21 June 2010

harm reduction - Restraint + Seclusion Training

For those of you new to this weblog, I work at a large psychiatric inpatient facility.

A couple of years ago the facility where I work established a goal to eliminate the use of mechanical restraint and seclusion.
     Although this effort was first met with opposition, and there were a significant number of direct service staff who fearfully argued that such an approach would result in more assaults and injuries, in fact, the opposite occurred. Statistics show that as restraint interventions became less frequent, the number of injuries and assaults went down. Another thing that was done [thanks, in part due to mandates from the Center for Medicare and Medicaid Services] was to dramatically limit the length of time that a person could legally be placed in mechanical restraints.
     Perhaps most important, the values that provided the foundation behind the move to eliminate mechanical restraints are based on the premise that people with long term "chronic mental illnesses" often can and do recover; if the treaters would but recognize this truth.
     As these values translate into organizational policy [and clinical practice], the state's Department of Mental Health's training manual on "Safe Recovery Orientated Environments", teaches the following:
Safe recovery orientated environments have several essential cultural characteristics. Our focus is on these three:
• Risks are continuously prevented and managed to provide the safest environment possible.
• Care is customized to the individual and is focused on fostering recovery – our focus today is on helping people self regulate dangerous behavior.
• All people are treated with respect and dignity. As such, the use of R/S imposed as a means of coercion, discipline, convenience, or retaliation by staff is not permissible. Instead, everyone works together to find paths to recovery.

The best way for you to BE safe is to help your patients FEEL safe
     Translating these points into everyday clinical protocols is a dramatic remove from the conventional wisdom practiced at most psychiatric facilities. Instead, industry standards are more often based on the flawed teachings of Dr. Benjamin Rush, who, in 1813 published a treatise entitled Medical Inquiries and Observations Upon the Diseases of the Mind, indicating his recommended treatment for "the Mad."
...if all the means that have been mentioned should prove ineffectual to establish a government over deranged patients, recourse should be had to certain modes of coercion:
   1- confinement by means of a straight waistcoast or of a chair...
   2- privation of their customary pleasant food;
   3- pouring cold water under their coatsleeves, so that it may descend into the armpits and down the trunk of the body;
   4- the shower bath continued for 15 to 20 minutes.
   If all these modes of punishment should fail in their intended effects, it would be proper to resort to the fear of death. - By the proper application of these mild and terrifying modes of punishment chains will seldom, and the whip, never, be required to govern mad people.
" page 181
[the chair shown just to the right is what Rush had patented as his "tranquilizer chair"]
     Rush is widely regarded as "the father of modern psychiatry". His writings first codified his beliefs almost 200 years ago. His premise was that forced, brutal and coercive treatments were what worked best. Even now what continues to pass for inpatient psychiatric care goes back to that, and many still [who work with "the MAD"] do not seem to question Rush's opinions since the day he penned them.
     Although there is still a coercive tone to the place, in the past decade where I work has changed dramatically. Many staff, if they do not actually embrace these new values, recognize that they are expected to comply with their enactment. And there still remain some who yearn for the "good old days" when they could tie down people for days at a time without any oversight or official complaint. That still has to change ~ not just where I work, but throughout the "system". More sobering, the place where I work is just one of hundreds [thousands?] such facilities across the continent.
     While progress is slowly being made on eliminating mechanical restraints, there is still scant consideration regarding the widespread use of chemical restraints that are psychiatric medications.
     Virtually nothing is done about treatment-induced ailments such as: learned helplessness, clinically encouraged self-absorption or the disdain for self-determination. There are also the traumatizing effects of living with the impacts of cumulative institutionally induced emotional and psychological manipulation and abuse; of being constantly treated and regarded as a less-then-normal patient/person. All these have bearing on a person's ability to get to that state of "recovery".
     And I'm not even going to begin to address the total lack of clinical interest in seeking non-harmful interventions that are outside the mainstream, nor the aversion to spiritual quest paths as a means of healing one's self.
     Administrators - both in-state and elsewhere, boast we are among the best of the lot. They should not yet rest upon their laurels. And for the "patients" in the other places? We - and society - still has a long, long way to go before truly becoming coercion free.

COMMENTARY SITES ON THE STATE OF THE MENTAL ILLNESS INDUSTRY: 1- Beyond Meds; 2- The Standard Review / Diversity Rules; 3- The Icarus Project
COMMENTARIES ON MIND/SOCIAL CONTROL: Are your thoughts your own? Turn off the TV Set!; Richard Gosden's Coercive psychiatry, human rights and public participation [first published in 1999, ever bit as relevant today.
IMAGE INFO: Dr. Benjamin Rush's "Tranquiliser Chair." Rush, ironically, was one of the signatories of the US Declaration of Independence; Pillhead found online some time ago; source unknown

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