I have been in the field now for more than forty years. As a teenager, I started as a high school volunteer in a local special school with my best friend, at first perhaps more interested in the ice cream than the school, but something about that experience started my professional career. Hence, I continued as a volunteer and then as a camp counselor for one summer.
As part of my undergraduate program, I had two influential professors who gave me the opportunity to conduct an observational study on patterns of interaction between staff and adults with disabilities, a topic I discussed this morning with contemporary service providers. Some things were different then and in institutional services you saw things that you do not often see today. Adults who had lived all their lives in the same location away from their family and society; an adult with tertiary syphilis; and, indeed, a few individuals with continuous restraint.
Enter a young adult, let’s call him Max. In his early twenties Max had spent almost all of his life institutionalized and tied to his wheelchair due to chronic uncontrollable self-injury. He has blinded himself in one eye and usually had multiple open wounds one his face and elsewhere. Staff and professionals were at a loss as to how to help him. Restrained on all four limbs, he continued to devise ingenious ways to harm himself. When his teeth were removed, Max quickly learned to smash himself in the face with his knees. Surprisingly, with a good, concerned and hard-working supervisor, staff figured out how to get Max to feed himself and be out of restraint without hurting himself. There were no BCBAs then, but I learned the importance of staff training in producing client outcomes.
Over the next few years, I met quite a few people like Max; sometimes I had success and sometimes I did not. Reading early classics such as Thompson and Grabowski’s Behavior Modification of the Mentally Retarded* and academic journals such as the Journal of Applied Behavior Analysis* was a great help, but Richard Foxx’s training film and associated publications with client “Harry” were inspirational- giving me guidance to what could be done. (I quite enjoyed almost being thrown out of the university library for playing the movie to my class because it disturbed the delicate librarians too much.) Gaining a few years of practical experience did not make me a polished behavior analyst, but it did give me plenty of practice with many different cases and my clinical psychology colleagues were happy to pass these clients to me while they did Important Therapy in their comfortable offices.
*No royalties, kickbacks, or other payments go to Professor Sturmey, ABAC, or employees of ABAC for posting the link to this book, journal, or other resources.
In the 90’s, like many other states, Texas was being sued by the US Department of Justice for, as the rubric goes, “flagrant and egregious abridgement” of the constitutional rights of its institutional residents. One example of this was excessive use of restraints, not just for specific individuals, but across an entire legal class of individuals. How were we to reduce restraints safely across the board for a residential service for hundreds of individuals?
Safe Restraint Reduction
At the time there was little contemporary literature on this problem. (I since have learned that nineteenth century institutional superintendents including John Langdon Down, of Down Syndrome fame, were quite effective in eliminating restraint in the nineteenth century.) There were some models for group intervention, again from work by Richard Foxx, and a few individual papers here and there on large scale reduction of restraint. These papers typically involved measurement of restraint and identification of and work with high-risk individuals and hot spots within services, goal setting, staff training, and feedback.
To my surprise, I found that large scale reduction of restraint was not that hard, but did require hard work and persistence. Individual function-based behavior plans were helpful, but only a part of the picture. Often both professional and direct care staff had limited or no relevant skills and too often focused on the process of paper work and meetings, and not on client outcomes. Often this work identified difficult and long-standing personnel issues which managers were often reluctant to even acknowledge, let alone address.
Several of Texas’ institutions were quite effective in achieving large-scale restraint reduction over extended periods of time. Unfortunately, the state exited the Federal lawsuit and within weeks cut funding and, as one of my former psychologists sadly professed, aspired to provide “three hots and a cot.” I saw the writing on the wall and got out quickly! Fortunately, the US Department of Justice opened a new class action lawsuit only a few years later and gave the state the dubious honor of having all of its facilities being sued as part of the class. Again, they identified the excessive use of restraint as a key issue. Texas’ new lawsuit has been ongoing for several years and is not yet resolved.
Out of the Institution and Into the Classroom: Contemporary Excessive Use of Restraint
Some of you may read the preceding blog text and feel reassured that the problem of restraint is something of the institutional past. But a bit of casual googling will reveal restraint-related deaths in contemporary special education and residential services, leading some authors to describe the problem of restraint as being one that has been moved to a new location but not solved.
Last year (2020) the Chicago Tribune in collaboration with Propublica ran a series of restraint scandal stories documenting excessive restraint and restraint-related injuries across numerous special education school – both public and private – in Illinois. Tracking the response to the expose is an interesting illustration of how state agencies bluster when exposed and then walk back their initial grand plans. The Chicago tribune described the situation as one in which school districts often fail to act effectively and prefer to place students with restraint in isolated special education units, privately run schools, and out of state providers with little oversight. Out of sight, out of mind! Things may be little better in contemporary services for adults with disabilities. Restraints are also widely used in many other settings including youth facilities, nursing homes, immigration and deportation services, prisons, and by the police.
Despite the scale of the problem there are reasons to be cautiously optimistic. Resources in services for children and adults with disabilities are much greater than in the past, even if the resources are often not used optimally. We now do have a modestly adequate technology for safely reducing restraints for many individuals, primarily based on applied behavior analysis. In addition, we have many models for reducing restraint at the level of an organization using a variety of approaches, some of which are explicitly behavior analytic.
If you are interested in safe restraint reduction there are now plenty of models readily available out there and resources for you to use. If you want to improve the quality of life of individuals with disabilities and others experiencing excessive restraint, give it a shot! You might be pleasantly surprised.