No matter what part of the human services field in which you work, reducing the use of restraint is one of the major goals. In some states and provinces, the push to reduce restraint comes from advocates, in others it comes from regulatory bodies and in others it is service providers. The term “restraint free” is used often to describe the ultimate goal of the movement to reduce restraint use, and many people have asked us during Mandt System® training what this really means.

Several years ago I got a call from the person coordinating Mandt training at Cedars Community Services in Omaha. She shared that in the past year, they had not used physical restraint at all, and because they were a community based service, they also did not use mechanical restraint or seclusion. Her question to me was whether or not they could use the term “restraint free” even though they still taught restraint to staff, and even though they might have to use restraint in the future.

My response was that the term “restraint free” was more of a culture point than a data point. The term has not been clearly contextualized and therefore has different meanings to different entities. Entities have stated they are restraint free because they do not count manual restraints or chemical restraints and don’t use mechanical restraints.

The term “restraint free” may better reflect a snapshot in time and a philosophical goal. Valley Mental Health Services in Morgantown, WV, serving over 1,000 people a year in a combination of community, emergency, and in-patient mental health services, has done a total of 3 restraints in 10 years. While their data point is not zero, I do consider their culture to be one where people are free of not only restraint, but the fear of restraint. It happens so infrequently and is used only in cases of immediate risk, not imminent risk.
There is a big difference between these two words, imminent and immediate. Most legal standards for police officers require an immediate risk of harm before force can be used. Almost anything can be imminent! Imminent means that some event could occur in the near future, while immediate means that it will occur, and the steps towards immediate risk have already been taken.

Organizations whose culture point is restraint free are organizations where staff are so good at non-physical interactions and interventions that physical interventions are simply not necessary, unless there is an immediate risk of harm that is so severe restraint is needed. By the very fact that the skill level in prevention and de-escalation is high, staff let non-physical skills work longer, they are more patient and supportive. It is this trust in prevention and de-escalation that empowers staff to stand back a bit, lower their tone of voice, reach out in empathy and with full respect for the person say “I’m so sorry you are upset, do you feel safe?”

There is a perception of safety among the service users and the service providers in organizations that have reached this culture point. It is seen in the satisfaction surveys conducted by Developmental Services of Nebraska several years after they had implemented Mandt. In fact, they are now part of a movement known as “Coercion-Free Nebraska” which takes this whole notion of restraint free and pushes the envelope even further. Reducing restraint use means focusing on building healthy relationships where people feel safe, and adding preventative skills of focusing on unmet needs, improving communication skills, understanding the neurodevelopmental impact of trauma and resolving conflict in a way that meets the needs of all the people involved, and finding ways to invite behavior change through the implementation of Positive Behavior Supports.

The last thing I want to mention about restraint reduction is that it saves money. In their article on “The Business Case for Restraint Reduction”, the authors point out the economic costs of restraint and the benefits of not doing restraint on the bottom line of an organization. Froedtert Community Hospital in Menominee Falls, WI was paying over $200,000 a year in workers compensation costs due to patient aggression before using Mandt, and today their costs are at or near zero. In 2011, Sheppard-Pratt Psychiatric Hospital’s Adolescent Services program, in Towson, MD, had no staff injuries at all. Independent Opportunities in Kentucky has saved over $1.8 million dollars in workers compensation costs since changing to The Mandt System five years ago.

Saving money is not the goal of restraint reduction, it is a benefit. The goal is to increase the emotional, psychological, and physical safety of individuals served and the staff who serve them. When we focus on safety, when our foundation is the respectful relationships we have with all the people in our organizations and in our family homes, then our cultures will be restraint free.

Bob Bowen

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