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By Laura Steckley

Date Posted: Saturday, 12 December 2009
Laura Steckley is the Course Director of the MSc in Advanced Residential Child Care at the Glasgow School of Social Work, a Joint School of the Universities of Strathclyde and Glasgow. In this article she examines the use of physical restraint in residential child care and, linking it to aspects of psychodynamic theory, argues that if deployed at the right time, for the right reasons, in the right way and in the right wider circumstances, physical restraint can be a part of an overall therapeutic experience for some young people. She also stresses that by providing therapeutically containing environments for young people and staff, physical restraints can be reduced and, where possible, eliminated. Therapeutic Containment and Physical Restraint in Residential Child Care Introduction
Sometimes it can feel like walking on a knife edge-this work in residential child care. Decisions often have to be made quickly under intense pressure, and the consequences of those decisions may have long term and significant impacts. Sometimes it can appear no good decision is possible, just a choice between wrong ones. Physical restraint is firmly located on possibly the sharpest edge of practice.

There have long been concerns about physically restraining children. The potential for things to go wrong is great. Restraint has been and probably continues to be misused, violating children's basic rights, damaging the relationships that are meant to heal, and sometimes traumatising or re-traumatising children. Even when properly implemented, there remain significant risks of physical and psychological harm-both to children and to staff. Yet, some children in residential child care have had such damaging life experiences that they act out their pain and confusion in harmful ways. And sometimes, staff are unable to find a way to keep everyone safe without resorting to restraining a child.

This piece will discuss a large research study in Scotland that explored the views and experiences of staff and children in residential child care related to physical restraint. While much of what has been written about physical restraint has been negative, the findings of this study reveal a subtler and more complex picture-one that can be better understood by applying theories of therapeutic containment and holding environments. These theories will be explained first and then used as one way of making sense of what study participants had to say.

Before starting all that, though, it makes sense, first, to define exactly what is meant by restraint. In some countries, chemical restraints (drugs), mechanical restraints (chairs or beds with straps) and/or locked rooms are used to stop behaviour. In Scotland and for the purposes of this piece, physical restraint is defined as:

an intervention in which staff hold a child to restrict his or her movement and [which] should only be used to prevent harm.

Also, in this piece the terms 'child' and 'children' are used to refer to all young residents of residential child care, with no disrespect to those older children who are sometimes referred to as 'young people'. It is simply less clumsy than 'child and young person' or 'children and young people'. It also bears reflection that the young people referred to in this piece are still children, legally and in many ways, developmentally.
Therapeutic containment
The term 'containment' can often be used in residential child care pejoratively-simply to mean 'keeping a lid on things'. It can also have a connotation of controlling or constraining. Actually, the concept of therapeutic containment offers a way of understanding the needs of children, and the needs of staff for that matter, that can ground the work in residential child care and give it a beneficial focus.

The concept of containment was introduced by Bion . He described the importance of the parent or primary care giver (in Bion's day, the mother) hearing her infant's distressed cries and responding with nourishment, a nappy change, holding, rocking or whatever was needed-but most importantly, a response that is soothing and provides comfort. The infant goes from a state of unbearable pain, discomfort, fear or confusion to a state of comfort and of everything being manageable again. Essentially, the parent 'takes away' the unbearable, or uncontainable, and replaces it with something manageable. This process, which starts at birth and happens again and again, over days and weeks, months and years, makes possible the development of thinking in order to make sense of and manage raw experience and emotion. This ability is so fundamental that it is often taken for granted, yet it is vitally necessary for human development. Unfortunately, many children (and their families) face difficult circumstances and experience significant disruptions to these early processes of containment.

As children grow, processes of containment also take on the dimension of adults helping them to make sense of and learn from mistakes and painful experiences. This adds to the process of the child developing the capacity to manage (or contain) previously unmanageable (or uncontainable) feelings.

Many children in residential child care have not had 'good enough' experiences of containment, and as a result, their cognitive and emotional development will have been affected. This can be the resulted of trauma, abuse, neglect or a combination of the three. It can also be a more subtle result of being cared for by adults who have not had their own containment needs met, either when they were children, at the time they are providing care, or both. A person who is unable to make sense of and manage their own experiences and feelings will be less able (or unable) to meet the containment needs of a child.

For children who have not had good enough experiences of containment, when negative feelings get triggered, they can be more intense due to the pain of 'unsoothed', unresolved feelings that also get triggered-similar to the pain of prodding an infected wound that hasn't healed properly. In addition, these children will have an underdeveloped ability to manage these more intense feelings. Double whammy.

Much of the work of residential child care is to provide therapeutic containment for children, helping them to develop the ability to better manage their experiences and emotions. While practitioners might not explicitly draw from containment theory, the idea of teaching children to 'talk it out' rather than 'act it out' will be familiar and resonates on a basic level with the work of containment.

Containment work, however, is complex and demanding. It involves helping children to feel safe and valued so that they can begin to make sense of painful experiences and emotions. This is not a free for all, where any and all behaviour is accepted because of the pain that underlies it. It also is not about creating a constricting environment in order to keep behaviour under control. Sometimes to provide containment means to poultice out rather than to dampen down. Often this means more tolerance and space for children to work through behaviours that make us uncomfortable. How different from the 'lid on things' way this word is normally used.

It is also important to highlight that therapeutic containment is an ongoing process, rather than an aim that is achieved. The processes of containment happen primarily within the context of relationships, though the physical environment, rituals, routines, clear expectations, predictable structures and use of activities in a residential child care establishment are important as well.

But it is not just children with difficult histories that require containment. We all need varying levels of containment at any given time. It is important to remember that containment is about the ability to use one's mind in order to make sense of and manage experiences and emotions. We all have better days and worse days in this regard, even if it (hopefully) is not nearly at the same level of difficulty as the children we care for. However, most of us can probably recall a time when we were so upset or distressed that we could not think clearly. We may have needed the help of another to get through the worst of it, and to gain some perspective. This is not necessarily a sign of not having 'good enough' levels of containment in our own childhood (though this is possible and should not be discounted), but is a normal part of being human.

The need for containment can also be much more subtle. Anxiety and other difficult feelings, which are regularly triggered in the day to day work in residential child care, do have an impact on clear thinking. And we can often be unaware of it. In addition, in the process of providing containing environments we often feel the intense, unbearable feelings that children are experiencing. This is called absorption. Children who struggle to understand or contain their feelings have an uncanny way of making the adults around them feel these feelings instead, and they do it unconsciously. There have been interesting studies that have charted, using brain scanning technology, the emotions of an upset infant being absorbed by the mother, those emotions being calmed by the mother, and then those calmer emotions being received by the infant. We can actually see the process of absorption taking place in the brain.

It is important to be aware of the processes of absorption. It is also important to be aware of and manage one's own feelings that can be triggered by children's behaviour. Staff can have feelings of anger, hostility, vindictiveness, fear and victimization, amongst others. Acting on them would be unprofessional and unacceptable, but because of this, staff can have difficulty being honest and talking openly about them.

It can be very difficult to separate out which feelings belong to the adult, and which are a product of absorption, particularly if no one acknowledges or speaks about them. This is why it is vitally important for organisations to provide containment for their staff. This also takes place within the relationships, physical environment, policies, practices and activities in place for adults. Staff need support to manage the difficult experiences and emotions that are part of this work. They need clear and reasonable expectations, and policies and practices that are congruent with meeting the needs of the children they care for. And, they need times and places to make sense of the complex and uncertain areas of their practice. The more obvious times and places for this are team meetings, supervision and sessions with a consultant. All too often, however, the opportunities to do this work are missed.
Containment and physical restraint
So what does all of this have to do with physical restraint? Physical restraint can be seen as the extreme, literal form of physical containment. In fact, some authors have referred to restraint as simply a form of physical containment. Given the seriousness of the practice, and the significant related risks, consideration as to whether or not a restraint is part of an overall process of therapeutic containment or whether it is simply a crude (and possibly abusive) form of containment warrants reflection. It may even be unhelpful to think in 'whether or not' terms. The way restraint is experienced can often be much more complicated than a simple either or proposition.

It may come as a surprise to consider physical restraint in a positive light at all, and indeed some children have experienced nothing positive in being physically restrained. However, other children have had positive things to say about their experiences. It is to all of these experiences, and those of staff, that we will now turn our attention.
The Study
This part of the piece will focus on a large study that explored the views and experiences of 37 children and 41 staff, from 20 different residential child care establishments all over Scotland. The table below gives more information about them.

Residential Child Care Establishments

Funding

Local Authority:10

Voluntary (not for profit) or Private:
10

Type

Children's Homes:9

Residential Schools:8

Secure:3
(+1 Close support)

Individual participants (people who were interviewed)

Children

Male26

Female11

Total37

Age range10-17 years old

Staff

Male17

Female24

Total41

Experience in Residential Child Care
1-29 years

Those people who were interviewed will be referred to as study participants, or participants. In interviews, staff and children were asked various questions about physical restraint, including: things that generally happened before and after the restraint; their thoughts about it generally; and their experience of a recent or memorable restraint. Before jumping into these questions, participants first were asked for their views about four different vignettes, or scenarios, where children were exhibiting behaviour that may be viewed as problematic or risky. Each vignette had three levels of escalation, and this part of the interview enabled participants to talk about what they thought should and should not happen in that situation. For some, it seemed easier to talk about some other situation and the vignettes gave them a way to share their views without having to talk in a more personal way. For others, they immediately linked what was happening in the vignette to their own experiences, quickly shifting into a more personal level of self-disclosure.

These interviews were recorded and then transcribed (typed up), word for word. These transcriptions were read over and over, and different themes were identified that were dominant across many interviews. There were several broad themes initially identified. The first was that staff and children were nearly unanimous in their view that physical restraint was necessary in certain situations. These usually related to occasions where there was harm happening or about to happen (though they often used other words, like risk or danger). Staff were also consistent in viewing restraint as a last resort, and that other ways of dealing with the situation should be tried, when possible, first. As interviews progressed, issues of what actually constituted harm and how far things should be allowed to go (while attempting other ways of dealing with the situation) proved to be far more complex, and there was less consistency in people's answers.

Children complained of restraints that were too rough, sometimes causing them soreness, carpet burns or other abrasions. Both children and staff spoke of witnessing or experiencing restraints that they thought happened too soon into a situation, and some which were simply unjustified (i.e. they did not perceived enough risk of harm to warrant the restraint). Children expressed a range of feelings about restraint, including: hatred or aggression towards themselves, hate or aggression towards staff, frustration, embarrassment, sadness, regret, and the most dominant emotion-anger. Some children also spoke more positively about restraint, arguing that they felt safe, cared about and glad that staff stopped them from doing something that they would regret. No member of staff spoke of experiencing positive emotions during a restraint. The dominant feelings they expressed included guilt, doubt and defeat, along with the physical experiences of distress.
Findings: containment and physical restraint
All of the names of study participants (used below) were changed in order to protect their privacy.

No participant spoke about the theory of containment in relation to their work. Some, however, talked about what can be called containing aspects of the care they provided, and this was particularly related to physical restraint:

Brenda : We have a few that recognize that they're out of control and by us holding onto them, it's just, just holding them until they calm down. They don't know how to calm down. They've never been taught. A wee guy I work with at the moment, I said to him 'it's like a baby learning to walk and talk'. He's just not learned how to control his anger yet and there's a lot of emotional stuff as well and, it's weird, I held him to control his anger. (staff)

Brenda makes an intuitive link between this boy's inability to control his anger and development that goes on during infant years. As discussed above, this is where many of the early processes of containment take place. Brenda also mentioned control. Around half of the staff interviewed also mentioned a child losing control as one of elements of in situations that lead to restraint. Some showed an awareness of how uncomfortable or distressing it can be for a child to lose control, and how taking control, even when it involves physically taking control, can sometimes be a relief for the child.

A few children also spoke about losing control, and this was most often connected with violence. They highlighted the important role staff took on these occasions in literally containing their violent behaviour:
Interviewer: So were you going to do something?
Andy : I was going to punch his lights out. I was going to blooter them.
Interviewer: So did you think staff were right or wrong in holding on to you at that time?
Andy : Holding onto me was right because I would have hit, I would have hurt that boy very badly.
Interviewer: OK, so the times they've held on to you
Andy : Because this boy, this boy was the same age as me but he was, I don't think, he wouldn't have the same strength as me.
Interviewer: Yeah, so they were protecting the boy?
Andy : Well they were doing what was right.
Interviewer: ... Were they protecting you in some sort of way as well by holding on to you?
Andy : Aye, they were protecting me from hurting another boy. I don't really like it, but if I lose my temper I can hurt somebody. (child)

Indeed, the loss of control can be a key indication that a child needs help with containment.

In addition to preventing harm and taking control of out of control behaviour, staff spoke about children who appeared to seek out physical restraint in order to meet touch related needs:

Jean : I think it's because physical aggression is the only way he knows to show how he is feeling, to get out his aggression, to get out of how he is feeling. It's like a younger child who is maybe having a temper tantrum, you hold them and this is his way of getting that physical, it's terrible but to me that's how it is. "I want this physical contact, I want you to hold me so I can get this out, get it over and done with because I don't know how else to do it." (staff)

For an infant, being held is indeed a central part of developing containment. Controlling forms of touch can often be involved in helping a toddler through tantrums. As children develop cognitively and emotionally, the need for frequent and intense forms of holding usually recede. This is sometimes not the case for children in residential child care. At the same time, trusting adults not to hurt and exploit them can be too great a demand for children who have been hurt and exploited by other adults. This can be an extremely difficult place for a child to be-literally unable to contain all of the pain and confusion, but also unable to conceive of anyone being trustworthy enough or able to help.

Some children spoke about purposely getting restrained or witnessing peers do so:

Jason: There's times where you need to be restrained and you feel yourself, there's some boys in here in the, even, see in [name of establishment] there's boys that speak to each other and like say, aye I feel like I like getting restrained to take my anger out away.

Interviewer: Some boys say they like getting restrained to get their anger out?

Jason : Aye, aye, some boys feel that's the way to take their anger away from them. (child)
Sharon: Some kids just need to be held to comfort them.
Interviewer: As a comfort thing?
Sharon: Yeah.
Interviewer: So sometimes do they get held when they haven't, when they're not putting anybody at risk, but they just need the comfort of being held? OK.
Sharon: Well they won't, but like you have to go mad before they can do it.
Interviewer: Oh, I see. So maybe a kid really just needs the comfort, but they have to kind of go into that 'putting at risk' place to be able to get the hold. Aye? That, what do you think about that?
Sharon: Well I've done it a few times.
Interviewer: Yeah? That's really honest. If there was a way to be able to get that need met without having to go mad, would you have liked to have had a way to do that?
Sharon: Hmm [affirmative].
Interviewer: Yeah?
Sharon: I don't know how to for, [pause] you don't, you need to get all your anger out and then you just go mad and then you need to be held. (child)

Sharon was 16 years old at the time of the interview and showed an unusually high level of candour and insight. This was likely due, at least in part, to being older and further along, developmentally, than most of the other young study participants. She also stated that she hadn't been restrained in over a year, explaining that she had outgrown it.

Is it possible that Sharon experienced therapeutic containment within her residential child care establishment, of which the physical restraints were a part? Or is it possible that if her residential establishment provided a more therapeutically containing environment, through supportive relationships and meaningful activities, that she would not have needed to have been physically restrained? Or both? Based simply on the interview, there is no way to know for certain. However, her ability to reflect on and discuss her experiences so insightfully, coupled with her statement that she no longer needed to be restrained, indicate the possibility of an overall therapeutically containing experience. Her discussion about staff also supported this possibility:

Sharon: Mine [physical restraints] were all pretty comfortable because I felt comfortable with those people...
Interviewer: How would you make a person understand what you meant by using the word comfortable?
Sharon: Like, you don't feel unsafe and some dirty person's going to hold me to try and do something to me and stuff. You feel comfortable with it. It's, I don't know. It's not like trying to hurt you or that, they're trying to keep you safe.

Sharon's trust in her staff is inherent in this quote and trust was a key ingredient for children in terms of their relationships with staff. Other children in the study spoke of the importance of trusting staff to do the restraint properly, not to hurt them and to avoid the restraint when possible. Some spoke of a general trust in staff to help them, or a more specific trust to help them avoid the behaviour that led to restraint. Some children also linked trust with feeling understood by staff.

Children also spoke of distrusting staff. Some differentiated between staff who tried hard not to hurt them, and those who did not; this was a criterion for whether they could trust. At least two children spoke of staff whom they believed restrained too roughly on purpose. One child indicated that he assessed whether he could trust a member of staff by how that staff restrained him.

Staff also spoke about the importance of trust; they also linked it to doing their best to help avoid the restraint and avoid hurting the child. Knowing the child, and responding based on that knowledge, was one of the most frequent elements of practice that staff emphasized in talking about trust, building relationships and responding to situations that may lead to physical restraint.

Relationships were discussed by children and staff alike, and their central importance came through as a dominant theme. When asked how they thought event(s) of physical restraint impacted the relationships between those involved, there were a range of views. Some children felt it damaged the relationship:
Interviewer: Did you have good relationships with any of the staff there?
Kevin: "Yeah, yeah."
Interviewer: How about the ones that restrained you? How were your relationships with them?
Kevin: "It was fine up until that day."
Interviewer: And then after that, how was it, how did it affect the relationship?
Kevin: "I hated them."
Interviewer: Yep, always after that you hated them?
Kevin: "Aye, and I wish I'd never met them."

Kevin's response was by far the most negative in answering this question, though close to a third of children did indicate negative impacts on their relationships. About half of these felt the impacts were more short-term, and the other half (including Kevin) experienced longer term damage.

Most children gave neutral replies, stating that they felt the restraint didn't have much impact. About a third of the children felt that their relationships had been strengthened:
Interviewer: What about the other side of the coin? Has it ever made you feel like the relationship's a bit better, in some way, after a staff member has held on to you?
Brian: Sometimes, because it makes, like, they're protecting me, man. They feel like you're, you feel like they're protecting you, so you feel got up with your confidence with them...
Interviewer: So you feel more confidence with them? Maybe trust?
Brian: Like, because I've only ever been held with the likes off of Collin, my key worker. That made me feel a wee bit better in my relationship with him.

Brian connected the improvement in the relationship with Collin with feeling protected, and this feeling of protection strengthened his confidence. It would seem impossible for this improved confidence to have occurred if Brian felt emotionally or physically harmed by the restraint, particularly if he felt it was intentional. It is also possible that Brian's increased confidence was a result of finding out that Collin could indeed contain whatever was going with Brian that led up to the restraint.

Staff also gave a similar range of views about the impact of restraint on their relationships with children. As these discussions progressed, with children and with staff, it became clear that it wasn't just the restraint that was responsible for the positive, negative or neutral impact. It was the whole situation, of which the restraint was only a part, and even the wider relationships and cultures within the residential establishments that affected how the child felt about the relationships afterward.
Discussion

We know that children have suffered terrible experiences of physical restraint. We know that restraining children carries serious risks, including physical and emotional harm, and even death. We know that some children speak in a remarkably neutral way about their experiences of restraint. Whether this because the subject matter was too personal to speak more candidly or whether they had experienced some form of emotional shut down, we don't know. We also know that some children have described their experiences of restraint in more positive ways. So what are we to make of this?

Thinking about restraint without an appreciation for wider related issues-issues of relationships, how behaviour is worked with, and ultimately how the work of residential child care is understood-will be unlikely to produce useful answers. Physical restraint affects and is affected by all of these issues.

Evidence of efforts to avoid restraint that seemed divorced from some of these wider issues did crop up in interviews. For example, one child spoke of running away from his children's home so many times (he cited 123) that he found himself in a deeply entrenched habit and on the verge of going into secure accommodation. While there may have been other relevant circumstances which he chose not to share, he did indicate that he wished staff had stopped him much sooner into this process-even if that meant physically holding him to stop him.

Another participant, this time a member of staff, spoke with pride about how she and her colleagues did not physically stop a child who proceeded to wreak devastating damage to all of the communal areas of the home-pride because she felt it demonstrated their commitment to avoiding physical restraint. She showed no insight as to the impact this may have had on the child's relationships with the other children living in the home, nor how it may have affected the child's own sense of self-control or self-worth.

Theories of containment offer one way of understanding the work of residential child care in a way that can reduce the use of physical restraint while still meeting the needs of children. Indeed, there was evidence of work happening in at least some of the establishments that could be understood as basic, but significant, containment.

For a staff member to be able to therapeutically contain a child in more extreme situations, situations that can lead to restraint, it is not simply the ability to physically hold that is so important. There can sometimes be confusion about this, with the result that some members of staff get thrust into a bouncer-type of role during escalating situations. When this happens, the use of physical restraint is much more likely. When the designated bouncer appears on the scene, most people involved expect one of two things to happen: either the child to back down out of fear, or the child to be restrained-in this case it can be considered a self-fulfilling prophesy. In either case, therapeutic containment is extremely unlikely. This type of situation more reflects crude containment.

This bouncer example highlights an important key to this discussion: how restraint is thought about affects how much it is used and how its use impacts those involved. While this might seem obvious, it is easy to lose sight of and, when examined more closely, one can see that this is a complex consideration. The above-mentioned situations of avoiding restraint in a way that did not seem in the best interest of the child may actually reveal a view of physical restraint as only forceful, violent and/or coercive. And across the establishments, staff and children certainly described their experiences of restraint in a way that matches such a view. In a previous article published in Children Webmag , Hegstrup writes about Winnicott's very similar theories of holding and relates them to physical restraint:

As time passed, holding was less and less used the way it was intended by Winnicott. Holding is now more than ever used as a restraint or "use of force" method. In practice it is less about holding the child's emotional and physical environment and more about using force to get the child to calm down. This process can be quite brutal and have the opposite effect on the child...

Because of this, Hegstrup argues that wherever possible, restraint should be avoided and that the child be 'held' in other ways, mainly through communication.

An important question remains, however, about how physical restraint is thought about: many writers acknowledge that it may not be possible to completely eliminate the need for physical restraint, and the participants of this study agreed. However, is it possible that our belief in its necessity makes it necessary? Or at the very least, prevents us from making it unnecessary? Our beliefs are extremely powerful; they shape our thoughts and our actions. Is the belief that it is possible to eliminate physical restraint while still meeting the containment needs of children (rather than simply abandoning them to their own destructiveness or to the hands of police) a necessary condition to make it possible to eliminate it? Certainly, theories of containment make it possible to imagine other ways of 'holding' children.

If the other elements of a therapeutically containing relationship and environment are strong, physical holding may indeed not be necessary. If children feel 'held' or contained, they may not end up in such extreme states of being uncontained-those states that manifest in behaviour that leads to physical restraint. These elements include: remaining emotionally available to the child, continuing to be authentic, genuinely conveying warmth and care, all while clearly and firmly holding child-centred boundaries in place. To be able to do this consistently and effectively requires knowledge, skill and personal strength; it also requires organisational support that enables clear thinking in the face of significant challenge. It requires that staff are provided with containment so that they can do containing work with children. Unfortunately, evidence of containment for staff was very limited in this study.

However, Sharon's candid revelations about her need to be physically held should not be too quickly dismissed. She was not the only child who spoke about using restraint in this way, and staff also spoke about situations where they perceived the child as making the restraint happen in order to be held. Reverting back to the days before methods of and training in physical restraint does not seem possible or desirable. Yet, we need to envision a way forward that enables us to meet the touch related needs of children. Whether this sometimes might involve holding is fraught with complex difficulties, but we must ask ourselves whether being held through one's most painful moments is a legitimate need? If so, we need to find a way to meet that need, when it arises, that is not simply equated with force and coercion. Particularly when the alternatives are more damaging.

For Winnicott, holding was used to help the adult and child develop a bond, a sense of trust and a feeling of security. Within this process, the adult used herself as a physical barrier to set a boundary and apply restraint-so that the child, over time, could develop self-restraint. For this to be possible, the holding had to be infused with firmness, but also with care, emotional availability, and respect for the child.

Clearly, in some of the establishments that participated in the study, physical restraint was also thought about as helpful and caring, albeit under difficult and violent circumstances. There were indications that staff were able to convey care and respect on some occasions of restraint. While the ability to remain respectful and convey care via one's affect, action and communication in the face of violence is an extremely tall order, it is one we must repeatedly rise to-whether to make it possible to help a child without resorting to restraint, or whether to make it possible that the restraint is part of an overall experience of therapeutic containment.
Conclusion
To be equal to the task of reducing or eliminating physical restraint, and to ensuring that when physical restraints do happen, they are experienced in a way similar to a significant minority of children in this study, requires commitment and resources. It requires the commitment and resources of front line staff to continually build their knowledge and skills, to fortify their inner strength and to honestly and candidly challenge themselves and each other in a way that builds trust, openness and clear seeing. For staff to be able to do this, establishments must commit to and resource forums and processes that support staff. These include resources for staff to gain adequate and relevant qualifications (calling into question current qualification requirements in the UK); ongoing investment in regular, relevant and effective training; ongoing support for robust supervision, staff meetings, and staff development days; and regular investment in outside consultancy that can help to provide containment for staff. At a wider level, political will is required in order that residential child care, and those working and living in it, are properly valued.

It is also necessary that relevant, useful theories for understanding children, and the work we do with them, guide the process of meeting their needs. Theories of containment show promise, but current misunderstandings and misuse of the term limits this possibility. The words we use reflect, and reinforce, our deeper beliefs and understandings. Perhaps by replacing the pejorative use of the word 'containment' with 'constRainment' or 'crude containment', along with using the term 'therapeutic containment' and the ideas associated with it to more robustly inform our practice, we may better yield the benefits it has to offer in helping us to reduce or eliminate physical restraint in residential child care.
This piece has been written primarily with the front line staff in mind. It has been drawn from a few academic papers, but has been written more as a practice paper. These articles are:
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.

Steckley, L., & Kendrick, A. (2008). Physical restraint in residential child care: The experiences of young people and residential workers. Childhood, 15(4), 552-569.

Steckley, L., & Kendrick, A. (2008). Young people's experiences of physical restraint in residential care: Subtlety and complexity in policy and practice. 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. Washington, D.C.: Child Welfare League of America.

If you have found this subject interesting, there is more related information in these articles and chapter. The guidance document, Holding Safely, was informed by the study discussed in this piece, and is available online at URL:
http://www.sircc.org.uk/library/practicepapers/holding_safely_complete
Click on the words: Holding_Safely.pdf

© goodenoughcaring.com and Laura Steckley : December, 2009

06 Jan 2010, Cynthia Cross writes

I found this an extremely useful and helpful article. I think that there is also a case to be made for "holding" not always being a last resort. If you are in a primary relationship with a child it is sometimes possible to hold a child (contain and calm them) before they become unmanagable and therefore avoid some of the distress to all concerned.

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Therapeutic Containment and Physical Restraint in Residential Child Care

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By Laura Steckley Date Posted: Saturday, 12 December 2009 Laura Steckley is the Course Director of the MSc in Advanced Residential Child Care at the Glasgow School of Social Work, a Joint School of the Universities of Strathclyde and Glasgow.

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Even when really good support plans are in place, there may be times when challenging behaviours occur. At such times, carers will often need to intervene in order to prevent harm to the person concerned or to themselves.

'Reactive strategies' are used once challenging behaviours occur and provide carers with clear plans for how to respond to them when they do. Their use will not result in any future change in the pattern of a person's behaviour. Their goal is simply to help carers achieve fast, safe, and effective control of challenging behaviours. Reactive strategies must never be used on their own, but should instead be employed within the context of an overall Positive Behaviour Support plan.

QUICK READ

Physical interventions

The term 'physical interventions' refers to any method of responding to challenging behaviour which involves some degree of direct physical force to limit movement.

There are three broad categories of physical intervention:

Direct physical contact between the carer and person with challenging behaviour (e.g. holding down of arms)

The use of barriers to limit freedom of movement (e.g. locked doors)

The use of materials or equipment to restrict or prevent movement (e.g. the use of arm splints)

Using physical interventions

This is a sensitive topic which creates many ethical and practical concerns. Some guidelines (designed by the British Institute of Learning Disabilities) to help services improve their practice in this area are:

Physical interventions should only be used in the best interests of the person with learning disabilities

They should only be used alongside other strategies to help people learn to behave in non-challenging ways

They should be individualised and reviewed regularly

They should use minimal force and not cause pain

Reducing the use of reactive strategies

We know that the use of restrictive practices can be significantly reduced in services that:

Have leaders that have reducing the use of restrictive practices as a clear priority

Record and closely monitor how often they are used

Use procedures such as risk assessments that are known to work

Involve service users in planning to reduce restrictive practices

Good debriefing procedures so that lessons are learnt when things go wrong/ right.

Develop the appropriate skills in staff

Use Positive Behaviour Support Plans

To download the full version of the Challenging Behaviour Foundation information sheet ' Physical Interventions for Challenging Behaviour,' by Professor David Allen, Abertawe Bro Morgannwg University Health Board & Welsh Centre for Learning Disabilities, Cardiff University click here.

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Even when really good support plans are in place, there may be times when challenging behaviours occur. At such times, carers will often need to intervene in order to prevent harm to the person concerned or to themselves. 'Reactive strategies' are used once challenging behaviours occur and provide carers with clear plans for how to respond to them when they do.

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Restraint Reduction Network: Reducing Restraint Through Policy & Practice

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The Act has three main effects:

1. You can seek justice in a British court

It incorporates the rights set out in the European Convention on Human Rights (ECHR) into domestic British law. This means that if your human rights have been breached, you can take your case to a British court rather than having to seek justice from the European Court of Human Rights in Strasbourg, France.

2. Public bodies must respect your rights

It requires all public bodies (like courts, police, local authorities, hospitals and publicly funded schools) and other bodies carrying out public functions to respect and protect your human rights.

3. New laws are compatible with Convention rights

In practice it means that Parliament will nearly always make sure that new laws are compatible with the rights set out in the European Convention on Human Rights (although ultimately Parliament is sovereign and can pass laws which are incompatible). The courts will also, where possible, interpret laws in a way which is compatible with Convention rights.

Find out more about human rights and how they play a part in our everyday lives: what are human rights?

Download a full copy of the Human Rights Act.

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The Human Rights Act allows you to defend your rights in UK courts and ensures that public organisations respect and protect your human rights.

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What is meant by physical restraint in a mental health context? An international broad definition describes it as the prevention of a person's free movement (Bleijlevens et al, 2016). This is defined more specifically in the UK as direct contact with an intention to prevent, restrict or subdue a person's movement (Department of Health, 2014) in order to prevent harm or give treatment (Bowers et al, 2012).

Physical restraint is also defined within the literature as a hard form of coercion commonly observed in mental health inpatient settings (see Lidz et al, 1998; and Szmukler & Appelbaum, 2008, for examples of a hierarchy of different types of coercion). It is a controversial element of mental health treatment and perhaps symbolises for many a lack of genuine participation in one's own treatment, especially at times of distress. Indeed, recent media reports of findings from an independent review of the Mental Health Act describe an increasing use of detentions in mental health services and concern regarding the manner in which people are treated.

Recently Matthew Broome blogged here on The Mental Elf about whether or not shared decision-making is helpful for people with psychosis and commented on a complex dynamic between collaboration and coercion impacting on therapeutic relationships. The administration of physical restraint is an example commonly seen in mental health practice where distressed behaviour directly confronts practitioners' professional responsibilities and accountabilities. It presents practitioners with a difficultly of balancing both the rights and wellbeing of individual patients with those of other people. During physical restraint, shared decision making is severely lacking.

In this blog, I discuss a paper by Cusack and colleagues (Cusack et al, 2018) that, to some extent, touches on the complex dynamic previously highlighted by Matthew Broome. Cusack and colleagues note that most research to date has focused on quantitative approaches measuring the administration of restraint and perspectives about its use, rather than the impact of it. The authors report their findings from an integrative review aiming to explore the physical and psychological impact of physical restraint on people admitted to mental health inpatient settings.

Methods

As the name suggests, this review integrates and synthesises literature relevant to physical restraint in mental heath inpatient settings, including both experimental and non-experimental research. The authors took a 5-stage approach as recommended by Cooper (1998) for integrative reviews (problem identification, literature review, data evaluation, data analysis, and presentation of results).

Five online databases (CINAHL, EMBASE, PsycINFO, MEDLINE and Cochrane), a manual search of reference lists and journals and professional networking were all utilised to retrieve articles. As part of the inclusion criteria, only articles published from 2000 were considered to reflect the publication of the first UK national guidance in 2000 regarding adult abuse in health and social care settings (Department of Health, 2000).

Following a robust 3-stage screening process and critical appraisal, 10 papers were included in the final analysis (1 quantitative, 2 mixed methods and 7 qualitative).

Results

Following comparison of these 10 papers, the authors identified 8 themes:

1. Trauma and Retraumatisation

For some people, being physically restrained brought back memories of previous trauma and was experienced as 'retraumatising'. Consequently, restraint can also be perceived as 'anti-recovery' and can make some people fearful of future treatment. In terms of a staff perspective of administering restraint, some became 'hardened' to it and with no emotional reaction regarding it.

2. Dehumanisation

This included the conditions a person might be left in during and following restraint (e.g. left in urine soaked clothing) and also the feeling of being 'subhuman' as a consequence of being restrained. Some people being restrained also believed that excessive force had been used by staff who lacked empathy. Consequently, some people perceived that staff were punishing them and exerting power over them, leading to feelings of worthlessness, powerlessness, losing control, helplessness, being abused, self-blame and low self-esteem.

3. Distress

Being restrained can lead to feelings of distress during the time of restraint and for a period of time following it, both for patients and staff. Additionally, it can also cause distress for those witnessing a restraining incident. Some findings, particularly related to staff perspectives, suggest that restraint is necessary to the extent where a restraint-free clinical environment is not possible. Interestingly, staff might use laughter to reduce stress during physical restraint or act on autopilot without any emotional response. Of particular interest is that female staff can feel distressed when administering restraint whereas male staff can be detached and indifferent to those being restrained.

4. Fear

Staff can be fearful of patients, which can contribute towards their administration of physical restraint. By contrast, patients' fear of restraint can also contribute towards aggressive behaviour. (It would be helpful to have a more in-depth understanding of this relational dynamic). As such, a culture of fear is reported wherein restraint is perceived as a negative experience for both staff and patients.

5. Feeling ignored

This theme captured a disconnection between staff and patients. For example, patients' perceive that staff ignore their distress prior to restraint, leading to staff at a later point intervening to restrain patients' distressed behaviour.

6. Calm

In contrast to most of the findings, some patients reportedly perceive physical restraint to have a calming effect. This resonates with findings under the 'control' theme (below), both of which imply that being physically restrained is perceived by a subsection of patients as a method of achieving a positive outcome in some way.

7. Power

Central to physical restraint is the issue of power. For some people this is perceived as an excessive or abusive use of power, whereby staff display power over patients. There are also potential breaches of human rights in relation to this. Consequently, some people feel powerless as a result of being physically restrained.

8. Control

Some people being restrained reportedly feel a loss of control and believe that restraint is a way for staff to control patients. One finding suggests that a subset of female patients can feel out of control prior to restraint and, consequently, display behaviour that engages staff to administer physical restraint in order to gain control over their feelings.

Conclusions

The authors state that it is important for a more in-depth understanding of the impact of physical restraint to enable improvement in the quality of inpatient mental health care. As such, they note the importance for nurses, as the largest professional group, to engage with patients as active partners in care, to undertake education and training to reduce restrictive interventions and to promote therapeutic alliances between staff and patients.

Strengths and limitations

This is an interesting review analysing research from both experimental and non-experimental research. The authors develop themes that resonate with findings elsewhere in the literature, particularly in relation to coercive practice regarding issues such as power, feeling dehumanised and traumatised.

The authors provide helpful details regarding the methods of the review. In this respect this is an excellent example for anyone wishing to similarly complete an integrative review. However that said, I would have found it helpful had the authors provided a more detailed account of how they integrated the single quantitative and both mixed-methods studies with the qualitative findings.

Implications for practice

Although the authors state that power is central to restraint, for some staff and patients this seems to manifest as fear. It is important to explore ways of engaging effectively during periods of increased distress through more proactive methods. However, the increasing pressure in which many mental health services currently operate provides an unhelpful backdrop in which proactive therapeutic approaches can be difficult to provide consistently.

I was interested to read about the perspectives from both people being restrained and those administering the restraint. Having set out to explore the impact of physical restraint, Cusack and colleagues achieve this to some extent through their 8 themes. For example, female staff can feel distressed when physically restraining but male staff can become emotionally detached; and some female patients reportedly want to be restrained in order to gain control of their distress or find it calming when being physically restrained. Learning more about findings such as these is important in order to improve our understanding of the complex dynamics within inpatient settings.

Conflicts of interest

No conflicts of interest.

Links

Primary paper

Cusack P, Cusack FP, McAndrew S, McKeown M, Duxbury J. (2018) An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. Int J Ment Health Nurs. 2018 Jan 19. doi: 10.1111/inm.12432. [ PubMed abstract]

Other references

Bleijlevens MHC, Wagner LM, Hamers JPH. (2016) Physical restraints: consensus of a research definition using a modified Delphi technique (PDF). Journal of the American Geriatrics Society, 64 (11), 2307-2310.

Bowers L, Van Der Merwe M, Paterson B, Stewart D. (2012) Manual restraint and the shows of force: the city 128 study. International Journal of Mental Health Nursing, 21, 20-20. [ PubMed abstract]

Department of Health (2014) Positive and Pro Active Care: Reducing the need for restrictive interventions (PDF).

Lidz CW. (1998) Coercion in psychiatric care: what have we learned from research? (PDF) Journal of the American Academy of Psychiatry and the Law Online, 26, 631-637.

Szmukler G, Appelbaum PS. (2008) Treatment pressure, leverage, coercion, and compulsion in mental health care. Journal of Mental Health, 17, 233-244. [ Abstract]

Photo credits

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The impact of physical restraint on people in mental health settings - National Elf Service

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What is meant by physical restraint in a mental health context? An international broad definition describes it as the prevention of a person's free movement (Bleijlevens et al, 2016). This is defined more specifically in the UK as direct contact with an intention to prevent, restrict or subdue a person's movement (Department of Health, 2014) in order to prevent harm or give treatment (Bowers et al, 2012).

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Restrictive interventions:
Types of
restrictive interventions:

* Social
intervention – where harmful or destructive behaviour can be contained and
moderated with the use of language including facial expressions and words, this
intervention may be and should be used as a primary action.

• Mechanical intervention – the use of devices to prevent or contain a
person’s movement such as highchairs, stair gates, barrier erection, locked
doors.

• Physical intervention – using actual bodily contact which should only
be used with clear justification and in guidance of the settings policies and
procedures and staff training. Physical intervention may only be used upon
ensuring safeguards are in place for the member of staff and also the person
involved and when social and mechanical intervention is not sufficient.
Moderate risk to prevent danger to others should be expected but physical
intervention may not be used if there is a substantial risk of injury or it
conflicts with any individual care plans in place.

• Planned Intervention - using evidence from observations, assessments,
care plans and risk assessments. A planned intervention may be ensuring that a
member of staff sits with a child at group times to support, facilitate and
moderate their behaviour towards the other children.

• Emergency intervention – actions taken to diffuse/deflect unpredicted
events.

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Below are some of
the behaviours that may require intervention:

Repetitive/Obsessive
• Give responsibilities to the child for them to engage in (this helps build up
self-esteem)
• Side step any confrontations
• Agree a response plan if any confrontations develop
• Give choices to the child

Withdrawn
• Ensure the child is included in all activities
• Encourage the child to try new situations with support from an adult
• Develop a circle of friends

Aggressive
• Try to calm the child by talking with them, explaining it is not nice to be
aggressive
• Remove from situation using distraction techniques
• Provide support

Self-injurious
• Remove the child from the situation
• Provide support

Disruptive
• Remove the child from the situation by encouraging them to choose another
activity
• Reward positive behaviour

Anti-social or illegal
• Remove the child from the situation
• Give the child support

Verbally abusive
• Explain that verbal abuse is not acceptable
• Remove the child from the situation.

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Praise helps children and teens feel good about themselves, which boosts their confidence. Praise can also encourage children to behave in positive ways.

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What are the 4 stages of social learning theory?

The social learning theory proposes that individuals learn through observation, imitation, and reinforcement. According to the theory, there are four stages of social learning:

1. Attention: In this stage, individuals must first pay attention to the behavior they are observing. This requires focus and concentration on the model's behavior.

2. Retention: In this stage, individuals must remember the behavior they observed. This involves cognitive processing and memory storage.

3. Reproduction: In this stage, individuals attempt to reproduce the behavior they observe. This may involve practicing and refining the behavior until it can be performed accurately.

4. Motivation: In this stage, individuals must have a reason or motivation to perform the behavior. This may involve reinforcement, punishment, social approval, disapproval, or other incentives.

What is the main idea of social learning theory?

Social Learning Theory, proposed by Albert Bandura, posits that people learn through observing, imitating, and modeling others' behavior. This theory posits that we can acquire new behaviors and knowledge by watching others, a process known as vicarious learning.

Bandura emphasized the importance of cognitive processes in learning, which set his theory apart from traditional behaviorism.

He proposed that individuals have beliefs and expectations that influence their actions and can think about the links between their behavior and its consequences.

Why is social learning theory important?

Social learning theory helps us understand how our environment and the people around us shape our behavior. It helps explain how individuals develop new skills and behaviors by paying attention to the behavior of others and then trying to reproduce that behavior themselves.

It is an important theory for psychologists, educators, and anyone interested in human behavior and development.

Who is Albert Bandura?

Albert Bandura was a prominent Canadian-American psychologist known for his work in social learning theory and the concept of self-efficacy.

His groundbreaking research on observational learning, through experiments such as the Bobo Doll experiment, shifted the focus of psychological theory from behaviorism to cognitive processes.

Bandura's work significantly influenced the understanding of how individuals learn within social contexts.

Albert Bandura is best known for his contributions to the field of psychology, particularly in the areas of social learning theory, self-efficacy, and aggression. He is considered one of the most influential psychologists of the 20th century.

Bandura's work has significantly impacted our understanding of human behavior and has informed fields such as education, psychology, and social work.

References

Ahn, J. N., Hu, D., & Vega, M. (2020). "Do as I do, not as I say": Using social learning theory to unpack the impact of role models on students' outcomes in education. Social and Personality Psychology Compass, 14(2), e12517.

Bagès, C., Verniers, C., & Martinot, D. (2016). Virtues of a hardworking role model to improve girls' mathematics performance. Psychology of Women Quarterly, 40(1), 55-64

Bandura, A. Ross, D., & Ross, S. A. (1961). Transmission of aggression through the imitation of aggressive models. Journal of Abnormal and Social Psychology, 63, 575-582

Bandura, A. (1965). Behavioral modification through modeling procedures. In L. Krasner & L. P. Ullman (Eds.), Research in behavior modification. New York, NY: Holt, Rinehart & Winston.

Bandura, A. (1969). Principles of behavior modification. New York, NY: Holt, Rinehart & Winston.

Bandura, A. (1971). Social learning theory. New York: General Learning Press.

Bandura, A. (1972). Modeling theory: Some traditions, trends, and disputes. In R. D. Parke (Ed.), Recent trends in social learning theory (pp. 35-61). New York: Academic Press.

Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall, Inc.

Bennett, S., Farrington, D. P., & Huesmann, L. R. (2005). Explaining gender differences in crime and violence: The importance of social cognitive skills. Aggression and Violent Behavior, 10(3), 263-288.

Cheryan, S., Siy, J. O., Vichayapai, M., Drury, B. J., & Kim, S. (2011). Do female and male role models who embody STEM stereotypes hinder women's anticipated success in STEM? Social Psychological and Personality Science, 2(6), 656-664.

Dasgupta, N. (2011). Ingroup experts and peers as social vaccines who inoculate the self-concept: The stereotype inoculation model. Psychological Inquiry, 22(4), 231-246.

Deaton, S. (2015). Social learning theory in the age of social media: Implications for educational practitioners. Journal of Educational Technology, 12(1), 1-6.

Fryling, M. J., Johnston, C., & Hayes, L. J. (2011). Understanding observational learning: An interbehavioral approach. The Analysis of verbal behavior, 27, 191-203.

Grusec, J. E. (1994). Social learning theory and developmental psychology: The legacies of Robert R. Sears and Albert Bandura.

Huesmann, L. R., & Kirwil, L. (2007). . Cambridge University Press.

Lin-Siegler, X., Ahn, J. N., Chen, J., Fang, F. F. A., & Luna-Lucero, M. (2016). Even Einstein struggled: Effects of learning about great scientists' struggles on high school students' motivation to learn science. Journal of Educational Psychology, 108(3), 314-328.

Lockwood, P., & Kunda, Z. (1997). Superstars and me: Predicting the impact of role models on the self. Journal of Personality and Social Psychology, 73(1), 91-103.

Marx, D. M., & Ko, S. J. (2012). Superstars "like" me: The effect of role model similarity on performance under threat. European Journal of Social Psychology, 42(7), 807-812.

Nabavi, R. T. (2012). Bandura's social learning theory & social cognitive learning theory. Theory of Developmental Psychology, 1(1), 1-24.

Overskeid, G. (2018). Do we need the environment to explain operant behavior?. Frontiers in Psychology, 9, 302037.

Rosenthal, L., Levy, S. R., London, B., Lobel, M., & Bazile, C. (2013). In pursuit of the MD: The impact of role models, identity compatibility, and belonging among undergraduate women. Sex Roles, 68(7-8), 464-473.

Schunk, D. H. (2012). Learning theories an educational perspective (6th ed.). Boston, MA: Pearson Education Inc.

Stout, J. G., Dasgupta, N., Hunsinger, M., & McManus, M. A. (2011). STEMing the tide: Using ingroup experts to inoculate women's self-concept in science, technology, engineering, and mathematics (STEM). Journal of Personality and Social Psychology, 100(2), 255-270

Weiner, B. (1979). A theory of motivation for some classroom experiences. Journal of Educational Psychology, 71(1), 3-25.

Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education

Associate Editor for Simply Psychology

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Saul Mcleod, PhD
Educator, Researcher

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, Ph.D., is a qualified psychology teacher with over 18 years experience of working in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Albert Bandura's Social Learning Theory In Psychology

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Social Learning Theory, proposed by Albert Bandura, posits that people learn through observing, imitating, and modeling others' behavior. This theory posits that we can acquire new behaviors and knowledge by watching others, a process known as vicarious learning.

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Social Learning Theory: Bandura’s Bobo Beatdown Experiments

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Simply Psychology | Self-Care, Theories, Famous Studies & More

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We're committed to being your expert and trustworthy source for psychology theories, relationship advice, and mental health information. Whether you want to learn about theories or studies, understand a mental health disorder, or how to improve your relationships, get the guidance you need to be healthy and happy.

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Behaviorism, also known as behavioral learning theory, is a theoretical perspective in psychology that emphasizes the role of learning and observable behaviors in understanding human and animal actions.