Roadmap to Restraint and Seclusion Free Services at LRC Lisa L. Franz, MBA, CPHQ Quality Improvement Coordinator HHS Dan Powers, JD Consumer Liaison -

Roadmap to Restraint and Seclusion Free

Services at LRC

Lisa L. Franz, MBA, CPHQQuality Improvement Coordinator HHS

Dan Powers, JDConsumer Liaison - Program Specialist

Agenda Overview Goal: Reduce / Eliminate R & S NAC/SMHA and SAMHSA Pilot Project Training Materials Future State

Overview Seclusion - Involuntary confinement of a patient alone

in a room where the patient is physically prevented from leaving including: Manual or Electronic Locks Staff Proximal to the Room, Preventing Exit

Restraint - Involuntary method of physically restricting a patient’s freedom of movement, NOT including: Security transport Medical purposes / Protective devices Manual holds of less than 5 minutes

Goal: Reduce / Eliminate S & R

“Seclusion and restraint – with their inherent physical force, chemical or physical bodily immobilization and isolation – do not alleviate human suffering.”

Charles Curie, Administrator of Substance Abuse and Mental Health Services Administration

Staff Perspective

“A kid will refuse to go to the quiet area or a kid will refuse to go to the quiet room and the staff will think, OK, if I don’t follow up on this the other kids will see they don’t have to listen to me and my authority will be challenged.”

Staff Person

Consumer Experience “It was terrifying, dehumanizing,

degrading and painful. Not only was the leather biting into my wrists, my body had been invaded by a substance that caused a feeling of intense internal violation.”

Consumer, NACSMHA In Our Own Voices Survey, 2001

Premise Seclusion and restraint

reflects treatment failure

New Era Tighter controls 1999 Federal and State mental health authorities

furthered policy change National Association of State Mental Health

Program Director’s (NASMHPD), Created Violence and Coercion Free Mental Health Environments: A National Initiative and Call to Action

State of Pennsylvania demonstrated commitment with their “Leading the Way Seclusion and Restraint Initiative.”

Success 1997 – Pennsylvania Department of Pubic

Welfare’s OMHSAS pursue the elimination of seclusion and restraint

Since 1997, seclusion and restraint were reduced by 90 percent, and the hours of use fell by 95 percent

By July 2000, one state mental hospital had not used seclusion for over 20 months

Pilot Project 30 Staff members of LRC will attend training

March 31, April 1, April 2 AFS, STC, FS 2/3 Direct Care, 1/3 Administration

8 Of these will participate in pre-assessment Feedback will be collected from the

participants Current S/R data will be compared to post-

implementation data

SAMHSA Substance Abuse and Mental Health Services

Administration Provided Funding for Roadmap Project Federal agency Improve the quality and availability of

prevention, treatment, and rehabilitative services

Reduce illness, death, disability, and cost to society

National Association of Consumer/Survivor Mental Health Administrators

Developed materials for Roadmap Program Founded in 1993 State mental health agency senior managers

who are current or former recipients of mental health services

Offer technical assistance to State Mental Health Agencies on exemplary practice

NAC/SMHA

Insight Provided By Steering Committee, representing virtually

every stakeholder organization American Psychiatric Association National Association of Protection and Advocacy

Services National Mental Health Association JCAHO CMS

Consumers from around the country Psychiatric line staff Current literature

Roadmap Focus: Early identification and intervention in

conflict situations Understanding the experience from the

perspective of the individuals involved Improving communication and problem-

solving skills Decreasing and ultimately eliminating the

damaging effects of restraint and seclusion

Training Materials Module 1 - personal experience of restraint

and seclusion Module 2 - impact of trauma on consumers

and on line staff Module 3 - change needed to ensure cultural

change within an institution Module 4 - resiliency and recovery from the

consumer perspective

Training Materials Module 5 - strategies that will lead to the

reduction and elimination of restraint and seclusion

Module 6 - strategies to prevent restraint and seclusion

Module 7 - sustainable change through consumer and staff involvement

Module 8 - development of both personal and workplace action plans

Effective Approaches Peer-delivered services Self-help techniques New medications Emphasis on recovery Understanding the relationship between

trauma and mental illness Medical Directors of the National

Association of State Mental Health Program Directors report on Restraint and Seclusion (1999)

Options Take a walk Do physical exercise Read my Wellness Recovery Action Plan

(WRAP) Cry; chemical restraints often prevent this Have someone sit with me for a while Take shower or bath Draw Yell

Options Relax in a homey setting –A big over stuffed,

vibrating, heated chair with a blanket, headphones and gentle soft music

Be allowed to have something of my own to comfort me

In Crisis, I Need PersonsWho Can:

BE with me Acknowledge my pain without trying to ‘fix’ it Not be afraid of my sexual abuse Ask what would help

In Crisis, I Need PersonsWho Can:

Understand the coping role of suicidal thoughts as giving a sense of some control

Know the difference between “I want to die” (despair, hopelessness) and “I want to kill myself” (anger, defiance)

Give me options and choices, and respect me

Helpful to Hear Let’s sit down and talk about the problem It’s your choice to discuss, I only have to

restrain if you start hurting someone You are going to be ok We are here to help you

Helpful to Hear You are a person and allowed to make

mistakes All feelings are normal It will get better You are all right, but your behavior is

inappropriate

Grounding Methods for stopping the re-experiencing of a

trauma and getting back to the here and now Focus on something in one or more of the five

senses in the present

Maintain Visual Contact

Stay out of dark or dim areas, or turn on the lights

Don’t allow hiding Make sure eyes remain open

Describe the color of the walls or carpet Give a favorite object and assist the person

in noticing how it looks, feels, and smells Present previously developed flashcards

Maintain Visual Contact

Maintain Personal Contact

Say that person’s name Tell him/her where s/he is and the full date Use normal voice tones (not soft or rhythmic) Tell the consumer you know s/he is frightened,

but s/he is safe Ask the consumer to look at your face and try to

make direct, focused eye contact If frightened by eye contact, redirect to a different

part of your body, like hair or shirt

Focus on Physical Ask the consumer to start naming what s/he sees

in the room Suggest s/he feels own weight, or the chair s/he is

sitting on, or notices how his/her feet feel on the floor

Help the consumer take a walk, stamp feet Recommend the consumer get in the ‘in control’

body posture

Focus on Present If not alarmed by it, help consumer look in

the mirror and see that s/he is an adult, not a child in a traumatic situation

Call the consumer’s attention to a calendar and/or a clock and help him/her figure out what day and time it is.

Focus on Present Ask the consumer questions about the

present Ask the consumer about her/his interests or

activities, such as recreational activities or a pet

Direct and assist in writing or drawing about something positive

Debrief Help reassure consumer and normalize

event/current situation If consumer is able, assist with relaxation

techniques Try to identify what causes the consumer’s

symptoms When possible and reasonable, help the

consumer work out how to avoid their triggers until better able to ground her/himself and cope more effectively

Debrief Determine body postures that accompany

feelings of being flooded and/or overwhelmed

Plan new ways to attempt to cope with stress Develop a crisis response plan for the next

occurrence

Daily Maintenance Plan Triggers Early Warning Signs Symptoms that Occur When the Situation is

Worse Crisis Plan/Post Crisis Plan

WRAP

As A Group…. Decrease the % of restraints Decrease the % of seclusions Decrease the # of hours of restraint Decrease the # hours of seclusion The top three things we could do The action plan

Future State

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.”

Margaret Mead