BEHAVIOUR SUPPORTS AND RESTRICTIVE PRACTICES: A Victorian perspective

by Padraig Walsh

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Hadn’t people living in Victorian times a wonderful existence! Living in a pre-global warming age, surrounded by magnificent architecture in an era where dynamic growth, new inventions and varying modes of life constantly changed the way people played out their existence. Prudishness and conventionality were the standards to live one’s life by.

Appearing different in that age of Conservatism must have been difficult. Having an intellectual disability would certainly have presented its own obstacles fuelled by ignorance. Ridicule, institutionalisation, seclusion and restraint would most likely have been part of daily life for many of these individuals. This would particularly be the case should the person present with behaviours that challenged the system within which they lived.

Thankfully, the prudishness and conservatism that characterised most of Victorian politics is not a feature of modern- day Victoria’s (Australia) current service provision to individuals with an intellectual disability.

Founded during the mid-1800s gold-rush, modern-day Victoria is Australia’s smallest mainland state (227,146 km2), with a population of over 5 million people. Victoria’s state government sits in Australia’s cultural and sporting hub, Melbourne. With over 3 million people, Melbourne is the most inclusive and culturally diverse city in Australia. Melbournians are as likely to be eating Bánh h i, Pad Thai and Penne Pollo as they are to be tucking into a famous Australian pie! This inclusive and accepting philosophy does not just apply to their immigration policies, but also to the disability legislation and the services that operate within Victoria.

With its foundations firmly grounded in the Charter for Human Rights, Victoria’s Disability Act (2006) aims to enact new legislation for people with a disability, reaffirming and strengthening rights and responsibilities, while recognising that this requires support across the government and community. The Act has succeeded in impacting upon service provision right down to frontline level, and upon the people working within behaviour supports. Having experienced the past six months working in this system, I feel some of the ‘Victorian’ ideas, if adopted, could certainly impact upon the role of positive behaviour support in Ireland.

Fundamental aspects of Disability System of Victoria that influence the promotion of Positive Behaviour Supports:

The flexibility of individualised funding and the abundance of independent agencies

Individuals with an intellectual disability who have been deemed eligible through the Disability Services Assessment process receive individual funding. The amount depends upon their circumstances and their level of need. From there, families, individuals with an intellectual disability and/or an appointed advocate can prioritise services that they require (e.g. day service, case management, accommodation, respite options, specialist services and assessment etc.).

Disability agencies (of which there are hundreds in Melbourne) provide services and are paid directly by the individual from their funding package. Families are free to choose the appropriate services for their son or daughter and to change them at any time, knowing that there are many other similar services eager to provide a service for their offspring.

Is this an example of outsourcing and the free market benefitting those most vulnerable in society? Imagine my delight as a behaviour support specialist, when I found that no longer would the 23-year-old man with autism, who dislikes noise and being indoors, have to stay in the day program he was in. Instead, there was another agency down the road that had spotted a niche in the market for this client group. It provides all-day outdoor work for young men supported by men with a background in disabilities and gardening!!

What about the man who does not like the house that he lives in…the parents who need respite…the assessment that would take six months on the public waiting list? All of these are accessible if individualised funding is prioritised for these. (And as an aside, it makes behaviour support recommendations much easier to implement!)

The Existence of a statewide behaviour intervention specialist team

The Behaviour Intervention Specialist Team (BIST) is a team of professionals who have expertise in working with people with a disability whose complex behaviours can sometimes pose significant concerns for themselves or others. BIST provides specialist intervention services based on Positive Behaviour Support for eligible individuals, their families, carers and service providers where the person displays behaviours of concern. Accessible to all agencies, BIST’s role includes:

  • Assessment or assistance in the assessment of a client’s challenging behaviours together with the client and relevant others.
  • Developing or assisting in the development of appropriate behaviour intervention programs which focus on the particular behavioural needs of a client.
  • Implementing or assisting in the implementation a client’s behaviour intervention program.
  • Providing consultancy services to those who live or work with clients who display challenging behaviour.
  • Providing education and training to families, staff and tertiary students.
  • Evaluating behaviour intervention programs to ensure the continuation of effective services.
Structures promoting accountability from agencies

In Victoria, Regional Quality Advisors (RQA) act as the link between agencies and the Department of Human Services (DHS) and they aim to support regional implementation of the Quality Framework across community service organisations. There is constant liaison between the DHS and individual agencies to ensure that agreed standards are being met, as outlined within the Act.

The Office of the Senior Practitioner (OSP) is appointed to ensure that legislation within the Disability Act (2006) is followed through upon. There is a focus upon reducing levels of restraint and seclusion and ensuring that they are monitored systematically.

In order to ensure that the state’s Disability Act is followed, the supports to ensure success have been put in place, with the OSP position created to ensure that the human rights of individuals with an intellectual disability are not infringed upon through the unreasonable or unsanctioned use of restraint and seclusion. Below is a summary of the main areas relating to restraint and seclusion covered by the Disability Act (2006).

Restrictive practices and the use of restraint and seclusion

Definition: Restraint: (r-strnt) n. Loss or abridgment of freedom; An influence that inhibits or restrains; a limitation; An instrument or a means of restraining; Control or repression of feelings; constraint

Question: Disability Act 2006

What is restraint and why is it used?
Restrictive interventions are practices used by disability service providers designed to prevent a person with an intellectual disability harming themselves and others, or destroying property that may result in harm. Restrictive intervention is defined in the Bill to mean ‘any intervention that is used to restrict the rights or freedom of movement of a person with a disability including chemical restraint, mechanical restraint and seclusion.

How can we keep track of its use?
Any agency receiving funding from the Department of Human Services to provide a service to someone with an Intellectual Disability must report all instances of restraint (physical, chemical and mechanical) and seclusion to the RIDS (Restrictive Intervention Data System). This data is then used to analyse the state-wide use of restrictive intervention.

Who sanctions the use of restraint?
Each independent agency must appoint someone internally to authorise the use of restraint within a Behaviour Support Plan. This APO (Authorised Program Officer) is reportable to the Office of the Senior Practitioner. On the front-line, authorisation must be sought from a direct line manager and each instance of restraint reported.

How do we ensure that the least restrictive intervention is used?
An agency must produce a behavior support plan and reactive strategy outlining when restraint (including PRN medication) is appropriate to use before they intend to use it.

When do we explain to an individual with an Intellectual Disability that restraint will be used?
An independent person (not associated with the agency) must be appointed to explain the recommendations of the Behaviour Support Plan and also the intended use of restraint with them.

The Use of Chemical Restraint

What is chemical restraint?
Means the use, for the primary purpose of the behavioural control of a person with an intellectual disability, of a chemical substance to control or subdue the person but does not include the use of a drug prescribed by a registered medical practitioner for the treatment,or to enable the treatment of a mental or physical illness.

When is psychotropic medication not defined as chemical restraint?
Psychotropic medication is not defined as chemical restraint only if it is used to treat a physical or mental health condition diagnosed by the appropriate professional.

When can we use chemical restraint?
In order to use psychotropic medication for behavioural difficulties, a number of steps must be followed:

  • A Behaviour Support Plan outlining potential functions, alternative supports for the person and reasons for medication use is designed;
  • A review date for its use (within 6 months) is agreed;
  • This Plan is approved by an appointed officer within an organization;
  • It is submitted to the Office of the Senior Practitioner.

What about PRN?
The guidelines above must be followed as well as:

  • Staff on duty must contact ON CALL Manager, who then gives the approval after communicating with staff on duty who describe the level of behaviours;
  • Its administration and details of use is reported on RIDS.

Where will we find a psychiatrist with experience in dual-diagnosis who could carry out an in-depth assessment of this service-user?

The VDDS (Victorian Dual Disability Service) work with specialist mental health services in Victoria to assess, treat and manage people with a dual disability. They work in partnership with BIST (Behaviour Intervention Specialist Team) and aim to align mental health and behavioural services for individuals with an intellectual disability.

How would these questions be answered with Irish disability services?

Within Irish disability services, much emphasis has been placed upon person-centeredness, rights for individuals with intellectual disabilities and the promotion of positive behaviour supports. Significant benefits have been observed for service-users as a result of these efforts. Unfortunately, national legislation, funding structures and supports currently do not reinforce these efforts. Legislation with tangible support and structures (OSP, BIST etc.) such as those introduced in Victoria would certainly be welcomed by all persons working in Irish disability services and would represent a positive step towards promoting the rights of individuals with an intellectual disability, and especially those who display behaviours that challenge.

Glossary

OSP—Office of the Senior Practitioner
The Senior Practitioner is generally responsible for ensuring that the rights of people who are subject to restrictive interventions and compulsory treatment are protected, and that appropriate standards in relation to restrictive interventions and compulsory treatment are complied with. The Senior Practitioner has extensive powers to set standards and guidelines, and monitor direct disability service providers in relation to the use of restrictive interventions and compulsory treatment.

DHS—Department of Human Services
DHS cover the responsibilities of the Ministers for Health, Mental Health, Senior Victorians, Community Services and Housing

APO—Authorised Program Officer
An Authorised Program Officer is appointed internally by an agency and must ensure that any supervised treatment used in the provision of a disability service for which the Authorised Program Officer is responsible is administered in accordance with this Division.

RIDS—The Restrictive Interventions Data System
RIDS assists the Office of the Senior Practitioner in effectively monitoring Restrictive Interventions and provide the basis for conducting meaningful analysis on the practice of Restrictive Interventions throughout Victoria.

Further information is available on the following websites:
Disability Act 2006—www.dhs.vic.gov.au/

Padraig Walsh has an MA in Applied Behaviour Ananysis (ABA), and is currently working with the Behaviour Intervention Specialist Team (BIST) of the Department of Human Services (DHS) in the North and West Metropolitan region of Melbourne, Victoria. Correspondence regarding this article should be sent to: walsh.padraig@gmail.com

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