The Opt-Out Sequence-When to Hold and When to Let Go

CPI programmes teach us to use non-restrictive, empowering, person-centred approaches as preferred methods of managing risk, de-escalation and achieving tension reduction.

However, when risk behaviours occur, ones that pose an immediate or imminent risk to self or others, then restrictive interventions may be a reasonable and proportionate response.

In those circumstances, choosing not to respond to maintain the safety of a vulnerable person, allowing significant harm to occur, is a professional position that could be viewed as negligent.

Questions around restrictive interventions

A topic of discussion that is often asked of Certified Instructors, surrounds “how long should staff hold for?”, “when is it safe to let go?” if staff have chosen to use restrictive interventions.

Whilst guidance such as NICE (NG 10, 2015) is helpful to clarify this, there is not one definite answer to these questions.

Every risk behaviour, individual and context is different, giving rise to a complex dynamic decision making.

Getting to know the individual(s) and having a plan in place to be proactive in reducing restrictive interventions is best practice.  

The Safety Intervention programme offers staff the Opt-Out Sequence as a theoretical model to support good decision making.

This model directs staff to immediately question and challenge the rational for using restrictive interventions in the moment, to ensure this is only happening for the least time necessary. 

The Opt-out Sequence gives four main questions that a team must consider in real time if they are holding an individual experiencing an emotional crisis.

Why are we holding?

What is it about the person’s risk behaviours, others and the environment that necessitates the intervention? If there is no clear rationale, then letting go must be the safest option. If there remains a significant risk of harm, then holding may be justified. We must also consider letting go and giving space as an alternative way of managing a risk, not only once the risk is no longer present.

What are the risks?

As there are known risks associated with restrictive interventions, the detrimental psychological and physical impact of holding must be considered. This, balanced against any risk we anticipate if we choose to let go. As well as considering the reast restrictive option, staff must also consider which decision will have the least negative outcome.

What can be done to reduce the risk?

Often the answers to achieving tension reduction are in the immediate environment. Think about the precipitating factors that have influenced the behaviour. Can we remove the trigger from the environment or make the environment safe whether that be from another person, triggering object, or something of danger. If this is not possible, could moving to a less restrictive position or safer environment achieve the decrease in physical and emotional energy?

Can we let go?

Having made changes, staff should re-assess if they can let go. This should always be our goal and achieved as soon as safely possible. Do everything that you can to maximise safety and minimise harm.

This series of questions should be constantly asked, not only by the staff involved, but by others in the vicinity who may be better placed to help manage the incident and make good professional decisions.

Alongside the Opt-Out Sequence, staff need to take a trauma-informed approach.

Prolonged holding has associated risks including causing additional trauma. The psychosocial impact of holding an individual should never be overlooked in addition to the physical risks for the individual and the staff team.
If the individual is a young person, consider the impact that holding may have upon their future. If the individual is an adult, consider their past-history and previous experiences of trauma potentially by being restricted.

Safety Intervention teaches us to consider the risk of doing something and the risk of doing nothing. Trauma should always be a consideration when weighing up the risks and staff teams should always decide to use the least restrictive option by being trauma responsive.

A common misconception related to holding an individual is that the person needs to be “calm” and still in order for the staff team to let go. Although the person being calm might be an ideal outcome, this may not always be possible immediately and should not be a requirement for letting go of someone.

There will typically be movement during an intervention, movement is not always a sign of aggression, but can be misinterpreted due to staff anxiety. Sudden movement could also be a warning sign of distress and the individual wanting the staff team to leave them. What is the person communicating via their movement? Orienting yourself to why they are moving could be a key detail.

Although a staff member may find it safer to continue to hold for their own safety if there is lots of movement, why not try letting go if it is possible? The team could always re-engage in a hold if there is a continued significant risk of harm. However, letting go could be the fastest and safest way of achieving tension reduction.

Following a restrictive intervention, work with the individual and the staff team in investigating future alternatives to holding and negotiate future approaches, expectations and behaviour. The process of re-establishing positive communication through therapeutic rapport with all involved will support any future interventions.

Being proactive and recognising behaviours at the anxiety and defensive levels can reduce the use of restrictive practices, supporting Care, Welfare, Safety and Security for all.

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References
Violence and aggression: short-term management in mental health, health and community settings
NICE guideline [NG10] 28 May 2015