It's Time To Talk About Restrictive Practices

Everyone is talking about the sector impact of the new NDIS Restrictive Practices and Behaviour Support Rules 2018 (The Rules) but understanding the human element, the context and the history is also paramount to progress. Australia have signed up to the United Nations Convention on the Rights of Persons with Disabilities (CRPD) that says that all people have equal rights to recognition before the law, to liberty and security of person, freedom from torture, cruel, inhuman or degrading treatment, freedom from punishment, exploitation, violence and abuse. It does not create new rights, it affirms that people with disability have equal rights. Yet, there have been numerous inquiries in to the violence, abuse and neglect of people with disability in Australia that illustrate how we as a nation have a long way to go.

Evidence suggests that restrictive practices are harmful and may actually exacerbate the behaviours they intend to control and that most restrictive practices can and should be eliminated over time (NDIS Quality and Safeguards Framework, 2016). There is a strong human rights framework that underpins these changes and understanding the ‘why’ is in some ways just as important as understanding the Rules. As the ‘why’ will be the moral compass that will drive the cultural shift toward the reduction and elimination of restrictive practice. The ‘why’, is how we will bring people with us, to work in a unified effort to bring about change.  

As we move to a national system that includes new audit requirements, behaviour support plan development and reporting, it is only natural that panic is rising about how providers will cope with the additional (or changing) administrative burden. Some providers are channelling their efforts in to legitimising current practices under the new Rules. Understandable, many are feeling financially stretched and change fatigued.  

Others say this doesn’t affect us, we don’t use restrictive practices. This is fine if true, but I have a sneaking suspicion that many conceptualise restrictive practices in ways that don’t enter the familiar. The reports that capture the attention of the media and the major inquiries tend to focus on those cases so blatant and disturbing that we can distance ourselves, lynch in hand.

Yet I worry that by focussing only on those overt human rights violations we might overlook the need for self-reflection. Subtle restrictions pale in significance to what we see playing out in the media. Many well-meaning providers denounce the use of restrictive practice but might impose restrictive rules in response to unfounded perceptions of risk. These subtle restrictions fuel the power imbalance that leave people with disability more vulnerable to abuse and neglect. I don’t suggest for one minute that we step back and overlook our duty of care to the people we support but I do believe as a sector we impose excessive restriction on people without basis. Further, by constantly intervening, we deprive people of the opportunity to fail, learn and problem solve. Developing resilience is key to reducing vulnerability and strengthening one’s own natural safeguards.

Another way to re-think our practice is to go back to the concept of an ordinary life. If this were me, how would I feel? I come back to this measure time and time again. I imagine catching up with friends, chatting with them about a new home I moved in to. I tell them it has an amazing view, purpose built facilities and meals included. The only catch is I have to go to bed at 8pm, ask to use my kitchen, the landlord locks up my medication in case I overdose and my money in case I spend it. I have to ask someone to unlock the door for me before I can leave and I have to sign in and out. My bewildered friends might ask to come around to suss it out, but I’m not allowed to have them over without permission from the landlord. You know what my mates would say to me? Well that is just weird.  

By only focussing on extreme cases of restrictive practice we might overlook the fact that it often takes subtle, less recognisable forms. Service providers often rationalise rules they have no right to impose under the guise of duty of care. But in any other environment those rules might be considered unlawful imprisonment, battery or assault (Office of the Senior Practitioner (SA), 2018). The former South Australian Senior Practitioner gave a great departing presentation on human rights and restrictive practices, which is available on the NDIS Quality and Safeguards Commission website for those who are interested.

The other thing we hear is it’s okay, mum and dad authorised it. Having the consent of a parent (whether they are a legal guardian or not) does not override the approval and reporting requirements around the use of restrictive practices by an NDIS service provider. It also doesn’t erode an individual’s equal human rights.

There are also some providers in the sector that are taking this opportunity to open up the conversation. To look deep within and work out where we are going wrong. They aren’t chastising staff that have learnt from those before on how to manage complex behaviours, they are putting the dirty laundry on the bench to sort with their sleeves rolled up.

They are listening to their staff to understand how incredibly difficult it is to manage complex behaviour on limited ratios, without clear leadership, procedures or the right training. Those leaders are facilitating a shift within their organisations that say enough is enough. We’ve had the upper hand for too long. I borrow this term from this great study that shows how an organisation achieved a 99% decrease in restraint as well as a number of organisational benefits, financial savings and an increase in client goal mastery.[1] As the Pantene phrase goes, it didn’t happen overnight, but it did happen.

The new restrictive practice rules are really complex, so we expect to see more direction on operationalising these from the NDIS Quality and Safeguards Commission as it matures. Until such time, service providers can go to the Senior Practitioner and behaviour support team for advice on these matters.

I reflect back on my own experience, entering the community services industry nearly 20 years ago as a naïve teen. I saw things that made me feel un-easy but had limited leadership on those issues. I have seen the use of restrictive practice to manage things like staff shortages or behaviours that make us feel uncomfortable. I have seen organisations impose blanket rules on people regardless of their individual capacity. I, for one, am thrilled to see some strong leadership on this issue from our government. I just sincerely hope this brings about real change in the sector not just another signing sheet. Now, is the time to step back and have some candid conversations. People with disability are now our customers and as a sector we need to work hard to be worthy of their custom. 

[1] Craig, J.H. & Sanders, K.L. Adv Neurodev Disord (2018) 2: 344.https://doi.org/10.1007/s41252-018-0076-2

Image: ‘Not titled’ by Fulli Andrianopoulou, recent work, installation, ink on paper. Image courtesy of Arts Project Australia.