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SAMHSA Video on Alternatives to Seclusion and Restraint

February 11, 2011

In modern times, restraints are considered treatment failure. In the spirit of offering positive alternatives to replace their use, SAMSHA is offering a free video entitled Leaving the Door Open: Alternatives to Seclusion and Restraint. For anyone who is asking for positive recommendations concerning what can be done to protect safety other than restraints and seclusion, this video has a number of very specific answers and recommendations. Most importantly, the material in this video represents, not only a change in techniques, but a change in the entire culture of residential treatment facilities. Instead of the harsh, authoritarian atmosphere of the past that does not consider the patient as a human being who actively participates in their own treatment, SAMHSA’s approach works with the patient as a partner in his or her treatment and this approach is working extremely well. The people featured in the video are actual patients and professionals from a variety of different disciplines (nurses, psychiatrists, social workers, psychologists, patient advocates) who actual work in the trenches with these patients. No more can it be said that people opposed to restraints have never worked with such populations because the people in this video are the people who directly work with patients.

Contrary to popular belief, the video and SAMHSA’s materials make it clear that research has shown that the belief that restraining people protects safety is a myth. When restraints are reduced and alternatives put in place, violence actually goes down and the patients and staff are more safe.  The principles in this video also apply to those in private practice who are recommending restraints and in that kind of situation, with no institutional oversight, patients are even more vulnerable. People adopt methods such as seclusion and restraint because they don’t know what else to do. This video provides several alternatives that have been shown to work well. People tend to look at a situation after the person has become violent and out of control and falsely conclude they have no choice, when if they go back and examine what happened in the moments leading up to the situation, prevention of  the situation from escalating to that point could have occurred earlier on.

The people who are likely to be most resistant to change are the professionals who have worked within the system for years and may be dismissive of alternatives being proposed, believing that they will never work. SAMHSA’s attitude is not to blame these people — they were doing the best they could with the knowledge that they had. However, now it is possible to learn better and more humane ways that will make for a better experience for all the patients, as well as the staff.  Use of such alternatives to restraint and seclusion, now in a number of facilities has proven that they do work and eliminate the need for restraints in the vast majority of cases.

For those few instances where restraint becomes necessary, current guidelines universally agree that it has to be only in an immediate emergency situation, never for behavior control, never as an authoritarian tool to show the patient who is boss and certainly no so-called therapeutic holds are allowed. Afterward, there must be a full debriefing of not only the staff who were involved but also the patient. The patient is given the opportunity to give feedback on what might have prevented the situation and patients are taught how to self-sooth and to select various ways that would work for them. Through such debriefings (not the same as the controversial trauma debriefings — these are for evaluation and information purposes), more data is collected and ways to prevent situations from escalating are developed.

The message on this video is clear:

The use of restraint and seclusion are not treatments; they represent treatment failure. Restraints are no longer considered a valid treatment.

I ordered this video and the fortuitous timing of its arrival coincided with a guest lecture I gave for Bruce Thyer’s program evaluation class, which consisted of masters level social work students. As part of my presentation, which was on pseudoscience and potentially harmful treatments, I stressed the importance of positive, empirically supported alternatives and played this video for them, which stimulated much discussion. After the video, I asked the class how many people had worked in residential treatment facilities and several people had, so I invited them to share their experiences with regard to the use of restraint and seclusion. Some of the students had worked in facilities that were making efforts along the lines of SAMHSA’s recommendations to eliminate or at least greatly reduce their use and others were working in facilities that were still behind the times and not considering any alternatives. Those who had worked in the more up to date facilities that were employing alternatives reported very positive experiences. Those who had worked in facilities where restraints were used and alternatives not considered reported that there was a great deal of fear among the patients and struggle with those in charge, who were viewed as negative authorities. In the new system, the staff are viewed as partners in their healing who work with the patients. One student had the experience of having worked in a facility that was employing alternatives to restraint and then having to be transferred to a facility that was not. The difference between the two facilities was very apparent to him, but he reported that he was, at least, able to use some of the skills he had learned at the first facility to work with the patients.

For anyone who is wondering about very specific, positive alternatives to restraint and seclusion this is the video to order and it is available free from SAMHSA. For those who think that this would not apply to their case, keep in mind that the people these techniques have been used on are people who are considered to be the most seriously mentally ill and sometimes the most violent and this has included children, adolescents and adults. There is no reason to believe that internationally adopted children would be an exception to this and that they must therefore continue to be subjected to what in my opinion are barbaric, authoritarian interventions that have not been well tested with randomized, controlled trials for safety and efficacy.  The entire approach is the opposite – instead of taking everything away from the child, forcing the child to perform hard labor to “earn” everything and requiring snappy, cheerful unquestioning obedience (see Nancy Thomas’ writings for examples of this approach), the child is provided with compassion, support, and what it is for that particular individual that will work to comfort and calm him or her.  This is a learning experience for the child as well, teaching the child what to do to self soothe rather than spinning out of control into a meltdown. Through such positive reinforcement, a well-tested well empirically supported approach, forceful restraint becomes unnecessary and behavior improves.  The alternatives SAMHSA is proposing are geared towards patients who have histories of severe trauma and it is a trauma informed approach. An entire section of the video is devoted to this topic and explains how people with trauma backgrounds are especially triggered by the use of seclusion and restraint and an atmosphere that promotes it.

Time and time again, what the behavioral research has shown is that in the long run, punishment doesn’t work and positive reinforcement does. Whether or not people wish to deny that restraints are punishment, they fit the behavioral definition of punishment and a large percentage of patients who have been restrained view and experience it as punishment, so such denial is not very credible. SAMHSA’s program is a living example of the principle of replacing punishment with positive reinforcement, good, sensitive clinical skills and making the patient a partner, rather than the object of a treatment.

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