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Restraint 3

I  am currently on a committee formed to take a look at our current methods of physical restraint, and their philosophies of use. We have recently opened a crisis center that will be equipped with a Reflection/Time-out room. We are looking for any information pertaining to the use of such rooms, as well as any other methods of physical restraint being used with aggressive youth aged 10-16yrs. Your help would be appreciated.

Debbie

...

There is a considerable amount of writing and research on the use of time out and seclusion rooms. In teaching and thinking about these issues we prefer to begin by framing the discussion perhaps differently than is suggested by the reflection/time-out notion you mentioned. If the goal is to create spaces and places where youth can be alone to reflect and/or to regain their composure and internal sense of control these can be thought of as positive experiences and therefore the way we think of these spaces is different than when we think of them as punitive places. When the discussion is framed by the notion that you need a place of isolation so you can do some reflective thinking and get control, the results tend to be not very effective. Now this doesn't mean that we don't also have to create places where staff and kids can be safe, but it does mean to us that the way we think about this is quite different than many places think of time out rooms. Don't know if this helps - would be glad to share more info later.

Mark Krueger
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As Lorraine Fox once mentioned: why on earth would you want a child who is upset, has an impulse control issue, low self esteem and poor problem solving skills to sit alone in a time-out and reflect on just how really pissed off they are?

It reminds me of programs that have "Off Program" status for kids who are so disruptive that they need to lose their privileges. The title Off Program is odd; wouldn't a youth that needed extra staff support actually be On Program? I wish that time-outs were used as you describe them, Mark :)

Peter Rosenblatt
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You should look at the Cornell Therapeutic Crisis Intervention Training packages.

Frank Ainsworth
___

I would like to hear from individuals who are working in home-based services (Family Preservation Programs) and dealing with restraints within the home. I am curious to know your organizations’ position on using restraints (as a last resort, of course) in managing dangerous situations in a client’s home that would otherwise result in personal injury. I would be interested in hearing about the types of training available to child and youth care workers and the "spirit" of any policies you are currently working with at your agencies. I would also be interested in hearing your opinions on whether parents should be trained to use appropriate restraint techniques along with teaching all of the other pro-active strategies. In the past we have instructed parents on the proper use of restraints but plan on discontinuing this practice. I know in most cases dealing with children 12 years of age and older that police involvement is often necessary and appropriate but I am thinking more in terms of children younger than 12. Your responses would be greatly appreciated.

Mike McKenna

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In response to inquiries about restraints, their appropriateness in client homes, and the practice of teaching parents proper restraint technique: When all else has failed, and safety is an issue, of course manual restraint is an option for a child and youth care worker. Most of the parents of these troubled children are looking for help in managing their child's behavior. A physical management that is done when needed, and in a caring and responsible way, can be very helpful. Of course, in terms of policy, I would be sure that this type of intervention complies with the expectations of the contracting entity. Many expect this, and others frown upon it.
 
As for teaching parents how to use restraint, I would be very cautious about this. When you put yourself out there as an 'instructor' of a physical intervention you invite all sorts of negative liability. If a parent, or anyone else for that matter, harms someone and then claims that they were merely doing what you taught them to do, you will have legal problems. Again, I would discuss this with the contracting entity. Perhaps they want the parent(s) to have the training, and I could see this in some cases. If so, they should be willing to pay a certified trainer to conduct this training. (See I would not, however, provide this training myself if I were you).

Jeff Glass
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I agree with Jeff's comments in which he advises caution in training others, in this case parents, some of the methods and techniques involved in physical intervention. The liability is extensive. Pennsylvania has just revised its child care regulations to reflect the concern regarding physical restraint techniques and the necessity of training. We will soon see this all across the U.S. There is pending legislation before Congress regarding the use of such techniques, principally because of public concern over deaths of persons in care while they were being restrained. The primary factor in many of these cases was incorrect and dangerous interventions by staff, especially at a time when the staff did not have control of themselves and reacted rather than pro-acted. In addition to JKM Training (SPMCI), I would also like to refer people to PART-2000 (Professional Assault Training-2000).

Nick Smiar
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Jeff, thanks for your comments. I guess I did not add enough information to my original query. I agree that if parents were trained it would only be by a "qualified" trainer not just someone familiar with the use of restraints. This training would also include all of the pro-active interventions and definitely restraints would be stressed as a last resort due to safety concerns.
 
Mike McKenna
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Are there any courses around that focus 99.99% of the course on non-violent alternatives to restraint procedures?

Besides the danger involved in restraint procedures (to the person being restrained and to the restrainers), use of restraint gives everyone a bunch of unethical messages, such as this is how we deal with power imbalances in society, violence is ok, you do what I say and not what I do, older people force younger people, etc, etc.

Restraint is also hugely ineffective (except in the short-term suppression of whatever behaviour it was that happened immediately before the restraint). In fact there is a great deal of evidence that restraint simply perpetuates cycles of violence. For many people, the physical contact involved in restraint is highly reinforcing. Many people learn to escalate until they are restrained (I feel upset, I will blow up, someone will intervene physically, I will feel relaxed and comforted). Chains of habitual behaviours are easily learned. Instead of learning to avoid restraint, the person actually learns to engage in a pattern of violence that ends in release from restraint (the behaviour that occurs immediately before the release is most heavily strengthened, but the entire chain of behaviours leading up to that behaviour is also strengthened).

People will model whatever other high status people do. Everyone watching you as you restrain is learning that it is OK to restrain others as a way of solving problems. Everyone will learn that it is OK to assault the person being restrained. When you are not around that person is highly likely to be assaulted (harrassed) by his/her peers with both words, actions, and attempts to set that person up to blow again. People cannot learn much when they are highly emotional. Restraint procedures (no matter how calmly done) induce high, high levels of arousal and so they interfere with learning. The self talk that goes along with restraint includes messages like "I blew it again, I always blow it, I can't control myself, Others must control me, I got caught again, I better not act that way when THEY (the restrainers are around) . . ."

It is difficult to build a sensitive, caring relationship with anyone who you are assaulting (except a very warped, abusive type of relationship) - the person being restrained is highly likely to use restraint to control others (e.g. lovers, spouses) in the heat of the moment. By restraining someone you are putting them at high risk for eventually being charged for restraining (assaulting) others. Restraining people crosses their boundaries and puts them at high risk for being assaulted (and accepting being assaulted) in less structured situations including sexual assault (in other words, restraint can be viewed as a form of 'grooming', 'life preparation' for learning not to resist). Restraint cuts off communication (interestingly restraint is most often used when communication has been cut off - Deaf people get restrained A LOT by hearing people who can't sign or can't sign well).

There is a book by John McGee called Gentle Teaching that goes through these issues and the ethics of restraint in relation to treatment of people with disabilities in institutional settings. I feel (obviously strongly) that these same issues apply to work with teenagers and all beings. I know that many teenagers have learned to be extremely dangerous as a way of controlling their surroundings, feeling good about themselves, comforting themselves, relating to others. I know that staff have to be prepared to keep the environment safe for everyone else and to respond to emergencies with skill.

At the same time, I am very concerned about the normalization of and 'certification' of restraint procedures as part of the skill set of what youth and child care workers do. I hope that child care training programs are spending A LOT of time questioning the use of restraints, learning about the history of use of restraints, looking at long-term effects of restraints, talking to teens who have spent lots of time in restraint, and then discussing alternatives to restraint, prevention of restraint, and debriefing/reporting procedures following any use of restraint with the goal of NOT resorting to restraint in the future.

A colleague of mine used to justify his use of restraint with the phrase "Anger is a therapeutic technique." If you find yourself arguing with this post, I hope you look closely at your rationalizations and justifications for assaulting people we are hired to look after, look out for, and re-educate about human relations.

Linda Hill
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Linda - I agree that restraint can very often be misapplied ... wrong reason, wrong time, wrong person, etc. The place of restraint in a therapeutic program depends on the core values which are stressed and then lived out. If it is vitally important that everyone be treated with dignity and that safety within the environment be always present, then restraint, as a technique, should be taught within that context. When emergency interventive procedures are taught, they should be taught within a context of problem-solving and pro-active teaching and modeling. The teaching should begin with a consideration of our purpose in even being there (and our agency's purposes in regard to the residents) and then proceed to a deep understanding of what professional and professionalism mean.
 
The hallmark of the professional is the ability to maintain balance, focus, and self-control in a volatile situation. As professionals, we should develop the habit of preparing ourselves to enter the workplace and the skills of identifying what is happening around us. Interventions should be geared to the event in front of us and to our primary goals of dignity and safety through problem solving. The primary questions should be: "Is the behavior dangerous?" Our problem solving skills will guide us through the series of answers.

I have found that the goals of the person in the midst of the event are the primary shapers of the behaviors of staff and residents at this critical point. If the goal is control, then the methods will be applied without regard for all of the elements which you mentioned in your e-mail. If the goal is that everyone will be safe, then the decisions and the methods will clearly emphasize SELF-control, pro-active problem solving, and safety.
 
I have been shocked at times, during training, to see and hear people making decisions that clearly are based on retribution, physical control, and revenge for an ego wound. The basic problem is often that the staff member has crossed a boundary, has established a second role (controller, avenger, "super hero," etc.) and abandoned or relegated to the background the necessary role of professional.
 
Much of the emphasis on requirements for training in physical intervention and restraint are coming from liability concerns and from reactions to horrible situations where someone has been seriously injured or even killed. This explains the emphasis on restraint and the lack of emphasis on the effectiveness of training in other, more immediately effective teaching and modeling methods.

Physical restraint should be an extremely rare occurrence in a residential facility, and when it does occur, it should be very clear to both residents and staff exactly what has happened and why this method is being employed ... and that intervention should be only so long as to maintain safety. The restraint should not be in isolation from other prior methods, nor should it be considered an ordinary intervention.

Let me re-iterate: I agree that methods other than restraint are more likely to produce the kind of behavioral change and emotional healing we seek with our residents. Restraint, when it does occur, should produce a sense of safety in the environment and a sense of predictability.

I have lots more to say about this topic, but I will defer to the discussion thread now.

Nick Smiar
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Dear Linda:

 Your comments regarding the use of restraint techniques take me aback as I consider myself to be very professional in how I practice and in the interventions I choose to use. As a child and youth care worker for over 9 years and as an instructor of non-violent physical intervention for over 6 years I take exception to some of your comments.
 
I don't believe that my decision to hold a client has anything to do with a power imbalance. I physically intervene if a child is going to hurt themselves, someone else or in the event that may do property damage, e.g. break a window which might result in an injury to themselves or someone else.
 
When I teach crisis intervention I spend more time on how to be pro-active or intervene successfully before having to touch a client. BUT if that client has reached the point where they have stopped thinking rationally and they act out, I may feel it is necessary to physically intervene. Your suggestion that child and youth care workers are assaulting clients and teaching them to assault others is overly generalized and insulting. Physical intervention is without a doubt the most intrusive intervention but what would you do if a client is assaulting another client or a staff? I agree that during a physical intervention learning does not take place. BUT it is the responsibility of the worker to get together with this client to process the incident afterwards. Whether the staff uses CPI's COPING model or the Life Space Interview doesn't matter. It's the processing afterwards that creates the opportunity for learning and this is where I consistently see staff not making the time to process with the client. It has been my own experience that processing an incident with a client has actually allowed me to develop a stronger caring relationship with many clients. The kids know that they have lost control and for an adult to help them regain control and give them back their dignity is important. Many of the kids I've worked with are used to being beaten and hurt when they act out, so for me to intervene without hurting them and without judging them makes a major difference.
 
You are right that some clients will intentionally escalate a crisis in order to be held by staff. It's important for staff to process each incident with their team members. It's during these discussions that staff should assess the client's needs. In my work with youth who are emotionally disturbed the team may decide that some clients will not be restrained. In some cases clients have been sexually abused and restraint may elicit memories. In other instances restraints may stimulate the client. I would appreciate hearing more from you about the evidence that restraints perpetuate the cycle of violence and I will check out the book you referred to in your e-mail.

Gord White
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Linda,
I am pleased to read your very strongly held opinions on restraint and how it interferes with our goals. We often do things that are the opposite of our stated intentions. I don't want to get into specifics or the ongoing debate about "that's all well and good, but what do you do when..." I do know that programs and people who don't consider restraint a legitimate response are more successful in being creative about handling behavior and don't have the amount of aggression problems that others do.

Jack Phelan
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My students recently inquired why physical restraint training was not part of the curriculum in the 2 year Child and Youth Care diploma program. My reply to them was as follows:

I firmly believe almost all physical restraint situations with youth can be avoided through effective child and youth care practice. If you as a child and youth care counsellor have formed a relationship with the youth/child and provided them with a sense of belonging, then rarely are you in a position where things have escalated to the point that the youth is endangering themselves or others. That relationship allows you as the counsellor to know the young person intimately enough to recognize early signs of a young person’s growing frustration and changes in behaviour. Intervening at that prior stage generally proves to be more effective in the long run. Recognizing and dealing with those early warning signs requires effective child and youth care skills of counselling, listening, and being there with the youth.
 
Too often I have seen people receive restraint training and then almost create a situation (goad or box the young person into a corner) where the young person is threatened and feels he/she has no other option than to respond in a physically violent manner.

I am not naive enough to believe that all restraints are avoidable as there are some young people in such a state that they are endangering themselves or others that they do require restraint.

I encourage students to look at restraint carefully as a last resort only and to concentrate on developing the skill that best enables them to enter in a relationship with youth to provide them with a sense of belonging. Restraint training can be taken at a workshop if they feel they really need it.

Varley Weisman
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The debate over physical restraint, seclusion, and the use of medications to control behavior has been raging for the past several years here in Texas. The lines are drawn and everyone seems to have chosen a side. There are two basic positions:

(1) Using physical or medical means to control youth is wrong and professionals in this field should not do it. If the young people admitted to the program are so violent that they are dangerous, then either call the police or have them removed from the program. Training staff in physical restraint techniques and/or establishing policies for seclusion or PRN medication will simply increase the frequency with which these methods of controlling behavior are employed without making anyone safer. In fact, the way to keep everyone safe is to outlaw or severely restrict the use of any physical or medical interventions. Then, freed from issues of physical control, professionals can reach the youth with respect and caring attitudes and the youth can gain a new sense of their own worth.

(2) The youth who need help in our society are sometimes violent and dangerous, especially in the early stages of care and treatment. While simply refusing to accept more difficult youth, having them arrested and placed in the juvenile justice system when they are violent, or removing them from the program may work for many programs, there must be programs that are willing to step up and provide care and treatment for these youth. As part of an overall care plan, the professional caregivers must be well trained in how to safely contain violent behavior and they must use physical restraint, seclusion, or PRN medications when all else fails. Prisons are not the solutions for all of society's problems with its youth. Over time, in a good program, the youth learn to deal with problems in less violent and destructive ways, the number of physical interventions decline, and the youth are returned home rather than to the juvenile justice system.

The people on each side of this debate hold their views strongly and these days there is little room for compromise or even understanding across the lines that have been drawn. Here, the State of Texas is working on new regulations on restraint and seclusion that are in their third major rewrite. Federal legislation on restraint and seclusion is winding its way through the U.S. Congress.

From 30 years in this field, working in a variety of settings, I have concluded that most direct-care youth workers are poorly trained and poorly paid. They generally do a good job under very difficult circumstances with youth that are increasingly more challenging and violent. No one believes that there are enough resources to recruit or train youth workers adequately, so the solution for most problems is to avoid the problem by passing more regulations that affect the youth workers' ability to do a caring and effective job with the kids who really need help.

There are too many unnecessary restraints, seclusions, and PRN medication usages. The real solutions, however, involve more training, better salaries, and professionalization of the people who care for the youth. Locking more kids up in jail will not solve this problem and closing the few programs that can competently care for and treat the most difficult youth will not solve the problem. Too many careless words proposing simple solutions will only make it worse.

David Thomas
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Dear Nick and Gord,
Thank you both for your thoughtful replies to my strongly worded cautions against the use of restraint by child and youth workers.

1. Nick said: "The place of restraint in a therapeutic program depends on the core values which are stressed and then lived out." So this means that clarification of organizational values and employees roles in carrying out those values must be an integral part of restraint training programs and must precede the 'how to restrain' teachings. Nick, my guess is that when values clarification is part of a training program, then restraint would be used much less often than when it is simply taught as a technique. Is that correct?
Nick said: "Much of the emphasis on requirements for training in physical intervention and restraint are coming from liability concerns and from reactions to horrible situations where someone has been seriously injured or even killed." Many children and other vulnerable individuals have been seriously injured or killed by use of physical restraints. Dave Reynolds of Advocates for Full Community Inclusion is keeping thorough records of cases in which injuries and deaths have occurred. You can email him and arrange to subscribe to his regular newsletter.

2. Nick also said: The primary questions should be: "Is the behavior dangerous?" Our problem solving skills will guide us through the series of answers. If the goal is that everyone will be safe, then the decisions and the methods will clearly emphasize SELF-control, pro-active problem solving, and safety. Physical restraint should be an extremely rare occurrence in a residential facility."
 
This says to me that child care workers should be viewing restraint as an emergency procedure that they are VERY unlikely to use and that will be followed up by a thorough investigation if it is used. Learning to restrain should be parallel to knowing how to respond to a fire. We get the training, do all we can do to prevent a fire from occuring, and 99.9% of us go through our careers without actually responding to the fire. The 0.1% of us who do have to respond to a fire also have to participate in extensive follow up investigations: what was the cause of the fire, what could have been done to prevent it, who did what when, and what is the plan for preventing future fires. If I was involved in responding to a fire more than 2 or 3 times, my competence as a safe child care worker would be thoroughly questioned. Perhaps I am doing something to CAUSE those fires????? My job would be on the line. We should be asking the same questions about specific organizations or specific staff members within organizations who are using restraint frequently. For example, what is that organization or that staff person doing to contribute to the restraining of children and youths in their care?

Nick thanks for the work you are doing, and the writing you are doing to help people think deeply about boundaries, respect, dignity, and safety.

Gord said: "I don't belieive that my decision to hold a client has anything to do with a power imbalance." Gord, your very ability to hold a client means that there is a physical power imbalance. Recognizing and dealing with the existence of power imbalances between professionals and clients is essential to preventing abuse of our power.
 
Gord said: "Your suggestion that child and youth care workers are assaulting clients and teaching them to assault others is overly generalized and insulting." I use the word 'assault' deliberately. After reading John McGee, I began to use the word 'assault' to describe what I had previously called 'restraint' so that I remain profoundly aware that any time anyone is touched against their will, they are being assaulted. Perhaps a person who is being dangerous needs to be assaulted in order to protect oneself or others. Calling the intervention ‘assault’ instead of 'non-violent restraint' keeps me from justifying what I am doing as anything other than taking extreme action in an emergency. Physical restraint - even non-violent crisis intervention - is a highly intrusive procedure used by people in authority. Restraint is meant to be aversive (as you said - if the person seems stimulated by the restraint you would be less likely to use it). The behaviour of people in authority is highly likely to be modelled, especially if that person is a positive reinforcer for those he/she is responsible for. This means that if a person who is restraining a child or youth has a positive relationship with that individual or with other children and youth who are watching, then those children and youths are MORE likely to use restraint on others than if he/she has a poor relationship with those kids and is not respected by them. If you are a well-liked, highly respected child care worker and you use restraint, your use of restraint WILL be imitated (as everything you do will also be imitated). This is a basic principle of how we learn. The literature on modelling (Bandura and his students), and on reciprocal interaction (Patterson et al from Oregon) shows how cycles of any kind are perpetuated (positive reciprocity and negative reciprocity).

Thanks again for responding deeply to these ethical, value-based questions about how we interact with children and young people and each other.

Linda D. Hill
...

Nick and Gord have made some wonderful points that all true, caring, Child Care Professionals should attend too. Unfortunately, Linda, at the end of her remarks, stated flatly that arguing with any of her points confirms her point of view. This is a common type of 'logic' that I encounter from the kids I work with each day. I never expected to find it on CYC-NET...oh, well. Some obviously found Linda's comments to be insulting. I have encountered them before and am simply amused. I have worked with many people over the past 20 years in field child and youth care. Several have come off with the attitude that Linda has. I have been called a Neanderthal, a beast, a Nazi, etc. for insisting on teaching and performing responsible restraint techniques. What is amusing about it is that it is these same people who are first on the phone screaming for a 'Neanderthal' to come bail them out as soon as one of the kids gets in their face and starts to threaten them!

For example, a few years ago the school hired a new teacher for the SED classroom across the hall from me. The new teacher came in and immediately alienated everyone by announcing that there would be no need for assistance or restraint in her classroom. That such silly things are outdated and brutish. We all said fine and good luck and went about our jobs. Early the first afternoon I heard someone across the hall blowing a whistle frantically. When I investigated I found a crying teacher and a dozen students running wildly around the classroom. It was like something out of a cartoon! I calmed the class and had everyone get back to their seats (without touching anyone), then I tried to calm the teacher. She said to me, "this isn't supposed to be happening; I just got my Master's Degree and they should listen to me! I told them that when I blow my whistle they should stop doing whatever they are doing."
 
I explained that the kids really don't care what kind of degree you have, if they think that they can take over the classroom they will. Unfortunately, I found myself in the classroom calming these students each of the next several days until that teacher finally resigned. I find it to be unfortunate that people like this who have wonderful potential often come into the field with their own agendas. They have set ideas that often do not conform with the expectations of the program or the field in general. More often than not we end up losing these people to other fields.
 
The simple facts are that restraint techniques, if taught and applied in a caring and appropriate manner, are an effective tool for the Child and Youth Care Professional. But, they are just that ... a tool. If they are seen as more than that, there is a problem. If they are seen as less than that, there is a problem as well. A carpenter must know how and when to use a saw, how to cut to precise angles, and when it is correct to use another tool. If he does not know how to use a saw, he is not much of a carpenter. The very same is true for a child and youth care professional; understand your tools and use them correctly in the correct circumstances. But, to deny that a carpenter will ever have to use a saw is a denial of plain reality. Reality dictates that disturbed individuals who come from highly dysfunctional environments will occasionally resort to violence to 'resolve' problems. One of the goals of treatment is the replacing of this mind set with more appropriate means of solving problems and resolving conflict. However, until this goal is met or approximated the professional staff must be able and competent at maintaining the safety of the program for everyone. At times this may require the use of proper restraining techniques. Everyone has rights. Staff, clients, acting-out clients, the community, etc. have the right to not be injured by someone who has temporarily lost physical control. We must act in a way that takes into account the rights of everyone, not just the individual who has lost control.

Jeff Glass
...

Jeff, quite rightly, pointed out the following: "Unfortunately, Linda, at the end of her remarks, stated flatly that arguing with any of her points confirms her point of view. . . Some obviously found Linda's comments to be insulting . . ."

Yes, Jeff, re-reading my first post, I see that my words were an out-and-out attack against the use of restraint that cornered people rather than opening things up for back and forth dialogue that might lead to mutual learning. I apologize for my ill-choice of words that insulted my colleagues instead of deepening our reflections on this list about these very difficult ethical issues.
 
Thanks for being amused rather than insulted and telling a good story to make your point about the differences between ivory tower idealism and front line reality. I'll tell two quick stories to help you understand my front line reality a little.
 
1. Because of experiences supporting a family member, I have become involved in the psychiatric survivor movement. We are fighting a social justice struggle against abuses in psychiatric facilities that include use of chemical, physical, and electrical restraints, and solitary confinement procedures. (Pushing for mandatory training in non-violent crisis intervention is one of the actions we are taking in our efforts to decrease abuse of patients by staff).

2. Another part of my reality is many years of working closely with a number of adults who were victims of years of on-going abuse at Jericho Hill School for the Deaf in BC. I think my history with former Jericho students is one reason I was triggered during the recent discussions about restraint training. The abuse was covered up for many years. Like survivors of a war, the former students all have varying degrees of severe post trauma stress reaction related to the violence they endured. Common memories of the violence includes being physically restrained by staff for complaining about abuse or for becoming upset and losing control in reaction to abuse. The staff-to-student and student-to-student violence was extensive (harrassment, physical assaults, rapes etc). One of the many investigations into the tragedies noted that the only training the child care workers (most not professionally trained) in that facility ever requested was training in physical restraint. In a context where a culture of violence had developed, physical restraint seems to have only served to silence the children more effectively. (Now, almost a decade later, we see huge positive changes at the new residence for Deaf students in BC. The supervision of staff appears to be excellent and the staff who have been hired have extensive professional training followed by on-going in-service training in communication, respectful interactions, relationship building, and activity-based programming).

You showed me the central issue when you said that: "Reality dictates that disturbed individuals who come from highly dysfunctional environments will occasionally resort to violence to 'resolve' problems. One of the goals of treatment is the replacing of this mind set with more appropriate means of solving problems and resolving conflict. However, until this goal is met or approximated the professional staff must be able and competent at maintaining the safety of the program for everyone.

I should not generalize from my experiences with abusive institutions where restraint was normalized and became part of daily life, to tar and feather all settings. It seems that we all agree that the only appropriate use of restraint is to maintain safety. These crises should be rare in respectful settings with well-trained, professional staff who have many other tools that they use 99.9% of the time to teach peaceful life skills. Perhaps a more constructive direction would be to explore:

a) the various tools child care workers and other professionals who work with children and youth need if we are to be able and competent at maintaining safety. In addition to physical restraint used as an emergency intervention, what other kinds of training is being emphasized and seems to be effective?
b) what precautions and additional training do child care workers and other professionals need so that we do not use restraint or any of our other tools as weapons. Nick talked about values clarification. Gord talked about debriefing. What other checks and balances are there?

I will go to the back copies of CYC-ONLINE and carefully read Nick's article in the focus on violence section. I am sure some of the answers I am looking for are there. In addition, I will continue to explore peaceful ways of replacing violent "mind sets" that exist in some institutions with peaceful means of solving problems and resolving conflict. I am proud to be part of the noble and mostly joyous profession of Child Care. My training and experience as a child care worker has been a major life preparation for learning to stand up against institutional and societal violence.

Linda Hill
...

Linda, et al,

I thank you for the clarification of your remarks and background. Your stories and information were very helpful to me. In fact, I believe that we are all not very far apart on these issues. Only dialog will eventually lead us to a common understanding. However, there is a division, currently, among us on this issue. As some have pointed out here, if we do not resolve it others will.

In my opinion, having government resolve this issue for us is not something that we should applaud, as some here have. To me, government intervention usually results in more confusion and lower quality of results. It is our problem, we should provide the clarifications. Since my posts on this subject I have gotten e-mail both supporting and refuting my comments. I expected that and welcome it. We should continue the debate. However, I find it very hard to understand individuals who want to deny that young people can be violent. In addition, there are those who would deny these kids services and recommend calling police, excluding them from programs, etc. In contrast, I will spend all of the time that is needed, struggle day in and day out, before I call in the police or exclude a child from services. Who is better qualified and able to handle a young person is crisis? Me and my staff or the police? The answer is obvious.

When a violent or potentially violent young person leaves my care they do not stop hurting, needing or existing! It may make our lives easier to exclude children from our programs, but it merely passes a problem on to someone else. Then, we can post on this board that restraint is not needed at our facility. Of course restraint isn’t needed when you send young people away who present you with this sort of challenge. Where do these folks end up? Often times it is with me! So, what am I to do when sixteen-year-old Jimmy decides that he will to punch fifteen-year-old Tim? Call the police? Let him do it? I really think that some out there believe that I would advocate to use restraint as a 'first option' or something. We teach that this tool is only to be used as a last resort. Nobody looks forward to using this essential tool. However, I will use it when needed and I will not reject a child or youth because I was forced to use it. That, in my view, would be truly irresponsible.

Jeff
...

I support the strong message of using restraint as a last resort. Keep it very deep and hard to find in the tool box. I am not sure I support not teaching elements of it to students as described in Varley Weisman's response.(Hi Varley.)

I see the job of pre-employment education of professionals as being responsible for providing the basics from which experience in the work place will build on. Is it fair to have students believe that although they are going to be working in potentially volatile situations it is not necessary to know some basic self-preservation and/or restraint techniques? If a restraint situation arises it leaves the untrained student no option but to handle it the best way they know how which may not be safe for the child or the student.
As a last resort option restraints might be compared to a Police Officer's use of a side arm. Although most will never use it at work and are trained to work through situations without using that level of force, they don't hand it to them when they show up for work just in case they might need it. They are trained to use it responsibly under the most difficult circumstances. Child Care Workers should know about restraints long before they may have to be involved in one. If trained properly they won't choose to use it just because they know how.

Relationship building, avoiding power struggles and de-escalation training should be at the top of the tool box for dealing with difficult situations but restraint techniques should be in there somewhere.

Tim Cooper
...

Response to Tim ...
Just a quick point of clarification Tim. I agree that child and youth workers need training in how to effectively do a restraint. When workshops are available, I do inform the students of the learning opportunity. I still believe however that emphasis and focus of training should be on the development of skills and strategies that optimally prevent situations and interactions with youth that culminate in restraint.

Varley
...

This debate about restraint, for me, focuses on several of the central issues for youthwork. The issues of power, perception and practice vary widely within our field and point to divisions amongst us that create quite different environments for youth.

Jeff's comments, however, reflect a world quite different from my experience and I would like to propose that there is a "reality" different from his that is not simply "amusing." I have also spent most of my life in youth services and in all those years have never had to restrain a child. I have worked in psych wards, jails, foster care, emergency shelters, group homes etc. I would like to say that such an experience is due to my extraordinary skill as a youthworker :) but that seems a bit unlikely.

What I have noticed is that the need for restraint seems to be directly correlated with the beliefs the staff and the program hold about young people, the corresponding predictions about their behavior, the level of disciplinarity built into the program and resultant power relations between staff and youth.

The question then is not, what do you do "when," but how do you structure a program in a way that "when" does not happen. My experience would indicate that such a program structure would be one in which power relations between adults and young people are taken seriously and in which there is true partnership (a rather tricky proposition, since of us as adults have essentially no experience in institutional partnership or actual democratic structures).

In his post Jeff stated that, "to deny that a carpenter will ever have to use a saw is a denial of plain reality." It is only the western carpenter who uses a saw. Carpenters and other builders in other parts of the world or from other cultures have not found a need to develop saws. There are many "plain realities" some of which include the use of disciplinary force; some of which (equally effectively) use radically restructuring of the relationship between young people and adults in ways that significantly reduce or eliminate acts of violence within their program.

One last point: it has been my experience that seeing your view as reality and having that reality be comprised of your ability to see others clearly is one recipe for building programs in which the "other" will find it necessary to resist you. The young people I work with are not disturbed or disturbing individuals, nor are the environments from which they come "dysfunctional." They are simply people like me, who are having a bad go. And like me, if treated on their own terms and dealt with equitably will overcome their current circumstance and go on to something else. It is not the young person who is the determinate factor in precipitating violence which necessitates restraint - it is the disciplinary structures of the program and the inherent inequities and power differentials that require resistance.

Hans Skott-Myhre
...

Hans is helping to prove my point. Hans says that "The young people I work with are not disturbed or disturbing individuals, nor are the environments from which they come ‘dysfunctional.’ They are simply people like me, who are having a bad go. And like me, if treated on their own terms and dealt with equitably will overcome their current circumstance and go on to something else."

That's very respectful. What emphasis do you place on their ecological environments?

He says: "It is not the young person who is the determinate factor in precipitating violence which necessitates restraint - it is the disciplinary structures of the program and the inherent inequities and power differentials that require resistance."

That's very outside of the box, I like it. What role does the young person play? Simply as reactor? Passive, active, both, or neither?

Tracey Young
...

Tracey: Just a point of clarification:

 I am not proposing restraint as a last resort or any kind of "resort"; nor am I proposing that relationship, acceptance, and genuine warmth, affection and care are sufficient to prevent violence.

I am proposing that those programs that seriously investigate issues of power and privilege between youth and staff (and I'm not talking about the specifics of power struggle, but rather the dynamics of youth/adult relational and structural inequities) will have considerable less reason for worry about violence.
 
In my view, violence is the articulation of either brutal privilege and power - or rank disenfranchisement and oppression. With youth in care I would propose it is the latter and that it is the models of "care" themselves which prompt such responses. The fact that violence is available to youth as a result of their history is a separate issue from the impetus to use it within a particular context.
 
If we are finding restraint necessary in our work then it is to that work that we should return for the solution. The need for restraint does not reside in the youth or families we serve but in our own power practices and privileged positions.

Hans Skott-Myhre
...

I truly appreciate the comments that are flowing in on this issue. Perhaps some in the "pantheon of muckity-mucks" in this field should consider putting together a symposium or major conference on the issue. A well-balanced program that fully incorporates the entire range of ideas on the subject would be well received. We can all write about it here until we are 'blue in the fingers' without coming to much of an understanding. As I've stated before (and Dave from Texas said very well indeed), if WE do not do something, then someone who has no clue (government) will. The issue of whether or not to train child and youth care staff in the proper use of physical management has been a warm one on this board. I guess 'my reality' has now been fine tuned to include that some have the option to train it or not. In Pennsylvania we have been required to train all staff in 'passive restraint' since the introduction of the 6000 regulations in the 1970's. This encompasses all of my years in the child care field.

As for the theory that physical management training creates restraints, there is simply no evidence to this effect. I have seen studies which have stated this, and I have also seen those that show no relationship between the two factors at all. In our agency we maintain close records of all holdings, and perform yearly statistical work-ups from the data. We have never seen a significant increase in holdings following our annual 12 hour physical management workshops or any other training on the subject. But, here again I think that the nature of the training is very important. The more you train staff the better they feel about whatever skill you are trying to convey.

Our staff are usually very confident about their ability to handle nearly any violent situation. This confidence, and lack of fear, can also go a long way in reducing the number of restraints. Like it or not, many needed restraints go undone due to fear. The same is true of many of the unnecessary restraints; staff are afraid and react out of that fear. Fear is a major factor in most physical situations and must be addressed in training. I'm sure that some of you gasped at the fact that I do 12 hour annual physical management workshops. Well, I also do two 2 hour refreshers at four month intervals throughout the year. In total, we spend about 18 hours each year working with staff on their physical management skills. We also spend 18-20 hours each year teaching the other skills that staff need to avoid physical situations with youth. Since we began this training pattern in 1995 we have realized a 29% decrease in the average number of holdings we experience each year. In that same time period the youth that we serve have been generally more disturbed. We have seen a higher number of referrals to the agency of young people with histories of violent behaviors. You see, teaching staff important skills does not make them worse at their jobs. Giving staff confidence and the tools to do their jobs well, no matter the circumstances, makes them and your program more effective overall. Quality training, lots of time to practice, training that allows staff to talk about their fears and concerns, well stated and intentioned expectations for staff, and effective supervision are the key elements in physical management and any other skill in child and youth care.

Jeff
...

Interesting discussion thread! A few comments on messages in this thread:

* There is nothing inherently wrong with the use of brief physical restraint as an emergency interventive method, when the situation warrants it, that is, when there is imminent, foreseeable risk of harm to self or others and when other methods do not seem to be sufficient to ensure safety. And, as Jeff says, we SHOULD train child and youth care workers...but we should train them well [high quality of instruction which is competency-based and requires demonstration of knowledge and skills] AND supervise them on a regular basis AND provide ongoing and high quality training and "refreshers" AND ensure that the agency's philosophy and procedures reflect a positive and therapeutic stance in regard to physical intervention. safety, and dignity.
 
* The analogy Jeff used regarding the police officer's gun and the training to use that gun as a last resort does limp just a bit. We must be careful NOT to train staff that it is NECESSARY to go through all of the other interventions BEFORE using a physical restraint. What is necessary is to ask the question "Is the behavior dangerous?" and the critical questions which follow that: "If dangerous, how immediate is the danger?" "Will words be sufficient?" "Can I or others evade the danger?" "If the danger is still present and escalating, is a brief physical intervention necessary NOW?" "If it is necessary, do we have enough trained personnel to do the physical intervention safely?" In other words, we must train ourselves to (1) maintain or regain self-control so that we can think clearly and (2) engage in critical thinking and problem solving in a rapid response time.

 * I disagree with the statement that any time we lay hands on another person that is assault. It is accurate to say that any time we prevent a person from what she or he wishes to do, when what she or he wishes to do is not dangerous to self or others, we are violating that person's civil rights. [This is true in the context of American constitution and law). However, when we do stop a person by laying on hands and we are doing it in our capacity as caregivers, we are still violating the civil rights of that person, and we must have sufficient reason, a reason which could be demonstrated to a court...the best reasons are danger to self or others and least restrictive intervention. Assault is a different matter. Assault occurs when there is imminent danger, that is, there is a real, believable, "do-able" threat, the person seems to have the intent of doing injury, and the danger is close or imminent. Note the distinction between assault and assault and battery. Assault occurs in words; assault and battery occurs in words and actions. In terms of the response to assaultive behavior, we must train ourselves to take dangerous and threatening words seriously, determine if there is real danger present, and select an intervention that keeps EVERYONE safe. That intervention might be a brief restraint.

* In my training experiences, I have noted how critical it is to pay attention to the goal(s) we set in a physical intervention. If the goal is to limit the person's ability to do harm while keeping everyone safe, then the likelihood of a successful intervention increases dramatically. The trouble occurs when the goal is absolutely to immobilize the person or, worse yet, to "pay him/her back," that is, retribution. This is the point at which true professionalism can be seen in the professional's self-control, focus, and decision-making based on the client's best interests and the therapeutic goals for the person and the program.

Nick Smiar
...

I want to add a footnote to my last rambling message.
When I was defining assault as words and then commented about physical restraint, I did not mean to imply that an appropriate response to verbal threat (simple assault) is a physical intervention. We learn to match our response to the danger presented. If the danger is in words, the appropriate and defensible response is words (de-escalation, "ego loan," whatever you wish to call a verbal intervention which is non-threatening, therapeutic, and non-inflammatory). If the threat or danger is physical harm (assault and battery), then the response is evasion (moving out of harm's way; in British law and common law - the "duty to withdraw"). If the threat or danger is aggravated assault and battery, in which serious injury is about to occur, then a brief manual restraint MAY be warranted.

These physical interventions are emergency responses to emergency situations, not a regular part of a treatment plan. Training in physical intervention should be as a back-up for the regular treatment plan, when that plan fails and a back-up is needed.
 
I recommend some reading from Fritz Redl's When We Deal With Children, regarding physical restraint. Fritz always had such a level head about issues like this.

Nick Smiar
...

Nick, I agree with your statements regarding physical management.

One quick note: the analogy of 'restraints as a gun' were not mine. Frankly, I think that the comparison is much too severe and inflammatory in nature. Due to that, it does not 'limp' but is purely lame. A gun, for a policeman, is to be used as a 'last resort'...true. However, the implications of lethal force simply do not apply.

Now, of course, we will get back that there have been people who have died while being restrained. This is true and most unfortunate. However, I have examined many of these situations through the literature, papers, etc. In nearly all of the cases there has been a severe problem with the staff intervention or agency norms. These include lack of proper(or any!) training, use of outdated and dangerous holds, insufficient staff in the unit, lack of understanding by the staff of a client's serious health problem(s), lack of clear agency policy regarding restraints, and the like.

Certainly these cases point to the act of physical management as an area of grave concern. However, they also point to other things as well. Just how effective is the agency training program? How effective is the supervision? What techniques (if any) are being trained to staff? What are our policies? Are we staffing each unit with the bare minimum or the right number to best serve clients and keep everyone safe? Is there a follow up/review procedure involving supervisors after a restraint? Are we informing our staff about a client's special health concerns and medical histories? ALL of these things are essential for making sure that the physical management tool is properly used and not abused. I have trained physical in many agencies over the years. I have been shocked to find agencies with virtually no policy guidelines, no training, staff with no access to information about client health concerns, etc.

Any good examination of this issue must include these factors as well.

Jeff
...

I have been following with great interest the debate on physical intervention with violent children and youth. The issues have been nicely captured by many on this list and by some authors in this area.

-power and oppression as experienced by the youth
-power and control as desired by some workers
-fear of injury as experienced by the front-line practitioner (especially the new one)
-fear of litigation, death, injury, etc. as experienced by the government policy makers
-ignorance about how to de-escalate violent situations and/or predict-see the need for intervention
-an appalling lack of debate on the issues over a 25 or 30 year time span
- it seems to be easier to ignore it -lack of consistency in education and training for new practitioners regarding intervention in violent situations (including what the rights of the worker are in these situations and how employers should support those who have been attacked)
-an 'increasingly' violent society or culture in which we live.

I have educated and trained practitioners in this area, and have had my own share of situations where I have had to use restraint, because circumstances were such that de-escalation just wasn't possible. (What DO you do when everyone in the residence met the kid an hour ago, no-one else has a child and youth care background, and all his workers are outside picketing!)

I would have to support the call for further focused debate and add to that call the need for a comprehensive examination of the research in this area (published and unpublished - sounds like there is some great data out there).

Carol Stuart
...

Hans, I think one of, if not the, chief difficulty in discussing the issue of 'restraint' is that we all have our version of what it means to 'restrain'. My sense of this discussion is representatives from both extremes and every degree in between are expressing themselves (and hopefully learning from each other vs simply trying to justify our own narrow viewpoints).

Some folks may have 2 steps before restrain is the last resort others may have 25 steps before relenting to the tool of restraint. And what happens when you get there? Some may have a whole process where being restrained means you begin a process of slow reintegration back to regular program. Others would simply restrain to avoid further crisis, debrief, resolve, and get on with life. For particular programs restraint may mean locked up in some fashion, held by many or one person, used in a punishing manner or delivered as caringly as possible.

Until we understand each others' contexts some of the things we say become meaningless because we can only interpret from our own contextual knowledge base. {and of course we all know that our way is the 'right' way}.

Tim Cooper
...

Our child and youth care program in Edmonton had a good way of introducing students to restraint or the lack of use of it. Students are required to go through their two years of field placement without learning restraint techniques until the last semester. We were allowed to assist in restraints if required. This forces students to learn all of the other ways of behavioral management before learning to physically intervene. In a nut shell you learn to talk your way out of many interesting situations.

The other part of this I'd like to comment on is most of the focus is on the youth in this discussion. Lets not forget exactly how stressful it is on the staff that have to restrain a child. For some staff it is old hat, but I for one almost get physically sick after a restraint and I replay the situation in my mind for almost a week afterward not to mention the heaps of paperwork that you have to do after a intervention. The majority of the workers are in this field because we care what happens to these kids (definitely not for the money) and physical intervention is definitely our last resort, but part of the job that is there to keep us safe and our clients.

Neil Hosler
...

I have been following the debate regarding restraint with much interest. I have been "in the field" for seven years and worked with a wide variety of programs and individuals including adults with developmental disabilities and incarcerated youth. I have been trained in at least three versions of safe physical intervention techniques and all have emphasized training de-escalation techniques so that physically intervening is used as a last resort rather than as a control procedure. As a "control procedure," physical intervention is not always our best option as it can lead to further escalation and more potential for harm (both physically and emotionally, to staff and individual).
 
Depending on the program, simply putting your hand on someone to guide them or to interfere with the behavior (self-injurious behaviors, for example) is considered a restraint. For me, I try to be aware of what the consequence of my interfering will be: will this stop or halt the behavior or only make it worse? Is it really necessary or do I have other options? Am I turning this into a power struggle? If so, why do I want one?

Personally, I do not like to use physical restraints. I understand the philosophy behind them and recognize that there are times when they become necessary (individual is at risk to hurting self or others) but I also believe that there are other choices. I have been in situations where all my attempts at de-escalation have failed, have experienced working with individuals who "need" to be restrained either to meet psychological needs or because it is the only way they can let go of all their feelings, and been in situations where I feel that there may have been other options that I could not see at the time.
 
That said, Linda asked what other checks and balances exist. Every program I have worked in has required that the use of a physical intervention program be approved by a human rights committee (often made up of various agency staff, board members, families, other professionals who work with the individuals), that emergency use of a physical intervention be documented (your basic Antecedent-Behavior-Consequence that includes what else was tried, what you could have done differently, etc.) and sent out to all team members and reviewed by the human rights committee. Any intervention program must include options to physical restraint that are to be used first: taking a walk, going to a quiet place, listening to music, being given another choice, etc.

For those individuals that have physical interventions as part of their behavior programs, the use and procedure is very clearly stepped out. Often included are the clues to when the individual is starting to get agitated and what can be done to de-escalate them. When a physical intervention is used, the staff involved files a report. Again, your basic ABC. This report typically goes to the staff's supervisor, the individual's team members, and to the individual's file. This is a great learning tool - what was done, why, did it help? why or why not? For the staff involved, this is one step in the debriefing process.

Debriefing can also include team meetings where the incident is discussed and other staff can give alternatives or help identify where a staff or individual "lost it" and physical intervention was used. When there have been many physical interventions with one individual, other professionals and team members are often asked to look at what is happening. Is there a need for a medication change, staff retraining, change in the behavior program, are there areas where more freedoms and choices can be given to the individual so that they are not getting angry in the first place, etc.?

These are my experiences and thoughts, I hope it helps.

Cece Kudela
...

As a child and youth care student I have been avidly following the dialogue on restraint issues. A term was mentioned that I am unfamiliar with and would appreciate some clarification - "ego-loan" was mentioned. What does it mean? I wil be working with children/youth with varying 'special needs' for the summer and have no experience with restraint and have been told that it has occurred at this summer camp. Another problem I have is with the term 'special needs' it seems to be required , but is it respectful? Are not all children special and with individual needs? Any feedback for a green child and youth care worker?

Laurie Gow
...

Laurie - "Ego loan" is a term derived from psychoanalytic and ego psychology theory to refer to the loan of strengths to a person who has lost or suspended the use of those strengths, such as self-control, the ability to make critical judgments about behaviors and their consequences, and delay of gratification. Fritz Redl used the concept and the term in his works, especially When We Deal With Children, in the context of discussions about behavioral interventions. In regard to physical restraint, we are literally putting a boundary around the person's physical acting out, providing a temporary and emotionally neutral limit until the person regains her/his own control and functions. If we conceptualize this intervention in this way (rather than as an imposition of total control for the sake of total control or as a form of retribution or punishment), we are more likely to remain focused on the therapeutic goal, safety, and dignity.

Nick Smiar
...

Brian, I truly do wish that maturation of staff was a factor. However, I do not think that it is, or could be. During the same amount of time that I reported statistics on I experienced anywhere from 50% to 80% in annual staff turnover! Only with a static (or fairly so) staff could you include maturation as a variable over time. I have been able to hang on to a few staff who have been here/in the field for several years. These have largely been elevated to supervisory positions. The rest turnover at an alarming rate. I am situated in South Central (near Harrisburg) Pennsylvania, USA. The unemployment rate in this area is virtually 0%. There are many more jobs than there are people without jobs. It has been like this for many years. Due to this, the market for employees is a highly competitive one. I compete for staff with the state government, federal government, the military, the many huge corporations in the area, and all of the smaller "service" companies that continue to spring up out of the ground all around me. So, the child and youth care field, with it's paltry wages and rotten hours, suffers from very high turnover of staff. There are many variables that influence the number of restraints that an agency has. Many of them reflect directly to the overall health of an agency. For example, in 1993 this agency was experiencing a financial crisis. Unfortunately, we were forced to lay off several non-direct care staff people. This action sent shock waves through the entire agency and shook everyone to the very core. On the plus side, we came through that time much stronger, with a better management style, and a better focus on how to succeed as an agency. On the negative side, 1993 was a tough year for our clients. Restraints at the facility ballooned and rose over 50% during that year! Clearly, the stress that was being experienced throughout the agency flowed 'downhill' straight to the kids. We have been doing our own, private statistical workups of this data since 1990. So, 1993 always sticks out like a sore thumb in any review of the numbers. If you throw that year out, we showed a fairly steady restraint rate from 1990 through 1995. We began our 'new and improved' training schedule in 1995 and, from 1996 to present we have experienced the significant decrease in the number of restraints. Other factors, such as how the data is defined, also is significant. What one agency calls a restraint another may call an escort or nothing at all. I agree that studies must be done. However, I must warn you that agencies will not be a very open to sharing their numbers with people. This is true here. I can freely talk about the bottom line, but the specific numbers, reports, etc. are closed due to confidentiality and other concerns.

Jeff Glass
...

Thank you Nick, for the informative reply. It helped me to understand the concept of 'restraint' in a kinder manner! I think it is the word that brings up negative connotations for me.

Laurie Gow
...

Laurie, You're welcome. Thanks for the opportunity to discuss it.

The conceptual framework we have and use regarding physical interventions, especially physical restraint, has a great deal to do with the results. If we conceptualize the intervention as a reaction, or "punishment," or "retribution," or control - all with strong negative emotional and attitudinal undertones -, the result is neither therapeutic nor helpful.

I just finished a workshop on professionalism as an important factor in maintaining safety in volatile situations and environments. The professional takes responsibility for mood, attitude, and performance...and acts in the client's best interests first, before acting out of her or his own interests. It is the disciplined application of what we know, what we value, and what we can do in situations in which violence is a threat or an actuality which increases safety, ensures dignity, and manages risk best.

Nick Smiar
...

Hi Nick,  Thanks for your response. I like the part about disciplined action. I will be more aware of my interactions and the responsibilities that entail my work as a child and youth care worker. This tool (CYC-Net) has allowed me to continue my education even after classes are finished and the real stuff gets goin'.

Laurie
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