This blog article was written by Glenys Bristow,  Senior Specialist, Therapeutic Residential Care, CETC.

Restrictive practice in therapeutic care

The Royal Commision into Violence, Abuse and Exploitation of People with Disability defines restrictive practices as:

• “[…] a term used in Australia to refer to any action, approach or intervention that has the effect of limiting the rights or freedom of movement of a person. Restrictive practices can be used across Australia, as a last resort, to prevent or protect people from harm. This includes a perceived risk of harm. This may include preventing or protecting an individual or others from behaviours referred to as ‘challenging behaviours’ or ‘behaviours of concern’.
  Issue Paper – Restrictrive Practices, 2020, p.1

This definition, as you can see, creates grey areas in practice and interpretation of practice.

The NSW Government developed the Behaviour Support in Out-of-Home Care Guidelines (2021) which includes restricted and prohibited practices, as both a broad practice outline and to inform the development of guidelines for non-government out of home care service providers.

NARANG BIR-RONG Aboriginal Corporation also has a really useful practice document for their Foster Carers, which includes restrictive practice requiring the development of a comprehensive Behaviour Support Plan. Behaviour Management in Out-of-Home Care | NBAC

The challenge!

The challenge with restrictive practice policy and practice is that a judgement must be made about when it is legitimate to restrict young people and what type of restriction is acceptable. In setting out policy and legislation to operationalise these questions, the State is empowering services, in this case out-of-home-care and its workers, to implement restrictions on young people’s freedoms in certain circumstances. However, context, in this case, the therapeutic care of young people who have highly complex needs, is essential to understand.

We know therapeutic residential care needs stability and consistency in staffing by highly skilled, courageous, trustworthy and nurturing workers. This means clear house routines, expectations, natural consequences, and follow-through. We need to focus on building strong and trusting relationships with children and young people and be courageous enough to see them through. These practices are firmly underpinned by a focus on the human rights of the children and young people in residential care and their rights to participate in the decisions that affect their lives.

‘It’s not what’s wrong with you – but rather what has happened to you?’

Shifting our practice to be therapeutic takes time, support, and understanding from our residential team supervisors, child protection, and line management from all statutory and non-statutory organisations.

Somewhere in this change process, confusion has arisen about what constitutes “restrictive practices” and how we balance it against the need for safety within the therapeutic residential space without putting practitioners and young people at risk.

This lack of clarity surrounding the term “restrictive practices”, particularly in therapeutic residential care, has become increasingly more problematic to navigate for residential practitioners, service providers, and line managers. The differing interpretations have led to situations where residential workers are unclear how to navigate best practice, carrying out instructions to avoid risk of a quality-of-care investigation or disciplinary action. The situation is also unclear for young people and does not promote safe caring therapeutic practice, which needs routine, stability, clear guidelines, and natural consequences, as well as the energy, courage, and heart to carry them out.

Case examples of these (mis)interpretations…

In these two case examples, consider your interpretation of “restrictive practices” and how it applies to these situations:

• A 15-year-old young person purchases a thick permanent marker and openly states he intends it for graffiti. Workers assess the potential criminal action and resulting arrest as a risk of harm to both the young person and to the community, and calmly explain their rationale as they take his pen. The young person demands to speak to the on-call manager to claim his rights are being violated. The on-call manager directs the residential workers to give the young person back his pen, as taking away belongings that he paid for is a restrictive practice.
• A 12-year-old young person loves playing games on her tablet. At her previous placement, she established a consistent routine of playing games for an hour after school and an hour after dinner, handing the tablet over to workers to charge overnight. This consistency in routine has been working well at the current placement, but sometimes she feels angry about handing over her tablet and wants to continue playing. The House Supervisor decides that taking away her belongings against her wishes constitutes a restrictive practice and allows her unrestricted access to her tablet. The young person begins to stay home from school to play games all day.

Reflection

Do you think these two case examples are restrictive practice in the context of therapeutic care?