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.


 Kirkwood, S. (2003) Practicing Restraint. Children's Voice, September/October 2003, CWLA