Restrictive practices: RACGP advocates for person-centred approach

Anastasia Tsirtsakis

28/09/2020 5:09:32 PM

A college submission to the disability royal commission includes proposed changes to help prevent, avoid, or minimise restrictive practices.

Young girl with disability.
Certain restrictive practices are subject to regulation under the NDIS.

‘It worries me; the majority of people, I think, will benefit from having less medication. But there is this group of people that may well miss out on medication when that would be the best option for them.’
That is Chair of the RACGP Specific Interests Disability network, Associate Professor Robert Davis who contributed to the RACGP’s submission to the Restrictive Practices issues paper for the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability.
Under the National Disability Insurance Scheme (NDIS) (Restrictive Practices and Behaviour Support) Rules 2018, certain restrictive practices – including medication and chemical, physical and environmental – are subject to regulation.
In its submission, the RACGP notes that the decision to apply a restrictive practice ‘should only be made as a last resort’ and that people with disability should be ‘empowered, encouraged and feel safe to make their own decisions and choices’.
‘A clear rationale is required for restrictions, with careful monitoring of its implementation, and regular assessment for the duration of the restriction,’ the submission states.
However, given the nuances in each person’s situation, Associate Professor Davis told newsGP the use of restrictive practices as a broad term, is a ‘complex issue’.
‘I’ve seen both sides of the story,’ he said.
‘There’s certainly elements where medication has been abused, and continues to be abused. Rather than deal with the non-pharmaceutical, the physical and the interpersonal environment, people would use medication instead. This [the Royal Commission] is a process of trying to deal with that, but at the moment there may be a bit of overreach, I think, in the way it’s interpreted.
‘Take for instance, the mother of a child who’s had behaviour problems and needs to have a medication to function at school. The NDIS at the moment requires that they be labelled as having restrictive practice, and that it is monitored every month.
‘Imagine how that mother would feel: “I’m chemically enslaving my child”. So it can be quite emotive language.’
The legislation also classes certain physical and environmental practices as restrictive. In some instances, Associate Professor Davis says they may be ‘the least restrictive’ options to help the person lead the best quality life.
‘For instance, a person who bangs their head against a wall and causes themselves injury repeatedly is put in a helmet – that’s considered restrictive,’ he said.
‘In most cases, I've found that they’re pretty useless because the person just hits their head harder, [so] sometimes they need a bit of medication that stops it. So again, it’s a complex situation.’
To prevent or address challenging behaviours, the RACGP’s submission suggested alternatives to restrictive practices, such as: 

  • non-pharmaceutical positive behaviour approaches that ensure provision of appropriate physical and interpersonal environments tailored to best fit the person’s individual needs
  • provide more training and support for staff and carers on how to best manage challenging behaviours, particularly for staff in more isolated settings with less access to external supports
  • increase availability of crisis-response services to avoid delays and entrenchment of challenging behaviours
 But Associate Professor Davis said it’s not black or white.
‘There are some instances where the individual will really struggle, even with the best of those services put in place. Likewise, it’s often very hard to get all those services for that individual; it’s sometimes impossible,’ he said.
‘So in the end, you have to make a judgement as to what is the least restrictive alternative for that person in that situation, to provide them with the best possible life. And that’s a complex issue because you have to look at it from the perspective of the person [and] perspective of the people around them.
‘There are all sorts of issues to consider – and sometimes, medication might be needed.’
Australian research shows more than 40% of children with intellectual disability have mental health problems, as do 32% of adults.

Associate Professor Bob Davis says more impetus should be placed on accountability and individualising the approach for each patient.

However, under the current legislation, without a mental health diagnosis, the care provider is required to report the use of ‘any medication or chemical substance for the primary purpose of influencing a person’s behaviour’ to the NDIS once a month.
This includes selective serotonin reuptake inhibitors (SSRIs) – commonly prescribed by GPs.
Associate Professor Davis said this may raise a concerning ‘impetus’ for care providers to get a psychiatric diagnosis, which research has shown can raise challenges of its own.
‘One study in the UK showed that if we use the standard criteria for the diagnosis of psychiatric disorder with people with intellectual disability, we would miss two in three diagnoses,’ he said.
‘So there has been a more specific diagnostic category developed for this group by psychiatrists specialising in the area. But access to public psychiatry is quite limited for this population, and the training of psychiatrists is also limited in this area.
‘So you have a system in place that says “you cannot use drugs of restraint unless you have a psychiatric diagnosis”, but getting the diagnosis is the problem.’
When it comes to SSRI’s in particular, Associate Professor Davis is concerned its inclusion as a restrictive practice is ‘overarching bureaucracy’, which he deems ‘unnecessary’.
‘Anyone on anti-psychotic medication should be monitored, whether they’ve got a diagnosis or not, because they can have some nasty side effects. But these medications (SSRIs) really only work if they treat the depression or anxiety, they don’t sedate the individual [and] they don’t change behaviour,’ he said.
‘Also, if every person who has anxiety has to be seen by psychiatrists that would just overwhelm the system, particularly the public system. So it’s impractical – and like I said, it’s not restraining the person at all.’
Rather he says there should be more impetus on individualising the approach and accountability, whether or not the person has a psychiatric diagnosis.
‘There should be a system where non-pharmaceutical approaches are put in place and if not, a reason for it, and that if a person ever goes on a psychotropic medication they should be monitored,’ he said.
‘Has it done what it’s supposed to have done? If not, the person’s taken off it and something else is tried, and it should be reviewed on a regular basis.’
To help prevent, avoid, or minimise restrictive practices, the submission put forward a number of changes for consideration, including:
  • appropriate accommodation support to meet individual needs
  • increased support and funding to meet NDIS needs
  • increased training and education to address skill shortages and support existing staff to better address and prevent challenging behaviours using non-restrictive methods
  • increase staff remuneration in services such as disability care and residential aged care facilities (RACFs)
Though the NDIS has given carers greater access to support behaviour programs, when it comes to paid carers a high turnover of staff remains an issue, which Associate Professor Davis says has consequences for the minimisation of restrictive practices.
‘The structure of some of the houses is such that it’s very hard to manage not only if the direct support worker is changing over, but the house supervisor is as well,’ he said.
‘When I first started, it was in a general practice in this country town and we set up a house for people with challenging behaviours. We trained local staff in appropriate behaviour management technique, and we had a house of individuals that had major problems who settled within the year and have been settled almost ever since, living in this house for more than 20 years.
‘But we didn’t have any turnover of staff. We had whatever the Commonwealth industrial pay rate was … [and] all these people had access to training interstate and overseas. So they stuck around and saw it as a profession.’
If there is to be a silver lining of the coronavirus pandemic, Associate Professor Davis says he hopes that society becomes ‘a little bit more caring’, and that Federal Government funding for the disability sector is balanced.
‘NDIS has been a game changer. But governments have a budget to spend on things, and when it comes down to people with disability, they’re on the end of that line,’ he said.
‘It’s a bit like aged care. We’re now having the fallout of age care decisions made that [meant] you don’t need nursing staff in aged care. Well, that didn’t work out, did it?’
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