Josh K. Pritchard, PhD, BCBA-D (Florida Institute of Technology)
Marc D’Antin, M.A., BCBA (Lodestone Academy)
Guest Authors
After reading the article “5 Considerations Before Using Restraints and Seclusions” [1], we sat down to write a response. Our first thought was – where are the data that support these assertions? What about the number of highly trained behavior analysts who have a long history of taking some people with the most severe behavior problems (that others cannot or will not work with) and made massive improvements in their quality of life? This progress was often made possible with the use of programmed restraint and seclusion. These weren’t failures of their treatment plans, these were part of their treatment plans. Our concern arises from the fact that this article has the potential to vilify these behavior analysts that work with a population on whom others have given up. These few behavior analysts are in the trenches with the kinds of consumers who have no one left to advocate for them.
As we began to write our response, and started to collect the necessary data, we realized that someone had already done so. We recommend that all readers become very familiar with the Association for Behavior Analysis International’s policy statement on this subject matter [2]. The experts they brought together for the task force did a much better job than we can in such a short space, and have a long list of references [3] that support their perspective.
So – based on this policy statement and our personal experience, we would refute the assumptions upon which the 5 considerations are based.
Assertion: Restraints and seclusions are not function-based interventions.
Restraints/seclusion can indeed be a part of a function-based treatment approach. For instance, using seclusion for escape-maintained problem behavior is contra-indicated.
Assertion: Restraints and seclusions break relationships down.
The use of restraints/seclusion does not automatically degrade relationships or reduce rapport. We do agree that we hope behavior analysts do find that restraining another person is aversive.
Assertion: Using restraint and seclusion as problem-solving tools can shape our own behavior in very unhealthy ways.
As behavior analysts we are trained to recognize when our behavior (or that of those we supervise) is being negatively reinforced. If this is occurring, it is our duty to examine the situation and make a change in the environment. This is not a reason to preemptively cast out potentially effective interventions. Our advice – the goal should be a reduction in restrictive interventions. If behavior analysts graph their restraints/seclusion it would provide the occasion to determine whether they are, in fact, being over-used.
Assertion: Restraint and seclusion frequently results in injuries, and restraints can kill.
Restraints/seclusion (done by folks with proper training and clear criteria) can actually be safer than allowing escalations and continuation of dangerous response patterns. Moreover, the injuries and deaths that are paraded in the media tend to be instances of neglect or in cases in which there was no training, no plan, and the caregivers were simply left to their own devices.
Assertion: Every time a restraint or seclusion happens, we lose something.
There is nothing inherently lost (integrity or otherwise) with the use of restraints or seclusion. As indicated in the ABAI policy statement, restraints and seclusions can be an ethical part of behavior change procedures.
In the spirit of list making, we would like to re-iterate the three guiding principles from the ABAI policy statement, as we agree whole-heartedly with these:
“1. The Welfare of the Individual Served is the Highest Priority- Clinical decisions should be made based upon the professional judgment of a duly formed treatment team that demonstrates knowledge of the broad research base and best practice. Included in this process are the individuals being served and their legal guardians. The team should be informed by the research literature, and should determine that any procedure used is in that individual person’s best interests. These interests must take precedence over the broader agendas of institutions or organizations that would prohibit certain procedures regardless of the individual’s needs. A core value of ABAI with regard to behavioral treatment is that welfare of the individual being served is the absolute highest priority.
2. Individuals (and Parents/Guardians) Have a Right to Choose- ABAI supports the U.S. Supreme Court ruling that individuals have a right to treatment in certain contexts, and that many state and federal regulations and laws create such rights. Organizations and institutions should not limit the professional judgment or rights of those legally responsible for an individual to choose interventions that are necessary, safe, and effective. A regulation that prohibits treatment that includes the necessary use of restraint violates individuals’ rights to effective treatment. The irresponsible use of certain procedures by unqualified or incompetent people should not result in policies that limit the rights of those duly qualified and responsible for an individual through the process of making informed choices.
3. The Principle of Least Restrictiveness – ABAI supports the position that treatment selection should be guided by the principle of the least restrictiveness. The least restrictive treatment is defined as that treatment that affords the most favorable risk to benefit ratio, with specific consideration of probability of treatment success, anticipated duration of treatment, distress caused by procedures, and distress caused by the behavior itself. One may conclude from this premise that a non-intrusive intervention that permits dangerous behavior to continue while limiting participation in learning activities and community life, or results in a more restrictive placement, may be considered more restrictive than a more intensive intervention that is effective and enhances quality of life.”
We don’t believe the author had the intention of vilifying the unsung heroes who work with the population of consumers who require these kinds of intensive treatment. We imagine the author has experienced the misapplication of restraints/seclusion, potentially with individuals for whom it was not appropriate, and was frustrated by that. We, too, have witnessed this and believe it is very important that restraints and seclusions are used only after other less restrictive approaches have failed. We do, however, want to make sure that the people willing to serve consumers who have been failed by these less-restrictive procedures are not labeled as un-ethical or unsophisticated practitioners. Without them, this group of consumers might have nowhere else to turn.
References
[1] Sigaud, Clelia. (2016, February 14) Five Considerations Before Using Restraints and Seclusions [Web log post]. Retrieved from http://www.bsci21.org/five-considerations-before-using-restraints-and-seclusions/
[2] Statement on Restraint and Seclusion (2010) Retrieved from https://www.abainternational.org/about-us/policies-and-positions/restraint-and-seclusion,-2010.aspx
[3] Reference List: Statement on Restraint and Seclusion (2010, June 10) Retrieved from https://www.abainternational.org/media/7794/randsreferences.pdf
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Thank you for the thoughtful rejoinder! I appreciate the clearly evident concern for ethical practice and the preservation of client rights.
Thank you for writing this.
Thank you for coming out with an excellent response to yesterday’s article. Our agency works with individuals with significantly challenging behaviors. At times, the use of appropriate restraint has been absolutely necessary for the safety of the individual and those around them. We use Professional Crisis Management (PCM), developed by a BCBA, that emphasizes maintaining human dignity throughout crisis situations.
So glad to be part of a community that facilitates and explores these types of discussions. Well said, Josh
Well done, Josh and Marc.
Well said, Pritchard and D’Antin! The reference to the very cautious, thorough review of empirical evidence and then recommendations related to restraint and seclusion by the ABAI Task Force that formed the foundation of the cited ABAI policy statement is an important addition to consideration of issues raised in the article by Siguad. While I strongly endorse important principles underlying the position taken in the article (e.g., interventions addressing problematic behavior must be function-based, incorporate high frequencies of positive reinforcement of alternative behaviors, be minimally restrictive and aversive, be ethically and legally justifiable), I think that some of the conclusions drawn in the original article lack empirical support. As other commenters have noted, for interventions for some people whose problematic behaviors have long histories of inadvertent reinforcement and pose immediate severe safety risks, all evidence-based tools must be available to compassionate, highly-trained behavior analysts who are well versed in the relevant ethical and legal considerations. Extended periods of using highly proficient but minimally effective, minimally restrictive interventions when other function-based interventions, possibly more restrictive ones, incorporating high frequency of positive reinforcement of alternative behavior might be used and quickly reduce the risk of severe injury opens serious questions regarding whether the former, less restrictive approach actually is the more humane and compassionate. I know from the research and from over 40 years of clinical experience that minimally restrictive interventions typically are adequately efficacious within a reasonable time period and that highly restrictive interventions seldom are needed when interventions are function-based and incorporate frequent reinforcement of alternative behaviors. Yet, a few instances can be identified when temporary usage of effective, highly restrictive interventions can be in a person’s best interests and are ethically and legally justifiable.
I’d like to point out that the responses to the “assertions” are no less “assertions” themselves, and the link to the reference-list document does not make them any less so. In addition, it is far from clear which of the references in the linked document might be useful in regards to which of the counter-assertions. I sincerely hope that the counter-assertions are not resting on, for example, the following early-1970s-vintage reference-list items:
Barton, E. S., Guess, D., Garcia, E., & Baer, D. M. (1970). Improvement of retardates’ mealtime behaviors by timeout procedures using multiple baseline techniques. Journal of Applied Behavior Analysis, 3, 77-84.
O’Brien, F., Azrin, N., & Bugle, C. (1972). Training profoundly retarded children to stop crawling. Journal of Applied Behavior Analysis, 5(2), 131-137.
Are mealtime behaviors and crawling behaviors among the situations in which the ABAI supports seclusion and restraint as an “ethical part of behavior change procedures”?
Joanne Juhnke,
You’re right – we are simply refuting the assertions (and then backing it up by the policy statement of the international organization of our science). Their policy statement is the one backed by data. We started to refute with citations, but in the interest of space and time, we decided not to re-invent the wheel. The studies you’ve identified from the early 1970s, are likely included in the reference list as part of their discussion about what would and what would not be included. Happily, instead of just looking for a few of the oldest studies, a reader can determine what would and would not be included by focusing on the block quote we included (the principles). To answer your question directly, no – those situations would likely not be targeted with restraint/seclusion based on principles 1(individual welfare) and 3 (least restrictive). If one were to read the actual policy statement, it includes that the use of restraint must be “consistent with the scientific literature and current best practices”. Fortunately, our science has progressed significantly in this space since the early 1970s.
Frankly, ABAI’s credibility on ethical matters is challenged by its attitude to the misuse of electric shocks at the Judge Rottenberg Centre. The text of the policy statement may say that treatment should be “consistent with the scientific literature and current best practices” and yet the JRC does not use what Brian Iwata considers to be FA and yet uses aversive procedures without having identified the function of the target behaviour. The JRC is an ABAI conference sponsor and have been approved by ABAI as being aligned with its mission to contribute to the well-being of society.
The use of restraint, seclusion, shock and other restrictive procedures are all problematic. There are situations where they may be necessary and where they genuinely are the least restrictive option. Different behaviour analysts will operate under different legal frameworks and it is these frameworks as much as anything that determine if these options are available. It is, however, unfortunate that more often that we should be comfortable with, where these options are available for use legally, they are often misused or abused.