Training curriculum for health coaches Tom Bodenheimer This curriculum (a work in progress) can be accessed at the UCSF Center for Excellence in Primary Care website Primary care clinicians can no longer do what they are supposed to do. There is not time in the 15 (or even the 20) minute visit to handle all the problems that patients bring – acute, chronic, preventive, and more. Good
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Raodmap to seclusion manual_front.inddRoadmap to Seclusion and Restraint Free Mental Health Services Children’s Mental Health Poster Contest – 2000 Minnesota Association for Children’s Mental Health Roadmap to Seclusion and
Mental Health Services
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
Roadmap to Seclusion and Restraint Free Mental Health Services ACKNOWLEDGMENTS
Numerous people contributed to the development of this training manual (see Project Steering Committee). The document was prepared by the National Association of Consumer/Survivor Mental Health Administrators for the Substance Abuse and Mental Health Services Admin-istration (SAMHSA) under Task Order #OMB No. 0990-0115 with SAMHSA, U.S. Depart-ment of Health and Human Services (DHHS). Paolo del Vecchio and Carole Schauer served as the Government Project Ofﬁ cers.
The views, opinions, and content of this publication are those of the authors and contribu-
tors and do not necessarily reﬂ ect the views, opinions, or policies of CMHS, SAMHSA, or
Public Domain Notice
All material appearing in this document is in the public domain and may be reproduced with-
out permission from SAMHSA. Citation of the source is appreciated. However, this publica-
tion may not be reproduced or distributed for a fee without the speciﬁ c, written authorization
of the Ofﬁ ce of Communications, SAMHSA, DHHS.
Electronic Access and Copies of Publication
This publication may be accessed electronically through the following Internet World Wide
Web connection: www.samhsa.gov. For additional free copies of this document, please call
SAMHSA’s National Mental Health Information Center at 1-800-789-2647 or 1-866-889-
Roadmap to Seclusion and Restraint Free Mental Health Services. DHHS Pub. No. (SMA)
05-4055. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental
Health Services Administration, 2005.
Originating Ofﬁ ce
Center for Mental Health Services, Substance Abuse and Mental Health Services Administra-
tion, 1 Choke Cherry Road, Rockville, MD 20857.
Roadmap to Seclusion and Restraint Free Mental Health Services FOREWORD
In 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) set forth a bold vision to reduce and ultimately eliminate the use of seclusion and restraint in behavioral healthcare settings. These practices are detrimental to the recovery of persons with mental illnesses. Too often, the use of seclusion and restraint results in trauma, injury, and even death. We can and must do better to protect the lives and well-being of those whom we serve. SAMHSA has established seclusion and restraint as a priority area and has developed a National Action Plan to reach our vision of seclusion and restraint free mental health services.
Roadmap to Seclusion and Restraint Free Mental Health Services represents a key compo-nent of this National Action Plan. It will increase the knowledge and skills of mental health service direct care staff, administrators, and consumers on alternatives to the use of seclusion and restraint. We also see this training as a tool to assist you with mental health system trans-formation—creating mental health services and supports that facilitate recovery and promote resiliency.
Many training manuals exist, but this curriculum is unique. The President’s New Freedom Commission on Mental Health called for consumer- and family-driven approaches that sup-port recovery. The material in this manual is recovery based and developed by consumers. It draws on the published writings and research of the leaders in the recovery movement—consumers. It was developed with the assistance of the National Association of Consumer/Survivor Mental Health Administrators, and consumers from around the country were asked to provide insight derived from their experiences of seclusion and restraint and offer their guidance for the elimination of these practices. The expert opinion of direct care staff was also gathered and current literature on the topic was reviewed so that references could be provided. A Steering Committee, comprised of representatives from nearly every stakeholder organization within the mental health system, provided technical assistance and insight. Finally, the training was pilot tested with direct care staff and administration at two hospitals. We welcome you to join us in our collective efforts to ﬁ nd and use creative approaches and strategies to ensure that we help and not harm those whom we serve.
Charles G. Curie, M.A., A.C.S.W.
Administrator Substance Abuse and Mental Health Services Administration Roadmap to Seclusion and Restraint Free Mental Health Services The past decade has yielded many divergent views on the practice of seclusion and restraint. It is an area rife with tension, disagreement, and fear. One consumer recently said that he thought restraint was “too polite” a term for what he had experienced. He went on to say (NAC/SMHA In Our Own Voices Survey, 2001): “I was tied up and tied down. It was terrifying, dehumanizing, degrading, and painful. Along with the restraint was the forced injection of Haldol. Not only was the leather biting into my wrists, my body had been invaded by a substance that caused a feeling of intense internal violation.” In 1999, landmark national legislation led to tighter controls on the use of restraints in psy-chiatric hospitals. Federal and State mental health authorities furthered the development and implementation of policy change and the active pursuit of a reduction and ultimate elimina-tion of seclusion and restraint. The National Association of State Mental Health Program Directors (NASMHPD) publication, Creating Violence and Coercion Free Mental Health Environments: A National Initiative and Call to Action, identiﬁ es mandatory systemic changes that must occur when reducing the use of seclusion and restraint. The State of Pennsylvania demonstrated successfully that commitment to reform does indeed make a difference with their Leading the Way Seclusion and Restraint Initiative. External monitoring holds the key to eliminating seclusion and restraint according to some leaders. Others suggest strong administrative leadership. Some suggest a legislative solution. Some suggest better behavioral intervention strategies. However, virtually every constituent group involved in meaningful systems reform recognizes the need for ongoing training and education efforts. Roadmap to Seclusion and Restraint Free Mental Health Services explores sustainable solu-tions and strategies towards supporting the belief in the elimination of seclusion and restraint in the treatment of people with serious mental illness or children with serious emotional disturbance.
“It is not possible to solve a problem with the same consciousness that created it” (Albert Einstein). This manual is intended to build bridges and increase respect and understanding between consumers and direct care staff. All stakeholders must be present at the table and engage in the dialogue to develop seclusion and restraint free environments. It is the underlying premise of this manual that the role of the direct care staff is critical to meaningful system change. Together, we are partners and champions in the reduction and elimination of seclusion and restraint. Roadmap to Seclusion and Restraint Free Mental Health Services HOW TO USE THIS MANUAL
The goal of this curriculum is to provide direct care staff the tools and knowledge needed to improve their skills in preventing and ultimately eliminating the use of seclusion and re-straint. “Direct care staff” refers to individuals who work directly with consumers, such as nurses, psychiatric technicians, therapists, psychologists, and many others. Administrators will also ﬁ nd this training helpful. The curriculum is unique in that it is written from consumer perspectives, and thus helps direct care staff work from a consumer-based philosophy. It can be used in a variety of settings, such as State institutions, hospitals, or outpatient centers, for staff development, training, and in-service education. This training package provides all the background material, lecture points, and PowerPoint slides necessary for a facilitator to implement the seven training modules that demonstrate how to eliminate the use of seclusion and restraint. All the handouts for the participants are included. This is a valuable resource in places where facilitators cannot obtain needed and up-to-date information. Instructions on how to obtain optional resources, such as videos, are included.
Prior training for facilitators is not necessary; however, facilitators must be familiar with consumer perspectives of the mental health system to be effective in teaching this curricu-lum. Co-facilitating with a consumer/survivor, family member, or direct care staff helps bring more than one perspective to the training. To get the maximum beneﬁ t, it is recommended that at least one facilitator be a mental health consumer. Training formats that have proven particularly effective include teams of staff and former consumers working together as trainers. This team approach ensures that the perspectives of both parties are reﬂ ected. It also provides a model of clear and direct communication between the parties involved. The team approach can be used regardless of setting or population. Teams involving children and youth or individuals with developmental disabilities can be particularly powerful as an illustration of how people with diverse skills and experiences can work together.
Curriculum content is based on the concept that recovery and wellness are essential in pro-viding alternatives to the use of seclusion and restraint. Individuals must be treated with respect. The use of seclusion and restraint strips a person of dignity, privacy, and poten-tially, safety. When a person is put in restraints, it implies that he or she is less than human. Everyone’s human rights are cheapened when the dignity of a vulnerable person in society is ignored. The use of seclusion or restraints does nothing to advance an individual’s recovery, resilience, or self-determination, but has the opposite effect.
Roadmap to Seclusion and Restraint Free Mental Health Services Several States that have adopted comprehensive approaches to reducing the use of seclusion and restraint have found that staff training is a critical component of their initiatives. Train-ing interventions have reduced the use of seclusion and restraint, helped staff understand the experience from the perspective of the individuals involved, and improved communication and problem-solving skills. Training that includes a dialogue between staff and consumers about their experiences addresses the impact that seclusion and restraint has on the individuals involved, and is a powerful tool for creating a safe and respectful milieu. Training programs that focus on early identiﬁ cation and intervention in conﬂ ict situations are also essential for achieving this result.
Note about terms used: Many terms have been used to refer to individuals who have per-
sonal experience with psychiatric disabilities. The words client, patient, and consumer, are
common, as are the words ex-patient and survivor. Some people use the term consumer/
survivor/ex-patient, or c/s/x for short. The language of people ﬁ rst continues to evolve. Not
everyone agrees on using the same terms. Thus, the training modules use a variety of these
terms throughout. The language you decide to use must denote respect for the individual
and his/her ﬁ rsthand experience.
The training is divided into seven modules plus a resources section: • Module 1, through the perspectives of mental health consumers and direct care staff at State hospitals, increases the understanding of the participants of the personal experience of seclusion and restraint. • Module 2 discusses the impact of trauma on consumers and on direct care staff. • Module 3 explores the change needed to ensure cultural change within an institution. The role that staff play is discussed. Survey results from consumers across the country are reviewed. A model for reform is also reviewed. • Module 4 explores the concepts of resiliency and recovery from the consumer perspective. • Module 5 identiﬁ es, from the consumer and staff perspectives, strategies that will lead to the reduction and elimination of seclusion and restraint. • Module 6 discusses sustainable change through both consumer and staff involvement. • Module 7 presents a review of the ﬁ rst six modules and the development of both personal and workplace action plans to reduce and eliminate the use of seclusion and restraint. • The Resources section contains Web sites and policy and position statements of various The entire training takes approximately 21-24 hours to complete. The facilitators can deter-mine the schedule of the training. It can be done in 3 full days, 6 half days, or in some other arrangement. Each module requires approximately 3 hours, but can be shortened or length-ened to meet the needs of the training group. Modules are freestanding and can be presented individually, although each module builds on the preceding one and the course should be presented in its entirety. Roadmap to Seclusion and Restraint Free Mental Health Services Participants should be provided with ring binders with blank pages for notes and writing as-signments. They will be asked to write on Journal topics and Take Action Challenges during the training to integrate their learning with their work and develop action plans. Upper man-agement must be present and supportive when the participants are developing their Work-place Action Plans. We suggest printing out the required number of copies of the handouts that you choose to use with your class before the training begins. You can also print out the background reading (Background for the Facilitators pages) and lecture notes (Presentation pages) for yourself and any other facilitators. See the table of contents page for the list of handouts. In addition to the pages marked “Handout,” you may also wish to print out items from the Resources section and slides from the PowerPoint presentation (these include the learning objectives for each module). To print the Power Point slides in the most readable format, select “Print,” “Handouts,” and “Pure Black and White.” The ring binders should be large enough to accommodate all of these handouts.
The following is a list of materials, other than handouts, that are needed for each training module. Please note that in some cases, the facilitators will need to obtain materials such as videos and permission to use articles in advance. For all sessions, have the following materials on hand: • Nametags or name tents• Chalkboard/chalk/white board/ﬂ ip chart• Paper/pens/markers• Scissors• Tape• Overhead projector or LCD projector/screen• Ring binders with blank pages for participants Special arrangements are needed for the following: • Arrange for panel of consumers and direct care staff o Microphones for panel participants as neededo Table/chairs for panel participantso Water/glasses for panel participantso Stipends for consumer participants • Apply for permission to use Hartford Courant articles Roadmap to Seclusion and Restraint Free Mental Health Services • Obtain Pennsylvania Model video • TV/VCR• 3 x 5 index cards • Make designs for communication exercise • Obtain Advance Crisis Planning video from University of Illinois, Chicago• TV/VCR • Jana Stanﬁ eld CD, If I Were Brave• Boom box Roadmap to Seclusion and Restraint Free Mental Health Services ROADMAP TO SECLUSION AND RESTRAINT FREE
MENTAL HEALTH SERVICES
PROJECT STEERING COMMITTEE
American Psychiatric Association
Attorney and Advocate
National Association of Protection
Sister Witness International
and Advocacy Systems
Center for Mental Health Services,
Bazelon Center for Mental Health Law
Substance Abuse and Mental Health
Paolo del Vecchio
National Mental Health Association
National Association of Consumer/
National Association of State Mental
Survivor Mental Health Administrators
Health Program Directors
Joint Commission on Accreditation
of Healthcare Organizations
Health Care Financing Administration
University of Pennsylvania
The Federation of Families For Children’s
National Council for Community
Pennsylvania Department of Public
Child Welfare League of America
Department of Children and Families
American Psychiatric Nurses Association
American Psychological Association
Richard H. Hunter, Ph.D.
Roadmap to Seclusion and Restraint Free Mental Health Services CONTENTS
MODULE 1: The Personal Experience of Seclusion and Restraint
Background for the Facilitators
Overview Exercise: Getting to Know You (15 minutes)Challenge AssumptionsConsumer ComplaintsLack of Uniform National StandardsLack of Adequate Staff TrainingSafety Inappropriate Uses of Seclusion and RestraintTreatment Approaches to Reduce Seclusion and RestraintSpecial Needs PopulationsConsumer Panel (1 hour) Exercise: Hartford Courant articles (20 minutes) Exercise: Personal Perspective: Consumers (15 minutes) Exercise: Personal Perspective: Direct Care Staff (20 minutes) Handouts for Participants
Preventing, Reducing, and Eliminating Seclusion and Restraint with Special Needs PopulationsDeadly Restraint—Hartford Courant seriesConsumer QuotesDirect Care Staff QuotesReferences MODULE 2: Understanding the Impact of Trauma
Background for the Facilitators
Overview Exercise: Trauma Background (25 minutes)Deﬁ nitions Related to Trauma Roadmap to Seclusion and Restraint Free Mental Health Services Exercise: Common Reactions to Trauma (20 minutes) Differential Response to ThreatsAssessment of Trauma Exercise: Assessment of Trauma (20 minutes) Retraumatization via HospitalizationDe-Escalation Preferences Exercise: De-Escalation Preferences (20 minutes)What Survivors Want in Times of CrisisStaff Trauma (Secondary Traumatization)Healing from TraumaGrounding Techniques Exercise: Grounding Techniques (10 minutes)Journal/Take Action Challenge (15 minutes) Handouts for Participants
Journal Topics and Take Action Challenges for Modules 1 & 2National Association of State Mental Health Program Directors (NASMHPD) Position Statement on Services and Supports to Trauma Survivors Excerpts from Kate Reed’s SpeechPosition Paper on Trauma and Abuse HistoriesWhat Can Happen to Abused ChildrenSome Common Reactions to TraumaTrauma Assessment for Department of Mental Health Facilities/ Guidelines for De-Escalation Preference FormDe-Escalation Form for Department of Mental Health Facilities/ Excerpts from Dealing With the Effects of Trauma: A Self-Help Grounding TechniquesWeb Sites Related to TraumaResources on Secondary TraumaReferences MODULE 3: Creating Cultural Change
Background for the Facilitators
Roadmap to Seclusion and Restraint Free Mental Health Services Presentation
Exercise: “Flowers Are Red” (10 minutes)OverviewPennsylvania: A Model for Reform Video: Leading the Way: Toward a Seclusion and Restraint Free Environment (17.5 minutes)Cultural Change Exercise: “My Organizational Culture Currently Is…” (30 minutes) Exercise: “People With a Mental Health Diagnosis Are…” (15 In Our Own Voices Exercise: What Would Have Been Helpful to Hear (15 minutes) Handouts for Participants
“Flowers Are Red”“My Organizational Culture Currently Is…”NASMHPD Review of Literature Related to Safety and Use What Would Have Been Helpful in Preventing the Use What Would Have Been Helpful for You to Hear?What Other Options May Have Been Beneﬁ cial?References MODULE 4: Understanding Resilience and Recovery from the
Background for the Facilitators
Someone Who Believed in Them (20 minutes) Recovery Exercise: Recovery as a Journey of the Heart (35 minutes) Exercise: What Are We Recovering From? (15 minutes)Journal/Take Action Challenge (20 minutes) Handouts for Participants
Journal Topics and Take Action Challenges for Modules 3 & 4Someone Who Believed in Them Helped Them to Recover Roadmap to Seclusion and Restraint Free Mental Health Services Recovery as a Journey of the HeartRecovery From Mental Illness—Guiding VisionResources: Self-Help GuidesReferences MODULE 5: Strategies to Prevent Seclusion and Restraint
Background for the Facilitators
OverviewWellness Recovery Action Plan (WRAP) Exercise: Developing a Wellness Recovery Action Plan (30 minutes)Drop-In CentersRecovery Through the ArtsComfort RoomsService AnimalsPsychiatric Advance Directives Exercise: Creating My Own Psychiatric Advance Directive (30 minutes)Prime DirectivesCommunication Strategies Exercise: How Hard Can Communication Be? (15 minutes)Alternative Dispute Resolution/MediationTechnical Assistance Centers Handouts for Participants
Examples of Consumer WRAPsDeveloping a WRAP How to Set Up a Comfort RoomWhy Should I Fill Out a Psychiatric Advance Directive?Ten Tips for Completing an Effective Advance DirectivePsychiatric Advance Directive Practice WorksheetSix Essential Steps for Prime DirectivesAnticipated Beneﬁ ts of Prime DirectivesChildren’s and Adolescents’ Mental Health Services Technical Assistance and Research CentersResearch, Training, and Technical Assistance CentersReferences Roadmap to Seclusion and Restraint Free Mental Health Services MODULE 6: Sustaining Change Through Consumer and Staff
Background for the Facilitators
Overview Leadership Exercise: National Technical Assistance Center Networks (15 minutes) Exercise: Direct Care Staff Leadership (15 minutes) Debrieﬁ ng Exercise: Debrieﬁ ng Role Play (25 minutes) Advance Crisis Planning Video: Increasing Self-Determination: Advance Crisis Planning (13 minutes) Data Collection External Monitoring Role of the Champion Journal/Take Action Challenge (20 minutes) Handouts for Participants
Journal Topics and Take Action Challenges for Modules 5 & 6 Protection and Advocacy List National Technical Assistance Center Networks Newsletter Debrieﬁ ng Survey for Consumers References MODULE 7: Review and Action Plan
Background for the Facilitators
ReviewPersonal Action Plan Exercise: Personal Action Plan (1 hour)Workplace Action Plan Exercise: Workplace Action Plan (1 hour)Certiﬁ cates of CompletionWrap Up and Evaluation Roadmap to Seclusion and Restraint Free Mental Health Services Handouts for Participants
Personal Action PlanWorkplace Action PlanCertiﬁ cate of CompletionEvaluation RESOURCES
Web SitesPolicies and Position Statements1. American Nurses Association2. American Psychiatric Nurses Association3. Federation of Families for Children’s Mental Health4. NAMI5. National Association of State Mental Health Program Directors6. National Mental Health Association7. Pennsylvania: Restraints, Seclusion and Exclusion in State Mental
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