Understanding, Recognising, and Reducing Restrictive Practices

Purpose of this guide

This guide is intended to promote a better understanding of, and ultimately reduce, the use of restrictive practices, as well as support more dignified care for vulnerable individuals.

Disclaimer: The information in this document provides general guidance only. It does not constitute professional or legal advisory and should not be relied upon as a statement of law in any jurisdiction. Please seek professional advice for any areas of concern related to restrictive practices.

Content warning

This document contains detailed information about restrictive practices in care settings, including chemical restraint, physical restraint, seclusion, and other practices that may limit an individual’s human rights, freedom, or autonomy.

Some readers, particularly those with lived experience of restrictive interventions or trauma, may find this content distressing.

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1 – What are restrictive practices?

Restrictive practices are broadly defined as any intervention that has the intention or effect of restricting a person’s freedom, movement, or access with the primary intention of modifying a person’s behaviour or mood.

Restrictive practices can and often do infringe on the human rights of the person receiving them. They can cause significant and long-lasting physical, psychological, and emotional harm. In some cases, restrictive practices have resulted in death.

The five main types of restrictive practices include:

• Chemical restraint
• Environmental restraint
• Mechanical restraint
• Physical restraint
• Seclusion.

Defining restrictive practices

At the intersection of ethics, law, and care, there is no universal definition of what makes for a ‘restrictive practice’. Instead, what constitutes a restrictive practice depends on the following:

1. The type of restrictive practice.
2. The specific regulatory context.
3. The guiding legislation that applies in a particular situation.
4. The setting in which the practice occurs.
5. The purpose of the intervention.
6. The impact the intervention has on the individual.

The same intervention could be classified differently depending on where it takes place. For example, a practice might be considered restrictive when it occurs within a disability service setting, but the identical practice might not be considered restrictive when done in a hospital or school setting, even with the same individual.

This points to inconsistencies in how restrictive practices are defined and regulated across different sectors. Even though the fundamental nature of the practice itself hasn’t changed, what’s considered appropriate practice continues to evolve.

The NDIS Act 2013 defines restrictive practices as: “any practice or intervention that has the effect of restricting the rights or freedom of movement of a person with disability.”

For the purpose of this text, restrictive practices will be defined and referred to according to the legal framework established in the NDIS Act 2013 and further detailed in the NDIS (Restrictive Practices and Behaviour Support) Rules 2018.

 

2 – What are the different types of restrictive practices?

Restrictive practices are disproportionately used on people who are already vulnerable – namely, people with disability, the elderly, or children in care settings. In other words, people who are already disadvantaged or marginalised in society are much more likely to have their freedoms restricted by these practices than the general population. This creates a concerning pattern where those with the least power, resources, and social standing face the highest levels of control and restriction of their autonomy.

Highlighted below are different types and examples of restrictive practices.

 

Chemical restraint

Chemical restraint uses medication or chemical substances to control or modify a person’s behaviour rather than to treat a diagnosed health condition. This practice involves administering medications primarily to manage behaviour considered challenging or to restrict freedom of movement. Under NDIS regulations, this includes situations where medication is used to manage behaviour without proper therapeutic justification or appropriate consent.

Case Study: Chemical Restraint in a Supported Accommodation Setting

In the following case study, ‘Steven’ is used as a pseudonym to protect the identity of the individual involved, and all identifying details have been changed.

Scenario:

Steven is a 47-year-old man who has recently moved into a three-person supported accommodation residential setting with 24-hour staff support under the NDIS. Steven has an intellectual disability and autism, with limited functional communication skills. His sleeping patterns are irregular, and he often calls out and vocalises loudly late into the night and early morning. The other residents have complained that the noise disrupts their sleep.

What occurred: Staff requested that Steven’s GP prescribe Risperidone at night to manage his sleep and calling-out behaviour. This would constitute chemical restraint, as the medication is being used primarily to control Steven’s behaviour rather than treat a medical condition.

Potential consequences if chemical restraint had been used:

• Increased drowsiness and confusion.
• Risk of side effects.
• Further disruption to the sleep-wake cycle.
• Diminished quality of life and personal agency.

Considerations: Instead of resorting to chemical restraint, a person-centred approach was implemented:

• GP referred Steven to a specialist physician for medical and sleep assessment.
• Functional behaviour and ecological assessment were undertaken to understand the unmet needs underlying the behaviour of concern.
• Family consultation revealed Steven’s fear of being alone at night for long periods of time and his love of television.
• A speech pathologist was consulted to increase Steven’s functional communication skills and support.
• Staff trained in Person-Centred Active Support strategies.

 

Environmental restraint

Environmental restraint restricts a person’s free access to or movement within different environments or restricts their access to certain items or activities. This can include locked doors, gates, or other barriers that prevent independent movement. It may also involve removing mobility aids, restricting access to personal items, or designing environments in ways that limit independent navigation and choice.

Case Study: Environmental Restraint in a Supported Accommodation Setting

Scenario: Jamie is a 19-year-old man with an intellectual and psychosocial disability living in a Supported Disability Accommodation (SDA) setting with 24-hour Supported Independent Living (SIL) staff support. Jamie engages in behaviours of concern that cause risk of harm to others, such as physical aggression. Jamie is unable to meet his own needs independently.

What occurred: To manage safety and the potential risk of harm from the behaviour, Jamie is able to access the community only when he is being supported by at least two staff members at a time.

Potential consequences:

• Restricted access to the community and environments outside of the residential facility when two staff are not available or rostered.
• Lack of autonomy and freedom of choice.
• Limited meaningful engagement and skill-enriching opportunities.
• Potential impacts on mental health and interpersonal relationships.

Considerations: 

Understanding the context, unmet need, and pattern regarding both the behaviour of risk and the restrictive practice is important. Restricting a person’s access to the general community and public can have a considerable impact on the individual, their quality of life, and overall health and well-being. In these instances, it is imperative that the person’s freedom and dignity of risk are balanced alongside a duty of care as analysed via risk assessment and mitigation planning.

 

Mechanical restraint

Mechanical restraint involves the use of devices, equipment, or physical objects that restrict a person’s movement. This includes devices attached to or adjacent to a person’s body that cannot be removed by the person and restrict their free movement or normal access to their body. Examples include specialised restraint chairs, lap belts, splints, or other devices when used primarily for behavioural control rather than therapeutic positioning.

Case Study: Mechanical restraint to prevent self-injury

Scenario: Marion, who has a lifelong intellectual disability, has recently begun demonstrating behaviours of concern in her residential service. She constantly picks and scratches at her skin, sometimes causing bleeding. Her torso shows scars, abrasions, and shallow ulcers that bleed when she picks at them.

What occurred: Care staff dressed Marion in an ‘all-in-one’ bodysuit, overalls, and outer clothes that zip at the back. While this prevented her from reaching areas of her body and reduced self-injury, it also meant Marion was restricted from accessing certain parts of her own body, could no longer toilet herself independently and required either pads or staff assistance. She often became distressed when trying to toilet herself and being unable to undress.

Potential consequences:

• Loss of autonomy and agency.
• Loss of independence.
• Emotional distress and frustration.
• Potential impact on dignity and self-esteem.
• Possible hygiene issues if toileting assistance is delayed.
• Reinforcement of dependence on others.

Considerations: This intervention constitutes mechanical restraint as clothing is being used as a device to restrict Marion’s free movement (access to her own skin and independent toileting), even though the intention is to prevent self-harm. Such interventions require:

1. Proper assessment from an authorised professional, such as an occupational therapist.
2. Documentation as to the body suit’s purpose, instructions for use and non-use, and less restrictive alternatives and strategies.
3. Consent according to relevant state/territory legislation and principles.

Importantly, in this case, staff sought medical attention for the new behaviour, which led to a diagnosis of atypical scabies. With proper medical treatment, the skin condition resolved quickly, eliminating the need for restrictive practice. This highlights the critical importance of investigating potential medical causes as underlying reasons for new behaviours of concern before implementing restrictive practices.

 

Physical restraint

Physical restraint involves the use of physical force to restrict, subdue, or prevent movement of an individual’s body or part of their body for the primary purpose of influencing their behaviour. This may include physically holding a person, blocking their movement, or using physical pressure to restrict mobility. Under NDIS regulations, physical restraint does not include physical assistance or gentle physical guidance used without force to support participation in activities, such as meal-time assistance.

Case Study: Physical Restraint at a Specialist School

Scenario: Maria is a 10-year-old child who has autism, intellectual disability, acquired brain injury, and severe expressive and receptive communication impairment. She lives at home with her family, goes to a specialist school, and receives in-home support from paid carers from the NDIS.

What occurred: When she is upset or frustrated, Maria will, at times, punch herself in the face and head with a closed fist. She may also bite the back of her hands or wrists. When this occurs, adults will stand behind Maria and physically hold her straightened arms against her body until she stops trying to bite or hit herself.

Potential consequences:

• Increased agitation and distress.
• Feelings of powerlessness, fear, and isolation.
• Risk of injury.
• Relationship rupture and distrust.
• Disruption to learning and adaptive skill development.
• Escalation of maladaptive coping and response patterns to distress.

Considerations: This form of restraint requires proper assessment, documentation, and consent according to relevant legislative requirements. To address Maria’s unmet needs, the care team appropriately sought the following:

1. Multidisciplinary support and resources, including Behaviour, Occupational Therapy, and Speech Pathology support
2. Family support and assistance
3. GP assessment and preventative health and dental check
4. Universal supports and strategies across all environments to proactively meet Maria’s needs and reduce the likelihood of behaviours of concern/risk

 

Seclusion

Seclusion is the solitary confinement of an individual in a room or area from which they cannot freely exit – whether physically prevented, implied through social/environmental cues, or coerced. This practice involves isolating a person in a space where they either physically cannot leave or understand/believe they cannot leave, separating them from others. Seclusion differs from environmental restraint in that it involves active confinement of a person alone rather than simply restricting movement from environments or items.

Case Study: Seclusion through unmet mobility needs

Scenario: Billy has hearing, vision, and mobility impairments and cannot walk without assistance. He lives in a residential accommodation service and frequently wants to move between his room and communal areas. Because he is not independently mobile, Billy will often request to return to his room after short periods in shared spaces and then ask to be taken to another part of the house soon after.

What occurred: Staff, frustrated with repeatedly assisting Billy to mobilise, began ignoring his requests and communications. Although Billy’s room was unlocked, his mobility limitations meant he was unable to leave independently without support. Therefore, this practice constitutes seclusion.

Potential consequences:

• Feelings of social isolation, loneliness, and despair.
• Increased boredom and frustration.
• Unmet communication and relational needs.
•  Possible deleterious effects on mental health.
• Loss of autonomy and choice.
• Rupture of trust and relationship in support staff.

Considerations: This situation constitutes seclusion because Billy is alone and unable to leave by himself due to his disabilities. Staff are deliberately not proactively meeting BIlly’s communication, mobility, and relational needs, and this is preventing his freedom to move and go where he wants to.

When Billy raised concerns about spending long periods alone in his room and explained his dilemma (boredom in his room but inability to engage in common room activities), a person-centred solution was implemented. The multidisciplinary care team and staff worked with Billy to identify areas of unmet need via assessment and coordination and prepared a collaboratively written person-centred plan with training in universal strategies and supported communication methods. These practices were implemented and reviewed as part of the behaviour support plan, addressing the underlying need while avoiding restrictive practices.

 

3 – Restrictive practices across different environments

Restrictive practices may be initiated differently depending on the specific setting in which they occur. While the fundamental principles remain consistent, understanding how these practices are implemented and regulated across education, disability services, mental health, and aged care contexts is essential for recognising when rights are being inappropriately restricted.

Below is a closer look at how restrictive practices can look in various contexts.

 

Restrictive practices in education

Students with disability experience the use of restrictive practices at disproportionately higher numbers than their non-disabled peers. When considering restrictive practices utilised in educational settings, the most common and frequent practices are:

• Physical restraint: Physically restricting, preventing, or directing a student’s body movement through hands-on approaches. This could look like holding a child’s arms or hands against their body or holding them back by their torso so that they cannot move freely.
• Chemical restraint: Providing medication to a student in order to subdue, calm, or modify an agitated mood or aggressive behaviour.
• This does not include the use of medication prescribed for the purposes of treating a diagnosed medical or health condition such as ADHD.
• Mechanical restraint: The use of a device, such as a harness or restrictive clothing, to restrict a student’s movement or access to their body.

Other types of less obvious types of restrictive practices occur at a much higher frequency than those cited above, especially amongst vulnerable students with unmet needs such as trauma-affected students and those with a disability or neurodivergence. These practices include:

• Restricting a student who is perceived to pose a risk to the safety of themselves or others to a singular room or area of the school with or without adult supervision, outside of the general classroom environment and away from peers.
• Restrictions or limitations on enrolment through partial attendance, limited durations, and restricted timeframes for attendance.
• Restricted access to certain or otherwise communal areas of the school or environment.

Oftentimes, these sorts of restrictive practices in schools are implemented in response to a significant incident or risk to students or staff. However, these practices can fly under the radar of being considered restrictive practices because often the student is off-site.

The practice of exclusion, isolation, and restricted enrolments can create an adverse educational experience that further perpetuates the risk of harm if not managed effectively. In these circumstances, the best evidence-based approach for reducing the risk associated with behaviour in schools is School-Wide Positive Behaviour Support.

 

Restrictive practices in disability services

Restrictive practices are legally authorised and sanctioned violence that targets people with disability on a discriminatory basis. This is at odds with the human rights of people with disability.

A significant concern with restrictive practices within this context is that the concept has emerged within a particular policy and legislative framework that is applied specifically to a targeted group of people—those with a disability, as distinct from broader legal and social definitions of violence. This context is a problem when understanding what constitutes ‘violence’ against people with disability differs from how violence is understood in the broader community.

Examples of some common restrictive practices within disability settings include:

• Use of psychotropic medications such as antipsychotics, benzodiazepines, and sedatives to reduce the engagement in or likelihood of behaviour of concern in an individual with an intellectual disability or autism that is not prescribed for the treatment of a diagnosed medical or mental health condition.
• Locking a door to restrict the person from leaving the environment or from accessing an area or item, such as the refrigerator.
• Use of a ‘body suit’ or clothing designed to limit a person’s access to parts of their body or to prevent engagement in a particular behaviour that is not prescribed by an occupational therapist for a mobility or therapeutic purpose.

 

Restrictive practices in mental health

Seclusion and restraint are examples of restrictive practices in a mental health and secure care setting. A restrictive practice is any practice or intervention that restricts a person’s rights, including their freedom to move (Australian Government 2014; SQPSC 2016). Restrictive practices within mental health and secure settings include provisions relating to the treatment of people on an involuntary basis, which means that under some specific circumstances, an order can be applied to provide treatment that can include medication and therapeutic interventions without the person’s consent.

Restrictive practices in mental health and secure settings are often used in response to managing the aggressive or agitated behaviours of service users and to promote individual and practitioner safety. The fast-paced nature of acute mental health care services can mean that there is a limited tolerance of agitated and aggressive behaviour, and thus, restrictive practices are implemented as a means to manage and control service users.

In situ, these practices can include things like:

• Confining a person at any time alone in a room or area from which free exit is prevented.
• The use of hands-on immobilisation techniques by staff, such as clasping a person’s hands together to stop them from hitting.
• The application of devices on a person’s body to restrict their movement, such as belts or straps, or tying or cuffing a person to a chair or bed.
• Giving the person a sedative to calm them or reduce aggression.

Studies show that the use of restrictive practices, and seclusion in particular,  is associated with experiences of fear, feelings of neglect and powerlessness. Some service users reported feeling abandoned, some ruminated on aggressive feelings toward staff, and others reported not understanding the reasons for seclusion. Negative reports of the effects of seclusion are not universal, and in one study, service users preferred seclusion to mechanical restraints.

 

Restrictive practices in aged care

The Australian Government Department of Aged Care defines restrictive practices as “any action that restricts the rights or freedom of movement of a care recipient” and includes seclusion, chemical, physical, mechanical, and environmental restraint.

There are strict requirements for the use of restrictive practices in residential aged care. Informed consent needs to be given by the care recipient or a substitute decision-maker who can provide informed consent.

Examples of commonly used restrictive practices within aged care settings include: 

• Using sedative or antipsychotic medications to subdue or modify a person’s mood or behaviour.
• Locking or restricting access to environments to prevent a person from wandering outside the residential environment or into otherwise communal areas.
• Using equipment or mechanical aids such as belts, straps, splints, rails, and tray tables with the primary intention of restricting or limiting the person’s unaided mobility or movement.
• Using anti-libidinal medication to reduce a person with dementia’s problematic sexualised behaviours.

 

Restrictive practices are often implemented in order to manage a perceived risk of harm to that person or others. Often, this stems from a motivation to keep people safe. This is usually applied and delivered within the context of behaviour management. Here’s the uncomfortable truth: ultimately, restrictive practices are something done to a person to make things more manageable for other people.

 

References

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