Transcript Fetal Alcohol Spectrum Disorders (FASD) Informed Care

Module 1
The Personal Experience of
Restraint and Seclusion
Learning Objectives
Upon completion of this module the participant will
be able to:
• 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
“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
This manual was funded by the
Center for Mental Health
Services and is written from
consumer perspectives. The goal
is to bridge the differences and
build a recovery-based
partnership between mental
health consumers and direct care
staff.
Listen
When I ask you to listen to me and
You start giving me advice,
You have not done what I have asked.
When I ask you to listen to me and
You begin to tell me why I shouldn’t feel that way
You are trampling on my feelings.
When I ask you to listen to me and
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
Exercise:
Getting to Know You
Overview
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
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).
Consumer Complaints
Ray & Rappaport, 1993
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 national standards has
reportedly generated wide
variability in the use of restraint
and seclusion – including
potentially dangerous and unsafe
practices.
Safety
Conflicting Definitions of
Safety
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
Inappropriate Uses of
Seclusion and Restraint
• Control the Environment
• Coercion
• Punishment
Treatment Approaches to
Reduce Seclusion & Restraint
• Peer-delivered services
• Self-help techniques
• New medications
• Emphasis on recovery
• Understanding the relationship between
trauma and mental illness
Reading: NASPMHD Review of
Literature Related to Safety and
Use of Seclusion and Restraint
Special Needs Populations
Participant Manual:
Special Needs Populations
Personal Perspectives:
Consumers
Exercise:
Hartford Courant Articles
Reading:
Hartford Courant Articles
Exercise:
Personal Perspectives - Consumers
Personal Perspectives:
Direct Care Staff
“When I participated in my first
restraint experience I vomited.”
(Interview with mental health
worker)
Exercise:
Personal Perspectives: Direct
Care Staff
Reading: Direct Care Staff
Quotes
Module 2
Understanding the
Impact of Trauma
Learning Objectives
Upon completion of this module the participant will
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
“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
“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
Exercise: Trauma Background
Definitions Related to
Trauma
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.
Dissociations
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.
Common Reactions to
Trauma
Exercise: Common Reactions to
Trauma
Participant Manual: Some
Common Reactions to Trauma
Some Common Reactions to Trauma
Mary S. Gilbert, Ph.D.
Physical
Reactions
Nervous
energy,
jitter,
muscle
tension
Upset
stomach
Rapid Heart
Rate
Dizziness
Lack of
energy,
fatigue
Teeth
grinding
Mental
Reactions
Changes in the way you
think about yourself
Changes in way you think
about the world
Changes in the way you
think about other people
Heightened awareness of
your surrounding
(hypervigilance)
Lessened awareness,
disconnection from
yourself (dissociation)
Difficulty concentrating
Poor attention or memory
problems
Difficulty making decision
Intrusive images
Emotional Reactions
Behavioral
Reactions
Fear, inability to feel safe
Sadness, grief, depression
Guilt
Anger, irritability
Numbness, lack of feelings
Inability to enjoy anything
Loss of trust
Loss of self-esteem
Feeling helpless
Emotional distance from
others
Intense or extreme
feelings
Feeling chronically empty
Blunted, then extreme
feelings
Becoming withdrawn or
isolated from others
Easily startled
Avoiding places or
situation
Becoming
confrontational and
aggressive
Change in eating habits
Loss or gain in weight
Restlessness
Increase or decrease in
sexual activity
Self-injury
Learned helplessness
Addictive behaviors
Effects of Trauma
on the Brain
Effects of Trauma on the Brain
•
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 hyper-aroused and hyper-vigilant 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.
Effects of Trauma on the Brain
www.ChildTrauma.org
Differential Responses
to Threat
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
Assessment of Trauma
Assessment of Trauma
• 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 (MMH, 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.
“Never being asked about trauma is like
the abuse as a child.”
Survivor from Maine
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 mis-diagnosis 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)
Survivors and Trusted Professionals Speak about
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)
Exercise:
Assessment of Trauma
Retraumatization via
Hospitalization
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)
Survivors and Trusted Professionals Speak about
Retraumatization via Hospitalization - Creating Safe
Places for Healing: What Helps
•
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)
De-Escalation Preferences
Exercise: De-Escalation
Preferences
What Survivors Want in
Times of Crisis
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.”
Staff Trauma (Secondary
Traumatization)
Reading:
Adult Survivors of Childhood Sexual
Abuse in the Mental Health System:
Involuntary Intervention,
Retraumatization, and Staff Training
Healing from Trauma
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
Participant Manual: Dealing with
the Effects of Trauma: A SelfHelp Guide
by Mary Ellen Copeland
Grounding Techniques
Exercise: Grounding
Techniques
Journal/Take Action
Challenges
Module 3
Creating Cultural
Change
Learning Objectives
Upon completion of this module the participant will
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
Exercise: Flowers are Red
Participant Manual:
Flowers are Red
Overview
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)
Seclusion and Restraint are not
evidence-based practices
•
The research on the use of seclusion and 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 1960’s 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
seclusion and restraint.
A Public Health Model that eliminates the
use of seclusion and restraint would support:
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
Primary Prevention
Preventing and reducing the
need for seclusion and
restraint
Secondary Prevention
Using the least restrictive
methods possible
Tertiary Prevention
Intervention to reverse or
prevent negative
consequences
Pennsylvania: A Model for
Reform
Leading the Way: Toward a Seclusion and
Restraint Free Environment by the
Pennsylvania Office of Mental Health &
Substance Abuse
Pennsylvania Model
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
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
Pennsylvania Model Policy
•
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
Cost Effective
Entire initiative used current
staff and had no increased
costs associated with it
Pennsylvania Restraint Usage
Pennsylvania Seclusion Usage
Public Access to Data
Public access to data created
healthy competition among State
hospitals to continue further
reduction of seclusion and
restraint
Decreased Staff Injuries
DECREASED STAFF
INJURIES!
Cultural Change
Cultural Change and Consumer
Recovery
Cultural changes created
quicker consumer recovery,
hospital discharges and
community reintegration.
Partnerships Consumers and
Caregivers
Stronger partnerships among
consumers and caregivers
Social Justice Levels of Change



Intrapersonal – occurring within
the individual mind or self
Interpersonal – involving
relationships between persons
Systems/Cultural Change
Ghandi Quote
“Be
the change you want to see
in others.”
Mahatma Ghandi
Defining Culture
Culture:
Who we are and how we do
things
Cultural Building Blocks
• Norms
• Climate
• Organizational Support
• Values
Exercise: My Organization
Currently Is…
Exercise: People with a Mental
Health Diagnosis Are…
Participant Manual: My
Organization Currently Is…
In Our Own Voices
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?
Participant Manual: What
Would Have Been Helpful
Exercise: What Would Have
Been Helpful to Hear
What would have been helpful
for you to hear? – pg 1
•
•
•
•
•
•
•
•
•
•
•
•
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?
No one is 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
What would have been helpful
for you to hear? – pg 2
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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?
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 over stuffed, vibrating, heated chair with a
blanket, headphones and gentle soft music
“…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 4
Understanding Resilience and
Recovery from the
Consumer Perspective
Learning Objectives
Upon completion of this module the participant will
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
elimination of seclusion and restraint.
Overview
Resilience
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., 1999
Resources to Be Developed


“Young people are resources to be developed,
not problems to be solved.” Karen Pittman,
Ph.D.
We could substitute, “people diagnosed with a
mental illness” in Dr. Pittman’s quote – and that
is exactly the paradigm shift we are moving
towards. People diagnosed with a mental illness
are resources to be developed, not problems to
be solved.
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
Exercise: Someone Who Believed
in Them Helped Them to Recover
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!”
Recovery
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).
Recovery is…
…“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).
Exercise: Recovery as a
Journey of the Heart
Participant Manual: Recovery
from Mental Illness: A Guiding
Vision of the Mental Health
Service System in the 1990’s
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.
Recovery Assumptions
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.
Exercise: What Are We
Recovering From?
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
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
Journal/Take Action
Challenges
Module 5
Strategies to Prevent
Seclusion and Restraint
Overview
“It is rather impressive how
creative people can be when
restraint is simply not a part of
the treatment culture.”
JCAHO Testimony
John N. Follansbee, M.D.
Northern Virginia Mental Health Institute
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
“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.”
Charles Curie
General Benefits of
Consumer-Driven Supports (CDS)
• 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:
• Empowerment
• Independence
• Responsibility
• Choice
• Respect & Dignity
• Social Action
Key Elements for
Consumer/Survivor Self-Help:
• Peer Support
• Hope
• Recovery
Wellness Recovery Action
Plan (WRAP)
The Wellness Recovery Action Plan
(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 (including Wellness Toolbox)
• Triggers
• Early Warning Signs
• Symptoms that Occur When the Situation is Worse
• Crisis Plan
• Post Crisis Plan
“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
Participant Manual:
Examples of Consumer WRAP
Plans
Exercise: Developing a Wellness
Recovery Action Plan (WRAP)
Drop-In Centers
“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 Centers Activities
•
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?
• 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
Recovery Through the Arts
Comfort Rooms
What would have been helpful in preventing
the use of seclusion or restraints for you?
• A homey setting – soft chairs, drapes,
pictures
• A big over-stuffed, 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)
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.
Participant Manual:
How to Set Up a Comfort Room
by Gayle Bluebird
Service Animals
Psychiatric Advance
Directives
“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
• 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.)
Participant Manual: Why
Should I Fill Out a Psychiatric
Advance Directive?
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.









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
Exercise: Creating My Own
Psychiatric Advance Directive
Advance Directive Resources
•
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
Use of My Prime Directive
Journal and My Prime
Directive is completely
voluntary and is NEVER to
be mandatory
Prime Directives are self-help
tools and DO NOT replace a
treatment plan.
SIX ESSENTIAL STEPS FOR
PRIME DIRECTIVES
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.
SIX ESSENTIAL STEPS FOR
PRIME DIRECTIVES
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
• “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.”
What Professionals Are Saying About
Involving Youth In Their Services and
Systems
• “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)
ANTICIPATED BENEFITS/OUTCOMES
FOR YOUNG PEOPLE
• 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.
ANTICIPATED BENEFITS/
OUTCOMES FOR PROGRAMS
• 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.
“An important shift occurs when
we begin to work with our clients
as partners in their treatment,
instead of working on them.”
Cheryl Villiness
Devereux Georgia Treatment Network
Focal Point, Fall 2000
Communication Strategies
Exercise: How Hard Can
Communication Be?
Old & New Language
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
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
You and I
by Elaine Popovich, adapted by Laurie Curtis
From the Consumer Network News, Autumn 1995
I am a resident. You reside.
I live in a program. You live in a home.
I am placed. You move in.
I am learning daily living skills. You hate housework.
I get monitored for tooth brushing. You never floss.
I have to be engaged in “meaningful activity” every day. You take mental health days.
I am learning leisure skills. Your shirt says I am a “couch potato.”
I am aggressive. You are assertive.
I am aggressive. You are angry.
I am depressed. You are sad.
I am depressed. You grieve.
I am depressed. You try to cope with stress.
I am manic. You are excited.
I am manic. You are thrilled.
I am manic. You charge the limit on your credit card.
I am non-compliant. You don’t like being told what to do.
I 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.
“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 Consumers Want to Hear
From Staff
•
•
•
•
•
•
•
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?
What Consumers Want to Hear
From Staff
•
•
•
•
•
•
•
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
ROAD BLOCKS TO ACTIVE
LISTENING
•
•
•
•
•
•
•
•
•
Attraction
Physical Condition
Concerns
Over eagerness
Similarity of problems
Prejudice
Differences
Defensiveness
Anger
Exercise: Road Blocks to
Active Listening
Alternative Dispute
Resolution
Alternative Dispute Resolution
Definition:
The term Alternative Dispute
Resolution applies to the
creative solving process that
does not engage in litigation
through the courts.
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.
In mediation the goal is to
clearly identify:
• 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.
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.
The following are the usual
steps in the mediation process:
• Those in dispute identify the problems
(issues).
• Those in dispute explore possible solutions.
• Those in dispute select a solution.
• Those in dispute sign an agreement.
In order for mediation to be successful
participants should be willing to:
• Solve the problem
• Tell the truth
• Listen without interrupting
• Be respectful
• Take responsibility for carrying out
the agreement
• Keep the situation confidential
Research, Training, and
Technical Assistance
Centers
Participant Manual:
Research, Training, and Technical
Assistance Centers
Participant Manual: Children’s
and Adolescent’s Mental Health
Services Technical Assistance
and Research Centers
Module 6
Sustaining Change through
Consumer and Staff
Involvement
Learning Objectives
Upon completion of this module the participant will
be able to:
•
Recognize leadership roles for administration, staff, and
consumers as it relates to the elimination of seclusion and
restraint
•
Describe the role of the Office of Consumer
Affairs/Consumer Advocate and the role they play in
eliminating the use of seclusion and restraint
•
Identify key elements of debriefing, advance crisis
management, and data collection and analysis
•
Outline the pro’s and con’s of having an external monitoring
system related to seclusion and restraint
•
Identify key characteristics of the Role of the Champion
“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
Overview
Leadership
Administrators can sustain
change by providing:
•
Policies & 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
Meaningful Consumer
Involvement means:
• Beyond tokenism
• Beyond review and comment
• Beyond advice
• Beyond sign-off
An Office of Consumer
Affairs (OCA) is a vehicle to
ensure that a variety of
consumer/ survivor voices are
heard with meaningful system
change initiatives.
Benefits of an Office of
Consumer Affairs
• 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
• Policy and Regulation Development
• Program Planning
• Evaluation and Monitoring
• Training
• Finance and Contract Management
• Complaints and Grievances
Goals of Consumer Advocates
• Represent consumers/families/
guardians from their perspective
• Promote highest standard of care for
people receiving treatment for a
mental illness
Job of Consumer Advocate
Protect Consumer Rights!
Consumer Advocate Roles
• Administer De-escalation Form
• Making regular rounds on units
• Being part of policy making and new initiatives
(e.g., Comfort Rooms, special programs,
recognition, festivities)
• Being present at team meetings
• Being the “eyes and ears” for the administrator
P&A Nationwide Network
Protection and Advocacy is a
nationwide network of
congressionally mandated,
legally-based disability rights
agencies
P&A Responsibilities:
• Provide legal representation
• Maintain a presence in facilities, if
possible
• Monitor, investigate and attempt to
remedy adverse conditions
Participant Manual: Listing of
Protection & Advocacy
Offices
Exercise: National Technical
Assistance Center Networks
Participant Manual: National
Technical Assistance Center
Networks Newsletter
Exercise:
Direct Care Staff Leadership
Debriefing
“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
Debriefing can be used for
different purposes:
• Risk Management
• Quality Improvement
• Staff Support
Staff Debriefing Sessions
include the following:
• 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
Debriefing Model Rupert Goetz, M.D.
• Facts
• Feelings
• Education
• Planning
Participant Manual:
Debriefing Survey for
Consumers
Exercise:
Debriefing Role Play
Advance Crisis Planning
“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
Data Collection
External Monitoring
Goals of External Monitoring
• Improve and enhance the quality of
life for consumers
• Promote effective communication
between consumers, staff, and
families
What Monitors are Looking For
•
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
Monitors are typically trained
in the following areas:
•
•
•
•
•
•
•
•
•
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)
Role of the Champion
“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.
Journal/Take Action
Challenge
Module 7
Review and Action Plan
Learning Objectives
Upon completion of this module the participant will
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
“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.
Review
Module 1:
The Personal Experience of
Seclusion and Restraint
“When I participated in my first
restraint experience I vomited.”
(interview with direct
care staff from Minnesota)
Module 2:
Understanding the Impact of
Trauma
“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 3:
Creating Cultural Change
“The hospital’s culture dictates
whether, in what circumstances,
and how often seclusion and
restraint interventions are used.”
Robert Okin, M.D., Former Commissioner of
Mental Health in Massachusetts and Vermont
“It is not possible to solve a
problem with the same
consciousness that created it.”
Albert Einstein
Module 4:
Understanding Resilience and
Recovery from a 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 Curie, Administrator, SAMHSA
Module 5:
Strategies to Prevent
Seclusion and Restraint
“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
“It is rather impressive how
creative people can be when
restraint is simply not part of the
treatment culture.”
John N. Follansbee, M.D., Northern
Virginia Mental Health Institute
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
Personal Action Plan
Exercise:
Personal Action Plan
Workplace Action Plan
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
Exercise:
Workplace Action Plan
Certificate of Completion
Evaluation
Thank you!