Restraint Reduction Initiatives
Restraint and seclusion reduction initiatives have made great headway across the nation and in many parts of the world thanks to the work of leaders such as Beth Caldwell, Kevin Huckshorn, Janice LeBel, Kenneth Duckworth and many others along with national agencies including the National Association for State Mental Health Program Directors (NASMHPD), the National Technical Assistance Center (NTAC), and the Substance Abuse and Mental Health Service Administration (SAMHSA). The Six Core Strategies, a framework developed by NASMHPD is a proven evidenced based practice approach and continues to guide successful efforts in preventing seclusion and restraint (Caldwell et al., 2014; Huckshorn, 2006); NASMHPD, 2014). Thanks to the work of Tina Champagne, occupational therapy and the use of sensory modulation interventions have become a key component of these initiatives and the Core Strategies (Huckshorn, 2004; Champagne & Stromberg, 2004).
Six Core Strategies for Reducing Seclusion and Restraint Use - NASMHPD pdf
Despite these advances, my travels across the country reveal that we still have a long way to go and that many facilities are still utilizing restraint and seclusion on a regular basis. This is unfortunate given that the fact that research is showing that the use of these practices adversely affect clients and staff and can lead to physical injuries such as bruises and broken bones, asphyxiation, severe emotional trauma and even death (Frueh et al., 2005; Mohr, Petti, & Mohr, 2003; NASMHPD, 2006; SAMHSA, 2011). There are many barriers, the greatest of which might be the need for a culture change in programs and institutions that have relied on the use of seclusion and restraint for years despite research that shows that these interventions are re-traumatizing, humiliating, psychologically damaging and not effective for teaching people to self-regulate and to deal with emotions effectively. Given the increased acuity facilities are reporting and an over-all increase in violence, it is understandable that the use of restraint and seclusion might be necessary on rare occasions, but it needs to be the exception and not the rule; over time, when alternative interventions including sensory modulation approaches are fully accepted and routinely practiced it is possible that seclusion and restraint can be avoided in even the most difficult of cases. I have heard people say, "You don't understand. It can't be done." But, it can be done. The State of Pennsylvania has all but eliminated the use of seclusion and restraint and forced medications in their State Hospital system (Smith et al., 2005). If they can do it every state and every institution can do it.
Sam's Story
My commitment to helping to work towards the reduction and elimination of seclusion and restraint was reinforced recently by a young woman named Sam. Sam, who is blind, describes her experience in a "calming room" (which in this case was a euphemism for a seclusion room). Some people see the use of seclusion as a more humane alternative than restraint. From a sensory point of view it might be equally as devastating and perhaps even more so. Solitary confinement is an inhumane punishment. Detriment includes sensory and occupational deprivation. In June of 2016 Sam wrote to me and told me this story.
"Sadly in my state, the hospitals that I have been to are not very welcoming. They still use quiet rooms - as in cold, empty, dirty rooms where you're pinned against the wall and given a shot in the behind! And talk about no sensory stimulation. There is no "comfort box," nothing. The unit where I ended up frequently in the quiet room was very strict. All personal belongings were locked up. I'm blind and during this one admission my Braille reading device didn't have its charger because the staff lost it. So for a week I was basically sitting or lying around with nothing to have in my hands to play with, like polished rocks or stuffed animals or anything. Meanwhile other sighted patients at least could color or read magazines etc. even though those supplies were limited. I had many meltdowns during that time that I feel were just due to not having anything to tactically focus on. I'm used to holding something in my hands and playing with it almost all the time. To have nothing and to be blind and not have visual stimulation, contributed to, if not caused, the occasions when I went to the quiet room."
Sam has gone on to be a volunteer peer advocate in another hospital where she is advocating for a Sensory Room. She contacted me to get more information and also support to accomplish his goal.
The Benefit and Role of Occupational Therapy
Occupational therapists can serve a key role in helping patients with emotional regulation problems learn to self-sooth and take responsibility for their own safety and crisis management without the need for resorting to drastic measures such as restraint or seclusion. I have a saying, "Take control and you might help in the moment, teach control and you help for a lifetime." In 2015 AOTA produced a Fact Sheet on Occupational Therapy's Role with Restrain and Seclusion Reduction or Elimination. Occupational therapists help in many important ways including assessment, teaching self-regulation skills, helping clients develop a repertoire of sensory coping strategies, facilitating social participation, assuring environmental support, collaboration with care providers and family members, engaging clients in meaningful activities during hospitalization, and by helping them to return to valued roles post discharge (Champagne, 2015). Sensory modulation strategies and early intervention by paying attention to triggers and signs has proven to be effective in crisis intervention (D'Orio et al., 2004; Huckshorn, 2004; Johnson & Delaney, 2007). Many facilities are creating sensory carts, sensory rooms, sensory based "crisis boxes" and other environmental modifications that support self-regulation and provide a nurturing and positive environment for healing (Chalmers et al, 2012; Cummings, Grandfield & Coldwell, 2010; Novak et al, 2012). Sutton et al (2013) theorized that sensory interventions allow heightened emotions to be contained so that the person can engage in adaptive behaviors; the findings in their study of four inpatient mental health units in New Zealand supported this assumption. Evidence is mounting that sensory assessment and therapies are helping patients with emotional regulation resulting in a decrease in the need for physical restraints (Barton, Johnson & Price, 2009; Cahill & Pagano, 2015; Champagne & Stromberg, 2004; Gardner et al, 2012; LeBel and Champagne, 2010; Lee et al, 2010; Stuart et al, 2010; Sutton et al, 2013). Occupational Therapists have the educational background in sensory modulation necessary to work with clients safely and effectively in their exploration of sensory input activities and can help train other professionals and staff members to safely utilize sensory activities for treatment. Sensory input can be very powerful in both positive and negative ways. Assessment might also be needed to understand a person's sensory style and needs and also to watch for sensory sensitivities, sensory triggers and even sensory processing problems that might be contributing to anxiety, difficult behaviors and problems with self-regulation (Champagne, AOTA Fact Sheet, 2015: Champagne & Stromberg, 2004; Stuart, et al., 2010) The unique experience and expertise of occupational therapists in the use of sensory modalities may revitalize their role in mental health settings.
AOTA Fact Sheet Occupational Therapy's Role with Restraint and Seclusion Reduction or Elimination
UMASS Memorial Medical Center Restraint Reduction Initiative
The Acute Psychiatric Unit at UMASS Memorial Medical Center is one program that has taken a lead in the restraint reduction initiative and trauma informed care. Staff members and patients on this 28 bed unit where the author worked for more than ten years are already familiar with some of the positive results of sensory-based treatment. A Sense-ability Group is run daily on the unit and skill building groups often focus on coping through the senses strategies.
When a patient arrives on the unit a "Safety Tool" developed by the State of Massachusetts is used to acquire information to understand what strategies might be the most useful for a patient. Information that could help the patient in crisis is kept at the front of the chart. The occupational therapy department also documents any sensory strategies that the patient finds useful along with any sensory problems or sensitivities noted in evaluation or treatment.
Safety Tools and information on the MA Restraint Reduction Initiative
The Unit has a Sensory Room where patients can go to calm down, relax, and learn about helpful sensory input. Sensory supplies have been collected to help patients who are agitated, upset, or on the verge of losing control. Items are chosen according to the clinician's experience with the client and from information in the chart regarding sensory preferences and problems. The unit invested in weighted blankets which are very popular with some patients and clearly helps them to regain control and to calm down without the need for more drastic measures.
All of the staff members on the unit have received training regarding the use of sensory modalities to help patients remain in control and avoid the need for restraints or seclusion. Education of staff has been shown to be critical to the success of implementing sensory modulation programs (Sutton et al, 2013). Staff occupational therapists, nurses, psychologists, medical students, mental health workers, and several of the psychiatrists participated in a three hour workshop on sensory related treatment strategies. Participants received an informational packet that can be used for future reference. Posters and handouts were provided to the unit on Symptoms of Distress, Safe Sense, and Abdominal Breathing. Staff members were very receptive to the training and very grateful for having new tools and strategies to deal with volatile patients and crisis situations.
The unit plans to continue training with workshops on Trauma Informed Care and other restraint reduction strategies. The occupational therapists provide ongoing support to staff members regarding sensory related strategies.
Quality Improvement Study
Tina Champagne is an occupational therapist working in Western Massachusetts who spearheaded the development of Sensory Rooms at Cooley-Dickenson Hospital, North Hampton and the Berkshire Medical Center. A quality improvement study was performed at Cooley Dickenson Hospital after the introduction of the Sensory Room. Champagne and Stomberg's study evaluated consumers' perception of the sensory-based treatment delivered in the sensory rooms. 89% of the patients reported positive results. There was a reduction in restraint and seclusion episodes by 75% in the two year period that followed (Champagne & Stromberg, 2004).
Tina Champagne offers workshops throughout the year on Nonlinear Dynamics Approach to Sensory Modulation. She has participated in national as well as state initiatives to reduce restraint and helped to educate mental health professionals about the role that sensory approaches can play in helping patients to avoid the re-traumatizing experience of restraint. Information on this program can be found at: www.ot-innovations.com
The Emerging Science of Trauma Informed Care
NASMHPD (National Association of State Mental Health Program Directors) is leading a national initiative to reduce restraints in mental health facilities.
Learn more about their program on their website: www.nasmhpd.org
SAMPSHA (Substance Abuse and Mental Health Services Administration) is another national organization committed to the elimination of seclusion and restraint. They have an excellent article entitled "Finding Alternatives to the Use of Seclusion and Restraint;" it can be found by following this link.
The SAMSHA training program entitled "Road map to Restraint Free Mental Health Services" can be found by following this link.
Pennsylvania's Restraint and Seclusion Reduction Initiative has resulted in dramatic drops in mechanical restraints from almost 11,000 to slightly more than 90 in the period of February 1993 to February 2003. Several Pennsylvania State hospitals have not used restraints in over two years. Critical factors in their success include adequate prepared staffing, consumer involvement, patient and staff debriefing policies (reviewing details of restraint episode and development of plans for crisis intervention), and a care environment that prioritizes patient dignity. More information can be found by following this link....
Additional Resources and Articles
Mental Health Recovery: What Helps and What Hinders? A National Research Project
NTAC Training Curriculum for the Reduction of Seclusion and Restraint
NTAC Developing Trauma Informed Care Behavioral Health Systems
Pennsylvania State Hospital system's seclusion and restraint reduction program Smith et al 2005
Massachusetts Restraint/Seclusion Reduction Initiative tools and publications