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Use of restraint

2015

Hey guys, I’m a second year student in Child and Youth Care Counselling at Mount Royal University. Last semester I did an observation practicum at an intensive therapeutic treatment center for young kids, most of whom had horrific stories of abuse and neglect. It was an interesting learning experience, I still do not have a lot of exposure to the field but am both fascinated and passionate by the tremendous strength and courage in each one of these children.

I must however ask your professional opinions on your experience with counselling, and helping these children. One of the techniques used was restraint. Is the use of restraint effective when a child is escalated? If their file gives evidence of past physical abuse does this change the way staff approach this child? Lastly, how can the use of such a technique be used and trusted to staff who can be just as escalated as the child? Curious about your wisdom and opinions!

Thanks,
Rachelle Tang
...

Rachelle,

Welcome to youth care, it is a wonderful and opportunity to help the children and youth that come from homes of abuse and neglect.

I think all of our goals as child and youth care workers is not to do any further harm to these kids. I think we need to look at all other options before we put "hands on". However saying that sometimes a youth maybe so out of control that it is necessary. If the restraint is done probably and staff are not engaging the youth during this process, I can speak from experience that the results can be found to be a positive experience.

I was trained in a variety of restraint techniques, but by far the best was TCI (therapeutic Crisis Intervention ). The trainers were directly trained through the experts from Cornell University. This by far is a safe non-business restraint techniques that keeps the youth safe from harming themselves, and others.

Hope this helps.

Dave
...

Hello Dave,

Yes, I have to agree.... having done training in BMS (behaviour management systems) and having exposure to NVCI, TCI seems to be good. I was also trained in TCI but to date have not needed to use the restraints. I can appreciate that it can sometimes be very difficult when a child is hurting themselves or could potentially hurt others, but what I would suggest is that the very first step if "others" could be potentially be harmed is to make sure that the "others" leave or are not in the same vicinity as the child. Again, I cannot emphasize enough, restraints not only should be an absolute last resort, I would go as far as suggesting that the realization that restraints do not help or change behaviour is becoming more prevalent as models like like CPS are adopted.

Delphine
...

Hi Rachelle,

I think your questions are excellent ones. The idea of restraint reduction/elimination for youth who are presenting "out of control" behaviors has been a passion of mine throughout my career. Having worked 25 years in a large residential treatment center of 114 children near New York City as a direct practice CYC worker, Recreation Director, Girls Program Director and 13 years as Associate Director of the agency gave me the opportunity to view restraints at many levels. As a CYC worker I did a number of restraints before I was ever trained how, or had any idea what I was doing. Thankfully, no disasters but a lot of experience in why they are so awful for all involved. Interestingly enough although I remained having a lot of in the moment contact with kids in all the other roles I did not do a single restraint once I was trained to do so. Here-in lies the key. When one develops strong relationships with children, create a sense of safety together, and develop more confidence in intervention skills the need to restrain will usually fade away. I also taught the Cornell TCI course for over 20 years and served 12 years on the national Residential Advisory Board of Child Welfare League of America where restraint reduction was a consistent topic. I have had much direct experience with restraints in program work and teaching, and have heard so many of the rationales as to why they are "necessary". I don't but the necessary part very much at all.

Some reflections:

1. Restraint should never be viewed as a "last resort therapeutic intervention". It should be viewed as a "therapeutic failure". This doesn't mean the worker "failed" but rather the worker and the program should review whether they have the amount and quality of resources to serve children without restraining,

2. In many years of reviewing restraints as an executive level administrator the vast majority of restraints did not need to be done. There were clearly points in process where a different type of intervention technique, or higher skill level, would likely have prevented it completely. One major argument that you hear when the largest number of restraints in program are with the youngest group of children (8-11 years old) is that at that age "they don't talk it out as well". This is often used to justify the restraint to "keep the child safe". A key question to ask the worker (and program administrators) is whether the restraint that was done on this 120 pound child would have been done on a 6 foot 3 inch, 220 pound, 17 year old athlete presenting similar behaviors....and the answer is generally "No, it would not have been safe"...so, then the restraint on the younger child really wasn't "necessary" either...it was just more convenient.

3. To quote an old Cornell saying "Every one (restraint) is a big damn deal". All restraints should be reviewed at all program levels to see if they could have been prevented and what the child, worker, and program can learn from them. Workers should be responsible for their decisions and should be willing to justify their actions. The program should be responsible for supports provided to the worker.

4. I was able to fully eliminate restraints in the two years I was Director of the 40 bed adolescent girls program in the center, although not for the whole program when I was the Associate Director. However, we did reduce them dramatically over the 12 years I was in that role. One significant contributing factor was that I, at executive administrator level, taught the TCI course myself along with a direct service CYC worker once a month. There would be no "message drift" about the program philosophy about restraints in the training since it was coming straight from executive level. All workers including CYC workers, crisis intervention specialists, social workers, psychologists, program directors, secretaries, maintenance staff, interns, etc. were all required to take the course before they could begin their job. No, we did not want the secretaries or cooks doing restraints, but everyone was trained in the event of a real emergency....but most importantly: The more people who know a safe one will also know a bad one!....and we now had "monitors" to help keep children safer and minimize risk of abuse. It also set the program philosophy about minimizing or eliminating restraining very clearly for all.

I realize I have been provocative here and risk some saying "He is just out of touch now...there is a real world out there where kids can be very aggressive". I am still heavily involved in training and consulting with programs so I would love to think I am not all that out of touch...but I also know that is the same rationale I have heard for many years for very destructive restraints and in programs where they became all too "acceptable"...and yes, when that happens I don't shy away from the words "institutionalized abuse". All of us should be consistently looking for ways to move aggressively toward the elimination of restraints and programs that can't make large progress in that area, or don't prioritize it highly, should start to question their own validity.

Provocative food for thought! Please feel free to e-mail me at Fdelano24@aol.com if you want more elaboration.

Frank Delano
...

Hi Rachelle,

I totally agree with Frank. What hit home for me years ago when I did my first CPI training and years later becoming an instructor, is that generally more experienced CYC's do less restraints because they've honed their skills for de-escalation. Paying attention to those workers who don't need to do restraints will serve you better than those who resort to the physicality of a physical restraint

Deb Cockerton
...

It is unfortunate for anyone to generally think that restraint is therapeutic to the individuals we support. Restraint shouldn't have been used at all except when it becomes absolutely necessary for the safety of all the parties involved after every other supports has failed.

Having said that restraint could be therapeutic for individuals that recognizes such to get at their desire and unable to pictorially or verbally make such a request. For example an individual I know that normally would go and grab staff's chest, boobs in case of female staff. The individual does the grab to get squeezed or restraint which happens after the chest grabbing. That continued until staff got the message and taught the individual how to ask for a hug by showing it instead of boobs grabbing.

The key is to work hard in knowing our guys so that prevention of situations that may lead to restraint is eliminated. The action, restraint is of no good to the individual, peers and staff in general.

Ade Adejobi
...

Thank you Rachelle for your poignant questions and Frank for your candid and multi-level perspective. I too have concerns about the potential for restraints to do more harm than good. When working with children and youth in residential treatment we are often working with the most vulnerable of the vulnerable. Their boundaries have been violated, their trust in others and sense of self skewed, they often have a lack of voice, power, and certainly lack capacity for emotional regulation - this should be expected as a given. Emotional regulation capacities are learned through attuned, calm, loving, and attentive care. As an infant our self-regulatory capacities are directly impacted by our attachment relationships, or lack thereof, with our primary caregivers. Our brain grows more rapidly than it ever will again during the last trimester of pregnancy and the first year of life more than doubling in size in the fort year then dropping off to only 18% growth in the 2nd year. 5/6th of this growth in the first year is driven by attachment (being held, sung to, touched, nurtured, rocked, mutual gaze experiences etc). This rapid brain growth is largely right brain development (sights, sounds, smells, sensations of touch etc) in the first and second year with the left hemisphere (cognitive, language, the foundations for higher order and more complex functions) begins to come online in the 3rd and 4th year and continues developing into early adulthood. Peak periods of growth for the prefrontal cortex occur in our teen years beginning around 12 and completing development around 26-30. It is important to keep in mind that the rational cause and effect, if-then thinking that we expect children to utilize is of the last to develop. Add to that as youth our brain is primed to overestimate benefits and underestimate rewards. Essentially I would suggest we need to be asking ourselves a few key questions:

1) Are we aware of the impact trauma and attachment had on brain development? Trauma and attachment dysregulation impacts many areas including our executive functions (the ability to plan, organize information, initiate, inhibit impulses to name a few). The ability to concentrate, learn and retain information is also impacted.

2) Are we aware of the impact attachment dysregulation and trauma have on the developing nervous system and do we know how to promote regulation (bottom-up and top-down)? Attachment significantly impacts our developing nervous system setting the foundations for regulation accessed throughout the lifespan. Trauma and attachment dysregulation significantly impact the development of key regulatory skills such as emotional regulation, self-reflecting fictions, empathy, eye contact, and sensory processing.

When we are primed for threat and danger through early adverse experiences this also impacts our ability to attend to information, accurately perceive what is happening around us and also impacts our social engagement capacities including empathy and morality.

Do we know what dysregulation looks like? If not this is something we should learn. We can clearly track the state an individual is in based on observations of affect (for example whether they are perceiving safety, danger, or life threat). Strategies are going to be different according to the state they are in but all involve coregulation, sensory based regulation, mindful awareness, and the attuned support of a grounded and compassionate caregiver.

If we have awareness of the above and truly understand it are out expectations reasonable and possible?

3) Perhaps the most critical question is whether you are grounded and regulated yourself sufficient enough to respond in a manner that is safe, regulated, and empowering. As helpers we MUST provide children and youth with a different experience of how people and caregivers around us behave. If we want them to be regulated we need to be regulated ourselves. If we want them to identify and express their feelings and use appropriate boundaries we need to model this and help cultivate these skills.

Children and youth do not automatically know how they feel. If this is modelled for us we learn. Many children in care have not had this modelled and taught to them in a healthy manner. Many are allergic to relationships as they have learned that people hurt, are unpredictable, or leave. We as the caregivers in their lives need to help repair the relational traumas and perceptions of relationships they have formed. We need to act as their prefrontal cortex for them (as theirs is still developing and maybe yours is too!). This includes helping to increase awareness of emotional and physiological felt states, as well as identification and expression of needs, feelings and boundaries. It can be as simple as noticing and verbalizing: "It looks like you are feeling frustrated (or whatever feeling you observe) I wonder if (insert strategy here) might help?" There are many relational, sensory, and emotional strategies we can use to promote regulation. It is a process of trial and error to learn what strategy works for what youth and in what emotional state. Needs will be different with different emotions.

Caregivers should notice and regulate their own affect before responding. It takes seconds...but can save you hours!! Plant your own two feet on the ground, take a fe deep breaths, notice what you are feeling, notice any area of tension. Relax your shoulders, jaw, mouth, eyes, and tummy. Slow your breathing, lower and slow your speech to a gentle prosodic tone. Ask yourself do you have soft eyes, soft mouth, soft voice? These are communicated directly to the child's nervous system through right-brain to right-brain communication. They can auto-regulate through your calm presence or dysregulate further as you escalate. The latter tends to be exhausting and shame-filled for all involved. Most importantly though it does not build competency or restore power to the child - it takes it away which reinforces what they already know to be true - they are powerless and adults are stronger than them.

As with Frank I have worked in residential treatment, have provided crisis support on hospital psych floors, and have worked with high risk highly dysregulated and traumatized individuals for several years. I too have found that regulation without restraint is not only possible but probable. As a consultant that trains in trauma, attachment, and regulation I as many others am aware that people behave in predictable manners. Once we understand common reactions and responses of traumatized children and how to support the regulation process we often do not need to engage in restraint. Often this is reactive and driven by our own dysregulation and perceived loss of power. When our brain perceives inequality it doesn't like this and instinctively becomes defensive and reactive (largely at a level outside of our conscious awareness). If we are aware of our own feelings, physiological and emotional reactions, and how to ground ourselves this can go a very long way.

There are many fantastic resources and trainings to assist with the development of such skills. If interested in learning more please inquire and I'll gladly share some recommended resources.

This is by no means meant to offend anyone but rather to gently challenge you to consider your perceptions, your knowledge, your reactions, your triggers, and potential areas for continued development and growth. This is a continual process and we all are in this because of a passion to help children - however we too are humans and have perceptions that drive our reactions. We do the best we can with what we know when operating on autopilot. Awareness, conscious reflection, learning and reshaping allows us to be the best helper and support we possibly can be.

Wishing you a gentle day and thank you for the work you do!

Lori Gill

Hi Frank

I appreciate your thoughts on this. Your re-frame of ‘last resort’ to ‘therapeutic failure’ is very powerful and I agree with how you define that. It reminds me of a Barbara Docker-Drysdale comment that ‘All acting out takes place in the context of a breakdown in communication”). Barbara D-D was a pioneer of therapeutic residential care for children in UK. I am part of the Cornell TCI Instructor Team and am based in Ireland. I think it was Jeremy (second name gone from me!) in an earlier thread or maybe this one who said something like “it is time to put resources in solid programme / model design elements like appointing suitable people for the job”. If I remember rightly his argument went on “and less on expensive programmes of restraint.” I have no doubt that in Ireland TCI played / plays a major part in making residential care much better than it was – but that was only ‘round one’ or as the family therapist say, ‘the first wave’. The second wave in N. Ireland is evidence of five different models / programmes of care piloted by the five statutory child care bodies. Report available here http://www.scie.org.uk/publications/reports/report58/index.asp . The third wave – in my opinion – is how to make genuine models of therapeutic care available to ALL children and youth in alternative care. I worry that managers, policy makers and politicians think that training staff in programmes like TCI is enough and that restraint elimination is enough. These are my personal opinions.

Johnnie Gibson
...

Frank.

Thanks for your well thought out reply to Rachelle's post. Myself having 45 years as a CYC and program director in multiple residential settings, my transition to Relationship Youth Care Work did take much too long. I sincerely hope that Frank’s post is read by all in the field.

Steve Bewsey
...

A lot of great feedback and experiences here on this topic!

I will briefly add here, in the agreement to utilizing restraints as a last resort and how it speaks to "therapeutic failure". Restraint is about control; thus, there are concerns as to the use of control which often addresses the realm of power. Children and youth we work with are often oppressed and vulnerable: they act and react to the world around them. Every behaviour has a purpose (Garfat, 2002). We want to avoid control and instead form a caring connection with young people.

Having worked in various sectors over the last 20 plus years, I have seen the use of restraints, which in my mind was not necessary.

Further, authentic relational rapport and caring support system that we build with young people, on top of fitting and meaningful strategies as we walk alongside children and youth, can most certainly decrease, even eradicate, the use of restraints as an intervention. As shared, programs and systems also play a role; yet, we can advocate and create a difference in the places we work by being an example and light to other methods. Further, we can also promote, build and maintain a safe and secure environment for young people. Additionally, our own "self", both inner thoughts and outside action, become part of the environment; thus, being a reflective practitioner benefits the ways we interact.

One place in particular comes to my mind as it was rampant with restraints; however, it began to change through the aforementioned. One of the key factors is "us". How do we contribute and participate in such environments ? I have been trained, via the workplace, in many different behaviour management/restraint systems; however, I chose not to restrain (even if everyone else was...) and utilized alternative measures based on the individual and the status of our rapport, such as the following:

• sing, hum, read a book, or any other activity that soothes the child
• be their "inner voice" as a means to educate and bring about transference in communicating high states of emotion during a potentially escalating situations; it also helps with exploration of where these emotions come from and one's reaction to it
• have a space set up for calming with various items (I have co-created spaces with young people in which any individual in the environment can engage as needed; it also promotes it as a general space for all to use, diminishing the idea of being "punished" or centered out)
• find something I like about each child/youth (there is something to be said about the "vibe" we give off and how our own feelings about a young person can transfer into behaviour)

These are just a few examples, but the possibilities are endless for us to explore with those we serve.

Before I end here, I am curious as to the use of "restraining rooms" and other people's experiences. I find them quite scary myself, so I can only imagine what kids feel about them... I also question what the mere presence of such spaces says to children and youth. I am thankful that my discourse with young people in this type of environment was brief. Although I have been able to use a restraining room for alternative strategies, the very sight of them and their "label" is still out there being used as a deterrent for "undesirable" behaviour.
So, here we are back again to the fact that every behaviour has a purpose. Should we not be investigating the root cause and being supportive? Is not a young person's behaviour a means for their voice to get out, hoping someone will not only hear them but come to their aid? These are the children and youth we work alongside of.... thus, I feel the question we should be reflecting on is, "How are we going to respond?"

Mary Anne

Reference
Garfat, T. (2002, May). All behavior serves a purpose. CYC-On-line (40). Retrieved from http://www.cyc-net.org/cyc-online/cycol-0502-editor.html
...

 Hi all,

We just concluded working on a 3 year project with Texas Residential Treatment Centers to reduce restraint and seclusion using the "6 Core Strategies to Reduce the use of Restraint & Seclusion" and one of our favorite resources to share with residential youth-workers is Gordon Hodas' paper titled, "EMPOWERING DIRECT CARE WORKERS WHO WORK WITH CHILDREN AND YOUTH IN INSTITUTIONAL CARE". See the link below.

http://www.parecovery.org/documents/Hodas_Direct_Care_Worker.pdf

Jack Nowicki
...

Hello Everyone,

I am so glad that the concept of "therapeutic failure" with regards to restraints has been brought up. I agree very strongly with Mary Anne that restraint is about control, and I hope that more child and youth workers come to the realization that the strength of the therapeutic relationship can minimize or eradicate the use of restraints. Unfortunately, there are quite a number of child and youth workers who still do not have the necessary training or formal education in theoretical perspectives of why and how our own internal feelings externally affect the young people and children we work with. Thank you Mary Anne for your important contribution.

Delphine

Hi Mary Anne D,

My input to the restraint topic is a little bit late but I just wanted to let you know that I really enjoyed reading your response.

I am a second year student at Mount Royal University. I am in the child studies program, majoring in child and youth care counselling.

I am currently doing my practicum at a place I enjoy very much and have been learning a great deal. However, within my first day I saw my first restraint and it really bothered me. I do understand that when a youth is out of control and harmful to others that a restraint may need to take place but another part of me thought there could have been something else done to keep this youth under control.

I really enjoyed reading your response to the use of restraints as I too feel that many of them are really unnecessary and could have gone in a different direction.

I worked with one youth who would get restrained on a daily basis and I always thought there could be a different route to take. With reading your response I really liked your idea about having a space set up with different items, allowing any youth to engage in the items in that area which takes away the feeling of being punished. I think this is extremely important as I feel that if you take away the feeling of punishment that the individual will try new coping mechanisms when they get angry. I think this could be a great idea for the youth I work with.

This particular youth hates going to the QR ( quiet room). It's a really horrible experience for them and it just makes the situation worse. I think having a space that makes them comfortable is a better route to take because like you said it takes that feeling of punishment away. When you make a youth feel punished it makes them more upset and less valued as an individual which is not what we want. With this youth in particular, they have been through so much trauma that they do not need to go through anymore.

Your ideas really helped me and I hope more and more people consider using different techniques than using the restraint.

Thank you,

Jordan Turner
...

Hi Jordan,

No response is too late... I myself haven't been on for a bit, as I am also a student and self-care is my number one priority. We can't function well without it. I like to think of discussion boards as one way to engage in mutual dialogue in which we can learn and grow from one another. I appreciate you sharing your experiences, and hearing those of others, as it can help us to relate to professional issues, thoughts, comments, etc that arise in this field; further, it can cause us to reflect on our own experiences which impact how we do our practice.

As I read your response a few things came to mind:

First of all, how interesting that we give "neat" acronyms/names to spaces as if it would enhance the appeal to those using it. I am sure there are some of us that can relate to the naming of spaces, and how it can pose a contradiction to and for the young people we work alongside. Regardless of the names we place on various rooms to "correct" a youth's behaviour, more times than not they are  perceived by young people as a place of punishment, not a place that heals or supports. Jordan, your example spoke to this idea. How we use space is important to the development and growth of children and youth as it does have impact. Which brings me to the next thought...

Spaces are the places children and youth live in every day. As child and youth care professionals, every moment is an opportunity to care for, support, and empower young people. There's a great book that was highly recommended by my teaching prof that I have acquired for my shelf of valuable sources. It is called Right here, right now: Exploring life-space intervention for children and youth by Kiaras Gharabaghi and Carol Stewart. It is an easy insightful read for anyone interested. 
 
As I indicated in my initial response, how we respond does have impact and in ways we can only imagine. What we say and do (or not say and  do) ultimately effects those we work alongside; all we are, as part of their space, is perceived through the eyes of the child. I feel it is important to remind ourselves we are here for children and youth, and that does require mindfulness on our part as professionals in this field.   It is in tough circumstances, as we have shared, that I am reminded of why I am here in this profession: to be there for the children and youth, not for any other purpose. Thus, it is my job to serve them in an ethical and responsible way. I have also seen how children and  youth pick up on how we attend to such difficult situations, thus, our example can influence how they chose to attend to their own struggles. Not only do we want to care for and support young people, but utimately we want to empower them in their own life journey.

Let us keep supporting one another to be the best we can be, and make a difference in the field of Child and Youth Care.

Thanks
Mary Anne
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