Roadmap to Restraint
and Seclusion Free
Services at LRC
Lisa L. Franz, MBA, CPHQ
Quality Improvement Coordinator HHS
Dan Powers, JD
Consumer Liaison - Program Specialist
Agenda
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Overview
Goal: Reduce / Eliminate R & S
NAC/SMHA and SAMHSA
Pilot Project
Training Materials
Future State
Overview
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Seclusion - Involuntary confinement of a patient alone
in a room where the patient is physically prevented
from leaving including:
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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:
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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
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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
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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
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30 Staff members of LRC will attend training
March 31, April 1, April 2
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AFS, STC, FS
2/3 Direct Care, 1/3 Administration
8 Of these will participate in pre-assessment
Feedback will be collected from the
participants
Current S/R data will be compared to postimplementation data
SAMHSA
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Substance Abuse and Mental Health Services
Administration
Provided Funding for Roadmap Project
Federal agency
Improve the quality and availability of
prevention, treatment, and rehabilitative
services
Reduce illness, death, disability, and cost to
society
NAC/SMHA
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National Association of Consumer/Survivor
Mental Health Administrators
Developed materials for Roadmap Program
Founded in 1993
State mental health agency senior managers
who are current or former recipients of
mental health services
Offer technical assistance to State Mental
Health Agencies on exemplary practice
Insight
Provided By
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Steering Committee, representing virtually
every stakeholder organization
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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:
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Early identification and intervention in
conflict situations
Understanding the experience from the
perspective of the individuals involved
Improving communication and problemsolving skills
Decreasing and ultimately eliminating the
damaging effects of restraint and seclusion
Training
Materials
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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
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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
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Peer-delivered services
Self-help techniques
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New medications
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Emphasis on recovery
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Understanding the relationship between
trauma and mental illness
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Medical Directors of the National
Association of State Mental Health Program
Directors report on Restraint and Seclusion
(1999)
Options
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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
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Relax in a homey setting –A big over stuffed,
vibrating, heated chair with a blanket,
headphones and gentle soft music
Be allowed to have something of my own to
comfort me
In Crisis, I
Need Persons
Who Can:
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BE with me
Acknowledge my pain without trying to ‘fix’ it
Not be afraid of my sexual abuse
Ask what would help
In Crisis, I
Need Persons
Who Can:
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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
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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
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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
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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
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Stay out of dark or dim areas, or turn on the
lights
Don’t allow hiding
Make sure eyes remain open
Maintain Visual
Contact
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Describe the color of the walls or carpet
Give a favorite object and assist the person
in noticing how it looks, feels, and smells
Present previously developed flashcards
Maintain Personal
Contact
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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
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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
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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
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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
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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
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Determine body postures that accompany
feelings of being flooded and/or
overwhelmed
Plan new ways to attempt to cope with stress
Develop a crisis response plan for the next
occurrence
WRAP
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Daily Maintenance Plan
Triggers
Early Warning Signs
Symptoms that Occur When the Situation is
Worse
Crisis Plan/Post Crisis Plan
As A
Group….
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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
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“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