Module 1 The Personal Experience of Restraint and Seclusion
Learning ObjectivesUpon completion of this module the participant will be able to: • Outline the issues and concerns regarding the practice of restraint and seclusion • Describe the use of restraint and seclusion with special needs populations • Understand the personal experience of restraint and seclusion for people diagnosed with a mental illness • Understand the personal experience of restraint and seclusion for front line staff
“The initiative to reduce the use of seclusion and restraint is part of a broader effort to reorient the State mental health system toward a consumer focused philosophy that emphasizes recovery and independence…Seclusion and restraint with its inherent physical force, chemical or physical bodily immobilization and isolation do not alleviate human suffering. It does not change behavior.” Charles Curie, Administrator SAMSHA
This manual was funded by the Center for Mental Health Services and is written from consumer perspectives. The goal is to bridge the differences and build a recovery-based partnership between mental health consumers and direct care staff.
ListenWhen I ask you to listen to me andYou start giving me advice, You have not done what I have asked.When I ask you to listen to me and You begin to tell me why I shouldn’t feel that wayYou are trampling on my feelings.When I ask you to listen to me and You feel you have to do something to solve my problem,You have failed me. Strange as that may seem.Listen: All that I ask you to do is listen.Not talk or do – just hear me.When you do something for meThat I can and need to do for myselfYou contribute to my fear and inadequacy.But when you accept as a simple factThat I feel what I feel, no matter how irrationalThen I can quit trying to convince youAnd get about this business of understanding what’s behind them.So please listen and just hear me. And, if you want to talk, wait a minute for your turn And I’ll listen to you.Anonymous
Assumptions to be Challenged • Seclusion and restraints are therapeutic • Seclusion and restraints keep people safe • Seclusion and restraints are not meant to be punishment • Staff know how to recognize potentially violent situations
A New York study indicated that 94% of consumers who had been restrained had at least one complaint with one-half complaining of unnecessary force and 40% indicating psychological abuse (Weiss, 1998).
Consumer ComplaintsRay & Rappaport, 1993 Consumers who have been restrained or secluded indicate: • Predominately negative reactions • Did not know the reason for the restraint/seclusion • It was humiliating, punishing, and depressing • Staff control was a primary factor
Lack of national standards has reportedly generated wide variability in the use of restraint and seclusion – including potentially dangerous and unsafe practices.
Inappropriate Uses of Seclusion and Restraint • Control the Environment • Coercion • Punishment
Treatment Approaches to Reduce Seclusion & Restraint • Peer-delivered services • Self-help techniques • New medications • Emphasis on recovery • Understanding the relationship between trauma and mental illness
Reading: NASPMHD Review of Literature Related to Safety and Use of Seclusion and Restraint
“When I participated in my first restraint experience I vomited.”(Interview with mental health worker)
Module 2 Understanding the Impact of Trauma
Learning ObjectivesUpon completion of this module the participant will be able to: • 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/seclusion/restraint 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
“Being a survivor is feeling isolated, not daring to share that part of my life (trauma) with people for fear of being rejected, feeling defective, feeling powerless, lack of understanding from professionals that whatever behaviors we took on was our way of calling for help even if it doesn’t fit society’s view of what is ‘normal’ behavior.” Survivor from Maine
“What helps me (deal with trauma) is professionals who have the ability to take care of themselves, be centered, and not take on what comes out of me – not hurt by what I say – sit, be calm and centered and not personally take on my issues.”Survivor from Maine
Definition of Trauma: Extreme stress that overwhelms someone’s ability to cope.
Flashback A recurring memory, feeling or perceptual experience of a past event, usually traumatic, including losing awareness of present reality. The person feels like they are re-experiencing the past as if it were happening right now.
Dissociations A wide range of responses that are usually some form of numbing or “tuning out.” The person is disconnected from full awareness of self, time, and/or external circumstances.
Triggers Cues that remind a person of the trauma (often unconsciously) and start the response of re-experiencing or avoiding the trauma. Identifying triggers and realizing they are a normal response to trauma is part of the healing process.
Effects of Trauma on the Brain • Trauma can activate various systems in the brain that actually change neuron response and cognitive pathways. • Children can develop systems in their brains that cause them to be constantly hyper-aroused and hyper-vigilant or dissociate. • Trauma affects the autonomic nervous system. • Trauma may be associated with abnormal activation of the amygdala, abnormal levels of cortisol, epinephrine, and norepinephrine, and structural changes to the hippocampus. • The incidence of other serious illness, including chronic pain with no medical basis, cardiovascular and digestive problems, is higher among people who have experienced severe trauma.
Differential Response to Threat Dissociation Hyperarousal Detached Hypervigilance Numb Anxious Compliant Reactive Decreased Heart Rate Alarm Response Suspension of Time Increased Heart Rate De-realization Freeze: Fear Mini-psychoses Flight: Panic Fainting Fight: Terror Source: Perry, M.D., Ph.D. www.childtraumaacedemy.com
Assessment of Trauma • Mental Health professionals cannot develop appropriate treatment plans or interventions for clients in the absence of knowledge about their histories of physical or sexual abuse (MMH, Accreditation Manual for Mental Health, 1995). • All clients need to be asked about their history of sexual, physical, and verbal abuse in all clinical settings.
“Never being asked about trauma is like the abuse as a child.”Survivor from Maine
Survivors and Trusted Professionals Speak about Recognizing (or Avoiding) the Prevalence, Indicators and Impact of Trauma: What Hurts • The way questions were asked was impersonal, cold and intimidating. (Survivor) • It is fearful to disclose the abuse. • “You risk being judged, being penalized, being discredited, invalidated, and having your feelings minimized.” (Survivor) • “When you get a mental illness label, you lose all credibility.” (Survivor) • The consequences of mis-diagnosis include: wrongful medication, over-medication, tardive dyskinesia and other reactions to medications, inappropriate and ineffective treatment. (Professional) • Stigma in the mental health field is a problem. It takes a longer time for men to disclose abuse than women. • “Men do not disclose their histories of sexual and physical abuse because of the stigma attached to being a male survivor.” (Professional)