3120bb 02^ bDSS 7 Massachusetts Department of Mental Health Task Force on the Restraint and Seclusion of Persons who have been Physically or Sexually Abused Report and Recommendations January 25, 1996 Prepared by the Task Force Elaine Carmen, M. D. (Chair) Bill Crane, J. D. (Co-chair) GOVERNMENT DOCUMENTS COLLECTION Margaret Dunnicliff, Ph. D. Steve Holochuck N0V 0 2 1999 Laura Prescott, B. A. Unwersfty upy Depository Patricia Perri Rieker, Ph. D. Susan Stefan, J. D. Nan Stromberg, R. N., C. S. ii Membership Task Force on the Restraint and Seclusion ofPersons who have been Physically Sexually Abused Elaine Carmen, M. D. (Chair) Medical Director, Brockton Multi-Services Center Professor ofPsychiatry, Boston University School ofMedicine 165 Quincy Street MA Brockton, 02402 508-580-0800 ext. 256 Bill Crane, J. D. (Co-chair) Special Assistant forHuman Rights Department ofMental Health Central Office 25 Staniford Street MA Boston, 021 14-2575 727-5500 ext. 420 Margaret DunniclhT, Ph. D. Director ofClient Services Child and Adolescent Services DMH Central Office 727-5500 ext. 531 Steve Holochuck Director Office ofConsumer and Ex-Patient Relations DMH Central Office 727-5500 ext. 406 Laura Prescott, B. A. Human Rights Coordinator Massachusetts Department ofMental Health Western Massachusetts Area Office P. O. Box 389 MA Northhampton, 01060 413-584-1644 Ext. 260 Patricia Perri Rieker, Ph. D. AssociateProfessor ofPsychiatry (Sociology) Harvard Medical School , Director ofPsychosocial Research Dana Farber Cancer Institute 44 Binney Street MA Boston, 02115 617-632-3150 Susan Stefan, J. D. Associate Professor University ofMiami School ofLaw P. O. Box 248087 Coral Gables, FLA 33124-8087 305-284-2672 Nan Stromberg, R. N., C. S. Utilization Management Coordinator Dr. Solomon Carter Fuller Mental Health Center 85 East Newton Street MA Boston, 021 18 617-266-8800 ext. 215 Research findings suggest that at least half of all women and a substantial number of men treated in psychiatric settings have histories of physical or sexual abuse, or both (Carmen, Rieker, and Mills, 1984; Bryer et al., 1987; Craine et al., 1988). We assume that clients currently being treated through the Massachusetts Department of Mental Health (DMH) are no exception. Anecdotal evidence available to Task Force members confirms these statistics. Analysis of data on children and adolescents in DMH secure treatment settings suggests even higher percentages. Task Force members have reason to believe that the reported statistics may underestimate the total number of people receiving mental health services who have histories of abuse. Although JCAHO standards for 1995 mandate that possible victims of abuse and neglect are identified in community and hospital based treatment settings (MHM 1995, PE.1.15), we suspect that most DMH public and contracted treatment settings are substantially out of compliance with this requirement. (Appendix I) For many people diagnosed with a major mental illness, the occurrence of physical and sexual abuse across the life span has served to confound treatment oftheir illness. These mentally ill survivors often become high users of mental health services around such issues as substance abuse, suicidally, self- injury, assaultiveness, and repeated victimization. As a consequence of inadequate assessment and inappropriate treatment, neither hospital-based nor crisis services have been able to meet the needs of these clients for more than temporary respite. Indeed, there is growing evidence that in most mental health settings, such clients are likely to be retraumatized, leaving them in a continuing cycle of trauma and response. Retraumatization occurs through failure to recognize, understand, and respond appropriately to the survivor's symptomatology. also occurs through It the use of restraint and seclusion, the lack of physical safety in institutional settings, and fragmented and inconsistent treatment. Consumer advocates have made Task Force members aware of the extent to which restraint and seclusion DMH remobilize the trauma in abuse survivors. Client statements in the Core Curriculum on Alternatives to Restraint and Seclusion Training Manual (November, 1993, pp 8,9) illustrate the traumatic impact that restraint may have on abuse survivors: "It is related by a client that once while in restraints, she was handled by males, and one of them pulled her pants and underwear down in preparation for a chemical restraint. 'I was terrified being touched by males,' she said. This was as a result of previous repeated abuse by a family member." "One client stated that as a child she was tied down and raped. Whenever she is placed in four-point restraint, it reminds Massachusetts DMH Restraint/Seclusion/Abuse SurvivorTask Force Report, 1/25/96: Carmen, Crane, Dunnicliff, Holochuck, Prescott, Rieker, Stefan, and Stromberg her of the incident, so that instead of getting in control, she becomes more out of control." Many survivors have had personal experiences with abusers who had restrained them, forced drugs, and locked them away in closets, car trunks, and rooms, and invaded their privacy by watching them in bathrooms, showers, bedrooms, etc. Thus, something as routine to inpatient staff as turning the lights off in a child's room or a 15 minute room check at night may be viewed with intense fear by a trauma survivor. Through these accounts, we came to recognize that restraint and seclusion, although employed to de-escalate agitation and loss of control, often serve to worsen the situation because of their similarity to prior traumatic experiences. The Final Recommendations on the Use ofRestraint and Seclusion ofthe New York State Office ofMental Health (June 1994) recognizes this when it states that the "potential negative impact of restraint and seclusion must be addressed in the decision to use these interventions, especially with patients who have a history of physical or sexual abuse." (Appendix 2) The Task Force recommends that the Department of Mental Health take action to address this problem in the following areas: Assessment Procedures I Use of Restraints II DMH-DMA III Draft Purchasing Specification IV Emergency Services V A Pilot Project for all-Women Units VI Office of Internal Affairs VII Training Assessment Procedures I Mental health professionals cannot develop appropriate treatment plans or interventions for clients in the absence of knowledge about their histories of physical or sexual abuse (MHM 1995). Clients should be asked about their history of sexual or physical abuse in all clinical settings. This would enable professionals to develop more effective treatment plans, provide more appropriate treatment, and allow the Department to begin to collect data to assist in planning for the development offuture programs for its clients. Trauma Assessment Form (Appendix 3) The Task Force recommends the Trauma Assessment Form as a guide to gathering information with clients about a possible trauma history. It is 2 Massachusetts DMH Restraint/Seclusion/Abuse Survivor Task Force Report, 1/25/96: Carmen, Crane, Dunnicliff, Holochuck, Prescott, Rieker, Stefan, and Stromberg recommended for use as part ofthe intake assessment for DMH clients of all ages in all settings (inpatient, outpatient, emergency, crisis stabilization, day treatment, etc.). For children who are too young or unable to provide this history, much ofthe information can be gathered from parents or guardians. Other child assessment tools may be needed for very young children, such as anatomically correct dolls. The information obtained through the assessment should be used to develop the most effective and relevant treatment for the client. Restraint Reduction Form (Appendix 4) The Department's review of restraint and seclusion practices within each of its ten contracted inpatient facilities ("replacement units") found that several replacement units had a process to determine directly from the client, as part of the initial nursing assessment, what strategies had been effective to reduce or avoid the use of restraint and seclusion. The process was also used to help clients identify interventions that might further traumatize them. The replacement units using these processes found them helpful in reducing the use of restraint and seclusion and making restraint less traumatic. All replacement units indicated that such a process may be useful. (Crane and Weeks, 1995, p 3). Building on this, the Task Force recommends the Restraint Reduction Form as a guide to gathering information with clients for the development of strategies to de-escalate agitation and distress. In this way, the use of restraint and seclusion can be decreased or eliminated. The form is recommended for use in conjunction with the Trauma Assessment Form in all acute care facilities, such as acute inpatient units, crisis stabilization and other diversion units, and psychiatric emergency rooms, when clinically indicated, namely, when the client has a history of loss of impulse control. Information about children can also be gathered from parents or guardians, who may have developed useful strategies for calming a very distressed or out of control child. The process of obtaining this information is the beginning of an important clinical intervention Use of Restraints II An abuse survivor with a history of frequent hospitalizations was repeatedly restrained following episodes of agitation. She became more assaultive when she was approached by male staff. It was not until she was moved to an all-women's trauma unit that it was understood that these episodes represented terrifying flashbacks of the abusive experiences. On the acute psychiatric units, the abuse experience was actually re-enacted when male staff members forced her into restraints with legs spread apart just as her father had forcibly restrained her. In contrast, on the trauma 3 Massachusetts DMH Restraint/Seclusion/Abuse SurvivorTask Force Report, 1/25/96: Carmen, Crane, Dunnicliff, Holochuck, Prescott, Rieker, Stefan, and Stromberg unit, a female staff member was able to talk her through the dissociative episode, gently reminding her that she was safe in the present and was experiencing intense and overwhelming psychological and "body" memories from the past. The client, curled up on the floor, was allowed to stay there while staff provided a soothing presence and a reality-based focus. The precipitating event for the client's escalating distress was a flashback about her father's sexual abuse. In the first instance, the staff could not tolerate the client's sudden screaming, distress, and thrashing. Without a way of understanding her behavior, they responded to her behavior as a control issue. This lack of clinical understanding clearly escalated the client's distress to the point that she lost control. In the second instance, knowledge about severe trauma-related symptomatology in conjunction with the safety provided on an all- women's unit served to provide a therapeutic intervention rather than an experience offurther damage. Understandably, freedom of movement, privacy, and control over one's body are of primary importance to all clients, and especially those who have been physically or sexually abused. In an environment designed to be healing and therapeutic, restraint is often experienced as abusive and confusing, in the same way that abuse in families is experienced as confusing (Rieker and Carmen, 1986; Carmen and Rieker, 1989). Rape imagery permeates all of society, consequently, even those without a trauma history understand the symbolic meaning of the spread-eagle position. Because of the likelihood that restraints will retraumatize an abuse survivor, the Task Force emphasizes the importance of using the restraint reduction assessment to decrease the use of restraints. Several examples that might be considered less traumatizing are safety coats and papoose boards, among others, which should be more widely available in adult programs. Currently, these devices are used in children's secure treatment programs as containing options along with physical holds to de-escalate crises and reduce restraint use. It is often the case that a child (or adult) has been "held down" for a sexual assault so that certain "hands on" interventions are distinctly re-traumatizing. For other children, a firm but gentle physical hold may be all that is needed to de- escalate a situation. When appropriate, the safety coat or papoose board are the interventions selected for sexually abused children. The staff member assigned to 1:1 with the client during and after the restraint should be a female or the opposite gender of the perpetrator(s) of abuse, unless the client has a different preference. Although both men and women can be abusers, sexual offenses against males and females are usually committed by males. Thus, it is critical to discuss gender preferences with clients as it relates to the aftermath of a restraint or 1:1. Finally, the need for client feedback is critical after a restraint episode, and clients should be asked for 4 Massachusetts DMH Restraint/Seclusion/Abuse SurvivorTask Force Report, 1/25/96: Carmen, Crane, Dunnicliff, Holochuck, Prescott, Rieker, Stefan, and Stromberg feedback more than once, especially regarding what would have worked better to avert the restraint or to make the restraint less traumatic. The Department's "patient comment form" is intended to obtain this client feedback but is often used in aperfunctory way. Given age limitations, children and adolescents should be offered a less structured option for comment as found in the child and adolescent comment form. Proposed Changes in DMH Restraint and Seclusion Regulations (Appendix 5) As discussed above, the Task Force recommends the use of a Trauma Assessment Form and a Restraint Reduction Form as guides to gathering critical information necessary for the appropriate care and treatment of clients with a history of abuse. Facilities should have some discretion in deciding the precise wording ofthe forms and how they will be integrated into their assessment process. The Task Force recommends that, as a matter of DMH policy, there should be a minimum requirement that each facility have a process to obtain information relevant to (i) history of abuse, (ii) de-escalation strategies that have worked and, (iii) what forms of restraint/seclusion are most helpful and least traumatic. We have therefore recommended that the DMH restraint/seclusion regulations be amended to include this minimum requirement. Similarly, the Task Force concludes that there are several other minimum requirements that should be observed in order to minimize the potential of re- traumatizing persons with a history of abuse. These additional proposed CMR changes to subsection 104 3.12(4) prevent the use of mechanical restraint requiring a patient's legs to be spread apart when the patient has a history of CMR sexual abuse. Additions to subsection 104 3.12(9)(a) address the need, if a patient has a history of sexual abuse, for a staff person in attendance during restraint who is female or the opposite gender of the perpetrators of abuse, unless the patient requests otherwise. Ill DMH-DMA Draft Purchasing Specification (Appendix 6) The experience of our Task Force is that it is imperative for clinicians to routinely inquire about and understand the implications of a history of abuse in order for the mental health system to provide appropriate care and treatment to the many mental health consumers who are survivors of physical and/or sexual abuse. The suggested language additions are intended to highlight this concern: 5 Massachusetts DMH Restraint/Seclusion/Abuse SurvivorTask Force Report, 1/25/96: Carmen, Crane, Dunnicliff, Holochuck. Prescott, Rieker, Stefan, and Stromberg Special Needs The MCO shall develop clinical protocols with its specialized providers and DMH to address consumers with the following special needs: dually diagnosed (i.e. substance abuse and mental illness or mental retardation and mental illness), persons with a history of physical and/or sexual abuse, deaf and hearing impaired, elderly, chronically violent, etc. The MCO shall ensure the availability of child-trained clinicians and clinicians with training and/or experience with elders in its Designated Emergency Programs (Emergency Program Standards) and the availability of clinicians with training and/or experience with clients who have a history of physical and/or sexual abuse. Cultural Competence , The meaning of cultural competence should be extended to include an understanding of gender-specific needs as it relates to clinical treatment. The definition of safety as it is usually understood in a psychiatric treatment setting may be quite different and possibly at variance with the kind of safety necessary for the therapeutic care ofwomen suffering from traumatic stress syndromes. For example, locked units are frequently contraindicated for women who have histories of being held captive and who were literally or figuratively "locked up." Female clients may need the presence of a female staff member during an interview with a male clinician. A recent clinical example illustrates these concerns. A male psychiatrist on an acute inpatient unit insisted that a female client meet for an initial interview in her bedroom because no other private space was available. This aroused severe anxiety and terror in the client who immediately began to dissociate. Although she was able to refuse to meet alone in her bedroom with the psychiatrist, her ability to establish appropriate boundaries that would ensure her safety was misunderstood. She was labeled as manipulative and resistant to treatment. Assessment and Treatment Planning Assessments will include, at a minimum: the history of the psychiatric illness; past psychiatric history, past medical history, family and social histories, substance abuse history, history of physical and/or sexual abuse, mental status exam, present medications, diagnosis, treatment plan, and level offunctioning. Restraint and Seclusion in Emergency Programs See Section IV 6 Massachusetts DMH Restraint/Seclusion/Abuse SurvivorTask Force Report, 1/25/96: Carmen, Crane, Dunnicliff, Holochuck, Prescott, Rieker, Stefan, and Stromberg