Reducing the Use of Restrictive Practices with People who have Intellectual Disabilities: A Practical Approach

Citation

Deveau, R. (2012), "Reducing the Use of Restrictive Practices with People who have Intellectual Disabilities: A Practical Approach", Tizard Learning Disability Review, Vol. 17 No. 1, pp. 49-51. https://doi.org/10.1108/13595471211207147

David Allen has provided an admirably concise and comprehensive guide to one of the most important policy and practice areas for people with intellectual disabilities (ID). The 67 pages contain a very useful summary of evidence related to the subject, and as such, should be on the shelf of service providers, commissioners and advocates of people with ID. The importance of seeking to reduce the use of restrictive practices has been emphasised in many investigations including those into Sutton & Merton and Cornwall NHS Trusts. Allen has been involved for many years in pursuing better governance and more judicious use of physical interventions. This work reflects this extensive involvement.

The text is presented in six chapters, from “Introduction” through to “Looking Forward”, the latter suggesting service users, purchasers and commissioners should require data on restrictive practice reduction be made available to those seeking support from a particular organisation. It ends “If existing reports on restrictive practice reduction are correct […] their wider application may lead to less restraint, seclusion and emergency medication use” (p. 53). We can all sign up to that aspiration.

Chapter 1, and throughout, allies the publication to the work of the British Institute of Learning Disabilities (BILD) in promoting good practice, especially in physical intervention training and its more recent focus on improving and reducing restrictive practice within an overall context of positive behaviour support (PBS). Definitions for physical restraint, seclusion and rapid tranquilization are given; as this ambitious booklet considers all three areas as being prominent restrictive practices. As well as describing these different restrictive practices, evidence is also drawn from different service user groups including people with intellectual disability, children and adults with mental health problems. Subsequent chapters present reasonably convincing evidence to suggest that the different groups have sufficiently shared circumstances that similar approaches are applicable to all groups.

Chapter 2 reviews the literature regarding frequency of use and impact of restrictive practices. The chapter notes that the lack of robust evidence for the effectiveness of such practices in “making people safe and managing difficult behaviour” (p. 15) has not prevented their continued widespread use.

Chapter 3, perhaps the heart of the booklet, presents the evidence from two broad areas on the reduction of restrictive practices. This chapter relies heavily upon describing and summarising a number of other reviews of the literature. The first area consists of studies demonstrating reductions in restrictive practices with individuals or small groups often using experimental research approaches and based upon applied behaviour analysis. Emerging literature on changing staff attitudes and approach, e.g. teaching staff “mindfulness” or “acceptance” is included. Second, whole organisation interventions are summarised. These organisational interventions are largely based upon work from the USA; developing legal approaches from Australia are mentioned. This section would benefit from also considering the literature describing the impact of legal approaches in Norway. Entirely in line with the evidence‐based approach Allen employs, the review warns that these broad organisational interventions are complex and multi‐faceted and that the precise drivers of change remain unclear. Despite the variety of interventions described, a range of commonly cited “critical ingredients” is noted including: leadership, using data to inform practice, workforce development, specific reduction tools, consumer involvement, clear crisis management and debriefing strategies. Allen concludes this chapter “though there is a lack of robust experimental evidence, there is significant practice‐based evidence to suggest that restrictive practices can be reduced across a variety of user groups and settings” (p. 28).

Chapter 4 introduces the background to and potential application of PBS as an important encompassing “service system” for organisations seeking to reduce restrictive practices. The features of restrictive practice reduction and PBS are compared and PBS is found to offer similar strategies to the reduction approaches described in the previous chapter. PBS is presented as a potentially useful comprehensive package of principles and practice for organisations wishing to reduce restrictive practices.

Chapter 5 focuses upon a “project planning” template which is available from BILD's web site. Allen advises rightly that the template should be used flexibly, depending on the organisational context, e.g. size and complexity. The rationale for taking a project planning approach is described and the characteristics of successful and unsuccessful projects outlined. Allen sees planning as the central requirement to reducing restrictive approaches – “the old adage of failing to plan is planning to fail is undoubtedly true” (p. 42). The project planning template invites organisations to answer 45 “key things to think about” in nine stages – how they (organisations) plan to do this, by whom, by when and date achieved. For example, stage 1 “committing the organisation” includes: having a clear goal to reduce restrictive practices in the mission statement, designating somebody to have prime responsibility and establishing a project group, stage 2 “collecting baseline and ongoing data” includes frequency of use of restraint, seclusion and as required medication, stage 9 “celebrate success and take remedial action where necessary” includes regularly publicise positive results (for example, in staff newsletters and in communications with stakeholder agencies).

Chapter 6 invites readers to look forward and suggests that organisations and services that embrace the principles and methods described will adopt a data driven approach. This approach will enable them to demonstrate progress to users, purchasers and commissioners who “should” require and consider such data when allocating contracts. This would enable the differentiation of those who can walk the walk as opposed to just talk the talk.

Chapter 5 is the one section where an additional perspective may be useful to balance its reliance upon rationalist structural organisational interventions and project planning. The difficulties in turning planning into action have been discussed in relation to person‐centred approaches by Mansell and Beadle‐Brown (2004). The propensity for planning and working groups to lose momentum or delay action and change on the ground is an ever‐present possibility. Action is required to achieve change. An alternative view of organisations involves complex adaptive systems (CAS) – systems of interacting networks of social relationships and interactions. In CAS social influence, within networks, rather than structures is the main agent of change and adaptation.

The centrality of leadership within the broader organisational approaches, along with other critical elements, is reflected in the project planning template. This encompassing template may be appropriate for planning but hinder action. Simpler descriptions may be more accessible and effective. Deveau and McDonnell (2009) suggested just three essential features for reducing restrictive approaches: leadership, use of data to inform practice and individual or service interventions, e.g. PBS and active support. The centrality of leadership to organisational change probably requires it be given greater attention, here, and in the intellectual disability sector more generally.

Leadership is the exercise of social influence within the network of organisational relationships and interactions involved in any setting. It is what provides organisations with energy, momentum and direction. Clearly, when described like this, all people in an organisation can exercise leadership. However, those who hold formal positions of power should be able to influence most. Leaders have many ways of expressing influence within networks including by asking “simple” questions, e.g. “why do we do this?” “How much restraint do we use?” In this example, leadership would result in data collection that can answer the questions.

Leadership thus becomes the driving force and independent variable for change. The use of mission statements or planning groups to drive change has a long and distinguished history of giving us “old wine in new bottles”. As the management leader Peter Drucker puts it “Plans are only good intentions unless they immediately degenerate into hard work”. Providing good leadership entails data or information becoming, not just a means for assessing the contribution of variables to achieving change (as in experimental studies), but a means for developing direction in an organisation. Leaders, able to lead, will have a great variety of ways to influence the networks of relationships and interactions (values and culture) in their organisations; this should be their focus, especially initially. Any need to alter the arrangement of some or all of the organisation's structures, to support reduction of restrictive practices, will become clearer as the network of relationships is reformed by leadership.

Allen reaches the positive conclusion that it is perfectly feasible for us to reduce the use of restrictive practices. This booklet will greatly assist in achieving this goal.