CPU European conference 2014
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SAFER services:
Defining our own pathways to
reduction goals.
Karl Tamminen
Humber Trust
Practice innovation.
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What is this presentation about?
Dispelling a few myths.
Challenging a few assumptions.
Not about teaching people how “to suck
eggs”, but discussing alternative
perspectives.
Ideas for changes in the ways service
users and staff work together.
A pathway to closer, more productive
working relationships between service
users and staff which serves to reduce
engagement in restraint .
….But first a couple of questions….
Question 1:
What do the following things have in common?
What do the following have in common?
Question 2:
What do these people have in
common?
What do these people have in common?
The quiz answers:
What do they have in common?
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Answer one: These are all reasons
people have been restrained,
Answer two: These are all people who
have tragically died, following restraint
(initiated for the above reasons).
Was that a surprise?
Which are valid reasons to engage in
restraint?
What do these people have in common?
Myth or true?
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Restraint and seclusion are never used as
punishment.
Restraint and seclusion are always used as a last
resort.
Restraint and seclusion are a valid treatment
option.
Restraint and seclusion are the main tools we
have to maintain a safe environment.
When we utilise restraint or seclusion we are
always acting within the legislation.
Professional practice is about developing and
improving the way we use restraint and seclusion.
There is no evidenced based alternative to
restraint and seclusion
who
Age/
when
where
why
outcome
Adam
Rickwood
14
(2004)
Hassockfield
Secure Training
Centre in County
Durham UK.
Refused to move from
the table he was sitting
at with friends
Psychological
impact of
restraint. Nose
punch technique.
Terrified child.
Found dead by
hanging in his
bed space after
resolution of
restraint/
seclusion.
Angelika Arndt
7.
(2006)
Children's
Hospital in
Minneapolis
(US)
Refused to stop gargling milk.
Fell asleep in seclusion,
restrained to ensure she
“learned her lesson” Restraint
as a consequence. Restraint
to reinforce positive
behaviour and disincentives
negative
complications
from chest
compression
asphyxiation and
said the restraint
hold used by the
staff at the
centre may have
contributed to
her death.
Gareth Myatt.
15
(2004)
Rainsbrook
Secure
Training
Centre (UK)
Refused to clean out
a toaster when
directed by prison
staff
Positional
asphyxia
who
Age/
when
David (Rocky)
Bennet
41 (1998)
Jacob Michael
25 (2011)
Faith Finlay
Edith Campos
where
why
outcome
Altercation with
fellow patient around
phone use. Racist
language used
." Mr Bennett's
capacity to breathe
was restricted and
the restraint
"continued for
substantially longer
than was safe".
UK
Called police for
support, he refused
to come out of his
bedroom and
threatened when
police responded
Up to eleven police
personnel.
Pronounced dead
when taken into
custody. Verdict
misadventure
17 (2008)
US
Damaging her own
property in her own
room
Prone restraint.
Positional
asphyxiation
15 (1998)
US
Refused to hand
over family
photograph
(personal
possessions against
policy)
Positional
asphyxiation
UK
What are the facts in the British cases?
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The People Who Died:
● The people who died ranged in age from 9 to 95 years old.
● Nearly one-third of those who died were over the age of 65, with 14
seniors over the age of 80 at the time of their deaths.
● The four youngest children to die in restraints were 9 years old.
● Almost three-quarters of those who died were male.
● Nearly 75% of those who died had a psychiatric history, with the most
common known diagnoses being schizophrenia, other psychotic
disorders and mood disorders.
● More than half of those individuals admitted with a psychiatric
diagnosis had been admitted for psychiatric treatment on three or more
prior occasions.
● Twenty-five percent of those who died had a history of intellectual
disabilities, learning disorders or other developmental disabilities.
● Nearly half of those who died had limited or no communication skills,
due to medical circumstances that limited their awareness or
consciousness.
SOURCE: (NATIONAL REVIEW OF RESTRAINT RELATED DEATHS OF CHILDREN AND ADULTS WITH DISABILITIES:
The Lethal Consequences of Restraint (2011))
The IAP reported that between the 1st January 1999 and the 31st December 2009,
there were 6,151 deaths in state custody in all services. In 22 of these cases,
restraint was involved
Table 1 Deaths by age range
setting
No of
restraint
related
deaths
Age range
11-20
2130
prisons
1
0
1 0 0 0 0 0
Secure Young People’s
1
1
0 0 0 0 0 0
Immigration Removal Centres
0
0
0 0 0 0 0 0
Police
15
0
1 6 3 2 1 1
In-pt mental health setting
5
0
2 3 0 0 0 0
TOTAL
22
1
4 9 3 2 1 1
estates
3140
4150
5160
6170
7180
Why do we need to change?
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People die whilst being secluded and restrained.
People are injured whilst being restrained and
secluded.
People suffer harmful psychological affects whilst
being restrained and secluded.
People have “flash backs” about restraint and
seclusion.
For the main part neither staff or service users
like to engage in restraint or seclusion.
Restraint and seclusion, as a measure of risk, can
keep people in Mental Health services longer.
I am here today to talk about the ingredients of a
restraint and seclusion reduction programme.
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Restraint and seclusion is seen as a normal,
expected and natural part of every day life
within a mental health unit…do you think that is
how it has to be?
What is the current and
predominant approach to restraint?
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1. Have we trained people correctly
to avoid injuries and to give people
the tools to maintain a safe and
effective working environment?
2.Do we have the paper work
necessary for defensible practice?
In short do we do it right and can we
evidence it was done correctly?
… That’s fine as far as it goes, but
what we seldom ask is “why did we
end up restraining in the first place?”
Challenging the status quo?
If the training and the paper work
is “correct”…
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Is this a case of “its not broke so
don’t fix it?”
No.
It cant be.
People ask me the same question:
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“You know about restraint and
seclusion Karl, got any tricks we
could use to change the patients
behaviour?”
The answer?
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The “trick”, if there is one, is to
change the question, its not about
changing the way patients behave…
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about changing the way
we behave.
Is there another way?
Yes…
Who has written about “other” ways?
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Dr Bennington Davis and Dr Tim
Murphy “pathway to restraint free
services” (engagement and
empowerment model)
Dr Sandra Bloome “finding
sanctuary (recovery focussed
model)
Ann Alty and Tom Mason “break
with the past (1994)
Joy Duxbury,
Empowerment and engagement model is used in
the Salem Hospital Oregon and the recovery
focussed models are used across all the
hospitals in Pennsylvania and Oregon.
Salem hospitals: They attempted to
reduce across both fronts
The changing trend from 1994
Number of Seclusions by Year, 1994 through 9/2007 at Salem Hospital Psychiatry
400
368
350
309
301
291
287
300
250
222
Review ed data & recovery/
traum a m odel 1999-2000
200
Im plem ented m odel, 2001
150
96
100
53
50
10
3
1
0
0
0
2003
2004
2005
2006
2007
0
1994
1995
1996
1997
1998
1999
2000
2001
2002
The Salem Oregon project
Total Annual Hours of Seclusion, 2000-9/2007 at Salem Hospital Psychiatry
1600
1450
1400
1200
1000
Hours 800
600
400
260.7
200
36.85
2.25
0.25
0
0
0
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
Pennsylvania: across all hospitals and
fronts: area one
Area two: mechanical restraints
Area three: physical restraint
So where do we start?
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Owning change?
Who needs to own it?
Trust board? Clinicians? Service
Users? Families and carers?
In short…..We all need to own it and
champion it in what ever way we
can. If we don’t all make the
process of change our own…then it
will not happen.
Identifying the layers of change
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Policy and procedure (embedding change)
Daily rituals of practice
Engagement of staff and service Users
Approaches to restraint
Avoiding inappropriate restraint
Remaining empowered to restrain as a last
resort measure
Utilising data to inform practice
Education and training
Support and reflection
Creating a learning, sharing system
Pathway to restraint free services:
what are the ingredients?
Reclassify: restraint and seclusion are not
treatment options they represent treatment
failures and breakdowns
 Intensify: Scrutinise restraint. (use
evidence and data to learn/ develop
improve) feed that data into practice.
 Choices: Give staff alternatives and
service users more meaningful choices.
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Pathway to restraint free services:
what are the ingredients? Cont.
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Clinical focus: engage with Service Users and
Care plan for a restraint and seclusion free
therapeutic environment.
Practice focus: examine the daily lives of our
service Users, identify points of avoidable conflict
and develop new ways of running wards
Operational focus: directors and managers need
to get behind the change, own it and support it.
Reflect and relearn: Where it does happen, learn
from it and plan try different approaches to avoid
in the future. (restraint and seclusion reduction
group)
Break the mould: Dare to be different.
Pathway to restraint free services:
what are the ingredients? Cont.
Reinvent: Be the pioneers for services
by introducing innovative, ground
breaking, evidence based approaches
to violence and aggression
management which sets the tone for all
other services.
 Archaeology: Take up the challenge to
unearth the evidence and generate the
evidence that this approach works.
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Pathway to restraint free services:
what are the ingredients? Cont.
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Support: Management and clinical leads
need to support staff in innovative approaches
as alternatives to restraint and seclusion.
Empower: Empower and engage with service
users in new and innovative ways which do
not blur boundaries
New philosophy: Move away from staff total
control to shared responsibility for maintaining
a safe environment. (within the professional
envelope we retain responsibility for)
Why us? Why here?
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There is at least twenty years of
evidence out there that the
foundations of and the ingredients to
alternative approaches which we
have discussed here is sound.
Its not easy, there are no magical
solutions, successes are born out of
hard work, positive risk taking,
making mistakes, learning from them
and addressing the challenges again
and again
Why us? Why here?
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There is no step by step guide that
cam take us through each aspect on
a guaranteed pathway to seclusion
and restraint reduction and
elimination….. but there is a
framework.
We have the skills to do this.
We are ready for the challenge.
We are ready for change.
So what about the Humber Centre
project?
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We know where we want to get to~ the
position where seclusion and restraint are
indeed a last resort intervention.
We want to minimise “last resort” scenarios
existing.
We know where the evidence is of what
works and we will use it to build our new
approach.
We want to work collaboratively with our
service users to develop new approaches
which are embraced by staff and service
users, and are effective for us.
We are treading our own pathways to
restraint and seclusion free services…
…….can you see yours?
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Any questions?