Psychiatric residential treatment centers in North Carolina will test a new de-escalation method for dealing with youth in crisis, the state Department of Health and Human Services announced last week.
Commonly known as PRTFs, these facilities offer inpatient treatment for children with complex behavioral health needs. When one of these patients gets angry or agitated, staff will often put them in restraints or isolation rooms. These practices have drawn scrutiny from lawmakers in North Carolina and investigations in other states.
A 2024 WUNC investigation looked at conditions at PRTFs in North Carolina. A review of more than 500 psychiatric residential treatment facility inspection reports since 2018 showed dozens of accusations of staff hitting, kicking, or punching children in these facilities. More than half of PRTF residents came from foster care.
The new method is known as Ukeru, a Japanese word that means "to receive." The idea is to provide comfort to youth in crisis, instead of trying to control them. If a child gets upset, staff will use soft foam pads to separate themselves from the youth and verbal prompts to calm them.
"When I first walked into a facility and I saw the pads that they use, I was, I'll call it skeptical," said Kelly Crosbie, Director of the Division of Mental Health, Developmental Disabilities, and Substance Use Services at the North Carolina Department of Health and Human Services. "I was trying to understand if I was a young person and I saw that pad, what kind of impression I would get."
While the pads can be used to protect staff, Crosbie said they're not brought out only when a crisis is unfolding. A key part of Ukeru, she said, is building an association between the pads and comfort. So, they're kept in common areas for youth to use however they like. "They lay on them, they recline on them, and they just become part of a culture. They are these cushy, comfortable things that are for my comfort," Crosbie said.
Verbal prompts are the other component of the Ukeru method. During training, PRTF staff are taught to be mindful of body language and tone of voice. They should offer praise and positive reinforcement and ask "what is going with..." questions to try and calm the child. The pads are also available if needed.
"(PRTF staff are) trained to walk backwards," Crosbie said. "They're never trained to approaching, never towards, never blocking, but to protect the staff person and to offer that space between the staff person and the youth."
Corye Dunn, policy director at Disability Rights North Carolina, said she welcomes any strategy that will reduce restraint and isolation of children. However, she cautioned that Ukeru should not be seen as a panacea that will fix problems in the PRTF system.
Ukeru's success, Dunn said, will depend on staff training and attitudes. "We have seen other systems that purport to be designed to reduce seclusion and restraint used inappropriately. So, it is really critical that the people who are expected to be able to use this in a time of stress are given high quality, thorough and probably repeated training in order to to get that benefit."
Dunn and her colleagues at Disability Rights North Carolina have long argued that the PRTF model of care is broken. "I have heard from too many children and too many families that children's experiences in these congregate settings were troubling at best and traumatizing in many cases," she said. "And while I want children's experiences in these settings to be less traumatic and more recovery-focused. I also want fewer children to go into these settings to begin with."
Ukeru was developed by Grafton Integrated Health, a Virginia-based behavioral health system. Psychiatric facilities and school systems around the country have adopted the system. North Carolina's pilot project will last two years. PRTFs in the program are still allowed to use restraint, but Crosbie emphasized it should be a last resort option.
"We do not want seclusion or restraints, period," she said. "Anytime an incident like that happens, it has to be reported."
