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 with Special 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

11. AgencyRestraintsSeclusions Buckeye Ranch 5 year period 99% reduction 46% reduction Klingburg 2000-2004 500 to 100 per year 300 to 50 per year Brewer-Porch 2002-2004 25 – 0 per month 18 – 1 to 2 per month Cambridge CAU 2000 - Present From 140 R/S events per 1000 client days to 0

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 YearRestraintsYouth Injuries Requiring Medical Attention Staff Injuries Due to Physical Management (Workers Comp) 19981447636 1999660227 20001690 4 200193312 2002169017 2003116011 200415115 20057703 20066713

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 YearSeclusions 19982642 19992114 20001259 2001940 2002607 2003386 2004 (Jan-Jun) 201 [1 st Q = 166 2 nd Q = 35] July 2004Stopped Seclusion

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. From “controlling” to “connecting”: A Move Away from Behavior Modification Behavior Mod  External control  Short-term benefits  Can be punitive Relationships  Shares control  Long-term benefits  Communicates caring and teaches by using natural and logical consequences

33. 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

34. 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

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

36. 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

37. 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].

38. 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.

39. 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

40. 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

41. 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

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

43. 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. 2 nd 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.

44. Resources Trauma Informed Care Bloom, S. (In print). Creating sanctuary for kids: Helping children to heal from violence. The International Journal for Therapeutic and Supportive Organizations. 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)

45. 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)