to Coercive Techniques (ACT) Initiative
Pennsylvania is joining the nation-wide movement
to enhance trauma-informed care and services within residential
facilities. Best practices, high quality programming, and well-trained
staff are critical in providing care that reduces the need for the
use of restraint, while ensuring the safety of all residents and
staff. Resources listed at the bottom of this page are intended
to assist residential facilities in achieving the ultimate goal
of eliminating the need for the use of coercive techniques in residential
In the 1990s, new policies regarding the use of seclusion and restraint
were implemented in Pennsylvania’s state hospitals. These
policies were implemented after leadership’s attitudinal shift
from restrictive to recovery focused treatment. It was emphasized
that consumers are to be treated with dignity and respect and the
use of restraint and seclusion are not in line with this belief.
In February of 1993, 5,292 hours of seclusion and 10,724 hours of
mechanical restraint were used in Pennsylvania’s state hospitals.
As of January 2008 the monthly average for seclusion use is 2 hours
and the monthly average for mechanical restraint is approximately
9 hours. Pennsylvania’s changes were successful because of
a cultural transformation in which leadership supported the change,
the staff to patient ratio was increased, performance improvement
measures were implemented, staff training was increased, and an
attitude change occurred that fostered an environment of care which
was safer and less traumatizing for consumers and staff. For more
information about the Pennsylvania State Hospital initiative on
reducing and eliminating seclusion please contact Brandi Kennedy
at 610-740-3416 or 1600 Hanover Ave, Allentown, PA, 18109-2498.
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Pennsylvania State Hospital System's Seclusion
and Restraint Reduction Program, Gregory W. Smith, MS,
Commitment to Eliminating the Use of Seclusion and Restraint,
Charles Curie, MSW, ACSW
Reducing the Use of Seclusion and Restraint: A
NASMHPD Prioirty, Robert W. Glover, PhD
and Restraint Risk Management Guide
Use of Seclusion and Restraint
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Bibliography on Alternatives to Seclusion and Restraint
prepared by Gordon R. Hodas, M.D., Statewide
Child Psychiatric Consultant to OMHSAS
The documents identified within this annotated bibliography have
been grouped according to the six core strategies identified by
the National Association of State Mental Health Program Directors
(NASMHPD). These core strategies involve: 1) leadership toward organizational
change, 2) use of data, 3) workforce development, which is further
subdivided, 4) use of seclusion/restraint reduction tools, 5) consumer
roles/advocacy, and 6) debriefing activities. Additional resources
are available from the Substance Abuse and Mental Services Administration
web site under Seclusion and Restraint Activities, and from NASMHPD.
Leadership Toward Organizational Change
- Curie, C. (2005). SAMHSA's
commitment to eliminating the use of seclusion and restraint.
Psychiatric Services, 56 (9), 1139-1140. Mr. Curie, former
administrator of the Substance Abuse and Mental Health Services
Administration (SAMHSA), initiated restraint and seclusion reduction
in the State Hospital System while in Pennsylvania. Here, he highlights
the need for a vision of recovery and culture change, and identifies
SAMHSA's efforts to promote these.
- Glover, R. (2005). Reducing
the use of seclusion and restraint: A NASMHPD priority. Psychiatric
Services, 56(9), 1141-1142. Dr. Glover, executive director
of the National Association of State Mental Health Program Directors
(NASMHPD), indicates that restraint reduction has been NASMHPD's
priority for the past decade. He supports a trauma informed, recovery
based system of care.
- Gunn, S. (2000). Organizational
systems to minimize restraint and maximize dignity, effective
treatment and safety. Presentation to Walker Trieschman Conference,
May 11, 2000. This paper is applicable to any system serving
children and adolescents in care. It offers an overview of 10
organizational systems needed to provide a safe environment that
respects the dignity of the individual and minimizes the use of
restraint. These systems are: leadership, treatment program, assessment
and care planning, Human Resource issues, accountability and client
rights, restraint processes, review of selected training programs,
sentinel events and root cause analysis, and risk management.
- Smith, G., Davis, R., Bixler, E., Lin, H., Altenor, A, Altenor,
R., Hardenstine, B., Kopchick, G. (2005). Pennsylvania
State Hospital System's seclusion and restraint reduction program.
Psychiatric Services, 56(9), 1115-1122. The authors provide
an excellent overview of the restraint and seclusion reduction
initiative in Pennsylvania 's State Hospital System, which became
a national model and continues to influence efforts in other states.
Use of Data
- Hughes, W (2002). Replacing
control with empowerment is a proven solution. Networks. Alexandria
, VA. National Technical Assistance Center for State Mental Health
Planning, Special Edition, Summer/Fall 2002, 17. The author,
chief executive officer of the Columbia Behavioral Health System,
a division of the South Carolina Department of Mental Health,
relates how a reduction process involving education with both
staff and consumer involvement dramatically reduced use of restraint
and seclusion with consumers in acute state psychiatric facilities.
Sensitivity training helped staff appreciate the needs of consumers.
- LeBel, J., and Goldstein, R. (2005). The
economic cost of using restraint and the value added by restraint
reduction or elimination. Psychiatric Services, 56(9), 1109-1114.
The Massachusetts restraint initiative in adolescent inpatient
facilities was not only effective – a 91% restraint reduction,
based on 2003 data as compared to 2000 data – but also highly
cost effective. The aggregate cost of restraint was reduced by
92%, a substantial savings for facilities. In addition, there
was a 98% decrease in staff workdays missed due to restraint-related
injury, and an 80% decrease in staff turnover.
- Rivard, J., Bloom, S., McCorkle, D., Abramowitz, R. (2005).
results of a study examining the implementation and effects of
a trauma recovery framework for youths in residential treatment.
Therapeutic Community: The International Journal for Therapeutic
and Supportive Organizations, 26(1), 1-12. Outcomes related
to treatment environment and youth coping were monitored in this
study comparing implementation of the Sanctuary Model in residential
treatment units with other units that did not implement the Model.
Among the findings was an increase in: safety for staff and clients,
help and support within the community, open expression of feelings,
and self-sufficiency and independence in decision-making.
1. EPIDEMIOLOGY OF CHILDHOOD TRAUMA AND MALTREATMENT:
- National Center for Injury Prevention and Control (2005) Child
maltreatment: Fact Sheet. This document offers data on
trauma and maltreatment that can help staff understand the likely
life experiences of many children and youth in their care. Child
maltreatment is discussed in terms of occurrence, consequences,
and risk and protective factors.
- Hennessey, M., et al (2004). Trauma
among girls in the juvenile justice system. Washington, DC:
Juvenile Justice Working Group of the National Child Traumatic
Stress Network, www.NCTSNet.org.
Data from many sources indicate that females in the juvenile
justice system are highly likely to have experienced trauma, especially
direct victimization. These individuals are at high risk of substance
use, involvement in violent activity, further victimization, and
development of mental health problems. Ensuring safety in care
is essential. In addition, gender-specific programming is needed.
2. NEUROBIOLOGY AND CONSEQUENCES OF CHILD TRAUMA AND MALTREATMENT:
- Perry, B (2000). Traumatized
children: How childhood trauma influences brain development.
Journal of the California Alliance for the Mentally Ill. 11(1):
48-51. Starting with a clinical vignette, Perry describes
changes in brain structure and neurobiology that occur in children
subjected to trauma, and how this may influence the child's functioning.
The Child Trauma Academy website has many related articles.
3. HIRING, ORIENTING. TRAINING, SUPERVSIING, AND EVALUATING DIRECT
- Hodas, G. (2005). Empowering
direct care workers who work with children and youth in institutional
care. Harrisburg, PA: Office of Mental Health and Substance
Abuse Services. In recognition of the key role of direct care
workers in reducing the use of restraint, the paper proposes a
systematic approach to the hiring, orientation, training and supervision,
performance evaluation, and mentoring of direct care staff, so
that they can provide appropriate interventions consistent with
trauma informed care.
4. UNDERSTANDING AND IMPLEMENTING TRAUMA INFORMED CARE:
- Bloom, S. (2005). The
Sanctuary Model of organizational change for children's residential
treatment. Therapeutic Community: The International Journal
for Therapeutic and Supportive Organizations, 26(1), 65-81. This
paper offers a good overview of the Sanctuary Model, highlighting
the role of leadership and the need for culture change in order
to create a therapeutic community. Specific elements of the Model,
to be implemented by staff, are described.
- Mahoney, K., Ford, J., Ko, S., Siegfried, C. (2004). Trauma-focused
interventions for youth in the juvenile justice center. Washington,
DC : Juvenile Justice Working Group of the National Child Traumatic
Stress Network, www.NCTSNet.org.
Many children and youth in juvenile justice facilities have
experienced trauma and maltreatment, and it is essential that
their trauma-related needs be recognized and addressed. The authors
discuss the importance of pretreatment assessment, trauma-focused
interventions, treatment of co-occurring disorders, and family
based interventions with this population.
- The Sanctuary Model
Use of Seclusion/Restraint Reduction Tools
- Hodas, G. (2005). Parameters to consider in response to frequent
restraint use. Harrisburg, PA: Pennsylvania Office of Mental Health
and Substance Abuse Services. This document offers a systematic
approach to analyzing possible contributing factors, when there
is frequent use of restraint in a facility. The information obtained
can then be used to develop an action plan.
- Masters, K. (2005) How
to create and evaluate a seclusion and restraint prevention plan.
AACAP News, 36 (3), 110-111. This brief column identifies
10 elements that should be addressed in a safety plan. Many current
protocols incorporate some but not necessarily all of these elements.
(Used by permission of the American Academy of Child and Adolescent
- Alliance to Prevent Restraint, Aversive Intervention, and Seclusion
(APRAIS) (2005). In
the name of treatment: A parent's guide to protecting your child
from the use of restraint, aversive interventions, and seclusion.
Baltimore: TASH. This publication, developed by the Alliance
to Prevent Restraint, Aversive Interventions, and Seclusion (APRAIS),
provides education and guidance to families regarding the dangers
of restraint, seclusion, and aversive interventions in education
and care. In addition to discussion of Positive Behavior Support,
the following are addressed: dangers and risks to children, rights,
evaluating the program, warning signs, and taking action.
- Robins. C., Sauvageot, J., Cusack, K., Suffoletta-Maierle, S.,
Frueh, B. (2005).Consumers'
perceptions of negative experiences and “Sanctuary Harm”
in psychiatric settings. Psychiatric Services, 56 (9), 1134-1138.
Even though this article describes negative experiences of
adult psychiatric patients in Inpatient treatment, the emerging
themes are much more broadly applicable. Individuals in care can
be traumatized by restraint or perceived threats of physical violence.
Rules often appear arbitrary to them. They not infrequently experience
disrespect and humiliation from staff, and need to be listened
to and understood as unique individuals.
- The Department of Public Welfare, Office of Mental Health and
Substance Abuse Services has identified working with community
hospitals to eliminate the use of seclusion and restraint as a
priority action. At the May 2008 OMHSAS Adult Advisory Committee
meeting, the Chambersburg
Hospital presented their efforts in this partnership to eliminate
seclusion and restraint.
Direct Care Workers Who Work with Children and Youth in Institutional
Care, by Gordon R. Hodas, M.D. Used by permission of Gordon
Sanctuary: Creating Trauma-Informed Systems That Promote Recovery,
by Sandra Bloom, M.D.; presentation at ACT forums on September
21 and 25, 2006. Used by permission of Sandra Bloom.
Systems to Minimize Restraint and Maximize Dignity, Effective
Treatment and Safety, by Steve Gunn; presentation to Walker
Trieschman Conference, May 11, 2000. Used by permission of Steve
Bibliography, also used by permission of Steve Gunn.
Definitions and Data Collection for Residential Care Facilities'
Use of Restraint and Seclusion, by Lloyd Bullard, Residential
Group Care Quarterly (5), 1, 1-14.
Seclusion and Restraint Use in Child and Youth Settings: Changing
Our Cultures of Care, presentation by Kevin Huckshorn, National
Association of State Mental Health Program Directors. Used by
- Reducing Seclusion and Restraint Use in Child and Youth Mental
Health and Related Settings: Changing our Cultures of Care, list
of references prepared by Kevin Huckshorn, National Association
of State Mental Health Program Directors. Used by permission.
to Childhood Trauma: The Promise and Practice of Trauma Informed
Care, by Dr. Gordon R. Hodas.
Core Strategies© to Reduce the Use of Seclusion and Restraint:
Planning Tool, by Kevin Ann Huckshorn
- A Snapshot of Six
Core Strategies for the Reduction of Seclusion and Restraint
- Strategies and
Practices to Reduce Unnecessary Use of Restraint, Special
Transmittal from the Department of Public Welfare, January 30,
- The Silver
Springs Model of Trauma Recovery and Resiliency for Children
and Adolescents. Used by permission.
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