The Good and the Bad: TCI and De-escalations

TCI stands for therapeutic crisis intervention and is the training that every MHY employee must be cleared on to work on the units and to be alone with the children. During NEO, the TCI training was a full week long because it is a very in-depth training experience. TCI involves physical restraints and verbal de-escalation, both of which I used throughout my internship. The children that come to MHY have a lot of mental and behavioral issues and so part of our job is protecting the kids from themselves and well as protecting ourselves while around them. More often the TCI physical restraints were used to stop the children from hurting themselves, sometimes it is from moments when the child is trying to cut themself or bang their head against glass. When the restraints are used because a staff member has to protect themself it is often because the child has an aggressive tendency and failed to regulate their emotion and turned to hurt the closest person, which will always be a staff member since we would never let two kids hurt each other. During this session we were taught by TCI certified trainers and they were our "kids" through all the scenarios to allow us to practice.

The beginning of training started by teaching us protective stances, such as having our feet spread, knees slightly bent and arms down by our side palms open. We were taught how to break free from being grabbed in front and behind, how to break a choke hold, what to do if someone grabs your hair/ponytail, and how to deflect punches. Once the basics were established we moved on to the restraints. There were four poses that we are allowed to bring a child into since they have been tested to be the most effective way to hold a child in order to stop them from hurting themselves or others and to calm down by burning through any extra energy. 

The first position is called Yoke, two staff members will step to the child, facing the opposite way of the child press their hip into the child so the subject is unable to be jostled. The next step is to grab the child's forearm with your arm farthest from the child while placing your other arm closet to the child under their armpit, bending at the elbow so your bicep and forearm is squeezing the child’s bicep. Once both staff members are comfortable they will rotate inward so their shoulders are now touching and the child's arms are suspended at their sides by each of the staff members. This position keeps the kids from punching, scratching, biting, or slapping anyone. For the next two positions the yoke is always the first step to getting into the restraint. 

The next restraint is called the Wall Sit, in order to enter into this restraint you must be by a wall, it will not work without one. For this move, the Yoke is the first position the staff member goes into. Once in Yoke the staff will walk back until their backs hit the wall, the staff push their hips together and bend their knees to ease down onto the floor. If the child locks their knees the staff would end up just staying in Yoke up against the wall but if the child does unlock their knees the staff brings the child down into a sitting position with them. In the sitting position each of the staff on the child's arms put one leg over the child's leg. This way all the child's extremities are stopped from movement. The extra staff that will show up when going into a restraint will go to the child's legs and lay on the child's shins so the other staff members on the child's arms can pull their legs back. 

The third restraint is called Supine because the child's final position will be flat on their back. After entering the Yoke position, each staff member on the arms will take a large step forward with the leg farthest away from the child, they will bend at the knee moving into a lunge potion until their knee closest to the child is on the ground. At this point the other staff member will move onto the child's legs this time they need to be above the child's knees and facing the child’s face instead of their feet. Once the third staff is on legs the two on arms move up towards the child's head folding the child’s arms into a V with their hands near their hand. It is the same positions you place your arms into when completing sit-ups. For extra security, the staff members straddle the child’s arms while keeping a grip on the child's forearm and bicep. The staff must never grip a child on a joint because that could potentially hurt the child. 

The fourth and final restraint is called Small Child, this is the only restraint that can be done with a single staff member. This restraint can only be completed on a child that is shorter than the staff member's shoulder, requiring the staff member to be bigger than the child and able to hold them on their own. This position does not require the Yoke hold. Instead, the staff member steps up to the child from behind and pushes the back of the child's upper arms forward and together. One arm will go over the other as they naturally hook on each other. Once the child's arms are crossed the staff members moves their hold the child's forearms and pulls them down and against the child's sides. They then take a step back and down, keeping the child tight against their chest to cushion the child’s decent. The final position will have the staff on the knees but upright with the child siting on their butt pulled tight against the staff's chest. It keeps the kid's arms held back and keeps them from standing up.

Anytime a restraint is initiated, the duration of the restraint, the steps leading up to it, the positions the child was held in, any injuries that may have occurred, and the steps that followed are always documented. The Mangers of the units are always called as well as a nurse to check out the child and staff members. After the restraint is over the Manger who was called will always make contact with the parent or guardian of the child to let them know what happened. MHY takes care to limit the amount of physical restraint's their staff enter into and if they have to, that the restraints are done as properly as possible. 

The other important part of TCI was the LSI interviews and the de-escalation techniques we would use daily. The LSI interviews stands for Life space interviews and must always follow a restraint. These are a chance for staff to talk to the child about the behavior that built to the restraint happening and how they could change the behavior to react differently and avoid the restraint. The LSI is important to just help the kid see what went wrong, often their emotions take over and they black-out for the restraint so they have no clue what happened and the LSI helps fill in the black spaces. 

The de-escalations were involved in training from the start by using protective stances and helping the kids get through the activity by encouraging them, moving them away from the problem, distracting them, talking to them about their emotions, validating their emotions and other lots of small things that just help the staff get through the day with less issues. When down properly, the kids did not know that they were being managed they just felt better after a tense situation.

In the end, putting a child into a physical restraint is never a fun or enjoyable part of our job, but it is necessary and I am happy to say that MHY prepared me enough that when the day came and I had to complete a restraint I felt confident I wasn’t hurting the child and that this would help them in the end.