A Closer Look: How They Did It
A Review of How Six Children's Residential Mental Health Facilities
are Attempting to Reduce or Eliminate the Use of Seclusion and Restraint
A publication of the Ohio Legal Rights Service (OLRS)
May 2003
Contents:
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Copyright © 2003 Ohio Legal Rights Service. All rights reserved.
Dear Colleagues,
In 2000, Ohio Legal Rights Service (OLRS) recognized the value of creating a data collection system to monitor Major Unusual Incident reports submitted by Children's Residential Treatment Facilities to the Ohio Department of Mental Health. Utilizing this data system over the past several years has enabled OLRS to develop a rich data base that provided the ability to track trends and patterns and fulfill our obligation to monitor health and safety, remedy systemic problems, and provide assistance.
This document, "A Closer Look, How They Did It" is the fifth in a series of publications based on the OLRS data base for Children's Residential Treatment Facilities. Earlier publications included: 1) "A Closer Look - Seclusion and Restraint Practices in Children's Residential Facilities," 2) "A Closer Look - A Review of Psychotropic Medication Practices in Children's Residential Facilities in Ohio," 3) "A Closer Look - Families and Our Kids: Living in the Residential Maze," and 4) "Resource booklet."
OLRS staff reviewed and analyzed statewide seclusion and restraint data and discovered that some facilities had reduced the use of seclusion and restraint. This Closer Look publication identifies the struggles and successes of six facilities that were able to develop or maintain a culture that is more children friendly and less hostile by reducing the use of seclusion and restraint. "How They Did It" presents a realistic view of system change by noting the framework within which change occurred in six facilities — the conflicts, staff time, effort, resources, money, and determination required to affect change.
The intent of this document was to demonstrate that children's mental health residential treatment facilities can significantly reduce or eliminate the use of seclusion and restraints. My challenge to administrators of children's residential mental health facilities is for you to recognize that the use of seclusion and restraint oftentimes re-traumatizes children and reflects a treatment failure rather than treatment, and to use this document to motivate you and your staff to implement a plan to reduce or eliminate the use of seclusion and restraint in your facility. The children will thank you!
Sincerely,
Carolyn S. Knight, Executive Director
Ohio Legal Rights Service
May 2003
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In Ohio, some mental health residential treatment facilities for children are taking proactive steps to reduce or eliminate the use of seclusion and restraint in their facilities. Ohio Legal Rights Service took a "Closer Look" at how they did it — here are the results.
Ohio Legal Rights Service's (OLRS) MUI data base revealed that some mental health residential treatment facilities for children decreased the use of seclusion and restraint over the past several years.
Additional information obtained through OLRS casework and investigations also suggested reductions in the use of seclusion and restraint.
In order to follow up on this promising information, OLRS developed a survey to see why and how reductions were occurring. OLRS wanted to determine if facilities had made an administrative decision to reduce or eliminate seclusion and restraints, and/or had changed policies or programming to reflect that administrative decision. OLRS sent a three question survey (the "preliminary survey") to the 20 children's mental health treatment residential facilities that have 10 or more beds. Facilities that responded yes to all three questions were asked to forward their new policies to OLRS.
OLRS chose six facilities to visit — to investigate how they are attempting to reduce or eliminate the use of seclusion and restraints. The six facilities were chosen based on OLRS's baseline data and on the results from the preliminary survey of all twenty facilities.
In an effort to reliably gather the same information from each of the six facilities that was visited, OLRS developed an interview survey tool (the "on-site survey") of several questions.
A two person team from OLRS implemented the survey tool at each of the six facilities. All on-site visits lasted approximately two hours, and were conducted during December 2002. OLRS staff met with facility representatives who were responsible for the reduction or elimination of the use of seclusion and restraint.
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An analysis of the survey data collected at the six facilities revealed common approaches, barriers, and observations in the facilities' efforts to reduce or eliminate the use of seclusion and restraint. There were ten significant commonalties, which are outlined in the following pages.
Ten Common Experiences
Ten commonalties experienced by facilities in their efforts to reduce or eliminate the use of seclusion and restraint were:
- Active Support of Administration;
- Increased Staff Training;
- Development of a Planning Team;
- Benefits from Data Collection and Analysis;
- Positive and Negative Outcomes;
- Barriers Encountered;
- Including Children and Families;
- Research on Alternative Programming;
- Increased Costs;
- Professionalizing the Role of Direct Care Workers.
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Staff at every facility related that their administration supported or initiated the movement toward a seclusion and restraint free facility.
The facilities indicated that administrative backing and support were necessary to assure sufficient resources, funding, and support since culture change crosses staff and program issues.
During the site visit interviews, facility administrators shared several reasons for the philosophical change to reduce or eliminate the use of seclusion and restraint. Take a look at what the administrators reported:
"Needed to change the treatment culture and wanted strength based treatment."
"We wanted a culture of not restraining kids — seclusion and restraint are not good for kids."
"The use of restraints is re-traumatizing and not therapeutic."
"Wanted to stop re-traumatizing kids."
"View our facility as a trauma treatment center — we don't want to re-traumatize kids."
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Staff training was a major component in each facility's system change process. Each of the facilities indicated that they have increased the number of staff training hours.
A common theme among all facilities was training which decreased the focus on learning physical restraints, and at the same time, increased the use of de-escalation techniques. Training focused on identifying and avoiding power struggles over "programmatic compliance issues" and learning new therapeutic approaches.
Each facility adopted its own approach to staff training. Most of the facilities designated specific staff members who were trained and certified in the crisis intervention model the planning team had chosen. These certified staff members provided ongoing training and mentoring within the facility. Facility trainers provided direct care staff with alternative crisis intervention methods.
Most facilities conducted training on campus. However, one held trainings away from campus and another offered web based training.
What follows are training models and requirements at each facility:
Facility 1
- 4 trainers on staff (plans are to train 3 more).
- Staff receive 16 hours of seclusion and restraint training initially.
- Staff receive 6 more hours of training after completing probation.
- After first year, staff must complete 8 hour trainings annually.
- Optional re-mentoring and re-coaching is available.
Facility 2
- 2 trainers on staff.
- Trainers receive yearly 3 day recertification in Non Violent Crisis Intervention (NVCI).
- Direct care staff receive 8 hours of NVCI training.
- Quarterly updates or NVCI boosters are provided to all staff.
- NVCI stresses de-escalation techniques only, physical holds are not part of the training.
Facility 3
- 2 trainers on staff.
- Staff receive training which includes:
- 3 hours of Aggressive Client De-escalation through Therapeutic Assault Prevention System (TAPS).
- 0.5 hours on how staff can get out of or break a physical choke or hold.
- 2.5 hour session on aggression and its causes.
- Staff also required to enroll in the first 3 tiers (60 hours) of Child Care Certification.
- Weekly staff meetings are held to reinforce and train staff how to avoid power struggles.
- The facility also contracts with consultants for specialized training.
Facility 4
- Staff receive 40 hours of orientation training, including 12 hours of Crisis Intervention.
- Training is trauma focused and uses case scenarios that reflect the reality of the lives of the children.
- All staff receive ongoing monthly training.
Facility 5
- Outside trainers for the Family Teaching Model provide training to staff.
- Staff receive 40 hour certified training in the Family Teaching Model.
- 16 training hours are devoted to de-escalation.
- Yearly, staff receive 4 hour refresher course.
Facility 6
- 7 staff trainers on staff.
- Trainers completed the Cornell Model for Crisis Intervention.
- Training staff are re-certified every other year.
- Facility staff receive an 8 hour training during orientation.
- Facility staff receive additional 8 hours after 6 months. (Note: Facility decided that split training was a more effective way to train staff, and that it saved the agency time and money if the staff member left before 6 months. The second part of the split training allows the trainers to use real situations that the staff member was confronted with the first 6 months of employment to see how they would react to that situation now.)
- Yearly, staff receive 6 more hours of training which focuses on the crisis cycle and de-escalation techniques.
- Staff are tested after each training.
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All of the facilities developed a team to address the changes required of the system.
The planning teams provided structure and direction for the facility during the research, development, marketing, implementation, and evaluation of the programmatic strategies to reduce or eliminate the use of seclusion and restraint.
Although the membership of each planning team varied across facilities, the following members were represented:
- Children in the facility
- Families
- Foster parents
- Clinicians
- Quality Improvement/Risk
- Management Personnel
- Ohio Legal Rights Service
- Program Directors
- Physicians
- Facility Administrators
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Facility administrators reported that a key component to changing their system was to use the seclusion and restraint data to establish a baseline.
Some facilities improved their data collection and analysis processes and over time were able to develop sophisticated and empirically based conclusions and concerns.
Administrators, using data analysis, identified seclusion and restraint trends and patterns in individual units and within the whole facility. These analyses enabled administrators to measure successes and focus on areas that needed to be addressed and improved. The use of computer program software applications to gather, analyze and display data allowed them to use and access the data in new and creative ways.
Facility administrators reported that they:
- Shared seclusion and restraint data and results with all staff including direct care, client rights officer, middle managers, and medical staff.
- Gave data to program directors for further analysis to develop alternative treatment options or alternative ways to run the milieu.
- Looked more closely at each episode and tried to determine what triggered the child's behavior that led to the restraint.
- Incorporated QI reviews into clinical care committee.
- Established monthly cap limits on the number of seclusion and restraint episodes to measure progress and motivate staff. When the goal was met, the cap would be lowered establishing a new target.
- Developed a more thorough seclusion and restraint reporting form that required identifying all variables involved in the episode.
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Facilities observed both positive and negative consequences as they implemented programs to reduce or eliminate the use of seclusion and restraint. Facility administrators reported the following:
Positive Consequences
- A decrease in the number of injuries to children;
- Kids report they feel safer and more respected;
- Fewer allegations of abuse;
- Decrease in Major Unusual Incidents (MUI);
- Kids are happier because they are not getting restrained;
- Staff are happier because they don't have to restrain kids;
- Staff and kids are happier because it is not a hostile environment;
- Less staff turnover;
- Decrease in worker compensation claims;
- Staff feel more professional and better about their jobs;
- Staff feel as if they have failed if they have to restrain a child. They take it personally because they were unable to connect with the child.
Negative Consequences
- Strained relationships with the therapists due to the professionalization of the role of the direct care staff;
- Staff expressed frustration because they lost ability to restrain and seclude children;
- Initial increase in staff injury and property destruction (over time, however, reports of staff injury and property damage decreased).
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All facilities encountered barriers in their efforts to reduce the use of seclusion and restraint. Listed below are some of these barriers:
- Some staff were defensive and unwilling to change with the new culture.
- Some senior staff members were defensive if they felt they were being told what to do and how to do it.
- Facilities had to assure that staff had adequate training to be successful.
- Facilities bore cost for training.
- Facilities had to try to find creative and effective ways to transform the culture.
- All the facilities reported a variety of reactions from staff:
- Some quit their job.
- Some reacted with shock, disbelief and denial.
- Some felt the administration was simply trying to stir up trouble.
- Some wanted to maintain the status quo.
- Some saw the value of a restraint free environment and motivated their peers to accept the change.
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Facilities viewed meaningful involvement of children and families as essential to the process of reducing or eliminating the use of seclusion and restraint.
Facilities realized that the only way to understand a child's perspective on seclusion and restraint is to ask them, listen to them, and value their input by implementing their suggested changes. Increased information from children heightened staff's sensitivity to the needs of the children.
Facilities reported the following methods for giving children and families a voice in the process of system change:
- Involved kids in decisions about how to change culture and environment by asking them what they thought a seclusion and restraint free facility would look like i.e. asked kids how to modify the unused seclusion rooms — their suggestions were to add teddy bears, soft colors, soft music and to make it a safe place where they can make choices.
- Developed a Children's Council where kids are able to speak with administrators about the program.
- Established a sub QI committee of families and kids that studies outcomes and identifies problems.
- Kids developed a self control plan. Staff then meet regularly with kids to discuss the plan and ideas to help the child learn to self-control their behavior.
- Talked to child and family at admission to identify what de-escalation techniques have worked in the past.
- Developed feedback sheets to enable children to comment on their concerns or questions.
- Encouraged children to decorate and create a mural on the wall.
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Planning teams at facilities studied alternative programming in order to get ideas on how to implement their plan to decrease seclusion and restraint. One facility selected an evidence based practice program which addressed all aspects of programming at their facility. Other facilities adopted a new crisis intervention de-escalation model. Overall, facilities took a variety of avenues to identify approaches to alternative programming:
- Researched other programs
- Visited other facilities
- Reviewed literature to identify best practice models
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All the facilities that OLRS visited had costs associated with developing a culture that emphasized reducing or eliminating the use of seclusion and restraint. The facilities reported increased costs for the following:
- Training for new staff
- Overtime for training for existing staff
- Cost for training materials
- Costs for certified trainer — meals, lodging, etc.
- More 1:1 time with kids resulting in overtime costs
- Costs associated with increased salaries to professionalize role of direct care workers
- Replacing materials and equipment due to property destruction
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Associated with the increased and improved staff trainings, many of the facilities proactively professionalized the role of the direct care worker.
Some facilities developed career paths or career ladders to reduce staff turnover and to encourage staff to be more invested in their program. The availability of career opportunities and options motivated staff to participate in additional trainings and to continue to demonstrate competencies in de-escalation techniques.
One facility required new staff to have at least a 2 year degree. Another facility used color coded badges to reflect those staff who had advanced training and demonstrated competency in de-escalation techniques.
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The intent of OLRS' survey was to demonstrate how children's residential treatment facilities are reducing or eliminating the use of seclusion and restraint. Ten prominent themes, or common experiences, emerged from the survey. They were:
- Active Administrative Support;
- Increased Training;
- Development of a Planning Team;
- Benefits from Data Collection and Analysis;
- Positive and Negative Outcomes;
- Barriers Encountered;
- Including Children and Families;
- Study of Alternative Programming;
- Increased Costs;
- Professionalizing the role of the direct care worker.
These 10 common experiences were consistent across the facilities. It is anticipated that any facility that attempts to reduce or eliminate the use of seclusion and restraint will have these experiences — the experiences are likely to frame the path of change toward elimination of seclusion and restraint.
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In addition to the ten common experiences, administrators identified examples of programmatic and policy changes that they now use in their efforts to reduce or eliminate the use of seclusion and restraint. The following are examples of changes in programming, staffing and training that occurred at the facilities surveyed.
Programming Changes
- Increased physical activity in children's daily schedule.
- Established a mentoring program that pairs a child with an adult. The child and his/her mentor stayed on site to share a meal or simply to provide the child 1:1 time with an adult.
- Re-wrote resident rules for kids — took out the "don't do this," made all rules positive, not negative, and thanked children for doing something.
- Changed and developed the entire treatment culture by increasing positive verbal praise and stickers. Children may lose points, but can earn them back.
- Looked more closely at each incident to clinically determine what is triggering the child's behavior.
- Discontinued self investigations. The county Department of Job and Family Services does all investigations at the facility.
Staff walked through and looked at the facility's physical environment to make it more child friendly i.e. converted the seclusion room into a choices room.
- Transferred children to crisis stabilization when their level of care changed. Facilities do not keep kids they are not equipped to handle.
Staffing Changes
- Tutor is provided at night to assist children with homework.
- Used a small group approach — each staff was responsible for 4 kids — not 4 staff responsible for 16 kids.
- If a child appeared to connect with a specific staff member, staffing patterns were designed to allow for the child and staff to work together whenever possible.
- Reviewed staffing patterns for the program and made changes to provide increased direct care staffing.
- Viewed diversity of staff as a strength — old, middle age, and young — males and females from a variety of ethnic backgrounds.
Training Changes
- Staff education included training to help staff understand today's child — one who is in multiple systems and severely traumatized.
- Clinical psychologist meets with residential staff weekly for mutual discussions. Psychologist helps staff understand power struggles, and staff have a forum to have concerns heard.
- Staff learned to deal with the child in the calmest way possible: to "give them a way out," and to give the child a chance to do what is requested.
- If they are forced to restrain a child, it is the policy to not straddle those children who were victims of sex abuse or have sexually perpetrated.
- Facility trainers met every other week to assure consistency among trainers and to maintain the efficacy of staff training.
- The facilities reported that they did not alter their admission policies during this programmatic transition period. They stated, however, that they were more cognizant of trying to determine the level of care a child needed, and would not admit children who met the criteria for inpatient hospitalization. Several facilities reported that they do face to face screenings in the child's home or current placement to assure that the child will benefit from programming and to see if the child is willing to commit to treatment. It was not unusual for the facilities to request voluntary agreement from the child to engage in treatment.
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The intent of this document was:
- to show the process facilities used in their attempt to reduce or eliminate the use of seclusion and restraint,
- to encourage administrators at children's residential treatment facilities to consider reducing or eliminating the use of seclusion and restraint, and
- to describe a framework within which change took place in several Ohio facilities, with the goal of making the culture change within a facility more manageable for other facilities.
OLRS encourages all facilities to consider this document as preliminary research in their effort toward reducing the use of seclusion and restraint. Facility administrators will most certainly encounter their own unique challenges in shaping the shift toward no seclusion and restraint. But the ten common experiences identified by the survey can help facilities establish a framework for change. Further, the practical changes made by facilities in policy, programming, staffing and training can generate ideas for action toward eliminating seclusion and restraint.
OLRS hopes that this document stimulates discussion with Ohio's children's residential treatment facilities, and serves a catalyst to promote change. Ohio's children in residential treatment facilities deserve quality, therapeutic care provided in an environment free from seclusion and restraint.
Finally, we share with you comments children made upon finding out that staff were trying to stop using seclusion and restraint. These words echo best the reason for change.
"Thank you for helping me."
"I'm glad you didn't use mace."
"I was reminded of the last time I got in trouble with the Police but you didn't hurt me as much."
"I don't like to be touched."
"That was better than being tied up."
"I like that better than being drugged."
"That restraint was different than others I've had — like at the hospital."
"You guys don't restrain very hard."
"You talked to me more than other placements."
"Thanks for listening."
In order to eliminate the use of seclusion and restraint, the administrators and staff of the facilities surveyed had to change the culture of their facilities. System change was not easy — but all involved placed great value in the ideal of reducing or eliminating the use of seclusion and restraint and the concomitant positive impact on children.
None of the administrators interviewed said they regretted the decision to change. Rather, their feelings can be summarized in the following statement: System change was time consuming, difficult and threatening — all this, and in the end — well worth it.
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This publication was produced by the Ohio Legal Rights Service, 50 West Broad Street, Suite 1400, Columbus, Ohio 43215-5923. Telephone 614-466-7264/800-282-9181 TTY 614-728-2553/800-858-3542 Web site: http://olrs.ohio.gov
Ohio Legal Rights Service and this publication are funded in part by grants under the following federal laws:
- Developmental Disabilities Assistance (DD) Act, administered by the Administration for Children and Families;
- Protection and Advocacy for Mentally Ill Individuals Act (PAIMI), administered by the Center for Mental Health Services of the U.S. Department of Human Services; and the
- Rehabilitation Act of 1973 as amended, administered by the Office of Education Services and the Rehabilitation Services Administration of the U.S. Department of Education.
Ohio Legal Rights Service does not discriminate in provision of service or employment because of race, color, religion, sex, sexual orientation, national origin, military service, disability, or age.
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