An Application of TIC to Reduce Restraint and Seclusion
Craig and Sanders (2018) is an open-access article that evaluates a recent application of trauma-informed practices to reduce use of restrictive procedures at a large behavioral service provider based out of Winchester, Virginia, USA. Over 3,000 clients accessed the trauma-informed treatment model, including 444 in community-based group homes, 99 in educational settings and 217 in the applied behavior analysis program. In the year before the program began (2003) there were 6,646 incidents of restraint and seclusion within the organization and in the last year evaluated (2016) there were 53 total incidents.
This philosophy taught response blocking, promoted an understanding of behavioral intent and client needs, and encouraged the development of creative solutions that were alternatives to restraint and seclusion. This culture shift asked employees to reassure clients, ask questions instead of making assumptions, be flexible, let go of the upper hand, and treat others with kindness and respect. The belief was that many situations in which a restraint or seclusion was used could be better resolved by a non-coercive, caring intervention from a person focused on peaceful conflict resolution who was willing and able to spend time with the upset or angry individual.
Craig and Sanders (2018)
TRAUMA-INFORMED METHODS & OUTCOMES
The Grafton company assumes trauma as part of their foundational model. This is a universal precaution approach to trauma. Similar to using universal precautions in other contexts, such as always wearing gloves during hygiene routines, the approach provides trauma-informed care to all clients regardless of whether a risk for re-traumatizing exists. This approach protects clients with undetected trauma experiences.
The approach includes these seven components:
- LeadershipIncluded presence of administrators for modeling and coaching during crisis
- CommunicationIncluded routinely sharing results and progress toward goals
- TrainingIncluded teaching knowledge and skills to keep clients and staff safe
- MeasurementData to determine whether progress was being made to guide subsequent steps in the process
- DebriefingFollowing each incident there is a review of the antecedents to avoid and the supports needed to prevent restraint/seclusion in the future
- Alternative solutionsIncluded both proactive and responsive strategies toward the guiding philosophy
- Therapeutic treatment planningUsing a team to assess client strengths, needs, abilities, and preferences to develop strategies that promote personal growth and provide the individual with safety and security
This study on the application of TIC for crisis behavior reports incredible outcomes that may be difficult to accept and should be considered with a degree of caution. The Grafton company aimed to reduce use of restrictive procedures by 35% and report a reduction over 80%. The authors of the Craig and Sanders (2018) have affiliations with Grafton so the study was not an independent evaluation. Further, the Grafton company is marketing the crisis training program to interested providers, so the findings are simultaneously client outcomes research and advertising material.
Take-Away Lesson
At the time of this course was developed in 2019, research applications of the trauma-informed approach were still developing. There are several key aspects of the TIC approach that have independently been associated with higher-quality care:
- Organization commitment to change. Ultimately it will be the organization that determines the climate of any treatment facility, residential placement, or school.
- Focus on antecedents. In the case of triggers, eliminate and minimize where possible and then teach avoidance and coping.
- Understanding behavioral intent. In addition to identifying functional relations, emphasis on the client’s history is critical.
- Model and coaching. This tenant is supported by over 15 years of behavioral skills training (BST) demonstrations published in behavior analysis journals.