The Complexities of Physical Restrain in Residential Child Care: A Call to Action
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Presentation by Dr Laura Steckley at the SIRCC Conference 2019
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The Complexities of Physical Restrain in Residential Child Care: A Call to Action
- 1. The Complexities of Physical Restraint in Residential Child Care: A Call to Action Laura Steckley SIRCC Annual Conference, 4 June 2019 CELCIS/School of Social Work and Social Policy University of Strathclyde
- 2. Aims • To facilitate consideration of physical restraint from multiple perspectives, including: • Care experienced people, direct practitioners, close-in managers, external managers, care inspectors • Ways of understanding the phenomena and the wider context within which it takes place. • To (further) energise efforts, turning them into a collective endeavour to: • reduce and where possible eliminate physical restraint in residential child care establishments; • and where physical restraints do occur, to increase the likelihood that they are (and are experienced as) an act of care rather than brutality.
- 3. In order to provide developmental care to children and young people whose development has been interrupted, we need to bring our heads, our hands and our hearts to the endeavour. Physical restraint is a clear example. Knowing, Doing and Being
- 4. Some Basics • Definition ‘an intervention in which workers hold a child to restrict his or her movement and [which] should only be used to prevent harm’ (Davidson et al., 2005. p. viii). • Criteria: • Serious, imminent harm • ‘last resort’ • Least amount of time and force necessary. CompositioninRed,BlueandYellow,Mondrian
- 5. Language • Physical restraint, safe holds • Pain-based behaviour • Love • Containment, contained.
- 6. Containment ≠ Constrainment Term is often (mis)used disparagingly to mean keeping a lid on or warehousing kids.
- 7. Containment • Involves the development of thinking to manage experiences and emotions. • This development can be disrupted due to adverse early life experiences. • Reflected in our language – e.g. ‘falling apart at the seams’, ‘trying to hold it together’. • Experiences of uncontainable emotions and experiences are normal; they can be the everyday norm for some. • Useful in thinking about adults’ and organisational processes as well. • The experience of being contained can restore the ability to think and self- regulate; multiple experiences can help to develop it when that development has been disrupted (Steckley, 2010) WilfredBion,FatherofConttainmentTheory
- 9. Containment for Containers Necessary nesting function of containment Containing relationships & processes between staff and young people Systems of Staff Support Staff meetings Consultancy Supervision Other functions of management
- 10. When the environment, processes and relationships are robustly containing… i.e. they absorb and make experiences and emotions more manageable, more containable… the need for physical restraint will be reduced or rendered unnecessary. Physical restraint is the most extreme form of containment • Therapeutic, developmental, restorative containment Or • Crude, even brutalising containment.
- 11. Trauma SelfPortrait,JaneFox • Most linkage of trauma and restraint is around potential of restraint to traumatise or re-traumatise (Allen, 2008; Mohr, 2008). • In addition, what must be considered: • Trauma history of children and young people – developmental trauma • Trauma history of carers • Links between trauma, aggression and violence • Vicarious trauma
- 12. Secure Care Census, 2018 Represents snapshot of all children and young people in secure care on 1 day in 2018 (Gibson, forthcoming)
- 14. • 70% of child welfare workers reported at least one ACE category • 54% two or more; 16% four or more • 31% reported four or more ACE categories
- 15. Complexities and Tensions Assessment of serious, imminent harm: • How serious? How imminent? Whose harm? • Under conditions of threat, adrenaline, own possible triggers. • Authoritative vs. authoritarian • Assessment of the young person, other young people, fellow practitioners, organizational expectations. Last resort: • How far is too far? Wider Context • RCC last resort. • Stigmatisation, of children and young people, of staff. • Issues of recruitment and retention. • History of no qualification, low qualification, wrong qualification. • Setting-specific questions (secure, services for younger children)
- 16. Restraint and RCC as Last Resort • Significant evidence that some (sometimes a majority of) children and young people with experience of both, prefer residential care to foster care (Anglin, 2002; Berridge & Brodie, 1998; Duncalf, 2010; Hill, 2009; Lawlor, 2008) • Too many children and young people must “fail their way” into residential care (Whittaker et al., 2015, p. 330). • multiple placements • broken attachments, blocked attachment • stigma • (further) developmental trauma
- 17. Experiences and Meaning Large-scale, in-depth qualitative study of experiences and views of physical restraint in RCC: • All young people spoke of negative experiences of physical restraint • Over a third also spoke of some restraints having a positive impact on their relationship • Distinguishing factors – good reason, whether hurt, what happened after • Overall a theme of trust – avoidance, trying to help, feeling understood (Steckley, 2010, 2012)
- 18. Touch and our Bodies • Comparative study – Denmark, Hungary, England – Early childhood (Jensen, 2011). ‘The body is allowed to be there’ in Danish practice, as opposed to ‘the way the body has been reduced to a head’ in English practice • A significant minority of young people (10%) and just under a quarter of staff spoke of restraints being used for release: to cry and get out anger. • Many were linked to multiple restraints; over half of the staff also spoke of being unable to break out of cycles of repeated restraints, and over 20% connecting this as a factor in placement moves. (Steckley, 2012, 2018)
- 19. What’s needed • Dialogue • Professionalism – to define in terms of what children and young people need (and tell us they need), to demand, and to live up to • Fortitude to hold the complexity – in all of the levels (individual, organisational, systemic, societal) • Tolerance for ambiguity, uncertainty, the counterintuitive • Humility • Thinking outside the box: alternatives (e.g.sensory integration rooms) • Rigorous engagement of our heads, hearts, hands and bodies – a synthesis of knowing (in all its forms), doing and being.
- 20. References • Allen, D. (2008). Risk and prone restraint: reviewing the evidence. In M. A. Nunno, D. M. Day, & L. B. Bullard (Eds.), For Our Own Safety: Examining the Safety of High-risk Interventions for Children and Young People (pp. 87- 106). Arlington, VA: Child Welfare League of America, Inc. • Anglin, J. P. (2002). Pain, normality, and the struggle for congruence: Reinterpreting residential child care for children and youth. New York: The Haworth Press. • Berridge, D., & Brodie, I. (1998). Children's homes revisited. London: Jessica Kingsley. • Duncalf, Z. (2010). Listen up! Adult care leavers speak out: The views of 310 care leavers aged 17-78.Manchester: Care Leavers’ Association. • Emond, R., Steckley, L., & Roesch-Marsh, A. (2016). A Guide to therapeutic child care: What you need to know to create a healing home. London: Jessica Kingsley Publishers. • Gibson, R. (Forthcoming). Secure care census 2018. Glasgow: Centre for Youth and Criminal Justice.
- 21. References • Hill, M. (2009). Higher aspirations, brighter futures: Matching resources to needs report. Glasgow: Scottish Institute for Residential Child Care. • Jensen, J. J. (2011). Understandings of Danish pedagogical practice. In C. Cameron & P. Moss (Eds.), Social pedagogy and working with children and young people: Where care and education meet. London: Jessica Kingsley Publishers. • Lawlor, E. (2008). A false economy: How failing to invest in the care system will cost us all. Retrieved from https://neweconomics.org/uploads/files/f2728c5a93ccafac8c_55m6i2k0o. pdf • Mohr, W. K. (2008). Physical restraints: are they ever safe and how safe is safe enough? In M. A. Nunno, D. M. Day, & L. B. Bullard (Eds.), For Our Own Safety: Examining the Safety of High-risk Interventions for Children and Young People. Arlington, VA: Child Welfare League of America, Inc.
- 22. References • Steckley, L. (2010). Containment and holding environments: Understanding and reducing physical restraint in residential child care. Children and Youth Services Review, 32(1), 120-128. doi:http://dx.doi.org/10.1016/j.childyouth.2009.08.007 • Steckley, L. (2012). Touch, physical restraint and therapeutic containment in residential child care. British Journal of Social Work, 42, 537-555. doi:https://doi.org/10.1093/bjsw/bcr069 • Steckley, L. (2018). Catharsis, containment and physical restraint in residential child care. British Journal of Social Work, 48(6), 1645-1663. doi:https://doi.org/10.1093/bjsw/bcx131 • Webb, R., & Johnson, D. (forthcoming). The association between traumatic event exposure , post-traumatic stress disorder and aggression of looked- after young people. The Scottish Journal of Residential Child Care.
- 23. References • Whittaker, J. K., del Valle, J. F., & Holmes, L. (2015a). Conclusion: Shaping the future for therapeutic residential care. In J. K. Whittaker, J. F. del Valle, & L. Holmes (Eds.), Therapeutic residential care for children and youth: Developing evidence-based international practice. London: Jessica Kingsley.
- 24. Physical Restraint in Residential Child Care: Reflections and What Next? • Are you interested in contributing to a collective response to what you have heard today? • Join us in Room 506b, Level 5, Strathclyde Business School on Wednesday 12th June from 10.00-12.00 • Contact gordon.main@strath.ac.uk for more details
Editor's Notes
- Residential child care practice is intellectual work. By this I don’t mean it can or should only be done by brainy people. I mean that, to do it well consistently over time, it requires us to apply our intellect. It also requires us to engage with different forms of knowing – knowing that comes from the lived experience of being in care; knowing that comes from the lived experience of providing care, in all its myriad forms, knowing that comes from research and other forms of evidence, and knowing that comes from the road maps that have been tried and tested – theory. And we be open and scrutinise all of these forms of knowing, being curious and tolerating the uncertainty it brings. Our intellectual engagement, our emotional engagement, and our active, physical, tangible engagement are all necessary, but none of them are sufficient without all three being present. I would go so far to say that not incorporating any one of these on a regular basis in our practice, whether that be direct practice or indirect practice, is not acceptable. Just as it is unacceptable to be heartless in this work, or hide in the office avoiding young people day after day, it is also unacceptable to do this work without thinking deeply about what we are doing and continually building our knowledge to support that thinking.
- Language House/home/unit Physical Restraints/Safe Holds (from Holding Safely) You may have noticed already that we have avoided simply using the term restraint and instead have referred to restraining a child as just that – restraining a child. We deliberately chose to change this language to avoid losing sight of the child, who might otherwise be overlooked by the more clinical and depersonalised use of the word restraint. Physically restraining children is something which causes many staff, as well as children, a lot of anxiety. As it should – even when done properly it can be a traumatising experience for children and staff alike. As a result, some people may not want to be explicit about restraining children, and instead emphasise only the positive experiences of children in residential care. We donʼt believe this is good enough. Containment
- Developmental trauma and effects on ability to self-regulate, form and maintain relationships, know one’s own feelings, needs and motivations, use thinking to manage experiences and emotions.
- Extraordinary piece of research in relation to response rate – almost unheard of – related to the engagement of the researcher (who is also in direct practice with children and young people in relation to participation).
- First study was done in large, US RCC service (360 employees. 94 responded to survey. Second study : 250 child welfare professionals in one US state (Iowa)
- Children’s rights while still needing to hold boundaries, limits within a wider context of stigma and suspicion. Tolerance for disruption – a good shift isn’t always a settled shift – boundaries without repression Direct focus on physical restraint versus focus on culture, wider meeting of needs.
- Mention self-selecting nature of sample and how, albeit unavoidable, does skew the results.
- Professionalisation we need to claim what this means -- Love Stop catering to the lowest common denominator. Holding the micro and macro Humility Tolerating what’s counterintuitive, ambiguous or uncertain. Rigorous engagement of our heads, hearts and hands.