Roadmap to Seclusion and Restraint Free Mental Health

Transcription

Roadmap to Seclusion and Restraint Free Mental Health Services
Scott (from Minnesota) Grade 8
Children’s Mental Health Poster Contest – 2000
Minnesota Association for Children’s Mental Health
Roadmap to Seclusion and
Restraint Free
Mental Health Services
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
www.samhsa.gov
1
ACKNOWLEDGMENTS
Numerous people contributed to the development of this training manual (see Project Steering
Committee). The document was prepared by the National Association of Consumer/Survivor
Mental Health Administrators for the Substance Abuse and Mental Health Services Administration (SAMHSA) under Task Order #OMB No. 0990-0115 with SAMHSA, U.S. Department of Health and Human Services (DHHS). Paolo del Vecchio and Carole Schauer served
as the Government Project Officers.
Disclaimer
The views, opinions, and content of this publication are those of the authors and contributors and do not necessarily reflect the views, opinions, or policies of CMHS, SAMHSA, or
DHHS.
Public Domain Notice
All material appearing in this document is in the public domain and may be reproduced without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization
of the Office of Communications, SAMHSA, DHHS.
Electronic Access and Copies of Publication
This publication may be accessed electronically through the following Internet World Wide
Web connection: www.samhsa.gov. For additional free copies of this document, please call
SAMHSA’s National Mental Health Information Center at 1-800-789-2647 or 1-866-8892647 (TDD).
Recommended Citation
Roadmap to Seclusion and Restraint Free Mental Health Services. DHHS Pub. No. (SMA)
05-4055. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental
Health Services Administration, 2005.
Originating Office
Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.
DHHS Publication No. (SMA) 05-4055
2005
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FOREWORD
In 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) set
forth a bold vision to reduce and ultimately eliminate the use of seclusion and restraint in
behavioral healthcare settings.
These practices are detrimental to the recovery of persons with mental illnesses. Too often,
the use of seclusion and restraint results in trauma, injury, and even death. We can and must
do better to protect the lives and well-being of those whom we serve.
SAMHSA has established seclusion and restraint as a priority area and has developed a
National Action Plan to reach our vision of seclusion and restraint free mental health services.
Roadmap to Seclusion and Restraint Free Mental Health Services represents a key component of this National Action Plan. It will increase the knowledge and skills of mental health
service direct care staff, administrators, and consumers on alternatives to the use of seclusion
and restraint. We also see this training as a tool to assist you with mental health system transformation—creating mental health services and supports that facilitate recovery and promote
resiliency.
Many training manuals exist, but this curriculum is unique. The President’s New Freedom
Commission on Mental Health called for consumer- and family-driven approaches that support recovery. The material in this manual is recovery based and developed by consumers.
It draws on the published writings and research of the leaders in the recovery movement—
consumers. It was developed with the assistance of the National Association of Consumer/
Survivor Mental Health Administrators, and consumers from around the country were asked
to provide insight derived from their experiences of seclusion and restraint and offer their
guidance for the elimination of these practices. The expert opinion of direct care staff was
also gathered and current literature on the topic was reviewed so that references could be
provided. A Steering Committee, comprised of representatives from nearly every stakeholder
organization within the mental health system, provided technical assistance and insight.
Finally, the training was pilot tested with direct care staff and administration at two hospitals.
We welcome you to join us in our collective efforts to find and use creative approaches and
strategies to ensure that we help and not harm those whom we serve.
Charles G. Curie, M.A., A.C.S.W.
Administrator
Substance Abuse and Mental Health Services Administration
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PREFACE
The past decade has yielded many divergent views on the practice of seclusion and restraint.
It is an area rife with tension, disagreement, and fear. One consumer recently said that he
thought restraint was “too polite” a term for what he had experienced. He went on to say
(NAC/SMHA In Our Own Voices Survey, 2001):
“I was tied up and tied down. It was terrifying, dehumanizing, degrading, and painful. Along
with the restraint was the forced injection of Haldol. 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.”
In 1999, landmark national legislation led to tighter controls on the use of restraints in psychiatric hospitals. Federal and State mental health authorities furthered the development and
implementation of policy change and the active pursuit of a reduction and ultimate elimination of seclusion and restraint. The National Association of State Mental Health Program
Directors (NASMHPD) publication, Creating Violence and Coercion Free Mental Health
Environments: A National Initiative and Call to Action, identifies mandatory systemic changes
that must occur when reducing the use of seclusion and restraint. The State of Pennsylvania
demonstrated successfully that commitment to reform does indeed make a difference with
their Leading the Way Seclusion and Restraint Initiative.
External monitoring holds the key to eliminating seclusion and restraint according to some
leaders. Others suggest strong administrative leadership. Some suggest a legislative solution.
Some suggest better behavioral intervention strategies. However, virtually every constituent
group involved in meaningful systems reform recognizes the need for ongoing training and
education efforts.
Roadmap to Seclusion and Restraint Free Mental Health Services explores sustainable solutions and strategies towards supporting the belief in the elimination of seclusion and restraint
in the treatment of people with serious mental illness or children with serious emotional
disturbance.
“It is not possible to solve a problem with the same consciousness that created it” (Albert
Einstein). This manual is intended to build bridges and increase respect and understanding
between consumers and direct care staff. All stakeholders must be present at the table and
engage in the dialogue to develop seclusion and restraint free environments.
It is the underlying premise of this manual that the role of the direct care staff is critical to
meaningful system change. Together, we are partners and champions in the reduction and
elimination of seclusion and restraint.
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HOW TO USE THIS MANUAL
The goal of this curriculum is to provide direct care staff the tools and knowledge needed
to improve their skills in preventing and ultimately eliminating the use of seclusion and restraint. “Direct care staff” refers to individuals who work directly with consumers, such
as nurses, psychiatric technicians, therapists, psychologists, and many others. Administrators
will also find this training helpful.
The curriculum is unique in that it is written from consumer perspectives, and thus helps
direct care staff work from a consumer-based philosophy. It can be used in a variety of
settings, such as State institutions, hospitals, or outpatient centers, for staff development,
training, and in-service education.
This training package provides all the background material, lecture points, and PowerPoint
slides necessary for a facilitator to implement the seven training modules that demonstrate
how to eliminate the use of seclusion and restraint. All the handouts for the participants are
included. This is a valuable resource in places where facilitators cannot obtain needed and
up-to-date information. Instructions on how to obtain optional resources, such as videos,
are included.
Prior training for facilitators is not necessary; however, facilitators must be familiar with
consumer perspectives of the mental health system to be effective in teaching this curriculum. Co-facilitating with a consumer/survivor, family member, or direct care staff helps bring
more than one perspective to the training. To get the maximum benefit, it is recommended
that at least one facilitator be a mental health consumer.
Training formats that have proven particularly effective include teams of staff and former
consumers working together as trainers. This team approach ensures that the perspectives of
both parties are reflected. It also provides a model of clear and direct communication between
the parties involved. The team approach can be used regardless of setting or population.
Teams involving children and youth or individuals with developmental disabilities can be
particularly powerful as an illustration of how people with diverse skills and experiences can
work together.
Curriculum content is based on the concept that recovery and wellness are essential in providing alternatives to the use of seclusion and restraint. Individuals must be treated with
respect. The use of seclusion and restraint strips a person of dignity, privacy, and potentially, safety. When a person is put in restraints, it implies that he or she is less than human.
Everyone’s human rights are cheapened when the dignity of a vulnerable person in society is
ignored. The use of seclusion or restraints does nothing to advance an individual’s recovery,
resilience, or self-determination, but has the opposite effect.
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Several States that have adopted comprehensive approaches to reducing the use of seclusion
and restraint have found that staff training is a critical component of their initiatives. Training interventions have reduced the use of seclusion and restraint, helped staff understand the
experience from the perspective of the individuals involved, and improved communication
and problem-solving skills.
Training that includes a dialogue between staff and consumers about their experiences
addresses the impact that seclusion and restraint has on the individuals involved, and is a
powerful tool for creating a safe and respectful milieu. Training programs that focus on early
identification and intervention in conflict situations are also essential for achieving this result.
Note about terms used: Many terms have been used to refer to individuals who have personal experience with psychiatric disabilities. The words client, patient, and consumer, are
common, as are the words ex-patient and survivor. Some people use the term consumer/
survivor/ex-patient, or c/s/x for short. The language of people first continues to evolve. Not
everyone agrees on using the same terms. Thus, the training modules use a variety of these
terms throughout. The language you decide to use must denote respect for the individual
and his/her firsthand experience.
The training is divided into seven modules plus a resources section:
• Module 1, through the perspectives of mental health consumers and direct care staff at
State hospitals, increases the understanding of the participants of the personal experience
of seclusion and restraint.
• Module 2 discusses the impact of trauma on consumers and on direct care staff.
• Module 3 explores the change needed to ensure cultural change within an institution. The
role that staff play is discussed. Survey results from consumers across the country are
reviewed. A model for reform is also reviewed.
• Module 4 explores the concepts of resiliency and recovery from the consumer perspective.
• Module 5 identifies, from the consumer and staff perspectives, strategies that will lead to
the reduction and elimination of seclusion and restraint.
• Module 6 discusses sustainable change through both consumer and staff involvement.
• Module 7 presents a review of the first six modules and the development of both personal
and workplace action plans to reduce and eliminate the use of seclusion and restraint.
• The Resources section contains Web sites and policy and position statements of various
organizations.
The entire training takes approximately 21-24 hours to complete. The facilitators can determine the schedule of the training. It can be done in 3 full days, 6 half days, or in some other
arrangement. Each module requires approximately 3 hours, but can be shortened or lengthened to meet the needs of the training group. Modules are freestanding and can be presented
individually, although each module builds on the preceding one and the course should be
presented in its entirety.
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Participants should be provided with ring binders with blank pages for notes and writing assignments. They will be asked to write on Journal topics and Take Action Challenges during
the training to integrate their learning with their work and develop action plans. Upper management must be present and supportive when the participants are developing their Workplace Action Plans.
We suggest printing out the required number of copies of the handouts that you choose to
use with your class before the training begins. You can also print out the background reading
(Background for the Facilitators pages) and lecture notes (Presentation pages) for yourself
and any other facilitators. See the table of contents page for the list of handouts. In addition
to the pages marked “Handout,” you may also wish to print out items from the Resources
section and slides from the PowerPoint presentation (these include the learning objectives
for each module). To print the Power Point slides in the most readable format, select “Print,”
“Handouts,” and “Pure Black and White.” The ring binders should be large enough to
accommodate all of these handouts.
The following is a list of materials, other than handouts, that are needed for each training
module. Please note that in some cases, the facilitators will need to obtain materials such
as videos and permission to use articles in advance.
For all sessions, have the following materials on hand:
•
•
•
•
•
•
•
Nametags or name tents
Chalkboard/chalk/white board/flip chart
Paper/pens/markers
Scissors
Tape
Overhead projector or LCD projector/screen
Ring binders with blank pages for participants
Special arrangements are needed for the following:
Module 1
• Arrange for panel of consumers and direct care staff
o Microphones for panel participants as needed
o Table/chairs for panel participants
o Water/glasses for panel participants
o Stipends for consumer participants
• Apply for permission to use Hartford Courant articles
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Module 3
• Obtain Pennsylvania Model video
• TV/VCR
• 3 x 5 index cards
Module 4
• Obtain Pat Deegan video
• TV/VCR
Module 5
• Make designs for communication exercise
Module 6
• Obtain Advance Crisis Planning video from University of Illinois, Chicago
• TV/VCR
Module 7
• Jana Stanfield CD, If I Were Brave
• Boom box
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ROADMAP TO SECLUSION AND RESTRAINT FREE
MENTAL HEALTH SERVICES
TRAINING MANUAL
PROJECT STEERING COMMITTEE
American Psychiatric Association
David Fassler, M.D.
Attorney and Advocate
J. Rock Johnson, J.D.
National Association of Protection
and Advocacy Systems
Gary Gross
Sister Witness International
Laura Prescott
Center for Mental Health Services,
Substance Abuse and Mental Health
Services Administration
Paolo del Vecchio
Carole Schauer
Bazelon Center for Mental Health Law
Robert Bernstein, Ph.D.
National Mental Health Association
Brian Coopper
Joint Commission on Accreditation
of Healthcare Organizations
Mary Cesare–Murphy, Ph.D.
National Association of Consumer/
Survivor Mental Health Administrators
John Allen
Susan Kadis
Karen Kangas, Ed.D.
Nancy Kunak
Dan Powers
Joyce Jorgenson
Erica Buffington
Health Care Financing Administration
Catherine Hayes
University of Pennsylvania
Wanda K. Mohr, Ph.D., R.N., FAAN
The Federation of Families For Children’s
Mental Health
Gail Daniels
National Council for Community
Behavioral Healthcare
Charles Ray
Tom Liebfried (alternate)
Pennsylvania Department of Public
Welfare
Charles G. Curie
Child Welfare League of America
Lloyd Bullard
National Association of State Mental
Health Program Directors
Bob Glover
Rupert R. Goetz, M.D.
Jennifer Urff
American Psychiatric Nurses Association
Melissa Reese
Department of Children and Families
Hartford, CT
Gary M. Blau, Ph.D.
American Psychological Association
Richard H. Hunter, Ph.D.
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CONTENTS
MODULE 1: The Personal Experience of Seclusion and Restraint
Background for the Facilitators
Presentation
Overview
Exercise: Getting to Know You (15 minutes)
Challenge Assumptions
Consumer Complaints
Lack of Uniform National Standards
Lack of Adequate Staff Training
Safety
Inappropriate Uses of Seclusion and Restraint
Treatment Approaches to Reduce Seclusion and Restraint
Special Needs Populations
Consumer Panel (1 hour)
Exercise: Hartford Courant articles (20 minutes)
Exercise: Personal Perspective: Consumers (15 minutes)
Exercise: Personal Perspective: Direct Care Staff (20 minutes)
Handouts for Participants
Preventing, Reducing, and Eliminating Seclusion and Restraint with
Deadly Restraint—Hartford Courant series
Consumer Quotes
Direct Care Staff Quotes
References
MODULE 2: Understanding the Impact of Trauma
Presentation
Overview
Exercise: Trauma Background (25 minutes)
Definitions Related to Trauma
10
Common Reactions to Trauma
Exercise: Common Reactions to Trauma (20 minutes)
Effects of Trauma on the Brain
Differential Response to Threats
Assessment of Trauma
Exercise: Assessment of Trauma (20 minutes)
Retraumatization via Hospitalization
De-Escalation Preferences
Exercise: De-Escalation Preferences (20 minutes)
What Survivors Want in Times of Crisis
Staff Trauma (Secondary Traumatization)
Healing from Trauma
Grounding Techniques
Exercise: Grounding Techniques (10 minutes)
Journal/Take Action Challenge (15 minutes)
Journal Topics and Take Action Challenges for Modules 1 & 2
National Association of State Mental Health Program Directors
(NASMHPD) Position Statement on Services and Supports to
Trauma Survivors
Excerpts from Kate Reed’s Speech
Position Paper on Trauma and Abuse Histories
What Can Happen to Abused Children
Some Common Reactions to Trauma
Trauma Assessment for Department of Mental Health Facilities/
Vendors
Guidelines for De-Escalation Preference Form
De-Escalation Form for Department of Mental Health Facilities/
Vendors
Excerpts from Dealing With the Effects of Trauma: A Self-Help
Guide
Web Sites Related to Trauma
Resources on Secondary Trauma
References
MODULE 3: Creating Cultural Change
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Presentation
Exercise: “Flowers Are Red” (10 minutes)
Overview
Pennsylvania: A Model for Reform
Video: Leading the Way: Toward a Seclusion and
Restraint Free Environment (17.5 minutes)
Cultural Change
Exercise: “My Organizational Culture Currently Is…” (30 minutes)
Exercise: “People With a Mental Health Diagnosis Are…”
(15 minutes)
In Our Own Voices
Exercise: What Would Have Been Helpful to Hear (15 minutes)
“Flowers Are Red”
“My Organizational Culture Currently Is…”
NASMHPD Review of Literature Related to Safety and Use
of Seclusion and Restraint
What Would Have Been Helpful in Preventing the Use
of Seclusion and Restraints for You?
What Would Have Been Helpful for You to Hear?
What Other Options May Have Been Beneficial?
References
MODULE 4: Understanding Resilience and Recovery from the
Consumer Perspective
Presentation
Overview
Resilience
Exercise: Someone Who Believed in Them (20 minutes)
Recovery
Exercise: Recovery as a Journey of the Heart (35 minutes)
Exercise: What Are We Recovering From? (15 minutes)
Someone Who Believed in Them Helped Them to Recover
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Recovery as a Journey of the Heart
Recovery From Mental Illness—Guiding Vision
Resources: Self-Help Guides
References
MODULE 5: Strategies to Prevent Seclusion and Restraint
Presentation
Overview
Wellness Recovery Action Plan (WRAP)
Exercise: Developing a Wellness Recovery Action Plan
(30 minutes)
Drop-In Centers
Recovery Through the Arts
Comfort Rooms
Service Animals
Psychiatric Advance Directives
Exercise: Creating My Own Psychiatric Advance Directive
(30 minutes)
Prime Directives
Communication Strategies
Exercise: How Hard Can Communication Be? (15 minutes)
Alternative Dispute Resolution/Mediation
Technical Assistance Centers
Examples of Consumer WRAPs
Developing a WRAP
How to Set Up a Comfort Room
Why Should I Fill Out a Psychiatric Advance Directive?
Ten Tips for Completing an Effective Advance Directive
Psychiatric Advance Directive Practice Worksheet
Six Essential Steps for Prime Directives
Anticipated Benefits of Prime Directives
Children’s and Adolescents’ Mental Health Services Technical
Assistance and Research Centers
Research, Training, and Technical Assistance Centers
References
13
MODULE 6: Sustaining Change Through Consumer and Staff
Involvement
Presentation
Overview
Leadership
Exercise: National Technical Assistance Center Networks
(15 minutes)
Exercise: Direct Care Staff Leadership (15 minutes)
Debriefing
Exercise: Debriefing Role Play (25 minutes)
Advance Crisis Planning
Video: Increasing Self-Determination: Advance Crisis Planning
(13 minutes)
Data Collection
External Monitoring
Role of the Champion
Protection and Advocacy List
National Technical Assistance Center Networks Newsletter
Debriefing Survey for Consumers
References
MODULE 7: Review and Action Plan
Presentation
Review
Personal Action Plan
Exercise: Personal Action Plan (1 hour)
Workplace Action Plan
Exercise: Workplace Action Plan (1 hour)
Certificates of Completion
Wrap Up and Evaluation
14
Certificate of Completion
Evaluation
RESOURCES
Web Sites
Policies and Position Statements
1. American Nurses Association
2. American Psychiatric Nurses Association
3. Federation of Families for Children’s Mental Health
4. NAMI
5. National Association of State Mental Health Program Directors
6. National Mental Health Association
7. Pennsylvania: Restraints, Seclusion and Exclusion in State Mental
Hospitals and Restoration Center
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MODULE 1
The Personal Experience of
Seclusion and Restraint
1
MODULE 1
The Personal Experience of
“When I participated in my first
restraint experience I vomited.”
—Mental health worker
Learning Objectives
Upon completion of this module the participant will be able to:
• Outline the issues and concerns regarding the practice of seclusion and restraint.
• Describe the use of seclusion and restraint with special needs populations.
• Understand the personal experience of seclusion and restraint for people diagnosed with
a mental illness.
• Understand the personal experience of seclusion and restraint for direct care staff.
Module 1
The Personal Experience of Seclusion and Restraint
2
MODULE 1: THE PERSONAL EXPERIENCE OF SECLUSION
AND RESTRAINT
Background for the Facilitators. . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Presentation (3 hours) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: Getting to Know You (15 minutes) . . . . . . . . . .
Challenge Assumptions. . . . . . . . . . . . . . . . . . . . . . . . . . .
Consumer Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lack of Uniform National Standards . . . . . . . . . . . . . . . . . .
Lack of Adequate Staff Training . . . . . . . . . . . . . . . . . . . . .
Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inappropriate Uses of Seclusion and Restraint . . . . . . . . . . .
Treatment Approaches to Reduce Seclusion and Restraint. . .
Special Needs Populations. . . . . . . . . . . . . . . . . . . . . . . . .
Consumer Panel (1 hour) . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: Hartford Courant articles (20 minutes). . . . . . .
Exercise: Personal Perspective: Consumers (15 minutes) .
Exercise: Personal Perspective: Direct Care Staff . . . . . .
(20 minutes)
Handouts for Participants . . . . . . . . . . . . . . . .
Preventing, Reducing, and Eliminating Seclusion
and Restraint with Special Needs Populations
Deadly Restraint—Hartford Courant series . . . .
Consumer Quotes . . . . . . . . . . . . . . . . . . . . .
Direct Care Staff Quotes . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . .
Module 1
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3
Overview
This module covers three areas: (1) a brief overview of concerns and issues associated with
the practice of seclusion and restraint; (2) providing staff an opportunity to hear from people
diagnosed with a mental illness about what it is like to be secluded and restrained; and (3)
providing direct care staff an opportunity to hear from each other about the personal effects
of putting people in seclusion and restraints.
Module 1 is designed to enhance awareness of the personal experience of restraints and the
devastating and dehumanizing reality that such traumatic experience brings to the lives of
individuals. Direct care staff and consumers live with many assumptions about people diagnosed with mental illnesses. But each of these assumptions (e.g., “They are chronics,” “Seriously and persistent mental illness (SPMI’s),” “They are crazy and do not need to be listened
to,” “We must decide what is best for them) is a cliché that could be discarded if there were
openness to alternative ways of understanding. This is the first step in changing a culture.
It is not easy. In general, people are not comfortable with change. But we all must begin to
really understand the effect of the practice of restraints and challenge long held perceptions.
It is about really hearing someone else—hearing the voice of the consumer. When we truly
understand the experience, changes can begin within ourselves, as well as within the culture
of the system.
Various requirements regarding seclusion and restraint continue to be issued. The Federal
Government, Joint Accreditation Commission of Hospital Organizations (JACHO), consumer
and family organizations, professional organizations, and State mental health authorities are
all invested in the reduction and elimination of seclusion and restraint as a practice within
treatment settings. Although regulations are critically important, in order for sustainable
change to occur a shared vision must be present. In order for a shared vision and commitment
to occur, we must begin by listening.
Key issues related to seclusion and restraints include deaths, physical injuries, lack of reporting, consumer complaints, use of seclusion and restraint with high-risk populations, and
overuse of restraints. In addition, lack of uniform national standards, lack of adequate staff
training, and fears related to staff safety also impact the practice of seclusion and restraint.
Module 1
4
BACKGROUND
BACKGROUND FOR THE FACILITATORS: THE PERSONAL
EXPERIENCE OF SECLUSION AND RESTRAINT
In mental health treatment settings, it is very common for consumers and providers to see the
world through different lenses and to have different meanings for common words. Much of
the conflict that arises in these settings results from people operating from their own worldview without acknowledging that of another. Definitions of safety depend, quite often, on
who is doing the defining. The information in this section comes directly from the National
Technical Assistance Center’s report on managing conflict cooperatively (National Association of State Mental Health Program Directors [NASMHPD], 2002).
The use of seclusion and restraint with special needs populations needs to be critically examined. Children are twice as likely as adults to be restrained (Weiss, 1998). More than 26
percent of deaths reported in the Hartford Courant series in 1998 were children — almost
twice the proportion of their population in psychiatric hospitals. A large percentage of women
receiving treatment have a past history of trauma and/or abuse, and seclusion and restraint
can cause further damage (NYS OMH, 1994; MA DMH, 1996). In one study, Caucasian
hospital staff physically restrained non-Caucasian consumers nearly four times as often as
they restrained Caucasian consumers (Bond et al., 1988). Persons who are hospitalized on
an involuntary basis are more likely to be subject to seclusion and restraint than those hospitalized on a voluntary basis (Solof et al., 1989). The National Association of State Mental
Health Program Directors (NASMHPD) has made several recommendations regarding
special needs populations.
Personal Perspective: Consumers
A New York study indicated that 94 percent of consumers who had been restrained had at
least one complaint with 50 percent complaining of unnecessary force and 40 percent indicating psychological abuse (Weiss, 1998). Research analyses by Ray and colleagues (1996) also
indicated that consumers (1) had predominately negative reactions to seclusion and restraint,
(2) did not know the reason for their seclusion, (3) felt that it was humiliating, punishing, and
depressing, and (4) thought that staff control was a primary factor.
Module 1
5
BACKGROUND
Safety
New and emerging treatment approaches and services make it possible to treat people with
severe symptoms without resorting to coercive strategies. There is a significant gap between
what we know about preventing violence and creating a safe clinical environment and what is
practiced in many mental health settings.
Consumer Panel—Highlight of This Module
One of the activities in this module includes a panel presentation by consumers who have
experienced either seclusion and/or restraint. This panel presentation is part of the uniqueness of this training, which is based on the consumer perspective. Consumers bring a wealth
of knowledge through lived experience. Four panel members are strongly recommended: two
adults who have experienced seclusion and/or restraint and two adults who as adolescents,
experienced seclusion and/or restraint. It must be made clear that they cannot and do not represent all consumers. Your local Office of Consumer Affairs in the Department of Human Services should be able to help you locate panel members. Another good resource would be local
or State consumer organizations. Compensation or a stipend for panel members is strongly
recommended. This further validates the consumer experience and is a sign of respect.
Personal Perspective: Direct Care Staff
Participants will have an opportunity to hear their colleagues talk about the experience of
putting people in seclusion and restraint. Most direct care staff members are dedicated, hard
working people who have no malicious intent toward the individual people with whom they
work. Direct care staffs are often shorthanded, underpaid and undervalued. They are professionals with minds, hearts and souls. Promising practices indicate that training direct care staff
is a key to eliminating the use of seclusion and restraint. Direct care staffs possess the informal
power to contribute to system changes that eliminate the use of seclusion and restraint.
Module 1
6
BACKGROUND
A powerful way to understand the personal experience of seclusion and restraint is to hear
from people who have had this experience. Consumers and members of the professional
mental health community are beginning to realize the importance of establishing and maintaining rapport as an effective means of developing productive communication. This increases the likelihood of understanding each other, promotes beneficial treatment outcomes,
and decreases and/or eliminates the use of seclusion and restraint. Developing trust, mutual
understanding, and respect are essential in building needed rapport and creating alliances for
eliminating the use of seclusion and restraint.
As facilitators, you will set the tone for the entire training in this first
session. Welcome participants and introduce yourselves as facilitators,
including who you are and how you became interested in this work. The
participants will get a chance to introduce themselves in the first exercise.
It is important to create a respectful learning atmosphere where disagreement is welcomed and various viewpoints are heard. Also, the norms you
set for coming back on time from breaks and participating in class will
carry on throughout the training. Always make sure everyone has a
nametag or name tent.
Begin by going over the learning objectives.
Learning Objectives
Upon completion of this module the participant will
be able to:
Module 1
•
Outline the issues and concerns regarding the
practice of restraint and seclusion
•
Describe the use of restraint and seclusion with
special needs populations
•
Understand the personal experience of restraint
and seclusion for people diagnosed with a mental
illness
•
Understand the personal experience of restraint
and seclusion for front line staff
7
PRESENTATION
PRESENTATION
Overview
The issue of reducing/eliminating the use of seclusion and restraint is about a total shift to
a recovery-based model.
• For a shared vision and commitment to occur, we must begin by listening. Some of the
things you hear may be difficult and feel challenging. Some of the things you have to say
may be hard to say. This training was designed to implement change—so please hear and
say the difficult things.
• The goal is to create an environment where all viewpoints are heard, including ones that
are not in agreement with the philosophy of this manual.
• What we are asking from each participant is a commitment to really listen and hear
each other.
• As we conduct this training, we want to be sensitive to the language we use because it
sends a message. Language can set up a barrier between people. We are trying to build
bridges between people.
• In this manual, we have chosen to use “direct care staff” instead of “front line staff”.
“Front line staff” suggests the experience of war. We are trying to create a healing
environment, not a war zone.
• We have also chosen to use the word “consumer” or “person diagnosed with a mental
illness” rather than “patient.” We will cover language more extensively later on.
Put up the Power Point of the “Listen” poem, and either read the poem
yourself or ask different participants to read each section.
Module 1
8
PRESENTATION
“The initiative to reduce the use of seclusion and
restraint is part of a broader effort to reorient
the State mental health system toward a
consumer focused philosophy that emphasizes
recovery and independence…Seclusion and
restraint with its inherent physical force,
chemical or physical bodily immobilization and
isolation do not alleviate human suffering. It
does not change behavior.” Charles Curie,
Administrator SAMSHA
When I ask you to listen to me and
You start giving me advice,
You have not done what I have asked.
You begin to tell me why I shouldn’t feel that way,
You are trampling on my feelings.
You feel you have to do something
to solve my problem,
You have failed me. Strange as that may seem.
Listen: All that I ask you to do is listen.
Not talk or do—just hear me.
When you do something for me
That I can and need to do for myself
You contribute to my fear and inadequacy.
But when you accept as a simple fact
That I feel what I feel, no matter how irrational
Then I can quit trying to convince you
And get about this business of understanding what’s behind them.
So please listen and just hear me.
And, if you want to talk, wait a minute for your turn
And I’ll listen to you.
—Anonymous
Module 1
9
PRESENTATION
Listen
Getting to Know You
OBJECTIVE:
Give an opportunity for participants to get to know one another
and begin discussing their own experiences related to seclusion
and restraint.
PROCESS:
Ask participants to pair up with a person they don’t know very well.
Have them introduce themselves to each other and share their first
experience with seclusion and restraint. If time allows, also have
them tell their most difficult seclusion and restraint experience.
What was their most recent experience with seclusion and restraint? Have each participant introduce their partner and at least
one feeling word (e.g., sad, elated, scared, frightened, powerful,
repulsed) to describe their experience. On the chalkboard or dry
erase board, keep a list of feelings expressed.
DISCUSSION
QUESTIONS:
What are the similarities you heard about first experiences of
seclusion and restraint? Which feelings were most common?
How has your experience of seclusion and restraint changed/stayed
the same over time?
MATERIALS
REQUIRED:
Chalkboard or dry erase board and writing utensil
APPROXIMATE
TIME REQUIRED:
15 minutes
Module 1
10
PRESENTATION
Exercise/Discussion—Module 1
Assumptions to be Challenged
• Seclusion and restraints are therapeutic
• Seclusion and restraints keep people safe
• Seclusion and restraints are not meant to
be punishment
• Staff know how to recognize potentially
violent situations
• Seclusion and restraints are not therapeutic. There is actually no evidence-based research
that supports the idea that restraints are therapeutic.
• Seclusion and restraints do not keep people safe. The harm is well documented; not only
the physical harm, but also the emotional and mental harm. Restraints actually harm and
can cause death. Broken bones and cardiopulmonary complications are associated with
the use of seclusion and restraint (FDA, 1992; NYS OMH, 1994).
• Even though most staff would say that seclusion and restraints are not used as punishment, 60-75 percent of consumers view it as punishment for refusal to take meds or
participate in programs.
• Holzworth and Wills, 1999, conducted research on nurses’ decisions based on clinical cues with respect to patients’ agitation, self-harm, inclinations to assault others, and
destruction of property. Nurses agreed only 22 percent of the time on what constituted a
violent situation. The longer nurses have worked in mental health positively correlates
with greater consistency in determining potentially violent situations.
• In 1998, the Hartford Courant completed a series of investigative reports concerning the use
of seclusion and restraints and found an alarming number of deaths. The majority of deaths
related to seclusion and restraint are a result of asphyxiation or cardiac-related issues.
Module 1
11
PRESENTATION
Challenge Assumptions
• This training challenges the following assumptions that are often present in mental health:
Consumer Complaints
A New York study indicated that
94% of consumers who had been
restrained had at least one
complaint with one-half
complaining of unnecessary force
and 40% indicating psychological
abuse (Weiss, 1998).
• In prison, seclusion is seen as one of the worse punishments possible. Is it any different
in a mental health facility?
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12
PRESENTATION
• Even more disturbing was that many of the deaths were unreported. Few States require
the reporting and investigation of a death in a private or State psychiatric facility. The
Harvard Center for Risk Analysis at the Harvard School of Public Health estimated that
the annual number of deaths range from 50 to 150 per year—which translates into one to
three deaths every week (Weiss, 1998).
Consumers who have been restrained or secluded
indicate:
•
Predominately negative reactions
•
Did not know the reason for the
restraint/seclusion
•
It was humiliating, punishing, and depressing
•
Staff control was a primary factor
Lack of Uniform National Standards
Lack of national standards has
reportedly generated wide
variability in the use of restraint
and seclusion – including
potentially dangerous and unsafe
practices.
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13
PRESENTATION
Consumer Complaints
Ray & Rappaport, 1993
Lack of Adequate Staff Training
• A lack of adequate staff training has been cited as contributing significantly to deaths,
injuries, and other abuses (Weiss, 1998).
• Currently, there are no national uniform minimum training standards for the use of
seclusion and restraint.
• Three States– California, Colorado, and Kansas – license aides in psychiatric facilities
with required training.
• Decreases in staffing patterns may increase risk factors.
Safety
• The rate of injuries among mental health workers in hospitals is higher than the number
of workers injured in the construction and lumber industries.
• Often times, one of the staff fears about eliminating seclusion and restraint is that there
will be more staff injuries. Research indicates that the opposite happens. As the rate of
seclusion and restraints decreases, so does the rate of staff injuries.
• In mental health treatment settings, it is very common for consumers and providers to see
the world through different lenses and to have different meanings for common words.
• Much of the conflict that arises in these settings results from people operating from their
own worldview without acknowledging that of another.
• “Safety” is often used in hospitals to justify the use of procedures such as seclusion
and restraint and may mean very different things to consumers and staff. Laura Prescott
initially developed the following chart and it was adapted at the National Technical
Assistance Center for State Mental Health Planning (NTAC) Expert’s meeting.
Module 1
14
PRESENTATION
• National standards continue to evolve. However, there are no uniform national standards
governing how and when to use seclusion and restraint in psychiatric facilities.
• The Joint Commission on Accreditation of Hospital Organizations (JCAHO) and the
American Psychiatric Association (APA) have guidelines on this topic – but neither of
these are mandated.
• Landmark patients’ rights legal findings (Wyatt v. Stickney, 1972; Younberg v. Romeo,
1982) set forth minimum legal requirements regarding seclusion and restraint, but do not
address issues surrounding clinical standards.
SERVICE RECIPIENTS
SERVICE PROVIDERS
Safety = minimizing loss of control Safety = minimizing loss of control
over their lives
over the environment and risk
Safety Means
•Maximizing choice
•Authentic relationships
•Exploring limits
•Defining self
•Defining experiences without judgment
•Receiving consistent information ahead of
time
•Freedom from force, coercion, threats,
punishment, and harm
•Owning and expressing feelings without
fear
Safety Means:
•Maximizing routine and predictability
•Assigning staff based on availability
•Setting limits
•Designating diagnoses
•Judging experiences to determine
competence
•Rotating staff and providing information as
time allows
•Use of force (medication, restraint,
seclusion) to prevent potentially dangerous
behavior
•Reducing expressions of strong emotion
Source: The Critical Step: Seeing Different Perspectives (from the National Technical Assistance
Center’s report on managing conflict cooperatively [NASMHPD, 2002])
• The chart illustrates how the word “safety,” which is often used in hospitals to justify
the use of procedures such as seclusion and restraint, may mean very different things to
consumers and staff.
• Understanding these different definitions is critical to seclusion and restraint reduction.
• New and emerging treatment and service approaches make it possible to treat people with
severe symptoms without resorting to coercive strategies.
• There is a significant gap between what we know about preventing violence and creating
a safe clinical environment and what is practiced in many mental health settings.
• In 2002, the National Association of State Mental Health Program Directors and the
National Technical Assistance Center for State Mental Health Planning (NTAC) sponsored a national experts’ meeting on Managing Conflict Cooperatively: Making a
Commitment to Nonviolence and Recovery in Mental Health Treatment Settings.
The following section on safety is taken directly from their report.
Module 1
15
PRESENTATION
Conflicting Definitions of
Safety
Inappropriate Uses of
• Control the Environment
• Coercion
• Punishment
Treatment Approaches to Reduce Seclusion and Restraint
• The Medical Directors of the National Association of State Mental Health Program
Directors reviewed the literature and identified factors in their report (NASMHPD, 1999)
that contribute to a safe environment in which the use of seclusion and restraint is minimized and factors that are present when seclusion and restraint are more likely to be used.
• The Medical Directors of the National Association of State Mental Health Program
Directors report on restraint and seclusion (NASMHPD, 1999) indicates the following
well-documented, effective practices exist to reduce violence and simultaneously reduce
or eliminate the use of restrictive measures such as seclusion and restraint:
Module 1
16
PRESENTATION
Inappropriate Uses of Seclusion and Restraint
• Seclusion and restraint practices are sometimes used to:
° Control the environment – to curtail a consumer’s movement to compensate for having
inadequate staff on the ward, or to avoid providing appropriate clinical interventions.
° Coerce – to force a consumer to comply with the staff’s wishes.
° Punish – to impose penalties on consumer behaviors.
• Peer-delivered services
• Self-help techniques
• New medications
• Emphasis on recovery
• Understanding the relationship between
trauma and mental illness
Distribute participant handout on Preventing, Reducing, and Eliminating
Seclusion and Restraint with Special Needs Populations.
Children
• More than 26 percent of deaths reported in the Hartford Courant series were children
— almost twice the proportion of their population in psychiatric hospitals.
• Children are twice as likely as adults to be restrained (Weiss, 1998; Cooper, 1998;
Milliken, 1998).
• Children are further traumatized by being restrained and most see this as a form of
punishment (Mohr, 1999).
Women
• At least 70 percent of women in psychiatric facilities have a past history of trauma and or
abuse, and seclusion or restraint can cause further damage (Craine et al., 1988).
People of color
• In one study, Caucasian hospital staff physically restrained non-Caucasian consumers
nearly four times as often as they restrained Caucasians (Bond et al., 1988). Other studies
have had similar results.
Module 1
17
PRESENTATION
Treatment Approaches to
Reduce Seclusion & Restraint
Involuntary hospitalizations
• Persons who are hospitalized on an involuntary basis are more likely to be subject to
seclusion and restraint (Solof et al., 1989).
CONSUMER PANEL (1 hour)
Please refer to Background for the Facilitators for advice on selecting the
Consumer Panel.
Panel members should be asked to speak about seclusion and restraint from
their experience. They should tell more than just what happened, but how it
happened. What was the personal impact of seclusion and/or restraint upon
each? What would have prevented the use of seclusion and restraint?
Sample ground rules for panelists and the audience
• Listen to others and try to be open to their ideas.
• Share your ideas in order to learn from each other.
• Show respect for each other by not carrying on secondary conversations when someone else is talking.
• Respect one another by letting the other person have their say without
interruption.
• Stay within predetermined time limit.
Checklist of supplies for the panel
• Table/chairs
• Microphones if needed (check to make sure they work)
• Water/glasses
• Paper/pens
If possible conduct a rehearsal to predetermine and inform speakers of
the following:
• Time allowed for each speaker
• Subject matter
• Order of speaking
• Question-and-answer period at the end
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18
PRESENTATION
Geriatric mental health
• Geriatric mental health is defined as specialized services for individuals 65 years old
or older
• Aging may cause changes in the ability to communicate. Individuals who are unable to
communicate will be more likely to experience seclusion and restraint (NASMHPD, 1999).
Hartford Courant Articles
The Hartford Courant articles highlight the fact that 142 people, many of them children,
died in one year as a result of improper or excessive use of restraints. These articles
illustrate the need for the elimination of the use of seclusion and restraint. It often takes
articles such as these to get systems and the general public to sit up and take notice.
OBJECTIVE:
To review the information in The Hartford Courant articles concerning seclusion and restraint.
PROCESS:
Permission to reprint or copy these articles must be obtained from
The Hartford Courant at www.tmsreprints.com/forms/reprints/
hartford.html or call (800) 661-2511.
Divide participants into six groups. Give each group a different
Hartford Courant article and have them read it. Ask each group to
develop some creative way to relay the information to the large
group. They can talk, use the chalkboard, etc. Encourage creativity.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
APPROXIMATE
TIME REQUIRED:
How many of you had heard this information previously?
What did you learn from the articles?
Copies of The Hartford Courant articles
Chalkboard, whiteboard, or flip chart and writing utensil
20 minutes
Module 1
Presentation
19
PRESENTATION
Personal Perspective: Consumers
OBJECTIVE:
To give an opportunity for participants to discuss consumer experiences and feelings around the practice of seclusion and restraint.
PROCESS:
Groups of no more than six participants each. Distribute the
handout Consumer Quotes. Have each group facilitate a discussion
about the quotes.
DISCUSSION
QUESTIONS:
What are the common themes among consumer experiences?
How are consumer experiences similar/different to the experiences
of people diagnosed with a mental illness on the panel?
MATERIALS
REQUIRED:
Consumer Quotes handout
APPROXIMATE
TIME REQUIRED:
15 minutes
Module 1
20
PRESENTATION
Personal Perspective: Direct Care Staff
OBJECTIVE:
To give an opportunity for participants to discuss direct care staff
experiences and feelings around the practice of seclusion and
restraint.
PROCESS:
Groups of no more than 6 participants each. Distribute the
handout Direct Care Staff Quotes. Have each group facilitate a
discussion about the quotes. Are their personal experiences similar
or different to those of the people quoted? Why or why not?
DISCUSSION
QUESTIONS:
What are the common themes among direct care staff experiences?
How are direct care staff experiences similar or different to the
experiences of people who were on the consumer panel?
MATERIALS
REQUIRED:
Direct Care Staff Quotes handout
APPROXIMATE
TIME REQUIRED:
20 minutes
Module 1
21
PRESENTATION
Preventing, Reducing, and Eliminating Seclusion
and Restraint with Special Needs Populations
Participants in the August 2000 meeting hosted by the National Association of State Mental
Health Program Directors (NASMHPD) Medical Directors Council focused on five special
needs populations: (1) children and adolescents; (2) older individuals; (3) individuals with
mental illness and a co-occurring disorder of mental retardation and/or developmental disability; (4) individuals with co-occurring mental illness and substance abuse or dependence;
and (5) individuals being served in forensic programs.
These populations offer valuable lessons for achieving NASMHPD’s goal of preventing, reducing, and eliminating seclusion and restraint. Children and adolescents teach us that seclusion
and restraint decisions must take into account the child’s physical and cognitive development,
rather than just his or her chronological age. Older individuals may be fragile and present with
complex medical, psychological, and physical conditions best served from a multidisciplinary
perspective (e.g., physicians, nurses, pharmacists). Individuals with co-occurring disorders of
mental illness and mental retardation and/or developmental disability often communicate by
means of behavior which must be assessed in context when considering the use of seclusion
or restraint. Individuals with co-occurring disorders of mental illness and substance abuse or
dependence must be assessed to determine their capacity for exercising self-control and taking
personal responsibility in weighing the use of seclusion and restraint. Treatment of individuals in forensic psychiatric programs must balance public safety against therapeutic issues in the
use of seclusion and restraint. Many issues and recommendations identified in this report apply
equally to all special needs populations, while others may apply only to one or more, but not all.
Children and Adolescents
Findings
Treatment settings for children and adolescents are diverse. More children are served in
residential and group treatment programs than in State hospitals or other inpatient settings.
Others receive mental health services in detention centers and secure facilities for those adjudicated delinquent. Standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Health Care Financing Administration (HCFA) regarding seclusion
and restraint apply to hospitals, including State psychiatric hospitals, serving children and
adolescents. In addition, HCFA has developed regulations to address the use of seclusion and
restraint in child and adolescent residential settings. Promising practices to reduce and
eliminate seclusion and restraint may differ between hospital and residential settings.
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Reducing the Use of Seclusion and Restraint Handout
22
HANDOUT
Reducing the Use of Seclusion and Restraint: Part II
Findings, Principles, and Recommendations for Special Needs Populations
Special Needs Populations (continued)
Staff of child and adolescent programs are at risk, in an especially immediate way, of confusing their own childhood experiences and child-rearing practices in their own families with
their duties as professionals to the children they serve. Training and supervision that recognizes and addresses these tensions are important for maintaining clear professional boundaries.
Recommendations
• Families, custodians, and/or guardians should be informed of a program’s seclusion and
restraint policies and procedures when their children are admitted. Programs should
provide timely notification to these parties if their children are secluded or restrained and
give them an opportunity to participate in debriefing each event.
• Mental health programs should develop standardized assessment protocols to identify
children who have experienced physical, psychological, or sexual trauma, including
abuse, and those at high risk for seclusion and restraint events for any reason. Physical
and psychological risk assessments should be completed within 24 hours of admission,
and before any seclusion or restraint is used.
• Assessment should include a review of the child’s medical condition and disability, if any.
Substance abuse or dependence should be evaluated in the assessment process for individuals of all ages.
• Initial treatment plans should include positive interventions to avoid the use of seclusion
and restraint, especially for children most likely to lose self-control.
• In the event a child is restrained, he or she must be continually observed to prevent physical harm. These observations should be included in debriefing the event with the child
and with staff.
• Children who have experienced seclusion and restraint and who can articulate the effects
of these experiences should be involved in shaping program policies and procedures and
in training staff.
• Child and adolescent programs should involve consumers, families, and other advocates to
improve all treatment services, and specifically to reduce and eliminate seclusion and restraint.
• Many State mental health agencies currently do not have Offices of Consumer Affairs
specifically for child and adolescent treatment services. States should be encouraged to
develop or support specialized advocacy programs for children and adolescents.
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Reducing the Use of Seclusion and Restraint Handout
23
HANDOUT
Seclusion and restraint decisions for children and adolescents must be made using a developmental model, and not be based solely on chronological age. Such decisions must take into account children’s physical, cognitive, and developmental age. For example, in any use of seclusion and restraint, program staff must take special care to avoid damaging the formative growth
plates in children’s long bones. Children’s level of cognitive development governs the accuracy
of their understanding of social interactions and situations. Children’s sexual development also
must be considered so as to avoid or minimize trauma when staff respond to crisis situations.
Aging may cause changes in the ability to communicate, some obvious, others subtle.
Dementia and delirium may profoundly compound loss of thinking and speaking ability.
The effects of depression may be less dramatic, but may also seriously impair the ability
to communicate. An individual unable to communicate will be more likely to experience
Aging may lead to sensory impairments, incontinence, falls, and cognitive disabilities. Older
individuals affected by degenerative brain disease may be unusually loud, may become combative
when approached or touched, or may intrude upon others. In addition, older individuals served in
combined, general adult mental health programs may be vulnerable to stronger, more aggressive
younger individuals. The design of treatment spaces should contribute to safety and support.
Cultural and generational factors of staff and the individuals served may determine if and
how programs use seclusion and restraint. Family dynamics also play a role in how older
individuals are treated in mental health programs. Some research indicates that seclusion and
restraint events with older individuals increase following family visits. Adult children who
place elderly parents in treatment may react with grief or guilt and those placed may feel
anger toward their adult children for being placed in unfamiliar situations.
Recommendations
• Individuals, families, custodians, or guardians should be informed of program policies
and procedures for use of seclusion and restraint at the time older individuals are admitted. Programs should provide these parties timely notification and an opportunity to
participate in debriefing sessions if their relatives or wards are secluded or restrained.
• A biological/psychological assessment should be conducted within 24 hours of an individual’s
being admitted to a mental health program. The assessment should pay special attention to the
individual’s medical condition and unusual fragility (e.g., possible swallowing difficulties).
Restraints or PRN medications should not be administered until assessment is completed.
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HANDOUT
Older Individuals
Findings
Geriatric mental health is defined as specialized services for individuals 65 years old or older;
this definition is found both in law and Federal and State funding decisions. However, age
is not necessarily proportionally related to an individual’s functional status and the kinds of
interventions that may be therapeutic. Despite this, an older individual’s functional level is
often not a large factor in determining services or settings. Older individuals may present
multiple, complex diagnostic issues, including medical, psychological, and physical needs
calling for attention by a multidisciplinary team of physicians, nurses, and pharmacists.
Children and Adolescents
• Mental health programs for children and adolescents appear qualitatively different from
other mental health settings. How is physical contact with children and adolescents
distinguished from restraint? Can contact to prompt, guide, or console a child be clearly
distinguished from restraint? Can “time-out” in the child’s room be defined and practiced
so as not to constitute seclusion?
• Children and adolescents, as well as others, rely on learned behavior to cope with difficult
situations. If children learn early to rely on seclusion and restraint imposed by others to
help control their behavior, can they later learn other less restrictive and coercive means
of regaining control? Can critical components of developmentally acceptable seclusion
and restraint be identified and provided in staff training?
Source: National Association of State Mental Health Program Directors. (2001). Reducing the use
of seclusion and restraint. Part II: Findings, principles, and recommendations for special needs
populations. Alexandria, VA: National Technical Assistance Center.
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HANDOUT
• Staff should be trained to recognize and treat chronic and acute diseases, to understand
the dynamics of control issues, and the effect of these issues on interactions with older
individuals. Staff training should not be compromised by high employee turnover rates.
• Physicians and nurses should consult with qualified pharmacists to assess the effects
medications may have on individuals (e.g., gait problems, incontinence), including the
use of PRNs, psychotropic medications, and polypharmacy considerations.
• An older individual should never be restrained on his or her back due to risk of choking
on aspirated material.
• Only soft restraints should be used with older individuals. Leather restraints should never
be used as these may cause lesions or fractures, especially in cases of osteoporosis.
• Programs should encourage individuals and families to use advance mental health directives when feasible. Advance directives spell out treatment preferences and may include
alternatives to seclusion and restraint that individuals believe are safer, more effective,
and humane.
• Many States have ombudsmen for older individuals. Mental health programs should be
open to working with older consumers, ombudsmen, and other advocates, particularly to
reduce and eliminate seclusion and restraint.
A Nationwide Pattern of Death
By ERIC M. WEISS
With reporting by Dave Altimari, Dwight F. Blint and Kathleen Megan
This story ran in The Courant on October 11, 1998
R
oshelle Clayborne pleaded for her life.
Slammed face-down on the floor, Clayborne’s arms were yanked across her chest,
her wrists gripped from behind by a mental
health aide. I can’t breathe, the 16-year-old
gasped. Her last words were ignored.
A syringe delivered 50 milligrams of
Thorazine into her body and, with eight
staffers watching, Clayborne became, suddenly, still. Blood trickled from the corner of
her mouth as she lost control of her bodily
functions. Her limp body was rolled into a
blanket and dumped in an 8-by-10-foot room
used to seclude dangerous patients at the
Laurel Ridge Residential Treatment Center
in San Antonio, Texas.
The door clicked behind her.
No one watched her die.
But Roshelle Clayborne is not alone.
Across the country, hundreds of patients have
died after being restrained in psychiatric and
mental retardation facilities, many of them in
strikingly similar circumstances, a Courant
investigation has found.
They died pinned down on the floor by hospital aides until the breath of life was crushed
from their lungs. They died strapped to beds
and chairs with thick leather belts, ignored
until they strangled or their hearts gave out.
Those who died were disproportionately
young. They entered our health care system
as troubled children. They left in coffins.
All of them died at the hands of those who
are supposed to protect, in places intended to
give sanctuary.
If Roshelle Clayborne’s death last summer
was not an isolated incident, neither were the
recent deaths of Connecticut’s Andrew McClain or Robert Rollins.
A 50-state survey by The Courant, the first
of its kind ever conducted, has confirmed
142 deaths during or shortly after restraint
or seclusion in the past decade. The survey
focused on mental health and mental retardation facilities and group homes nationwide.
But because many of these cases go unreported, the actual number of deaths during or
after restraint is many times higher.
Between 50 and 150 such deaths occur
every year across the country, according to
a statistical estimate commissioned by The
Courant and conducted by a research specialist at the Harvard Center for Risk Analysis.
That’s one to three deaths every week, 500
to 1,500 in the past decade, the study shows.
“It’s going on all around the country,” said
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HANDOUT
Deadly Restraint — Day One
A Hartford Courant Investigative Report
Deadly Restraint—Day One (continued)
The regulators don’t ask, and the hospitals
don’t tell.
As more patients with mental disabilities
are moved from public institutions into
smaller, mostly private facilities, the need
for stronger oversight and uniform standards
is greater than ever.
“Patients increasingly are not in hospitals
but in contract facilities where no one has
the vaguest idea of what is going on,” said
Dr. E. Fuller Torrey, a nationally prominent
psychiatrist, author and critic of the mental
health care system.
Because nobody is tracking these tragedies,
many restraint-related deaths go unreported
not only to the government, but sometimes to
the families themselves.
“There is always some reticence on reporting problems because of the litigious nature
of society,” acknowledged Dr. Donald M.
Nielsen, a senior vice president of the American Hospital Association. “I think the question is not one of reporting, but making sure
there are systems in place to prevent these
deaths.”
Typically, though, hospitals dismiss restraint-related deaths as unfortunate flukes,
not as a systemic issue. After all, they say,
these patients are troubled, ill and sometimes
violent.
The facility where Roshelle Clayborne died
insists her death had nothing to do with the
restraint. Officials there say it was a heart
condition that killed the 16-year-old on Aug.
18, 1997. Bexar County Medical Examiner
Vincent DiMaio ruled that Clayborne died of
natural causes, saying that restraint use was
a separate “clinical issue.” But that, too, is
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HANDOUT
Dr. Jack Zusman, a psychiatrist and author of
a book on restraint policy.
The nationwide trail of death leads from a
6-year-old boy in California to a 45-year-old
mother of four in Utah, from a private treatment center in the deserts of Arizona to a
public psychiatric hospital in the pastures of
Wisconsin.
In some cases, patients died in ways and
for reasons that defy common sense: a towel
wrapped around the mouth of a 16-yearold boy; a 15-year-old girl wrestled to the
ground after she wouldn’t give up a family
photograph.
Many of the actions would land a parent
in jail, yet staffers and facilities were rarely
punished.
“I raised my child for 17 years and I never
had to restrain her, so I don’t know what gave
them the right to do it,” said Barbara Young,
whose daughter Kelly died in the Brisbane
Child Treatment Center in New Jersey.
The pattern revealed by The Courant has
gone either unobserved or willfully ignored
by regulators, by health officials, by the legal
system.
The Federal government—which closely
monitors the size of eggs—does not collect
data on how many patients are killed by a
procedure that is used every day in psychiatric and mental retardation facilities across
the country.
Neither do State regulators, academics or
accreditation agencies.
“Right now we don’t have those numbers,”
said Ken August of the California Department of Health Services, “and we don’t have
a way to get at them.”
Yet the great tragedy is that many of the
deaths could have been prevented by setting
standards that are neither costly nor difficult:
better training in restraint use; constant or
frequent monitoring of patients in restraints;
the banning of dangerous techniques such as
face-down floor holds; CPR training for all
direct-care workers.
“When you look at the statistics and realize
there’s a pattern, you need to start finding out
why,” said Dr. Rod Munoz, president of the
American Psychiatric Association, when told
of The Courant’s findings. “We have to take
action.”
Mental health providers, who treat more
than 9 million patients a year at an annual
cost of more than $30 billion, judge themselves by the humanity of their care. So the
misuse of restraints—and the contributing
factors, such as poor training and staffing—
offers a disturbing window into the overall
quality of the nation’s mental health system.
For their part, health care officials say
restraints are used less frequently and more
compassionately than ever before.
“When it comes to restraints, the public
has a picture of medieval things, chains and
dungeons,” said Dr. Kenneth Marcus, psychiatrist in chief at Connecticut Valley Hospital
in Middletown. “But it really isn’t. Restraints
are used to physically stabilize patients, to
prevent them from being assaultive or hurting themselves.”
But in case after case reviewed by The
Courant, court and medical documents show
that restraints are still used far too often and
for all the wrong reasons: for discipline, for
punishment, for the convenience of staff.
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typical in restraint cases. Medical examiners
rarely connect the circumstances of the restraint to the physical cause of death, making
these cases impossible to track through death
certificates.
The explanations don’t wash with Clayborne’s grandmother. “I’ll picture her lying
on that floor until the day I die,” Charlene
Miles said. “Roshelle had her share of problems, but good God, no one deserves to die
like that.” With nobody tracking, nobody
telling, nobody watching, the same deadly
errors are allowed to occur again and again.
Of the 142 restraint-related deaths confirmed by The Courant’s investigation:
Twenty-three people died after being restrained in face-down floor holds.
Another 20 died after they were tied up in
leather wrist and ankle cuffs or vests, and
ignored for hours.
Causes of death could be confirmed in 125
cases. Of those patients, 33 percent died of
asphyxia, another 26 percent died of cardiacrelated causes.
Ages could be confirmed in 114 cases.
More than 26 percent of those were children—nearly twice the proportion they constitute in mental health institutions.
Many of the victims were so mentally or
physically impaired they could not fend for
themselves. Others had to be restrained after
they erupted violently, without warning and
for little reason.
Caring for these patients is a difficult and
dangerous job, even for the best-trained
workers. Staffers can suddenly find themselves the target of a thrown chair, a punch, a
bite from an HIV-positive patient.
After she was restrained, Roshelle Clayborne lay in her own waste and vomit for five
minutes before anyone noticed she hadn’t
moved. Three staffers tried in vain to find
a pulse. Two went looking for a ventilation
mask and oxygen bag, emergency equipment
they never found.
During all this time, no one started CPR.
“It wouldn’t have worked anyway,” Vanessa Lewis, the licensed vocational nurse on
duty, later declared to State regulators.
By the time a registered nurse arrived and
began CPR, it was too late. Clayborne never
revived.
In their final report on Clayborne’s death,
Texas State regulators cited Laurel Ridge for
five serious violations and found staff failed
to protect her health and safety during the
restraint. They recommended Laurel Ridge
be closed.
Instead, the State placed Laurel Ridge on a
one-year probation in February and the center remains open for business. In a prepared
statement, Laurel Ridge said it has complied
with the State’s concerns—and it pointed
out the difficulty in treating someone with
Clayborne’s background.
“Roshelle Clayborne, a ward of the State,
had a very troubled and extensive psychiatric history, which is why Laurel Ridge
was chosen to treat her,” the statement said.
“Roshelle’s death was a tragic event and we
empathize with the family.”
With no criminal prosecution and little
regulatory action, the Clayborne family is
now suing in civil court. The Austin chapter
of the NAACP and the private watchdog
group Citizens Human Rights Commission
of Texas are asking for a Federal civil rights
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“As a nation we get all up in arms reading
about human rights issues on the other side
of the world, but there are some basic human
rights issues that need attention right here at
our back door,” said Jean Allen, the adoptive
mother of Tristan Sovern, a North Carolina
teen who died after aides wrapped a towel
and bed sheet around his head.
Others have a simple explanation for the
lack of attention paid to deaths in mental
health facilities.
“These are the most devalued, disenfranchised people that you can imagine,” said
Ron Honberg, director of legal affairs for the
National Alliance of the Mentally Ill. “They
are so out of sight, so out of mind, so devoid of rights, really. Who cares about them
anyway?”
Few seemed to care much about Roshelle
Clayborne at Laurel Ridge, where she was
known as a “hell raiser.”
But Clayborne had made one close friendship—with her roommate, Lisa Allen. Allen
remembers showing Clayborne how to throw
a football during afternoon recess on that
summer afternoon in 1997.
“She just couldn’t seem to get it right and
she was getting more and more frustrated.
But I told her it was OK, we’d try again tomorrow,” said Allen, who has since rejoined
her family in Indiana.
Within three hours, Clayborne was dead.
She had attacked staff members with
pencils. And staffers had a routine for hell
raisers.
“This is the way we do it with Roshelle,”
a worker later told State regulators. “Boom,
boom, boom: [medications] and restraints
and seclusion.”
The same aide had pinned her arms across
her chest. Thorazine was pumped into her
system. She was deposited in the seclusion
room.
“It felt like my lungs were being squished
together,” Allen said.
But Lisa Allen was one of the lucky ones.
She survived.
Additional research was contributed by
Sandy Mehlhorn, Jerry LePore and John
Springer
Copyright © 1998 The Hartford
Courant Co.
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investigation into the death of Clayborne.
Medications and restraint and seclusion.
Clayborne’s friend, Lisa Allen, knew the
routine well, too.
For six years, Allen, now 18, lived in
mental health facilities in Indiana and Texas,
where her explosive personality would often
boil over and land her in trouble.
By her own estimate, Allen was restrained
“thousands” of times and she bears the
scars to prove it: a mark on her knee from
a rug burn when she was restrained on a
carpet; the loss of part of a birthmark on her
forehead when she was slammed against a
concrete wall.
Exactly two weeks after Roshelle Clayborne’s death, Lisa Allen found herself in the
same position as her friend.
Little Training, Few Standards,
Poor Staffing Put Lives at Risk
By KATHLEEN MEGAN and DWIGHT F. BLINT
With reporting by Dave Altimari
S
he was a 15-year-old patient, alone in a
new and frightening place, clutching a
comforting picture from home.
He was a 200-pound mental health aide bent
on enforcing the rules, and the rules said no
pictures. She defied him; the dispute escalated.
And for that, Edith Campos died. She was
crushed face down on the floor in a “therapeutic hold” applied by a man twice her size.
Shy and well-behaved as a girl growing up
in Southern California, Edith had problems
as a teen. She ran away, took drugs, hung
with the wrong crowd. Her family hoped
treatment at the Desert Hills psychiatric
center in Tucson, Ariz., would help.
But Edith Campos died—as did Andrew
McClain and Roshelle Clayborne and countless others—when a trivial transgression
spiraled into violence. Too often, it’s a reaction built right into our system that cares for
people with psychiatric problems and mental
retardation.
The people who make and execute the critical
decisions to use physical force or strap a patient
to a bed or chair are often aides, the leasttrained and lowest-paid workers in the field.
They must make instantaneous decisions
affecting patients’ physical and psychological well-being against a backdrop of staffing
cuts that result more in crowd control than in
patient therapy.
“I can’t understand why patients don’t die
more often with all the things that happen
on a daily basis,” said Wesley B. Crenshaw,
a psychologist who has conducted one of
the few national surveys on restraint use.
“You have people who are ‘cowboying’ it,”
Crenshaw said, “people who really want to
get in there and show they’re the boss.”
Yet only three States-- California, Colorado
and Kansas—actively license aides in psychiatric facilities. Licensing of aides is nearly
non-existent in the mental retardation field as
well, although a handful of States do certify
aides. So, while individual States and facilities may set their own standards, there is no
uniform, minimum training for psychiatric or
mental retardation aides nationwide—even
in life-saving techniques such as CPR.
In the Edith Campos case, aide Daniel
Thomas Walsh successfully fought negligent
homicide charges by arguing he had followed
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Deadly Restraint — Day Two
Deadly Restraint—Day Two (continued)
Yet children are both a vulnerable and
challenging population.
Firm diagnoses often cannot be made
until late adolescence or early adulthood, so
providers are less sure how to treat children.
And many troubled children enter the mental
health system with histories of physical or
sexual abuse—so even the threat of physical
force can be traumatizing.
For their part, many patients say improper
or frequent use of restraints hurts their recovery and defeats the very reason they were admitted. In interviews with more than a dozen
children and adults, The Courant’s investigation found these patients were left confused,
angry and afraid. They rarely felt better.
Researchers are finding the same. In a
1994 New York study, 94 percent of patients
restrained or placed in seclusion had at least
one complaint about the process. Half complained of unnecessary force, 40 percent
cited psychological abuse. In a study published this year, Mohr interviewed children
after their hospital stays and found many
were further traumatized when they were
restrained or secluded—or even watching
others undergo the procedure. Usually,
she found, children saw such treatment
as punishment.
The leader of the nation’s psychiatric
association acknowledged the problem.
“It must be especially frightening for a
child,” said Dr. Rod Munoz, president of
the American Psychiatric Association.
“It’s a struggle of wills where the most
powerful win.”
And troubled children are the ones
who lose.
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hospital guidelines. And the guidelines didn’t
say he needed to watch Edith’s face for signs of
distress, the judge found. “It was a tragedy that
this girl died in our care,” said Kirke Cooper,
director of business development for Desert
Hills. “But I don’t feel there was any wrongdoing on the part of our staff. They are all welltrained in physical control and seclusion.”
Done correctly, a restraint can protect a
patient and worker from harm. Done under
the right circumstances, patients say, it can
be beneficial. Yet too often, it is done badly
and for the wrong reasons. Nowhere is this
tragedy more apparent than in the deaths of
children.
A Courant investigation has found more
than 26 percent of restraint-related deaths
over the past decade involved patients 17
and under. Yet children make up less than 15
percent of the population in psychiatric and
mental retardation facilities, according to
federal statistics. The death rate should come
as no surprise.
“You can’t believe how many times a kid
gets slammed into restraints because an argument will ensue after calling a staff member
a name,” said Wanda Mohr, director of psychiatric mental health nursing at the University of Pennsylvania. She and other analysts
say children disproportionately bear the brunt
of the misuse and overuse of restraints. A
1995 New York study, for instance, found
children almost twice as likely as adults to be
restrained. “It’s socially acceptable to spank
and punish children,” said Mohr, reflecting the responses of other experts who say
our culture tolerates a physical response to
unruly children.
control and ought to exercise their authority.”
Yet in certain facilities, physicians give staffers virtual carte blanche by issuing an order
to restrain as needed. “It’s a go-ahead to slap
restraints on a person without evaluating why
the patient was acting up in the first place,”
said Dr. Moira Dolan, a medical consultant
in Texas, where standing restraint orders
are allowed in certain facilities. “There’s no
guidance on when to restrain someone.”
Despite such responsibility, minimum hiring standards are few and pay is typically
low for aides. A survey by The Courant last
spring, for example, found aides were paid as
little as $10 per hour in Connecticut. When
federal investigators began looking into the
quality of care at Western State Hospital in
Staunton, Va., last summer they found the
$15,000 starting pay was less than what an
employee could make at the nearby department store. “When you can make $10 an
hour working at the new Target,” asked
union representative Allen Layman, “what
incentive is there to come here?”
Especially when the work can be demanding and dangerous. For every 100 mental
health aides, 26 injuries were reported in a
three-state survey done in 1996. The injury
rate was higher than what was found among
workers in the lumber, construction and mining industries. “Depending on the situation,
it’s scary, it’s violent,” said David Lucier, a
veteran mental health worker at Natchaug
Hospital in Mansfield, Conn. “Oftentimes,
patients are kicking and punching and spitting and verbally abusive.”
Over a 19-year career, Lucier said, he has
developed communication skills that allow
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Elaina Huckin, 17, of Granby, Conn., is
still so disturbed by a restraint five years
ago that she can barely speak about it. She
was put in a “body bag,” a sort of neck-totoe straitjacket. “They tie you in it. They
pull it tighter and tighter. I couldn’t move to
breathe,” Huckin said. “I was screaming and
pleading, ‘Somebody, please, somebody take
me out.’ “It made you so much more suicidal,” she said.
As mental health aides take this step that
can do such physical and psychological
harm, they are poorly monitored much of the
time. Although most institutions require a supervisor to oversee a physical restraint, The
Courant found such rules are often ignored.
When 11-year-old Andrew McClain was
restrained last March at Elmcrest psychiatric
hospital in Portland, Conn., the duty nurse
sat nearby eating breakfast. She ignored the
initial cries of distress from Andrew, whose
chest was crushed during the restraint.
The decision to strap a patient to a bed or
chair, or cuff their hands, must be cleared
by a doctor, according to many hospital and
State policies. If a doctor is not available, efforts must be made to contact one as soon as
possible. But in more than a dozen cases reviewed by The Courant, patients were tied to
their bed or chair for several hours at a time
without regular review by a physician. Mental health advocates say doctors must keep a
closer eye on how long their patients are restrained. “The ultimate responsibility falls to
the doctors, who are supposedly the kings in
these places,” said Curtis L. Decker, executive director of an organization representing
patient advocates nationwide. “They’re in
institutions, they end up with only two
people doing the work of four people,” said
Tom Gallagher of the Indiana Protection &
Advocacy Services office. “That’s when
problems occur.”
At least six of 23 recent deaths reviewed
in depth by The Courant occurred during a
restraint executed by only one or two people.
Another six patients died in seclusion or
mechanical restraints after being left,
unmonitored, for several minutes or more.
“Hospitals have cut their staffing to a bare
minimum,” said Dr. David Fassler, a psychiatrist, author and chairman of the Council
on Children, Adolescents and Their Families.
The same fiscal pressures, he said, have led
institutions to reduce training as well.
All this at a time when patients particularly
need skilled help. As managed care limits
access to hospitals, most analysts say patients
are entering the system in more troubled
conditions than ever before. In the wards,
staffers feel the pressure.
Pausing during a recent double shift at
Western State Hospital in Virginia, a 375-bed
facility for adults, nurse Judy Cook talked
about the need to devote time to patients.
“Every time we’ve had a downsizing of
staff we’ve had an increase in restraints and
seclusions,” said Cook, who has seen 23
years of trends at Western. “When you have
more staff you can intercede better and you
don’t have to just place someone in restraints
to calm them down.” But reducing the use
of restraints requires a financial and philosophical commitment—a commitment to
use force only as a last resort, and only by
well-trained staff who care about the patient.
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him to rarely touch patients. The skills
described by Lucier are gained by training
and by understanding the patients.
At some hospitals, though, staff are moved
about like pawns in a chess game, leaving
them little chance to know their patients. To
fill less-desirable shifts such as weekends,
institutions use less-trained, part-time workers. When faced with wide fluctuations in the
numbers of patients, they resort to shuffling
workers from one unit to another.
A staff shortage landed aide Spero Parasco
on Andrew McClain’s unit March 22.
Parasco, who usually worked with adults,
had never met Andrew before that morning at
breakfast and had not read the child’s medical chart. Indeed, Andrew’s ward that Sunday
was staffed largely with part-time workers.
So when Andrew defied Parasco’s instructions to move to another table at breakfast,
the dispute escalated into a “power struggle.”
Had workers known more about Andrew, had
Parasco been better-versed in ways to calm
him, the boy would not have died, a State
investigation concluded.
Better staffing also reduces the risk of a
restraint, like the face-down floor hold in
which Andrew died. The American Psychiatric Association recommends at least five
people—one for each limb, plus someone to
watch—be involved in any physical restraint.
That would have been nearly impossible in
Andrew’s case. A total of five staffers were
on duty in the unit that Sunday morning,
overseeing 26 children. As it was, just two
aides were involved in Andrew’s restraint.
“A takedown requires four staff members
and, with staff cuts being made at many
HANDOUT
Across the nation, the commitment is too
often absent.
Last summer, a staff shortage at Western
State forced nurses to call on security guards
to help perform restraints. One guard, who
didn’t want his name used, showed little
interest in the patients he might forcibly restrain. Or much interest in doing it correctly.
“I didn’t get hired,” he said, “for all this
bull-crap interacting with people or tackling
psychotic patients.”
Courant Staff Writer Eric M. Weiss
contributed to this story.
Courant Co.
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Patients Suffer in a System Without Oversight
By ERIC M. WEISS and DAVE ALTIMARI
H
ad Gloria Huntley been able to move,
had she not been bound to her bed with
leather straps for days on end, perhaps she
would have tried to draw the attention of the
inspectors who were conducting a three-day
tour of Central State Hospital. Had she been
able to move, had she not been pinned down
by the wrists and ankles, she might have held
up a sign, as she had done before when a visitor came through Ward 7. Her handwritten
plea was simple: “Pray for me. I’m dying.”
But the inspection team from the nation’s
leading accreditation agency never noticed
Gloria Huntley before leaving the Petersburg,
Va., psychiatric hospital.
The three inspectors from the Joint Commission on the Accreditation of Healthcare
Organizations issued Central State a glowing
report card—92 out of 100 points. They also
bestowed the commission’s highest ranking
for patients’ rights and care when they concluded their review on June 28, 1996.
The next day, Gloria Huntley died. She was
31. Her heart, fatally weakened by the constant use of restraints, had inflamed to 1 1/2
times its normal size. In her last two months,
she’d been restrained 558 hours—the equivalent of 23 full days. Nine months later, the
Joint Commission gave Central State an even
better score in a follow-up review—even
though Huntley’s treatment would ultimately
be labeled “inhumane” by the Commonwealth of Virginia and condemned by the
U.S. Justice Department.
“How could JCAHO give Central State
the highest rating in human rights when they
were killing people?” asked Val Marsh, director of the Virginia Alliance for the Mentally Ill. The way the country’s health care
system works, how could it not?
The Courant’s nationwide investigation of
restraint-related deaths underscores just how
faulty—how rife with conflicts of interest,
how self-protective, how ultimately ineffective—the system of industry oversight and
government regulation really is. The health
care industry is left to police itself, but often
doesn’t. Time and again, The Courant found,
when it comes to the quality and safety of
patient care, the interests of the industry far
outweigh the public interest. “One reason
you have overuse and misuse of restraints is
because oversight is practically nonexistent,”
said Dr. E. Fuller Torrey, a nationally prominent psychiatrist and author of several books
critical of the nation’s mental health system.
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Deadly Restraint — Day Three
Deadly Restraint—Day Three (continued)
spected were found to have shortcomings that
needed to be addressed. “Joint Commission
accreditation is intended to say to the patient:
This is a place that does things well and is
constantly working to improve things,” said
Dr. Paul M. Schyve, a psychiatrist and senior
vice president of the Joint Commission.
If the industry is not adequately watching
itself, neither is the government. The nation’s
top mental health official says he has little
latitude when it comes to tougher regulation and oversight. “Most rules governing
health care have been left to the States,” said
Dr. Bernard S. Arons, director of the U.S.
Center for Mental Health Services. When it
comes to mental retardation facilities, in fact,
inspection is left largely to the States.
But their record is not much better.
The General Accounting Office, the investigative arm of Congress, has found that
State regulators are loath to punish State-run
facilities. In a study of State mental retardation centers, the GAO found “instances in
which State surveyors were pressured by
officials in their own and in other State agencies to overlook problems or downplay the
seriousness of deficient care in large State
institutions.” When State regulators do show
up, their inspections are scheduled with such
predictability that facilities can beef up staff,
improve services and even apply fresh coats
of paint. Often, only the new paint remains
after the inspectors leave. “These visits provide only a snapshot,” said William J. Scanlon, director of health care studies for the
GAO. “And it may be a doctored snapshot.”
It is only when the system utterly collapses, as in the Gloria Huntley case, that the
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“And the health industry doesn’t want oversight.” The chain of agencies, boards and
advocates that is supposed to provide oversight—the kind of oversight that might have
prevented Huntley’s death and hundreds like
it—often breaks down in multiple places.
But the heavy reliance on the Joint Commission—an industry group that acts as the
nation’s de facto regulator—lies at the core
of the problem.
The federal government relies on the private nonprofit agency’s seal of approval for a
psychiatric hospital’s acceptance into Medicare and Medicaid programs. And 43 States,
including Connecticut, accept it as meeting
most or all of its licensing requirements.
But the Joint Commission doesn’t answer
to Congress or the public. It answers to the
health care industry.
The Joint Commission was founded in 1951
by hospital and medical organizations, whose
members still dominate the commission’s
board of directors. The commission is funded
by the same hospitals it inspects. How tough
are its inspections? Of the more than 5,000
general and psychiatric hospitals that the Joint
Commission inspected between 1995 and
1997, none lost its accreditation as a result
of the agency’s regular inspections. None.
When extraordinary circumstances arise—
a questionable death, for instance—the Joint
Commission may conduct additional inspections. Even then, less than 1 percent of facilities overall lost accreditation. Central State
was not among them.
Joint Commission officials are the first to
say they are not regulators. Participation is
voluntary, and 83 percent of hospitals in-
Even if the Joint Commission inspectors
had missed Huntley in particular, there were
other cases at Central State that should have
raised red flags. One patient was restrained
for 1,727 hours over an eight-month period,
yet another for 720 hours over a four-month
period, according to a U.S. Justice Department report. So, in many respects, the investigation into Huntley’s death is most
remarkable in that it happened at all. When
she died on June 29, 1996, the police were
never called. It took a hospital employee’s
anonymous call to a citizens watchdog
group, days after Huntley’s death, to tip off
the outside world that she died while being
restrained—and not in her sleep as hospital
officials told family members.
The Courant’s investigation found at least
six cases in which facilities, wary of lawsuits
and negative publicity, tried to cover up or
obscure the circumstances of a restraint-related death. “It’s sort of a secretive thing,” said
Dr. Rod Munoz, president of the American
Psychiatric Association. “Every hospital tries
to protect itself.” “The incentive is to settle
with the family, fix it internally and move
on,” said Dr. Thomas Garthwaite, deputy
undersecretary of health for the U.S. Department of Veterans Affairs.
Many States, including Connecticut, have
laws that shield discussions among doctors
that explore what went wrong. The laws are
designed to promote candid discussions, but
the solutions often don’t leave the closed
hospital conference room. Garthwaite and
other experts said hospitals need to share
problems and solutions to prevent deadly errors from being repeated. Just a year ago, the
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federal government intervenes to set rules
for patient care.
Justice Department abuse investigators,
who have authority to intercede when civil
rights violations are suspected in publicly
run facilities, often find these same facilities
were recently given clean bills of health by
licensing agencies or the Joint Commission.
“The use of restraints is clearly a very big
problem and a very significant issue in nearly
all of the institutions we investigate,” said
Robinsue Froehboese, the top abuse investigator at the Justice Department. But with a
staff of 22 attorneys, Froehboese’s office can
undertake only a handful of major investigations each year.
“Nineteenth-century England had a better oversight system than we have now,”
said Torrey, describing an English system
that used full-time government inspectors
to check every psychiatric facility without
prior notice.
At Central State, the warning signs should
have been apparent. But Joint Commission
inspectors review just a sampling of patient
records—a sampling that may not include
problem cases like Gloria Huntley’s. Anyone
who did look at Huntley’s records would have
known her health was failing—and that heavy
use of restraints was a primary reason. Two
years before Huntley’s death, a doctor warned
officials at Central State that she would die if
they didn’t change her restraint plan. “Staff
members should watch their conscience, and
those in charge must always remember that
following physical struggle and emotional
strain, the patient may die in restraints,” stated
the ominously titled “duty to warn” letter.
Advocates say they have too little funding for their broad charge, and are fought
every step of the way by hospitals and doctor
groups. Scarce money and staffing are used
just to secure basic information. “It’s a David
and Goliath battle,” said Curtis L. Decker,
executive director of the group representing
advocacy organizations nationwide. “And
Goliath is winning.”
Hospitals see no need for drastic change,
let alone more government intervention.
“Given the speed of government, it is often
better to allow the private market to work
issues out,” said Nielsen of the AHA. “Joint
Commission standards have been revised recently and are continually being improved.”
Huntley’s family might take issue with that
assessment. They have filed a civil rights
lawsuit in federal court seeking $2 million, and a wrongful death lawsuit in State
court seeking $450,000. “We knew from the
get-go things weren’t right when they told
us she died in her sleep,” said Paige Griggs,
Huntley’s sister-in-law. “We thought she was
being taken care of.”
Courant Staff Writers Kathleen Megan and
Dwight F. Blint contributed to this story.
Courant Co.
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VA began a comprehensive system to track
all deaths and mistakes. But a plan by the
Joint Commission to do the same all across
the nation has been stymied so far by the
powerful American Hospital Association.
The AHA notified the Joint Commission in
January that the proposal had created a “firestorm” among its members, who worried that
they would have to turn over “self-incriminating” documents. “We’ve tried to make the
program workable, so people would not be
afraid to report on a voluntary basis,” said
Dr. Donald M. Nielsen, a senior vice president of the American Hospital Association.
He said the two groups agreed last month on
some ground rules regarding the issue. With
the industry failing to monitor itself, with
government regulators unwilling to challenge the industry, uncovering abuse is left to
“protection and advocacy” agencies established by Congress in each State. Despite
$22 million in federal funding this year and
broad authority to root out and litigate cases
of abuse, even some advocates turn a blind
eye to investigating deaths.
Desperate for help, Gloria Huntley turned
to one of these organizations in her last
months of life. Not only was her complaint
not investigated, but three weeks after her
death Huntley was sent a letter saying the
advocacy agency was dropping her case because it hadn’t heard from her in 90 days. The
letter ends: “It was a pleasure working with
you to resolve your complaint. I wish you the
best of luck in your future endeavors.”
“People Die and Nothing Is Done”
By DAVE ALTIMARI
With reporting by Dwight F. Blint and John Springer
S
heriff Geno D’Angelo remembers the
first time staffers at the Broome Developmental Center in Binghamton, N.Y., called
his office for help last year.
A deer had been killed by a car in front of
the center the evening of Nov. 24. The staff
wanted it removed. But no one from the State
mental health facility had called D’Angelo
four months earlier when William Roberts
fell to his side, vomited and died after being
ALVINA GAUTHIER and her family fought
for a thorough investigation of the death
of her daughter Sandra Gordon at the
Rosewood Terrace Care Center in Salt
Lake City in January. After an autopsy,
the 45-year-old woman’s death—originally
deemed an accident—was ruled a homicide. The State of Utah eventually closed
the facility.
restrained in a timeout room. “I wonder how
many of these deaths occur at that facility or
others in this State that [police] never know
about,” said D’Angelo, who first learned
about the death from a Courant reporter.
The Courant’s investigation has found the
nation’s legal system falters time and again
when it comes to restraint-related deaths. Just
as the medical establishment fails to provide
the kind of internal oversight that might prevent patients from dying, the legal system
offers little hope for justice after they
are dead.
Law enforcement officials, lawyers and
mental health advocates say it isn’t always
easy, or appropriate, to place blame on the
ill-trained mental health aides who typically
execute restraints. But without thorough
investigation, the system too often fails to determine whether a death is a tragic accident or
an act of criminal negligence. And whatever
the circumstances, they say, patients’ families
are entitled to answers.
Yet the normal investigative process falls
apart at each step, The Courant found.
Hospital workers cover up or obscure the
circumstances of a death. Autopsies are not
automatically performed. Police are not routinely summoned. Investigators often defer
to the explanations offered by the institutions
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making it hard to prove criminal intent.
Others have found staffers reluctant to
blow the whistle on colleagues.
“Despite the legal and ethical obligations
to report and protect patients from abuse, a
strong code of silence among direct care staff
still exists,” California investigators found
last year after an investigation into restraint
abuses at Napa State Hospital. Two people
have died in restraint-related incidents at
Napa State in the past six years. The California report found a system rotting from
within. It cited a survey in which two-thirds
of psychiatric aides statewide believe there
to be a “code of silence.” Workers, the report
said, consider themselves victims of a bad
and abusive system.
In Pennsylvania, Costen intends to propose
legislation to put the system, corporations
and administrators, on trial—and not simply
the low-paid aides who work for them. “We
have to make it possible to attack the corporate structure and hold them accountable for
criminal actions,” Costen said. His proposal
would carry no prison sentence, instead fining
corporations or, in the worst cases, putting
them out of business.
But punishment can only follow investigation. Police and prosecutors typically rely on
medical examiners to trigger a criminal case
by issuing a homicide ruling. The trigger is
infrequently pulled.
In 23 recent deaths examined in depth by
The Courant, only three were ruled homicides. In the other cases, including the Binghamton death, medical examiners ruled the
deaths to be accidental or attributed them to
the patient’s existing medical problems.
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involved. “It’s easier to just say it was an
accident and forget about it,” said Michael
Baden, a former New York State medical
examiner who now serves on a State board
that investigates deaths in institutions.
Thus, few are ever punished. Prosecutors
rarely pursue arrests in restraint deaths and,
when they do, they typically accept plea
bargains to minor charges.
“The way the system runs, people die and
then nothing is done about it,” said Raul
Campos, whose 15-year-old daughter, Edith,
died while restrained in a dispute over a
photograph. Hers was a rare case in which
criminal charges were filed. But an Arizona
judge found restraint deaths are such a “rarity” that it would have been unreasonable to
expect the aide to notice Edith’s distress. He
tossed the case out.
Families of dead patients, angry with the
lack of accountability in the criminal justice
system, then turn to civil court where they
face one last obstacle to justice: jurors who
must place a monetary worth on people at
the bottom rung of society. “The law is not
disability-friendly. If you’re disabled or mentally retarded, you don’t have any value,”
said Pennsylvania attorney Ron Costen, who
represents families in abuse cases.
A former prosecutor, Costen is familiar with
the flaws of criminal investigations into restraint deaths. Among the common problems
he cited: Scenes are not preserved because
staff immediately clean up the room where
the restraint occurred. Staffers develop a story
emphasizing the patient’s existing physical
problems. And workers say they were just
protecting themselves or others from harm,
shy away. “There’s enormous variability from
State to State and even county to county on
what the district attorney feels is a prosecutable offense,” said Robinsue Froehboese, the
U.S. Justice Department’s top abuse investigator. “Unfortunately,” she said, “the jurisdictions that don’t prosecute these cases far
outweigh those who do.”
Take the case of Melissa Neyman of
Tacoma, Wash. Gerald A. Horne, a Pierce
County prosecutor, would not pursue charges
in Neyman’s death—even though the State
attorney general’s office urged criminal
prosecution against the owner and a worker
at the Judith Young Adult Family Home.
Tied to her bed in a makeshift restraint on the
night of July 23, 1997, Neyman managed to
climb out a window before becoming entangled in the straps. The 19-year-old autistic
woman had been dead six hours before workers finally noticed her—hanging from the
window about 3 or 4 feet from the ground.
“We don’t charge persons who had goodwill
and were doing the best job they could,”
Horne said.
“They didn’t have any intent to hurt
anybody.”
But the staffer did put Neyman in a restraint without a physician’s permission—
a direct violation of Washington State law.
The same staffer was not authorized to care
for clients, did not check on Neyman for
several hours, and lied to investigators about
the circumstances of the death, the attorney
general’s office found.
When prosecutors do press charges or get
indictments from grand juries, they rarely
follow through and go to trial. More often
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Baden, of New York, said these rulings fail
to take into account the full context in which
the patient died. “Positional asphyxiation has
this very nice ring to it,” said Baden, referring to a common cause of death in restraint
cases. “Like maybe somebody did it to
themselves instead of their chests being compressed.” Most medical examiners say they
struggle with restraint cases, but ultimately
cannot issue a homicide ruling if staffers
are working within the scope of their jobs.
“It’s difficult to say whether a hold put on a
person has any role in their death unless it’s
clear-cut they were doing the hold wrong,”
said Vincent DiMaio, the Texas medical
examiner who ruled that Roshelle Clayborne
died of natural causes after being restrained
in a San Antonio, Texas, facility.
Such clarity is nearly impossible. Across
the country, The Courant has found, there are
no clear, uniform standards on restraint use,
and no minimum training standards for staffers. So prosecution is rare, too. “If a medical examiner rules a death accidental or by
natural causes, it does make getting a criminal indictment more unlikely than not,” said
John Loughrey, a prosecutor in Monmouth
County, N.J.
In June, Loughrey presented to a grand jury
his case against two staffers at the Brisbane
Child Treatment Center. Staffers said 17year-old Kelly Young’s hair was hiding her
face during a restraint—so they didn’t notice
that her lips were turning blue.
But the grand jury refused to issue indictments after hearing the death had been ruled
accidental. Faced with unfamiliar cases that
are difficult to prove, most prosecutors simply
In fact, few lawsuits involving restraint
victims ever make it before a jury because
they are settled quietly and out of court. In
the mere handful of jury verdicts over the
past two decades, awards typically fell under
a half-million dollars, according to legal
experts and a national tracking service. When
a case does go to trial, families face a final,
common hurdle. Take the case of Roshelle
Clayborne. “What’s the life of a poor, black,
mentally ill girl who has been institutionalized for several years going to mean to a
jury?” said Martin Cirkiel, the Texas attorney
who represents Clayborne’s family. “I think
the answer,” Cirkiel said, “is not much.”
Courant Staff Writers Colin Poitras, Kathleen Megan and Eric M. Weiss contributed to
this story.
Courant Co.
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they settle for a plea bargain that calls for
no jail time. Kimberlye Montgomery was
originally charged with involuntary manslaughter and gross negligence, a felony with
a maximum 15-year sentence, in the restraint
death of 9-year-old Earl Smith in Detroit in
November 1995. Montgomery, a child-care
worker at the Methodist Children’s Home
Society, sat on Smith and ignored his pleas
for air because it was “typical of the ruses
used by children to get themselves released
from restraints,” she said in a court deposition. Montgomery eventually pleaded guilty
to a misdemeanor and received an 18-month
suspended sentence and 100 hours of community service.
Nancy Diehl, the Wayne County prosecutor who handled the Smith case, said she had
little choice because many of the witnesses
were other troubled children. “We gave her
a great plea because we felt we might have
some problems convincing a jury of the original charge,” Diehl said. “It certainly isn’t
easy because your witnesses are other young
kids who have various problems. That’s why
they are in the home.”
After navigating the criminal justice system and ending up empty-handed, the Smith
family ended where many aggrieved families do—in civil court. Detroit attorney Julie
Gibson, who represented the Smiths, said
her clients eventually realized it was best to
settle the case.
From “Enforcer” to Counselor
By ERIC M. WEISS
W
ill Overton used to be called “The
Enforcer.” With 280 pounds of solid
Tennessee muscle wrapped around a 6-foot-3
frame, the aide at the Harold W. Jordan Center was called in to help “shuffle” patients—
slamming them to the ground face-down
if they acted up or disobeyed. And the 30
mentally retarded and mentally ill patients—
people accused of murder, rape and other
crimes—often disobeyed. “I used to be a bad
boy,” said Robert Hall, a short, wiry patient
with the energy of a wound rubber band.
“I was shuffled about every day.” Not anymore. Behind the Nashville center’s locked
gates and razor wire a radical turnaround has
occurred in the last year. Shuffling is now
forbidden, staff has been increased and given
intensive training.
Tennessee’s example shows that, with
strong leadership, the physical restraint of
patients can be minimized—indeed, nearly
eliminated—safely and without exorbitant
cost.
“If we could do it here,” said Frances
Washburn, deputy superintendent of Clover
Bottom Development Center, which includes
the Jordan unit, “it can be done anywhere.”
But the routine and frequently dangerous use
of restraints persists elsewhere, even though
the solutions are often simple and straightforward: better training, stronger oversight,
uniform standards and the collection and
sharing of information.
Federal officials and health groups say they
are working on it. The U.S. Center for Mental Health Services has begun a five-state
pilot program to collect restraint and seclusion data. The U.S. Department of Veterans
Affairs is tracking deaths more closely.
The Joint Commission, the nation’s leading hospital accreditation organization, has
strengthened its guidelines on restraint and
seclusion. And the American Medical Association has begun studying the use of restraints on
children. “Those steps sound pretty inadequate
to me,” said Dr. Joseph Woolston, medical
director for children’s psychiatric services at
Yale-New Haven Hospital. “This sort of halfhearted patchwork approach will probably do
more harm than good by giving an illusion that
something is happening when it is not.”
So for now, it is left to individual hospitals
to find their own way. Those committed to
the task illustrate what can be done.
Riverview Hospital for Children and
Youth, a State-run psychiatric hospital in
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Deadly Restraint—Day Five (continued)
share more information and learn from the
mistakes of others. Techniques found to be
dangerous, such as face-down floor holds
and mouth coverings, have been outlawed
in certain places as a result. But tough lessons learned by individual hospitals typically
aren’t shared with facilities on the other side
of town or 10 States away. Each hospital is
left to reinvent procedures or learn the hard
way—through the death of a patient.
It doesn’t have to be that way.
New York State has reduced restraint use
and the number of related deaths by requiring
the reporting of usage rates and by investigating all deaths. After New York required all
mental health facilities to say how often they
use restraints—and published the numbers—
the top three users revamped their policies
and brought their numbers down.
When it came to deaths, the State used to
allow each hospital to decide which ones were
questionable enough to report. It was notified
of 150 cases over three years. Once mandatory reporting of every death was instituted
20 years ago, the number of deaths requiring further investigation rose to 400 a year.
“When people have a choice in classifying
deaths—with one choice resulting in tremendous scrutiny, the other resulting in none,
what do you think they’re going to do?” said
Clarence Sundram, the former chairman of the
independent New York agency that tracks and
investigates deaths. Accountability has produced results. Restraint-related deaths in the
past five years have been cut nearly in half as
compared with the preceding five years, New
York State records show. Nationwide accountability could accomplish the same.
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Middletown, Conn., uses an intensive training program that emphasizes non-physical
intervention when a patient loses control.
“These situations are often chaotic and
unpredictable, and without proper training,
staffers are just winging it,” says Linda Steiger, executive director of Wisconsin-based
Crisis Prevention Institute.
CPI, a leading private training company,
provides instruction to Riverview workers.
The cost is minimal: $895 per person for a
four-day program to teach a small number
of designated staffers, who then instruct their
peers. Tighter procedures also emphasize
that every restraint is a major step—literally,
a matter of life and death.
At Riverview, a staffer is required to
constantly monitor anyone in mechanical
restraints. That ensures a patient’s vital signs
remain strong, and provides an incentive to
end the intervention as soon as the patient
regains control.
At Tennessee’s Jordan Center, patient treatment plans that include the use of restraint
are, for the most part, rejected. And every
use of emergency restraint is investigated
and must be defended. “When forced to go
through the self-analysis and justifications,
they solve it at a lower level the next time
and without restraints,” said Thomas J.
Sullivan, who heads Tennessee’s Division
of Mental Retardation Services. “Of course,
this requires staff to give up total control.”
Emergency restraints are so infrequent now
that Sullivan gets an e-mail message every
time they are used. He’s gotten an average of just two to three e-mails per month
since January. Accountability means staffers
More than money, though, many analysts
say a culture in which restraints are used
too soon, too frequently and for the wrong
reasons must be changed. “The single biggest prevention method is the avoidance of
restraints to begin with,” Sundram said. “It
is often the training and opinions of staff
that dictate restraints, rather than patient
behavior.”
In Tennessee, “the changes were topdown, bottom-up and a hard sell everywhere,” Sullivan said. Before taking the
top Tennessee job, Sullivan spent 27 years
as an official in Connecticut’s Department
of Mental Retardation. Reducing restraint
use was just one of many changes forced on
Tennessee by two lawsuits filed by the U.S.
Department of Justice and by patient advocates. “It was a system that was disintegrating,” said Ruthie Beckwith of People First
of Tennessee, a patient advocacy organization that sued the State.
The State responded with new leadership,
more money and staff and an intensive training regimen emphasizing calming words
instead of brute force. The total cost for the
Jordan Center: $12,665 for training in restraint use and alternative methods; $255,372
annually in additional staffing to address not
only restraint issues but massive deficiencies
in overall patient care. The changes in technique weren’t easy on staff. About a halfdozen aides quit. Others groused. But most
stayed and changed. “It was a rough couple
of months,” said Robert Zavala, an aide at
Jordan. “At first, they just told us we couldn’t
put our hands on them. Everyone was like,
‘Oh, so all I can do now is run away?’ “
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“There needs to be some kind of Stateby-State evaluation to gather comparative
statistics and give an annual report to
Congress,” said Dr. E. Fuller Torrey, a
prominent psychiatrist and author. “Until you
embarrass the individual States,” Torrey said,
“nothing will be done.” The federal government has shown a willingness to intercede on
this very issue—in response to charges that
the elderly were being abused.
When the U.S. Food and Drug Administration estimated in 1992 that more than 100
people annually were killed through the use
of mechanical restraints in nursing homes,
the agency tightened rules on their use. “We
also thought these cases were flukes,” said
the FDA’s Carol Herman, “until we started
digging.” The FDA now considers lap and
wheelchair belts, fabric body holders and
restraint vests to be prescription devices.
Manufacturers are subject to FDA inspections to ensure quality control.
Such steps, advocates say, have both reduced and improved the use of restraints. In
the mental health field, strong and independent government oversight can weed out bad
practices and bad facilities as well, they say.
“We can’t do it alone,” said Curtis L. Decker
of the National Association of Protection and
Advocacy Systems. “The only way to truly
protect patients is through a large, comprehensive monitoring program.” That means
a system where government regulators, not
the industry, are charged with oversight, he
said. An internal patient grievance system
would be bolstered by a well-funded network
of independent advocates trained in death
investigations.
more of a counselor or big brother than an
enforcer,” Overton said. Like a Cold War
relic, he now uses skills other than just his
brawn, such as his woodworking knowledge,
which he passes on to patients in a new class
he teaches. “I used to get shuffled a whole lot
of times when I would go off and hit someone,” said David Holland, 24, who has been
at the Jordan Center for 2 1/2 years. “Now,
they give us a lot more time to chill out, calm
down. It’s getting better each day.”
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Bernard Simons, the Clover Bottom
superintendent who oversaw the transition,
remembers a defining moment. He received
a frantic call from staffers at Jordan saying a patient was smashing furniture and
asking whether they could restrain him. “I
said, ‘Let him break it,’ “ Simons said. “So
you’re going to risk hurting yourself or the
patient for a $100 coffee table? The State
will buy a new one.” The changes are both
profound and surprising to staff and patients
who remember the old ways. “Before, we
weren’t earning their respect, it was just
fear,” said Overton, the burly aide who still
wears a belt that says “Boss.” “Now, I’m
T
he death of 11-year-old Andrew McClain
in a Connecticut psychiatric hospital in
March prompted a team of Hartford Courant reporters and researchers to investigate
the use of restraints and seclusion. The
investigation began in May and concluded
five months later. The team ultimately pored
through thousands of pages of policy reports
and academic studies, traveled to 10 States,
surveyed federal databases and electronic
news archives, and spoke to hundreds of
regulators, industry officials, analysts,
workers and patients.
As its first step, the reporting team conducted a 50-state survey to document deaths
that occurred during or shortly after restraint or seclusion. The team concentrated
on the period from 1988 to the present.
The reporters contacted officials in health
care and licensing agencies, child fatality
review boards and patient advocates in each
State. In most States, many more calls were
made to public officials and others. As part
of its investigation, the team compiled a
database of 142 patient deaths in psychiatric
hospitals, psychiatric wards of general hospitals, group homes and residential facilities
for troubled youths, and mental retardation
centers and group homes. Deaths that were
confirmed and fact-checked by Courant
researchers were compiled in a database
now available on our Internet site at
www.courant.com. Throughout the report-
ing, though, it became clear that many
deaths go unreported.
For example, only New York State requires the reporting and investigation of
every death in a private or State facility to
an independent State agency. New York
found that 64 people died during or shortly
after restraint or seclusion in targeted institutions from 1988 through 1997. In contrast,
only 12 confirmed cases could be uncovered
in California in the same period—because
the State simply does not collect the data.
“I hope [your story] doesn’t reflect that
these are the only deaths in California,”
said Colette Hughes, the State’s top abuse
investigator for a patient advocacy group.
“There is no doubt that this is the tip of a
huge iceberg.”
To better determine the national death
rate, The Courant hired statistician Roberta
J. Glass. Glass is a research specialist for
the Harvard Center for Risk Analysis at the
Harvard School of Public Health. She has
14 years’ experience in the field of statistical projections.
In her projection, Glass used data from
the State of New York, the U.S. Department
of Health and Human Services and earlier
academic studies on restraint use, among
other sources. If facilities throughout the
rest of the country used restraints as often as
those in New York State, Glass found, there
would be 50 deaths annually nationwide.
But Glass noted the rest of the country was
not necessarily like New York State. New
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How The Courant Conducted Its Investigation
HANDOUT
How The Courant Conducted
Its Investigation (continued)
York monitors restraint use more closely,
and facilities in New York use restraints
at a lower rate than national surveys have
found elsewhere in the country. Thus, Glass
projected the annual number of deaths could
range as high as 150. “Admittedly, the
estimates are only rough approximations,”
Glass said. “The data needed for precise
estimation are not collected in a systematic
way nationwide. “But it is clear that greater
attention should be paid to this issue,
especially in light of the fact that it affects a
particularly vulnerable patient population.”
Project reporters: Eric M. Weiss,
Dave Altimari, Dwight F. Blint and
Kathleen Megan.
Additional reporting: John Springer,
Colin Poitras and Hilary Waldman.
Project researchers: Jerry LePore
and Sandy Mehlhorn.
Courant Co.
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HOSPITAL CITED IN RESTRAINT MISUSE
The Hartford Courant (CT)
Author: COLIN POITRAS; Courant Staff Writer
February 16, 2002
F
ederal inspectors have found that Connecticut’s largest psychiatric hospital has
been improperly restraining patients, even
after the State led a national movement to
restrict such techniques. The findings forced
Gov. John G. Rowland last week to propose
spending $1.8 million for training and additional staff to prevent the loss of $50 million
in federal aid.
Staff members at Connecticut Valley
Hospital routinely violated patients’ rights
by tying them to their beds and placing them
in seclusion to control their behavior, inspectors found during tours of the hospital and
its Whiting Forensic Division last October.
Such measures are supposed to be used
only in emergencies when patients pose
a serious threat.
In one instance, inspectors noted, a potentially dangerous 22-year-old male patient
was placed in four-point bed restraint at
Whiting for an entire month. Other Whiting
patients were placed in mechanical restraints
for days and weeks at a time and remained in
restraints even while sleeping, according to
the inspectors’ report.
The inspection was conducted by the U.S.
Department of Health and Human Services’
Centers for Medicare and Medicaid Services,
formerly known as the federal Health Care
Financing Administration. It was the first time
that the hospital had undergone such a com-
prehensive federal inspection in six years.
If the State didn’t take immediate corrective action, the agency warned that it would
no longer provide the hospital with millions
in Medicare reimbursements.
Connecticut Valley Hospital’s chief operating officer, Garrell S. Mullaney, said this
week that the hospital has already changed
its restraint and seclusion practices and that
the $50 million in federal reimbursement is
once again ensured.
Rowland included $1.8 million to address
the issue in his amended budget proposal
presented to legislators last week. The money
will be used to hire 13 additional staff members, train existing staff in the new rules for
restraint and create a special eight-bed housing unit for particularly difficult patients,
officials said.
But the inspection’s conclusions were
potentially embarrassing for the State, whose
two U.S. senators—Christopher J. Dodd and
Joseph I. Lieberman—sponsored the landmark national legislation that led to tighter
controls on the use of restraints in psychiatric
hospitals two years ago. Dodd and Lieberman
sponsored the bill after an investigation by
The Courant documented that 142 people,
many of them children, had died in psychiatric facilities throughout the country as a
result of improper or excessive restraints.
Mullaney said that Connecticut Valley was
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PSYCHIATRIC FACILITY BROKE NEW RULES
Hospital Cited in Restraint Misuse (continued)
Instead of placing inmates in seclusion or
restraints when they pose a threat, staff is
now being training in “de-escalation’’ techniques to help them recognize and address
potential problems before they turn serious.
The hospital has also started using a “patient
preference form’’ that asks patients what they
feel will work best to help them calm down
when their behavior becomes a concern.
In more serious instances in which restraints may have once been used, Mullaney
said the hospital now relies on intense patient
supervision—one-to-one, two-to-one and
sometimes even three-to-one staff observations—to ensure both the patients’ and staff’s
safety.
Carole Burgess, a forensic treatment specialist at Whiting, said the new requirements
for supervision are driving up overtime costs
and forcing staff to often work double shifts.
“We’re really working hard to keep within
the guidelines,’’ Burgess said. “But it’s very
demanding to work with people in that way.
And when people are understaffed and overtired, it’s very difficult for them to do their
best work.’’
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proud of the fact that it had reduced restraint
use by about 40 percent in the past two years.
Yet he and others were not anticipating the
strict interpretation of the new federal guidelines adopted by the inspectors from the
Centers for Medicare and Medicaid Services,
or CMS, during their unannounced visit
on Oct. 4.
Mullaney said the national Joint Commission on Accreditation of Healthcare
Organizations, as well as State law, allows
psychiatric hospitals to use restraints if a
patient poses an “imminent’’ threat to himself or others. But the guidelines adopted by
CMS permit mechanical restraints only in the
most severe situations and require them to be
removed as soon as a patient calms down.
Any impression that Connecticut Valley
is an archaic facility that punishes its patients by placing them in restraints would be
wrong, Mullaney said.
“This is a very, very progressive facility,’’
Mullaney said.
Mullaney said the 22-year-old patient who
was restrained to his bed for a month was
particularly aggressive and injured 44 staff
members over the past year, Mullaney said.
Mullaney said the hospital immediately adopted CMS’ interpretation of restraint guidelines after the inspection and is in the process
of creating a new behavior management
program that complies with federal rules.
Inspectors returned to the hospital in late
January and found no additional evidence
of improprieties, federal authorities said.
Consumer Quotes
As an adolescent, age 12, I was put in a psychiatric unit for adolescents. I was there for abuse
situations and the duration of my stay I was put into seclusion, which we called the padded
room. I was put in there and stripped down, to nothing, and I was forced to stay there for 5
hours because I refused to watch a sexual assault video. Instead of letting me stay in my room
and talk to my nurse at that time, they said if I don’t follow the rules this is where I have to go.
—Female in seclusion and restraint as an adolescent
I think they should talk to you when you want them to talk to you. Basically you are a
human being, not an animal. Even an animal being strapped down flat on the floor the
Humane Society would have a fit with that.
—Male
They say act like an adult. If they want me to act like an adult, they should treat me like one.
The way I should be treated and the way you would want to be treated.
—Female
I have been in seclusion about seven times. I’ve had experiences where I’ve had 7 or 8
people take me down and I’ve had experiences where I have had less. It’s very degrading
because when they put you there even as a girl or woman, all you’re left is your underwear
and a paper gown and a mattress that has nothing on it.
—Female
Fear basically is a big thing. You’re vulnerable. Seclusion room is sometimes used as a
punishment not as a therapy. I don’t think treating someone like an animal is really a therapy.
I think a lot of the staff are scared of the patients. And they react to that fear by controlling
the patients and not trying to treat the patients.
—Male
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The big problem I have with restraints is that you start feeling vulnerable and you start thinking imaginary things like the people are going to hurt you, especially like the staff. Since they
are required by law to always chart you, you are always seeing them staring at you through
the window while you are lying there like, you know and it’s scary. Very scary.
—Male
Consumer Quotes (continued)
Then they have these restraints; they really are kind of sadistic in a way. You are spread-eagled
so you really can’t move. You can’t have any circulation. You can’t do anything. And they do
and when they do it on your stomach lying down, you really can’t even breathe. And the human
instinct when you are spread-eagled is to get up so you are constantly fighting these things.
—Male
I’ve heard about people trying to pull their feet out of restraints and getting hurt. I’ve never
tried that, my feet are too big and I was afraid I might lose them.
—Male
I usually would end up hurting myself more because of what they had done, instead of less.
—Female
It’s the fear factor. I get paranoid and that’s why I sign myself into a place like that. I get
more paranoid while I go through the process cause basically because of my energy level I
scare people. I’m not a mean person. I don’t hurt people. I don’t pull wings off flies. I’m a
nice guy; I don’t even hunt or fish. I don’t even put worms on hooks; it’s not my thing. But I
am very loud and very energetic and it does frighten people. And I am fairly big and that also
frightens people. But unless I want to go on a starvation diet and get my vocal chords cut,
lose my legs just so they can treat me well at a State hospital when I am paranoid.
—Male
They said as soon as I stopped being angry, they would let me out. Meanwhile you are naked on
your bed, strapped down with your door open and they wondered why you weren’t mellowing out.
—Female as an adolescent in restraint and seclusion
Seclusion room, same thing with the people viewing you. They are always looking at you
with them beady eyes. It’s very frightening; it’s very frightening.
—Male
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HANDOUT
The only way to survive in there is to turn inward and that just made me more angry.
Consumer Quotes (continued)
When you’re like this (head back, arms straight out) you want something to prop your head
up. A little kindness. There was nurse that is now a doctor that talked to me once when I was
really paranoid. If the staff is paranoid of you, what’s the difference if the patient is paranoid?
There are more staff than there are of you. They got you outnumbered and they got the keys.
And if they are scared, why can’t I be scared? I mean, isn’t that fair?
—Male
I know it deepened my fear. I was in there to get help so I wouldn’t injure myself anymore
and become a better person. It just made me more angry and didn’t help nothing.
You are spread-eagled and on the floor and can’t move. They are much happier. It’s more
convenient to restrain a patient or put him in the seclusion room.
—Male
From interviews with consumers in Minnesota.
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HANDOUT
After they unlocked the door and they dragged me in there, they said, well you can’t keep
your clothes for danger issues. And they made strip me down. They kept a video on me the
whole time. For a girl who is awkward and is in there for issues of abuse at home, all that did
was extend my hate.
Direct Care Staff Quotes
I feel that it is overused and could be prevented a great deal of the time. I think that we got to
train staff to avoid it where it’s at all possible.
The first time that I helped with a restraint, a four-point restraint, I walked out of the room
in tears because I thought it was one of the most horrible things I had ever seen. A lot of
staff are really inflexible as to, I feel like they need to have the last word and then if the kid
doesn’t do exactly what they say, where they say, their alternative is that they need to go into
seclusion.
I’ve had my peers report to me on particular event. I remember she had been monitoring a
seclusion and I don’t remember if the patient had cut himself or had a bloody nose or what
and had smeared the blood all over and she said, “I smelled that, I smelled that all the time.”
The problem I’ve seen through the years in this setting is depending on what staff is working.
Sometimes it becomes more of a control issue than an issue of the best outcome or avoiding
a seclusion.
I’ve been injured from time to time. Bruises, nothing severe. Yeah, sometimes I get
headaches. I get shaky.
When you get to that point you feel as though you have failed. It seems like you’ve missed
something when you could have prevented it beforehand. I never liked doing that (restraints),
but it’s about maintaining safety and you just never want that to happen. You feel like you
have failed. There’s always something you could have seen earlier if you had been there a
little sooner, if you had know the client a little better. You could have prevented the situation.
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HANDOUT
One of the things that doesn’t get talked about very much is the trauma of the staff. We talk
about the trauma paradigm for our clients or people in recovery. But not very often in my 20
years of work in the field of mental health have I heard much about what happens to us, the
workers, and I think that’s an area where we need to do some work. I’ve seen some pretty
traumatic things from when I first started 20 years ago. Some of those things still haunt me.
Direct Care Staff Quotes (continued)
Often what leads up to that is a manual escort. We frequently ask kids to go to a quiet area
to calm down which in not too restrictive, just an area away from the group where they can
take time to calm down and get back on track and re-join the activity. However, what I see
a lot of the time is 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. So what they will do is
manually escort them to the quiet room or area. At that point the kids will resist three-fourths
of the time. When the kids resist they might end up just struggling and trying to get away and
inadvertently bumping or hitting or shoving staff or they might actually bite or kick them or
something like that which aggression toward staff is usually a justification for seclusion and
they will end up in that seclusion whereas if that hands on escort to the quiet area or quiet
room wasn’t initiated that seclusion wouldn’t happen. So that’s my big beef.
I know that after a couple of difficult incidents on a unit, I certainly felt like I had symptoms
of PTSD, about being hyper-aware when I walked to my car because some of the things I say
and that I was involved with were very traumatic. And I think consumers talk about what it is
like to be in restraints, it is also traumatizing to put people in restraints in the same way that
I think it is traumatizing for soldiers to go to war and kill other people. We don’t often talk
about the impact of that either.
From interviews with direct care staff in Minnesota.
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HANDOUT
I had an altercation in the past week with a patient that left some scratching on my face.
The next day I woke up and was sick to my stomach and I couldn’t come back to work.
MODULE 1 - REFERENCES
Angold, A. (1989). Seclusion. British Journal of Psychiatry, 154, 437-444.
Betemps, E., Buncher, C., & Oden, M. (1992). Length of time spent in seclusion and restraint by
patients at 82 VA medical centers. Hospital and Community Psychiatry, 43, 912-914.
Betemps, E., Somoza, E., & Buncher. (1993). Hospital characteristics, diagnoses and staff reasons
associated with use of seclusion and restraint. Hospital and Community, 44, 367-371.
Bond, C.F., DiCandia, C., & MacKinnon, J. (1988). Response to violence in a psychiatric setting.
Personality and Social Psychology Bulletin, 44, 448-458.
Busch, A.B., & Shore, M.F. (2000) Seclusion and restraint: A review of the literature. Harvard
Review of Psychology, 8, 261-270.
Campbell, J. (1989). People say I’m crazy. San Francisco: Department of Mental Health.
Cooper, W. (1998. November 21) Mentally ill teen girl dies after being restrained. The Palm Beach
Post.
Craine L.S., Henson, C.E., Colliver, J.A., et al. (1988). Prevalence of a history of sexual abuse
among female psychiatric patients in a State hospital system. Hospital and Community
Psychiatry, 39, 300-304.
Daar, M., & Nelson, T. (1992). Reforming seclusion and restraint practices: An advocacy manual.
Sacramento, CA: Protection and Advocacy, Inc.
Davidson, L., & Stayner, D. (1997). Loss, loneliness, and the desire for love: Perspectives on
the social lives of people with schizophrenia. Psychiatric Rehabilitation Journal, 19(3), 3-12.
Fisher, W. (1964). Restraint and seclusion: A review of the literature. American Journal of
Psychiatry. 151, 1584-1591.
Food and Drug Administration. (1992). Safe use of physical restraint devices. FDA Backgrounder.
Rockville, MD: Author.
Hersen, M., Ammerman, R.T., & Sisson, L.A. (1994). Handbook of aggressive and destructive
behavior in psychiatric patients. New York: Plenum Press.
Holzworth, R., & Wills, C. (1999). Nurses’ judgments regarding seclusion and restraint of psychiatric
patients: A social judgment analysis. Research in Nursing and Health, 22, 189-201.
Leghmann, L.S., et al. (1983). Training for the prevention of assaultive behavior in a psychiatric
setting: St. Thomas Hospital. Hospital and Community Psychiatry, 34, 40-43.
Martinez, R., Grimm, M., & Adamson, M. (1999). From the other side of the door: Patient views
of seclusion. Journal of Psychosocial Nursing, 73(3), 3-22.
Massachusetts Department of Mental Health. (1996). Report and recommendations of the task
force on the restraint and seclusion of persons who have been physically or sexually abused.
Boston: Author.
Megan, K., & Blint, D.F., (1998, October 12). Little training, few standards, poor staffing put lives
at risk. Hartford Courant.
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Altimari, D. (1998, October 14). People die and nothing is done. Hartford Courant.
Module 1 - References (continued)
Milliken, D. (1998). Death by restraint. Canadian Medical Association Journal, 158, 1611-1612.
Mohr, W.K. (1999, April 13). Statement of Wanda K. Mohr on behalf of NAMI, the National Alliance
for the Mentally Ill, before the Labor, Health and Human Services, and Education Subcommittee,
Senate Committee on Appropriations.
National Association of Consumer/Survivor Mental Health Administrators. (2000). In Our Own
Voices Survey. An unpublished survey.
National Association of State Mental Health Program Directors. (1999). Reducing the use of
seclusion and restraint: Findings, strategies, and recommendations. Alexandria, VA: National
Technical Assistance Center.
National Association of State Mental Health Program Directors. (2001). Reducing the use of seclusion and restraint. Part II: Findings, principles, and recommendations for special needs populations. Alexandria, VA: National Technical Assistance Center.
National Association of State Mental Health Program Directors. (2002). Managing conflict cooperatively: Making a commitment to nonviolence and recovery in mental health treatment settings.
Alexandria, VA. National Technical Assistance Center.
Norris, M., & Kennedy, C. (1992). The view from within: How patients perceive the seclusion
process. Journal of Psychosocial Nursing and Mental Health Services, 30, 7-13.
Nelson, T., Daar, M., & Chandler, D. (1993). Seclusion and restraint practices in eight California
counties. Sacramento, CA: Protection and Advocacy, Inc.
New York State Office of Mental Health. (1994). Final recommendations on the use of restraint and
seclusion. Albany, NY: Author.
Poitras, C. (2002, February 16). Hospital cited in restraint misuse: Psychiatric facility broke new
rules. Hartford Courant.
Ray, N., & Rappaport, M. (1993). Fluctuating odds: Estimating one’s chances of being restrained
or secluded in New York’s psychiatric hospitals. Albany: NY State Commission on Quality of Care
for the Mentally Disabled.
Ray, N.K., Myers, K.J., & Rapport, M.E. (1996). Patient perspectives on restraint and seclusion
experiences: A survey of former patients of New York State psychiatric facilities. Psychiatric
Rehabilitation Journal 20(1), 11-18.
Solof, P.H., Gutheil, T., & Wexler, D. (1985). Seclusion and restraint in 1985: A review and update.
Hospital and Community Psychiatry, 36, 652-657.
Solof, P.H., McEnvoy, J., Ganguli, R., & Ganguli, M. (1989). Controversies in psychiatry: Is seclusion
therapeutic? Psychiatric Annals, 19(1).
Walsh, E., & Randell, B. (1995) Seclusion and restraint: What we need to know. Journal of Child
and Adolescent Psychiatric Nursing, 8, 28-40.
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Miles, S., & Meyers, R. (1994). Untying the elderly: 1989 to 1993 update. Clinics in Geriatric
Medicine, 10, 513-525.
Weiss, E.M. (1998, October 15). From “enforcer” to counselor. Hartford Courant.
Weiss, E.M. (1998, October 11). Deadly restraint. Hartford Courant.
Wheeler, E., Barron, D., & Anthony, S. (1994). Violence in our schools, hospitals, and public
places: A prevention and management guide. CA: Pathfinder Publishing.
Page 3 of 3
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Weiss, E.M., & Altimari, D. (1998, October 13). Patients suffer in a system without oversight.
Hartford Courant.
MODULE 2
Understanding the Impact of Trauma
1
MODULE 2
“What helps me (deal with trauma) is professionals who have
the ability to take care of themselves, be centered, and not take on
what comes out of me—not hurt by what I say—sit, be calm
and centered and not personally take on my issues.”
—Survivor from Maine
“Traumatic experiences shake the foundations of our beliefs
about safety and shatter our assumptions of trust.”
—David Baldwin
Learning Objectives
• Define trauma and describe how it can impact consumers in mental health settings.
• List common reactions to trauma and identify how trauma affects the brain.
• Understand how hospitalization/seclusion/restraint can be retraumatizing for consumers.
• Incorporate trauma assessment and de-escalation forms into current practices.
• Recognize and utilize positive coping mechanisms to deal with secondary traumatization.
Module 2
2
MODULE 2: UNDERSTANDING THE IMPACT OF TRAUMA
Presentation (3 hours) . . . . . . . . . . . . . . . . . . . . . . . .
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: Trauma Background (25 minutes) . . . . . . .
Definitions Related to Trauma . . . . . . . . . . . . . . . . . .
Common Reactions to Trauma . . . . . . . . . . . . . . . . . .
Exercise: Common Reactions to Trauma (20 minutes)
Effects of Trauma on the Brain . . . . . . . . . . . . . . . . .
Differential Response to Threat . . . . . . . . . . . . . . . . .
Assessment of Trauma . . . . . . . . . . . . . . . . . . . . . . .
Exercise: Assessment of Trauma (20 minutes) . . . . .
Retraumatization via Hospitalization . . . . . . . . . . . . .
De-Escalation Preferences . . . . . . . . . . . . . . . . . . . .
Exercise: De-Escalation Preferences (20 minutes) . . .
What Survivors Want in Times of Crisis . . . . . . . . . . .
Staff Trauma (Secondary Traumatization) . . . . . . . . . .
Healing from Trauma . . . . . . . . . . . . . . . . . . . . . . . .
Grounding Techniques . . . . . . . . . . . . . . . . . . . . . . .
Exercise: Grounding Techniques (10 minutes) . . . . . .
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Handouts for Participants . . . . . . . . . . . . . . . . . . . . . . . .
Journal Topics and Take Action Challenges for . . . . . . . . .
Modules 1 and 2
National Association of State Mental Health Program . . . .
Directors (NASMHPD) Position Statement on Services
and Supports to Trauma Survivors
Excerpts from Kate Reed’s Speech . . . . . . . . . . . . . . . . .
NAC/SMHA Position Paper on Trauma and Abuse Histories
What Can Happen to Abused Children . . . . . . . . . . . . . .
Some Common Reactions to Trauma . . . . . . . . . . . . . . .
Trauma Assessment for Department of Mental Health . . .
Facilities/Vendors
Guidelines for De-Escalation Preference Form . . . . . . . . .
De-Escalation Form for Department of Mental Health . . . .
Facilities/Vendors
Module 2
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Excerpts from Dealing With the Effects of Trauma:
A Self-Help Guide
Grounding Techniques . . . . . . . . . . . . . . . . . . . .
Web Sites Related to Trauma. . . . . . . . . . . . . . . .
Resources on Secondary Trauma . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Module 2
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4
Overview
A useful resource you may wish to read is In Their Own Words: Trauma Survivors and
Professionals They Trust Tell What Hurts, What Helps, and What Is Needed for Trauma
Services (Maine Trauma Advisory Groups Report, 1997). All of the consumer quotes used
in this module are from this source. For copies, please call the Maine Department of Mental
Health, Mental Retardation and Substance Abuse Services, Office of Trauma Services at
(207) 287-4250.
Adult survivors of trauma are disproportionately represented in the mental health system.
Research suggests that at least half of all women and a substantial number of men who are
diagnosed with a mental illness have a history of physical or sexual abuse or both (Brennan,
1997). Data on children and adolescents suggest even higher percentages (Massachusetts
Department of Mental Health, 1995). Traditional treatment modalities, including the use of
seclusion and restraint, are not always appropriate for trauma survivors, and may in fact be
retraumatizing. “Any intervention that recreates aspects of previous traumatic experiences or
that uses power to punish is harmful to the individual involved” (NASMHPD, 1998). It is important for staff to recognize the impact trauma can have on people diagnosed with a mental
illness. Understanding how seclusion and restraint can in fact retraumatize and further abuse
individuals who are already coping with a number of issues is vital to the elimination of the
practice of seclusion and restraint.
(Source: www.childtraumaacademy.com)
Trauma can be defined as extreme stress that overwhelms a person’s ability to cope. Some
of the behaviors that developed in response to the initial trauma were survival strategies that
no longer work. Many factors affect how any one person responds to trauma, including life
experiences before and after the trauma, the age at which the trauma first occurred, the length
and frequency of the trauma, the coping skills developed to deal with the trauma, who caused
the trauma, and what help was provided after the trauma. Symptoms of trauma can include
self-injury, assaultiveness, suicidality, substance abuse, impaired interpersonal relationships,
repeated victimization, flashbacks, dissociation, and disturbances of mood and self-esteem.
Flashbacks are reoccurring memories, feelings, or perceptual experiences of a past event.
Most times, flashbacks are traumatic and the person may lose awareness of present reality.
The person re-experiences the past as if it were happening right now.
Module 2
5
BACKGROUND
BACKGROUND FOR THE FACILITATORS:
UNDERSTANDING THE IMPACT OF TRAUMA
Triggers are clues that remind a person of the trauma (often unconsciously) and start the
response of re-experiencing or avoiding the trauma. Identifying triggers and realizing they
are a normal response to trauma is part of the healing process. People who have experienced
trauma often refer to themselves as “survivors.”
Common reactions to trauma can include physical reactions such as nervous energy, muscle
tension, grinding one’s teeth, and upset stomach. Mental reactions to trauma may vary from
a heightened sense of awareness of surroundings to a lessened sense of awareness or even
disconnection from oneself. Difficulty making decisions and difficulty concentrating are also
common. Fear, inability to feel safe, loss of trust and self-esteem, and feeling chronically
empty are common emotional reactions. Finally, behavioral reactions include changes in eating habits, an increase or decrease in sexual activity, becoming withdrawn or isolated from
others, and becoming confrontational.
We are just beginning to understand and recognize the physiological, neurological, and
cognitive responses to trauma. Trauma in childhood can permanently alter neuron response
and cognitive pathways in the brain. Trauma also affects the autonomic nervous system,
which reaches into every major organ of the body. Trauma may be associated with abnormal
activation of the amygdala, abnormal levels of cortisol, epinephrine, and norepinephrine,
and structural changes to the hippocampus. All of these brain structures and neurochemicals
play key roles in regulating our emotional, behavioral, physical, and mental health. Finally,
the incidence of other serious illnesses, including chronic pain with no medical basis and
cardiovascular and digestive problems, is higher among people who have experienced severe
trauma. They are also more likely to have high blood pressure, atherosclerotic heart disease,
abnormal thyroid and other hormone functions, and to be more susceptible to infections and
other immune system disorders.
Differential Response to Threat
Research indicates that people generally respond in one of two ways to a perceived threat:
dissociation or hyperarousal (Perry, www.ChildTrauma Academy.com). People who dissociate become detached, numb, compliant, have a decreased heart rate, and experience a suspension of time, de-realization, “mini-psychoses,” and fainting. People who respond
with hyperarousal may become hypervigilant, have anxiety, be reactive and have an alarm
response, have an increased heart rate, and experience either fight (terror) or flight (panic).
Module 2
6
BACKGROUND
Dissociations are a wide range of responses that are usually some form of numbing or “tuning
out.” The person is disconnected from full awareness of self, time, and or/external circumstances.
A trauma paradigm helps both staff and persons with a mental illness understand and change
behaviors that no longer work. For all people who have a background of experiencing trauma, a clinical assessment of specific circumstances that elicit potentially harmful behaviors
and what responses may help de-escalate problem behaviors is necessary and required by
Joint Commission on Accreditation of Healthcare Organizations standards (JCAHO, 1995).
Accurately diagnosing trauma early on in hospitalization can significantly decrease the use
of seclusion and restraint. Misdiagnosis is common and can lead to inappropriate medication,
and wrong or ineffective treatment. Consumers are often reluctant to disclose a history of
trauma because they are fearful of being judged, invalidated, or not believed. It is important
for staff to recognize that how they ask about a history of trauma can significantly influence
how a consumer responds. It is recommended that trauma history questions be asked routinely as part of a standard interviewing process, and the information, once obtained, be used
to help guide treatment choices and recovery. In addition, staff needs to be trained in understanding behavior from a trauma paradigm.
Gayle Bluebird, a nurse and a consumer, developed tools for assessing trauma and de-escalation preferences for consumers with trauma histories. Similar forms have been developed by
the Massachusetts Department of Mental Health Services and are available as handouts. We
strongly encourage participants to take these forms back to their facilities and adapt them
for their own use. An essential step to include is how this information will be used on a daily
basis once it has been gathered.
Consumers often view hospitalization itself as retraumatizing, not to mention the use of seclusion and restraints. “You are terrified and you try to get away from them and you strike out
to protect yourself. Then they call you ‘assaultive’ and that follows you to the next hospital
and they say to you, ‘I hear you hit someone.’” Unfortunately, people who are labeled as the
most difficult clients often end up getting restrained or secluded. It is important to recognize
the secondary traumatization of seclusion and restraint for both consumers and staff.
Module 2
7
BACKGROUND
Understanding and using a trauma paradigm can be significant in creating and sustaining cultural
change on a unit. A trauma paradigm includes examining how a person with a mental illness
might be retraumatized, particularly by the use of seclusion and restraint. People who have been
sexually assaulted have said repeatedly that the retraumatization of being stripped and strapped
down by staff was unbearable and caused further harm. “After they unlocked the door and they
dragged me in there, they said, well you can’t keep your clothes for danger issues. And they made
me strip down. They kept a video on me the whole time. For a girl who is awkward and is in there
for issues of abuse at home, all that did was extend my hate.”
In general, if staff thinks about what they would want in times of crisis, the same would hold
true for consumers. It is often the simple things. For example, “I want someone who can BE
with me when I am in distress; be present with me when I am in pain.” “I want someone who
will acknowledge my pain without trying to ‘fix’ it. This takes someone who knows his/her
own pain and is not afraid of it or of yours.”
Staff members can experience both primary and secondary traumatization in their work
environment. We know that 60 percent of all direct care staff are injured at some point in their
work, which is a type of primary traumatization (JCAHO, 1999, George Blake testimony).
Secondary traumatization is known by many names: compassion fatigue, secondary or vicarious traumatization, and burn out. The symptoms of secondary traumatization are usually less
severe, but can affect the livelihoods and careers of mental health workers. It is important for
staff to examine their own trauma, recognize their own symptoms and triggers, and develop
their own plan of self-care in this demanding line of work. Finally, we cannot forget secondary traumatization that may occur for consumers and staff as they witness the violence
(seclusion and restraint) that may happen on a unit. This is an area that needs much more
exploration in the literature.
Healing From Trauma
Sue Coates from Turning Points, an agency in Grand Rapids, MI, in a presentation listed the
following five elements necessary for healing from trauma: safety, empowerment, creation or
restoration of positive self-regard, reconnecting to the world, and intimacy.
Grounding refers to methods for stopping the re-experiencing of a trauma, or related symptoms, and getting back to the here and now. When a consumer reports/appears unusually
anxious or vulnerable, is nonresponsive, or is reacting in other ways suggestive of re-experiencing trauma, try to help him or her focus on something in the present using one or more of
the five senses: sight, smell, hearing, taste, or touch. For example, looking at a calendar with
a current date on it may be helpful.
Module 2
8
BACKGROUND
Gathering information, in advance, from consumers about what helps and what hurts during
times of crisis is key. Consumers can often tell staff specifically what works for them and
what triggers them in advance of a crisis. This information needs to be readily accessible for
staff and discussed well in advance of any crisis. An example of a de-escalation preference
form that can be used as a template is included in the handouts.
Welcome participants and review names. Make sure everyone has a
nametag or name tent. It may be helpful to provide a quick review of
Module 1: The Personal Experience of Seclusion and Restraint. Then go
over the learning objectives.
Learning Objectives
be able to:
•
Define trauma and describe how it can impact consumers in
mental health settings
•
List common reactions to trauma, and identify how trauma
affects the brain
•
Understand how hospitalization/seclusion/restraint can be
retraumatizing for consumers
•
Incorporate trauma assessment and de-escalation forms into
current practices
•
Recognize and utilize positive coping mechanism to deal with
secondary traumatization
Overview
• This module is an overview of trauma and how trauma can impact working with consumers and direct care staff. Included is how hospitalizations, seclusion, and restraint can be
retraumatizing to consumers and/or direct care staff that have a history of abuse or trauma.
• Adult survivors of trauma are disproportionately represented in the mental health system.
Depending on how the research was conducted, it appears consistently that approximately
70 to 80 percent of consumers diagnosed with a mental illness also have a history of
trauma. Trauma is often underdiagnosed. Little research is available on the rates of direct
care staff with histories of trauma.
• Early childhood trauma actually physiologically impacts brain development. Many of the
behaviors associated with trauma may be a result of this altered brain functioning.
• “Any intervention that recreates aspects of previous traumatic experiences or that uses
power to punish is harmful to the individual involved” (NASMHPD, 1998).
• When working from a trauma paradigm, difficult behaviors are not pathologized, but
rather are seen as brilliant coping mechanisms developed as a response to previous trauma.
• Ideally, trauma would be assessed and included in the treatment plan for all consumers/
survivors, and direct care staff would be aware of and trained in issues of trauma.
Module 2
9
PRESENTATION
PRESENTATION
“Being a survivor is feeling isolated, not
daring to share that part of my life
(trauma) with people for fear of being
rejected, feeling defective, feeling
powerless, lack of understanding from
professionals that whatever behaviors we
took on was our way of calling for help
even if it doesn’t fit society’s view of what
is ‘normal’ behavior.” Survivor from Maine
• For consumers, there is a real fear of sharing trauma histories with direct care staff,
because oftentimes it negatively impacts how they are treated.
“What helps me (deal with trauma) is
professionals who have the ability to
take care of themselves, be
centered, and not take on what comes
out of me – not hurt by what I say –
sit, be calm and centered and not
personally take on my issues.”
Survivor from Maine
• Consumers are really asking for direct care staff to be present with them—not to fix the
trauma or its outcome, but to really listen and be present.
• Trauma often feels like a loss of control. For consumers, being in the hospital also feels
like loss of control. Being secluded or restrained really feels like loss of control.
Module 2
10
PRESENTATION
• The quotes and information from consumers in this module come from In Their Own
Words: Trauma Survivors and Professionals They Trust Tell What Hurts, What Helps,
and What Is Needed for Trauma Services. The Maine Trauma Advisory Groups
compiled this report in 1997.
Trauma Background
OBJECTIVE:
Familiarize participants with trauma paradigms.
PROCESS:
Divide the class into four groups. Assign each group a different
one of the four articles listed below and distribute copies to each
participant. Have each group report to the large group on the
article they read. They should tell the group who wrote the article
and which stakeholder groups the author(s) represents. Then they
should share three key points they think are the most important
things to know about the information in the article they read.
Facilitate a discussion.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
APPROXIMATE
TIME REQUIRED:
What was most compelling to you about these articles?
What do you disagree with?
What has your experience been dealing with trauma survivors?
Copies of each article for each participant to take home:
• National Association of State Mental Health Program Directors—
Position Statement on Services and Supports to Trauma Survivors
• Excerpts from Kate Reed’s speech
• National Association of Consumer/Survivor Mental Health
Administrators—Position Paper on Trauma and Abuse Histories:
The Prevalence of Abuse Histories in the Mental Health System
• What Can Happen to Abused Children When They Grow Up—
If No One Notices, Listens, or Helps? (Maine Office of Trauma
Services, 2001)
25 minutes
Module 2
11
PRESENTATION
Definition of Trauma:
Extreme stress that
overwhelms someone’s
ability to cope.
Flashback
A recurring memory, feeling or
perceptual experience of a past
event, usually traumatic, including
losing awareness of present reality.
The person feels like they are reexperiencing the past as if it were
happening right now.
Module 2
12
PRESENTATION
It is important to be on the same page using the same language about trauma. This training
will use the following definitions related to trauma:
A wide range of responses that are
usually some form of numbing or
“tuning out.” The person is
disconnected from full awareness
of self, time, and/or external
circumstances.
Triggers
Cues that remind a person of the
trauma (often unconsciously) and
start the response of reexperiencing or avoiding the
trauma. Identifying triggers and
realizing they are a normal
response to trauma is part of the
healing process.
Module 2
13
PRESENTATION
Dissociations
OBJECTIVE:
Familiarize participants with common reactions to trauma.
PROCESS:
Ask participants to think of people they have worked with who are
trauma survivors and then ask them to brainstorm common reactions to trauma. Keep track of the list on the overhead/chalkboard/
paper. Once they have listed as many as they can think of, hand
out the Some Common Reactions to Trauma article.
DISCUSSION
QUESTIONS:
Which common reactions to trauma did we miss?
Which common reactions to trauma do you most frequently deal
with on the unit?
Which common reactions to trauma are the most difficult to deal
with and why?
MATERIALS
REQUIRED:
Some Common Reactions to Trauma by Mary S. Gilbert, Ph.D.
APPROXIMATE
TIME REQUIRED:
20 minutes
Module 2
14
PRESENTATION
Science is just beginning to understand the physiological, neurological, and cognitive
responses to trauma. The following information is from www.childtraumaacademy.com.
•
Trauma can activate various systems in the brain that actually
change neuron response and cognitive pathways.
•
Children can develop systems in their brains that cause them to be
constantly hyperaroused and hypervigilant or dissociate.
•
Trauma affects the autonomic nervous system.
•
Trauma may be associated with abnormal activation of the
amygdala, abnormal levels of cortisol, epinephrine, and
norepinephrine, and structural changes to the hippocampus.
•
The incidence of other serious illness, including chronic pain with no
medical basis, cardiovascular and digestive problems, is higher
among people who have experienced severe trauma.
www.ChildTrauma.org
• “These images illustrate the negative impact of neglect on the developing brain. In the CT
scan on the left is an image from a healthy 3-year-old with an average head size. The image
on the right is from a 3-year-old child suffering from severe sensory-deprivation neglect.
Module 2
15
PRESENTATION
Differential Response to Threat
• Many factors affect one’s response to trauma, including life experiences before and after
the trauma, age at which the trauma occurred, length and frequency of the trauma, coping
skills, who caused the trauma, and help that was available after the trauma.
• Responses to threat vary greatly from individual to individual.
• The flight (panic) or fight (terror) response is a well-documented reaction to danger. Our
bodies have the same physiological reactions to dangers, whether it is a charging tiger or
an episode of restraint.
• Other responses to trauma include dissociation and hyperarousal or a combination of
the two.
• Children may not be able to fight or flee during times of threat—and may therefore use
dissociation as a coping mechanism.
• We all use dissociative mental mechanisms even when we are not threatened—
for example, daydreaming.
Differential Response to
Threat
Dissociation
Hyperarousal
Detached
Numb
Compliant
Decreased Heart Rate
Suspension of Time
De-realization
Mini-psychoses
Fainting
Hypervigilance
Anxious
Reactive
Alarm Response
Increased Heart Rate
Freeze: Fear
Flight: Panic
Fight: Terror
Source: Perry, M.D., Ph.D. www.childtraumaacedemy.com
Module 2
16
PRESENTATION
This child’s brain is significantly smaller than average and has abnormal development of
cortex.” These images are from studies conducted by a team of researchers from the Child
Trauma Academy (www.ChildTrauma.org) led by Bruce D. Perry, M.D., Ph.D.
• Mental health professionals cannot develop
appropriate treatment plans or
interventions for clients in the absence of
knowledge about their histories of physical
or sexual abuse (JCAHO, Accreditation
Manual for Mental Health, 1995).
• All clients need to be asked about their
history of sexual, physical, and verbal
abuse in all clinical settings.
• When doing an assessment, it is important to gather accurate information. At the same
time, it is important not to reopen a traumatic event without having the resources available to adequately deal with it. This can be a source of tension on short stay units. However, it is important to ask the questions about trauma directly.
“Never being asked about trauma is like
the abuse as a child.”
Survivor from Maine
• The following material and quotes were taken from In Their Own Words, a work of over
200 women and men in the State of Maine who hope that the truth and wisdom of their
work will be heard by those who are in power.
Module 2
17
PRESENTATION
• Misdiagnosis of trauma may lead to ineffective treatment.
Survivors and Trusted Professionals Speak About
Recognizing (or Avoiding) the Prevalence, Indicators,
and Impact of Trauma: What Hurts
•
The way questions were asked was impersonal, cold, and intimidating.
(Survivor)
•
It is fearful to disclose the abuse.

“You risk being judged, being penalized, being discredited, invalidated, and
having your feelings minimized.” (Survivor)
“When you get a mental illness label, you lose all credibility.” (Survivor)
•
The consequences of misdiagnosis include wrongful medication, overmedication, tardive dyskinesia and other reactions to medications,
inappropriate and ineffective treatment. (Professional)
•
Stigma in the mental health field is a problem. It takes a longer time for
men to disclose abuse than women.
•
“Men do not disclose their histories of sexual and physical abuse because
of the stigma attached to being a male survivor.” (Professional)
Recognizing (or Avoiding) the Prevalence,
Indicators, and Impact of Trauma: What Helps
•
Staff who are calm, who will sit and listen in a relaxed
manner, are essential. (Survivor)
•
The person doing the intake should understand the fear (of
disclosing abuse).
“Threats from the past are still present. If you tell, you will
die, your sister will die.” (Survivor)
•
Training is needed in looking for, identifying, assessing, and
treating mental health clients in the framework of trauma.
(Professional)
•
Training is needed in putting aside one’s own beliefs and
expectations, and meeting clients where they are at, rather
than where I think they may be. (Professional)
Module 2
18
PRESENTATION
• Both survivors of abuse and professionals they trust gave voice to their experiences with
the individuals, organizations, and systems that have been shaped and influenced in such
a way that they frequently harm, instead of help, consumers.
Module 2
19
PRESENTATION
• Massachusetts has worked extensively in this area and has developed a Trauma
Assessment Form that can be used as a guideline for obtaining trauma histories.
• Once the information has been collected, it is critical to do the next step of designing
treatment plans using the trauma information.
• It is also critical to obtain information from the consumer on what strategies have been
effective to reduce or avoid the use of seclusion and restraint. This includes identifying
interventions that might further traumatize them.
• Massachusetts has developed a Restraint Reduction Form that is also included in the
intake session with a consumer.
• It is important to know the gender of the perpetrator and give consumers a choice about
who will be with them during and after a restraint episode.
• In summary, it is critical to obtain information relevant to (1) history or abuse,
(2) de-escalation strategies that have worked, and (3) what forms of seclusion/restraint
are most helpful and least traumatic.
OBJECTIVE:
Familiarize participants with one method of assessing trauma.
PROCESS:
Direct participants to pair up. One person will role-play a consumer.
It may be helpful for staff to think of a specific consumer to use as
a model for this role-play. Have the person role-playing the consumer think of what kind of trauma (known or unknown) might be
present for the consumer. The consumer is not allowed to look at
the form as the staff person is filling it out.
Use the Trauma Assessment for Department of Mental Health
Facilities/Vendors and have the person role-playing a staff person
fill out the form. Facilitate a discussion.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
APPROXIMATE
TIME REQUIRED:
What worked well about this kind of assessment form?
What concerns do you have about using this type of form?
How is this similar or different from intakes you currently do on
your unit?
Trauma Assessment for Department of Mental Health Facilities/
Vendors handout
20 minutes
Module 2
20
PRESENTATION
Survivors Speak About Retraumatization via
Hospitalization - Creating Safe Places for
Healing: What Hurts – pg 1
•
There is a lack of knowledge/training for survivors and
staff regarding therapeutic approaches and the link
between trauma histories and the presenting symptoms
causing the need for hospitalization. (Survivor)
•
There is a general disrespect for patients as human
beings that should be valued as full partners in the
treatment and recovery process.
•
“They take your clothes away and watch you take
showers.” (Survivor)
•
Insurance payments control the length of
hospitalization.
Survivors Speak About Retraumatization via
Hospitalization - Creating Safe Places for
Healing: What Hurts – pg 2
•
“You’re sick enough to stay when you have insurance. You’re
suddenly improved enough to leave as soon as your insurance
runs out.”
•
Seclusion and restraint techniques are retraumatizing and
inhumane approaches to managing symptoms.
•
“I would rather die than go back to the hospital.”
•
“It involves 5-6 guys chasing you down, holding you down – just
like rape. So you are terrified and you try to get away from
them and you strike out to protect yourself. Then they call you
’assaultive’ and that follows you to the next hospital and they
say to you, ‘I hear you hit someone.’” (Survivor)
Module 2
21
PRESENTATION
•
Training needs to be offered that addresses all the aspects
of trauma recovery (staff and client issues).
•
“Training needs to be done in (1) how the staff can avoid
being reactive; (2) recognizing when the staff or the client
is in a state when they cannot receive information, for
example because of high anxiety; and (3) when the staff
should be interactive.” (Professional)
•
Survivors need training also.
•
“When asking survivors about seclusion and restraint, ask
them about what responsibility they have in the situation.
Do not automatically put the person in a victim role.”
(Survivor)
• Gathering information about what helps and what hurts consumers during times of crisis
is useful.
• Consumers can often tell staff specifically what works for them and what triggers them in
advance of a crisis.
• If this information is gathered in advance, and all staff are aware of the information, it
can be very helpful in defusing a crisis situation.
Module 2
22
PRESENTATION
Retraumatization via Hospitalization - Creating Safe
Places for Healing: What Helps
OBJECTIVE:
Familiarize participants with one method of determining
de-escalation preferences.
PROCESS:
Direct participants to pair up in the same pairs as in the previous
exercise. This time, switch roles; one person will play a consumer
and the other will play a staff member.
Hand out the Guidelines for De-Escalation Form.
Have the person role-playing a staff person fill out the
De-Escalation Preference Form.
Facilitate a discussion.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
APPROXIMATE
TIME REQUIRED:
What worked well about this kind of preference form?
What concerns do you have about using this type of form?
What do you see as the pros and cons of asking consumers these
types of questions?
Guidelines for De-Escalation Form handout
De-Escalation Preference Form handout
20 minutes
Module 2
23
PRESENTATION
Survivors: When I am in
crisis, I need persons:
•
“Who can BE with me when I am in distress; be
present with me when I am in pain.”
•
“Who will acknowledge my pain without trying to
‘fix’ it. This takes someone who knows his/her own
pain and is not afraid of it or of yours.”
•
“Who is not afraid of my sexual abuse. I don’t
need someone else’s fear.”
•
“Who has worked with their own sexual abuse –
another survivor can do this.”
Survivors: When I am in
crisis, I need persons: (pg 2)
•
“Who will ask what would help and trust I know whether or
not I need hospitalization.”
•
“Who understands the coping role of suicidal thoughts, as a
relief, and end to the pain, as giving a sense of some
control.”
•
“Who knows the difference between “I want to die”
(despair, hopelessness) and “I want to kill myself” (anger,
defiance).”
•
“Who will understand, control, and prevent me from hurting
myself when I am in danger, but still give me options and
choices, and respect me in a way that doesn’t treat me like
an animal.”
• What consumers and direct care staff want in times of crisis is universal. We all want the
same things.
Module 2
24
PRESENTATION
• Think about a time you were in crisis. What did you want? Have the group brainstorm
ideas out loud.
Healing From Trauma
• Sue Coates, from Turning Points, an agency in Grand Rapids, MI, in a presentation listed
five necessary elements for healing from trauma. (See slide.)
Five Necessary Elements for Healing From
Trauma - “Turning Points” by Sue Coates

Safety

Empowerment

Creation or Restoration of Positive Self
Regard

Reconnecting to the World

Intimacy
Module 2
25
PRESENTATION
• Working in mental health is a demanding career that impacts all of us. Whatever happens
on the units, impacts direct care staff and consumers.
• Secondary traumatization is known by many names: compassion fatigue, secondary or
vicarious traumatization, absenteeism, and “burn out.”
• Secondary traumatization affects primarily the workers who help trauma and disaster
victims—including mental health staff.
• The symptoms of secondary traumatization are usually less severe than Post-Traumatic
Stress Disorder like symptoms (e.g., hypervigilance, flashbacks to previous trauma, difficulty concentrating), but they can affect the livelihoods and careers of mental health
workers.
• Secondary traumatization can also occur when one is a witness to violence. For example,
other consumers watching a forceful escort to the seclusion room might experience secondary traumatization. Staff members watching another staff member get hurt in a take
down could also experience secondary trauma.
Distribute the handout Grounding Techniques by Mary Gilbert and take
10 minutes to do the exercise on grounding techniques.
Journal/Take Action Challenge
Give participants time to write on one to two Journal topics and at least
one of the Personal Take Action Challenges and one of the Workplace
Take Action Challenges. They will use these Take Action Challenges
extensively on the last day of the training.
Module 2
26
PRESENTATION
• Safety includes physical needs such as food, clothing, and shelter. It also includes feeling
psychologically and emotionally safe with those around you—knowing you will not be
abused or harmed. If consumers are witnesses to other consumers’ seclusion and restraint,
this may impair their feelings of safety.
• Empowerment restores the hope that one has the potential and ability to recover.
Consumer-driven supports, such as the Wellness Recovery Action Plan, the advance
psychiatric directive, and peer mentoring are examples of empowerment.
• Creation or restoration of positive self-esteem naturally flows from empowerment.
As consumers learn to rely on their own abilities and skills, their outlook on their lives
and future improves and enhances their positive self-esteem.
• Reconnecting to the world gives consumers a sense of normalcy.
• All human beings need intimacy or closeness with another human being. Establishing
positive relationships adds to a consumer’s ability to heal from trauma.
• The Center for Mental Health Services, within the Substance Abuse and Mental Health
Services Administration, published a booklet, Dealing With the Effects of Trauma:
A Self-Help Guide. To see the complete publication, go to the Web at
www.mentalhealth.org/publications/allpubs/SMA-3717/default.asp.
• Assisting consumers to develop their own coping mechanisms around trauma can
be very empowering.
OBJECTIVE:
Familiarize participants with grounding techniques.
PROCESS:
Have two volunteers do a role-play. One person will play the role
of the consumer who is having flashbacks and/or dissociating.
If possible, pick a person to play the role of the direct care staff
member who has experience in grounding techniques. Facilitate
a discussion.
DISCUSSION
QUESTIONS:
What types of things were most helpful in this role-play for grounding techniques?
What concerns do you have about using these types of techniques?
Which of these techniques do you typically use on a regular basis
on your unit?
MATERIALS
REQUIRED:
Grounding Techniques by Mary S. Gilbert, Ph.D.
APPROXIMATE
TIME REQUIRED:
10 minutes
Module 2
27
PRESENTATION
Journal Topics
Pick one or two questions and respond. Your responses are confidential.
1. Consider the impact that using seclusion and restraints has had on you as a staff
member. Write about your first experience with seclusion and restraint. Describe the
incident in as much detail as possible and how it made you feel.
2. How have you personally changed as a result of secluding and restraining others?
3. What do you see as the pros and cons of using seclusion and restraints?
4. Write about your own trauma or secondary trauma.
5. How could you incorporate stress management skills into your life and/or your
workplace?
6. How would your daily work change if the mental health system wholeheartedly
adopted the underpinnings of a trauma model?
Personal Take Action Challenges
Pick one topic and develop a plan. You will use this plan on the last day of training.
1. Make a list of three things that you personally can commit to every day at work
to prevent the use of seclusion and restraint. Make a detailed plan of how you will
implement these changes.
2. Find one area in your life where you could work recovering from trauma. Make a list
of two things you can personally commit to in your daily life to move you forward in
your own journey of recovery from trauma.
Workplace Take Action Challenges
1. Make a list of three things that you can personally commit to doing when you get
back to work to help change the system to eliminate seclusion and restraint.
2. Who has the power to eliminate seclusion and restraint in your facility? How could
you design an alliance with them?
3. How could you utilize the trauma assessment form and/or de-escalation preference
form in your workplace?
Module 2
28
HANDOUT
JOURNAL TOPICS AND TAKE ACTION CHALLENGES
FOR MODULES 1 & 2
National Association of State Mental Health Program Directors
The National Association of State Mental Health Program Directors (NASMHPD) recognizes
that the psychological effects of violence and trauma in our society are pervasive, highly disabling, yet largely ignored. NASMHPD believes that responding to the behavioral health care
needs of women, men, and children who have experienced trauma from violence is crucial
to their treatment and recovery and should be a priority of State mental health programs. The
goal of recovery from trauma is a fundamental value held by NASMHPD and its individual
members, State mental health authorities. Toward this goal, it is important to develop an understanding of the resiliency factors, and the kinds of treatment, services, and supports
that contribute to recovery.
The experience of violence and trauma can result in serious negative consequences for an
individual’s mental health, self-esteem, use of substances, and involvement with the criminal
justice system. Indeed, trauma survivors can be among the people least well served by the
mental health system as they are sometimes referred to as “difficult to treat” —they often
have co-occurring mental health and substance use disorders, can be suicidal or self-injuring
and are frequent users of emergency and inpatient services.
Trauma is an issue that crosses service systems and requires specialized knowledge, staff
training, and collaboration among policymakers, providers, and survivors. Study findings indicate that adults in psychiatric hospitals have experienced high rates of physical and/or sexual abuse, ranging from 43 to 81 percent. Other research recently has found that 92 percent
of homeless women and 81 percent of non-homeless women in poverty had been physically
and/or sexually abused. Trauma is also frequently experienced as highly stigmatizing and often can create a reluctance to seek help. There is reason to believe that men may significantly
under-report childhood abuse.
Services for trauma survivors must be based on concepts, policies, and procedures that provide safety, voice, and choice as defined by consumers/survivors. Trauma services must focus
first and foremost on an individual’s physical and psychological safety. Services to trauma
survivors must also be flexible, individualized, culturally competent, and promote respect
and dignity. Innovations in trauma services are becoming a focus of increased discussion and
change within the public mental health system. A number of State mental health authorities
have begun to address the needs of trauma survivors in the mental health system by revising
seclusion and restraint guidelines to prevent the repetition of the experience of trauma, adopting clinical guidelines for people with serious mental illnesses who have histories of trauma,
Page 1 of 2
Module 2
29
HANDOUT
Position Statement on Services
and Supports to Trauma Survivors
NASMHPD Statement (continued)
NASMHPD is dedicated to furthering the understanding of the effects of physical and/or
sexual abuse and increasing its treatment within the public mental health system. State mental health authorities are committed to recognizing and responding to the needs of trauma
survivors with mental illnesses and their families. It should be a matter of best practice to
ask persons who enter mental health systems, at an appropriate time, if they are experiencing or have experienced trauma in their lives. NASMHPD recognizes that some policies and
practices in public and private mental health systems and hospitals, including seclusion and
restraint, may unintentionally result in the revictimization of trauma survivors, and therefore
need to be changed.
NASMHPD is committed to working with States, consumers/survivors, and experienced
professionals in the trauma field to explore ways to improve services and supports for trauma
survivors. These efforts may include, but are not limited to, developing improved methods
for reducing stigmas related to trauma; developing and disseminating information and technical assistance on best practices; providing forums for a national dialogue on the needs of
trauma survivors; and cooperating with other State and national organizations to develop
prevention and education initiatives to address the issue of trauma.
Passed unanimously by the NASMHPD membership on December 7, 1998.
Page 2 of 2
Module 2
30
HANDOUT
developing statewide strategic action plans, producing training materials, and empowering
statewide committees to develop and improve trauma services.
Excerpts from Kate Reed’s Speech
I’m very moved by being here. I feel teary. There’s a lot of emotion because this is something
that I lived with in silence for 35 years of my life. To be sitting here and seeing other women
and men share their experiences, and know that it takes an enormous amount of courage to
live in terror on a daily basis and just put your feet on the floor every morning. But there are
many people who are not here who did not live through it and I want to say that I hold them
in memory now, too….
I was incested at the age of 2 ½ and it lasted until the time I was 8. It was by my paternal
grandfather who lived right next door. It lasted for approximately 8 years and the incest
progressively got worse and later on it involved bodily penetration. Those are the criteria
that sort of set people up for having long-term psychological problems. Judith Hermann, an
incredible feminist psychiatrist who writes about trauma issues, says that a single source of
trauma like rape of an adult with an existing healthy personality can abrade that personality,
can start eroding the health. But for women who have multiple traumas throughout childhood, the trauma itself both forms and deforms the personality. What we are hearing from
women talking about their experiences is the amount of reconstruction work you have to do.
This is not the walking wounded. I was lucky to come out with my life. I had multiple suicide attempts. I overdosed and wound up in intensive care. To me, suicide held out a hope
that the terror, the pain, all of it would stop. I had some control. If that’s the only control I
had I knew at some point I would say I’m not going to commit suicide today, maybe I will
tomorrow. That’s the reality. I had emotional problems right from the start. I struggled with
depression. I struggled with low self-esteem that was off the charts. I mean low self-esteem
is putting it mildly when you think of yourself as evil, as bad, as holding some energy that is
incredibly dark.
I think I lived with just an enormous amount of terror. I was victimized again and again by
my grandfather and I lived in terror. I didn’t know when he was going to start again. I didn’t
know where. I was always on the lookout for what was coming; what was going to broadside
me, and my body remembers that terror. I could forget. I could say that my childhood was
fine, but my body remembered in a way that I could not forget, and my body reminds me
frequently that it’s still in charge. The post-traumatic stress is for me the hyperarousal level
where your arousal level, your base line of anxiety level might hover around a 4 or 5. So that
anything that happens can spike me into panic in an instant.
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Feeling safe is really hard….and this is the one place where I feel really unsafe because I
work in the system. I can sit up here and share my experience, but in the back of my mind I
wonder if I approach one of you in the Department for a job, you might take that and hold it
against me…..
Kate Reed’s Speech (continued)
When I say I have made multiple suicide attempts and been hospitalized many times, I worry
about what some of you do with that in your head. Because I think that what happens in the
system that has historically happened – is that they look at me or any of us who spoke and
said what’s wrong with you; what is wrong with you! I want to say it takes an enormous
amount of courage to do what we have all done and I’m really grateful to be in the presence
of women who have been creative and survived by hook or by crook in whatever way we
could. When I look at myself, I think today I can be an incredibly compassionate judge of
myself and others. I can be very nurturing; I have nurturing skills. I have an incredible ability
to figure out how to heal myself in the face of a system that only retraumatized me, and I’ve
hooked up with other people who were healing. I have wonderful people in my life today.
I’m in a graduate program; I hope to have a private practice where I will treat incest survivors. My life to me is very hopeful today.
I want to talk a little bit about how I got here. I think one of the things that helped me to heal
was to not label myself, because I needed to be a human being with human feelings, even if
they were in the kind of extreme range of intense emotions. When my divorce was happening and I was getting a lot of incest memories, I had always had a few picture memories but I
never had the affect. Then, it was like strap your seat belt; put your crash helmet on and hold
on because now here come the pictures WITH the affect. There was an enormous amount
of rage; there was an enormous amount of grief; there was an enormous amount of terror,
and that went on for 3 or 4 years while I was getting the memories. What helped for me is
my husband and I had built a house on the backside of Peaks Island. It was oceanside and it
was a beautiful, beautiful setting and I had the backside of the island pretty much to myself.
I would be flooded with grief and I would be on the floor in a fetal position just sobbing for
hours and then in the middle I’d sort of stop and kind of try to regroup. Then I had my way
of a rage that would go on and this process went on for a long, a long time. I had two Escort
wagons where the dashboard was broken on both of them because I would be in the car and
the rage would just be…like it was too much to contain the intensity of the emotion of the
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I lost most of my life to trauma. I made choices out of the lie that I was forced to live, and my
marriage was a victim of my healing process. I was hospitalized at the age of 21 and it took
me 3 or 4 years to come out of that bout. What happened is that I got triggered into a string of
post-traumatic stress where it was like getting tumbled over and over again in a wave; every
time I tried to come out something else would hit me and I’d go back into the terror and I’d
come back out and I’d go back into the terror and I lived that way pretty much daily, suicidal,
in an enormous amount of pain and shame for probably 3 years at the first round. Then I
managed to crawl out kind of like by the skin of your teeth and your nails to a place where I
got married, had children. That was sort of a quiet period for a while and then my marriage
was unraveling and I got incest memories at the same time.
What I did was I got a therapist who was herself a survivor and she believed very simply that
the baseline was that we can heal ourselves; that we have an internal healer and given the
proper environment, we can initiate a healing process that will take us to where we need to
go. It didn’t take any fancy technology; for me it didn’t take any medication; it didn’t take
any psychiatric diagnoses.
I want to put in perspective how the psychiatric community can come to use and try to help
us; try to be of service to us. I got rid of as many of the system pieces in my life as I could
because I realized that for the last 3 years I’ve been healing from the “help” that I got. I was
thrown into restraints when I was suicidal; I was thrown into a straight jacket. I was coming
out of an overdose and somebody said to me “What do you want do” and I said, “I want to go
out to dinner” and they said “No.” I was in a State hospital for a while and I’ve been in the
fashionable Institute of Living in Hartford, Connecticut.
What really worked for me was to frame my experience not in a diagnosis but in a spiritual
experience. It became a spiritual journey for me. I just let the feelings go. I tried to learn
to trust my process and trust my inner healer and that worked for me. I danced a lot; just a
dance that would sort of ground the enormous energies that were moving through me. I did
a lot of externalization of the internal energy. I did Elizabeth Kübler Ross work where you
basically get in a room with 80 people and they throw mattresses on the floor and it’s like
being in Dante’s Inferno, but it’s all of that dark stuff that we hold on to. It’s all of the rage;
it’s all of the grief; it’s all of the stuff that’s actually very fertile because I think if you mind
those emotions that what you come out with is an incredible gift, and I do believe that there
are gifts in the experience of healing from incest, for me, I will say. I think you have to be in
a certain place in a certain time in your recovery to acknowledge that, and some people may
never want to and that’s their choice, but for me there have been an enormous amount of gifts
in the process. too.
I went to a 12-step program. I had a lot of shame and what worked for me was for somebody
else to listen to me talk and to just accept who I was at that moment. To look back at me as
another human being and to say, by the way they were holding me with their expression, that
I was okay.
So I guess what I want to say is there’s no technique stuff that’s really the total answer. To me
the people who were most powerful in my life were other people who could be with me in
the intensity of my pain and just acknowledge that they were there. They didn’t necessarily
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experience that I was going through; just to try to have it tip all the scales of what I could
possibly cope with.
I also had trouble getting a therapist. I also had trouble paying for my therapist because she
was not reimbursable and she was my therapist of choice. I worked with her for 5 years and I
had to pay out of pocket.
I just want to say I’m glad that everyone is here; I’m glad that the topic is on the table. I think
it kills people all of the time and it’s time to start ending the silence around it. Thank you.
This selection is excerpts from a speech by Kate Reed, Maine, trauma survivor and mental
health professional, from In Their Own Words: Trauma Survivors and Professionals They
Trust Tell What Hurts, What Helps, and What Is Needed for Trauma Services, Maine Trauma
Advisory Groups Report, 1997.
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know how to help me sometimes but that they were there with me and I didn’t have to be in
terrified place alone.
National Association of Consumer/Survivor Mental Health Administrators
The Prevalence of Abuse Histories
in the Mental Health System
In the last decade, the mental health system has begun to demonstrate some awareness of the
prevalence of abuse histories among its clientele. Studies consistently confirm a 50-80 percent prevalence rate of sexual and physical abuse among persons who later acquire diagnoses
of mental illness (Breyer, 1987; Beck & Van der Kolk, 1987; Rose et al, 1992; Craine et al,
1988; Stefan, 1996). While many professionals in the field still deny the validity of work
documenting these histories, the mental health system is beginning to catch up with groups
that have addressed violence toward women, child abuse, and runaway adolescents in realizing the connections between abuse and later difficulties (Alexander & Muenzenmaier, 1998;
Smith, 1995; Harris, 1994; New York State Office of Mental Health, 1993; Mental Health
Association in New York State & New York State Office of Mental Health, 1994).
Among consumers/survivors/ex-patients (C/S/Xs) themselves, the commonality of abuse
histories has begun to be acknowledged. With that acknowledgment, the irrelevance of much
of their “treatment” in the mental health system has begun to make sense in a new way. Many
whose treatment focus has changed from medical model interventions to trauma-oriented therapies, whether professional or peer-run, have recovered in ways once considered impossible.
It would seem, therefore, that the mental health system’s recognition of abuse histories would
be welcome news among C/S/Xs. However, for many who know the system well, the news is
greeted with deep ambivalence. For some, it is somewhat ironic, given the history of silence
among most mental health professionals about abusive treatment that is often routine in
mental health settings. Others are deeply relieved by professionals’ long-overdue recognition of trauma as a primary issue to be addressed therapeutically, but fear that a system so
entrenched in punitive ways will not be able to incorporate the kind of work necessary to heal
from trauma (Kalinowski & Penney, 1998).
Some C/S/Xs have learned that the abuse in their histories has been the primary formative
factor in what was called their “mental illness.” Others see abuse or trauma as part of what
affected them, but also believe that their symptoms had a variety of origins, including socioeconomic, spiritual, and/or biological causes. Whatever view individuals hold concerning
the role of trauma and abuse in the etiology of their problems, their experiences in the mental health system may color their reaction to the system’s new-found interest in trauma and
abuse. Many people have spent years in the system without being asked about their trauma
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Position Paper on Trauma and Abuse Histories
NAC/SMHA Position Paper (continued)
Until recently, the term “survivor,” as used within the C/S/X movement, meant one who
survived the irrelevance and frequently the harm of psychiatric interventions. Commonly,
individuals have needed to recover from the effects of being labeled and institutionalized in
order to begin addressing the issues that led to their encounter with psychiatry. Now that the
term means “survivor of abuse” to many practitioners, C/S/Xs seek evidence that the abuse
perpetrated by the mental health system itself is also recognized. They are deeply skeptical
of trusting clinicians who have never questioned the criteria for involuntary commitment
and deprivation of civil rights for so many diagnosed persons. People who have experienced
trauma and abuse perpetrated by the very system which purports to help them may have a
hard time believing that this same system is now willing and able to assist them in overcoming the effects of trauma.
Thus, C/S/Xs who advocate against forced and punitive treatment as traumatizing violations
of their humanity, now point out that the majority of diagnosed individuals are actually being retraumatized in psychiatric settings (New York State Office of Mental Health, 1993). In
the words of one C/S/X, if one was not a trauma survivor before entering the mental health
system, one is sure to become one once labeled and locked up. In other words, no matter
what theory an intervention is based on, unless the coercive culture of psychiatry is radically
altered, many persons will continue to be traumatized, whether or not such experience is
repetitious of their pasts.
In regard to the theory itself, some C/S/Xs are relieved by the long-overdue recognition of
trauma and abuse as primary factors in the development of symptoms that were once adaptive coping strategies. Believing that this recognition must preclude further violations, they
want to do therapeutic work on the issues that trauma and abuse created. Their choice might
be to work on this and only this in individual or group work with professionals and/or peers.
Others see the traumatic aspect of their histories as part of what affected them, but also believe they have biological or socioeconomic reasons for “symptoms” as well. Thus, they see
multifaceted approaches as the only viable way to work.
Regardless of what C/S/Xs believe about the etiology of their difficulties, they want what
they have always stated to be important: to be heard and treated as individuals and to have
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history or other aspects of their personal stories; their behavior, rather than their experience,
has been the focus of treatment. Many have also felt constantly threatened with the loss of
autonomy and civil rights (Blanch & Parrish, 1993). For these individuals, it may be difficult
to appreciate the professional world’s “discovery” of a new theory of mental illness, regardless of its relevance to the majority of people caught up in the mental health system.
C/S/Xs frequently report that they were never asked about trauma or abuse, and if they
were, divulging such history did not yield a specifically responsive result. Most believe the
relevance of abuse and trauma should be communicated sensitively, early, and consistently
throughout encounters with the system. However, it must be understood that such an
approach is still only theory until chosen as useful by the individual consumer/survivor.
Given the documentation that the majority of people with psychiatric diagnoses are abuse
survivors, many C/S/Xs think the most effective way to address trauma and abuse histories is
to assume that all C/S/Xs are potentially abuse survivors. It should be considered integrally
important to one’s development up to assessment/admission, and the process of encountering
the mental health system can be assumed as potentially retraumatizing or at least “triggering”
of previous experience. If trauma were presumed, anyone entering the system would be subject to a more humane, considerate, and relevant approach. Importantly, this would eliminate
the need for separate units for “trauma survivors” as if they were different people from those
called “mentally ill.” Interventions such as restraint and seclusion would be deemed too traumatizing for anyone in crisis, not only for one whose trauma history is known.
This becomes more of an issue as mental health professionals begin to address how to treat
abuse survivors, particularly on an inpatient basis. Indeed, the “trauma models” they use
often appear much more humane and respectful of the person than do traditional approaches
to people with psychiatric diagnoses, and some who specialize in this area believe the new
paradigm should dominate the field, regardless of what has brought a person to a mental
health crisis. However, as psychiatry gains a foothold in the area, a new division of “patients”
can be seen: trauma survivors, with diagnoses like Dissociative Identity Disorder (DID) and
Post-Traumatic Stress Disorder (PTSD) vs. (and sometimes co-occurring with) more standard
diagnoses of mental illness. In this context, the system continues to employ inhumane methods, such as forced medications or restraints, with some diagnosed persons, while an effort is
made to avoid “retraumatizing” others.
This division is disturbing to C/S/Xs who see a new hierarchy of oppression forming before
their eyes after years of fighting for the full human rights of all who cross the path of the
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their subjective experience and self-perception respected. Also consistent with C/S/Xs’ stated
wishes over the years is the desire to be perceived and treated with hope (Zinman, Harp. &
Bead, 1987; Campbell, 1989; Chamberlin, 1990; Knight, 1991; Fisher, 1994; Penney, 1995).
It is difficult to count on a system that has routinely dashed hope to now operate from a belief
that recovery is possible. But this is essential to any therapeutic plan and one seldom emphasized in professional training.
The issue of power differentials is crucial here. Abuse is about one person subjugating another—the violent assertion of one’s will over another. Traumatic experiences, while not always
interpersonal, similarly leave people feeling as helpless victims whose control was usurped
by a more powerful condition or event. The risk for anyone entering the mental health system
is fundamentally a loss of power. Even voluntary admissions to in- or out-patient services are
governed by the coercive power held by psychiatry. The loss of power over one’s life, which
usually accompanies a diagnosis, is traumatizing for all people, whatever their past history of
trauma or abuse.
Most C/S/Xs want to believe that practitioners care about outcomes beyond cost efficiency
and behavior control. Thus, it is crucial in their opinion that practitioners be aware of the
often dramatic improvements in the lives of C/S/Xs that result from being listened to and
treated as individuals. This also means not forcing a trauma-related diagnosis or traumamodel services on individuals who are not comfortable with that approach. Again, individuals need to be listened to; while it might be useful to have theories suggested, no success is
possible when one is imposed.
Mental health professionals would do well to consider how survivors managed all the years
their abuse histories remained hidden. The strengths of individuals, peer support, and selfhelp gain new respect when it is recognized that for many, these have been the only avenues
that have been available to them for support. The incorporation of trauma theories into the
design and delivery of mental health services can provide a new opportunity to consider the
integration of peer-run and other community resources as equally important to professional
interventions.
Possibly the most important area being explored in services specific to trauma is one that
C/S/Xs have also been exploring and advocating for years—that of advance directives (Backlar & McFarland, 1996; Sherman, 1994). Out of efforts to avoid retraumatizing survivors of
abuse, some mental health assessments now include questions about what triggers difficulty
for individuals and what they find most helpful in especially troubled moments. Perhaps this
is because trauma survivors are seen as more capable of knowing themselves and what helps
them, but it is a way of planning in partnership with professionals that C/S/Xs have long been
aware of and supported. Many would go so far as to say that recovery is only possible where
this kind of partnership is built and honored.
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mental health system. They do not wish to see two groups of diagnosed individuals set up in
opposition to each other, one treated with concern and compassion because of their trauma
histories, the other treated in coercive, inhumane ways because they are thought to have a
biological illness.
References
Alexander, M.J., & Muenzenmaier, K. (1998). Trauma, addiction and recovery: Addressing public
health epidemics among women with severe mental illness. In Levin, B., Blanch, A., & Jennings,
A. (Eds.), Women’s mental health services: A public health perspective. Thousand Oaks, CA:
Sage.
Backlar, P., & McFarland, B. (1996). A survey on use of advance directives for mental health
treatment in Oregon. Psychiatric Services, 47, 12.
Beck, J., & Van der Kolk, B. (1987). Reports of childhood incest and current behavior of chronically
hospitalized women. American Journal of Psychiatry, 144, 1474.
Blanch, A., & Parrish, J. (1993). Alternatives to involuntary treatment: Results of three roundtable
discussions. Rockville, MD: Center for Mental Health Services, Community Support Program.
Breyer, J., et al. (1987). Childhood sexual abuse as factors in adult psychiatric illness, American
Journal of Psychiatry, 144, 1426-1427.
Campbell, J. (1989). In pursuit of wellness: The Well-Being Project. Sacramento, CA: California
Network of Mental Health Clients.
Chamberlin, J. (1990). The ex-patients’ movement: where we’ve been and where we’re going.
Journal of Mind and Behavior, 11(3-4), 323-336.
Craine, L., Henson, C., Colliver, J., & MacLean, D. (1988). Prevalence of a history of sexual
abuse among female psychiatric patients in a State hospital system. Hospital and Community
Psychiatry, 39 (3), 300- 304.
Fisher, D. (1994). A new vision of healing as constructed by people with psychiatric disabilities
working as mental health providers. Psychosocial Rehabilitation Journal, 19(3), 67-81.
Harris, M. (1994) Modifications in service delivery and clinical treatment for women diagnosed with
severe mental illness who are also survivors of sexual abuse trauma. Journal of Mental Health
Administration, 21, 4.
Kalinowski, C., & Penney, D. (1998). Empowerment and women’s mental health services. In Levin,
B., Blanch, A., & Jennings, A. (Eds.), Women’s mental health services: A public health perspective. Thousand Oaks, CA: Sage.
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Given the dominance of the medical or biological model of mental illness in the field at
this time, C/S/Xs are eager to use what is effective from the framework of trauma survival.
A great deal of difference could be made in the lives of individuals if this growing body of
information were used to support holistic and hopeful views of what is happening to them
and what is possible for their futures. As one C/S/X put it, perhaps the “Decade of the Brain”
could give way to the “Decade of Recovery”—recovery only being possible when all aspects
of a person’s development in context are given equal value, and a spectrum of healing possibilities are offered as real choices.
Mental Health Association in New York State & New York State Office of Mental Health. (1994).
Proceedings from the forum on sexual abuse survivors in the mental health system. Albany, NY:
Office of Mental Health.
New York State Office of Mental Health (1993). Report of the task force on restraint and seclusion.
Albany, NY: Author.
Penney, D.J. (1995). Essential elements of case management in managed care settings: A service
recipient perspective. In L.J. Giesler (Ed.), Case management for behavioral managed care
(pp. 97-113). Cincinnati, OH: National Association of Case Management.
Rose, S., Peabody, C., & Stratigeas, B. (1991). Undetected abuse among intensive case management clients. Hospital and Community Psychiatry, 42, 5.
Sherman, P. (1994). Advance directives for involuntary psychiatric care. Evergreen, CO: Resources
for Human Services Managers.
Smith, S. (1995). Restraints: Retraumatization for rape victims? Journal of Psychosocial Nursing,
33, 7.
Stefan, S. (1996). Reforming the provision of mental health treatment. In Moss, K. (Ed.),
Man-made medicine: Women’s health, public policy, and reform (pp. 195-218). Durham, NC:
Duke University Press.
Zinman, S., Harp, H., & Bead, S. (Eds.). (1987). Reaching across: Mental health clients helping
each other. Sacramento, CA: California Network of Mental Health Clients.
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Knight, E. (1991). Self-directed rehabilitation. Empowerment, 2(7), 1-4.
Some Statistics from the Research
For purposes of this document, “abuse” and “trauma” are defined as interpersonal violence
in the form of sexual abuse, physical abuse, severe neglect, loss, and /or the witnessing of
violence.
If no one notices, listens, or helps, childhood abuse can lead in adult years to—
SERIOUS MENTAL HEALTH PROBLEMS
The mental health system is filled with survivors of prolonged, repeated childhood trauma.
• Fifty to 70 percent of all women and a substantial number of men treated in psychiatric
settings have histories of sexual or physical abuse, or both. (Carmen et al., 1984; Bryer et
al., 1987; Craine et al., 1988)
• As high as 81 percent of men and women in psychiatric hospitals with a variety of major
mental illness diagnoses have experienced physical and/or sexual abuse. Sixty-seven percent of these men and women were abused as children. (Jacobson & Richardson, 1987)
• Seventy-four percent of Maine’s Augusta Mental Health Institute patients, interviewed as
class members, report histories of sexual and physical abuse.
(Maine BDS, 1998)
• The majority of adults diagnosed with Borderline Personality Disorder (81 percent) or
Dissociative Identity Disorder (90 percent) were sexually and/or physically abused as
children. (Herman et al., 1989; Ross et al., 1990)
• Women molested as children are four times more at risk for Major Depression as
those with no such history. They are significantly more likely to develop bulimia and
chronic PTSD. (Stein et al., 1988; Root & Fallon, 1988; Sloane, 1986; Craine, 1990)
• Childhood abuse can result in adult experience of shame, flashbacks, nightmares, severe
anxiety, depression, alcohol and drug use, feelings of humiliation and unworthiness, ugliness, and profound terror. (Harris & Landis, 1997; Rieker & Carmen, 1986; Herman,
1992; Janoff-Bulman & Frieze, 1983; van der Kolk, 1987; Brown & Finkelhor, 1986;
Rimsza, 1988)
• Adults abused during childhood are:
o more than twice as likely to have at least one lifetime psychiatric diagnosis
o almost three times as likely to have an affective disorder
o almost three times as likely to have an anxiety disorder
o almost two and a half times as likely to have phobias
o over ten times as likely to have a panic disorder
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What Can Happen to Abused Children When They
Grow Up—If No One Notices, Listens, or Helps?
SUICIDE AND SELF-INJURY
• There is a highly significant relationship between childhood sexual abuse and various
forms of self-harm later in life, i.e., suicide attempts, cutting, and self-starving, particularly. (van der Kolk et al., 1991)
• For adults and adolescents with childhood abuse histories, the risk of suicide is increased
4- to 12-fold. (Felitti et al., 1998)
• Most self-injurers have childhood histories of physical or sexual abuse. Forty percent of
persons who self-injure are men. (Graff & Mallin, 1967; Pattison & Kahan, 1983; Briere
& Runtz, 1988)
ALCOHOL AND DRUG ABUSE
• Nearly 90 percent of alcoholic women were sexually abused as children or suffered
severe violence at the hands of a parent. (Miller & Downs, 1993)
• Up to two-thirds of both men and women in substance abuse treatment report childhood
abuse or neglect. (SAMHSA CSAT, 2000)
• Teenagers with alcohol problems are 21 times more likely to have been sexually abused
than those without such problems. (Clark et al., 1997)
• Seventy-one to 90 percent of adolescent and teenage girls and 23 to 42 percent of adolescent and teenage boys in a Maine inpatient substance abuse treatment program reported
histories of childhood sexual abuse. (Rohsenow et al., 1988)
• HMO adult members who had experienced multiple childhood exposures to abuse and
violence had a 4- to 12-fold increased risk of alcoholism and drug abuse, and a 2- to 4fold increase in smoking. (Felitti et al., 1998)
• Adults abused during childhood are more than twice as likely as those not abused during
childhood to have serious substance abuse problems. (Stein et al., 1988)
• Fifty-five percent of Augusta Mental Health Institute class members with a dual diagnosis
of mental illness and substance abuse report histories of physical and/or sexual abuse.
(Maine BDS, 1998)
SERIOUS MEDICAL PROBLEMS AND HEALTH RISKS
• Medical impacts of childhood abuse include head trauma, brain injury, sexually transmitted diseases, unwanted pregnancy, HIV infection, physical disabilities (back injury,
orthopedic, neck, etc.) chronic pelvic pain, headaches, stomach pain, nausea, sleep
disturbance, eating disorder, asthma, shortness of breath, chronic muscle tension, muscle
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What Can Happen (continued)
o almost four times as likely to have an antisocial personality disorder (Stein et al., 1988)
• Ninety-seven percent of mentally ill homeless women have experienced severe physical
and/or sexual abuse. Eighty-seven percent experienced this abuse both as children and
as adults. (Goodman, Johnson, Dutton, & Harris, 1997)
DELINQUENCY, VIOLENCE, AND CRIMINAL BEHAVIOR
Reenactment of childhood victimization is the major cause of violence in our society.
• Numerous-studies have documented that most violent criminals were physically or sexually abused as children. (Groth, 1979; Seghorn et al., 1987)
• Over 95 percent of perpetrators who sexually abuse female children and over 80 percent
of those who abuse male children, are men. Most of these men were abused themselves in
childhood. (Fergusson & Mullen, 1999)
• Children from violent homes are 24 times more likely to commit sexual assault than their
counterparts from nonviolent homes. (Dinzinger, 1996)
• Of 14 juveniles condemned to death for murder in the United States in 1987, 12 had been
brutally physically abused and 5 had been sodomized by relatives as children. (Lewis et
al., 1998)
• A study of convicted killers reports 83.8 percent suffered severe physical and emotional
abuse and 32.2 percent were sexually violated as children. (Blake et al., 1995)
• Eighty-five percent of boys and girls committed to the Maine Youth Center report a history of childhood trauma. (MAYSI: Massachusetts Assessment Youth Screening Inventory
Assessment, Sept. 1999)
• Over 75 percent of juvenile girls identified as delinquent by courts have been sexually
abused. When they run away from the abuse at home, they are often labeled as delinquent. (Calhoun et al., 1993)
• Eighty percent of women in prison and jails have been victims of sexual and physical
abuse. These women are far more likely to be abused while in prison. (Smith, 1998)
• Without help, one-third of those abused in childhood may abuse or neglect their own
children, perpetuating an intergenerational cycle of abuse. (Kaufman & Zigler, 1987)
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spasms, elevated blood pressure. (Prescott, 1998; Cunningham et al., 1988, Morrison,
1989; Springs & Friedrich, 1992; Walker et al., 1988)
• Adults who had experienced multiple types of abuse and violence in childhood compared
to those who had not, had a 2- to 4-fold increase in smoking, poor self-rated health, 50+
sexual intercourse partners, sexually transmitted disease, a higher rate of physical inactivity, and severe obesity. (Felitti et al., 1998)
• A major HMO study reports adverse childhood exposures showed a relationship with the
presence of adult diseases, including ischemic heart disease, cancer, chronic lung disease,
skeletal fractures, and liver disease. (Felitti et al., 1998)
• Research reveals severe and prolonged childhood sexual abuse to underlie damage to
the brain structure, resulting in impaired memory, dissociation, and symptoms of PTSD.
(Briere, 1997; van der Kolk, 1996; Perry, 1994)
SEVERE SOCIAL PROBLEMS
Homelessness
• Seventy percent of women living on the streets or in shelters report abuse in childhood.
Over 70 percent of girls on the streets have run away to flee violence in their homes.
(Goodman, 1991; Chesney-Lind & Shelden, 1998)
Prostitution
• Victims of child sexual abuse are at high risk of becoming prostitutes in adolescence or as
adults. More than 50 percent of prostitutes were sexually abused as children. (Silbert &
Pines, 1981; Bagley & Young, 1987)
Poverty and Welfare
• More than 40 percent of women on welfare with multiple persistent problems in leaving
the welfare roles were sexually abused as children. (DeParle, 1999)
• Sixty percent of housed, low-income mothers on AFDC, experienced severe childhood
physical abuse and 42 percent were sexually molested as children. (Bassuk et al., 1998)
Truancy, Running Away, Risky Sexual Behavior
• Childhood abuse has been correlated with increased adolescent and young adult truancy,
running away, and risky sexual behavior. (Briere, 1997)
REVICTIMIZATION
Predators look for weak or vulnerable people. Having been abused as a child—especially
having been sexually abused, makes one vulnerable to being revictimized.
• Women who are sexually abused during childhood were 2.4 times more likely to be
revictimized as adults as women who were not sexually abused. (Wyatt et al., 1992)
• Sixty-eight percent of women with childhood history of incest reported incidents of rape
or attempted rape after age 14 compared to 38 percent of a random sample. (Russell,
1986)
• Girls who experience violence in childhood are three to four times as likely to be victims
of rape. (Browne, 1992)
• Childhood sexual assaults are associated with increased risk of adult assaults of both a
physical and sexual nature, whereas childhood physical assaults, by contrast, were not
related to adult victimization experiences. (Newman et al., 1998)
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DEVELOPMENTAL OR PHYSICAL DISABILITIES
• Violence is a significant causal factor in 10 to 25 percent of all developmental disabilities.
(Sobsey, 1994; Valenti-Hein & Schwartz, 1995)
• Three to 6 percent of all children will have some degree of permanent disability as a
result of abuse. (Sobsey, 1994; Valenti-Hein & Schwartz, 1995)
• Between 20 and 50 percent of abused children suffer mild to severe brain damage. (Rose
& Hardman, 1981)
References
SERIOUS MENTAL HEALTH PROBLEMS
Bryer, J.B., Nelson, B., Miller, J.B., & Krol, P. (1987). Childhood sexual and physical abuse as
factors in adult psychiatric illness. American Journal of Psychiatry, 144, 1426-1430.
Carmen, E., Rieker, P., & Mills, T. (1984). Victims of violence and psychiatric illness. American
Journal of Psychiatry, 141(3).
Craine, L.S., Henson, C.E., Colliver, J.A., et al. (1988). Prevalence of a history of sexual abuse
among female psychiatric patients in a State hospital system. Hospital and Community
Jacobson, A., & Richardson, B. (1987). Assault experiences of 100 psychiatric inpatients: Evidence
of the need for routine inquiry. American Journal of Psychiatry, 144, 908-913.
Augusta Mental Health Institute. (1988). Consent decree class member assessment. Augusta:
Maine Department of Mental Health, Mental Retardation and Substance Abuse Services.
Herman, J, Perry, C., & van der Kolk, B. (1989). Childhood trauma in Borderline Personality
Disorder. American Journal of Psychiatry, 164, 490-495.
Ross, C., Miller, S., Reagor, P., Bjornson, L., Fraser, G., & Anderson, G. (1990). Structured interview
data on 102 cases of Multiple Personality Disorder from four centers. Journal of Psychiatry, 147,
596-601.
Stein, J.A., Golding, J.M., Siegel, J.M., Burnam, M.A., & Sorenson, S.B. (1988). Long-term psychological sequelae of child sexual abuse: The Los Angeles Epidemiologic Catchment Area Study. In
G.E. Wyatt & G.J. Powell (Eds.), Lasting effects of child sexual abuse. (Sage Focus Ed., Vol. 100,
pp.135-154). Newbury Park, CA; Sage.
Root, M,, & Fallon. (1989). The Incidence of victimization experiences in a bulimic sample. Journal
of Interpersonal Violence, 4, 90-100.
Sloane, G., & Leichner, P. (1986). Is there a relationship between sexual abuse or incest and
eating disorders? Canadian Journal of Psychiatry, 31, 656-660.
Craine, P. Cited by Gondolf, E.W. (1990). Psychiatric responses to family violence: Identifying and
confronting neglected danger. Lexington, MA: Lexington Books.
Harris, M., & Landis. (Eds.). (1997). Sexual abuse in the lives of women diagnosed with serious
mental illness. Netherlands: Harwood Academic Publishers.
Page 5 of 9
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• Twice as many women with a history of incest as women without such a history are
victims of domestic violence, and twice as many also report unwanted sexual advances
by an unrelated authority figure. (Russell, 1986)
• Victims of father-daughter incest are four times more likely than non-incest victims to
be asked to pose for pornography. (Russell, 1986)
Herman, J. (1992). Trauma and recovery: The aftermath of violence—From domestic abuse to
political terror. New York: Basic Books.
Janoff-Bulman, R., & Frieze, I.H. (1983). A theoretical perspective for understanding reactions
to victimization. Journal of Social Issues, 39(2), 1-17.
van der Kolk, B.A. (Ed.). (1987). Psychological trauma. Washington, DC: American Psychiatric Press.
Brown, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the literature.
Psychological Bulletin, 99, 66-77.
Rimsza, M.E., Berg, R.A., & Locke, C. (1988). Sexual abuse: Somatic and emotional reactions.
Child Abuse and Neglect, 12(2), 201-8.
Goodman, L., Johnson, M., Dutton, M.A., & Harris, M. (1997). Prevalence and impact of sexual
and physical abuse. In M. Harris & Landis. (Eds.), Sexual abuse in the lives of women diagnosed
with serious mental illness. Netherlands: Harwood Academic Publishers.
SUICIDE AND SELF-INJURY
van der Kolk, B.A., Perry, J.C., & Herman, J.L. (1991). Childhood origins of self-destructive
behavior. American Journal of Psychiatry. 148, 1665-1671.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., &
Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the
leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American
Journal of Preventive Medicine, 14, 245-258.
Graff, H., & Mallin, R. (1967). The syndrome of the wrist cutter. American Journal of Psychiatry,
12A(1), 36-42.
Pattison, E.M., & Kahan, J. (1983). The deliberate self-harm syndrome. American Journal of
Psychiatry, 140(7), 867-872.
Briere, J., & Runtz, M. (1988). Post sexual abuse trauma. In G.E. Wyatt & G.J. Powell (Eds.),
Lasting effects of child sexual abuse. Newbury Park, CA: Sage.
ALCOHOL AND DRUG ABUSE
Miller, B., & Downs, W. (1993). Journal of Studies in Alcohol, Suppl. No. 11:109-117.
Center for Substance Abuse Treatment. (2000). Substance abuse treatment for persons with
child abuse and neglect issues. Treatment Improvement Protocol (TIP) Series, No. 36. (DHHS
Publication No. (SMA) 00-3357). Washington, DC: U.S. Government Printing Office
Clark, H.W., McClanahan, T.M., & Sees, K.L. (1997). Cultural aspects of adolescent addiction and
treatment. Valparaaiso University Law Review, 31(2).
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Rieker, P.P., & Carmen, E.H. (1986). The victim-to-patient process: The disconfirmation and
transformation of abuse. American Journal of Orthopsychiatry, 56(3).
Stein, J.A., Golding, J.M., Siegel, J.M., Burnam, M.A., & Sorenson, S.B. (1988). Long-term psychological sequelae of child sexual abuse: The Los Angeles Epidemiologic Catchment Area Study. In
G.E. Wyatt & G.J. Powell (Eds.), Lasting effects of child sexual abuse. (Sage Focus Ed., Vol. 100,
pp.135-154). Newbury Park, CA; Sage.
Augusta Mental Health Institute. (1988). Consent decree class member assessment. Augusta:
Maine Department of Mental Health, Mental Retardation and Substance Abuse Services.
SERIOUS MEDICAL PROBLEMS
Prescott, L. (1988). Women emerging in the wake of violence. Los Angeles: Prototype Systems
Change Center.
Cunningham, J., Pearce, T., & Pearce, P. (1988). Childhood sexual abuse and medical complaints in
adult women. Journal of Interpersonal Violence, 3, 131-144.
Morrison, J. (1989). Childhood sexual histories of women with somatization disorder. American
Journal of Psychiatry, 146, 239-241.
Springs, F., & Friedrich, W. (1993). Health risk behaviors and medical sequelae of childhood sexual
abuse. Mayo Clinic Proceedings.
Walker, E., Katon, W., Harrop-Griffiths, J., Holm, I., Russo, J., & Hickok, L (1988). Relationship
of chronic pelvic pain to psychiatric diagnosis and childhood sexual abuse. American Journal of
Briere, J. (1997). Child abuse trauma: Theory and tTreatment of the lasting effects. Newbury Park,
CA: Sage.
van der Kolk, B. (1996). The body keeps the score: Approaches to the psychobiology of posttraumatic stress disorder. In Van der Kolk et al. (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and dociety. Guilford Press.
Perry. (1994). Biological and neurobehavioral studies of Borderline Personality Disorder. In K. Silk
(Ed.) Progress in psychiatry, No. 45. American Psychiatric Press.
Page 7 of 9
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Rohsenow, D.J., Corbett, R., & Devine, D. (1988). Chemical Dependency Treatment Program,
Mid-Maine Medical Center, Waterville, ME: Molested as children: A hidden contribution to substance abuse? Journal of Substance Abuse Treatment, 5, 13-18.
Groth, A.N. (1979). Men who rape: The psychology of the offender. New York: Plenum.
Seghorn, T.K., Prentky, R.A., & Boucher, R.J. (1987). Childhood sexual abuse in the lives of sexually aggressive offenders. Journal of American Academy of Child and Adolescent Psychiatry,
26(2):262-267.
Fergusson, D., & Mullen, P. (1999). Childhood sexual abuse: An evidence-based perspective.
Newbury Park, CA: Sage.
Dinzinger, S. (1996). The real war on crime: The report of the National Criminal Justice
Commission. New York: Harper.
Lewis, D., Pincus, J., Bard, B., et al. (1988). Neuropsychiatric psychoeducational and family
characteristics of 14 juveniles condemned to death in the United States. American Journal
of Psychiatry, 145, 584-589.
Blake, B., Pincus, J.H., & Buckner, C. (1995). Neurologic abnormalities in murderers. Neurology,
45, 1641-1647.
MAYSI Massachusetts Assessment Youth Screening Inventory Assessment. September 1999
Calhoun, G., Jurgens,J., & Chen, F. (1993). The neophyte female delinquent: A review of the
literature. Adolescence, 28, 461-471.
Smith, B. (1998). An end to silence: Women prisoners’ handbook on identifying and addressing
sexual misconduct. National Women’s Law Center.
Kaufman. J., & Zigler, E. (1987). Do abused children become abusive parents? American Journal
of Orthopsychiatry, 57(2).
DEVELOPMENTAL OR PHYSICAL DISABILITIES
Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The end of silent
acceptance? Baltimore: Paul Brookes.
Valenti-Hein, D., & Schwartz, L. (1995). The sexual abuse interview for those with developmental
disabilities. Santa Barbara, CA: James Stanfield.
Rose, E., & Hardman, M.L. (1981). The abused mentally retarded child. Education and Training
of the Mentally Retarded, 16(2), 114-118.
SEVERE SOCIAL PROBLEMS
Homelessness
Goodman, L.A. (1991). The prevalence of abuse among homeless and housed poor mothers:
A comparison study. American Journal of Orthopsychiatry, 61(4), 489-500.
Chesney-Lind & Shelden. (1998, December). What to do about girls? Promising perspectives and
effective programs. ICCA Journal.
Page 8 of 9
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DELINQUENCY, VIOLENCE, AND CRIMINAL BEHAVIOR
Silbert, M.H. & Pines, A.M. (1981). Sexual child abuse as an antecedent to prostitution.
Child Abuse and Neglect, 5(4), 407-411.
Bagley, C., & Young, L. (1987). Juvenile prostitution and child sexual abuse: A controlled study.
Canadian Journal of Community Mental Health, 6, 5-26.
Poverty and Welfare
DeParle, J. (1999, November 28). Life after welfare. The New York Times.
Bassuk, E.L., Buckner, J.C., Perloff, J.N., & Bassuk, S.S. (1998). Prevalence of mental health and
substance use disorders among homeless and low-income housed mothers. American Journal of
Psychiatry, 155(11), 11.
Truancy, Running Away, Risky Sexual Behavior
Briere, J. (1997). Child abuse trauma: Theory and treatment of the lasting effects. Newbury Park,
CA: Sage.
REVICTIMIZATION
Wyatt, G.E., Guthrie, D., & Notgrass, C.M. (1992). Differential effects of women’s child sexual
abuse and subsequent sexual revictimization. Journal of Consulting and Clinical Psychology, 60,
167-173.
Russell, D.E.H. (1986). The secret trauma: Incest in the lives of girls and women. New York: Basic
Books.
Browne, A. (1992). Violence against women: Relevance for medical practitioners. Council on
Scientific Affairs, American Medical Association report. Journal of American Medical Association,
257, 23.
Newmann, J.P., Greenley, D., Sweeney, J.K., & Van Dien, G. (1998). Abuse histories, severe mental
illness, and the cost of care. In B.L. Levin, A.K. Blanch, & A. Jennings (Eds.), Women’s mental
health services: A public health perspective (pp. 279-308). Newbury Park, CA:Sage.
These references were prepared by the Office of Trauma Services, Department of Behavioral and
Developmental Services, 40 State House Station, Augusta, ME 04333.
Phone: 207-287-4250
TTY: 207-287-2000
Fax: 207-287-7571
E-mail: [email protected]
January, 2001
Page 9 of 9
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Prostitution
Some Common Reactions to Trauma
Physical Reactions
Nervous energy,
jitters, muscle tension
Mental Reactions
Emotional
Reactions
Changes in the way
you think about
yourself
Fear, inability to
feel safe
Upset stomach
Rapid heart rate
Dizziness
Lack of energy,
fatigue
Teeth grinding
Sadness, grief,
depression
Changes in the way
you think about the
world
Guilt
Inability to enjoy
anything
Becoming confrontational and aggressive
Change in eating
habits
Loss or gain in weight
Loss of trust
Restlessness
Lessened awareness,
disconnection from
yourself (dissociation)
Loss of self-esteem
Feeling helpless
Difficulty concentrating
Intrusive images
Easily startled
Avoiding places or
situations
Numbness, lack of
feelings
Heightened
awareness of
your surroundings
(hypervigilance)
Difficulty making
decisions
Becoming withdrawn
or isolated from
others
Anger, irritability
Changes in the way
you think about other
people
Poor attention or
memory problems
Behavioral
Reactions
Increase or decrease
in sexual activity
Emotional distance
from others
Intense or extreme
feelings
Feeling chronically
empty
Blunted, then
extreme, feelings
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by Mary S. Gilbert, Ph.D.
Trauma Assessment for DMH Facilities/Vendors
This form is a guide to gathering information with clients about a possible trauma history.
It is recommended for use as part of the intake assessment for all DMH clients in all settings
(inpatient, outpatient, emergency/crisis, day treatment, etc.). It should be used in conjunction
with the De-Escalation Form. After clinical review, information obtained should be incorporated into the client’s treatment plan.
1. Do you have a history of physical abuse (e.g., hit, punched, slapped, kicked,
strangled, burned, threatened with object or weapon, etc.)?
Yes___
No___
Don’t Know ___
If yes, in childhood? ___
adolescence? ___
adulthood? ___
at present? ___
By whom?
stranger ___
acquaintance ___
partner/spouse ___
parents ___
other family member ___
ritual abuse ___
2. Do you have a history of sexual abuse (e.g., unwanted kissing, hugging, touching,
nudity, attempted or completed intercourse)?
Yes___
No___
Don’t Know ___
adolescence? ___
adulthood? ___
at present? ___
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Commonwealth of Massachusetts
Department of Mental Health
Trauma Assessment (continued)
stranger ___
acquaintance ___
parents ___
partner/spouse ___
3. Have you ever been raped?
Yes___
No___
Don’t Know ___
adolescence? ___
adulthood? ___
recently? ___
By whom?
stranger ___
acquaintance ___
partner/spouse ___
parents ___
ritual abuse ___
4. Have you experienced an acute trauma such as a natural disaster, severe accident,
or threat to life, or have you witnessed a death or violence to someone else, or been a
victim of a crime?
Yes__
No __
Don’t Know ___
If yes, at what age and circumstances?
________________________________________________________________________
________________________________________________________________________
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By whom?
Trauma Assessment (continued)
Yes ___
No___
If yes, describe.
________________________________________________________________________
________________________________________________________________________
Please incorporate the information obtained in the trauma assessment into the treatment
plan for this client.
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5. If yes to any of the above, are you experiencing flashbacks, nightmares, insomnia,
numbness, confusion, memory loss, self injury, extreme fearfulness or terror, etc.,
related to the trauma?
Guidelines for De-Escalation Preference Form
1. The De-Escalation Preference Form should be completed within 24 to 72 hours of
admission.
2. It is preferable that this form not be included in the admission packet or completed along
with admission forms because most clients are not emotionally prepared to focus on these
questions during that time.
3. The form may be administered during an individual interview or a group session. Even though
the material is sensitive, it is often helpful to administer it in a group session. Persons sitting
together at a table may feel more comfortable talking about the information while they answer
the questions and may also encourage others to complete the form more thoughtfully. A group
setting offers a more informational-type gathering as opposed to a clinical setting. If given during a group session, there should be several staff members present to help individuals who need
support or assistance with reading, understanding, or answering the questions.
4. Careful consideration should be given as to who will administer the form. Ideally, it
should always be the same person, someone who is both familiar and comfortable with the
material. A consumer advocate employed by the hospital would be ideal, because peers are
often less threatening than professional staff. It must be understood by the person administering the form that the form is not presented as treatment or therapy, but as helpful information that can be included in the treatment plan.
5. To effectively provide information, persons administering the form should be knowledgeable
about the material. For example, it is helpful for a person to learn about additional efforts
that are being made at the hospital to reduce seclusion and restraint and how this information
will be used as part of that process. These persons should be able to answer questions about
the request for sensitive information. For example, it is important that the information about
touching at the hospital be presented as promoting appropriate, not inappropriate, touching.
6. When patients are not communicative enough to answer a question, they may be provided
an opportunity to answer the question at another time, if they so desire.
7. Patients must always be given the option to decline answering a question.
8. The form, when completed, should be placed in the patient’s file where it is known and
used effectively by staff.
9. Persons served should be told how the form is to be used. They should be given a copy of
the form to keep.
It may be helpful for the hospital to collect data on answers to these questions to
54
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by Gayle Bluebird
identify patterns and trends that are important to patients.
De-Escalation Form for DMH Facilities/Vendors
This form is a guide to gathering information with clients for the development of strategies
to de-escalate agitation and distress so that restraint and seclusion can be averted. It should
be used in conjunction with the Trauma Assessment Form. It is recommended for use in all
inpatient facilities, psychiatric emergency rooms, crisis stabilization and other diversion
units, when clinically indicated. Indications include a past history or likelihood of loss of
control of aggressive impulses. After clinical review, the information obtained should be
incorporated into the treatment plan for this client.
1. It is helpful for us to be aware of the things that can help you feel better when you’re
having a hard time. Have any of the following ever worked for you? We may not be
able to offer all these alternatives, but I’d like us to work together to figure out how
we can best help you while you’re here.
o voluntary time out in your room
o exercise
o listening to music
o using ice on your body
o voluntary time out in quiet room
o deep breathing exercises
o reading a newspaper/book
o putting hands under cold water
o sitting by the nurses station
o going for a walk with staff
o watching TV
o lying down with cold facecloth
o talking with another consumer
o taking a hot shower
o pacing the halls
o wrapping up in a blanket
o talking with staff
o other (please list)
o writing in a diary/journal
o calling a friend
_________________________________
o having your hand held
_________________________________
o calling your therapist
_________________________________
o having a hug
o pounding some clay
o punching a pillow
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Commonwealth of Massachusetts
Department of Mental Health
De-Escalation Form (continued)
Would you like them to come and visit you? (Y/N)
Can we assist in this process? (Y/N)
If you are in a position where you are not able to give us information to further your
treatment, do we have your permission to call and speak to
______________________________ (name) _________________ (phone)? (Y/N)
If you agree that we can call to get information, sign below:
Client signature _______________________
Date ______________
Witness _____________________________
Date ______________
3. What are some of the things that make it more difficult for you when you’re already
upset?
Are there particular “triggers” that you know will cause you to escalate?
o being touched
o being isolated
o bedroom door open
o people in uniform
o particular time of day (when?)
o time of the year (when?)
o loud noise
o yelling
o not having control/input (explain)
o other (please list)
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2. Is there a person who has been helpful to you when you’re upset? (Y/N)
Physically/Mechanically
Chemically
When?
Where?
What happened?
5. If you are escalating or in danger of hurting yourself or someone else, we may need to
use a physical, mechanical, or chemical restraint. We may not be able to offer you all
of these alternatives, but if it becomes necessary, we’d like to know your preferences.
o Quiet room
o Seclusion
o Physical hold
o Safety coat
o Papoose board
o 3-point restraint
Face up? ____
Face down? ____
o 4-point restraint
Face up? ____
Face down? ____
o Chemical restraint
6. Do you have a preference regarding the gender of staff assigned to you during and
immediately after a restraint?
o Women staff
o Men staff
o No preference
7. Is there anything that would be helpful to you during a restraint? Please describe.
_______________________________________________________________________
_______________________________________________________________________
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4. Have you ever been restrained in a hospital or other setting—for example, in a crisis
stabilization unit or at home?
________________________________________________________________________
________________________________________________________________________
9. We do room checks here to make sure you are okay at night. We are trying to make
these room checks as nonintrusive as possible. Is there anything that would make
room checks more comfortable for you?
_______________________________________________________________________
_______________________________________________________________________
Please incorporate the information obtained in the de-escalation form into the
treatment plan for this client.
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8. We may be required to administer medication if physical restraints aren’t calming
you down. In this case, we would like to know what medications have been especially
helpful to you. Please describe.
Things You Can Do Every Day to Help Yourself Feel Better
There are many things that happen every day that can cause you to feel ill, uncomfortable,
upset, anxious, or irritated. You will want to do things to help yourself feel better as quickly
as possible, without doing anything that has negative consequences, for example, drinking,
committing crimes, hurting yourself, risking your life, or eating lots of junk food.
• Read through the following list. Check off the ideas that appeal to you and give each of
them a try when you need to help yourself feel better. Make a list of the ones you find to
be most useful, along with those you have successfully used in the past, and hang the list
in a prominent place—like on your refrigerator door—as a reminder at times when you
need to comfort yourself. Use these techniques whenever you are having a hard time or as
a special treat to yourself.
• Do something fun or creative, something you really enjoy, like crafts, needlework, painting, drawing, woodworking, making a sculpture, reading fiction, comics, mystery novels,
or inspirational writings, doing crossword or jigsaw puzzles, playing a game, taking some
photographs, going fishing, going to a movie or other community event, or gardening.
• Get some exercise. Exercise is a great way to help yourself feel better while improving
your overall stamina and health. The right exercise can even be fun.
• Write something. Writing can help you feel better. You can keep lists, record dreams,
respond to questions, and explore your feelings. All ways are correct. Don’t worry about
how well you write. It’s not important. It is only for you. Writing about the trauma or
traumatic events also helps a lot. It allows you to safely process the emotions you are
experiencing. It tells your mind that you are taking care of the situation and helps to relieve the difficult symptoms you may be experiencing. Keep your writings in a safe place
where others cannot read them. Share them only with people you feel comfortable with.
You may even want to write a letter to the person or people who have treated you badly,
telling them how it affected you, and not send the letter.
• Use your spiritual resources. Spiritual resources and making use of these resources
vary from person to person. For some people it means praying, going to church, or reaching out to a member of the clergy. For others it is meditating or reading affirmations and
other kinds of inspirational materials. It may include rituals and ceremonies—whatever
feels right to you. Spiritual work does not necessarily occur within the bounds of an organized religion. Remember, you can be spiritual without being religious.
• Do something routine. When you don’t feel well, it helps to do something “normal”—
the kind of thing you do every day or often, things that are part of your routine, like
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Excerpt from Dealing With the Effects of Trauma:
A Self-Help Guide
Things You Can Do (continued)
• Wear something that makes you feel good. Everybody has certain clothes or jewelry
that they enjoy wearing. These are the things to wear when you need to comfort yourself.
• Get some little things done. It always helps you feel better if you accomplish something, even if it is a very small thing. Think of some easy things to do that don’t take
much time. Then do them. Here are some ideas: clean out one drawer, put five pictures
in a photo album, dust a book case, read a page in a favorite book, do a load of laundry,
cook yourself something healthful, send someone a card.
• Learn something new. Think about a topic that you are interested in but have never
explored. Find some information on it in the library. Check it out on the Internet. Go to
a class. Look at something in a new way. Read a favorite saying, poem, or piece of scripture, and see if you can find new meaning in it.
• Do a reality check. Checking in on what is really going on rather than responding to
your initial “gut reaction” can be very helpful. For instance, if you come in the house
and loud music is playing, it may trigger the thinking that someone is playing the music
just to annoy you. The initial reaction is to get really angry with them. That would make
both of you feel awful. A reality check gives the person playing the loud music a chance
to look at what is really going on. Perhaps the person playing the music thought you
wouldn’t be in until later and took advantage of the opportunity to play loud music. If you
would call upstairs and ask him to turn down the music so you could rest, he probably
would say, “Sure!” It helps if you can stop yourself from jumping to conclusions before
you check the facts.
• Be present in the moment. This is often referred to as mindfulness. Many of us spend
so much time focusing on the future or thinking about the past that we miss out on fully
experiencing what is going on in the present. Making a conscious effort to focus your
attention on what you are doing right now and what is happening around you can help
you feel better. Look around at nature. Feel the weather. Look at the sky when it is filled
with stars.
• Stare at something pretty or something that has special meaning for you. Stop what
you are doing and take a long, close look at a flower, a leaf, a plant, the sky, a work of art,
a souvenir from an adventure, a picture of a loved one, or a picture of yourself. Notice
how much better you feel after doing this.
• Play with children in your family or with a pet. Romping in the grass with a dog,
petting a kitten, reading a story to a child, rocking a baby, and similar activities have a
calming effect which translates into feeling better.
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taking a shower, washing your hair, making yourself a sandwich, calling a friend or
family member, making your bed, walking the dog, or getting gas in the car.
Things You Can Do (continued)
• Expose yourself to something that smells good to you. Many people have discovered
fragrances that help them feel good. Sometimes a bouquet of fragrant flowers or the smell
of fresh baked bread will help you feel better.
• Listen to music. Pay attention to your sense of hearing by pampering yourself with delightful music you really enjoy. Libraries often have records and tapes available for loan.
If you enjoy music, make it an essential part of every day.
• Make music. Making music is also a good way to help yourself feel better. Drums and
other kinds of musical instruments are popular ways of relieving tension and increasing
well-being. Perhaps you have an instrument that you enjoy playing, like a harmonica,
kazoo, penny whistle, or guitar.
• Sing. Singing helps. It fills your lungs with fresh air and makes you feel better. Sing to
yourself. Sing at the top of your lungs. Sing when you are driving your car. Sing when
you are in the shower. Sing for the fun of it. Sing along with favorite records, tapes, compact discs, or the radio. Sing the favorite songs you remember from your childhood.
Perhaps you can think of some other things you could do that would help you feel better.
Source: U.S. Department of Health and Human Services. (2002). Dealing With the Effects of
Trauma: A Self-Help Guide. DHHS Pub. No. SMA-3717. Rockville, MD: Center for Mental Health
Services, Substance Abuse and Mental Health Services Administration. www.mentalhealth.org/
publications/allpubs/SMA-3717/things.asp
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• Do a relaxation exercise. There are many good books available that describe relaxation
exercises. Try them to discover which ones you prefer. Practice them daily. Use them
whenever you need to help yourself feel better. Relaxation tapes that feature relaxing music or nature sounds are available. Just listening for 10 minutes can help you feel better.
• Take a warm bath. This may sound simplistic, but it helps. If you are lucky enough to
have access to a Jacuzzi or hot tub, it’s even better. Warm water is relaxing and healing.
Grounding refers to methods for stopping the re-experiencing of a trauma, or related symptom, and getting back to the here and now. Often those with a trauma history experience such
symptoms as flashbacks (a sudden, vivid memory of the event) or dissociation (various ways
of disconnecting with traumatic experiences mentally, emotionally, or both by disconnecting in current reality). These symptoms happen against the consumer’s will and feel out of
control. A staff member can often help ground consumers by asking questions or directing
them based on the suggestions below. Learning and applying grounding techniques are very
important parts of consumers gaining some control over these symptoms.
When a consumer reports/appears unusually anxious or vulnerable, is nonresponsive,
or is reacting in other ways suggestive of re-experiencing a trauma:
As an overall guide, mainly try to help the consumer focus on something in one or more of
the five senses in the present: sight, smell, hearing, taste, or touch.
• Crucial to maintain visual contact with environmental cues.
o Make sure the consumer is in a well-lit area—stay out of dark or dim areas, or turn on
the lights. Recommend a night-light. (Beware of nighttime—darkness, fatigue, and a
history of evening sexual abuse are often problems.)
o Don’t allow hiding in dark or confined places, even if s/he feels frightened or disorganized. Make sure eyes remain open.
o Assist the consumer in looking at and focusing on things around her/him. For example, describe the color of the walls or carpet. Or, if s/he has a favorite object, like a
stuffed animal, give that to her/him and assist the person in noticing how it looks, feels,
and smells. (Focusing on familiar, comforting objects helps the consumer remain in or
return to the present.)
o Present previously developed flashcards that assist the consumer in recognizing s/he is
only experiencing a flashback, not reality. (Statements on the cards need to come from
the consumer.) These can also be placed on a mirror, for example, so you can direct the
consumer’s attention to them when necessary.
• Maintain personal contact with the consumer.
o Say that person’s name and identify yourself. Tell him/her where s/he is and the full
date. Keep repeating this in reassuring, but 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 with the consumer. If
frightened by eye contact, redirect to a different part of your body, like hair or shirt.
Ask the consumer to move her/his eyes so as not to go into a daze. Be firm and direct.
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by Mary S. Gilbert, Ph.D.
Grounding Techniques (continued)
Source: Mary S. Gilbert, 2001. Partially adapted from Rebuilding Shattered Lives by Chu; and
Courtois & Briere.
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o Remind the consumer of significant others, such as a child or partner, if appropriate.
(These interpersonal connections can be very grounding.)
• Direct the consumer to focus on a physical sensation.
o Ask the consumer to start naming what s/he sees in the room, or what color her/his
shirt is, etc.
o 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 (try stamping feet) around the
room and notice all that s/he sees and feels. (These help remind the consumer that s/he
is in reality here and now, not a part of a memory or reliving the event.)
o Recommend the consumer get in the “in control” body posture.
• Focus on the present.
o 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.
o Call the consumer’s attention to a calendar and/or a clock and help him/her figure out
what day and time it is. (Again, this can help the consumer realize s/he is not back in
the midst of the trauma and return to the present.)
o Ask the consumer questions about the present, like what TV shows s/he likes, or
plans for the weekend, or the first thing s/he wants to do when s/he gets home.
o Ask the consumer about her/his interests or activities, such as recreational activities or
a pet. Don’t choose anything emotionally charged or related to his/her trauma.
o Direct and assist in writing or drawing about something positive. (These activities can
often be soothing.)
• After a period of loss of control:
o Help reassure consumer and normalize event/current situation.
o If consumer is able, assist with relaxation techniques to help consumer further calm down.
o Try to identify what causes the consumer’s symptoms. Attempt to determine any possible external triggers. Help the consumer identify preceding internal emotional events
or states. 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.
o Determine body postures that accompany feelings of being flooded and/or overwhelmed, as well as in control/adult body postures. Help the consumer describe and
practice the “in control” posture.
o Plan new ways to attempt to cope with stress in the future (e.g., redirecting, transitional
object, relaxation, etc.).
o Develop a crisis response plan for the next occurrence. Plan a simple strategy and note
what techniques worked best with consumer.
WEB SITES RELATED TO TRAUMA
www.childtrauma.org
The Child Trauma Academy is a nonprofit organization based in Houston, TX. The mission
of the Academy is to help improve the lives of traumatized and maltreated children and their
families. The Academy encourages innovations in clinical practice, program development,
and public policy. Many individuals and organizations share the Academy’s vision and hopes
for children; it is a central operating principle of the Academy to seek out, support, and work
side by side with these individuals and organizations—both public and private.
www.sidran.org
The Sidran Institute is a leading provider of traumatic stress education, publications, and resources. It is a national nonprofit organization dedicated to supporting people with traumatic
stress conditions, providing education and training on treating and managing traumatic stress,
providing trauma-related advocacy, and informing the public on issues related to traumatic
stress. Sidran is also a leading publisher of books about traumatic stress.
David Baldwin’s Trauma Information Pages—www.trauma-pages.com
These pages focus primarily on emotional trauma and traumatic stress, including PTSD
(Post-Traumatic Stress Disorder), whether following individual traumatic experience(s) or a
large-scale disaster. New information is added to this site about once a month. The purpose of
this site is to provide information for clinicians and researchers in the traumatic stress field.
Baldwin’s interests include both clinical and research aspects of trauma responses and their
resolution. For example,
1. What goes on biologically in the brain during traumatic experience and its resolution?
2. Which psychotherapeutic procedures are most effective for which patients with traumatic
symptoms, and why?
3. How can we best measure clinical efficacy and treatment outcome for trauma survivor
populations?
Supportive resources supplement the more academic or research information of interest to
clinicians, researchers, and students.
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www.rossinst.com
The Colin A. Ross Institute was formed to further the understanding of psychological trauma
and its consequences by providing educational services, research, and clinical treatment of
trauma-based disorders.
RESOURCES ON SECONDARY TRAUMA
Located in South Windsor, CT, the Traumatic Stress Institute has a dual mission: (1) to
promote understanding and improve treatment of traumatic stress and (2) to promote
psychology as a discipline and profession. This Institute has developed some very useful
resources for professionals struggling with secondary traumatic stress.
The Traumatic Stress Institute
Center for Adult and Adolescent Psychotherapy
22 Morgan Farms Drive
South Windsor, CT 06074
(860) 644-2541
www.tsicaap.com
The Traumatology Institute
The Traumatology Institute is the home of psychologist Dr. Charles Figley, a pioneer in the
field of compassion fatigue or secondary trauma. Dr. Figley is the founding editor of the
Journal of Traumatic Stress and has written many articles and books on compassion fatigue
or secondary traumatic stress.
The Traumatology Institute
School of Social Work
Florida State University
2407C University Center
Tallahassee, FL 32306-2570
(850) 644-4751
mailer.fsu.edu/~cfigley/TraumatologyInstitute.html
International Society for Traumatic Stress Studies (ISTSS)
ISTSS, founded in 1985, provides a forum for the sharing of research, clinical strategies,
public policy concerns, and theoretical formulations on trauma in the United States and
around the world. ISTSS is dedicated to the discovery and dissemination of knowledge and
to the stimulation of policy, program, and service initiatives that seek to reduce traumatic
stressors and their immediate and long-term consequences.
ISTSS
60 Revere Drive, Suite 500
Northbrook, IL 60062
(847) 480-9028
Fax: (847) 480-9282
www.istss.org
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The Traumatic Stress Institute/Center for Adult and Adolescent Psychotherapy
Resources on Secondary Trauma (continued)
APSAC’s mission is to ensure that everyone affected by child maltreatment receives the best
possible professional response. This organization has many useful scholarly and clinical
materials focused primarily at the professional audience. Nonetheless, caregivers working
with abused or maltreated children may find this a useful resource.
APSAC
P.O. Box 30669
Charleston, SC 29417
(843) 764-2905
Toll-free: (877) 402-7722
Fax: (803) 753-9823
www.apsac.org
The National Center for PTSD
The National Center for PTSD is a program of the U.S. Department of Veterans Affairs
and carries out a broad range of activities in research, training, and public information.
The primary focus of the Center has been combat veterans and their families. Over the last
few years, however, this focus has been expanded. The Center has many useful programs,
activities, and resources for anyone interested in the effects of traumatic stressors.
The PILOTS database is an electronic index to the worldwide literature on PTSD and other
mental health sequelae of exposure to traumatic events. It is available to Internet users
through the courtesy of Dartmouth College, whose computer facilities serve as host to the
database. No account or password is required, and there is no charge for using the PILOTS
database.
The National Center for PTSD
www.ncptsd.org
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American Professional Society on the Abuse of Children (APSAC)
Blanch, A., & Parrish, J. (1993). Alternatives to involuntary treatment: Results of three roundtable
discussions. Bethesda, MD: National Institute of Mental Health.
Bolen, J.D. (1993). The impact of sexual abuse on women’s health. Psychiatric Annals, 23(8),
446-453.
Brennen, K. (1997). Adult survivors of childhood sexual abuse in the mental health system:
Involuntary intervention, retraumatization and staff training. Tampa, FL: Department of
Community Health.
Cahill, C., Stuart, G., Laraia, M., & Arana, G. (1991). Inpatient management of violent behavior:
Nursing prevention and intervention. Issues in Mental Health Nursing, 12, 239-252.
Chu, J.A. (1998). Rebuilding shattered lives: Treating complex post-traumatic and dissociative
disorders. New York: Wiley.
Copeland, M.E. (2002). Dealing with the effects of trauma. DHHS Publication No. SMA-3717.
Rockville, MD: U.S. Department of Health and Human Services.
Doob, D. (1992). Female sexual abuse survivors as patients: Avoiding retraumatization. Archives
of Psychiatric Nursing, 6, 245-251.
Flynn, H. (1996, July). Mental health policy issues related to the use of seclusion and restraint
with adult survivors of childhood sexual abuse. Paper presented at the Florida Mental Health
Institute, Tampa, FL.
Gilbert, M.S. (2002). Materials from presentation at Pine Rest Hospital, Grand Rapids, MI.
Goren, S., Abraham, I., & Doyle, N. (1996) Reducing violence in a child psychiatric hospital
through planned organizational change. Journal of Child and Adolescent Psychiatric Nursing,
9(2), 27-36.
Hammond, W. (1996. January 7). Facing sexual abuse: State mental health system changing
treatment methods. Gazette Reporter.
Harris, D., & Morrison, E. (1995). Managing violence without coercion. Archives of Psychiatric
Nursing, 9(2), 203-210.
Jennings, A. (1994). Imposing stigma from within: Retraumatizing the victim. Resources,
6(3) 11-15.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1995). Accreditation
manual for mental health, chemical dependency, and mental retardation/developmental disability services. Vol.1, Standards; Vol. 2, Scoring guidelines. Oakbrook Terrace, IL: Author.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1999). Testimony at
Senate hearings.
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Bills, L. (1996). Abuse: Connecting the past with present symptoms. Office of Mental Health
Quarterly, 2, 13-15.
Maine Office of Trauma Services. (2001). What can happen to abused children when they grow up
if no one notices, listens, or helps? Augusta, ME: Maine Department of Mental Health, Mental
Retardation, and Substance Abuse Services.
Maine Trauma Advisory Groups. (1997). In their own words: Trauma survivors and professionals
they trust tell what hurts, what helps, and what is needed for trauma services. Augusta, ME:
Maine Department of Mental Health, Mental Retardation, and Substance Abuse Services.
Massachusetts Department of Mental Health. (1995). Trauma assessment for Department
of Mental Health facilities/vendors. Boston: Author.
Massachusetts Department of Mental Health (1996) Clinical guidelines: Department of Mental
Health clients with a history of trauma. Boston: Author.
National Association of Consumer/Survivor Mental Health Administrators. (1998). Trauma and
abuse histories: Connections to diagnosis of mental illness, implications for policy and service
delivery. Unpublished position paper.
Voices Survey. Unpublished.
National Association of State Mental Health Program Directors (NASMHPD). (1998). Position
statement on services and supports to trauma survivors. Alexandria, VA: Author.
Ridgely, S., & Van den Berg, P. (1997. April). Women and coercion: Commitment, involuntary
treatment, and restraint. Tampa, FL: Louis de la Parte Florida Mental Health Institute,
Department of Mental Health Law and Policy.
U.S. Department of Health and Human Services (DHHS). (2002). Dealing with the effects of
trauma: A self-help guide. Rockville, MD: Author. Online at www.mentalhealth.samhsa.gov.
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Kabat-Zinn, J. (1991). Full catastrophe living: Using the wisdom of your body and mind to face
stress, pain, and illness. New York: Delta.
MODULE 3
Creating Cultural Change
1
MODULE 3
“The hospital’s culture dictates whether, in what circumstances, and
how often seclusion and restraint interventions are used.”
—Ira Burnim, Bazelon Center for Mental Health Law
(Networks, Summer 1999)
“It’s not possible to solve a problem with the
same consciousness that created it.”
—Albert Einstein
Learning Objectives
• Understand seclusion and restraint from a primary, secondary, and tertiary public health
prevention model.
• Identify key components of successful programs that are eliminating seclusion and
restraint.
• Outline the key elements of cultural change, including intrapersonal change, interpersonal
change, and system change.
• Define safety from both a service recipient perspective and service provider perspective.
• Describe what consumers say would be helpful in preventing the use of seclusion and
restraint.
Module 3
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MODULE 3: CREATING CULTURAL CHANGE
Presentation (3 hours) . . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: “Flowers Are Red” (10 minutes). . . . . . . . . . .
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pennsylvania: A Model for Reform. . . . . . . . . . . . . . . . . .
Video: Leading the Way: Toward a Seclusion and . . . . .
Restraint Free Environment (17.5 minutes)
Cultural Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: “My Organizational Culture Currently Is…” . . .
(30 minutes)
Exercise: “People With a Mental Health Diagnosis Are…”
(15 minutes)
In Our Own Voices . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: What Would Have Been Helpful to Hear . . . . .
(15 minutes)
Handouts for Participants . . . . . . . . . . . . . . . . . . . . . . .
“Flowers Are Red” . . . . . . . . . . . . . . . . . . . . . . . . . . . .
“My Organizational Culture Currently Is…”. . . . . . . . . . . .
NASMHPD Review of Literature Related to Safety and Use
of Seclusion and Restraint
What Would Have Been Helpful in Preventing the Use . . .
of Seclusion and Restraints for You?
What Would Have Been Helpful for You to Hear? . . . . . . .
What Other Options May Have Been Beneficial?. . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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3
Overview
“Seclusion and restraint are not treatment; they reflect treatment failure.” —Charles Curie,
former Pennsylvania Deputy Secretary for Mental Health and Substance Abuse (Pennsylvania Department of Public Welfare, 2001)
Changing the culture of violence and coercion in mental health settings is crucial to the
elimination of seclusion and restraint. A working definition of cultural change is
• Lasting structural and social changes (within an organization or set of linked
organizations), PLUS
• Lasting changes to the shared ways of thinking, beliefs, values, procedures, and
relationships of the stakeholders (Allison Scammel, 1997)
An organization’s culture is determined by its policies and rules, both written and unwritten,
and by the acceptance of these policies and rules by key stakeholders. Cultural change often
requires a re-examination not only of the organization’s policies and rules, but of values,
beliefs, and the relationships between all stakeholders (administrators, direct care staff, and
consumers). This re-examination is often difficult because of the long-standing stigma and
discrimination associated with mental illness.
The National Association of State Mental Health Program Directors (NASMHPD) has issued
a report on the issue of the use of seclusion and restraint. It states in part, “this issue is about
how mental health systems treat the people they serve. If the goals of the public mental health
system are to treat people with dignity, respect, and mutuality, to protect people’s rights, to
provide the best quality care possible, and to assist people in their recovery, any use of seclusion and restraint must be rigorously scrutinized...In addition, using power to control people’s
behavior or to resolve arguments can lead to escalation of conflict and can ultimately result in
serious injury or even death.” (NASMHPD, 1999)
Rodney Copeland, former Vermont Commissioner, also has expressed strong views on the
need for cultural change within the mental health system. According to Copeland, “Recent
national exposés revealed alarming numbers of youth and adults with emotional disorders,
mental illnesses, and/or developmental disabilities dying as a result of seclusion and restraint
in treatment programs…I believe a major part of the answer lies in the overemphasis, even
dependency, in our treatment and rehabilitation practices on power, control, paternalism, and
ultimately coercion. Put another way, the mental health and developmental disabilities fields
have not clearly offered alternative practices to old styles of control, which can often lead to
significant levels of coercion. Deliberate examination of coercive practices viewed through
Module 3
4
BACKGROUND
CREATING CULTURAL CHANGE
Will Pflueger, a consumer from Minnesota, sums it up perfectly. “The terror of confinement,
the pain of restraint and the wound to my soul made me want to stay as far away from the
mental health system as possible.”
Ideas for Eliminating Coercion
(Source: Vermont’s Vision of a Public System for Developmental and Mental Health Services
Without Coercion by Rodney E. Copeland, Ph.D., Commissioner, Vermont Department of
Developmental and Mental Health Services, Fall/Winter 1999-2000)
• It is important that consumers have control over their own treatment and recovery.
• Educate providers and hospitals on the importance of the “partnership concept” with
consumers.
• Separate the issues around medications that “control behavior” versus the ones that
“make people feel better.”
• One size does not fit all—there are unique paths to recovery.
• Make full use of self-determination principles that allow citizens to take control of their
system of care and support.
• Make better use of each consumer’s knowledge of himself or herself.
• Make full use of informal alternatives, natural supports, and family/consumer-run
supports.
• Emphasize prevention and public health approaches.
• Adults with severe mental illness and developmental disabilities could benefit from a
prevention approach.
• Encourage ambitious public involvement and education for the community at large
regarding natural supports.
• Develop informal and, if necessary, formal systems to engage early on with citizens who
have previously experienced very coercive situations in our formal systems of care. This
early intervention and engagement would have the goal of preventing individuals from
experiencing the formal system as they had in the past.
• Once involved with the formal system, have more choice and chance to do the consumer’s
own work toward recovery.
• Positively address the culture of agencies regarding professional control.
• Develop grievance procedures that have a strong procedural justice base.
• Encourage the employment of consumers at all levels, including involuntary care settings.
• Have the option of peer support and self-advocacy support coming into the formal system.
Module 3
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BACKGROUND
the lenses of consumers in addition to scientific and clinical knowledge can assist us in the
shift away from coercion to positive practices. Consumer stories of experiencing coercion
are very powerful. One only has to listen briefly to hear the pervasive chilling and, in reality,
killing effect coercion has on the human spirit. None of us like coercion in any of its forms
applied to us. All coercion, regardless of its forms, damages and hurts.” (Copeland, 19992000, Fall-Winter)
(Source: www.power2u.org/downloads/Pennsylvania_S&R_Initiative.pdf)
In 1997, the Pennsylvania Department of Public Welfare instituted an aggressive program to
reduce and ultimately eliminate seclusion and restraints in its nine State hospitals. Charles
Curie, former Deputy Secretary of Mental Health and Substance Abuse Services, articulated
the philosophy behind the change in policy: “Most of our patients are already the victims
of trauma. There is no need to reinforce that trauma, or to retraumatize.” Three years later,
Pennsylvania had reduced incidents of seclusion and restraint in its nine State hospitals by
74 percent, and reduced the number of hours consumers spent in seclusion and restraints by
96 percent. Its program, which includes both forensic and civil commitments, has the highest
standards for seclusion and restraint in the Nation.
Pennsylvania’s hospitals experienced no increase in staff injuries. In addition, its changes
were implemented without any additional funds, using only existing staff and resources.
Charles Curie noted that preliminary data indicates that the number of both consumer and
staff injuries has decreased.
By July 2000, Pennsylvania reported that one State mental hospital had not used seclusion
for over 20 months. Another had used neither seclusion nor restraints for 8 of the previous
12 months. Three hospitals had been seclusion and restraint free for one or more consecutive
months and others were approaching zero use. In October 2000, Pennsylvania’s Seclusion
and Restraint Reduction Initiative received the prestigious Harvard University Innovations in
American Government Award.
Pennsylvania began its reform project by carefully tracking the use of seclusion and restraint,
and then used that 1997 data as its baseline to measure improvements. A workgroup of practicing hospital clinicians set about developing new policies and procedures, goals, strategies,
and monitoring systems to design and implement the new approach. Key among these goals
was developing a new philosophy of care, one that identified seclusion and restraint as treatment failure and restricted it to emergency use only.
Module 3
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BACKGROUND
• Train staff on the importance and value of communication skills and recovery.
• Encourage self-advocates to articulate clearly where and when paternalism and control
take place.
• Find examples in agencies where best practices are being followed and actively
disseminate those findings to others.
• Follow the strengths-based approach with children and give children a real voice in
individualized plans.
Also critical was changing the culture of State hospitals. Pennsylvania did this by requiring
open public access to seclusion and restraint data, by creating competition among hospitals to
reduce seclusion and restraint, and by giving awards and acknowledgments for improvement.
Key elements of Pennsylvania’s seclusion and restraint reduction policy:
• Seclusion and restraints must be the intervention of last resort.
• Seclusion and restraint are exceptional and extreme practices for any consumer. They are
not to be used as a substitute for treatment, nor as punishment, nor for the convenience
of the staff.
• Seclusion and restraint are safety measures, not therapeutic techniques, which should be
implemented in a careful manner.
• Staff shall include consumer strengths and cultural competence to prevent incidents of
• Staff must work with the consumer to end seclusion and restraint as quickly as possible.
• A physician must order seclusion and restraint.
• Orders are limited to 1 hour and require a physician to physically assess the consumer
within 30 minutes.
• The consumer and family are considered part of the treatment team.
• The consumer advocate is the spokesperson for the consumer (if the consumer desires it)
and is involved in care and treatment.
• Consumers being restrained cannot be left alone.
• Chemical restraints are prohibited.
• The treatment plan includes specific interventions to avoid seclusion and restraint.
• Consumers and staff must be debriefed after every incident, and treatment plans must
be revised.
• Staff must be trained in de-escalation techniques.
• Consumer status must be reviewed prior to utilizing seclusion and restraint. Voluntary
patients who did not agree to these procedures must be involuntarily committed before
these procedures may be initiated.
Module 3
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BACKGROUND
Mental health officials cite a number of innovations that were critical to the success of the
program. Among them were the following:
• Computerized data collection and analysis
• Strategies for organizational change
• Staff training in crisis prevention and intervention
• Risk assessment and treatment planning tools
• Consumer debriefing methods
• Recovery-based treatment models
• Adequate number of staff
For more information, please contact:
Office of Mental Health and Substance Abuse Services
Bureau of Hospital Operations
Beechmont Building, First Floor
Harrisburg, PA 17110
(717) 705-8152
Cultural Change
In order for sustainable cultural change to occur around the issue of seclusion and restraint,
all of the stakeholders must be present at the table for the discussion. No component or subset of a system IS the system…the parts interact to give it life. No one is blaming anyone for
how things have been. Consumers and staff are hoping to create new ways of being together,
which requires both consumers and staff to change how they interact with each other. This
manual approaches cultural change from three levels: intrapersonal, interpersonal, and system change. Intrapersonal change occurs within the individual mind or self and is reinforced
by the Personal Take Action Challenges. Interpersonal change involves relationships between
persons, e.g., consumers and staff. System change focuses on structural changes by addressing issues of policy, of local, State, and Federal legislation, and by implementing Workplace
Take Action Challenges.
In Our Own Voices
In December 2000, the National Association of Consumer/Survivor Mental Health Administrators (NAC/SMHA) developed and sent out a survey to people diagnosed with mental
illnesses to better understand the experience of people who had been secluded and/or restrained. The results from the survey laid the groundwork for this training manual. People
diagnosed with mental illnesses were asked to respond to four questions.
1. Have you ever been in seclusion or restraints?
2. What would have been helpful in preventing the use of seclusion or restraints for you?
3. Some people suggest that “talking to them” helps. What would you have wanted to hear?
4. What other options may have been beneficial?
Module 3
8
BACKGROUND
• Leaders of the hospital, clinical department heads, and ward leaders are accountable
at all times for every phase of a seclusion and restraint procedure. Accountability is
demonstrated as a component of the hospital's "performance improvement" index and
in staff competency evaluations.
• Data regarding the use of seclusion and restraint are made available to consumer and
family organizations and government officials.
What would have been helpful in preventing the use of seclusion or restraints for you?
“I don’t know what caused me being put in seclusion. I have asked for 26 years because I
NEVER want to cause that again.” What would have been helpful? “Not being processed
like cattle.” What would you have wanted to hear? “What was happening to me would end
soon. It would not last forever—hope—some explaining what was happening would be helpful.” What other options may have been beneficial? “To be able to cry, chemical restraints
often prevent this.” “Have someone sit with me for a while.”
The results from the survey may elicit a wide array of strong responses from staff members.
Be sure to allow plenty of time for processing all feelings—including defensiveness, anger,
sadness, and guilt. Remember, putting people diagnosed with mental illnesses in seclusion or
restraints is traumatic for the staff as well. This section provides an opportunity for staff to
hear the consumer’s perspective and process their own trauma around seclusion and restraint.
Module 3
9
BACKGROUND
Seventy-two percent of those responding reported being secluded or restrained. Here are
a few of the responses, some of which are heart wrenching. “I think…putting a patient in
restraints makes them feel like an animal or trapped bear in a trap.”
Welcome participants, review names, and make sure everyone has a
Module 2: Understanding the Impact of Trauma.
Ask each participant to share one of the Take Action Challenges from
Module 2 and report on their progress.
Go over the learning objectives.
Learning Objectives
be able to :
•
Understand seclusion and restraint from a primary,
secondary, and tertiary public health prevention model
•
Identify key components of successful programs that are
eliminating seclusion and restraint
•
Outline the key elements of cultural change, including
intrapersonal change, interpersonal change, and system
change
•
Define safety from both a service recipient perspective and
service provider perspective
•
Describe what consumers say would be helpful in preventing
the use of seclusion and restraint
Module 3
10
PRESENTATION
PRESENTATION
“Flowers Are Red”
OBJECTIVE:
Identify how behaviors in a culture become established.
PROCESS:
Distribute the handout “Flowers are Red.” Give the participants
time to read the poem. Facilitate a discussion.
DISCUSSION
QUESTIONS:
Think about what it might take to change this little boy’s image
of flowers at this point in his life.
• What would he have to change?
• How would the system have to change?
• What would the teacher have to understand to help the little boy?
MATERIALS
REQUIRED:
“Flowers Are Red” handout
APPROXIMATE
TIME REQUIRED:
10 minutes
Module 3
11
PRESENTATION
A working definition of
cultural change
• Lasting structural and social changes
(within an organization or set of
linked organizations), PLUS
• Lasting changes to the shared ways
of thinking, beliefs, values,
procedures, and relationships of the
stakeholders
Treatment of Consumers
In a fundamental way, the issue of
seclusion and restraint is about how
mental health systems treat the
people they serve. (National
Association of State Mental Health
Program Directors)
• Any intervention that recreates aspects of previous traumatic experiences or that uses
Module 3
12
PRESENTATION
Overview
• If the goals of the public mental health system are to treat people with dignity, respect,
and mutuality, to protect people’s rights, to provide the best quality care possible, and
to assist people in their recovery, any use of seclusion and restraint must be rigorously
scrutinized (NASMHPD, 1999).
• Historically, seclusion and restraint techniques have been a part of inpatient psychiatric
care since the Middle Ages and are ingrained in the habits, organization, and culture of
mental health facilities (Pennsylvania Department of Public Welfare, 2001).
Seclusion and Restraint are not
evidence-based practices
•
The research on the use of seclusion and restraint with
children or adults provides evidence that the experience
may actually cause additional trauma and harm (Finke, 2001).
•
There is no research to support a theoretical foundation for
the use of seclusion with children (Finke, 2001).
•
30 years of evidence demonstrates that seclusion does not
add to therapeutic goals and is in fact a method to control
the environment instead of a therapeutic intervention
(Finke, 2001).
•
“Seclusion and restraint are persistent national issues, even
though we have known with certainty since the 1960s that
their use is harmful, indeed life threatening at times.”
Rodney Copeland – former Vermont Commissioner
Seclusion and Restraint are not
evidence-based practices – pg 2
•
Most episodes of seclusion and restraint occur
within the first few days after admission, and the
majority of incidents occur with a very small
number of individuals (NASMHPD).
•
Our goal is to improve the system, rather than
placing blame on any one group for how it currently
exists.
•
Using a Public Health Model of Prevention may be
helpful for thinking about eliminating the use of
Module 3
13
PRESENTATION
power to punish or is harmful to the individual involved is unacceptable.
1.
The selection and use of the least possible
restriction consistent with the purpose of the
intervention
2.
Establishing a culture that minimizes the
occurrence of events that might lead to the use
of seclusion and restraint
3.
A culture that emphasizes the importance of
valuing what consumers say about what
contributes to a safe environment
4.
Identifying and resolving conflicts early, before
they escalate
A Public Health Model that eliminates the
use of seclusion and restraint would support:
5.
Training in techniques of early intervention for
all staff
6.
Policies and procedures that only allow safe use
of seclusion and restraint on those rare
occasions when it is required to maintain safety
7.
Staff and consumers being fully debriefed after
any use of seclusion and restraint and the
information obtained would be used to prevent
further episodes
• Depending on the context in which a particular tool is used, it may fit into more than
one category. For example, a Wellness Recovery Action Plan (WRAP) could be used as
primary, secondary, or tertiary prevention.
Module 3
14
PRESENTATION
A Public Health Model that eliminates the
use of seclusion and restraint would support:
Preventing and reducing the
need for seclusion and
restraint
• In the context of seclusion and restraint, primary prevention would include consumer
empowerment, utilizing resiliency and strengths-based models, changing physical environments, an organizational philosophy that articulates nonviolence in policy, procedures,
and practice, etc.
Secondary Prevention
Using the least restrictive
methods possible
• In the context of seclusion and restraint, secondary prevention would include use of a
comfort room, a consumer referring to their WRAP, de-escalation techniques, consumer
support groups, etc.
Module 3
15
PRESENTATION
Primary Prevention
Intervention to reverse or
prevent negative
consequences
• In the context of seclusion and restraint, tertiary prevention would include exploring the
precipitating factors that caused the seclusion or restraint, facilitating a debriefing session
with changes to the treatment plan, using only face up restraints if they are necessary at
all, and never leaving a consumer alone while she/he is in seclusion or restraint, etc.
For this segment, you may wish to use the videotape Leading the
Way: Toward a Seclusion and Restraint Free Environment by the
Pennsylvania Office of Mental Health and Substance Abuse. It is 17.5
minutes long. To obtain this video, please contact Robert Davis, M.D.
at [email protected] or at Department of Public Welfare,
Commonwealth of Pennsylvania, 502 Health and Welfare Building,
Harrisburg, PA 17105.
The information for this segment was obtained from Pennsylvania’s Web site, www.dpw.state.
pa.us. It is also available in Leading the Way Toward a Seclusion and Restraint Free Environment:
Pennsylvania’s Success Story by Bonnie Hardenstine, Director of Performance Improvement and
Forensic Services, Bureau of Hospital Operations, Office of Mental Health and Substance Abuse
Services, Department of Public Welfare, Commonwealth of Pennsylvania, 2001.
Module 3
16
PRESENTATION
Tertiary Prevention
1997 – Pennsylvania Department of
Public Welfare’s Office of Mental
Health and Substance Abuse Services
(OMHSAS) announced that all nine
State mental hospitals would actively
pursue the elimination of seclusion
and restraint.
Treatment Failure
Seclusion and restraint
reflects treatment failure
Module 3
17
PRESENTATION
Pennsylvania Model
Pennsylvania Model Success
•
Computerized data collection and analysis
•
Organizational change strategies
•
Medications that target aggressive behavior
•
Staff crisis prevention and intervention training
•
Risk assessment and treatment planning tools
•
Debriefing methods
•
Recovery-based treatment models
•
Adequate number of staff
• Essential to the initiative's success were computerized data collection and analysis,
organizational change strategies, medications that target aggressive behavior, staff crisis
prevention and intervention training programs, risk assessment and treatment planning
tools, consumer debriefing methods, recovery-based treatment models, and an adequate
number of trained staff.
• Today, Pennsylvania has a seclusion and restraint policy that exceeds all national
standards. The policy enhanced physician involvement and accountability, increased
consumer safety, and limited use of seclusion and restraint to use as a last resort
in situations involving imminent serious harm. The policy includes the following
requirements:
Module 3
18
PRESENTATION
• Stressing that seclusion and restraint techniques reflect treatment failure, the Office of
Mental Health and Substance Abuse Services (OMHSAS) first tracked the use of these
methods throughout the State mental hospital system. With data in hand, a workgroup
composed of practicing hospital clinicians developed a new policy that limited seclusion and restraint use to emergency situations only.
• The Pennsylvania model policy established clear goals, policies, strategies, and monitoring systems to reduce the use of these dangerous and restrictive measures.
•
A physician must order seclusion or restraint.
•
Orders are limited to one hour and require a physician to
physically assess the consumer within 30 minutes.
•
Consumers being restrained cannot be left alone.
•
Chemical restraints are prohibited.
•
Consumers and staff must be debriefed after every
incident, and treatment plans must be revised.
•
Data regarding use of seclusion and restraint are made
available to consumer and family organizations and
government officials.
Staff Involvement
Staff members encourage
consumers to creatively resolve
or avoid factors that cause or
escalate aggressive and selfinjurious behavior
• Staff members are encouraged to pay close attention to the factors that cause or escalate
aggressive and self-injurious behavior. They encourage consumers to creatively resolve
or avoid these factors and to develop alternative coping strategies that reinforce consumer
dignity and self-control and foster recovery and successful community reintegration.
Module 3
19
PRESENTATION
Pennsylvania Model Policy
Entire initiative used current
staff and had no increased
costs associated with it
• Pennsylvania's reduction initiative relied solely on existing staff and resources—without
increased cost to taxpayers.
Outcomes of the Pennsylvania Model
• Since 1997, the combined incidents of seclusion and restraint were reduced by 90 percent, and the hours of use fell by 95 percent. (See PowerPoint charts below.) By July
2000, one State mental hospital had not used seclusion for over 20 months.
Restraint Usage per 1000 Patient Days through 2/28/01
Module 3
20
PRESENTATION
Cost Effective
Public Access to Data
Public access to data created
healthy competition among State
hospitals to continue further
reduction of seclusion and
restraint
• This proactive initiative has fostered healthy competition among State hospitals to
aggressively continue further reduction of seclusion and restraint use.
• “The rate of work-related injuries is higher in mental health than in the construction
industry, and more staff injuries occur during the implementation of seclusion and
restraint than occur from unexpected assaults” (NASMHPD, 1999).
Module 3
21
PRESENTATION
Seclusion Usage per 1000 Patient Days to 2/28/01
DECREASED STAFF
INJURIES!
• The new policy has not put staff at greater risk. In fact, injury rates due to consumer
assaults decreased with seclusion and restraint reduction.
• The initiative has produced a cultural change conducive to expedited consumer recovery,
hospital discharge, and community reintegration. Seclusion and restraint are no longer
considered the acceptable response to aggressive or self-injurious consumer behavior.
Cultural Change and Consumer
Recovery
Cultural changes created
quicker consumer recovery,
hospital discharges, and
community reintegration.
• Since the policy actively involves consumers in their overall treatment, it has encouraged
much stronger partnerships among consumers and caregivers.
Module 3
22
PRESENTATION
Decreased Staff Injuries
Stronger partnerships among
consumers and caregivers
Cultural Change
• No component or subset of a system IS the system…the parts interact to give it life. No
one is blaming anyone for how things have been. Consumers and staff are hoping to create new ways of being together, which requires both consumers and staff to change how
they interact with each other.
• Thinking about systems is important to understand the context of the whole.
• To understand the system completely, all voices, including consumers, family members,
facility management, and direct care staff need to be present
• The challenge before all of us is how to create sustainable cultural changes in the mental
health system.
• Francis Meehan (1982) outlined a social justice movement model that identifies three levels of change that we will use as a framework for thinking about overall systems change.
Social Justice Levels of Change

Intrapersonal – occurring within
the individual mind or self

Interpersonal – involving
relationships between persons

Systems/Cultural Change
Module 3
23
PRESENTATION
Partnerships Among Consumers
and Caregivers
Gandhi Quote
“Be
the change you want to see
in others.”
Mahatma Gandhi
Interpersonal Change
• Webster’s Dictionary defines this type of change as “involving relationships between
persons.”
• This training focuses on interpersonal change by offering you many opportunities to build
bridges between consumers and staff, change your day-to-day work practices, and implement your Take Action Challenges.
Module 3
24
PRESENTATION
Intrapersonal Change
• Webster’s Dictionary defines this type of change as “occurring within the individual mind
or self.”
• This training focuses on intrapersonal change by asking you to respond in your journal so
that you become even more aware of your attitudes, gifts, and blind spots.
• The following quote from Gandhi illustrates intrapersonal change.
Defining Culture
Culture:
Who we are and how we do
things
Module 3
25
PRESENTATION
Systems/Cultural Change
• Webster’s Dictionary defines this type of change as “something arranged in a definite
pattern of organization.”
• This training focuses on how to make structural/system changes by addressing issues
of policy; addressing local, State, and Federal legislation; and implementing Workplace
Take Action Challenges.
• The primary interest is in making cultural changes that are sustainable and are adopted
at every level in the institution.
• Norms
• Climate
• Organizational Support
• Values
• Norms—expected and accepted behavior for both staff and consumers.
• Climate—includes a sense of community, shared vision, and positive outlook. These
social atmosphere factors enable constructive individual and collective change.
• Organizational support—the system of informal and formal structures, policies, and
procedures that maintain the culture.
• Values—heartfelt beliefs about the appropriate way to approach mental health issues.
• To create a change in culture, it is necessary to first identify the limiting beliefs that are
holding the group back. Then identify some more positive and enhancing beliefs and
start building and reinforcing those.
• The following exercise will assist in identifying underlying beliefs.
o Let’s first start with a picture of where your organization is right now—before
proposing any changes.
o Remember, all organizations have things they do well and things they could
improve on.
Module 3
26
PRESENTATION
Cultural Building Blocks
“My Organizational Culture Currently Is…”
OBJECTIVE:
Participants will identify current ecology, relationships, and leadership in their organization.
PROCESS:
Divide the class into groups of six. Assign one group ecology, one
group relationships, and one group leadership. If there are more
than three groups, two groups can work separately on the same
topic. All administrators need to have their own group so others
can share freely. Ask them to do an evaluation (positive and negative) of how their organization currently functions around these
issues as it relates to the reduction of seclusion and restraint. Have
each group report back their findings. The groups may want to
write key points on the board or on a flip chart.
Ecology
• Physical surroundings
• Formal policies and rules
• Resources
• The unit culture
• Attitudes
• Cultural norms
Relationships
• Direct care staff peer relationships
• Direct care staff to administration relationships
• Direct care staff to consumer relationships
• Administrative staff to consumer relationships
Leadership
• Inspire others to see their own potential
• Foster relationship building among all
• Challenge process, not people
• Teach “there could be a better way” attitude
• Remove barriers to possibility thinking
• Be a learning organization
Page 1 of 2
Module 3
27
PRESENTATION
“My Organizational Culture Currently Is…” (continued)
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
APPROXIMATE
TIME REQUIRED:
• Which of the three areas—ecology, relationships, and leadership
—is most likely to support the reduction of seclusion and restraint
at your facility?
• Which of the three areas might struggle with these changes
and why?
• What works well and what is a problem related to seclusion
and restraint?
“My Organizational Culture Currently Is…” handout
Chalk board or flip chart
30 minutes
Page 2 of 2
Module 3
28
PRESENTATION
“People With a Mental Health Diagnosis Are…”
OBJECTIVE:
To recognize the biases and stereotypes that impact work with
consumers.
PROCESS:
Divide the group into pairs. In each pair, assign one person to be
A and one person to be B. Person A will simply listen to B and after
each response say “thank you.” Person B will say “People with a
mental health diagnosis are _________” and fill in the blank. This
sentence is repeated over and over. If B cannot think of anything to
say, B can say the word “blank” and start over with the sentence.
After a few minutes, have A and B switch roles. Facilitate a
discussion.
DISCUSSION
QUESTIONS:
• What were the common themes?
• How do you think these biases and stereotypes impact working
with consumers?
• What was difficult about this exercise and why?
MATERIALS
REQUIRED:
None
APPROXIMATE
TIME REQUIRED:
15 minutes
Module 3
29
PRESENTATION
Survey Questions
1.
Have you ever been in seclusion or restraints?
2.
What would have been helpful in preventing the
use of seclusion or restraints for you?
3.
Some people suggest that “talking to them”
helps. What would you have wanted to hear?
4.
What other options may be have been
beneficial?
• Seventy-two percent of people diagnosed with a mental illness who responded stated they
had experienced seclusion or restraint.
Distribute handout on “What would have been helpful in preventing the
use of seclusion or restraints for you?” and discuss.
• The second question asked on the NAC/SMHA survey was “What would have been
helpful for you to hear?”
• The following exercise will illustrate the consumer responses of what they would have
liked to have heard during a stressful time.
Module 3
30
PRESENTATION
In Our Own Voices
• To end this session, we want to share with you responses from consumers regarding
• The National Association of Consumer/Survivor Mental Health Administrators developed
a survey to better understand the experience of seclusion and restraint.
• The survey was a paper and pencil mail questionnaire that asked four questions.
What Would Have Been Helpful to Hear
OBJECTIVE:
Identify words and phrases that consumers would like to hear
during stressful times.
PROCESS:
Before this module, prepare a 3x5 note card for each of the
following quotes from consumers:
• 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.
• Can we call someone for you?
• That someone was not going to hurt me
• Something gentle and kind
• I’m here to listen, I’m here for you.
• It will get better.
• This will pass.
• I won’t leave you.
• What I wanted to hear was that I can get better
• I would have wanted to hear I would soon feel calmer.
• How can we help?
• Your parents are coming.
• You are all right, but your behavior is inappropriate.
• I’m a person too and allowed to make mistakes
• All feelings are normal.
• I’m here to listen, I’m here with you.
• That I was OK, that I was safe
• Description of where I was and what was going on
• Do you want to talk about what you are feeling?
• Humor
• Could I get you something?
• Are you comfortable?
• I can see that you are hurting. Can we talk?
Page 1 of 2
Module 3
31
PRESENTATION
What Would Have Been Helpful to Hear (continued)
• I’m not sure it’s the exact words that are most important, but
rather the tone of voice, body language, and the physical environment of the verbalization. The words need to be firm but kind,
spoken by someone with whom the patient has had prior positive
experiences. The words should include references to experiences
and people that the staff has determined ahead of time will help
the patient become grounded.
Have participants sit in a circle. Pass out cards to participants.
Have participants read their cards to the group. Discuss what
feelings this exercise raised.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
APPROXIMATE
TIME REQUIRED:
• Which of these words/phrases do you currently use with
consumers?
• What other words/phrases have you said that have been helpful?
• What are some things you have heard staff say that are not
helpful?
3x5 note cards with quotes written on them
Optional—PowerPoint slide with the quotes given above
“What would have been helpful for you to hear?” handout
15 minutes
Page 2 of 2
Module 3
32
PRESENTATION
What Other Options May
Have Been Beneficial?
•
•
•
•
•
•
•
•
•
•
Taking a walk
Physical exercise
Read my Wellness Recovery Action Plan (WRAP)
To be able to cry; chemical restraints often
prevent this
Have someone sit with me for a while
Sometimes just to be heard helps
Take shower or bath
Draw
Being able to yell
A homey setting – soft chairs, drapes, pictures
What Other Options May
Have Been Beneficial?
•
•
•
•
•
•
With permission, a hand on a hand, an arm around a
shoulder – it is important to make contact EARLY
on with someone about to “lose touch”
Being allowed to have something of my own to
comfort me
Take time to review the file and ask questions
Getting everyone’s attention off of the
misbehavior and onto what caused it to happen in
the first place
Talking to the doctor more about the medications
A big overstuffed, vibrating, heated chair with a
blanket, headphones, and gentle soft music
Module 3
33
PRESENTATION
As a group, review the handout “What other options may have been
beneficial?”
“…my son was to be committed to the State
hospital. When the sheriff came to take
him, Mark said, “I’m not going.” Instead of
the sheriff putting restraints on Mark, he
said, “Can I come in?” He sat down and
talked to Mark for an hour. Mark finally
said, “If I have to go, I’ll go.” He walked
out to the car and rode in the front seat
with the sheriff 250 miles to the closest
State hospital. Talking, time, and patience
does work.”
Module 3
34
PRESENTATION
• One survey respondent wrote the following story:
The little boy went to the first day of school
He got some crayons and started to draw
He put colors all over the paper
For colors was what he saw
And the teacher said…what are you doing young man?
I’m paintin’ flowers he said
She said…it’s not the time for art young man
And anyway flowers are green and red
There’s a time for everything young man
And a way it should be done
You’ve got to show concern for everyone else
For you’re not the only one
And she said…flowers are red young man
Green leaves are green
There’s no need to see flowers any other way
Than the way they always have been seen
But the little boy said…there are so many colors in the rainbow
So many colors in the mornin’ sun
So many colors in a flower and I see every one
Well the teacher said… you’re sassy
And you’ll paint flowers the way they are
So repeat after me…
And she said…Flowers are red young man
Green leaves are green there’s no need to see flowers any other way
But the little boy said…
There are so many colors in the rainbow
So many colors in the morning sun
So many colors in a flower
And I see every one
Page 1 of 2
Module 3
35
HANDOUT
Flowers Are Red
Flowers Are Red (continued)
—Anonymous
Page 2 of 2
Module 3
36
HANDOUT
The teacher put him in a corner
She said…it’s for your own good
And you won’t come out
Til you get it right
And all responding like you should
Well finally he got lonely
Frightened thoughts filled his head
And he went up to the teacher
And this is what he said…and he said
Flowers are red, green leaves are green
Time went by like it always does and they moved to another town
And the little boy went to another school
And this is what he found
The teacher there was smilin’
She said…painting should be fun
And there are so many colors in a flower
So let’s use every one
But that little boy painted flowers
In neat rows of green and red
And when the teachers asked him why
This is what he said…and he said
Flowers are red, green leaves are green
My Organizational Culture Currently Is…
Gaps
Ecology
Physical surroundings
Formal policies and rules
Resources
Unit culture
Attitudes
Cultural norms
Relationships
Direct care staff peer
relationships
Direct care staff to
administration
relationships
Direct care staff to
consumer relationships
Administrative staff to
consumer relationships
Leadership
Inspire others to see their
own potential
Foster relationship building
among all
Challenge the process, not
people
Teach “there could be a
better way” attitude
Remove barriers to
possibility thinking
Be a learning organization
Module 3
37
HANDOUT
Strengths
Factors Related to Reducing the Use of Seclusion and Restraint
• Employing a public health model that stresses prevention and early intervention.
• Sensitizing staff to the power differential that exists between themselves and the people
they serve in order to prevent the misuse of power. Experiential training and training that
involves service recipients can be particularly useful in this regard.
• Implementing individualized treatment plans that are mutually determined by service
recipients and staff, and that effectively emphasize the individual recipient's assessment
of what works and what doesn't.
• Using clearly defined clinical interventions, including clinical algorithms.
• Making sure that multiple treatment options are available at all times.
• Involving families and others (with permission of the service recipient) who have helpful
information about what has worked and what hasn't in the past.
• Teaching skills of self-monitoring and self-control as part of the rehabilitation/recovery
process.
• Ensuring that both staff and service recipients have access to mechanisms for resolving
disputes without resorting to force.
• Creating a physical environment that minimizes the overstimulating conditions that may
lead to conflict or agitation, particularly (but not exclusively) for elderly individuals.
• Developing a clinical paradigm that addresses past trauma as part of the clinical picture.
• Considering the use of seclusion or restraint to reflect a failure to intervene earlier, and
aiming for the goal of using these interventions as close to "zero use" as possible.
• Ensuring adequate ongoing staff training specific to the situation and consumers being
served.
Similarly, many factors were identified that contribute to an environment in which safety
concerns are likely to emerge, and in which seclusion and restraint are likely to be misused.
These factors include
• Lack of adequate attention to safety issues and risk factors at intake. Most episodes of
seclusion and restraint occur within the first few days after admission, and the majority of
incidents occur with a very small number of individuals.
• Lack of an organizational culture of respect.
• Not believing what service recipients say; labeling people as "manipulative."
• Lack of adequate attention to language accessibility and cultural uniqueness (e.g., race,
gender, sexual orientation, and trauma history).
• Inadequate staffing, in quantity, training or both. Inexperienced staffs are assaulted more
frequently; short staffing and the use of temporary staff also increase the likelihood of
violence.
Page 1 of 2
Module 3
38
HANDOUT
From NASMHPD’s 1999 Report on Reducing
the Use of Seclusion and Restraint
NASMHPD’s 1999 Report (continued)
Page 2 of 2
Module 3
39
HANDOUT
• The assumption that “compliance” in and of itself is important for recovery. A culture that
permits misuse or display of power, even in "small" ways (e.g., using keys to intimidate).
• The assumption that “structure” and/or rules for behavior are in and of themselves therapeutic, or that they are the only mechanisms for maintaining a therapeutic milieu.
• Responding to violence with violence.
• Inadequate monitoring and debriefing; a culture of secrecy.
• A culture in which direct care staff feel disrespected and "pass on" that disrespect to
service recipients.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Listening
Finding good qualities and mentioning them
Teaching stress management exercises
Good ongoing relationship with treatment staff that involved trust and cooperation
If families were regularly included in treatment teams—and really considered to be valuable sources of insight into their ill family members, then situations leading to restraints
might be defused
If they had given me a stick of gum to chew or something to drink
If they had given me some paper and a pencil, I would have written out my thoughts
Naming and hearing what you’re doing that’s inappropriate and why
Stopping inside jokes that confuse people
Being allowed to listen to music
Snuggle in blankets
If the nurses had talked to me and offered alternatives first, like applying a warm washcloth to my forehead, like holding my hands or offering reassurance, such as “you are in
a safe place now.” “We are here to help you feel safe, to get away from the bad thoughts,
voices, or visions.”
I’m afraid of closed-in places and this is in my files. No one took time to look or even
read it.
All it would have taken was for someone to talk to me and HEAR what I had to say
To put it in simplistic terms: knowing the patient and educating the staff. All staff members need to know the patient’s personal history, diagnosis, treatment experiences, and
approaches which have been helpful in the past to avoid seclusion and restraints, i.e.,
avoid a one-size-fits-all response. This will necessitate a system which can more quickly
involve family members and past treatment providers.
Module 3
40
HANDOUT
What would have been helpful in preventing
the use of seclusion or restraints for you?
What would have been helpful for you 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
Can we call someone for you?
That someone was not going to hurt me
Something gentle and kind
I’m here to listen, I’m here for you
It will get better
This will pass
I won’t leave you
What I wanted to hear was that I can get better
I would have wanted to hear I would soon feel calmer
How can we help?
Your parents are coming
You are all right, but your behavior is inappropriate
I’m a person too and allowed to make mistakes
All feelings are normal
I’m here to listen, I’m here with you
That I was OK, that I was safe
Description of where I was and what was going on
Do you want to talk about what you are feeling?
Humor
Could I get you something?
Are you comfortable?
I can see that you are hurting. Can we talk?
I’m not sure it’s the exact words that are most important, but rather, the tone of voice,
body language and the physical environment of the verbalization. The words need to be
firm but kind, spoken by someone with whom the patient has had prior positive experiences. The words should include references to experiences and people that the staff has
determined ahead of time will help the patient become grounded.
Module 3
41
HANDOUT
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
What other options may have been beneficial?
•
•
•
•
•
Taking a walk
Physical exercise
Read my WRAP plan
To be able to cry; chemical restraints often prevent this
Have someone sit with me for a while
Sometimes just to be heard helps
Take shower or bath
Draw
Being able to yell
A homey setting—soft chairs, drapes, pictures
With permission, a hand on a hand, an arm around a shoulder—it is important to make
contact EARLY on with someone about to “lose touch”
Being allowed to have something of my own to comfort me
Take time to review the file and ask questions
Getting everyone’s attention off of the misbehavior and onto what caused it to happen
in the first place
Talking to the doctor more about the medications
A big overstuffed, vibrating, heated chair with a blanket, headphones, and gentle
soft music
Module 3
42
HANDOUT
•
•
•
•
•
•
•
•
•
•
•
Bloom, S. (1997). Creating sanctuary: Toward the evolution of sane societies. New York:
Routledge.
Brown, J., & Tooke, S. (1992). On the seclusion of psychiatric patients. Social Science and
Medicine, 35, 711-721.
Canatsey, K., & Roper, J. (1997). Removal from stimuli for crisis intervention: Using least restrictive methods to improve the quality of patient care. Issues in Mental Health Nursing, 18, 35-44.
Chandler, D. & Francis, P.S. (1995). A national survey on seclusion and restraint in State
psychiatric hospitals. Psychiatric Services, 46, 1026-1031.
Copeland, R.E. (1999-2000, Fall/Winter). Vermont’s vision of a public system for developmental
and mental health services without coercion. Burlington: Vermont Department of Developmental
and Mental Health Services. Online at www.ddmhs.state.vt.us/archives/rod.pdf.
Coursey, R.D., Alford, J., & Safarjan, B. (1997). Significant advances in understanding and treating
serious mental illness. Professional Psychology Research and Practice, 28, 205-216.
Delaney, K. (1994). Calming an escalated psychiatric milieu. Journal of Child and Adolescent
Psychiatric Nursing, 7(3), 5-13.
Davis, S. (2002). Autonomy versus coercion: Reconciling competing perspectives in community
mental health. Community Mental Health Journal, 38, 239-250.
Farber, S. (1993). Madness, heresy, and the rumor of angels: The revolt against the mental health
system. Chicago: Open Court Publishing.
Finke, L.M. (2001). The use of seclusion is not evidence-based practice. Journal of Child and
Adolescent Psychiatric Nursing, 14(4), 186-190.
Goren, S., Abraham, I., & Doyle, N. (1996). Reducing violence in a child psychiatric hospital
9(2), 27-36.
Holzworth, R., & Wills, C. (1999). Nurses’ judgments regarding seclusion and restraint of psychiatric
patients: A social judgment analysis. Research in Nursing and Health, 22, 189-201.
Johnson, M. (1998). A study of power and powerlessness. Issues in Mental Health Nursing, 19,
191-206.
Lehane, M. & Rees, C. (1996). Alternatives to seclusion in psychiatric care. British Journal of
Nursing, 5, 97-99.
Meehan, F.X. (1982). A contemporary social spirituality. San Francisco, CA: Orbis.
Page 1 of 2
Module 3
43
HANDOUT
Blanch, A., & Parrish, J. (1990, September). Report on round table on alternatives to involuntary
treatment. Bethesda, MD: National Institute of Mental Health.
Mohr, W., Mahon, M., & Noone, M., (1998). A restraint on restraints: The need to reconsider the
use of restrictive interventions. Archives of Psychiatric Nursing, 12, 95-106.
Morrissey, J.P., & Monahan, J. (1999). Coercion mental health services: International perspectives.
Research in Community Mental Health, 10, 25-27.
National Association of State Mental Health Program Directors (NASMHPD). (1999). Reducing
the use of seclusion and restraint: Findings, strategies, and recommendations. Alexandria, VA:
National Technical Assistance Center.
National Association of State Mental Health Program Directors (NASMHPD). (2002). Managing
conflict cooperatively: Making a commitment to nonviolence and recovery in mental health
treatment settings. Alexandria, VA: National Technical Assistance Center.
Pennsylvania Department of Public Welfare, Office of Mental Health and Substance Abuse Services.
(2001). Leading the way toward a seclusion and restraint free environment: Pennsylvania’s
success story. Harrisburg, PA: Author
Ringwald, C. (1997, March 6). Patient-restraint issues prompt call for reform. Times Union.
Scammel, A. (1997). Online at www.ukoln.ac.uk/services/elib/papers/tavistock/cultural-change/
intro.htm.
Taxis, C.J. (2002). Ethics and praxis: Alternative strategies to physical restraint and seclusion
in a psychiatric setting. Issues in Mental Health Nursing, 23, 157-170.
Page 2 of 2
Module 3
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HANDOUT
Morales, E., & Duphorne, P. (1995). Least restrictive measures: Alternatives to four-point restraints
and seclusion. Journal of Psychosocial Nursing and Mental Health Services, 33, 13-16; 42-43.
MODULE 4
Understanding Resilience and Recovery
From the Consumer Perspective
1
MODULE 4
Understanding Resilience and Recovery
From the Consumer Perspective
“…the initiative [Pennsylvania’s] to reduce the use of seclusion and restraint
is part of a broader effort to reorient the State mental health system toward a
consumer-focused philosophy that emphasizes recovery and independence.”
—Charles G. Curie, Administrator, SAMHSA
Learning Objectives
• Define resilience.
• List characteristics of resilient people.
• Define recovery and list the eight assumptions of recovery.
• Effectively implement recovery and resilience strategies that lead to the elimination of
Module 4
Understanding Resilience and Recovery from the Consumer Perspective
2
MODULE 4: UNDERSTANDING RESILIENCE AND RECOVERY
FROM THE CONSUMER PERSPECTIVE
Background for the Facilitators . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Presentation (2 hours, 45 minutes) . . . . . . . . . . . . . . . . . . . . . . . . 6
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Exercise: Someone Who Believed in Them (20 minutes) . . . . . . . 9
Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Exercise: “Recovery as a Journey of the Heart” (35 minutes) . . . 13
Exercise: “What Are We Recovering From?” (15 minutes) . . . . . . 16
Journal/Take Action Challenge (20 minutes) . . . . . . . . . . . . . . . . . 18
Handouts for Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Journal and Take Action Challenges for Modules 3 & 4 . . . . . . . . . . 19
Someone Who Believed in Them Helped Them to Recover . . . . . . . 20
Recovery as a Journey of the Heart . . . . . . . . . . . . . . . . . . . . . . . 23
Recovery From Mental Illness—Guiding Vision . . . . . . . . . . . . . . . . 30
Resources: Self-Help Guides . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Module 4
3
Overview
This module will explain the concepts of resilience and recovery and how they relate to the
Resilience and recovery inspire hope. Both are empowering. Direct care staff and consumers
working together can “beat the odds,” and develop healthy lifestyles that do not include the
use of seclusion and restraint. A shift from deficit to strength-based assets of consumers can
also lend itself to the reduction and elimination of seclusion and restraint. Perhaps Dr. Pat
Deegan (2001) says it best: “Professionals who learn to collaborate with the active, resilient,
adaptive self of the client will find themselves collaborating in new and rewarding ways with
people who may have been viewed as hopeless by others.”
Resilience
In the 1980s, researchers examined risk factors underlying issues such as substance abuse,
mental illness, teenage pregnancy, suicide, and problem behaviors. However, identifying risk
factors does not provide enough information nor does it account for success stories.
The term “resilience” was originally borrowed from the engineering field and adapted for
use in social services. The engineering term refers to how much volume and weight (risk)
a bridge can sustain before incurring damage. In the mental health field, no agreement on a
single definition of resilience has been reached. However, it generally means the ability to
bounce back after adversity (Resnick, 2000).
The stories are countless of people who, in spite of all expectations and overwhelming odds
against them, are healthy and are contributing positively to society. The common variable in
increasing resilience is a positive connection with another human being. Oftentimes, people
who have overcome enormous adversity in their lives can pinpoint a single person who made
the difference for them. It is a person who took the time to listen, who believed in them and
offered them hope. The person may not have even been trying to increase the other person’s
resilience—it just happened.
Other science-based factors which contribute to resilience include caring relationships, high
expectations, adequate support, and opportunities to contribute. These factors might seem
quite obvious and based on common sense. Indeed, they are. As humans, we all want opportunities to belong, to be supported, and to contribute.
Module 4
4
BACKGROUND
BACKGROUND FOR THE FACILITATORS: RESILIENCE
AND RECOVERY FROM THE CONSUMER PERSPECTIVE
Recovery
Since the 1980s much has been written about recovery from the consumer’s, family member’s, and mental health worker’s perspectives. Recovery is based on the assumption that
people diagnosed with mental illnesses can and do become healthy and live meaningful lives.
The emergence of recovery as a philosophy in mental health came from the writings and
practices of the consumer movement. People diagnosed with mental illnesses challenged the
myth that the most they could hope for was stability. Mental health workers initially dismissed the idea of recovery until Yale researchers did a study of “chronic schizophrenics”
who were deinstitutionalized from Vermont State hospitals. The hospital staff had deemed
these “patients” hopeless and helpless—they could not even dress themselves. The researchers asked the “patients” what they would need to get out of the hospital and they told them—
jobs, friends, and a decent place to live. Almost 25 years later, one-half to two-thirds of the
“patients” showed no signs of schizophrenia (DeSisto et al., 1995).
Many have adopted recovery as a viable model. Empirical evidence has supported the positive outcomes of an individualized recovery process that includes hope, personal responsibility,
education, advocacy, empowerment, and respect (Anthony, 1993; Deegan, 1988; Leete, 1989;
Unzicker, 1989). “All services for those with a mental disorder should be consumer oriented and
focused on promoting recovery” (Mental Health: A Report of the Surgeon General, 1999, p. 455).
It is important for mental health workers to communicate that recovery is possible and to verbalize hope. “Hearing from a mental health professional that recovery is an achievable goal can make
a tremendous difference in a person’s approach to treatment and success” (Courtenay Harding,
Ph.D., Director of the Institute for the Study of Human Resilience, Boston University, 2001).
We all have our own processes of recovery, whether we are people diagnosed with a mental
illness, a family member, or a mental health worker. Recovery may include the use of the following tools: building and sustaining a strong support system; developing an individualized
plan to monitor and respond to symptoms; accessing good medical care and treatment which
may or may not include medication; and developing and maintaining positive coping mechanisms to support everyday life that enhance wellness. Recovery is a self-empowering concept
and critical to the successful collaboration between people diagnosed with mental illnesses
and mental health workers.
This section includes a personal story of recovery, definitions of recovery, assumptions of recovery, identification of what people are recovering from, and principles on which psychosocial
rehabilitation is based. We encourage you to add your own stories of recovery when applicable.
Module 4
5
BACKGROUND
We all have the capacity to increase resilience for people diagnosed with mental illnesses, their
families, and caregivers. This section on resilience is meant to inspire and encourage all of us to
internalize hope and pass it on to others. Included in this section are definitions of resilience, a
personal story of resilience, and characteristics of resilient people.
Module 3: Creating Cultural Change. Allot time to complete Journal/Take
Action Challenges covering Modules 3 and 4.
Learning Objectives
be able to:
• Define resilience
• List characteristics of resilient people
• Define recovery and list the eight
assumptions of recovery
• Effectively implement recovery and
resilience strategies that lead to the
Overview
• This module will explain the concepts of resilience and recovery and how they are
related to the elimination of seclusion and restraint.
• Words are so powerful. They can hurt or they can help. Choosing words that help—
like recovery, resilience, and hope—are useful.
• Recovery and resilience inspire hope.
• Resilience and recovery empower people diagnosed with a mental illness.
Module 4
6
PRESENTATION
PRESENTATION
Resilience
• There is no one definition of resilience in the literature.
• It is a difficult concept to describe.
• Following are some examples of resilience definitions.
Resilient People Beat the Odds
”Resilient people are those
who ‘beat the odds.’ They
have good healthy outcomes,
even in the presence of
enormous adversities in their
lives.”
Michael Resnick, Ph.D., 2000
• Dr. Resnick is a well-known researcher in the area of adolescent health. His work has
been influential in looking at what individuals, schools, and communities can do to
promote resilience.
• Researchers used to study what risk factors made it more likely for someone to have
health-related problems. Now our focus has changed to what keeps people, particularly
young people, from ever developing health-related problems, including mental illness.
These characteristics have also been called assets.
• One of the key outcomes of resiliency research has been shifting from a deficit frame of
mind to a resilient frame of mind.
Module 4
7
PRESENTATION
• Using resilience and recovery means a paradigm shift from deficit to strength-based
approaches.
• Assets of consumers assist in reducing and eliminating seclusion and restraint.
• There is no agreement on the definition of resilience in the mental health field. Generally,
it means the ability to bounce back after adversity.
• There are countless stories of people diagnosed with mental illnesses who, in spite of all
expectations and overwhelming odds, are healthy and contributing positively to society.
• One common variable in increasing resilience is a positive connection with another human
being. Very often a person who has overcome adversity can pinpoint a single person who
made a difference for them.
Resilience is…..
•
“… the power of the human spirit to sustain grief
and loss and to renew itself with hope and courage
defies all description.” Dr. Daniel Gottlieb, 1991
•
“…when success occurs despite major challenge”
Ann Masten, Ph.D.
•
“…self-righting capacities – the strengths people,
families, schools, and communities call upon to
promote health and healing.” SAMHSA
• As you can see, there are many definitions of resilience. What is important to know is
that you, as direct care staff, can foster resiliency in consumers diagnosed with mental
illnesses.
Module 4
8
PRESENTATION
• Here are a few definitions of resilience.
Someone Who Believed in Them
OBJECTIVE:
Participants will identify key concepts of human connection and its
role in fostering resilience.
PROCESS:
Distribute the handout Someone Who Believed in Them Helped
Them to Recover and give the participants time to read the article
in class.
Ask each participant to think of someone who believed in him or
her and inspired him or her with hope during a difficult time. Have
them write down three things that the person said or did that were
helpful. Ask for volunteers to share their experiences. Facilitate a
discussion.
DISCUSSION
QUESTIONS:
What kinds of relationships help foster resilience?
What characteristics of direct care staff could help consumers to be
more resilient?
MATERIALS
REQUIRED:
Someone Who Believed in Them Helped Them to Recover handout
APPROXIMATE
TIME REQUIRED:
20 minutes
Module 4
9
PRESENTATION
End this section on some kind of positive, inspirational note. You may use
the Starfish poem or some of your own materials.
• The following poem is an example of resiliency and how one person can make a difference.
As the old man walked along the beach at dawn,
he noticed a young woman ahead of him picking up
starfish and flinging them back into the sea.
Finally, catching up with her,
he asked why she was doing this.
The answer was that the starfish would die
if left until the morning sun.
“But the beach goes on for miles and there must be
millions of starfish,” said the old man.
“How can your effort possibly make a difference?”
The young woman looked at the starfish in her hand,
Threw it to safety in the waves and said,
“It makes a difference to this one!”
Module 4
10
PRESENTATION
• Resilience is an interaction of changing the external environment as well as inspiring
hope in individuals.
• Research shows the following foster resilience:
o Caring relationships
o High expectations
o Adequate support
o Opportunities to contribute
• People who are resilient have some common characteristics.
Recovery is…
…a common human experience and
a deeply personal, unique process
of changing one’s attitudes,
values, feelings, goals, skills or
roles toward our understanding
of mental illness (Anthony, 1993).
Module 4
11
PRESENTATION
Recovery
• Recovery is based on the assumption that people diagnosed with mental illnesses can
and do improve, become healthy, and live meaningful lives.
• Recovery initially emerged from the consumer movement in the 1980s.
• Science-based evidence supports a philosophy of recovery.
• The Surgeon General said in 1999, “All services for those with a mental disorder
should be consumer oriented and focused on promoting recovery” (US DHHS, 1999).
• The Resources handout has information on how to access Self-Help Guides for
Recovering Your Mental Health.
• Just as there are many definitions of resilience, there are many definitions of recovery.
Here are a few examples:
…“a process, an outcome, and a vision.
We all experience recovery at some
point in our lives from injury, from
illness, from loss, or from trauma.
Recovery involves creating a new
personal vision for one’s self.
(Spaniol, Gagne, & Koehler, 1997).
• Pat Deegan, Ph.D., has written and spoken extensively about recovery.
• Dr. Deegan is associated with Boston University’s Institute for the Study of Resilience.
• For those of you who are interested, you may want to visit her Web site at
www.patdeegan.com. Many of her articles and speeches are available online
and serve as an excellent resource for consumers as well as staff.
• We recommend using the video Recovery as a Journey of the Heart by Pat Deegan.
To obtain a copy of the video, contact Dr. Deegan at [email protected] or at Pat
Deegan, Ph.D., & Associates, LLC, P.O. Box 208, Bayfield, MA, 01922.
Module 4
12
PRESENTATION
Recovery is…
“Recovery as a Journey of the Heart”
OBJECTIVE:
Participants will identify key concepts of recovery from a personal
recovery story.
Participants will uncover their own biases about the recovery
process for people diagnosed with mental illnesses.
PROCESS:
Distribute the handout Recovery as a Journey of the Heart.
Play the 13-minute excerpt from Recovery as a Journey of the
Heart video.
Ask each participant to write down three things that promote and
three things that hinder recovery.
Divide the group into four or five smaller groups and have each
person share their findings. Tell each group to pick a recorder to
keep track of the responses and a reporter who will report the
major themes back to the larger group.
Have each group report to the larger group. If time allows,
facilitate a large group discussion.
DISCUSSION
QUESTIONS:
• What were the similarities among all the groups?
• We are all recovering from something. What have your own
experiences of recovery been like?
MATERIALS
REQUIRED:
• Video—Recovery as a Journey of the Heart
• A copy of the Recovery as a Journey of the Heart article for each
participant.
APPROXIMATE
TIME REQUIRED:
Module 4
35 minutes
13
PRESENTATION
Distribute the article by Bill Anthony, Recovery from Mental Illness: The Guiding
Vision of the Mental Health Service System in the 1990s. (Please read the article
so you as the facilitator can discuss each of these assumptions. Instruct participants
to read it on their own time. )
Recovery Assumptions
Recovery can occur without professional
intervention.
2. A common denominator of recovery is the
presence of people who believe in and
stand by the person in need of recovery.
3. A recovery vision is not a function of
one’s theory about the causes of mental
illness.
4. Recovery can occur even though
symptoms reoccur.
1.
• #1 – Professionals do not hold the key to recovery; consumers do. The task of professionals is to facility recovery. The task of consumers is to recover. What prompts recovery is
not just an array of mental health services. It is essential to have adult education, sports,
clubs, churches, self-help groups, families, and friends.
• #2 – Individuals need people who believe in them and can be there in time of need.
• #3 – The cause of the mental illness does not matter.
• #4 – Mental illness is episodic in nature. Just because an individual has an episode does
not mean he or she is not in recovery.
Module 4
14
PRESENTATION
• We are all recovering from something.
• Bill Anthony, Ph.D., has also written extensively about recovery. Dr. Anthony is
associated with Boston University’s Center for Psychiatric Rehabilitation.
• For those of you who may be unfamiliar with his work, you may want to visit his Web
site at www.bu.edu/cpr. Several of his articles and speeches are available online and
are great resources for both consumers and staff.
• In 1993, he wrote a seminal article outlining the assumptions of recovery.
Recovery changes the frequency and
direction of symptoms.
6. Recovery does not feel like a linear
process.
7. Recovery from the consequences of the
illness is sometimes more difficult than
recovering from the illness itself.
8. Recovery from a mental illness does not
mean that one was not “really mentally
ill”.
5.
• #5 – Even though symptoms may reoccur, they are most often less severe and last for a
shorter amount of time.
• #6 – Recovery does not feel systematic and planned. Often there are steps forward, then
back, and then forward again.
• #7 – The barriers faced when one is categorized as “mentally Ill” can be overwhelming.
The discrimination in employment and housing and lack of opportunities is disempowering.
• #8 – At times, people who have successfully recovered have been discounted as not having
“really” been mentally ill. Individuals in recovery are often not seen as a model, but
rather as an aberration or even a fraud.
• All have their own recovery process, whether they are consumers, direct care staff, or
family members.
• Even if you have never personally experienced mental illness, you still have a recovery
process.
• Because we all have a recovery process, it is important to look at what exactly we are
recovering from.
Module 4
15
PRESENTATION
Recovery Assumptions
“What Are We Recovering From?”
OBJECTIVE:
To increase participants’ awareness that consumers, caregivers,
and families each have a recovery process.
PROCESS:
On either a chalk board or flip chart, write the question, “What are
people diagnosed with a mental illness recovering from?” Have the
group brainstorm as many responses as possible.
What Are Consumers
Recovering From?
•
•
•
•
•
•
•
•
•
•
•
Major losses of people and opportunities
The catastrophe of mental illness
Trauma from mistreatment
Negative professional attitudes
Lack of recovery skills of professionals
Devaluing and disempowering programs, practices, and
environments
Lack of enriching opportunities
Stigma and discrimination from society
Lack of opportunities for self-determination
Crushed dreams
Lack of a sense of self, valued roles, and hope
On either a chalk board or flip chart, write the question, “What are
direct care staff and/or families recovering from?” Have the group
brainstorm as many responses as possible.
Page 1 of 2
Module 4
16
PRESENTATION
“What Are We Recovering From?” (continued)
What Do Direct Care Staff
and/or Families Recover From?
•
•
•
•
•
•
•
•
Worn out beliefs
Hopelessness and helplessness
Need to be in control
An unbalanced relationship
Disbelief in consumer’s ability
Fear of mental illness
Discrimination
Hopes and expectations
DISCUSSION
QUESTIONS:
•
•
•
•
What are the similarities between the two lists?
What helps/hinders people in recovery?
How can you as a professional best assist recovery?
What advice would you give to a person in the first stages
of recovery?
• How do you think professionals view the process of recovery?
• What do you think about individuals speaking out about their
mental illness?
• Have you had personal experience(s) with stigma concerning
mental illness? How does stigma affect recovery?
APPROXIMATE
TIME REQUIRED:
15 minutes
SOURCE:
Recovery material from Spaniol, Gagne, & Koehler (1997)
Page 2 of 2
Module 4
17
PRESENTATION
Give participants time to respond to one to two questions from the
Journal section and at least one question from each of the Personal
Take Action Challenges and the Workplace Take Action Challenges.
They will use these Take Action Challenges extensively on the last
day of the training.
Module 4
18
PRESENTATION
JOURNAL/TAKE ACTION CHALLENGE
Journal Topics
Pick one or two questions and write your responses. Your responses are confidential.
• What do you like/dislike about cultural change theory?
• When you have been in a stressful situation in the past, what has been helpful for you
to hear? What has not been helpful?
• What are words or phrases that you use that might be helpful/hurtful to consumers?
• How do the concepts of recovery relate to you personally?
• What scares and inspires you most about people diagnosed with a mental illness working
in the mental health field?
• How could you implement programs based on models of resiliency and recovery?
• How would your daily work change if the mental health system wholeheartedly adopted
the underpinnings of resilience and recovery?
• Where do you feel empowered to make changes? Where do you feel disempowered
to make changes? What can you do about it?
• What are the unwritten and/or unspoken rules or beliefs about seclusion or restraint in
your work environment? Do you agree or disagree with these rules/beliefs? How do
these rules/beliefs get perpetuated and what would it take to change them?
• Find one area in your life where you could work on fostering your own resilience
or recovery. How would your life look different if you adopted these philosophies?
• Make a list of two things you can personally commit to in your daily life to move you
forward in your own resilience and recovery.
• What do you see as your professional responsibility in changing the culture at work as
it pertains to eliminating seclusions and restraint?
• Find one area where you could expand on the philosophy of resilience and recovery
philosophy in your daily work. How would it change how you currently interact with
consumers? How would things stay the same?
• Make a list of two things that you personally can commit to every day to incorporate
resilience and recovery into your work. Make a detailed plan of how you will implement
these changes.
Module 4
19
HANDOUT
FOR MODULES 3 & 4
Someone Who Believed in Them Helped Them to Recover
People who have significantly recovered from mental illness frequently say they were greatly
helped by someone who believed in them. One woman stated that there was a doctor who “Believed in me. She never gave up. She was the only one who didn’t give up as far as [my] being in
the hospital.” Another woman stated that for her it was a caring therapist. She said, “He was the
first person I encountered out of the ordeal that actually had some sort of feeling. He was sympathetic at least and was understanding. He was really helping me out and motivating. Motivating
me to keep on fighting, don’t give up...Don’t let them get their way, just keep on fighting.”
A nurse working with me reflected that the most important elements to her recovery were
“Having a mentor, a connection and a relationship...someone I made a strong connection to
and they made one to me and they believed in me and I knew it...There was a knowing in
their eyes that I saw that said I see you and I really believe in you. Someone that carried me.
Somehow that encouraged me to not fall backwards.”
Another woman in describing the residential counselor as the most important person in her
recovery stated, “She believed in me...She sent me a card that said, ‘keep up the good work.’
She saw a spark in me. She told me from the start I had a good deal going for me. She helped
encourage me and put courage in me. She gave me incentive.”
The people who work in residential services are often the ones whose belief made a difference in someone’s recovery. Jim is an example of such a worker. For 8 years he has patiently
and respectably offered his heart and hand to consumer/survivors. Recently he described
a priceless moment with a consumer/survivor, Eric, whom everyone else had written off.
During a walk with Eric, Jim commented on the beauty of the sky. Eric replied, “It is of no
importance to me now; why are you telling me about it.”
Jim was delighted. It was one of the first times that Eric had expressed a strong emotion directly
to another person. It was also one of the first times that he stated that his needs were different
from those of others. Jim thinks that Eric now feels safe enough to express strong feeling within
their relationship. Over several years, Jim has carefully won Eric’s trust through listening to
his deepest requests. For instance, Eric has bitterly complained that he has not felt alive on his
major tranquilizer. Jim has been able to help Eric to negotiate a much lower dose. Though in the
past Eric suffered increased paranoia when his medication was lowered, he has not done so this
time. I am sure this is because of his close relationship with Jim which has allowed him to feel
safe with greater feelings. Eric has also started to listen to different music. For many years he
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by Dan B. Fisher, M.D., Ph.D., National Empowerment Center
Someone Who Believed in Them (continued)
When I asked other staff about Jim they said he reminds them of Yoda, the wise being from
Star Wars. When he walks into a room everyone feels a sense of calm and peace, yet he can
be firm. A consumer called and was abusive to him on the phone. He calmly said, “I won’t
talk with you when you treat me that way. When you can have a civil conversation call me
back.” In a few minutes she did and they had a productive conversation. He has a sense of
humor. One day a consumer was getting very angry on the bus. Others felt threatened, but
Jim suddenly burst out laughing and so did the consumer. When I asked Jim what he felt
was most important in his relating with consumer-survivors, he said, “I just accept them, the
real person. Then they will present more and more of themselves to you.” Such an elusively
simple description of the beauty he weaves.
Jim’s manner reminds me deeply of the contact I yearned for and occasionally found in my
own journey to recover my own lost self. After a year with an emotionally remote analyst, I
sought a different kind of therapist, one that was more human and showed more of himself
to me. I made one request at the start of our therapy. “Could you please be a real person with
me?” He said he would try to and the combination of his acceptance of my request and his
humility planted the roots of trust. There were many tests of our relationship, but he was
consistent in his support of me at a deep level. When I told him I wanted to become a psychiatrist he said he would be there for my graduation and he was, even though I was no longer
in therapy with him. When I would thank him for an insight he would insist that I had done
the work and the healing. He said he had merely provided the setting. When I asked how he
felt about my attending a group with another therapist. He said he trusted that I knew what I
needed to heal.
Equally compelling is the centering and spiritual renewal coming for the person who does the
believing in another. Whether it is for our children, lover, pet, or person in need of help, there
is deep meaning for the person who can step outside their world to support another’s. A client
I had seen through many hospitalizations recently had a long period free of such episodes.
She clearly had a new light in her eye. When I asked what had changed she said now that she
was working as a provider she had a sense of meaning and purpose in her life. Helping others
gave her sufficient meaning that she felt her life was worth living.
These observations recall the research of Carl Rogers into the nature of the helping relationships. He stated that “the safety of being liked and prized as a person seems a highly
important element in a helping relationship” (On Becoming a Person, 1961). Martin Buber
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would only listen to heavy metal which Jim felt he needed to listen to because it was needed to
drown out his painful thoughts. Now Eric is able to listen to soft rock and folk.
Someone Who Believed in Them (continued)
These descriptions, however, were mostly for people with moderate emotional problems.
When someone is labeled with mental illness, it is as if all that has been learned to be helpful
in therapy is thrown out. Medical students are taught to medicate, not to converse with mental patients. They are told that people labeled with mental illness have a brain disease and you
cannot talk to a disease. Our lived experiences speak otherwise. Our lives show that people
labeled with mental illness need a therapist and other people who believe in them.
We, who have been labeled with mental illness, remain just as human if not more so than others who are temporarily not labeled. Our needs are human needs of which the most basic is to
enter into trusting, loving, and caring relationships. These relationships need to be nurtured and
cultivated for us to find the compass of our true self to guide our recovery. Any system of care
which disturbs or interferes with these relationships is preventing, not promoting, recovery.
Reprinted by permission of NEC.
Copyright ©1999, National Empowerment Center, Inc. All rights reserved.
www.namiscc.org
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also describes the importance of having someone believe in you. He calls this characteristic
“confirming the other...Confirming means accepting the whole potentiality of the other. I can
recognize in him the person he has been created to become.” Rogers goes on to State that “if
I accept the other person as something fixed, already diagnosed and classified...then I am doing my part to confirm this limited hypothesis. If I accept him as a process of becoming, then
I am doing what I can to confirm or make real his potential.
Recovery as a Journey of the Heart
…We pass on knowledge about mental illness. Students emerge from school with knowledge
about neurotransmitters and schizophrenics and bipolars and borderlines and multiples and
OCDs. They become experts in recognizing illness and disease. But this is where we so often
fail them. We fail them because we have not taught them to seek wisdom—to move beyond
mere recognition in order to seek the essence of what is. We have failed to teach them to reverence the human being who exists prior to and in spite of the diagnosis we have placed upon
them. Just as the generic, anatomical heart does not exist, neither does “the schizophrenic” or
“the multiple” or the “bipolar” exist outside of a generic textbook. What exists, in the truly
existential sense, is not an illness or disease. What exists is a human being, and wisdom demands that we see and reverence this human being before all else. Wisdom demands that we
wholeheartedly enter into a relationship with human beings in order to understand them and
their experience. Only then are we able to help in a way that is experienced as helpful.
Those of us who have been labeled with mental illness are first and foremost human beings.
We are more than the sum of the electrochemical activity of our brains. Our hearts are not
merely pumps. Our hearts are as real and as vulnerable and valuable as yours are. We are
people. We are people who have experienced great distress and who face the challenge of
recovery.
The concept of recovery is rooted in the simple yet profound realization that people who have
been diagnosed with mental illness are human beings. Like a pebble tossed into the center of
a still pool, this simple fact radiates in ever larger ripples until every corner of the academic
and applied mental health science and clinical practice are affected. Those of us who have
been diagnosed are not objects to be acted upon. We are fully human subjects who can act
and in acting, change our situation. We are human beings and we can speak for ourselves. We
have become self-determining. We can take a stand toward what is distressing to us and need
not be passive victims of an illness. We can become experts in our own journey of recovery.
The goal of recovery is not to get mainstreamed. We don’t want to be mainstreamed. We
say let the mainstream become a wide stream that has room for all of us and leaves no one
stranded on the fringes.
The goal of the recovery process is not to become normal. The goal is to embrace our human
vocation of becoming more deeply, more fully human. The goal is not normalization. The
goal is to become the unique, awesome, never to be repeated human being that we are called
to be. The philosopher Martin Heidegger said that to be human means to be a question in
search of an answer. Those of us who have been labeled with mental illness are not de facto
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by Patricia E. Deegan Ph.D.
Recovery as a Journey of the Heart (continued)
To be human means to be a question in search of an answer. However, many of us who have
been psychiatrically labeled have received powerful messages from professionals who in
effect tell us that by virtue of our diagnosis the question of our being has already been answered and our futures are already sealed. For instance, I can remember such a time during
my third hospitalization. I was 18 years old. I asked the psychiatrist I was working with,
“What’s wrong with me?” He said, “You have a disease called chronic schizophrenia. It is a
disease that is like diabetes. If you take medications for the rest of your life and avoid stress,
then maybe you can cope.” And as he spoke these words I could feel the weight of them
crushing my already fragile hopes and dreams and aspirations for my life. Even some 22
years later those words still echo like a haunting memory that does not fade.
Today I understand why this experience was so damaging to me. In essence the psychiatrist
was telling me that my life, by virtue of being labeled with schizophrenia, was already a
closed book. He was saying that my future had already been written. The goals and dreams
that I aspired to were mere fantasies according to his prognosis of doom. When the future has
been closed off in this way, then the present loses its orientation and becomes nothing but a
succession of unrelated moments. Today I know that this psychiatrist had little wisdom at that
time. He merely had some knowledge and recognized me as “the schizophrenic” who had
been handed down through the generations by Kraeplin and Bleuler. He did not see me. He
saw an illness. We must urge our students to seek wisdom, to move beyond mere recognition
of illness and to wholeheartedly encounter the human being who comes for help. It is imperative that we teach students that relationship is the most powerful tool they have in working
with people.
Beyond the goals of recovery, there is the question of the process of recovery. How does
one enter into the journey of recovery? Today I would like to begin a conceptualization of
recovery as a journey of the heart. We will begin in that place where many people find themselves—in that place of being hard of heart and not caring anymore.
Prior to becoming active participants in our own recovery process, many of us find ourselves
in a time of great apathy and indifference. It is a time of having a hardened heart. Of not caring anymore. It is a time when we feel ourselves to be among the living dead: alone, abandoned, and adrift on a dead and silent sea without course or bearing. If I turn my gaze back
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excused from this most fundamental task of becoming human. In fact, because many of us
have experienced our lives and dreams shattering in the wake of mental illness, one of the
most essential challenges that faces us is to ask, “Who can I become and why should I say
‘yes’ to life?”
…During this time people would try to motivate me. I remember people trying to make me
participate in food shopping on Wednesday or to help bake bread or to go on a boat ride. But
nothing anyone did touched me or moved me or mattered to me. I had given up. Giving up
was a solution for me. The fact that I was “unmotivated” was seen as a problem by the people
who worked with me. But for me, giving up was not a problem, it was a solution. It was a
solution because it protected me from wanting anything. If I didn’t want anything, then it
couldn’t be taken away. If I didn’t try, then I wouldn’t have to undergo another failure. If I
didn’t care, then nothing could hurt me again. My heart became hardened. The springs came
and went and I didn’t care. Holidays came and went and I didn’t care. My friends went off to
college and started new lives and I didn’t care. I remember sitting and smoking and saying
almost nothing. And as soon as the clock struck 8, I remember interrupting my friend in midsentence and telling her to go home because I was going to bed. Without even saying goodbye, I headed for my bed. My heart was hard. I didn’t care about anything.
I trust that the picture I am painting here is familiar to many of us. We recognize this picture
of apathy, withdrawal, isolation, and lack of motivation. But if we go beyond mere recognition in search of wisdom we must dig deeper. What is this apathy, indifference, hardness of
heart which keeps so many people in a mode of survival and prevents them from actively entering into their own journey of recovery? Is it merely the negative symptoms of schizophrenia? I think not. I believe that becoming hard of heart and not caring anymore is a strategy
that desperate people, who are at the brink of losing hope, adopt in order to remain alive.
Hope is not just a nice sounding euphemism. Hope and biological life are inextricably intertwined. Martin Seligman’s (1975) work in the field of learned helpless offers us great insight
into the chiasmic intertwining of hope and biological life.
…I would say that when those of us with psychiatric disabilities come to believe that all of
our efforts are futile. When we experience that we have no control over our environment;
when nothing we do seems to matter or to make the situation better; when we follow the
treatment team’s instructions and achieve their treatment goals for us and still no placement
opens up in the community for us; when staff decide where we will live, with whom we will
live, under what rules we will live, how we will spend our money, if we will be allowed to
spend our money, when we will have to leave the group home, and at what time we will be
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I can see myself at 17 years old, diagnosed with chronic schizophrenia, drugged on Haldol
and sitting in a chair. As I conjure the image, the first thing I can see are the girl’s yellow,
nicotine-stained fingers. I can see her shuffled, stiff, drugged walk. Her eyes do not dance.
The dancer has collapsed and her eyes are dark and they stare endlessly into nowhere.
Of course, the great danger is that staff will fail to recognize the intensity of the existential
struggle that the person who is hard of heart is struggling with. The danger is that the staff
will simply say, “Oh, this person just has a lot of negative signs and symptoms and that’s a
poor prognosis and we mustn’t expect much from this person.” Or staff may become judgmental and dismiss us as simply being lazy and unmotivated. Or the staff may succumb to
their own despair and simply write us off as being “low functioning.”
…However the staff must not fall into despair, feel like their efforts are futile, grow hard of
heart, and stop caring themselves. If they do this, then they are doing exactly what the person
with a psychiatric disability is doing. Staff must avoid this trap. They must do what the person cannot yet do. Staff must role model hope and continue to offer options and choices even
if they are rejected over and over again.
Additionally, environments must include opportunities for people to have accurate information. Information is power and information sharing is power sharing. People who feel powerless can increase their sense of self-efficacy by having access to information. People who feel
powerless also feel that what they say does not matter. Taking the time to listen to people and
to help them find their own unique voice is important. Having a voice in developing rules as
well as having a say in the hiring and evaluation of staff are important ways of exercising a
voice that for too long has been silenced. Finally, it is important to have other people with
psychiatric disabilities working as paid staff.
Role models provide hope that maybe I, too, can break out of this hardened heart and begin
to care again. People who are defending themselves against the possibly lethal effects of
profound hopelessness must see that there is a way out and that actions they take can inch
them ever closer to their desired goal. They need to see that the quality of life can get better
for people who have been similarly diagnosed. They need to see that there are opportunities
for improving their situation. That is why hiring people with psychiatric disabilities as mental
health professionals and staff is so important. It is also why exposure to peer support, self
help, and mutual support are so important.
Choice, options, information, role models, being heard, developing and exercising a voice,
opportunities for bettering one’s life: these are the features of a human interactive environment which support the transition from not caring to caring, from surviving to becoming an
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allowed back into it, then a deep sense of hopelessness, of despair, begins to settle over the
human heart. And in an effort to avoid the biologically disastrous effects of profound hopelessness, people with psychiatric disabilities do what other people do. We grow hard of heart
and attempt to stop caring. It is safer to become helpless then to become hopeless.
As for myself, I cannot remember a specific moment when I turned that corner from surviving to becoming an active participant in my own recovery process. My efforts to protect my
breaking heart by becoming hard of heart and not caring about anything lasted for a long
time. One thing I can recall is that the people around me did not give up on me. They kept
inviting me to do things. I remember one day, for no particular reason, saying “yes” to helping with food shopping. All I would do was push the cart. But it was a beginning. And truly,
it was through small steps like these that I slowly began to discover that I could take a stand
toward what was distressing to me.
I know that anger, especially angry indignation, played a big role in that transition. When that
psychiatrist told me the best I could hope for was to take my medications, avoid stress, and
cope, I became enraged. (However, I was not smart enough to keep my angry indignation
to myself because the #1 rule is never get enraged in a psychiatrist’s office if you’re being
labeled with chronic schizophrenia!) I also remember that just after that visit I made up my
mind to become “a doctor.” I was so outraged at the things that had been done to me against
my will in the hospital as well as the things I saw happen to other people, that I decided that
I wanted to get a powerful degree and have enough credentials to run a healing place myself.
In effect I had a survivor mission that I felt passionately about.
I was also careful not to share my newfound aspiration with anyone. Imagine what my psychiatrist would have said to me if I had announced at age 18, having virtually flunked out of
high school, with a combined GRE score of under 800, with a diagnosis of chronic schizophrenia, that I was planning on getting my Ph.D. in clinical psychology. “Delusions of grandeur!” But in essence that is precisely what I did. Starting with one course in English Composition at the local community college, I slowly made my way. Dragging my textbooks into
the mental hospital with me or trying to read with double vision due to Prolixin, I inched my
way forward. I had a strong spirituality that really helped. I had a strong therapeutic alliance
with a psychotherapist. I lived with latter-day hippies who had tolerance for lots of weird
behavior, including my psychotic episodes. After some experimenting in my early teens, I
somehow intuited that drugs and alcohol were bad news for me and I did not use them even
though the people around me did. In retrospect, I know this was a wise decision. I read books
about healing and psychopathology and personality theory in an effort to understand myself
and my situation. I was always trying new ways of coping with symptoms, including my relentless auditory hallucinations. And perhaps most importantly of all, when I got out of bed in
the morning, I always knew the reason why—I had a purpose in life, I had been called, I had
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active participant in one’s own recovery process. Creating such environments are the skills
which tomorrow’s mental health professionals must master.
My journey of recovery is still ongoing. I still struggle with symptoms, grieve the losses that
I have sustained, and have had to get involved in treatment for the sequel child abuse. I am
also involved in self help and mutual support and I still use professional services including
medications, psychotherapy, and hospitals. However, now I do not just take medication or go
to the hospital. I have learned to use medications and to use the hospital. This is the active
stance that is the hallmark of the recovery process.
There is more to the recovery process than simply recovering from mental illness. We must
also recover from the effects of poverty and second class citizenship. We must learn to raise
our consciousness and find our collective pride in order to overcome internalized stigma.
Finally, many of us emerge from mental health treatment settings with traumatic stress disorders related to having sustained or witnessed physical, sexual, and/or emotional abuse at the
hands of staff. “Sometimes I scream at night because I dream about the hospital I was raped
in or some other hospital I’ve been in” (LaLime, 1990). Sometimes recovering from mental
illness is the easy part. Recovering from these deep wounds to the human heart takes longer.
Recovery does not mean “cure.” It does not mean stabilization or maintenance. Rather recovery is an attitude, a stance, and a way of approaching the day’s challenges. It is not a perfectly
linear journey. There are times of rapid gains and disappointing relapses. There are times of
just living, just staying quiet, resting, and regrouping. Each person’s journey of recovery is
unique. Each person must find what works for them. This means that we must have the opportunity to try and to fail and to try again. In order to support the recovery process, mental
health professionals must not rob us of the opportunity to fail. Professionals must embrace
the concept of the dignity of risk and the right to failure if they are to be supportive of us.
A new age is upon us. …Understanding that people with psychiatric disabilities are first and
foremost people who are in process, growing, and changing is the cornerstone of understanding the concept of recovery. We must not let our hearts grow hard and callused toward people
with psychiatric disabilities. Our role is not to judge who will and will not recover. Our job is
to create environments in which opportunities for recovery and empowerment exist. Our job
is to establish strong, supportive relationships with those we work with. And perhaps most of
all, our greatest challenge is to find a way to refuse to be dehumanized in the age of managed
profit and to be bold and brave and daring enough to remain human hearted while working in
the human services.
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a vocation, and I kept saying yes to it. Even in the present I must make a daily affirmation of
my vocation in order to keep going. The temptation to give up is still strong sometimes.
LaLime, W. (1990). Untitled speech used as part of Lowell M-POWER’s anti-stigma workshop,
Lowell. MA. Cited in Deegan, P. (1990). Spirit breaking: When the helping professions hurt.
The Humanistic Psychologist, 18(3), 301-313.
Lefcourt, H.M. (1973). The function of the illusions of control and freedom. American Psychologist,
28, 417-425.
Seligman, M.E.P. (1975). Helplessness: On depression, development, and death. San Francisco:
Freeman.
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References
by William A. Anthony
William A. Anthony, Ph.D., is Executive Director of the Center for Psychiatric Rehabilitation
at Boston University, Boston, Massachusetts
Abstract: The implementation of deinstitutionalization in the 1960s and I970s, and the
increasing ascendance of the community support system concept and the practice of psychiatric rehabilitation in the 1980s, have laid the foundation for a new 1990s vision of service
delivery for people who have mental illness. Recovery from mental illness is the vision that
will guide the mental health system in this decade. This article outlines the fundamental services and assumptions of a recovery-oriented mental health system. As the recovery concept
becomes better understood, it could have major implications for how future mental health
systems are designed.
The seeds of the recovery vision were sown in the aftermath of the era of deinstitutionalization. The failures in the implementation of the policy of deinstitutionalization confronted us
with the fact that a person with severe mental illness wants and needs more than just symptom relief. People with severe mental illnesses may have multiple residential, vocational,
educational, and social needs and wants. Deinstitutionalization radically changed how the
service system attempts to meet these wants and needs. No longer does the State hospital
attempt to meet these multiple wants and needs; a great number of alternative community-based settings and alternative inpatient settings have sprung up since deinstitutionalization. This diversity has required new conceptualizations both of how services for people
with severe mental illnesses should be organized and delivered, and of the wants and needs
of people with severe mental illness. This new way of thinking about services and about the
people served has laid the foundation for the gradual emergence of the recovery vision in
the 1990s.
As a prelude to a discussion of the recovery vision, the present paper briefly describes the
community support system (CSS) concept and the basic services integral to a comprehensive
community support system. Next, the more thorough understanding of the total impact of
severe mental illness, as conceptualized in the rehabilitation model, is succinctly overviewed.
With the CSS service configuration and the rehabilitation model providing the historical and
conceptual base, the recovery concept, as we currently understand it, is then presented.
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Recovery From Mental Illness: The Guiding Vision
of the Mental Health Service System in the 1990s
Recovery From Mental Illness—Guiding Vision (continued)
The essential components of a CSS have been demonstrated and evaluated since its inception. Test (1984) concluded from her review that programs providing more CSS functions
seem to be more effective (with fewer rehospitalizations and improved social adjustment in
some cases) than programs that provide fewer CSS functions. More recently, Anthony and
Blanch (1989) reviewed data relevant to CSS and concluded that research in the 1980s documented the need for the array of services and supports originally posited by the CSS concept.
It appears that the need for the component services of CSS has a base in empiricism as well
as in logic. Most comprehensive mental health system initiatives in the 1980s can be traced
to the CSS conceptualization (National Institute of Mental Health, 1987).
Based on the CSS framework, the Center for Psychiatric Rehabilitation has refined and
defined the services fundamental to meeting the wants and needs of persons with long-term
mental illness. Table 1 presents these essential client services.
The Impact of Severe Mental Illness
This new understanding of the importance of a comprehensive, community-based service
system is based on a more thorough and clear understanding of that system’s clients. The
field of psychiatric rehabilitation, with its emphasis on treating the consequences of the illness rather than just the illness per se, has helped bring to this new service system configuration a more complete understanding of the total impact of severe mental illness. The psychiatric rehabilitation field relied on the World Health Organization’s 1980 classification of the
consequences of disease to provide the conceptual framework for describing the impact of
severe mental illness (Frey, 1984).
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The Community Support System
In the mid-1970s, a series of meetings at the National Institute of Mental Health (NIMH)
gave birth to the idea of a community support system (CSS), a concept of how services
should be provided to help persons with long-term psychiatric disabilities (Turner & TenHoor, 1978). Recognizing that post-deinstitutionalization services were unacceptable, the
CSS described the array of services that the mental health system needed for persons with
severe psychiatric disabilities (Stroul, 1989). The CSS filled the conceptual vacuum resulting from the aftermath of deinstitutionalization (Test, 1984). The CSS was defined (Turner &
Schifren, 1979, p. 2) as “a network of caring and responsible people committed to assisting
a vulnerable population meet their needs and develop their potentials without being unnecessarily isolated or excluded from the community.” The CSS concept identifies the essential
components needed by a community to provide adequate services and support to persons who
are psychiatrically disabled.
Service
Category
Description
Consumer Outcome
Treatment
Alleviating symptoms and
distress
Symptom relief
Crisis
intervention
Controlling and resolving critical
or dangerous problems
Personal safety assured
Case
management
Obtaining the services client
needs and wants
Services accessed
Rehabilitation
Developing clients’ skills and
support related to client’s goals
Role functioning
Enrichment
Engaging clients in fulfilling and
satisfying activities
Self-development
Rights protection
Advocating to uphold one’s
rights
Equal opportunity
Basic support
Providing the people, places,
and things client needs to
survive (e.g., shelter, meals,
health care)
Personal survival
assured
Self-help
Exercising a voice and a choice
in one’s life
Empowerment
Adapted from Cohen, A B., Nemec, P.B., Farkas, M.D., & Forbess, R, (1990). Psychiatric rehabilitation training technology. Case management (trainer package). Boston: Boston University, Center
for Psychiatric Rehabilitation.
In the 1980s, proponents of psychiatric rehabilitation emphasized that mental illness not only
causes mental impairments or symptoms but also causes the person significant functional limitations, disabilities, and handicaps (Anthony, 1982; Anthony & Liberman, 1986; Anthony, Cohen, & Farkas, 1990; Cohen & Anthony, 1984). The World Health Organization (Wood, 1980),
unlike mental health policymakers, had already developed a model of illness which incorporated not only the illness or impairment but also the consequences of the illness (disability and
handicap). As depicted in Table 2, these terms can be reconfigured as impairment, dysfunction,
disability, and disadvantage. This conceptualization of the impact of severe mental illness has
come to be known as the rehabilitation model (Anthony, Cohen, & Farkas, 1990).
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Table 1
Essential Client Services in a Caring System
Table 2
The Negative Impact of Severe Mental Illness
Stages
I. Impairment
II. Dysfunction
III. Disability
IV. Disadvantage
Definitions
Any loss or
abnormality of
psychological,
physiological,
or anatomical structure or
function
Any restriction
or lack of ability
to perform an
activity or task
in the manner
or within the
range considered normal for
a human being
Any restriction
or lack of ability
to perform a
role in the manner or within the
range considered normal for
a human being
A lack of opportunity for an
individual that
limits or prevents
the performance
of an activity or
the fulfillment
of a role that is
normal (depending on age, sex,
social, cultural
factors) for that
individual
Examples
Hallucinations,
delusions, depression
Lack of work
adjustment
skills, social
skills, ADL skills
Unemployment,
homelessness
Discrimination
and poverty
Adapted from Anthony, W.A, Cohen, M.R., & Farkas, M.D. (1990). Psychiatric rehabilitation.
Boston: Boston University, Center for Psychiatric Rehabilitation.
Recovery: The Concept
The concept of recovery, while quite common in the field of physical illness and disability
(Wright, 1983), has heretofore received little attention in both practice and research with
people who have a severe and persistent mental illness (Spaniol, 1991). The concept of recovery from physical illness and disability does not mean that the suffering has disappeared,
all the symptoms removed, and/or the functioning completely restored (Harrison, 1984). For
example, a person with paraplegia can recover even though the spinal cord has not. Similarly,
a person with mental illness can recover even though the illness is not “cured.”
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The development of the concept of a comprehensive community support system, combined
with the rehabilitation model’s more comprehensive understanding of the impact of severe
mental illness, has laid the conceptual groundwork for a new vision for the mental health
service system of the 1990s. Based on the insights of the 1970s and 1980s, service delivery
promoting recovery from programs and systems will be guided by a vision of promoting
recovery from mental illness (Anthony, 1991).
Recovery from mental illness involves much more than recovery from the illness itself.
People with mental illness may have to recover from the stigma they have incorporated
into their very being, from the iatrogenic effects of treatment settings; from lack of recent
opportunities for self-determination; from the negative side effects of unemployment; and
from crushed dreams. Recovery is often a complex, time-consuming process.
Recovery is what people with disabilities do. Treatment, case management, and rehabilitation
are what helpers do to facilitate recovery (Anthony, 1991). Interestingly, the recovery experience is not an experience that is foreign to services personnel. Recovery transcends illness
and the disability field itself. Recovery is a truly unifying human experience. Because all
people (helpers included) experience the catastrophes of life (death of a loved one, divorce,
the threat of severe physical illness, and disability), the challenge of recovery must be faced.
Successful recovery from a catastrophe does not change the fact that the experience has occurred, that the effects are still present, and that one’s life has changed forever. Successful
recovery does mean that the person has changed, and that the meaning of these facts to the
person has therefore changed. They are no longer the primary focus of one’s life. The person
moves on to other interests and activities.
Recovery: The Outcome
Recovery may seem like an illusory concept. We still know very little about what this process
is like for people with severe mental illness. Yet many recent intervention studies have in fact
measured elements of recovery, even though the recovery process went unmentioned. Recovery is a multi-dimensional concept: there is no single measure of recovery, but many different
measures that estimate various aspects of it. The recovery vision expands our concept of service
outcome to include such dimensions as self-esteem, adjustment to disability, empowerment, and
self-determination. However, it is the concept of recovery, and not the many ways to measure it,
that ties the various components of the field into a single vision. For service providers, recovery
from mental illness is a vision commensurate with researchers’ vision of curing and preventing
mental illness. Recovery is a simple yet powerful vision (Anthony, 1991).
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In the mental health field, the emerging concept of recovery has been introduced and is most
often discussed in the writings of consumers/survivors/clients (Anonymous, 1989; Deegan,
1988; Houghton, 1982; Leete, 1989; McDermott, 1990; Unzicker, 1989). Recovery is
described as a deeply personal, unique process of changing one’s attitudes, values, feelings,
goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even
with limitations caused by illness. Recovery involves the development of new meaning and
purpose in one’s life as one grows beyond the catastrophic effects of mental illness.
Table 3 provides an overview of the major consumer outcome focus of the essential community support system of services. The services mainly directed at the impairment are the
traditional “clinical” services, which in a recovery-oriented system deal with only a part of
the impact of severe mental illness (i.e., the symptoms). Major recovery may occur without
complete symptom relief. That is, a person may still experience major episodes of symptom exacerbation, yet have significantly restored task and role performance and/or removed
significant opportunity barriers. From a recovery perspective, those successful outcomes may
have led to the growth of new meaning and purpose in the person’s life.
Recovery-oriented system planners see the mental health system as greater than the sum of its
parts. There is the possibility that efforts to affect the impact of severe mental illness positively
can do more than leave the person less impaired, less dysfunctional, less disabled, and less disadvantaged. These interventions can leave a person not only with “less,” but with “more”—more
meaning, more purpose, more success, and more satisfaction with one’s life. The possibility
exists that the outcomes can be more than the specific service outcomes of, for example, symptom management and relief, role functioning, services accessed, entitlements assured, etc. While
these outcomes are the raison d’etre of each service, each may also contribute in unknown ways
to recovery from mental illness. A provider of specific services recognizes, for example, that
symptoms are alleviated not only to reduce discomfort, but also because symptoms may inhibit
recovery; that crises are controlled not only to assure personal safety, but also because crises may
destroy opportunities for recovery; that rights protection not only assures legal entitlements, but
also that entitlements can support recovery. As mentioned previously, recovery outcomes include
more subjective outcomes such as self-esteem, empowerment, and self-determination.
Basic Assumptions of a Recovery-Focused Mental Health System
The process of recovery has not been researched. The vagaries of recovery make it a mysterious process, a mostly subjective process begging to be attended to and understood. People
with severe disabilities (including psychiatric disabilities) have helped us glimpse the process
through their words and actions (Weisburd, 1992). In addition, all of us have directly experienced the recovery process in reaction to life’s catastrophes. Based on information gained
from the above, a series of assumptions about recovery can be identified.
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A Recovery-Oriented Mental Health System
A mental health service system that is guided by the recovery vision incorporates the critical
services of a community support system organized around the rehabilitation model’s description
of the impact of severe mental illness—all under the umbrella of the recovery vision. In a recovery-oriented mental health system, each essential service is analyzed with respect to its capacity
to ameliorate people’s impairment, dysfunction, disability, and disadvantage (see Table 3).
Recovery development of new meaning and purpose as one grows beyond the catastrophic
effects of mental illness.
Impact of Severe Mental Illness
Mental Health
Services (and
Outcomes)
Treatment
Impairment
(Disorder
in thought,
feelings, and
behavior)
Dysfunction
(Task
performance
limited)
Disability
(Role
performance
limited)
Disadvantage
(Opportunity
restrictions)
X
X
X
X
X
X
X
X
X
X
(Symptom relief)
Crises Intervention
X
(Safety)
Case Management
X
(Access)
Rehabilitation
(Role functioning)
Enrichment
(Self-development)
Rights Protection
X
(Equal opportunity)
Basic Support
X
(Survival)
Self-Help
X
X
(Empowerment)
1. Recovery can occur without professional intervention. Professionals do not hold the key
to recovery; consumers do. The task of professionals is to facilitate recovery; the task of
consumers is to recover. Recovery may be facilitated by the consumer’s natural support
system. After all, if recovery is a common human condition experienced by us all, then
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Table 3
Focus of Mental Health Services
It is important for mental health providers to recognize that what promotes recovery is
not simply the array of mental health services. Also essential to recovery are non-mental
health activities and organizations, e.g., sports, clubs, adult education, and churches.
There are many paths to recovery, including choosing not to be involved in the mental
health system.
2. A common denominator of recovery is the presence of people who believe in and stand by
the person in need of recovery. Seemingly universal in the recovery concept is the notion
that critical to one’s recovery is a person or persons in whom one can trust to “be there”
in times of need. People who are recovering talk about the people who believed in them
when they did not even believe in themselves, who encouraged their recovery but did not
force it, who tried to listen and understand when nothing seemed to be making sense.
Recovery is a deeply human experience, facilitated by the deeply human responses of others. Recovery can be facilitated by any one person. Recovery can be everybody’s business.
3. A recovery vision is not a function of one’s theory about the causes of mental illness.
Whether the causes of mental illness are viewed as biological and/or psychosocial generates considerable controversy among professionals, advocates, and consumers. Adopting
a recovery vision does not commit one to either position on this debate, nor on the use or
nonuse of medical interventions. Recovery may occur whether one views the illness as biological or not. People with adverse physical abnormalities (e.g., blindness, quadriplegia)
can recover even though the physical nature of the illness is unchanged or even worsens.
4. Recovery can occur even though symptoms reoccur. The episodic nature of severe mental
illness does not prevent recovery. People with other illnesses that might be episodic (e.g.,
rheumatoid arthritis, multiple sclerosis) can still recover. Individuals who experience intense psychiatric symptoms episodically can also recover.
5. Recovery changes the frequency and duration of symptoms. People who are recovering
and experience symptom exacerbation may have a level of symptom intensity as bad as
or even worse than previously experienced. As one recovers, the symptom frequency and
duration appear to have been changed for the better. That is, symptoms interfere with functioning less often and for briefer periods of time. More of one’s life is lived symptom-free.
Symptom recurrence becomes less of a threat to one’s recovery, and return to previous
function occurs more quickly after exacerbation.
6. Recovery does not feel like a linear process. Recovery involves growth and setbacks,
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people who are in touch with their own recovery can help others through the process.
Self-help groups, families, and friends are the best examples of this phenomenon.
7. Recovery from the consequences of the illness is sometimes more difficult than recovering from the illness itself. Issues of dysfunction, disability, and disadvantage are often
more difficult than impairment issues. An inability to perform valued tasks and roles, and
the resultant loss of self-esteem, are significant barriers to recovery. The barriers brought
about by being placed in the category of “mentally ill” can be overwhelming. These disadvantages include loss of rights and equal opportunities, and discrimination in employment
and housing, as well as barriers created by the system’s attempts at helping, e.g., lack of
opportunities for self-determination, disempowering treatment practices. These disabilities
and disadvantages can combine to limit a person’s recovery even though one has become
predominantly asymptomatic.
8. Recovery from mental illness does not mean that one was not “really mentally ill.” At
times people who have successfully recovered from severe mental illness have been discounted as not “really” mentally ill. Their successful recovery is not seen as a model, as
a beacon of hope for those beginning the recovery process, but rather as an aberration, or
worse yet as a fraud. It is as if we said that someone who has quadriplegia but recovered
did not “really” have a damaged spinal cord! People who have or are recovering from
mental illness are sources of knowledge about the recovery process and how people can be
helpful to those who are recovering.
Implications for the Design of Mental Health Systems
Recovery as a concept is by no means fully understood. Much research, both qualitative and
quantitative, still needs to be done, Paramount to the recovery concept are the attempts to
understand the experience of recovery from mental illness from those who are experiencing
it themselves. Qualitative research would seem particularly important in this regard.
However, it is not too early for system planners to begin to incorporate what we currently
think we know about recovery, For example, most first-person accounts of recovery from
catastrophe (including mental illness) recount the critical nature of personal support (recovery
assumption #2). The questions of system planners are: Should personal support be provided
by the mental health system? And if so, how can this personal support be provided? Should
intensive care managers fill this role? What about self-help organizations? Should they be
expanded and asked to perform even more of this function?
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periods of rapid change and little change. While the overall trend may be upward, the
moment-to-moment experience does not feel so “directionful.” Intense feelings may overwhelm one unexpectedly. Periods of insight or growth happen unexpectedly. The recovery
process feels anything but systematic and planned.
Recovery, as we currently understand it, involves the development of new meaning and purposes in one’s life as one grows beyond the catastrophic effects of mental illness. Does the
mental health system help in the search for this new meaning? Does it actively seek to provide opportunities that might trigger the development of new life purposes? Is this the type of
service professionals and survivors talk about when the value of “supportive psychotherapy”
is mentioned? Is there the support of therapists trained to help persons with mental illness
control their lives once again—even without fully controlling their mental illness?
There are a number of possible stimulants to recovery. These may include other consumers
who are recovering effectively. Books, films, and groups may cause serendipitous insights to
occur about possible life options. Visiting new places and talking to various people are other
ways in which the recovery process might be triggered. Critical to recovery is regaining the
belief that there are options from which one can choose—a belief perhaps even more important to recovery than the particular option one initially chooses.
Recovery-oriented mental health systems must structure their settings so that recovery “triggers” are present. Boring day treatment programs and inactive inpatient programs are characterized by a dearth of recovery stimulants. The mental health system must help sow and nurture the seeds of recovery through creative programming. There is an important caveat to this
notion of recovery triggers. At times the information provided through people, places, things,
and activities can be overwhelming. Different amounts of information are useful at different
times in one’s recovery. At times denial is needed when a recovering person perceives the information as too overwhelming. At particular points in one’s recovery, denial of information
prevents the person from becoming overwhelmed. Information can be perceived as a bomb
or a blanket—harsh and hostile or warm and welcome. Helpers in the mental health system
must allow for this variation in the time frame of information they are providing—and not
routinely and simply characterize denial as nonfunctional.
Similarly, the range of emotions one experiences as one recovers cannot simply be diagnosed
as abnormal or pathological. All recovering people, whether mentally ill or not, experience
strong emotions and a wide range of emotions. Such emotions include depression, guilt,
isolation, suspiciousness, and anger. For many persons who are recovering from catastrophes
other than mental illness, these intense emotions are seen as a normal part of the recovery
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If personal support is characterized as support that is trusting and empathic, do human resource development staff members need to train helpers in the interpersonal skills necessary
to facilitate this personal relationship? Quality assurance personnel would need to understand
the time it takes to develop such a relationship and figure out ways to assess and document
this process.
Concluding Comments
Many new questions and new issues are stimulated for system planners by a recovery-oriented
perspective. While we are nowhere near understanding the recovery concept nor routinely
able to help people achieve it, a recovery vision for the 1990s is extremely valuable.
A vision pulls the field of services into the future. A vision is not reflective of what we are
currently achieving, but of what we hope for and dream of achieving. Visionary thinking
does not raise unrealistic expectations. A vision begets not false promises but a passion for
what we are doing (Anthony, Cohen, & Farkas, 1990).
Previous “visions” that guided the mental health system were not consumer-based. They did
not describe how the consumer would ultimately benefit. For example, the deinstitutionalization “vision” described how buildings would function and not how service recipients would
function. Similarly, the CSS “vision” described how the service system would function and
not the functioning of the service recipients. In contrast, a recovery vision speaks to how
the recipients of services would function. Changes in buildings and services are seen in the
context of how they might benefit the recovery vision. In contrast to the field of services,
biomedical and neuroscience researchers have a vision. They speak regularly of curing and
preventing severe mental illness. They have helped to declare the 1990s “the decade of the
brain.” Recovery from mental illness is a similarly potent vision. It speaks to the heretofore
unmentioned and perhaps heretical belief that any person with severe mental illness can grow
beyond the limits imposed by his or her illness. Recovery is a concept that can open our eyes
to new possibilities for those we serve and how we can go about serving them. The 1990s
might also turn out to be the “decade of recovery.”
The author acknowledges contributions from the personnel of the Center for Psychiatric
Rehabilitation in the development of this paper.
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process. For persons recovering from mental illness, these emotions are too quickly and
routinely considered a part of the illness rather than a part of the recovery. The mental health
system must allow these emotions to be experienced in a nonstigmatizing and understanding
environment. Helpers must have a better understanding of the recovery concept in order for
this recovery-facilitating environment to occur
Anonymous (1989). How I’ve managed chronic mental illness. Schizophrenia Bulletin, 15,
635-640.
Anthony, W.A. (1982). Explaining “psychiatric rehabilitation” by an analogy to “physical
rehabilitation.” Psychosocial Rehabilitation Journal, 5(l), 61-65.
Anthony, W.A. (1991). Recovery from mental illness: The new vision of services researchers.
Innovations and Research, 1(1), 13-14.
Anthony, W.A., & Blanch, A.K. (1989). Research on community support services: What have we
learned? Psychosocial Rehabilitation Journal, 12(3), 55-81.
Anthony, W.A., & Liberman, R.P. (1986). The practice of psychiatric rehabilitation: Historical,
conceptual, and research base. Schizophrenia Bulletin, 12, 542-559.
Anthony, W.A., Cohen, M.R., & Farkas, M.D. (1990). Psychiatric rehabilitation. Boston: Boston
University, Center for Psychiatric Rehabilitation.
Cohen, B.F., & Anthony, W.A. (1984). Functional assessment in psychiatric rehabilitation. In A. S.
Halpern & M.J. Fuhrer (Eds.), Functional assessment in rehabilitation (pp. 79-100). Baltimore:
Paul Brookes.
Cohen, K R., Nerner, P.B., Farkas, A.D., & Forbess, R. (1990). Psychiatric rehabilitation training
technology; Case management (trainer package). Boston: Boston University, Center for
Psychiatric Rehabilitation.
Deegan, P. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation
Journal, 11(4), 11-19.
Frey, W.D. Functional assessment in the ‘80s. A conceptual enigma, a technical challenge. In A.
S. Halpern & M.J. Fuhrer (Eds.), Functional assessment in rehabilitation (pp- 11-43). Baltimore:
Paul Brookes.
Harrison, V. (1984). A biologist’s view of pain suffering and marginal life. In F. Dougherty (Ed.),
The depraved, the disabled, and the fullness of life. Delaware: Michael Glazier.
Houghton, J.F. (1982). Maintaining mental health in a turbulent world. Schizophrenia Bulletin, 8,
548-551
Leete, E. (1989). How I perceive and manage my illness. Schizophrenia Bulletin, 15, 197-200.
McDermott, B. (1990). Transforming depression. The Journal, 1(4), 13-14.
National Institute of Mental Health. (1987). Toward a model plan for a comprehensive,
community-based mental health system. Rockville, MD: Author.
Spaniol, L. (1991). Editorial. Psychosocial Rehabilitation Journal, 14(4), 1.
Stroul, B. (1989). Community support systems for persons with long-term mental illness:
A conceptual framework. Psychosocial Rehabilitation Journal, 12, 9-26.
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References
Turner, J.E., & Shifren, I. (1979). Community support systems: How comprehensive?
New Directions for Mental Health Services, 2, 1-23.
Turner, J.E., & TenHoor, W.J. (1979). The NIMH Community Support Program: Pilot approach
to a needed social reform. Schizophrenia Bulletin, 4, 319-348.
Unzicker, R. (1989). On my own! A personal journey through madness and re-emergence.
Psychosocial Rehabilitation Journal, 13(1), 71-77.
Weisburd, D. (Ed.). (1992). The Journal, 3, 2 (entire issue).
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Test, M.A. (1984). Community support programs. In A.S. Bellack (Ed.), Schizophrenia treatment,
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RESOURCES
Recovering Your Mental Health
Consumer Information Series, Volume 4
SMA-3504 Printed 2002
Building Self-Esteem
Making and Keeping Friends
Dealing with the Effects of Trauma
Developing a Recovery and Wellness Lifestyle
Speaking Out for Yourself
Action Planning for Prevention and Recovery
Consumer Information Series,Volume 10
These publications can be accessed electronically at www.samhsa.gov. For copies of the
publications, please call SAMHSA’s National Mental Health Services Information Center at
800-789-2647.
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Recovering Your Mental Health Self-Help Guides
Anthony, W. (1993). Recovey from mental illness: The guiding vision of the mental health service
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Bernard, B. (1992). Fostering resilience in kids: Protective factors in the family, school. and
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Deegan, P. (1993). Recovering our sense of value after being labeled mentally ill. Journal of
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MODULE 5
Strategies to Prevent Seclusion and Restraint
1
Module 5
“It is rather impressive how creative people can be when restraint
is simply not a part of the treatment culture.”
—John N. Follansbee, M.D.
JCAHO testimony,1999
Learning Objectives
• Define and outline the benefits, underlying values, and key elements of consumer-driven
supports.
• Develop and apply a Wellness Recovery Action Plan (WRAP).
• Identify benefits of drop-in centers, recovery through the arts, technical assistance
centers, and service animals.
• Name key elements to implement a comfort room and describe what staff can do to
support these consumer-driven supports.
• Guide a consumer in developing a Psychiatric Advance Directive/Prime Directive.
• Identify and implement effective communication strategies that prevent the use of
seclusion and restraints, including Alternative Dispute Resolution and Mediation.
Module 5
2
MODULE 5: STRATEGIES TO PREVENT SECLUSION AND RESTRAINT
Presentation (4 hours, 45 minutes) . . . . . . . . . . . . . . . . . .
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Wellness Recovery Action Plan (WRAP) . . . . . . . . . . . . . . . . .
Exercise: Developing a Wellness Recovery Action Plan . . .
(30 minutes)
Drop-In Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recovery Through the Arts . . . . . . . . . . . . . . . . . . . . . . . . .
Comfort Rooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Service Animals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Psychiatric Advance Directives. . . . . . . . . . . . . . . . . . . . . . .
Exercise: Creating My Own Psychiatric Advance Directive .
(30 minutes)
Prime Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Communication Strategies . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: How Hard Can Communication Be? (15 minutes) .
Alternative Dispute Resolution/Mediation . . . . . . . . . . . . . . .
Technical Assistance Centers . . . . . . . . . . . . . . . . . . . . . . . .
Handouts for Participants . . . . . . . . . . . . . . . . . . . . . . . . .
Examples of Consumer WRAPs . . . . . . . . . . . . . . . . . . . . .
Developing a WRAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How to Set Up a Comfort Room . . . . . . . . . . . . . . . . . . . . .
Why Should I Fill Out a Psychiatric Advance Directive? . . . . .
Ten Tips for Completing an Effective Advance Directive . . . .
Psychiatric Advance Directive Practice Worksheet . . . . . . . .
Six Essential Steps for Prime Directives . . . . . . . . . . . . . . .
Anticipated Benefits of Prime Directives . . . . . . . . . . . . . . .
Children’s and Adolescents’ Mental Health Services Technical
Assistance and Research Centers
Research, Training, and Technical Assistance Centers . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Module 5
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3
Overview
“Consumer/survivor operated self-help programs are a relatively recent phenomenon. Over
the last twenty years, consumers/survivors have shifted from passive recipients of mental
health services to become increasingly involved in planning, providing, and evaluating mental health services. The U.S. Department of Health and Human Services cites the following
benefits of self-help groups: peer support, coping strategies, role models, affordability, education, advocacy, non-stigmatizing, and “helper’s principle.” In addition, several other features
distinguish self-help from other forms of professional services: non-reliance on professionals,
voluntary participation, egalitarian and peer-based, non-judgmental, and informality” (U.S.
Department of Health and Human Services, 2001).
Self-help is a concept, not a single program model. Self-help is a way in which people become empowered, begin to think of themselves as competent individuals and present themselves in new ways to the world. Self-help, by its very nature, combats stigma and discrimination. The negative images of mental health consumers as needy and helpless ultimately
must give way to the reality of consumers managing their own programs and taking on
increased responsibility for their own lives.
Consumer-run programs that develop independently differ from those that grew directly out
of mental health system initiatives to promote self-help. Members of mental health consumer
movement programs tend to be skeptical about the value of the mental health system and
traditional psychiatric treatment. Individuals usually gravitate to consumer movement programs because they have had negative experiences in the mental health system. Often they
are angry and the program members see their anger as healthy. At the same time, members,
despite their distrust of the system, may simultaneously be involved in professionally run
programs. Members of consumer-run services are free to combine their participation in selfhelp groups with professionally run services, in whatever proportion and combination each
member determines.
There is no question that self-help programs foster autonomy. Members are encouraged to
look to themselves and to one another for support and understanding, and to see themselves
as having strengths and abilities. The experience of being a helper is empowering. Encouraging group members to turn to one another develops and strengthens natural support networks.
This helps to end the isolation that is characteristic of many who have a mental illness. Similar to other kinds of groups and organizations, consumer-run programs may experience problems and difficulties. This can be discouraging to group members and may serve to confirm
some of the negative beliefs about themselves. These experiences also have a positive aspect
since they can be used to help members see that problems and difficulties are normal events
Module 5
4
BACKGROUND
BACKGROUND FOR THE FACILITATORS: CONSUMER
STRATEGIES TO PREVENT SECLUSION AND RESTRAINT
Successfully functioning self-help groups also serve indirectly to educate clinicians and
family members who initially may have been doubtful of a group’s ability to manage itself.
Either by direct observance of a group’s activities, or through hearing group members make
presentations about their work, many former skeptics have become convinced of the value of
self-help and have come to see the strength and abilities of psychiatrically labeled people, not
just their deficits and needs.
Through successes experienced in self-help groups, members are enabled to take a stronger
role in advocating for their own needs within the larger mental health system. Empowerment
within the groups leads to a sense that members should have a say in mental health matters
generally and a rejection of the role of passive service recipient. Group members find themselves moving naturally into the role of advocate and representing the needs of consumers
through membership on panels, boards, committees. and the like. This may require some accommodation on the part of other members, such as administrators, policymakers, legislators,
family members, and others who typically have listened to everyone but consumers about
consumer needs.
Direct care staff, such as psych techs, nurses, and therapists, play a critical role in the elimination of seclusion and restraint. This module explores how communication that includes
listening as well as speaking can be an effective tool, especially in times of crisis. This
module also explores environmental factors and the role they can play in behavior and mood.
Establishing “comfort rooms” is one tool that can add to the efforts to eliminate seclusion
and restraint. And finally, Alternative Dispute Resolution and mediation are more formalized
strategies that staff can employ. Although both Alternative Dispute Resolution and mediation
do require special training beyond the scope of this manual, it is well worth the effort.
Consumers, once given the opportunity, learn to speak for themselves. Staff learns new
techniques that minimize the need for adversarial techniques. Mediation promotes dialogue
and fosters a less confrontational atmosphere.
On the national level, all staffs are being urged to reduce and/or eliminate the use of seclusion and restraint. Charles Curie, SAMHSA Administrator, sets his agenda as follows.
“Reducing use of seclusion and restraint of individuals in mental health treatment is one of
my major priorities. Seclusion and restraint—with their inherent physical force, chemical or
physical bodily immobilization and isolation—do not alleviate human suffering. They do not
change behavior. And they do not help people with serious mental illness better manage the
Module 5
5
BACKGROUND
as people work together and that the group has the ability to solve problems in the same way
that other groups do. In this way power struggles, personality conflicts, or differences in
organizational style become recognized as “normal problems” rather than being specific to
people who have been psychiatrically labeled. Solving these problems becomes a confirmation that group members have resources to cope with life’s ups and downs.
Wellness Recovery Action Plan (WRAP)
Literature on the WRAP is found in the works of Mary Ellen Copeland, the developer of the
plan and a mental health educator/consumer from Vermont. The WRAP appears in her books
Wellness Recovery Action Plan (2000) and Winning Against Relapse (1999). Portions of the
WRAP and the use of the Wellness Toolbox also appear in her books Living Without Depression and Manic Depression: A Workbook for Maintaining Mood Stability (1994) and The
Depression Workbook (2001).
The WRAP can be used by anyone who wants to create positive changes in the way they feel,
or increase their enjoyment in life. WRAP is a structured system for monitoring symptoms
through:
• Planned responses, that reduce, modify, or eliminate symptoms
• Planned responses from others when you need help to make a decision, take care of
yourself, or keep yourself safe
The WRAP is divided into six sections:
• Daily Maintenance Plan
• Triggers
• Early Warning Signs
• Symptoms that Occur When the Situation is Worse
• Crisis Plan
• Post Crisis Plan
Mary Ellen Copeland’s resources are available through her Web site: www.mentalhealth
recovery.com or by checking your local bookstore. In addition to books and workbooks,
audio and videotapes are available.
The booklet, Recovering Your Mental Health: A Self-Help Guide is available for free from
the Center for Mental Health Services. This booklet was developed with the assistance of
a focus group of ten people from around the country, people who are working on their own
recovery. You can get free copies from SAMHSA’s National Mental Health Information
Center at 1-800-789-2647 or www.mentalhealth.samhsa.gov. Refer to booklet SMA#3504.
We strongly recommend that facilitators read this resource and have a copy on hand for
the training.
Module 5
6
BACKGROUND
thoughts and emotions that can trigger behaviors that can injure them or others. Seclusion
and restraint are safety measures of last resort. They can serve to retraumatize people who
already have had far too much trauma in their lives. It is my hope that we can create a single,
unified policy—a set of primary principles that will govern how the Federal Government
approaches the issue of seclusion and restraint for people with mental and addictive
disorders” (Curie, 2002).
(Source: www.mhselfhelp.org)
A consumer run drop-in center is a central place for consumer self-help, advocacy, and education about mental health issues and resources. Through a drop-in center, consumers develop their own program to supplement existing mental health services or provide an alternative
to those services.
“My concept of a drop-in center is a self-help clubhouse that serves as a meeting
place for socialization and advocacy efforts. It’s an opportunity to empower consumers through involvement in these activities.” —Brian Disher
Consumers are often socially isolated and lonely. They may not have the emotional support
they need to help them deal with their problems. At a drop-in center, consumers can come together to make friends and socialize. The drop-in center offers a non-judgmental atmosphere,
acceptance, and true empathy from people who have “been there.” It can be hard for consumers to find these qualities in programs managed by mental health professionals, in their
families, and in the community.
Instead of focusing on whether people are sick and in need of treatment, drop-in center activities focus on the wellness, capabilities, and talents of their participants. Through joining
in a variety of meaningful activities, consumers build their self-confidence, self-esteem, and
employment skills.
Drop-in center activities vary depending on the particular wishes and needs of the consumers
involved. These activities may include self-help group meetings (also called mutual support
or rap sessions); weekly or monthly socials or parties; guest speakers; a consumer speakers’
bureau or “mental health players” group as a community-education project; individual and
systems advocacy to protect people’s rights, help people get services and/or financial
benefits, and improve mental health services; a referral bank for mental health services;
and assistance with employment or housing searches, such as a roommate referral network.
A drop-in center may also simply be a place to come and talk over a free cup of coffee.
(Source: Reaching Across with the Arts: A Self-Help Manual for Mental Health Consumers, edited
by Gayle Bluebird)
We strongly encourage you to read Reaching Across with the Arts: A Self-Help Manual for Mental
Health Consumers as background for teaching this section. To order, write to Blue Bird Consultants, Gayle Bluebird, 110 Charley Ave., Ft. Lauderdale, FL 33312, call (954) 967-1493, or e-mail
[email protected]. The manual provides a wonderful overview of the many modalities
of arts that can be used as empowerment tools and offers excellent examples of artwork.
Module 5
7
BACKGROUND
Drop-In Centers
The mental health system is beginning to recognize the importance of art. Art therapy has
been a part of the hospital environment, but many art therapists have been interpreters of art
instead of helpful art instructors. A self-help approach to art encourages consumers to do their
work without being scrutinized for pathology. Artists must feel that anything they create is
acceptable. There are many modalities that can be used in recovery through the arts including
journal writing, poetry, music, and alternative healing methods.
Susan Spaniol, arts professor at Lesley College in Massachusetts, writes extensively on the
subject of art therapy. Her Web site is www.lesley.edu/faculty/estrella/spaniol.html.
Comfort Rooms
Our environment impacts our mood and behavior. Health care has been using the concept of
“comfort rooms” in a variety of settings for many years. For example, some hospitals have
special rooms for family members while they are waiting for their loved ones during surgery.
Often, oncology units have rooms furnished with couches, fish tanks, and reading materials.
Birthing centers market a “home-like atmosphere.” The Mayo Clinic even has a room filled
with reclining chairs and soft lighting for consumers and families to use at their leisure.
Most inpatient psychiatric facilities do not convey a warm and welcoming environment. The
walls are often stark white with few home-like decorations. The sparse furnishings are often
outdated.
Gayle Bluebird has used her innovative work in using comfort rooms as a preventive tool to
reduce the need for seclusion and restraint at Atlantic Shores Hospital in Florida. Comfort
rooms were one part of an overall task force plan that successfully reduced the use of seclusion and restraints. Gayle Bluebird originally developed the material on comfort rooms.
Please give her credit as you are presenting this material.
As people diagnosed with mental illnesses are empowered in their recovery process, we must
listen to what they have to say about their surroundings and environment. We as staff, get to
go home to our own “comfort rooms” at the end of the shift. Let’s provide the same opportunities for the people we serve.
Module 5
8
BACKGROUND
The arts can serve as a vehicle for creative self-expression, social change, and personal
empowerment. They enable people who have been labeled with stigmatizing diagnoses to
convey their personal experiences of madness and recovery to others. Arts can be used as a
means of self-healing and spiritual growth—for connecting mind, body, and spirit. The ability to experiment and explore one’s inner self through a variety of mediums helps to build
self-confidence and self-worth.
Service Animals
Mental health service providers are increasingly recognizing that service animals are an
excellent resource for consumers. Service animals can provide companionship, physical
assistance, and often help develop therapeutic bonds that provide psychological, emotional,
and social benefits. Scientific research has begun to validate the role of service animals/
service dogs for people with disabilities. A 1996 study by Allen and colleagues found that
people with disabilities that had service dogs scored higher for psychological well-being,
self-esteem, community integration, and the amount of control they could exert over their
environment. The same study also found that the number of human care hours decreased by
an average of 78 percent—which represents a significant savings in health care costs (Allen,
1996). Other documented research benefits include improved self-esteem, independence,
social acceptance, lowered blood pressure, moderation of stress, improved motivation,
decreased serum cholesterol, and mitigation of the effects of loneliness.
The Americans with Disabilities Act (ADA Title III, 28 Code of Federal Regulations Sect.
36.104) states that a service animal is any animal that is individually trained to help a person with a disability. By law, service animals are not pets and they may be of any breed or
size. Service animals can do mobility, hearing, guide, seizure alert, emotional support, and
other work needed by the person because of their disability (Federal ADA 28 CFR Sect.
38.302). State laws protect the rights of individuals with disabilities to be accompanied by
their trained service animals in taxis, buses, stores, restaurants, doctors’ offices, school, parks,
housing, and other public places.
If you are not familiar with service animals, please look them up on the Web before presenting this section. One place to start is www.deltasociety.org. If possible, find a local consumer
to come in and talk about his or her service animal.
Psychiatric Advance Directive (PAD)
(Adapted from www.nmha.org and www.bazelon.org)
In the past 30 years, thinking in the field of medicine has shifted significantly. Years ago, the
physician made all of the decisions related to health care. Today, the “patient” has a much
stronger voice and is a partner in making decisions about his or her own health care.
Module 5
9
BACKGROUND
This section includes a definition of a comfort room, items that might be included in a comfort room, guidelines for using a comfort room, an exercise to identify characteristics of
calming rooms, the importance of input and feedback from people diagnosed with mental
illnesses, and a step-by-step plan for establishing a comfort room. If the participants you are
working with already use the concept of a comfort room, you may want to skim over this
material.
Psychiatric advance directives offer several key benefits. Correctly implemented and
executed, they can:
• Promote individual autonomy and empowerment in the recovery from mental illness;
• Enhance communication between individuals and their families, friends, healthcare
providers, and other professionals;
• Protect individuals from being subjected to ineffective, unwanted, or possibly harmful
treatments or actions; and
• Help in preventing crises and the resulting use of involuntary treatment or safety interventions such as restraint or seclusion.
Anyone creating an advance directive must be able to do so without coercion, with choices
regarding implementation and revocability, and with full knowledge and understanding of the
implications of his or her decisions.
Most States require the appointment of an agent or proxy in order for an advance directive to
be valid. The agent can be authorized to make decisions about the person’s health care that
may or may not be in a PAD. It is critical that the agent be someone who can be trusted and
who understands the wishes of the person diagnosed with a mental illness. In nearly every
State, PADs are irrevocable after the loss of capacity to make informed decisions. Reasons
why a PAD may be overridden include (1) a court order to prevent physical injury; (2) after
a specified period of time if a particular treatment choice is unsuccessful; (3) “emergency”
situations, and (4) a civil commitment. In most States, the agent cannot make decisions
unless the person diagnosed with a mental illness is determined unable to make decisions.
Prime Directive
The prime directive for young people under the age of 18 is based on the advance directive.
My Prime Directive and its companion, My Prime Directive Journal (Tenney, 2001) are selfhelp tools for young people and were developed by Lauren Tenney of the New York State
Office of Mental Health, Bureau of Children and Families. Their purpose is to open the
lines of communication between young people and the professionals who are serving them.
It gives young people a voice about the services they are receiving. The young person can
choose to share or not to share their directive and journal.
My Prime Directive Journal was designed to offer young people hope for the future, educate
them about alternative coping mechanisms, and outline a concrete way for them to start planning for the rest of their lives. The first part of the journal includes notes that include insights
Module 5
10
BACKGROUND
A psychiatric advance directive offers a clear written statement of an individual’s medical
treatment preferences or other expressed wishes or instructions. It can also be used to assign
decision-making authority to another person who can act on that person’s behalf during times
of incapacitation.
The journal also encourages young people to think about things such as “I feel my best/worst
when...” “The real me is…” “Someday I’d like to…” “Ten years from now I’d like my life
to be or not to be…” and “For my life to look like that in 10 years, I would have to do the following things in the next 5 years…” Young people can poignantly articulate what it is they
think they need from the mental health system. These self-help tools give them an opportunity to express their wishes in an organized manner.
Most mental health workers have extensive training in active listening. The goal of this
section is not necessarily to teach new skills, but to provide an opportunity to hear things in
new ways. Communication is especially critical in times of crises. As leaders, it is important
not only to communicate the viewpoint of people diagnosed with a mental illness, but also
to carefully listen to the perspectives of mental health workers. They, too, have experienced
trauma and are struggling in their own ways within the system. By creating a dialogue, this
section sets the tone for more the complicated issues that follow.
This section includes issues of power and control, the use of respectful language, types of
listening and necessary conditions for listening, ways of verbally responding, things people
diagnosed with a mental illness would like to hear, humor, and roadblocks to active listening.
Alternative dispute resolution (ADR) techniques have been widely used in a variety of settings such as education, employment, and family disputes. Mental health settings have been
slow to adopt these techniques. These techniques include mediation, negotiation, facilitation,
conciliation, and dialogue. The Center for Conflict Management in Mental Health, based at
the University of South Florida, is working to change this. One major difference in the mental health setting is that there is unequal power between providers and consumers.
The Center for Conflict Management in Mental Health provides different services. Some of
these include product development and testing, research and evaluation, consultation and
technical assistance, information sharing, and conflict management skills training. This
training is for consumers, family members, mental health providers, and mental health
administrators. They also sponsor national and regional conferences and provide workshops
in mediation skills.
Module 5
11
BACKGROUND
such as “It’s okay to be different,” “No matter where you have been or what you have been
through, you can move on,” and “Don’t let people’s judgments affect you. Be confident who
you are and accept yourself.”
Judi Higgenbotham, Human Rights Coordinator at Arizona State Hospital in Phoenix, states,
“It almost always boils down to a communication issue—the doctor or treatment team either
hasn’t listened to what the consumer is saying or hasn’t explained things well”(Blanch, 2000).
The Center for Conflict Management in Mental Health believes that alternative conflict resolution strategies can minimize the need for and the consequences of adversarial techniques.
This preserves dignity, enhances empowerment, and promotes recovery.
Mediation is a process where parties distance themselves from their positions and discover
the underlying reason or interest in their positions. It is a process for people to discover their
own solutions. Mediation promotes dialogue.
Consumers and family members have been trained as mediators in some States. Ohio has
taken the lead. It has revised its consumers’ rights regulations to include mediation at any
stage. An Associate Professor of Nursing and Psychiatry at the Ohio State University notes,
“This is the beginning of a cultural change in the mental health field. Conflict resolution is so
compatible with the recovery movement—they mesh together completely. Consumers learn
to speak for themselves and have control over their lives” (Blanch, 2000). Mediation fosters a
less confrontational atmosphere.
The Substance Abuse and Mental Health Services Administration, Center for Mental Health
Services supports technical assistance centers and the National Institute on Disability and
Rehabilitation Research. Services may include technical assistance, information and referrals,
on-site consultation, training, library services, publications, annotated bibliographies, and
other resources. Many services are available free of charge, but in some cases, charges may
apply. The technical assistance centers can be used as a resource for up-to-date information
relating to the elimination of seclusion and restraint.
Module 5
12
BACKGROUND
Laurie Curtis, a co-author of a curriculum on managing conflict in mental health systems,
points out, “Most mental health professionals support consumer choice, as long as everyone
agrees” (Blanch, 2000). She emphasizes that conflict management can help mental health
professionals and consumers understand concepts such as consumer directed services in
new ways.
Module 4: Understanding Resilience and Recovery from the Consumer
Perspective. Begin Module 5 by going over the learning objectives.
Learning Objectives
Upon completion of this module the participant will:
•
Define and outline the benefits, underlying values, and key elements of
consumer-driven supports
•
Develop and apply a Wellness Recovery Action Plan (WRAP)
•
Identify benefits of drop-in centers, recovery through the arts,
research and technical assistance centers, and service animals.
•
Name key elements to implement a comfort room and describe what
staff can do to support these consumer-driven supports.
•
Guide a consumer in developing a Psychiatric Advance Directive/Prime
Directive
•
Identify and implement effective communication strategies that
prevent the use of seclusion and restraints, including Alternative
Dispute Resolution and Mediation
Overview
• Over the past 20 years, consumers have shifted from being passive recipients of mental
health treatment to becoming increasingly involved in planning, providing, and evaluating mental health services.
• Direct care staff, such as psych techs, nurses, and therapists, play a critical role in the
• On the national level, all staff are being called on to reduce and/or eliminate the use of
• Charles Curie, SAMHSA Administrator, sets his agenda as follows.
Module 5
13
PRESENTATION
PRESENTATION
Charles Curie
• Consumer-driven supports can be divided into two categories:
○ Support systems which consumers develop, run, evaluate, and maintain on their own,
such as drop-in centers, crisis teams, art co-ops, and peer support.
○ Contributions consumers make to traditional mental health systems by being involved
in program development, policy formation, program evaluation, quality assurance,
system designs, education of mental health service providers, and provision of direct
services.
• “In order to maximize their potential contributions, their involvement should be supported in ways that promote dignity, respect, acceptance, integration, and choice. Support
provided should include whatever financial, educational, or social assistance is required
to enable their participation” (Position Statement on Consumer Contributions to Mental
Health Service Delivery Systems from the National Association of State Mental Health
Program Directors, 1998).
• This training will focus primarily on support systems that consumers develop, run,
evaluate, and maintain.
• First, let’s look at the research-based evidence related to consumer-driven supports.
• The U.S. Department of Health and Human Services cites the following General Benefits
of Consumer-Driven Supports (DHHS, 2001):
Module 5
14
PRESENTATION
“Reducing use of restraint and seclusion of individuals in mental
health treatment is one of my major priorities. Seclusion and
restraint - with their inherent physical force, chemical or physical
bodily immobilization and isolation - do not alleviate human suffering.
They do not change behavior. And they do not help people with
serious mental illness better manage the thoughts and emotions that
can trigger behaviors that can injure them or others. Seclusion and
restraint are safety measures of last resort. They can serve to
retraumatize people who already have had far too much trauma in
their lives. It is my hope that we can create a single, unified policy a set of primary principles that will govern how the Federal
government approaches the issue of seclusion and restraint for
people with mental disorders.”
•
Self-help is a way in which people become
empowered and begin to think of themselves as
competent individuals and present themselves in
new ways to the world.
•
Fosters self-advocacy
•
Fosters autonomy
•
Ends isolation
•
Educates family and providers
Underlying Values of Consumer
Self-Help Include:
Module 5
•
Empowerment
•
Independence
•
Responsibility
•
Choice
•
Respect & Dignity
•
Social Action
15
PRESENTATION
General Benefits of
Consumer-Driven Supports (CDS)
• Peer Support
• Hope
• Recovery
Wellness Recovery Action Plan
• Wellness Recovery Action Plan = WRAP.
• Mary Ellen Copeland is the developer of the WRAP and is a mental health educator/
consumer from Vermont.
• She has written several books, including Wellness Recovery Action Plan (1997).
If possible, please have a copy of this book to pass around.
• Her Web site, www.mentalhealthrecovery.com, is a great resource.
• One can develop a WRAP for work, using the same categories. It would revolve around
a work plan environment.
• A teen WRAP is also available and is modeled after the original WRAP.
• The WRAP can be used by anyone who wants to create positive changes in the way they
feel or increase their enjoyment in life, including those who do not have a mental illness.
It works well for those dealing with chronic physical illnesses as well.
Module 5
16
PRESENTATION
Key Elements for
Consumer/Survivor Self-Help:
• Planned responses that reduce,
modify, or eliminate symptoms
• Planned responses from others when
you need help to make a decision, take
care of yourself, or keep yourself
safe
• The WRAP stems from a self-care paradigm—which places the emphasis for health on
the consumer, not the medical system.
• The WRAP assumes it is the responsibility of each individual to do self-care to maintain
optimum health.
Module 5
17
PRESENTATION
The Wellness Recovery Action Plan
(WRAP) is a structured system for
monitoring symptoms through
•
Daily Maintenance Plan (including Wellness Toolbox)
•
Triggers
•
Early Warning Signs
•
Symptoms that Occur When the Situation is Worse
•
Crisis Plan
•
Post Crisis Plan
• The Daily Maintenance Plan includes writing down and reminding ourselves of the things
we all need to do every day to maintain our wellness.
• On the surface, the Daily Maintenance Plan may seem simple; however, it is a good
reminder of what “being well” feels like.
• The Wellness Toolbox is a list of things that help us stay healthy and on track.
• Triggers are external events or circumstances that, if they happen, may produce symptoms that are or may be very uncomfortable. We talked about some of these in Module 2:
Understanding the Impact of Trauma.
• It’s important to recognize triggers and respond to them so symptoms don’t get worse.
• Early warning signs are internal, subtle signs of change that may be unrelated to reactions
to stressful situations.
• Again, being aware of early warning signs helps prevent symptoms from worsening.
• Symptoms may progress to the point where they are very uncomfortable, serious, even
dangerous, and where the situation has gotten much worse but has not yet reached a crisis.
• At this point, it is necessary to take immediate action to prevent a crisis.
• Crisis situations mean that others will need to take responsibility for our care.
• This section is often the most difficult section to develop and needs to be done when you
are feeling well.
• The Post Crisis Plan is a new addition to the WRAP and is different from other parts of
the WRAP. It changes as you heal.
• It may be helpful to refer to your Wellness Toolbox.
• WRAP assists in keeping one well after release from the hospital.
Module 5
18
PRESENTATION
The WRAP is divided into six
sections:
Distribute the handout Examples of Consumer WRAPs, which includes
three actual WRAPs from consumers in Minnesota. Take a minute to look
these over.
Module 5
19
PRESENTATION
“I remember coming home from the
hospital, feeling great and as soon as I
got there I was bombarded with
loneliness, other peoples’ problems and
all the stuff that probably helped put
me in the hospital to begin with……”
L. Belcher, Consumer
Developing a Wellness Recovery Action Plan (WRAP)
OBJECTIVE:
Participants will understand how to develop a WRAP for themselves
and will be able to transfer these skills to their work with consumers.
PROCESS:
Refer participants to the handout Examples of Consumer WRAPs
and give them time to review the WRAPS in class. Give each participant a copy of the handout Developing a WRAP, which gives
instructions on how to complete a WRAP. Ask each participant to
develop one section of a WRAP. Remember, a recovery plan does
not have to be for psychiatric symptoms. It can be for any physical
condition or for recovery from a difficult or traumatic life experience.
Divide the group into four or five smaller groups and have each
person share one part of his or her WRAP. Reconvene as a large
group and facilitate a discussion.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
• What are the similarities between consumer and staff WRAPs?
• What are the differences between consumer and staff WRAPs?
• How could you use this tool in your work environment?
Paper and a writing utensil for each participant
Examples of Consumer WRAPs handout
Developing a WRAP handout
APPROXIMATE
TIME REQUIRED:
30 minutes
SOURCE:
WRAP materials from Mary Ellen Copeland
Module 5
20
PRESENTATION
“Ex-patients have similar feelings and
experiences and they can understand and
support each other in a way that’s
different from family or professional
services. We can do mutual support and
understand the way we were treated.
There’s nothing else out there on the
weekends and evenings.” Peg Sullivan
• Drop-in activities vary depending on the particular wishes and needs of the consumers
involved.
Module 5
21
PRESENTATION
Drop-In Centers
• Drop-in centers are a central place for consumer self-help, advocacy, and education about
mental health issues and resources.
• Through a drop-in center, consumers develop their own programs to supplement existing
mental health service or provide an alternative to those services.
• Consumers come together to make friends and socialize—which helps combat the isolation
and loneliness often associated with mental illnesses.
• A drop-in center could be a snack bar or canteen within a hospital setting. It can be a
place to gather and socialize.
• Drop-in center activities focus on the wellness, capabilities, and talents of their participants.
•
Rap sessions (self-help group meetings)
•
Socials or parties
•
Guest speakers
•
Individual and systems advocacy
•
Serve as a referral bank for mental health services
•
Assist with employment or housing searches
How can mental health workers support
consumer run, consumer-driven drop-in
centers?
Module 5
•
Advocate for space, financial support, zoning
•
Make referrals
•
Provide materials and resources, if asked
•
Offer to be a guest speaker
•
Referral bank for mental health services
•
Assistance with housing or employment searches
22
PRESENTATION
Drop-In Centers Activities
Comfort Rooms
Distribute the handout How to Set Up a Comfort Room by Gayle Bluebird.
• Our environment significantly impacts our mood and behavior.
• Health care uses the concept of a “comfort room” in other aspects of the hospital
environment. Examples include surgery waiting rooms, oncology family units, and
birthing centers.
• Typically, inpatient psychiatric facilities do not portray a warm and welcoming
environment.
• Gayle Bluebird, R.N., has does innovative work in using the comfort room concept as
a preventive tool to reduce the need for seclusion and restraint in Florida.
• Gayle’s Web site is www.contac.org/bluebird.
• As people diagnosed with a mental illness are empowered in their recovery process,
we must listen to what they have to say about their surroundings and environment.
• Consumers clearly indicated in the National Association of Consumer/Survivor Mental
Health Administrators survey (2000) that having a comfortable environment would help
prevent the need for seclusion and restraint. Here are some direct quotes from the survey.
Module 5
23
PRESENTATION
• The arts can serve as a vehicle for creative self-expression, social change, and personal
empowerment.
• The arts enable people who have been labeled with a stigmatizing diagnosis to convey
their personal experiences of madness and recovery to others.
• Arts can be used as a means of self-healing and spiritual growth—for connecting mind,
body, and spirit.
• The ability to experiment and explore one’s inner self through a variety of mediums helps
to build self-confidence and self-worth.
• Art therapy has been a part of the hospital environment, but many art therapists have been
interpreters of art instead of helpful art instructors.
• A self-help approach to art encourages consumers to do their work without being scrutinized for pathology. Artists must feel that anything they create is acceptable.
• There are many modalities that can be used in recovery through the arts including journal
writing, poetry, music, alternative healing methods, painting, and sculpting.
• Please add local resources related to recovery through the arts and/or show examples of
consumer artwork.
• A homey setting – soft chairs, drapes,
pictures
• A big overstuffed, vibrating, heated chair
with a blanket, headphones, and gentle soft
music
Comfort Room Definition:
The Comfort Room is a room that
provides sanctuary from stress
and/or can be a place for persons to
experience feelings within acceptable
boundaries. (Gayle Bluebird)
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24
PRESENTATION
What would have been helpful in preventing
the use of seclusion or restraints for you?
Comfort Room Door Sign
A special place where you may spend some
time alone. You may ask any staff member
to use this room. There are items that you
can sign-out to help you calm down and
relax (stuffed animals, soft blanket, music,
magazines, and more). Persons who wish to
use the room will be asked to first sign
their names in the sign-in book and talk to
a staff member before entering.
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25
PRESENTATION
• The comfort room is not an alternative to seclusion and restraint; it is a preventive tool
that may help reduce the need for seclusion and restraint.
• It is critical that people diagnosed with mental illnesses be made an integral part of
decision making for the development and policymaking of the comfort room.
• Consumers should ask to make comments and rate their degree of personal satisfaction
with the comfort room and make suggestions for improvement.
• The comfort room is to be used voluntarily, although staff members might suggest its use
and may be present if the person desires it.
• The comfort room is set up to be physically comfortable and pleasing to the eye. It may
include a recliner chair, walls with soft colors, murals (images to be the choice of persons
served on each unit), and colorful curtains.
• Comfort items can be made available to persons wishing to use the room.
○ Stuffed animals
○ Soft blanket
○ Headphones
○ Quiet meditative audio tapes
○ Bright colored pillow cases
○ Journaling materials
○ Reading materials
• Persons who wish to use the room will be asked to first sign their names in the sign-in
book and talk to a staff member before entering.
• A sign on the door may look like this:
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26
PRESENTATION
Service Animals
• Service animals can provide companionship and physical assistance, and often help humans
develop therapeutic bonds that provide psychological, emotional, and social benefits.
• Scientific research has begun to validate the role of service animals/service dogs for
people with disabilities.
• A 1996 study by Allen and colleagues found that people with disabilities that had service
dogs scored higher for psychological well-being, self-esteem, community integration, and
the amount of control they could exert over their environment.
• The same study also found that the number of human care hours decreased by an average of
78 percent—which represent a significant savings in health care costs (Allen et al., 1996).
• Other documented research benefits include improved self-esteem, independence, social
acceptance, lowered blood pressure, moderation of stress, improved motivation, decreased
serum cholesterol, and mitigation of the effects of loneliness (DHHS, 2001).
• The Americans with Disabilities Act (ADA Title III, 28 Code of Federal Regulations
Sect. 36.104) states that a service animal is any animal that is individually trained to help
a person with a disability.
• By law, service animals are not pets, and they may be of any breed or size.
• Service animals can do mobility, hearing, guide, seizure alert, emotional support, and
other work needed by the person because of their disability.
• Federal (ADA 28 CFR Sect.38.302) and State laws protect the rights of individuals with
disabilities to be accompanied by their trained service animals in taxis, buses, stores,
restaurants, doctors’ offices, school, parks, housing, and other public places.
• Encourage participants to look up service animals on the Web. One place to start is
www.deltasociety.org.
“What is a Psychiatric Advance
Directive (PAD)?”
A PAD is a legal document that becomes part
of the medical chart that provides the
following information:

Treatment preferences, including seclusion,
restraint, and medications

Naming an “agent” or proxy who will make
decisions about mental health care when the
person with a mental illness is not capable of
informed decision-making
Psychiatric Advance Directive
Module 5
•
Instructional – refers to a person’s treatment
wishes (i.e., what you want in the way of treatment
or services and also what you don’t want.) Also
known as a “living will.”
•
Agent Driven – gives another individual the power
to make decisions for you when you are deemed
incapable of making decisions for yourself (i.e.,
who you would want to make decisions for you.
Also called durable power of attorney, surrogate
decision maker, or a proxy.)
27
PRESENTATION
Psychiatric Advance Directives (PADs)
• Psychiatric Advance Directives are similar to other types of health advance directives.
Why Should I Fill Out a Psychiatric Advance
Directive? (Or, sometimes the best defense is a
good offense)
It is very important to work with the provider(s) and your
proxy in developing the PAD and to make sure significant
people have copies of the PAD.

Module 5
Maintain choice and control in treatment
Increase continuity of care
Decrease possibility of involuntary treatment
If hospitalized, PAD may affect kind/type treatment received
Provides opportunity to discuss crisis plan with family and friends
Establishes clear boundaries for release of information
Provides an effective alternative to court appointed guardian
Establishes plans for caring for family, finances, and pets
Restores self-confidence
28
PRESENTATION
The handout Why Should I Fill Out a Psychiatric Advance Directive?
is a more detailed version of the PowerPoint Slide.
Creating My Own Psychiatric Advance Directive
OBJECTIVE:
Each participant will fill out a Psychiatric Advance Directive practice
worksheet.
PROCESS:
Refer participants to the handouts Ten Tips for Completing an
Effective Advance Directive and Psychiatric Advance Directive
Practice Worksheet.
Divide the participants into small groups of 4 to 5 each. Ask each
participant to review the list of Ten Tips. Ask each participant to
think of their own “mental health,” whether it is stress or a diagnosed mental illness, and ask them to fill out the worksheet as
completely as possible.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
APPROXIMATE
TIME REQUIRED:
Module 5
• Why do you think a psychiatric advance directive is important?
How would you compare it to a living will, if at all? What are the
differences?
• When is the most appropriate time to write such a directive?
• What type of assistance, if any, should be offered? Cite some
reasons why this might be important.
• What do you believe are the goals or outcome of having such
a directive?
Handouts of Ten Tips for Completing an Advance Directive and the
Psychiatric Advance Directive Practice Worksheet.
30 minutes
29
PRESENTATION
•
National Mental Health Association www.nmha.org
or 800-969-6642
•
The Bazelon Center for Mental Health Law
www.bazelon.org/advdir.html or 202-467-5730
•
National Association of Protection and Advocacy
Systems www.napas.org or 202-408-9514
•
•
Peer Education Project 518-463-9242
Centers for Medicare & Medicaid Services (CMS)
www.cms.hhs.gov
Prime Directives
• The idea behind the Prime Directive is similar to the Advance Directive.
• In January 2000, the Prime Directive Initiative in New York State began with the vision
of former consumers of children’s mental health services who are now advocates.
• A group of young people, family members, professionals, and policymakers developed a
draft of My Prime Directive Journal (Tenney, 2001).
• This document was then presented at focus groups around New York State. These focus
groups were composed of young people, family members, and professionals.
• A final draft was then edited and made available for distribution.
• Pass around a copy of My Prime Directive Journal (Tenney, 2001).
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30
PRESENTATION
Advance Directive Resources
Prime Directives are self-help
tools and DO NOT replace a
treatment plan.
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31
PRESENTATION
Use of My Prime Directive
Journal and My Prime
Directive is completely
voluntary and is NEVER to
be mandatory
Distribute the handout Six Essential Steps for Prime Directives.
SIX ESSENTIAL STEPS FOR
PRIME DIRECTIVES
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1.
Getting the “buy-in” of the facility or
program that will pilot the project.
2.
Meeting with the core group of staff and
reviewing the materials and goals.
3.
Meeting with the staff of the
facility/program and review the materials
and goals.
32
PRESENTATION
• Six essential steps are seen as necessary to bring both the Prime Directive and Prime
Directive Journal to young people.
4.
Meeting with the young people, filling in a
survey, reviewing the materials and goals,
answering questions and developing a working
relationship with the young people.
5.
Ongoing technical assistance through the pilot
process.
6.
In three months, re-administer the surveys and
see if there was a notable difference.
What Young People Are Saying About
Involving Youth In Their Services and
Systems
Module 5
•
“We are young, but need to be treated as human
beings and not as a problem or disorder.”
•
“We are prototypes, not to be treated as
stereotypes.”
•
You can do all the research you want, but if you
forget who we are and what we need as people, and
if you don’t respond to our needs in the system and
in individual treatment, you will fail, the system will
fail, and we will bear the burden as we do now. You
must involve youth, bring us to the table, and when
we show up, you must listen. LISTEN.”
33
PRESENTATION
SIX ESSENTIAL STEPS FOR
PRIME DIRECTIVES
•
“Another step is being taken when individual young
people are able to speak with a powerful voice in
planning their own services….”
•
“Involving youth during treatment and service
planning….Proactively solicit treatment ideas and
therapeutic activities from the individual
youth…Offer more treatment options. True
informed consent is really about more treatment
options.” (Juliet K. Chol, consultant on children’s
mental health programs, Fall 2000)
• Both the Prime Directive and the Journal have anticipated benefits for the three groups
most affected: young people, their family members, and programs (professionals).
Distribute the handout Anticipated Benefits of Prime Directives.
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34
PRESENTATION
What Professionals Are Saying About
Involving Youth In Their Services and
Systems
• A concrete voice in treatment and service
planning, including wishes and concerns.
• Opportunities to ask questions that are
difficult to ask.
• A concrete plan for goals for future life.
• Increased self-esteem, hope and trust as
they begin on the road to recovery.
ANTICIPATED BENEFITS/
OUTCOMES FOR PARENTS
• A forum to hear from their children what
has been difficult to hear in the past.
• An intermediary when communication is
difficult.
• Insight to their children’s wants and needs.
• An active role in understanding their
children’s goals for recovery.
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35
PRESENTATION
ANTICIPATED BENEFITS/OUTCOMES
FOR YOUNG PEOPLE
•
Better informed recipients of services.
•
More aware/responsible program staff.
•
Provides a quality assurance mechanism.
•
Uses a recovery oriented model.
•
Reduction of seclusion, restraint, and coercion.
•
Better understanding of recipients wants and needs.
• The underlying goal of using consumer-driven supports such as prime directives and
psychiatric advance directives is to create partnerships between consumers and staff.
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36
PRESENTATION
ANTICIPATED BENEFITS/
OUTCOMES FOR PROGRAMS
Cheryl Villiness
Devereux Georgia Treatment Network
Focal Point, Fall 2000
• Many direct care staff have already been trained extensively in communication strategies.
• The purpose of this session is not necessarily to teach new skills, but provide opportunities to hear things in new ways.
• Direct care staffs have lots of valuable and important information about the practice of
seclusion and restraint—it affects you, too! So it’s important for us to hear what you
have to say.
• Communication is very complicated, even though it may appear to be simple. This next
exercise demonstrates this.
• Excellent communication is essential in times of crisis. It’s important to know who is
in charge, who makes decisions, and how this process will take place before a situation
escalates.
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37
PRESENTATION
“An important shift occurs when
we begin to work with our clients
as partners in their treatment,
instead of working on them.”
How Hard Can Communication Be?
OBJECTIVE:
To demonstrate the complexity of communication.
PROCESS:
Have participants get in pairs and sit back to back so they can’t see
each other. Have them choose who will be the talker and who will
be the listener.
Before the session, develop several designs on 8.5 X 11 paper
using markers. Use general shapes such as squares, circles, triangles, stars, straight lines, squiggly lines, etc. Give the talker a
copy of one of the designs. Give the listener a blank sheet of paper
and a pencil. The one with the design begins to give directions on
what to draw. The goal is to have the design and the drawing turn
out as similar as possible. The participant who is drawing cannot
ask questions or talk at all. Give 3 minutes to complete the task.
As participants finish, have them compare their drawings with
the original designs. Tape each pair’s results together as a visual
reminder during the rest of this module. Facilitate a discussion
around communication skills.
DISCUSSION
QUESTIONS:
•
•
•
•
What was it like to be the person giving directions?
What was it like to be the person drawing?
How does this exercise relate to the work environment?
How does this exercise relate to working with people diagnosed
with a mental illness?
MATERIALS
REQUIRED:
Blank paper, writing utensils, designs to hand out, and tape
APPROXIMATE
TIME REQUIRED:
15 minutes
Module 5
38
PRESENTATION
• There has been a great deal of debate in the field of mental health around terminology.
• For example, the word “patient” it is often associated with a lack of power, someone who
is “ill,” needs professional help to get better, and depends on the system to take care of
him or her, etc.
• Using the word “client” still puts the person in a one down position, but is a better choice
than the word “patient.”
• The word “consumer” may still be associated with a power differential, but it adds a
piece of power because it reminds us of the business strategy to listen to the “consumer”
or “customer.”
• What is our cultural attitude about “customers”?
• Among consumers, some prefer to be referred to as “people diagnosed with mental illnesses.” This may mean they do not accept the diagnosis, but a medical professional has
given it to them.
• Mental health has its own language and words that are used on a routine basis.
Module 5
39
PRESENTATION
Communication Strategies: Issues of Power and Control
• The words we all use to communicate are powerful and do indeed make a difference
• A consumer from Minnesota named David created the following cartoon.
• The cartoon is a good example of how sometimes everyday words and symbols may be
confusing and have multiple meanings.
OUT WITH THE OLD
IN WITH THE NEW
Resistant families
Families with unmet needs
Dysfunctional families
Overwhelmed and underserved
Case management
Service coordinator
We offer this
What do you need? Make it up as we go
Staff a case
Families and professionals creating intervention
plans together
The chronics
People with mental illnesses (person-first language)
Disturbed child
Child with emotional disturbance
The mentally ill
People with mental illnesses and consumers
Old & New Language
OUT WITH THE OLD
IN WITH THE NEW
Professionals as providers Families as preferred providers
Module 5
Schizophrenics
People with schizophrenia
We need placement for
this child; where to next?
Let’s develop a community plan with this child and
family
That’s your job
Match each other’s offers
SED, SMI
Say the words: Seriously Emotionally Disturbed,
Severe Mental Illness
Do an assessment on
Do an assessment with
Do treatment on
Do treatment with
Talk about
Talk with
Develop services for
Develop services with
40
PRESENTATION
Old & New Language
You and I
by Elaine Popovich, adapted by Laurie Curtis
From the Consumer Network News, Autumn 1995
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
am a resident. You reside.
live in a program. You live in a home.
am placed. You move in.
am learning daily living skills. You hate housework.
get monitored for tooth brushing. You never floss.
have to be engaged in “meaningful activity” every day. You take mental health days.
am learning leisure skills. Your shirt says I am a “couch potato.”
am aggressive. You are assertive.
am aggressive. You are angry.
am depressed. You are sad.
am depressed. You grieve.
am depressed. You try to cope with stress.
am manic. You are excited.
am manic. You are thrilled.
am manic. You charge the limit on your credit card.
am non-compliant. You don’t like being told what to do.
am treatment-resistant because I stop taking medication when I feel better. You never complete a ten-day
course of antibiotics.
I am in denial. You don’t agree with how others define your experience.
I am manipulative. You act strategically to get your needs met.
My case manager, therapist, R.N., doctor, rehabilitation counselor, residential counselor, and vocational counselor
all set goals for me for next year. You haven’t decided what you want out of life.
Someday I will be discharged…maybe. You will move onward and upward, perhaps even out of the mental health
system.
I have problems called chronic; people around me have given up hope. You are in a recovery process and get
support to take it one day at a time.
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41
PRESENTATION
• The following poem by Elaine Popovich clearly demonstrates the use of language
“I’m not sure it’s the exact words that are
most important, but rather, the tone of voice,
body language and the physical environment of
the verbalization. The words need to be firm
but kind, spoken by someone with whom the
‘patient’ has had prior positive experiences.
The words should include references to
experiences and people that the staff has
determined ahead of time will help the ‘patient’
become grounded.”
What makes up the meaning of an interaction?
• Words: 7%
• Facial expression: 55%
• Tone of voice: 38%
• So, not only the words we all use, but how we say them is critical and conveys our underlying feelings, assumptions, and beliefs.
Module 5
42
PRESENTATION
Communication Strategies: Listening
PRESENTATION
• At a recent training, people diagnosed with mental illnesses developed the following
list. This list was taken from Mary Ellen Copeland’s Mental Health Recovery Newsletter
(2002, February).
What Consumers Want to Hear
From Staff
•
•
•
•
•
•
•
Module 5
You’re doing well
How can I help you?
I’m here for you
We can work together through this
It’s OK to feel like that
I accept you and love you the way you
are
What do you need at this time?
43
•
•
•
•
•
•
•
Module 5
You’ve come a long way
You’re’ a strong person
I admire your courage in dealing with this
pain
I encourage you
Don’t give up
I can’t promise, but I’d do my best to help
I don’t understand. Please tell me what you
mean
44
PRESENTATION
What Consumers Want to Hear
From Staff
ROADBLOCKS TO ACTIVE
LISTENING
•
•
•
•
•
•
•
•
•
Attraction
Physical condition
Concerns
Overeagerness
Similarity of problems
Prejudice
Differences
Defensiveness
Anger
• Attraction. You find a person either attractive or unattractive. You pay more attention to
what you are feeling than to what the person is saying.
• Physical condition. You may be tired or sick. Without realizing it, you tune out some of
the things the person is saying.
• Concerns. You may be preoccupied with your own concerns. For instance, you keep
thinking about the argument you’ve just had with your partner.
• Overeagerness. You may be so eager to respond that you listen to only a part of what
the person has to say. You become preoccupied with your responses rather than with the
person’s revelations.
• Similarity of problems. The problems the person is dealing with are similar to your own.
While the person talks, your mind wanders to the ways in which what is being said
applies to you and your situation.
• Prejudice. You may harbor some kind of prejudice toward the person. You pigeonhole
him or her because of race, sexual orientation, nationality, social status, religious
persuasion, political preferences, lifestyle, or some other characteristic.
Module 5
45
PRESENTATION
Communication Strategies: Roadblocks to Active Listening
• It is easy to become preoccupied with ourselves and our own needs in such ways that we
are kept from listening clearly to those needing assistance.
• Everyone experiences roadblocks—the key is to recognize when it’s happening for you.
• Traditionally, conflict has been viewed as being destructive and divisive. However,
conflict can be managed effectively when recognized as an opportunity for growth.
• Conflict is the natural and unavoidable response to change. Every time we are asked to
do something differently, think of something differently, or encounter a new situation,
we experience change and conflict.
• Conflict encourages us to accept new roles and responsibilities. By embracing conflict,
individuals can learn to manage their way through turmoil while maintaining individual
respect, integrity, and team participation.
• With the help of a neutral party, those experiencing conflict with one another can enter
into creative solutions to their clearly defined problems.
• This training is not intended to teach how to do Alternative Dispute Resolution or
Mediation, but will just give a spoonful of information about these topics.
• If staff is interested in further training in this area, please seek out experts for this type
of training.
Alternative Dispute Resolution
Definition:
The term Alternative Dispute
Resolution applies to the
creative solving process that
does not engage in litigation
through the courts.
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46
PRESENTATION
• Differences. The person and his or her experience are very different from you and
your experience. The lack of commonalities is distracting.
• Defensiveness. A person takes another’s difference of opinion as an attack upon
him/herself.
• Anger. Anger in a person or within a group may distort communications.
Mediation Definition:
Mediation is not the practice of
law; it is the art and science of
bringing disputing parties to
mutual agreement in resolving
issues. Mediation does not find
fault or blame.
Another definition of
Mediation:
Mediation is a dispute
resolution process in which a
neutral third party assists
the participants to reach a
voluntary and informed
settlement.
Module 5
47
PRESENTATION
• There are several forms of alternative dispute resolution. The most common form
is mediation.
• The issues,
• The needs of the disputants with respect
to the issues,
• A range of possible solutions, and
• A solution agreeable to all parties involved.
• A key component to any mediation process is letting each person tell his or her own
story and then feel as if someone understands his/her perspective. Just knowing someone
understands reduces the tension level in the conflict.
The following are the usual
steps in the mediation process:
• Those in dispute agree to mediation.
• Those in dispute agree upon a mediator.
• Those in dispute agree upon the ground
rules.
• Each person tells his/her own story.
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48
PRESENTATION
In mediation the goal is to
clearly identify:
• Solve the problem
• Tell the truth
• Listen without interrupting
• Be respectful
• Take responsibility for carrying out
the agreement
• Keep the situation confidential
• Mediation provides a problem-solving approach to disputes, focusing on the needs and
interests of the participants, with consideration to fairness, privacy, self-determination,
and the best interest of all.
• The Substance Abuse and Mental Health Services Administration, Center for Mental
Health Services supports technical assistance centers, including consumer and consumer
supporter technical assistance centers.
• Services may include technical assistance, information and referrals, on-site consultation,
research, training, library services, publications, annotated bibliographies, and other
resources.
• Many services are available free of charge, but in some cases, charges may apply.
• Many times consumers may not be aware of these resources. You can help by making
sure consumers know about these resources.
• If you are not familiar with these resources, we strongly encourage you to check out
several of the Web sites in the handouts.
Distribute the handouts Research, Training, and Technical Assistance
Centers and Children’s and Adolescents’ Mental Health Services Technical
Assistance and Research Centers.
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49
PRESENTATION
In order for mediation to be successful
participants should be willing to:
Wellness
Toolbox
Listen to soothing music, talk to my parrot, read, talk to a support person, go
for a walk, play on the computer, e-mail, watch TV
Daily
Maintenance
Plan
Things I must do: feed my parrot, eat regular meals, take medications, bathe
regularly.
Triggers
TV news, anniversaries of hospitalizations and episodes, being overtired and
stressed, family friction, being judged, self-blame, being around abuse or
someone who reminds me of past abuse
Early Warning
Signs
Anxiety, feeling slowed down, overeating, compulsive behavior, secretiveness,
feelings of abandonment and rejection, beginning irrational thought patterns
Things I must do during Early Warning Signs
Do daily maintenance whether I like it or not, talk to a support person about
what’s going on, check in with a friend once a day, spend extra time with
my parrot, listen to soothing music and sing with it, spend time in nurturing
places like Barnes and Noble and The Good Earth
When Things
Are Breaking
Down
Feeling very needy, feeling fragile, irrational responses, racing thoughts, risktaking behaviors, bizarre behaviors, dissociation, suicidal thoughts, paranoia
Crisis Plan
None
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50
HANDOUT
Consumer WRAP #1
Wellness
Toolbox
Crochet, bake/cook, treadmill, attend support group, take a nap, connect with
therapist, play computer games, talk to therapist, talk to a friend, listen to
music, journaling, wear makeup, work on genealogy, go fishing
Daily
Maintenance
Plan
What I’m like when I’m well
Calm, capable, confident, content, organized, reliable, focused, reserved,
competent, neat/clean, productive, flexible, intelligent, articulate, professional,
analytical, determined, positive
What keeps me feeling well: things I do every day
Use treadmill 30 minutes a day, eat regular meals, get 7½ hours sleep a
night, have time alone, take medications, regular schedule/routine
Extra things to do to stay well (weekly/monthly): Bake, spend time
with kids, crochet, shop, socialize, intellectual conversation, clean house, play
computer games, watch a movie with spouse, play cards, visit family, take a
bike ride, meet with job coach
Triggers
Being judged/criticized, anniversary of traumatic event, overstimulation,
spending time with family (mother) on holidays, someone else’s anger, stress,
financial problems, feeling left out, medication changes that are not effective
Triggers Action Plan
Check in with therapist or psychiatrist, positive self talk, take a nap, vigorous
exercise, be assertive, verbally express my feelings, take a break/time out/go
home, journaling, ask others for support, follow daily maintenance plan
Early Warning
Signs
Helplessness/hopelessness, negative thinking/talk, apathetic, lack of motivation, avoiding daily maintenance routine, isolating/withdrawing, back pain/
pressure, short tempered/irritated, crying, increased appetite, irrational fear
of abandonment
Early Warning Signs Action Plan
Check daily maintenance plan and follow it, contact therapist, ask for help from
people around me, attend a support group, take a nap, exercise, express feelings
When
Things Are
Breaking
Down
Suicidal thoughts/wanting to die, no appetite, racing thoughts, intense feelings,
waking up between 3 and 6 AM, not feeling, respond as a victim, inability to follow
through with commitments, not wanting to leave home, doing things in excess
Breaking Down Action Plan
Talk to a support person, make appointment with therapist, readdress/focus
on wellness plan, avoid outside stimulation, take time for self, exercise,
journaling, follow daily maintenance plan
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Consumer WRAP #2
Consumer WRAP #2 (continued)
Crisis Plan
When feel out of control:
Supporters: spouse, sister, therapist, coworker
Don’t want: mother, father (no understanding of mental illness)
Medications: prozac
Don’t want: serzone, wellbutrin, generic prozac works, not currently taking:
lithium, nortriptyline
Don’t want: depakote, paxil
Treatments: day treatment at mental health center
Facilities: St. Cloud Hospital
Help from others: spouse: hold me while I cry
ALL: don’t talk about my problems
Spouse: take care of financial responsibilities
Things that make it worse: Pushing me to do things I’m not ready to do.
Being angry or aggressive. Criticism.
If I am in danger, take me to the community hospital.
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Not able to get out of bed after 10 AM, quitting job, missing appointments,
isolating, staying in bed, crying and rocking, neglecting personal hygiene,
not getting dressed, not taking shower, staring into space, not responding to
anyone around me
Wellness
Toolbox
Attend support group, take a nap, do crossword puzzles, play cards, play computer games, pool therapy, take a warm bath, listen to classical music, read,
journaling, deep breathing/focusing, call a friend, put picture albums together,
meditate, creative activity like quilting or crocheting.
Daily
Maintenance
Plan
What I’m like when I’m well
Natural leader, happy/content, endearing, responsible, reliable, calm, persistent, optimistic, capable, spontaneous, confident, competent, supportive, kind
What keeps me feeling well
Taking medications, eat 3 healthy meals, quiet time before bed, 30 minutes of
meditation, cup of herbal tea, shower/wash hair, get up by 8 AM, go to bed at
same time—11 PM, avoid junk food, keep a routine, drink 8 glasses of water a
day, take Vitamin C, brush my teeth
Extra things to do to stay well
Plan something fun for weekend, spend time with grandchildren, read, play
games, cards with family and friends, plan a vacation
Triggers
Dad’s death—April, movies about abuse, overtired, being interrupted, relationship ending, too many needy people, excessive stress, overstimulation,
car problems, loud noises, arguing—especially family holidays and especially
Christmas
Triggers Action Plan
Do everything on daily maintenance list, screen phone calls, get feedback
from supporters, listen to classical music, take time off for myself, on holidays
take care of my emotions and express what I’m feeling
Early Warning
Signs
Forgetfulness, anxiety, anger, irritable, physical problems, obsession with
something, negative thinking, impulsive, irrational thought patterns, feeling
inadequate/worthless
Early Warning Signs Action Plan
Do everything on daily maintenance list whether I want to or not, call supporter/therapist, readjust schedule/slow down, do one hour of something fun from
the Toolbox, relaxation exercises, ask someone to do housework—especially
the dishes
Things I would choose to do
Make an appointment with doctor, read a good book, listen to good music, ask
friends who are positive to spend time with me
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Consumer WRAP #3
Consumer WRAP #3 (continued)
Unable to sleep for 2 days, increased physical pain—back and neck, avoid eating,
wanting to be totally alone, racing thoughts, pacing, spacing out, not feeling, obsessed with negative thoughts that can’t be controlled, paranoid, defensiveness
Breaking Down Action Plan
Call psychiatrist, call physical doctor, do everything on daily maintenance
list, take time off from work, journal, ask daughter to come over and stay
with me, give medications, checkbook, car keys to adult children, do 3 deep
breathing exercises, do 2 focusing exercises
Other things I may choose
Do a creative activity—crocheting & crafts, ask doctor to check my medications
Crisis Plan
Symptoms when supporters take responsibility:
Not sleeping for one week, excessive pacing, can’t stay still, anger and weeping within 5 minutes time, poor decision making, severe pain, agitated depression, flat affect, not doing any home responsibilities for one month, extreme
guilt, disconnected sentences, anger that people don’t understand
Supporters:
Son: pick up mail, pay bills
Son: keep car running
Daughter: visit me, cancel appointments, bring clothes and personal items
Daughter-in-law: clean house before coming home, feed cat, change litter
Daughter-in-law: visit me, bring grandchild
Son-in-law: mow lawn, shovel snow, visit me
Coworker: cancel any trainings or appointments, handle messages
Medications:
Currently use: depakote, zoloft, vioxx, lipitor
Medications to use if necessary: ativan
Avoid: antihistamines, sulfa
Treatments: massage therapy, pool therapy, cognitive therapy
Treatment to Avoid: ECT
Facilities: St. Cloud Hospital
Avoid: Regional Treatment Center (State hospital): increases symptoms
Help from others:
Listen to me, let me pace, encourage me, validate my feelings, let me rest,
feed me good food, check on me, call me, stay overnight
Don’t:
Talk constantly
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When
Things Are
Breaking
Down
Developing a WRAP
Daily Maintenance Plan
• Describe yourself when you are feeling well. Make a list of descriptive words.
• Make a list of things you know you need to do for yourself every day to keep yourself
feeling all right.
• Make a list of things it would be good to do.
Triggers
• Make a list of those things that, if they happened, might cause an increase in your
symptoms. They may have triggered or increased symptoms in the past.
• Make a list of what you will do if triggers occur.
• Make a list of additional things you could do that would be helpful.
Early Warning Signs
• Make a list of Early Warning Signs for you.
• Make a list of things you must do when you experience Early Warning Signs.
• Make a list of things you could choose to do if they feel right.
Symptoms
• Make a list of the symptoms which, for you, mean that things have worsened and are
close to the crisis stage.
Crisis
• Make a list of what you are like when you are well.
• Make a list of symptoms that would indicate to others that they need to take over responsibility for your care and make decisions in your behalf.
• Make a list of people who you want to take over for you when the symptoms you list
come up. They can be family members, friends, or health care professionals. Have at least
five people on your list of supporters. You may want to name some people for certain
tasks like taking care of the children or paying the bills. For each person, list his or her
name, connection/role, and phone number. Also make a list of people that you do not want
involved in your care and why you do not want them involved.
• Medication. Make a list of the medications you are currently using and why you are taking them. List those medications you would prefer to take if medications or additional
medications became necessary and why you would choose those. List those medications
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In your Seclusion and Restraint Journal, please complete the following information for a
WRAP. Remember, a WRAP does not have to be related to psychiatric symptoms—it could
be for any physical condition or recovery from a difficult or traumatic life experience.
Developing a WRAP (continued)
Post-Crisis Planning
• Describe how you would like to feel when you have recovered from this crisis.
• List post recovery support people.
• List things you must do after returning home, things others can do for you, things that can
wait until you feel better.
• List things you must do for yourself every day.
• List people and things to avoid.
• List signs that may be the beginning to feeling worse and list Wellness Tools to use to
help you.
• Issues to consider:
○ People to thank
○ People to apologize to
○ People with whom you need to make amends
○ Medical, legal, financial issues that need to be resolved
○ Things you need to do to prevent further loss (i.e., canceling credit cards, getting
official leave from work, etc.)
• Develop a reasonable timeline for resuming responsibilities.
• Consider whether any changes are needed in your WRAP.
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that would be acceptable to you if medications became necessary and why you would
choose those. List those medications that should be avoided and give the reasons.
• Treatments. List the particular treatments that you would like in a crisis situation and
some that you would want to avoid.
• Home/Community Care/Respite Center. Many people are setting up plans so that they can
stay at home and still get the care they need if they are in a crisis by having around-theclock care from supporters and regular visits with health care professionals. List what you
have planned for this.
• Treatment Facilities. Using your personal experience and information you have learned
through your own research or though talking with others, list those treatment facilities
where you would prefer to be hospitalized if that became necessary, and list those you
with to avoid.
• Help from others. List those things that others can do for you that would help reduce your
symptoms or make you more comfortable.
• Describe the symptoms, lack of symptoms, or actions that indicate supporters no longer
need to use this plan.
How to Set Up a Comfort Room
1. Establish a plan for comfort room and submit it to the hospital administration. Approval
from top-level administration is necessary including attendance at planning meetings
and memoranda to support the effort.
2. Organize a planning committee which includes all levels of staffing. Two coordinators
are helpful, one whom will work directly with staff and clients.
3. Involve people diagnosed with a mental illness in every aspect of planning. Allow them
to actively participate in decorating the room with their input regarding preferences in
design.
4. Conduct research regarding all furnishings and equipment that will be used in the comfort room for safety as well as comfort.
5. Create a comfort box with items that can be used in the comfort room including stuffed
animals, headphones, reading materials, and other requested items.
6. Conduct training with staff and people diagnosed with a mental illness regarding the
guidelines for usage.
7. Develop the room in graduated steps, introducing each new item and testing for
efficiency, safety, and satisfaction.
8. Have sign-up book for each person to sign before and after using the comfort room.
9. Make sure a de-escalation preference form is filled out and placed on the record for
helping to insure individual preferences about what is helpful and what is not in times
of stress.
10. Keep an accurate record of progress.
11. Inform total staff with regular progress reports.
12. Congratulate direct care staff for participating in the implementation of the comfort
room. Allow staff to participate in presentations or tours. Encourage their feedback or
suggestions for improvement.
13. Collect data regarding use of and feedback for research purposes.
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by Gayle Bluebird
Why Should I Fill Out A Psychiatric Advance Directive?
An advance directive spells out what you want done in a time of crisis as a result of your mental
illness. It also enables you to choose who you want to make medical decisions for you. It can
also let others know your plans for the care of your children, pets, or home. This directive does
not “activate” unless your capacity to make rational decisions becomes impaired. You can also
use this document to describe those behaviors which are “indicators” of impaired capacity and
which you think ought to activate the advance directive. An advance directive helps you maintain control in a time of mental health crisis and may prevent the crisis from worsening. Here
are a number of important reasons why consumers should consider completing advance directives for mental health care:
1. An advance directive helps you maintain choice and control in the treatment you
receive, according to your knowledge of what works best for you in managing your
mental health care. This includes medication and treatment you do and do not want.
2. An advance directive increases the possibility that there will be continuity of care in
times of crisis, including place, type, and personnel involved in treatment.
3. An advance directive may decrease the possibility of involuntary treatment.
4. If involuntary treatment does occur, a mental health care directive may have a direct
impact on the treatment you do receive, including time in the hospital, the use of medications, place of treatment, and treatment plan upon release.
5. Preparing a mental health care directive affords an excellent opportunity to develop an
effective crisis intervention plan and to discuss it with family, friends, and others before
the crisis arises. This includes the opportunity to discuss approaches that are effective
and those that hinder rather than help in times of crisis.
6. An advance directive allows you to authorize the release of information at a time when
your capacity to make authorization is clear, and it enables you to state whom you do
and do not want notified at the time of hospitalization.
7. An advance directive, particularly the appointment of a proxy whom you trust, can be
an effective alternative to the court-appointed guardian.
8. An advance directive can include how you want your family, pets, and finances cared
for while you are receiving treatment.
9. The implementation of an advance directive can help restore self-confidence and allay
fears and panic in a time of crisis. This helps in terms of stabilization and recovery.
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(or, sometimes the best defense is a good offense)
Ten Tips for Completing an Effective Advance Directive
2. Write your advance directive at a time when your illness is not severe enough to impair
your judgment or to raise questions about the validity of the document. You probably
do not want to fill out an advance directive while you are in the hospital or under commitment; unless the professionals treating you agree that your capacity is presently not
impaired. If this is the case, consider asking them to witness your document.
3. Sit down and discuss the directive with people you trust and who can give you good
feedback about your concerns and problems in times of crisis. Ask them what they
would include in the directive if they were you. You do not have to include their suggestions, but shared wisdom may produce a stronger document with others invested in
making it work.
4. Discuss your treatment concerns and the instructions you are thinking of putting in
the directive with those who will be involved in your treatment and care. This should
include your doctor, case manager, therapist, personal care assistant, and others directly
involved in your care. Do this before you write your directive.
5. Discuss the contents of your advance directive with the person who will be your proxy
before you finalize the directive. Can that person carry out the instructions as you wish
and be a good advocate for you? If not, can you live with whatever limits that person
may have?
6. Although it is important to get the opinions, thoughts, and ideas of those involved in
your life and care, you, of your own free will, must decide what goes into the directive.
If you are not comfortable with the directive, if it reflects pressure from others rather
than your own choices, then it is more likely that you will reject the directive at a time
when you are in crisis. Therefore, family, friends, and providers must be careful not to
pressure you into choices that are not really yours.
7. Include your knowledge of what works for you based on your own experiences. While
this is a legal document, you do not need to write it in legalese. Use your own words
to describe your needs in time of crisis; what has worked and not worked for you; and
what has caused negative reactions or actually hindered progress. You can use a story
format, but do not make it too long.
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1. Think of your directive as a relapse prevention plan or crisis intervention plan. Who do
you need to be involved in your plan to make it work?
Ten Tips (continued)
9. Think about the following things that may need to be put into your directive:
• What is the best way to describe my mental health problem?
• What triggers my crisis, in particular, the point at which I would like to be hospitalized or given medications? Answering this question gives you an idea of when your
directive should kick in.
• What are your experiences, wishes, and concerns about medications and ECT?
Would you prefer seclusion to the use of emergency medications? Are seclusion and
restraints out of the question because they are contraindicated by your personal history?
• What other concerns do you have about the way you might be treated?
• What else has worked well for you in the past? Individual or group therapy? Time to
be alone? Regular visits from particular family members or friends? Assurances that
the rent is paid or your family is being cared for?
• If you are a smoker, think about how your need to smoke may be addressed, particularly if there are hospital limitations on smoking.
• If you want to be treated in the hospital by a particular doctor, make sure that doctor
has hospital privileges.
10. Be reasonable in what you put in the directive. Do not include treatment or services
that you know that you will not be able to get, particularly while in the hospital. Also,
if your directive is not reasonable, you may be raising questions about the validity of
your directive.
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8. Read over the form until you understand it and do drafts of your directive before you
actually write up your final document. Do not be afraid to ask for help figuring out the
parts you do not understand. If you fill out the directive without really understanding it,
you may end up writing a directive that is not valid.
Psychiatric Advance Directive Practice Worksheet
Advance directives are based on the principles of personal choice and self-determination.
The preferences you express regarding future treatment or services, a person you authorize to
make decisions for you, the ability to revoke your advance directive, or any other issues are
for you to decide, without anyone exerting any control or coercion over you. You also have
the right to change your mind and change your advance directive at any time, but it is your
responsibility to make sure that all copies of the advance directive are kept up to date and
copies are shared with the appropriate people.
This practice worksheet is not a legal document, but is designed to help you start thinking
about what you want to include in your own advance directive. It can also help you start
gathering the information you will need when you write one that is legally binding. More detailed information about psychiatric advance directives is available from the National Mental
Health Association.
Your “Expressed Wishes”
An advance directive is your opportunity to express what treatments or services you choose
to have, or not to have, during a psychiatric crisis. These statements are known as your expressed wishes. If you have ever been hospitalized before, think back about those things that
were helpful to you, and those things that were not.
What types of treatments or services are helpful to you during a crisis? This can include
medications (and dosages), what facilities or healthcare professionals you want to be involved in your care, what helps you calm down if you’re feeling overly agitated, who can
help you in other ways (such as taking care of children, pets, plants, or paying bills), people
you want as visitors if you’re hospitalized, etc. Try to be as specific as possible. You may
need to use additional sheets of paper:
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(Source: www.nmha.org)
Practice Worksheet (continued)
Your Choice of Agent(s)
An agent is someone who you authorize to make decisions for you at a time when you
have been determined unable to make decisions for yourself. It’s important that you choose
someone you trust and who you think will do a good job as your advocate. You may wish to
choose one person as the primary agent, and choose a second person as a backup in case the
first person is no longer able or willing to serve as your agent.
1st Agent’s Name:
Address:
City, State, and Zip:
Daytime phone:
Evening phone:
Mobile phone:
E-mail address:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
2nd Agent’s Name:
Address:
City, State, and Zip:
Daytime phone:
Evening phone:
Mobile phone:
E-mail address:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
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What types of treatments or services are NOT helpful to you during a crisis? This can
include medications (and dosages) that you know will not be helpful, what facilities or health
care professionals you wish to avoid, ways that people treat you that make you upset or angry, people who you don’t want to see if you are hospitalized, etc. Again try to be as specific
as possible:
Practice Worksheet (continued)
If it is determined you are unable to make your own decisions, and you choose to revoke
your advance directive at that time, your agent will no longer be able to advocate for your
expressed wishes, you will lose the benefits of having an advance directive, and it will be as
though you never had one. You may wish to discuss this issue with your friends, relatives,
and/or healthcare providers before you decide whether or not your advance directive should
be revocable.
Please circle the answer that’s right for you: Even if I were in the middle of a psychiatric
crisis, I (would) (would not) want to be able to revoke my advance directive.
Explanation of your choice of revocability, if you choose to give one:
Summary
Hopefully this worksheet helped you to get started thinking about what you want in your
own psychiatric advance directive. Some States require that advance directives be done in
a particular way for them to be considered legal documents. You should consult with an
attorney or someone from your State’s Protection and Advocacy (P&A) program (www.
napas.org or 202-408-9514) for legal information specific to your State.
For more information on psychiatric advance directives issues and for a listing of additional
resources, see the National Mental Health Association’s Psychiatric Advance Directives
Toolkit, available by calling 800-969-6642 or visiting www.nmha.org
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Your Choice of Revocability
Revocability is a controversial issue. Some individuals want to be able to revoke their
advance directive even while they’re in crisis, possibly because they may change their minds
about their expressed wishes or because they may become dissatisfied with the decisions their
agent was making. Other people know that they don’t make good decisions when they are in
crisis, want the decisions they made ahead of time to apply throughout a crisis, and therefore
want their advance directive to be irrevocable. Laws around revocability vary from State to
State. Therefore, you will need to consult your State law before drafting these provisions.
Six Essential Steps for Advance Directives
2. Meet with the core group of staff, review the materials and goals.
3. Meet with the staff of the facility/program, review the materials and goals.
4. Meet with the young people, fill in a survey, review the materials and goals,
answer questions, and develop a working relationship with the young people.
5. Get ongoing technical assistance through the pilot process.
6. In three months, readminister the surveys that were given earlier to the young people and
see if there is a notable difference.
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1. Get the “buy-in” of the facility or program that will pilot the project.
Anticipated Benefits of Prime Directives
Anticipated benefits/outcomes for parents
• A forum to hear from their children what has been difficult to hear in the past.
• An intermediary when communication is difficult.
• Insight into their children’s wants and needs.
• An active role in understanding their children’s goals for recovery.
Anticipated benefits/outcomes for programs
• Better informed recipients of services.
• More aware/responsible program staff.
• Quality assurance mechanism.
• Recovery-oriented model.
• Reduction of seclusion, restraint, and coercion.
• Better understanding of recipients’ wants and needs.
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Anticipated benefits/outcomes for young people
• A concrete voice in treatment and service planning, including wishes and concerns.
• The opportunity to ask questions that are difficult to ask.
• A concrete plan for goals for future life.
• Increased self-esteem, hope, and trust as they begin on the road to recovery.
Services, support the following Technical Assistance, Research, and Training Centers and
Clearinghouses. Services may include technical assistance, information and referral, on-site
consultation, training, library services, publications, annotated bibliographies, etc. Many
services are available free of charge, but in some cases, charges are applicable.
Center
National Indian Child Welfare Association
5100 SW Macadam Ave.
Suite 300
Portland, OR 97239
Phone: (503) 222-4044
Fax: (503) 222-4007
www.nicwa.org
Services Provided
• Technical assistance for community
development
• Public policy development
• Information exchange
• Technical assistance and training for
Tribal grantees of the Child, Adolescent
and Family Branch of the Center for
Technical Assistance Partnership for
Child and Family Mental Health
• Education, family involvement and advocacy
1000 Thomas Jefferson Street, NW
Suite 400
Washington, DC 20007-3835
Phone: (202) 403-5600
Fax: (202) 403-5007
www.air.org/tapartnership
• Peer mentors
Center for Evaluation of Child Mental
Health Systems
• On-site consultation on management
information systems
Judge Baker Children’s Center
53 Parker Hill Avenue
Boston, MA 02120
Phone: (617) 232-8390; (800) 779-8390
Fax: (617) 232-8399
• Meetings and conferences
Research and Training Center on Family
Support and Children’s Mental Health
• Research and training focused on family
support issues, family/professional
collaboration, and diverse cultural groups
Regional Research Institute of Portland
State University
P.O. Box 751
Portland, OR 97207-0741
Phone: (503) 725-4040
Fax: (503) 725-4180
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• Child welfare
• Youth coordinators
• Topic-based conference training modules
• Networking and organization collaborations
• Annual research conference on family
support issues
• Information on publications and events
through an electronic bulletin board
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Children’s and Adolescents’ Mental Health Services
Technical Assistance and Research Centers
Research, Training, and Technical Assistance Centers
Center
Services Provided
• Psychiatric rehabilitation research and
training in 9 major areas: peer support
and consumer service delivery, treatment
models, vocational rehabilitation, managed care, women’s issues, HIV/AIDS,
familial experience, diversity issues, and
transition-age youth
National Research and Training Center
on Psychiatric Disability
104 South Michigan Avenue
Suite 900
Chicago, IL 60603
Phone: (312) 422-8180
Fax: (312) 422-0740
www.psych.uic.edu/uicnrtc
• Extensive dissemination and technical
assistance at replacement cost or no cost
• Workshops, seminars, academic courses,
and training to providers
• Technical assistance to Federal, State, and
local agencies for public policy initiatives
The Evaluation Center Human Services
Research Institute
• Consultation program through site visits
or telephone/e-mail
2269 Massachusetts Avenue
Cambridge, MA 02140
Phone: (617) 876-0426
Fax: (617) 497-1762
www.tecathsri.org
• Topical evaluation network program
• Tool kits to provide evaluators with tested
methodologies and instruments
• Evaluation materials program
• Mini-grant program for system-of-change
evaluation projects
• Training program on evaluation-related
skills
• Multicultural issues in evaluation
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Services supports these Research, Training, and Technical Assistance Centers. Services may
include technical assistance, information and referrals, on-site consultation, training, library
services, publications, annotated bibliographies, and other resources. Many services are
available free of charge, but in some cases, charges may apply.
Research, Training, and Technical Assistance Centers (continued)
• Consultation and training using psychiatric rehabilitation technologies and topics
related to rehabilitation and recovery
Boston University
940 Commonwealth Avenue West
Boston, MA 02215
Phone: (617) 353-3549
Fax: (617) 353-7700
www.bu.edu/sarpsych
• Workshops, conferences, professional
development programs, and academic
degree programs
• Service demonstration programs for consumer/survivor rehabilitation and recovery
• Information dissemination via a newsletter, journal, Web site, and catalog
• Research on psychiatric rehabilitation and
related topics
National Mental Health Consumers’
Self-Help Clearinghouse
• Consumer information and referrals
1211 Chestnut Street
Suite 1207
Philadelphia, PA 19107
Phone: (800) 553-4539
Fax: (215) 636-6312
www.mhselfhelp.org
• Training events
Center for Support of Mental Health
Services in Isolated Rural Areas
• Knowledge synthesis
Frontier Mental Health Services
Resource Network
Western Interstate Commission for Higher Education
Mental Health
P.O. Box 9752
Boulder, CO 80301
Phone: (303) 541-0256
Fax: (303) 541-0291
www.wiche.edu/MentalHealth/Frontier
• Human resource development
National Resource Center on Homelessness
and Mental Illness
• On-site technical assistance to demonstration grantees on topics related to service
delivery, program organization, research
design, and instrumentation
• On-site consultation
• Teleconferences and national conferences
• Consumer library
• Newsletter
• Consumer and consumer-supported
nationwide database
• Technical assistance to organizations
Policy Research Associates, Inc.
345 Delaware Avenue
Delmar, NY 12054
Phone: (518) 439-7415
Fax: (518) 439-7612
Email: [email protected]
www.prainc.com
• Conferences and workshops
• Demonstrations and evaluations
• Workshops, training institutes, and
substantive papers on issues related to
service delivery to homeless persons with
serious mental illnesses
• Database of 4000+ articles, annotated
bibliographies on topic clusters, and
specialized database searches
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Center for Psychiatric Rehabilitation
Sargent College of Health and
Rehabilitation Sciences
• Special topic technical assistance and
training
National Association of State Mental Health
Program Directors
66 Canal Center Plaza
Suite 302
Alexandria, VA 22314
Phone: (703) 739-9333
Fax: (703) 548-9517
www.nasmhpd.org/ntac.cfm
• Consensus development conferences and
teleconferences
• Consultant database
• Publications and reports
• Model service system standards review
and analysis
• Centralized repository for training and
technical assistance information and
coordination for federally mandated
Protection and Advocacy (P&A) programs
Training and Advocacy Support Center
(TASC)
National Association of Protection and
Advocacy Systems
900 Second Street, NE
Suite 211
Washington, DC 20002
Phone: (202) 408-9514
Fax: (202) 408-9520
TTY: (202) 408-9521
www.napas.org
• Information dissemination via a Web page,
online interactive library, publications, and
public service announcements
• Technical assistance with expertise
rosters/brokering and P&A legal backup
centers
• On-site peer consultation, development
of model policies and procedures, and
outcome measures to increase P&A
effectiveness
• On-site training, conferences, tapes and
other visual or auditory training tools,
and development of competency-based
curriculum systems
Projects for Assistance in Transition
from Homelessness (PATH) Technical
Assistance Center
• Training curricula in topic areas identified
through a comprehensive needs assessment of State PATH contacts
Advocates for Human Potential, Inc.
490-B Boston Post Road, Suite 200
Sudbury, MA 01776
Phone: (978) 443-0055
Fax: (978) 443-4722
www.ahpnet.com
• Ad hoc technical assistance to State and
local PATH programs in response to special
requests
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• State, regional, and national consultation
National Technical Assistance Center
(NTAC) for State Mental Health Planning
• Integrated technical assistance network
for knowledge development
• Analysis of state-of-the-art practices and
synthesis documents
Policy Research Associates, Inc.
The GAINS Center
345 Delaware Avenue
Delmar, NY 12054
Phone: (800) 311-4246
Fax: (518) 439-7612
Email: [email protected]
www.prainc.com
• Targeted fact sheets, briefs, and
brochures
• Specially designed training sessions and
workshops delivered on-site and via
e-mail
• Resource center for consumers/survivors/
ex-patients and consumer-run organizations across the United States
Consumer Organization and Networking
Technical Assistance Center (CONTAC)
West Virginia Mental Health Consumers
Association
P.O. Box 11000
Charleston, WV 25339
Phone: (888) 825-TECH (8324)
(304) 345-7312
Fax: 304-345-7303
www.contac.org
• Services include materials development
and dissemination, training, skill
development, interactive communication
opportunities, networking, and other
activities to promote self-help, recovery,
and empowerment
• Technical assistance to organizations in
identifying and exemplifying points of
entry into consumer programs
• Outcome orientation for non-traditional
services
• Leadership and organizational
development
• Information sharing through a national
Web network
• Information and referrals
National Consumer Supporter Technical
Assistance Center
• Technical assistance on site and by phone
2001 N. Beauregard Street, 12th Floor
Phone: (800) 969-6642
Fax: (703) 684-5968
www.ncstac.org
• Resource library
• Coordination of local coalitions
• Training conference
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The National GAINS Center for People
with Co-Occurring Disorders in the
Criminal Justice System
• Technical assistance in developing programs of assertive community treatment
Colonial Place Three
2107 Wilson Boulevard
Suite 300
Arlington, VA22201
Phone: (703) 524-7600
(800) 950-NAMI (6264)
TDD: (703) 516-7227
Fax: (703) 524-9094
www.nami.org/about/pact.htm
• Teleconferences on various aspects
of PACT program planning and
implementation
• Information dissemination via mail and
a Web site
National Center for American Indian and
Alaska Native Mental Health Research
• Research, research training,
University of Colorado Health Sciences Center
Department of Psychiatry
Nighthorse Campbell Native Health Building
P.O. Box 6508, Mail Stop F800
Aurora, CO 80045-0508
Phone: (303) 724-1448
Fax: (303) 724-1474
www.uchsc.edu/ai/ncaianmhr
• Technical assistance provided on American
Indian and Alaska Native populations.
National Empowerment Center
• Consumer/survivor ex-patient TA
599 Canal Street
Lawrence, MA 01840
Phone: (800) 769-3728
Fax: (978) 681-6426
www.power2u.org
• Information and referrals
• Information dissemination
• Cross site evaluation of 9 sites in the
Circles of Care grant program.
• Technical assistance on site and by phone
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National Alliance for the Mentally Ill
Alty, A. (1997). Nurses’ learned experience and expressed opinions regarding seclusion practices
within one NHS Trust. Journal of Advanced Nursing, 25, 786-793.
Blackwell, B. (Ed.) (1997). Treatment compliance and the therapeutic alliance. Amsterdam:
Harwood Academic Publishers.
Blanch, A. (2000, Fall). Mental health systems try new approaches to conflict resolution. Networks.
Online at www.nasmhpd.org/ntac.
Blanch, A., Glover, R., Mazade, N.. & Petrila, J. (1995). Enhancing problem-solving in the public
mental health system through mediation: Final report to the Center for Mental Health Services.
Alexandria, VA: National Association of State Mental Health Program Directors; Tampa, FL:
The Florida Mental Health Institute, University of South Florida.
Bluebird, G. Comfort rooms. Presentation materials used with permission.
www.contact.org/bluebird
Bluebird, G. (2001). Reaching across with the arts: A self-help manual for mental health
consumers. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration, Center for Mental Health Services.
Campbell, J. (1989) People say I’m crazy. San Francisco: California Department of Mental Health.
Cassou, M., & Cubley, S. (1996). Life, paint, and passion: Reclaiming the magic of spontaneous
expression. New York: G.P. Putnam.
Clay, S. (Ed.). (1982). Take horses for instance: A poetry book. Portland Coalition of the
Psychiatrically Labeled. Out of Print.
Clement, J.A., & Schwebel, A.I. (1997). Mediation: An intervention to facilitate empowerment of
mental health consumers. In E. Kruk (Ed.), Mediation and conflict resolution in social work and
human services (pp. 195-210). Chicago, IL: Nelson-Hall.
Copeland, M.E. (1994). Living without depression and manic depression. Oakland, CA:
New Harbinger Publications.
Copeland, M.E. (1997). Wellness Recovery Action Plan. W. Dummerston, VT: Peach Press.
Copeland, M.E. (1999). Winning against relapse. Oakland, CA: New Harbinger Publications.
Copeland, M.E. (2001). The depression workbook (2nd ed.). Oakland, CA: New Harbinger
Publications.
Copeland, M.E. (2002, February). Mental Health Recovery Newsletter. W. Dummerston, VT.
Cousins, N. (1981). Anatomy of an illness as perceived by the patient: Reflections on healing and
regeneration. New York: Norton.
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Allen, K. (1996). The role of pets in health and illness. In C. Klug (Ed.), Studies in health and
human services: Vol. 25. Suicide: The constructive/ destructive self. Lewiston, Ontario: Edwin
Mellen Press.
Darby, M. (1996). Use it or lose it: Humor and the treatment of mental illness. Omaha, NE:
Surprise!!! Publishing.
Davidson, L., & Strauss, J.S. (1992). Sense of self in recovery from severe mental illness. British
Journal of Medical Psychology, 65, 131-145.
Fleischner, R.D. (1998). Advance directives for mental health care: An analysis of State statutes.
Psychology, Public Policy, and Law, 4(3), 788-804.
Harding, C.M., & Zahniser, J.H. (1994). Empirical correction of seven myths about schizophrenia
with implications for treatment. Acta Scandinavica, 90, 140-146.
Harding, C.M., Zubin, J.,& Strauss, J.S. (1992). Chronicity in schizophrenia: Revisited. British
Journal of Psychiatry, 161 (Supp.18), 27-37.
Holzworth, R., & Wills, C. (1999). Nurses’ judgments regarding seclusion and restraint of
psychiatric patients: A social judgment analysis. Research in Nursing and Health, 22, 189-201.
Jamison, K.R. (1993). Touched with fire: Manic depressive illness and the artistic temperament.
New York: Simon & Schuster.
Jennings, A. (1994). Imposing stigma from within: Retraumatizing the victim. Resources,
6(3), 11-15.
191-206.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1999). Testimony at
Senate hearings.
Katz, A.H., et al. (Eds.). (1992). Self-help concepts and applications. Philadelphia, PA: Charles
Press.
Lehane, M., & Rees, C. (1996). Alternatives to seclusion in psychiatric care. British Journal of
Nursing, 5, 97-99.
Ludwig, A.M. (1996). The price of greatness: Resolving the creativity and madness controversy.
New York: Guilford Press.
Martinez, R., Grimm, M., & Adamson, M. (1999). From the other side of the door: Patient views
of seclusion. Journal of Psychosocial Nursing, 73(3),13-22.
Maier, G. (1996). Managing threatening behavior. The role of talk down and talk up. Journal of
Psychosocial Nursing, 9, 25-30.
Mazade, N., Blanch, A., & Petrila, J. (1994). Mediation as a new technique for resolving disputes in
the mental health system. Administration and Policy in Mental Health 21(5), 431-445.
Morales, E., & Duphome, P. (1995). Least restrictive measures: Alternatives to four-point restraints
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Curie C. (2002) A conversation with Charles Curie, SAMHSA Administrator. Online at http://www.
omh.state.ny.us/omhweb/omhq/q1202/SAMSHA.htm.
National Association of State Mental Health Program Directors (MASMHPD). (1998). Position statement on consumer contributions to mental health service delivery systems. Alexandria, VA: Author.
National Mental Health Association. (2004). Psychiatric advance directive practice worksheet.
Accessed online at www.nmha.org/position/advance directives/PAD/Worksheet.pdf
Petrilla, J., Mazade, N., Blanch, A., & Glover, R. (1997). Mediation: An alternative for dispute
resolution in managed behavioral healthcare. Behavioral Healthcare Tomorrow, 6(1), 26-32.
Retzinger, S. (1990). Mental illness and labeling. Mediation Quarterly, 8, 151-159.
Ridgely, S., & van den Berg, P. (1997, April). Women and coercion: Commitment, involuntary
treatment, and restraint. Tampa, FL: Louis de la Parte Florida Mental Health Institute,
Department of Mental Health Law and Policy.
Rogers, J. (1995). Work is key to recovery. Psychosocial Rehabilitation Journal, 18(4), 5-10.
Rooney, R.H. (1992). Strategies for work with involuntary clients. New York: Columbia University
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Quarterly 16(1), 71-84.
Schwebel, A.I., & Clement, J.A. (1996). Mediation as a mental health service: Consumers’ and
family members’ perspectives. Psychiatric Rehabilitation Journal, 20(1), 55-58.
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mental illness. Unpublished doctoral dissertation, Boston University, Boston, MA.
Stevenson, S. (1991). Heading off violence with verbal de-escalation. Journal of Psychosocial
Nursing, 29, 6-10.
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Morrison, E. (1992). A coercive interactional style as an antecedent to aggression in psychiatric
patients. Research in Nursing and Health, 15, 421-431.
Tenney, L. (2001). My prime directive. Albany, NY: New York State Office of Mental Health.
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Self-Help Programs: A Technical Report. Rockville, MD: Substance Abuse and Mental Health
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A self-help guide. DHHS Pub. No. SMA-3504. Rockville, MD: Author.
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guide. DHHS Pub. No. SMA-3719. Rockville, MD: Author.
White, B.J., & Madera, E.J. (1998). The self-help source book: Finding and forming mutual aid
self-help groups. Cedar Knolls, NJ: American Self-Help Clearinghouse.
Wooldridge, S.G. (1996). Poemcrazy. New York: Three Rivers Press.
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Tenney, L. (2001). My prime directive journal. Albany, NY: New York State Office of Mental Health.
MODULE 6
Sustaining Change Through Consumer and
Staff Involvement
1
MODULE 6
Sustaining Change Through Consumer and
Staff Involvement
“The terror of confinement, the pain of restraint, and the wound to my soul
made me want to stay as far away from the mental health system as possible.
It didn’t matter that it might offer me something helpful; I didn’t want any of it
if that horrible experience was going to be a part of the package.”
—Will Pflueger, Consumer
“I encourage you to make meaningful changes regarding physical restraint
standards in psychiatric facilities by seeking the help of Psychiatric Technicians
as change agents and champions of the cause.”
—George Blake, Ph.D., American Association of Psychiatric Technicians
Learning Objectives
Upon completion of this module, the participant will be able to:
• Recognize leadership roles for administration, staff, and consumers in the elimination of
• Describe the role of the Office of Consumer Affairs/Consumer Advocate and the role they
play in eliminating the use of seclusion and restraint.
• Outline key elements of debriefing, advance crisis management, and data collection.
• Outline the pros and cons of having an external monitoring system related to seclusion
and restraint.
• Identify key characteristics of the role of the champion.
Module 6
Sustaining Change Through Consumer and Staff Involvement
2
MODULE 6: SUSTAINING CHANGE THROUGH CONSUMER
AND STAFF INVOLVEMENT
Presentation (3 hours) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: National Technical Assistance Center Networks . . . .
(15 minutes)
Exercise: Direct Care Staff Leadership (15 minutes) . . . . . . .
Debriefing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise: Debriefing Role Play (25 minutes) . . . . . . . . . . . . .
Advance Crisis Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Video: Increasing Self-Determination: Advance Crisis Planning
(13 minutes)
Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
External Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Role of the Champion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Journal/Take Action Challenge (20 minutes) . . . . . . . . . . . . . . .
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Handouts for Participants . . . . . . . . . . . . . . . . . . . . . . . . .
Protection and Advocacy Offices . . . . . . . . . . . . . . . . . . . .
National Technical Assistance Center Networks Newsletter . .
Debriefing Survey for Consumers. . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Module 6
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3
Overview
Change is hard work. Once change has begun, it is necessary to sustain positive changes
through consumer and staff involvement if the goal of eliminating seclusion and restraint is
to be reached. Various strategies for sustaining change are addressed in this module.
Leadership
Every group within the mental health system has a leadership role. Each should take
responsibility for making sustainable changes in the system.
Administrative/Management Leadership
The administration/management has the most power to make structural changes within the
system. Administrative/management staff sets the stage in creating a culture that minimizes
the use of seclusion and restraint while promoting a safe environment for clients and staff.
First, administrators/management must carefully examine their own beliefs and assumptions
about seclusion and restraint in order to wholeheartedly buy into a respectful treatment
system without the use of seclusion and restraints.
The administration/management controls the policies and the overall climate of the system.
Mission statements, formal policies, and everyday practices need to be examined. The administration/management provides the leadership, vision, and planning for moving to a restraintfree environment. On a practical level, when top administration/management is involved
with every post-seclusion/restraint debriefing in a supportive and problem-solving manner,
(not a fault-finding manner), the use of seclusion and restraint decreases. It is administration/management’s job to provide for ample staffing, staff training, and continuing in-service
trainings. In order to maintain a level of consciousness about seclusion and restraint, administration has the responsibility to ensure the issue of seclusion and restraint is on the agenda
in every facility, from the housekeeping department to the board of directors. Leadership at
this level is critical in developing the atmosphere of respect and concern for consumers that
is necessary to minimize the use of seclusion and restraint.
Consumer Leadership
Consumers bring a unique perspective; their experiential knowledge is vital to any discussion
about cultural change. All persons deserve to participate in decisions that affect their lives; no
one can speak for consumers. Multiple perspectives from all stakeholders are keys to good
decisionmaking.
Module 6
4
BACKGROUND
BACKGROUND FOR THE FACILITATORS: SUSTAINING
CHANGE THROUGH CONSUMER AND STAFF INVOVLEMENT
Office of Consumer Affairs/Consumer Advocates
In January 2005, 45 States had Office of Consumer Affairs (OCA) positions within State
mental health agencies. An OCA is a vehicle to ensure that a variety of consumer/survivor
voices are heard within meaningful system change initiatives, at local, regional, and statewide meetings, forums, legislative hearings, and workgroups that focus on policy and regulations. OCAs support ongoing training to all stakeholders and agencies providing services to
people using mental health services on the principles of recovery, self-determination, advance
crisis planning, etc.
OCA positions strategically placed within State hospitals and on executive teams demonstrate
commitment to the principles of equality and inclusion of consumers and advocates in changing the culture that tolerates seclusion and restraint. For further information on establishing
an OCA position within State hospital settings, go to the National Association of Consumer/
Survivor Mental Health Administrators Web page at www.nasmhpd.org.
The goal of a consumer advocate is to represent consumers/families/guardians from their
perspective, and to promote the highest standard of care for people receiving treatment for
mental illnesses. The job of a consumer advocate is to ensure that consumer rights are protected. This may include receiving and assessing complaints regarding a consumer’s rights,
dignity, care, and treatment. On a local or regional level, a consumer advocate provides
education, advice, or consultation on issues, standards, and policies to promote the highest standard of care and treatment for persons diagnosed with a mental illness. This means
meeting with families, guardians, consumers, and staff to provide training and consultation
on consumer rights. The consumer advocate may review and monitor facility policies and
procedures that impact consumer rights. The consumer advocate also reviews and responds
to all incident reports and makes recommendations as needed.
The Protection and Advocacy (P&A) System and Client Assistance Program (CAP) comprise
the nationwide network of congressionally mandated legally based disability rights agencies.
P&A employees encourage a nonadversarial approach and strive for a partnership perspective in their work. P&A Offices were established to address the public outcry in response
to the abuse, neglect, and lack of programming in institutions for persons with disabilities.
P&A agencies have the authority to provide legal representation and other advocacy services,
under all Federal and State laws, to all people with disabilities (based on a system of priori-
Module 6
5
BACKGROUND
The term “meaningful involvement” is frequently heard. What does this mean? According to
Darby Penney (1999), meaningful involvement is:
• Beyond tokenism: Involved in sufficient numbers to have real influence.
• Beyond review and comment: Involved in framing the issues and setting the agenda.
• Beyond advice: Participating in governance and policymaking.
• Beyond sign-off: Directing one’s own recovery.
Direct Care Staff Leadership
Leadership qualities are important to individuals who are responsible for the safety of consumers as well as their own safety. Direct care staff can play many roles. Examples include
being an advocate, a whistle blower, or assisting with the tracking of data. The exercise in
this section empowers staff to acknowledge and develop their own skill set.
Debriefing
Debriefing should always be done after an incident of seclusion or restraint. Debriefing can
be used for different purposes, such as risk management, quality improvement, or staff support. For example, if the purpose of a debriefing is risk management, then it will be important
to conduct a root cause analysis, including a behavioral and physical assessment, observation
procedures, care planning process, staffing, training, competency, supervision, communication, etc. However, if the purpose of the debriefing is to assist quality improvement, it would
be important to look at what part of the system failed and how the incident could be prevented in the future. And finally, if the purpose of the debriefing is staff support, it would be
important to focus on the physical, psychological, and emotional needs of the staff involved
in the traumatic incident. The purpose of the debriefing will help determine who should be
present, e.g., staff, consumer/survivor, family members, or advocates.
One staff member, trained in the debriefing process, sets the stage for the debriefing. This
person explains the situation and the purpose of the meeting and establishes ground rules.
Examples of ground rules include confidentiality, no one is forced to talk, and only respectful
communication is allowed to promote emotional safety.
One debriefing model (adapted from Rupert Goetz, M.D., Medical Director, Hawaii State
Hospital, 2002) has four distinct sections: facts, feelings, education, and planning. The facts
section reviews what is known to be true. Rumors, hearsay, and speculation are labeled as
such. In the next phase, feelings are explored. It is important to separate the facts from the
feelings. During the feelings section, each person has an opportunity to express his or her
own feelings about the situation. Often, a wide variety of feelings are expressed and it is
important to validate all of them. During the education section, it is often helpful to review
normal adaptive responses to stress as well as maladaptive responses. It is often helpful for
staff and consumers to be reminded of common reactions to stress and trauma. Finally, in the
planning section, the facilitator discusses any follow-up and recommends steps for members
of the debriefing team to take.
Module 6
6
BACKGROUND
ties for services). These agencies also devote considerable resources to ensuring full access
to inclusive educational programs, financial entitlements, health care, accessible housing,
and productive employment opportunities. A listing of P&A Offices by State is included in
the handouts for this module. For more information on Protection and Advocacy, please visit
www.napas.org.
The University of Illinois at Chicago National Research and Training Center on Psychiatric
Disability (phone: 312-422-8180) has developed a toolkit and training manual, Increasing
Self-Determination Through Advance Crisis Management in Inpatient and Community Settings: How to Design, Implement, and Evaluate Your Own Program. As a facilitator, you
may find it useful to use this toolkit. The fundamental values underlying the Advance Crisis
Management initiative is the belief that people’s crises would be addressed more humanely
if they were allowed to specify in advance actions to be taken during times when they are too
distressed to make decisions.
Another resource is the Wellness Recovery Action Plan (WRAP) developed by educator/consumer Mary Ellen Copeland. One section in the WRAP specifically addresses the need for
advance crisis planning.
Data Collection
The Bazelon Law Center for Mental Health Web site at www.bazelon.org suggests the following regarding reporting of seclusion and restraint use: Facilities are required to report any
serious occurrence, such as death, serious injury, or a suicide attempt to the State Medicaid
agency and the State protection and advocacy agency, unless prohibited by State law. This
reporting must occur by the close of business of the next business day after the occurrence
and include the name of the resident; a description of the occurrence; and the name, street address, and telephone number of the facility. Staff must document in the resident’s record that
this report was made and keep a copy of the report in the resident’s record. Reporting of the
death of any resident must also be made to the Centers for Medicare and Medicaid Services
(CMS) regional office.
In addition, every incident of seclusion and restraint should be documented and reported in
a systematic way so trends can be analyzed and improvements made. Pennsylvania found
that making data publicly accessible was one of the key components to decreasing the use of
seclusion and restraint in their State hospitals (Pennsylvania Department of Public Welfare,
2001). Making data public fostered a healthy competition between hospitals to decrease the
incidences of seclusion and restraint. A performance improvement and monitoring program
designed to continuously review, assess, and analyze the facility’s use of seclusion and
restraints should also be in place.
Module 6
7
BACKGROUND
Individual treatment plans have goals and interventions jointly defined by the consumer, family, and treatment team to eliminate the need for seclusion and restraints. When an incident of
seclusion or restraint occurs, it is important to document all forms of de-escalation that were
attempted to prevent seclusion and restraint and their effects. Input from the consumer about
what worked and what didn’t should also be included. Finally, treatment plans need to be
easily accessible and readily available to staff.
Monitors are allowed to visit, unannounced at any time—24 hours a day, 7 days a week.
Monitors document items such as time of day, number of consumers on the census, number
of consumers currently on the unit (and where they are if not on the unit), activities, amount
of interaction between staff and consumers, physical surroundings, overall appearance and
cleanliness of the facility, how consumers are dressed, supplies available to consumers,
quality and choice of food, etc. Monitors file a written report within an agreed upon time
period—typically 2 to 5 days after their visit. The facility coordinator responds to the report
in a timely manner. In order to make sure the monitoring system is functioning smoothly, it is
important for key staff (e.g., CEO, Director of Nursing, and Facility Coordinator) and monitors to meet on an ongoing basis. Often this is done quarterly.
External monitors can raise the consciousness of key State and local policymakers, educate
the public about the needs and problems of consumers, and encourage the development of
effective community-based alternatives. A successful example of this type of program is the
Child Watch Visitation Program, an initiative of the Children’s Defense Fund. A document on
this program, Checking Up on Juvenile Justice Facilities: A Best Practices Guide, released
by the National Mental Health Association (www.nmha.org/children/justjuv/checking
UpOnJJFacilities.cfm), could be used as a guide for developing external monitoring
programs (Siegfried, 1999).
Initially, hospital staff may be resistant to having outsiders evaluate the physical surroundings and milieu. Over time, however, external monitors and staff often see the advantages
of working together and they join forces to improve the overall experience for consumers.
Typically, a staff person is designated as the facility coordinator for the external monitoring
group. The facility coordinator also helps train both monitors and staff. Monitors go through
an extensive training that covers topics such as confidentiality, what to look for on a site visit,
how to accurately document, how to write a report, how to follow up on issues, and how to
report emergency issues. Included in the training is a clear understanding that monitors are
not there to evaluate clinical issues—they are there to evaluate milieu issues. Staff are also
trained in these issues so there is no misunderstanding about the purpose and parameters of
external monitoring.
Module 6
8
BACKGROUND
External Monitoring
External monitoring groups may consist of consumer advocates, family members, and concerned citizens. The overall goal of citizen monitoring groups is to improve and enhance the
quality of life for consumers while they are receiving mental health treatment. In addition,
external monitoring groups promote effective communication between consumers, staff,
and families. According to NAMI, “Some State hospital systems and some facilities such as
Delaware, Massachusetts, New Hampshire, New Jersey, and Pennsylvania, have reduced the
use of seclusion and restraints by using third party citizen, consumer, and family monitoring
groups” (see www.nami.org).
The role of the champion is a difficult and sometimes lonely role. If someone chooses to
accept this role, the rewards are many. Change is up to the individual. Nobody can make
someone else change. All we can do is offer suggestions and increase awareness. The privilege and responsibility is up to the individual. Shared vision is rooted in personal vision.
Mandates attempt to establish visions from the top. But real vision comes from within. It is
about solving the day-to-day problems by keeping that personal vision in mind. It is our hope
that people who participate in this training will, with a personal commitment, join in establishing a treatment culture dedicated to eliminating seclusion and restraint within psychiatric
treatment settings for all people of all ages.
Module 6
9
BACKGROUND
Given the magnitude and complexities of the mental health system and its bureaucracy, many
roles are open for systems change agents. Some are in administration. Some are in the legislature and consumer and family organizations. However, each one of us here has a personal
and professional role to play—the role of champion. It is our personal commitment to making a difference wherever we are and in whatever capacity we find ourselves. For example, if
someone were using language that is stigmatizing or telling a joke at the expense of another,
what would a champion do? If one were asked to serve on a committee to look at policies
within the unit or facility, what would a champion do? How does a champion implement or
suggest to his or her supervisor that a philosophy of recovery be implemented on the unit?
Module 5: Strategies to Prevent Seclusion and Restraint. Ask each participant to share one of the Take Action Challenges from Module 5 and report
on their progress. Then go over the learning objectives for this module.
Learning Objectives
be able to:
Module 6
•
Recognize leadership roles for administration, staff, and
consumers as they relate to the elimination of seclusion and
restraint
•
Describe the role of the Office of Consumer
Affairs/Consumer Advocate in eliminating the use of
seclusion and restraint
•
Identify key elements of debriefing, advance crisis
management, and data collection and analysis
•
Outline the pros and cons of having an external monitoring
system related to seclusion and restraint
•
Identify key characteristics of the role of the champion
10
PRESENTATION
PRESENTATION
Overview
• In an ideal world, there would be no use of seclusion or restraint.
• However, we understand we do not always live in an ideal world and recognize that
sometimes seclusion and restraints are used.
• This module will explore ways of sustaining change through consumer and staff involvement in eliminating the use of seclusion and restraint via leadership, Office of Consumer
Affairs, debriefing, updating treatment plans, data collection, and external monitoring.
• Staff and consumers have important leadership roles in eliminating the use of seclusion
and restraint.
• In the unfortunate event that seclusion and restraint do occur, several key things need
to happen.
• All consumers, family members, or identified significant others need to be informed
immediately about any use of seclusion and/or restraint.
• Consumer advocates need to be included in debriefing sessions and their knowledge
utilized for preventing future seclusion and restraint.
• The Office of Consumer Affairs can ensure that a variety of consumer/survivor voices are
heard within meaningful system change initiatives and can provide ongoing training for
all stakeholders.
• Following any use of seclusion and/or restraint, consumers should participate in debriefing sessions with their primary caregivers using clear words that consumers can understand.
This helps with symptom recognition and earlier de-escalation, and promotes problemsolving and conflict resolution skills.
Module 6
11
PRESENTATION
“The terror of confinement, the pain of
restraint, and the wound to my soul made
me want to stay as far away from the
mental health system as possible. It didn’t
matter that it might offer me something
helpful; I didn’t want any of it if that
horrible experience was going to be a part
of the package.”
Will Pflueger, Consumer
Leadership
• Every group within the mental health system has a leadership role. This includes
administrators/managers, direct care staff, consumers, and families.
• Each group should take responsibility for making sustainable changes in the system.
Administrative/Management Leadership
• Administrative staff sets the stage in creating a culture that minimizes the use of seclusion or restraint while promoting a safe environment for clients and staff.
• Administrators must carefully examine their own beliefs and assumptions about seclusion
and restraint in order to wholeheartedly buy into a respectful treatment system without
the use of seclusion and restraints.
• Administrators and leaders from all levels of the organization need to make highly visible
statements and actions in support of change.
Administrators can sustain
change by providing:
Module 6
•
Policies and procedures that move toward a seclusion and
restraint free environment
•
Adequate staffing
•
Staff training and continuous in-service training
•
Placing seclusion and restraint training on all meeting
agendas from the housekeeping department to the board of
directors
•
Personal involvement in debriefing after every incident of
seclusion or restraint in a supportive and problem-solving
manner
12
PRESENTATION
• Staff also needs to debrief on their own involvement in the seclusion and restraint.
• Advance crisis management needs to take place, including updating treatment plans.
• It is critical to collect data and make it readily available. Data is particularly helpful in
looking at trends over time and understanding potential underlying reasons for the use of
• External monitoring can improve communication between staff, consumers, and families
and can help to improve the overall quality of life for consumers.
Meaningful Consumer
Involvement means:
• Beyond tokenism
• Beyond review and comment
• Beyond advice
• Beyond sign-off
•
•
•
•
Beyond tokenism: Involved in sufficient numbers to have real influence.
Beyond review and comment: Involved in framing the issues and setting the agenda.
Beyond advice: Participating in governance and policymaking.
Beyond sign-off: Directing one’s own recovery through self-management (e.g., advance
directives, WRAP).
• Educating consumers and nonconsumers through articles, lectures, and workshops as
exemplified in the exercise using the Networks newsletter article.
• As of January 2005, 45 States have Offices of Consumer Affairs (OCAs).
Module 6
13
PRESENTATION
Consumer Leadership
• Consumers bring a unique perspective; their experiential knowledge is vital to any
discussion about sustaining cultural change.
• According to Darby Penney, past president of NAC/SMHA, “Consumers need
meaningful involvement” (Penney, 1999).
• An OCA is an element of empowerment for people who have been diagnosed with
mental illness or psychiatric disability.
• Although an Office of Consumer Affairs is representative of consumer concerns and
issues, it must take into consideration other stakeholders’ opinions as well if the office
is to ensure that the consumer voice is heard and considered in policy, planning, and
practice development.
• The OCA is a focal point for consumer/survivor/ex-patient concerns and information.
• The Director advocates for the consumer perspective within the mental health authority
and works to increase consumer participation in a variety of areas to produce change in
types of services and how they are provided.
Module 6
14
PRESENTATION
An Office of Consumer
Affairs (OCA) is a vehicle to
ensure that a variety of
consumer/survivor voices are
heard within meaningful
system change initiatives.
• De-stigmatizing people diagnosed with
mental illness or psychiatric disability
• Ongoing process of consumer participation
• Recognizing the civil and human rights of
people diagnosed with mental
illness/psychiatric disabilities
OCA Areas of Responsibility
Module 6
•
Policy and Regulation Development
•
Program Planning
•
Evaluation and Monitoring
•
Training
•
Finance and Contract Management
•
Complaints and Grievances
15
PRESENTATION
Benefits of an Office of
Consumer Affairs
Goals of Consumer Advocates
• Represent consumers/families/
guardians from their perspective
• Promote highest standard of care for
people receiving treatment for a
mental illness
• The job of a consumer advocate is to ensure that consumer rights are protected.
Module 6
16
PRESENTATION
• The OCA serves as a system change agent. As a change agent within government, the
OCA is responsible for raising tough issues.
• Some of the issues are protection of consumer rights, the coerciveness of forced treatment, and any other topics that consumers raise as important issues to shape future policy,
reshape services, or change priorities where other stakeholders may not be in agreement
with consumers.
○ The goal of a consumer advocate is to represent consumers, families, and guardians
from their perspective and to promote the highest standard of care for people receiving
treatment for a mental illness.
Protect Consumer Rights!
• Protecting consumer rights might include receiving and assessing complaints regarding
a consumer’s rights, dignity, care, and treatment.
• On a local or regional level, a consumer advocate provides education, advice, or
consultation on issues, standards, and policies.
• Consumer advocates meet with families, guardians, consumers, and staff to provide
training and consultation on consumer rights.
• The consumer advocate may also review and monitor facility policies and procedures that
impact consumer rights.
• In relation to seclusion and restraint, a consumer advocate reviews and responds to all
reports and makes recommendations as needed.
• Other responsibilities of a consumer advocate may include those shown on this slide:
Module 6
17
PRESENTATION
Job of Consumer Advocate
•
Administering de-escalation form
•
Making regular rounds on units
•
Being part of policymaking and new initiatives (e.g.,
comfort rooms, special programs, recognition,
festivities)
•
Being present at team meetings
•
Being the “eyes and ears” for the administrator
• Protection and Advocacy (P&A) Offices were established to address the public outcry in
response to the abuse, neglect, and lack of programming in institutions for persons with
disabilities.
P&A Nationwide Network
Protection and Advocacy is a
nationwide network of
congressionally mandated,
legally based disability rights
agencies
Module 6
18
PRESENTATION
Consumer Advocate Roles
• Provide legal representation
• Maintain a presence in facilities, if
possible
• Monitor, investigate, and attempt to
remedy adverse conditions
Distribute handout Protection and Advocacy Offices. Tell participants to
visit www.napas.org for the latest information.
Module 6
19
PRESENTATION
P&A Responsibilities:
National Technical Assistance Center Networks
OBJECTIVE:
Participants will explore personal feelings related to
seclusion and restraint inspired by the essay of a consumer
leader. Participants will be familiar with resources available
(e.g., National Technical Assistance Center (NTAC) Networks
newsletter).
PROCESS:
Ask each participant to read a copy of the National Technical
Assistance Center Summer/Fall 2002 Networks newsletter
article by Will Pflueger, “Consumer View: Restraint Is Not
Therapeutic.” Read the discussion questions out loud. Direct
participants to spend 5 minutes writing in their journal
about any feelings they may have experienced as they
participated in seclusion and restraint. Ask participants if
anyone is willing to share their feelings with the group.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
• What kinds of feelings have you experienced as a result
of using seclusion and restraint?
• What is the personal impact on you when you use
seclusion and restraint?
• How accurate do you think this consumer is about the
shame?
National Technical Assistance Center Summer/Fall 2002
Networks newsletter article by Will Pflueger
APPROXIMATE
TIME REQUIRED:
15 minutes
SOURCE:
NTAC Networks newsletter
Module 6
20
PRESENTATION
Direct Care Staff Leadership
OBJECTIVE:
Identify how direct care staff can use their leadership skills
to eliminate seclusion and restraint.
PROCESS:
Lead a brainstorming session, asking participants to
list things they can do as leaders to change the culture
within their workplace environment to move towards the
elimination of seclusion and restraint. Write all ideas on the
board. Highlight themes.
DISCUSSION
QUESTIONS:
How can you take what you have learned from this training
back to the unit?
MATERIALS
REQUIRED:
Chalkboard/dry erase board, chalk/markers
APPROXIMATE
TIME REQUIRED:
15 minutes
Module 6
21
PRESENTATION
“I don’t know what caused me
being put in seclusion. I have
asked for 26 years because I
NEVER want to cause that again.”
Consumer, NAC/SMHA Survey
• If seclusion and/or restraint does occur, it is important to discuss what happened and
how to prevent it from happening again.
• The following information on debriefing has been adapted from Rupert Goetz, M.D.,
Medical Director, Hawaii State Hospital, an expert on seclusion and restraint (Goetz,
2002).
• Debriefing is always done after an incident of seclusion or restraint.
• Debriefing can be used for different purposes, such as risk management, quality
improvement, or staff support.
Module 6
22
PRESENTATION
Debriefing
• Risk Management
• Quality Improvement
• Staff Support
• Depending on the purpose of the debriefing, it may look different from time to time.
• Some facilities recommend doing two separate debriefings. The first one is a face-to-face
discussion between the consumer and all staff involved, and discusses the circumstances
that led to the use of seclusion or restraint and strategies that could be used to prevent
future use. Parents or legal guardians may participate when appropriate.
• A second debriefing is held among all staff members involved in the emergency safety
situation and appropriate supervisory and administrative staff. These sessions include a
discussion of the emergency safety situation that led to the use of seclusion or restraint,
alternative techniques, any staff procedures that may be used to prevent the reoccurrence,
and the outcomes.
• It is important that the debriefing not be a “blame game.” This type of attitude will make
debriefing ineffective.
Module 6
23
PRESENTATION
Debriefing can be used for
different purposes:
• Discussion of the emergency safety
situation that led to the use of seclusion or
restraint
• Alternative techniques
• Staff procedures that may be used to
prevent the reoccurrence
• Outcomes
• A staff member who is trained in the debriefing process sets the stage for the meeting.
This person explains the situation and the purpose of the meeting and establishes
ground rules.
• Examples of ground rules include confidentiality, no one is forced to talk, and only
respectful communication is allowed to promote emotional safety.
• One model of debriefing, adapted from Rupert Goetz, M.D. (2002) has four distinct
sections: facts, feelings, education, and planning.
Module 6
24
PRESENTATION
Staff Debriefing Sessions
include the following:
Rupert Goetz, M.D.
• Facts
• Feelings
• Education
• Planning
• The facts section reviews what is known to be true. Rumors, hearsay, and speculation are
labeled as such.
• During the feelings section, all feelings are explored. Each person has an opportunity to
express his or her feelings. It is important for the leader to validate all feelings.
• During the education section, it is helpful to review normal adaptive responses to stress as
well as maladaptive responses. It is often helpful for staff and consumers to be reminded
of common reactions to stress and trauma.
• In the planning section, the facilitator discusses any follow-up that is going to happen and
recommends steps for members of the debriefing team to take.
• One useful tool, original source unknown, has been a survey for consumers. It can be
given to the consumer/survivor to fill out before a debriefing session.
Distribute handout Debriefing Survey for Consumers.
Module 6
25
PRESENTATION
Debriefing Model -
Debriefing Role Play
OBJECTIVE:
Understand the different roles for implementing an effective
debriefing session.
PROCESS:
Invite the participants to volunteer for the following roles:
Consumer Advocate, Director of the Office of Consumer
Affairs, Consumer, two Direct Care Staff who restrained
the consumer, one Consumer Family Member, Director of
Nursing, Administrative Supervisor, Medical Director, and
the Physician who ordered seclusion and restraint. You may
adjust these roles as necessary, given the size of the class.
If possible, have several people role play the role of the
consumer—they can switch on and off with each other. Set
the stage by reading out loud the following scenario:
The consumer was admitted on an inpatient psychiatric
locked unit early this morning. Initially, the consumer
was cooperative with the admission procedure. When the
admitting nurse began asking questions related to past
trauma, the consumer became agitated and began to rock
back and forth on the chair. The admitting nurse stopped
asking questions about trauma and asked the consumer
what would be helpful. The consumer said that all that
would be helpful would be to “get out of here.” When the
response from the nurse was, “No, that’s not possible at
this time,” the consumer began to raise her/his voice, stand
up, and look for a way out. The admitting nurse called for
security which further agitated the consumer, who began
looking for ways to protect her/himself. As the security
staff approached the consumer, he/she began kicking,
screaming, making threats, and attempted to bite two direct
care staff. The consumer was subdued and forcefully taken
down and removed to the seclusion/restraint room. The
consumer continued to “struggle” and was subsequently
put in four-point restraints face up. The consumer regained
control and was released after 25 minutes in restraints.
A debriefing session was set up for later that afternoon.
Page 1 of 2
Module 6
26
PRESENTATION
Debriefing Role Play (continued)
Each person assumes a role and attempts to act out an
effective debriefing session based on the above scenario.
First, the staff will debrief by themselves. Next, the
consumer and staff will jointly debrief the session. The
audience is to listen and observe both the verbal and nonverbal language of all participants. Once the role play is
completed, each actor gets to briefly discuss what it was like
for him or her to be in that role. Finally, ask the audience to
provide feedback along with the actors on what went well
and what could have been done differently.
DISCUSSION
QUESTIONS:
•
•
•
•
•
What did staff do well in this debriefing?
What did the consumer do well in this debriefing?
How did the consumer advocate help?
How did the Office of Consumer Affairs help?
What could have been done to make this debriefing more
useful for both staff and the consumer?
MATERIALS
REQUIRED:
None
APPROXIMATE
TIME REQUIRED:
25 minutes
Page 2 of 2
Module 6
27
PRESENTATION
Show the first 13 minutes of the video Increasing Self-Determination:
Advance Crisis Planning with Mental Health Consumers in Inpatient and
Other Settings.
Module 6
28
PRESENTATION
• Advance crisis management is essential to preventing further use of seclusion and
restraint.
• The fundamental value underlying the Advance Crisis Management initiative is the belief
that a person’s crisis would be addressed more humanely if he or she were allowed to
specify in advance actions to be taken during times when he or she is too distressed to
make decisions.
• One of the important aspects of debriefing and updating treatment plans is to identify any
triggers or precursors that might lead to the use of seclusion and restraint.
• Individual treatment plans have goals and interventions jointly defined by the consumer,
family, and treatment team to eliminate the need for seclusion or restraints.
• Information for the individual treatment plan can be obtained from the initial assessment
from the consumer when he or she entered the hospital. (Modules 2 and 5 addressed
this issue.)
• In Mary Ellen Copeland’s WRAP, there is a section on crisis planning which is covered
in Module 5. Refer back to it if needed.
• Documentation of all forms of de-escalation that were attempted to prevent seclusion
and restraint and their effect should be included in the treatment plan.
• Input from the consumer about what worked and what didn’t should also be in the
treatment plan.
• We recommend using the video Increasing Self-Determination: Advance Crisis Planning
with Mental Health Consumers in Inpatient and Other Settings developed by the University of Illinois at Chicago, National Research and Training Center on Psychiatric Disability. The video may be obtained in one of the following ways: (1) calling Jeff Parks at
(312) 422-8180, ext. 10 or Tina Carter, ext. 11; (2) writing to the National Research and
Training Center on Psychiatric Disability, Attn: Dissemination Coordinator, 104 South
Michigan Avenue, Suite 900, Chicago, IL 60603, or (3) visiting the Web site at www.
psych.uic.edu/mhsrp.
• Information from the treatment plan needs to be accessible. Some hospitals have been
very creative with this. One example is having an index card easily accessible to staff that
lists de-escalation techniques that the staff and consumer have jointly agreed upon.
Data Collection
• Every incident of seclusion and restraint needs to be documented and reported in a
systematic way so trends can be analyzed and improvements made.
• Facilities should maintain documentation for each use of seclusion and restraint (Public
Law 106-310, Children’s Health Act of 2000, Parts H and I, sections 591 through 595B of
the Public Health Service Act (42 U.S.C. 290jj-290jj 2)).
• There is no mandatory, consistent, and publicly accessible system of reporting on
seclusion/restraint uses, serious injuries, or deaths.
• When a minor is involved, the parent or legal guardian should be notified as soon as
possible, but not later than 24 hours after the occurrence.
• Among States that have succeeded in lowering their use of seclusion and restraint,
mandatory reporting has been a critical tool for improving outcomes.
• Such reporting should include consumer deaths and serious injuries, the number of
seclusion/restraint incidents, the duration of the use of seclusion, medication errors,
falls, staff injuries, and airway obstructions (California Senate Office of Research, 2002).
• A performance improvement and monitoring program designed to continuously review,
assess, and analyze the facility’s use of seclusion and restraints is vital.
Module 6
29
PRESENTATION
“I’m afraid of closed in places
and this is in my files.
No one took time to look at it
or even read it.”
Consumer, NAC/SMHA Survey
Goals of External Monitoring
• Improve and enhance the quality of
life for consumers
• Promote effective communication
between consumers, staff, and
families
• External monitors can be used to raise the consciousness of key State and local policy
makers, educate the public about the needs and problems of consumers, and encourage
the development of effective community-based alternatives. A successful example of this
type of program is the Child Watch Visitation Program, an initiative of the Children’s
Defense Fund. E-mail: cdfi[email protected]. Phone: (202) 628-8787.
Web: www.childrensdefense.org.
Module 6
30
PRESENTATION
External Monitoring
• Some State hospital systems and some facilities in Delaware, Massachusetts, New Hampshire, New Jersey, and Pennsylvania, have reduced the use of seclusion and restraints by
using third party citizen, consumer, and family monitoring groups (www.nami.org).
• External monitoring groups can consist of family members, consumer advocates, and
citizens.
• The goals of external monitoring are to (1) improve and enhance the quality of life for
consumers and (2) promote effective communication between consumers, staff, and
families.
•
Overall appearance and cleanliness of unit
•
Census, number of staff, number of consumers on the unit
•
Interaction between consumers and staff
•
Activities currently available
•
Number of consumers sleeping or in their rooms
•
Quality and choices of food
•
Number of incidents of seclusion and restraint
•
Supplies/equipment available to consumers
• Typically the facility designates a Facility Coordinator to work with the monitoring
group.
• The Facility Coordinator and the Monitoring Chairperson work together to provide
training for monitors and staff.
• Training for monitors is extensive and includes the following:
Module 6
31
PRESENTATION
What Monitors Are Looking For
•
•
•
•
•
•
•
•
•
Confidentiality
What to look for on a site visit
How often to visit
When to visit
How to accurately document
How to write a report
How to follow up on issues reported
How to report emergency issues
How to evaluate milieu issues (not clinical
issues)
• The Facility Coordinator and the Monitoring Chairperson train staff in these same issues.
• Training staff and having clear expectations of how the monitoring system works in
advance help to avoid misunderstandings and mistrust.
• Several key issues ensure an effective monitoring program.
• Monitors are allowed to visit at any time—24 hours a day, 7 days a week.
• Typically, a staff person accompanies monitors on their rounds so both parties can see
exactly what is being monitored. The monitor is allowed to go anywhere in the facility
that has been previously agreed upon by all involved parties.
• Oftentimes, staff will ask monitors to report certain things that they have not been able
to change through their own channels of communication.
• In general, monitors are looking at the overall milieu of the unit—not clinical issues.
• The monitors file a written report after their visit. A copy of this report goes to the
Facility Coordinator, the CEO, and the Director of Nursing.
• The Facility Coordinator responds, in writing, to the report within a specified period
of time, such as 2 weeks.
• A copy of the original report and the response then gets forwarded to the appropriate
personnel at the State level, for example, the Office of Consumer Affairs and the
Commissioner.
• To ensure the monitoring system is working properly, a meeting between key facility
personnel and monitors is held periodically.
Module 6
32
PRESENTATION
Monitors are typically trained
in the following areas:
“Cowardice asks the question – is it safe?
Expediency asks the question – is it politic?
Vanity asks the question – is it popular?
But conscience asks the question – is it right?
And there comes a time when one must take a
position that is neither safe, nor politic, nor
popular, but one must take it BECAUSE it is
right.”
Dr. Martin Luther King, Jr.
• Seclusion and restraint is no longer “right.”
• Seclusion and restraint do not change behavior.
• Seclusion and restraint do not help people with serious mental illnesses better manage
the thoughts and emotions that can trigger behaviors that can injure them or others.
• Seclusion and restraint can retraumatize people who have already had far too much
trauma in their lives.
• Seclusion and restraint is traumatizing to staff.
Module 6
33
PRESENTATION
• The role of the champion is a difficult and sometimes lonely one. If someone chooses
to accept this role, the rewards are many.
• Change is up to the individual.
• No one can make someone else change.
• Shared vision is rooted in personal vision. Real vision comes from within.
• There are many roles for systems change agents.
• Dr. Martin Luther King eloquently outlined the role of the champion in the following quote:
Give participants time to respond to one or two questions from the
Journal section and at least one question from each of the Personal Take
Action Challenges and the Workplace Take Action Challenges for Modules 5
and 6. They will use these Take Action Challenges extensively on the
last day of the training.
Module 6
34
PRESENTATION
JOURNAL/TAKE ACTION CHALLENGE
Journal Topics
Pick one or two questions and respond in writing. Your responses are confidential.
• Which consumer-driven supports would you like to learn more about and why?
• Why do you think consumers feel it is important to have a place that is not run by mental
health professionals?
• What ideas do you have about ways to prevent emergency situations that might lead to
seclusion and restraint?
• What are your communication strengths and weaknesses? What could you do to improve
on your weaknesses?
• What language do you hear at work that might be hurtful to consumers?
• Write about your own ideal “comfort room.” What kinds of things make you feel more
comfortable (e.g., music, soft lighting, taking a bubble bath, going for a walk, sitting
outside, meditating, essential oils, being held, watching your favorite movie, reading
a book)?
• Which of the ideas from your own personal “comfort room” could be incorporated into
your workplace?
• What do you personally need to do to take care of yourself after an incident of seclusion
or restraint? How can you make sure this happens? What do you find helpful about the
debriefing process? What do you dislike about the debriefing process? What do you see
as the administration's role in the debriefing process? How do you think data collection
about seclusion and restraints should be gathered and who should have access to this
information?
• Create a wellness plan for your own mental health based on the WRAP outline. Include
the following: What are you like when you feel your best? How much of your time is
spent feeling your best? What changes in your life would you have to consider accomplishing to maintain your wellness plan every day? Name at least three things you need
to do on a daily basis to keep yourself healthy. List at least five things that help you when
you are feeling stressed.
• Find a place in your personal life that could improve from using the information from
Communication Strategies, Comfort Rooms, or Alternative Dispute Resolution/Mediation. Make a list of two things you can personally commit to in your daily life to move
forward in one of these areas.
Page 1 of 2
Module 6
35
HANDOUT
FOR MODULES 5 & 6
Journal Topics/Take Action Challenges (continued)
• Look up consumer-driven supports on the Internet and make a list of Web sites that would
be helpful for staff and consumers to know about.
• Find one area in your work setting where you could implement the strategies from
Communication Strategies, Comfort Rooms, or Alternative Dispute Resolution/Mediation. Make a list of two things that you can personally commit to every day at work to
move your workplace forward in one of these areas. Make a detailed plan of how you
will implement these changes.
• Do you have access to the information you need in the treatment plan? If not, how could
this information be made more readily available to you?
• How does a seclusion/restraint incident affect the treatment milieu? What could be done
to help the other residents and staff on the unit cope with an incident of seclusion/
restraint?
• How are family members and/or friends involved in treatment planning and debriefings
of seclusion and restraints? How would you like to see them involved?
• What do you think is the best way to balance the rights of people diagnosed with a mental
illness with the rights of the staff? What would need to change if these are out of balance?
How could you make that change happen?
Page 2 of 2
Module 6
36
HANDOUT
• Do you have access to the information you need in the treatment plan? If not, how could
this information be made more readily available to you? How does a seclusion/restraint
incident affect the treatment milieu? What could be done to help the other residents on
the unit cope with a seclusion/restraint incident?
PROTECTION AND ADVOCACY OFFICES
State Protection and Advocacy Agencies for Persons with Developmental
Disabilities and Mental Illness, and the Client Assistance Program
ALABAMA
ALASKA
CAP
Jerry Norsworthy, CAP Director
Division of Rehabilitation Services
and Children’s Rehabilitation Services
2125 East South Boulevard
Montgomery, AL 36116
Phone: 1-800-228-3231 Voice/TDD
(in-State only)
1-800-441-7607 (out-of-State)
Fax: 334-288-1104
Web site: www.sacap.org
CAP
Pam Stratton, CAP Director
ASIST, Inc.
2900 Boniface Parkway, #100
Anchorage, AK 99504-3195
Phone: 907-333-2211; 1-800-478-0047
Fax: 907-333-1186
PADD/PAIMI/PAIR/PABSS/TBI/PAVA
Ellen Gillespie, Interim Director
Alabama Disabilities Advocacy Program
The University of Alabama
Box 870395
Tuscaloosa, AL 35487-0395
Phone: 205-348-4928; 1-800-826-1675
(in-State only)
TDD: 205-348-9484
Fax: 205-348-3909
[email protected]
Web site: www.adap.net
Dave Fleurant, Executive Director
Disability Law Center of Alaska
3330 Arctic Boulevard, Suite 103
Anchorage, AK 99503
Phone: 907-565-1002 voice/TDD;
1-800-478-1234 (in-State only)
Fax: 907-565-1000
E-mail: dfl[email protected]
Web site: www.dlcak.org
AMERICAN SAMOA
CAP/PADD/PAIMI/PAIR/PABSS/
TBI/PAVA
Marie Ma’o, Executive Director
Client Assistance Program and
Protection & Advocacy
P. O. Box 3937
Pago Pago, American Samoa 96799
Phone: 011-684-633-2441
Fax: 011-684-633-7286
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For more information please visit www.napas.org.
Protection and Advocacy Offices (continued)
TBI/PAVA
Leslie Cohen, Executive Director
Arizona Center for Disability Law
100 North Stone Avenue, Suite 305
Tucson, AZ 85701
Phone: 520-327-9547 voice/TTY;
1-800-922-1447 voice/TTY (nationwide)
Fax: 520-884-0992
Web site: www.acdl.com
Catherine Blakemore, Executive Director
Protection & Advocacy, Inc.
100 Howe Avenue, Suite 185N
Sacramento, CA 95825
Phone: 916-488-9955 Admin. Office;
916-488-9950 Legal Office
1-800-776-5746 (nationwide)
Fax: 916-488-2635 or 9962
[email protected]
Web site: www.pai-ca.org
COLORADO
ARKANSAS
TBI/PAVA
Nan Ellen East, Executive Director
Disability Rights Center
1100 North University Ave., Suite 201
Little Rock, AR 72207
Phone: 501-296-1775 voice/TTD;
1-800-482-1174 voice/TTD (nationwide)
Fax: 501-296-1779
[email protected]
Web site: www.arkdisabilityrights.org
TBI/PAVA
Mary Anne Harvey, Executive Director
The Legal Center
455 Sherman Street, Suite 130
Denver, CO 80203
1-800-288-1376 (nationwide)
Fax: 303-722-0720
[email protected]
Web site www.thelegalcenter.org
CONNECTICUT
CALIFORNIA
CAP
Sheila Conlon-Mentkowski, Chief
Client Assistance Program
Department of Rehabilitation
2000 Evergreen Street
Sacramento, CA 95815
Phone: 916-263-7372; 1-800-952-5544
TTY: 916-263-7465; 1-866-712-1085
Fax: 916-263-7464
Web site: www.rehab.cahwnet.gov
TBI/PAVA
Jim McGaughey, Executive Director
Office of P&A for Persons with Disabilities
60B Weston Street
Hartford, CT 06120-1551
Phone: 860-297-4300; 1-800-842-7303 (inState only)
TDD: 860-566-2102
Fax: 860-566-8714
Web site: www.state.ct.us/opapd/
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ARIZONA
FLORIDA
CAP
Melissa H. Shahan, CAP Director
United Cerebral Palsy, Inc.
254 East Camden-Wyoming Avenue
Camden, DE 19934
Phone: 302-698-9336; 1-800-640-9336
Fax: 302-698-9338
TBI/PAVA
Hubert A. Grissom, Interim Executive Director
Advocacy Center for Persons with Disabilities
The Times Building, Suite 513
1000 N. Ashley Drive
Tampa, FL 33602
Phone: 813-233-2920; 1-866-875-1794
TDD: 1-866-875-1837
Fax: 813-233-2917
E-mail: [email protected],
[email protected]
Web site: www.advocacycenter.org
PADD/PAIMI/PAIR/PABSS/
TBI/TBI/PAVA
James McGiffin, Executive Director /
Brian Hartman, Administrator
Community Legal Aid Society, Inc.
Community Services Building, Suite 801
100 W. 10th Street
Wilmington, DE 19801
Phone: 302-575-0660 voice/TDD
Fax: 302-575-0840
DISTRICT OF COLUMBIA
TBI/PAVA
Jane Brown, Executive Director
University Legal Services
220 I Street, NE, Suite 130
Phone: 202-547-0198
Fax: 202-547-2083
Web site: www.dcpanda.org
GEORGIA
CAP *
Charles L. Martin, CAP Director
Georgia Client Assistance Program
123 N. McDonough
Decatur, GA 30030
Phone: 404-373-3116
Fax: 404-373-4110
Web site: www.theOmbudsman.com
TBI/PAVA
Ruby Moore, Executive Director
Georgia Advocacy Office, Inc.
One Decatur Town Center
150 E. Ponce de Leon Avenue, Suite 430
Decatur, GA 30030
1-800-537-2329 (nationwide)
Fax: 404-378-0031
[email protected]
Web site: www.thegao.org
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DELAWARE
IDAHO
CAP
Edmund Cruz, Executive Director
Parent-Agencies Network, CAP
J. Madarang Dental Building
2238 Route 16, Suite 1-B
P.O. Box 23474
GMF, Guam 96921
Phone: 1-671-637-4227
Fax: 1-671-637-4211
TBI/PAVA
Jim Baugh, Executive Director
Co-Ad, Inc.
4477 Emerald Street, Suite B-100
Boise, ID 83706-2066
1-866-262-3462 (nationwide)
Fax: 208-336-5396
[email protected]
Web site: users.moscow.com/co-ad
Daniel Somerfleck, Executive Director
Guam Legal Services
113 Bradley Place
Hagatna, Guam 96910
Phone: 1-671-477-9811
Fax: 1-671-477-1320
HAWAII
TBI/PAVA
Gary Smith, Executive Director
Hawaii Disability Rights Center
900 Fort Street Mall, Suite 1040
Honolulu, HI 96813
Fax: 808-949-2928
[email protected]
Web site: www.hawaiidisabilityrights.org
ILLINOIS
CAP *
Kathy Meadows, CAP Director
Illinois Client Assistance Program
100 N. First Street, 1st Floor
Springfield, IL 62702
Phone: 217-782-5374
Fax: 217-524-1790
TBI/PAVA
Zena Naiditch, Executive Director
Equip for Equality, Inc.
20 N. Michigan Avenue, Suite 300
Chicago, IL 60602
Phone: 312-341-0022;
1-800-537-2632 (nationwide)
TTY: 1-800-610-2779
Fax: 312-341-0295
Web site: www.equipforequality.org
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GUAM
KANSAS
CAP/PADD/PAIMI/PAIR/PABSS/TBI/
PAVA
Tom Gallagher, Executive Director
Indiana Protection and Advocacy Services
4701 N. Keystone Avenue, Suite 222
Indianapolis, IN 46204
1-800-622-4845 (nationwide)
Fax: 317-722-5564
Web site: www.IN.gov/ipas
CAP
Sharon Kearse, CAP Director
3640 SW Topeka Boulevard, Suite 150
Topeka, KS 66611
Phone: 785-266-8193;
1-800-432-2326
Fax: 785-266-8574
Web site: www.ink.org/public/srs/CAP
Rocky Nichols, Executive Director
Kansas Advocacy & Protective Services
3745 SW Wanamaker Road
Topeka, KS 66610
Phone: 785-273-9661
Fax: 785-273-9414
IOWA
CAP
Harlietta Helland, CAP Director
Division on Persons with Disabilities
Lucas State Office Building
Des Moines, IA 50310
Phone: 515-281-3957; 1-800-652-4298
Fax: 515-242-6119
KENTUCKY
Sylvia Piper, Executive Director
Iowa P&A Services, Inc.
950 Office Park Road, Suite #221
West Des Moines, IA 50265
Phone: 515-278-2502;
1-800-779-2502 (nationwide)
TTY: 515-278-0571; 1-866-483-3342
Fax: 515-278-0539
[email protected]
Web site: www.ipna.org
CAP
Gerry Gordon-Brown, CAP Director
209 St. Clair, 5th Floor
Frankfort, KY 40601
Phone: 502-564-8035; 1-800-633-6283
Fax: 502-564-2951
Web site: kycap.ky.gov
Maureen Fitzgerald, Executive Director
Kentucky Protection and Advocacy
100 Fair Oaks Lane, 3rd Floor
Frankfort, KY 40601
Phone: 502-564-2967; 1-800-372-2988 TDD
(nationwide)
Fax: 502-564-0848
Web site: www.kypa.net
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INDIANA
MARYLAND
PAVA
Lois Simpson, Executive Director
Advocacy Center
225 Baronne Street, Suite 2112
New Orleans, LA 70112-2112
Phone: 504-522-2337 Voice/TDD;
1-800-960-7705 (nationwide)
Fax: 504-522-5507
Web site: www.advocacyla.org
CAP
Beth Lash, CAP Director
Maryland State Department of Education
Division of Rehabilitation Services/MD
Rehabilitation Center
2301 Argonne Drive
Baltimore, MD 21218-1696
Phone: 410-554-9359; 1-800-638-6243
Fax: 410-554-9362
MAINE
Gary Weston, Executive Director
Maryland Disability Law Center
The Walbert Building, Suite 400
1800 N. Charles Street
Baltimore, MD 21201
Phone: 410-727-6352;
1-800-233-7201 (in-State only)
TDD: 410-727-6387
Fax: 410-727-6389; 410-234-2711
Web site: www.mdlcbalto.org
CAP*
Steve Beam, Program Director
CARES, Inc.
47 Water Street, Suite 104
Hallowell, ME 04347
Phone: 207-622-7055; 1-800-773-7055
Fax: 207-621-1869
Web site: www.caresinc.org
Kim Moody, Executive Director
Disability Rights Center
24 Stone Street
P.O. Box 2007
Augusta, ME 04338
Phone: 207-626-2774;
1-800-452-1948 TDD (in-State only)
Fax: 207-621-1419
[email protected]
Web site: www.drcme.org
MASSACHUSETTS
CAP *
Barbara Lybarger, CAP Director
Massachusetts Office on Disability
One Ashburton Place, Room 1305
Boston, MA 02108
Phone: 617-727-7440
Fax: 617-727-0965
Web site: www.state.ma.us/mod/MSCAPBRO.
html
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LOUISIANA
MICHIGAN
TBI/PAVA
Elmer Cerano, Executive Director
Michigan P&A Services
4095 Legacy Parkway, Suite 500
Lansing, MI 48911-4263
1-800-288-5923 (in-State only)
CAP only: 1-800-292-5896
Fax: 517-487-0827
Web site: www.mpas.org
MINNESOTA
TBI/PAVA
Brenda Jursik, Administrator
Minnesota Disability Law Center
430 First Avenue North, Suite 300
Minneapolis, MN 55401-1780
Phone: 612-332-1441;
1-800-292-4150 (in-State only)
Fax: 612-334-5755
Web site: www.mndlc.org
MISSISSIPPI
CAP
Presley Posey, CAP Director
Easter Seal Society
3226 N. State Street
Jackson, MS 39216
Phone: 601-982-7051
Fax: 601-982-1951
Rebecca Floyd, Executive Director
Mississippi P&A System for DD, Inc.
5305 Executive Place, Suite A
Jackson, MS 39206
1-800-772-4057
Fax: 601-981-8313
Web site: www.mspas.com-ms
MISSOURI
PAVA
Shawn de Loyola, Executive Director
Missouri P&A Services
925 S. Country Club Drive, Unit B-1
Jefferson City, MO 65109
Phone: 573-893-3333;
1-800-392-8667 (nationwide)
MO Relay TDD: 1-800-735-2966
Fax: 573-893-4231
Web site: www.moadvocacy.org
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TBI/PAVA
Christine Griffin, Executive Director
Disability Law Center, Inc.
11 Beacon Street, Suite 925
Boston, MA 02108
Phone: 617-723-8455; 1-800-872-9992
TTY: 617-227-9464; 1-800-381-0577
Fax: 617-723-9125
E-mail: cgriffi[email protected]
Web site: www.dlc-ma.org/
TBI/PAVA
Bernadette Franks-Ongoy, Executive Director
Montana Advocacy Program
400 North Park, 2nd Floor
P.O. Box 1681
Helena, MT 59624
1-800-245-4743 (nationwide)
Fax: 406-449-2418
Web site: www.mtadv.org
NATIVE AMERICAN
PADD/PAIMI/PAIR/PABSS/TBI
Therese Yanan, Executive Director
Native American Protection &
Advocacy Project
3535 East 30th Street, Suite 201
Farmington, NM 87402
Phone: 505-566-5880;
1-800-862-7271 (intakes & clients only)
Fax: 505-566-5889
NEBRASKA
CAP
Victoria Rasmussen, CAP Director
P.O. Box 94987
Lincoln, NE 68509
Phone: 402-471-3656; 1-800-742-7594
Fax: 402-471-0117
TBI/PAVA
Timothy Shaw, Executive Director
Nebraska Advocacy Services, Inc.
134 South 13th Street, Suite 600
Lincoln, NE 68508
1-800-422-6691
Fax: 402-474-3274
NEVADA
CAP *
Margaret Moroun, CAP Director
1820 E. Sahara Avenue, Suite 109
Las Vegas, NV 89104
Phone: 702-486-6688
Fax: 702-486-6691
Web site: members.delphi.com/nvcap/index.
html
Jack Mayes, Executive Director
Nevada Advocacy & Law Center, Inc.
6039 Eldora Avenue, Suite C-3
Las Vegas, NV 89146
Phone: 702-257-8150; 1-888-349-3843
(nationwide)
TTY: 702-257-8160
Fax: 702-257-8170
E-mail: [email protected] for Las Vegas
Office
[email protected]
[email protected] for Reno office
Web site: www.ndalc.org
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MONTANA
NEW MEXICO
CAP*
Bill Hagy, Ombudsman
Governor’s Commission on Disability
57 Regional Drive
Concord, NH 03301-9686
Phone: 603-271-2773
Fax: 603-271-2837
Web site: www.state.nh.us/disability/
caphomepage.html
TBI/PAVA
James Jackson, Executive Director
Protection & Advocacy, Inc
1720 Louisiana Boulevard, NE, Suite 204
Albuquerque, NM 87110
1-800-432-4682 (in-State only)
Fax: 505-256-3184
Web site: www.nmpanda.org
Richard Cohen, Executive Director
Disabilities Rights Center
18 Low Avenue
Concord, NH 03302-4971
Phone: 603-228-0432
TDD: 1-800-834-1721
Fax: 603-225-2077
Richard [email protected]
Web site: www.drcnh.org
NEW YORK
NEW JERSEY
PAVA
Sarah Wiggins-Mitchell, Executive Director
New Jersey P&A, Inc.
210 S. Broad Street, 3rd Floor
Trenton, NJ 08608
Phone: 609-292-9742;
1-800-922-7233 (in-State only)
TTY: 609-633-7106
Fax: 609-777-0187
[email protected]
Web site: www.njpanda.org
PAVA
Gary O’Brien, Executive Director
New York State Commission on Quality of Care
for the Mentally Disabled
401 State Street
Schenectady, NY 12305-2397
Phone: 518-388-2892; 1-800-624-4143 TDD
(nationwide)
Fax: 518-388-2890
[email protected]
Web site: www.cqc.state.ny.us
NORTH CAROLINA
CAP
Kathy Brack, CAP Director
North Carolina Department of Health and
Human Services
2806 Mail Service Center
Raleigh, NC 27699-2806
Phone: 919-855-3600; 1-800-215-7227
Fax: 919-715-2456
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NEW HAMPSHIRE
N. MARIANAS ISLANDS
CAP/PADD/PAIMI/PAIR/PABSS/TBI
Lydia Fujihira Barcinas, Executive Director
Northern Marianas
Protection and Advocacy System, Inc.
P.O. Box 503529
Saipan, MP 96950-3529
Phone: 1-670-235-7274/3
Fax: 1-670-235-7275
E-mail: nmpasi@vzpacifica.net
Web site: www.NMPASI.com
OHIO
NORTH DAKOTA
CAP
Dennis Lyon, CAP Director
North Dakota Client Assistance Program
600 South 2nd Street, Suite 1B
Bismarck, ND 58504-4038
Phone: 701-328-8947; 1-800-207-6122 CAP
only
Fax: 701-328-8969
Web site: www.state.nd.us/cap/
Teresa Larsen, Executive Director
North Dakota Protection & Advocacy Project
400 E. Broadway, Suite 409
Bismarck, ND 58501
Phone: 701-328-2950; 1-800-472-2670
1-800-642-6694 (24-hour line)
(in-State only)
TDD: 1-800-366-6888
Fax: 701-328-3934
Web site: www.ndpanda.org
TBI/PAVA
Carolyn Knight, Executive Director
Ohio Legal Rights Service
8 E. Long Street, 5th Floor
Columbus, OH 43215
Phone: 614-466-7264; 1-800-282-9181 (inState only)
TTY: 614-728-2553; 1-800-858-3542
Fax: 614-644-1888
Web site: olrs.ohio.gov/ASP/HomePage.
asproper
OKLAHOMA
CAP
James Sirmans, CAP Director
Oklahoma Office of Handicapped Concerns
2401 NW 23rd, Suite 90
Oklahoma City, OK 73107
Phone: 405-521-3756; 1-800-522-8224
Fax: 405-522-6695
Web site: www.ohc.state.ok.us
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TBI/PAVA
Allison Bowen, Acting Executive Director
Governor’s Advocacy Council for
Persons with Disabilities
1314 Mail Service Center
Raleigh, NC 27699-1314
1-800-821-6922 (in-State only)
Fax: 919-733-9173
Web site: www.Gacpd.com
TBI/PAVA
Ilene Shane, Executive Director
Pennsylvania P&A, Inc.
1414 N. Cameron Street, Suite C
Harrisburg, PA 17103
Phone: 717-236-8110; 1-800-692-7443
(nationwide)
TTY: 717-346-0293; 1-877-375-7139
Fax: 717-236-0192
Web site: www.ppainc.org
OREGON
PUERTO RICO
PAVA
Robert Joondeph, Executive Director
Oregon Advocacy Center
620 SW Fifth Avenue, 5th Floor
Portland, OR 97204-1428
Phone: 503-243-2081;
1-800-452-1694 (nationwide)
TDD: 1-800-556-5351
Fax: 503-243-1738
[email protected]
Web site: www.oradvocacy.org
TBI/PAVA
Jose Raul Ocasio, Executive Director
Office of the Governor
Ombudsman for the Disabled
P.O. Box 41309
San Juan, PR 00940-1309
Phone: 787-721-4299; 787-725-2333;
1-800-981-4125 (in-State only)
TTY: 787-4014
Fax: 787-721-2455
[email protected]
Web site: www.oppi.gobierno.pr
PENNSYLVANIA
CAP
Stephen Pennington, CAP Director
Center for Disability Law and Policy
1617 JFK Boulevard, Suite 800
Phone: 215-557-7112; 1-888-745-2357
Fax: 215-557-7602
RHODE ISLAND
TBI/PAVA
Ray Bandusky, Executive Director
Rhode Island Disability Law Center, Inc.
349 Eddy Street
Providence, RI 02903
Phone: 401-831-3150;
1-800-733-5332 (in-State only)
TDD: 401-831-5335
Fax: 401-274-5568
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TBI/PAVA
Kayla Bower, Executive Director
Oklahoma Disability Law Center, Inc.
2915 Classen Boulevard, Suite 300
Oklahoma City, OK 73106
Phone: 405-525-7755;
1-800-880-7755 (in-State only)
Fax: 405-525-7759
E-mail: odlcokc@flash.net
kbower1@flash.net
Web site: www.oklahomadisabilitylaw.org
TENNESSEE
CAP
Dr. Larry Barker, CAP Director
Office of the Governor
Division of Ombudsman and Citizen Services
1205 Pendleton Street
Columbia, SC 29211
Phone: 803-734-0285; 1-800-868-0040
Fax: 803-734-0546
[email protected]
Web site: www.govoepp.state.sc.us/cap/
PAVA
Shirley Shea, Executive Director
Tennessee P&A, Inc.
P.O. Box 121257
Nashville, TN 37212
Phone: 615-298-1080 voice;
615-298-2471 TTY;
1-800-287-9636 (nationwide)
Intake Unit: 901-458-6013;
901-343-4241 TTY;
1-800-342-1660 (nationwide)
TTY: 1-888-852-2852 (nationwide)
Fax: 615-298-2046
E-mail: [email protected]; shirleys@tpainc.
org
Web site: www.tpainc.org
Gloria Prevost, Executive Director
Protection & Advocacy for People
with Disabilities, Inc.
3710 Landmark Drive, Suite 208
Columbia, SC 29204
1-866-275-7273 (in-State only)
Fax: 803-790-1946
[email protected]
Web site: www.protectionandadvocacy-sc.org
SOUTH DAKOTA
PAVA
Robert Kean, Executive Director
South Dakota Advocacy Services
221 S. Central Avenue
Pierre, SD 57501
1-800-658-4782 (in-State only)
Fax: 605-224-5125
Web site: www.sdadvocacy.com
TEXAS
PAVA
Mary S. Faithfull, Executive Director
Advocacy, Inc.
7800 Shoal Creek Boulevard, Suite 171-E
Austin, TX 78757
Intake 1-800-315-3876
1-800-252-9108 (nationwide)
Fax: 512-323-0902
[email protected]
Web site: www.advocacyinc.org
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SOUTH CAROLINA
VIRGIN ISLANDS
TBI/PAVA
Fraser Nelson, Executive Director
Disability Law Center
The Community Legal Center
205 North 400 West
Salt Lake City, UT 84103
Phone: 801-363-1347;
1-800-662-9080 (nationwide)
TTY: 801-924-3185
Fax: 801-363-1437
Web site: www.disabilitylawcenter.org
TBI/PAVA
Amelia Headley LaMont, Executive Director
Virgin Islands Advocacy, Inc.
63 Estate Cane Carlton
Frederiksted, VI 00840
Phone: 340-772-1200
TDD: 340-772-4641
Fax: 340-772-0609
[email protected]
Web site: www.viadvocacy.org
VIRGINIA
VERMONT
TBI/PAVA
V. Colleen Miller, Executive Director
Virginia Office for Protection & Advocacy
1910 Byrd Avenue, Suite 5
Richmond, VA 23230
1-800-552-3962 (in southern VA only)
Fax: 804-662-7057
Web site: www.vopa.state.va.us
CAP
Nancy Breiden, CAP Director
Vermont Disability Law Project
57 N. Main Street, Suite 2
Rutland, VT 05701
Phone: 802-775-0021;
1-800-769-7459
Fax: 802-775-0022
Edward Paquin, Executive Director
Vermont Protection & Advocacy, Inc.
141 Main Street, Suite 7
Montpelier, VT 05602
Phone: 802-229-1355;
1-800-834-7890 (nationwide)
Fax: 802-229-1359
[email protected]
Web site: www.vtpa.org
WASHINGTON
CAP
Jerry Johnsen, CAP Director
2531 Rainier Avenue South
Seattle, WA 98144
Phone: 206-721-5999; 1-800-544-2121
Fax: 206-721-4537
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UTAH
TBI/PAVA
Lynn Breedlove, Executive Director
Wisconsin Coalition for Advocacy
16 N. Carroll Street, Suite 400
Madison, WI 53703
Phone: 608-267-0214;
1-800-928-8778 TTY
Fax: 608-267-0368
E-mail (Madison): [email protected]
[email protected]
(Milwaukee): [email protected]
Web site: www.w-c-a.org
WEST VIRGINIA
WYOMING
TBI/PAVA
Edward W. Rugeley, Jr., Interim
Executive Director
West Virginia Advocates, Inc.
Litton Building, 4th Floor
1207 Quarrier Street
1-800-950-5250 (nationwide)
Fax: 304-346-0867
[email protected]
Web site: www.wvadvocates.org
TBI/PAVA
Jeanne Thobro, Executive Director
Wyoming Protection & Advocacy
System, Inc.
320 West 25th Street, 2nd Floor
Cheyenne, WY 82001
Phone: 307-632-3496
1-800-624-7648 (in-State only)
Fax: 307-632-3496
Web site: wypanda.vcn.com
WISCONSIN
CAP
Linda Vegoe, CAP Director
Department of Agriculture
Trade and Consumer Protection
2811 Agriculture Drive
P.O. Box 8911
Madison, WI 53708-8911
Phone: 608-224-5070; 1-800-392-1290
Fax: 608-224-5069
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Module 6
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HANDOUT
TBI/PAVA
Mark Stroh, Executive Director
Washington P&A System
315 Fifth Avenue South, Suite 850
Seattle, WA 98104
Phone: 206-324-1521;
1-800-562-2702 (nationwide)
TTY: 206-957-0728; 1-800-905-0209
Fax: 206-957-0729
[email protected]
Web site: www.wpas-rights.org
NTAC Summer/Fall 2002 Networks Newsletter
by William Pflueger*
It is difficult to write about my experiences with seclusion and restraint. Someone who has
experienced it wouldn’t want to read any further, and for someone who hasn’t, how can it
be explained? A comparison that comes to mind is describing the practice of whipping as a
control and conditioning mechanism for slaves to an audience from the 1850s. Depending on
the sympathies of the reader, possible reactions could be, “How ghastly! How wrong! This
practice must be ended!” or, “Understandably upsetting to the squeamish, but a necessary,
albeit unpleasant treatment to maintain control and safety for all involved.”
Fortunately for me, it has been a number of years since I was locked up and tied down. It
always seemed like overkill. Here I am in a locked facility and I get put in a locked room and
then strapped and locked to a bed. I was expecting that next a canvas bag would be put over
me and I would be dropped into a river.
I can’t bring myself to describe the moment-by-moment struggles and shear gut-wrenching terror of being put into five-point restraint. Tears well up in my eyes and I feel a dark
hole opening below me. I don’t feel comfortable wearing watches any more and for a long
time belts were out of the question. Just the smell of leather and jingle of the hardware were
enough to trigger memories of those horrible times. The faces of the people who put me in
restraints are stamped in my mind as indelibly as members of my family. The whole experience made me feel ashamed and that my soul had been dishonored. I sense that some of the
shame rubbed off on the people who were ordered to do that to me. The terror of confinement, the pain of restraint, and the wound to my soul made me want to stay as far away from
the mental health system as possible. It didn’t matter that it might offer me something helpful; I didn’t want any of it if that horrible experience was going to be a part of the package.
So then where does one go with the feelings that are swirling around in the aftermath of that
experience?
The trauma of the treatment is not something that can be discussed with the person who ordered it. How can a doctor acknowledge that the first tenet of the Hippocratic Oath has been
violated at his or her own hand? The standard professional response is, “unfortunate but
necessary. Let’s not dwell on the past.”
Page 1 of 2
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Perspectives From the Field
Consumer View: Restraint Is Not Therapeutic
Perspectives From the Field (continued)
If we could all just recognize and acknowledge that the ordeal of seclusion and restraint is
harmful, it would be a wonderful beginning for creating a mental health system that is truly
about recovery, wellness, and helping the whole person.
*Mr. Pflueger is the Treasurer of the Statewide Mental Health Consumer/Survivor Network of
Minnesota.
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The techniques normally don’t leave any permanent physical scars, but if the practitioners
could see the psychological damage done they would know that the treatment causes more
harm than good. It is like amputating someone’s leg to deal with a broken ankle. The mental
condition that you leave with shouldn’t be worse than the one you arrived with, but when a
human being is treated like a non-human, that insult and injury is added on to the diagnosis
that you already have. However it is not acknowledged by anyone but the person who
experienced it.
Debriefing Survey for Consumers
1. I was acting in a manner that could have been dangerous to myself or others.
2. Someone tried to calm me down or resolve my problem.
3. The reasons why I was restrained or secluded were explained to me.
4. Staff said my behavior was inappropriate, however, my behavior was not dangerous.
5. I was given medication.
While in seclusion or restraint…
1. I was allowed to take a drink of water and/or eat at mealtime.
2. I was released every two hours and given an opportunity to move about and exercise.
3. Hospital staff checked on me every 30 minutes to see if I was okay.
4. I was examined by a physician.
5. I was allowed to use the bathroom at least every hour.
6. Unnecessary force was used.
7. I was physically injured.
8. I was physically abused.
9. I was sexually abused.
10. I was psychologically abused, ridiculed, or threatened.
Module 6
53
HANDOUT
Before staff put me in seclusion or restraint…..
Campbell, J. (1997). How consumer/survivors are evaluating the quality of psychiatric care.
Evaluation Review, 23(3), 357-363.
Copeland. M.E. (2002). Wellness Recovery Action Plan. West Dummerston, VT: Peach Press.
Flynn, H. (1996, July). Mental health policy issues related to the use of seclusion and restraint
with adult survivors of childhood sexual abuse. Paper presented at the Florida Mental Health
Institute, Tampa, FL
Goetz, R.R. (2002). Debriefing critical incidents: A basic model. Presentation materials used with
permission. Clackamas County Mental Health, Oregon.
Harris, D., & Morrison, E., (1995). Managing violence without coercion. Archives of Psychiatric
Nursing, 9(2), 203-210.
Jennings, A. (1997). Strategic action plan for creating a system of care responsive to the needs
of trauma survivors. Augusta: Maine Department of Mental Health, Retardation and Substance
Abuse Services.
Joint Commission on Accreditation of Healthcare Organizations. (1996, January/February).
Standards for restraint and seclusion. Joint Commission Perspectives, RS1-RS8.
Kiesler, C.A. (1992). U.S. mental health policy: Doomed to fail. American Psychologist, 47(9),
1077-1082.
Martin, K. (1995). Improving staff safety through an aggression management program. Archives
Mohr, W., Mahon, M., & Noone, M. (1998). A restraint on restraints: The need to reconsider the
NAMI. The Citizen’s Mental Health Monitoring Project [Video]. East Longmeadow, MA: Veritech
Corporation.
National Association of Consumer/Survivor Mental Health Administrators. (1999). An unpublished
presentation by Darby Penny.
National Technical Assistance Center. (1999, Summer) Seclusion and restraint: Debate gains
momentum. Networks.
National Technical Assistance Center. (2002, Summer/Fall). Violence and coercion in mental health
settings: Eliminating the use of seclusion and restraint. Networks (Special Edition). Online at
www.nasmhpd.org/general_files/publications/ntac_pubs/networks/SummerFall2002.pdf
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California Senate Office of Research. (2002). Seclusion and restraints: A failure, not a treatment.
Online at www.sen.ca.gov/sor/reports/REPORTS_BY_SUBJ/HEALTH/RESTRAINTS.HTP.
Penney, D. (1999). Unpublished presentation.
Pennsylvania Department of Public Welfare, Office of Mental Health and Substance Abuse Services.
(2001). Leading the way toward a seclusion and restraint free environment: Pennsylvania’s
success story. Harrisburg, PA: Author
Pflueger, W. (2002, Summer/Fall). Perspectives from the field: Consumer view: Restraint is not
therapeutic. National Technical Assistance Center Networks Newsletter.
Ray, M,, & Myers, K. (1994). Lowering restraint and seclusion use: The leader may make a
difference. Quality of Care. Albany, NY: New York State Commission on Quality of Care for the
Mentally Disabled.
Reith, K.A., & Bennett, C.C. (1998). Restraint-free care. Part 1: Legal and regulatory mandates.
Part 2: Creating a restraint-free environment. Nursing Management, 29(5), 36-39.
Siegfried, C. (1999). Checking up on juvenile justice facilties: A handbook for child mental health
advocates. Alexandria, VA: National Mental Health Association. Online at www.nmha.org/children/justjuv/checkingup.pdf
Siegfried, C. (1999). Checking up on juvenile justice facilities: A best practices guide. Alexandria,
VA: National Mental Health Association. Online at www.nmha.org/children/justjuv/checkingUpOnJJFacilities.cfm.
Steele, E. (1999). Seclusion and restraint practice standards: A review and analysis, 1999.
Alexandria, VA: National Mental Health Association, Consumer Supporter Technical Center.
University of Illinois at Chicago National Research and Training Center on Psychiatric Disability.
(2002) Increasing self-determination through advance crisis management in inpatient and
community settings: How to design, implement, and evaluate your own program.
Phone: 312-422-8180. Web site: www.psych.uic.edu/mhsrp.
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Palmer, L., Abrams, F., Carter, D., & Schluter, W. (1999). Reducing inappropriate restraint use in
Colorado’s long-term care facilities. Journal of Quality Improvement of the Joint Commission on
Accreditation of Healthcare Organizations, 25(2), 78-94.
MODULE 7
Review and Action Plan
1
MODULE 7
“Cowardice asks the question – Is it safe?
Expediency asks the question – Is it politic?
Vanity asks the question – Is it popular?
But conscience asks the question – Is it right?
And there comes a time when one must take a position that is neither safe,
nor politic, nor popular, but one must take it BECAUSE it is right.”
—Dr. Martin Luther King, Jr.
Learning Objectives
• Identify key concepts from Modules 1–6.
• Develop a personal action plan for reducing seclusion and restraint.
• Develop a workplace action plan for reducing seclusion and restraint.
Module 7
2
MODULE 7: REVIEW AND ACTION PLAN
Presentation (4 hours) . . . . . . . . . . . . . . . .
Review . . . . . . . . . . . . . . . . . . . . . . . . . .
Personal Action Plan. . . . . . . . . . . . . . . . .
Exercise: Personal Action Plan (1 hour) .
Workplace Action Plan . . . . . . . . . . . . . . .
Exercise: Workplace Action Plan (1 hour)
Certificates of Completion . . . . . . . . . . . . .
Wrap Up and Evaluation . . . . . . . . . . . . . .
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Handouts for Participants .
Personal Action Plan. . . .
Workplace Action Plan . .
Evaluation. . . . . . . . . . .
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Module 7
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3
Overview
This is the last module in this curriculum and the final time to work together as a group.
Discussion questions are provided to help stimulate conversation. It is important to remind
people of the confidential nature of these sessions.
Review
The precedingt six modules have provided participants with many opportunities to increase
their understanding and explore a consumer-directed philosophy. In the first part of this
session, you will review highlights from each module.
Give the participants time to review all of their personal action plans and journal entries from
the first six modules and develop an overall action plan for eliminating the use of seclusion
and restraint.
Give the participants time to come together as a group and develop a strategic plan for the
elimination of seclusion and restraint in their facility. The participants will set several goals
and devise action plans for achieving these goals. Discussion questions are provided to help
you stimulate the conversation.
Closure
Play the If I Were Brave CD for one final moment of reflection and then present the
Certificates of Completion and say goodbyes. As always, please be sure to thank everyone
in the group for their active participation.
Module 7
4
BACKGROUND
REVIEW AND ACTION PLAN
Module 6: Sustaining Change Through Consumer and Staff Involvement.
Set aside a minimum of 2 hours to develop personal and workplace
action plans.
Begin by going over the learning objectives.
Learning Objectives
be able to:
• Identify key concepts from Modules
1-6
• Develop a personal action plan for
reducing seclusion and restraint
• Develop a workplace action plan for
reducing seclusion and restraint
Module 7
5
PRESENTATION
PRESENTATION
Overview
• This training has covered an enormous amount of material.
• You have been given a sample of many different resources that are available to you
for eliminating the use of seclusion and restraint.
• We hope you have learned a little bit about many things and will pursue further
information on your own.
• We will do a brief review of each module, highlighting the key points.
Module 7
6
PRESENTATION
“Cowardice asks the question – is it safe?
Expediency asks the question – is it politic?
Vanity asks the question – is it popular?
But conscience asks the question – is it right?
And there comes a time when one must take a
position that is neither safe, nor politic, nor
popular, but one must take it BECAUSE it is
right.”
Dr. Martin Luther King, Jr.
“When I participated in my first
restraint experience I vomited.”
(interview with direct
care staff from Minnesota)
• The most powerful way of understanding the personal experience of seclusion and
restraint is to hear from people who have had this experience.
• Consumers and members of the professional mental health community are beginning to
realize the importance of establishing and maintaining rapport as an effective means of
developing productive communications.
• Promising practices indicate that training direct care staff is a key to eliminating the use
• Direct care staff possess the informal power to contribute to system changes that
eliminate the use of seclusion and restraint.
Module 7
7
PRESENTATION
Module 1: The Personal Experience of Seclusion and Restraint
“What helps me (deal with trauma) is
professionals who have the ability to take
care of themselves, are centered, and not
take on what comes out of me – not hurt by
what I say – sit, be calm and centered and
not personally take on my issues.”
Survivor from Maine
“Traumatic experiences shake the
foundations of our beliefs about
safety, and shatter our
assumptions of trust.”
David Baldwin
Module 7
8
PRESENTATION
Module 2: Understanding the Impact of Trauma
Module 3: Creating Cultural Change
“The hospital’s culture dictates
whether, in what circumstances,
and how often seclusion and
restraint interventions are used.”
Ira Burnim, Bazelon Center
for Mental Health Law
Module 7
9
PRESENTATION
• Adult survivors of trauma are disproportionately represented in the mental health system.
• Data on children and adolescents suggest even higher percentages of traumatization.
• Traditional treatment modalities, including the use of seclusion and restraint, are not
always appropriate for trauma survivors and may in fact be retraumatizing.
• Accurately diagnosing trauma early on will significantly decrease the use of seclusion
and restraint.
• Secondary traumatization can occur for consumers who witness coercive techniques
and staff who administer it.
• It is important for staff to examine their own trauma, recognize their symptoms,
recognize triggers, and develop their own plan of self-care.
• Changing the culture of coercion in mental health settings is crucial to eliminating the
use of seclusion and restraint.
• In 1997, the Pennsylvania Department of Public Welfare instituted an aggressive program
to reduce and eliminate seclusion and restraint in its nine State hospitals.
• In three years, Pennsylvania had reduced incidents of seclusion and restraint by
74 percent.
• All stakeholders must be present at the table.
Module 7
10
PRESENTATION
“It is not possible to solve a
problem with the same
consciousness that created it.”
Albert Einstein
“…the initiative (Pennsylvania’s) to
reduce the use of seclusion and
restraint is part of a broader effort
to reorient the State mental health
system toward a consumer-focused
philosophy that emphasizes recovery
and independence.”
Charles Curie, Administrator, SAMHSA
• Original recovery work as a philosophy in mental health emerged from the writings and
practices of the consumer movement.
• It is important for mental health workers to communicate that recovery is possible and
to verbalize hope.
• Resiliency is that characteristic that gives someone the ability to bounce back after
adversity.
• Often people who have overcome adversities can pinpoint a single person who made a
difference to them. It is a person who took the time to listen, who believed in them, and
offered hope.
Module 7
11
PRESENTATION
Module 4: Understanding Resilience and Recovery From the
Consumer Perspective
“Ex-patients have similar feelings and
experiences and they can understand
and support each other in a way that’s
different from family or professional
services. We can do mutual support
and understand the way we were
treated.
Peg Sullivan, Consumer
• Self-help is a concept, not a single program model.
• A consumer-run drop-in center is a center for consumer self-help, advocacy, and education.
• Mental health service providers are increasingly recognizing service animals as an
excellent resource for consumers.
• The Wellness Recovery Action Plan (WRAP) is a consumer-based structured system
for monitoring symptoms.
• Psychiatric advance directives and prime directives support a partnership in making
decisions about mental health issues.
Module 7
12
PRESENTATION
Module 5: Strategies to Prevent Seclusion and Restraint
John N. Follansbee, M.D.,
JCAHO testimony, 1999
• Gayle Bluebird used her innovative work in comfort rooms as a preventive tool to reduce
the need for seclusion and restraint.
• The Center for Conflict Management for Mental Health believes that alternative resolution
(including mediation) strategies can minimize the need for and the consequences of
adversarial strategies.
• “It almost always boils down to a communication issue, the doctor or the treatment team
hasn’t really listened to what the patient is saying or hasn’t explained things well” (Judi
Higginbotham, Human Rights Coordinator, Arizona State Hospital, Phoenix).
Module 7
13
PRESENTATION
“It is rather impressive how
creative people can be when
restraint is simply not part of
the treatment culture.”
“The terror of confinement, the pain
of restraint, and the wound to my soul
made me want to stay as far away from
the mental health system as possible.
It didn’t matter that it might offer me
something helpful; I didn’t want any of
it if that horrible experience was going
to be a part of the package.”
Will Pflueger, Consumer
• Focus on the role of personal and professional responsibility for change in the lives
of people.
• Change is hard work.
• You will be given time to develop a personal action plan that relates to the elimination of
seclusion and restraint in your workplace.
• By the end of this session, you should have a workable plan, with concrete action steps
and a timeline.
Module 7
14
PRESENTATION
Module 6: Sustaining Change Through Consumer and
Staff Involvement
OBJECTIVE:
Participants will commit to personal action to eliminate
PROCESS:
Distribute the handout Personal Action Plan. Have
participants review all of their personal action plans from
Modules 1 through 6. Give them time to develop four or
five realistic goals for themselves for the next 6 months.
Once participants have finished, divide them into groups of
three or four and have them share the parts of their plans
that they feel comfortable sharing with the small group.
Instruct participants to ask for help from their colleagues
on following through with their personal action plans.
Specifically, what kind of help would they like from their
colleagues?
DISCUSSION
QUESTIONS:
How can you support each other as a team in carrying out
your personal action plans?
MATERIALS
REQUIRED:
Personal Action Plan handout
APPROXIMATE
TIME REQUIRED:
1 hour
Module 7
15
PRESENTATION
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
• You will be given time as a group to develop a workplace action plan that relates to the
elimination of seclusion and restraint in your workplace.
• By the end of this session, you should have a workable plan, with concrete action steps
and a timeline.
• Organize yourselves in whatever way you think will work best, given your organization.
• Pick one or two areas to concentrate on. Areas could include trauma, recovery, resilience,
data, debriefing, staff training, and consumer support.
Module 7
16
PRESENTATION
OBJECTIVE:
Participants will commit to workplace action to eliminate
seclusion and restraint
PROCESS:
Distribute the handout Workplace Action Plan. Have
participants review all of their workplace action plans from
Modules 1 through 6. As a group, have them define the
following goals: In the next year, we want to decrease the
number of restraints by _____; the number of seclusions
by ____; the hours of restraints by _____; and the hours of
seclusion by _____. Have the participants focus on two or
three overarching goals. Goals might include incorporating
a trauma paradigm, supporting resilience and recovery
with consumers, enhancing a debriefing session, creating a
comfort room, establishing an external monitoring system,
incorporating service animals on the unit, etc. Each of the
two or three overarching goals should have four or five
action steps, including dates and who will be responsible
for implementing these steps. An evaluation component
also is needed. Finally, make a plan for educating other
staff members who have not gone through the training.
It is important that management representatives participate
in and support this process.
DISCUSSION
QUESTIONS:
MATERIALS
REQUIRED:
APPROXIMATE
TIME REQUIRED:
• What kind of support/help will the staff need to ensure all
of these goals are met?
• How will you know if you are on track throughout the year?
Workplace Action Plan handout
Restraint and seclusion data from the past year
1 hour
Module 7
17
PRESENTATION
• All trainers sign the Certificate of Completion. If possible the name on
the Certificate should be done in calligraphy.
• Hand participants a Certificate of Completion and personally thank them
for completing the training.
• As a facilitator, you may want to outline what you see as the specific
strengths and challenges for this particular organization as they move
forward in eliminating seclusion and restraint.
Wrap Up and Evaluation
• Hand out evaluation forms. Encourage participants to be as descriptive
as they can be. Evaluations are anonymous.
Module 7
18
PRESENTATION
Goal
Action Steps
Date
What Kind of Support
Would I Like?
Example:
• Be aware of when I use
“patient” by tracking myself for
two weeks
• March 15
• Gentle reminders from my
colleagues
• Ask the people I work with what
they would like to be called
• Daily
• Gentle reminders from the
people I serve
• Ask my colleagues to tell me
if they hear me using the word
“patient”
• March 10
• Other staff members to be
working on the same issue
Change my
language
Page 1 of 2
Module 7
19
HANDOUT
Review your Personal Take Action Plans from the entire training. Pick four or five goals that
you are personally willing to work on to eliminate/reduce seclusion and restraint. Make the
goals realistic, measurable, and doable!
Personal Action Plan (continued)
Action Steps
Date
What Kind of Support
Would I Like?
Page 2 of 2
Module 7
20
HANDOUT
Goal
Previous Year
Year to Date
GOAL for 12 months
from now
# of Seclusions
# of Restraints
Hours of Seclusion
Hours of Restraints
Goal
Example:
Have peer-run
support groups
meeting in-house
once a week
Action Steps
Who is
Responsible
Date
• Contact outside consumer
organization for facilitating
peer support groups.
• Nancy Jones, Therapist
• March 1
• Coordinate meeting
between outside facilitators
and staff.
• Nancy Jones, Therapist
• March 15
• Reserve space.
• Kim Sung,
Therapist
• March 15
• Notify consumers on units
of peer support group
opportunities.
• Ferdinand Lopez, Nurse
Manager
• March 30
• Order refreshments.
• Sam Smith,
Nutritionist
• March 30
Page 1 of 2
Module 7
21
HANDOUT
Seclusion/Restraint Rates
Workplace Action Plan (continued)
Action Steps
Who is
Responsible
Date
Page 2 of 2
Module 7
22
HANDOUT
Goal
This certifies that
has successfully completed the training for
Roadmap to Seclusion and Restraint Free
_________________
Date
_________________
Trainer Signature
_________________
Trainer Signature
_________________
Trainer Signature
Evaluation
Please list the four most important things you learned from the training and how you will use
the information.
What did I learn?
How will I use it?
A.
A.
B.
B.
C.
C.
D.
D.
Page 1 of 2
Module 7
24
Evaluation (continued)
2. The content presented during the training was useful to me:
1
Not at all
2
Not really
3
So so
4
Definitely
5
Extremely
3. What did you learn that will help you the most in your work?
4. Other comments, suggestions, etc.
Page 2 of 2
Module 7
25
RESOURCES
Resources
1
RESOURCES
Web Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Policies and Position Statements . . . . . . . . . . . . . . .
1. American Nurses Association . . . . . . . . . . . . . . . .
2. American Psychiatric Nurses Association . . . . . . . .
3. Federation of Families for Children’s Mental Health .
4. NAMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. National Association of State Mental Health. . . . . .
Program Directors
6. National Mental Health Association . . . . . . . . . . . .
7. Pennsylvania: Restraints, Seclusion, and Exclusion.
in State Mental Hospitals and Restoration Center
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Resources
2
WEB SITES
This list of Web sites is a selected sampling. It is not intended to be all-inclusive.
Advocates, Inc.
Advocates mission is to help people with psychiatric illness, chemical dependency, developmental disabilities, or other problems in living.
They provide community-centered services that
empower people to deal effectively with their
difficulties, to pursue their own individual aspirations, and to realize satisfaction in their relationships, their work, and their communities.
27 Hollis Street
Framingham, MA
Phone: 508-620-0024
Fax: 508-626-0356
www.advocatesinc.org
American Academy of Child and Adolescent
Psychiatry (AACAP)
3615 Wisconsin Avenue, NW
Washington DC 20016-3007
Phone: 202-966-7300
Fax: 202-966-2891
AACAP assists parents and families in understanding developmental, behavioral, emotional,
and mental disorders affecting children and
adolescents.
www.aacap.org
ANA is the only full-service professional
organization representing the Nation’s entire
registered nurse population. From the halls of
Congress and Federal agencies to board rooms,
hospitals, and other health care facilities, ANA
is the strongest voice for the nursing profession and for workplace advocacy.
American Nurses Association (ANA)
8515 Georgia Avenue
Suite 400
Silver Spring, MD 20910
1-800-274-4ANA
www.ana.org
The American Psychiatric Association is an
organization of psychiatrists working together
to ensure humane care and effective treatment
for all persons with mental illnesses, including
substance use disorders. It is the voice and
conscience of modern psychiatry. Its vision is
a society that has available, accessible quality
psychiatric diagnosis and treatment.
American Psychiatric Association
Suite 1825
Arlington, VA 23209-3901
Phone: 703-907-7300
www.psych.org
APNA provides leadership to advance psychiatric-mental health nursing practice, improves
mental health care for culturally diverse individuals, families, groups, and communities,
and shapes health policy for the delivery of
mental health services.
The American Psychiatric Nurses
Association (APNA)
1555 Wilson Boulevard, Suite 602
Arlington, VA 22209
Phone: 703-243-2443
Fax: 703-243-3390
www.apna.org
The American Psychological Association is a
scientific and professional organization that
advances psychology as a science and profession and as a means of promoting health and
human welfare.
American Psychological Association
750 First Street, NE
Phone: 800-74-2721 or
202-336-5500
www.apa.org
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Resources (continued)
Bazelon Center for Mental Health Law
The Judge David L. Bazelon Center for Mental
Health Law is a nonprofit legal advocacy organization based in Washington, DC. The Center’s
name honors the Federal appeals court judge
whose landmark decisions pioneered the field
of mental health law, and its advocacy is based
on the principle that every individual is entitled
to choice and dignity.
1101 15th Street, NW
Suite 1212
Phone: 202-467-5730
Fax: 202-223-0409
TDD: 202-467-4232
www.bazelon.org
Bluebird Consultants
Bluebird Consultants, an innovative “traveling
technical assistance program,” comes to you
with years of expertise in the mental health
field. Each program is designed to your specific
needs providing a diverse array of services,
such as the development of new consumerrun programs, troubleshooting, trainings for
professionals as well as consumers, conference
planning, or assistance with the development
of policies and procedures.
Gayle Bluebird, R.N.
110 SW 8th Avenue
Fort Lauderdale, FL 33312
Phone: 954-467-1431
www.contac.org/bluebird
The Centers for Medicare and Medicaid Services (CMS) is a Federal agency within the U.S.
Department of Health and Human Services.
CMS runs the Medicare and Medicaid programs.
In partnership with the Health Resources and
Services Administration, CMS runs the State
Children’s Health Insurance Program (SCHIP).
Centers for Medicare & Medicaid Services
(formerly Health Care Financing
Administration)
7500 Security Boulevard
Baltimore, MD 21244-1850
Phone: 877-267-2323 or
410-786-3000
www.cms.hhs.gov
The Center for Mental Health Services within
the Substance Abuse and Mental Health Services Administration is charged with leading
the national system that delivers mental health
services. The goal of this system is to provide
the treatment and support services needed by
adults with mental disorders and children with
serious emotional problems.
Center for Mental Health Services
Office of Consumer Affairs
1 Choke Cherry Road
Rockville, MD 20857
Phone: 800-789-2647
Fax: 240-276-1340
www.mentalhealth.samhsa.gov
This Center is a research, training, and service
organization dedicated to improving the lives
of persons who have psychiatric disabilities by
improving the effectiveness of people, programs, and service systems.
Center for Psychiatric Rehabilitation
at Boston University
930 Commonwealth Avenue, W
Boston, MA 02215
Phone: 617-353-3549
Fax: 617-353-7700
www.bu.edu/cpr
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Child Welfare League of America
The Child Welfare League of America is the
oldest and largest national nonprofit organization developing and promoting policies and
programs to protect America’s children and
strengthen America’s families. The League is
committed to engaging people everywhere in
promoting the well-being of children, youth,
and their families, and protecting every child
from harm.
Headquarters—
440 First Street NW, 3rd Floor
Program Office—
50 F Street NW, 6th Floor
Phone: 202-638-2952
Fax: 202-638-4004
www.cwla.org
Consumer Organization and Networking
Technical Assistance Center (CONTAC)
A national technical assistance center,
CONTAC serves as a resource center for
consumers/survivors/ex-patients and consumer-run organizations across the United States,
promoting self-help, recovery, and empowerment. CONTAC was developed utilizing research
on ideal consumer self-help programs, successful consumer-run programs, community support service philosophy about service delivery,
descriptions of mature mental health systems,
and management and leadership skills.
P.O. Box 11000
Phone: 888-825-Tech or
304-346-9992
Fax: 304-345-7303
http://contac.org
The mission of the Connecticut Department
of Children and Families is to protect children,
strengthen families, and help children and
youth reach their fullest potential.
Connecticut Department of Children and
Families
Office of Public Relations
505 Hudson Street
Hartford, CT 06106
www.state.ct.us/dcf
Federation of Families for Children’s Mental
Health
1101 King Street, Suite 420
Phone: 703-684-7710
Fax: 703-836-1040
The Federation is a parent-run organization
focused on the needs of children and youth
with emotional, behavioral, or mental disorders
and their families.
www.ffcmh.org
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
The Joint Commission, an independent, nonprofit organization, evaluates and accredits
health care organizations and programs in the
United States. JCAHO’s mission is to continuously improve the safety and quality of care
provided to the public through the provision of
health care accreditation and related services
that support performance improvement in
health care organizations.
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Phone: 630-792-5000
Fax: 630-792-5005
www.jcaho.org
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Mental Health Recovery Self-Help
Strategies
Mary Ellen Copeland is a mental health
recovery educator and author. Her focus is
on self-help. She has learned the concepts,
skills, and strategies she teaches from her
own personal experience with extreme mood
swings and from her ongoing studies with
people who experience psychiatric symptoms.
Mary Ellen Copeland, M.S.,M.A.
P.O. Box 301
West Dummerston, VT 05357
Phone: 802-254-2092
Fax: 802-257-7499
www.mentalhealthrecovery.com
National Alliance for the Mentally Ill
(NAMI)
NAMI is a nonprofit, grassroots, self-help,
support and advocacy organization of consumers, families, and friends of people with severe
mental illnesses, such as schizophrenia, major
depression, bipolar disorder, obsessive-compulsive disorder, and anxiety disorders.
Colonial Place Three
Suite 300
Arlington, VA 22201
Phone: 703-524-7600;
NAMI Help Line: 1-800-950-NAMI [6264]
www.nami.org
National Association of Consumer/Survivor
Mental Health Administrators (NAC/SMHA)
Karen Kangas, President
CT Department of Mental Health and Addiction
Services
410 Capitol Avenue
P.O. Box 341431, MS 14CED
Hartford, CT 06134-1431
Phone: 860-418-6948
Fax: 860-418-6786
Dan Powers, Vice President
Consumer Liaison
Office of Community Mental Health
Division of Health and Wellbeing
Department of Health and Human Services
POP Box 94728
Lincoln, NE 68509-4728
Phone: 402-479-5193
Fax: 402-479-5162
NACS/MHA represents State mental health
department senior managers who are current
or former recipients of mental health services.
The Association provides a forum for members
to develop strategies for balancing the often
disparate demands and expectations of the
two constituencies they serve: consumers/
survivors and mental health bureaucracies. The
organization serves as a vehicle for networking
and peer support, and is committed to expanding the participation of consumers/survivors in
all aspects of the public mental health system.
The Association offers technical assistance
to State mental health departments who are
interested in developing offices of consumer/
ex-patient relations.
www.nasmhpd.org
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National Association of Protection
and Advocacy, Inc.
The Protection and Advocacy (P&A) System
and Client Assistance Program (CAP) comprise
the nationwide network of congressionally
mandated, legally based disability rights agencies. P&A agencies have the authority to provide legal representation and other advocacy
services, under all Federal and State laws, to
all people with disabilities (based on a system
of priorities for services). All P&As maintain
a presence in facilities that care for people
with disabilities, where they monitor, investigate, and attempt to remedy adverse conditions. These agencies also devote considerable
resources to ensuring full access to inclusive
educational programs, financial entitlements,
health care, accessible housing, and productive
employment opportunities.
900 Second Street, NE, Suite 211
Phone: 202-408-9514
Fax: 202-408-9520
www.napas.org
Program Directors (NASMHPD)
66 Canal Center Plaza
Suite 302
Phone: 703-739-9333
Fax: 703-548-9517
www.nasmhpd.org
National Council for Community Behavioral
Healthcare
12300 Twinbrook Parkway
Suite 320
Rockville, MD 20852
Phone: 301-984-6200
Fax: 301-881-7159
NASMHPD organizes to reflect and advocate for
the collective interests of State Mental Health
Authorities and their directors at the national
level. NASMHPD analyzes trends in the delivery
and financing of mental health services and
builds and disseminates knowledge and experience reflecting the integration of public mental
health programming in evolving healthcare
environments.
The National Council for Community Behavioral
Healthcare, a nonprofit trade association, is the
Nation’s oldest and largest membership organization dedicated to ensuring that appropriate
and affordable community-based mental health
and substance abuse services are available for
all individuals.
www.nccbh.org
National Empowerment Center, Inc.
The mission of the National Empowerment
Center (NEC) is to carry a message of recovery, empowerment, hope, and healing to
people who have been diagnosed with mental
illnesses. NEC carries the message with authority because it is a consumer/survivor/expatient-run organization. Each member is living
a personal journey of recovery and empowerment that is not just the privilege of a few, but
possible for each person who has been diagnosed with a mental illness.
599 Canal Street
Lawrence, MA 01840
Phone: 800-769-3728 or
978-685-1494
Fax: 978-6816426
www.power2U.org
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National Institute of Mental Health
The mission of the National Institute of Mental Health (NIMH) is to diminish the burden of
mental illness through research. This public
health mandate demands that powerful scientific tools be harnessed to achieve better
understanding, treatment, and, eventually,
prevention of mental illness.
6001 Executive Boulevard,
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or
866-615-6464
Fax: 301-443-4279
TTY: 301-443-8431
www.nimh.nih.gov
National Mental Health Association
The National Mental Health Association (NMHA)
is the country’s oldest and largest nonprofit
organization addressing all aspects of mental health and mental illness. NMHA works to
improve the mental health of all Americans,
especially the 54 million individuals with mental disorders, through advocacy, education,
research, and service.
2001 N. Beauregard Street
12th Floor
Alexandria, VA 22314-2971
Phone: 703-684-7722
Fax: 703-684-5968
Resource center: 800-969-NMHA
TTY: 800-433-5959
www.nmha.org
National Mental Health Consumers’
Self-Help Clearinghouse
The National Mental Health Consumers’ SelfHelp Clearinghouse provides consumer information and referrals, on-site consultation,
training events, teleconferences and national
conferences, a consumer library, a newsletter, and a consumer and consumer-supported
nationwide database.
1211 Chestnut Street
Suite 1207
Phone: 800-553-4539
Fax: 215-636-6312
www.mhselfhelp.org
PACER (Parent Advocacy Coalition for
Educational Rights)
The mission of PACER is to expand opportunities and enhance the quality of life of children
and young adults with disabilities and their
families, based on the concept of parents
helping parents. With assistance to individual
families, workshops, and materials for parents
and professionals, and leadership in securing
a free and appropriate public education for all
children, PACER’s work affects and encourages
families in Minnesota and across the Nation.
8161 Normandale Boulevard
Minneapolis, MN 55435
Phone: 952-838-9000
Fax: 952- 838-0199
www.pacer.org
Pennsylvania Department of Public Welfare
– Office of Mental Health and Substance
Abuse Services
Health and Welfare Building
Room 502, P.O. Box 2675
Harrisburg, PA 17105-2675
Phone: 717-787-6443
Fax: 717-787-5394
www.dpw.state.pa.us
Pennsylvania’s mental health services
range from community to hospital
programs with emphasis on helping
people to remain in their communities.
Community services are emphasized, with
the aim to develop more services to help
people who have serious mental illnesses
break the cycle of repeated hospital
admissions.
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Research and Training Center on Family
Support and Children’s Mental Health
The Center’s activities focus on improving services to children and youth who have mental,
emotional, or behavioral disorders and their
families.
Portland State University
Portland, OR 97207
Phone: 503-725-3000
www.rtc.pdx.edu
U.S. Psychiatric Rehabilitation Association
This organization is dedicated to promoting,
supporting, and strengthening communityoriented rehabilitation services and resources
for persons with psychiatric disability.
601 N. Hammonds Ferry Road
Suite A
Linthicum, MD 21090
Phone: 410-789-7054
www.iapsrs.org
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POLICIES AND POSITION STATEMENTS
American Nurses Association
Position Statement
Reduction of Patient Restraint and
Seclusion in Health Care Settings
Summary
Dilemmas in patient care situations are an inevitable consequence of professional accountability. With regard to use of restraints, nurses struggle with conflicts stemming from patients’ rights
of freedom, nurses’ feelings of obligation to “protect” patients, and family and peer pressure to
use restraints. ANA believes only when no other viable option is available should restraint be
employed. In those instances where restraint, seclusion, or therapeutic holding is determined to
be “clinically appropriate and adequately justified,” registered nurses, who possess the necessary knowledge and skills to effectively manage the situation, must be actively involved in the
assessment, implementation, and evaluation of the selected intervention.
Background
Nursing has a history of being involved with attempts at reduction in the use of restraint
going back well over one hundred years. Frequently, when restraint was employed it was
in the belief that such action would promote patient safety. It was this belief, in part, which
led to the increase in restraint use in the nursing home population. As concern about the
quality of patient care in that setting rose, the Nursing Home Reform Act (a part of the
Omnibus Reconciliation Act of 1987) was adopted into law. The results of this law, which
greatly affected the quality of care received through increased assessment of and care planning for the patient as well as through reduction of both physical and chemical restraint, have
implications for individuals with mental illness as well. The patient populations affected are
the elderly, psychiatric patients (adults and children), and disoriented or physically aggressive
patients. The settings of restraint use include psychiatric facilities and residential sites
for those with mental illness, developmental or behavioral problems; general hospitals,
emergency departments, and nursing homes (Sullivan-Marx & Strumpf, 1996).
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Definitions
Restraint is...
any involuntary method (chemical or physical) of restricting an individual’s freedom of
movement, physical activity, or normal access to the body.
Chemical restraint is…
the use of a sedating psychotropic drug to manage or control behavior. Psychoactive
medication used in this manner is an inappropriate use of medication.
Physical restraint is…
the direct application of physical force to a patient, without the patient’s permission, to
restrict his or her freedom of movement (JCAHO, 2000). The physical force may be human,
mechanical devices, or a combination thereof. This definition does not apply to (1) interactions with patients that are brief and focus on redirection or assistance in activities of daily
living, such as hygiene, and (2) the use of any psychoactive medication that is a usual or
customary part of a medical diagnostic or treatment procedure, and that is used to restrict
a patient’s freedom of movement (JCAHO, 2000).
Seclusion refers to…
the involuntary confinement of a person in a locked room (JCAHO, 2000).
Therapeutic holding is…
the physical restraint of a child by at least two people to assist the child who has lost control
of behavior to regain control of strong emotions (American Academy of Pediatrics, 1997).
In the past, when restraint was employed, it was in the belief that such action would promote
patient safety and without effective restraint and seclusion practices, patients were considered
to be in danger of injuring themselves or others, including nursing staff, or being injured by
other assaultive patients. The danger of employing such restraint, however, has been demonstrated to be problematic. There is a need for additional research to explore patient safety factors related to restraint and seclusion and the role of the registered nurse in their elimination.
A 50-State survey by a Connecticut newspaper (Hartford Courant 1998), revealed at least
142 deaths related to the use of physical restraint or seclusion since 1988. The report also
noted that the true number of deaths is much higher since data about many such deaths is not
public information. In one case, a patient at Virginia’s Central State Hospital died after being
restrained for 300 hours, including two intervals of approximately 110 hours each. Young
men in a residential treatment facility in Pennsylvania and at a private psychiatric hospital in
North Carolina died shortly after being physically restrained by personnel who were caring
for them. According to statistical projections commissioned by The Courant and conducted
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by the Harvard Center for Risk Analysis, between 50 and 150 such deaths occur every year
across the country due to improper restraint procedures. The National Alliance for the Mentally Ill (NAMI, 1999) has received reports from 15 States about 24 incidents related to the
use of restraints and/or seclusion, ranging from a 16-year-old in California who died while
restrained by four staff members to an Ohio man who died in restraints running a temperature
of 108 degrees. Situations such as these can not be allowed to continue. There is a critical
need for mandated monitoring of the use (frequency, methods, etc.) of restraint and seclusion.
ANA supports the rights of patients of all ages and in all settings to be treated with dignity
and concern, and to receive safe, quality care. Developmentally appropriate methods of restraint must be used in the least restrictive manner. The family members, guardians, or
significant others of individuals placed in restraint must be informed immediately.
ANA recognizes that seclusion and/or restraint may be more likely to be employed inappropriately—that is, for nonemergency situations and/or for circumstances where no significant risk
of harm exists—when hospital unit staffing is inadequate or staff is inappropriately trained to
provide less restrictive interventions. Where the hospital cannot provide for an assessment by
a physician or other appropriately licensed health care professional within an hour, ANA supports that all the following requirements should apply: (1) a registered nurse shall confer by
telephone with a physician or other health care professional permitted by the State and hospital
to order restraint or seclusion within an hour after the restraint or seclusion is initiated. (This
requirement is also consistent with ANA’s proposal on obtaining telephone orders within an
hour after instituting the procedure if an order cannot be obtained beforehand). (2) The reasons for a patient not being seen within the hour shall be documented in the patient record. (3)
The patient must be physically assessed by a registered nurse hourly until a physician or other
appropriately licensed health care professional arrives to see the patient. (4) The patient must
be seen by an R.N. or physician or other health care professional permitted by the State and
hospital to order restraint or seclusion within one hour after being placed in restraint or seclusion. Adding such language to the current requirements assures that the patients’ safety is not
compromised by delay in assessment.
To achieve reduced restraint care, formal mission statements and policies that clearly state
the intent to promote a reduced restraint environment for patients must be adopted. Such
statements must include a focus on (1) intention to comply with policy standards; (2) environmental designs to facilitate restraint reduction; and (3) implementation of an individualized approach grounded in the following principles: 1) all behavior has meaning; 2) patient
needs are best met when behavior is understood; and 3) a systematic approach of assessment,
intervention, and evaluation is the best means to respond to behavior.
When instituting change toward reduced restraint care, initial educational efforts must
address fundamental components of such care. Open communication and dialogue at board
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and highest administrative levels, and including staff from all disciplines, as well as community representatives, are essential to implementing change. Early success with less complex
problems, such as eliminating restraints for positional support with substitution of wedge or
roll cushions, fosters confidence for handling more difficult situations. If systems lack internal resources to provide education and specialist intervention, independent nursing consultation services can be contracted to provide for these needs.
Targeting specific units or groups of patients, such as all new admissions, and then identifying those who are restrained (and why) lays the groundwork for interventions aimed at eliminating restraints. Interventions may take the form of actions categorized as pharmacologic,
physiologic, psychosocial, activity, or environment.
Physiologic approaches include such efforts as pain relief, comfort measures, or investigating symptoms indicative of developing complications, such as hypoxia or fever. Psychosocial
interventions focus on the meaning of patient behavior and address that need, e.g., is the
agitated patient fearful of impending surgery? Activities can include talking with the patient,
physical exercise/therapy, involvement in activities, meaningful distraction, or contact with
familiar persons or places, even by telephone. Environmental adjustments may range from
simple use of light to facilitate vision or relocation of the patient to another bed or room, to
specifically designed units that reduce the hazards of falling. To foster transition to reduced
restraint care and sustain lasting change, beliefs must be altered and knowledgeable practice
enhanced through education, intensive clinical evaluation, and consistent reinforcement of
standards and policy (Sullivan-Marx & Strumpf, 1996).
Finally, it must be recognized that psychotropic medications are not merely “chemical restraints” but treatment strategies which can result in a decreased need for therapeutic holding
and/or physical restraint. However, there must be an adequate number of professional nurses
available to provide the necessary care. Staff must be educated in the use of alternatives to
restraint, and such alternatives must be made available to them both through organizational
policy and in fact. Only then can the safety and quality of patient care be assured.
There is a critical need to provide educational opportunities for nurses to assist them to develop the necessary assessment and intervention skills to prevent the need for restraint and seclusion. ANA is concerned that lack of personnel to provide adequate monitoring of patients
and less restrictive approaches to behavior management may place patients at greater risk of
violation of their rights and of harm caused by being placed in seclusion and/or restraints.
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References
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine (1997). The use of
physical restraint interventions for children and adolescents in the acute care setting (RE9713).
Pediatrics, 99(3).
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements.
Washington, DC: American Nurses Publishing.
American Psychiatric Nurses Association. (2000). Position statement on the use of seclusion and
restraint. Washington, DC: Author.
Health Care Financing Administration. (2000, January). Quality standards: Patients’ rights
conditions of participation. www.hcfa.gov/quality/4b.htm.
International Society of Psychiatric-Mental Health Nurses. (1999). A position statement on the
use of restraint and seclusion. Philadelphia: Author.
Joint Commission on the Accreditation of Healthcare Organizations. (2000). Automated
comprehensive accreditation manual for behavioral health care. Oakbrook Terrace, IL: Author.
Maier, G. (1996). Managing threatening behavior: The role of talk down and talk up. Journal
of Psychosocial Nursing, 34, 25-30.
National Alliance for the Mentally Ill. (1999, October). Cries of anguish: A summary of reports of
restraints and seclusion abuse received since the October 1998 investigation by The Hartford
Courant. www.nami.org/update/hartford.html.
Occupational Safety and Health Administration. (1998). Guidelines for preventing workplace violence
for health care and social service workers (OSHA Publication No.3148). Washington, DC: Author.
Strumpf, N., & Tomes, N. (1993). Restraining the troublesome patient: A historical perspective
on a contemporary debate. Nursing History Review, 1, 3-24.
Sullivan-Marx, E.M., & Strumpf, N.E. (1996). Restraint-free care for acutely ill patients in the h
ospital. AACN Clinical Issues: Advanced Practice in Acute and Critical Care. 7(4), 572-573.
Weiss, E. (1998, October). Deadly Restraint: A nationwide pattern of death. The Hartford Courant.
Effective Date: October 17, 2001
Status: Position Statement
Originated By: Congress on Nursing Practice and Economics
Adopted By: ANA Board of Directors
Related Past Actions:
1. 2000 HOD Reduction of Patient Restraint and Seclusion in Health Care Settings
(Action
Report)
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American Psychiatric Nurses Association
Position Statement on the Use of Seclusion and Restraint
Introduction
Psychiatric-mental health nursing has a 100-year history of caring for patients in psychiatric
facilities. Currently, nurses serve as frontline workers as well as unit-based and executive
level administrators in virtually every organization providing inpatient psychiatric treatment.
Therefore, as the professional organization for psychiatric-mental health nurses, the American Psychiatric Nurses Association (APNA) recognizes that the ultimate responsibility for
maintaining the safety of those in the treatment environment and for maintaining standards
of care in the day-to-day treatment of these clients rests with nursing and the hospital or
behavioral health care organization that supports the unit. Thus, APNA supports a sustained
commitment to the reduction of seclusion and restraint and advocates for continued research
to support evidence-based practice for the prevention and management of behavioral emergencies. Furthermore, we recognize the need for and are committed to working together with
physicians, clients and families, advocacy groups, other health providers, and our nursing
colleagues in order to achieve the vision of eliminating seclusion and restraint.
Background
In the mid-1800s proponents of “moral treatment” of psychiatric patients advocated the
elimination of the practice of restraining patients. Despite the relative success of this movement in England and Europe, psychiatrists in the United States concluded that restraints
could never be eliminated in the United States (Bockoven, 1963; Deutsch, 1949; Freedman,
Kaplan, & Sadock, 1975; Strumpf & Tomes, 1993). To this day, belief in the necessity for
continuing the practice of secluding and restraining patients persists. Fisher (1994) concludes
from his review of the literature that not only is it “nearly impossible to operate a program
for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint” (p. 1584) but that these methods are effective in preventing injury and reducing
agitation. However, the determination of the efficacy of the use of seclusion and restraint is
not grounded in research that supports the therapeutic efficacy of this intervention, but upon
the observation that the intervention interrupts and controls the patient’s behavior (Walsh &
Randell, 1995).
Recent research has prompted psychiatric-mental health nurses to question the therapeutic
benefit of secluding and restraining psychiatric patients. Some of these studies underscore
the potential negative impact of this practice on patients. These studies bring to the fore the
ethical dilemmas inherent in the use of seclusion and restraints (Binder & McCoy, 1983;
Browne & Tooke, 1992; Johnson, 1998; Mohr, Mahon, & Noone, 1998; Norris & Kennedy,
1992). On the one hand, this practice has the potential for physically and/or psychologically
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harming patients (Brown & Tooke, 1992; Fisher, 1994; Martinez, Grimm, & Adamson, 1999)
and for violating the patient’s right to autonomy and self-determination (Moss & La Puma,
1991; Stilling, 1992). On the other hand, studies of violence on inpatient units underscore
the reality that violence cannot be predicted. Since the nursing staff are held responsible for
maintaining the safety of all of the patients, they often see seclusion and restraint as a necessary last-resort intervention to maintain that safety (Alty, 1997; Steele, 1993). Furthermore,
studies of the impact of assault on those who care for patients must be taken into consideration when developing standards for practice and when addressing organizational strategies
to assure equal commitment to worker as well as patient safety (OSHA, 1998; Lanza, 1992;
Poster & Ryan, 1989; Ryan & Poster, 1989).
Other studies have highlighted the influence of unit philosophy and culture, treatment philosophy, staff attitudes, staff availability, staff training, ratios of patients to staff, and location in the United States on either the disparity in the incidence of seclusion and restraint or
the perpetuation of the practice of secluding and restraining psychiatric patients (Browne &
Tooke, 1992; Holzworth & Wills, 1999; Kirkpatrick, 1989; Harris & Morrison, 1995; Johnson & Morrison, 1993; Morrison, 1990, 1992, 1993, 1994). From the research, it appears
that the key to seclusion and restraint reduction is prevention of aggression by (1) assessing
the patient and intervening early with less restrictive measures such as verbal and nonverbal
communication, reduced stimulation, active listening, diversionary techniques, limit setting
and prn medication (Canatsey & Roper, 1997; Lehane & Rees, 1996; Maier, 1996; Martin,
1995; Morales & Duphorne, 1995; Richmond et al., 1996; Stevenson, 1991) and (2) changing
aspects of the unit to promote a culture of structure, calmness, negotiation, and collaboration
rather than control (Cahill, Stuart, Laraia, & Arana, 1991; Delaney, 1994; Harris & Morrison,
1995; Johnson & Morrison, 1993; Whittington & Patterson, 1996). To date, there is some
evidence that changes in a unit’s treatment philosophy can lead to changes in patient behavior that will ultimately impact the incidence of the use of seclusion and/or restraints (Goren,
Abraham, & Doyle, 1996).
Despite the best efforts at preventing the use of seclusion and restraint, there may be times
that these interventions are necessary. Thus, it is important to be cognizant of the vulnerability of clients who are secluded or restrained and the risks involved in using these interventions
(Weiss, 1998). Moreover, the dangers inherent in the use of seclusion and restraint include
the possibility that the client’s behavior is a manifestation of an organic or physiological
problem that requires medical intervention and may therefore predispose the client to increased physiological risk during the time the individual is secluded or restrained. Therefore,
skilled assessments of clients who are restrained or secluded will not only ensure the safety
of clients in these vulnerable conditions but also ensure that the intervention is discontinued
as soon as the client is able to be safely released.
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Position Statement
APNA believes that psychiatric-mental health nurses play a critical role in the provision of
care to clients in psychiatric settings. Therefore,
• We take responsibility for providing ongoing opportunities for professional growth and
learning for the psychiatric-mental health nurse whose treatment promotes client safety
as well as autonomy and a sense of personal control.
• We promulgate professional standards that apply to all populations and in all settings
where behavioral emergencies occur and that provide the framework for quality care for
all individuals whose behaviors constitute a risk for safety to themselves or others.
• We advocate and support evidence-based practice through research directed toward
examining the variables associated with the prevention of and safe management of
behavioral emergencies.
• We articulate the following fundamental principles to guide action on the issue of
seclusion and restraint:
○ Clients have the right to be treated with respect and dignity and in a safe, humane,
culturally sensitive, and developmentally appropriate manner that respects client choice
and maximizes self determination.
○ Seclusion or restraint must never be used for staff convenience or to punish or coerce
patients.
○ Seclusion or restraint must be used for the minimal amount of time necessary and only
to ensure the physical safety of the individual, other patients, or staff members and
when less restrictive measures have proven ineffective.
○ Clients who are restrained must be afforded maximum freedom of movement while
assuring the physical safety of the client and others. The least number of restraint points
must be utilized and the client must be continuously observed.
○ Seclusion and restraint reduction requires preventative interventions at both the individual and milieu management levels using evidence-based practice.
○ Seclusion and restraint use is influenced by the organizational culture of a setting that
develops norms for how patients are treated. Seclusion and restraint reduction efforts
must include a focus on necessary culture change.
○ Hospital and behavioral healthcare organizations and their nursing leadership groups
must make commitments of adequate professional staffing levels, staff time and resources to assure that staff are adequately trained and currently competent to perform
treatment processes, milieu management, de-escalation techniques, and seclusion or
restraint.
○ Oversight of seclusion and restraint must be an integral part of an organization’s performance improvement effort and these data must be open for inspection by internal and
external regulatory agencies. Reporting requirements must be based on a common definition of seclusion and restraint. Specific data requirements must be consistent across
regulatory agencies.
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Acknowledgments
APNA Seclusion and Restraints Task Force: Lynn DeLacy (Chair), Terri Chapman, Sue
Ciarmiello, Kathleen Delaney, Germaine Edinger, Carole Farley-Toombs, Mary Johnson,
Lyn Marshall, Marlene Nadler-Moodie, Marilyn Nendza, Pamela Nold, Linda Ovitt, Brenda
Shostrom, Mary Thomas, Linda Wolff
Approved by APNA Board of Directors, May 15, 2000
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References
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Binder, R., & McCoy, S. (1983). A study of patients’ attitudes toward placement in seclusion.
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Bockoven, J.S. (1963). Moral treatment in American psychiatry. New York: Springer.
Brown, J., & Tooke, S. (1992). On the seclusion of psychiatric patients. Social Science and
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Cahill, C., Stuart, G., Laraia, M., & Arana, G. (1991). Inpatient management of violent behavior:
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Delaney, K. (1994). Calming an escalated psychiatric milieu. Journal of Child and Adolescent
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Deutsch, A. (1949). The mentally ill in America. New York: Columbia University Press.
Fisher, W. (1994). Restraint and seclusion: A review of the literature. American Journal of
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Goren, S., Abraham, I., & Doyle, N. (1996). Reducing violence in a child psychiatric hospital
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Harris, D., & Morrison, E. (1995). Managing violence without coercion. Archives of Psychiatric
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Holzworth, R. & Wills, C. (1999). Nurses’ judgments regarding seclusion and restraint of
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Lanza, M. (1992). Nurses as patient assault victims: An update, synthesis, and recommendations.
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Martin, K. (1995). Improving staff safety through an aggression management program. Archives
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Morales, E., & Duphorne, P. (1995). Least restrictive measures: Alternatives to four-point restraints
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Morrison, E. (1994). The evolution of a concept: Aggression and violence in psychiatric settings.
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Walsh E., & Randell, B. (1995). Seclusion and restraint: What we need to know. Journal of Child
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Federation of Families For
Children’s Mental Health
Position on the Use of Seclusion and Restraints
The Federation is strongly opposed to the use of physical, chemical, or mechanical restraints
and seclusion with any child but especially for children and youth who have mental, emotional, or behavioral disorders or children and youth who have been exposed to violence.
We view restraint and seclusion as inhumane, cruel, and ineffective. These techniques, at
best, may temporarily relieve stress for the adults in charge and always increase stress for the
child or youth. There is no evidence that the use of restraints or seclusion has any therapeutic
benefit whatsoever.
Restraint and seclusion are not appropriate forms of treatment. Children and youth who are
“out of control” need services, supports, and highly specialized attention—not seclusion.
When implementation of an IEP, service, or treatment plan fails to achieve the desired or
appropriate behavior, there must be a review and revision of the plan. Subjecting a child or
youth to restraints and seclusion in such situations is equivalent to punishing the victim. No
service or treatment plan should EVER include provisions for the routine use of seclusion
or restraints. Seclusion or “time out” or any form of restraint are punishments that should
be eliminated from the behavioral contracting and discipline protocols of schools, day and
residential treatment centers, group homes, hospitals, and juvenile detention and correctional
facilities.
Holding children should be a loving act, not a violent one. Restraining children teaches them
that it is acceptable to treat others with physical force when they do things you don’t like.
This is a very bad message. Children and youth, whose behavior is (or appears to be) very
difficult for them and those who care for them to control, need first and foremost a comprehensive assessment to learn what is causing this behavior and also figure out what function(s)
it is serving. A specific and individualized service plan consisting of effective therapeutic,
medical, social, educational, and rehabilitative supports and services can then be drawn up
by the family and youth along with their team of service providers and advisors. Such a plan
must build on the child’s and family’s strengths and address the behavioral issues of greatest
concern to them first. The overarching goal of any service plan should be to support the child
and family so the child can live safely at home (or as close to home as possible), go to school
and be successful in the general curriculum, and fully participate in the cultural, spiritual, and
recreational life of the community.
Time out must be distinguished from seclusion. We would define time out as giving the child
or youth the opportunity to temporarily and VOLUNTARILY remove her or himself from a
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situation to PREVENT further escalation of stress or anxiety. Time out must also be supervised and the child should be allowed to talk to a professional or supportive and trusted adult
if she or he so wishes. Time out should end when the child feels ready to return to the group.
There may be rare instances where safety makes it necessary to use seclusion or restraints,
such as in a life-threatening situation where there is absolutely no other way to safely protect a child whose behavior is violent or insure the safety of others who are in danger from
that behavior. In such cases, only the responsible chief administrator or attending physician
should authorize the procedure and
• the child should NEVER be left alone—professional staff (not child care attendants or
peers) trained in de-escalation and conflict resolution should be working with the child
throughout the episode;
• seclusion should be ended or restraints be removed as soon as the behavior begins to subside AND an effective therapeutic intervention should be initiated within no more than 15
minutes of the onset of the incident;
• the child’s parents or family should be notified as soon as the seclusion or restraint is
initiated;
• the IEP, service, or treatment plan should be reviewed within 24 hours and revised if
necessary.
There should be no instances of seclusion or restraints that last more than a few minutes
(i.e., 15 minutes). If they do, the child should have ready (on demand) access to food,
water, bathroom facilities, and be allowed to make a phone call to a predetermined, trusted,
family member, professional, or support person. Any child who is secluded for more than 15
minutes should be provided with appropriate and safe learning materials and instruction.
Denial of contact with family members should never be used as tool to control or manipulate
behavior. All uses of restraints, seclusion, or physical intervention should be immediately
documented in the child’s file and a copy of the report should be provided to the child’s parent or guardian within 24 hours of the incident. The child’s family should be allowed to insist
that restraints and seclusion not be used for their child under any circumstances and this
should not jeopardize the child’s admission to or treatment at the facility.
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NAMI
Seclusion and Restraint Position Paper
(Summarized from the NAMI Policy Platform)
The use of involuntary mechanical or human restraints or involuntary seclusion is only justified as an emergency safety measure in response to imminent danger to a patient or others.
These extreme measures can be justified only so long as, and to the extent that, an individual
cannot commit to the safety of him or herself and others.
Restraint and seclusion have no therapeutic value and should be used only for emergency
safety by order of a physician with competency in psychiatry or a licensed independent mental health professional (LIP). A physician trained in psychiatry or a LIP should see the patient
within one hour after restraints are initiated. Restraints should be continued only for periods
of up to one hour at a time, and a face-to-face examination of the patient by the physician or
LIP must occur prior to each time a restraint order is renewed.
Alternatives to the use of restraint and seclusion should be used. De-escalation techniques
and debriefings should be used after each restraint and seclusion incident.
A Clear Pattern of Abuse Exposed
In October 1998, The Hartford Courant published a five-part investigative series that revealed an alarming number of deaths resulting from the inappropriate use of physical restraints in psychiatric treatment facilities across the United States. A 50-state survey conducted by the newspaper documented at least 142 deaths in the past decade connected to the use
of physical restraints or to the practice of seclusion. The report also suggested that the actual
number of deaths is many times higher because many incidents go unreported. According to
a separate statistical estimate commissioned by The Courant and conducted by the Harvard
Center for Risk Analysis, between 50 and 150 restraint- or seclusion-related deaths occur
every year across the country.
As a result of The Hartford Courant series and NAMI’s communications with its members,
NAMI members have shared their horror stories of abuse and death. These are compiled in
NAMI’s report, Cries of Anguish. More than 60 personal stories of incidents from 24 States
and the District of Columbia were reported as of August 2000.
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Understanding the Issue
Restraints are human or mechanical actions that restrict freedom of movement or normal
access to one’s body. Since the development of more effective psychotropic medications,
emergency situations have become increasingly rare. In fact, some hospitals have moved to
restraint-free policies.
In current practice, physical restraints are sometimes imposed on a patient involuntarily for
control of the environment (curtailing individual behavior to avoid the necessity for adequate staffing or clinical interventions); coercion (forcing the patient to comply with the
staff’s wishes); or punishment (staff punishing or penalizing patients). NAMI rejects these
as legitimate reasons to impose restraints.
Federal Protections Enacted in 2000
In October 2000, President Clinton signed the Children’s Health Act of 2000, P.L. 106-310.
This significant new law established national standards that restrict the use of restraint and
seclusion in all psychiatric facilities that receive Federal funds and in “non-medical community-based facilities for children and youth.”
NAMI will be following the implementation of key provisions under the general requirements, which include:
Restraints and involuntary seclusion (R/S) may only be imposed to ensure the physical safety
of a patient. They cannot be used as punishment or for staff convenience.
R/S may be imposed only under the written order of a physician or other licensed practitioner permitted to issue such orders under State law. Orders must specify the duration of and
circumstances for the R/S.
Although no timeframe is specified for conducting face-to-face evaluations of patients who
have been or will be restrained or placed in seclusion, the legislation declares that the lack of
a specified timeframe should not be interpreted as offsetting or impeding any Federal or State
regulations that provide greater protections for patients. This declaration then affirms hospital
rules promulgated last year by the Health Care Financing Administration (HCFA), including
the “one-hour rule” that requires face to-face evaluations by licensed professional practitioners within one hour of initiating R/S.
Facilities must report every death that occurs within 24 hours after a patient has been removed from R/S or where it is reasonable to assume that a death is the result of R/S. Reports
must be made to agencies determined appropriate by the Department of Health and Human
Services (HHS), which most likely will include State protection and advocacy agencies.
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Within 12 months, HHS also must issue regulations specifying adequate numbers of staff for
facilities and appropriate training for the use of R/S and its alternatives.
For children’s non-medical community programs:
R/S may be used with children in community programs only in emergencies and to ensure
immediate physical safety for the child or others. Mechanical restraints are prohibited. Seclusion is allowed only when a staff member continuously monitors a child face-to-face. Time
outs, however, are not considered seclusion, and physical escorts are not considered physical
restraints.
Only individuals trained and certified by a State-recognized body may impose R/S. Until a
State certification process is in place, R/S can be used only when a supervisory or senior staff
person with skills and competencies specifically listed in the legislation conducts a face-toface assessment of the child within an hour after R/S is imposed. The use of R/S must then be
monitored by the supervisory or senior staff person.
Required skills and competencies include an understanding of the needs and behaviors of the
populations served, relationship-building, avoiding power struggles, de-escalation methods,
alternatives to R/S, time limits, monitoring signs of physical distress, position asphyxia,
obtaining medical assistance, and familiarity with relevant legal issues.
Within 6 months, States (which license such facilities) must develop licensing and monitoring rules and HHS will begin to develop national staffing standards and guidelines.
These R/S standards apply only to psychiatric treatment facilities that receive Federal funding. They do not affect use of restraint and seclusion in schools, wilderness camps, jails,
or prisons. P.L. 106-310 also does not impede any Federal or State laws or regulations that
provide greater protections than written in the Children’s Health Act of 2000. Thus, rules
issued by the Health Care Financing Administration in 1999 that included a requirement for
face-to-face evaluations by mental health professionals within one hour of initiating restraint
are affirmed.
NAMI’s Advocacy Goals and Strategies
NAMI strongly supports full implementation of the restraint and seclusion provisions
included in P.L 310-106.
NAMI will monitor the progress of the Department of Health and Human Services in issuing
national guidelines and regulations specifying adequate number of staff in facilities and
appropriate training in the use of R/S and their alternatives.
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NAMI will also advocate for a national standard in schools, wilderness camps, jails,
and prisons.
What Should You Do If You Experience Restraint and Seclusion Abuse?
If you or your family member has experienced abuse of R/S in a treatment facility, you
should take the following action:
• Contact your State’s Protection and Advocacy program. For the phone number of your
State’s program, call the National Association of Protection and Advocacy Systems
(NAPAS) at 202-408-9514. If a P & A does not assist you, let NAMI know by contacting
Kim Encarnation at 703-312-7895 or by E-mail at [email protected].
• File a complaint with the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) hotline at 1-800-994-6610 and/or [email protected]
• File a complaint with your State’s health and hospital-licensing agency.
• File a complaint with your U.S. Health Care Financing Administration (HCFA) regional
office. There are 10 regional offices in the United States. To find yours, call the HCFA
Medicare Hotline at 1-800-638-6833. You can also call the HCFA Office of Medicare
Customer Assistance, 410-786-7413.
• Share your story in writing and submit it to be included in NAMI’s Cries of Anguish report.
Contact Kim Encarnation at 703-312-7895 or [email protected]
• Consider sharing your story with your local media.
• Consider retaining an attorney if you believe your legal rights have been violated.
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Program Directors (NASMHPD)
Position Statement on Seclusion and Restraint
The members of the National Association of State Mental Health Program Directors
(NASMHPD) believe that seclusion and restraint, including “chemical restraints,” are safety
interventions of last resort and are not treatment interventions. Seclusion and restraint should
never be used for the purposes of discipline, coercion, or staff convenience, or as a replacement for adequate levels of staff or active treatment.
The use of seclusion and restraint creates significant risks for people with psychiatric disabilities. These risks include serious injury or death, retraumatization of people who have a history
of trauma, and loss of dignity and other psychological harm. In light of these potential serious
consequences, seclusion and restraint should be used only when there exists an imminent risk
of danger to the individual or others and no other safe and effective intervention is possible.
It is NASMHPD’s goal to prevent, reduce, and ultimately eliminate the use of seclusion and
restraint and to ensure that, when such interventions are necessary, they are administered in
as safe and humane a manner as possible by appropriately trained personnel. This goal can
best be achieved by (1) early identification and assessment of individuals who may be at risk
of receiving these interventions; (2) high quality, active treatment programs (including, for
example, peer-delivered services) operated by trained and competent staff who effectively
employ individualized alternative strategies to prevent and defuse escalating situations; (3)
policies and procedures that clearly State that seclusion and restraint will be used only as
emergency safety measures; and (4) effective quality assurance programs to ensure this goal
is met and to provide a methodology for continuous quality improvement. These approaches
help to maintain an environment and culture of caring that will minimize the need for the use
In the event that the use of seclusion or restraint becomes necessary, the following standards
should apply to each episode:
• The dignity, privacy, and safety of individuals who are restrained or secluded should be
preserved to the greatest extent possible at all times during the use of these interventions.
• Seclusion and restraint should be initiated only in those individual situations in which an
emergency safety need is identified, and these interventions should be implemented only
by competent, trained staff.
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As part of the intake and ongoing assessment process, staff should assess whether or not
an individual has a history of being sexually, physically, or emotionally abused or has
experienced other trauma, including trauma related to seclusion and restraint or other prior
psychiatric treatment. Staff should discuss with each individual strategies to reduce agitation
which might lead to the use of seclusion and restraint. Discussion could include what kind of
treatment or intervention would be most helpful and least traumatic for the individual.
• Only licensed practitioners who are specially trained and qualified to assess and monitor
the individual’s safety and the significant medical and behavioral risks inherent in the use
of seclusion and restraint should order these interventions.
• The least restrictive seclusion and restraint method that is safe and effective should be
administered.
• Individuals placed in seclusion or restraints should be communicated with verbally and
monitored at frequent, appropriate intervals consistent with principles of quality care.
• All seclusion and restraint orders should be limited to a specific period of time. However,
these interventions usually should be ended as soon as it becomes safe to do so, even if
the time-limited order has not expired.
• Individuals who have been secluded or restrained and staff who have participated in these
interventions usually should participate in debriefings following each episode in order to
review the experience and to plan for earlier, alternative interventions.
States should have a mechanism to report deaths and serious injuries related to seclusion and
restraint, to ensure that these incidents are investigated, and to track patterns of seclusion and
restraint use. NASMHPD also encourages facilities to conduct the following internal reviews:
(1) quality assurance reviews to identify trends in seclusion and restraint use within the facility,
improve the quality of care and patient outcomes, and help reduce the use of seclusion
and restraint; (2) clinical reviews of individual cases where there is a high rate of use of these
interventions; and (3) extensive root cause analyses in the event of a death or serious injury
related to seclusion and restraint. To encourage frank and complete assessments and to ensure
the individual’s confidentiality, these internal reviews should be protected from disclosure.
NASMHPD is committed to achieving its goals of safely preventing, reducing, and ultimately
eliminating the use of seclusion and restraint by (1) encouraging the development of policies
and facility guidelines on the use of seclusion and restraint; (2) continuing to involve consumers, families, treatment professionals, facility staff, and advocacy groups in collaborative
efforts; (3) supporting technical assistance, staff training, and consumer/peer-delivered training
and involvement to effectively improve and/or implement policies and guidelines; (4) promoting and facilitating research regarding seclusion and restraint; and (5) identifying and disseminating information on “best practices” and model programs. In addition, NASMHPD supports
further review and clarification of developmental considerations (for example, youthful and
aging populations) which may impact clinical and policy issues related to these interventions.
Approved by the NASMHPD membership on July 13, 1999.
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The National Mental Health Association
Position Paper
The Rights of Persons with Mental Illness
Purpose and Summary
This statement expresses the convictions of the National Mental Health Association (NMHA)
with regard to the rights of persons involved with the mental health system and/or who are
recovering from mental illness (including children, adolescents, and their families). The
NMHA is committed to promoting adherence by all treatment systems to the policies and
principles set forth herein and to assisting our State and local affiliates in working with their
State and local governments to do likewise. This pledge also includes adherence to the ADA,
IDEA, the Rehabilitation Services Act, the Fair Housing Act, and other legislation that protects the rights of citizens, especially those recovering from mental illness. This statement
consolidates prior policies that addressed rights issues.
Background
Equal justice under the law is a fundamental concept in American jurisprudence. Yet persons
with mental illness are often denied equal justice in virtually every part of our country. Too
often discriminatory practices proceed from the misconception that people who are in the
mental health treatment system are incapable of exercising the rights of citizenship. In fact,
the decision to institutionalize people or treat them against their will may be based upon the
assumption that to resist treatment recommendations is evidence that one is incapable of making such a judgment. This completely ignores the principle that a person is competent unless
legally proven otherwise. While major strides have been made, people with mental illness
continue to be denied rights as citizens, dignity as human beings, and a life free from stigma.
The NMHA recognizes that myths and misinformation prohibit the full participation of individuals recovering from mental illness in their communities. For example, despite common
misperceptions, persons with mental illness are not more violent than people without mental
illness. NMHA has worked to educate the public, as well as legal and medical advisors, providers, educators, and the media about laws protecting rights and to provide information that
counteracts stigmatizing attitudes, language, and behavior.
Specific Rights
The NMHA reaffirms its commitment to equal justice and protection of legal rights for all
persons with mental illness, including children, adolescents, and their families. To carry out
this principle, NMHA pledges itself to protecting the civil rights of persons who are recovering from mental illness. The following rights are specifically identified because they are most
likely to be abridged:
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Rights Regarding Benefits and Service Delivery
• The right to receive timely, culturally appropriate, and complete information about rights
upon enrollment in a health plan, upon entering the treatment system, and at any time
upon request. This information must include benefits and services, as well as information
about how to access available services, appeal a decision, lodge a complaint, and/or get
help to navigate a service delivery system.
• The right to be fully informed of all beneficial treatment options covered and not covered,
including related costs.
• The right to have advance directives about treatment preferences—and the right to have
them honored.
• The right to insurance parity, including freedom from limits based on annual and lifetime
expenditures, days or visits, co-payments, or diagnosis.
• The right to the least restrictive and least intrusive response to a need for mental health
services.
• The right to sue the health plan for authorization denials that result in harm to the
consumer.
• The right to expedited reviews and appeals from one's health plan when the situation is
emergent or urgent.
• The right to access services in one's own community, including but not limited to crisis
intervention, emergency, diversion, rehabilitation, outreach, housing, employment, and
mobile services, including the right to seek care from a provider who does not participate
in the health plan if the provider network is insufficient.
• The right to be fully involved in treatment, referral, and discharge plans as they are developed, implemented, and revised. Parents and guardians have the right to meaningful involvement in developing and implementing the treatment plan for their children who are
still minors, as well as for their adult children if consent is given by the adult consumer.
• The right to be fully informed of treatment side effects and treatment alternatives in order
to make informed decisions without coercion or the threat of discontinued services.
• The right to selectively refuse undesired treatment services without the loss of desired
services.
• The right to receive services from providers who have appropriate language skills and
linguistic support services.
• The right to be directed to treatment modalities that are culturally competent according
to ethnicity, sexual orientation, religious beliefs, and disability.
• The right to access medically necessary and effective medications without being
subjected to "fail first" policies, discriminatory or excessive co-payments, or timeconsuming prior authorization paperwork.
• The right to receive appropriate, specialized, and individually tailored education as a
component of treatment for youths.
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• The right to receive treatment services in one’s own community, with reasonable efforts
to serve children and adolescents while they remain in their homes.
• The right to be transported to treatment facilities by medical personnel, rather than law
enforcement agents.
Rights Related to Preservation of Liberty and Personal Autonomy
• The right to receive treatment services in a setting and under conditions that are the most
supportive of personal liberty, with restrictions of that liberty only as needed to preserve
safety.
• The right to easy access to any available rights protection service and other qualified
advocates, including federally funded protection and advocacy systems.
• The right to assert grievances and to have them addressed in a timely manner, as well
as with an external reviewer upon request, with no negative repercussions.
• The right to the use of voluntary admission procedures wherever possible.
• The right to receive treatment and services only with informed consent, except as
overridden by a court.
• The right to establish advance directives and living wills and to appoint surrogate
decisionmakers (with durable power of attorney), specifying how one wishes to be
treated in an emergency or if s/he is incapacitated, as permitted by law.
• The right to be free from any form of corporal punishment.
• The right to a humane treatment environment affording appropriate privacy and personal
dignity and protection from harm.
• The right to converse with others privately, to have convenient access to the telephone
and mail, and to see visitors during regularly scheduled hours in inpatient or residential
facilities.
Rights Related to Competency
• The right to be deemed competent to exercise all constitutional, statutory, and common
law rights and privileges and to manage one's own affairs unless restricted or limited
through appropriate due process procedures.
• The right to inexpensive, stigma-free guardianship procedures that are the least intrusive
necessary to accomplish the provision of appropriate services and which include a
delineation of the duties of the guardian.
• The right to have all restrictions explicitly enumerated in the court order and to have
copies provided to the interested parties.
• The right to legal counsel for every threat of loss of a privilege or right.
• The right to easy access to a person's attorney or legal representative while under a
commitment order.
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• Where involuntary commitment to an inpatient facility is deemed necessary, the
following rights should apply (at a minimum):
o due process hearing, provision of counsel,
o minimum burden of proof of “clear and convincing” evidence,
o a jury trial (at their election),
o presentation of witnesses and opportunity for cross examination,
o clear standards for commitment based upon constitutional principles, and
o commitment based on proof that:
1. the person requires the confinement being sought by the petitioner,
2. the place of confinement can provide the treatment being sought by the petitioner,
3. there are no less restrictive but suitable alternatives to the placement being sought, and
4. A specific overt act of dangerousness (including a stated threat).
Rights Related to Seclusion and Restraint
• Seclusion and restraint should be used only after other less restrictive techniques have
been tried and failed, and only in response to violent behavior that creates extreme threats
to life and safety.
• Seclusion and restraint procedures should not be used on individuals with medical
conditions that would render this dangerous.
• Facilities should have written procedures governing the use of seclusion, restraints, and
restraining procedures. These procedures should require the documentation of alternative,
less intrusive intervention approaches that were tried and the rationale why these failed
or were not appropriate.
• Facilities should never use seclusion or restraint as punishment or for the convenience
of staff.
• Use of restraints and seclusion should always be implemented by experienced and trained
staff, overseen by senior medical staff, approved by a physician, and be well-documented
and justified in a consumer's file.
• Seclusion and restraining procedures should be used only for the amount of time needed
to restore safety and security of the consumer and others.
• People in seclusion and restraints should be monitored on a continuous basis.
• Facilities should be sufficiently staffed to reduce the need for physical and chemical
restraints and the use of seclusion.
• All staff should be trained and demonstrate competence in non-physical intervention
techniques and in safe use of restraining procedures.
• Facilities must be held accountable for all uses of seclusion and restraints, collect data,
and report it to the appropriate State agency or regulatory bodies. Failure to produce
appropriate data or adhere to clinical guidelines should result in sanctions.
o Facilities should apply the use of advance directives, where they exist, that address
the use of seclusion and restraint.
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• Consumers should be informed that specific behaviors may result in the use of restraining
procedures or seclusion. Cooperation of the consumer with the procedure should
be sought.
• An individual's age, developmental needs, gender issues, ethnicity, and history of sexual
or physical abuse should be taken into account when implementing seclusion and
restraining procedures.
Rights Related to Privacy and Information Management
• The right to access and supplement one's own mental health record.
• The right of parents or guardians to access their minor children's mental health records,
except where such information is protected by law.
• The right to receive information about confidentiality protocols when consumers join a
new health plan or begin treatment with a new clinician, as well as on request on an
ongoing basis.
• The right to withdraw, narrow, or otherwise modify terms of consent for information to
be released.
• Consumers have the right to be informed of:
o the type(s) of information that will be disclosed (nature and extent);
o who has the authority to disclose information;
o to whom the information will be disclosed; and
o for what purpose(s) the information is needed.
Approved by the NMHA Board of Directors June 11th, 2000
Expires on December 31st, 2005
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Pennsylvania: Use of Restraints, Seclusion, and Exclusion
in State Mental Hospitals and Restoration Center
Mental Health and Substance
Abuse Services Bulletin
Commonwealth of Pennsylvania * Department of Public Welfare
DATE OF ISSUE
June 1, 2001
EFFECTIVE DATE
July 1, 2001 NUMBER: SMH-01-02
SUBJECT
Use of Restraints, Seclusion and Exclusion in State Mental Hospitals and Restoration Center
BY:
Deputy Secretary for Mental Health and Substance Abuse Services
SCOPE:
State Mental Hospitals and Restoration Center
PURPOSE:
To update and synthesize statewide policies and procedures for the use and monitoring of
Restraint, Seclusion and Exclusion in OMHSAS operated facilities.
POLICY:
State mental hospitals and South Mountain Restoration Center shall adopt and implement the
attached procedures and practices relating to the use and monitoring of Seclusion/Restraint
and Exclusion, and shall revise local policies and procedures, staff training requirements and
monitoring practices accordingly.
BACKGROUND:
It is the Office of Mental Health Substance and Abuse Services’ belief that Seclusion and
Restraint are not treatment but reflect treatment failure. Since 1999, OMHSAS has become a
recognized national leader in an emerging national movement to substantially reduce and ultimately eliminate these dangerous, emergency practices. The attached policies reflect the substantial reduction in OMHSAS’s use of these modalities since the first standardized policy was
released in 1999, and take further steps toward the goal of ultimate elimination of their use.
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This Bulletin synthesizes OMHSAS policies relating to seclusion and restraint developed
since 1999, establishes additional controls on the use of restraint as a so-called protective
device, integrates recent changes in HFCA and JCAHO requirements and adds evidence
based best practices regarding seclusion and restraint safety and reduction.
OBSOLETE BULLETINS:
OMHSAS 99-01 Use of Restraints, Seclusion and Exclusion in State Mental Hospitals;
SMH-00-01 Use of Physical Restraint in State Mental Hospitals
COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE
DIRECTED TO:
The Medical Director’s Office at 717-772-2351 or Bureau of Hospital Operations 705-8159
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USE OF RESTRAINTS, SECLUSION, AND EXCLUSION IN STATE
MENTAL HOSPITALS
I. Philosophy of Care
The use of restraints, seclusion, and exclusion in a treatment setting must be directed
by the values of the organization providing treatment. In order to affirm why and how
restraint/seclusion/exclusion procedures are used, it is necessary to establish organizational
values that guide and direct all administrative oversight and team involvement in providing
treatment, while maintaining the safety of each individual patient.
Each facility/treatment setting under the scope of this document establishes and adheres
to the following value statements:
___ Restraint/seclusion/exclusion procedures may only be used as an intervention of last
resort following a series of efforts by staff to promote less restrictive problem-solving
by the patient and used only in emergency situations to prevent patients/residents from
seriously harming themselves or others;
___ Use of a restraint/seclusion/exclusion procedure is viewed as an exceptional or extreme
practice for any patient;
___ Once a restraint/seclusion/exclusion procedure is initiated, it shall be as limited in time
as possible. Staff and the patients need to work together to lessen the incidence and
duration of these procedures;
___ All clinical staff with a role in implementation of restraint/seclusion/exclusion procedures must be trained and demonstrate competency in their prevention and proper and
safe usage;
___ Leaders of the hospital, leaders of clinical departments, and leaders of wards/units are
held accountable at all times for the initiation, usage, and termination of restraint/seclusion/exclusion procedures. This accountability is demonstrated as a component of the
hospital’s Performance Improvement efforts and staff competency evaluations;
___ The patient and family, as appropriate, are recognized members of the treatment team;
as appropriate, family members shall be notified of each seclusion and restraint incident
and of the department’s policy regarding seclusion/restraint use.
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___ The Client Representative or Patient Advocate is recognized as a spokesperson for the
patient and shall be involved in care and treatment, if the patient so desires (within the
parameters of current law/regulation);
___ The treatment plan shall address specific interventions to be used to avoid restraint/
seclusion/exclusion procedures and shall address patient strengths and cultural issues;
___ All decisions to initiate restraint/seclusion/exclusion procedures shall be based on assessment of the patient; assessments shall address history of sexual or physical abuse,
violence history, and medical/psychiatric issues that may be pertinent to seclusion or
restraint practices.
___ Patient/staff involvement in a post-procedure debriefing and discussion is essential
to determine how future situations may be prevented or de-escalated by employing
alternative problem-solving measures;
___ Patient dignity shall be maintained to the extent possible during these procedures;
___ Restraint/seclusion/exclusion procedures shall not be initiated or maintained as a
substitute for treatment, as punishment, or for the convenience of staff;
___ Restraint and seclusion are emergency safety interventions, not therapeutic techniques,
but shall be implemented in a manner designed to protect the patient’s safety, dignity,
and emotional well being.
___ In administering restraints and seclusion, as well as in attempting to prevent its use and
the necessity for subsequent/recurrent use, staff shall recognize and use the strengths of
the patient, and remain sensitive to issues of cultural competence; and
___ The commitment status of the patient requiring seclusion/restraint/exclusion shall be
reviewed prior to initiating any of these procedures.
1. Patients who are involuntarily committed may be placed in seclusion, restraint, or exclusion if indicated, but only when less restrictive measures and techniques have proven
ineffective.
2. If a patient in voluntary treatment (Legal Section 201) requires seclusion, restraint, or
exclusion, it is possible to utilize such measures if this has been agreed upon in the initial
evaluation signed by the patient as part of the voluntary commitment procedure or via an
advance directive. However, if the patient retracts or denies this agreement concerning
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possible restrictions and restraints, and refuses their use, an involuntary commitment must
be obtained as soon as possible under the criteria, standards, and procedures of Legal
Section 302 or 304C if seclusion, restraint, or exclusion is ordered.
3. Residents of the State Restoration Center are not subject to the provision of seclusion,
restraints, or exclusion. Should a resident require the use of one of these modalities for
psychiatric reasons, commitment to a psychiatric treatment facility shall be initiated.
___ The specific methods of implementing and monitoring these values are detailed in the
following sections.
II. Family Notification
On admission of the patient, the patient’s family shall be informed of the hospital’s policies/procedures regarding the use of seclusion, restraint, and exclusion. With the patient’s
informed consent, as documented in the medical record, designated family members shall be
informed of their opportunity to be notified of each incident of seclusion/restraint within a
time frame agreed to by the family and to participate in the patient debriefing, as appropriate.
III. Staff Training
It is the Office of Mental Health and Substance Abuse’s philosophy and policy that restrictive interventions may only be used as a last resort to protect patients and other persons from
physical injury. Consequently, staff training shall focus upon the development of skills and
abilities needed to assess risk, identify escalating behaviors, and effectively assist patients to
maintain control and learn safer ways of dealing with stress, anger, fear, and frustration.
Training of staff shall focus upon identifying the earliest precipitant of aggression for patients
with a known, suspected, or present history of aggressiveness, and on developing treatment
strategies to prevent exacerbation or escalation of these behaviors. Patient involvement in the
identification of precipitants is paramount.
Training shall encompass the primary importance of patient safety, at all times, during the
eclusion or restraint process. This shall include the time preceding the placement of a patient
into seclusion or restraint as well as the time spent in seclusion or restraint. Training shall be
provided to all direct-care staff during employment orientation and on an annual basis.
Staff training in seclusion and restraint techniques and policies shall result in initial certification/demonstration of competency for each staff person who will be authorized to employ
them. Retraining, re-certification, and demonstration of competency in the use of physical
restraint shall occur annually.
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Training in safe physical intervention techniques shall be provided only by approval/
certified instructors using methodologies approved by OMHSAS.
Specific training components shall include:
1. hospital and OMHSAS policies and procedures relating to the use of, Documentation,
and monitoring of seclusion and restraint;
2. assessment skills needed to identify those persons who are at risk of violence to self
or others;
3. treatment interventions that will reduce the risk of violence and increase the patient’s
capacity to benefit from psychosocial rehabilitation and educational programs;
4. skills in developing patient education programs that will assist patients in learning more
adaptive ways of handling the stress, frustration, or anger that precipitates aggressive
behavior;
5. treatment planning skills that will enable staff to better plan and coordinate treatment
activities that will reduce the incidence of assaultive behaviors;
6. conflict resolution, mediation, therapeutic communication, de-escalation, and verbal
violence prevention skills that will assist staff to diffuse and safely resolve emerging
crisis situations;
7. the nature and identification of the possible negative psychological effects these measures
may have upon some individuals, and positive therapeutic strategies to combat such effects;
8. medical precipitants to aggressive behavior;
9. understanding of how age, gender, cultural background, history of abuse or Trauma, and
other personal experiences may affect a patient’s response to physical contact, holds,
mechanical restraints, seclusion, or exclusion.
10. use of verbal de-escalation and crisis management techniques;
11. identification and use of less restrictive alternatives;
12. first aid and CPR;
13. use of safe physical intervention techniques and restraint techniques and devises;
14. use of alternative adaptive support or assistive devises and care strategies in lieu of
protective restraints for body positioning and falls prevention;
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15. recognition and management of signs of patient physical and psychological distress
during seclusion and restraint, and appropriate follow-up;.
16. recognition of the behavioral and psychological indicators that restraint/seclusion may
be safely terminated;
17. participation in debriefings; and,
18. expectations for documentation in the patient’s medical record, the SI-815, and other PI
data collection systems.
IV. Patient and Staff Debriefing
After each incident of seclusion, restraint or exclusion, a mental health professional and
members of the treatment team shall meet with the patient for the purpose of:
1. assisting the patient to develop an understanding of the precipitants which may have
evoked the behaviors necessitating the use of the restrictive technique;
2. assisting the patient to develop appropriate coping mechanisms or alternate behaviors
that could be effectively utilized should similar situations/emotions/thoughts present
themselves again;
3. developing and documenting a specific plan of interventions for inclusion in the Comprehensive Individualized Treatment Plan, with the intent to avert future need for restrictive
techniques; and,
4. evaluating whether alternate staff responses and interventions could be more effectively
used in the future.
The team member shall document the debriefing process in the patient’s medical record.
Findings from the staff debriefing and proposed administrative changes or strategies to
prevent recurrence shall also be documented on the SI-815 incident report to facilitate
hospital internal review.
The debriefing processes shall be initiated within 24 hours of the end of each incident of
seclusion, restraint, or exclusion, unless further delay is clinically indicated.
V. CONTINUOUS PERFORMANCE IMPROVEMENT MONITORING
The leadership staff of each State mental hospital shall maintain a performance improvement
program designed to continuously review, monitor, and analyze the use of seclusion, restraint,
and exclusion and issues related to these processes. Ongoing efforts to reduce utilization of
these measures shall be employed.
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The facility Chief Executive Officer and Assistant Superintendent for Clinical Services of
each State mental hospital are responsible for assuring that ongoing documentation and
monitoring of patients placed in seclusion, restraint, or exclusion are maintained.
Monitoring shall consist of reviewing the necessity for use or continuation of these measures
based upon documentation of unsuccessful, less restrictive alternatives, and appropriate
rationale and justification. Patient “debriefing,” health teaching, clinical response to seclusion, treatment plan revisions, and incidents where the physician involved does not see the
patient within thirty (30) minutes of the initiation of seclusion shall also be monitored.
Seclusion or restraint incidents in excess of 12 continuous hours, or more than one seclusion/
restraint incident within 12 hours, shall be reported to the ASCS or his/her designee. Thereafter, the leadership is notified every 24 hours if either of the above circumstances continues.
Events triggering notification of the ASCS noted in “c” above shall prompt ASCS review of
the patient record, and consultation with the patient’s psychiatrist and other treatment team
members regarding alternatives to seclusion and restraint. All incidents of seclusion, exclusion, and restraint, regardless of type, shall be documented on the State’s Risk Management
Incident Reporting form (SI-815).
VI. Seclusion
A. Definition
A brief, time-limited placement of a patient into a safe, well ventilated, furniture free,
visually observable locked room for the purpose of assisting the individual to
regain emotional and physical control over his/her dangerous, destructive behaviors.
NOTE: Seclusion is not a modality utilized in the State Restoration Center.
B. Indications
Prior to the use of seclusion, the following criteria must be met:
1. All less restrictive options/interventions, including changes in pharmacological interventions, have been considered and attempted and have failed to diminish the patient’s
immediate danger to self and/or others. Documentation of all such efforts shall be entered
into the patient’s medical record, in addition to rationale and justification of the need for
seclusion;
2. Unless clinically contraindicated, prior to the use of seclusion the patient shall be given
a choice of treatment options that may assist with limiting the environmental stimuli and
their consequent effects on the patient’s emotional status. The reason/justification for seclusion shall be communicated clearly to the patient. Treatment expectations and the outcomes
which should occur within brief, time-limited intervals shall be carefully explained.
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C. Contraindications
Seclusion shall not be used for patients who exhibit suicidal or self-injurious behaviors or
who have any known medical condition which precludes the safe application of this modality (such situations shall be determined by the attending/on-call physician on a case-bycase basis).
D. Procedures
1. Each patient shall be made aware of the specific behaviors that necessitated the use of
seclusion and those behaviors and mental status components which will terminate
seclusion;
2. Individual treatment plans shall have goals and interventions established to change the
behaviors precipitating the need for seclusion;
3. Seclusion shall be used only with a physician’s order. In emergency situations, a registered
nurse may initiate the use of seclusion for the protection of the patient and/or others.
The physician on duty/on-call shall be contacted immediately, and a verbal order may be
obtained. The physician’s order shall not exceed one (1) hour. Orders shall specify “up to”
one (1) hour, rather than a predetermined amount of time. The physician involved shall
see the patient within thirty (30) minutes of the initiation of seclusion (barring extenuating
circumstances), and then shall write/countersign the order for the seclusion and document
his/her assessment of the patient in the medical record. Specific behavioral criteria written
by the physician shall specify when the seclusion may be discontinued, to insure minimum
usage. When a physician’s order has expired, the patient must be seen by a physician and
his/her assessment of the patient documented before seclusion can be reordered;
4. Patients in seclusion shall be continuously monitored, face to face, through the seclusion
room window or in the room itself.
5. Patients are to be removed immediately from the seclusion room once the danger to self or
others is no longer imminent;
6. During the seclusion process, each patient’s dignity and need for physical care shall be carefully monitored and addressed. Each patient’s safety is of paramount concern and, as such,
potentially dangerous clothing and objects shall be removed from the patient and the seclusion area. This, however, does not prohibit the use of appropriate non-dangerous attire or
such things as may be therapeutically indicated (i.e., soft inanimate objects, magazines, etc.);
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7. Patient physical needs shall be met promptly. Opportunity for personal care, including
fluids, bathroom use, exercise, meals, and hygiene, shall be provided, and the patient’s
physical condition assessed and documented at no less than 15-minute intervals during the
seclusion incident.
VII. Restraint
A. Restraint for Emergency Behavior Control
1. DEFINITION
The use of manual holds or mechanical devices used to restrict movement of all or part
of a patient’s body in emergency situations in which the patient’s violent behavior presents
an immediate risk of physical harm to self or others, and less restrictive interventions have
failed.
2. EXPECTATIONS
a. All members of the treatment planning team shall be involved in preventing and reducing
the need for restraints by resolving the underlying problem which necessitates restraint.
b. Prior to the use of physical or mechanical restraint for aggressive behavior which presents
an immediate danger to self and/or others, the patient (unless clinically contraindicated)
will be given a choice of treatment options to enable him/her to regain self-control over the
injurious behavior. The reason for restraint shall be communicated clearly to the patient.
Behavioral expectations shall be clearly explained as conditions for release from restraint.
Restraint shall never be used as substitute for treatment, as punishment, or for convenience
of staff.
c. Only restraint devises and techniques approved by OMHSAS may be used according to
manufacturer’s instructions and for the purpose intended. See Attachment #A.
d. Staff shall demonstrate competence in recognizing signs of escalating behavior that could
potentially lead to physically aggressive behavior, by intervening in a therapeutic manner
to prevent escalation, and to assisting persons to learn alternative ways of dealing with
stress and/or anger.
e. The patient’s Comprehensive Individualized Treatment Plan shall describe the therapeutic
interventions to be used by staff when a patient’s behavior is starting to escalate.
f. Behaviors necessitating the use of restraints must be addressed on the patient’s treatment
plan. The overall goal is to eliminate the use of restrictive interventions. In doing so, it
is essential that the patient’s treatment plan clearly describe the dangerous behaviors
necessitating treatment, identify the antecedents or causes of such behavior and prescribe
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coordinated and integrated treatment approaches that reduce or eliminate the dangerous
behaviors. The treatment plan should also include treatment goals for the patient that will
provide positive alternatives to behavior that is physically harmful to self or others.
g. Individual treatment plans shall have goals and interventions written to eliminate the need
for restraints. Plans shall also include behavioral indicators of impending violent behavior
and positive, constructive crisis interventions.
3. PROCEDURES FOR THE USE OF MECHANICAL RESTRAINT DEVICES
a. Restraints are prescription devices and shall be used only with a physician’s order. In emergency situations, a registered nurse may initiate the use of restraints for the protection of
the patient and/or others. The physician on duty/on-call shall be contacted immediately and
a verbal order may be obtained. The physician’s order shall not exceed one (1) hour.
Orders shall specify “up to” one (1) hour, rather than a predetermined amount of time. The
physician involved shall see the patient within thirty (30) minutes of the initiation of the
restraints (barring extenuating circumstances), and then shall write/countersign the order
for the restraints and document his/her assessment of the patient in the medical record.
Specific behavioral criteria written by the physician shall specify under what conditions
the restraints may be discontinued, to insure minimum usage. When a physician’s order
has expired, the patient must be seen by a physician and his/her assessment of the patient
documented before restraints can be reordered;
b. Patients in mechanical restraint devises shall be placed on constant 1:1 observation (at
arm’s length), and this action is to be documented by attending staff;
c. Physical needs shall be met promptly. The patient’s physical condition shall be assessed,
and the opportunity for personal care, including fluids, bathroom use, exercise, meals and
hygiene, shall be provided and documented throughout each restraint incident at no less
than 15-minute intervals.
4. PROCEDURES GOVERNING THE USE OF PHYSICAL RESTRAINT/HUMAN HOLDS
a. Physical Restraint(PR) will only be used in situations where the person’s behavior presents
a clear threat of harm to self or others and it is necessary to use approved physical restraint
techniques to prevent injury to self or others; this includes restraint necessary to apprehend
an involuntary patient attempting to go AWOL. Staff shall always attempt to assist the
person to regain control without the use of physical restraint or any other restrictive
intervention.
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b. PR may only be used as long as absolutely necessary to protect the patient from injuring self or others. However, use of PR shall not exceed 10 minutes. If the patient has not
gained control within this time period, the patient shall be transitioned to seclusion or
mechanical restraint.
c. The deliberate use of floor restraint techniques shall be avoided whenever possible. However, if floor techniques are used either inadvertently or by necessity, a minimum of two
staff shall be involved in the restraint application, with a third staff person observing the
patient for duress throughout the use of floor restraint. If insufficient staff are vailable to
meet this condition, staff shall attempt to disengage from the floor hold, and wait for the
patient to rise before reapplying restraint, if physical restraint continues to be needed.
d. Use of physical restraint requires a physician’s order. Physician’s orders for physical restraint shall not exceed 10 minutes. The physician shall conduct a face to face evaluation
of the patient within 30 minutes of initiation.
e. Whenever physical restraint is used on a living area, or any area under the supervision of
nursing staff, the Registered Nurse in charge of the patient’s living area shall ensure that a
Registered Nurse assesses the patient’s mental and physical status within 10 minutes of PR
initiation, the physician is notified, and a physician’s order obtained.
f. If the incident necessitating PR occurs on grounds, in an area not under the direct supervision of nursing staff, the following procedures are to be followed:
It is the responsibility of the supervisor of the staff who utilized PR to ensure that: the
nursing supervisor responsible for the patient’s ward is immediately notified and provided
with the following information:
• a description of what happened and why it was necessary to employ PR;
• any injuries to the patient or staff involved;
• the current physical and behavioral status of the patient;
• the immediate need for additional staff assistance, if indicated.
• The incident is properly documented and the SI-815 is initiated by the person applying
or observing the application of the restraint;
• The patient is safely returned to the ward, as soon as possible after the incident;
• Debriefing is provided to all staff involved in the incident.
It is the Nursing Supervisor’s responsibility to ensure that:
• a Registered Nurse notifies the physician and obtains a verbal order,
• a Registered Nurse is promptly dispatched to the site of the restraint to assess and
monitor the patient and determine next steps, and,
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• additional staff are sent to the site to ensure staff and patient safety and to assist in the
patient’s safe return to the ward, if necessary.
• Physical restraint use may continue only so long as is needed to return the patient to
his living area.
g. If an incident requiring the use of physical restraint occurs off grounds, and a Registered
Nurse is unavailable, the person applying or observing application of the restraint shall:
• attempt to ensure the safety of the patient, staff, and the public in a manner affording
the patient the most privacy and dignity possible;
• contact the hospital nursing department for assistance and direction, following local
policy and procedure, as soon as it is safe to do so;
• provide the hospital contact person with the following information:
○ a description of what happened and why it was necessary to employ PR;
○ any injuries to the patient or staff involved;
○ the current physical and behavioral status of the patient;
○ the immediate need for additional staff assistance, if indicated.
The Nursing Supervisor shall:
• designate a nurse assigned to the patient’s ward to assess the emotional and physical
status of the patient immediately upon return to the hospital, and
• ensure that the attending psychiatrist or on-site physician is notified and a physician’s
verbal order for use of the restraint is obtained.
h. A physician’s order for any use of physical restraint must be obtained and the physician
shall examine the patient within 30 minutes. If the incident occurs off grounds, the Registered Nurse shall notify the physician promptly when the patient is returned to the hospital
and the physician examination shall occur within 30 minutes of the patient’s return.
i. Physical restraint shall only be used by staff with demonstrated competency in its use.
j. Physical restraint used in an off grounds emergency may be used only so long as necessary
to return the patient to his hospital living area.
k. It is recognized that there may be emergency situations that require an individual to act
quickly to prevent harm to the patient or others. Individual staff members should refrain
from attempting to use physical management techniques alone unless absolutely essential.
The following guidelines should be followed in a psychiatric emergency that involves
violent behavior or the potential for violent behavior:
• Attempt to establish rapport with the patient. Speak to the person in a calm manner.
• Acknowledge the patient’s emotions and offer to help.
• At the first sign of escalating behavior, staff shall immediately summon help
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• If other patients or visitors could be placed in danger due to the escalating behavior,
remove them from the area as soon as possible.
• Keep other patients from entering to the area.
• Unless absolutely necessary to protect the patient, self or others, do not attempt to
employ PR techniques alone. Wait for help to arrive.
If physical restraints are essential, only approved interventions in which the employee has
demonstrated competency, may be employed.
Before and during use of any physical restraint technique, staff applying or observing the
technique shall explain to the patient what is happening, why the restraint is being used, and
what the patient must do to obtain release.
l. Documentation requirements:
At least one staff person directly involved in the administration or observation of the physical restraint episode must document the incident in the patient’s medical record;
The RN who assessed the patient must also record the findings of the assessment, along
with any follow-up actions recommended. The physician order and assessment shall all
be documented in the medical record, as well as any ordered or recommended treatment
changes.
m. Documentation shall provide at least the following information:
• when and where the incident occurred;
• a clear description of the behaviors that necessitated use of PR;
• a description of prior interventions tried and patient response;
• a description of the PR techniques used and their duration;
• a description of the patient’s physical and emotional response during and subsequent
to the restraint episode;
• a description of how the patient’s physical and emotional response was monitored
during the incident;
• a description of any injuries observed or suspected by staff, or reported by the patient;
• the time and location of the nursing assessment;
• the name of the physician notified , time of notification, name/title of employee notified,
and any instructions or orders received from the physician upon notification;
• the time of physician examination and physician findings and orders.
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B. Protective Restraint
1. DEFINITION
The use of restraint devices to restrict the movement of a person with a medical condition
to prevent falls, achieve maximum body functioning, or promote normal body positioning,
when the patient is unable to remove the restraining device without assistance.
2. INDICATIONS
Protective restraint involving the use of Geri chairs, chairs with trays, bed rails, straps or
cloth devices used to position the patient, restrict freedom of movement or access to one’s
body, prevent falls, maintain posture and for other medical purposes shall only be used as a
last resort, when:
a. adaptive or assistive devices or environmental changes have failed to prevent patient
injury,
b. assessment of the patient’s history and condition indicates the strong probability that
substantial harm to the patient will occur in absence of temporary restraint;
c. the risks of potential injury exceeds the known risks of injury and death associated with
use of protective restraint.
3. EXPECTATIONS
a. As with restraint used for behavioral control in emergency situations, it is the goal of the
OMHSAS to ultimately eliminate the use of protective restraint.
b. Use of alternative interventions shall be added to the treatment plan to reduce the need
for protective restraint. Such alternatives include physical therapy, ambulatory assertive
devises, recliner chairs, alarms, perimeter beds, non-slip cushions or shoes, beds with
shortened legs and safety belts removable by the patient.
c. Use of protective restraint requires the written time limited order of the physician.
d. The patient in protective restraint must be continually monitored and reassessed and the
restraint removed as soon as the alternative measures for safety are feasible.
4. PROCEDURES FOR THE USE OF PROTECTIVE RESTRAINT
a. Restraints are prescription devices and shall be used only with a physician’s order. In
emergency situations, a registered nurse may initiate the use of restraints for the protection
of the patient and/or others. The physician on duty/on-call shall be contacted immediately
and a verbal order may be obtained. The physician’s order shall not exceed one (1) hour.
Orders shall specify “up to” one (1) hour, rather than a predetermined amount of time. The
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physician involved shall see the patient within thirty (30) minutes of the initiation of the
restraints (barring extenuating circumstances), and then shall write/countersign the order
for the restraints and document his/her assessment of the patient in the medical record.
Specific behavioral criteria written by the physician shall specify under what conditions
the restraints may be discontinued, to insure minimum usage. When a physician’s order
documented before restraints can be ordered;
b. Patients in restraint devises shall be placed on constant 1:1 observation (at arm’s length),
and this action is to be documented by attending staff;
c. Physical needs shall be met promptly. The patient’s physical condition shall be assessed,
and the opportunity for personal care, including fluids, bathroom use, exercise, meals and
hygiene, shall be provided and documented throughout each restraint incident at no less
than 15 minute intervals.
5. PROTECTIVE RESTRAINT DOES NOT INCLUDE:
a. use of adaptive, assistive, or positioning devices that can be moved or removed by the
patient;
b. helmets used to prevent head injury;
c. wheelchairs, Geri chairs or trays, safety belts, postural supports, orthopedic devices, or bed
rails, if the patient can remove these devices, and,
d. alarmed chairs, beds, or doorways.
e. Family notification, patient/staff debriefing, continuous quality improvement and staff
training requirements contained in sections II through V of this bulletin shall also be
applicable to the use of protective restraint.
C. Restraint for the Purpose of Administering Necessary Medication or Medical Treatment
1. INDICATIONS
Physical or mechanical restraints may be applied briefly to enable clinical staff to administer
necessary medication or medical treatment consistent with established protocol in the following situations:
a. To facilitate necessary medical treatment of a resisting or uncooperative patient who is
adjudicated to be incompetent to make informed decisions about medical care, when a
substitute decision-maker has given permission for the necessary treatment, under the
provisions of Mental Health Bulletin 99-83-26;
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b. To permit administration of prescribed psychoactive medication or facilitate veni-puncture
for laboratory studies required by the use of psychoactive medication to a physically resisting patient, in accord with Mental Health Bulletin 99-85-10.
2. EXPECTATIONS
a. Every effort to gain patient cooperation for essential medical procedures has occurred
but failed.
b. The restraint will be used only so long as is necessary to successfully complete the
procedure.
c. A time-limited physician’s order for the restraint procedure is obtained reflecting the
anticipated length of the procedure. PRN’s and standing orders may not be used.
d. The treatment plan shall be modified to address the patient’s need for restraint.
e. Provisions for patient debriefing, staff training, and continuous quality improvement
contained in this bulletin are met.
f. Procedures for mechanical or physical restraint use described in this bulletin are followed,
depending on the type of restraint used. (SectionVII, A3 or Section VII 4d).
D. Contraindications and Conditions for Use ff Physical Holds and Mechanical
Restraints
1. Physical restraint may not be used on persons who have known medical or physical
conditions where there is reason to believe that such use would endanger their lives
or exacerbate a medical condition, e.g. fractures, back injury, pregnancy, etc.
See Attachment B.
2. Choice of mechanical restraint devises and positioning of the body within shall be
designated by a physician based on assessment of the patient’s physical and psychiatric
condition. See Attachment B.
E. Human Holds or Mechanical Devises Used to Restrict Movement of All or Part of
The Patient’s Body Do Not Constitute Restraint Under the Following Circumstances:
1. Physical prompting, escorting or guiding of a person to assist in development or use
of ADL’s;
2. Physically holding a cooperative person in a manner that is necessary to administer needed
medical, dental or nursing care;
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3. Physically redirecting a nonresistant person to avoid a physical confrontation with another
person;
4. Locked areas or wards for security or safety purposes;
5. Use of mechanical restraints for security purposes on forensic patients subject to criminal
detention, outside of the forensic center’s secure perimeter or in security emergencies, as
required by law and Bulletin SMH 97-04.
F. Chemical Restraint
1. DEFINITION
Chemical restraint shall mean the use of drugs or chemicals for the specific and exclusive
purpose of controlling aggressive patient behavior, which restricts the patient’s freedom of
movement by rendering the patient semi-stuperous or unable to attend to personal needs.
Drugs administered on a regular basis, as part of the individualized treatment plan, and for
the purpose of treating the symptoms of mental, emotional, or behavioral disorders, and for
assisting the patient in gaining progressive self-control over his/her impulses, are not considered chemical restraints.
2. POLICY
It shall be the policy of the Department of Public Welfare and the Office of Mental Health
and Substance Abuse Services that chemical restraints are not utilized at any State mental
hospital or the Restoration Center.
3. CONTINUOUS PERFORMANCE IMPROVEMENT MONITORING
The Chief Executive Officer of each State mental hospital and the Restoration Center, in
conjunction with the Medical Staff, is responsible for assuring that ongoing drug utilization monitoring of patients/residents is maintained to ensure that chemical restraints are not
prescribed. Leadership staff (including Nursing, Pharmacy, and Quality Improvement) and
the facility Pharmacy and Therapeutics Committee shall maintain compliance with the provisions of this policy through the institution of performance improvement programs designed
to continuously review, monitor, and analyze drug utilization.
VIII. Exclusion
A. Definition
The therapeutic removal of a patient from his/her immediate environment and the restriction
of this individual to an unlocked (quiet) room for a brief, time-limited period not to exceed
30 minutes, for the purpose of assisting the individual to regain emotional control. Exclusion
involves the patient’s cooperation in leaving the immediate environment and in remaining in
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another, specified area (e.g., unlocked seclusion room) with the door open and unlocked for a
specified period of time. Each facility shall designate rooms/areas to be utilized for exclusion.
B. The Following Events Are Not Considered Exclusion:
1. A patient’s request to spend time in a private, unlocked room is not considered exclusion
and should be granted where feasible and not clinically or therapeutically contraindicated;
2. Quarantine or other preventive health measures are not considered exclusion; and
Exclusion is not a modality utilized in the State Restoration Center.
C. Indications
Prior to the use of exclusion, the following criteria must be met:
1. All lesser restrictive treatment options/interventions, including the use of alternative pharmaceutical interventions have been considered and attempted and have failed to diminish the patient’s escalating behavior. Documentation of all such efforts shall be entered
into the patient’s medical record as well as the necessary rationale and justification of the
exclusion need;
2. Unless clinically contraindicated, prior to the use of exclusion the patient shall be given
a choice of treatment options that may assist with limiting the environmental stimuli and
their consequent effects on the patient’s emotional status. The reason/justification for
exclusion shall be communicated clearly to the patient. Treatment expectations shall be
carefully explained, including the outcomes which should occur within brief, time-limited
intervals; and
3. Exclusion is an adjunct to treatment with defined clinical parameters of expected care and,
therefore, shall never be used in a punitive or otherwise non-therapeutic manner.
D. Contraindications
Exclusion shall not be utilized for patients who exhibit suicidal or self-injurious behaviors
for who have a known seizure disorder or any other medical condition, which precludes the
safe application of this modality (such situations shall be determined by the attending/on-call
physician on a case-by-case basis).
E. Procedures
1. Each patient shall be made aware of the specific behaviors that necessitated the use of
exclusion and those behaviors and mental status components which will terminate the
exclusion;
2. Individual treatment plans shall have goals and interventions established to eliminate the
need for exclusion;
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3. Exclusion shall be used only with a physician’s order. In emergency situations, a registered
nurse may initiate the use of exclusion. Immediately the physician on duty/on-call shall
be contacted and a verbal order may be obtained. The physician’s order shall not exceed
30 minutes. Orders shall specify “up to” thirty (30) minutes, rather than a predetermined
amount of time. The physician involved shall see the patient within thirty (30) minutes of
the initiation of exclusion (barring extenuating circumstances) and then shall write/countersign the order for the exclusion, and document his/her assessment of the patient in the
medical record. Specific behavioral criteria written by the physician shall specify when
the exclusion may be discontinued, to insure minimum usage. When a physician’s order
documented before exclusion can be reordered;
4. Patients in exclusion shall be monitored/checked at routine intervals not to exceed fifteen
(15) minutes;
5. Exclusion shall not affect the rights of an individual to basic sustenance, clothing, or
communication with appropriate or responsible persons (i.e., family, attorneys, physicians,
patient advocates, or clergy); however, any person wishing to visit the patient in exclusion
must gain authorization from the attending/on-call physician;
6. Patient physical needs shall be met promptly. Opportunity for personal care, including
fluids, bathroom use.
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Commonwealth of Pennsylvania
Department of Public Welfare
February 3, 1999
SUBJECT: Guidelines for the use of physical management and mechanical restraint
techniques
TO: CEOs, State Mental Health Facilities and Assistant Superintendents for Clinical
Services FROM: Steven Karp, D.O., Medical Director
In recent months national attention has been directed toward the techniques used to restrain
and physically contain persons hospitalized for psychiatric treatment, living in residential
treatment settings, residing in nursing homes and even those who are incarcerated, during
crisis in which their behavior poses a danger of harm to self or others. Following press
reports of the death of persons subject to physical or mechanical
restraint, the National Alliance for the Mentally Ill called upon the federal government to
investigate and provide oversight into patient deaths in restraint. Pennsylvania Protection
and Advocacy has requested we officially ban restraint practices which may have adverse
medical consequences, and JCAHO had published a summary and analysis of sentinel event
restraint death root causes, with recommendations for safer practice.
We have subsequently affirmed that each hospital’s use of physical and mechanical restraint
application techniques is based on a variety of private sector training and certification programs. These programs usually include verbal and nonverbal crisis de-escalation techniques,
self-defense and physical containment strategies to promote safe physical management of the
patient. Training in these certified programs is required at the time of employment, usually
for all staff in patient contact assignments, and annually for all direct care staff engaged in
actual physical management of patients (i.e. nursing).
Internal hospital policies were subsequently developed to require use of the techniques
taught in these programs.
Safe physical management technique training was originally mandated for all direct care
staff in State mental hospitals over 15 years ago, using a copyrighted training program
provided by OMH through a private vendor. During subsequent years, some hospitals
have updated the curricula, or contracted with new vendors for this service. Consequently,
the systems in place across the State are no longer consistent. Although none of these systems
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appears to teach techniques that are now known to increase risk of harm during the physical
management or restraint of patients, they may not explicitly prohibit the methods and
techniques that are more likely to incur a risk to patient safety nor describe the reasons
for such risk.
The purpose of this memorandum is to apprise all Superintendents and Assistance
Superintendents for Clinical Services of the following risk factors and guidelines for the
prevention of restraint deaths. They shall ensure that hospital policy and direct care staff
training reflect these guidelines.
A. Factors Contributing to Risk of Asphyxia During Physical Management and Restraint
___ Cocaine induced excited delirium (impaired thinking, disorientation, visual hallucinations,
etc.) may increase the heart rate to a critical level when the patient is being restrained
or is confined to restraints.
___ Drug or alcohol intoxication reduce respiratory drive, diminishing the individual’s
realization that suffocation is occurring.
___ The patient who engages in extreme violent activity and struggles may be more
vulnerable to subsequent respiratory failure during physical intervention and restraint.
___ Sudden unresponsiveness or limpness during or immediately after a struggle may
indicate cardiopulmonary events that warrant immediate medical attention.
___ Preexisting risk factors combined with body position can compound the risk of sudden
death, particularly following a struggle. These risk factors include:
___ Obesity
___ Alcohol and drug use
___ An enlarged heart (stress and low blood oxygen enhance the susceptibility to cardiac arrest)
___ Smoking
___ Deformities that preclude proper restraint positioning
___ Emphysema, bronchitis, asthma, colds, and other respiratory conditions enhance risk,
especially if the patient is placed face down.
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B. Procedural Factors That Increase Risk During the Restraint Process
___ All of the above preexisting risk factors are exacerbated when the patient is placed in a
face down position and/or when “hands are held behind the back” holds or restraints are
employed.
___ When the patient is held or restrained in a face down (prone) position, lungs are compressed and breathing may become labored. The more pressure that is applied to the
person’s torso, the more compression is increased.
___ Restraint in a supine (face up) position may predispose the patient to aspiration.
___ Inadequate numbers of staff to safely manage mechanical restraint application may increase the likelihood that staff will place their body weight across the patient’s back,
or use other unsafe practices which enhance the danger of patient injury.
___ Failure to search the patient for contraband when placed in mechanical restraints can
result in fire from attempted use smoking materials, or other self-harm.
___ Placing a pillow, blanket, or other item under or over the patient’s face as part of a restraint
or holding process, especially when the patient is in a prone position, may result in
suffocation.
___ Use of high neck vests are blamed for strangulation deaths in geriatric patients, as are use
of unprotected split side bed rails.
___ Incorrect application of a mechanical restraint device enhances strangulation potential.
___ Techniques which pull the patient’s or employee’s arms across the neck contribute to risk
of asphyxiation.
___ Leaving a patient in mechanical restraints without continuous staff observation precluded
timely corrective action in response to physical distress.
C. Guidelines for Safe Physical Management and Restraint
Effective immediately, the following practices shall be adopted and incorporated into
staff training curricula:
1. No fewer than 3 staff persons shall be present to apply mechanical restraints. If insufficient
staff are available to safely control and restrain a patient in a psychiatric crisis, staff should
remove others from harm’s way and get help before attempting physical management or
restraint.
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2. At no time is pressure to be placed upon the patient’s back while the patient is in the prone
position in a floor control situation. Patient arms, shoulders, and legs are to be immobilized. Staff body weight is not to be applied to the torso or above the upper thighs.
3. Patients in restraints must be placed under a physician’s order for constant staff observation for the duration of the restraint.
4. Patients placed in seclusion or restraint must always be promptly searched for contraband.
5. High neck vests or waist restraints are not to be used for body positioning in geriatric or
long term care settings, nor is any patient to be restrained to a bed with unprotected split
side rails.
6. Never place a towel, bag, blanket, or other cover over a patient’s face during the physical
management process.
7. If a patient is placed under floor control in a prone position for the purpose of administering an injection or application of mechanical restraint, the patient shall be rolled/turned to
the supine (face up) position as soon as the procedure is completed, unless the risk or act
of vomiting is present.
8. When restraining patients in a supine position, ensure that the head is free to rotate. The
head of the bed should be elevated to minimize the risk of aspiration, unless clinically
contraindicated.
9. Physicians writing initial and renewed orders for restraint shall assess, consider, and
document the patient’s preexisting physical condition when ordering the body position,
number and manner of mechanical restraints.
Deviation from the above guidelines for clinical reasons in individual cases must be
documented and approved by the Assistant Superintendent for Clinical Services.
In the coming months, I will be reviewing available physical management technologies and
training programs with the Assistant Superintendent for Clinical Services and the Statewide
Risk Management Committee to select a statewide training curriculum. Until then, please be
sure that your staff are made aware of the aforementioned risk factors and policy guidelines.
cc: Mr. Curie
Mr. Kopchick
Ms. Hardenstine
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Commonwealth of Pennsylvania
Department of Public Welfare
May 15, 2000
SUBJECT: Mechanical Restraint Devises
TO: CEOs, State Mental Health Facilities
FROM: Steven Karp, D.O, Medical Director, OMHSAS, and George A. Kopchick, Jr.,
Director, Bureau of Hospital Operations
The purpose of this memorandum is to revise OMHSAS 99-01, specifically the section
entitled Restraints: Treatment Expectations, Section B, located on p.8 of that Bulletin,
which describes the mechanical restraint devises which are acceptable for use for psychiatric
purposes in the State mental hospital system.
This memorandum is also intended to delete obsolete devises currently listed in the ERPS
Manual, Appendix B.
Effective immediately, restraint devises which can be legitimately used for psychiatric
purposes are limited to those found in the following list. The two-letter code adjacent to
the devise is the ERPS code for the devise, which will be incorporated into the SI-815 in
the very near future.
Permitted Devises:
Soft Velcro Leather Restraint
a a one point b c two point
a b two point b i three point
a c three point b i four point
a d four point
a f soft mitts
All body restraints listed in the OMHS 99-01 and/or the ERPS Bulletin, Appendix B are
henceforth prohibited for psychiatric purposes. The category of “Psychological Restraint”
coded on Appendix B, code sheet 3, of the E/R/P/S Manual is also abolished.
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Items (c b) helmets and (d b) geri chair may continue to be used as “protective or adaptive
devises” under the conditions listed on p. 7 of OMHSAS 99-01, under the section entitled
“Excluded from the Definition of Restraint,” but are not to be used as restraint devises to
control acute or episodic aggressive behavior.
Metal restraints may be used only in forensic units, for security purposes, and only during
the transport of such patients outside of the forensic unit’s secure perimeter as described in
Bulletin SMH-95-02. Metal restraints may not be used to control acute or episodic aggressive
behavior or as a substitute for other restraint devises for any purpose described in Bulletin
OMHSAS-99-01.
Any mechanical restraint not included in the list of approved devises listed above is
prohibited. Requests to introduce new or additional devises to the above list must be
approved in writing by the OMHSAS Chief of Clinical Services and the Director, Bureau
of Hospital Operations.
cc: Mr. Curie
Assistant Superintendents for Clinical Services
Performance Improvement Directors
Assistant Superintendents for Nursing Services
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