I was wondering what your thoughts were on the use of Therapeutic Crisis Intervention (TCI) when working with Adolescent males in the Residential School environment. As much as we try to avoid safe holds and use the full range of TCI techniques we have at our disposal sometimes it is unavoidable and to keep everyone safe we may be required to enter into a safe hold.
In my opinion and due to the majority of our client group being physically mature, the safe hold element of TCI can be ineffective. Is there anything better that we could introduce?
Thanks for reading,
Reply to Joe from Scotland
There are alternatives to TCI, but you need to think very carefully before changing what you do. I suggest you should talk to Judy Furnivall at SIRCC (0141-950 3683). In the meantime, have you seen Holding Safely, the Scottish Executive guide on physical restraint? There are copies in SIRCC Library, and you can view or download it at:
University of Strathclyde
Hi Joe, The technique which is used in my employment is called C.A.L.M.
(Crisis Aggression Limitation management). Have you heard of this before? It may be a similar strategy to your own, I don't know.
In reply to a much earlier discussion here I expressed scepticism with regard to any system that labels its techniques as "safe". Since then I have had occasion to respond professionally to a number of incidents where techniques were referred to in this way but were profoundly unsafe, placing children at immediate risk of severe harm. That said the passionate support / opposition that your query will arouse with regard to specific systems does not help people such as yourself who are earnestly seeking realistic solutions to the dilemmas presented when physical intervention becomes a requirement.
My advice, Joe, would be to begin with a blank sheet. Consider first your agency ethos, the values that you are centred around and the culture that you wish to create. From this platform look around to see what is on offer that matches and supports your position. All the providers will tell you that their system is what you need but when you look inside they will not all do what it says on the box. There is no need to accept any system that in any way contradicts the ethos, values and culture of a 21st century caring agency as there are providers of systems that are compatible.
The Bild accreditation scheme is a good place to start but be aware that it should not be taken at face value - you need to look deeper into the accredited organisations to be sure you get a good fit. The SIRCC publication Holding Safely should help with this process. Make sure anything you opt for allows you to meet the standards of Holding Safely as this should also reflect your agency ethos.
I hope this helps.
By the TCI safe hold do you mean the when two staff are holding a client in a prone position?
Hi Joe from Scotland
There are other programs that I believe provide more effective "holds", one of which I am a co-author and co-owner. However, it is not possible to provide such training via internet and it would be expensive to bring us to Scotland. It might be cheaper for you to come to California and get the training yourself, if that is in your budget. Then you could compare and contrast. I suggest you look up the ProActtraining.com website for more information.
yes, there are alternatives to TCI and CALM. Check out Team -Teach, and also RAP (Response Ability Pathway) trainings. These are both highly effective systems in working with troubled youth in residence.
If you need to get in touch re these systems, I can be reached at firstname.lastname@example.org .
I keep telling myself I should start focusing on my own work and stop joining CYC-Net discussion threads but then Joe Gibb comes up with a stimulating question and it is impossible not to be tempted to join the discussion. I have decided that by responding to the temptation I am not being prodigal in 'wasting my substance on riotous living' because that might be seen - to mix parables - as burying any talent I may possibly have. My job is child care and I really welcome the opportunity that CYC-Net gives me to talk about it ! It feels safe to have so many potential therapists out there.
Joe's question about 'safe holds' aroused thoughts in me which I fear are not an answer to his question but that I believe are relevant to it. I know of two women teachers who worked together for almost 20 years at a small school. ( Actually it was not called a school, it was called a 'unit'. Why is it that kids who have troubles with school are often sent to what is referred to as a 'unit' and not another school ? "What school did you go to Jack ?" "Oh ! I didn't go to a school, I went to a unit. " Says it all really).
Anyway to get back to this small school
in the south of England ; it was for youngsters of both sexes between 14
and 16 years who had been rejected by their mainstream schools
invariably because of their behaviour. Amongst them were youngsters who
had been said to be aggressive and who had needed to be physically
restrained by staff at their previous schools. The two female
teachers I am describing refused to use any form of physical
restraint. In those twenty years none of their students were rejected by
them and only two incidents of violence occurred which involved on
one occasion a female student starting a fight with a male student and
on the other occasion there was a fight between two male students.
Both situations were resolved through immediate verbal intervention and negotiation. On occasions the local authority who employed these women directed them to take what was called 'restraint training' in which they would be taught 'safe restraint holds'. They always refused to attend the training and interestingly their employing authority took no action to discipline them for refusing. I can only imagine that the authority may have found itself in difficult legal territory if it were to insist that staff must be prepared to restrain youngsters.
Now I come to the thoughts that Joe's question throws up for me and I would make it clear that I am not implying that these in any manner represent what I may imagine Joe's views are. These are thoughts that have come into my head and so their source is me.
Should we employ staff to look after troubled youngsters if they are not prepared to restrain them? Well I have to say the idea that I might have had to restrain kids when I first became a teacher and then a residential worker did not enter my head and I was shocked when I found I was expected to do so, and always felt a sense of despair and anguish after I had been involved in physically restraining a youngster. Afterwards I would go home and would find myself crying like a forlorn child.
The two female teachers at the small school I mentioned always argued that the atmosphere of their school was such that there was no expectation of violence and therefore there was not an ever-present threat that if need be staff would control by physical force and, because there was no such threat the two teachers held the view that it was difficult for anyone to build up group energies which would encourage the possibility of violence.
Two other things that occurred to me on reading Joe's letter were firstly about gender and secondly about who actually ends up being restrained. Joe particularly asks about the restraint of male adolescents. What about female adolescents ? Is there a general assumption that only male adolescents ought to be restrained ? And would this assumption lead to the implication that female staff should not restrain ? If this were the case would this make female staff some kind of second class practitioner ? Or does it imply that men should be hard and women gentle ? This is a can of worms which I think we have been sometimes been frightened to open.
To be sure, I have used restraint but in the last 15
years of my own practice I eschewed it and concentrated solely on the
emotional strength of my relationship with the young people. When I
think about all the times I have witnessed or been involved in 'safe
holding' it has never been a neat clinical operation - sometimes
it may have been in the physical sense because a youngster has been
'efficiently' overpowered - but in the long term emotionally it
messes up relationships by encouraging the development of the notion
that it is acceptable for relationships to be governed by the physically
powerful. Particularly it may encourage kids - both male and
female - to think that the world is controlled by the physical power of
mainly adult males. I have sometimes also thought that 'safe
holding' training appeals to staff who are not confident in their
relationships with youngsters.
I have noticed also a tendency to restrain those kids who are not really big enough or aggressive enough to pose a real physical threat. I have also sensed that offering a staff team 'safe' physical restraint training leads to increased incidents of restraint in the home or the school. In a sense it 'legitimises' the restraint as a method of relating. When I have been involved in post-event analysis when restraint has been used, invariably the source of the problem has lain in a failure of communication by staff (usually unnoticed or unacknowledged by the staff), which has occurred hours and sometimes days before the actual restraint and its consequences allowed to fester without any intervening negotiation or reparative work taking place.
As I say I have used restraint in the past. I am almost certain that I would not use it again unless I was absolutely certain that it might save someone intent on harming themselves. As for a youngster harming others I would hope that my feeling for the emotional climate of the home or school would be such that conflict of that kind would be dissipated before it reached physically threatening proportions.
As an aside as a younger worker I was once admonished for preventing a youngster - a newly admitted to a children's home - jump out of a second floor window by grabbing him by the leg. I was admonished because I had not been given the appropriate 'safe holding' training even though it was acknowledged I had probably saved him from serious injury.
I am aware there are many 'ifs' and 'buts' here. I cannot with certainty be prescriptive about this whole issue - who knows what we may need to do to do to keep children and ourselves safe - but I think it needs thinking through more and my own tendency is to believe that the underlying ethos of the two women teachers I mentioned is the direction we should be going in.
Healthy relationships are the key.
Have a look at previous threads on this subject. - Eds.
There is no such thing as a risk-free hold, if that is what you mean by a safe hold. Any time that you are faced with high danger from a person's behavior, it may be necessary to limit the person's ability to deliver the injury. That should be the sole objective of any sort of physical intervention. Otherwise, you will discover persons holding for other unacceptable reasons, e.g., immobilization, retribution, etc. The interveners/staff should have their own self-control, which should then enable them to think critically about the crisis in front of them and to do effective problem solving. No two situations are the same, and so teaching principles to the staff rather than techniques is likely to be more effective.
I am part of a group known as Pro-ACT. I invite you to look at our website, www.proacttraining.com. I would be happy to answer any questions you might have.
I'm wondering: if a male adolescent is warranting a hold which would suggest their unsafe or tenuous behaviours, would this not justify a call to the police?
Firstly this missive is not meant to sound condescending or patronising and I sincerely hope it doesn't come across that way but I thought you might find our recent investigative experience interesting. I have not been trained in TCI but am aware of it and read the manual from the course. I hope the below will make my thinking clear.
You and indeed all of us know the "safe hold" that will hold all individuals in all circumstances has not been invented and the best technique is never to have to restrain but that is also a situation seemingly only found in Nirvana!
This being the case, we all look for the best crisis management system for our organisations. I say that because your needs will most likely be very different from another company/service.
Having recently battled with this very issue we have decided that in general the 'safe holds' part of many systems are very similar and are, it is hoped, seen very much as a last resort. Ok so what about the theory behind these 'systems'. Again these are similar, they need to be otherwise they won't meet the 'Bild' criteria and will therefore, for intents and purposes be useless in the UK there will be similar accrediting bodies in North America, Australia etc I'm sure.
However such things as rationale; assessment, safety, implementation of behaviour support plans, accessing the environment, the individual, liability; administrative issues etc, etc basically the systems ethos' are far more varied. We decided we wanted and felt able to provide, more input in this area yet currently we are given none. We are an intelligent organisation with intelligent people with loads of knowledge around young people and how they operate, why then should we have zero input in the provision of such knowledge (a hugely important aspect of any company) to our new inductees and consequently to our
teams as they progress with the company. Being comparatively small we also needed more flexibility in the internal provision of the training.
We are changing to Safe Crisis Management (SCM). Be clear though it has nothing to do with how effective the current system we use is in terms of the physical interventions available, it is to do with how that system 'fits' our organisation and yes there is cost implication of course. This last is more manageable because we will have the ability to internally train our staff from theory to practical, an ability we don't have at present. We can also adapt (without damaging the core course) the theory to provide more exactly what we want our people to know about the use physical intervention, why it might be needed, what effects that can have on the individual being held and the individual doing the holding etc etc , but, more importantly, the steps we can take to avoid a most unpleasant and belittling and possibly unsafe course of action. For me/us the theory is the most important part hence our belief that we need to be more involved in that aspect.
I guess what I'm saying comes back to the very first line I wrote here and the only way I know around that is a far more draconian system i.e. pain restraint, or tools such as stun guns, batons etc!!! which we are certainly not equipped to provide, thank goodness. But we do have a police force who are compelled to assist when we feel we can no longer keep our charges safe. For me I have always found my mouth and brain, in no particular order to be the best tool!!
I do hope this is enlightening and good luck with finding a solution I know we would all be interested to read about it when you find it.
Without intending to set the heather alight (but
well aware that I probably will do so), it is incorrect to suggest that
"in general the 'safe holds' (sic) part of many systems are very
similar" and also that the "theory"
components of those systems are similar.
Bild (British Institute for Learning Disability) Accreditation must not be taken at face value as it is the system as a whole that is accredited, not individual techniques or theories. Recognising that all systems have the potential to be misused, with or without intent, the important criteria of Bild Accreditation is that there are suitable safeguards to limit the potential for harm to be done.
Therefore, within the broad spectrum of accredited systems there are techniques that carry foreseeable risk of specific injury occurring, that will inflict pain, that incorporate hyperflexion, that are highly likely to inhibit breathing occurring and that will probably have a greater likelihood of impacting negatively on the relationship between adult and child than other available restraint options. Similarly, some systems have well-developed "theory" while others are outdated and have at best a flimsy evidence base.
The bottom line has to be the value base that the system is founded upon. Hence systems that were developed by professionals within a care sector would tend to be preferable in a CYC context to systems that were developed for use in contexts where the relationship between professional and service user is fundamentally different, e.g. penal services, health care or education. Systems designed to be applied without the context of professional relationships may be best avoided. (I also have greater caution regarding systems that were developed by ex-forces personnel looking for new avenues to apply their skills base but who have no credentials relating to behaviour management in care contexts).
Having narrowed down the marketplace in this way it becomes a less daunting task to examine the detail of the remaining systems and to enquire as to whether the approaches and techniques contained are compatible with the ethos and culture you intend to create and espouse. It is possible to apply a good system in a way that is hostile, confrontational and unbalances power. However, some systems fundamentally make it difficult to develop a more positive context, where growth, development and even change are facilitated.
Please note that my intention is to be neither prescriptive nor proscriptive about what systems are more or less fit for purpose. The system an agency opts to use speaks volumes as to the quality of service they are able to provide, so carefully considered selection from the range of differing options is essential. Don't just read the label; have a good look inside and make sure it contains what it says on the tin.
I would agree with all you say. I was not meaning to suggest that "all" systems are the same or that simply because they are BILD accredited that they are excellent safe systems with up-to-date theory components. I couldn't hope or want to know all the systems out there.
I was saying that in our investigation those I looked at were very similar in those aspects. I agree that any system is only as good as the individual interpreting and using it. Common sense is a prerequisite and pain is in my view completely unacceptable in any environment so I have not ever looked at such systems.
In our investigations though we did consider how the theory and techniques would 'match' our company; that is a given in taking on anything new such as these.
I do hope this helps to clarify my original thoughts
As a long time trainer of TCI, with knowledge and
ability to train other methods, as well as many years of experience as a
senior administrator in a large residential center with over 115 kids I
think TCI has been extremely effective, and clearly the method I prefer,
but I don't think there is any such thing as a "safe hold". The most
impressive part of TCI for me has always been the non-physical
intervention techniques and the (hopefully delivered by the trainers)
significant underlying message that it is not a course in "holding", but
rather one to avoid the need to do a hold with effective interventions
and a good overall relationship with the kid. I strongly suggest any
program using TCI or any other physical holding method have at least one
very senior administrator regularly teach the course with a direct
service worker to give a clear message from the top about the "message"
I believe that all programs should hold a thorough and open debate as to whether a physical hold is a last resort therapeutic intervention or a therapeutic failure? We all struggle with the word "failure" and if we can get beyond the word itself to focus on our ethical responsibility to be reflective about our practice with children (especially where it involves an intervention that can be extremely re-traumatizing to child and sadly even result in deaths) I think we can go a long way to keeping children (and adults) safer and enhance the therapeutic value of our practice by looking at each hold as a therapeutic failure and honestly focus in on what WE could have done better to prevent it. I don't believe that if a hold takes place it is inherently abuse or bad practice, but I think it can never be considered any version of best practice. We should always do a very thorough follow up of every hold with a meeting between the child, worker doing the hold, a senior administrator, child's social worker and parent (if treatment plan advisable) to thoroughly replay the event in an effort to learn from it and prevent another. This method will also significantly cut into holds where there worker may see it as a frustration induced intervention that is easier than continuing the process. The focus should be that a therapeutic hold should mean that we view each one as an outcome of either not having enough resources available to support the child and prevent the physical intervention, or a result of not using the resources we have well enough.
A few years ago I wrote a point/counterpoint article in the Child Welfare League of America Residential Group Care Quarterly Journal that elaborates on these points and shares a few more experiences. You can view the article by going to the CWLA website at www.cwla.org and search for “Point/Counterpoint: Locked Isolation: Is it Best Practice or Abuse?”, CWLA Residential Group Care Quarterly Fall 2000 in the back issues segment. If not found you can e-mail me at email@example.com and I would be happy to send a copy along.
Although not hard data to call on, I have experienced a number of occasions when the "message" that restraints are a therapeutic failure, or in a couple of cases simply no longer allowed, that restraints in that program have been drastically reduced, and on two significant occasions in my career, simply disappear.
Hope this is helpful and hope that it may open a debate thread here: Are restraints a last resort therapeutic intervention or a therapeutic failure?
New York, NY
I am trained to teach and implement about 10 different restraint models. I took the entire training course of each one of these models to see for myself. My top (and only preference) is Handle With Care. HWC is the only one that allows a smaller person to effectively and safely hold a larger person. HWC also easily allows for only one person to make safe holds - but they also teach if two persons are needed. They also teach a different hold for smaller person - to gently hold in a very safe manner. They also allow for other modification if a child is injured, has breathing difficulty has asthma, is pregnant and so on.
Of course, if no one has to be held, that is the best method - and that is strongly reinforced.The de-escalation techniques and verbal skill section are far superior to anything I have seen. Everything is based on the relationships and adult role modeling (creating a Solid Object for the attachment to occur). Injuries to both youth and staff have significantly reduced since we have incorporated these methods. I have witnessed so many places using unsafe methods and just having a difficult time. Many of these other methods have a slick marketing department and send out volumes of high glossy brochures to promote their product - many received by administrators who are enamored by the mailing and may not be that understanding of what goes on by those "who work in the trenches". HWC does not do that - it is only word of mouth and reputation.
HWC is easy to teach - easy to retain - especially if one does not restrain very often and suddenly encounters a dangerous situation that needs safe attention. HWC is very "brain friendly" using body language and communication techniques to help all children in their most difficult moments. It is very effective for trauma reactive youth. Please contact me if you would like more information.