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Children's Voice Article, September/October 2003
Practicing Restraint
By
Scott Kirkwood
Restraint and seclusion were once considered
acceptable, even valuable tools in maintaining control of unruly
children in residential group homes. But the call for alternatives
is growing louder.
The 11-year-old girl stood outside New York's Andrus Children's
Center with a pile of rocks at her feet. She picked up one of those
rocks and started carving words into the side of the agency's
van--words that can't be printed here. When the staff tried to
approach her, she threatened them, grabbed a rock from the pile at
her feet, and took aim.
What would you do?
In the past, many supervisors at residential facilities would have
found a way to physically restrain the child, bringing an end to the
vandalism and the threat to the staff. But for some time now, Andrus
staff have sought alternative approaches to restraint, recognizing
the danger it poses to residents and staff alike, and the
conflicting message it sends in what is ostensibly a therapeutic
environment.
So the staff stood by and watched closely to make sure the girl was
in no danger until her rage subsided, she put down the last rock,
and she simply walked away. In the end, the child was spared any
physical trauma, the workers were unharmed, and the agency had a
memorable automobile insurance claim.
More
Harm than Good
The
negative effects of restraint have been well-publicized in recent
years, most notably in a 1998 series in the
Hartford
(Connecticut) Courant implicating restraint in the death of
dozens of children each year.
"Facilities that use seclusion and restraint have a much higher rate
of injuries and sometimes deaths than institutions that don't use
seclusion and restraint," says Kevin Ann Huckshorn, Director of the
Office of Technical Assistance for the National Association of State
Mental Health Directors in Virginia. "Before the Hartford Courant
expose, many people thought, 'We use restraint because we have
to--it's a serious intervention that must be done well,' but now
we're starting to ask why we're using restraint at all."
If the Courant series revealed the lethal physical component
of restraint, new research reveals the mental component is just as
important.
"Children who are victims or witnesses to abuse experience
significant changes in the way they regulate their emotions over
time, creating all kinds of problems as they get older," Huckshorn
says. And yet as these children escape violent, abusive
surroundings, they are all too often subject to violence in a venue
designed to protect them.
"I think we've confused what's therapeutic in terms of
intervention," says Janice LeBel, Director of Program Management for
the Child and Adolescent Division of Massachusetts's Department of
Mental Health (DMH). "There was a tacit belief that containing
children, setting harsh limits, and imposing a physical restraint or
seclusion was somehow therapeutic. How we got the idea that meeting
a child's history with violence was somehow going to be palliative
and restorative, we don't know."
If a child's past is the powder keg that makes potential conflict so
explosive, it's often the staff who provide the spark. "In reviewing
restraint episodes involving children, we noticed a pattern," says
Nan Stromberg, Director of Nursing and Licensing for Massachusetts
DMH. "When kids were in trouble and in distress, the staff would set
limits, and the kids would then become more agitated--a recipe for
restraint."
"Research that looks at why restraint increases [stress] points to
the phenomenon of counteraggression," says Paul Jones, Staff
Development Coordinator at Home of the Innocents in Louisville,
Kentucky. "When you feel like you're being attacked, there may be an
[instinctive] reaction, and a staff member [may be contributing to
that situation]. Counteraggression prevents people from being able
to let those verbal assaults or other things go."
"Everyone [is vulnerable to counteraggression], whether they admit
it or not," Jones warns, "but the extent to which it happens
decreases with experience and training."
When Stromberg and LeBel decided to investigate the backgrounds of
children involved in the most restraints, they found that more than
85% had significantly well-documented trauma histories.
"These kids weren't seeking out restraint, they were traumatized,"
Stromberg says, "and their needs were being expressed and being
poorly met. Restraint was not only countertherapeutic, it was
[repeating] the abuse they had already experienced. Once we
understood that was a critical variable, we were forced to step back
and do business in a different way."
At New York's Bellevue Hospital, where restraint is not used at all
in the child unit, and only rarely in the adolescent unit, Stromberg
and LeBel found a staff committed to doing whatever it took to see a
child through a crisis by talking through the situation.
"In the adolescent unit, we saw a remarkable example where a girl
was very out of control, pounding the wall," Stromberg says.
"Instead of offering the usual 'You've got to lower your voice and
get in control,' the nurse manager was validating her anger, saying,
'I know you're angry, and that makes sense--I'd be angry too.'" The
staff were able to escort the other children from the room, and in
that quieter setting, the situation was quickly diffused.
But to the DMH officials, it all seemed too simple. "We grilled the
directors," LeBel says, "looking at numbers of staff and training
and how much they paid their workers, figuring there had to be some
big difference that allowed them to be restraint free, but there
wasn't one. But there was crystal-clear, rock-solid leadership
[committed to finding another way], and a group of people who
understood they could negotiate any kind of crisis without resorting
to restraint."
Stromberg and LeBel brought others to Bellevue and immersed them in
the experience as well. And because they knew it was not enough to
mandate the abolition of restraint, they set up training
opportunities, connected agencies to one another so they could share
best practices, brought in a consultant to answer questions, and
supported the effort statewide. After just 2 1/2 years, the use of
restraint and seclusion was down 78% in licensed child facilities
across Massachusetts, 65% in agencies with a mix of child and
adolescent services, and 44% in adolescent service agencies.
A
Philosophical Change
Of
course, the numbers aren't an end in and of themselves. Often, the
numbers are just the beginning. Many agencies find the process of
simply monitoring restraint more closely has a remarkable affect on
its use.
"Once you start measuring something, it's a pretty powerful tool to
get people to start looking at their actions," says Steve Karp,
Chief Psychiatric Officer for the Pennsylvania Department of Public
Welfare. "When we throw a graph up on the wall, [staff at one
hospital] can recognize they're not doing as well as some of the
other hospitals, and that really motivates them to bring their
numbers down. There was a decent disparity among hospitals
initially, but now they're all very successful because the ones that
weren't doing so well communicated with the others and asked what
they were doing to get their numbers down."
When a physical intervention raises a red flag, people think twice
before choosing restraint. Karp and others say making people
accountable for such decisions forces them to ask, "Is this really
worth the trouble?" Of course, management needs to show the new
approach is designed to help residents, not punish staff.
"In the past, a staff person got called on the carpet if they
performed a hold and something went wrong--if a kid got hurt, or
someone filed a complaint, or child protective services filed a
report," says Brian Farragher, Director of Campus Programs for Julia
Dyckman Andrus Memorial in Yonkers, New York. "But the idea of
[reviewing these incidents] all the time diminishes that. It's not
that you screwed up when you hurt a kid, it's that this is an
intervention we prefer we not use. If you're doing it because you
think you're trying to keep a kid safe, you need to justify that
decision and be sure the child's behavior was more risky than the
hold. That's a tough call to make."
If the issue turns into nothing more than a numbers game, agencies
can find ways around it. Some agencies have manipulated medication
levels to reduce restraint numbers. One agency called the police for
every conflict, preventing the staff from resorting to restraint.
That's why a complete philosophical change is a big part of the
transition.
"Our belief now is that restraint is a treatment failure," Farragher
says. "We end up physically holding kids when our program isn't
holding them. To change that requires a team approach." Andrus's
restraints went from 40 in one month to 20 the next, then slowly
continued to decrease until only two holds were done in the month
last tracked--and Farragher believes those could have been avoided
as well.
A big part of that philosophical change must come from the leaders
of the organization. Several people interviewed for this article
have seen agencies try to make changes, only to have the leadership
end the process. "If you don't have 100% buy-in from management,
you're wasting your time," Jones says. "That's why senior managers,
even CEOs, should get the same training as staff, so they know
firsthand what's expected."
Many crisis-resolution training programs spend 90% of the allotted
time focusing on restraint techniques, while others spend 90% on
negotiation skills and only 10% on safe restraint. If the CEO
doesn't understand the content, he or she can't choose the right
training and can't help his or her staff by supporting and
reinforcing their work after training.
Finding
Better Ways
But
if the leadership backs the new approach, the rewards can be
handsome. When workers are forced to stop relying on restraint, they
find different ways to negotiate the inevitable conflicts, and that
often reveals deeper reasons for their causes.
Farragher tells of a young girl who was restrained on a regular
basis. Once that option was removed, the root of the problem was
exposed.
"Every night, [she] would get very agitated, and she would end up
moving furniture around her room," Farragher says. "As soon as the
staff heard noises, they would come into her room, correct her, and
move the furniture back where it belonged. Inevitably this would
escalate into a hold. But once we sat down and talked about [the
situation], we learned she had a history of sexual abuse at
bedtime--she was moving her furniture against her bed to make a
barricade. The staff were getting agitated by all this activity when
she should have been settling down to sleep, so it turned into this
tragic reenactment--all of these provocative activities led the
staff to respond by holding her down."
Two simple things ended the vicious cycle: The agency bought the
girl a bunk bed, even though she was in a single room, thinking she
might like having something above her, and they bought her a giant
stuffed dog for her to sleep behind. She went from being restrained
about eight times in a two-week period to not being restrained for
six or seven weeks, and only rarely after that. "We put our heads
together and figured out a different strategy," Farragher says. "If
you have no motivation to do that, if you don't see restraint as a
treatment failure, you have no motivation to change."
But motivation isn't always enough. It's easy to tell staff not to
restrain residents, but unless you provide alternatives, you're
unlikely to change their actions. As one supervisor noted, "If the
only tool in your toolbox is a hammer, you'll treat everything like
it's a nail." So how do you increase the selection of tools with a
limited amount of time and an already overworked staff?
"These kids require your time one way or the other," Farragher says.
"You can either give it, or they'll take it. Sure, [training new
approaches] is labor-intensive, but restraints are too, and they
usually happen when you least want to invest that time. These kids
are complicated; they're not so easy to figure out. Restraint takes
a lot of brawn, but not a lot of brains. Sometimes, it's easier to
use restraint than to think through a situation and figure out how
to avoid it."
The move away from physical restraint may have an unforeseen
positive effect on workforce retention and turnover. "We recruit a
lot of kids out of college ... who don't think of this work as
rolling around on the floor wrestling with kids," Farragher says.
"The work they want to do is more cognitive. Turnover is exacerbated
by an environment with lots of restraints. Our retention has
improved dramatically over the last couple of years, and the fact
that staff aren't wrestling with kids every day is a contributing
factor."
Stromberg agrees. "Instead of functioning as custodians and police,
staff have been elevated to be teachers and role models."
Minimizing restraint goes beyond a single staff member dealing with
a single child. That's where witnessing and debriefing come into
play. Some agencies make sure that as soon as a potential conflict
situation arises, at least one staff member is brought into the room
to observe. When the debriefing occurs within 24 hours of the
restraint, it's much easier for that individual to provide the most
objective view of the event.
It's also a good idea to talk to the patient and speak to family
members if possible to see if some deeper issues may be at work.
Huckshorn recalls a case in a Florida mental hospital: A large young
man in his mid-20s had entered the hospital's care; based on his
record, the staff was very prepared for problems. He was surrounded
by security guards and watched closely--staff were instructed to
physically restrain him as soon as any conflict arose. The third day
of his stay, the young man was put into restraint, and the process
left him and three staff members with serious injuries.
When the staff analyzed the situation afterward, they learned the
young man was manicdepressive and had entered a manic stage during
group therapy, when he was expected to stay seated. When he tried to
leave the room to watch television, three male guards told him to
stay put, and the physical assault began. A debriefing with the
patient's mother revealed the patient had been abused by his father
for years and had grown leery of men; if he had been approached by a
woman, he would have been more likely to talk through the situation.
Once the staff accounted for the man's special needs, he was never
again restrained in the two years Huckshorn remained at the
hospital.
Relinquishing Control
Such
situations point to potential problems that can occur when staff
perceive the need to control residents. "[In] any residential
environment where people are being treated in an institutional sense
... the traditional culture is characterized by control," Huckshorn
says. "The mantra has been when you have a large group of people in
[your care], you need to control them ... That's extremely conducive
to using violence to make people do what they think they should do."
Mental hospitals may need to rely on physical interventions more
than do children's residential centers, but if that field can make a
commitment to lowering restraint, critics charge, then surely
residential facilities for children can do the same.
"If you're looking at facilitating the growth or rehabilitation of
kids who've already been traumatized and haven't had good role
models, and you're trying to make them productive adults, you don't
do that by forcing, coercing, controlling, and ruling them,"
Huckshorn says. "If you include the people in your facility in some
of the decisions, give them some choices, and allow them to make
some decisions, you have much less conflict."
When Andrus changed its approach, "there was an initial sense that
we were giving away the store, the kids were going to walk all over
us, and we were going to have terrible behavior management
problems," Farragher says. "But all the ... major behavioral
indicators, like AWOL, physical aggression, property damage, and
assault, have gone down, and I think it's because aggression breeds
aggression. The more you try to control, the more resistance you're
going to encounter. Ultimately, we're not going to make these kids
change [if they don't want to], so it's important they be in an
environment where they understand they have some responsibility,
some role in their own treatment."
"All models of recovery are based on empowerment,
self-determination, collaboration, partnerships," Huckshorn adds.
The more control an agency yields to its residents, the more
opportunity for growth.
The notion of relinquishing control also applies in more systematic
ways, too. Several hospitals and agencies have abandoned structured
programs for some of their more challenged residents, adapting
programs that allow for greater choice. For example, rather than
require residents to attend group therapy or other activities based
on a rigid schedule, some facilities provide four or five activities
simultaneously and allow residents to choose.
Many agencies let their clients tell them what they need. The
children at Pittsburgh's Bradley Center came up with 10 ways to cope
with crisis and made posters that were distributed all over the
units. "When Johnny is having trouble, the rest of the kids will
say, 'Pick number eight, or pick number seven!'" says COO Dan Hunt.
"Although leadership must drive the change, it can't be [forced on
people]--your frontline staff, your kids, and families all have to
get involved."
Odds are any approach to lowering restraint will also improve
conditions on every level as children begin to see staff as
supportive agents rather than potential adversaries. "Our agency is
a kinder, gentler place--and these places have to be safe, because
kids come here with multiple traumas, where people who were supposed
to take care of them hurt them," Farragher says. "There's a real
pull to use physical force because of the way some of the kids
behave and some of the issues they bring in, but we've lost the
sense that we need to control the kids--the kids are encouraged to
control themselves."
"I was looking out the window of my office," he continues, "and saw
two members of my staff with a kid who was storming the grounds, but
they've just been shadowing her, making sure she's safe, and
nobody's touching her. She'll blow off steam, then she'll be able to
talk ... Ten years ago, we would've tackled her, and what would that
do? She's not unsafe, she's not running into traffic, she's walking
around a fairly pristine little campus here. Sure, it's frustrating
for the people shadowing her, but at the end of the day, they'll all
be OK."
Scott Kirkwood is Managing Editor of Children's
Voice.
In
Harm's Way
Those who cling to restraint as a valuable practice generally cite
one potential problem with other approaches: What do you do if a
child poses a serious danger to himself or others?
"Whoever is asking the question hasn't thought ahead," says Janice
LeBel, Director of Program Management for the Child and Adolescent
Division of Massachusetts's Department of Mental Health (DMH). "When
you get to the point where somebody is self-harming, you've lost the
chance to intercede early, to respond to the triggers that preceded
that self-harming behavior."
"Behavior does not come out of the blue--it's triggered by
something," adds Nan Stromberg, Director of Nursing and Licensing
for DMH. "To work with a child and the parents to identify those
triggers [beforehand], you need to plan and identify some actions
that will help if the child gets upset--maybe coloring, maybe being
in a rocking chair, being held, playing a game, telling jokes."
LeBel cites a push in Massachusetts for providers to adopt a public
health approach. "The primary component is doing all your
frontloading--thinking, planning how to avoid the use of physical
intervention, and creating policies and procedures that can mitigate
the need for restraint. The second component involves looking at the
tools: Do we have the tools? Are they being used? Are they being
incorporated into treatment plans? And lastly, if something untoward
does happen, the third stage allows you to debrief: What happened?
What went wrong? What can we learn? And it feeds right back into the
process of retooling your whole system."
No matter how much planning one does, there's always a chance a
youth will attempt to hurt herself or others. But even then, is
restraint the only solution?
"If a kid is punching out windows, he could really be hurt, so we
teach our staff to position themselves between the object and the
kid, to reduce risk, and to try to talk them down," says Andrus
Memorial's Brian Farragher. "But in reality, kids rarely do things
like that--they may punch a window, but usually that's the end of
it. They punch a window, it breaks, they're either scared by it, or
they just stop. It's very rare for a kid to go from window to
window. In the past, if a kid broke a window, we'd tackle him, but
once the damage is done, it's done."
It's also rare for a youth to strike a staff member without warning
or provocation. In general, Farragher says, if a resident hits a
staff member, that means the staff member got too close. "Your first
step is backwards," he says. "It's hard to train people to do
something that counterintuitive, or to tell someone who just got
punched in the nose that they made a mistake, but people are
starting to get it--they realize there's a lot of risk involved in
putting their hands on a child."
Silent Killer
Certain restraint positions can result in positional asphyxia, a
condition that occurs when a person's body position interferes with
respiration, resulting in suffocation. Any body position that
obstructs the airway or interferes with the muscular or mechanical
components of breathing may result in positional asphyxia.
For breathing to occur, the central nervous system must activate the
respiratory muscles, causing the ribcage to expand and the diaphragm
to descend into the abdomen, creating a larger internal chest space.
This size change causes the internal chest air pressure to be less
than the external air pressure. When the airway opens, this pressure
difference causes air to flow into the lungs, producing inhalation.
Relaxing the diaphragm and ribcage muscles results in a smaller
chest space, and internal air pressure becomes greater than external
air pressure. When the airway opens, the pressure differences causes
air to flow out of the lungs, producing expiration. If the internal
chest air pressure cannot change because the size of the chest space
cannot be changed, no air movement occurs.
When a patient is placed facedown, with forceful compression of the
shoulders and chest, chest expansion is seriously restricted or
prevented altogether. By forcefully compressing the patient's lower
back or hips against a surface, the abdomen is compressed,
preventing the diaphragm from descending into the abdomen and
changing the size of the chest space. Thus, forceful prone restraint
significantly restricts or prevents inhalation. Abdominal fat places
overweight individuals at greater risk for interference in breathing
and a more rapid onset of restraint asphyxia when forcefully prone
restrained.
Often, a patient is restrained after aggressive or violent behavior
and extreme physical exertion brought on by alcohol or drug use,
traumatic head injury, psychiatric disorders, low blood sugar, or
seizures--all of which can result in extreme total body exhaustion.
The patient usually expends more energy wrestling with or avoiding
intervenors.
Physical intervention at this point frequently involves forceful
prone restraint--the patient is placed facedown, usually with one or
more people kneeling on the patient's shoulders or back and lower
back or hips. This position immediately impedes the exhausted
patient's ability to breathe. The patient's body continues to expend
extreme energy in a desperate struggle to breathe. This struggle is
often misinterpreted as a continued threat to the patient and
others, so the forceful prone restraint is maintained.
The energy required to fuel the patient's muscular ability to
breathe can become completely exhausted within seconds. Once the
patient cannot change the size of his or her chest space to move air
in and out of the lungs, he or she rapidly enters respiratory
arrest, followed swiftly by cardiac arrest.
In addition, during the extreme physical activity preceding and
during the restraint, the patient's body produces abnormally large
amounts of adrenalin and other body chemicals, creating a
hypercatabolic state that weakens all muscles, but especially
results in severe respiratory muscle fatigue, and stresses the heart
by increasing its workload. When a patient with severe respiratory
muscle fatigue, an increased heart workload, and an increased need
for oxygen is placed in a body position that interferes with or
prevents breathing, it's easy to understand why certain restraint
positions can be dangerous.
Source: "Restraint Asphyxia: Silent Killer," by
Charly D. Miller, published in the Summer 2001 issue of Residential
Group Care Quarterly.
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