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
In-Service Training
Seclusion and Restraint Matrix Work Group
Rockville, MD
February 2, 2005
PowerPoint version
Attached is the text prepared for delivery; however, some material may have
been added or omitted at the time of delivery.
[SLIDE 1. Title slide]
Good afternoon to all of you. Mr. Curie is not able to join us to open today’s discussion, but he sends his regrets. I know that he was looking forward to describing his work in Pennsylvania that moved that State…and the field…several giant steps closer to creating a seclusion- and restraint-free environment for people living with mental illnesses and addictions.
In his absence, I can tell you that the Pennsylvania model, developed under Mr. Curie’s direction, virtually eliminated the use of seclusion and restraint in their State hospital system. In fact, their approach to seclusion and restraint earned the prestigious Innovations in Government Award. Since then, many others have adopted the Pennsylvania model. It is truly an example of what is possible!
We are here today in large part because of Mr. Curie’s pioneering efforts in Pennsylvania. Because there is still much more work to be done. We know of scores of cases across the country in which people with mental health and addiction problems—a disproportionate number of them children—have died tragic deaths as a result of these practices…deaths more suited to Medieval torture chambers than to 21st century America.
Our objective today is to direct a spotlight on the issues of seclusion and restraint…so that we can gain a better understanding of its use…and the human impact of these interventions.
We will cover a lot of ground in the next two hours. We’ll look back more than 200 years in history to examine how the debate around the use of these practices began. We’ll look at the impact these practices are still having today. And we’ll look ahead at what SAMHSA has on the agenda to help put an end to the abusive use of these practices…our vision for a future that fosters a culture of caring for people who already have had far too much trauma in their lives.
[SLIDE 2. A 200-year journey]
The use of seclusion and restraints has been part of the culture of inpatient psychiatric care for hundreds of years…since the days when practices such as bleeding, purging, blistering and confinement with chains were thought to be effective treatments for people with mental illnesses.
In 1794, French psychiatrist, Dr. Phillipe Pinel, the leading authority on mental illness in France at the time, became the director of the Bicêtre, an asylum for men in Paris. There, Pinel discovered patients who had been chained to a wall for 30 years. About half of these men died as a result of these conditions.
Pinel launched a movement…a movement to advocate for the “moral treatment” of people with mental illnesses. Pinel unchained the patients at Bicêtre…and the mortality rate dropped by about 75 percent. Pinel believed in engaging the patients rather than isolating them. He kept records on the treatments given each patient. It was the beginning of the modern age of psychiatry.
In the United States, similar efforts toward eliminating the use of seclusion and restraint have been made. The story of the National Mental Health Association’s bell is a prime example. Chuck Ingoglia will say a few words about the bell and all that it symbolizes.
(Chuck will give brief remarks and present the bell)
Unfortunately, more than 200 years after Pinel broke the chains at Bicêtre, reports of injuries and death due to the use of seclusion and restraint confirm that we are still struggling with this issue.
You may recall the case almost seven years ago of an 11-year-old boy named Andrew McLain. Andrew was in a Connecticut psychiatric hospital. One morning, Andrew would not obey a staff member in the breakfast room. He refused to move to another table. A struggle ensued, and in an effort to restrain him, two guards sat on him and crushed him to death. Andrew weighed only 96 pounds.
I wish I could say the case of Andrew McLain case was an isolated event. But, an investigative series that ran in the Hartford Courant newspaper in the aftermath of Andrew’s death reported startling data from the Harvard Center for Risk Analysis: 150 people die each year from the use of seclusion and restraint. More than 26 percent of those who died were children under the age of 17.
Children are at high risk of injury and death from these practices. We know from other research that there are a number of risk factors that not only increase the probability for the use of seclusion and restraint…but also, intensify the resulting outcomes. One of the significant risk factors is alcohol or drug use. We have reports from detox centers, emergency rooms and residential treatment facilities that substantiate this fact. Significant numbers of people in recovery are impacted by these practices!
We’re not here today to blame anyone, or to point fingers. We’re here today because we must address this problem. The elimination of seclusion and restraint is a high priority for SAMHSA…and has been since Mr. Curie made the issue one of SAMHSA’s matrix priority programs when he was named Administrator four years ago. Today, ending the use of seclusion and restraint is a mental health system transformation imperative. The Final Report of the New Freedom Commission on Mental Health, Achieving the Promise provides a new mandate to address seclusion and restraint as a high priority issue.
That’s why we assembled a Seclusion and Restraint Matrix Work Group and I would like to acknowledge its members …Anita Everett, Nancy Kennedy, Susanne Rohrer, Rosallah Karim, Cathie Alderks, Paul Wohlford, John Morrow, Karen Armstrong, Chuck Ingoglia, Robert DeMartino, Michelle Subwick, and Paolo del Vecchio. I would also like to acknowledge Carlton Speight for his behind-the-scenes efforts in staging this event. Information sessions like these are critical to bringing the practice of seclusion and restraint to expanding our knowledge and understanding of the issue at hand…as a foundation for formulating a solution.
Quite frankly, there is a lot we don’t know about this issue. Part of the problem is that good data is hard to come by – comprehensive records are not kept on how many patients are restrained or secluded, and what happens as a result.
But even without a complete statistical picture, we know that this is a life-and-death issue. We know that having even one person die or be injured from these practices is one too many. We know that there are effective alternatives that can be put in place to protect the health and safety of people of all ages with mental illnesses and addictions.
As a first step in our process of gaining a better understanding of these issues, I think it is critical that we clarify exactly what we mean by the terms. These definitions are drawn from our reauthorization legislation, the Children's Health Act of 2000:
[SLIDE 3. Definitions]
- Seclusion is a behavior control technique involving locked isolation.
- A physical restraint is a physical hold by another person that immobilizes, or reduces the ability of an individual to move his or her arms, legs, or head freely.
- A mechanical restraint is a device attached or adjacent to the resident’s body, that he or she cannot easily remove, that restricts freedom of movement or normal access to his or her body.
These clinical descriptions are easy to comprehend. But it is much harder to grasp what it really feels like to be locked in a room by yourself for hours at a time…or to be physically restrained by someone stronger—perhaps two or three persons…or to be tied down to a bed or to a chair.
[SLIDE 4. Consumer views]
Consumers have told us these practices make them feel completely powerless. (refer to the quote on the slide). We have to pay attention to their words. We need to get a real feel for these issues…a real sense of what these practices are all about. I believe that then…and only then…will we be able to create a system that can do a better job of protecting those who cannot protect themselves.
(Hold up restraints and pass around.) I’d like each of you to take a closer look at one of the devices that is currently being used to restrain consumers and people in recovery across this country. As you examine these restraints, imagine what it might feel like to be subjected to this practice. Be inspired by these feelings. When you leave here today, let these feelings be the fuel that moves you to personal action…to help us do what must be done to better protect the dignity, privacy and safety of those we serve.
[SLIDE 5. Today’s Program]
This afternoon, we’ll take an in-depth and intimate look at the impact of seclusion and restraint on the individuals who are subjected to these practices, their families, and staff members in facilities nationwide. We’ll examine how SAMHSA is responding to this issue. I know this is the kind of issue that evokes many deeply held thoughts and opinions. There will be plenty of time for your questions and discussion.
[SLIDE 6. What is the Impact? ]
- Let’s begin with Inside Out: Perspectives on Restraint and Seclusion, a video produced by the Connecticut Department of Children and Families and the Klingberg Family Center, with funding support from SAMHSA. This video presents the innermost thoughts and feelings of children and youth that have been restrained or secluded. It also provides parent and staff perspectives. No actual restraint or seclusion is shown, but through reports, re-enactments, sounds and images, you will get a real—and potentially disturbing look—at this practice through the eyes of those who live with its consequences. We will have time after the video and presentations for you to discuss your reactions.
- (Show video)
- Next, please join me in welcoming Karen and Robert Wilson from Mason City, Iowa. The Wilson’s lost their 11-year-old son, Tanner, who died from a deadly restraint administered in a psychiatric medical institution for children located in their Mason City community-just four years ago. Let’s listen as they share their deeply personal story of losing a child to these deadly practices.
- (Karen and Robert Wilson speak)
- Thank, you Karen and Robert.
- Now, we’ll hear from consumer advocate Tom Lane. Tom is Vice President of the Recovery Supports Division for New Horizons of the Treasure Coast, a non-profit community mental health and substance abuse provider based in Ft. Pierce, Florida. Tom has worked at NAMI National and with many consumer-run State programs across the country promoting integrated systems of care. He is a founding faculty member of NASMHPD’s National Technical Assistance Center initiative on reducing and eliminating seclusion and restraint. Tom is also a nationally recognized expert in the intersection of law enforcement, criminal justice, and mental health systems…providing training and consultation to the FBI, the National Institute of Corrections and several crisis intervention teams and state law enforcements organizations. Let’s all give Tom a warm welcome.
- (Tom Lane speaks)
- Thank you, Tom. Are there questions or comments?
[SLIDE 7-21. What is SAMHSA’s response?]
Now, let’s look at what SAMHSA is doing to address this issue. (Kathryn: Speak from slides)
[SLIDE 22. Introduce Kevin]
Next we’ll hear from Kevin Ann Huckshorn about the Alternatives to Restraint and Seclusion State Inventive Grant program and the regional trainings we are conducting to help encourage the use of alternatives to seclusion and restraint.
Kevin Ann Huckshorn, RN, MSN, CAP, ICADC is the Director of the Office of Technical Assistance at the National Association for State Mental Health Program Directors (NASMHPD) and the new National Coordinating Center for Seclusion and Restraint Reduction. She is a licensed and certified mental health nurse and substance abuse clinician with practical knowledge from 24 years of professional frontline experience working in various public and private mental health organizations and systems and substance abuse programs. Kevin has demonstrated experience managing technical assistance projects and monitoring the full range of services and products—from action plans to pragmatic tools and training on evidence-based practices. Ms. Huckshorn also represents the state mental health agencies on the JCAHO Professional Advisory Committee for Behavioral Health and is on the editorial boards of two peer reviewed mental health publications.
I’m sure you will be interested in what she has to say. Please join me in welcoming Kevin Ann Huckshorn.
(After Kevin’s Presentation)
Thank you, Kevin.
Now, I’d like to hear from all of you. I am especially interested in hearing your thoughts on the impact these practices have on people with addictions. Do you see the use of seclusion and restraint as a major concern for this population? Do you have suggestions for what SAMHSA could and should be doing to create a restraint-free environment for people with mental illnesses and addictions? (Take questions/comments)
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