Currently, NDIS providers are struggling to reduce the use of restrictive practices in service delivery. A report by the NDIS Quality and Safeguards Commission showed that there were more than a one million incidents of unauthorised restraints in 2020 – 2021, a 240% increase from the previous 12 months. The restraints included use of sedation, strapping down a person or depriving them of their personal belongings. (Henriques-Gomes, 2021 report of NDIS quality and safeguards commission)

As described in Part 1 of this blog series, Sensory Modulation is an intervention shown to be effective for reducing restrictive practice. Sensory Modulation can be defined as “using your senses to change the way you feel” (O’ Sullivan, Fitzgibbon 2017). Sensory Modulation interventions involve:

• identifying problematic, or overwhelming sensory stimuli and developing strategies to reduce the input or promote self-regulation, with the goal of supporting the individual to continue to be able to engage in occupations.

• Identifying calming and soothing sensory strategies to prevent the use of and/or be an alternatives to restrictive practices.

Sensory Modulation can incorporate individual and group interventions and changing sensory spaces including lowered stimulus, increased sensory stimulation and specifically designed rooms known as sensory or comfort rooms.   Sensory Modulation can occur in any environment, and is optimally delivered by trained staff or through a care-plan designed by an occupational therapist. Sensory modulation strategies can be used in the person’s home or in the community, in group living environments, or in dedicated space such as Snoezelen rooms or multisensory environments anywhere where  the person has control over the sensory input to accommodate their unique sensory preferences.

The following case study illustrates the implementation of sensory modulation strategies in a mental health inpatient setting.

Note: Trigger warning for this article as behaviours of concern are discussed, such as self harm and restrictive practices. 

Marsha has been in a mental health unit for 3 months. While she was in hospital she had access and learnt to use Sensory Modulation strategies when she had urges to self harm. Marsha found these much more useful than taking medication. Marsha had previously experienced episodes where she had been chemically restrained by her support workers, and felt access to sensory modulation strategies would offer a better alternative in the future.  As part of her discharge planning, Marsha agreed it would be helpful to include sensory modulation strategies to enable her to safely transition home, and she also stated that it would be helpful for her to purchase a weighted blanket for calming, as well as some scents. Marsha had identified that one of the triggers for an urge to self harm was the smell of tobacco, as this reminded her of a traumatic situation in her past. Marsha had learnt that if she regularly applied a scent to her handkerchief and held it up to her nose, she could tolerate being around the tobacco without urges to self harm and even wait at the bus stop for her bus to TAFE.

Marsha’s plan manager explained that the NDIS do not fund sensory items and  Marsha was unable to purchase the weighted blanket and scents.

In this case study Marsha was using Sensory Modulation interventions on a Mental Health Unit. Sensory Modulation is a common intervention in Australian Mental Health Services and has extensive policy support as a strategy to reduce Seclusion and Restraint in Mental Health Units.  Both national  and State-level policy frameworks that support Sensory Modulation in mental health settings, are listed in detail in the ‘Where can I learn more?’ section below.

 In the disability context, the NDIS Quality and Safeguards Commission (2020) Regulated Restrictive Practices Guide highlights support for sensory interventions directly such as sensory rooms and sensory items, as well as indirect support such as recommending identifying and removing potential triggers and identifying environmental changes which could include changes to the sensory aspect of the environment.  For example, this document states (bold text added for emphasis):  

“Consideration should be given to the physical environment of the seclusion area and any items that can be offered to ensure the person has appropriate sensory input, subject to a risk assessment (Mckenna et al, 2014 cited in NDIS commission report)” P.28

“Some of the strategies aimed to increase Sue’s quality of life and help support the medication reduction plan and reduce the incidents of chemical restraint focused on:

"Having a quiet space in her home with sensory and relaxation items.” P.38

“Some of the strategies aimed to increase Emma’s quality of life and help support the reduction and elimination of seclusion focuses on:

A Sensory room was designed for Emma tailored to her sensory needs. It included different items and activities, some of which were portable and could be used within the community when she needed them. Over time, it was hoped that having a sensory room would replace the use of seclusion. The sensory room was to be used proactively to assist Emma to feel calm when she was beginning to show early signs of distress.” P. 55 & 56

Despite NDIS Quality and Safeguards Commission (2020) Regulated Restrictive Practices Guide highlighting support for sensory interventions, there continues to be challenges in ensuring these interventions are funded for people with disabilities through NDIS plans, for the purpose of reducing restrictive practice. These challenges include a lack of awareness of the benefits of Sensory Modulation on the part of NDIS planners. In addition, NDIS Guidelines indicate that sensory items will not be funded for children with autism or developmental delay – and this guideline is often interpreted as sensory interventions broadly  -including Sensory Modulation strategies – are not likely to be funded. Many occupational therapists are concerned that a proven intervention with capacity to reduce restrictive practice, is currently overlooked in the NDIS space  - while rates of restrictive practice, are growing exponentially.

It is hoped that the NDIS Quality and Safeguards Commission will  advocate for further sensory modulation options to be funded to support the reduction of restrictive practices for people with disabilities.

 

What could this mean for day-to-day work?

Allied health professionals trained to provide sensory modulation interventions can provide person centred and tailored strategies to reduce the need for restrictive practice for people with disabilities.

How can I influence change?

Raise awareness of the strong evidence-base and policy context for sensory modulation interventions through sharing with colleagues, policymakers and funding bodies.

 

 

Authors: Carolyn Fitzgibbon and Julie O’Sullivan

Carolyn and Julie are co-authors of the Sensory Modulation Resource Manual and co-directors of Sensory Modulation Brisbane.

 

References:

Helene Andersson, Daniel Sutton, Ulrika Bejerholm & Elisabeth Argentzell (2021) Experiences of sensory input in daily occupations for people with serious mental illness, Scandinavian Journal of Occupational Therapy, 28:6, 446-456, DOI: 10.1080/11038128.2020.1778784

Andersen, Kolmos, A., Andersen, K., Sippel, V., & Stenager, E. (2017). Applying sensory modulation to mental health inpatient care to reduce seclusion and restraint: a case control study. Nordic Journal of Psychiatry, 71(7), 525–528. https://doi.org/10.1080/08039488.2017.1346142

Azuela, Gilbert (2019). The implementation and impact of sensory modulation in Aotearoa New Zealand adult acute mental health services: Two organisational case studies

Bailliard and Whigham’s  (2017 cited in Wilson 2020) scoping review of 149 studies on Sensory Processing and mental illness  found that interventions targeting sensory processing skills such as sensory rooms may contribute to cognitive gains and improve occupational performance.

Brown, C., Stoffel, V., & Munoz, J. P. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia: F.A. Davis Co. Chapter 22 Catana Brown, Patricia Steffen-Sanchez and Rebecca Nicholson

Champagne,T (2018) Sensory Modulation in Dementia Care: Assessment and Activities for Sensory-enriched Care, Jessica Kingsley Publishers, London, 2018, 168 pp., pbk £15.99, ISBN 13: 9781785927331. - Volume 39 Issue 8

Dorn, Emma, Hitch, Danielle and Stevenson, Christopher 2020, An evaluation of a sensory room within an adult mental health rehabilitation unit, Occupational therapy in mental health, vol. 36, no. 2, pp. 105-118, doi: 10.1080/0164212X.2019.1666770.

Im D. S. (2021). Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review. Harvard review of psychiatry, 29(1), 35–80. https://doi.org/10.1097/HRP.0000000000000282

Henriques-Gomes, L. 10 Nov, 2021 Guardian Australia

MacLennan, K., O’’ Brien, S., and Tavassoli, T (2021) In our Own Words: The Complex Sensory Experiences of Autistic Adults. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-021-05186-3

O’Sullivan, J and Fitzgibbon, C. (2017) Sensory Modulation Resource Manual.

Matson, R., Kriakous, S and Stinson, M (2021) The Experiences of Women with a Diagnosis of Borderline Personality Disorder (BPD) Using Sensory Modulation Approaches in an Inpatient Mental Health Rehabilitation Setting, Occupational Therapy in Mental Health, 37:4, 311-331, DOI: 10.1080/0164212X.2021.1933674

NDIS Quality and Safeguards Commission (2020).Regulated Restrictive Practices Guide. Penrith. Australia: NDIS Quality and Safeguards Commission.

Seckman, Angela ; Paun, Olimpia ; Heipp, Biljana ; Stee, Marie ; Keels‐Lowe, Vonda ; Beel, Frank ; Spoon, Cari ; Fogg, Louis ; Delaney, Kathleen R, Evaluation of the use of a sensory room on an adolescent inpatient unit and its impact on restraint and seclusion prevention Journal of child and adolescent psychiatric nursing, 2017-05, Vol.30 (2), p.90-97

Tavassoli, T., Bellesheim, K., P, M,. Wang, A. T., Halpern, D., Gorenstein, M., Grodberg, D., Kolevzon, A., and Buxbaum, J.D. (2016) Measuring Sensory Reactivity in Autism Specrum Disorder: Application and Simplification of a Clinician-Administered Sensory Observation Scale. Journal of Autism and Developmental Disorders, 46 (1), 287 – 293. Hyyps://doi.org/10.1007/s10803-015-2578-3

Van den Boogert F, Sizoo B, Spaan P, Tolstra S, Bouman YHA, Hoogendijk WJG, Roza SJ. (2021) Sensory Processing and Aggressive Behavior in Adults with Autism Spectrum Disorder. Brain Sci. 14;11(1):95. doi: 10.3390/brainsci11010095. PMID: 33466570; PMCID: PMC7828723.

Verhulst, I., MacLennan, K., Haffey, A., & Tavassoli, T. (2022, January 12). The perceived casual relations between sensory reactivity differences and anxiety symptoms in autistic adults.

Unwin, K. L., Powell, G., & Jones, C. R. (2021). The use of Multi-Sensory Environments with autistic children: Exploring the effect of having control of sensory changes. Autism. https://doi.org/10.1177/13623613211050176

Werkman, M.F., Landsman, J.A., Fokkens, A.S. et al. (2022) The Impact of the Presence of Intellectual Disabilities on Sensory Processing and Behavioral Outcomes Among Individuals with Autism Spectrum Disorders: a Systematic Review. Rev J Autism Dev Disord https://doi.org/10.1007/s40489-022-00301-1

Wilson, Haley, "Mental Health Inpatient Hospitalization: What Nursing Can Learn From "Sensory Rooms."" (2020). Honors Theses. 3315. https://scholarworks.wmich.edu/honors_theses/3315

Wright, L. Bennett, S, Meredith, P (2020) ‘Why didn't you just give them PRN?’: A qualitative study investigating the factors influencing implementation of sensory modulation approaches in inpatient mental health units https://doi-org.ezproxy.library.uq.edu.au/10.1111/inm.12693

Zeanah, C. (2018) Handbook of Infant Mental Health Fourth edition. Chapter 19: Sensory Over-responsivity Timothy W Soto, Vivian Ciaramitaro, Alice Carter.

Zimmermann, D. P. S. (2020). Use of a serenity room for sensory modulation (Order No. 28002838). Available from ProQuest Dissertations & Theses Global. (2420652212). https://www.proquest.com/dissertations-theses/use-serenity-room-sensory-modulation/docview/2420652212/se-2?accountid=14723

 

Australian National Policies, Reports and Frameworks that contain references to Sensory Modulation, Sensory Items, Sensory Rooms or Sensory Approaches.

• NDIS QUALITY & SAFEGUARD COMMISSION (2020) Regulated Restrictive Practices Guide

• National Mental Health Commission

• National Principals to Support the Goal of Eliminating Mechanical and Physical Restraint in Mental Health Services (Mental Health Commission)

• Australian National framework for recovery-oriented mental health services: Guide for practitioners and providers (2013)

 

State Policies, Reports and Frameworks that contain references to Sensory Modulation, Sensory Items, Sensory Rooms or Sensory Approaches.

• Mental Health Act 2016 Chief Psychiatrist Policy Mechanical Restraint, QLD (2020) :

• Mental Health Act 2016 Chief Psychiatrist Policy Physical Restraint, QLD (2020) :

• Admission of children and adolescents to acute mental health inpatient units – Queensland Health Guideline (2021)

• Suicide Prevention Health Taskforce – Phase 1 Action Plan (2017) Qld Health

• Mental Health Safety and Quality NSW

• Chief Psychiatrist Restraint and Seclusion Standard A standard to reduce and eliminate where possible the use of restraint and seclusion applied under the Mental Health Act 2009 (2021) South Australia:

• South Australia Policy: Guideline Restraint and Seclusion in Mental Health Services Policy Guideline

• Health framework for reducing restrictive interventions Victoria: Victoria Positive Practice Framework

• Attachment and Trauma in People with an Intellectual Disability (2008), Positive Solutions in Practice, Office of the Senior Practitioner.

• Mental Health Restraint Policy West Australia(2020) West Australia Prevention and early intervention strategies