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Framing the Issue

• The reduction of seclusion, restraint and coercive practices (sometimes including law enforcement intervention) requires a CULTURE CHANGE that resonates with recovery and the transformation of our mental health systems

• Although there is no one way to do this, best practice core strategies have been identified

• However, change is slow

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Traditional Healthcare

• Healthcare systems including behavioral health continue to be fragmented

• Not customer-friendly or person-centered

• Not outcome-oriented

• Resources are wasted

• Poor communication between providers

• Practices not based on evidence(NFC, 2001; IOM, 2003)

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Facilitating Culture Change in Healthcare Organizations

• Institute of Medicine recommend health care services characterized by:– Continuous healing relationships– Customized to individual needs/values– Consumer is source of control– Free flow of information/transparency– Anticipation of needs– Use of Best Practices

(IOM, 2001, 2005)

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Facilitating Culture Change in MH: The New Freedom Commission

• Called for System Transformation• System Goal=“Recovery for everyone”• Services/supports are consumer centered• Focus of care must increase consumers’ ability

to self manage illness and build resiliency• Individualized Plans of Care critical• Consumers and Families are full partners

(NF Commission, 2003)

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Keys to changing the culture from weapons to words

• Prevention approach

• Recovery/Resiliency Values/Principles

• Training and knowledge

• Effective Leadership Principles

• Establish data collection

• Partner with consumers

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Weapons, Violence, Trauma, Injuries + Deaths during Crisis Intervention

• We have struggled to deal with these issues• Often have chosen control and coercion, not

knowing what else worked• This has been traditional practice

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Traditional Approaches to Violence in Mental Health Settings

• “Professionals” have mostly focused on the “patient” as the cause of violence, we were trained in this model

• The focus? Demographic & Clinical Characteristics

• Age, race, diagnosis, certain symptoms, substance abuse history, foster care or DJJ involvement, forensic involvement, medication compliance

• Result: We still cannot predict violence well, this approach has not reduced events, but this approach gave us a rationale to lean on – so we ignored other factors…

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Internal Model of Violence• The “Internal Model” is used for many

reasons - including ease of research methodologies, lack of knowledge, and an insidious discriminatory paradigm

• The “them” not “us” focus is more comfortable and does not result in any changes in our own behaviors

• Is convenient but often inaccurate

(Duxbury, 2002)

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External Model• The “External Model” is another way

to look at violence causal factors (has emerged from UK)

(Duxbury, 2002)

• This approach takes another view of violence, by asking: “What is the role of the environment in violent events?”

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Popular media’s take on Institutional Cultures

• The 1960’s saw the release of a movie (Cuckoo’s Nest) and a documentary (Titicut Follies) that portrayed “life” in inpatient settings as one based on staff control, coercion, punishment, idiosyncratic rules, lack of safety, and as fundamentally flawed in providing for basic human rights or ethical treatment. The documentary was banned from 1967 to 1992 by a US state Supreme Court.

(Kesey, 1962; Wiseman, 1967)

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“Inconvenient Truths?”1. We “professionals” have been poorly prepared

and expected to work from intuition; lacking sophisticated theory, philosophy, or best practice missions

2. We have been conditioned, in some settings, to an acceptance of ineffective, often non-existent, leadership or supervision

3. We have been inculcated to insidious, discrimination as evidenced in practices and language

4. We have rarely or never been introduced to an understanding of role of institutional triggers in violence

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“Inconvenient Truths?”5. Our practices have not changed in any

significant manner, over the last 30 years, as evidenced by:

– Many homogeneous treatment activities, one size fits all

– a lack of risk prevention – a lack of individualized treatment planning or

full use of assessment information – the exclusion of kids/family members from

service planning and– a primary focus on “control” to manage

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Lessons Learned• Seems we could be missing the “boat.”

As leaders we need to:– Redefine our personal treatment philosophies,

values, and desired outcomes including the elimination of coercion

– Understand how to assure for and measure adequate staff leadership, supervision, & training

(Anthony, 2004)

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Lessons Learned• We must acknowledge:

– That “we” may not have factored in our own contributions to institutional violence

– That some of our practices are discriminatory, in care settings

– And that we may be unaware or in denial about actual practices in the systems of care that we oversee

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Consider This …

Martin Luther King JR. said that:

“Violence is the language of the unheard”

Seems to be a particularly germane statement regarding our problems with violence.

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And for those skeptics out there…

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Training Comments