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SAMHSA Takes Strong Position Against Restraints and Proposes Alternatives
SAMHSA has just taken a very strong position against restraint and seclusion and has recently released a free videotape and a detailed and extensive training manual that can be downloaded free in PDF format that thoroughly demonstrates that in most cases restraint and seclusion are not necessary and that well supported alternatives do exist. The material they have provided is so important to any mental health professional working in this area, that I plan to devote several postings to this topic.
For those of you who are unfamiliar with this agency, SAMHSA stands for Substance Abuse and Mental Health Services Administration. Click here for a complete description and overview of what this agency does. In brief, SAMHSA targets not only substance abuse but also mental health services and its policies address people who have very serious mental illness and thus, their material on restraints very much applies to the populations I have been discussing here with regard to restraints. I note this because some people have argued that for children and/or adults with serious mental health problems, there is no alternative to restraints. SAMHSA’s latest materials have conclusively demonstrated that this is not the case with this population which is their focus. Moreover, restraints represent treatment failure, not a valid treatment plan and that when restraints are not an option, valid, safe and noninvasive alternatives do emerge and do work.
Proponents of restraint will often state that it is not intended as punishment. However, all too often, the way restraints are actually used do fit the behavioral definition of punishment, interventions that are designed to decrease or extinguish given behaviors. As one of my mentors, Bruce Thyer likes to point out, this principle is demonstrated vividly in the movie, The Madness of King George. However, extensive behavioral research has indicated that while punishment works in the short term, it does not work in the long term and in the long term, it might actually increase undesirable behaviors in some people because any attention might be seen as a positive reinforcer. Therefore, if someone has a child involved in a program that is employing restraint and appears to be getting worse, take that very seriously since claims that a person has to get worse before they get better, when it comes to punishment, are not borne out by research.
Another important point made in the manual is that although proponents of restraint claim it is not punishment, research has shown that the vast majority of people who have actually been restrained do experience it as punishment. Let’s listen to them. It’s easy to say it is not punishment, but try telling that to the people who are actually restrained. Being restrained, regardless of the intent of the restrainer is often experienced as a traumatic, dehumanizing, degrading experience. In the case of people with serious abuse histories it can also be highly retraumatizing. The entire first module (second PDF download) deals with the personal experience of seclusion and restraint and it is not a positive one, to put it mildly.
SAMHSA’s Module 1 challenges the following myths about restraint:
- Seclusion and restraint are therapeutic
- Seclusion and restraint keep people safe
- Seclusion and restraint are not meant to be punishment
- Staff know how to recognize potentially violent situations
It turns out that none of these are true, none are borne out by research. SAMHSA’s response is:
- Seclusion and restraints are not therapeutic. There is actually no evidence-based research that supports the idea that restraints are therapeutic.
- Seclusion and restraints do not keep people safe. The harm is well documented; not only the physical harm, but also the emotional and mental harm. Restraints actually harm and can cause death. Broken bones and cardiopulmonary complications are associated with the use of seclusion and restraint (FDA, 1992; NYS OMH, 1994)
- Even though most staff would say that seclusion and restraints are not used as punishment, 60-75 percent of consumers view it as punishment for refusal to take meds or participate in programs.
- Holzworth and Wills, 1999, conducted research on nurses’ decisions based on clinical cues with respect to patients’ agitation, self-harm, inclinations to assault others, and destruction of property. Nurses agreed only 22 percent of the time on what constituted a violent situation. The longer nurses have worked in mental health positively correlates with greater consistency in determining potentially violent situations.
Lack of proper staff training is often cited as a cause for restraint deaths. However, SAMHSA points out that no national uniform training standards currently exist for the use of seclusion and restraint. Thus, practices vary widely from state to state or even from institution to institution. So much for trusting the knowledge and competency of someone just because they have experience working in institutions, since many such institutions have been shown to be very dangerous places.
SAMHSA also addresses the myth that staff often believe that if seclusion and restraint are eliminated, they will be less safe when in fact, research indicates the opposite is the case. As seclusion and restraint practices decrease, so do staff injuries. They also point out that the word, “safety” has different meanings for staff than it does for the recipients of the service.
SAMHSA also lists inappropriate but common usages of restraint including:
- Control the environment
Regarding children and restraint, they note:
- More than 26 percent of deaths reported in the Hartford Courant series were children — almost twice the proportion of their population in psychiatric hospitals.
- Children are twice as likely as adults to be restrained (Weiss, 1998; Cooper, 1998; Milliken, 1998).
- Children are further traumatized by being restrained and most see this as a form of punishment (Mohr, 1999).
So these things have been known for more than a decade, but only recently are there serious attempts to change things. Additionally, Caucasian staff are nearly four times more likely to restrain people of color so whether conscious are not, there may also be an element of racism involved.
Module 1 also includes a full reprint of the Hartford Courant series on restraint.
The last part of the SAMHSA manual also has a list of current policies. Even the agents that still allow restraints place very stringent limitations, such as limiting the duration to 10 to 15 minutes and using them only when there is an immediate danger to self and/or others — not potential danger, not to show the person who is in control, but an immediate danger. Additionally, SAMHSA has provided in their manual, a number of alternatives that should always be tried first to attempt to deescalate a situation or prevent a person from becoming violent in the first place.
The boot-camp style interventions I have criticized, rather than calming a person down, often provoke anger, rage and violence, even if that is not the proponent’s intention. After all, how would you feel if you were stripped of everything familiar to you, isolated from everyone except for one or two people and forced to do lengthy manual labor to earn things that would normally be given to a child? Is it any wonder that these children explode into a rage? I would be more concerned about human beings who would just take that all in stride and remain calm. SAMHSA’s approach is just the opposite. Every way possible is found to identify and eliminate triggers for rage and violence and to help the person find ways to anticipate problematic behaviors and calm down. For example, they recommend comfort rooms, places where an agitated patient can go that provide a pleasant environment to calm down in — not a padded cell or a seclusion room, but rather, a nice, comfortable room with stuffed animals, reading material, relaxing tapes or anything else that a particular individual finds helpful in calming down. People can learn to recognize signs within themselves that they are moving towards a meltdown and learn ways that work to calm down before it reaches the point of no return where they may present a danger to themselves and others. I will write more about this in subsequent postings.
And remember, this is SAMHSA, not some so-called “fringe advocacy group”. To be continued.