DMR Director for Human Rights There continues to be some confusion about the difference between emergency restraints and holding used as duly authorized behavioral interventions in Level II Behavior Modification Plans. The question raised is when is holding written in a plan an Intervention for treatment purposes under 115 CMR 5.14. When it is, the agency is not required to report the holding as a restraint. If the clinician puts an emergency provision inside the behavior plan solely to keep the individual safe through use of restraint, people get confused as to how or if this should be reported as a restraint in HCSIS. The Department’s Human Rights Advisory Committee recently recommended the Commissioner adopt the following approach, and she has agreed to this in principle. Clinical guidance will be forthcoming once crafted. She further intends to look at the behavioral regulations to update and revise them as a whole. The recommendations are as follows:
If holding is in the plan the clinician must declare the intent behind its inclusion; to provide for safety in an emergency or for treatment purposes, i.e. to physically support an individual in a manner intended to reduce the target behavior.
That if a hold is for safety only, clinical guidance regarding individual needs during an emergency should be written as an emergency protocol to be attached to the plan to avoid confusion.
It is sound clinical practice to anticipate times when a planned intervention may not succeed and give guidance through an emergency protocol about the physical and psychological needs of an individual in an emergency.
To add a protocol for emergency intervention to a behavior modification plan does not constitute establishing a treatment purpose to the holding.
When adding such a protocol to a plan, instructions should be given to require staff to fill out emergency restraint forms in these circumstances.
If holding is truly a behavioral intervention in the plan, it has a well-articulated treatment role in decelerating the target behavior it is intended to address. Behavioral data will be captured to measure the effectiveness of the holding. The team needs to continually reassess to determine if it is fulfilling its treatment role.
An example of how holding can be used in a treatment intervention involves holding early in the cycle of escalation of a behavioral event, before an emergency exists, to interrupt a path to dangerous outbursts with an eye to keeping an emergency event from happening and help teach the person how to gain control for their selves. A technical definition can also include any intervention where the treatment procedure must be physically enforced to overcome the individual’s active resistance, such as an escort to time out.
One myth in the system is that if a person has too many restraints it establishes a pattern that is “planned and predictable” and can no longer be defined as emergency events. This is false. If there is a certain frequency of emergency restraints (more than two in a week or three in a month) the team must assess the situation and identify teaching or other strategies or interventions that will reduce the need for emergency restraint. In other words, they have an obligation to figure out what is going on and intervene.
Another myth is that the Department punishes programs that have “too many” Level II plans. The Department is invested in the progress of all persons in maximizing their ability to fully integrate into typical life activities and settings. While programs trying to help persons change behavior that limits their community participation have an obligation to try less restrictive interventions first, if an agency has Level II plans and can demonstrate less restrictive interventions tried, and the behavioral data shows the Level II plans are working, these agencies will be applauded, not criticized.
If holding is found by the Peer Review Committee, the Human Rights Committee and the team, as a legitimate intervention with a clear treatment role articulated in a behavior modification plan, the holding is not required to be reported as an emergency restraint.