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Safety WithoutSeclusion and Restraint

November 10, 2015Presenters: Karyn Harvey and Kim Sanders

FACILITATORS: SHERRY PETERS AND EILEEN ELIAS

© 2014 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY

Diverse settings:

• Residential in all child‐serving systems

• Community‐Based

• School settings

• Foster Care

Sensory Modalities and

“Comfort Rooms”

Positive Behavior

Interventions and Supports

(PBIS)

How to get the message across

to all staff

Requests for specifics to cover in today`s webinar

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9 Introductory

Videos8 Modules

Partnership with JBS

International

LINKS TO THE TOOL:http://gucchdtacenter.georgetown.edu/TraumaInformedCare/

or http://trauma.jbsinternational.com/traumatool

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5 Issue Briefs

7 Sets of Annotated Resources

Other Summary Documents

27 Content Videos (over 11 hours total)


Over 188,000 views

103 CountriesMost views in

US, Canada, and Australia

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Video Clip from New Video

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Today’s Presenters Appear in the Clip

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Screen Shots from “Trauma Informed Care: Perspectives and Resources”, Module 2: Trauma Informed Child‐Serving Systems

TRAUMA, BEHAVIOR, AND WHAT HELPSKaryn Harvey, PhD.Assistant Executive DirectorARC Baltimore

THE BEHAVIORAL PYRAMID

Behavioral Issues:

Emotions Expressed

Often Rooted in Trauma

When we only address the behavior,we miss the true cause and root of difficulties

BEHAVIOR

EMOTION

TRAUMA

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Trauma is pervasive

At the heart of many or most behavioral crises that result in

seclusion and restraint

“Big T Trauma” and “Little t trauma”

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Failure after failure

Devalued

Experience negated

Grief over losses

Feelings over a lifetime:

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Feelings of powerlessnessFeelings of

powerlessnessFeeling unsafeFeeling unsafe

Repeated over a lifetime

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Focus on symptoms as the problem‐may be ignoring person’s inner experience and history

What does NOT help

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• False assumption‐ behavior always to gain an outcome or manipulate –person may be freaked out by memories of trauma

•Assumption the person has control over behavior in a crisis situation

•Oversimplified focus on contingencies

•Restriction or control (fuels feelings of powerlessness, power struggles)

What does NOT help

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Actions as Communication

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BEHAVIORBEHAVIOR

When people cannot express feelings efficiently in words

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When people feel threatened

To keep safe & To keep safe & keep people

away

Aggression occurs

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INGREDIENTS NECESSARY FOR POST

TRAUMATIC RECOVERY

Perceived Safety

ConnectionEmpowerment


• Learn trauma triggers

• Detailed planning for trauma triggers

• Planning for safety• Real choices to reduce sense of powerlessness

• FUNCTIONAL COMMUNICATION

Increase safety, comfort, feeling of control

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Positive Identity

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• Achievement• Sense of purpose• Feeling valued‐ staff

member wants to talk with me

• Finding things the person can do well

• Meaningful work


• Pleasure

• Engagement

• Positive Relationships

• Achievement

• Meaning

• Happiness plan

Increase happiness

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Assess and plan for happiness

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• Daily conversation time

• Strong listening skills

• Foster friendships with peers

• Shift from shaping and modifying behavior to safety and comfort

• Instead of house parent role‐ shift to social coach and ally

In residential or day treatment setting –shift in staff role

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CAROL DWEK, PH.D.

THE POWER OF POSITIVE REGARD “How you see someone determines how they are able to see themselves!”Teachers who thought they had gifted children got a significantly better performance from classes they were told were “average”. Even though they were the same!

RESILIENCY STUDIES

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Grafton Integrated Health Network

Our Journey to Minimize the Use of Restrictive Practices

Kim Sanders, President, Ukeru Systems

Who We Are

Provider

Therapeutic Day Schools

Psychiatric Residential Treatment

Therapeutic Group Homes

Early Intervention Services

Outpatient Treatment

Applied Behavior Analysis

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Where We Were

• As many as 250 physical restraints a month in just one service region

• Client injuries and a deathClientsClients

• High rate of employee injuries

• Controlling atmosphere breeding negativity

• Self perceived as “helpless” and “victims”EmployeesEmployees

• Teams resembling silos

• Negative outcomes affecting financial sustainability

• StuckOrganizationOrganization

It’s Time for a Change

• Minimize the use of physical restraint and seclusion without increasing employee or client injuries

Issues a Mandate

•What is our goal mastery/achievement rate?Asks a

Question

Grafton’s Philosophy

• Comfort vs. Control

• Trauma informed care

• Responsibility to teach

• Sense of urgency

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Grafton’s Model for Minimizing Restraint and Seclusion

Communication

Leadership

Training

Alternative Solutions

TherapeuticTreatment Planning

Debriefing System

Measurement

© 2015 Grafton Integrated Health Network

What is Ukeru?

The conversion (or diversion) of an aggressive act and channeling it elsewhere

Ukeru is about receiving, engaging, sensing, feeling and responding to what someone is trying to communicate to us through their actions, while maintaining the safety of all involved

The use of soft, cushiony materials to protect oneself from hits, kicks, punches, bites, hair pulls, etc i.e. Couch cushions/pillows, blocking pads,

bean bags, etc

The use of protective equipment such as gloves, shin guards to protect oneself

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Ukeru vs Physical Restraint Systems

Ukeru Physical RestraintUkeru may take longer time per incident.

Restraints usually take less time per incident.

Provides the opportunity to begin to use new skills he/she has learned.

Keeps control in the staff ’s hands.

Provides the opportunity to express or work through negative emotions or energy.

Attempts to repress negative energy which often resurfaces later. May damage or prolong treatment (and possibly traumatize or re-traumatize a person).

Requires teamwork, individualization and creativity.

Requires the use of specific techniques.

Injuries are generally less severe (bruises).

Injuries can be more severe (joint or bone damage, strained or pulled muscles are often joints).

Physical Skills Taught

• Blocking Upper Body Attacks

• Blocking Lower Body Attacks

• Team support during an occurrence

• What to do if you get backed against a wall

• Protecting against self-injurious behavior

• Release Techniques and Protective Strategies– Hair pulls, bites, chokes, clothing grabs, wrist grabs, physical

redirection

BENEFITS AND RESULTS

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Physical Restraints-ORGWIDE

3858

1458 15941429

271 526 38388 107 339 400 177 129

2788

23611871

586

12597

5548 14 22 58 61 25

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

6000

6500

7000

FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15

Physical Restraint Freq

uen

cy

Community‐Based Programs Residential Treatment Centers

* Totals do not include those physical restraints implemented as holds for medical techniques to be administered.

Client Induced Injuries - ORGWIDE

360

424400

292

220205

163145

173179

138 168

0

50

100

150

200

250

300

350

400

450

500

FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15

Staff Injuries from Restraints-ORGWIDE

110

126

86

32

17 17

39

18

95 7

0

10

20

30

40

50

60

70

80

90

100

110

120

130


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Lost Time & Modified Duty- ORGWIDE

1750

1139627

373 544338 471 391

164475 618

252

254 962

2576

1799

7881224

1328

842861

1533893

780

0

500

1000

1500

2000

2500

3000

3500


Modified Duty Days Lost Time Days

Lost Time Expense - ORGWIDE

$473,340

$319,467

$181,379

$111,512

$166,420

$105,294

$147,517$123,118

$54,514

$162,868

$216,287

$88,893

$0

$100,000

$200,000

$300,000

$400,000

$500,000


ROI = $15,159,438

$6,080,832

$3,529,471

$5,549,135

TURNOVER Savings Lost Time Savings WCOMP Policy Savings

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Goal Mastery & Restraint Occurrence Savings By Fiscal Year

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

$‐

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Annual Savings

Fiscal Years

Total Savings

PR used relative to baseyear

Goal Mastery ‐Percentage achieved

“At first people refuse to believe that a strange new thing can be done, then they begin to hope it can be done, then they see it can be done—then it is done and all the world wonders why it was not done centuries ago.”

• Frances Hodgson Burnett

Questions?

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• December 18, 2014 Georgetown WebinarHealing from Trauma‐Young Adult and Family Perspectives and Recommendations

• WEBINAR PLAYBACKPowerpoint Presentation (PDF)Adverse Childhood Trauma ImpactResilience QuestionnaireAdditional Resources

Additional Webinars to Explore


• January 22, 2015 Georgetown WebinarSupporting Champions for Cross‐System Collaboration in Trauma Informed Care, Presenters: Teams from Virginia and Indiana

• WEBINAR PLAYBACKPowerpoint Presentation (PDF)Additional Resources

Additional Webinars (continued)


• February 19, 2015 Georgetown WebinarBuilding Capacity for Trauma Informed Provider Organizations: Community‐Based and Residential, Presenters: Teams from South Carolina and Mississippi

• WEBINAR PLAYBACKPowerpoint Presentation (PDF)MS Summit ReportAdditional Resources

Additional Webinars (continued)

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