Prone Restraints: Should they ever be used?
Although ultimately I continue to favor a ban on prone restraints for the reasons I state at the end of this article, there actually is room, in my opinion, for legitimate debate on this topic and there are some who have made a convincing case that there are ways to do prone restraint that are safer than alternatives in some situations where there is truly an imminent, physical threat. In this posting, I am going to present that perspective. Note that I am not talking about the kind of prone restraint I have criticized earlier where the restrainers are sitting and/or laying on top of the child and/or restraints being used as therapy. That, according to the literature I have read, even from proponents of prone restraint I am about to discuss, is not acceptable and there is widespread consensus that restraints should never be used for anything other than imminent threats to safety, not for “therapy” and not to teach a child a lesson of any kind or show the child the parents or teachers are in control and not for behavior modification of any kind.
Proponents of prone restraints are maintaining that there are safe ways to do this procedure that does not restrict a person’s ability to breathe and can be used in the event of an emergency situation where alternatives for deescalation are not possible or have been tried and failed. There is a strong emphasis on preventing such a crisis in the first place, since the large majority of these situations can be prevented if teachers and/or parents are taught what signs to look for. I recently read a white paper entitled The Premature Call for a Ban on Prone Restraints: A detailed analysis of the issues and evidence by Merrill Winston, Neal Fleisig, and Laraine Winston of the Professional Crisis Management Association (PCMA) that makes a compelling case against a complete ban on prone restraints that is definitely worthy of consideration and in the interest of giving a legitimately balanced presentation on this blog, I am devoting this article to this topic. Note that their paper applies to institutional settings such as schools and they are not recommending this for parents to use when at home alone with their child.
Although a quite natural first reaction to PCMA is that they have a vested interest in promoting prone restraints, this actually is not the case since, as they point out on their website, they offer training in a variety of different behavioral techniques that do not involve restraint that need to be tried first, including deescalation techniques and prevention of a crisis situation developing in the first place and/or less extreme forms of restraint (for example, physically escorting a disruptive student out of the classroom, if possible). Hence, their income is not dependent on teaching prone restraint. They could easily drop it, if they deemed that it was not helpful and their income would not be affected. They are training in prone restraint because, according to what they have found, there are times when this is the choice that is in the best interest of all parties involved.
The white paper presents a case for properly training people in prone restraints so they can be done in a safer manner, rather than having an emergency arise where people act spontaneously and put people in prone restraints in ways that could be very dangerous and damaging and this is how many of the deaths occurred.
A few points to be made clear up front are: 1) These procedures are only recommended for usage when there is an imminent threat to safety, never for therapy or to show the child who is boss; 2) PCMA trains people to recognize early warning signs in children so the situation can be prevented from turning into a crisis in the first place that would require restraint; 3) PCMA teaches other, less extreme forms of restraint that could be used in some situations; 4) PCMA teaches deescalation techniques that should be tried first, wherever possible. Using such techniques will, in the majority of cases, make the use of restraints unnecessary and 5) The prone restraint technique they recommend should only be used by people who have been thoroughly trained in it. It is not something people should just read about in a book or manual and then go and do. They purposely keep diagrams out of their manual so the person trained cannot simply pass this along to colleagues who are not trained. Again, there are obvious differences between these methods and the ones I have criticized where diagrams are presented in books such as Ronald Federici’s Help for the Hopeless Child and parents are trained by therapists. The fact someone has worked in an institutional setting with children who have serious behavioral problems does not mean they are necessarily properly trained to use these procedures, much less train others in them.
The authors argue that not all prone restraint procedures are the same and there are a variety of ways to carry out prone restraint, some highly dangerous while others they contend are relatively safe. We also need to consider the consequences and danger of not restraining someone when there is an immediate threat to safety and weigh those against the risks of the procedure. Although the white paper does not present a diagram of the procedure they train in, here are some of the ways of doing prone restraint they do not recommend that are unsafe (see p. 20):
Although we strongly disagree that all forms of prone holding pose equal risks, we maintain that certain types of prone holds are very unsafe. Beginning on page 23, we discuss seven variables that we believe are critical in determining the degree of safety that will be present in any setting that uses any type of restraint. As outlined earlier in this document, there are forms of prone holding that have been performed that are not currently a part of any nationally known system of crisis management. These include the prone basket hold and any procedure that applies pressure to any part of the head, neck or torso. We also maintain that any procedure that allows the arms to rest under the person or that pulls the arms behind the person’s back are less safe as they increase thoracic compression by decreasing the surface area for the distribution of weight (Figure 2a.). Furthermore, we believe that any prone hold that only involves one staff member holds a higher degree of risk for several reasons and we therefore do not teach or allow the use of any one-person prone holds in our system. One-person prone holds pose several problems. The task of safely lowering a person to the floor with a single staff member can be very difficult to accomplish. It is also virtually impossible for only one staff member to safely restrain someone in a prone position without using a more restrictive and highly coercive technique or without lying on the torso with full or partial-weight. Some may maintain that it is possible to ―straddle‖ the torso while only holding the arms. However, we believe that any bridging or straddling across the torso can too easily ―drift‖ into lying on the torso if the struggle becomes intense enough or if the staff member becomes fatigued. In addition, one-person prone holds may not have the benefit of another staff member who can either act as a witness, monitor vital statistics of the person, provide assistance if the level of aggression becomes too great or give corrective feedback if some part of the procedure is performed improperly.
They make it very clear that no one is ever positioned over the torso of the child, not even straddling because the risk for asphyxiation is too great.
The white paper also lists several points of agreements with advocates who are opposed to prone restraints (see p. 18-20):
- That prone holds occur far too often. PCMA is strongly emphasizes prevention and deescalation techniques, as well as less restrictive forms of restraint.
- That prone holds occur when there are no clear criteria for initiation or termination
- Prone holds occur in the absence of a heirarchy of less restrictive procedures
- Prone holds are being used because of lack of appropriate behavioral analysis and treatment
- Prone holds or other holds are not regulated by policy
- Prone holds are not properly documented
- Prone or other holds are often not disclosed to parents
- Staff who conduct prone holds are often untrained or lack proper supervision and experience
- Certain forms of prone holds are very unsafe
Their points of contention with people who are proposing a complete ban on prone restraints include (p. 21-23):
- The belief that banning all prone restraints will stop them from occurring. Here, they argue that the danger is that situations will spontaneously arise where people react and perform highly dangerous methods of prone restraint that, if properly trained, they would not do.
- The belief that effective behavioral programming will completely eliminate the need for restraint for all children.
- The largely unstated belief that a procedure is either entirely safe or entirely unsafe
- The belief that prone holds cannot be conducted safely and responsibly
The upshot of this is that although there is a legitimate controversy over whether or not prone restraints should be entirely banned as they have been in some states (except for very brief transitional holds), the widespread consensus is that there are some forms of prone restraint that are very dangerous and that restraints of any kind should be used only for safety, not therapy or to show the child who is in control. Hence, even though a compelling case can be made for some forms of prone restraints in some situations, my criticisms of the methods I have previously discussed, stand unrefuted (and note that PCMA proponents are not intending to refute me, they agree with me), as this paper actually supports those criticisms.
At the end of the day, however, there still is a good case to be made for banning all prone restraints, especially since proponents of the safer methods of prone restraints do not seem to be willing to issue any specific criticism against those individuals and businesses that are teaching the more dangerous methods and state boards seem highly reluctant to take any action. If the profession refuses to discipline itself by calling their colleagues out on their use of dangerous methods then the bottom line is that children and our most vulnerable citizens need to be protected and state and federal legislation is the way to go and I support such legislation.
If people want to make an argument for the use of safe, prone restraints then they need to garner the courage to take a stand against those who are using the more dangerous methods and refuse to allow certain others who attempt to mischaracterize such criticism as personal attacks, to make them feel guilty for doing so. Unfortunately, for many mental health professionals, making nice with other mental health professionals whatever the cost is their highest value. Some feel it isn’t “nice” to name names. My response is that what is not “nice” is to stand by while potentially dangerous interventions are being practiced and do nothing. That is not the least bit “nice” to the victims.
As good as this particular white paper is, it is not enough. While the authors do make a convincing case for the use of safer methods of prone restraint and have demonstrated very well that not all prone restraints are the same, if there is no way to control who uses what methods, then it is better that it not be used at all.
Mental health professionals and State Licensing Boards who are refusing to take action, take note: If you are unwilling to hold your own accountable for safe practices, ultimately the government will have to do it for you, exercising its proper function to protect people from the initiation of force. People who have loved ones harmed will come forward and demand it.