Myths and Assumptions about Seclusion and Confinement in Disability Services Jeffrey Chan, PhD Chief Practitioner Disability and Director of Forensic Disability Queensland Advocacy Inc. Seclusion and Solitary Confinement 27 July 2011, Banco Court, Brisbane

Myth and Assumption – Restraint and seclusion keep people we serve safe 142 deaths found from 1988 to 1998, reported by the Hartford Courant 50 to 150 deaths occur nationally each year due to seclusion and restraints estimated by the Harvard Center for Risk Analysis (NAMI, 2003) At least 14 people died and at least one has become permanently comatose while being subjected to S/R from July 1999 to March 2002 in one state alone (Mildred, 2002)

What do people with disabilities feel when they were subject to restrictive practices? They do not feel safe They recount their trauma and negative experience They feel violated and go through cycle of psychological distress They feel practices are unethical They feel helpless, hopeless and “spirit broken” They view their behaviours are in response to an offending or maladaptive environment Ramcharan et al. (2009) Strout (2010)

Myth and Assumption – Restraint and seclusion keep staff safe For every 100 mental health aides, 26 injuries were reported in a three-state survey done in 1996 The injury rate was higher than what was found among workers in: –Lumber –Construction (Weiss et al., 1998) –Mining industries (Weiss et al., 1998)

Myth and Assumption – Restraint and seclusion are used when absolutely necessary, not punitive and for safety reasons Andrew McClain was 11 years old and weighed 96 pounds when two aides at Elmcrest Psychiatric Hospital sat on his back and crushed him to death. Andrew’s offense? Refusing to move to another breakfast table.

Myth and Assumption – Restraint and seclusion are used when absolutely necessary, not punitive and for safety reasons Edith Campos, 15, suffocated while being held face-down after resisting an aide at the Desert Hills Center for Youth and Families. Edith’s offense? Refusing to hand over an “unauthorized” personal item. The item was a family photograph. (Lieberman, Dodd, & De Lauro, 1999)

Myth and Assumption – Restraint and seclusion are used when absolutely necessary, not punitive and for safety reasons Ray, Myers, and Rappaport (1996) reviewed 1,040 surveys received from individuals following their New York State hospitalization Of the 560 who had been restrained or secluded: –73% stated that at the time they were not dangerous to themselves or others –¾ of these individuals were told their behavior was inappropriate (not dangerous)

Myth and Assumption – Restraint and seclusion are used when absolutely necessary, not punitive and for safety reasons Analysis of six studies reported 58 – 75% conceptualized seclusion as punishment by staff Many persons-served believed:  Seclusion was used because they refused to take medication or participate in treatment program  Frequently, they did not know the reason for seclusion

Assumption: Staff know how to identify potentially difficult situations Holzworth & Willis (1999) conducted research on nurses’ decisions based on clinical cues of patient agitation, self- harm, inclinations to assault others, and destruction of property Nurses agreed only 22% of the time When data was analyzed for agreement due to chance alone, agreement was reduced to 8% Nurses with the least clinical experience (less than 3 years) made the most restrictive recommendations (Holzworth & Willis, 1999)

Assumption: Staff know how to de-escalate potentially difficult or violent situations In a study conducted by Petti et al. (2001) of content from 81 debriefings following the use of seclusion or restraint, staff responses to what could have prevented the use of S/R included:  36% blamed the patient  Example: “He could have listened and followed instructions”  15% took responsibility  Example:“I wish I could have identified his early escalation”

Assumption: Staff know how to de-escalate potentially difficult or violent situations Other responses included:  15% provided no response  12% were at a loss  Example:“I don’t see anything else…all alternatives used.”  11% blamed the system  Example:“Need to make a plan for shift change”  9% blamed the level of medication (Petti et al, 2001)

The dollars of restraint and seclusion: Organisational cost Flood, Bowers & Parkin (2008) – study on conflict and containment using an interview schedule with key staff and event data from 136 wards and costs from 15 wards. –Cost of a single episode of physical restraint = $ and seclusion = $ –50% of all UK nursing resources were expended to manage conflict and implement containment procedures

The dollars of restraint and seclusion: Organisational cost US restraint use of an adolescent inpatient service claimed (Lebel, 2011) – –> 23% of staff time –> $1.4M in staff related costs –40% of operating budget Medication – hrs staff time - $287 per event Physical – 25 – hrs staff time - $302 per event Mechanical – 25 – hrs staff time - $309 per event Combination – 29 – hrs staff time - $355 per event

Grafton Inc., Virginia – Four year data reveal 41.2% reduction in client-related staff injuries 10% reduction in staff turn-over and estimates annual savings of $500K 94% reduction in employee lost time and lost time expenses 50% reduction in workers’ compensation claims 21% reduction in liability premiums Cumulative savings in excess of $1.2M $483K cumulative workers compensation costs savings Increased staff satisfaction and staff perception of greater safety

Other evidence John Hopkins Hospital – 75% reduction in restraints and seclusion with no increase in staff or consumer injuries Florida State Hospital – 54% restraint reduction and realised nearly $2.9M in cost savings from reduced workers compensation, staff and consumer related injuries, and length of stay costs Forster et al (1999) – staff training decreases use of seclusion and restraint in an acute psychiatric hospital resulted in 13.8% reduction in annual restraint rates, 54.6% decrease in average duration of restraint per admission and 18.8% in reduction in staff injuries

Mindfulness – Singh et al Adult offenders with intellectual disability – Singh et al (2008): Reduction in lost work hours to $2244 from $53K 12 months prior. (Note: further unpublished studies note significant reduction in overall organisational cost benefits), reduction in physical. Other studies by Singh et al showed reduction in restraints and seclusion, increase in staff well-being, increase in staff satisfaction and happiness, and safety. Improvement in client well-being. See also studies on parents of children with autism.

Lebel & Golstein (2005) – restraint reduction strategy Benefits for the person – –Decreased injuries, length of stay and readmissions –Significantly increased functioning at discharge Benefits for staff and facilities – –Decreased injuries, sick time, replacement staff –Decreased staff turnover, hiring costs, workers compensation (medical claims and compensation) –Increase in cost savings and redeployed staff

Characteristics of success in safe elimination strategies Leadership with clear goals in policy direction and implementation driven by compassion and human rights Systematic collection and analysis of the evidence (e.g. episodes of incidents and restrictive interventions, OHS data, support plans data, processes etc) Translating evidence into organisational practice and learning – preventative environmental and support strategies, communication strategy etc Quality support plans and monitoring of implementation Practice leadership in supporting and training staff Implementation of a range of protective supports (e.g. debriefing, staff training and support, staff well- being/mindfulness etc)

Myths Facts (Lebel, 2011) Need more $$ Flexible use of resources More staff or new staffCore staff, OPEN to change Micromanage Pragmatic teaching, mentoring State of the art environmentFlexible and creative use of space Control and limitationCollaborate and negotiate No data or strict use of dataData drives practice and meaningful

Andy Pond, LICSW President & CEO of Justice Resource Institute “Restraint and seclusion are costly in all kinds of ways – they are just plain costly. Whatever new costs we had were minimal. Most of the training we put in place to reduce restraint and seclusion were really good clinical practice and what we should be doing anyway.”

Questions and discussion