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Questions for Dr. Ronald Federici

March 29, 2010

Licensed psychologists and other licensed mental health professionals are accountable to the people they serve. Most importantly, they are accountable to demonstrate that the interventions they use are safe, that they do no harm. The mere assertion that they are safe is not enough. They must demonstrate this through the use of references to evidence, not authority. Being licensed does not automatically mean that the person will make the best choices for their clients. The burden of proof is on the professionals offering their services to prove that they are safe, not on others to prove that they are not.

In this spirit, I have a few questions for Ronald Federici, PsyD about the most recent, 2003 edition of his book, Help for the Hopeless Child. In it, he recommends and provides instructions for the use of a prone restraint procedure which involves two adults restraining a child. To see the restraint method illustrated in Federici’s book, click here and scroll down or go to the book’s site on Amazon:

Search in the book for “SEQUENCE ONE HOLDING” and go to where this phrase appears on page 111.

He assures the readers that this procedure is safe and used in hospitals. However, my own perusal of the literature has led me to evidence that prone restraints are not safe and have led to states such as Ohio issuing a ban on all prone restraints. I realize that Dr. Federici does not practice in Ohio. Nevertheless, I have some questions for Dr. Federici about the procedures he has recommended in his book, particularly the procedure he calls the Sequence One Hold, which is a prone restraint procedure executed on a child by two adults, usually the parents. He cautions that the parents should be trained in this procedure. However, that does not respond to whether there is any research evidence that such training would be sufficient to ensure the safety of such a procedure, particularly when parents who typically would have no professional credentials would be alone with the child, at home, when presumably carrying it out. Is any form of prone restraint safe? Apparently the State of Ohio and other states that have banned it, even under highly supervised conditions such as in hospitals, didn’t think so.

Dr. Ronald Federici has defended his recommended Sequence One Hold, a prone restraint procedure he recommends in his 2003 edition of his book, Help for the Hopeless Child (see pp109-111), maintaining that this is a safe procedure used in state hospitals with severely disturbed children and other residential treatment facilities. More recently, he has continued to publicly defend it as a safe, hospital-based technique. See his response at the bottom of this webpage . He still recommends this book on his website as of the date of this posting.

And my question about safety is just the most basic one, not the only one. There are also questions about the emotional aftereffects this type of procedure could have on a child and its potential to traumatize or retraumatize and what the long-term effects would be. Testimonials just don’t cut it.

My question for Dr. Federici is whether he can name one JCAHO-approved state hospital (or a JCAHO-approved private one) that uses this restraint procedure, the one recommended in his book that involves two adults as depicted in the book’s diagram. Can he name one JCAHO-accredited hospital or residential treatment facility that currently uses this procedure? Note that I am emphasizing currently because in the past, similar prone face-down restraint procedures have been used and have resulted in deaths that have gotten them banned, and that is in hospitals where the procedures are strictly monitored. All I’m asking for is one name of an accredited hospital. If he can do this and that facility can confirm that this is their current practice, I might consider re-evaluating the opinion I currently hold, which is that I have serious concerns about this procedure under even the best of circumstances, based on my reading of the literature on the dangers of prone restraints and the fact that some states have banned them entirely.

If it is this dangerous that even hospitals in certain states don’t even do it at all anymore…not even under the most strictly supervised conditions that must pass periodic inspection…what does this say about parents using it after being “trained” and left on their own with their child?

I respectfully ask, please help me to understand the following, Dr. Federici. My understanding of his description of this procedure is that although it is called a therapeutic hold, it is to be used for the child’s safety and not as therapy and that he does not do this for the same reason that the holding therapists do it. He describes it as a “therapeutic holding for safety and security”.

There are contradictions, however. He recommends that the parents follow through with this, even if the child backs down and tries to talk the parents out of following through and promises to be good, etc. If the child is backing down and promising to be good, where is the imminent danger to the child or others that would necessitate a restraint procedure of any kind? The child had the presence of mind to back down. Federici’s rationale appears to be that if the parents give in to the child and don’t do the sequence one hold, this will lead to future bad behavior. However, the only valid rationale for using a restraint procedure of any kind would be imminent (immediate) danger, not long-term concern over the child’s behavior.

He recommends that this Sequence One Hold be carried out by parents whenever the child disobeys during Phase One of his intervention, yet he turns around later and insists it is only for physical safety. Does a child’s disobedience always put that child in imminent physical danger requiring physical restraints? Of course not. There are better, empirically supported methods of behavior management to help improve behavior in the long-term. I worked for a neuropsychologist for nearly five years who, like Dr. Federici, had many children with very serious behavior problems as patients. I saw him work with literally thousands of children and not once did I ever see him have to recommend that the parents use restraint on the child. Instead, he trained parents in non-physical, behavior modification techniques and more often than not, they worked.

In the Dateline NBC video, Saving Dane, my understanding is that the parents are portrayed employing this procedure after they asked the child to use the bathroom and the child refused to do so, saying he didn’t have to go. Where is the imminent danger there? I’m confused, Dr. Federici. Please help me understand how doing this was necessary when all the current guides I have read for managing an emotionally out of control individual, recommend trying measures other than any kind of restraints first, unless there is a pressing, imminent danger presented by the individual. Imminent means immediate danger to the safety of self and/or others, not something that may occur in the future. How was refusing to go to the bathroom an imminent danger to the child or others? How would it be justified to use this procedure, even if the child backs down and promises to be good and hence, is not presenting any immediate physical danger to anyone or self?

I ask because experts I have consulted, licensed professionals who are working in the area, have informed me that in their opinion, this procedure is one that was once used as part of Aggression Control Techniques but is no longer used, due to serious concerns about its safety. A number of deaths have resulted from the use of prone restraints, which is why some states have already chosen to ban it. Thus, consumers and other citizens have every right to ask for specific evidence showing that a recommended prone restraint procedure is safe and I mean actual evidence, not vague references to authority.

I welcome a response from Dr. Federici or any other mental health professional who wishes to comment here. However, personal attacks on me or anyone else who questions Dr. Federici’s approach will not be welcome here. The reason for this caution is that in the past, people who have criticized Dr. Federici’s approach, such as Charly Miller, have been personally smeared online with completely baseless and false accusations (read the rebuttal here) and that sort of libelous smear tactic is not acceptable on this blog.

Will Dr. Federici choose to answer my questions or will he attempt to suppress this blog entry? Will his supporters continue to anonymously post lies about me in retaliation for my questions and sincerely-held concerns?

Stay tuned.

Update: Dr. Federici responded. Click here for links to his response and my further response.

  1. Will Bishop permalink

    Unfortunately, page 111 is currently excluded from the free online preview of the book. Is there another place we can look to see a photo or diagram of the “holding”? I’m no expert on copyright law, but as far as I know, a properly cited scanned and uploaded image would qualify as fair use on the grounds of critical commentary.

  2. I just rechecked and you are correct. Thanks for letting me know. There may have been something wrong with the link. I just edited the article and fixed the link and now it does work and bring up p. 111, so try again and it should work now.

  3. It seems that the child in the orphanage was more calm and protected than in your host families. What you are doing is violence and provocation tantrums. If your child aggressive and beating his head against the floor …… it would be much better if the child was not there for you. If the child does not want to or can not love you ….. you have to move away from the child and stop torturing him. You took a pretty sweet child of Russian orphanage. He did not fight without threatening or hitting his head on the wall. Now this child became uncontrollable and aggressive. You should ask the child: “You want to live in this house?” “Do you want to live next to these people?” If the child says “NO. I DO NOT WANT. I HATE THEM” You have to give the child the opportunity to live without you. In the U.S. there are boarding schools? For God’s sake get away from the Russian children. Violence does not create love and affection but without the presence of your child will be safer and more stable. He does not want you! IT’S HARD TO UNDERSTAND?

Trackbacks & Pingbacks

  1. Dr. Federici Responds « Potentially Harmful and Other Questionable Therapies
  2. Just One More Thing, Dr. Federici « Potentially Harmful and Other Questionable Therapies
  3. State of Connecticut Directive on Prone Restraints « Potentially Harmful and Other Questionable Therapies

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