1. Roadmap to a Restraint Free Environment for Persons of All Ages National Association of Consumer/Survivor Mental Health Administrators

2. Roadmap to a Restraint Free Environment for Persons of All Ages Dear Joyce, I wanted you to know that I have only been in the hospital 1 hour,

3. Roadmap to a Restraint Free Environment for Persons of All Ages and already 7 people have come to me about the conference and how it changed their life,

4. Roadmap to a Restraint Free Environment for Persons of All Ages and one person said, "The train has left the station. We are already doing great things and we will continue to do even better."

5. Roadmap to a Restraint Free Environment for Persons of All Ages Another person used the word ‘patient’ and corrected themselves in front of others.

6. Roadmap to a Restraint Free Environment for Persons of All Ages “I don't know if I like the word consumer, but it's what people with psychiatric illness want to be called and it is their right to have us do that."

7. Roadmap to a Restraint Free Environment for Persons of All Ages They talked about the profound change that occurred for everyone in the room on Wed.

8. Roadmap to a Restraint Free Environment for Persons of All Ages They said, "It was as though the earth moved and shifted inside all of us.”

9. Roadmap to a Restraint Free Environment for Persons of All Ages This was a life changing experience and I will never be the same again.

10. Roadmap to a Restraint Free Environment for Persons of All Ages There are already plans for a monthly workgroup. I am so thankful that you, Carol and Erica came to us now and are helping to shift the paradigm.

11. Roadmap to a Restraint Free Environment for Persons of All Ages Thank you for all the wonderful presentations. We are very blessed to know you. Susan

12. Roadmap to a Restraint Free Environment for Persons of All Ages “ Be the change you want to see in others.” Mahatma Ghandi

13. Roadmap to a Restraint Free Environment for Persons of All Ages MESSAGE FROM SAMHSA ADMINISTRATOR INTRODUCTION HOW TO USE THIS MANUAL

14. Roadmap to a Restraint Free Environment for Persons of All Ages MODULE 1: THE PERSONAL EXPERIENCE OF RESTRAINT AND SECLUSION A. Background for the Facilitator B. Setting the Stage C. Overview D. Special Needs Populations E. Personal Perspective: Consumers F. Personal Perspective: Line Staff G. Journal/Take Action Challenge H. Wrap Up and Evaluation I. Resources for the Facilitator

15. Exercise: Getting to Know You

16. Roadmap to a Restraint Free Environment for Persons of All Ages OBJECTIVE:To give an opportunity for participants to get to know one another and begin discussing their own experiences related to seclusion and restraint.

17. Roadmap to a Restraint Free Environment for Persons of All Ages PROCESS:Ask participants to pair up with a person they don’t know very well. Have them introduce themselves to each other and share their first experience with seclusion and restraint. If time allows, also include their most difficult restraint and seclusion experience. What was their most recent experience with restraint and seclusion? Have each participant introduce their partner and at least one feeling word (e.g. sad, elated, scared, frightened, powerful, and repulsed) to describe their experience. On the chalkboard or dry erase board, keep a list of feelings expressed.

18. Roadmap to a Restraint Free Environment for Persons of All Ages DISCUSSION QUESTIONS: What are the similarities you heard about first experiences of seclusion and restraint? Which feelings were most common? How has your experience of restraint and seclusion changed/stayed the same over time?

19. Roadmap to a Restraint Free Environment for Persons of All Ages MATERIALS REQUIRED: Chalkboard or dry erase board and writing utensil. APPROXIMATE TIME REQUIRED: 30 minutes. SOURCE: Buffington, Geisler, Jorgenson, 2002

20. Staff Responses to Participating in Seclusion/Restraint Reliving violence from the past Feeling helpless, what are we supposed to do?

21. Staff Responses to Participating in Seclusion/Restraint Chaos Unpleasant Little training-need to think quickly

22. Staff Responses to Participating in Seclusion/Restraint Not sure if I could do it Once hands on— I had to help Felt bad

23. Staff Responses to Participating in Seclusion/Restraint Intensity - hair rising on back of neck Choking First memory—faceless— body bag, person got out somehow

24. Staff Responses to Participating in Seclusion/Restraint Awful, painful experience Cold wet sheets, kids tied to chairs Violent, handled with greater force than necessary

25. Staff Responses to Participating in Seclusion/Restraint First experience with her mother, never forget Scared Indignity of stripping, cold wet sheets

26. Journal/Take Action Challenge

27. Roadmap to a Restraint Free Environment for Persons of All Ages MODULE 2: UNDERSTANDING THE IMPACT OF TRAUMA A. Background for the Facilitator B. Setting the Stage C. Overview D. Definitions Related To Trauma E. Common Reactions to Trauma F. Effects of Trauma on the Brain G. Differential Response to Threats H. Assessment of Trauma I. Retraumatization via Hospitalization J. De-Escalation Preferences K. What Survivors Want in Times of Crisis L. Secondary Traumatization M. Healing from Trauma N. Grounding Techniques O. Stress Management P. Journal/Take Action Challenge Q. Wrap Up and Evaluation R. Resources for the Facilitator

28. Take Action Challenge From Module 1

29. Module 2 Understanding the Impact of Trauma

30. Learning Objectives Upon completion of this module the participant will: Define trauma and describe how it can impact consumers in mental health settings List common reactions to trauma, and identify how trauma affects the brain Understand how hospitalization/restraint/ seclusion can be retraumatizing for consumers Incorporate Trauma Assessment and De-escalation forms into current practices Recognize and utilize positive coping mechanism to deal with secondary traumatization

31. Dealing with the Effects of Trauma: A Self-Help Guide by Mary Ellen Copeland

32. Roadmap to a Restraint Free Environment for Persons of All Ages MODULE 3: CREATING CULTURAL CHANGE A. Background for the Facilitator B. Setting the Stage C. Overview D. Pennsylvania: A Model for Reform E. Cultural Change F. Safety G. In Our Own Voices H. Journal/Take Action Challenge I. Wrap up and Evaluation J. Resources for the Facilitator

33. Roadmap to a Restraint Free Environment for Persons of All Ages Intrapersonal – occurring within the individual mind or self Interpersonal – involving relationships between persons Systems/Cultural Change

34. Roadmap to a Restraint Free Environment for Persons of All Ages “ Be the change you want to see in others.” Mahatma Ghandi

35. Defining Culture Culture: Who we are and how we do things

36. Exercise: My Organization Currently Is…

37. Lecture Let’s first start with a picture of where your organization is right now – before proposing any changes. Remember, all organizations have things they do well at and things they could improve on. Exercise/Discussion “My Organization Currently Is…”

38. Exercise: My Organization Currently Is… OBJECTIVE: Participants will identify current ecology, relationships, and leadership in their organization.

39. PROCESS:Divide the group into three similar sized groups. Assign one group ecology, one group relationships, and one group leadership. Ask them to do an evaluation (positive and negative) of how their organization currently functions around these issues as it relates to the reduction of seclusion and restraint. Have each group report back their findings. The groups may want to write key points on the board or on a flip chart. Exercise: My Organization Currently Is… PROCESS:Divide the group into three similar sized groups. Assign one group ecology, one group relationships, and one group leadership. Ask them to do an evaluation (positive and negative) of how their organization currently functions around these issues as it relates to the reduction of seclusion and restraint. Have each group report back their findings. The groups may want to write key points on the board or on a flip chart.

40. Exercise: My Organization Currently Is… Leadership: · Inspires others to see their own potential · Foster relationship building among all · Challenge process not people · Teach “there could be a better way” attitude · Remove barriers to possibility thinking · Be a learning organization

41. Exercise: My Organization Currently Is… Ecology: · Physical Surroundings · Formal Policies and Rules · Resources · The Unit Culture · Attitudes · Cultural Norms

42. Exercise: My Organization Currently Is… Relationships: Front line staff peer relationships Front line staff to administration relationships Front line staff to consumer relationships Administrative staff to consumer relationships

43. Exercise: My Organization Currently Is… DISCUSSION QUESTIONS: · Which of the three areas, ecology, relationships, and leadership, is most likely to support the reduction of seclusion and restraint at your facility? · Which of the three areas might struggle with these changes and why? · What works well and what is a problem related to seclusion and restraint?

44. Exercise: My Organization Currently Is… MATERIALS REQUIRED: Handout Module 3 – My Organization Currently Is…” Chalk Board or flip chart. APPROXIMATE TIME REQUIRED: 30 minutes SOURCE: Exercise by Geisler, Buffington, Jorgenson, 2002

45. Roadmap to a Restraint Free Environment for Persons of All Ages MODULE 4: UNDERSTANDING RESILIENCE AND RECOVERY FROM THE CONSUMER PERSPECTIVE A. Background for the Facilitator B. Setting the Stage C. Overview D. Resilience E. Recovery F. Journal/Take Action Challenge G. Wrap Up and Evaluation H. Resources for the Facilitator

46. Deegan Quote “People diagnosed with mental illness are resilient and are more than passive victims of disease processes. Professionals who learn to collaborate with the active, resilient, adaptive self of the client will find themselves collaborating in new and rewarding ways with people who may have been viewed as hopeless by others who reify [to regard (something abstract) as a material or concrete thing] diagnoses and related prophecies of doom” (Deegan, Ph.D., 2001).

47. Roadmap to a Restraint Free Environment for Persons of All Ages I DID WANT TO UPDATE YOU ON AN EXCITING EXPERIENCE LAST WEEK. I WAS ON THE UNIT WHEN A PATIENT TRIED TO HARM HERSELF, THEN SWUNG AND KICKED AT STAFF WHEN THEY INTERVENED…A MANUAL HOLD

48. Roadmap to a Restraint Free Environment for Persons of All Ages ONE STAFF NOTICED CUES THAT THE PATIENT WAS CALM AND MAY NOT BE AN IMMEDIATE THREAT AND BEGAN A DIALOGUE IS THERE ANOTHER WAY WE CAN DO THIS WITHOUT THE RESTRAINT SO THAT WE CAN KEEP EVERYONE SAFE

49. Roadmap to a Restraint Free Environment for Persons of All Ages DO YOU PROMISE NOT TO HURT ANYONE NOW? THE STAFF ASSESSESD THE INFORMATION TO BE CREDIBLE AND THE TEAM DISENGAGED THE RESTRAINT PROCESS. Leah

50. Roadmap to a Restraint Free Environment for Persons of All Ages MODULE 5: STRATEGIES TO PREVENT RESTRAINT AND SECLUSION A. Background for the Facilitator B. Setting the Stage C. Overview D. Consumer Driven Supports E. Journal/Take Action Challenge F. Wrap Up and Evaluation G. Resources for the Facilitator

51. Roadmap to a Restraint Free Environment for Persons of All Ages MODULE 6: STRATEGIES TO PREVENT RESTRAINT AND SECLUSION A. Background for the Facilitator B. Setting the Stage C. Overview D. Communication Strategies E. Comfort Room F. Alternative Dispute Resolution/Mediation G. Journal/Take Action Challenge H. Wrap Up and Evaluation I. Resources for the Facilitator

52. Roadmap to a Restraint Free Environment for Persons of All Ages As we talked about communicating with the consumers, I had an overwhelming sensation of grief and guilt

53. Roadmap to a Restraint Free Environment for Persons of All Ages and realized that as a nurse I tell patients that I am going to keep them safe

54. Roadmap to a Restraint Free Environment for Persons of All Ages and one way of doing this is to take from them anything that we see as dangerous such as shoe laces, belts

55. Roadmap to a Restraint Free Environment for Persons of All Ages so they can’t hurt themselves with anything that could be a weapon.

56. Roadmap to a Restraint Free Environment for Persons of All Ages But when they are very upset and losing control,

57. Roadmap to a Restraint Free Environment for Persons of All Ages we come along with our restraint bag— our bag of weapons

58. Roadmap to a Restraint Free Environment for Persons of All Ages and we do hurt them and use harsh words. It doesn’t make sense.

59. Roadmap to a Restraint Free Environment for Persons of All Ages “It’s crazy making when we tell consumers that we are doing this to help them be safe!” Jane B. Child/Adolescent Unit Manager

60. Communication Strategies

61. Exercise: How Hard Can Communication Be?

62. Roadmap to a Restraint Free Environment for Persons of All Ages

63. Comfort Rooms

64. Comfort Room Definition: The Comfort Room (formerly called the Quiet or Time Out room) is a room that provides sanctuary from stress, and/or can be a place for persons to experience feelings within acceptable boundaries. (Gayle Bluebird)

65. Comfort Room Door Sign A special place where you may spend some time alone. You may ask any staff member to use this room. There are items that you can sign-out to help you calm down and relax (stuffed animals, soft blanket, music, magazines, and more).

66. Exercise: What Makes Me Comfortable?

67. Handout: How to Set Up a Comfort Room by Gayle Bluebird

68. Roadmap to a Restraint Free Environment for Persons of All Ages MODULE 7: SUSTAINING CHANGE THROUGH CONSUMER AND STAFF INVOLVEMENT A. Background for the Facilitator B. Setting the Stage C. Overview D. Leadership E. Debriefing F. Updating Treatment Plans G. Data Collection H. External Monitoring I. Journal/Take Action Challenge J. Wrap Up and Evaluation K. Resources for the Facilitator

69. Roadmap to a Restraint Free Environment for Persons of All Ages

70. MODULE 8: ROLE OF THE CHAMPION A. Background for the Facilitator B. Setting the Stage C. Review D. Role of the Champion E. Personal Action Plan F. Workplace Action Plan G. Certificate of Completion H. Wrap Up and Evaluation I. Resources for the Facilitator

71. “It is rather impressive how creative people can be when restraint is simply not a part of the treatment culture.” JCAHO Testimony John N. Follansbee, M.D. Northern Virginia Mental Health Institute

72. Roadmap to a Restraint Free Environment for Persons of All Ages RESOURCES A. Web Sites B. Policies and Position Statements 1. American Nurses Association 2. American Psychiatric Nurses Association 3. Federation of Families for Children’s Mental Health 4. National Alliance of the Mentally Ill 5. National Association of State Mental Health Program Directors 6. National Mental Health Association

73. Roadmap to a Restraint Free Environment for Persons of All Ages Wow Joyce ! This is incredibly impressive work. I can’t wait to see the completed manual.

74. Roadmap to a Restraint Free Environment for Persons of All Ages To pair this type of consciousness raising with an actual program to reduce restraints is outstanding.

75. Roadmap to a Restraint Free Environment for Persons of All Ages How can I access a copy of the manual when it is ready? I am so pleased that my paper is part of it. Pat

76. Roadmap to a Restraint Free Environment for Persons of All Ages I found the most valuable aspect of the training to be the self-awareness that was awakened in me, and the awareness I saw awakened in other participants.

77. Roadmap to a Restraint Free Environment for Persons of All Ages As you know, our desire to obtain training was based in our commitment to eliminate restraint and seclusion, but setting goals and achieving them are two different things, as you pointed out.

78. Roadmap to a Restraint Free Environment for Persons of All Ages Your training showed us it can be done, that it has been done elsewhere, and I believe you built in us the internal strength to get it done.” David K. Clinical Services Director