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TREATMENT, NOT TRAUMA Dr. Curie recounted his experience while at the Pennsylvania Department of Mental Health, where he led an initiative to reduce and eliminate restraint and seclusion. He characterized restraint as "immoral", and makes its elimination a leadership issue. He made the point that the overwhelming majority of people who enter the field, enter it with the best of intentions, in order to help others. Restraint is not treatment, but the failure of treatment. The vision for clients is life in the community and the goal is to build resilience and promote recovery. SAMHSA has launched a national campaign to eliminate restraint and seclusion. Steps:
The thrust of the Pennsylvania program and of Dr. Curie’s remarks was mental illness and its treatment. The philosophic point is that recovery is the goal and that recovery is possible. Patients and clients need to be helped toward independence and self-advocacy. It cannot be about control. He spoke at some length about the use of medication, stating that the modern, second generation of psychotropic drugs, are far more effective than the old ones and carry fewer side effects. Their proper use greatly reduces the need for restraint and seclusion. He indicated his impatience with their lack of wide-spread use due to cost issues, making the point that they are less costly than the results of poor treatment. Dr. Curie related stories illustrating the abuse of restraint and seclusion in which legitimate efforts at independence and self-advocacy were seen by staff members as a power struggle and led to abusive restraints. Dr. Curie addressed the argument staff use that restraint and seclusion is necessary for safety. In Pennsylvania, since the virtual ban on restraint and seclusion, injuries to staff and clients are down by 67%. Historically, injury during restraint had been a leading cause of injury. He repeatedly used the qualifying phrase, "in most situations". He stressed that simply deciding one day to eliminate restraint and seclusion would be ineffective and dangerous. What is needed is a complete change of atmosphere – to pull it off, everything must change. Dr. Curie cited the following as critical elements in producing this change:
Policy options:
Questions and Answers Question: In your presentation, much emphasis was placed on the use of second-generation psychotropics. Isn’t this just another form of restraint? Answer: The new generation of medications work much better, and with fewer side effects. They are used in the context of a doctor’s care and as a part of a comprehensive treatment program. A culture of prevention, through good treatment planning and being proactive rather than reactive, is a good way to promote a climate of dignity and respect, so that when a crisis occurs, restraint and seclusion are less likely, and recovery has a better chance. It is crucial to use "Recovery" as THE fundamental aim of practice, policy, and financial decisions. Question: What is the best way to bring line staff on board? Answer: Get them actively involved in the development and improvement of the model treatment program. There has to be "ownership" at all levels. Simply legislating the sweeping changes of philosophy and program will not work. Testimony from individuals who had been traumatized by their experiences in restraint and seclusion followed. A general theme was the feelings of fear, helplessness, lack of control, and isolation. Most of the testimony, both direct and in reference, told of the use of mechanical restraints for long periods of time, and complete isolation, also for lengthy periods. This was not treatment leading to recovery, but rather trauma that delayed recovery. Additional Testimony Thomas Kirk, Ph. D., Commissioner of the Dept of Mental Health and Addiction Services The Commissioner talked about their program at CVH. He stated that eliminating restraint and seclusion is not a project, but a "systems change", which is absolutely necessary. The participants, both staff and patients involved in face-to-face delivery, must be listened to and be involved in the process of change. "Recovery is not an event, but a process leading to greater and greater independence and improvement in the quality of life." They have a "Patient’s Personal Preference Policy" which asks the patient "How do you want to be treated when you become upset? What are your triggers? What is effective for you in dealing with a crisis?" Patients are involved in debriefings following a crisis. Much stress is placed on clients being actively involved in meaningful activities and in their treatment itself. One of their primary goals is the elimination of as much unstructured time as possible. Robert Plant, PhD from Riverview spoke for DCF Restraint and seclusion are viewed as treatment failures, not options. He stressed the awareness of the trauma that kids enter the system with, and the importance to avoid any further trauma. Restraint and seclusion are very dangerous in this respect.
One very troubling finding was that the rates of restraint and seclusion varied along racial and ethnic lines. This appears to have roots in history, communication problems and stereotypes. The issue was addressed directly in the trainings, study circles, and by establishing a more welcoming atmosphere to racial and ethnic groups. Considerable improvement was made with reference to Hispanic children, but not as much improvement as it relates to African-American children. Conclusion The seminar was sponsored by organizations whose philosophy is that restraint and seclusion must be outlawed. Their use is risky and can result in trauma and does indicate a failure of treatment, rather than the provision of treatment. The individuals who testified about their own traumatic experiences spoke of long periods of isolation from human contact, rather than interacting with/in the company of facility staff. The use of TCI, and I AIM, puts facilities in a good position, since the programs use the principles of individual treatment planning, progression towards independence and empowerment, debriefing, goal setting, planning and problem solving techniques for the individual. Unstructured time is dangerous, and involvement in meaningful activity is crucial. Staff levels need to be adequate in order to provide adequate programming, and to have the ability to be proactive in dealing with potential crises. It is not enough to respond quickly to crises. The aim is to develop the program to the point where crises do not have the opportunity to escalate to a dangerous level, where restraint and seclusion are the only options.
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