At the end of 2003, Kim Sanders realized Grafton Integrated Health Network, where she’d spent more than a decade, first in direct care and then later as an executive, was falling apart. Treatment outcomes, as well as staff and parent satisfaction, had begun to plummet. During that year, while serving 220 people, Grafton staff did over 6,600 restraints and more than 1,500 seclusions. As a result, staff injuries spiked and so did staff turnover, at a whopping 54 percent, and the team had just been notified that they’d been dropped from their workers’ compensation insurance. “It was our lowest moment.” Sanders says that over the decades, the company had slipped further and further away from the person-centered ethos that had been a core tenet of Grafton when it opened as a school in 1958. Ruth Birch, a mother who had tired of how traditional education gave up on and underestimated the capabilities of children with disabilities, founded the school to build learning around each child’s strengths. Over the years, Grafton grew and today serves children and adults across a spectrum of disabilities and mental health diagnoses.“We held onto that client-focused approach for many years, but then in the ‘80s and ‘90s, it shifted toward traditional behavior modification, which meant restrictive practices and controlling culture. The initial core values lessened and began to disappear.”
Veering from a person-centered approach also had financial implications, derailing Grafton economically as it had to bring in new hires while paying out injured staff. To get the company back on track, Grafton hired Jim Gaynor as the new CEO. Sanders said hiring Gaynor was what saved the organization: his ‘can-do’ attitude and leadership style transformed Grafton from an example of what-not-to-do into an innovator that developed Ukeru Systems, a model of care that reduces and works to eliminate restraint and seclusion. “He was clear that no matter how bad it was, everything was going to be okay, and no one was better suited to solve the problem than us. It’s exactly what we needed to hear.”
Off the bat, Gaynor tasked his team to find a system that minimized the use of seclusion and restraint without compromising client and staff safety. Sanders immediately set off to find a program that fit, spending long hours researching and attended conferences. She discovered that many crisis intervention programs have excellent de-escalation techniques, but when they didn’t work, restraint was still the fallback. “That’s what was getting us into trouble, and the existing programs left our problem unanswered.” After coming back with her findings, Gaynor told Sanders they’d just have to come up with their own system, which the team found both exciting and intimidating. “We’d never done anything like this before, but all of us had direct care experience, which helped us examine what leads staff to do restraints and seclusions in the first place.”
Staff Restrain and Seclude Because of Fear and Frustration
Brainstorming sessions quickly revealed that people working in direct care often are and feel unsupported. When discussing why they had restrained clients, Sanders and her colleagues shared that the primary reason was fear. “If we get right down to it, sometimes we were super scared. Maybe we had been punched, scratched, bitten, or hit the day before and didn’t want it to happen again, so we jumped to restraint faster than we needed to out of fear.” Another reason why direct care staff may use restraint before necessary is out of frustration at work or home. Sanders says when a staff member is exasperated, it’s easy to perceive what clients do as intentional and take their behavior personally. Frustrations mount, she says, but in direct care roles when they don’t address these issues, it can result in injury or dismissal, or both. What Sanders and her colleagues noticed was that Grafton needed to boost support of its staff. “We are people, not robots, and need to talk about our moods and our level of tolerance for frustrating situations.”
The realization that staff needed increased support developed into Grafton adopting a Trauma-Informed environment for clients and staff, and mixing it with what Sanders and her teammates call Comfort vs. Control. “The idea is that when you’re working with a client or co-worker who is at his or her worst, you need to be at your best.” Sanders says this doesn’t mean there aren’t boundaries or limitations. For example, if a client wants cake before dinner, he must wait until after dinner like everyone else, but the staff communicates the language positively. “Let’s say Johnny wants a big piece of chocolate cake five minutes before dinner, it doesn’t mean that you say, ‘Oh, trauma-informed plus comfort means I have to let him have the cake,’ but it’s also not harsh. It’s us saying to the kid, ‘You know what, chocolate cake is my favorite cake too, so right after we eat, you and me, we’re going after that cake. You get the first piece.’”
Creating an environment of compassion carried right over to Grafton staff who Sanders says today aren’t just kind and caring toward each other but express a genuine, sincere interest in one another. This culture produces a safety net for staff when they are struggling. For example, if a staff member calls out two Mondays in a row, his supervisor may ask if the person is doing okay. “If we see a trend that’s concerning, we are going to sit down with the person. He might respond and say, ‘Yeah, everything is fine. Why?’” The objective is to ask if he needs support. “We are digging into the why just like we do with our clients: what is the person experiencing and how can we help?” Before adopting this approach, Sanders says the person would have likely been put on probation and told, “If you’re late again, you’re fired.” She says supervisors and management hadn’t been paying attention to their staff, only their clients, and they had to do both to create the environment they needed. “It’s the right thing to do, and if we treat our staff better, they’ll treat our clients better.”
Couch Cushions and Extraordinary Blocking
Trauma-Informed Care (TIC) plus Comfort vs. Control swiftly improved the Grafton culture, but there were still times where words didn’t sufficiently deescalate a situation. “If I tried all my non-physical de-escalation techniques and a client is trying to bite me in the face, what in the world can I do?” Sanders says, in those scenarios, staff began blocking with couch cushions, beanbags, and throw pillows while maintaining communication with the client using TIC and Comfort vs. Control. She and her colleagues didn’t know what to expect but witnessed immediate positive results. “Even early on it worked. Turns out, direct care staff is much more patient and compassionate when they know they are safe.”
Within the first six months of using pillows and cushions to do what Grafton calls Extraordinary Blocking, Sanders and her teammates realized the objects couldn’t withstand kicks and hits. She went back to Gaynor and said, “Look at this beanbag; it’s not durable enough.” He responded, “Well, I guess you’re going to have to make some.” Around the same time, Sanders and Gaynor wrote a peer-reviewed article about Extraordinary Blocking + TIC that made waves in Victoria, Australia. “We spent four years going back and forth between the United States and Australia, and after one of our presentations, there was a line going out the door of people waiting to speak with us. It was unbelievable. Jim looked at me and said, ‘Kim, I think we need a name.’” Sanders found that name in a martial arts article on how strength isn’t about force but instead when a person can accept another person’s energy, not fight against it. The term to receive another person’s energy is Ukeru.
Blocking Buys Time to Continue Person-Centered Techniques
Now that they had the name, Sanders and her team needed to come up with a design that could sufficiently withstand use. They tried karate training shields, but the equipment was heavy and made for direct hits. “When clients are angry, they kick from every direction.” Also, she said the training shields only came in black or red, both aggressive colors. The last straw was when the supplier sent Grafton shields featuring their new logo: a large first on the front. “Here we are teaching Comfort vs. Control, but we’re going to use blocking shields that feature a fist? That wasn’t going to work.” Sanders went back to the drawing board and found a manufacturer in Rhode Island to make Ukeru’s blocking shields, gloves, and shin guards out of out soft, cushiony, and durable material that would protect both clients and staff. To date, Ukeru is in 161 organizations across the United States and Canada. At Grafton facilities, the gear is everywhere, indoors and out, and visible with handles faced outward, ready to be used. Clients play with them, particularly kids and teens who enjoy using them to make forts. “Sometimes, people ask whether we are just giving kids a weapon to use against staff. That’s not how it works. We want kids to mess with the pieces, so they aren’t scared of them. Also, if someone is that mad, they aren’t going to pick up the softest thing in the room, basically a big pillow. We just don’t see that.”
Though a critical component of the system, Sanders says the point of Extraordinary Blocking is to buy time. She says that when the team first introduced the philosophy, with beanbags and cushions, the number of restraints fell, but they still had a high number of incidents. It took time to create the compassionate people-centered culture needed to minimize the need for blocking at all. “As the number of restraints went down, the number of blocking occurrences went up. That was okay because we just wanted to keep people safe, but over time, as we have gotten better at TIC and Comfort vs. Control, the number of incidents has gone down.” Sanders says this development is sometimes disappointing for people who want to tour Grafton’s facilities in hopes of witnessing blocking techniques. “They don’t want to see us doing Comfort vs. Control. People say, ‘I want to see blocking,’ and I have to tell them there’s slim chance that you will see blocking because it just doesn’t happen like it used to because our culture has shifted.”
Sanders says adults and kids perceive seclusion and restraint as retaliation while the blocking technique creates protection for clients and staff, but clients don’t view it as retaliatory. She never restrained kids to hurt them or to be mean to them, but that is how they saw it, and each time she did so, it broke the relationship. The kids wouldn’t talk to her for days, and she had to rebuild trust. Sanders says the cycle would happen all over again with each restraint. “What’s different with blocking is that trust is maintained and, when clients calm down, what they remember is how kind you were when they were at their worst.”
#CrisisTalk is committed to sparking ongoing dialogue on behavioral health crisis and including diverse perspectives and experiences. We’d like to hear what you think about this or any of our articles. Here’s how to send a letter to the editor.