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1. Reducing Restraints and Eliminating Seclusion: Struggles and Strategies presented by: Keith a. Bailey, Ph.D. keith@keithbaileyconsulting.com www.keithbaileyconsulting.com

2. A National Movement in the U.S. • 1996 -- Pennsylvania State Mental Health Hospitals begin reduction initiative • 1997 -- American Academy of Pediatrics position paper on “Therapeutic Holding” vs. mechanical/chemical restraints • 1998 -- Hartford Courant investigative report • 2000 -- Children’s Health Act defines standards for restraint and seclusion • 2001 -- CMS writes more stringent standards for youth services • 2001 -- SAMHSA funds study with 7 youth programs • 2003 -- President’s New Freedom Commission on Mental Health report comments on restraint and seclusion • 2003 -- CWLA and NTAC begin nationwide training events • 2004/2007 -- SAMHSA funds grants for 8 states for reduction efforts • 2004 -- State of Tennessee requires more stringent standards for use of restraint and seclusion • 2009 -- State of Tennessee enacts laws regarding use of restraints and seclusions withSpecial Education students

3. International Concern and Action • Canada • 2001 – Patient Restraints Minimization Act • 2003 – Implementation of The Six-Point Action Plan for youth residential facilities licensed under CFSA • 2006 – Review suggested addressing restraint usage in amendments to the Safe School Act (2000) • Great Britain • Australia • Israel

4. New Developments • Prohibiting use of prone (face down) restraints by some licensing bodies in U.S.

5. The Personal Side There is a risk of serious injury or death each and every time we attempt to restrain or seclude a child!

6. True and Tragic Accounts

7. Edith Campos • 15 years old

8. Chris Campbell • 13 years old

9. Angellika Arndt • 7 years old

10. Stories of Success • Buckeye Ranch – Ohio • Klingburg Family Centers – Connecticut • Brewer-Porch Children’s Center – Alabama • Cambridge Hospital Child Assessment Unit – Massachusetts • Holston Home - Tennessee

12. Holston Home • Started as an orphanage in 1895 • Multi-program agency • Continuum of Care Model • Foster Care (100 youth) • medically fragile, low intensity, therapeutic • In-Home Services (20-30) • Adoptions (60 placements in 2005-2006 FY) • special needs, domestic, international • Child Day Care (100, infant – 5 yrs. old)

13. Holston Home • Day Treatment School (75 youth, K-12) • Residential Group Care & Treatment (84) • Assessment (8) • Boy’s Treatment (40 – Lv. 2 & Lv. 3) • Girl’s Treatment (8) • Girl’s Developmental Home (8) • Boy’s Group Home (8) • Preparation for Adult Living (12) • Juvenile Justice and Social Services Youth • [2007 Residential Numbers: 50] • Staff : 175+ in four sites • Budget: $10 M

14. Why Change? • It looked bad and felt bad • 1998 – 1400+ restraints, 2600+ seclusions • High number of disruptions, “bouncebacks,” and runaways • Staff were not given enough skills to appropriately deal with negative behavior • Some staff began to raise concerns about the therapeutic quality of our “treatment” approach

15. Culture Analysis –Crisis Creators • High staff turnover • Inexperienced staff • Poor training • Shorter ALOS of youth • Higher numbers of more difficult youth • Older youth • Leadership turnover • poor leadership in various positions • Perceived lack of support from administrative staff • Control-oriented culture of care • Fear (With Gayle Mrock)

16. Beginning the Change • Decision by leadership • Move to new crisis intervention model (1997) • CWLA Consultant • Change in Behavior Management Plans • More strengths based approach • Youth requested “time-outs” • Create a culture where restraints are viewed negatively by both staff and youth • Researched/explored what others were doing

17. Beginning the Change • Setting goals for % reduction • Tracking through CQI process • More responsibility on directors and supervisors to hold staff accountable • More training in de-escalation techniques and more instructors • Changes in Behavior Management Plans • Restraint review process put in place

18. Restraint Reduction

19. Restraint Reduction • Ratio - restraints : 1,000 client days [Residential treatment, day treatment, group care] • 1998 - @ 40 : 1,000 (1447 restraints) • 2005-2006 - 3.2 : 1,000 (70 restraints)

20. Seclusion Reduction

21. 2003 • 80% of restraints were associated with the use of seclusion • 2004 January – May • 8 staff injuries due to seclusion • 4 staff injuries due to restraint

22. Mistakes & Successes Mistakes • Went cold turkey • Didn’t give other “tools” early on • Some hired-in directors didn’t buy in • Held on to some staff who didn’t buy in Successes • Support from leadership • Data and goal-setting • Training on staff resistance • Training, Training, Training • Celebration • Consistent review process

23. Restraint Review Committee: Attendees • Administrator of Residential Services (Chair) * • Administrator of Best Practices • TCI Instructor * • Residential Directors * • Therapist • Staff from outside of residential treatment * • Other staff as needed (e.g. direct care, supervisor)

24. Restraint Review Committee: Purpose • Tracking through data gathering • Emphasis on detail of report writing • Identifying trends • Sending a message of importance • Giving feedback to staff • Learn from mistakes and successes

25. Restraint Review Committee: Agenda • Follow-up items from previous meeting • New restraints presented (narrative read) • Critique/Questions/Discussion/Suggestions • Corrective action assigned (via director) • Minutes typed and distributed

26. Review Serious Incident Report Includes: • Child’s name • Program • Date of incident • Time of incident • Contract information • Precipitating behavior (including any children or staff involved) • Alternatives offered/de-escalation techniques • WHAT IS THE SAFETY ISSUE JUSTIFYING THE RESTRAINT? • Restraint technique used • Positioning of staff • Length of restraint • Processing/debriefing completed, and by whom • Accident and injury report

27. Post Restraint / Seclusion Debriefing • With youth involved • With youth who witness the event • With staff involved • To reduce the impact of trauma • To learn from the event

28. Seclusion • Not as much attention given to seclusion • Sometimes addressed alongside restraints, but few, if any unique strategies given for reduction • Often used as a behavior modification technique to extinguish behavior vs. a safety technique • Like restraints, should only be used for safety • Can give implicit negative messages and be traumatizing

29. PRN Medication • Can be overused as a way to avoid physically intrusive interventions • Can become a substitute for teaching coping strategies • Can set up a dependency on the drug and/or the system to supply the drug

30. Sustaining Success • Cannot focus on restraint and seclusion alone • Requires a culture change!

31. Holston Home’s Changes in Culture Holston Home • Treatment Model Task Force - 1999 • Training in Mediation – 2001 • Expanded Staff Training – Addition of Staff Development & Training Coordinator - 2001 • Best Practices Department Created - 2003 • A move away from points and levels and to a relational model of care – using natural and logical consequences, “refocusing”, making amends • From “controlling” to “connecting”

32. What We Learned • It gets worse before it gets better • When you take away a tool, you have to put another one in its place • Plan thoroughly and prepare staff • Orientation and ongoing training is essential !!! • Power struggles must be recognized and redirected • Staff have to be supported and empowered • Involve youth – listen and learn

33. What We Learned • Training – Training – Training • Data collection is key – show them the numbers! • Review process is critically important • It is a process • Expect resistance and address it! • You must address all aspects of the agency culture

34. SUCCESS in beginning and maintaining restraint and seclusion reduction efforts requires nothing less than … …a change in the culture [mindset] of care

35. Changing the Culture of Care Treatment • Understanding children’s behavior and where it comes from • Understanding treatment • Treatment statements • More than a mission & values statements • Understandable and applicable by all staff and youth • Including the family and community

36. Sample Treatment Statement: Cognitive – Behavioral approach: [The Agency] uses a treatment approach that emphasizes positive thinking skills, emotional coping skills, and appropriate choices for behavior in an environment that is safe and supportive to all [youth and staff].

37. Changing the Culture of Care Guiding Principles related to use of restraint and seclusion: • Restraints and seclusions are not therapeutic techniques. • They can, in fact, further traumatize youth • Restraints should only be used as a last resort, when all other interventions have failed, and only when there is an imminent risk of harm to the youth or others if a restraint is not properly used.

38. Changing the Culture of Care Infrastructure that supports treatment • Staff • Hiring – Firing – Credentials – Scheduling – Training • Supervision and Support • Physical environment • Space – Décor – Upkeep • Policies and Procedures • Forms - documentation

39. Changing the Culture of Care Training • Child Development and Children’s Mental Health • Trauma Informed Care • Bruce Perry, MD, Ph.D. – impact on brain and development • Sandra Bloom, M.D. – Sanctuary Model • Goals of Behavior/Behavioral Support • Parenting • Treatment Techniques • Communication and Mediation Skills • De-escalation Techniques Skills • Processing Skills

40. Changing the Culture of Care Supervision and Accountability • Training – skill development • A style that promotes a parallel process of support and growth between direct care staff and youth • A Balance • Administration • Accountability of staff • Coaching – Support

41. Commitment to Culture Change - Schein • “Converting” staff: 20 / 50 / 30 Rule • 5-15 years to change a culture

42. Resources Organizational Change Leaf. S. (1995). The journey from control to connection. Journal of Child and Youth Care 10 (1), 15-21. Organizational Culture Schein, E. (1992). Organizational culture and leadership. 2nd edition. San Francisco: Jossey Bass Publishers. Restraint and Seclusion Reduction Child Welfare League of America. (2002). CWLA best practice guidelines for behavior management. Washington, DC: CWLA. Child Welfare League of America. (2003). Reducing the use of restraint and seclusion: Promising practices and successful strategies. Washington, DC: CWLA.

43. Resources Trauma Informed Care Bloom, S. (In print). Creating sanctuary for kids: Helping children to heal from violence. The International Journal for Therapeutic and SupportiveOrganizations. ww.magnasystems.com/c-5-childhood-trauma.aspx (DVD’s -Dr. Bruce Perry) www.childtrauma.org (on-line trainings - Dr. Bruce Perry) www.nctsnet.org/nccts/nav.do?pid=ctr_cwtool (fully developed curriculum & tutorial)

44. Resources NTAC-NASMHPD Six Core Strategies for reducing and eliminating restraints and seclusions • Role of Leadership toward Organizational [Culture] Change • Analysis of Data to Inform Practice • Staff Development and Training • Debriefing Techniques • Use of Restraint Reduction Tools • Youth and Family Input National Technical Assistance Center - National Association of State Mental Health Program Directors Training Curriculum for the Reduction of Seclusion and Restraint, 2004)