National Association for Rights Protection and Advocacy


 The Journey from Coercion to Collaboration
 Bob Bowen & Arryce Hayes

Abstract Relationships are the context in which human services are provided to and received by individuals served.  Non-coercive relationships are key to reducing the use of restraint.  To help people recover from traumatic experiences, the relational environment created by staff interactions must promote growth through the non-coercive implementation of treatment plans.

Outline:

Overview

    It is easier to de-escalate with someone you know and trust than with someone you either do not know and do not trust or someone you know and do not trust. 

    “Relationship is the single most important therapeutic modality for ameliorating threats of violence, emotional crisis and the need for restraint.  Peter Breggin, M.D., JCAHO 1999” (Quoted in Bowen, 2005.   

    In 2004 the National Association of State Mental Health Program Directors (NASMHPD) held a conference and published the proceedings under the title:  Moving From Coercion to Collaboration in Mental Health Services (Pollack, 2004).  In the introduction to the proceedings, David Pollack wrote about (paraphrased) coercion, the apparent need to use physical force and isolation, as the root cause in the vast majority of situations where restraint and seclusion have been used.   When systems focus on the development of healthy relationships and prohibit the use of coercion, the result will be a reduction in the use of restraint and seclusion.

    This has been the focus of the Mandt System which has provided training to service providers for over ten years.

    History of Non-Physical Coercion in Human Services

    In the middle part of the 19th century (1825-1875) there were many instances in which people were literally set free from the chains that bound them. The Charter of Sheppard-Pratt Psychiatric Hospital in Baltimore, Maryland called for patients to be treated compassionately, and forbade the use of pain.  As a devout member of the Religious Society of Friends (Quakers), Pratt wanted his non-violent approach to be reflected in the work that was to be done in the Hospital.  This approach was seen in the work of Dorothea Dix, Philippe Pinel, and others.

    With the advent of behavioral models of psychology in the late 1800’s, the concept of using external coercion for the good of the person (ALLEGEDLY) who could not make a reasonable decision independently became the norm.  The more professionals became aware of the power of operant conditioning, the easier it became to use that power.  Human relationships in general society became more and more coercive as the hierarchical structure of the bureaucracy became the norm within the business community.

    Northern Arizona University defines Positive Behavior Support, in part, as a process of “continually moving away from coercion.”  There are times when coercion may be necessary to prevent death or significant injury.  There is never a reason to use coercion to force “COMPLIANCE WITH A GOAL OR A REQUEST.”   The people who are served in human service “TREATMENT” settings have a high rate of trauma (NASMHPD, 1999, 2004) and the use of coercion also re-traumatizes that person. 

    Recovery from trauma is a journey (Reagan, 2007), and to help people recover those of us who are in paid relationship must be invited to participate in that recovery.  They (WE?) are the servants, and must understand their role.  Finding ways to continually move away from coercion as we journey towards the hope of healing is difficult, but has some clear markers:

    1. Understanding that all “challenging behavior” communicates an unmet need.
    2. Identifying that unmet need is the first goal of the recovery.
    3. Partnering with the person to change the environment first and then, if desired by the person, helping the person learn new behaviors to help them meet their goals.
    4. Aligning the components of human services to support the person’s recovery is critical to success.

Learning Goals:

  1. Identify the basic needs underlying all behavioral challenges
  2. Examine how trauma impacts outcomes, especially regarding coercion.
  3. Compare outcomes of organizations using non-coercive approaches with national outcome data.

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