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Spring 2009 | Vol 12 No 3

Focus

No safe haven

Restraints reform targets traumatizing hospital practices

By Anne Ptasznik

Tonier Cain’s voice trembles as she recalls being put into isolation on an inpatient psychiatric unit for refusing to go into her room. Had staff asked, she may have told them she was afraid of being alone in the dark.

As a young child, she had been sexually assaulted by acquaintances her mother would entertain at night in their apartment. Years later, Cain, who started drinking at age 9 to cope with her mother’s abandonment and neglect, became addicted to crack cocaine. She was assaulted many times when she was homeless.

Being put into isolation triggered her trauma. “One of the worst things you can do to somebody who is a victim of neglect and abandonment is put them in a room and shut it,” says Cain. So when staff would bring her a tray of food, she would not want to eat and would strike out, which landed her in restraints. Her memories of these experience in the psychiatric facility in Annapolis, Maryland, are vivid: “Now they’re restraining me, they’re holding me down – a rape victim, a victim of sexual assault – they’re holding me down. That was scary, that was torture.”

Over the past decade, recognition has been growing of the harms of using seclusion and restraint in psychiatric facilities. A Cochrane review in 2000 of 2,155 articles showed that beneficial effects of restraint and seclusion could not be substantiated and that many adverse effects were found, including death and injury. This recognition grows alongside the emergence of trauma-informed care, which acknowledges and responds to the high rates of lifetime trauma exposure, post-traumatic stress disorder (PTSD) and complex trauma reactions among people with mental health and substance use problems.

As Cain’s story makes painfully clear, psychiatric treatment can be experienced as traumatic and retraumatizing, particularly if compulsory interventions such as involuntary treatment, restraint and seclusion are used. The practice of seclusion and restraint is precisely the kind of “treatment” that trauma-informed care advocates against.

“We still have hospitals that use seclusion and restraint for someone who curses at staff, lies down in the middle of the floor and won’t get up, refuses to obey an order, won’t go to bed, or refuses treatment programming,” says Kevin Huckshorn, director of the Office of Technical Assistance of the U.S. National Association of State Mental Health Program Directors (NASMHPD). This happens even though U.S. federal law forbids the use of restraints or seclusion, except in the face of imminent danger.

Huckshorn had been the chief nursing officer of the South Florida State Hospital, a 350-bed facility serving people with serious mental illness and forensic patients, which had successfully reduced restraints and seclusion by 97 per cent. Her team’s work now is to help train mental health providers across the United States and Canada to see seclusion and restraint not as a “therapeutic intervention” but as “a safety measure of last resort.”

When Huckshorn was developing her training curriculum, she came across a program in Salem, Oregon, that took a trauma-based approach. Within two years, the program no longer needed to use seclusion and restraints, although that had not been the original goal. Huckshorn realized that by implementing a system that did everything possible to avoid traumatizing people on the unit – from being aware of one’s tone of voice to monitoring noise levels to watching how patients are talked to and calmed down – seclusion and restraint would be reduced as a result. Huckshorn’s six core strategies for reducing seclusion and restraint use (PDF) reflect a trauma-informed care philosophy that recognizes the high number of people in the mental health and addiction system who have experienced trauma and are at risk of being traumatized by the system.

One of Huckshorn’s colleagues has a unique perspective when she trains mental health providers to assume that the people they are dealing with have experienced trauma. Just four years after participating in a trauma program designed for pregnant women serving time in prison, Cain is now the team lead for NASMHPD’s National Center for Trauma-Informed Care. Cain says that her healing finally began when someone finally asked, not what was wrong with her, but what happened to her. Cain can easily tell when a facility has a trauma-informed approach: rooms are colourful and soft music is playing; patients and staff walk down the hallway side-by-side talking; there is no Plexiglas or boundaries marked out on the floor keeping patients away from staff.

Dr. Joan Gillece, program manager of NASMHPD’s Seclusion and Restraint Reduction Initiative and project director of the National Center for Trauma-Informed Care, says it is critical to inform staff about alternative strategies, including sensory approaches, patient safety plans and therapeutic communication. Otherwise, staff feel they are being asked to give up the only tools they have to control their environment. On site visits, Gillece talks with direct care staff about what it feels like for them to take someone down and the importance of getting support if they have experienced trauma themselves. Once staff come to understand how retraumatizing restraints can be to someone who has been held down against their will or raped, they begin to move away from a “we versus they” culture.

For this approach to be successful, leadership involvement is critical, creating a learning environment where staff can practice different approaches and not be afraid of making mistakes. It is also important that the administration participate along with the direct care, maintenance and kitchen staff, peer specialists and community partners in learning how to determine whether a person is being triggered and having difficulty self-soothing and the actions to take in response.

Another tool discussed in training is sensory objects. Gillece tells about one young woman who was regularly kept in seclusion and restraints because staff could not get her to stop self-cutting. Gillece spoke with the woman and discovered that hearing a male staff member scream triggered her trauma. When Gillece asked what would help soothe her, it was the very items the woman found calming – earphones so she could listen to religious music and a pen to write – that staff had taken away for fear she would hurt herself with them. Gillece worked with the staff to determine a safe way for the woman to have access to these items when she needed to self-soothe.

But what about clients who cannot seem to be de-escalated or negotiated with, for example, an intoxicated person acting violently who is brought to emergency by police who are having difficulty subduing him? Huckshorn says she realizes that there are situations where seclusion and restraint may be necessary, but that even in such situations, it remains important to create the calmest, safest environment, where people are respected and are given as much empowerment and dignity as possible and the opportunity to make some choices. She says it is essential in these situations to have well-trained staff who know how to build a therapeutic alliance with the person very quickly and help them settle down with the goal of removing the restraint as quickly as possible.

For people who are psychotic when they are admitted, Huckshorn recommends providing a quiet safe place and medication, and waiting to develop the treatment plan, just as would happen with someone who had been in a serious car accident. But once the person starts to be able to talk, “You don’t continue to treat them like they can’t,” says Huckshorn, adding that staff must immediately begin to involve them. Advance directives or personal safety plans, which outline the types of supports people need when they are becoming stressed or triggered, are useful for preventing escalation.

Courtney, a former inpatient at the Centre for Addiction and Mental Health (CAMH) in Toronto, has experienced restraints. She says that advance plans may have some value, but they need to be “administered properly, through people that you feel care about you.” She believes that staff need to spend more time circulating through their units, building relationships with patients. She also recommends that independent, objective observers be available whenever a code white, indicating a psychiatric disturbance, is called, as people on the unit can be seen as lacking credibility if they complain about how they are treated.

At the same time, the second-year law student understands nurses’ concerns about violence in the workplace. She recommends that they be involved in developing, implementing and evaluating anti-restraint polices. She also proposes that patients be engaged in individualized programming according to their interests, rather than having no choice but to sit around watching television and waiting for medications to take effect.

Cheryl Rolin-Gilman, an advanced practice nurse, works with CAMH’s addictions and women’s programs, which actually provide trauma treatment through individual and group programming. She says that providing structure can “limit agitation because if clients have nothing to do during the day and they are already overwhelmed by their feelings or their spiralling negative thoughts, there’s nothing to pull their focus away.” Rolin-Gilman says the concept of trauma-informed care was introduced CAMH-wide at a two-day leadership training about seclusion and restraint reduction a year ago.

The leadership training was just one step in CAMH ’s overall efforts to reduce seclusion and restraints. CAMH developed a least restraint policy in 2002 after the Psychiatric Patient Advocate Office conducted a review in 2000 (PDF) of the seclusion and restraint practices in Ontario’s provincial psychiatric hospitals and the former Queen Street Mental Health Centre, now part of CAMH. More than 50 per cent of clients interviewed said that at the time they were restrained or secluded, they had not posed a threat to themselves or others. Almost half did not know what was required of them to be released once in restraint. Clients also reported that staff were not available for them to talk to about their fears while in restraints or to provide emotional support. In response to these findings, CAMH managed to successfully reduce the number of incidents of restraint by 67 per cent from 2005 to 2008. It was prompted to further action by the recent coroner’s inquest (PDF) looking into the restraint-related death of CAMH forensic inpatient Jeffrey James in July 2005. The inquest recognized CAMH’s work in this area and recommended that the organization take a leadership role with other psychiatric facilities across the province.

“We aspire to provide safe therapeutic care and services in a restraint and seclusion-free environment,” says advanced practice nurse Athina Perivolaris, who co-leads CAMH’s Prevention of Restraint and Seclusion Initiative (PDF). She adds that the initiative, which is founded on the six core reduction strategies identified by Huckshorn, is focusing on updating CAMH ’s restraint and seclusion policy to incorporate best practices and the coroner’s recommendations. This policy will be shared with all psychiatric facilities in Ontario. CAMH has also had several external requests for consultation and collaboration regarding the initiative. In response to these recommendations, CAMH has already increased the number of peer support workers and is providing ongoing education sessions about prevention and the use of alternatives, and is offering consultation to staff to support clients in managing their distress.

Jennifer Chambers, co-ordinator of the Empowerment Council at CAMH, says that many of the strategies now proposed by experts are changes that clients have been recommending for years. “For example, consumer/survivors have maintained that if someone is in restraints, they should have support and comfort always available to them, and an explanation of how to get out of restaints,” she says. She is pleased that their suggested policy changes have now largely been included in the inquest recommendations.

Courtney sums it up this way: “A change in the environment, a complete culture change, is the only real way you can reduce restraints and violence and make everybody happy.”

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The verdict and recommendations from the coroner’s inquest are available on the Ministry of Community Safety and Correctional Services website. Under About Your Ministry, choose “Chief Coroner” and then “Verdicts and Recommendations.” Do an alphabetical list search on the name “Jeffrey James."