Restrictive Practices

The use of restrictive practices can be a threat to quality of care and individual human rights. A paper that reviewed physical/mechanical and chemical restraint and the factors that may result in the use and maintenance of restraint found that the rate, type and intensity of behaviours that challenge, and the age of the individual with intellectual disability and the type of residential placement have been found to be the major factors that put people with intellectual disability at risk for restraint (Matson and Boisjoli, 2009).

Various international instruments are of relevance to the use of restrictive practices. These are the United Nations Convention on the Rights of Persons with Disabilities (CRPD/Disability Convention) (UN, 2006), the European Convention on Human Rights (ECHR) and the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (‘MI Principles’) (UN, 1991). Due regard should always be given to the need to respect the right of the person with intellectual disability to dignity, bodily integrity, privacy and autonomy, which is in line with the requirements

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of Article 8 of ECHR (European Court on Human Rights and Council of Europe, 1950).

[QI 2, QI 8, QI 11, QI 13]

The right to respect for private life in Article 8 of the European Convention on Human Rights, includes a person’s physical and psychological integrity i.e. what happens to our bodies and our minds. The objective of Article 8 is to

“protect against unjustified interference with personal integrity”.

Medical treatment without consent will not be an interference under Article 8 with private and family life if the State can convincingly show that it was necessary and the individual was not in a position to give informed consent – due to incapacity. However, the Courts have said that

“the position of inferiority and powerlessness which is typical of patients confined in psychiatric hospitals calls for increased vigilance in reviewing whether the Convention has been complied with.”

The Convention reflects the principle of proportionality requiring that any interventions in a person’s life must be in proportion to the aim to be achieved, also known as the least restrictive alternative, both of which are important human rights principles (Keys, 2007). [QI 7, QI 11, QI 12, QI 13, Q I2, QI’s 14 - 28, QI 31, QI 32, QI 37]

The Irish Mental Health Commission has issued a Code of Practice Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities

which defines ‘restrictive practices’ as including, but not limited to ‘the use of mechanical restraint, physical restraint, psychotropic medication as restraint and seclusion’ (Mental Health Commission, 2009). A European Union Green Paper ‘Improving the Mental Health of the Population’, emphasised the urgent need to

‘improve the quality of life of people with mental ill health or disability through social inclusion and the protection of their rights and dignity’ (European Commission, 2005). [QI 13]

Chemical restraint has been defined as:

‘… both deliberate and incidental use of pharmaceutical products to control behaviour and/or restrict freedom of movement, but which is not required to treat a medically identified condition. These drugs may be

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purposively administered to sedate a patient as a means of convenience. Convenience is any action not in the patient’s best interests, to control or manage behaviour’ (Mott and Poole, 2005).

However it should be noted that many clinicians consider the term ‘chemical restraint’ pejorative, since it does not reflect the possibility that ‘forced’ medication may be clinically necessary. [QI 8, QI 11, QI 13, QI 14]

A rapid review (Slevin et al., 2011) undertaken using a framework adapted from the NHS Centre for Reviews and Dissemination and the Rapid Review Methodology aimed to search for, evaluate and prioritise studies or other robust literature that have focused on people who challenge and others. One recommendation only in relation to medication use was made by the authors, Box 2.1.

Medication Recommendation - People who Challenge: Practice and Services

Medications should only be used when indicated for the treatment of physical causes of behavioural problems or treatment of psychiatric illness and be used to supplement other interventions rather than as a stand-alone treatment.

Box 2.1 Medication Recommendation - People who Challenge: Practice and Services

In the discussion of these review findings, Slevin and colleagues state that

‘With respect to interventions the review found some expected outcomes that have remained unchanged for a number of decades. Medications are a highly used treatment for people who challenge but there are now clearer guidelines on use for behavioural management. Behavioural interventions, based on a positive behavioural support (PBS) model have been found most effective in supporting people with intellectual disability who have behaviours that challenge’ (Slevin et al., 2011). [QI 5, QI 6]

The incidence of restraint in Australia (23-28%) is considered high compared with the UK where it is reported that between seven and seventeen percent of adults with a disability are subjected to restraint. A practice guide has been prepared by the Australian Psychological Society, the aim of which is to reduce restrictive practices in the disability sector by increasing the use of positive behaviour support programs (Australian Psychological Society, 2011). The Queensland Government had developed

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a Restrictive Practice Identification Tool and has recently produced Amendments to restrictive practices in Queensland with changes that focus on ensuring a robust

system of effective safeguards for adults subject to restrictive practices and reducing red tape for disability service providers so they can focus on supporting people (Queensland Government, 2014).

The results of a cross sectional study (Emerson et al., 2000) investigated aspects of the treatment and management of challenging behaviour among adults with intellectual disabilities receiving various forms of residential supports included the following:

1) 53% of participants were reported to have shown at least one ‘moderately serious’ or ‘severe’ form of challenging behaviour in the previous month; 2) The most commonly employed management strategies were physical restraint

(44%), sedation (35%); seclusion (20%) and mechanical restraint (3%); 3) The most commonly employed ‘treatment strategies’ were goal setting within

individual programme plans (used with 62% of people showing challenging behaviour), antipsychotic medication (49%), written intervention programmes (23%) and written behaviourally orientated intervention programmes (15%). In the discussion of their results, the authors noted that residents with challenging behaviour are over three times more likely to receive antipsychotic medication than they are to receive behavioural support. They further note that

‘such an inequitable pattern of provision clearly violates the principle of evidence based practice’.

In this sample, the receipt of antipsychotic medication was not predicted by the presence of psychiatric disorder, but by factors which included the severity of challenging behaviour and the setting. [QI 5, QI 9, QI 13]