The Mandt System Putting People First Restraining Skills - Standing Each chapter of the Relational, Conceptual and Technical Skills Training builds upon skills learned in previous chapters. You should review and practice those skills before beginning this chapter. However, physical interaction skills should be used only after nonphysical interaction has proven to be insufficient to ensure the safety of everyone involved. Review the chapter pre-requisites to ensure you have all the tools in your toolbox. Purpose Restrictive physical interaction should only be used for the purpose of protection, and should not be used for the purpose of changing behavior in situations where no protective need is present. The safety of all individuals is paramount and only the least restrictive interaction needed to adequately protect the person or others should be used. All physical interaction should be terminated as soon as the need for protection is over. Use of restrictive physical interaction must be individualized and should be included in the plan your facility or agency requires. The person and their legal representative should be involved throughout the process of developing this plan. An independent advocate (i.e., a person who is not an employee of the facility, agency, or program, and has no conflict of interest) should participate, at the request of the person or his legal representative, in the development and evaluation of any plan which includes the use of restrictive physical interaction. What is Restraining? Restraining is physically limiting and redirecting but not immobilizing a person s movements, providing proper support and assistance so that the person does not get hurt, in situations where the person has tried to harm themselves and/or someone else. You may have to restrain someone in order to protect that person from harming himself or others. A standing or kneeling physical restraint may be applied by one person or with the help of another properly trained staff. Learning Objectives 1. Describe the criteria for when to use physical restraint. 2. Define what the term restraining means. 3. List the key points to follow when faced with a situation that may require the use of restraint. 4. Describe the possible dangers of asphyxiation when using physical restraint. 5. Demonstrate each of the skills taught in this chapter. 6. Identify what is meant by threat that is believable, capable, and immediate. 7. Identify how restraint can traumatize or re-traumatize people. 8. Identify the meaning of the stimulus transfer point. 9. List prohibited practices.
Three Types of Asphyxiation The General Accountability Office (GAO)of the United States estimates that 150 people per year die in their country due to asphyxiation resulting from restraint. In 1999, The Hartford Courant published a study of 142 deaths and clearly identified asphyxiation as the major reason for death. The General Accountability Office and the National Disability Rights Network published findings of restraint deaths in schools in 2009, and the US Department of Justice has continued to focus on states where injuries and deaths due to restraint have occurred. Generally speaking, there are 3 types of asphyxiation associated with restraint: 1. Positional Asphyxiation occurs when the position of the restraint inhibits the expansion of the diaphragm or the chest muscles between the ribs (called intercostals). That is why The Mandt System requires that staff make sure that the arm of the individual restrained is at or slightly below the waist, so the ability to breathe is not affected by the position of the restraint. 2. Compression Asphyxiation occurs when the chest cavity is compressed and the individual cannot breathe as a result. This is most commonly seen in restraints on the floor. That is why The Mandt System prohibits anyone from sitting on, straddling and/or putting weight on the chest, lungs, sternum, diaphragm, back, or abdomen. 3. Restraint Asphyxiation occurs when the stress of the restraint (either physical or psychological) results in increased stress on the cardio-vascular system. This can result in an increase in a specific neuro-transmitter known as catecholamine, which can lead to a heart attack. This can occur during a restraint or up to 24 hours after a restraint. That is why Public Law 106-310, The Children s Health Act of 2000, and subsequent federal regulations, require a medical assessment within one hour of the use of a restraint. Currently, this law only applies to Psychiatric Residential Treatment Facilities serving individuals under 21. While the law does not specify what type of assessment should be conducted, a typical assessment may include temperature, pulse, respiration, and blood pressure. The Mandt System teaches there are two reasons to physically restrain a person: 1) to protect the person from harming himself and 2) to protect the person from harming others. Page 178 Chapter 10 Restraining Skills 2010 The Mandt System, Inc.
Physical Restraint There are risks inherent in any restraint. In Chapter 7 (Medical Risks of Restraint) we taught that there is no such thing as a safe restraint. We minimize the risk of Mandt System restraints through (1) the design of the restraint, (2) decreasing the intensity of restraint use by telling you to relax; (3) decreasing the duration of restraint to a recommended maximum of 3 minutes, and (4) decreasing the frequency of restraint use. We would challenge you and your organization to reduce the frequency of restraint use by 50% per year. Many of the organizations using The Mandt System serve individuals with histories of physical, sexual, and emotional abuse. Restraint can be a re-traumatizing experience for these individuals, and we recommend the use of a de-escalation preference tool as a way of programming the R.A.D.A.R. of the staff. We also recommend that individuals be given a choice of which restraint method they would prefer, and that this be done while they are at their baseline. This information is taught in more detail in Chapter 4 of the Mandt System, Trauma Informed Services. The Mandt System teaches there are two reasons to physically restrain a person: 1) to protect the person from harming himself and 2) to protect the person from harming others. We believe that there is no other acceptable reason to physically restrain a person. Just because a person has become verbally offensive and/or is screaming loudly does not warrant physical restraint. The Mandt System does not encourage any type of physical restraint. However, we realize that, in (Protection from Harm) some cases, the skill to perform such techniques is necessary to protect people from harm. We feel that it is better to teach appropriate physical restraint techniques rather than to not teach staff anything and have them resort to inappropriate physical action and restraint due to fear, anger, frustration, or desperation. We encourage and teach the use of a graded system of alternatives, which uses the least amount of external management necessary in all situations. The entire philosophy of The Mandt System is based on the principle that all people have the right to be treated with dignity and respect. We believe that all individuals should be seen as people first and that every person has the right to a personal identity, the right to normalization, access to citizenship, and the right to the least restrictive and most appropriate environment. The Mandt System recommends that restraints are only to last a maximum of 3 minutes. In most states and provinces, high school and college wrestlers are allowed to wrestle for no more than 3 minutes before taking a mandatory rest period. They are in much better shape than most of the staff and individuals served. Yet for their safety, a decision was made to limit the amount of time during which they can physically exert themselves. If they are given a time limit of three minutes, then it makes sense that the same time limit would apply to the use of restraint. When people are being restrained, they are not only exerting themselves physically, they are also experiencing a sense of fear, which may be heightened by past histories of trauma. Staff may also be feeling fear and anxiety in that they may be hurt, or may hurt the person with whom they are working. Limiting the frequency, duration, and intensity of restraint use maximizes everyone s safety! Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over. Chapter 10 Restraining Skills 2010 The Mandt System, Inc. Page 179
Key Points of Restraining Principles of Restraint: There are no hard and fast rules that work in every situation. However, it is important to understand that when a person is being physically restrained, that person may escalate and become more agitated. The following key points are important before, during, and after any kind of physical restraint: Prevention: Know the person; watch for any signs of stress and try to use interpersonal communication skills. Use distance and stay out of the person s way. Make an assessment: Determine what stage of the crisis cycle the person is in, and what type of appropriate response is required. Ask yourself, Why should this person be restrained (i.e., hurting self, hurting others)? Do I need help, and is it close by or on the way? What am I going to do after I restrain this person? Do not overreact: This will be evident by your nonverbal and verbal skills as well as your choice of words, physical presence, body positioning, and physical touch. Talk to the person if it is appropriate, using the person s name and speaking in a calm and even voice. Make sure you use a gradual and graded system of alternatives: Give the person some time and options. Don t fight force with force or get into a power play; manage people; do not people. Treat people with dignity and respect: Never cause pain or discomfort; pain never de-escalates anyone. If the person says, I can t breathe or You re hurting me, make an adjustment. Know your limitations and the limitations of this course: Do not be a HERO. It is OK to ask for and receive assistance. In this section, only the standing physical restraints for adults and the kneeling physical restraints for adults and children will be discussed and taught. The key principles in restraint use are: Keep yourself and others on balance. Stay close! If you are doing a restraint, close is safe! Relax! Use the minimum amount of force needed to maintain the integrity of the restraint. If talking, keep verbalizations short, using a low tone of voice, emphasize safety. Don t fight force with force. person, don t resist them. Redirect the Practice often. Restraint is ideally a low frequency event, with high risk. The longer the restraint lasts, the more likely it is the person will transfer the stimulus from the person who was the stimulus to the staff doing the restraint. Be aware of this and follow the steps outlined in the section on stimulus transfer. Know your limitations and the limitations of this course. Page 180 Chapter 10 Restraining Skills 2010 The Mandt System, Inc.
The Stimulus Transfer Point When people become upset and aggressive towards others or themselves, physical restraint may be needed. Usually, when people realize they are being restrained they will continue to struggle to harm the other person or themselves for a brief period, usually less than 30 seconds. When they realize they cannot get to the other person or themselves, they then begin to struggle against the restraint. When they realize they cannot release the restraint, most people will stop and look at how they are being held and try to figure out how to release the restraint. The point at which the person is analyzing the restraint is called the stimulus transfer point. The individual is now You have 1-2 changing the stimulus from seconds to the other person or himself realize this to the person or people is happening engaged in the restraint. You and begin the have 1-2 seconds to realize process of this is happening and begin releasing the the process of releasing the restraint. restraint. If you wait past the stimulus transfer point, you are now the stimulus and it will be more difficult to release the restraint. Steps for release: 1. From a standing one-person one arm restraint (See pages 290-292 of this chapter.), quickly move the hand closest to the elbow of the individual being restrained from his forearm to the lower part of the upper arm, with the hand in a C position, thumb on the inside, fingers on the outside. DO NOT SQUEEZE the arm of the individual. 2. At the same time, make sure the upper body of the staff person is as relaxed as possible. 3. Using a combination of verbal and nonverbal skills, talk to the individual, using phrases such as It s going to be OK;, you re safe now etc. 4. Remember that the individual was probably upset at someone else, not you. If you release the restraint prior to the transfer of the stimulus from someone else to you, he may still be verbally upset. Verbal aggression is not a reason to restrain someone. 5. For the side-body hug restraint (see pages 286-289 of this chapter), remove the hand around the back of the person and return it to their upperarm, shoulder. Listen to what the person is telling you, both through their words and their body language. What you will feel is that the person is struggling to get at the other person or himself; then he will either stop struggling momentarily or decrease the intensity of the struggle while he analyzes the restraint. Remember that people in stage 3 of the crisis cycle have limited reasoning and analyzing skills. To analyze the restraint means the person has to de-escalate himself. Use this and begin to release the person, maintaining a position with the ability to re-engage the restraint should it prove necessary. The key here is to listen with your body and look for the point at which the person begins to transfer the stimulus from others or him to you. You do not want to be the stimulus, because it will be more difficult to release the restraint when the person is upset with you. Chapter 10 Restraining Skills 2010 The Mandt System, Inc. Page 181
Monitoring When Using Restraint (Observing) Application: A trained individual should be present whenever possible to observe during the use of restrictive physical interaction skills, maneuvers or techniques. Several states require this, and in recent Settlement Agreements, the US Department of Justice has included the requirement for an independent monitor in the final settlement in Texas. Designated staff should receive special training in observation with regard to Prohibited Practices (at the beginning of this chapter), and Medical Issues. Possible Causes: An observer is responsible for monitoring all the persons involved, giving direction to protect all people from possible danger or harm. Because of the observer s vantage point, the observer may be the leader during the interaction. Mechanics: 1. Look at the person being restrained: Look at his face; what color is it; is it turning red; is it turning blue? Look to see if his face is indicating he is in any pain. Is he breathing all right, and is his airway clear of any food or anything else that may obstruct his airway? Is he trying to talk or communicate with you in any way? 2. Look at any staff who is involved in the restraint: Look at the staff s face; what color is it; is it turning red; is it turning blue? Look to see if his face is indicating he is in any pain. Is he breathing all right? Is he trying to talk or communicate with you in any way? Does he need someone else to take his place? Do you need to tell him to begin to release the person being restrained? Is the restraint a power play or staff control issue? 3. The observer may be the leader during this interaction: If more staff members become involved, make every effort to communicate with each staff person, using their names. Being the observer and staying calm helps all the people involved remain calm. When talking with the person who is being restrained, ask questions that require short or yes-no answers. In addition, the observer may be required to assist in any releases (biting, hair pulling, grabbing) that may be necessary to maintain the safety of all participants. Cautions: The safety of the individual being restrained is always paramount, make sure that you, as the observer, are watching that individual very closely looking at the indicators of distress taught in Chapter 7. Pay special attention to the staff members positioning and technique as well as to any indicators of distress on the part of staff. Discontinuing the one-person observing. The Mandt System teaches that restraints are to last no longer than 3 minutes. You should remember the Stimulus Transfer Point to ensure that you do not continue the restraint past the point at which the person may become upset with you after the person with whom they were upset originally has become safe. Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over. Page 182 Chapter 10 Restraining Skills 2010 The Mandt System, Inc.
One-Person, Standing Side Body Hug Restraint (Protection from Harm) Application: The one-person, standing side body hug restraint simply means you are standing beside and/ or slightly behind the person you are restraining, hugging the person s upper body and holding one of the person s arms to his side. Your left arm is placed across the front of the person s body, with your left armpit over the person s left bicep area, and your left hand is holding the person s hip. Your right arm comes across the person s back, and the right hand is placed on the person s hip area. Possible Causes: Some amount of freedom, relationship, personal property, self-esteem, memory, information, physical movement, and/or self-control has been lost or diminished. The person is experiencing severe or persistent pain, fear, frustration, anger, confusion, racing mind, and/or delusions. All interpersonal communications (verbal, nonverbal) have been unsuccessful. The person has now become a danger to himself or others. Mechanics: 1. As the staff member moves toward the person from the left side, hands are up in a non threatening position, elbows in close to the body. Stance is appropriate for staff s body size. 2. Say excuse me for touching. Touch the individual between the elbow and shoulder with both hands at the same time. Keep your body close to the person by placing your abdomen and chest on the person s side using a wide stance. Make contact with the inside of your left thigh to the outside of the left thigh of the person being restrained. 3. Extend your left hand and arm in front of the person and step forward with the left foot at the same time. Your entire body is in contact with the person (close is safe). Your left arm pit will make contact between their elbow and shoulder. Your left hand reaches for the person s right hip area. This will ensure that your arm is not on the diaphragm of the person being restrained. 4. Extend you right hand and arm behind the person being restrained and reach for the person s right hip area. Tuck your head behind the left shoulder. Relax yourself. Your belt buckle area should be on the person s left hip area. Note: If you are coming in from the right side, reverse these directions. Cautions: Remember close is safe. Remember do not immobilize instead move with the person. Do not be a HERO. Get some help, if help is available. Discontinuing the one-person standing side body hug restraint: The Mandt System teaches that restraints are to last no longer than 3 minutes. You should remember the Stimulus Transfer Point to ensure that you do not continue the restraint past the point at which the person may become upset with you after the person with whom they were upset originally has become safe. Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over.. Chapter 10 Restraining Skills 2010 The Mandt System, Inc. Page 183
Two-Person, Side Body Hug Standing Restraint Application: There may be times when you cannot restrain a person by yourself, either because of aggressive behavior or because of the size of the other person or because the person may be moving around and somewhat out of control. In such instances, two people may be able to manage the person by having each staff member simultaneously doing a one-person, standing side body hug, one on each side of the person being held. This is the same as the one-person side body hug restraint except two people are doing it at the same time, one on each side. Make sure you do not place the person in danger by placing arms behind the person s back or by hyperextension of any joints (e.g., wrists, elbows, shoulders, etc.). Possible Causes: The individual being restrained is too large for one staff member to manage alone. The individual is pulling or dragging the staff member around the area; the second staff member can aid in stabilization for safety purposes. The first staff member may be small, but may have excellent rapport with the individual, and may need to stay to assist the second staff with de-escalation of the individual. Mechanics: 1. While the first staff member has the person in a standing side body hug with the person s left arm secured, you approach from slightly behind and on the right side to manage the person s free right arm. As you move closer, your hands and arms should be close together for protecting your face and chest in case the person swings his arm. Use caution, as the person s free arm could be quite dangerous. 2. Approach with hands visible in a non-threatening manner; your hands gently touch the right upper arm of the person who is being restrained. Your right foot steps forward (now you are in a wide stance). 3. Also at the same time, reach across the front of the restrained person s body, reaching for the person s left hip or waist area, securing the person s right arm with your right armpit over the person s right bicep area, and your right hand is holding the person s left hip. Your right arm is under the left arm of the first staff member, ensuring it is not on the diaphragm of the person who is being restrained. Your left arm comes across the person s back, and the left hand is placed on the person s hip area. Your right inside thigh makes contact with their right outside thigh area. Your head is tucked in behind the person. 4. Extend your left arm behind the person being held and reach for the person s left hip or waist area, helping to secure and trap the restrained person s right arm to his right side. You should keep your body (chest and abdomen) close to the person s backside. If needed, you may tuck your head behind the person s body to protect your face from head butting. 5. Keep your body close to the person by resting your stomach and chest on the person s back/side and helping the first staff member to restrain the person s upper body and arms. Your head should be behind the restrained person s right shoulder. You now have two people restraining the person. Page 184 Chapter 10 Restraining Skills 2010 The Mandt System, Inc.
Two-Person, Side Body Hug Standing Restraint (Con t) Cautions: Since two staff persons are involved, make sure that only one staff person talks to the individual at a time. Maintain proper stance. You should keep your body (chest and abdomen) close to the person s back. If needed, you may tuck your head close to the person s body to protect your face from head butting. As staff members, make sure you communicate with one another at all times. Be prepared to back out when the person is de-escalated. Remember that close is safe! If the person moves, move with him or her, redirecting if necessary, using small steps, always maintaining the integrity of the technique through proper stance and balance, body mechanics and movement, and body positioning. Discontinuing the two-person standing side body hug restraint: The Mandt System teaches that restraints are to last no longer than 3 minutes. Remember the Stimulus Transfer Point to ensure that you do not continue the restraint past the point at which the person may become upset with you. Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over. If a two person restraint was needed because the person being restrained was aggressing towards a staff member (usually the first staff member initiating the restraint), the person who was the initial target of aggression is the stimulus and they need to remove themselves in order to facilitate de-escalation. Notes: As staff members, make sure you communicate with one another at all times. Be prepared to back out when the person is de-escalated. Remember that close is safe! Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over. Chapter 10 Restraining Skills 2010 The Mandt System, Inc. Page 185
One-Person, One-Arm Standing Restraint Application: The one-person, one-arm standing restraint simply means you are standing behind and slightly to the side of the person you are restraining, holding one of the person s arms in front with both of your hands. Possible Causes: Some amount of freedom, relationship, personal property, self-esteem, memory, information, physical movement, and/or self-control has been lost or diminished. The person is experiencing severe or persistent pain, fear, frustration, anger, confusion, racing mind, and/or delusions. All interpersonal communications (verbal, nonverbal) have been unsuccessful. The person is now a danger to herself or others. Mechanics: 1. Approach from the back and on the left side. Page 186 2. Explain to the person what you are going to do and say excuse me for touching. Place your left hand slightly above the elbow as you would if you were going to pick up a glass of water, with your thumb on the inside of his arm and fingers on the outside. Caution: Do not squeeze the person s arm with your fingers and thumb, i.e., the palm of hand should touch very softly. 3. Place your opposite hand in an open and relaxed position on his hip area. 4. With your left hand above the person s left elbow, step forward with your left foot (now you are in a front stance) and guide his arm slightly forward and to the right, moving the arm across the person s body. 5. Move your right hand from resting on the person s right hip area to reach under the right arm, around his right side; grasp his left forearm above his wrist (now in front of his body) with your right hand. 6. Stand slightly to the side of the person, so that your chest area makes contact with his back, and your abdomen makes contact with his left hip area. Your chest and abdomen will act as a sensor as they touch the person s body, placing you in the best body position in case the person goes limp or tries to drop to the floor. The closeness will give the person you are restraining a secure feeling of support. 7. Let go of his left arm with your left hand, place you hand under the arm between the arm and body and slide your palm along the forearm (knuckles facing the body), and grasp the person s left forearm with your left hand near the elbow. You now have both of your hands on his left arm and your arms are underneath the person s armpits. This prevents undue pressure on the diaphragm/chest area and allows better protection should the person slip or drop straight down. Maintain the individual s arm at the waist or belt area. Make sure you hold the person s forearm above his wrist joint, and your hands are rotated forward so that your grasp is more secure and thumbs are on the outside. Tuck your head looking over the person s left shoulder. Relax yourself. Caution: Remember close is safe. Remember to relax and breathe. Maintain a good stance with knees flexed. You should keep your body (chest and abdomen) close to the person s back. If needed, you may tuck your head close to the person s body, looking over the shoulder of the elbow you grasped, to protect your face from head butting. Move with the person; do not try to immobilize him. If the person moves, move with him or her, redirecting if necessary using small steps, always maintaining the integrity of the technique. Discontinuing the one-arm standing restraint. The Mandt System teaches that restraints are to last no longer than 3 minutes. You should remember the Stimulus Transfer Point to ensure that you do not continue the restraint past the point at which the person may become upset with you. Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over. To discontinue the restraint, release in reverse order. Chapter 10 Restraining Skills 2010 The Mandt System, Inc.
Two-Person, One-Arm, Standing Restraint Application: There may be times when you cannot restrain a person by yourself, either because of aggressive behavior or because of the size of the other person. Because the person may be moving around and somewhat out of control, you may have to use the two-person standing restraint. Two people may be able to manage the person by having the first staff member do a one-person one-arm standing restraint and the second staff member do a one-person side body hug. Possible Causes: The individual being restrained is too large or strong for one staff member to manage alone. The individual is pulling or dragging the staff member around the area; the second staff member can aid in stabilization for safety purposes. The first staff member may be small, but may have excellent rapport with the individual, and may need to stay to assist the second staff with de-escalation of the individual. Mechanics: 1. The first staff member applies a One-Person, One-Arm Standing Restraint with the person s left arm being held in front. When a need for assistance is communicated, the second staff member approaches from slightly behind and on the right side with elbows in and their hands up in an non threatening position. 2. As they excuse their touch, the staff member places hands gently on the restrained person s right upper arm area, then the staff s right foot steps forward (into a stance appropriate to staff s size and body type), as she/he reaches across the front of the restrained person s body, placing their right hand fingers and thumbs slightly above the left elbow, securing the restrained person s left arm to his/her left side. The staff s left hand reaches across the restrained person s lower back to the left hip area. The staff person tucks his head behind the person s right shoulder facing inward. Both staff relaxes. Caution: Make sure you do not place the person in danger by placing arms behind the person s back or by hyperextension of any joints (e.g., wrists, elbows, shoulders, etc.). Maintain a good stance and move with the person. Use hips and legs to slow the person down. Take several deep breaths and relax. Remember the idea is to de-escalate the individual and move away. Do not try to immobilize the person. Discontinuing the two-person standing restraint. The Mandt System teaches that restraints are to last no longer than 3 minutes. You should remember the Stimulus Transfer Point to ensure that you do not continue the restraint past the point at which the person may become upset with you after the person with whom they were upset originally has become safe. Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over. To discontinue the restraint, release in reverse order. Chapter 10 Restraining Skills 2010 The Mandt System, Inc. Page 187
Moving Restraint: One- or Two-Person Application: A moving restraint is used to physically remove a person from potential danger (protection from harm). This technique is a follow-up procedure to the standing restraint. For example, if the person being restrained has to be moved away from potential danger, a one-person or two-person moving technique may be used. This technique is to be used for a short distance only (i.e., 6 to 10 feet) and in two- to three-foot stages. When a staff member is using a moving restraint technique, the person he or she is restraining may attempt to drop to the floor. Be prepared. Possible Causes: The staff person has determined that the individual needs to be moved away from potential danger, but only for a short distance. Mechanics: 1. Ask the person to move on his own. If you have exhausted all efforts and have come to the conclusion that you must move the person, walk the person forward a few steps and stop, again requesting that he move on his own. The staff member on the right will use the left side of his chest, left leg, and stomach to move the person forward. The person on the left reverses the roll. If you have difficulty moving the person forward because he uses his legs and feet as brakes, keep him in the standing restraint and use your legs and abdomen to gently move the person by walking or sliding forward, stopping every two or three feet. If you get the person s hips to move forward, in most cases, you can get the person s feet to move forward. Move only a short distance. 2. If you have difficulty moving the person forward because he stops the forward movement with his legs and feet as brakes, keep the person in the same standing restraint and walk him slowly backwards a few feet, then stop. Make sure the person s back rests on your chest and abdomen; otherwise, the person may feel as if he is being pulled backwards or off balance. If he feels like he is losing his balance, he may struggle more or drop to the ground. If he does drop to the ground, it may be safer to follow the person down, gently allowing the person to sit on the floor. If the person you are moving goes limp but does not drop to the ground, you may slide him backwards a short distance using small steps, moving slowly and carefully. Once the person has been removed from harm, and is still limp, it may be safer to follow the person down, gently allowing the person to sit on the floor. Cautions: Keep your body close to the person by keeping your chest and abdomen close to the restrained person s back and hips. Remember, close is safe. Move only a short distance and do it in two- to three-foot stages. Remember, when using a moving restraint technique, the person may drop to the floor. If needed, you may tuck your head close to the person s body to protect your face from head butting. Discontinuing a moving restraint. The Mandt System teaches that restraints are to last no longer than 3 minutes. You should remember the Stimulus Transfer Point to ensure that you do not continue the restraint past the point at which the person may become upset with you after the person with whom they were upset originally has become safe. Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over. Page 188 Chapter 10 Restraining Skills 2010 The Mandt System, Inc.
Chapter 10 Supplement Training Following a Person to the Floor Application: When doing either a side body hug or one arm restraint, the person may fall to the floor. Staff must assess the situation and make a decision as to whether or not to follow them to the floor to minimize the risk of injury to the individual without increasing the risk of injury to the staff. The policies and procedures of the organization may give guidance as to the expectations of the organization. Possible Causes: The person may have lost consciousness or their ability to stand, they may have gone to the floor to escape the restraint, they may have tripped. In either case, the safety of staff and the individual served are of equal importance. Mechanics: 1. One person application in Restraint: - Used only when the person goes to the floor NOT A TAKEDOWN! 2. From the wide front stance the staff are using in the restraint, staff will lower their center of gravity, keeping their back straight. 3. If a two person technique has been used, the second person will quickly step out. 4. As the person goes to the floor, staff will shift their back foot and lower themselves to one knee. 5. Let the person go, and stand up again, moving away with hands up in a non-threatening position. Chapter 10 Restraining Skills 2010 The Mandt System, Inc. Page 189
Restraining a Person of Short Stature/ Child (Protection from Harm) One-Person Kneeling, Child/Person Standing Application: When physically restraining a child, it may be necessary for the staff member to be in a kneeling position. This is due to size difference. Possible Causes: Interpersonal communications (nonverbal, verbal) have been unsuccessful in helping the person to de-escalate. The child has now become a danger to himself or others. Restraint of Persons of Short Stature: Generally speaking, this technique would be applied to children or in some cases with adults whose caregivers are substantially taller than the person served. The general guideline is this: if you as the caregiver can not place both your hands, palm down, between the elbow and the wrist of the individual without going across the wrist, similar to the positioning of the hands in the arm restraint, then this technique may be advisable. As you learned in Chapter 7, children under the age of 5 should not be restrained at all unless their behavior is so dangerous that to not use a physical restraint would be more dangerous than to impose one. Children, especially those under the age of five, can easily dislocate joints because their bone and ligament structures are, in layman s terms, more elastic than in older children and adults. The possibility of injury or death with children is such that we would encourage the use of environmental modifications, body positioning, removing other people, etc. before ever considering the use of physical restraint. This is the highest risk technique taught in The Mandt System and must be used only when the risk of not using the restraint is greater than the risk of using the restraint. The basic principles of stance and balance, body mechanics and movement, and body positioning relative to the other person are the basis for all the techniques taught in The Mandt System, including the following two techniques: Kneeling Restraint This technique is an adaptation of the standing restraint taught earlier in this chapter. Staff are using a modification of a front stance, but the knee is down in the back. For instance, if you were in a right foot forward front stance, in this technique your right foot would be forward and your left knee would be on the ground, bringing you to a lower height. This ensures both, for the safety of the individual served and staff (better balance). You will be better able to talk to the individual because there is less distance between the head Remember that children can be re-traumatized by restraint even if you do everything right! Page 190 Chapter 10 Restraining Skills 2010 The Mandt System, Inc.
Restraining a Person of Short Stature/ Child of the staff and the ears of the individual served. Mechanics: 1. Using the example of the right foot forward (kneeling) front stance above place your right hand, in a C hand position on the upper right arm of the individual, with the heel of the hand above the elbow. The left hand is on the hip. 2. After your right hand achieves stability (no squeezing!), your left hand goes under the individual s left armpit and reaches around the individual. 3. Place your left hand on the right arm of the individual, exactly where the right hand currently is while simultaneously removing the right hand. 4. The thumb of the left hand is held closely to your fingers with the weak point of the left hand facing in to the body of the individual. Do not grab the bicep of the individual served. 5. The right hand can rest on the shoulder or be removed entirely if this position is all that is needed to temporarily restrain the individual. 6. If more stability is needed, the right hand can reach across the body for the opposite hip, making sure to go under the left arm. 7. Relax. 8. If you are concerned about being kicked, you can scissor your legs slightly in to each other, providing some protection without losing balance. You should place your head in a position that minimizes the possibility of head butting. If the child is attempting to kick or scratch, they are communicating! Listen to them and begin to initiate the release using the principles of the Stimulus Transfer Point. Cautions: Do not squeeze the child s arm with your fingers and thumb, i.e., the hand should touch very softly. If the child is large and aggressive, you may need other staff members to provide support to you with interpersonal communication and/or physical assistance (i.e., a two-person, standing side body hug restraint, in a kneeling position). They may also be useful for documentation and witnessing, if needed. Keep your abdomen and chest close to the child s back and hips. Monitor the child frequently, ask if they can breathe, if they feel they are being held too tightly, etc. Make any adjustments needed for the safety of the child! Remember that children can be re-traumatized by restraint even if you do everything right! If you can get the child to talk, you may be able to let them go and deal with the situation verbally. Discontinuing a kneeling restraint. The Mandt System teaches that restraints are to last no longer than 3 minutes. You should remember the Stimulus Transfer Point to ensure that you do not continue the restraint past the point at which the person may become upset with you after the person with whom they were upset originally has become safe. Remember, we do not restrain people until they are calm, we restrain only until the need for protection is over. Chapter 10 Restraining Skills 2010 The Mandt System, Inc. Page 191
Physical Restraint: Special Applications There may be times when people affected by physical disabilities use behavior in a way that poses a threat of harm to themselves and/or others. In these cases, The Mandt System has recommendations for adapting and adjusting to each situation, keeping in mind the principles of: Always treating people with dignity and respect. Keeping your R.A.D.A.R. on! Ensuring their needs are met (Maslow) and your needs are met as well. Knowing where they and others, including you, are in the Crisis Cycle. Using the 3 foundations of physical interaction Stance and Balance; Body Mechanics and Movement, and Body Positioning to respond to the individual in a way that maximizes their safety and the safety of others, including staff. The following are to be taken as suggestions, and must be individualized by the certified Mandt trainer when working with individuals. 1. People using wheelchairs for ambulation Self-Injurious Behavior in the case of self-injurious behavior (SIB), if non-physical interventions have proven to be ineffective to ensure safety, physical intervention may be necessary, but restraint of the body would not be one of the interventions. Rather, the staff can use redirection or deflection to move the person s arm away from them when they are trying to harm themselves. When the person moves their arm and hand towards the part of themselves they are attempting to injure, guide the arm away, never fighting force with force. Staff will probably need to adjust their stance to lower themselves, perhaps even being on one knee (the back leg). When redirecting, be aware of where your hands/arms are to prevent being bitten. Aggressive Behavior Towards Others if a person using a wheelchair for ambulation becomes aggressive towards others, physical intervention may be necessary, but full physical restraint would not be one of the interventions. Rather, the staff can move the person by pushing the wheelchair. The act of moving the wheelchair is considered to be a restraint. 2. Self-Injurious Behavior on the Floor Typically, SIB on the floor involves hitting the head against the floor. We would first recommend a Functional Behavior Analysis (FBA) to determine the reason behind the behavior. To protect the person, the first rule is never restrain the head while on the floor. The risk of injury to the neck is extremely high. Instead, plan ahead and procure several kneeling pads used to weed Dignity and respect in all interactions! a garden, mop a floor, etc. Super-glue two of them together, place them strategically around the room, and use them to respond to this behavior by placing them between the head and the floor. If the person moves their head to hit the floor instead, then you know this is a voluntary behavior and the person is at either the Baseline Phase or Stimulus or Trigger Phase. Page 192 Chapter 10 Restraining Skills 2010 The Mandt System, Inc.
Physical Restraint: Special Applications 3. People affected by physical disabilities (hemiplegia). Cerebral Palsy or Traumatic Brain Injury can result in a condition where an individual has limited physical movement on one side of their body. This is known as hemiplegia. In such a case, when a person engages in self-injurious behavior, redirecting their arm may be an option. It is critical that staff ensure that the person does not lose their balance, and full physical restraint may be safer in this case. Restraint, if done, would be on their unaffected side to ensure stability and because this is the side that most likely would be used to harm themselves. In the case of aggressive behavior towards others, staff would again use physical interventions when non-physical interventions have proven to be ineffective at ensuring the safety of all persons in the environment. Again, if physical restraint were utilized, it would be utilized on their unaffected side to ensure better balance and because this is the side that the person would be using when engaging in aggressive behavior. Important Things I want to remember...: Chapter 10 Restraining Skills 2010 The Mandt System, Inc. Page 193
Self Study Questions Circle the letter beside the correct answer(s) that apply in following questions: 1. The Mandt System does not encourage the use of physical restraint; therefore, why is instruction in its use provided by The Mandt System training? (Pg 179, S17) A. We feel that it is better to teach appropriate physical restraint techniques rather than have staff improvise B. If they do not know how to restrain, they may resort to inappropriate physical action and restraint due to fear, anger, frustration, or desperation C. All staff need to know how to do a restraint regardless of where they work 2. The dangers associated with the use of physical restraint as taught in Chapter 7 are: (Pg 122; S7 Ch 7) A. Re-traumatization B. Death after restraint has ended due to catecholamine C. Risk of injury to staff, including death D. Death due to compression asphyxiation E. Death due to positional asphyxiation F. Injury to individuals served 3. In the Stimulus Transfer Point concept:(pg 181; S21) A. If people continue to be restrained after safety has been established, they will probably transfer the stimulus from the person with whom they were originally upset to the person(s) performing the restraint B. If they begin to analyze the restraint, they are transferring the stimulus at that point and the person(s) performing the restraint should initiate release C. Stimulus transfer as a concept is irrelevant while restraining someone 4. List at least three Prohibited Practices according to The Mandt System.:(Pg 137 S 5-9) 5. The level of threat a person presents must be determined before we interact physically. What three questions must be asked in determining if there is a clear and present danger? (Pg 154, S4) 1)Is the threat? 2)Is the person of carrying out the threat? 3) Is the threat of harm? 6. Match the following to the list below: The maximum recommended time limit of a physical restraint. (Pg 179; S14) Prohibited practice according to The Mandt System. (Pg 137; S 5-9) Individual trained in the technical level of The Mandt System (therefore knowledgeable of the prohibited practices and signs of distress ) watching carefully and directing during restraint use (Pg182, S22) Hand placement during side body hug. (Pg 183) Arm placement in a one arm one person standing restraint (Pg 186) A. Across the person s chest B. On person s hip C. Take downs; forcing the person to the floor D. Observer/ Monitor E. 5 minutes F. 3 minutes G. In front across the person s waist or belt line Congratulations, you have completed the The Mandt System training. Word Bank: Believable, Hyperextension, Immediate, Take-downs, Pressure point and pain, Capable, Pressure causing chest compression, Sitting on any part of the body, Choking Page 194 Chapter 10 Restraining Skills 2010 The Mandt System, Inc.