The NYS Justice Center for the Protection of People with Special Needs (Justice Center) is committed to supporting and protecting the health, safety, and dignity of people with special needs.   Justice Center efforts to fulfil this commitment include abuse prevention initiatives that target specific areas of abuse and neglect, such as this Spotlight on reducing the use of restraints and preventing the deliberate inappropriate use of restraints for people in care.  

Placing a person in a restraint puts the person and staff member at risk of trauma, injury, and even death.  According to one study, between 50 to 150 people die each year in the United States as a result of seclusion and restraint practices.  Furthermore, injury rates to staff in mental health settings where seclusion and restraint are used have been found to be higher than injuries that are sustained by workers in high-risk industries including lumber, construction and mining.iii Medical providers now recognize that placing a person in care in a restraint can be highly traumatic and often works against the model of trauma informed care.iii      While crisis management programs support the use of restraints when absolutely necessary, restraints are commonly used to address loud, disruptive, resistant behavior and can originate from a power struggle between a person in care and staff.iv The Medical Director’s Council of the National Association of State Mental Health Program Directors (NASMHPD) have deemed the use of restraint as a “treatment failure,” and recommend a focus on preventing the use of restraint and seclusion.  Given the risks associated with restraints for everyone involved, it is important to aim to find safe alternatives for de-escalating and preventing a crisis.  

Commonly used crisis management programs currently in place at provider agencies in New York State include: 

  • Positive Relationships Offer More Opportunities to Everyone (PROMOTE) 
  • Strategies for Crisis Intervention and Prevention Revised (SCIP-R) 
  • Therapeutic Crisis Intervention (TCI),  
  • Crisis Prevention and Management (CPM) and  
  • Preventing and Managing Crisis Situations (PMCS).   

These programs encourage the use of a wide range of non-physical skills, prevention and de-escalation techniques to assist staff in reducing the need for a restraint.  Crisis management programs provide staff members with the skills and knowledge needed to recognize patterns or cues, including environmental factors and the effect of staff’s interactions which precede a person in care going into crisis.  In addition, these programs encourage debriefing for the person in care and all staff members involved to identify necessary supports and steps that need to be taken to return to normal conditions.   

Despite the availability of these crisis management programs, the Justice Center has received numerous reports of incidents involving a person in care being subjected to a deliberate, inappropriate use of a restraint.  A deliberate, inappropriate use of a restraint is defined in NYS Social Services law.  It means the technique or amount of force used, or situation in which the restraint was used was inconsistent with a person’s treatment plan, generally accepted treatment practices and/or applicable state laws, regulations or policies except when the restraint is used as a reasonable emergency intervention to prevent imminent risk of harm.v  Restraint is defined by statute as any manual, pharmacological or mechanical measure or device used to immobilize or limit the ability of a person to freely move their arms, legs or body.  

The Justice Center analyzed two and half years of data on substantiated cases of deliberate inappropriate use of restraints to identify the factors contributing to this form of abuse, and to identify strategies to prevent it.  Twenty-three percent of these cases involved a category two substantiation for deliberate inappropriate use of restraints indicating that the staff who conducted the restraint seriously endangered the health, safety or welfare of a person in care.  The information and documentation collected during the investigation that was included in the case record was analyzed to develop this Spotlight on Prevention.vi  The findings support current research on restraints that reinforce the importance of rigorous use of prevention and de-escalation strategies to prevent hands on interventions and to keep everyone safe.vii   

The areas analyzed included: 

  • precipitating factors leading to the restraint,  

  • time and location of the restraint,  

  • demographic information on the person in care and staff member(s) including length of employment of the staff, and  

  • injury and/or impact of the restraint on the person in care.   

The leading precipitating factors to the deliberate and inappropriate use of a restraint were verbal or physical aggression by either the person in care or the staff member(s) and/or evidence that the person in care was agitated.  This data suggests that power struggles between staff members and people in care can unnecessarily escalate a situation.  This finding reinforces the importance of more rigorous efforts to use consistent and well thought out prevention and de-escalation techniques to avoid unnecessary physical contact.  De-escalation techniques did not appear to be applied effectively in the substantiated cases reviewed.   

Over ninety percent of the cases reviewed involved the use of a manual restraint and the majority occurred during the day in a common area within the program.  This finding indicates there is a high likelihood that there are often witnesses to the restraint who may also be impacted by the event.  Given the high rates of trauma in the people served, it is important to ensure that everyone, including those who witnessed a restraint, are debriefed and offered support.   

The age range for the victims involved in the deliberate inappropriate use of a restraint was between nine and eighty-five years of age, with a median age of seventeen years old.  The victims were primarily male.  The length of employment for the staff person involved in the substantiated allegation of a deliberate, inappropriate use of restraint was also examined.  Some staff involved in these substantiated cases had been employed less than a year and others had been working in the field more than five years.  These findings reinforce the importance of a thorough debriefing of both the staff member(s) and the person in care as an opportunity to learn from the incident including identifying the precipitating factors to the restraint, assessing effectiveness of the intervention, and identifying de-escalation and crisis prevention skills in need of improvement.   

The deliberate inappropriate use of a restraint resulted in a physical injury sixty percent of time in the substantiated cases reviewed.  The most common injuries included head injuries, scratches, scrapes and bruising.  In several cases the person in care demonstrated psychiatric distress following the restraint.   

Programs that have reduced or eliminated restraints have reported a number of positive outcomes including: reduced injuries to people in care and staff, reduced staff turnover, high staff satisfaction, reduced lengths of stay for people in care, sustained success in the community after discharge and a significant cost savings.viii  An environment that emphasizes a commitment to safe, therapeutic, and trauma informed care can be promoted by setting a goal to reduce or eliminate restraints, monitoring the use of restraints, and supporting staff members to ensure that they are receiving the training and self-care they need.  

Whether you are a person receiving services, care provider, agency administrator, friend or family member, or advocate for people receiving services, you have an important role in preventing a needless tragedy from happening.  The information provided in this toolkit is aimed at raising awareness of the serious dangers of restraints, and encouraging the reduction or elimination of restraints by promoting positive alternatives.  The toolkit includes: 

  • case reviews and lessons learned; 

  • fact sheets for providers, staff members, advocates and people in care;  

  • a sample debriefing policy; and 

  • a sample staff self-care document. 

 

 

 

 

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