Restraints Put on Hold

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Greeneville, Tenn.—Staffers at the Holston United Methodist Home for Children painfully recall days in the mid-1990s when they dreaded coming to work. Some say the daily routine was a physical battle, “us vs. them”: youth workers vs. the troubled youth they were supposed to help.

Every day, staff members restrained emotionally or behaviorally troubled teens who acted up, sometimes wrestling them to the floor. “We were so busy restraining kids that we weren’t getting anywhere with treatment,” recalls Gayle Mrock, administrator of residential services for Holston, which serves 450 youths at facilities in two states.

“The kids were so used to being restrained that they just expected to be restrained,” says CEO Arthur Masker.

Holston set out to do something and things immediately got worse. In 1998, the number of restraint incidents at Holston facilities hit 1,447, causing 36 staff injuries that required medical attention.

But by 2001, the number of restraints was down to 93, with a dozen staff injuries. Today, other agencies turn to Holston for guidance on how to reduce restraints.

Holston’s transformation took its administrators and staff through a series of self-examinations and reforms: analyzing all of its restraints for patterns and explanations; training and retraining staff in alternatives to restraints and safer restraint techniques; and changing part of the agency’s culture.

It hasn’t been painless – some staffers quit and the changes cost money – but workers say Holston has become a different place – “a happier place to be for the kids and the staff,” says Freda Davis, principal of Holston’s on-campus school here.

A Rough Badge of Honor

Founded in 1895, Holston serves emotionally and behaviorally troubled youth at six sites in Tennessee and southern Virginia.

The wooded campus on the outskirts of Greeneville, a charming city of 16,000, serves as an administrative center. The campus includes cottage-style residences for 32 boys and eight girls, ages 10 to 17, while another 70 adolescents live in group homes near the campus or in town. A Beacon School on campus has 75 students.

Holston employs a staff of 198 on a $10.3 million annual budget. Almost 79.5 percent of Holston’s funding comes from fees for services, most involving state contracts. Another 14.5 percent comes from private donations and 6 percent is from Holston’s endowment.

Holston administrators say the increase in restraints in the mid-1990s came as state foster care policies evolved to emphasize placing children with foster families rather than in institutional settings. As a result, Holston began getting more of the most troubled, older teens. (The average age at the on-campus boys’ residences rose from about 13 to 16.

“They were tougher kids,” Masker says. “They were without hope. They didn’t feel they were headed toward placement in a home. They sensed they had nothing to gain and nothing to lose.”

Administrators now see that physical restraints essentially became Holston’s means for enforcing its rules.

“We were totally focused on structure, routine, consistency, rules and consequences,” says Keith Bailey, administrator of best practices. “We were using a behavior modification model. We gave out points – kids moved up or down” according to the points system. “And you could lose everything you’d worked for over three or four months in one bad day.”

Staffers say the youths expected to be restrained, with some kids treating it almost as a badge of honor. “It teaches kids to think they need someone else to control them because they can’t control themselves,” Bailey says.

And physical intervention by staff provided a sort of safety net. “Some kids thought, ‘I can threaten other kids all I want, because eventually the staff will restrain me,’ ” says Mrock. “We had an environment of external control of their behavior.”

But “our staff just didn’t feel good about the restraints,” she says, “and we started questioning the care we were providing – the very model of care we were using.”

Early Stumble

In 1997, Holston began using the Therapeutic Crisis Intervention (TCI) program developed at Cornell University in New York.

Holston officials say they picked TCI because it seemed to emphasize the “de-escalation” techniques that Holston wanted to incorporate in staff training. The idea was to defuse situations and avoid physical force.

(There is heated controversy among some training organizations about when to employ physical restraints and de-escalation tactics and which methods to use. This story focuses on one agency’s experience and is not an endorsement of one approach over another.)

But when the number of restraint incidents continued to rise in 1998, Holston looked for further outside help. That August, Holston invited Lloyd Bullard for a visit.

Bullard, director of residential care services for the Child Welfare League of America and a known advocate of reducing restraint use, spent two days talking to workers and youths at Holston. Then, at a meeting with administrators and staff, he made a pronouncement that is widely remembered at Holston as almost a historic moment: “You’ve got to change the culture here.”

“The culture of an agency,” Bullard says now, “is very critical to the number of restraints used.”

“We laughed when he said it,” Bailey recalls. “It sounded so simple. Right away, we even drew up a plan to do it that would take nine months.”

“Boy,” says CEO Masker, “was that naïve.”

Staff Training

Change of the sort Holston was seeking takes patience, persistence and money. Holston administrators now know this now.

Also crucial, Bullard says, is that “Holston had effective and supportive leaders willing to spend the time and provide the resources.”

As for Holston’s original nine-month plan to examine its program, visit other agencies, decide on a new model of care, train staff and implement the new program, Bailey says, “We’re still doing it.”

Step one was giving direction to the staff, Mrock says. “We went to them and said that from now on restraints aren’t OK, and the majority said, ‘We agree – that’s not what we want to be about.’ ”

A Physical Restraint Review Committee was formed to review each restraint incident, looking at the need for the restraint and the procedures involved. Some of the committee’s early meetings lasted three or four hours. (Today, with the number of incidents down and their use tracked and better understood, the meetings typically last about 30 minutes, Mrock says.)

She insists that staff members sensed they were “empowered” rather than criticized by the close examination in the committee sessions. “They wanted feedback,” she says.

By state regulation, all cases of physical restraint or seclusion now must also be reported the state Division of Children’s Services.

Nevertheless, not all staffers bought into the added monitoring and training. “We had some people leave,” Bailey says. “They didn’t change with us.”

Masker believes that sending staff members to visit other agencies that were using practices Holston wanted to emulate helped sway doubters. Workers visited 10 facilities in six states, including Starr Commonwealth in Albion, Mich., and Glad Run Lutheran Services, outside of Pittsburgh.

“They saw a difference that was working,” Masker says. “They came back believers, and they helped make other staff members believe.”

“The staff has to believe,” he adds, “or you merely drive [unwanted] behaviors underground.”

Holston found that constant staff training – as one Holston memo said, “training, training, training” – was critical. Holston has a staff turnover of 25 to 28 percent a year, Bailey says. Both new and old staff members must be cautioned repeatedly against improvising, reverting to old methods or using restraint practices learned elsewhere.

One worker was fired after he used a restraint technique that was not part of the training and didn’t report the incident for committee review, Bailey says.

New youth workers at Holston get four weeks of “core” training – 84 hours of classroom work and one week on the job. The TCI training program for crisis intervention takes 24 of those hours. Staffers get six hours of refresher sessions every six months.

Using a train-the-trainers approach, TCI says it has certified about 5,000 trainers at facilities in 40 states and several foreign countries. Bailey and two others at Holston are certified TCI trainers.

One important concept stressed in training is that touching an agitated youngster in a crisis situation or threatening consequences for bad behavior often triggers more aggression. The training encourages staff to get youths to talk about what’s bothering them and to make statements that reflect an understanding of how the youths feel.

“Statement of understanding should precede requests,” says Bailey, citing a TCI maxim, as in, “I see you’re upset. What’s going on?”

Holston administrators used their review process to track incidents involving restraints and to analyze the contributing factors.

They found, for example, that incidents often followed difficult phone calls from home or other bad news. “You have to be observant,” says Missy Mains, director of Holston’s boys’ residence. “They might get an upsetting phone call – and you’d have to recognize that.”

Many incidents occurred during so-called transition periods – after weekends or holidays that the youths spent back home.

Building Relationships

Holston’s new treatment philosophy, which it calls a “relational approach to care,” emphasizes one-on-one relationships between youth and youth workers. The idea is that altercations can be more easily defused when youngsters have close or trusting relationships with specific youth workers.

“Every student has one, two or three people who they’re more comfortable with,” says Davis, the principal.

“If the focus of their anger is on one staff member,” says Bailey, “others step forward and say, ‘Let me see if I can help.’ ”

Teenage residents at Holston with varied experiences in juvenile detention or other treatment facilities agree that the agency is different from others. “This is the best place I’ve been,” says a 17-year-old boy who’s spent eight months at Holston in preparation for independent living. “The staff, they’re always trying to talk to you.”

But a 15-year-old boy who has run away once and been physically restrained twice during his two-month stay declares, “I hate it here.”

Nevertheless, he admits that the restraints, one coming after he had had a “bad phone call,” prevented him from hurting other kids. “You’ve got a hundred things on your mind, and they keep asking questions. Sometimes, I actually end up feeling better,” he says.

Davis says teens often arrive at Holston with expectations about restraints based on their experiences elsewhere. “Some kids who’ve been to juvenile [detention], where the regimen is much tougher, come in with a mindset that ‘you’re going to have to restrain me,’ ” she says.
Holston staffers say they try to impress on these youngsters that things need not be that way.

“The staff here try every last resort before they put their hands on you,” says another 17-year-old resident. “I’ve been to several places, and this one is much better. They try to help you turn around, rather than try to frighten you into doing what they want you to do.”

The pivotal question for staffers in situations involving the possible use of physical restraint is whether the youngster is about to hurt himself or others. Bailey describes the approach by example: “If a kid was punching a hole in the wall – before, we’d restrain him,” he says. “Now, we would rather have kids wreck something than restrain them – that is, if it doesn’t put their or others’ safety at risk.

“If a kid hits a staff member who’s not injured, the staff member can back away. Some kids threaten all day long, but they won’t follow through.”

Showing Results

Holston’s statistics indicate that its approach has reduced conflicts. The agency reports that restraints steadily dropped from the high of more than 1,400 in 1998 to 378 in 1999, then 169 in 2000 and a low of 93 in 2001. The agency says there are fewer staff injuries, fewer runaways, more cost savings for workmen’s compensation, and less property damage and vandalism.

In the past, Davis says, “We were more focused on managing behavior than relating to kids. … Now we’re dealing with what’s behind the behavior.”

When Masker reported on Holston’s progress in the Child Welfare League of America’s Residential Group Care Quarterly in 2001, he says, 184 agencies from 49 states contacted Holston for information about its success. Mrock and Davis also reported on Holston’s efforts at CWLA’s annual conference in Washington in March 2003.

By then, restraints had actually risen to 157 in 2002; they dipped to 115 last year. Last November, after the number of restraint incidents hit 100, Bailey found that only 29 kids were involved, and that 13 of them were restrained only once. The rest of the incidents – 87 percent of the total – involved 16 kids.

“We have a few kids who continually have problems,” says Bailey, surmising that because of certain factors (including mild mental retardation), Holston’s group living approach “may not be exactly the right kind of program for them.”

But even as youth workers at Holston studied such details and searched for ways to further reduce the use of physical force, an unexpected phenomenon unfolded. Alumni of the Greeneville campus started coming back months later to visit the youth workers who had helped them.

Perhaps that doesn’t sound like such a big deal. But youth workers at Holston saw it as a significant triumph, another validation of the changes they’d made. Says Bailey: “The kids coming back was something that never happened before.”


Keith A. Bailey
Administrator of Best Practices
Holston United Methodist Home for Children
404 Holston Dr.
P.O. Box 188
Greeneville, TN 37744-0188
(423) 787-8771

Therapeutic Crisis Intervention
Cornell University
Martha Van Rensselaer Hall
Ithaca, NY 14853-4401
(607) 254 5337

Crisis Prevention Institute
3315-K North 124th St.
Brookfield, WI 53005
(800) 558-8976

Handle With Care
184 McKinstry Road
Gardiner, NY 12525
(845) 255-4031

Mandt System
P.O. Box 831790
Richardson, TX
(972) 495-0755