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What Works: Alternatives to physical restraint

August 26, 2016

Sometimes the best ideas come from those who have been in the weeds the longest.

With a history of using traditional, physical, crisis-management tactics, Grafton Integrated Health Network, a Winchester, Va.-based not-for-profit behavioral health and special education services provider, found it could no longer advocate for the approach. By 2003, the organization had a direct-care staff turnover rate of 54%. Numerous injuries to staff members by patients in crisis also drove up its worker’s compensation insurance premium to an untenable $2.5 million. Relations between staff and clients were strained.

“There was seclusion, restraint, timeout, restitution—everything you could imagine when you think of restrictive practices,” says Kim Sanders, executive vice president at Grafton. “Over time, as that culture grew, it was highly controlling and somewhat negative. We had staff who felt like helpless, hopeless victims. They were working with the toughest individuals who couldn’t be served in schools or live with their families. They’d come in day in, day out, and get hurt or injured.”

Sanders, who has been with Grafton since 1989, experienced firsthand the challenges direct-care staff faced: Among her past roles, she served as a residential instructor from 1990 to 1993, providing residential care and supervision of students with severe disabilities and maladaptive behaviors.

Turning point

CEO Jim Gaynor, who arrived at Grafton in 2002, told his leadership team that changes needed to be made, particularly in the company’s crisis management protocols. In time, working hours were rearranged, but the bigger change was the home-grown development of an alternative to restraint for crisis management.

The “Ukeru” program is based on the principle that restraint is unnecessary and unproductive and that intervention should be built on comfort, not control. Instead of using restraint or seclusion to quell potentially combative clients, staff were instructed to use soft materials, such as a beanbag, to shield themselves while talking with clients to de-escalate them.

Feelings of fear and frustration had plagued staff at Grafton in the past, Sanders says. Implementing less aggressive protocols addressed that and strengthened the therapeutic alliance between staff members and clients.

“If I can hold up a beanbag and block you while you are being aggressive and trying to attack me, I take away the majority of that feeling of fear,” Sanders says. “I’m much calmer and can stick with you. I’m not going to do anything intrusive like hold you against your will. I can continue to say kind, compassionate things to you if that’s what works for you.”

Otherwise, care staff could react in counterproductive ways that escalate the crisis, by running away or shouting, for example.

Staff initially used couch cushions, throw pillows and large beanbags as shields. Umpire’s gear and karate blocking pads were also implemented before Grafton teamed with an outside vendor to develop proprietary pads.

An orientation process known as “presenting the pad” helps familiarize clients with the pads. The pads are kept out in the open at Grafton, and It’s not uncommon to see clients leaning on them to watch TV or for children at a Grafton facility to use the pads to build forts, Sanders says.

Dramatic improvement

With the implementation of the program, Grafton reports a significant reduction in the use of restraint at its facilities, as well as the elimination of the use of seclusion, according to Sanders. Direct-care staff turnover has been reduced to 30%. Grafton leaders estimate the use of Ukeru has saved the company over $15 million since 2004.

In December, Grafton announced the launch of Ukeru Systems as a commercial product available to other treatment centers. Sanders says the organization hopes it can help behavioral healthcare providers relying on traditional physical crisis management protocols find alternatives.


Are your behavioral healthcare organization’s crisis management protocols up to par? Consider the following indicators:

  • Track the use of restraint and seclusion. By 2003, Grafton direct care staff was using restraint 6,600 times and seclusion 1,500 times for the 220 individuals served in a given year, prompting the organization to begin exploring physical alternatives.
  • Review your worker’s compensation costs. Because of numerous injuries to staff members, Grafton faced a worker’s compensation insurance premium of $2.5 million in 2003 and struggled to find a private insurance provider.
  • Listen to your staff. Before the implementation of Ukeru, Sanders says Grafton employees felt a sense of hopelessness and helplessness. As a result, the organization saw a direct care staff turnover of 54%.
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