Kim Masters M.D.
In inpatient and residential units aggressive behavior is contained because it is disruptive and dangerous to treatment. Recent attempts to decrease the use of seclusion and restraint have focused on ways to help individuals regain self control without physical interventions. Some examples include:
- a program that received an award for innovation, committed itself to abolish restrictive interventions and removed the door from its seclusion room (Child Assessment Unit 2003),
- another unit offered children alternative groups to attend if the one assigned provoked resistance or opposition, and
- instead of restricting an angry child to a room, a residential program permitted a staff member to walk with him around the yard until he worked through his frustration (NETI, 2003).
A common thread relating these interventions is the involvement of patients in designing their own deescalation programs.
JCAHO has given the effort to decrease seclusion and restraint a boost in its support for “the psychological advance directive,” which asks patients for the most effective manner to help deal with their frustration and anger. The answer prompts a review by the child/ adolescent and staff of past experiences with restrictive interventions and leads to development of de-escalation strategies.
Another approach, Narrative Therapy, can provide staff a window through which to understand patients’ perspectives about their own behavior. If successful, it can direct aggression into prosocial channels (Zimmerman, 2002).
From this point of view, children who curse and threaten, or adolescents who give staff members “the finger” and sport the “make me” body posture, become people with problematic narratives not problem children.
For example, in a prevention class on seclusion and restraint for staff, one might introduce the above situations, and then pose these questions to encourage an alignment with individual child/adolescent’s narrative:
- “Have you been in a situation in which someone labeled you or gave you an identity that you knew was untrue?”
- “Have you ever been labeled ‘the problem’ in a relationship?”
- “Did anyone try to take charge of the direction of your life or knew what was best for you?
- "What effects occurred as a result of these experiences?”(Ibid)
From the children described above, we would likely hear tales of behavioral outbursts in response to provocations by peers and rejection by adults, followed by exclusion from activities. While this is typical victim fare, this perspective would likely sabotage behavior contracts or a CBT course.
In a Narrative Therapy, on the other hand, the therapist shares the eyes of the child and helps construct a story which ties these rejection experiences together, while at the same time emphasizes personal aspirations and desires. Questions about how “trouble” began and grew may help the child/ adolescent understand for what goals they were striving before their life got derailed. For example, if the teen described above remembered playing a superhero as a child trying to chase bad guys, then he might be persuaded to return to this theme and review how his current beliefs and relationships have evolved. Is he still a superhero? Did the imagined enemy become authority or kids who challenged him? Had he given up and joined forces with the bad guys? Questions should lead to a life narrative describing how past thoughts and experiences produced current perceptions and behaviors. It should also detail how current views and feelings could be expressed to achieve the goal for which the adolescent is striving, i.e., to be a hero, a helper, or a savant, etc. Similar narratives can be obtained from children, but may have more dissonant elements. There may not be an evolution of roles, just a superhero at play, and a lost or disorganized person in daily life. With all children and adolescents, the therapist’s role is that of an inquiring biographer. He/She strives to understand enough to help exchange the role of the rejected for that of participant in their worlds. There are many ways this inquiry can be carried out. For example, the therapist can be a Sancho Panza to the child’s Don Quixote, or an assistant helping the adolescent alchemist change emotional “lead into gold.”
Once the narrative study is complete, it can be reinforced by encouraging the child or adolescent to share the findings with peers and demonstrate its effect on daily activities. The narrative then becomes its own “manifest destiny.”
Of course, some children and adolescents will not be able to use this approach because of cognitive limitation or inability to empathize with the plights and struggles of their peers. It will also not work well in crises, because safety concerns may require the therapist to abandon the role of an inquiring assistant. However, when introduced at the outset of a hospital or residential stay, it can form the basis of a treatment alliance and be the overriding source of personal change and growth. Anyone game to try this approach?
Child Assessment Unit Cambridge Hospital (2003), A More Compassionate Model for Treating Children with Severe Mental Disturbances, Psychiatric Services 54, 11, 1529-31.
National Executive Training Institute (2003), Training Curriculum For the Reduction of Seclusion and Restraint, Alexandria, VA.
Zimmerman, J, Beaudoin, JN ( 2002) Cats Under the Stars: A Narrative Story, Child and Adolescent Mental Health 7,1, 31-40.
Dr. Masters is Medical Director of Focus by the Sea, a private psychiatric hospital on St. Simons Island, Georgia. He is also co-author of AACAP’s Practice Parameter on the Prevention of Aggressive Behavior.