Seclusion continues to be used in disability and mental health services despite a lack of evidence in support of its effectiveness (De Hert et al 2011). Indeed, research indicates that seclusion contributes to significant negative physical and psychological effects (Palazzolo 2004).
It can also be considered that the restrictive practice of seclusion is at odds with the person-centred values within current disability services, going against the principles of personalisation, choice and control, policy documents and legislation (including Valuing People Now and the Care Act 2014).
This research contends that seclusion may stop a behaviour in the short-term, but that it does not address the underlying cause of the behaviour and therefore is unlikely to be effective in the long term.
The research seeks to understand why seclusion continues to be used in disability services by examining its reported use in Victoria, Australia, over a three-year period, to support the development of strategies to safely prevent its use.
The research examined reported use of chemical and mechanical restraint and seclusion in disability services in Victoria, Australia over a period of three years. Disability services in Victoria are required to report such practices to the Senior Practitioner and as such the data was extracted from the ‘Senior Practitioner database’.
In Victoria, seclusion is defined as the sole confinement of a person with a disability at any hour of the day, or, not in any room or area where disability services are being provided. Chemical restraint relates to medication being used to control behaviour, and mechanical restraint is defined as materials used to restrain a person’s movement that are not for treatment or safe transport.
The research found that 146 people had been secluded at some time during the 3 years spanning June 2008-July 2011, and 2482 people had been restrained, but never secluded. It was also found that those secluded had, on average, been reported as having received a restrictive intervention (seclusion or restraint) for a much longer period of time (852 days) than those who were restrained but never secluded (666 days).
The research noted that people with autism or a psychiatric disorder were more likely to be secluded than restrained. Presence of autism, psychiatric diagnosis and harm to others were high individual risk factors associated with seclusion, whereas age (older individuals) and harm to self were both negatively related to seclusion.
Results in respect of organisational factors showed that people who lived in an institution or a shared house in the community were more likely to be secluded than people housed in ‘other settings’, such as day and respite services. People were also more likely to be secluded in metropolitan areas as opposed to rural areas.
The authors conclude that their findings are consistent with previous research carried out in the U.K, but that the results demonstrate that certain organisational characteristics were also risk factors for seclusion, in addition to recognised individual factors.
The authors identify the production and review of high-quality behaviour support plans, enabling support staff to know how to teach individuals ‘replacement behaviour’, as a practical means of reducing the use of seclusion in disability services.
Strengths and limitations
The authors have noted that research of this nature in disability services has largely focused on individual characteristics of those subjected to seclusion and it is helpful that this research has identified organisational factors impacting on frequency of the use of seclusion.
However, a key limitation in this research is the comparison between it and research carried out in the UK. The authors have not offered a comparison between their findings and those in other geographical areas within Australia, where practices and demographics are arguably likely to have greater similarities. It is quite possible that the cultures and practices within Australia could be quite different to that in the UK, therefore undermining the assertion of consistency. Furthermore, the authors acknowledge that direct comparisons between the current study and previous research is difficult in light of the large variation in samples.
It is also unclear as to whether the definitions of chemical and mechanical restraint could offer an accurate comparison with research carried out in the U.K, and neither seem to include physical restraint – a further restrictive practice which continues in some disability services.
The authors identify that definitions of congregate care, institutions and community living might not be the same within the two respective countries, making direct comparison difficult. Certainly, it is interesting that the research found seclusion more likely in a “shared house in the community” than in day and respite services.
The research later refers to “residential services in the community” experiencing higher levels of seclusion than in day services. In the U.K, a “shared house” would likely be a “supported living” model, where individuals are tenants rather than ‘residents’ and seclusion would be highly unlikely; it is not clear what form of community model this research refers to when drawing conclusions from its findings. Do the authors define a ‘shared house’ as a ‘residential service’, as this would not fit with U.K community models.
Summary and analysis
The authors suggest that behaviour support plans should be produced and utilised effectively in order to reduce the need for seclusion, and it is welcome that the research proposes a practical method in seeking to minimise such a disempowering and restrictive practice.
The findings that individuals with autism or psychiatric disorder are more likely to be secluded raises some interesting questions. There remains a stigma surrounding mental ill health and indeed autism. Research such as this is naturally limited, in that it can only analyse data and lacks knowledge of individuals’ personalities and their nuanced needs and behaviours. It would be interesting to see further research carried out to assess whether those with autism and psychiatric disorder were secluded due to displayed behaviours and associated risks, or whether they might have been deemed a ‘risk’ due to their diagnoses and consequently secluded more readily by staff, despite behaviours potentially being less ‘risky’ than those without such a diagnosis.
There are likely to be numerous differences between UK disability services and those in Australia. Whilst there would no doubt be similarities as well, it nevertheless makes comparison somewhat unreliable. It would be beneficial therefore, for further research to be carried out within other regions in Australia in order to draw more accurate comparisons and identify reliable individual and organisational themes.
Webber L, Richardson B, Lambrick F, Individual and organisational factors associated with the use of seclusion in disability services, in Journal of Intellectual and Developmental Disability Vol. 39, Iss. 4, 2014 [abstract]
De Hert, M. Dirix, N. Demunter, H. Correll. C. U. (2011) Prevalence and Correlates of seclusion and restraint use in children and adolescents: A systematic review. European Child and Adolescent Psychiatry, 20, 221-230
Palazzolo, J. (2004) About the use of seclusion in Psychiatry: The patient’s point of view. L’Encephale, 30, 276-284