Book Review - Person centred restraint reduction

Book Review

Updated: Feb 11, 2019

A Review of Roy Deveau and Sarah Leitch's 'Person centred restraint reduction: planning and action' (May 1 2018), Written by CEO Professor Andrew McDonnell


In our experience, the subject matter of this book can often be viewed by people in the field as an area in which great progress has been made in the UK. Sadly, there remains a real need for this type of material in Britain. Restraint and other restrictive practices are an emotive subject within the field of care giving. The Winterbourne View experience in 2011 placed these issues at the forefront of professional practice, demonstrating the continuing need to review and reassess the ways in which vulnerable people are cared for. It is debatable how much learning occurs after our living rooms are invaded by the sight of substandard practices. Views on restrictive practices can range from zero tolerance to a frightening acceptance of the need to restrict and control. Across the globe people can often view physical interventions as a 'necessary evil’, and other European countries have their own equivalents of the Winterbourne View experience. For example, in the Republic of Ireland, an RTE Undercover documentary focusing on the abuse of adults at Aras Attracta demonstrated that issues of restraint and the need for restraint reduction literally transcends cultures.


It is often easy to be overwhelmed by rhetoric about restraint reduction, especially without a strong enough focus on how to achieve, as far as possible, restriction-free lives for the people we support. Initially, I was a little alarmed to read the expression 'person centred' in the title. However, in my view the authors have provided a guide that focuses on auditing practice and in effect encouraging staff teams to be solution-focused in their work. The authors provide a menu-based approach to supporting people to reduce restraint in their practice. The book also illustrates the still relative paucity of data driven approaches to restraint reduction.


The first two chapters provide a guide for practice leaders to focus on when developing a strategy towards tackling restrictive practices and auditing practice. It is a very simple message, namely; make your approach 'data driven'. In Chapter Three, the authors focus on strategies ranging from Active Support and Periodic Service Review, to Practice Leadership and Organisational Approaches. For me, there is a slight danger that some cultures may decide that they are doing OK and stop here. Chapter Four goes on to discuss a key range of reactive strategies, from the work of Gary LaVigna to my own. These include many useful strategies that people may try, although I stress that such approaches should be data driven and, where possible, systematically applied.


Chapter Five focuses on restrictive responses with a small number of evidence-based approaches. When reading this chapter, it reminded me how difficult it can be for practice leaders to effect change in environments with 'restrictive cultures'. What we do know is that practice can change if people are motivated to effect that change. The structure of this book should be a guide to create solution-focused, empathic and reflective approaches to a problem. The title for Chapter Six, 'Turning Ideas into Action', allows the reader to reflect on their 'Plan of Action'. The seven guidance points for plans are both simple and easy to understand.


It is quite difficult to write a forward to a book such as this without offering some additional guidance. Practice leaders must focus on simple strategies and encourage real change. However, where restrictive practices present a high risk of harm, solutions may need to be more rapid; effectively, 'Deeds Not Words'. In Chapter Seven there is a useful case study presented, which provides a helpful learning framework for the reader. I would actively encourage more case examples to illustrate the many useful strategies described in this book.


In addition, I particularly like the idea of Practice Leaders coaching their colleagues. The authors mention the EDDY approach (Explain, Demonstrate, Do under Supervision, You have a go). If there is a weakness in the field of staff training (especially in physical interventions), it is that too much teaching takes place in classrooms with insufficient emphasis on coaching. Role modelling best practice must be an essential component of the approach.


The values we apply to these situations also help us to reflect on solutions. In many cases a simple focus on Human Rights can be enough to reduce restrictive practices. If there is an over-arching theme of the book for me it is a positive message to empower people to focus on solutions to restrictions. In effect, the goal is to create cultures where restrictions can be lessened. My own personal experience is that even in poor quality environments, much can be done to create restriction free services. In addition, training in crisis management is necessary, but not sufficient to achieve success. Many contributing factors influence the reduction of restrictive practices; for example, organisational factors such as practice leadership, which combine with other elements ranging from low arousal approaches to PBS and mindfulness. This book is a very useful stepping stone towards a more scientific approach to what still can be described as a 'Cinderella Area', long neglected by clinicians.


This book is a useful resource for service providers who wish to focus on restraint and restrictive practice reduction. I hope that it is the first of many guides that provide attention to detail on this important subject. Moving from 'rhetoric to reality' is the goal. If there has been a lesson in the poor practice exposed in the last 30 years, it is that we ignore restrictive practices at our peril. In my opinion, the vast majority of organisations should use this guide to reflect on their organisational culture.


Andrew McDonnell, PhD

CEO Studio3,

Visiting Professor of Autism Studies,

Birmingham City University.

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