Creating Violence-Free Mental Health Settings: Changing our Cultures of Care Hogg Foundation for Mental Health Teleconference Tuesday, April 4, 2006 Kevin Ann Huckshorn RN, MSN, CAP National Technical Assistance Center NASMHPD

2 Outline The Development of a Curriculum to Reduce S/R Use in MH and other Settings Identification of Key Constructs Six Core Strategies for S/R Reduction© Developing a S/R Reduction Plan Training Activities and Next Steps Closing Comments

3 Development of a Curriculum to Reduce the Use of S/R NASMHPD Bias/Values: We hold that all use of S/R should be restricted to situations of imminent danger and that the majority of our efforts need to be focused on preventing the need to use coercive interventions. We also hold that while we are reducing use it is of extreme importance to use S/R as safely and briefly as possible (NETI, )

4 NASMHPD Training Definitions (2003 to present) Restraint: “A manual method or mechanical device, material or equipment attached or adjacent to a person’s body that is not easily removed and that restricts the person’s freedom or normal access to one’s body” (HCFA Interim Rules, 1999) NOTE: Suggest that child facilities separate out manual holds from mechanical restraint

5 NASMHPD Training Definitions (2003 to present) Seclusion: “The involuntary confinement of a person in a room where they are physically prevented from leaving or believe they are” (NETI, 2005)

6 Development of a Curriculum to Reduce the Use of S/R Extensive Review of Literature to present Qualitative Reports emerging from personal experiences (self and colleagues) with direct experiences in successful reduction projects across the country Core strategies emerged in themes over time Expert Meeting(s) held in DC in 2001, 2002, 2003 to refine.

7 Key National Activities Supporting Ongoing Efforts IOM describes new rules to transition the redesign and improvement in care (IOM, 2001, 05) Continuous healing relationships Customized to individual needs/values Consumer is source of control Free flow of information/transparency Reducing risk to ensure safety Anticipation of needs Use of Best Practices

8 Key National Activities-MH Specific The New Freedom Commission A Call for System Transformation System Goal=Recovery for everyone Services/supports are customer/family centered Focus of care must increase service user’s ability self manage illness and build resiliency Individualized Plans of Care critical Consumers and Families are full partners (NF Commission, 2003)

9 The Identification of Core Constructs to Guide Project Public Health Prevention approach Recovery/Resiliency Principles Important Role of Leadership Consumer and Staff Self Reports Valued Trauma Knowledge utilized Framework of CQI

10 The Public Health Prevention Model The Public Health approach is a model of disease prevention and health promotion and is a logical fit with a practice issue such as S/R reduction This approach I.D.’s contributing factors and creates remedies to prevent, minimize and/or mitigate the problem if it occurs It reconciles our focus on “safer use” to preventing use in the first place

11 The Public Health Prevention Model Primary Prevention (Universal Precautions) Interventions designed to prevent conflict in the environment by anticipating risk factors Secondary Prevention (Selective Strategies) Early interventions to immediately minimize and resolve conflicts when they occur Tertiary Prevention (Indicated Interventions) Post S/R interventions designed to mitigate effects, analyze the event, take corrective action, and avoid in future

12 Recovery/Resiliency Principles Partnerships, locus of control, life in the community, illness self- management, provision of hope Concepts apply to adults and kids The use of S/R is counter-intuitive Coercive or traumatizing settings do NOT foster hope, healthy relationships, prosocial behaviors or trust (NF Commission, 2003)

13 Recovery/Resiliency Principles Related Developmental Theories re S/R The ability to form healthy relationships is highly dependant on learned social skills Children’s social skill learning is directly related to the chx of their environments Disordered environments=dysfunctional skills Violence teaches withdrawal, anxiety, distrust, over-reaction and/or aggression as coping behaviors (Saxe et al., 2003; SG Report, 1999)

14 Recovery/Resilience Principles National Child Traumatic Stress Network Extreme behaviors are rooted in dysregulated emotional states Effective interventions must target px in social environ (milieu) and the child Therapeutic milieus ensure safety and limit exposure to stressors Effective interventions are not shame based, punitive or triggering (Saxe et al., 2003)

15 Traumatized Children: Observations and Experiences World is threatening and bewildering World is punitive, judgmental, humiliating and blaming Control is external, not internalized People are unpredictable and untrustworthy Defend themselves above all else Believe that admitting mistakes is worse than telling truth (Hodas, 2004)

16 J. Garbarino’s “lost boys” research Issues of shame are paramount, allowing child to “save face” important Violence can be seen as an attempt to achieve justice as child sees it These children cannot afford empathy as their needs are so great and overwhelming; tend to de-personalize others (Hodas, 2004)

17 Self Reports on S/R Experiences Research studies have found that people who were secluded experienced vulnerability, neglect, shame Express feelings of fear, rejection, anger and agitation Felt they were being punished Do not feel protected from harm Feelings of bitterness and anger 1 yr later (Wadeson et al., 1976; Martinez et al., 1999; Mann et al., 1993; Ray et al., 1996)

18 Staff Self Reports/Experiences Female direct care staff: I know that after a couple of difficult incidents on a unit, I certainly felt like I had symptoms of PTSD, about being hyper-aware when I walked to my car, because some of the things that I saw and that I was involved with were very traumatic. I think consumers talk about what it is like to be in restraints, it is also traumatizing to put people in restraints in the same way that I think it is traumatizing for soldiers to go to war and kill other people. We don’t often talk about the impact of that either.

19 Principles of Trauma Informed Systems of Care Definition - Health Care that is grounded in and directed by: a thorough understanding of the neurological, biological, psychological and social effects of trauma and violence on humans and the prevalence of these experiences in children and adults who receive mental health and related services. (NETI, 2005)

20 Prevalence of Trauma Mental Health Population 90% of public mental health clients have been exposed to trauma (Muesar et al., in press; Muesar et al., 1998) 51-98% of public mental health clients have been exposed to trauma (Goodman et al., 1997, Muesar et al, 1998) Most have multiple experiences of trauma (Muesar et al, in press; Muesar et al, 1998) 97% of homeless women with SMI have experienced severe physical & sexual abuse – 87% experience this abuse both in childhood and adulthood (Goodman et al., 1997)

21 Prevalence of Trauma Mental Health Population Current rates of PTSD in people with SMI range from 29-43% (CMHS/HRANE, 1995; Jennings & Ralph, 1997) Canadian study of 187 adolescents reported 42% had PTSD American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSD

22 What does this tell us? The majority of adults and children in psychiatric treatment settings have trauma histories Presume clients have had experiences of traumatic stress Impact of Trauma can be major regardless of diagnosis (Hodas, 2004, Cusack et al.; Muesar et al., 1998; Lipschitz et. Al, 1999, NASMHPD, 1998)

23 Impact of Trauma over the Life Span Effects are pervasive (neurological, biological, psychological and social): Changes in brain neurobiology Social, emotional & cognitive impairment Adoption of health risk behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self harm, sexual promiscuity, violence) Severe and persistent behavioral health, health and social problems including premature death (Felitti et al, 1998; Herman, 1992)

24 Trauma Informed Care Systems Integrate philosophy of care that guides all interventions and interactions Are based on current literature Are inclusive of the consumer’s perspective Recognize that coercive interventions can cause trauma and re-traumatization and are to be avoided Key Principles of TIC ( Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)

25 Trauma Informed Care Systems Key Features Recognition that mental health treatment environments and related settings are often traumatizing, both overtly and covertly Recognition that the majority of human service staff are uninformed about trauma and its sequelae, do not recognize it, do not treat it, and are not trained to do either ( Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.; Jennings, 1998; Prescott, 2000 )

26 Systems without Trauma Sensitive Characteristics Service users are labeled & pathologized as “manipulative,” “needy,” attention seeking Misuse or overuse of displays of power such as keys, security, demeanor Culture of secrecy - no advocates, poor monitoring of practices Culture of control, rules, consequences ( Fallot & Harris, 2002 )

27 How do we use this information to reduce S/R use? Develop a formal S/R Reduction Action Plan (NETI, 2005) Action Plan Essential Framework Prevention-Based Approach Continuous Quality Improvement Principles Individualized for the Facility or Agency Focus on what to change (physical environs, attitudes, leadership, oversight, policy and procedures, rules and regulations, staff management?)

28 The Six Core Interventions© (taken from NETI, 2005) Leadership Toward Organizational Change Use Data To Inform Practices Develop Your Workforce Implement S/R Prevention Tools Actively recruit and include service users and families in all activities Make Debriefing rigorous

29 1 st Core Strategy: Leadership The most important component in successful reduction projects. Have the authority to make the changes that are necessary for success: Make/keep S/R reduction a high priority Reduce/eliminate organizational barriers Provide the necessary resources Hold people accountable for their actions

30 1 st Core Strategy: Leadership Leadership Creates the Vision Plan for your System Issue Policy Statement on S/R Define rationale (why) for agency Mandate inclusion of all key stakeholders & people served Review facility S/R policy & procedures

31 1 st Core Strategy: Leadership Organize S/R Reduction Team Leadership Assigns Team – Identify Internal S/R Champions and skeptics – All levels of staff – Include consumers/advocates – Routine and consistent meetings

32 1 st Core Strategy: Leadership Organize S/R Reduction Team Assign plan responsibilities to people, not groups Document assignments Manageable time frames Sign off and monitor plan implementation

33 1 st Core Strategy: Leadership Elevate oversight of all S/R Events In Curriculum called “Witnessing” Refers to 24/7 off site executive level on call response (by phone) to each event Every event becomes high priority Executive role is to ask “Why” questions Assigns new responsibilities to all staff Daily rounds are also suggested

34 2 nd Core Strategy: Use of Data Using Data To Reduce Use Gather baseline data by event/hours (6 m to 1 yr) to start Set realistic goals Gather event data by unit/day/shift/time/age/dx/gender/ race/individuals involved/MD/Date of Admission Post data on units monthly (transparency) Group outliers

35 2 nd Core Strategy: Use of Data Using Data To Reduce Use Monitor Progress Discover new best practices Target certain units/staff for training Create a healthy competition Assure that everyone knows what is going on Executive staff review data at least weekly

36 3 rd Core Strategy: Workforce Development Integrate S/R Reduction in HRD Activities Monitor Progress New Hire procedures Job Descriptions and Competencies Performance Evaluations New Employee Orientation Annual Reviews

37 3 rd Core Strategy: Workforce Development Staff will require education on key concepts: Common Assumptions about S/R Experiences of Staff and Consumers with S/R The Neurobiological/Psych Effects of Trauma Creating Trauma Informed Systems and Services Principles of Recovery/Resiliency Building non-coercive relationships Use of S/R Reduction Tools (violence, death/injury, de-escalation, trauma, etc.)

38 3 rd Core Strategy: Workforce Development Note about S/R Application Training Very important while reducing use Senior S/R Champions need to experience whatever S/R application training you are providing Empower staff to question rules, policies and procedures and to make decisions. THIS MAY BE A BIG CULTURE CHANGE! Reward Excellent Practice

39 4 th Core Strategy: S/R Prevention Tools Choose and Implement S/R Prevention Tools Assess risk factors for violence and S/R use Universal Trauma Assessment Assess risk factors for death and Injury Use Safety Plans/Crisis Plans/Advance Directives: identify triggers/preferences/ and use

40 4 th Core Strategy: S/R Prevention Tools Choose and Implement S/R Prevention Tools Use of comfort/sensory rooms Incorporate Person First Language Building Relationships Training Guidelines (De-escalation models) Effective Treatment Activities Manage overcrowding

41 5 th Core Strategy: Full Customer Inclusion Consumer/Family Inclusion Inclusion-MAKE IT HAPPEN! This is not easy and usually a big change for staff and executives sometimes Clarify available roles (age dependant) Value information transparency “Nothing about us without us”

42 5 th Core Strategy: Full Customer Inclusion Hire people in recovery, family members/community advocates as staff members, use volunteers Make information available Use to interview service user post-event Attend meetings - all levels Empower and support participation

43 6 th Core Strategy: Debriefing Debriefing Specifics Define what Debriefing is and what it is not Implement both types of Debriefing Acute - immediate post event response to gather info, manage milieu, assure safety Formal - rigorous problem solving event R

44 6 th Core Strategy: Debriefing Acute and formal debriefing events are best facilitated by a senior staff person not involved in event –Include the service user –Include the staff –Entire staff team Use a template or guideline/checklist

45 6 th Core Strategy: Debriefing Use root cause analysis steps Non-punitive approach (be consistent) Goal is to find out what happened, mitigate and how to prevent reoccurrences New info should change practice, policies and operational rules

46 NASMHPD S/R Training Evaluation National Executive Training Institutes (NETI) SAMHSA/CMHS funded First 12 states trained/8 sent data 6-12 month pre-training data and 3-6 month post-training data compared Not research, simple evaluation Not studied as to change “why’s”

47 NASMHPD S/R Training Pre/Post Data (NRI, 2003) 5 of 8 hospitals reduced hours of restraint 5 of 7 reduced hours of seclusion 7 of 8 had fewer consumers restrained 6 of 7 had fewer clients secluded 5 of 7 had fewer restraint events 6 of 6 had fewer seclusion events (Conley et al., 2004)

48 NASMHPD S/R Training Pre/Post Data (NRI, 2003) The data also showed that S/R hours were reduced by as much as 79%, the proportion of consumers in S/R was reduced by as much as 62%, and the incidents of S/R events in a month were reduced by as much as 68%. (Conley et al., 2004)

49 NASMHPD/NTAC Activities and Next Steps NETI Training (50 states/DC/territories) completed in 2003, State Incentive Grants to identify alternatives to reduce use awarded in 2004 (HI, IL, KY, LA, MA, MD, MO, WA) Three year project includes large scale research study with HSRI, ongoing TA & NREPP application

50 Seclusion/Restraint Reduction Final Comments Significant S/R reduction is possible Keep focus and vision on Prevention and Improved Safety for all Done correctly, these efforts positively change our treatment cultures S/R Reduction is primarily a Leadership responsibility

51 Seclusion/Restraint Reduction Final Comments Develop and implement a formal Action Plan (aka treatment plan to reduce S/R) While reducing assure for safe use Provide workforce with new tools/data Support and include service users in new roles and in managing their own care Make Debriefing activities effective

52 Contact Information Kevin Ann Huckshorn Director, Office of Technical Assistance National Association of State Mental Health Program Directors 66 Canal Center Plaza, Suite 302 Alexandria, VA (703) ext. 140