Featured Article: How to implement organizational change

Solomon, a sensitive 16-year-old, nervously held the microphone and began to offer his advice in a low voice and somber tone. Speaking to fellow residential peers who have experienced restraint and seclusion, Solomon shared his strategy for managing in the moment: “I figured it out: When you see staff running at you, just lay down on the floor and then you just ask God to not make it hurt and wait for it to be over. It’s shorter that way–and you don’t get hurt as much.” His wrenching recommendation was offered to other adolescents at a youth forum last August on restraint and seclusion prevention.

Youth gathered at a forum on restraint and seclusion last August to share their experiences in the child welfare, mental health, and juvenile justice systems.

Among the participants at the forum, held in Westborough, Massachusetts, was Brenda, a 17-year-old with a pensive look and flair for fashion, who nodded and then shared her views. “The first time I got restrained was when I was six, in a hospital,” she said. “I want to go to law school and become a lawyer so I can help other kids one day, so this doesn’t happen to them. Restraints only set kids back and make them distrust staff and adults.” Then Julio, 14, described different restraint methods he’s experienced: handcuffs in juvenile justice programs, safety coats, papoose boards, leather wrist and ankle restraints in mental health settings, and physical restraints in public and residential schools. “If my foster parents did to me at home the stuff staff did in my old programs, they’d be talking to a judge,” he said. “I know they’re supposed to be used like in an emergency or something, but that’s not what’s going down. You can get restrained for just looking the wrong way at someone, dissin’ a teacher, or saying no. One program I was in, this dude would start his shift and say, ‘I feel like breakin’ a few heads tonight’…. That’s scary!” Alisha, 18, summed up the group’s comments. “Restraining and secluding someone isn’t just tying them down or locking them up–it affects everyone. But it’s harder for kids because we don’t have the power. It teaches [us to] resolve our problems with violence. I think what’s important is that we respect each other, listen, and not touch anyone without their permission.”

The collective experience of these youth supports some of the findings of the federal government and legal advocates who enumerated the harmful effects of these procedures. More than a decade ago, the Government Accountability Office (GAO) conducted an investigation on restraint and seclusion practices in residential and hospital settings following a 1998 Hartford Courant expose on restraint and seclusion deaths. This past May, legal advocates sounded the alarm on the use of these violent procedures in public and private schools, which prompted another GAO investigation, a Congressional hearing, and a national uproar.

Restraint and Seclusion Investigations

The five-part Hartford Courant series exposed injuries and deaths related to restrain and seclusion, bringing national attention to this issue. The following year, the Medical Director’s Council of the National Association of State Mental Health Program Directors (NASMHPD) studied the issue and was the first professional group to conclude, after a thorough review of the research, that the use of restraint and seclusion was a “treatment failure.” They recommended a focus on preventing the use of restraint and seclusion.

In 2001, national organizations including the Substance Abuse and Mental Health Services Administration, CWLA, the Federation of Families for Children’s Mental Health, and NASMHPD began work to support programs to prevent and reduce the use of restraint and seclusion. Between 2001 and 2009, SAMHSA funded a number of activities, including:

• developing a training curriculum based on research and best practices in the field framed as the Six Core Strategies(c): leadership, using data to inform practice, workforce development, family-driven/youth-guided care, primary prevention tools, and debriefing;
• delivering training programs to groups of leadership staff from residential and hospital programs in nearly all 50 states;
• developing a rigorous evaluation tool and onsite consultation in residential and hospital programs using this tool;
• conducting two large-scale evaluations, each across eight states and multiple residential and hospital programs; and
• creating an “Alternatives to Seclusion and Restraint Recognition Program,” with more than 60 hospitals and residential programs submitting data and summaries of their success outcomes.

SAMHSA’s work paid off; they created a national momentum that began in mental health but expanded to child welfare, juvenile justice, and education. Leaders in hundreds of hospitals, residential programs, day programs, and schools committed to prevention and reduction efforts, with most using all or most of the Six Core Strategies(c) to realize significant success. The first eight-state evaluation determined that the Six Core Strategies(c) met the application criteria to be recognized as an evidenced-based intervention.

Youth participated recently in a Massachusetts Department of Mental Health program called Express Yourself. This program is a success-oriented, creative arts programs staffed by professional performing artists and youth mentors who go to a range of services where DMH youth are served, including hospitals, locked treatment programs, residential programs, and schools.

SAMHSA intends to continue the momentum. “We are increasingly aware of how coercive practices reintroduce trauma into the lives of children who often bring significant trauma histories into residential and school programs,” says SAMHSA’s Senior Advisor on Children, Dr. Larke Huang. “Promoting coercion-free care is critical to the healing and resiliency of these youth. We also know there are frameworks and practices that have an empirical basis for reducing and even eliminating seclusion and restraint.” Huang supports legislation that recently passed in the House of Representatives, the Keeping All Students Safe Act (H.R. 4247), which brings attention to the harmful effects of these practices in schools.

Successful Programs

Several CWLA member agencies have embraced the Six Core Strategies(c) as a framework for making the necessary culture change to eliminate or significantly reduce the use of restraint and seclusion. It is interesting to note that leaders from school, day, shelter, and foster care programs have joined a wide variety of residential programs in implementing these best practices. In 2007, leadership at The National Youth Advocate Program (NYAP), which operates a range of different services in seven states, began a serious focus on eliminating the use of restraints (seclusions were not used). By the following year, they had eliminated the use of restraint in their Ohio programs, realized a concurrent significant reduction in injuries to staff, and saw an approximate 50% reduction in runaways and reductions in calls to police. NYAP focused primarily on three of the Six Core Strategies(c): leadership, workforce development, and youth-guided care. Leadership committed to operationalizing values of respect and trauma sensitivity, focusing on providing staff with training and opportunities for discussing the desired culture change. They emphasized youth empowerment through supporting youth in identifying individual triggers and strategies to help them learn to calm themselves when distressed.

In Nebraska, Cedars, a multiservice agency serving more than 3,500 children annually, has eliminated restraint in several programs. Its two shelter programs have been restraint-free since October 2005 and its 14-bed residential treatment center went from 363 restraints and 315 seclusions in 2004-2005 to no restraints or seclusions in 2007-2008. Cedars has not used an “invasive strategy” since April 2007. Cedars utilized each of the Six Core Strategies(c) to achieve success; they did not focus on elimination, but rather had a goal to build a treatment environment that was coercion-free.

Cedars established two overall goals: 1) youth would become proficient at using language to communicate needs, ideas, feelings, and opinions, and 2) youth would become proficient in self-management and self-regulation. Restraint and seclusion were found to be incompatible strategies to accomplish these goals. Cedars places a heavy emphasis on supporting youth and family involvement and empowerment.

Griffith Centers for Children in Colorado serves approximately 1,600 children annually in a variety of residential and community programs. Their intensive residential programs have a capacity of 250 youth and their group homes serve 30 youth. Between 2004 and 2007, Griffith realized a greater than 70% reduction in restraints and significant reduction in workmen’s compensation claims (350% over the same period). Of the Six Core Strategies(c), they focused on leadership, workforce development, use of data, and debriefing. Their culture change focus was dedicated to implementing practices consistent with trauma-informed and strength-based care; additionally, they supported youth empowerment of their own care.

Many programs not associated with CWLA have also achieved success in significantly reducing the use of restraint and seclusion, including Catholic Charities Child and Family Services, which operates a number of programs throughout Maryland. Their Villa Maria Continuum, consisting of a Residential Treatment Center (RTC) and school programs, and their St. Vincent’s Center, a diagnostic and evaluation treatment program, have both utilized the Six Core Strategies(c) to realize significant reductions. St. Vincent’s, which does not use seclusion, reduced restraints by 85% between 2002 and 2008. Villa Maria Continuum RTC reduced restraints by 88% and seclusions by 99.9% between 2004 and 2008. Their school programs reduced restraints by 75% and seclusions by 100% in this same time period.

Villa Maria and St. Vincent’s dedicated themselves to organizational cultural transformation to achieve reduced use of physical interventions. They implemented practices consistent with their mission, vision, and values to promote dignity, autonomy, respect, and recovery. They put emphasis on trauma- informed care and creating a culture of caring. They focused on both family-driven and youth-guided care, supporting strong family and provider partnerships (hiring parent representatives to assist in training staff, evaluating services, and mentoring families) and sharing the opinions and recommendations of youth into staff training programs, as well as having youth provide feedback on agency policies and procedures. They also focused on youth empowerment through the implementation of individual safety plans.

Continuing the Momentum

The knowledge and practice of restraint and seclusion prevention has advanced in an array of child-serving settings. Programs and schools that previously used these procedures as ‘therapeutic interventions’ now recognize the problems associated with their use and the benefits of implementing prevention-based alternatives. In so doing, providers are raising the standard of care to which all youth-serving providers will be measured. For programs contemplating this work and seeking guidance on facilitating culture and practice change, program leaders make the following recommendations.

Do:

1. Learn about and embed the Six Core Strategies(c) into a Quality Improvement Plan. Call other providers who have successfully implemented the core strategies and learn from them.
2. Talk with staff, families, and youth about how and why restraint and seclusion are used in your program. Simply elevating the oversight of their use typically results in immediate reductions. Unfortunately, reductions will not be sustained over time unless a dedicated quality improvement project is also undertaken to support the overall effort.
3. Undergo a comprehensive review and analysis of harmful practices within the program. Recognize that extracting restraint and seclusion is more than simply changing practice; it also demands changing program culture. This is a fundamental exercise in values reexamination and clarification.
4. Be patient. This is not a “quick fix” task. Some have likened the long-term work as a marathon for sustainable culture change, not a race to zero episodes of restraint or seclusion. Being prepared for this process and supporting staff throughout the effort are crucial.
5. Involve staff. Staff asked to make this change must be part of the process; otherwise early buy-in and support for the new direction will be compromised. Staff often know far better where the operational obstacles lie and have pragmatic ideas about how to address them.
6. Share the data. Everyone involved needs to know what the starting point is so progress can be measured and change can be recognized. It is notuncommon to feel threatened by publicizing and posting this data, but many states, organizations, and programs use their websites and bulletin boards to raise employee consciousness about this work. According to the NASMHPD, one youth-serving program in New York posts their data and restraint/seclusion reduction initiative updates in the staff restrooms and time clock so staff are continually reminded about the important work being done.
7. Consider innovative ways to engage youth and families. They have much to contribute and are acknowledged by some experts as the fastest way to bring about meaningful organizational culture change. For example, youth in some Massachusetts programs were hired to:
   1. Participate in interviewing prospective staff and educating new staff about what it is like to be in a program, how restraint and seclusion make them feel, and what staff could and should do instead;
   2. Review and edit a brochure, website, staff training curriculum, and schedules to be sure a youth perspective and preferences are well represented.
   3. Develop a youth position statement on restraint and seclusion and declare their perspective and recomm-ended remedies to managing conflict and the potential for violence.
   4. Hire youth and family members to serve in key roles within the organization. If new roles are created, prepare staff and value the role by having the person in the new position report to the leadership.

Don’t:

1. Don’t change the goals and focus frequently. Message clarity and consistency is important. One provider’s efforts were set back by changing the focus from restraint reduction, then to restraint elimination, and then to restraint prevention. Restraint and seclusion prevention–in tandem with trauma informed-care principles–is a logical framework to adopt.
2. Don’t hire just one youth and/or family member. Being a lone voice is problematic and can lead to a sense of tokenism, marginalization, and an incomplete perspective. It can also be a lonely place for a sole advocate to be.
3. Don’t expect your staff to embrace the new consumer role. One adolescent program talked with staff about creating Young Adult Peer Mentor roles for almost a year, but when the young adults actually started on the job, staff concerns came to the surface. Ongoing staff supervision is needed throughout this process.
4. Don’t wait. Perhaps Napoleon Hill, author and success strategist, said it best: “Don’t wait. The time will never be just right.” Systemic change is difficult, but the treatment and economic advantages are clear and far outweigh the cost of doing nothing.

Restraint and seclusion are violent, high-risk procedures with the potential to harm youth and staff. Youth are now actively and publicly declaring the toxic impact of these methods from their unique and powerful perspectives as residential service consumers and the next generation of adults to enter the workforce and shape the future. Many programs are successfully reducing their use of restraint and seclusion–some to the point of full replacement–raising the standard of care for all providers. Ongoing recognition at the national, federal, and state levels requires agency leaders to hold their organizations accountable to these fundamental changes toward nonviolent, more supportive care. Fortunately, powerful resources are readily available to help facilitate this important change.

Beth Caldwell MS is president of Caldwell Management Associates, Inc., in Housatonic, Massachusetts. Janice LeBel PhD is the Director of Program Management in the Child/Adolescent Division of the Massachusetts Department of Mental Health in Boston, Massachusetts.

For information on the Six Core Strategies(c), visit www.nasmhpd.org/srcoordinatingcenter.cfm and scroll down to ‘Six Core Strategies.’