Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Reducing and Eliminating Seclusion and Restraint Is Transformation in Action!
January 9, 2007
Washington, DC
Thank you, Joan [Gillece], for your kind introduction and your longstanding commitment at both the State and Federal Level to individuals impacted by trauma. Your leadership on this critical issue has helped galvanize policymakers, providers, and consumers to make the important and necessary changes that promote consumer-driven, recovery-focused, and evidence-based systems of care for individuals of all ages with mental illnesses and co-occurring substance use disorders. We know that seclusion and restraint have no place in a transformed system of care.
I am especially pleased today to greet the eight new Alternatives to Seclusion and Restraint grantees and to welcome back representatives of the eight original States. In my brief remarks this morning, I want to make very clear my sincere belief that the challenging and important work you do represents the embodiment of a public health approach to mental health transformation.
We must examine and embrace a public health approach to reducing and eliminating seclusion and restraint because, fundamentally, these practices are harmful. They are not treatment practices; they are treatment failures. They keep consumers at the margins, not the center of care. Individuals can’t learn to manage their illnesses and their lives when they are under external control—either physical or chemical. Worse, they may keep individuals from seeking needed treatment because they fear loss of autonomy and control.
In 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) attributed 153 deaths to seclusion or restraint in the United States, with asphyxiation as the primary cause of death. Earlier this year, in upstate New York, a 13-year-old autistic boy named Jonathan Carey was improperly restrained in a van when aides took him for an outing to the local mall. One of the aides compressed his body against the boy’s and caused him to stop breathing. It’s small comfort to Jonathan’s parents that the aide received 5 to 15 years in State prison, because no amount of jail time will bring Jonathan back.
We can count the number of deaths due to incidents of seclusion or restraint, but there are no data that fully capture the extent of physical and emotional trauma experienced both by patients and staff during and after episodes of seclusion and restraint. However, we can and must listen to their stories.
Stories like those told by consumer advocate William Pflueger of Minnesota, who wrote about his experiences in a special issue of the National Technical Assistance Center’s newsletter, Networks. “I can’t bring myself to describe the moment-by-moment struggles and shear gut-wrenching terror of being put into five-point restraint,” he said. “Tears well up in my eyes and I feel a dark hole opening below me…The terror of confinement, the pain of the restraint, and the wound to my soul made me want to stay as far away from the mental health system as possible.”
As Kevin Huckshorn has stated so eloquently, seclusion and restraint are “mythological practices based on no scientific evidence…We must return to the philosophy of being helpers and healers, not enforcers and caretakers.” And we owe it to the Jonathan’s and the William’s whom we serve to adopt a public health approach to reducing and totally eliminating these outmoded, harmful, and counterproductive practices.
The Public Health Approach
What do I mean by a public health approach? The Institute of Medicine has defined public health as “what society does collectively to assure the conditions for people to be healthy.”
Perhaps one of the best ways to understand public health is to compare it to clinical care, which focuses on the treatment of individuals as opposed to whole communities. Doctors usually treat individual patients one-on-one for a specific injury or illness. Public health professionals monitor and diagnose the health concerns of entire communities and promote healthy practices and behaviors to ensure that our populations stay healthy.
In essence, public health is community health, and it acknowledges the fact that each of us must be healthy for all of us to be healthy. We know that both individuals with mental illnesses and the staff who serve them can be traumatized by incidents of seclusion or restraint, and we have data that confirm the benefits to both groups when we actively pursue the reduction of these harmful practices. For example, one of the hospitals in Pennsylvania that became virtually seclusion and restraint free saw a 67 percent decline in disabling injuries among both patients and staff. This is mental health transformation in action!
The public health model is based on the notion that we must promote health and prevent disease before it begins, and this focus on health promotion and disease prevention is a logical fit with our efforts to reduce and eliminate seclusion and restraint.
Clearly, within our hospitals and other institutional settings—including emergency rooms, nursing homes, and schools—it is far better to promote an individual’s ability to provide self-care and to prevent the possibility of violence before staff feel the need to use seclusion or restraint to control the individual or defuse the situation. I understand this is a significant change in approach to the issue of conflict and violence in our treatment settings, but it squares perfectly with the underlying goal of mental health system transformation, which is to promote an individual’s recovery from mental illness so he or she can live, work, learn, and participate fully in the community.
And, thanks to efforts at the Federal, State, and local level, including the hard work of the first group of Alternatives to Seclusion and Restraint SIGs, we know what has to be done at both the State and facility level to make this happen.
I want to touch on three elements that are critical for reducing and eliminating seclusion and restraint in your facilities:
- A vision statement or action plan that clearly articulates the goal of reducing, and eventually eliminating, seclusion and restraint;
- The development of systems of care that are trauma-informed; and
- A commitment to the principles of recovery, including partnerships with consumers.
A Vision Statement
First and foremost, reducing the use of seclusion and restraint must start with clear leadership and a specific plan, at both the State and the facility level. Leaders at the highest levels must define and articulate a mission and philosophy about seclusion and restraint reduction and outline staff roles and responsibilities. In both research and practice, consistent, supportive leadership has been associated with reduced rates of seclusion and restraint.
When Illinois became an Alternative to Seclusion and Restraint grantee in 2004, staff of the Elgin Mental Health Center, under the leadership of Raul Almazar, who addressed you yesterday, realized that their first task was to define what they wanted this initiative to be about. With input from consumers, it became clear that they wanted more than a reduction in the use of restraints and seclusion.
Raul said, “We wanted a culture that is very strong on primary prevention strategies that would help us avoid conflict in the first place, exemplifying a partnership between staff and the person served.”
Thus was born the facility’s Coercion-Free Environment Initiative. Its authors understood that they had little control over certain factors, such as consumers’ reactions to their environment. Instead, the Initiative is based on changing the attitudes and practices they can control.
According to data we have gathered thus far on the first eight Alternatives to Seclusion and Restraint SIGs, 75 percent of participating States and 92 percent of facilities in those States have vision statements or policies that identify the goal of reducing and eliminating the use of seclusion and restraint. This is transformation in action!
Trauma-Informed Care
One of the underlying tenets of any policy statement guiding the reduction and elimination of seclusion and restraint must be the need to create a trauma-informed system of care. In recent studies, trauma prevalence rates are reported at 52 to 90 percent in people who have serious mental illnesses and co-occurring disorders. Traumatic events include the personal experience of interpersonal violence, such as sexual abuse, physical abuse, severe neglect, loss, or the witnessing of violence. Many of the consumers we serve are re-traumatized within the mental health system when they are subject to any kind of forced treatment.
To fully address the needs of survivors within the public mental health service system, we must adopt a systemic approach, characterized both by trauma-specific diagnostic and treatment services and by a “trauma-informed” environment capable of sustaining these services.
Clinical psychologist Roger Fallot, Director of Research and Evaluation at Community Connections in Washington, DC, has written extensively about what it means to be “trauma-informed.” Trauma-informed systems, he tells us:
- Incorporate knowledge about trauma—including its prevalence and impact—in all aspects of service delivery;
- Are hospitable and engaging for survivors;
- Minimize revictimization; and
- Facilitate recovery.
Recovery
This is an excellent segue to my final point, which is about the essential nature of consumers directing their own recovery. Seclusion and restraint cannot co-exist with a recovery-oriented system of care. And, indeed, when consumers are able to choose their own care, there will be far less need for any type of coercive treatment.
We know what works to support and promote an individual’s recovery from serious mental illnesses and co-occurring disorders. Both research and practice have shown that consumers are capable of and interested in sharing decisions about their care, and when they do so, they can and do take more responsibility for their behavior.
At SAMHSA, we support the development of tools for illness self-management, including psychiatric advance directives and Wellness Recovery Action Plans. These tools help consumers think about possible emotional or environmental triggers and plan strategies to de-escalate potential crises to keep them, and the staff who serve them, safe from harm. These tools should be universally available to all consumers.
We also know that any successful strategy to reduce and eliminate seclusion and restraint must involve the full and formal inclusion of consumers, children, and family members in various roles and at all levels in the organization. This includes consumers of services in oversight, monitoring, debriefing interviews, peer support services, and significant roles in key facility committees.
I would encourage you to pay special attention to the role of consumers in providing peer support. We know that having hope is essential to an individual’s recovery, and consumer staff send a powerful message of hope—not only to consumers but to facility staff, as well. They communicate by their presence and their experiences that recovery is real and a psychiatric disability need not be an impediment to pursuing one’s hopes, dreams, and aspirations.
Wrap-up and Conclusion
I began my remarks by sharing with you some painful stories about the impact of seclusion and restraint, and I know you could share similar accounts, as well.
But I, too, have hope. As a former victim services advocate, and in my role as Director of the Center for Mental Health Services, I have seen the enormous potential and inspiring ability of individuals to recover from trauma, mental illnesses, and co-occurring disorders when we help promote their healthy self-care and prevent future harm. This is transformation in action!
I want to leave you with these words from Teddy Roosevelt, who said, “In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can is nothing.”
We can no longer afford to do nothing about the coercive, harmful, and potentially dangerous practices of seclusion and restraint.
We have spent many years doing the wrong thing, but the time has come to do the right thing by individuals of all ages with mental illnesses and co-occurring disorders. We can and must stop the violence and start the healing. The time to begin is now.
Thank you. If we have time, I’d be happy to take your questions.
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