NADD Bulletin Volume XII Number 4 Article 2

Complete listing

Soft Power and the Elimination of Restraints

Karyn Harvey, Ph.D., Emerge, Inc.

 

In 1990, Harvard Professor of International Relations Joseph Nye introduced the term "soft power"(Nye, 1990).  Soft power is the concept of affecting change through dialogue and affirmation of shared values rather than through physical force or "hard power." Nye eloquently makes the case that long-lasting change is much more likely to come from the use of soft power than through the brute force of hard power.

The concept of soft power can be compared to the use of positive psychology in the field of behavioral intervention with individuals with intellectual disabilities; it works through affecting the internal make-up of the individual. Through engaging in dialogue and self-discovery, the individual can redefine him- or herself and naturally change his or her behavior (Seligman, 2002).  The concept of hard power can be compared to the use of traditional applied behavioral analysis with its intent to "control" and "manage" the behavior of individuals with intellectual disabilities.  This management occurs through manipulating environmental contingencies rather than acknowledging and engaging with the actual individual.  By comparing these two approaches and offering a model for training staff to implement positive psychology techniques, the road away from physical restraints and towards the fostering of internal motivation and self-mastery becomes clear.

Joseph Nye outlines in his 1990 book, Bound to Lead: The Changing Nature of American Power, that the fundamental premise of power is the act of influencing others to get them to do what you may want them to do. He asserts that there are three basic ways to do that: one is to "threaten them with sticks;" the second is to "pay them with carrots;" and the third is gain their attention and interest so that they naturally come to want what you want (Nye, 1990).  Hard power is, of course, "threatening with sticks."  However, Nye does not view "paying them with carrots" as far from hard power because the goal and the means are still enacted through external controls.  These controls cause individuals to become dependent on the carrots, rather than being internally motivated.

This is the dilemma that we face in the field of Intellectual Disabilities (ID) : How to effect behavioral change in the least restrictive manner?  I assert that soft power is the only way to maintain the change without ongoing intervention and controls.  When we train staff in traditional behavioral psychology, we set up an expectation that engenders the use of hard power. We teach the staff that they are able, through the use of these techniques, to control the behaviors of the individuals with whom they are working.  When those individuals are not "complying" behaviorally, it is thus implied that it is the fault of the staff.  Staff are seen as not adequately asserting control through techniques that they should have mastered in the training that they have been given.  The individual with ID is actually viewed not as a human being but as a something or someone to be controlled as in animal training. The concerns are how and when to give rewards, how and when to pull positive attention away, and how and when to assert limits. The implementer should be able to gain control over behavior through the use of these techniques.  When staff feel that they are failing, they may resort to more restrictive, perhaps physical, forms of intervention.

However, adults with ID are adults. Children may respond to such techniques and be taught socially acceptable behavior in this way, but adults have had years of experience and years of emotion.  They more than understand, regardless of IQ, behaviors expected of them.  Some rewards are helpful, but what really makes the difference is the internal state of the individual.    Interestingly, adults do not respond to environmental contingencies with the same efficiency and level of performance as rats and pigeons   (Shimoff, Catania, & Matthews, 1981). By the time people are adults, they no longer focus entirely on the rewards they will achieve.  Many other complex factors go into comprising the motivation of each adult and the resultant behavioral manifestations.  Motivation is complex, as many psychologists have demonstrated, and the behaviors of adult humans, regardless of their IQ, are difficult to control through external manipulation after a certain point of development.    

Revelle (1991) describes motivation as the "vital link between knowing and doing, between thinking and action and between competence and performance." He also asserts that on top of those links are the complex layers of individual differences and subsequent performances, all contributing to the complex understanding of motivation.  This must also be the case with individuals with intellectual disabilities.   They cannot merely be reduced to organisms responding to stimuli prior to or as a consequence of their actions. They, too, carry the complex story of motivation in each and every one of their actions.

During the time of the behavioral episode, the state of the individual is one of heightened emotion.  Much research has been done on various states of emotional arousal and behavior. In reviewing research on this topic, Thayer (1989)  discusses the primary importance of energetic and tense arousal as well as affective direction, or emotion, both positive and negative, in the behavior of all people.

Interviews with individuals with ID and behavioral incidents commonly reported in incident reports within community based agencies often indicate that individuals are upset, angry, hurt, or in some other aroused emotional state over an issue or situation.  Individuals in the midst of behavioral incidents are not calculating how to get a reward (or consequence) or how to increase the ratio of positive reinforcement. They are not calculating that their behavior will gain a certain response from staff that will get the individual a desired effect.  Instead, they are responding to emotional and aroused internal states that may have been triggered by interactions in the environment, but are not controlled by or contained by them.

All of us, as adults, have learned to manage our emotions and to redirect ourselves towards situations that we can change rather than those that frustrate us. We quit jobs, change relationships, and control our lives in order to avoid situations in which we have heightened emotion and high levels of frustration.   When you do not have real choices in your life (e.g., choices over where you work, where you live, or with whom you live), you are more likely to experience increased emotional states of anger and frustration.  You do not have hope. You cannot comfort yourself with how you are going to quit your job, or move out of the house, or, even, get divorced.  There is no hope and, therefore, no logical source of comfort. Emotions, in hopeless situations, can become extreme. In addition, when there is no hope of procuring one's emotional and physical needs in a way that maintains dignity, individuals are likely to manifest their frustrations behaviorally. This may entail engaging in negative assertion of force or power with staff, which is likely to lead to a power struggle.   

Luiselli, Bastien, and Putnam (1998) conducted a study exploring the antecedents, or triggers, of situations in which in-patient children and adolescents were restrained by staff.  The highest incidence of triggers were staff-initiated encounters.  This study may have been exploring restraints against children and adolescents with psychiatric issues, but those of us who have worked with adults with ID know that the same, staff-initiated dynamic often exists within staff/adult-with-ID interactions.  The staff member makes a demand and the individual, who has lost hope of being treated with dignity or respect, resists, and restraint is used.   

When there is hope, there is strength. Strength can bring emotional control as well as positive motivation.  What produces hope? Seligman believes it is the accessing of internal resources of happiness.  Martin Seligman (2002) states that people gain self control, the ability to defer gratification and the ability to focus on a long term goal, when they report having hope for future fulfillment and a sense of purpose in their lives.  This sense of hope and purpose translates into happiness.  Happy people don't have severe behavioral issues. They maintain a certain level of self-mastery and positive motivation.

Which people with ID have hope for future fulfillment and a sense of purpose in their lives?  In my clinical experience, often it is the people who have jobs in the community and feel that their job and their role in the community is important.  Many individuals with severe behavioral difficulties have changed completely as a result of successful supported employment placements.  People with ID who are in a relationship with a significant other also have a  sense of purpose and fulfillment as a result of their role as partner to their loved one.  These are some situations that often cause almost miraculous changes in behavior, and, yet, the behavior changes have not occurred as a result of staff's manipulation of consequences, rewards, and limits.  People have gained hope and a sense of purpose and have bought into the social values of the community, thus changing negative behaviors into positive ones in a natural manner. Motivation, strength, and hope are generated from within and sustain positive external change. Restraints are not needed.

In addition, this natural change is strengthened as the individuals with ID redefine themselves. They are now the worker, the husband or wife, or the boyfriend or girlfriend; they are no longer the person who is the "R word" and the "Behavioral Problem."  They are internally motivated through their definition of themselves and through the way that they see themselves.  There is boundless hope.  There is a reason to self-comfort and redirect themselves when they may become upset. There is a role to play and a life to look forward to. 

Seligman (2002) defines three levels of happiness: pleasure, engagement, and meaning.  Pleasure is passive enjoyment - such as watching a favorite TV show.  We have become good at providing this level of happiness to the people we serve, sometimes forcing them to earn it and sometimes giving it away. However, Seligman stated, based on his research, that the level of engagement, which is when the individual is actively involved, actually produces higher and longer lasting levels of happiness.  This may include crafts, bowling, sports, games, video games, and so on. The highest level of happiness, which lasts the longest according to Seligman, is meaning.  That means having a sense of overall purpose and meaning in one's life.  That produces the highest amounts of happiness and fulfillment in life, according to his research.

The use of soft power means helping the individual with ID to have access to his or her own unique happiness.  That process includes becoming a part of the world, engaging in enjoyable activities, as well as finding a meaningful role in that world. In that way, the individual naturally finds the motivation from within to act in accordance with the shared values of that world.

Soft power also means providing the opportunities to have real choices and to gain the emotional support needed to access internal emotional control.  This may mean therapy. This may mean training staff to listen and support rather than control. This definitely means empowering the individual to make real choices and effect real change in his or her own life.

Many years ago, the agency where I work, Emerge, Inc., took an individual out of  a state institution who was restrained an average of two to three times per week and had seriously injured more than one staff person during behavioral incidents.  This person has had good days and bad days but is never restrained. She volunteered at a nursing home, visited elderly people, and had several significant love relationships.  She has never hurt a staff person while at the agency. Recently, this same agency took another individual from an institution, whom, we were told by the psychology associate, could not be served without being restrained at least weekly.  She has lived happily for many months without one restraint being implemented. No one has gotten hurt, she has a level of self-control, and a new outlook on life.

We need to explore sources of soft power and re-train staff to support individuals on an emotional level. Training in sensitivity can create empathy within most staff. More importantly, simple training in active listening, problem solving, and processing skills can be taught to staff and can drastically reduce behavioral incidents.  In addition, staff can be trained in choice provision in a manner which can open up new vistas of hope for the individuals.  There can be dialogue between staff and individuals that ultimately facilitates the individuals' own pursuit of their true happiness and ongoing positive motivation,

Recently, UN Ambassador Anwarul K. Chowdhury stated that violence comes from poverty (Chowdhury, 2008).  Poverty, however, may not only be material. Poverty of opportunity is also a source of violence. In this article, I have explored means to reduce violence through hope as a behavior intervention. I argue that we can create opportunity instead of compliance and can build motivation through a sense of purpose rather than fear and obedience.

The very serious matter behind the issue of restraints and the use of hard power is also the deaths that have resulted from the use of restraints. The Harvard Center for Risk analysis estimates that 1 to 3 deaths per week in this nation are due to the use of seclusion and restraints (Weiss, 1998).  They report that a number of those restraints are used with individuals with co-occurring mental illness and intellectual disabilities. Martin Luther King once said, "The means we use must be as pure as the ends we seek."  Let us use soft power to increase hope, opportunity and internal motivation.  Let's be the example of the values we, in the field of ID, promote: values of peace, growth and self- mastery.

References

Chowdhury, A. (2008) Speech given at Culture of Peace Seminar, Washington D.C.

Luiselli, J.K., Bastien, J. S., & Putnam, R.F. (1998). Behavioral assessment and analysis of mechanical restraint utilization on a psychiatric, child and adolescent inpatient setting.  Behavioral Interventions, 62, 366-374.

Nye, J. ( 1990)  Bound to lead: The changing nature of American power.  New York: Basic Books. 

Revelle, W. (1991). Individual differences in personality and motivation: 

'Non-cognitive' determinants of cognitive performance. In A. Baddeley & L. Weiskrantz (Eds.) (1993). Attention: selection, awareness and control: A tribute to Donald Broadbent (pp 346-373). Oxford: Oxford University Press..

Shimoff, E. Catania, A.C. &Matthews, B.A. (1981). Uninstructed Human Responding: Sensitivity of low-rate performance to schedule contingencies. Journal of Applied Behavioral Analysi, s36 (2), 207-220.

Seligman, M. (2002). Authentic happiness New York: Random House.. 

Seligman, Martin (1975). Learned helplessness. San Francisco: Freeman.

 

Thayer, R. E. (1989). The biopsychology of mood and arousal. New York. Oxford.

Weiss, E.M. (1998, October 11).  Deadly restraint: A nationwide pattern of death. Hartford Courant, A1.

 

For further information, please contact Dr. Harvey at: kharvey@emergeinc.org