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Roadmap to Restraint and Seclusion Free Services at LRC Lisa L. Franz, MBA, CPHQ Quality Improvement Coordinator HHS Dan Powers, JD Consumer Liaison - Program Specialist Agenda Overview Goal: Reduce / Eliminate R & S NAC/SMHA and SAMHSA Pilot Project Training Materials Future State Overview Seclusion - Involuntary confinement of a patient alone in a room where the patient is physically prevented from leaving including: Manual or Electronic Locks Staff Proximal to the Room, Preventing Exit Restraint - Involuntary method of physically restricting a patient’s freedom of movement, NOT including: Security transport Medical purposes / Protective devices Manual holds of less than 5 minutes Goal: Reduce / Eliminate S & R “Seclusion and restraint – with their inherent physical force, chemical or physical bodily immobilization and isolation – do not alleviate human suffering.” Charles Curie, Administrator of Substance Abuse and Mental Health Services Administration Staff Perspective “A kid will refuse to go to the quiet area or a kid will refuse to go to the quiet room and the staff will think, OK, if I don’t follow up on this the other kids will see they don’t have to listen to me and my authority will be challenged.” Staff Person Consumer Experience “It was terrifying, dehumanizing, degrading and painful. Not only was the leather biting into my wrists, my body had been invaded by a substance that caused a feeling of intense internal violation.” Consumer, NACSMHA In Our Own Voices Survey, 2001 Premise Seclusion and restraint reflects treatment failure New Era Tighter controls 1999 Federal and State mental health authorities furthered policy change National Association of State Mental Health Program Director’s (NASMHPD), Created Violence and Coercion Free Mental Health Environments: A National Initiative and Call to Action State of Pennsylvania demonstrated commitment with their “Leading the Way Seclusion and Restraint Initiative.” Success 1997 – Pennsylvania Department of Pubic Welfare’s OMHSAS pursue the elimination of seclusion and restraint Since 1997, seclusion and restraint were reduced by 90 percent, and the hours of use fell by 95 percent By July 2000, one state mental hospital had not used seclusion for over 20 months Pilot Project 30 Staff members of LRC will attend training March 31, April 1, April 2 AFS, STC, FS 2/3 Direct Care, 1/3 Administration 8 Of these will participate in pre-assessment Feedback will be collected from the participants Current S/R data will be compared to postimplementation data SAMHSA Substance Abuse and Mental Health Services Administration Provided Funding for Roadmap Project Federal agency Improve the quality and availability of prevention, treatment, and rehabilitative services Reduce illness, death, disability, and cost to society NAC/SMHA National Association of Consumer/Survivor Mental Health Administrators Developed materials for Roadmap Program Founded in 1993 State mental health agency senior managers who are current or former recipients of mental health services Offer technical assistance to State Mental Health Agencies on exemplary practice Insight Provided By Steering Committee, representing virtually every stakeholder organization American Psychiatric Association National Association of Protection and Advocacy Services National Mental Health Association JCAHO CMS Consumers from around the country Psychiatric line staff Current literature Roadmap Focus: Early identification and intervention in conflict situations Understanding the experience from the perspective of the individuals involved Improving communication and problemsolving skills Decreasing and ultimately eliminating the damaging effects of restraint and seclusion Training Materials Module 1 - personal experience of restraint and seclusion Module 2 - impact of trauma on consumers and on line staff Module 3 - change needed to ensure cultural change within an institution Module 4 - resiliency and recovery from the consumer perspective Training Materials Module 5 - strategies that will lead to the reduction and elimination of restraint and seclusion Module 6 - strategies to prevent restraint and seclusion Module 7 - sustainable change through consumer and staff involvement Module 8 - development of both personal and workplace action plans Effective Approaches Peer-delivered services Self-help techniques New medications Emphasis on recovery Understanding the relationship between trauma and mental illness Medical Directors of the National Association of State Mental Health Program Directors report on Restraint and Seclusion (1999) Options Take a walk Do physical exercise Read my Wellness Recovery Action Plan (WRAP) Cry; chemical restraints often prevent this Have someone sit with me for a while Take shower or bath Draw Yell Options Relax in a homey setting –A big over stuffed, vibrating, heated chair with a blanket, headphones and gentle soft music Be allowed to have something of my own to comfort me In Crisis, I Need Persons Who Can: BE with me Acknowledge my pain without trying to ‘fix’ it Not be afraid of my sexual abuse Ask what would help In Crisis, I Need Persons Who Can: Understand the coping role of suicidal thoughts as giving a sense of some control Know the difference between “I want to die” (despair, hopelessness) and “I want to kill myself” (anger, defiance) Give me options and choices, and respect me Helpful to Hear Let’s sit down and talk about the problem It’s your choice to discuss, I only have to restrain if you start hurting someone You are going to be ok We are here to help you Helpful to Hear You are a person and allowed to make mistakes All feelings are normal It will get better You are all right, but your behavior is inappropriate Grounding Methods for stopping the re-experiencing of a trauma and getting back to the here and now Focus on something in one or more of the five senses in the present Maintain Visual Contact Stay out of dark or dim areas, or turn on the lights Don’t allow hiding Make sure eyes remain open Maintain Visual Contact Describe the color of the walls or carpet Give a favorite object and assist the person in noticing how it looks, feels, and smells Present previously developed flashcards Maintain Personal Contact Say that person’s name Tell him/her where s/he is and the full date Use normal voice tones (not soft or rhythmic) Tell the consumer you know s/he is frightened, but s/he is safe Ask the consumer to look at your face and try to make direct, focused eye contact If frightened by eye contact, redirect to a different part of your body, like hair or shirt Focus on Physical Ask the consumer to start naming what s/he sees in the room Suggest s/he feels own weight, or the chair s/he is sitting on, or notices how his/her feet feel on the floor Help the consumer take a walk, stamp feet Recommend the consumer get in the ‘in control’ body posture Focus on Present If not alarmed by it, help consumer look in the mirror and see that s/he is an adult, not a child in a traumatic situation Call the consumer’s attention to a calendar and/or a clock and help him/her figure out what day and time it is. Focus on Present Ask the consumer questions about the present Ask the consumer about her/his interests or activities, such as recreational activities or a pet Direct and assist in writing or drawing about something positive Debrief Help reassure consumer and normalize event/current situation If consumer is able, assist with relaxation techniques Try to identify what causes the consumer’s symptoms When possible and reasonable, help the consumer work out how to avoid their triggers until better able to ground her/himself and cope more effectively Debrief Determine body postures that accompany feelings of being flooded and/or overwhelmed Plan new ways to attempt to cope with stress Develop a crisis response plan for the next occurrence WRAP Daily Maintenance Plan Triggers Early Warning Signs Symptoms that Occur When the Situation is Worse Crisis Plan/Post Crisis Plan As A Group…. Decrease the % of restraints Decrease the % of seclusions Decrease the # of hours of restraint Decrease the # hours of seclusion The top three things we could do The action plan Future State “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.” Margaret Mead
