1. American Public Health Association, Washington D.C., November 6, 2007
Creating safer mental health treatment settings:
The Movement in Texas to Reduce Seclusion and Restraint Use
Melissa Cook, J.D., LMSW, & Lynda Frost, Ph.D., J.D.
Hogg Foundation for Mental Health, The University of Texas at Austin
Kevin Ann Huckshorn, RN, MSN, ICADA
National Coordinating Center for Seclusion and Restraint Reduction
Statement of the Problem
Approach
Intervention Utilized
Implications for Policy & Practice
Widespread and unnecessary use of seclusion and restraint presents serious risk of physical and psychological harm to consumers and staff. This reality is true across many treatment environments including
juvenile detention centers, state hospitals, private hospitals, residential treatment centers, and schools.
The Hogg Foundation for Mental Health employed several
strategies to encourage safer and more effective treatment
practices for mental health consumers in Texas. Through a
collaboration between the Foundation and Kevin Ann
Huckshorn of the National Association of State Mental
Health Program Directors, provider organizations received
comprehensive training and technical assistance to change
their cultures of care and increase consumer involvement.
Texas-based agencies developed reduction plans using
NASMHPD curriculum “Creating Violence Free and
Coercion Free Mental Health Treatment Environments for the
Reduction of Seclusion and Restraint.” (NASMHPD, 2006)
Over the past three years, the Foundation has identified
several elements that are essential to successfully
reducing seclusion and restraint use in Texas-based
agencies:
1. While at first agencies resist a cross-agency
approach, over time they recognize the value
added by comparing ideas and successes across
treatment environments.
2. Successful reduction statewide requires work at
many levels, including consultation at the facility
level to address idiosyncratic issues around
implementing a reduction plan, training within
specific systems such as juvenile justice or child
welfare, and policy work at the state level to
improve data collection, uniformity in service
delivery throughout multiple settings, and rapid
introduction of best practices.
3. Consumers and family members play a critical and
central role in improving treatment environments
and changing agency culture.
4. Recruitment, training, and retention of mental health
workers are significant challenges to creating and
maintaining a positive treatment environment, given
severe workforce shortages in the state.
SIX CORE STRATEGIES TO REDUCE THE USE OF
SECLUSION & RESTRAINT PLANNING TOOL ©
142 deaths related to seclusion and
restraint use from 1988 to 1998 (Hartford
Courant, 1998)
STRATEGY 1: LEADERSHIP TOWARDS ORGANIZATIONAL
CHANGE
STRATEGY 2: USING DATA TO INFORM PRACTICE
STRATEGY 3: WORKFORCE DEVELOPMENT
STRATEGY 4: USE OF S/R REDUCTION TOOLS
STRATEGY 5: CONSUMER ROLES IN INPATIENT SETTINGS
STRATEGY 6: DEBRIEFING TECHNIQUES
KEY EVENTS
-Hogg Foundation highlights Seclusion and Restraint
Reduction at the 13th RLS Conference (December 2004)
-Hogg Foundation releases Safe and Appropriate
Behavioral Interventions publication and CD (2005)
-79th Texas Legislature passes SB 325 which mandates
human services agencies in Texas to promulgate
regulations that, among other things, include new
definitions for emergency and seclusion, prohibit restraints
that obstruct airways, and restricts use of prone and
supine holds. (May 2005)
-Cross-agency Behavior Management Task Force mandated
by SB 325 completes report with recommendations on best
practices in a variety of settings (2006)
-Hogg Foundation hosts Seclusion and Restraint Reduction
Training Institute for over 300 participants representing 29
facilities, state agencies, and policy makers. Participating
organizations send leadership teams of up to 14 staff
members to develop a seclusion and restraint reduction
plan for their facility. (September 2006)
-Hogg Foundation convenes a cross-agency Leadership
Group representing consumers, family members,
advocates, state agencies, and private providers to
establish leadership support for changing the culture of care
in Texas agencies (February 2007)
-Leadership Group assists Texas’ Health and Human
Services Commission in applying for a SAMHSA grant
(Spring 2007)
-Hogg Foundation sponsors a follow-up conference for
participants of the 2006 Training Institute to provide
advanced training in workforce development, trauma-
informed care, and roles of consumers and family
members. (June 2007)
-State of Texas Alternatives to Restraint & Seclusion
(STARS) Project is funded by SAMHSA in full—
$213,817 each year for three years (September 2007)
50 to 150 deaths occur nationally each
year due to seclusion and restraints
estimated by the Harvard Center for
Risk Analysis (NAMI, 2003)
Outcomes
26 injuries occur for every 100 mental
health aides. The injury rate was higher
than what was found among workers in
lumber, construction, and mining
industries (Weiss et al.,1998)
A number of facilities reported a significant drop in seclusion and
restraint use. 23 of the 29 Texas-based agencies that developed Seclusion and Restraint Reduction plans report success in reducing rates of seclusion and restraint use by implementing several successful strategies in the areas of staff training, facility environment modifications, data collection and analysis, and consumer involvement.
All Health and Human Services Agencies in Texas are engaged in
rule revisions in accordance with best practice recommendations of
the SB 325 Report.
References
Purpose
For a complete reference list, see
This project aims to reduce seclusion and restraint use by
supporting Texas-based agencies serving people with
mental illness in changing their cultures of care from control
to collaboration, increasing consumer voice, and preventing
power struggles.
Effective cross-agency leadership is essential to promote
and support the culture change needed for seclusion and
restraint reduction.
One children’s residential treatment center converted
two seclusion rooms into soothing rooms and report
over 50% reduction in seclusion and restraint
incidents.
National Alliance for the Mentally Ill. (2003, January 11). A summary of reports of restraints & seclusion abuse received since the October 1998 investigation by The Hartford Courant. Retrieved January 11, 2003 from
National Association of State Mental Health Program Directors (NASMHPD). (2006). Training curriculum for the reduction of seclusion and restraint: Creating violence free and coercion free service environments. Alexandria, VA: National Technical Assistance Center for State Mental health planning (NTAC)
Weiss, E. M., Altimari, D., Blint, D.F. et al. (October 1998). Deadly restraints. The Hartford Courant.
A juvenile probation department reports a 60%
reduction in seclusion and restraint use in the first
quarter of 2007 when compared to the first quarter
of 2006.
Leadership in Texas
To further support the gains made by Texas
agencies, the Hogg Foundation launched
the cross-agency Seclusion and Restraint
Reduction Leadership Group in February of
2007. Composed of mental health
consumers, family members, advocates,
and representatives of private and public
agencies, the group serves as a resource
in the state, providing leadership to support
and guide culture change in Texas
agencies.
Since attending the September 2006 training institute,
one private psychiatric hospital realized a 61%
reduction in seclusion and restraint use campus-wide.
Grant funding provided by SAMHSA allows Texas to continue
seclusion and restraint reduction efforts in state hospitals. The
anticipated benefits and lessons learned will be distributed
across agencies through the guidance of the Leadership Group.
The SAMHSA-funded STARS Project will include a rigorous
evaluation of outcomes over the next three years.
What We Know About
Seclusion and Restraint
Harm from seclusion and restraints is well
documented; the positives are not substantiated
Seclusion and restraints are not evidence-
based practices
Significant culture change is needed
Contact
Lynda Frost, Ph.D., J.D. Associate Director Hogg Foundation for Mental Health
Kevin Ann Huckshorn, RN, MSN
Director, National Technical Assistance Center
National Association of State Mental
Health Program Directors
American Public Health Association, Washington D.C., November 6, 2007