Unmasking Australia's Restrictive Practices: A Call for Reform and Rights

The Disability Royal Commission continues its work, and it's clear it's 'not for turning' in its critique of the practices of disability service providers and others working in the 'support and care' sectors in supporting people with disability to have choice, control and agency in their own lives.

In a report entitled, 'Restrictive Practices: A Pathway to Elimination (the clue is in the name) released by the Commission in June 2023, the authors have reviewed and interrogated Australia's restrictive practice regime and called for its termination.?The report, prepared by researchers from the University of Melbourne, University of Sydney, and University of Technology, Sydney, provides a caustic critique of Australia's approach to the application of restrictive practices across various sectors, including guardianship, mental health, aged care, education, employment, and justice.?

In providing this critique, the report defines restrictive practices as being, " ...legally authorised and/or socially and professionally sanctioned violence that targets people with disability on a discriminatory basis." This includes restraints, forced sterilisation, and involuntary mental health treatment, among others.

The report argues that such practices violate international human rights and deeply impact the dignity and well-being of people with disability, causing suffering, pain, harm, trauma, and more.

The report identifies multiple interconnected factors that enable such practices, including:

• Individual: Behaviours of concern are misinterpreted as dangerous or distressing.
• Relationships: Trust is eroded, perpetuating power imbalances.
• Institutional: Segregated settings increase the risk, as do cultures of silence and blame.
• ?Societal: Ableist views and legally permitted practices further the divide between people with disabilities and service providers.

The report criticises the overreliance on Positive Behaviour Support (PBS), which it claims has 'an inconclusive evidence base', although others would beg to differ. It also identifies concerns about the scope of staff training, finding that training staff in restrictive practices can actually increase their use, as such training solidifies the belief that they're necessary.

In terms of effective training, however, the report found that trauma-informed support produces some positive results, with a study indicating a 99% decrease in restraint frequency when staff used this method. The report also found that existing methods are inefficient, with a focus on regulation and training and not on the core reasons behind restrictive practices.

For those (like myself) who find the interface between restrictive practices on the one hand and worker health and safety on the other to be a challenging issue, the report devotes a sub-chapter (4.2.3) to these issues.

It argues there are Australian organisations that, '... justify increased use of restrictive practices by reference to occupational health and safety concerns of staff.' Leaving to one side the loaded language, the report goes on to say, 'Additionally, and at the same time, other research suggests that there is a pervasive ‘misrepresentation’ of facts ... whereby it has become commonly assumed that the occupational health and safety concerns of staff are somehow ‘mutually exclusive’ to the human rights realisation for people with disability. ... 'This misrepresentation of facts results in the rights of people with disability being seen by some staff as ‘secondary to taking an action that was perceived to increase staff safety’.

I would challenge this analysis (and am equally comfortable being challenged on my own) to the extent that workers in the 'care and support' sectors have as much right as anyone else to work in a safe and healthy work environment so far as is reasonably practicable. This is simply a statement of current Australian law. Balancing the rights of individuals to live free from restrictive practices, and other individuals to live free from the fear that they may be seriously injured at work or in their home, demands more of us than simply branding elements of this debate as a 'misrepresentation of facts', which allows us to abolish restrictive practices in all circumstances, altogether. To be clear, in my view the application of any restrictive practices to people with disability should always be severely limited and done only after all other options have been explored and found wanting, but taking them off the table altogether may lead to significant health and safety issues, not just for the workforce, but also for other people with disability and the public.

As if in anticipation of such a critique, the report's authors constructively identify three notable international strategies that have been adopted by various countries to reduce restrictive practices in mental health settings:

1. No Force First Project (England): Prioritizing 'choice, self-determination, and personhood', this approach believes that coercion undermines recovery. While effective in general and crisis mental health wards, its application in forensic learning disability wards saw a higher prevalence of physical restraint and harm compared to forensic mental health wards, even after its introduction.
2. Six Core Strategies (USA): Focused on a trauma-informed approach, these strategies encompass leadership for change, data-driven practices, workforce development, preventive tools, patient roles in inpatient settings, and debriefing techniques. While proven effective in the US across various mental health settings, its recent adaptation in Australia (2019) hasn't undergone a formal evaluation yet.
3. Safewards Model (England): Created to manage conflict in mental health settings, Safewards aims to provide a safer environment for staff and patients. Its broader focus is on understanding conflict origins and staff reactions. Despite positive effects in general mental health settings, its global implementations, including in Australian regions, have shown mixed outcomes.

The report closes out with a constructive 8-point action plan that includes prohibiting restrictive practices, acknowledging past wrongs, focusing on deinstitutionalisation, recognising the autonomy of people with disability, applying trauma-informed support, ensuring adequate resources for independent living, and providing a redress scheme for victims.

This report represents significant and important research into a controversial and contentious topic and provides a very solid basis for further operational policy discussion and debate within the support and care sectors.

The full report of 347 pages is available on the Royal Commission’s website here: https://disability.royalcommission.gov.au/publications/restrictive-practices-pathway-elimination