by Grant J Everett
Constructively working towards improving the rights and dignity of people with disability
by Grant J Everett
WARNING: This article deals with the issue of physical restraint and seclusion. Please talk with someone if you feel distressed by it.
Dr Jeffrey Chan of the NDIS Quality and Safeguards Commission was the keynote speaker for Flourish Australia’s 2018 Annual General Meeting. His address centred around restraint and seclusion, and how commonly these practises are used on people who have a disability for the purposes of behavioural management. Rather than just wanting to reduce the frequency of restraint and seclusion that is currently being used on Australians who have a disability, Dr Chan wants to see the end of their use in this country altogether.
Part of Dr Chan’s job at the NDIS Quality & Safeguards Commission is to deal with detailed updates on all the instances of restraint that happen across the country, and to submit weekly reports about it to the rest of the Commission. Statistically, he found that the people who are most likely to experience being restrained or secluded in Australia are those with mental health issues, intellectual issues or behavioural issues, as well as people who are elderly, people in the corrective system, and children and youth in the justice system. As an estimated half a million Australians with some form of disability have a high chance of experiencing restraint in some form, Dr Chan said it was understandable that the Commission takes a very strong approach in regulating its use.
Dr Chan has spent fifteen years studying restraint and seclusion in Australia, which can be broadly defined as “anything that restricts the rights and freedom of movement of a person.” Depending on a range of factors, some workers (such as psychiatric nurses in mental health units) currently have the power to restrain and seclude people under their care whenever it is deemed necessary to prevent harm. This kind of intervention can be used on people who display “challenging behaviours” or “behaviours of concern” like aggression, self-harm, fire lighting and property damage. A restraint response is supposed to be a last resort, as well as being proportionate to the potential harm it is attempting to avoid. Whenever restraint is used, all efforts need to be made to apply the least restrictive kind for the shortest possible time. In addition to mental health units, restraint also happens in supported accommodation, general hospitals, aged care facilities and prisons.
After all this time, Dr Chan has come to the conclusion that not only do restraint and seclusion provide no therapeutic benefit, but they are inherently dangerous to everybody involved, no matter what precautions are taken. He found there’s no such thing as a “safe” kind of restraint that can prevent all potential injuries from happening to either party, regardless of training. As restraint attempts can cause anything from nose bleeds and bruising to hairline fractures and even death, Dr Chan told us that 100% safe restraint techniques simply do not exist. On top of that, staff who are formally trained in using restraint are statistically more likely to attempt its use than staff members who haven’t. Although many people might believe they know how to use restraint safely, Dr Chan has seen quite a few reports where the injuries were caused while people were learning these “safe” methods!
Dr Chan’s extensive studies into restraint practises across many settings have unequivocally found that restraint does not reduce antisocial behaviours or increase pro-social behaviours, and only raises the chances of future conflict and ill-will. From an economic perspective, restraint practises are much more likely to incur a cost without providing anything in return, an investment that never pays a dividend. As mental health workers are trained to operate from a therapeutic perspective, Dr Chan has come to the conclusion that restraint practises are not consistent with the recovery model, and have no place in contemporary mental health management. Dr Chan told us the NDIS Quality and Safeguards Commission has examined the international evidence and made a commitment to “raise the bar” for the rights of persons with disabilities. Although the USA, UK and Europe are all focussed on reducing restrictive practises, Dr Chan told us that his agency is committed to upholding the rights and dignity of people with mental health issues in this country, and are dedicated to bringing our mental health system into the 21st Century by eliminating restrictive practises altogether.
“We make no apologies for that,” Dr Chan said. “The status quo for people with disabilities must change. The NDIS in itself is a significant social policy reform agenda, and this is an opportunity for us to change the paradigm of how we view people with disability. And so it is no longer just talking about improving quality of life, it’s also about safeguarding dignity. I make this distinction based on the difference between dignity versus quality of life.”
A key tool that Dr Chan and his peers are using to rid our system of restraint is breaking down the myths that surround it. Dr Chan has had many face-to-face interviews with people who have experienced being restrained, those who do the restraining, as well as the families of the restrained. He found that being restrained can create feelings of violation, and if it happens to an already-traumatised person it can greatly increase their odds of suffering distressing flashbacks.
The staff members who apply restraint generally don’t feel safe doing it, either, and this can lead to anger and distress. If a staff member has a background of trauma, for instance, simply witnessing somebody chancing an injury can cause them to re-experience these past hardships. It can also lead to a higher incidence of leave and psychological distress.
Chemical, mechanical, physical, and environmental restraint are all about restricting someone’s movement. This can mean injecting strong psychotropic medication, bolting or strapping someone in place, or physically pinning them down. All forms of restraint carry risks, from medication side effects to muscle wastage and injuries to both parties, and there are many rules in regards to how these techniques are used. However, it would be naive to say that these rules are always adhered to. Seclusion traditionally means preventing somebody from exiting a room, but it’s broader than that. Dr Chan has seen group homes where masking tape spells out where residents can and can’t go. None of these techniques are supposed to be used as a form of discipline or retaliation.
What is Flourish Australia’s policy?
Flourish Australia staff are PROHIBITED from using restraint and seclusion. We don’t tackle, inject, or lock people in a room. If somebody accessing a Flourish Australia service becomes distressed, simply taking them aside for a positive, strengths-based, de-escalating chat can work wonders. This can help both parties to develop a shared understanding of the cause of the distress, allowing them to build on their strengths and gain new skills, and hopefully decrease the frequency and impact of future distress.
What did the audience think?
Jessica B, who accesses Flourish Australia’s YCLSS service at Penrith, saw Dr Chan’s talk. “I think pretty much everything he said was spot on,” she said. Jessica has had personal experience of restraint, restrictive practises and seclusion, and tells her story on pages 10 and 11 of this issue Panorama.
Following Dr Chan’s talk, Janet Meagher AM, recipient of the Order of Australia and a lifelong advocate of the rights of people with mental health issues, commented on how she has personally been subjected to restraint and seclusion, and how many of us have gone into these systems as traumatised people seeking help, only to end up even more traumatised as a result.
If Australia can showcase a system that no longer relies on restraint, who knows how far it could spread? Could this be the start of something huge?
In his work with the NDIS Quality and Safeguards Commission, Dr Chan also plays a role with improving NDIS support and services across Australia, actively regulating the NDIS market, providing national consistency, promoting safety and quality in services, resolving problems, and identifying areas for improvement.
“Restrictive Practices: The use of restrictive practices in Australia”, Australian Law Reform Commission
ABOVE: Janet Meagher AM commenting on her personal experiences with being physically restrained. PHOTO Neil Fenelon