13 June, 2012

What are restraints?

A lot of staff people talk about restraints like they are not the greatest thing, but it seems like they don't understand what is wrong with them. I am not an expert but this is just how I feel.

I think a lot of people feel like restraints are bad because they are scary-looking. To be honest a lot of people don't even seem to feel that much(1), but anyway. Some people and places are "restraint-free." They believe in being gentle. The question is: is gentleness restraint-free?

I have always been told stuff like, ask someone what shirt they want to wear not whether they want to get dressed(2). Make statements about what's happening, don't ask questions. The idea is that if you do this the idea of disagreeing with what you're doing won't even enter the person's head. Which is supposed to be the ideal thing--no conflict. But these "tricks"--presented as innocently as advice on how to transfer someone--are intended to keep a person from making decisions about their own life that might be inconvenient to you. Is this extremely different from physically making it so the person can't move?

Picture a staff person who reacts with complete sweetness and friendliness to a resident who's trying to do something like get up when he is supposed to be asleep. The staff person distracts the resident with conversation while gently guiding him back to his bed, and it seems that she has successfully caused him to forget what he had planned to do.

I can't think of any supervisor I know who would watch this interaction and not come away thinking, "wow, what a good staff person." The person is avoiding conflict and keeping the resident (apparently) calm and happy, while still efficiently controlling him. The supervisor might even think that this is a staff person who really cares about her residents because she is so "gentle" and didn't do anything that came off as angry or aggressive.

But what is actually caring about not allowing someone to make a choice, and not even having enough respect to tell them what you're doing? Is it caring to try to trick someone to the point that they won't even know what is going on? (If someone has a disability like dementia, is it really going to help them keep skills as long as possible if you are trying to control them by making them confused?)

There are other things that aren't always recognized as restraints, like failing to offer someone the support they need to do something you don't agree with. But I feel like these this are sometimes recognized as restraints. Like in Ohio, leaving someone in a locked wheelchair is a restraint, which seems to be along the right lines. (Chairs are not though, which is weird since at least some people could unlock a wheelchair.)

I feel like the idea is that it's bad to do something that would look immediately abusive at a glance or look like someone's stereotype of a restraint. Merely being controlling isn't recognized as wrong and the implications and affects of trying to manipulative someone into doing what you want are not considered.

(1)In my nurse aide class, we were told that while we would be shown how to put someone in restraints, we didn't need to learn how to do it because it was no longer on the state test. As part of the class we were taught and tested on lots of things that could be considered attitudes or ethics, like "don't try to convert residents to your religion" or "be willing to listen to a resident talk about their problems." Our various teachers, who were nurses, would give us advice from their experiences about how to treat residents properly.

But absolutely no subjective comments were ever made about restraints and why they were no longer on the state test. No one even said, "it's better not to use restraints" or the most basic thing in support of more facilities being restraint-free.

When one of our teachers put a student in a restraint to show us, everyone just watched like it was normal. Except one girl was really creeped out. She said, "I have a friend who can't stand being held still and if you did that to her she would go crazy. Anyone would go crazy if you did that to them. It's wrong." She said this almost to herself, not like she expected a response, and no one gave her one.

(2)When I described this "trick," Pancho Ruiz suggested that it could work not because the person has actually been kept from considering other options, but because assuming consent like this would be sufficiently scary to stop the person from disagreeing with staff.


  1. As always, I love reading your take on things. I don't really have a response in the institutional context, BUT. . .

    We do the verbal judo (that's what they call it in the airline industry. They teach it to flight attendants as a way to "verbally disarm" a passenger who is violent or panicked) thing with Lily. So your post made think specifically about how we parent her. And probably it's not the same as what you're talking about, but I'll share anyway. . . cause you know. . . that's what I do.

    When we get Lily ready for school if we present her with a question about whether she wants to put on shoes, for example, she will say no. Putting her shoes on her then seems almost like reinforcing to her that no matter WHAT she says, it's going to happen. That she has zero agency and that our questions are meaningless. So we don't ask. We say, "time to put on shoes." This limits her options, as you suggested, but. . . really, she has to go to school. . . with shoes on.

    Lily also does better at making "her own decisions" when her options are limited. If we ask her what she wants to watch on TV, she may not answer at all, stuck on all the possibilities, or she may pick something and then when we give it to her immediately move on to the next thing then the next. . . but if we hold out two DVD's that we know she enjoys and say, "Lily which movie do you want to watch?" she'll typically pick one and be okay with it.

    Again, we're limiting her options. . . but she does SEEM to function more contentedly when her options are limited, when there aren't so many questions or possibilities to consider.

    1. I appreciate why Zoe responded the way she did but I actually was thinking about some of what you are saying, I just didn't include it in the post because I thought it wasn't really on topic. Because they really are different things even though they might superficially look the same and even be hard to tell apart.

      It might seem like the thing that allows someone to be the most independent and in control of their life is asking "What do you want to do?" or "When do you want to get up?" But this isn't necessarily true at all for some people with disabilities or some certain kinds of life experiences.

      Like if you keep asking someone "what do you want to do" and the person is so overwhelmed they can't respond, that isn't supporting them in making their own decisions! In some situations I would even think the person asking the question could be taking advantage of the fact that they're effectively making the other person helpless. Or even if they are just being ignorant...they would do a better job if they understood how best to help the person approach decisions.

      So being like "here are some things you could do, which one or ones look most appealing?" could actually be you caring MORE about a person's right to make their own decisions even though the same question could also be the opposite.

      This also covers some related things at some point to what you were saying about how Emma can argue with you: http://www.farnorthernrc.org/mylifemychoice/Dave%20Hingsburger.htm

      I know it's about sex so it seems a little early but I find all the ideas pretty cool and applicable to other things. Like when he talks about saying your kid can't go to the mall to get a piercing but that's a different thing to say if your kid can't drive and doesn't have friends who can drive.

  2. I find NTs don't understand control issues with autistic people, maybe because they are so immersed in it, and everything has to do with control. They see us and want to "help" and help is equal to control - they can't always disentangle the two. I also find that children and adults both don't resent legitimate power differences. Example: You must go to school with shoes on. Or: At this facility, residents must ___ (whatever the rule is). But people get irritated when staff are just making up rules in the effort to "help" (meaning control), but knowing that it is not a real rule, they soften it as a pseudo-question like "don't you wanna sit over here?" - a question with only one correct answer. If the person being controlled is an autistic child, they often get really irritated at being dishonestly manipulated, and that irritation is then considered the kid's behavior problem.... arg.

    1. I agree arbitrary rules are rubbish. . . One thing we struggle with is the number of times we say "no" to both kids. The older NT child tests boundaries and pushes back and sometimes I find myself backpedaling internally wondering exactly why "no" HAD to be "no". At that point I'm either committed or, on occasion, give in and agree that "yes, you're right, there's really no good reason why you can't."

      My younger daughter, however, can't communicate that push back as understandably, except, I suppose, via behavior, which can make her point pretty eloquently.

  3. Jim, the difference is - your daughter is a child and you are her parents. That's different from people limiting the choices of adults who they supposedly work for. As in, so utterly different that what you're talking about is fairly irrelevant to what Amanda's discussing. Like it's cool that you're reflecting on your parenting, but at the same time I feel like you're making something about you that is actually about institutional abuse.

    1. there's definitely a difference. I didn't intend to hijack the topic. i think I indicated I didn't really know how to respond in the institutional context.

      Maybe it's a bad habit, but when i read posts, especially the ones I enjoy, I try to leave at least SOMEthing indicating. . . "hey, i read it, I liked it, it made me think." And Amanda's topic made me think about how I parent Lily, on or off topic.

      And I'm not really trying to make it about "me" so much as frame my response in a way that makes sense to me. . . which is to relate it to something I have experience with. Are the two topics really so different?

      The staff member who successfully limits the residents' options by redirecting or rephrasing a request is praised as "good". . . Amanda's point seemed to be. . . "is it really good, or are we removing options; resticting/restraining choices?" As a parent I do that every day. It just made me think. . . is that good parenting? Maybe sometimes it is. . maybe sometimes I should be more cognizant of developing Lily's ability to MAKE those choices instead of removing the option.

      I guess the alternative is to just read the post and not comment.

  4. Hm, Zoe, I'm not sure I agree. I think there are definite parallels between institutional forms of authority and the power parents have relative to children. Simply having a parent isn't the same as being in an institution, but people can definitely be raised in a way that they are damaged in a similar fashion to someone who has been institutionalized.

    I think Jim is actually being pretty discerning to see that this issue in one context might be relevant to him in another context and that as a parent he has to figure out what is helpful and what is manipulative/controlling/dangerous/etc.

  5. There are certain patterns of power abuses that are common to all institutions — all the way from jails (which exist entirely to limit people's personal freedom) to schools and hospitals, which ostensibly have other missions. But all institutions enforce arbitrary rules which are more about asserting power hierarchies and making things convenient for staff than they are about the needs of the people the institution serves.

    On top of this, there are certain groups (old people, people with disabilities, people with mental health issues) which our society routinely represents as incapable of making their own decisions, and so it's standard practice to infantilize and manipulate them — even in individual interactions outside of institutions.

    Finally, there's this power relationship that happens in health care settings, in which the "doctor" (or other care provider) is the expert and always knows what's best for the "patient," and so it's OK for providers to try to trick patients into doing things "for their own good."

    Long term care facilities are a convergence of all five of these factors: institutional setting/health care field, residents who are old AND disabled AND have mental health issues. Those power imbalances play out in day-to-day interactions as you've described many times here, and it's kind of horrifying. I think there really is no way to run a long term care facility (or MH facility) that truly respects the dignity and autonomy of residents — there are too many ways it can go wrong. Even when individual caregivers understand that certain ways of interacting are fucked up, there is just not much you can do as an individual when the whole system is rotten.

    I think it's almost always better to provide this kind of care in people's homes, and it's exciting to see that some states are moving on health care reform that directs more Medicare/Medicaid resources to in-home care and away from institutions. There are still power problems with in-home caregiving, of course, but the ones in institutions seem much more hard-wired.

  6. restraints like strait jackets are comfortable to ware and dont hurt anything but your dignity. 4 point reatraints are what hurt because you are allways in one posistion for hours or days.. restraints are needed doing without them is asking for trubble and is dangerous.. i been there under anger menegment and they are needed. it took 6 orderlyes to slow me down. what do you think would happen if somone that cant controll himself acts up and is not stoped.

    1. Dude what the fuck are you talking about? What does that have to do with trying to control tiny parts of a person's daily life?

  7. "I also find that children and adults both don't resent legitimate power differences. Example: You must go to school with shoes on. Or: At this facility, residents must ___ (whatever the rule is). But people get irritated when staff are just making up rules in the effort to "help" (meaning control), but knowing that it is not a real rule, they soften it as a pseudo-question like "don't you wanna sit over here?" - a question with only one correct answer."

    This makes so much sense! As an autistic self-advocate who also works with disabled people, I wrestle a lot with how to be a 'good' staff person. One thing I've been wrestling with is the difference between being controlling and keeping the person safe. And you just made it clear in my head. I should have seen this sooner.

    As a child (and still now, to a less absolute degree), I would only obey a command if I knew there was a valid reason behind it. I've heard some people claim that when children ask 'why?' about rules it's a delaying tactic - well, for me, it was a serious question, and if you gave a good answer I was instantly compliant.

    I may not always tell the person why, if they don't ask. But I should try to make sure I have an answer to why I'm making the person do this. For example 'I'm making you stay in the gym so both me and the program coordinator can see you and ensure that you're safe.' That would be something I'd have understood and accepted as a kid. Whereas 'I'm making you go into the pool when you don't want to because I know you'll like it once you're in there' is *not* acceptable, because they're better equipped to know that than I am.