Comfort versus Control—-Which Really Works?

When I think about the work Grafton has done over the last decade, two numbers (98 and 12 million), come to mind. Grafton has achieved a remarkable 98% reduction in the use of physical restraints and a total return of more than $12,236,934 through savings in employee lost-time, workers’ compensation costs and employee turnover.

When we talk about how we achieved these outcomes, a key phrase is “Comfort versus Control. It refers to a philosophical and paradigm shift that took place at Grafton and continues to shape and guide our treatment philosophy today.

Historically, within the company when clients exhibited challenging behaviors, employees responded by placing limits, saying no, exerting physical control over the individual and environment to manage the behavior at hand. Behaviors usually escalated and if these behaviors became dangerous to the point of imminent harm to self or others, physical restraint and/or seclusion were techniques employed to manage the behaviors. This sequence of events captures the “control” aspect that was in place at Grafton.

Nine years ago, Grafton committed to not only reduce the use of restraint and seclusion, but also to replace these procedures with alternatives that promote a safe, comforting and secure environment for clients and employees. A revolutionary technique, known as “Ukeru” was developed at Grafton. Ukeru was Grafton’s first alternative solution and it involves the use of soft-cushiony materials to protect oneself from aggressive behaviors and the use of protective equipment such as gloves, shin guards and umpire shields to protect clients and employees. Ukeru is about receiving, engaging, sensing, feeling and responding to what someone is trying to communicate to us through their actions while maintain the safety of all involved.

An organizational culture that embodies “comfort” is focused on practicing the golden rule of treating others like you would like to be treated. Creating such a culture requires us as professionals to put ourselves in the position of someone experiencing distress and let go of any perceived ‘upper hand’. It challenges us to rise to our best when those we support are at their worst. It ultimately requires professionals to be kind, courteous, respectful and to do whatever is needed to ensure that a person is safe, valued, respected and honored.

“There is no need for temples, no need for complicated philosophies. My brain and my heart are my temples; my philosophy is my kindness.” Dalai Lama

When clients were experiencing behavioral difficulties, employees were asked to consider:
• If I was the one experiencing this distress, how would I want someone to respond?
• What choices and alternatives can I offer to this client?
• Is there another employee who has a special connection with this client and can help alleviate the crisis?
• Have I asked the client what he/she needs right now?
• Does this situation require a hands-on intervention?
Over time, additional alternative solutions were developed simultaneously as the cultural shift of “comfort versus control” permeated the organization. These alternatives included body positioning, providing choices, teaching replacement behaviors and utilizing client preferred activities to promote a treatment environment to help clients succeed. Do these practices and techniques truly matter when we are working in the behavioral healthcare industry? The answer is an astounding YES! We are in an industry where historically, the mechanism utilized to make us feel less vulnerable has been coercive interventions like physical restraint. While many behavioral healthcare organizations continue to use restraint and seclusion, we have developed a better way. We have found that by being comforting and going back to our roots based on teaching those we serve new skills to increase their functional autonomy we can build a sustainable treatment model that focuses on giving those we serve choices about their own lives and ultimately the control they deserve and desire. Over the last nine years at Grafton, we have reduced the use of physical restraint significantly and continue to focus on this as a key quality indicator.

The practice of comfort versus control as a guiding principle has led to an improved quality of life for our clients as well as innumerable positive, sustainable outcomes including:
• Improved client treatment and programming
• Reduced employee and client injuries
• Significant fiscal benefits across the company
• Federal recognition from the Substance Abuse and Mental Health Services Administration (SAMHSA) for clinical best practices
Grafton’s model can be easily replicated in other behavioral healthcare organizations, schools and other treatment facilities.