By Clelia Sigaud, M.S.
bSci21 Contributing Writer
It’s hard to forget restraining someone. The exposure to intense aggression or self injury, along with screaming, struggling, threats and entreaties, possible injuries, and the myriad other manifestations of crisis behavior that are common during such procedures are far removed from what most of us have ever experienced in our lives outside of the field of human services.
When I first began working in special education, I attended a number of trainings and workshops related to the field, the content of most of which I have long since forgotten. I still vividly recall, however, one particular phrase from a training on restraint and seclusion legislation, “restraint and seclusion are indicative of treatment plan failure.”
To me, this phrase elegantly encapsulates why restraint and seclusion have no place in our treatment interventions. When we resort to physical means to forcefully control a client’s interfering behavior, our treatment plan has failed. When our treatment plan fails, then we, as behavior change agents, have failed. We have failed. Every time a restraint or seclusion happens, that is a failure, and should be recognized as such.
This is not to say that I am categorically opposed to all use of physical force in managing interfering behaviors. Although they are not and should not be classified or thought of as treatment tools, restraint and seclusion may sometimes be necessary. In the case of high-risk behaviors that are, in the moment, unresponsive to our interventions, it can become our duty to re-establish safety by utilizing a restraint or seclusion procedure. I am, however, strongly in favor of a model that conceptualizes restraint and seclusion as exactly what they are – red flags indicating that something about our services is inadequate or ineffective. Just as an engineer would analyze the causal links between her design and a subsequent vehicle malfunction, so should we use the debriefing process to examine what went wrong in our treatment planning or service delivery. Many workers in all kinds of roles are tasked with maintaining safety. We have a far more complex duty than the maintenance of safety – we need to create it.
As behavior analysts and supervisees, we are held to very high standards – standards to which many other professional conduct codes do not come close to aspiring. The potential burden of the standards are more than counteracted, however, by the amazing array of behavior change tools in which we are trained to use. We should not expect to be skilled in evidence-based interventions while simultaneously being permitted to habitually utilize very low skill, reactive procedures to temporarily address the very challenges that are inherently complex enough to warrant treatment to begin with. Below are five reasons to tread cautiously into the realm of restraints and seclusions:
Restraints and seclusions are not function-based interventions. They do not treat.
Restraints and seclusions break relationships down. They damage the all-important rapport that we work so hard to establish and maintain as the bedrock of our work with clients.
Using restraint and seclusion as problem-solving tools can shape our own behavior in very unhealthy ways. The relatively speedy attainment of a sense of re-established safety and control, albeit often a false one, can lead us to rely on such physical management techniques when they are not warranted. Restraining or secluding a client should be an aversive experience for us!
Restraint and seclusion frequently results in injuries, and restraints can kill. Even “proper” restraints have caused the death of both clients and staff members in the past.
Every time a restraint or seclusion happens, we lose something. We lose a piece of our integrity as behavior change agents. We lose the opportunity to truly intervene in a treatment oriented way. We risk the breakdown of relationships with clients, and possibly even other stakeholders, such as staff members and parents.
Anyone can restrain and seclude clients in order to render their interfering behavior less problematic in the moment. It takes a committed, ethically minded, and knowledgeable interventionist to engage in long term problem solving.
Note: Pritchard and D’Antin wrote a response to this article here.
Let us know your thoughts on the use of restraints and seclusions in the comments below, and be sure to subscribe to bSci21 via email to receive the latest articles directly to your inbox!
Clelia Sigaud, M.S. is a teacher to children with developmental disabilities in urban Maine (to the extent that “urban” and “Maine” can be used in the same sentence). She has several years of experience working with special needs individuals, from preschool through age 20, in a variety of settings. Outside of work, she is earning her doctorate in School Psychology from the University of Southern Maine. Her interests include functional communication training, interventions for sexualized aggression/sexually problematic behavior, treatment of self injury, paraprofessional training, and ethical practice within the field of ABA. In her spare time, she enjoys authoring her own social stories. You can contact her at [email protected].
This is a fantastic article, thank you!
Another great column! I am so in harmony with this article! You are a thoughtful writer–and I have gone through the mill on restraints and seclusion, so I am totally in harmony with your thoughts. In fact, I have always felt that HAVING some of these tools makes for a treatment plan that is flawed from the first. However, when we started a special education school the Massachusetts Department of Education wanted to see your restraint policy. I said that’s easy. Our policy is no use of restraints. They also wanted to see our time out room. We didn’t have one, and that was unacceptable to them. They never looked at our curricular materials, our token economy plan, our general approach to running an all positive program. NONE of that mattered.
However worse than the restraint and seclusion issues are the risks of using contingent shock or other punishers. The staff become targets for the anger of punished students, and the environment becomes increasingly dangerous and antithetical to education.
THANKS for another great article!
I have worked with adults who engaged in severe, potentially life-threatening self-injury and aggression. I was never trained to consider emergency use of restraint and seclusion as part of a treatment plan. And I did feel deep empathy for my clients, having made sure to be put in the restraints that to see what they would experience.
I do not believe it is helpful to teach people that each and every time that restraint or seclusion is used constitutes a “failure.” In fact, in some cases, the use of these may be necessary to protect the client from the side effects of certain function-based interventions (e.g., escape extinction). I also believe that the way in which we interact with a client during the use of restraint can lessen some the potential for relationship damaging aspects that may arise. Calm and dignified interaction can be maintained throughout.
Great comment! Thanks for reading.
I have to respectfully disagree. I have been working in the field of developmental disabilities for over 30 years and I have heard this kind of rhetoric many times, mostly by people who have not worked with individuals with severe aggression or self injury. This should be entitled “The improper use of restraint and seclusion” is treatment failure. Proper use of restraint is ABSOLUTELY a part of proper treatment for severe aggression and self injury. Have you ever worked within someone with Lesch-Nyan? Mechanical restraint is a humane treatment in those with that type of self injury as opposed to letting them damage themselves. This type of discourse can be just as dangerous as the restraints you proport to object. Do you know how many persons with disability are harmed, killed, or incarcerated unnecessarily because of the absence of proper restraints? I do and there are many. As behavior analysts, we need not shy away from this. Instead, we must use our technology in the proper use of restraint and seclusion. Like PCM or Safety Care. As, for seclusion, we as behavior analysts, know the effectiveness of time out, so to say that this is treatment failure is ludicrous. What, I believe, you really mean to say, is the “improper use of restraint and seclusionn”. Also, your statement about damaging relationships when using restraints is not necessarily true, if proper restraints are used. Restraints should not hurt or cause injury, if used properly. I am close to many clients where I have been involved with their restraints, including my ward. And none of them were harmed. If we divorce ourselves from this as part of treatment, then we prevent our awesome technology from being applied to this important area. And we leave it to people,untrained in behavior analysis and its humane orientation, to design and implememt restraints. Is that better?
Good points Ken!
Anyone who has studied ABA, or worked with populations with challenging behavior knows that interventions do not change drastic, life threatening behavior overnight. That isn’t how it works. Your article is rhetoric lacking appropriate citations and clearly formed on personal bias.
If you’ve read this article, I think it’s also imperative to read the response to it made by Pritchard and D’Antin. The link is at the end of this article.
I would say that most of this article is spot on. Restraints and seclusion should only be used in situations of safety for the person causing the injury to self or others. However, I disagree that when a person needs restraint it is because a treatment failed. We cannot put someone into a formula, even designed specially for them, and expect to have specific results every time. I absolutely believe that the plan is sometimes the trigger and needs to be reviewed, changed, and adhered to on a consistent basis. However, we are all individuals with needs that change for sometimes no obvious reason whatsoever. It’s our ability to communicate those changes that determines if the changes are profound enough to need physical intervention in response. A plan is a formula that is developed for each person needing that level of support, but we cannot lose sight of the individual’s humanity.A plan may not work because the individual being affected, determined that it wouldn’t work.
Wonderful article, thank you for writing it.
It really highlights how we ought to be approaching treatments and other supports in the field. I may only slightly disagree with the function point (everything we do has a function) but probably reword it as it’s not for social valid therapeutic reasons (we are using it when nothing else works as a necessity).
I also think those who are responding above in opposition are missing the key element in understanding restraints as necessary but not desired versus putting some type of apriori ban on restraints as a strategy in emergency situations.
I don’t know about others but that’s the only time restraints or any other type of aversive/potentially harmful procedures are put into place is when everything else fails. I certainly hope behavior analyst are using restraints or seclusions when other non-aversive, non-restrictive methods are available. So to claim it’s anything more than what we do when treatment fails is shocking. And if and when there are cases where restraint/seclusion is required (life or death), I would hope we would still consider this a failure and continue to advance our science to the point where we no longer have to.
This topic reminds me of this article, which is about a school (where I trained) that was able to get rid of most of their restraints, hospital visits, and injuries to students and staff.
It’s not meant to prove restraints are not necessary but does highlight some key issues surrounding this topic, including the perception that nothing else is working and restraints are the only option. They use to restrain all the time and thought it was just the way the clients were until they were able to get better practices in. But of course everyone anywhere that regularly uses restraints and seclusion says that. The JRC folks still say that, I asked for evidence last time and got anecdotes and some very loose case studies that did not ever document proper history of non-aversive, positive procedures with high fidelity under the right expertise.