The Last Resort

I did some disturbing math recently, not as disturbing as the Math Trailblazers curriculum my daughter's school uses, but it was pretty darn close. The problem went something like this: Michael has worked 60% of his life in human services. If it is now 2007 and he was born in 1956, when did Michael enter the field? Answer: A long, long time ago. One thing I've learned over the years is that if you do this work long enough—more than a few hours—you'll make mistakes. If you do it for many years you will make lots of mistakes, and you'll make them for someone else's own good.

I've done this work long enough to have made some really bad mistakes. With the very best intentions I've done things I wish I could undo. Some are merely embarrassing, like being a clueless 21-year-old undergraduate advising struggling single parents about child rearing. Other things are more painful to recall, as in the 1970s, when we would sometimes provoke people who found it difficult to manage their anger so we could "bring their behavior into contact with contingencies." You can imagine what those contingencies were. Stupid, stupid, stupid.

I remember once, very shortly after starting work at one agency, going on a transportation run to pick people up from their homes to bring them to a sheltered workshop. One young woman who lived with her parents didn't always want to go to the workshop and would refuse to go with us. This was problematic for her parents who themselves had to go to work. If she refused to go with staff, her behavior plan required staff to physically restrain her, take her to the floor, place her in a body-length mechanical restraint device, and carry her to the van.

"Are you kidding?" I said.
"It's okay," my co-workers assured me, "It's in her plan."
Oh, well, if it's in her plan...

Lots of good intentions. Lots and lots of mistakes. While I don't beat myself up anymore for things I did in the past, I don't agree with Lady Macbeth that things without all remedy should be without regard. I think it's vital to revisit our mistakes, not to flagellate ourselves but to deconstruct our erroneous thinking and to shine light on our current practice.

When the Hartford Courant published its shocking series Deadly Restraint in 1998 many providers, accrediting bodies, and regulatory agencies were confronted with some ugly truths. Consequently, most providers have now discontinued the use of programmatic restraint (restraint as treatment), and now use restraint only in an emergency to preserve safety. "We only use it as a last resort". While that should be reassuring, last resort is a far dodgier concept than you might think. We mean it when we say it, but it takes more than meaning it to make it real.

For the last several years, the National Technical Assistance Center (NTAC) for State Mental Health Planning has disseminated its Six Core Strategies for Reducing Seclusion and Restraint. Implicit in this effort is a public health prevention model, describing primary, secondary, and tertiary preventive practices. NTAC views primary prevention practices as "interventions designed to prevent conflict in the environment by anticipating risk factors." Secondary prevention measures are early interventions designed to "immediately minimize and resolve conflicts when they occur." Tertiary preventions are actually actions taken after an incident that are "designed to mitigate effects, analyze the event, take corrective action," and prevent future occurrences.1

Primary preventive practices are comprehensive, big picture efforts, like thoroughly understanding the person receiving services, knowing what is important to him, centering all planning and all supports on this understanding and including the person receiving services in the planning. In settings that do this well, the person receiving services, or someone very close to him, actually leads the support team. Other primary prevention includes facilitating the development of genuine friendships and other supportive relationships, building resilience and focusing on role recovery, improving quality of life, teaching useful, life-improving skills, ensuring the person can communicate his needs and wants, celebrating success, and focusing on the person's satisfaction with his life as well as his success. Primary preventive practices are respectful and collaborative, and create positive feelings for everyone involved in a person's life. 2

Primary prevention practices, in addition to being so charmingly alliterative, should prevent between 70 and 90 percent of most serious behavioral issues in any given setting. And subscribing as we do to the last resort principle, it follows that the same proportion of personal restraints would be prevented as well. Unfortunately, primary preventive practices are one of the least developed aspects of most psychiatric, habilitative, and educational service settings everywhere.

We know that aggression in behavioral health care settings is largely iatrogenic—we actually cause it by delivering services. We subject people to arbitrary authority, we crowd them, we make them live with people that scare them or annoy them, we traumatize and re-traumatize, we restrict their freedoms, we make them take drugs that alter their brains and bodies, we provide sitting-around therapy, doing-what-you're told therapy, and pointless-repetitive-task therapy. We fail to respond to the person's attempts to communicate, we fail to support the use of constructive alternatives to violence, and we fail to alter our practice based on what we have learned about a person's preferences, desires, needs, and concerns. We routinely create the conditions that provoke violence and aggression, leading inevitably to countless last resorts. We repeat our mistakes.

It may sound like I'm provider bashing, but really I'm not. I have tremendous respect for teachers and professional helpers. Anyway, I'm not exempt from this analysis; my path is strewn with bad decisions and poorly conceived interventions. And I know we're all learning from our collective mistakes, but we need to learn faster. Our careless practices can be eliminated if we confront them. Elimination requires illumination.

We tend to experience a serious behavioral incident as if we are viewing only the last few frames of a film. We see the escalating behavior and the events immediately triggering it, and we expect staff to de-escalate the person before harm is done. The broader context—the preceding 90 minutes of the film—is too often ignored.

De-escalation skills are critical in supporting people who sometimes have extreme behavior, but de-escalation is secondary prevention. The de-escalation moment is a late link in a long chain of causality, and all along that chain are numerous opportunities for developing relationship, encouraging trust, building resilience, altering the environment, creating choice, and eliminating the person's need to escalate in the first place.

If we fail to provide comprehensive supports while creating environments that elicit aggression, then our last resort will always look pretty much like our first resort, and if we respond to behavioral emergencies by restraining people in order to keep them safe, but don't alter the conditions creating those emergencies, our last resort becomes simultaneously necessary and irresponsible; at once protective and assaultive.

Addressing the widespread issue of aggression and restraint in helping environments without primary prevention is like trying to stop the spread of blood-borne pathogens without universal precautions. With infectious disease it's obvious, with violence, not so much.

1 Creating Violence-Free Mental Health Settings: Changing our Cultures of Care. Hogg Foundation for Mental Health Teleconference. April 4, 2006. Kevin Ann Huckshorn RN, MSN, CAP, National Technical Assistance Center NASMHPD

2 Therapeutic Options. 1999-2007. Michael Partie. Therapeutic Options, Inc.