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, OTD, 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: [email protected]

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: Application Guidelines  For more information regarding the guidelines for applying for technical assistance email:  [email protected]

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

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:[email protected]

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

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

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.

The Skills Development Workbook

The Skills Development Workbook 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).Skills Development Workbook

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):

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: [email protected]

Networking

As a networking web site, please consider submitting related works for consideration for inclusion on this web site. Email submissions to: [email protected]

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