Want to Reduce the Risks of Restraint? Master Your Supportive Stance.

My first encounter with physical restraint was witnessing one that never should have happened.

I was a psychology undergrad at a state university in my junior year and looking for a job. I was sitting at the back of a dusty lecture hall, listening to my abnormal psych professor talk about personality disorders and their classification under the DSM-IV. Shortly before the end of the class, he told us that his wife was a clinician at a nearby psychiatric hospital, and that they were looking for employees to maintain round the clock staffing of the patients. My interest was piqued.

Not long after, I found myself sitting in a large conference room at that psychiatric hospital with a wide variety of other people, about 20 in all. An administrator came into the room to start my first of 40 hours of training and orientation to work the overnight shift.

I was assigned to a specific unit within the adolescent wing of the hospital. I met coworkers, learned the unit chain of command, and was assigned my responsibilities. As part-time overnight staff, that meant I was mainly going to sit at the end of the long V-shaped hallway, allowing me to see the doorway to every patient’s room, while they slept.

After about a month of this I was offered the ability to cover a colleague’s second shift, which went from mid-afternoon to late evening. I jumped at the opportunity—I was more than ready to interact with the teens I had been “working” with on third shift.

I walked into the unit on second shift, and was instantly struck by the dramatic uptick in activity. Daylight poured in. Children and teens were talking with therapists in the main living area. I was ecstatic. I listened during the supervising nurse’s summary of the first shift and received my case load for the evening: three teens ranging in age from 14 to 17. I also met Rick.

Rick was an interesting guy.

Rick had been at the hospital for about nine years and was lead counselor of second shift. He ran the groups, assigned the duties, and maintained the schedule of the unit. Rick stood well over six feet in his early fifties, with a sharp buzz cut completely silver in color. Broad tattoos sat atop both forearms and he wore two large rings on either hand.

Rick didn’t talk much—but even in his silence, he had the resting demeanor of someone with a toothache.

The shift moved quickly. Soon I was in the kitchen preparing the meals our unit received from dining services. The patients were gathered in the dining area for a group session prior to the evening meal.

One of my assigned patients, Brit, became upset during the session. She left abruptly to go to her room.

After the group wrapped up, a nurse inquired where Brit was, and I told her what had happened. I was asked to find her and tell her it was dinner time—and that her presence was required.

I peeked into her room and saw her face down on her bed, a pillow wrapped around her face as she sobbed into it. I asked her to join us, but she didn’t respond.

As I backed out of the room to inform the nurse, Rick appeared in the doorway behind me. He positioned me at the foot of the bed and he went to the side. At first, Rick just talked to Brit.

He told her that group sessions can draw out emotions and that participants often get upset. Then he began to talk about what was for dinner, and what the schedule was after dinner.

Brit turned her face towards Rick and very clearly yelled, “F--- off, old man!”

Things got less therapeutic from there.

Rick’s tone quickly escalated to a no-nonsense volume and pace, telling Brit that she was going to lose privileges, and that she would be restricted to her room for the next day with heavier supervision.

Suddenly, Brit got up from the bed. This petite teenager looked squarely at Rick, her face red and hair matted with tears, and cursed at him again.

I’d felt my pulse start to race when Rick initially got louder, but now I couldn’t feel anything. I was completely still. I watched Rick. I couldn’t figure out what was going on—and I had no idea what he would do next.

Rick grabbed Brit by the arm and she spit on him, her free hand trying to pry his hands from his arm. He started to pull her from the room by her arm as she tried to plant her sock-clad feet firmly on her bed. I was a statue.

She took a swing at Rick and barely missed, but the motion allowed me to make eye contact with him as he yelled at me, breaking my paralysis. “Get over here and grab her!”

And before I knew it, Rick was directing myself and a third staff member to put a distressed patient—a child—into a prone restraint.

I tried to process what I had just seen and been part of. I felt sick. A scant debriefing was conducted by a nurse who had observed when the restraint started. Rick documented the event without my input, and I never heard about the “incident” again.

But it stuck with me.

As a mental health practitioner and a CPI Certified Instructor, I want every professional to understand that being supportive is the key to safe, effective de-escalation.

I learned a lot in my time at the hospital. I came to understand mental health in a direct and experiential way, gaining critical insight into what children and teens cope with. And that was largely very positive.

But I also have some truly horrible, gut-wrenching stories about what happened to the teens I worked with before, during, and after their hospitalization—and Brit’s story is one of those.

I think about Brit and that first restraint vividly each time I facilitate a Nonviolent Crisis Intervention^® training for my staff. I tell her story to illustrate how the best use of “restraint” isn’t physical—it’s restraining ourselves from reacting instinctively, and instead learning how to talk to people. How to listen to their issues and concerns. How to identify in ourselves what frustrates and drives our emotions—and being empathetic and nonjudgmental to others in turn.

“Restraint” begins a long time before any physical contact is made—if our attitude is one of prevention and support. And support is what Brit needed. Brit needed a staff person to listen to her, give her space, and offer her a way out.

The staff I train have heard many of my stories before—but every time I talk about Brit, I always get the same reactions. Wide-eyed astonishment, disbelief, and outright anger.

Brit’s story encapsulates everything that can go wrong in a restraint—even if nobody gets “injured.”

As a practitioner and instructor, I have made a lifelong commitment to never put a child in a situation like Brit, nor put a co-worker in the position I was put in that day. That is why I focus on the Supportive Stance^SM—both in how I train my peers, and what I practice with my students.

The Supportive Stance^SM is a critical tool for maintaining a nonthreatening physical presence in a crisis. However, it’s also vital for effectively defusing verbal escalation.

I teach my staff that the Supportive Stance^SM includes opening the ears and shutting the mouth, because listening to a person in crisis can sometimes de-escalate a situation all by itself. It enhances communication to listen to that person’s viewpoint—and to not try and explain what they did wrong, or why they are in this situation.

The Supportive Stance^SM is just that—supportive. Sometimes as practitioners, we need to simply be there for an individual in crisis. Regardless of why a situation is unfolding, in that moment, being supportive can help a person move through the moment without any physical contact being needed.

The safest restraint is the one that never happens.

When my trainings end, my goal is that every person understands that Care, Welfare, Safety, and Security^SM aren’t simply CPI’s guiding principles. These values are a mantra, a philosophy, and a pledge to each and every person I train, work with, and serve. By truly embracing and implementing Nonviolent Crisis Intervention^® training, I can reduce the likelihood of Brit’s story ever happening again.

ABOUT THE AUTHOR

Michael Somers III, NCSP, is principal of Chapel Hill Academy in Lincoln Park, NJ, a K-12 day school program for students with emotional disturbance and behavior disorders. He is a Master Level CPI Certified Instructor and has trained staff for ten years. Currently, Michael is pursuing his doctorate at Seton Hall University, focusing his dissertation on the use of professional development to decrease the number of restraints in special education schools.