With restraint…

The issue of physical restraint lies at the heart of the debate
about control of service users who are physically challenging.
Historically, physical restraint has been an accepted part of
practice within social care in both the US and UK. However, the
truth about the frequency, effects and safety of specific restraint
practices is often overlooked.

The use of restraint to prevent injury or damage to property is
relatively uncontroversial. Restraint has also been promoted –
principally in the US – as a “therapeutic” procedure in its own
right. Rising fatalities have made these approaches the focus of
mounting criticism.

The methods of restraint taught within training programmes are
inevitably subject to claims around safety, effectiveness and
therapeutic value. Such claims are seldom underpinned by valid,
empirical evidence. The common view is that seclusion and restraint
do work. However, more recent analysis of UK and US research, while
citing a range of beneficial outcomes, concludes: “Unfortunately,
the research indicates that none of the above outcomes can be
guaranteed from training, and negative results have also been
observed in each of the above areas.”¹

Research remains inadequate. An absence of reporting mechanisms on
assaults and restraints has maintained a climate in which high risk
and degrading restraint techniques continue to be used and
promoted.

Yet despite the inadequacy of research in this field, there is some
consistency in the conclusions and advice that emerge from it. The
key factor in the equation, which many appear reluctant to
consider, remains the method of restraint. Various sources indicate
the enhanced risks of specific techniques. Yet such techniques are
widely employed. In the US, the Hartford Courant database listed
142 restraint-associated fatalities in health and social care
services in the 10 years from 1988.

The database has spurred political action. Restraint use in US
child care services will be the focus of a federally-funded
three-year study, aimed at reducing the use of restraint. Different
training models will also be evaluated. The Child Welfare League of
America will act as the co-ordinating body. Each site will evaluate
its own programme. As many commentators observe, levels of
restraints are inevitably reduced merely as a consequence of making
this an explicit focus of a programme. The project’s lack of a
uniform, independent evaluation strategy will therefore detract
from the robustness of conclusions.

In the UK, investigative journalism has opened a Pandora’s box. In
the BBC’s McIntyre Under Cover programme the government’s
lack of policy on restraint was exposed. Consequently, the British
Institute of Learning Disabilities has received government funding
to develop a range of initiatives and policies around restraint.
Recent government guidance for learning difficulties, emotional
behavioural difficulties and autism services does acknowledge the
enhanced risks attached to specific techniques,² but
concerns remain about the financing and coherence of current
developments. The Scottish executive, meanwhile, is deafeningly
silent.

Nevertheless, belated inclusion of restraint within professional
and social policy agendas is to be welcomed. There is now a
considerable body of data and authoritative opinion suggesting that
specific techniques carry an increased risk of injury. Yet these
are still promoted and used in a wide range of UK and US service
sectors.

A coherent strategy would increase staff and client confidence and
reduce restraint-associated deaths and injuries. However, concern
with safety must also be balanced by the social validity of
specific restraint techniques. Surveys of service users suggest
that restraint is invariably a degrading and disempowering
experience, often described as tantamount to rape. Prone restraints
remain a particular focus of concern. Consequently, the development
and regulation of safe practice must involve meaningful
consultation with service users.

David Leadbetter is a researcher and former social worker,
and is director of Calm Training Services. Michael Budlong is
clinical director at the Methodist Home for Children and Youth in
Georgia.

References

² Department of Health and Department for Education and
Skills, “Guidance on restrictive physical interventions for people
with learning disability and autistic spectrum disorder,” in
Health, Education and Social Care Settings, Stationery
Office, 2002