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Sensory Diet Has Gone to the Dogs Print E-mail
By Alison Berryman M.Ed., OTR/L

Moegley is my 6 year-old yellow Labrador retriever who has suffered with anxiety for his entire life.  He has demonstrated fear-based aggression through full-blown panic attacks.  About a year ago, I thought he was having a psychotic break. He was running around the perimeter of the house, jumping up on my kitchen table trying to climb out windows, fighting with his brother (my other dog Jack) and at times literally trying to crawl inside of me for what seemed like a refuge from his torment. He looked possessed and nothing I did soothed his terror.  After a night of no-sleep I called his vet and was referred to an animal behaviorist. The vet did discover an ear infection but also witnessed one of his panic attacks, which confirmed my gut instinct that his anxiety was out of control.

I went to visit the behaviorist to talk about what was going on.  She had many theories as to the sudden onset of this episode (from obvious and logical (such as pain from the ear infections), to a little far stretched (a bear may have been trespassing on his property) to just down right obscure (a spirit in the house). She did provide me with some tools to try at home and much needed reassurance.  As I was about to leave she said, “I have one more thing you might want to try.  It’s worth a shot.  Have you ever heard of Temple Grandin and her work with autistic children?”   Being an OT, she now had my full attention.  She continued on to say that someone had created an “anxiety wrap” for animals that suffer from anxiety and asked if I would be willing to try it on Moegley.  I ecstatically shared with her the work I do on the psychiatric unit, which includes using deep pressure strategies (such as weighted blankets & vests) and of course I was willing to try it with Moegley.   And so began Moegley’s sensory diet. For six months we had a strict schedule to help him self-organize his system, providing him with fun positive physical activities in hopes that it would provide him with a feeling of safety and security.

Moegley’s Sensory Diet

6:20 am off leash run in the woods
7:00 am breakfast and Anxiety Wrap on
7:30 am Anxiety WrapTM off and KongTM filled toy* when I left for work
5:00 pm game of fetch or catch the snowball
5:30 pm Anxiety WrapTM on and 1/2 of his dinner
6:00 pm rest of dinner in Kong*  
6:30 pm Anxiety WrapTM off
7:00 pm clicker training
8:00 pm Anxiety WrapTM on
9:00 pm Anxiety WrapTM off
10:00 pm Greenie** to chew before bed.

* A KongTM is a heavy-duty hollow rubber toy that can be filled with treats. Many times I will fill it with some of his dog food and add 1/2 mashed banana, plain or vanilla yogurt and freeze. It provides him with a treat that is mentally and physically challenging. He has developed many techniques to access the goods inside.

kong_picture
** A GreenieTM is a soy-based chew that helps with alleviating the need to chew, cleans his teeth and is a clue it’s time for bed.
greenie_picture
In addition to these daily activities I was also advised to use a Comfort Zone D.A.P. TM(dog appeasing pheromone) plug-in diffuser. This releases the scent of a nursing mother dog, which is very soothing for distressed animals, and at times when his anxiety increased I would give him a few drops of Bach Rescue RemedyTM, an herbal concoction to alleviate stress and anxiety.

Every few days I would increase his time in the Anxiety WrapTM and within a few days of being on his sensory diet he was sleeping through the night.  He slept with the anxiety wrap on and actually would come running over to me when I would pick it up.

Almost 1 1/2 years later I can say his anxiety has dramatically decreased. Prior to Moegley’s sensory diet he feared going to the vets to the point that he would either refuse to get out of the car and/or go into a full panic attack which included loss of body function, trembling to the point he would collapse on the ground, panting and drooling profusely. He now easily jumps out of the car dressed in his Anxiety WrapTM and with a bit of encouragement and praise he breezes through exams, shots and even X-rays.
 
It’s been a stressful yet very rewarding journey in which I was able to carryover my professional knowledge and my passion for my dogs. 

Moegkong
Moegley wearing his Anxiety WrapTM and
working to find a treat in his KongTM
 
mogley_with_wrap_cute_resized.jpg
 
 
 
Links for products and services mentioned in this article:

Anxiety WrapTM: www.anxietywrap.com
There is an article written by an OT on this site.


KongTM products: www.kongcompany.com
Also available at any pet store


GreeniesTM: www.greenies.com
Also available at any pet store


Bach Rescue RemedyTM: www.bachflower.com/rescue_remedy.htm
Also available at Whole Foods


Comfort Zone D.A.P.TM available at most large pet stores

Special thanks to:
Kelley Bollen, animal behaviorist in Easthampton, MA. www.animalalliances.com

Dr. Amy Allen D.V.M and all the staff at Riverbend Animal Hospital in Hadley, MA (USA)






Last Updated ( Wednesday, 06 August 2008 )
 
Sensory Rooms in Mental Health Print E-mail

Sensory Room: An Umbrella Term

“Sensory Room” is an umbrella term used to categorize a broad variety of therapeutic spaces specifically designed and utilized to promote self-organization and positive change. There are multiple types of sensory rooms and purposes for use that have been created and implemented in different practice areas to date. When used appropriately, sensory rooms:
  • Help to create a safe space
  • Facilitate the therapeutic alliance
  • Provide opportunities for engagement in prevention and crisis de-escalation strategies, as well as a host of other therapeutic exchanges (to teach skills, offer a variety of therapeutic activities, etc.)
  • Promote self-care/self-nurturance, resilience & recovery 
Generally, to help guide conceptualization, there are a variety of therapeutic spaces that may be categorized under the sensory room umbrella: sensory modulation rooms, sensory integration rooms and snoezelen rooms are examples.

The Sensory Room Umbrella

sensory_room_chart
© Champagne, 2008

In mental health settings, there may be one or more sensory rooms created, which typically fall under the sensory modulation room category. For example, on an acute or long-term care unit, there may be converted quiet room spaces that are designed to be more sensory supportive and used primarily for the purposes of crisis de-escalation and/or prevention. However, other kinds of sensory rooms in mental health care also include any additional therapeutic spaces that have been enhanced or developed for sensory supportive, therapeutic purposes. In this way, all of these sensory room spaces are used primarily to promote sensory modulation. Whereas, sensory integration rooms are created and used specifically by occupational therapists who are trained in sensory integration techniques and these spaces contain very specific types of equipment and intervention processes. Snoezelen rooms are generally used with people with moderate to profound cognitive impairment (e.g., people with pervasive developmental disabilities or dementia), and are often used to promote relaxation, social interaction and/or to provide activities affording intense stimulation. In most cases, all but sensory integration rooms are used by inter-disciplinary staff with training or certification specific to the kinds of equipment and approaches offered within the space.

However, it is important to point out that a mixture of sensory modulation and snoezelen approaches may be combined if it is beneficial for the specific consumer population and practice setting. Additionally, sensory integration equipment and techniques may be utilized in either a sensory modulation or snoezelen room by a skilled occupational therapist. Further, therapeutic exchanges in sensory integration rooms may also focus on sensory modulation. Therefore, this sensory room categorization is meant to be flexible and is to be used only as a guide.

The enhancement of the physical environment, including the use of sensory rooms, affords a more nurturing and recovery-oriented therapeutic environment. Skilled nursing facilities, day treatment centers, schools, long-term care facilities, respite care homes, hospitals, emergency rooms and hospice care settings are just some of the organizations utilizing sensory rooms.

Creating & Naming the Sensory Room

The development of sensory rooms requires a collaborative process, evolving over time. Consumers and staff who are going to be using the space must be involved in the development process, as much as possible. Given the varied populations sensory rooms may be used with and purposes of use, naming a sensory room should also be a collaborative decision and reflective of the specific goals of use. For more information on the development and naming of sensory rooms refer to the section on setting up a sensory room on this web page.

Sensory Rooms in Mental Health?
The idea to expand the use of sensory rooms to acute inpatient mental health care settings with varied populations is a more recent application, incorporating a variety of sensory modulation approaches and modalities. Hence, the use of sensory rooms in mental health settings often falls under the sensory modulation category. An essential part of this mission is to maintain an emphasis on engaging in meaningful therapeutic activities and in recognizing the inter-relatedness and importance of the therapeutic use of self and physical environment. Offering humane and self-nurturing choices for prevention and crisis de-escalation is essential and afforded in an organized and safe manner through therapeutic exchanges in sensory modulation rooms.

Two recent articles demonstrate the purpose of the incorporation of the use of sensory rooms and additional sensory-related approaches into mental health inpatient practice (Champagne & Stromberg, 2004) and provide a guideline to assist in the evolutionary process (Champagne, 2006). Champagne’s book, available through this website’s product page, is another valuable resource available to assist in the process of developing and integrating sensory rooms and other sensory approaches into mental health care practice settings.


The skilled and responsible use of sensory rooms has become readily endorsed by the MA State Department of Mental Health (DMH) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and has become a focal point in hospital surveys and re-licensing visits. It is also being promoted by the National Technical Assistance Center, a division of the National Association for State Mental Health Program Directors (NASMHPD), as one of the instrumental interventions influencing the reduction of restraint and seclusion in mental health care settings. For more information on the restraint and seclusion reduction initiative click here to visit the restraint reduction section of this website.

There is limited literature and research available regarding the use of sensory rooms in acute care inpatient mental health settings with pediatric, adolescent, and adult populations. However, the following is an article regarding a quality improvement study conducted on the use of the sensory room at Cooley-Dickinson Hospital's acute care psychiatric unit:

pdf The Effects of the Use of the Sensory Room in Psychiatry
 A Quality Improvement Study

By: Tina Champagne, M.Ed. OTR/L & Edward Sayer, Psy.D

This quality improvement study was replicated on this unit in 2004 with astonishingly similar results. Among the patients who utilized the sensory room during group or individual sessions, most report having had a positive response and a decrease in perceptions of distress.

In 2006, Champagne published an article on creating sensory rooms for the American Occupational Therapy Association's Mental Health Special Interest Section. The reference information for this article is:

Champagne, T. (2006). Creating sensory rooms: Environmental enhancements for acute inpatient mental health settings. Mental Health Special Interest Section Quarterly, 29(4), 1-4.

AOTA members may download this article at: http://www.aota.org/Pubs/SISQs.aspx

The sensory room's purpose also corresponds with the purpose of the Safety Tool developed and promoted by the Department of Mental Health in the state of Massachusetts. The Safety Tool was developed in an attempt to facilitate trauma-informed care and to help to reduce the occurrences of seclusion and restraint by learning about each person's early warning signs, triggers and what helps each individual early in the therapeutic process. The safety tool is typically administered by nursing staff during the initial assessment. The information obtained through the use of the safety tool has been helpful to occupational therapists during the information-gathering period prior to initial therapeutic exchanges with each consumer.

Taking A Leadership Role


Occupational therapists are taking a leadership role in the planning and implementation of the use of sensory approaches across mental healthcare settings, including the focus on environmental modifications and enhancements, such as sensory rooms. As in other areas of practice, the education and knowledge base of occupational therapists helps to justify the unique role of the OT as the qualified professional to supervise the development and implementation of the "sensory room" and other sensory approaches. Currently, occupational therapists are also collaborating with administrators and other disciplines to ensure staff trainings and competencies are developed, implemented and maintained. Program evaluation is another important component of any new program initiative, and occupational therapists are also playing a key role in this area as well.

The first adult acute inpatient mental healthcare setting to develop a sensory room was Berkshire Medical Center (BMC) in Pittsfield, MA. With the help of consumers and staff, Tina Champagne, OTR/L initiated and coordinated the development and implementation of this sensory room for adult acute care psychiatry after receiving administrative approval in 1999. She used interviews and questionnaires with staff and consumers to collect the following types of information: what people wanted the purpose of the room to be, ideas for ways to utilize the space, ideas for what to have available in the room, how people wanted the space to be decorated, etc. At this time, there are many such rooms in existence within acute care mental health settings with varied themes and purposes.

The development and implementation of sensory rooms and sensory enhancements across settings is a process that typically evolves over time. This affords the ability to get staff and consumer involvement and assistance throughout the entire process. Thus, it is possible to start a room on a very low budget and to slowly develop the space. One of the differences between the types of sensory rooms Champagne promotes and the more traditional "Snoezelen" style rooms, is in the shift from spaces filled with expensive technical equipment, to a more normalizing and replicable environment. Safety considerations within locked acute care settings as well as the need to offer options that the consumers can replicate outside of the hospital setting are some of the other reasons behind the differences in both approach and décor. Snoezelen rooms and the kinds of sensory rooms Champagne promotes are also different from the sensory integration style treatment rooms used specifically by occupational therapists that are trained, certified and competent to use such specialized equipment and techniques. Hence, it is necessary to understand these distinctions due to the very different purposes of each of these sensory-related therapeutic environments.

An International Initiative

Lesley Pinkney is an occupational therapist that helped to pioneer the bringing together of "Snoezelen" and occupational therapy approaches with older adults with cognitive impairments, performing some of the initial studies with this population in the United Kingdom. Occupational therapists in China have used sensory rooms and gardens for older adult long-term residential settings for many years. Katherine Smith and Angie Turner are occupational therapists in Cornwall, England (UK). They have been instrumental within the Cornwall Partnership Trust's planning and re-modeling projects to create and offer more "sensory-friendly" environments. In 2003, they contracted Tina Champagne to come to Cornwall and hosted a sensory conference specifically for OT's in mental healthcare services across the Cornwall Partnership Trust. This international partnership continues today as they collaborate on different initiatives and projects.


 tina_and_katherine
Tina Champagne (left) & Katherine Smith (right) together on the shore of the Helford River, at Trebah Garden in the UK (2003).


Ultimately, the use of sensory approaches and sensory rooms has increased the focus on each individual's unique system's tendencies, patterns and preferences. Thus, the skilled use of sensory approaches has brought a host of more humane and recovery-focused therapeutic tools to mental healthcare services, which appears to have significantly influenced the quality of therapeutic exchanges occurring in mental healthcare service delivery across the world. Providing such skilled and supportive options empowers staff and consumers and embodies a person-centered approach to care. This is a significant culture shift and it is important to recognize that any significant change in the culture of care takes time, an interdisciplinary team effort, a lot of work and dedication.

Setting Up A Sensory Room


Involving both staff & consumers!

It is essential to involve both staff and consumers in each step of this process. Meaningful items and themes for rooms can only be determined through actively involving staff & consumers who will be using the treatment space. Therefore, no sensory rooms are ever the same because this is not a cookbook process. The information and lists provided on this web site are provided to assist with starting up a room, are not all-inclusive and the ideas presented may not be suitable for all settings or populations. Clinical reasoning and brainstorming sessions with staff and consumers are essential in order to individualize your sensory space, from the ground up. In this way, it will surely become a unique and meaningful therapeutic space!

Ideas for involving staff & consumers in the process:
  • Post a flyer on your unit stating the plan to create a sensory room, sensory area, sensory cart, sensory bins, bags or baskets.
  • Ask for any suggestions and/or donations of time to help with the organizing of the whole project.
  • Post sign up sheets to determine who is interested in helping to plan and create the room.
  • Circulate a unit survey to staff and consumers for ideas regarding how to decorate the room, what to offer in the space, on the cart, theme ideas, what to call the room, etc.
  • Include everyone in the process of creating and decorating.
  • Ask for volunteers to help you provide educational in-services to assure staff are qualified to utilize the space and the items in a manner that is appropriate each person's cognitive/emotional/physical status and that things get washed as per policy.
  • Ask for ideas when creating the policies and procedures for use of the space and the items in the space.
  • Provide opportunities for staff to explore their own sensory tendencies, preferences and to think about how these tendencies influence their daily routines and work habits.

Naming your sensory room

Sensory rooms go by many different names and are often related to the purpose of the space within each specific setting. Some examples of names of sensory rooms include:
  • The Sensory Modulation Room
  • The Sensory Room
  • The Zen Room
  • Chillville
  • The Serenity Room
  • The Comfort Room
Developing the policy & procedure

Sensory rooms all must have a policy and procedure for use. It is important to create a policy and procedure specific to the purpose and kinds of equipment in your sensory room.  The following is a sample of a general
sensory room policy:

pdf Sample sensory room policy and procedure

Sensory Equipment Suggestions


General "Sensory Room" Ideas

For adolescent and adult sensory rooms (29 KB)

General "Sensory Cart" Ideas

For adolescents & adults with moderate levels of cognitive impairment (27 KB)
For adolescents & adults with low levels of cognitive impairment (19 KB)  


adl_basket02
  Sensory Diet: ADL Basket


A Few Ideas for Sensory Baskets, Buckets, or Bins


• Keep a bucket, bin, or basket of fresh nature items for use during each season (things to sort through, smell, touch, etc.)
◦ For the fall season (pumpkins, gourds, larger-sized cinnamon sticks, fall flowers, Indian corn, etc.)
• A basket with assorted items for each of the sensory areas
• Create a men's grooming basket
• Create a women's skin & nail care basket
• Create a bin of beading supplies for jewelry making
• Create a craft basket
• Create a reminiscence basket


General Considerations Prior to Purchasing Equipment:

• One good rule of thumb before purchasing equipment is not to buy it if it can't be washed in the washing machine or in hot soapy water.
• Anything electrical always needs to go through your facility's inspections prior to being brought onto or used on the unit.
• Most units require rugs, curtains, beanbag chairs, and similar items to be made with fire resistant materials. Request this information prior to ordering, Certificates are often available upon request from companies who assure products are fire resistant.

How to keep track of what you have & where things are:

• Use of a dry erase board, checklist or clipboard for signing items in & out helps things from walking away or vanishing altogether!

General treatment precautions:

• Be aware of those consumers who have allergies and seizure disorders. Do not use items with people if there is any possibility they may be hypersensitive to it.
• Always ask the person if they have any hypersensitivies to what you are planning to use PRIOR to use.
• Be aware of any respiratory or cardiac precautions

Sensory Room Slide Shows

Community Integration


It is essential for consumers to leave hospital settings with discharge "packets" (an occupational portfolio) to share with out patient providers, family members and caregivers. This should be organized and contain worksheets and information regarding the variety of techniques learned and practiced, and plans for incorporating these skills and ideas into daily schedules and home, school and/or work environments. This is an essential part of the discharge planning process. This provides one of the necessary links between hospital and discharge environments to support success with the transition from inpatient to community level of care.

With this increased support, many consumers have created sensory spaces within their group homes with the assistance of staff. Others have created various types of "sensory spaces" within their own homes. Residential educational settings often request occupational therapy consultation services to create more "sensory-friendly" spaces and sensory rooms within classrooms and living quarters. Recommendations and planning for the transition from hospital to the community typically requires assistance to adapt what was helpful in the hospital for use at home and in community levels of care.

Sensory Room and Snoezelen References

The following is a growing listing of many of the articles and studies published about the use of sensory rooms available in the literature to date. If you are aware of any others please email those references to: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it . This will assist in keeping this resource list as up to date as possible for worldwide networking!


Sensory Room and Snoezelen References


Links to vendors of sensory room equipment
Last Updated ( Sunday, 27 April 2008 )
 
Sensory Modulation Symposium for Occupational Therapy in Mental Health Print E-mail
On April 25, 2006 at Westborough State Hospital a symposium was held for all occupational therapy practitioners working in MA State Department of Mental Health facilities to help prepare them to be resource professionals for the further development and implementation of sensory modulation approaches within their own facilities. The Symposium was funded by a grant obtained by the MA State Department of Mental Health as part of the MA State Restraint Reduction Initiative. It was coordinated by Laurie Adelstein, MS, OTR/L, a member of a work group of inter-disciplinary professionals who recognized the need for such a training for MA State DMH facilities.

symposium Eighty-seven participants attended the symposium. Approximately ninety-five percent of the OT practitioners who work in the MA state DMH facilities were in attendance. Occupational therapists who attended will participate in the training and education of staff members including nurses, psychiatrists, psychologists, social workers and mental health workers regarding safe and effective treatment approaches when using sensory modalities. Upon completion of these trainings, the goal is for all disciplines to be more actively involved in carrying out sensory modulation treatment approaches.

The new MA State DMH regulations now include the integration of the use of sensory approaches by all DMH licensed facilities. The skilled and responsible use of sensory modalities is now widely recognized as having the potential to help patients regulate emotions, maintain safety, and to avoid crisis situations, thus leading to the decreased need for the use of physical and chemical restraints.

Presenters

I had the pleasure of creating and presenting this conference with a talented and experienced clinician, Karen Moore.

karen_tina
Tina Champagne, OTR/L (left) & Karen Moore, OTR/L (right) at the Sensory Symposium, April 2006

Karen has extensive experience with the use of sensory modalities. She recently published her first set of books entitled the Sensory Connection Program (2005). These are valuable resources full of treatment ideas. For more information on her work refer to her website: www.sensoryconnectionprogram.com





The following were some of the key points made at the Sensory Symposium:

  • The most important and readily available sensory modulation approach is the therapeutic use of self.
  • Sensory-related therapeutic approaches are person-centered. This begins with helping to increase self-awareness and moves to self-care and self-regulation.
  • In order to be successful, patients need to be intimately involved in every step of therapeutic processes.
  • Therapeutic approaches using sensory modalities will be carried out by the coordinated effort of all disciplines.
  • Continuous training of patients, as well as staff, is essential in order to develop an appreciation of how and why sensory strategies work.
  • Occupational therapists have a key role in training others in the use of sensory-related therapeutic approaches due to their educational background and familiarity with these modalities and frames of reference.
  • The body of knowledge and evidence-based practice guidelines regarding sensory modulation evaluation and therapeutic exchanges comes primarily from occupational therapy research and clinical experience.
  • Occupational therapists are qualified to perform the assessments necessary to recognize aspects of behavior that may be driven by sensory-related problems and to match appropriate sensory activities for those with varied cognitive levels, symptoms, diagnostic concerns, sensory thresholds, receptivity to sensory stimulation, and personal preferences.
  • The centrality of the consumer throughout the assessment, planning and entire therapeutic process is crucial when utilizing sensory approaches or any other type of therapeutic approach.
  • Self-regulation (the ability to self-organize/self-modulate arousal to meet the demands of a situation) is a complex phenomenon influenced by many factors including cognition, emotions, physical state, environment, and spiritual considerations.
  • People seek the sensory stimulation they need adaptively or maladaptively! Our job is to offer healthy sensory choices to meet these needs and to recognize and address the sensory-related patterns (in addition to the many other patterns) of these behaviors.
  • Safety is paramount and everyone involved must receive training regarding symptoms of distress and potential problems related to patient diagnosis, symptoms and sensitivities.
  • When consumer's cognitive levels are low and they are unable to problem solve, generalize information, and plan for the future, care providers must be involved in plans for discharge and follow through with helpful sensory-related strategies.
  • The skilled use of sensory modalities must be integrated across the entire program so that consumers are afforded a variety of sensory experiences in order to determine their preferences, practice the use and identification of calming, alerting and grounding characteristics of sensory-related activities. Further, it is also important to help each individual to reflect upon and recognize when these different strategies may be the most useful.
  • Sensory rooms offer a therapeutic physical environment, which helps to promote the effective use of sensory activities. Sensory rooms are designed according to many factors.
      • What will be the main purpose of the room? Who will use it?
      • How will safety be maintained?
      • What space is actually available and how can it be adapted to fit the individual's therapeutic goals?
      • Does it need to be a simple and non-stimulating environment or a more complex one to stimulate the senses?
      • Who will supervise the environment?
      • How will equipment be cleaned and stored?

Protocols for the use of the room must be developed taking these and many other factors into consideration. Involving the entire inter-disciplinary staff and consumers in the development of the sensory room can make the space more valued, unit specific and more highly utilized.

  • Sensory carts help make sensory supplies mobile by making varied activities available whenever and wherever needed. In order to understand how to collaboratively assess what items/activities might be most beneficial, staff need proper training.
  • Certain sensory modalities require additional training and certification including the use of the Wilbarger Protocol, aromatherapy, and therapeutic listening.
  • Quality improvement and research studies are encouraged once sensory-related programming is established and skillfully running, which will help to examine the efficacy of sensory approaches.
  • Collaboration with nursing staff and all other mental health professionals will be quintessential in making this treatment approach viable and to reach the goal of reducing restraints. "It takes a village!"

Last Updated ( Sunday, 11 June 2006 )
 
The Seclusion and Restraint Reduction Initiative Print E-mail

The current initiative to reduce and/or eliminate the use of seclusion and restraint is being taken very seriously by healthcare facilities in general and by mental health organizations in particular. A person-centered model of care and the skilled integration of sensory approaches have become recognized internationally as being fundamental in facilitating a more humane and collaborative approach to the dynamics of crisis prevention and intervention. The knowledge base of occupational therapists justifies the role of occupational therapists as one of the primary and qualified professions to help supervise the development and implementation of sensory approaches within mental healthcare settings, as it has within other settings to date with other populations.

Currently, occupational therapists are collaborating with administrators and other disciplines, helping to bring person-centered care and sensory approaches into mental healthcare programming safely and responsibly. This increases the repertoire of what occupational therapists have to offer across levels of are within mental health services. When taking a central role in any initiative it is essential to become knowledgeable about it. The following information, and information from other pages on this website, offers an introduction to both the seclusion and restraint reduction initiative and to other innovations for those practicing in mental healthcare services.


The National Association for State Mental Health Program Directors (NASMHPD)

NASMHPD is a private, not-for-profit 501(c)(3) membership organization, helping to set the agenda and determine the direction of state mental health agency interests across the country, including state mental health planning, service delivery, and evaluation. NASMHPD was founded in 1959 and it is currently located in Alexandria, VA. It is the only national association to represent state mental health commissioners/directors and their agencies.

NASMHPD has a central role in the national S/R reduction initiative. For more information on NASMHPD visit: http://www.nasmhpd.org


The National Technical Assistance Center (NTAC)

NTAC is part of NASMHPD. NTAC's mission includes assisting state mental health agencies to implement the goals and recommendations of the President's New Freedom Commission on Mental Health final report Achieving the Promise: Transforming Mental Health Care in America. All technical assistance requests are required to meet/address at least one of the six goals in this New Freedom Commission report.


National Coordinating Center to Reduce and Eliminate the Use of Seclusion and Restraint

The Alternatives to Restraint and Seclusion State Infrastructure Grant Project (S/R-SIG) is an initiative of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS), designed to promote the implementation and evaluation of best practice approaches to preventing and reducing the use of seclusion and restraint (S/R) in mental health settings. NTAC spearheaded an initiative, with the support of SAMSHA, to develop and provide a national executive training institute for the chief executive officers of mental health organizations.


The National Executive Institute: Creating Coercion Free and Violence Free Mental Health Treatment Environments

NTAC coordinated the development of this training, which began in 2003, to explore and identify the multiple dimensions and variables involved in attempting to facilitate the significant culture changes necessary to more safely and effectively shift to the use of a more safe, trauma-informed and person-centered model of care. This training was entitled: The National Executive Institute: Creating Coercion Free and Violence Free Mental Health Treatment Environments (NETI).

Within this training, the use of sensory approaches (which includes sensory rooms) is promoted (in addition to many other tools) as being instrumental for facilitating both crisis prevention and crisis reduction. In this way, the skilled use of sensory approaches is viewed as essential to help facilitate the decreased need for the use of S/R. In 2003, Tina Champagne, M.Ed., OTR/L was asked by Kevin Huckshorn to join the training faculty of the National Executive Training Institute. Tina was the first OT to become involved as a faculty for this training and continues to work with this group to present on prevention approaches to S/R and to provide resources for inclusion in the training and resource manuals.

NTAC continues to offer this training but has broadened it's scope to include professionals at all levels of care, still emphasizing the importance of CEOs to attend and be a central part of both the trainings and the entire culture change process. For more information regarding the NETI trainings email:

This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

NTAC also helps to address systems issues by offering Technical Assistance (TA), which includes the following:
  • Assessing the role and function of the State Mental Health Agency within a managed care environment
  • Creating strategies for involving consumers and families in mental health service planning, delivery, and evaluation; building coalitions among key stakeholders within state systems
  • Implementing models of excellence and innovative practices (e.g., cultural competence, employment services, and co-occurring disorders).
  • Facilitates state, regional, and national consultation
  • Supports special topic technical assistance and training
  • Organizes consensus development conferences and teleconferences
  • Maintains a consultant database
  • Produces publications and reports
  • Promotes model service system standards review and analysis

NTAC accepts requests for TA aligned with the recommendation of the President's New Freedom Commission on Mental health from State Mental Health Agency directors on a continuous basis throughout the year. The following document provides guidelines information for applying for technical assistance: pdf Application Guidelines  For more information regarding the guidelines for applying for technical assistance email:  This e-mail address is being protected from spam bots, you need JavaScript enabled to view it


Culture Change

Essentially, in order to become successful in this mission, it is necessary to recognize the complexity of the factors involved. The following is a list of some of the core elements that together help to facilitate the kind of organizational change necessary to fully embrace this initiative.
  • Leadership (administrative and clinical leadership committed and centrally involved in the entire S/R initiative, etc.)
  • Timely & Responsive Treatment (collaborative, responsive and timely treatment planning and engagement, etc.)
  • Staffing (qualified staffing, adequate numbers, adding staffing during critical times, etc.)
  • Orientation & Training of Staff (quality, types, timeliness, etc.)
  • Programming (structure, content, quality, person-centered, etc.)
  • Physical Environment (sensory spaces, noise levels, body language, etc.)
  • Communication (ongoing communication and involvement of consumers and families/caregivers in all aspects of care)
  • Debriefing (processing after events with staff and consumers/families, etc.)
  • Quality Improvement/Research Studies (systems & program evaluation, etc.)
  • Evidence-based Practices
The following documents are provided courtesy of NTAC to serve as resources to all professions working toward decreasing or eliminating the use of S/R.

  1. Violence and Coercion in Mental Health Settings: Eliminating the Use of Seclusion and Restraint (Summer/Fall 2002) (pdf PDF) - References (pdf PDF)
  2. Six Core Strategies© to Reduce the Use of Seclusion and Restraint Planning Tool (pdf PDF)
  3. A Snapshot of Six Core Strategies© for the Reduction of S/R (pdf PDF)
  4. Policy and Procedure on Debriefing for Seclusion and Restraint Prevention/Reduction Projects (pdf PDF)
  5. Review of Recovery Literature: A Synthesis of a Sample of Recovery Literature (pdf PDF)
  6. Developing Trauma-Informed Behavioral Health Systems: Report from NTAC's National Experts Meeting on Trauma and Violence, August 5-6, 2002, Alexandria, VA (pdf PDF)
  7. White Paper, "Responding to Childhood Trauma: The Premise and Practice of Trauma Informed Care" (pdf PDF)
  8. Technical Paper, Phase II Technical Report, "Mental Health: What Helps and What Hinders?" (pdf PDF)

Curriculum on Restraint Reduction


SAMHSA has created a training curriculum to give mental health providers information on prevention strategies and alternative approaches to avoid and reduce the use of seclusion and restraint.

This curriculum is organized into seven modules and emphasizes the importance of creating culture change within organizations in order to influence a reduction in seclusion and restraint practices.

Click here for your free copy of the Roadmap to Seclusion and Restraint Free Mental Health Services from SAMSHA .

SAMHSA Grant Funding

In the news: SAMHSA Grant funding has been approved for the Vermont state restraint reduction initiative with lead consultant, Tina Champagne. This initiative will provide the opportunity to focus on the use of the sensory modulation program with child and adolescent populations at the Brattleboro Retreat and adult populations at Vermont State Hospital. The influence of the use of sensory approaches in the efforts to decrease the need for the use of restraint and seclusion, and to facilitate culture change, will be evaluated as part of this process. For more information go to this link and scroll down to the last third of the article: http://www.masspsy.com/leading/0712_ne_cover_SAMHSA.html

SAMHSA provides grant opportunities for state organizations to enhance their seclusion and restraint reduction efforts in addition to other grant affordances. For more information on potential resources and application information go to: http://www.samhsa.gov/grants/



The following power point presentation slides are excerpts from the National Executive Training Institute, created by Kevin Ann Huckshorn, RN, MSN, CAP, ICADC and colleagues. Ms. Huckshorn is the director of the Office of Technical Assistance of NASMHPD and has a central role in the NTAC. She is a leader in the national initiative to reduce and/or eliminate the use of seclusion and restraint.

The following power point presentations are copyrighted and provided for viewing on this website with the author's permission:

Reducing the Use of Seclusion and Restraint: A National Initiative for Culture Change and Transformation (Kevin Ann Huckshorn, RN, MSN, CAP, ICADC)

A National & International Review: What's New in Seclusion & Restraint Reduction Efforts? (Austin, TX, 2007) Presenters: Kevin Ann Huckshorn RN, MSN, CAP, ICADC & Janice LeBel, PhD

Creating Violence-Free and Coercion-Free Mental Health Treatment Environments for the Reduction of Seclusion and Restraint: The Emerging Science of Trauma Informed Care (Kevin Ann Huckshorn, RN, MSN, CAP, ICADC)

The Centers for Medicare & Medicaid Services (CMS) offers a web cast on the Reduction of the Use of Seclusion and Restraint in mental health settings, also featuring Kevin Ann Huckshorn. To view this web cast go to: http://cms.internetstreaming.com

In 2004, Ms. Huckshorn asked Tina Champagne to author one of a group of three continuing education articles. These articles were published in the September 2004 special restraint reduction edition of the Psychosocial Journal of Nursing and have been used as informational, continuing education and/or staff training materials. These articles include:

1. Huckshorn, K. (2004). Reducing seclusion and restraint use in mental health settings: Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services, 42(9), 22-33.

2. Champagne, T. & Stromberg, N. (2004). Sensory approaches in inpatient settings: Innovative alternatives to seclusion and restraint. Journal of Psychosocial Nursing, 42(9), 33-44.

3. Bluebird, G. (2004). Redefining consumer roles: Changing culture & practice in mental health care settings. Journal of Psychosocial Nursing, 42(9), 46-53.

Tina Champagne requested the co-authorship of Nan Stromberg, RN, MSN, CAP, ICADC for this article. Together they were able to demonstrate the value of a collaborative inter-disciplinary approach, integrating occupational therapy and nursing perspectives. Ms. Stromberg is the director of nursing for the licensing department of the MA State Department of Mental Health and she has been one of the core faculty for the NETI trainings. She specializes in the treatment of people with trauma histories and is a strong supporter of the skilled use of sensory approaches in the S/R reduction initiative.

MA State Department of Mental Health (DMH): Taking a Leadership Role

The MA State Department of Mental Health is one state that has been in a leadership role in this national restraint reduction initiative. This group has been actively engaged in conducting and authoring research articles and in creating tools on the subject.

In 2007, as part of the state’s restraint reduction initiative, the MA State Department of Mental Health and a host of experts in the area of restraint reduction in mental health published the resource manual Developing Positive Cultures of Care. This manual was created to assist programs in their efforts. Tina Champagne contributed four chapters to this manual on the topics of: nurturing environments, sensory approaches, touch and physical environment.

Developing Positive Cultures of Care is a compendium of information specifically created for those involved in providing mental healthcare services to child and adolescent populations. However, it may also serve as a helpful resource for those working with adults as well. This is a free resource guide that will be posted online in the future. Until then, to request a copy send an email to: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Additional publications

Several of the Massachusetts State Department of Mental Health staff authored the following article regarding their efforts and successes in this initiative across child and adolescent units across this state.

Child and adolescent inpatient restraint reduction: A state initiative to promote strength-based care
LeBel, J., Stromberg, N., Duckworth, K., Kerzner, J., Goldstein, R., Weeks, M., Harper, G., LaFlair, L., & Sudders, M.

Janice LeBel, Ed.D is the director of program management for the MA Dept of Mental Health's child & adolescent division. She co-authored the following articles:

LeBel, J. & Goldstein, R. (2005, September). The economic cost of using restraint and seclusion and the value added by restraint reduction or elimination. Psychiatric Services, 56(9), 1109-1114.

LeBel, J. (2008). Regulatory Change: A Pathway to Eliminating Seclusion and Restraint or Regulatory Scotoma? Psychiatric Services, 59(2), 194-196. View Article pdf2

The Safety Tool
 
The safety tool is a risk management, crisis prevention tool that may be modified to be age and program specific. It was developed to serve as a brief trauma screening and advance directive.

pdf MA State DMH Safety Tool - Adult Version


The following is an example of a safety tool modified for use on an inpatient acute care unit for use with adolescent and adult populations. This is a draft version modified by: Tina Champagne, M.Ed., OTR/L; Victor Petrella, MSN, CNS; Debra Dickson, MSN, CNS; Theresa Lamb, RN, BSN and Wendy Noonan, RN for Cooley-Dickinson Hospital in Northampton, MA (USA).

pdf Safety Tool Sample - Adolescent/Adult Version  (last updated 9/28/2006)


For a host of additional documents and tools regarding the Seclusion and Restraint Reduction initiative, visit the MA State DMH web site page:

Restraint/Seclusion Reduction Initiative (RSRI)

The Sensory Modulation Program

The Sensory Modulation Program (Adolescent/Adult version) was created by Tina Champagne, M.Ed., OTR/L at the request of many inter-disciplinary staff in order to help organize the components of the program into a practical and easy to use resource for staff trainings and for use as a therapist guideline. A general outline of the Sensory Modulation Program for adolescents and adults is provided on this web site and more information on this and many other related topics are available in the book Sensory Modulation and Environment: Essential Elements of Occupation (3rd Ed.). Research is currently being implemented on the effectiveness of the Sensory Modulation Program, which utilizes terminology that corresponds with the most current research available on this and related topics. The Sensory Modulation Program, when used by skilled therapists, is a useful guide for the implementation of the use of sensory approaches in general (across levels of care), and it may also be used in the efforts to decrease the need for the use of restraint and seclusion in mental health settings.
 
Sensorize Your Unit’s Safety Checks System!

The following tools were created in order to help operationalize the implementation and integration of sensory modulation strategies within an acute care setting’s safety checks system. The overall goal is to help staff become better observers of each client’s ability or difficulty with self-regulation and to provide strategies in a proactive manner, with considerations related to the degree of escalation/de-escalation. The Sensory Modulation Program strategies and one setting’s choice of using the non-violent crisis prevention institute’s training information & language (e.g., CPI - Crisis Prevention Institute), as part of a more pro-active approach to performing the unit’s safety checks process, resulted in the creation of following documents as resources to help guide staff in this process. These documents are provided as a free resource when giving reference to the primary author and may be modified for use across varied settings. It is often helpful to apply the specific language and approaches used to train staff in crisis de-escalation, to help people apply the sensory modulation strategies in a manner that also supports the crisis intervention trainings provided by each mental health organization.

Risk Management Summary pdf

Risk Management Calm pdf

Risk Management Anxiety pdf

Risk Management Defensive pdf

Risk Management Acting Out pdf

Risk Management Tension Reduction pdf

 

The Skills Development Workbook

The Skills Development Workbook pdf was created in 2006 for use with adolescent and adult populations admitted to the acute inpatient unit at Cooley Dickinson Hospital. It was created and used by Tina Champagne, OTR/L, Alison Berryman, OTR/L and the following mental health counselors: Bruce Bradley-Gilbert, Courtney Vearling, Stephanie Campbell and Joseph Gamba. This workbook has been used as a tool to help integrate the sensory modulation program and a host of other treatment approaches into the care delivery process. The Skills Development Workbook has been provided as a free, downloadable resource due to the many requests from practitioners to use it in practice, or to adapt it for applications for varied populations and settings. Note that some of these worksheets are also available in Champagne’s text, Sensory Modulation & Environment: Essential Elements of Occupation (2008). 
 
 
Tina Champagne Awarded: The 2008 Commissioner's
Distinguished Service Award & A State Senate Citation
 
On May 6, 2008 Tina Champagne, OTR/L was awarded the Massachusetts Department of Mental Health (DMH) Commissioner's Distinguished Service Award for Reducing and Eliminating Restraint and Seclusion. She also received a second award, a Senate citation, for her local, state-wide and national advocacy and innovative work in these areas. At the award ceremony at the State House in Boston, Commissioner Barbara Leadholm praised Champagne for her, "dedication in reducing restraint and seclusion locally and nationally, developing promising alternatives, such as, sensory rooms. Your body of work preventing restraint and seclusion has crossed local borders and informed many states and organizations of the latest research, helping to make Massachusetts a national and international hub of alternative advancement." For more information go to In The News
 
 
Making Sensory Approaches a MA State DMH Regulation

The MA State Department of Mental Health further demonstrated the sincere commitment to the skilled integration of the use of sensory approaches across mental healthcare services on April 3rd, 2006 when the use of sensory approaches became a state mandate for all licensed DMH facilities. In addition to this mandate they have been actively promoting the use of OT services to support the safe, skilled and responsible integration of sensory-related assessment, treatment and environmental approaches across levels of care and with varied age groups.

The support of OT involvement in all aspects of this initiated was once again demonstrated by hosting a one day training for all MA State occupational therapists employed by the Department of Mental Health. The Sensory Symposium was co-created and co-presented by Tina Champagne & Karen Moore. For more information on this event click here.


It Takes a Village

Working together in both principle and practice professionals across all levels (governmental/regulatory bodies through inter-disciplinary professionals) are able to better provide person-centered care. This is evidenced by the following case in point.

Case In Point: A Sensory Room in Acute Mental Healthcare Settings?

The idea of expanding the use of multi-sensory rooms to adolescent and adult acute care inpatient mental healthcare settings incorporates a variety of sensory approaches, while maintaining an emphasis on engaging in meaningful activities and the "therapeutic use of self" (the most valuable sensory modulation tool). Sensory rooms have been primarily used with clients with moderate to severe developmental delays and among geriatric populations with dementia or Alzheimer's disease. Skilled nursing facilities, day treatment centers, schools, long-term care facilities, respite care homes, hospitals, and hospices are some of the many organizations most commonly utilizing sensory rooms in the past.

The use of the "sensory room" in acute care inpatient mental healthcare settings has been a great success and readily endorsed by the MA State Department of Mental Health (DMH) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), during several recent hospital surveys. Further, it is promoted by NTAC, a division of NASMHPD, as one of the instrumental interventions influencing the reduction of restraint and seclusion in mental health care settings. Although there is limited literature and research available specific to the use of sensory rooms in acute mental healthcare settings with adolescent and adult populations, the following is an article regarding a sensory room (quality improvement) study conducted in 2003 at Cooley-Dickinson Hospital's acute care behavioral health unit in Northampton, MA (USA):

pdf The Effects of the Use of the Sensory Room in Psychiatry:
    A Quality Improvement Study
    By: Tina Champagne, M.Ed. OTR/L & Edward Sayer, Psy.D

This quality improvement study was replicated on this unit in 2004 with astonishingly similar results. Among the patients who utilized the sensory room during group or individual sessions, most report a positive response and a decrease in perceptions of distress.

In 2006, Champagne published an article on creating sensory rooms for the American Occupational Therapy Association's Mental Health Special Interest Section. The reference information for this article is:

Champagne, T. (2006). Creating sensory rooms: Environmental enhancements for acute inpatient mental health settings. Mental Health Special Interest Section Quarterly, 29(4), 1-4.

AOTA members may download this article at: http://www.aota.org/members/area3/links/link02.asp?QStatus=Y&ID=M

In 2007, Tina Champagne authored/co-authored 4 sections in the "Developing Positive Cultures of Care Resource Guide" published and funded by the Massachusetts State Department of Mental Health. It will soon be available on the MA State DMH website in it's entirety. For a free copy while supplies last contact: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Networking

As a networking web site, please consider submitting related works for consideration for inclusion on this web site. Email submissions to: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Consultation Services

Tina Champagne, M.Ed., OTR/L is an award winning occupational therapist offering consultation services on the topics of sensory modulation, trauma-informed care, restraint reduction and organizational change. She also consults on a range of other topics! For information on potential consultation services with Tina Champagne click here



Last Updated ( Monday, 01 December 2008 )
 
Motivational Interviewing Print E-mail

MOTIVATIONAL INTERVIEWING: Preparing People to Change Addictive Behavior is a book written by William R. Miller & Stephen Rollnick. It contains a wealth of information for professionals working with people who are “in need of change”. It includes a host of contributions from a variety of colleagues offering their unique perspectives and experiences with motivational interviewing (MI).

Although the authors acknowledge that one approach is not appropriate for all populations, this approach focuses on the professional’s ability to facilitate and enhance their client’s motivation to change. It is particularly useful with those struggling with ambivalence and addictive behaviors.

MI draws on strategies from client-centered counseling, cognitive therapy, systems theory, social psychology of persuasion, and can be used in conjunction with other treatment approaches. It has been based upon James Prochaska and Carlo DiClemente’s “transtheoretical” model and recommends determining the client’s Stage of Change, and focusing treatment specifically at that stage.

  • Precontemplation Stage: Not considering change

  • Contemplation Stage: Considering change, but is ambivalent

  • Preparation Stage: Has the desire to change, makes some effort/has some success

  • Action Stage: Extended periods of abstinence and intrinsically motivated to work

  • Maintenance Stage: Stable and abstinent

  • Relapse Stage: Begins to use after a period of stability and abstinence

The following is a general outline of the principles, strategies and skills used in MI.

The Five General Principles of MI:

  • Communicate emphatically

  • Develop discrepancy

  • Avoid of argumentation

  • Roll with resistance

  • Support self-efficacy

Strategies to enhance motivation for change: (A-H)

  • Give Advice

  • Remove Barriers

  • Provide Choice

  • Decrease Desirability

  • Provide Empathy

  • Provide Feedback

  • Clarify Goals

  • Active Helping

Examples of some of the basic skills and strategies used in MI:

*Communication strategies

  • Reflective Listening

  • Open-ended Questions

  • Affirmation – Genuine and matching both the rhythm and tone of the client

  • Summarization – Summary statements, which link together and reinforce what has been said, involving the client.

*Examination of the advantages and disadvantages of making a change

(Sample Chart)

 

Making a change:

Continuing to drink:

Advantages

*Will save my marriage
*Less money problems

*It relaxes me
*I like partying with friends

Disadvantages

*Boredom
*I’d need to change my whole lifestyle.

*Upsets my spouse/family
*Harmful to my health
*Spend too much money



Occupational Therapists are encouraged to increase their understanding of MI. Many occupational therapists working in mental health treatment settings have added it to their repertoire of treatment approaches.

Reference:

Miller, W. R., & Rollnick, S. R. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: Guilford Press.


Motivational Interviewing, Second Edition
by William R. Miller, Stephen Rollnick





Last Updated ( Sunday, 14 May 2006 )
 
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Attendee Comments

Comment from the January 2006 conference:
A Nonlinear Dynamics Approach to Sensory Modulation

Tina Champagne blew me away! She made me proud to be an OT and inspired to get back into psych OT! - Hollie Marron, OTR/L