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.