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Children's Voice Article, July/August, 2004

My Turn

Is There a Therapeutic Value to Physical Restraint?

By Dave Ziegler

In the article "Practicing Restraint" (September/October 2003), Children's Voice examined the call among some in the field for alternatives to physical restraint as a means of controlling unruly behavior in child and youth residential care-a goal to which CWLA is committed as it collaborates   in an initiative, supported by the Substance Abuse and Mental Health Services Administration, to serve as the Coordinating Center for the Best Practices in Behavior Support and Intervention Project. (See "Readers Write," page 4, in this issue.) In the interest of facilitating debate on this critical subject, we present here a counterpoint to that first article, asserting a therapeutic value to physical interventions.

A quick review of the published information on physical interventions over the last three years suggests a fundamental, universal shift has occurred, away from the use of therapeutic restraint and seclusion to address violent behavior in children. But this is somewhat deceptive.

Research has shown that young children most often present violent behavior in treatment settings and that, for more than a decade, treatment facilities have faced increasingly violent and assaultive children. Despite the impression one might get from recent media coverage, the reality is that in addressing violent behavior in young children, most treatment centers use physical interventions safely and effectively.

Although it's true physical interventions have been the subject of substantial training to ensure they are conducted according to national crisis management guidelines, it's not true that the mental health community has abandoned physical interventions.

Residential treatment programs are experiencing increasing pressure to become restraint and seclusion free. But is this direction in the best interest of the children? The answer will emerge only after a dialogue of the valid points on both sides, but to date, only one point of view has been advanced. My purpose here is to provide another perspective on the issue.

Professionals have used a variety of interventions over the years to address violent behavior among children and adolescents. In such settings as psychiatric hospitals and treatment programs, two of the most frequent interventions have been therapeutic holds, also called therapeutic restraint, and allowing the individual to regain self-control in seclusion or a quiet room.

Interventions less often used include mechanical restraints and using medications or chemical restraint. Criticized over the last decade as excessive and too restrictive, the use of mechanical and chemical restraints has declined in some programs and been eliminated in others, particularly in settings outside of hospitals.

More recently, critics have presented a host of arguments against using restraint and seclusion to address violent behavior in children--most notably, a 1998 investigative series in the Hartford (Connecticut) Courant. This exposť of injuries and deaths reportedly caused by the use of restraint and seclusion is often credited with starting the current wave of criticism of restraint and seclusion. The controversy has run the gambit from media coverage to policy change and new federal legislation.

The criticism directed at restraint and seclusion has one glaring absence, however--a review of the therapeutic benefits of physical holds to address violence among children. Although seclusion is often used interchangeably for therapeutic restraint, the two are very different interventions and raise very different issues. I focus here not on seclusion but rather the therapeutic components of physical restraint.

Harsh Criticism

Children's Voice's recent article, "Practicing Restraint," is a good example of the criticism directed at physical restraint. The article calls restraint violent, dangerous, and even potentially deadly to children. It makes the point that this intervention can actually cause further trauma due to such concerns as counteraggression by adults and repeating abuse the child has experienced in the past.

Experts cited in the article call restraint a violent means to maintain control and rule over children. Rather than physical restraint, the quoted experts recommend negotiating with the child, trying to understand the reasons behind her behavior, and giving the child choices. Some critics have gone so far as to say physical restraint should be avoided at all costs and that any use of physical restraint is a treatment failure.

In the face of such condemnation, is there any defense for physical interventions such as restraining violent children? I believe there is, but the starting point for discussing the therapeutic components of physical restraint must begin with an acknowledgement that even good interventions, when done poorly or at the wrong time, lose some or all of their therapeutic value.

All behavior management can become ineffective, demeaning, and even psychologically damaging if done poorly. It's safe to say that using a violence intervention to rule over children is poor behavior management. Like other types of behavior management, if physical restraint is done in a violent and dangerous way, it may be possible to replicate the past abuse of the child, at least in the child's mind.

But physical restraint is not step one of any intervention with a child. Physical restraint should not be a shortcut to taking the time to understand the child and the reasons behind his behavior. Nor is restraint at the opposite end of the continuum from appropriate negotiations and setting clear and meaningful choices. Physical restraint is properly used only when the adult is trying to understand the child, and other limit-setting techniques have failed to safely address the child's violent   behavior.

Nor are interventions therapeutic when based on a power struggle or when the adult is out of control. Any behavior management approach loses its therapeutic value if used to merely control the child without supporting and understanding her thoughts, feelings, and goals for the behavior. This is true for all behavior management interventions, whether time-outs, logical consequences, giving choices, negotiating, or physical restraint. The technique itself isn't necessarily what makes an intervention therapeutic--more often it's when, how, why, and by whom the technique is employed that makes the difference.

Therapeutic Value

To be a legitimate part of any behavior management plan, physical restraint must have the potential for therapeutic value when used appropriately. Nationally recognized crisis behavior management systems--such as the Crisis Prevention Institute and Professional Assault Response Training, for example--have clear guidelines for the appropriate use of physical restraint. They outline the safe, effective use of physical interventions after adults have used crisis deescalation techniques.

National accreditation organizations such as the Council on Accreditation and the Joint Commission on Accreditation of Health Care Organizations sanction the appropriate use of physical restraint. If any legitimate organization were to declare physical restraint a "treatment failure," an expression used by opponents of physical interventions, one would expect it to come from entities that hold organizations to the highest standards of the industry. Yet all major national accrediting bodies sanction the use of physical interventions. The American Academy of Pediatrics, the American Hospital Association, and the National Association of Psychiatric Health Systems all agree that "restraint and seclusion, when used properly, can be lifesaving and injury sparing interventions."

The age and developmental level of the child must always be considered. Here are some of the reasons why physical restraint, when done well, can be an important, effective, and therapeutic intervention to address the violent behavior of young children:
  • Physical touch can be very therapeutic to children, particularly in a crisis. Long before a child learns English, Spanish, or Swahili, the first language he learns is the language of touch. Touch is considered a basic need for all children. When a young child is frightened, his first instinct is to hold on to a trusted adult.

    Children who demonstrate serious acting out often do not know how to ask for what they need. Supportive, firm, and safe physical touch can give a child a message of reassurance. If touch is poorly used, such as slapping or striking a child, the message can be very frightening. But when a young child is in a crisis situation, touch can be one of the most reassuring interventions one can employ when it lets the child know the adult will manage the situation safely for everyone.

  • Emotionally defensive children can become psychologically more real and available after an emotional release during a physical restraint. This dynamic is not restricted to children. Often, when our emotions overwhelm us, we're open to learning something new from which we have defended ourselves.

    There's a parallel to this dynamic in psychotherapy, when a client has a difficult but insightful experience that usually includes being catapulted beyond his or her ability to keep out important information. For some children, getting to this place is difficult without some form of emotional meltdown that may accompany a physical intervention.

  • Young children with emotional disturbances need to know adults are safely and appropriately in control of the environment. Serious acting out is often their way of seeking this assurance. The adult is responsible for preventing the child from hurting herself or others. If other management methods fail, physical interventions may become imperative. Once the child has lost her inner control, the adult cannot place sole responsibility on the child to regain it. Children can regain their footing, but assistance from a supportive adult can be critical.

    Most emotional problems in children have their source in chaotic, abusive, or neglectful home environments at some point in their lives. To be in a home where the adults are not in control of themselves or the environment is like going down the road in the back seat of a car with no one driving--it's terrifying to a child who has been there. These children often push a new environment to the point that the child learns if the adults can manage the challenges. Often, when the child has such reassurance and can rely on others for basic needs, such as safety, she can once again get back to the task of being a child.

  • Young children with emotional disturbances need and often seek closeness with adults, and violence can be less emotionally threatening for the child than are other forms of intimacy. Behavior cannot always be taken at face value with children who experience violent rages. In fact, these children often act counterintuitively. They may push you away when they want closeness, they may strike at you when they are beginning to care about you, and they may act in ways to receive reassuring touch by becoming aggressive and violent to themselves or others.

    It's important to understand why a child is acting a certain way. At times, a frightened child seeks the reassurance of physical touch when he can't allow himself to ask for physical comfort. Young children often become violent with trusted adults because the children know they are safe and will get the reassurance they need. If they don't find this physical reassurance, they will often raise the level of acting out until they do.

  • Physical restraint is the surest and most direct way to prevent injury and significant property damage when a child loses control. The Children's Voice article "Practicing Restraint" opens with a description of a child doing significant damage to a car with a rock. Agency staff, who stood by and didn't stop the child, believed this was a better, if more costly, intervention. But this seems to defy common sense. Would any parent stand by as a child did thousands of dollars in damage to the family car?

    Recently, a child in our program picked up a rock, ran around a new car, and heavily scratched it--to the tune of $2,650 damage. Afterward, the child felt badly for such out-of-control behavior and said good kids didn't do such bad things. Children, like adults, view themselves in relation to their own behavior. It only makes sense, from a practical and therapeutic perspective, to stop children from hurting others and doing damage that will make them feel worse about themselves. Physical intervention may be the best way to ensure this.

    Besides, an intervention considered to be good parenting is likely to be good psychological treatment. Psychologists, family therapists, and parent trainers would all call stopping a child from running into a busy street good supervision and effective parenting. They would also recommend that a parent prevent an older and much larger sibling from physically harming a younger sibling.

    It isn't hard to imagine the same parenting consultants suggesting that when an angry child is headed for the family car with a baseball bat, the bat be taken away before the damage occurs. If these parenting interventions are basic common sense to most everyone, why would these same interventions be unhelpful and nontherapeutic for children with serious anger problems?

  • Traumatized children must learn that not all emotionally charged situations and physical touch end in being abused. Humans have several types of memory--factual (explicit), subjective (implicit), emotional, experiential, and body memories. Early experiences of touch can establish a lifelong trajectory of meaning attributed to physical touch.

    Children with emotional disturbances often have difficulty with caring touch. Body memories must be addressed while the child is still young, or she may avoid the very closeness she needs. Abused children learn that when someone gets angry, someone else gets hurt. Supportive physical restraint can help retrain the body not to fear touch from others.

  • Treatment programs are responsible for directly addressing violent behavior and not just skillfully preventing the behavior from presenting itself during treatment, only to reappear in the home or community after treatment. The argument that all physical restraints can and should be avoided at all costs may address the principle of prevention but misses the point of treatment.
In the extreme, all physical restraints could be avoided--this simply requires an adult to stand by passively and allow an enraged child do whatever he wants to do. One may call this "preventing" a restraint, but how does it address the responsibility of a treatment program to treat and extinguish serious violent and antisocial behavior?

The roles of prevention and treatment are quite different. Not intervening when a therapeutic response is called for isn't so much prevention as it is abdication of adult responsibility. If someone needed treatment for a debilitating phobia of spiders, a spider-free environment would prevent the symptoms, but this wouldn't treat the phobia.

Programs charged with treating violent behavior cannot simply ensure the symptoms never arise in the treatment environment, because they will certainly resurface once the child leaves that setting. In psychological terms, treatment often requires such steps as reexposure to stimuli, cognitive reprocessing, skill development, and practice and mastery--none of which will happen if preventing symptoms or avoiding a particular intervention at all costs is the goal.

Supported by Research

Does the appropriate use of physical interventions guarantee therapeutic benefits? No intervention comes with a guarantee, and there have been abuses of physical interventions, but research has demonstrated a therapeutic value in physical restraint when used properly:
  • Restraint has been found to shorten crises over other interventions.

  • Physical restraint has been found effective in reducing severely aggressive, self-injurious, and self-stimulatory behaviors.

  • Physical restraint has been found helpful in treating aggression with dissociative children.

  • Physical interventions have been recognized in the role of reparenting children who have not been taught limit setting due to absent parenting.

  • Physical restraint has been called an effective intervention to protect the child and others from harm and prevent destruction of property.

  • Physical restraint has been called ethically sound and recognized for significant therapeutic benefits.

  • Despite a frequently criticism that restraint removes the child's ability to learn and internalize self-control, two studies nearly a decade apart-one in 1989, the other in 1997-found that physical holding produced rapid gain in internal behavioral control.
Many interventions, including physical restraint, can have damaging consequences when improperly used; at times, however, the consequences of not using serious interventions can be even more damaging. I recommend a five-point evaluation of interventions for violent behavior:
  • Was safety ensured?
  • Was self-control internalized?
  • Was the intervention individualized and based on understanding the child?
  • Was the intervention therapeutically driven?
  • Did the intervention produce the desired result?
If we are to meet the challenge of increasing numbers of violent children in our system of care, we must carefully consider how to best meet their short- and long-term needs while ensuring the safety of other children, their parents, and the community at large. A reasoned approach would be careful consideration of all the issues, not a singular movement to reduce or eliminate physical interventions that have been found to be safe, ethical, effective, and therapeutic.

Dave Ziegler PhD is a licensed psychologist, Executive Director of SCAR/Jasper Mountain, Jasper, Oregon, and the author of three books on the psychological treatment of difficult children. Reference citations for the research referred to in this article are available by contacting the author at davez@scar-jaspermtn.org.

Clarifying Terms

It's important to distinguish the terms physical restraint and therapeutic holding from holding therapy. Physical restraint occurs when a trained adult stops a child from hurting himself or others by using approved crisis-intervention holds to protect the child until he is no longer a danger. A variety of approved holds exist, but all of them restrain the child from being violent and causing damage to himself or others.

Holding therapy, on the other hand, is a physically intrusive method to produce a crisis in a child and force her to experience physical or psychological pain. Holding therapy and other similar intrusive techniques are not sanctioned by any legitimate professional organization and are neither therapeutic nor valid psychological treatment.

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