Restraint: how to achieve low injury rates

The continuing absence of national restraint and injury reporting systems means that the level of injury and misery caused by the misuse of restraint remains an invisible epidemic, and one closely associated with dysfunctional and abusive services.

The child care and learning disability literature suggests that the most vulnerable service users continue to be those most likely to suffer the pain and degradation of frequent restraint use.

Community Care‘s article on the use of physical restraint in secure training centres exemplifies the different sides of the restraint debate. The prison service staff spokesperson argued that restraint was necessary to ensure safety the justice minister offered a welcome, if belated, review proposal and Lord Carlile condemned the government’s support for the use of restraint to secure compliance.

Regrettably, though, restraint use will always be necessary in a restricted range of situations to ensure safety and maintain the duty of care. It is the routine overuse of restraint, and the methods employed, which must be addressed.

Successive reports indicate that training in skills-based conflict management – such as de-escalation, restraint, breakaway – remains the most common agency response to service-user aggression, fuelling a free market economy of several hundred training providers. However, such responses effectively “individualise” the problem and reinforce blame cultures, obscuring the link between service quality and assault rates.

Contrary to the claims of many training providers, a growing volume of research suggests that such training, as a stand alone intervention, rarely produces positive outcomes and may frequently increase risk.

Community Care’s article rightly highlights the fact that many restraint methods are in widespread use despite being unsupported by research, medical assessment or formal approval. The training accreditation scheme administered by the British Institute for Learning Disability has made huge strides. However, its voluntary and under-funded nature and limited scope are widely perceived as restricting its effectiveness. Regulation of restraint training is now required.

Ultimately, any debate about one restraint system being better than another in many ways fatally misses the point.

In the US, restraint fatalities are estimated at between 50 and 150 a year. As in the UK, the hidden tragedy of restraint misuse was largely uncovered by media revelations. Significant Federal funding has been allocated to specific restraint and seclusion reduction initiatives, primarily in the mental health and child care sectors. Their conclusions chart an effective methodology which in many ways rejects the current UK approach and clearly demonstrates the need for an integrated agency response, effective leadership, and management ownership of the problem.

In child care, the principle response to media-generated controversy was the allocation of a Federal grant of $8m administered by the Child Welfare League of America to support a five-site, three-year study.

Restraint rates were monitored before and after training inputs by different training providers. The final report found that the site using CALM Training Services UK – the only non-US provider involved in the study – both eliminated seclusion use completely and achieved the lowest injury rates across all sites.

The final CWLA report also echoed earlier findings about the importance of strong leadership a person-centered environment relationship-based treatment prescriptive policies and procedures on assessment, behavior support planning, monitoring, and debriefing and tracking the use of restraint and seclusion through data.

The commonality of conclusions is striking. Although the proposed review of restraint safety by the UK government is crucial, it should not act as a smokescreen for systemic failure and lack of leadership at all levels.

David Leadbetter is a qualified social worker and director of CALM Training Services