a greater harm. For example, to prevent suicide or to prevent other people being harmed, or to prevent damage to property. The guidelines note that in the UK, people with learning disabilities can be detained lawfully under the Mental Health Act if they are deemed to have a mental disorder. However, following recent rulings by courts in the UK, there is debate about the legality of restricting the movements of people with learning disabilities who can not easily give consent, and are not properly detained under the Mental Health Act by virtue of having a diagnosed mental illness. Consequently, clinicians and those providing direct support to people with disability remain at risk of prosecution where they employ strategies that employ restraint and/or seclusion. Importantly, the BPS clinical practice guidelines (2004) identify that a successful outcomes for an intervention can be demonstrated if there is an improvement in quality of life for the person subject to the intervention where, for example, there is evidence of a reduced use of physical restraint by staff, even if the frequency of the behaviour has not significantly changed (p.36). The reduction and ultimate elimination of the use of restraint and seclusion is therefore considered to be a highly desirable clinical and administrative goal. Furthermore, the British Institute of Learning Disabilities (BILD) has published a major review of the use of physical interventions in the context of the law in England, Wales and Scotland (Lyon & Pimor, 2004). This wide-ranging and comprehensive report identifies among many things the various civil and criminal liabilities to which both service providers and their staff could be held accountable for the improper use of restraint and related strategies. While the report relates essentially to laws in the UK, given the relationships between the law in the UK and Australia, especially with respect to judicial precedent in the interpretation of the Common Law, the guidance provided in Lyon and Pimor (2004) could be considered informative for the development of policy and procedures in Australia. The current review however, will not attempt to summarise the report nor does it purport to offer legal interpretation. BILD has sponsored the development of a suite of resources designed to assist service providers evaluate and, where necessary, modify their use of restraint and related practices in keeping with current legal requirements, evidence-based practice and contemporary ethical standards of practice (e.g., Allen, 2004; Allen, 2002; Paley & Brooke, 2006). BILD has also been commissioned by the UK government to oversee a national training and accreditation programme in the safe use of physical interventions; see www.bild.org.uk/03behaviour_pi.htm. Elements of the BILD programme will be discussed later in the current report.

6.3 New Zealand

In New Zealand, the use of restraint and seclusion in some circumstances have been found to represent a breach of the New Zealand Code of Health and Disability Services Consumers' Rights. The complaints commission has on previous occasions found, for example: that the fitting of the restraints (to ensure the young man could not harm himself or others) was

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undertaken in a manner which ensured he was as comfortable as possible in the circumstances. However, the approach appeared to be to control behaviour rather than train and develop behaviours (Health Complaints Commission, 1996); and Prolonged restraint of the young man during his waking hours not only restricted him from participating in activities of which he was capable, but further hindered any ongoing development (Health Complaints Commission, 1997). In particular, the New Zealand Health Complaints commission has found the inappropriate use of restraint and seclusion to breach Right #3 and Right #4 of the Code of Health and Disability Services Consumer Rights: Right 3 Right 4 Every consumer has the right to have services provided that complies with legal, professional, ethical, and other relevant standards. Every consumer has the right to have services provided in a manner consistent with his or her needs. Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer. Every consumer has the right to have services provided in a manner that respects the dignity and independence of the individual.

More recently, the use of seclusion has been the subject of a two year review by the New Zealand Mental Health Commission (between 2002 and 2004) (Mental Health Commission, 2004). The Commissions report concludes that it would like to see a significant reduction in seclusion use and its eventual eradication (p. 13). The report proposes that eradication of the use of seclusion would require several years of development work including research, staff training programmes, which would promote ways to prevent seclusion and identify humane alternatives, and a strengthened monitoring regime. The report emphasises that the strengthened monitoring regime is of utmost importance. To further the purposes of monitoring, the Mental Health Commission recommended that all instances of seclusion be classified a critical incident or reportable event. The Mental Health Commissions report supported and encouraged further strengthening of the existing Restraint Minimisation and Safe Practice Standard 2001, with greater emphasis to be placed on the use of the least restrictive practice and demonstrated competence on the part of staff to use de-escalation skills. This is consistent with the recent findings of the New Zealand Human Rights Commission which has found that although New Zealands present legal framework does not breach human rights law, the way it is implemented does not sit easily with some New Zealands international commitments (Human Rights Commission, 2008; p. 6.). It would be worth while reviewing policy and practice in Victoria in a similar vein. In the New Zealand health system generally, the use of restraint and seclusion (seclusion is defined as a form of restraint) is regulated by the Mental Health Compulsory Assessment and Treatment Act 1992. The Act is explicit that that every service user is entitled to the company of others, except in certain circumstances when they may be placed in seclusion. The Act states that seclusion may be used for the care or treatment of the service user, or protection of other persons in the ward (section 71); legally, seclusion can be used as a therapy and as a containment procedure, while it cannot be used as a form of punishment. Each hospital or service must keep a register of seclusion (section 129b). The responsible clinician has the authority to use seclusion in accordance with the provisions of the Act and any concerns regarding the use of seclusion can be referred to the Director of Mental Health, who can direct District Inspectors to investigate any concerns. The Ministry of Health has a Restraint Minimisation and Safe Practice Standard (2001), which replaces the Procedural Guidelines for the Use of Seclusion (1995) as the primary reference document for practice (Standards New Zealand, 2001). However, in 2008, Standards New Zealand will issue a new Restraint Minimisation and Safe Practice Standard, to replace that existing standard originally published in 2001 (NZS 8141:2001). This document is expected to reflect changes in practices with a greater emphasis on restraint minimisation.

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With respect to disability services, New Zealand has specific legislation in the form of the Intellectual Disability Compulsory Care and Rehabilitation Act 2003. According to section 4, the Act provides a system for the compulsory care and rehabilitation of persons who have an intellectual disability and who have been charged with, or convicted of, an offence. There are two ways in which a person can become subject to the Act: (a) by an order made in the course of a criminal proceeding brought against the person; or (b) by changing the regime applicable to the person from one made under the Corrections Act 2004 or the Mental Health (Compulsory Assessment and Treatment) Act 1992 to an order under the new act. Such a change generally requires an order of the Family Court of New Zealand. Persons subject to this Act are known as care recipients. Care recipients who are special care recipients must receive secure care, while other care recipients may be eligible for supervised care; that is care that may be given in a place other than a secure facility. Under the New Zealand Legislation a care manager (a person specifically appointed by a Care Co-ordinator, and authorised by the Director General) may restrain a care recipient if that is necessary to prevent the care recipient from: (a) endangering the health or safety of the care recipient or of others; (b) seriously damaging property; or (c) seriously compromising the care and wellbeing of the care recipient or of other care recipients (S61). However, a care recipient may not be restrained by the application of a mechanical restraint if one or more authorised individuals can personally restrain the care recipient to achieve the purpose for which the care recipient is to be restrained; and it is reasonably practicable for those individuals to do so. When restrained, section 61 of the New Zealand legislation prescribes that a person exercising the power of restraint may not use a greater degree of force, and may not restrain the care recipient for longer, than is required to achieve the purpose for which the care recipient is restrained; a person exercising the power of restraint must comply with guidelines issued under section 148 that are relevant to the restraint of the care recipient; in an emergency, a care recipient may be restrained by a person who, under a delegation given by the care recipients care manager, has immediate responsibility for the care recipient, but that person must immediately bring the case to the attention of the care manager; the duration and circumstances of each episode of restraint must be recorded in a register kept in accordance with guidelines issued under section 148 of the Act. Section 60 of the New Zealand Act provides for the use of seclusion. It defines seclusion to mean the act of placing the care recipient without others in a room or other area that (a) provides a safe environment for the care recipient throughout the care recipients stay in the room or area; but (b) does not allow the care recipient to leave without help. The Act provides for the use of seclusion by an authorised care manager to prevent the care recipient from: (a) endangering the health or safety of the care recipient; or (b) seriously compromising the care and wellbeing of other persons. The Act requires that a person who places a care recipient in seclusion must ensure that the care recipient is not placed in seclusion for longer than is necessary to achieve the purpose of placing the care recipient in seclusion; and must comply with guidelines issued under section 148 that are relevant to placing the care recipient in seclusion. In particular, a care recipient may be placed in seclusion only in a room or other area that is specifically designed for the purpose of seclusion in accordance with guidelines issued under section 148. In cases other than an emergency, seclusion may be used only with the authority of the care recipients care manager. In an emergency, a care recipient may be placed in seclusion by a person who, under a delegation given by the care recipients care manager, has immediate responsibility for the care recipient, but that person must immediately bring the case to the attention of the care manager. The duration and circumstances of each episode of seclusion must be recorded in a register kept in accordance with guidelines issued under section 148 of the Act.

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7. Legislation Governing the Use of Restraint and Seclusion in Australia

It is only in recent years that restraint and seclusion have been the subject of legislation in Australia. Prior to this, regulation was at the level of documented procedures within individual organisations, or some policy guidance provided by state government departments. Livingstone (2007) notes that: the degree of variation in definitions and regulation of seclusion in Australian legislation is considerable. A need for national standards on appropriate use of seclusion is acknowledged in the Draft National Action Plan for Safety Priorities in Mental Health 2005. However, the Australian experience may be indicative of a wider problem, as can be seen in the international literature (p.7). Furthermore, most efforts to formally define and regulate these practices have been in the area of mental health services. Victoria is the first Australian jurisdiction to enact legislative provisions within disability specific legislation with respect to restraint and seclusion.

7.1 Victoria (VIC)

Legal and procedural issues concerning restraint and seclusion of persons with disability were investigated by the Victorian Law Reform Commission (2003), in its report titled People with Intellectual Disabilities at Risk: A Legal Framework for Compulsory Care. This report addresses issues concerning the detention of people with disability without their consent in order to prevent harm to themselves or others, and decisions about restrictive care practices that affect the freedom of people who have an intellectual disability. The practices considered by the commission in its report include: mechanical restraint, (for example using a belt to restrain a person to prevent self-injury or injury to others); chemical restraint, which involves prescribing a person drugs to change that persons behaviour; and seclusion, which involves locking a person in a room apart from other people. Subsequently, many of the commissions recommendations been reflected in the Disability Act 2006 and in the procedures governing the role of the Senior Practitioner, created under the Act. The Disability Act 2006 makes reference to restrictive interventions which are understood to mean any intervention that is used to restrict the rights or freedom of movement of a person with a disability including; (a) chemical restraint; (b) mechanical restraint; and (c) seclusion (S3). Under the Act, the use of restrictive interventions is limited to those that have been explicitly authorised following a formal application to the Secretary of the Department of Human Services (S135). A disability service provider who, except as provided in section 140 or 147 of the Act, uses restraint or seclusion to a person with a disability is guilty of an offence under the Act (S149). Restraint is understood in the context of mechanical restraint, defined as the use, for the primary purpose of the behavioural control of a person with a disability, of devices to prevent, restrict or subdue a person's movement but does not include the use of devices; (a) for therapeutic purposes; or (b) to enable the safe transportation of the person (S3). Explicit reference is also made to chemical restraint, defined as the use, for the primary purpose of the behavioural control of a person with a disability, of a chemical substance to control or subdue the person but does not include the use of a drug prescribed by a registered medical practitioner for the treatment, or to enable the treatment, of a mental illness or a physical illness or physical condition (S3). Seclusion is also defined in the Act, as the sole confinement of a person with a disability at any hour of the day or night; (a) in any room in the premises where disability services are being provided of which the doors and windows cannot be opened by the person from the inside; or (b) in any room in the premises where disability services are being provided of which the doors and windows are locked from the outside; or (c) to a part of any premises in which disability services are being provided (S3). The role of the Senior Practitioner has been established under the provisions of the new Disability Act (Victoria) 2006. The Senior Practitioner is charged with responsibility for leading, monitoring and enforcing best practice in the support of people with disability who exhibit behaviours of concern and for whom physical and chemical restraint is subsequently used as part of their overall programme of support (Disability Act, 2006; Division 5, S24).

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Consistent with the Act, the Department of Human Services has issued a Restrictive Interventions Implementation Guide (2007). As the current report has been prepared for the Victoria Department of Human Services, it is not the intention of the author to replicate information already available to the DHS in their own documentation. Consideration will therefore be given to legislative and procedural documentation from other jurisdictions. However, to assist the reader to draw comparisons, some details of the Victorian legislation will be briefly discussed. Under the provisions of the Disability Act 2006, restraint or seclusion can only be used where these are demonstrated by a service provider to be the option which is least restrictive of the person as is possible in the circumstances (S140). Explicitly, they can only be used: to prevent the person from causing physical harm to themselves or any other person; or to prevent the person from destroying property where to do so could involve the risk of harm to themselves or any other person; and if the use and form of restraint or seclusion is the option which is the least restrictive of the person as is possible in the circumstances (S140). The use and form of restraint or seclusion must be included in the person's behaviour management plan; and only applied for the period of time that has been authorised by the Authorised Program Officer (S140) (i.e., a person nominated by a service provider and whose name and qualifications have been registered with the OSP) (S139). Notification of the intention to include a restrictive practice in a behaviour management plan must be given in writing to the OSP and is subject to review by VCAT. Where seclusion is proposed, the person must be supplied with bedding and clothing which is appropriate in the circumstances; and the person must have access to adequate heating or cooling as is appropriate in the circumstances; and the person must be provided with food and drink at appropriate times; and the person must have access to adequate toilet arrangements (S140). Under section 147 of the Act, restraint or seclusion can be used in the absence of an approved plan only in an emergency situation and where a service provider is of the opinion that there is an imminent risk of a person with a disability causing serious physical harm to themselves or any other person; and it is necessary to use restraint or seclusion to prevent that risk. If restraint or seclusion is used, it must be in the form of the option which is the least restrictive of the person as is possible in the circumstances. Furthermore, it must still be authorised by the person in charge of the disability service and the Authorised Program Officer must be notified without delay. A report of the use of such emergency procedures must be notified to the OSP within 7 days. In Victoria, the Chief Psychiatrist has issued revised guidelines (Tanaghow, 2006) on the use of restraint and seclusion under the provisions of the Mental Health Act 1986. These will be discussed later in the current report, in so far as they provide guiding principles applicable for use in the context of community-based supported living for adults with intellectual disability.

7.2 Australian Capital Territory (ACT)

The ACTs Mental Health (Treatment and Care) Act 1994 provides for the use of restraint and seclusion where a psychiatric treatment order has been made (Section 35 [1]). However, no explicit definition of restraint or seclusion is provided in the Act. These procedures are permitted under the Act (i) to prevent a person from causing harm to himself, herself or someone else; or (ii) to ensure that the person remains in custody under a treatment order. As part of the restraint, the person can be subject to involuntary seclusion where this is determined to be the only way in which to prevent the person from causing harm to himself, herself or someone else. Specific reasons for the restraint and / or seclusion must be entered into the persons medial record by the treating psychiatrist, an entry made in the facilitys formal register of involuntary restraint or seclusion, and the Public Advocate must be informed in writing within 24 hours. All such procedures are subject to review against the Objects of the Act (Section 7), with make explicit reference to the need to provide treatment, care, rehabilitation and protection for mentally dysfunctional or mentally ill persons in a manner that is least restrictive of their human rights (S7 [a]). Similarly, the ACTs Mental Health (Treatment and Care) Act 1994 provides for the use of restraint and seclusion where a community care order has been made under the Act. In these circumstances a designated Care Co-ordinator (a Ministerial level appointment), or their formal delegate, may subject a person to the level of confinement or restraint that

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is necessary and reasonable to prevent the person from causing harm to himself, herself or someone else; or to ensure that the person remains in custody under the provisions of their Community Care Order. The Care Co-ordinator is subject to the same administrative and reporting requirements as a psychiatrist; they must enter specific details in the persons medical record, enter the details in the institutions restraint and seclusion register and advise the Public Advocate in writing within 24 hours.

7.3 New South Wales (NSW)

The NSW Mental Health Act 2007 does not make reference to the use of either restraint or seclusion. It makes only a broad provision for the detention of persons who are either mentally ill (Section 14) or mentally disordered (Section 15). These powers are vested in designated medical officers or accredited persons appointed by the Director General (S9). Here it should be noted that a person (whether or not the person is suffering from mental illness) is a mentally disordered person for the purposes of the Act if the persons behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care, treatment or control of the person is necessary: (a) for the persons own protection from serious physical harm, or (b) for the protection of others from serious physical harm (S15). However, Section 16 of the Act identifies a number of circumstances which, on their own, are not sufficient to classify the person as mentally disordered for the purposes of authorising detention. These circumstances include, but are not limited to developmental disability of mind (S16 [j]) and anti-social behaviour (S16 [l]). Section 31 of the Act provides for limitations on the detention of persons detained on the ground of being mentally disordered, in which circumstances detention cannot exceed 3 days (excluding weekends and public holidays). NSW Health in a policy directive on seclusion defines seclusion as the supervised confinement of a patient alone in a locked room, from which the patient cannot leave of their own accord, at any time and for any duration and for any purpose (NSW Health, 2007; p.4). Under this directive, informal patients (i.e., those persons not held under an existing mental health order) may be secluded with their advance consent. The issue of substituted decision making for minors and persons with a legal guardian is also addressed. Clear directives are made regarding documentation in the persons file as well as the need for a central reporting mechanism for all instances of restraint and seclusion. Similarly, a draft policy directive of NSW Health (2007), Restraint, Seclusion and Transport Guidelines for Patients with Behavioural Disturbance, defines seclusion as, the placing of a patient, at any time and for any duration and for any purpose, alone in an area with the door or other exit closed in such a way as to prevent the egress of the patient. This second definition makes it clear that seclusion, for the purposes of regulation and reporting, can be a procedure implemented for any purpose.

7.4 Northern Territory (NT)

The Northern Territorys Mental Health Act 2005 provides for restraint and seclusion of person who are mentally ill or mentally disturbed. The Act defines a person as mentally disturbed simply if their behaviour is so irrational as to justify the person being temporarily detained under the Act (S4). The Act defines restraint in the context of mechanical restraint; .the application of a device (including a belt, harness, manacle, sheet and strap) on a person's body to restrict the person's movement but does not include the use of furniture (including a bed with cot sides and a chair with a table fitted on its arms) that restricts the person's capacity to get off the furniture (S61). The Act makes explicit direction to the effect that mechanical restraint of a person in an approved treatment facility may only be applied where no other less restrictive method of control is applicable or appropriate and it is necessary for one or more of the following: (a) for the purpose of medical treatment of the person; (b) to prevent the person from causing injury to himself or herself or any other person; (c) to prevent the person from persistently destroying property (S61[3]). The restraint can only be authorised by an approved psychiatric practitioner; or in the case of an emergency, by the senior registered nurse at an approved treatment facility who must then, as soon as practicable, notify the person designated as being in charge of the facility. The person must be kept under continuous observation and be reviewed by a registered nurse at intervals not exceeding 15 minutes at a time. The person must be examined by a medical practitioner within 4 hours and by an authorised psychiatric practitioner if the restraint is to exceed 6 hours. Restraint

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would not ordinarily exceed 12 hours. The Act further provides for the persons minimum comforts, including bedding, clothing, food, drink, access to a toilet and any other psychological and physical care appropriate to the person's needs (S61[8]). The authorised facility is required to maintain a record of all instances of mechanical restraint; including the name of the person, the reason for use, how it was applied, for what period of time and the intervals of review. A copy of the facility record is to be kept on the persons individual file. All such records are subject to review by designated Community Visitors (at least every 6 months). The Northern Territorys Mental Health Act 2005 also provides a definition of seclusion, understood to mean the sole confinement, at any hour of the day or night, of a person; (a) in a room of which the doors and windows are locked from the outside; or (b) in an area approved by the Chief Health Officer (S62). A person may be kept in seclusion in an approved treatment facility where no other less restrictive method of control is applicable or appropriate and it is necessary for the following: (a) for the purpose of the medical treatment of the person; (b) to prevent the person from causing injury to himself or herself or any other person; (c) to prevent the person from persistently destroying property. A person may be kept in seclusion only where it is approved by an authorised psychiatric practitioner; or in the case of an emergency, by the senior registered nurse on duty at the facility. In the latter instance, the senior registered nurse on duty must notify an authorised psychiatric practitioner as soon as practicable after approving seclusion. Under Section 62 of the Act, the person who approves a person being kept in seclusion must specify the period that a person may be kept in seclusion and must record it in the person's case notes. A person kept in seclusion must be visited by a registered nurse at intervals not longer than 15 minutes. They must be examined by a medical practitioner at intervals not longer than 4 hours and they must be reviewed by an authorised psychiatric practitioner, if the person is kept in seclusion for more than 6 hours. Access to the same basic amenities as provide for during restraint are prescribed. The same review provisions as for the use of restraint are prescribed. Under Section 31 of the Northern Territorys Mental Health Act of 2005, an ambulance officer may detain a person being conveyed in an ambulance for up to 6 hours where the ambulance officer believes, on reasonable grounds, that the person may fulfill the criteria for involuntary admission to hospital. This power may only be exercised in order to (a) to prevent the person causing imminent harm to himself or herself, a particular person or any other person; (b) to prevent behaviour of the person that is likely to cause imminent harm to himself or herself, a particular person or any other person; (c) to prevent further physical or mental deterioration of the person; or (d) to relieve acute symptomatology. An ambulance officer who detains a person under such circumstances must convey the person to the nearest approved treatment facility or, if that is not practicable, to the nearest hospital, as soon as practicable after the person is detained; and on arriving at the approved treatment facility or hospital, must complete the approved form and deliver it to an authorised psychiatric practitioner.

7.5 Queensland (Qld)

In Queensland, the Mental Health Act 2000 considers restraint and seclusion along side the provisions for regulated and prohibited treatments and procedures (Part 3). The provisions of the Act apply only to those persons with a mental illness: a condition characterised by a clinically significant disturbance of thought, mood, perception or memory (S12[1]). The Act is explicit that intellectual disability on its own does not constitute mental illness (S12[2]), but it explicitly acknowledges that persons with intellectual disability might be subject to mental illness (S12[3]). Similar to the NSW legislation, the Queensland legislation makes it explicit that a person cannot be considered to have a mental illness on the sole basis that they engage in antisocial behaviour or illegal behaviour (S12[2]). The use of restraint or seclusion can only be used where, because of the persons illness there is an imminent risk that the person may cause harm to himself or herself or someone else; or the person is likely to suffer serious mental or physical deterioration; and there is no less restrictive way of ensuring the person receives appropriate treatment for the illness (S14). The Queensland Mental Health Act 2000 defines restraint in the context of mechanical restraint where by an appliance is applied which prevents the free movement of the persons body or a limb (S141). Authorisation is vested in a medical

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practitioner working in a designated facility, where they are of the view that it is the most clinically appropriate way of preventing injury to the person or someone else (S143). The medical doctor is required to enter into the persons individual record the reason for the restraint, the type of restraint, the circumstances under which it can be used, the maximum period of time for which it can be used, the intervals of observation, any special measures due to the persons individual circumstances and the time at which the authorisation ends (S144). Senior nursing staff are obliged to monitor the procedure and provide basic amenities, which are specified by the Act to include begging, clothing, food and drink, and access to a toilet. They must maintain detailed records of the form of restraint, the time applied, the intervals of observation and the time of removal. The Act defines seclusion as the confinement of the person at any time of the day or night alone in a room or area from which free exit is prevented (S148). The overnight confinement for security purposes of an involuntary person in a high security unit or an in-person facility of an authorised mental health service is not considered seclusion. Seclusion of an involuntary person in an in-person facility of an authorised mental health service may be authorised at any time, by a doctor; or in urgent circumstances, by the senior registered nurse on duty. However, seclusion of an involuntary person must not be authorised unless the doctor or nurse is reasonably satisfied it is necessary to protect the person or other persons from imminent physical harm; and there is no less restrictive way of ensuring the safety of the person or others. The order for seclusion must be in writing and be documented in the same manner as an order for restraint. The person must be continuously observed, unless the medical doctor states in the order that it is not clinically necessary to continuously observe the person while secluded; and the intervals (not longer than 15 minutes) at which the person must be observed. Nursing staff may cease seclusion if they are satisfied it is safe to do so. They may recommence seclusion, if the time period of the doctors order is current. Orders are subject to review by the director of the facility who must consider the Objectives defined in the Act. Note The recent Queensland Disability Service Act 2006 does not explicitly address restraint and seclusion. However, as part of implementing the Act, Disability Services Queensland have issues a new set of policy guidelines governing the use of restricted practices in both government and funded services.

7.6 South Australia (SA)

In South Australia, similar to NSW, the Mental Health Act of 1993 does not make reference to restraint or seclusion. The Act only makes broad reference to the powers necessary to detain a person who is mentally ill (i.e., any illness or disorder of the mind [S3]). These powers are vested in medial practitioners and subject to review by psychiatric specialists in designated facilities. The order to detain may only be made where the person has a mental illness that requires immediate treatment; and that such treatment is available in an approved treatment centre; and that the person should be admitted as a person and detained in an approved treatment centre in the interests of his or her own health and safety or for the protection of other persons (S12). Detention is subject to review by (and appeal to) the Guardianship Board established under the Guardianship and Administration Act 1993. However, the SA Department of Human Services Policy EDM P6-02, Restraint and Seclusion in Health Units (Including Mental Health Units) defines seclusion as the sole confinement of a person at anytime in any room or space where the exit(s) are locked from the outside and cannot be opened by the person from the inside (p. 6). The criteria for seclusion are not differentiated from those for restraint, and include, as well as immediate or imminent risk to the person or others, the need for medical and nursing procedures, the need for medical treatment, the destruction of property and the risk of absconding. The policy is intended to apply to voluntary as well as involuntary patients. Documentation and reporting procedures are prescribed in the policy. The 2002 policy prescribes minimum standards of practice: Mechanical restraint or seclusion must involve medical review as soon as practicable, but not later than one hour after initial restraint or seclusion. If the standard is not met, sufficient reason will be documented in the persons case notes. Restraint or seclusion without medical review should only be used where the circumstances require such action in order to prevent harm that may be caused by the conduct of that person if not restrained or secluded.

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 Where mechanical restraint is used, the time period of mechanical restraint should not exceed the time for sedatives or other medication to be effectively applied in lieu of the temporary mechanical restraint, for those persons where medication is appropriate. Soft form (not leather) devices should be used in all areas of the service. Sufficient reason should be documented in the case notes if this is not the case. All staff involved in applying physical or mechanical restraint or seclusion will be trained in aggression management and restraint techniques. Where security staff are employed or contracted by health services, the health service should ensure that security staff have adequate training in aggression management and mechanical and physical restraint techniques, and that security staff remain accessible to, accountable to, and under the direction of medical and nursing staff at all times. During the application of mechanical restraint, the person being restrained must be under the supervision of and visible to clinical staff at all times, with consideration for the privacy and dignity of the person being restrained. Restraint or seclusion will be clearly and accurately recorded, providing reasons, times and names of staff involved in the restraint or seclusion. A restraint and seclusion incident form will be retained in the persons personal medical file. A duplicate copy will be readily accessible for use in review processes. Persons in restraint or seclusion should be provided opportunity, wherever possible, to have any medical condition treated by medical staff. At the time of admission, information will be provided to consumers and their family and/or carer about the health units policy on restraint and seclusion. In South Australia, the Nurses Registration Board has developed comprehensive guidelines for the use of restraint (Nurses Board of South Australia, 2003). These guidelines have been used as a source of guidance in other jurisdictions. The guidelines include a definition of seclusion: the placement of a consumer in a room alone so that the consumer is unable to leave whether or not the door is locked or the consumer is kept in the room by other means, including leaving a person outside the room to prevent the consumer from leaving. This definition is unique among Australian definitions in that it includes reference to the person being prevented to leave the place of seclusion by another person.

7.7 Tasmania (Tas)

In Tasmania the Mental Health Act of 1996 is applicable only to those persons with a diagnosed mental illness. Similar to legislation in other jurisdictions, in Tasmania a mental illness is defined in terms of a mental condition resulting in: serious distortion of perception or thought; or serious impairment or disturbance of the capacity for rational thought; or serious mood disorder; or involuntary behaviour or serious impairment of the capacity to control behaviour (S4[1]). However, a diagnosis of mental illness may not be based solely on: antisocial behaviour; or intellectual or behavioural nonconformity; or intellectual disability; or intoxication by reason of alcohol or a drug (S4[2]). The Act defines restraint in terms of bodily restraint, understood to mean any form of physical or mechanical restraint that prevents the free movement of the limbs (S3). An involuntary person in an approved hospital may be placed under bodily restraint only if the restraint is necessary for medical treatment of the person; or to prevent injury to the person or to others; or to prevent the person from persistently destroying property; and is authorised by a medical practitioner or an approved psychiatric nurse for a period of less than 4 hours; and is applied for no longer than authorised or if the restraint is in accordance with guidelines issued by the Mental Health Tribunal (S34). Seclusion is defined in the Tasmania Mental Health Act 1996 in terms of the confinement of a person alone in a room of which the doors and windows are locked from the outside (S3). Seclusion may only be authorised for the protection of the person or other persons with whom the person would otherwise be in contact; and the seclusion is authorised by a medical practitioner or an approved psychiatric nurse; and the person is kept in seclusion for no longer than authorised. During the seclusion, the person must be visited by a member of the nursing staff at intervals of not more than

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15 minutes or in accordance with guidelines issued by the Mental Health Tribunal; and be examined at intervals of not more than 4 hours by a medical practitioner; and be provided with basic amenities, defined as bedding and clothing, food and drink, and adequate toilet arrangements. In addition to internal institutional review, any occasion where an involuntary person in an approved hospital is placed under bodily restraint or kept in seclusion is to be reported to the Mental Health Tribunal. To full fill this requirement, the senior approved medical practitioner in an approved hospital must, at the end of each month, send to the Registrar, in such form as may be directed by the President of the Tribunal, a report on the bodily restraint and seclusion of involuntary persons in the hospital during the month. The report must specify for each case of bodily restraint or seclusion: the name of the person; and the form of restraint or seclusion used; and the reasons for the restraint or seclusion; and the name of the person who authorised the procedure; and the period for which the person was kept under bodily restraint or in seclusion.

7.8 West Australia (WA)

As in other Australian jurisdictions (with the exception of Victoria), the West Australian state Disability Services Act 1993 does not address issues concerning restraint or seclusion. However, unlike most other state disability acts, section 53 of the Act does provide for an offence where a person ill-treats or wilfully neglects a person with a disability while that person is under his or her care, supervision or authority. In West Australia guidance with respect to restraint and seclusion is to be found in the Mental Health Act 1996. The Act is designed to apply to persons with a mental illness, defined by section 4 of the Act as a disturbance of thought, mood, volition, perception, orientation or memory that impairs judgment or behaviour to a significant extent. However the Act provides that a person cannot be classified as having a mental illness by reason of, among other things, having intellectual disability or demonstrating anti-social behaviour. The West Australia Mental health Act 1996 defines restraint in terms of mechanical bodily restraint; that is any restraint that prevents the free movement of the persons body or a limb by mechanical means, other than by the use of a medical or surgical appliance for the proper treatment of physical disease or injury (S121). The Act authorises the use of restraint for: the medical treatment of the person; the protection, safety, or well-being of the person or another person with whom the person might come in contact if the restraint is not used; or (c) preventing the person from persistently destroying property (S123). Restraint can only be authorised by a medical practitioner or, in an emergency, a senior mental health practitioner (i.e., a practitioner with at least 5 years experience in the treatment of persons who have mental illnesses, S3), who must then notify a medical practitioner as soon as is practicable. Records of restraint are to be maintained and reports of every such instance made to the Mental Heath Review Board of West Australia (S124). In West Australia, seclusion refers to the sole confinement of a person in a room that it is not within the control of the person confined to leave (S117). The grounds for using seclusion are the same as those for the use of restraint (S119). Similarly, the provisions for authorisation are the same as for the use of restraint, requiring a medical practitioner or, in an emergency, a senior mental health practitioner who must then notify a medical practitioner (S118). Interestingly, a time limit is imposed by the Mental Health Administration Regulations, which dictate that seclusion is considered only in terms of detention between the hours of 8am and 7pm. Where a person is kept in seclusion the treating psychiatrist is to ensure that provision is made for the basic needs of the person, including bedding, clothing, food, drink, and toilet facilities; the person is observed by a mental health practitioner at regular intervals, as prescribed by the regulations; the person is regularly monitored by a psychiatrist or another medical practitioner; and a report of the person being kept in seclusion is made as soon as is practicable to the Mental Health Review Board.

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8. Factors Influencing the Use of Restraint and Seclusion and Barriers to Implementing a Minimal Restraint or Restraint-Free Service Environment
There are a number of factors that influence restraint and seclusion practice, including systemic constraints, resource limitations, architectural issues, staffing and management processes, as well as service user characteristics (Black & Haralambous, 2005; McClintock, Hall, & Oliver, 2003; Mental Health Commission, 2004; Murphy, Kelly-Pike, McGill, Jones, & Byatt, 2003). It is important to understand these factors, in order to develop effective policy and procedural measures to minimise or eliminate the use of restraint and seclusion.

8.1 Policy
One major issue identified in New Zealand has been the lack of clarity at a policy level, which in turn leaves line managers and direct support personnel to make their own interpretations with respect to best and adequate or acceptable practice (Mental Health Commission, 2004). Some of the specific areas identified by staff as problematic include the need to differentiate between seclusion and procedures designed to provide for the overnight security of persons know to wonder (procedures referred to in New Zealand hospitals as Night Safety Orders). Also, while the New Zealand Mental Health Compulsory Assessment and Treatment Act 1992 refers to seclusion as a treatment, the New Zealand Restraint Minimisation and Safe Practices Standard (due for review in February 2008) indicates that seclusion is a containment procedure that can only be used to manage potentially violent or destructive behaviour. Seclusion as a therapy could encourage its use, to makes people better. However, seclusion conceptualised as a containment procedure, could discourage its use. It is important that such conflicting policy positions be avoided and / or eliminated. Similarly, the United Kingdoms Royal College of Psychiatrists (RCP) have identified the problems associated with the lack of clarity when distinguishing between restraint and seclusion procedures and those procedures commonly referred to as time-out. Time Out is described by the Royal College of Psychiatrists as a procedure whereby the patient is separated temporarily from a rewarding environment as part of a planned and recorded therapeutic programme to modify behaviour (1995, p. 7). However, the RCP cautions that the breadth of this definition is open to misuse, to encompass what is, in fact, seclusion and that in practice many clinicians do not fully understand the differences. RCP guidelines note that time-out is in widespread use, particularly with certain groups such as with children or those with a learning disability. They recommend that in clinical practice, rather simply prescribing the use of time-out, clinicians should clearly describe the procedures to be used in order that they be properly evaluated for the degree to which they represent restraint or seclusion and if proposed as part of a therapeutic process, appropriate consent, monitoring and review procedures should be established. Even where policy and procedures have been established, how these are communicated to staff members who have to implement them remains problematic. Murphy et al. (2003), in a UK survey of over 300 staff in learning disability services identified most staff to be unaware of national policies governing the use of restraint and seclusion.

8.2 Physical Environment

Congregate living arrangements, especially those characterised by overcrowding have been noted to be associated with high levels of restraint and seclusion. The New Zealand Mental Health Commission (2004) report findings that suggest the need to maintain order, to manage clients and staff, together with preventing damage to property in overcrowded facilities all converge to place pressure on staff who in turn cope by utilising a custodial model of care, creating a barrier to effective therapeutic interaction. They note that overcrowded facilities can be seen to encourage the use of seclusion as a containment procedure, to manage risk and to manage available resources (p.9). Added to this, poor facility design is also a potential factor influencing the use of restraint and seclusion. In particular, where facilities lack private and quiet areas for clients, there are more frequent and intense behavioral episodes and less opportunity to utilise de-escalation procedures, as an alternative to the use of restraint and seclusion. Few studies have addressed architectural issues associated with noise levels and personal space, though these have been found to be predictive of stress and violence in other settings (Kuo & Sullivan, 2001; Verderber & Reuman, 1987).

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Physical crowding in facilities appears not to be the only factor relevant to any appraisal of the physical environment. The location of the facility appears also as an important consideration. Crenshaw and Francis (1995) found that smaller hospitals tended to have higher rates of seclusion and restraint. However, this is in contrast to the finding of Harte and Burgess (2003) that rural hospitals had significantly lower rates of seclusion than either inner or outer metropolitan hospitals, and that outer urban hospitals had the highest rates of seclusion.

8.3 Staffing
Staffing factors have been identified as critical, though there is a lack of consensus in the literature as to how best to determine optimum staffing numbers. Higher staffing ratios have been suggested as a means of enabling early intervention and prevention of escalation. However, the availability of higher levels of staff have also been associated with a greater likelihood of staff using physical interventions, if for no other reason than they have the person power available to do so. Similarly, while lower staffing ratios make it practically more difficult to use restraint, lower staffing levels can also contribute to staff feeling anxious and consequently more likely to deploy restrictive practices earlier than they might otherwise do so had they the support (reassurance and security) of other staff close by who could offer assistance if required. Further research into these issues is necessary. Mattson and Sacks (1978) found that staffing levels, staff availability, general staff anxiety and staff training all affect the decision to seclude. Gerlock and Solomons (1983) concluded that staff attitudes towards seclusion could greatly influence timing, patient selection and duration of seclusion, due to the varying tolerance levels of staff towards disturbed behaviour, and Morrison and LeRoux (1987) found that the level of experience of the person in charge of the unit related most strongly to the use of seclusion. De Cangas (1993)) related a higher male-to-female staff ratio to an increased number of seclusion hours. Crichton (1997) found that seclusion rates were affected by staff demographics, work setting, experience and training and Castle and Banaszak-Holl (1997) noted that while high staff-to-patient rations predisposed to more episodes when the extra staff were nurse assistants, a similarly high ratio decreased episodes when the extra staff were registered nurses. In contrast, Schwab and Lahmeyer (1979) found no correlation between either the age or experience of (nursing) staff and the frequency with which seclusion was used. Crisis events leading to seclusion or restraint were noted by Schreiner, Crafton, and Sevin (2004) to occur most often at shift change, particularly the day-to evening shift. A further staff factor identified in the literature has been a failure to effectively communicate vital information between staff and across shifts, both within and between organisations (Black & Haralambous, 2005). On a related issue, Garrison (1984) reports seclusion as most frequent on Mondays, noted to be the staffs busiest day, and the lowest incidence of seclusion to occur on Saturdays and Sundays, reported as the staffs least busiest days. Staff knowledge and skill have also been identified as areas requiring attention in order to address the use of restraint and seclusion. Staff are either unaware of alternative procedures, have not been educated in the effectiveness of these procedures or of the implications (to clients and staff) of not using these procedures, their instruction in alternative procedures has been inadequate or their use of alternative procedures is not supported (in forced) at a local level by line managers. A more difficult factor to address is that of staff-client communication where difficulties arise as a function of staff speaking a first language that is not the first language of the client. Issues of both range of vocabulary and accent can feasibly contribute to a break down in communication, as a consequence, a higher likelihood of the emergence of behaviors of concern on the part of the client and a decreased capacity on the part of the staff to use some defusing procedures (Black & Haralambous, 2005). In addition to knowledge and skills, which are arguably subject to remediation by means of training, Gair (1985) asserted that discernable differences in staff attitudes can contribute to the use and duration of seclusion. While training and education might have some effect on values and attitudes, personality factors might be more readily addressed at the point of recruitment and staff selection.

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A further extension of these staffing issues are those studies examining organisational culture. Walsh, Brooke, and Randell (1995) observed that the time spent in seclusion or restraint often appears to be related to common or accepted practice within the staff team or organisation, rather than upon any objective clinical criteria. Similarly, Fisher (1994) and Crichton (1997) both identified the organisational culture as determining the staffs response to disturbed behaviour, rather than any objective clinical guideline. In the US, the Pennsylvania Office of Mental Health and Substance Abuse (Department of Public Welfare, 2006) reported that on the basis of data gathered between 1985 and 1990, almost half of the justifications for seclusion reflected the attitudes of the institutional culture and had little to do with an objective clinical appraisal of client behaviour (i.e., the degree to which the behaviour posed an objective threat of danger to the person or others).

8.4 Client Issues

In a meta-analytic study (covering a period of 30 years of research) examining risk factors associated with challenging behaviour in people with learning disability, typically associated with the use of restraint and seclusion, McClintock, Hall and Oliver, (2003) concluded that males were more likely to exhibit aggression than females and that people with more profound disability were more likely to exhibit self-injurious and stereotypical behaviours than people with lower support needs. They reported that persons diagnosed with autism were more likely than others to display aggression, and those with significant deficits in communication (expressive and receptive) were more likely to exhibit self-injury. It would be reasonable to conclude that people with such profiles are most at risk of being subject to restraint and seclusion. However, the literature reports mixed findings. Here though caution is warranted when interpreting the literature, as a large proportion if the available research has focused primarily on people with psychiatric illness. Concerning gender, earlier studies do not report any significant differences in patterns of restraint and seclusion between adult males and females (Binder, 1979; Hammill et al., 1989; Oldham et al., 1983; Plutchik et al., 1978; Soloff, 1979; Soloff & Turner, 1981; Tardiff, 1981). However, Garrison (1984), in a child study, and Miller, Walker and Friedman (1989), in a study involving adolescents, found that males were more likely to be subject to seclusion than females. Thompson (1986), in a study involving adults reported a similar gender bias. Way and Banks (1990) found that females were more likely to be secluded than makes. More recently, Ibikunle and Kettl (2000) did not find any evidence of a gender bias in patterns of restraint and seclusion, and nor did Frueh et al. (2005). Harte and Burgess (2003) however, reported a more complex relationship; whereby younger men and older women were the most likely to be secluded. Age would appear to be a significant factor that could help to identify those most at risk of being subject to restraint or seclusion. Early studies by Mattson and Sacks (1978) found that secluded patients were younger, as did Plutchik et al. (1978), and Schwab and Lahmeyer (1979). Oldham et al. (1983) in a retrospective study of 57 patients found that the average age of those secluded was 26.8 years; significantly younger than the average age of a non-secluded group (31.7 years). Fisher, 1994 reported a consistent relationship of patient age to the probability of seclusion, with older persons being less likely to be secluded than younger persons. Thompson (1986) reported a retrospective study of 66 patients in which the average age of a secluded patient was 36 years, significantly less than all other persons admitted to the facility (44.4 years). Similarly Mason (1996) reported that the likelihood of seclusion diminishes steadily with increasing age. More recently, Harte (2002) reported that secluded patients tended to be significantly younger (mean age 35.1 years) than the average age of all patients (38.2 years). In contrast, Soloff and Turner (1981) found in a study of 59 patients that those secluded were not significantly younger than non-secluded patients, and El-Badri and Mellsop (2002) and Freuh et al. (2005) found no significant association between age and the use of restraint / seclusion. Race and ethnicity have also been proposed as possible factors associated with incidence of a restraint and seclusion. In the US, Carpenter, Hannon, McCleery, and Wanderling (1988) found higher rates of seclusion in black patients, as did Soloff and Turner (1981) although this rate was not significant after controlling for a longer duration of admission for white patients. Smith et al. (2005) noted that seclusion rates were higher for racial or ethnic groups than for whites in the early years of the Pennsylvania program, but in a positive finding as the overall rate of seclusion declined, the rate decreased more sharply in this population. In New Zealand, El-Badri and Mellsop (2002) found that Maori patients and those from other backgrounds were secluded more frequently than persons of European descent.

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However, Hammill et al. (1989) found no distribution difference in the use of restraint and seclusion by race. Similarly, Fisher (1994) did not find evidence of ethnicity as a significant variable in seclusion. Mason (1996) reported that while the number of persons secluded who were recorded as coloured across the British forensic hospital system was proportionate to the hospital population, they tended to spend longer in seclusion. Harte (2002) found that there was no significant difference between secluded patients by country of birth. Diagnostic status has been explored as a possible indicator of the likelihood of a person being subject to restraint or seclusion. Again, the literature reports mixed findings. Plutchik et al. (1978) found that significantly more secluded patients than controls were diagnosed with schizophrenia. According to Binder (1979), patients with diagnoses of a psychosis had increased seclusion rates in comparison to those with non-psychotic diagnoses. Oldham et al. (1983) found that among psychiatric patients, those most likely to be secluded were those with a diagnosis of mania or excited schizoaffective disorder (35% of seclusions compared with only 12% of non-secluded controls). Furthermore, this study reported that the diagnosis of personality disorder was also associated with increased incidence of seclusion. Thompson (1986) found that diagnoses of bipolar affective disorder, schizophrenia and mental handicap were significantly associated with seclusion. Beck and van der Kolk (1987) reported that patients with a history of childhood incest were more likely than other patients to spend time in seclusion. These findings could be considered consistent with what we now know of the strong links between the experience of child abuse and the later manifestation of personality disorder (especially borderline personality). Betemps, Somoza, and Buncher (1993) found that patients with a diagnosis of schizophrenia accounted for over 65% of all incidents of seclusion and restraint, followed by 17.8% for those diagnosed as suffering from affective psychosis. Fisher (1994) found that "character disorders, manic symptoms, abnormal EEGs and mental retardation" were associated with higher seclusion and restraint rates. Swett (1994) found that the strongest diagnostic predictor was borderline personality disorder. Harte (2002) reported that there was a significant positive correlation between a diagnosis of a schizophrenic disorder and the probability of being secluded. However, in contrast, Plutchik et al. (1978) found personality disorder to be a protective factor, along with depression and drug and alcohol problems. Similarly Soloff and Turner (1981) found no significant differences in seclusion between diagnostic categories, apart from patients with a diagnosis of neurosis who were not secluded. Oldham et al. (1983) found that substance abuse was negatively associated with seclusion. Here the issue might not be a simple relationship between diagnostic category and the likelihood of the person being subject to restrain or seclusion. Rather, the issue could be related to the overall severity of behavioural symptoms and how the service / support system appraises these symptoms and subsequently responds. Swett (1994) found that one of the strongest predictors of seclusion was a patient's total assets score on the Nurses Observation Scale for Inpatient Evaluation (NOSIE). This scale measures positive and negative aspects of behavioural functioning. Similarly, Ibikunle and Kettl (2000), in a study of the use of seclusion in mentally ill children found that those children secluded were those on greater quantities of medications and who were recorded as staying longer in hospital, which was taken to be a defacto indicator of the severity of their condition. Harte (2002) reported that those persons secluded were those who had significantly longer admissions (mean 20.1 days) than those who were not secluded (mean 10.7 days). Linked to diagnoses and symptom severity, medication use has also been noted to be related to the incidence of restraint and seclusion. Chengappa et al. (2000) report a significant reduction in seclusion rates for persons in a risperidone treatment group. Similarly, Fisher (2003) reported that the aggressive use of clozapine was possibly instrumental in achieving a decrease in seclusion and restraint. These issues are subject to a separate review, specifically commissioned by the Office of the Senior Practitioner to examine chemical restraint.

8.5 Barriers to Implementing a Minimal Restraint or Restraint-Free Service Environment

Identifying policy, environment, staff and client factors associated with variations in the use of restraint and seclusion can assist in the development and implementation of process and procedures designed to minimise or eliminate the use of restraint or seclusion. However, there are a number of specific barriers to advancing these initiatives. Though primarily

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investigating these issues in the aged-care sector, Black and Haralambous (2005) found the main barriers to minimising the use of restraints to include: fear of client injury resulting in litigation; staff resource issues; lack of education in alternatives to restraint and seclusion; environmental issues; policy issues; consumer expectations and the expectations of families; and monitoring and review practices. Each of these issues is arguably relevant to any review of the service system supporting people with disability. Black and Haralambous (2005) reported a common concern among staff to be fear of litigation if they failed to prevent injury or other forms of harm to their clients. For these reasons staff commonly argued that restraints were needed for some residents to reduce falls and falls related injuries, for managing agitation and aggression, settling residents at night and preventing residents (especially those with dementia) wandering outside and away from the service. Staffing resource issues identified by staff in the study by Black and Haralambous (2005) included the high number of inexperienced staff on-shift at any one time and the high reliance on agency or casual staff to fill rosters. Staff also identified the significant influence of staff with entrenched ideas, who had been trained in the use restraints as being important for client safety. High staff turnover, including turnover among line managers and senior agency management was also noted to contribute to an environment that lacked the necessary checks and balances to regulate the use of restraint and seclusion. High turnover rates are known to be a feature of disability services (Larson & Hewitt, 2005). Direct support staff also reported on the lack of involvement of other professionals (e.g., medical practitioners, psychologists and allied health professionals) in regular assessment of clients in their care, and the over-reliance of medical staff on medications without exploring non-pharmaceutical strategies for some conditions such as depression and sleeping difficulties. Lack of staff time to spend with individual clients, attributed to low staff ratios (particularly at difficult times in the late afternoon and at and night) were also noted. Importantly, staff identified their lack of access to education and information about alternatives to restraint. They reported on the inadequacy of their own skills to manage aggression and agitation; and the broadly held perception that it is easier to apply restraints than use other approaches. Similar findings have been found among staff in communitybased services for people with learning disability in the UK (McVilly, 1995). Lack of information and education for families has also been identified as a potential barrier, as families commonly expect staff to use restraints to protect their relative. It has been noted that families are often reluctant to remove restraints (especially physical devices) previously applied as a safety device. Family concerns are primarily with respect to their relatives safety, and do not necessarily extend to a multi-factorial assessment inclusive of their family members rights and dignity. Families perceived that physical injury was of greater concern than resident rights, discomfort or distress. Staff have reported that the physical environment in which they are expected to work not only contributes to incidents involving behaviours of concern, but that these poorly designed and under resourced environments preclude the use of alternatives to restraint and seclusion. Some of these environmental issues have been identified to include the support of clients (known to be easily disturbed) in settings that are crowded, confined, cluttered, noisy and lacking in sufficient personal space. In particular, the lack of options for people to safely spend time outside, e.g., in a secure or easily observed garden environment, has been noted. Greater attention needs to be given to the architectural features of the environments in which people are expected to live and work. Procedures and practices governing assessment, authorisation and review of restraint and seclusion have been noted to contribute to the perpetuation of restraint and seclusion, in situations where they might not be necessary. The criterion for initial and on-going authorisation has commonly been focused on the clients immediate need for protection (and by inference, the staffs need to exercise a duty of care) without reference to the associated procedures necessary to evaluate the situation in an evidence-based environment. That is, there has been no formal requirement that prior to authorising the use of restraint or seclusion, or the continuation of its use, comprehensive assessment, including a functional assessment of the persons behaviour, is conducted and that positive programming is developed (Carr & Horner, 2007; LaVigna, Willis, Shaull, Abedi, & Sweitzer, 1994). Reviews have been reported by staff as commonly involving processes such as getting the signatures or refilling the prescription with no reference to undertaking a

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complete assessment. Furthermore, there has either been a lack of external scrutiny of such procedures or, where there has been a facility for external scrutiny, the absence of any effective administrative (or legal) consequences for not adhering to the expected procedures for external scrutiny has effectively nullified the effectiveness of these procedures.

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9. Promoting a Minimal Restraint or a Restraint-Free Service Environment by Means of Organisational Policy and Staff Educational Frameworks
There is evidence in the literature of a range of policies and strategies to support to progress towards, and the eventual establishment of, a minimal restraint or restraint free service environment. Furthermore, there is a strong consensus that a clearly articulated policy position is essential, supported by a well resourced programme of staff education and established systems to monitor, evaluate and inform the on-going development of service delivery.

9.1 Policy Frameworks

Carr (2007), reflecting on developments over recent decades in support services for people who display behaviours of concern, calls for a reappraisal of the service system. Carr notes that there are many service approaches we fail to question, assuming their scientific or legal justification. Carr asserts that if we are to bring about change, we need to reappraise the role of the service system and of the staff who work within it (Carr & Horner, 2007, p. 1): Our job is to redesign the counter productive and unfair environmental contexts that so many people, with and without disabilities, have to contend with every day of their lives Our job is to give people with skills, the coping strategies, and the desire to deal with the frustration that is an inevitable part of life, particularly the lives of people with disabilities We must give them and their loved ones the support they need to challenge and reconstruct systems that serve bureaucratic needs, rather than human needs The US Department of Health and Human Services (National Association of Consumer/Survivor Mental Health Administrators for the Substance Abuse and Mental Health Services Administration, 2005), in their road map to seclusion and restraint free mental health services identifies a number of key (curriculum) components to organisational development and staff education to minimise or, ideally, eliminate the use of restraint and seclusion. These core components are noted to include: Educational programmes incorporating management and staff exposure to consumer (and family) perspectives, and first hand accounts of consumer personal experience of seclusion and restraint; Instruction concerning trauma as a consequence of restraint and seclusion experiences and the effects of this on both consumers and staff; The need for cultural change and the historical background to the non-restraints movement; Policies, procedures and specific examples of strategies that staff can employ as alternatives to restraint and seclusion; and Mechanisms necessary to bring about and sustain change within an organisation, and external resources on which staff can call as they progress the process of change. The US National Association of State Mental Health Programme Directors (2001) recommends that: Individuals affected by mental retardation or developmental disability who become agitated or violent should be carefully assessed for an underlying medical condition that may be causing the behavioral change. Individuals with developmental disability may be victimised more easily than others. Mental health program staff should monitor peer interactions to prevent abuse. The habilitation or treatment program and environment should be evaluated to determine what factors may contribute to repeated events of seclusion and restraint. Mental health and MR/DD experts should jointly develop "promising practices" for individuals affected with cooccurring disorders of mental illness and developmental disability.

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 Individuals with mental retardation or developmental disability staying more than very short periods in psychiatric facilities should have habilitation plans and services developed by providers experienced in working with individuals who have a developmentally disability. Habilitation and treatment services for individuals with co-occurring disorders of mental illness and developmental disability should be integrated by behavior specialists and mental health program staff in consultation. Consumer, family, and advocacy organisations for individuals with co-occurring disorders of mental illness and developmental disability should be formed in each state and at the national level. The Pennsylvania Department of Public Welfares Office of Mental Retardation (OMR) recommends a three-tiered approach to the minimisiation and, ultimately, the elimination of the use of restraint and seclusion in services supporting people with disability: staff training; risk management; and comprehensive administrative review (Department of Public Welfare, 2006). The OMR does not endorse any one curriculum, but does provide a list of core curriculum content for inclusion in any staff training programme: Environmental design and social, physiological, and cultural motivators for behavior, including information on individuals who have experienced trauma such as abuse. This includes understanding the impact of environmental factors and triggers. Positive practices and behavioral support methods that include techniques to deescalate behavior; listening and communication skills; awareness of environmental factors that can cause disruptive behaviors; violence prevention and conflict resolution; and how to complete a functional analysis. Information on best practice methods for interacting with individuals who have a dual diagnosis of mental retardation and a mental illness. This includes the effects of medications, how medication changes can impact behavior, and teaching alternative strategies and other coping mechanisms. Person-centered alternatives to the use of restraint, including an understanding of which positive practices are most effective with particular individuals and teaching strategies that emphasise prevention of future negative incidents. This includes the integration of effective behavioral supports. Basic training in body mechanics that illustrates how to avoid hyperextensions and other positions that may endanger individual safety. Awareness of an individuals health history in order to assess increased risk that may occur during the application of a restraint. The use of physical restraints, including the proper application of restraints appropriate to the age, weight, and diagnosis of the individual. Also, possible negative psychological effects of restraint and monitoring an individuals physical condition for signs of distress or trauma. Definitions of restraint; policies on the use of restraints; the risks associated with the use of restraints; and staff experience the use of physical restraint applies to themselves. This includes debriefing techniques with the individuals they support as well as staff members. The Pennsylvania OMR further recommends that individual organisations have in place and implement a providerspecific plan to proactively address the prevention, detection, evaluation, and correction of any environmental factors and triggers that may lead to the use of restraints; a comprehensive and structured de-briefing programme that includes thorough analysis of events and forward planning to avoid similar events in the future; a internal review committee dedicated to the review of all critical incidents and the use of restraint. Administratively, the review of an organisations use of restraint and seclusion is to be taken in to account when considering licensing and future funding. In Pennsylvania, the OMR recommends that in the development of behaviour support plans, seclusion is not used. Here Seclusion is defined as:

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placing an individual in a locked room. A locked room includes a room with any type of engaged locking device, such as a key lock, spring lock, bolt lock, foot pressure lock or physically holding the door shut (Department of Public Welfare, 2006, p. 6). In Pennsylvania, mechanical restraints are not to be used. Here, a mechanical restraint is understood to be any device used to control acute, episodic behavior that restricts the movement or function of an individual or portion of an individuals body. Examples include anklets, wristlets, camisoles, helmets with fasteners, muffs and mitts with fasteners, waist straps, head straps, restraining sheets and similar devices. However, mechanical restraint does not include a mechanical device ordered by a medical practitioner to protect a person from possible harm following surgery or an injury or a wheelchair belt that is used for body positioning and support, or a helmet used for the prevention of injury during seizure activity. There remains some limited approval for the use of manual restraints or physical restraints, but only to be used as a last resort safety measure when the individual is in imminent danger of harming themselves and/or others, and other measures are ineffective. Manual restraint is defined as a hands-on technique that lasts more than 30 seconds. When a hands-on technique occurring for less than 30 seconds is used to guide or redirect the individual away from potential harm/injury, it is not considered to be a physical restraint. Where the need to use an emergency physical restraint is identified, the proposed procedure must be approved by a physician, though it is to be clearly established as an emergency response, and not as part of a persons usual behaviour support plan. With respect to physical restraint, the Pennsylvania OMR has identified a number of techniques that are known to increase the risk of injury and death. Consequently, they recommend: Prone (face down) manual (physical) restraint is not used. No manual restraint that inhibits the respiratory and/or digestive system is used. No manual restraint that involves compliance through the infliction of pain, hyperextension of joints, and pressure on the chest or joints is used. No use of takedown techniques in which the individual is not supported and/or that allows for free fall as the individual goes to the floor. An individuals physical condition is evaluated throughout the restraint in order to minimise the potential of individual harm or injury. Manual (physical) restraint does not exceed 30 minutes within a two-hour time period An individual is immediately released from physical restraint when they no longer present a danger to self or others. Support staff monitor the individual for signs of distress throughout the restraint process and for a period of time (up to two hours) following the application of a restraint. Similarly, chemical restraint is not to be used. Medication is only to be used when prescribed by a physician for the treatment of a diagnosed mental illness. Every instance where Pro Re Nata (PRN) medication is used, it is to be followed by a full incident review and reported in the context of a restraint. The Michigan State Board of Education (2006) recommends staff undergo training in the techniques of Positive Behaviour Support (PBS). PBS is understood by the Board to include strategies to build relationships, create predictable routines, teach skills, identify and introduce alternative/replacement behaviours, increase the functionality and reward the use of desired behaviours, and decrease the relevance/effectiveness of problem behaviours. The policy of the Michigan Board of Education recommends that staff training include: proactive practices and strategies that ensure the dignity of students; conflict resolution; mediation; social skills training;

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 de-escalation techniques; positive behavior support strategies; techniques to identify student behaviors that may trigger emergency safety situations; related safety considerations, including information regarding the increased risk of injury to students and staff when seclusion or restraint is used; instruction in the use of seclusion and restraint; identification of events and environmental factors that may trigger emergency safety situations; and instruction on the State Board of Education policy on Supporting Student Behavior: The Emergency Use of Seclusion and Restraint. The Michigan Board of Education identifies the critical components of a comprehensive education programme for staff to include: proactive practices and strategies that ensure the dignity of students; conflict resolution, mediation and de-escalation techniques; positive behavior support strategies and social skills training techniques; techniques to identify environmental factors and student behaviors that may trigger emergency safety situations; safety considerations, including information regarding the increased risk of injury to students and staff when seclusion or restraint is used, especially where students have known or unknown medical conditions; instruction in the use of emergency seclusion and restraint; how to monitor the physical signs of distress; and how to obtain medical assistance. the risk of using seclusion and restraint in consideration of a students known and unknown medical or psychological limitations; the effects of seclusion and restraint on all involved (students and staff); and instruction on the State Board of Education policy. The Joint Guidance for Restrictive Interventions, developed by the UK Department of Health and the UK Department of Education & Skills Development (2002) conceptualises restraint-based intervention practices in terms of physical interventions which involve the use of force to control a persons behaviour and can be employed using bodily contact, mechanical devices or changes to the persons environment (p.10). The guidelines distinguish between non-restrictive interventions (e.g., assisting a person to walk; protective equipment prescribed by a therapist to explicitly prevent self injury, such as a helmet; and environmental changes such as adjustment to temperature, light and sound to minimise distress); and restrictive interventions (e.g., holding a persons hand to prevent them hitting someone; arm cuffs or splints, even to prevent self-injury; seclusion or locked doors) (S3.1). The UK guidelines allow for restrictive interventions to be used only under limited circumstances: to break away or disengage from dangerous or harmful physical contact initiated by a service user; to separate the person from a trigger, for example, removing one pupil who responds to another with physical aggression; to protect a child or service user from a dangerous situation such as the hazards of a busy road (S3.2). The guidelines indicate that under UK law the use of force is likely to be legally defensible when it is required to prevent: self-harming; injury to other service-users or staff; damage to property; or an offence being committed (S3.5). However, the UK Guidelines (2002) note that there is elevate risk of harm to both the person subject to restraint and those applying the restraint. Procedures identified with elevated risk include: the use of clothing or belts to restrict movement; holding someone who is lying on the floor or forcing them onto the floor; any procedure which restricts breathing or impedes the airways; seclusion, where an adult or child is forced to spend time alone in a room against their will; extending or flexing the joints or putting pressure on the joints; pressure on the neck chest abdomen or groin areas.

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Consequently, strategies involving such procedures are not recommended. The BILD (Paley & Brooke, 2006) guidelines, discussed below, affirm and extend these cautions and formulate recommendations consistent with the UK Guidelines. The UK Joint Guidance (2002) includes a minimum standard for organisational policies concerning the use of physical and other restrictive practices. These guidelines include the requirement for agency policies and procedures to include: Strategies for preventing the occurrence of behaviours which precipitate the use of a physical intervention. Strategies for de-escalation or diffusion which can avert the need for a physical intervention. Procedures for post incident support and de-briefing for staff, children, service users and their families. The concept of reasonable force where reasonableness is determined with reference to all the circumstances, including: the seriousness of the incident; the relative risks arising from using a physical intervention compared with using other strategies; the age, cultural background, gender, stature and medical history of the child or service user concerned; and the application of gradually increasing or decreasing levels of force in response to the persons behaviour. The approach to risk assessment and risk management employed. The distinction between: seclusion (where an adult or child is forced to spend time alone against their will); time out (which involves restricting the service users access to all positive reinforcements as part of the behavioural programme); and withdrawal (which involves removing the person from a situation which causes anxiety or distress to a location where they can be continuously observed and supported until they are ready to resume their usual activities. The distinction between planned physical interventions (where incidents are foreseeable) and the use of force in emergency situations (which cannot reasonably be anticipated). First aid procedures to be employed and those responsible for implementation in the event of an injury or physical distress arising as a result of a physical intervention. A clear description of unacceptable practices that might expose service users or staff to foreseeable risk of injury of psychological distress. The 2002 UK Joint Guidance for Restrictive Physical interventions acknowledges that: policies will need to recognise situations where breakaway or disengagement strategies, which involve minimal use of pain or discomfort, may be sanctioned as the least intrusive method which is consistent with the safety of staff and service users. Such methods will be based upon a risk assessment, will be fully documented and will employ only the minimum amount of force required (p.24). The 2002 UK guidelines emphasis the importance of staff training and their adherence to specific techniques that have been identified and which are closely matched to the characteristics of individual service users (p.29). The guidelines note that the selection of a physical intervention should include consideration of the persons physical and psychological health status, their social and cultural values and beliefs, issues relating to their age and gender, and the setting (including staffing issues) in which the person is supported or in which the need for the intervention is foreseen. The UK guidelines enshrine two criteria for the evaluation of proposed strategies or those that have been used. First, the best interests criteria, determined on the basis of a comprehensive risk assessment. Secondly, the test of whether the strategy meets criterion for the minimum force needed to avert injury or damage, and applied for the shortest period of time. The UK guidelines emphasise that restrictive interventions should only be used as part of a planned intervention. In these situations, risk factors should be identified, interventions matched the needs of the individual and staff provided with specific training in the documented and authorised techniques. However, the guidelines also acknowledge that: Unplanned or emergency intervention may be necessary when a service user behaves in an unexpected way. In such circumstances, members of staff retain their duty of care to the service user and any

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response must be proportionate to the circumstances. Staff should use the minimum force necessary to prevent injury and maintain safety, consistent with appropriate training they have received (p.10). Harris, Allen, Cornick, Jefferson, and Mills (1996) identify three broad categories of physical intervention: direct physical contact (e.g., holding to prevent wandering onto a busy road, to stop self-injury arising from stereotypical behaviour, or prevent injury to another person); the use of physical barriers (e.g., locked doors or doors that cannot be readily opened by service users); equipment to restrict movement (e.g., wheelchair straps, helmets and splints). The authors note that on the rare occasions that physical interventions are justified, they should only be used in the best interests of the service user (p.3). They further emphasise that where physical interventions are to be used, there should be a clear policy statement that makes explicit the safeguards to be in place before a physical intervention is used, how it is to be used, for what duration or under what circumstances it can be maintained and the recording and review process that is to accompany its use. Harris et al. (1996), acknowledge the need for emergency or unplanned interventions, but stress that these should not constitute the typical way in which a person is supported, and that following the first instance of any such unplanned or emergency procedure, there should be a strategy developed to ensure that planned interventions are available for similar situations in the future. When evaluating what might constitute a reasonable intervention, Harris et al. (1996), consistent with the recommendations of Blunden (1987), assert that an assessment much be made as to the extent to which the intervention either impedes or promotes the persons wellbeing; their physical wellbeing, their emotional wellbeing, their material wellbeing and their social wellbeing. Intervention strategies should also be assessed against human rights laws and other legal obligations. On these issues, Lyon and Pimor (2004) provide guidance on how the use of restrictive practices, and physical interventions in particular, can constitute a breach of the criminal law. For example, common assault, battery, assault occasioning actual bodily harm, malicious wounding or inflicting grievous bodily harm, false imprisonment or, in a worst case scenario manslaughter or even murder. The authors also describe how the use of such interventions could also represent a breach of human rights law and form the basis of civil action against the person(s) using these techniques. Here the decision to use or not to use a restrictive intervention can effect the employers liability. The employer could be the subject of legal proceedings arising from their staffs improper use of restrictive practices with a client. However, the employer cold also be liable for failure to provide staff with a safe working environment and safe systems of work, which could include the need to provide policies and procedures that support the safe use of some restrictive practices in prescribed circumstances. The British Institute of Learning Disabilities (BILD), while emphasising restrictive practices and physical interventions should not be used as a primary intervention technique, acknowledge that there remains a necessity for their use under limited circumstances. Consequently BILD (2006) has developed a Code of Practice for the use of physical interventions. The BILD code outlines the requirements for staff development and prescribes that training in physical interventions must only occur after staff have been provided with (or in conjunction with) training: risk assessment and risk management; the role and development of individual support plans; strategies to promote alternative or functionally equivalent behaviours to the identified socially invalid (challenging) behaviours; behaviour assessment with an emphasis on determining the functional aspects of challenging behaviour; the role of multi-disciplinary assessment, planning and intervention; preventative strategies and alternative, non-restrictive responses to challenging behaviour. The BILD guidelines (2006) provide for the evaluation of physical intervention techniques, according to evidencebased, legal and best practice guidelines. These include criterion such as: the physical techniques must not impede the process of breathing; they must not inflict pain or be developed with pain compliance as an effective component of the technique; they must avoid contact with vulnerable parts of the body (e.g., neck, chest and sexual areas); they must not include techniques that involve hyperextension or hyperflection; and they must not utilise potentially dangerous postures or positioning that could for example impede breathing or give rise to a fracture or broken bone. The BILD guidelines, consistent with other guidelines (e.g., Department of Public Welfare, 2006; Leadbetter, 2002) do not support the use of the prone position due to the documented high risk of injury (and death). Rather, they emphasise the importance of, wherever possible, maintaining the person in an upward posture.

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9.2 Staff Educational Frameworks

There are a number of particular staff educational programmes which have been developed in recent years. Many of these claim to provide staff with the training necessary to work safely in either a restraint free or minimal restraint environment. However, there is little evidence in the literature of any formal evaluation of the effectiveness of most of these programmes, either with respect to changes in circumstances for clients or for staff. Also, while many programmes discuss physical intervention as a secondary option, anecdotal evidence suggests that staff teams are highly likely to focus on the physical intervention components of such training, and in practice resort to their use as a primary response strategy. These risks need to be considered by both educators and policy makers if adopting specific training programmes. A brief overview of ten such programmes are detailed below. This is not intended to be an exhaustive list of all programmes available, but only those for which there was some evidence of either formal evaluation data or a critical review in a reputable source such as a government report.

(a) Predict Assess Respond Training

Predict Assess Respond Training (formerly Professional Assault Response Training) (PART) is a staff training programme widely used in disability services throughout Australia, as well as in the USA and Germany. It is advanced as a proactive response approach to the prevention and management of aggression in the workplace that is consistent with a positive support framework. It is taught as a two or three day workshop. Trainers are accredited by means of a five day Trainthe-Trainer course. Re-accreditation is required every three years. PART emphasises the use of a single systematic approach, rather than a variety of techniques, to teach participants critical thinking and problem solving skills to apply in any situation. A basic premise is that employees who have developed a systematic approach are less likely to get injured than those relying on a variety of techniques. PART also emphasises that the program is to be used in conjunction with the professional treatment teams plan for the focus person and used only after the failure of the intervention plan; that is, as the back up plan when an immediate threat of injury exists. The programme is structured around learning 10 modules (Unger & Kelleher, 2004): Purpose of the training Professionalism among the workforce Preparation Identifying stressors and positive alternative outcomes Legal framework and response Crisis communication Response evasion Response restraint Documentation and debriefing Evaluation, giving and receiving feedback Participants in the training commence with developing an understanding of violent behaviours and how they are used by people to communicate their needs. There is a self-appraisal component in which participants reflect on why they do the work they do and if they are in fact suitable to work in their current work environment. Training includes consideration of assessing early warning signs and build-up related behaviours, together with developing strategies to avoid these situations or divert the person. Both individual factors and environmental irritants contributing to the emergence of behaviours are considered. Professional expectations and responsibilities, such as duty of care and reasonable force are addressed. Instruction is provided in evasion and release techniques as well as restraint techniques (including standing, seated, wall, floor and escort). Skills in report writing and incident evaluation are also addressed. However, it should be noted that there is a lack of any formal evaluation of the programmes effectiveness.

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(b) The Mandt System

The Mandt System was one of the first aggressive management programs developed in the USA, with the earliest version available in 1975 (Mandt & Associates, 1998). It is currently used in at least 45 states of the USA. The program was revised in January of 2002 to meet US regulatory and licensing requirements in a variety of human service settings. The programme emphasises de-escalation techniques for both staff and their clients. The theory underlying the programme is essentially behavioural. The content is organised into three levels: basic, intermediate and advanced. The basic level is taught as a five day course and has three modules including: (1) building healthy relationships (working as a team, causes of stress and the crises cycle, understanding emotions), (2) building communication (nonverbal elements in communication, vocal elements in communication and strategies for de-escalation) and (3) conflict resolution and problem solving. The intermediate level is taught as a five day course and has six modules including: (1) building conflict resolution, (2) behavior support, (3) assisting (body mechanics, posture, movement, one and two person physical assisting and supporting holds), (4) separating (holds, releases, biting and hair pulling), physical restraint (standing, moving restraint, falling down, sitting or kneeling restraint, child restraint), and (5) liability and legal issues. The advanced module, which incorporates train-the trainer components is taught as a four day programme (with refreshers required every two years) includes: an introduction to the Mandt System philosophy, the training approach, leadership and quality of care, conflict management and resolution, body movement and mechanics, unarmed attack, armed attack, changing a persons space, and lying down restraint (Mandt & Associates, 1998). No formal evaluation of this programme was identified, apart from claims by the authors with respect to decreasing behavioural incidents and decreasing use of restraint and seclusion.

(c) Nonviolent Crises Intervention

Nonviolent Crises Intervention (www.crisesprevention.com) has been available since the mid 1970s and is used the US, UK, and Australia. It is typically taught as a four day course, requiring re-certification every four years. The course consists of three sections: (1) prevention techniques, (2) team approach and therapeutic physical intervention and (3) post intervention. Instruction includes the use of a verbal de-escalation continuum as well as staff training in empathic listening. Prevention techniques include: nonverbal techniques such as empathic listening, and verbal techniques. Therapeutic physical intervention includes safety techniques to protect oneself from injury as well as team therapeutic physical intervention techniques. Examples of safety techniques addressed in the course include: a kick block, wrist grab release, hair pull release, choke release and bite release. Examples of team therapeutic physical intervention techniques include: control position (adult and child, interim) and transport techniques. The program does not include evasive techniques but does however include techniques designed to assist staff to gain release from various physical holds. The acronym COPING is used in the training process: c for control; o for orientation; p for patient patterns; i for investigation of alternatives; n for negotiation of alternatives; and g for give staff feedback. Limited attention is given to training in the analysis of precipitating factors and post-intervention procedures (Morrison & Love, 2003). Similar to other programmes, evaluation data is largely limited to that reported by the proponents of NCI.

(d) Therapeutic Options

Therapeutic Options (www.therops.com) proposes as a goal a violence free therapeutic environment with a decreased reliance on physical intervention skills when violent behaviours do occur. The training includes content concerning how institutions rob clients of their dignity and self-respect and the importance of giving clients a sense of self-determination. The program is based on the principles inherent in positive behavioral support (PBS) approaches. It incorporates the concepts and methods of applied behavioral analysis within a person centered approach. A functional model of behavior assessment and change is taught in which all behaviour is considered functional for the person. Although some material on self-awareness is included, the emphasis is more on staff managing stress and supporting others in a difficult situation. There is a large component of the training addressing the importance

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of developing a therapeutic relationship between staff and their clients, and of staff understanding the relative power relationships in support and how these can contribute to situations involving aggression and violence.

(e) Control and Restraint

In the UK, the first systematic approach to the management of dangerous and violent behaviours was that of Control and Restraint (C&R), developed during the 1980s. This approach to staff training was initially developed within the prison service. It was then adapted for use in the mental hospitals system and then for use in generic health and social services. It has informed the curriculum of a range of physical intervention training programmes in the UK, the USA and Australia. The basic techniques that form the C&R curriculum however, rely on pain compliance. That is, staff are taught to apply pressure against writs and across other joints, and to utilise hyper-flections and hyper-extension of limbs in order to gain compliance from the person. There is a growing body of literature that indicates that the dangers associated with the use of such techniques are far greater than any reported advantages. Some reports suggest that over 10% of clients are seriously injured during such procedures, and some 20% of staff are injured when implementing these procedures. Reports also indicate that up to 27% of staff are injured during training (Leadbetter, 2002). Apart from the risk of injury, the legality and ethical sustainability of these techniques in now in serious question. Blackburn (2006) discusses the use of some procedures extracted from the C&R curriculum which focus on breakaway strategies. These are designed for times when staff are in danger or where they have been physically assaulted by a client. However, the emphasis is on the use of specific techniques taught with reference to the individual client. Furthermore, the principle of the minimum force necessary remains paramount. Where staff are trained in the use of breakaway techniques, it is important that they be used solely to escape from potential harm, and not used in an aggressive manner which inflicts unnecessary pain on the person or used in a misguided attempt to teach the person a lesson. They should be used solely to enable the staff to escape from harm. They should not be used to gain control of the person. Such practices are unethical and likely to escalate the behaviours (BILD, 2006).

(f) Therapeutic Crisis Intervention

Concerns have been raised with respect to the Therapeutic Crisis Intervention (TCI) model developed at Cornell University, New York. This curriculum includes instruction in the use of prone restraints and basket holds, know to contribute to injury of clients and staff (Paterson & Leadbetter, 1996; Heron, 1996). A further criticism is that this curriculum places emphasis on teaching staff the techniques of physical restraint and the use of reactive strategies, with only secondary emphasis on preventative strategies. For these reasons, this programme and others like it could not be considered contemporary in terms of the legal and ethical imperatives guiding support services for people with disability.

(g) Strategies for Crisis Intervention and Prevention

Strategies for Crisis Intervention and Prevention (SCIP), now SCIP-R, claims to teach staff to recognise triggers, antecedents and setting events and to take appropriate action to resolve critical issues prior to escalation of the behaviour. Its techniques include an emphasis on interruption and redirection. The proponents emphasise the need to avoid conflict, but include training in what to do if things go wrong and, what the authors refer to as, the battle starting. The programme is typically taught as a 4 day course (each day consisting of 6 hours of instruction). One formal evaluation of SCIP indicated at three-month follow-up, staff felt more confident in the management of crisis, and more supported by their organisation. However, there were no significant effects on the number of incidents reported and data suggested an increased tendency on the part of staff to use a physical intervention relative to other methods following training (Barker & Bissmire, 2000).

(h) Person Focused Training

Person focused training (PFT) is a model of service delivery based on the principles of Positive Behaviour Support (as espoused by Carr and others). It includes an emphasis on developing staff skills in functional assessment techniques. The course comprises nine full days over a 6-month period. The content of the training was adapted from the assessment and intervention protocol developed by the Institute of Applied Behaviour Analysis (see www.iaba.com).

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Participants complete three written training assignments (i.e. behaviour assessment report, behaviour support plan and quarterly progress review) with respect to one individual with whom they directly work. All behaviour support plans specify interventions across four categories: ecological changes, skills teaching, direct interventions and reactive strategies. The reactive strategies component emphasis non-aversive, distraction and redirection techniques. Longitudinal data from a study of 138 cases suggest that implementation of staff-developed behaviour support plans through PFT is effective in reducing challenging behaviour in approximately 77% of cases (McClean et al., 2005). Grey & McLean (2007) implemented further research using a control group to evaluate treatment effectiveness, with wait-listed individuals with challenging behaviours matched against those selected for PFT over a 6-month period. Groups were matched on type of challenging behaviour, duration of challenging behaviour, gender and level of disability. Data on the frequency, management difficulty and severity of challenging behaviour was collected pre- and post-training using the Checklist of Challenging Behaviours (CCB) for both groups. Observational data were also collected and rates of psychotropic medication were tracked across the training period. The authors report significant reductions in the frequency, management difficulty and severity of challenging behaviour in the treatment group but not in the control group after 6 months. No significant changes were found in the use of psychotropic medication for either group over the 6-month period. The authors conclude the results suggest PFT is an effective model for providing support to individuals with challenging behaviours.

(i) Studio III

Studio III (1997) claims to be an evidence-based intervention model that draws on the experience of researchers, specialist movement skills trainers, psychologists (educational and clinical), speech and language therapists, lawyers, doctors, teachers and nurses. The authors report on several studies that demonstrate a decline in behavioural incidents following staff training and sustainability of gains several months post training. Studio III emphasises a non-violent, non aversive approach to supporting people with challenging behaviour. The approach incorporates staff training in techniques to better understand the person with disability and to respond primarily using low arousal techniques (e.g., conflict avoidance and de-escalation) and gentle physical guidance. Staff are also provided with instruction in breakaway techniques. When using breakaway techniques, staff are instructed not to offer resistance or to use strategies that are intended to inflict pain or discomfort on the person, but to move with the person to facilitate their relaxation and a situation in which staff can regain freedom of movement.

9.3 Other Systemic Intervention Strategies and Staff Development Programmes

(a) Multi-element systemic intervention, including Active Support
Active Support represents one form of multi-element systemic intervention (Felce, Jones & Lowe, 2002). Emphasis is placed on a person-centred approach to planning activities (Mansell, Elliot, Beadle-Brown, Ashman, & Macdonald, 2002) and the use of systematic techniques to provide support for engagement in meaningful daily activity (Felce, Lowe, & Jones, 2002). Many of the instructional/teaching techniques used in the implementation of Active Support are those traditionally associated with developmental programming (Jones et al., 1996). Active Support is implemented by means of a combination of structured staff education, staff coaching conducted in the work place, together with the development of organisational policy and procedure. Importantly, in the implementation of Active Support, policy and procedure give priority to supporting people to be involved in a range of ordinary everyday activities, together with the regular collection and use of data to evaluate and inform programme development, consistent with an evidence-based approach to practice (Jones et al.,2001). The effective implementation of Active Support has potential to enhance peoples engagement in meaningful activity, decrease their behaviours of concern and as a consequence staff reliance on restraint and restrictive practices. Active Support has been found effective in its use in Australia (Stancliffe, Harman, Toogood, & McVilly, 2007). In Victoria, to date, findings specific to the impact of Active Support on challenging behaviour have been mixed. However, of note is that a significant reduction has been observed in behaviours identified as self-injurious, stereotypical or severe

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withdrawal (Stancliffe, McVilly, Radler, Mountford & Tomaszewski, 2007). The first two of these categories of behaviour are commonly associated with the use of restraint and other restrictive practices. Miller, Hunt and Georges (2006) describe a multi-element intervention incorporating a monitoring committee and a comprehensive programme of policy development and staff education. They report a 59% reduction in the use of restraint procedures, over a 2 year 9 month intervention period, across two residential treatment services for children and adolescents with disability (409 children, with an average age of approximately 14 years and their average duration of stay being 315 days). The study was conducted as a quasi-experimental field study with the implementation of various elements of the intervention staged across the two facilities, allowing for inferences of causation to be made with respect to the different elements of the intervention. The first of the two major elements of the intervention was the instigation of a Restraint Reduction Committee. The committee established policy and was responsible for disseminating it through educational programmes for staff. Existing positive practices in the organisation were identified and publicised. Staff were also provided with training in less restrictive intervention techniques. While the training included specific courses, on-going training was incorporated into staff meetings and other forums. The second of the two major elements of the intervention described by Miller, Hunt and Georges (2006) was a milieu intervention, which brought about significant changes to the operational and cultural environment. Residents were offered a revised range of courses and other programmes based on their assessed interests. Where consequence strategies were used in response to disruptive or other undesired behaviour, they were specific to the setting in which the behaviour occurred, immediate and time-limited. In addition to reducing incidents of restraint, the organisations involved identified a number of secondary gains. These included less injury to staff and staff reporting a more positive feeling about their job. Sclafani et al., (2008) report on the success of a clinical case review approach to reducing the incidents of restraint use. They report their intervention to have reduced episodes of restraint in an in-patient setting for adults with developmental disability and mental illness from an average of 36 per month to nil, over the course of a 22 month intervention focusing on two nominated clients. The process included environmental assessment, individual case review of identified clients and the implementation of multi-element interventions/support strategies. An important element of the intervention identified by the authors was that staff culture changed, and the genesis/cause of many of the behaviours of concern were no longer attributed to the client, but rather staff recognised the importance of bringing about change to the physical and social environment and how they interacted with the clients. In addition to traditional assessment activities, the clinical specialists called in to work with the staff also spent up to 3 hours per day working along side staff, modelling the intervention strategies. Blackburn (2006) identifies a range of strategies evident in the literature that are recognised as best practice alternatives to physical or restrictive interventions. The author highlights the need for people to have a documented support plan, which has been formulated by means of a multidisciplinary collaboration. Importantly, the plan needs to include both short-term and long-term strategies that address the persons health care and educational needs, together with the physical and social environments in which they are supported. Those providing support need to have a well-developed understanding of the persons behaviour in terms of its functionality from the persons perspective and, where relevant, any biological factors contributing to the behaviour (e.g., where the behaviour emerges as a behavioural phenotype). In addition, staff need to have a well developed understanding of the circumstances likely to contribute to the emergence of the identified behaviour, specific triggers to the behaviour, and precursor or lower level behaviours which provide an early indication that an identified behaviour is likely to occur. Blackburn (2006) identifies a number of verbal skills in which staff need to have developed competence. For example: using a clam voice; speaking slowly; using open questions; not sounding accusatory or threatening; acknowledging the feelings of the person in a way that the person understands, and which is genuine; providing positive feedback; being patient and honest; and a preparedness to negotiate (rather than adopting a win at all cost approach). Similarly, Blackburn, consistent with Stevenson (1991), identifies a number of non-verbal techniques to be used when supporting people who might otherwise be subject to physical interventions and other forms of restraint. These include: moderating

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eye contact to maintain visual communication but without causing the person increased anxiety; keeping facial expression serious but calm and avoiding the expression of anger or fear; adopting an open physical posture (e.g., avoid crossing arms and adopting an accusatory or domineering stance); and avoiding physical contact with the person unless this is absolutely necessary or know to provide comfort and reassurance. An awareness of, and skills in managing personal space is also noted to be an important strategy in which staff need to be trained. Recommendations include: keeping distant, but still within range to maintain visual contact and to be able to hear the person clearly as well as to be heard by the person; standing off to the side (e.g., 90 to the side) rather than directly in front of the person; being on the same level as the person , rather than towering over them; ensuring there is a clear path for you to leave and exercising the option to leave where the danger escalates or you being to feel uneasy or concerned about the situation and your individual capacity to remain calm and safe. Blackburn (2006) discusses the importance of environmental strategies to manage difficult situations in order that more restrictive physical interventions can be avoided. Examples include: minimising noise and removal of items that could be dangerous (e.g., knives and small items of furniture); removing other people from the area or ensuring that staff who might not have a positive rapport with the client are not present or involved in the intervention; offering food and drink or the option of a preferred activity. Here it should be noted that staff should be aware that the de-escalation of a potentially dangerous situation by using a seemingly rewarding strategy should be considered a priority over the use of physical or other restrictive interventions. Such strategies are sometimes referred to as counter-intuitive strategies.

(b) Counter-intuitive intervention strategies

LaVigna and Willis (2002) describe the importance of the multi-element intervention model and, as part of that model, the use of counter-initiative strategies to avoid situations that would otherwise lead to the use of physical restrain and other restrictive practices. They note that staff are often resistant to the use of these counter-intuitive strategies as they defy logic and run contra to traditional service priorities that emphasis control and dominance of clients and client behaviours. Staff therefore require specific instruction in their use and organisational policy (and staff supervision practices) need to reinforce their use as valid (and preferred) clinical options. The first of these counter-intuitive strategies is to introduce and maintain a high density non-contingent reinforcement programmes. That is, even when the person engages in the use of challenging behaviour, their usual routine, including anticipated enjoyable events, should be maintained. This strategy lessens the likelihood of further challenging behaviour arising as a consequence of the absence of preferred activity. The removal of preferred activity from the persons schedule is only likely to be experienced as aversive and contribute to further challenging behaviour. The concern often advanced by staff is that continuing with preferred activity will reinforce and encourage the challenging behaviour. So long as the activity is not contingent on the behaviour (i.e., the behaviour does not itself gives rise to the event) and there is at least a short temporal delay between the behaviour and the preferred event, the evidence from behavioural science suggests that there is no danger of the challenging behaviour being reinforced. Indeed many people with intellectual disability do not have the cognitive capacity to identify that the cancellation of a planned activity had anything to do with their use of an undesirable behaviour. The cancellation of the event or discontinuation of their usual routine is not educational, only aversive and, consequently, likely to act as the setting event for further undesirable behaviours. The second counter-intuitive strategy is to avoid natural consequences to a behaviour. This is a particularly important strategy where people with a cognitive impairment are unlikely to learn from the consequences of their actions and the consequence is itself is likely to be an added frustration or aversive event that in turn becomes the setting or trigger for further behaviours of concern. Staff will commonly advance the position that natural consequences will teach the person or that it is their right to experience the consequences of their own actions. Natural consequences frequently cannot be justified on the basis of the persons capacity to learn and frequently only contribute to aversive environments that act as the setting events for further challenging behaviour. A third counter-intuitive strategy is not to ignore certain disruptive or undesired behaviour. Historically such strategies have been used with the idea that if social reinforcement was withdrawn, the behaviour would go without reinforcement and as a consequence be extinguished. This could be true if the function of the behaviour was solely to gain attention.

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However, functional analysis techniques suggest that people use challenging behaviour for a variety of purposes and to communicate a range of messages. Where these attempts to communicate go unheeded, the person is likely to escalate the behaviour or develop another behaviour that will typically be as challenging or possibly more so. It is often more important to respond promptly to low-level challenging behaviour as early as possible to avoid escalation and then later teach the person the more desirable alternative, reinforced by meeting their needs in the persons preferred way. A fourth counter-intuitive strategy is to eliminate punishment. Similar to the elimination of natural consequences, removing punishment serves to minimise aversive situations that act as the setting events of further escalations of the challenging behaviour which could then require ever increasing levels of restriction and restraint. LaVigna and Willis (2002) would recommend that rather than using punishment or restrictive practices that might be interpreted by people as punishment, staff need to be skilled in using diversion to a more compelling or reinforcing activity. And, arguably even more challenging for staff, they need to be taught the value of strategic capitulation; giving the person what they want, regardless of the staff perspective as to the appropriateness or normality of the request. Within the framework of a multi-element intervention, there will be time later to teach the person a more appropriate skills or coping strategies. Importantly, the authors stress that when the person is agitated, it is not a good time to attempt to teach them a lesson.

(c) Room-based interventions

There is some evidence in the literature for the acceptance and effectiveness of what is termed room-based intervention. However, these interventions are distinct from seclusion or traditional time-out procedures. Room based interventions involve staff actively working with the person while in the designated (sensory) room. In hospitals (e.g., Taunton Hospital, Massachusetts) and other institutional settings, environments which were previously used to control (or punish) behaviour are now being modified for uses as sensory rooms. These rooms are used both to provide a safe environment where people whose behaviour can be attributed to (following, for example, thorough functional assessment) over stimulation can be supported to calm down. Furthermore, these structured environments can be used to further assess their individual sensory needs and preferences, and provide a transitional setting from which these identified needs and preferences can be systematically incorporated into the larger surrounding environment in which they spend the majority of their day. The technology employed in the development of sensory rooms includes that developed by Snoezelen in The Netherlands (www.rompa.com/cgi-bin/Rompa.storefront). Snozelen technology has developed over the past 35 years and is recognised as therapeutically beneficial for people with many different types of disability, especially for those with profound and multiple disability and associated sensory impairments. Here it should be noted that it is this group of people who are commonly subject to restraint in an effort to prevent self-injury. In a similar vein, the Cohannet Academy (Massachusetts) for adolescents with emotional and behavioural regulation difficulties developed the concept of the The Getaway Room. This facility was used in conjunction with the application of a comprehensive programme of Dialectical Behaviour Therapy (DBT). In adult populations, DBT is commonly used in the treatment of people diagnosed Borderline Personality Disorder. Again, people diagnosed with personality disorders, due to their behavioural presentations, are a group at risk of being subject to restraint and seclusion. Other room-based interventions, such as Comfort Rooms, are also being developed in various facilities in the USA. Comfort Rooms, differ from sensory rooms in that there is no sensory-experimentation, stimulation or explicit therapeutic activity. Comfort Rooms are designed with consumers, for consumers, and are intended to be a place to relax and restore composure. Their use is not considered to be part of active therapy, and certainly not as a punishment.

(d) Sensory interventions

Adopting a similar approach, the National Association of State Mental Health Program Directors National Technical Assistance Center (NASMHPD-NTAC) curriculum includes training for staff in a variety of sensory interventions and the development of alternative environments to promote comfort. During 2003 and 2004, over 650 staff, including state mental health agency senior leadership and executive administrators of state-operated facilities from 26 US states were trained in the seclusion and restraint reduction curriculum. Eight of the initial states trained in 2003 provided pre- and

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post data. The initial results indicated hours of seclusion and restraint were reduced by as much as 79%, the proportion of consumers in seclusion and restraint was reduced by as much as 62%, and the incidents of seclusion and restraint events in a month were reduced by as much as 68% (Conley, 2004). Sensory and other occupational therapies are emerging in their importance as part of a comprehensive programme of support, alongside the more traditional skill development programmes. Sensory assessments of individual sensory diets to determine whether someone is sensory-seeking or sensory-avoiding are providing important information for developing individualised repertoires of interventions designed to teach self-soothing and self-calming skills. Likewise, techniques such as aromatherapy and therapeutic touch are also being used, including arm and hand massages, medicine ball massages, and the use of vibration (Champagne & Stromberg, 2004).

(e) Low arousal techniques

Another approach to the support of people exhibiting challenging behaviour, offered as an alternative to more restrictive interventions, and building upon knowledge of the persons sensory needs, are those based on low arousal techniques (Sturmey & Palen McGlynn, 2002). The low arousal approach represents a class of diffusion strategy. These strategies include staff identifying and systematically reducing potential points of conflict and the number of requests (demands) made of clients. Practically speaking this could include a review of the number of expectations or the level of compliance that staff expect of clients in particular settings or across the course of their day. It could also include a review of the expected standard of performance within individual activities. In this respect, those providing support are expected to be flexible to the behaviour or level of performance of their clients, adopting a client-centered approach to performance appraisal, rather than a staff-imposed expectation. Similarly, staff need to become aware of and intentionally avoid verbal and non-verbal communication styles (and content of communication) that are identified triggers to behaviour. While a longer-term strategy might be to teach the person a new way of thinking or enable their capacity to better cope with conversations styles and topics they currently find aversive, it must be acknowledged that, for people with cognitive impairment these are typically long-term goals and in the interim it is the responsibility of staff to modify their behaviour. Similar to the counter-intuitive approaches advanced by LaVigna and Willis (2002), it is reported that staff will commonly find the adoption of low-arousal approaches difficult as they either place responsibility on them to change, rather than the client, and/or the proposed strategies are contra to traditional approaches and service policies. For these reasons, in addition to specific instruction in their use, to be successful, these strategies require explicit policy-level support within agencies and for supervisory staff to emphasise their use through both direct modeling in situ and in regular staff supervision activities.

(f) Intensive Interaction

Intensive Interaction is both an approach to being and working with people with severe to profound intellectual disability and an intervention technique designed to facilitate the development of the most fundamental skills necessary for social interaction and communication (Nind, 1999). As such, it offers an approach to working with people with significant levels of intellectual disability and co-existing complex physical and sensory disability, who frequently present with severe behaviours of concern; and in particular self-stimulatory and self-injurious behaviours which are often seemingly resistant to other more behaviourally orientated intervention techniques. Intensive Interaction was first described by Nind and Hewitt 1988, and has since been subject to a series of systematic evaluations (e.g., Watson & Fisher, 1997; Watson & Knight, 1991). It is now a recognised as an evidence-based technique and has been incorporated into the English school curriculum for students with learning disability. It has also been observed to be effective as a technique when working with people with Autism Spectrum Disorder (Nind, 1999), though a more substantial empirical bases to these claims is necessary (Nind & Powell, 2000). Nind (1996) identified five central features of Intensive Interaction: (1) The creation of mutual pleasure and interactive games; (2) Staff adjustment of their personal behaviours in order to become more engaging and meaningful for the client; (3) Interactions flowing in time: with pauses, repetitions and blended rhythms; (4) The use of intentionality responding to the clients behaviours as if they were initiations with communicative significance; and (5) The use of

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contingent responding: following the clients lead and sharing control of the activity. The British Institute for Learning Disabilities (BILD) describes Intensive Interaction as: a practical approach to interacting with people with learning disabilities who do not find it easy communicating or being social; it helps them develop their communication abilities (BILD, 2005). In Intensive interaction the carer, support worker, speech and language therapist or teacher works on being a better communication partner and so supports the person with learning disabilities develop confidence and competence as a communicator. Intensive interaction is a fun process. The communication partner is guided by what we know about how communication ordinarily develops for young children. Studies have found beneficial effects of Intensive Interaction, which include childrens increased ability to initiate and maintain social contact and improved pre-verbal communication skills (Kellett, 2000; Nind, 1996; Watson & Fisher, 1997). Similarly, improved behaviour and communication have been observed for adults with severe or profound and multiple learning disabilities (Elgie & Maguire, 2001; Lovell, Jones, & Ephraim, 1998). In addition, Intensive Interaction has been found to be beneficial for building positive relationships between clients and their employed carers (Elsworth, 1999; Samuel, 2003; Watson & Knight, 1991). This last point is important given the critical influence of staff regard for their clients in both their interaction style and the effectiveness of the support they provide to clients exhibiting behaviours of concern (see section 8.8 staffing issues).

(g) Mindfulness techniques

Mindfulness and mindfulness-based interventions are being incorporated into staff training. Proponents claim that their use can positively effect staff behaviour towards their clients and in turn effect client behaviours. The mindfulness mechanism is proposed as leading to a clear, calm mind that is focused in the present and is aware of both external and internal conditions. A staff member employing this technique is asserted to attend not only to what is unfolding in the external environment (e.g., an individual is getting upset and aggressive), but also to what is occurring in his or her internal environment (e.g., changes in his or her own emotional state as a consequence of the individuals aggressive behavior). Thus, the staff member is more prepared to respond to the situation in a way that promotes the wellness of all involved. For reviews, see (Hayes, Follette, & Linehan, 2004; Segal, Williams, & Teasdale, 2002). Singh et al. (2006) provided group home staff with behavioral training and later with mindfulness training to assess the impact on aggressive behaviors and the number of learning objectives mastered by clients with intellectual disability. When compared to baseline, the number of staff interventions for aggression showed some reduction following behavioral training, but decreased substantially following mindfulness training. There was also some increase in the number of learning objectives mastered by the individuals following behavioral training, but greater and more consistent increases were obtained after mindfulness training. Improvements also occurred on the other measures assessed after behavioral training, but these were always greater and more consistent following mindfulness training. In addition, consistent gains followed behavioral training only with a high staff-resident ratio whereas the larger gains after mindfulness training occurred with both medium and low staff-resident ratios. The authors assert that mindfulness training considerably enhanced the ability of the group home staff to effectively manage the aggressive behavior and promote learning for the individuals with disability. Consistent with the mindfulness approach, an Australian development, Serenity Settling has been applied in the staff development programmes of nursing staff working in aged care and the support of people with dementia (see www.healthyoutlook.com.au/SerenitySettling ). The author claims significant improvement in both occupational outcomes for staff and patient outcomes with respect to their level of agitation and associated behaviours. However, this techniques is yet to be subject to systematic research.

9.4 The Support of People with Persistent Self-Injurious Behaviours

The issue of restraint in situations involving people who engage in stereotypy and self-injurious behaviours requires specific attention. This area includes a complex and emerging literature that requires a bio-behavioural understanding of both the genesis of behaviour and appropriate response strategies (Barrera, Violo, & Graver, 2007; Hall, Lightbody, & Reiss, 2008; Rapp & Vollment, 2005). Often times learning theory and traditional functional analysis techniques are

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insufficient to generate effective intervention strategies. As Matson and LoVullo (2008) observe, particularly in relation to the support of adults with Autism Spectrum Disorders: people who wish to be critical of restrictive treatment methods need much better data to support claims of harm, and they need to conduct direct comparison group studies to show that these so-called positive supports are near to or equally effective and produce fewer adverse side effects. What little data are available, for the most severe cases, actually contradict these assertions. The current state of affairs has involved attempts to ban or prohibit aversives with no readily available, proven, equally effective behavioral alternative. A vacuum has therefore been created, which ironically has been filled by even more restrictive pharmacological interventions or emergency restraint. This subject matter requires a dedicated review of the literature. However, for the purposes of the current review, some key issues will be addressed. Self-injurious behaviours cause harm to people themselves and significant psychological distress to staff providing support (Duperouzel & Fish, 2007). However, in some instances, it is hypothesises that self-injurious behaviours are an effective (albeit maladaptive) mechanism used by individuals to self-regulate anxiety (Barrera et al., 2007). In some instances, staff lack an understanding of the sociological, psychological and/or biological circumstances giving rise to the behaviour and as a consequence use restraint and seclusion in punitive ways (Babiker & Arnold, 1997). It is not uncommon for people who self-injury to be subject to restraint by means of either arm splints or protective clothing (Powers, Roane, & Kelley, 2007). The prevalence of self-injurious behavior (SIB) in persons with intellectual disability is estimated at between 4% and 14% (Oliver, 2008), with the incidence increasing with the assessed severity of disability. The most common forms being skin picking and scratching, biting and head-banging and punching (Griffin, Williams, Stark, Altmeyer, & Mason, 1986; Oliver, Murphy, & Corbett, 1987; Rojahn, 1986; Schroeder, Schroeder, Smith, & Dalldorf, 1978). It commonly presents as a behavioural phenotype associated with a number of known syndromes: Smith Magenis, Cornelia de Lang, Cri du Chat, Lowe and Lesch-Nyham. To gage the extent of the issues associated with the support of these individuals, Oliver et al. (1987) reported that, in a total population sample, 20% of individuals who self-injured to the point of tissue damage in a 4 month period selfinjured at least once an hour. A major issue in assessment of these individuals and the design of support strategies or interventions is that these behavioural profiles do not necessarily fit with the principles of either learning theory or applied behaviour analysis (e.g., functional analysis). As a consequence interventions have previously involved positive punishment contingencies. Such strategies have however been strongly criticised for being both ineffective and inhumane (Repp & Singh, 1990). When restraints are in use, there are two strategies that are described in the treatment literature which, to some extent, overcome the problems associated with positive punishment. These are: (1) the differential reinforcement of periods of non-SIB by the presentation of preferred forms of restraint; and (2) the fading of existing non-preferred restraints. However, it must be noted that the efficacy of using restraint as a contingency for periods of no SIB relies on restraint being reinforcing (e.g., Smith, Lerman, & Iwata, 1996). As one example of where restraint has been maintained but modified as part of an intervention, Oliver et al. (1998) describes the effects of introducing flexion into a straight-arm splint. Using a single-case design for two individuals self-injury was reduced to zero, while the overall level of restriction was also significantly reduced. The authors report that engagement in activities and social contact were not affected by the introduction of the new splint. Furthermore observations suggested there was no evidence of an increase in negative affect with the introduction of the new splint. However, and importantly, there was evidence of an increase in positive vocalisation. Jones et al. (2007), investigating support strategies used by staff working with clients who exhibit self-injurious behaviours identifies a continuum of strategies in common use, from those identified as the least restrictive to those considered as most restrictive:

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 Distraction Diversion to a reinforcing/compelling event (strategic capitulation) Verbal commands to reassure or calm the person Verbal commands to stop the identified behaviour Adaptations to the physical environment to minimise injury should it escalate Physical restraint Protective devices, such as helmets and mittens Appliances, such as splints or chair ties The authors assert that even when working with clients with self-injurious behaviours, staff training needs to focus on coaching in positive behaviour support strategies (PBS). Furthermore, policies and procedures should still direct staff attention to the need to minimise the use of personal and mechanical restraint (Sturmey & Palen McGlynn, 2002). The authors endorse the position established by Spain, Hart, and Corbett (1984), that staff need to ask a key question: Is there any alternative way of preventing damage, which would be non-reinforcing of the SIB, and which would allow the person to engage in other activities, and which would be feasible in practice given actual staffing levels? If the answer is no, then protective alternatives should be used in the interests of preventing harm. These could include physical holding or the use of an appliance adapted by an experienced therapist to meet the individual needs of the person (but the person must not be left unattended when the device is in use). Where holding techniques or a device is used, consideration must be given to the duration of the procedure and strategies to fade its use where ever possible. Also, strategies should be in place to enable the person to continue, as much as possible, with their usual routine, thus ensuring that the strategies used to prevent injury do not develop as a seclusion or punishment.

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