Kim J. Masters, M.D

As promised, this column reviews two seclusion and restraint reduction programs used in psychiatric facilities: that of the National Executive Training Institute (NET), which represents State Mental Health Treatment Environments, and the Psychoeducational Treatment Model (PEM) which was developed by the Girls and Boys Town Resource and Training Center.

Both programs have similar philosophies and see the use of seclusion or restraint, including chemical restraint, as a failure of the treating environment. They differ in the way they teach skills. The NET manuals offer educational experiences from state mental health settings along with findings and recommendations from conferences. The PEM Program is a specific program that is taught by trainers from its center using its manuals. Neither program is exclusive. The PEM Program is used by the New York State Office of Mental Health in some of its child and adolescent facilities. Suggestions from the NET manuals might be useful in treatment planning in PEM programs.

Philosophy: both programs stress the need for patient and staff collaboration in the prevention and management of aggressive episodes. The NET Program has four manuals: Resources; Training Curriculum; Working with Special Needs; and Working with the Deaf and Hard of Hearing.

The NET program guides identify the medical model and authoritarian (do it my way or else) approach of facilities as leading to coercive responses to patient behavior. This view is well described in Ken Kesey’s One Flew Over the Cuckoo’s Nest. The guides present data and discussion which show that requiring patient (consumer) adherence to rules, without considering the individual situation and needs, promoted a culture of institutional violence. It also fostered the use of seclusion and restraint which resulted in injury to staff and injury and death to patients. The guides show that when this philosophy is changed and replaced with a collaborative and authoritative one, treatment is more effective, injuries are reduced, and seclusion and restraint become strategies of last resort which are rarely used.

The NET resource manual shows impressive decrease in the use of seclusion and restraint in the Pennsylvania State Hospital System using the program strategies, from 93,370 hours per year of seclusion in 1990 to 290 hours per year in 2001, and from 137,924 hours of mechanical restraint per year in 1990, to 1,440 hours per year in 2001.

The NET program is based on training and supervision of all staff under the direction of senior management. It stresses: 1) the assessment of patients on admission for violence as well as the patients’ preferred method of dealing with it (this is called a psychological advanced directive); 2) the use of collaborative efforts with patients to find non-coercive ways of dealing with aggression; 3) limiting the time of any seclusion or restraint order to a maximum of one hour before physician review; 4) debriefing and processing of each seclusion and restraint by both patient and staff to find alternatives for future aggression driven episodes; and 5) the involvement of consumers—patients—in the reviewing and monitoring of the use of seclusion and restraint. The NET network fostered individual state programs, some of which have been described in the AACAP Journal (LeBel et al, 2004), and (Barnett et al, 2002), and in this column (Harper, 2003).

Because it is proprietary, the PEM program provides less information about its methods. However, in its overview, it resembles the NET strategies, of promoting its program through assessing aggression management needs and training of a facilities’ leadership and its staff. “The PEM Overview stresses on going training, practice of skills, and supervision of staff. It notes these program elements are essential to maintaining PEM effectiveness.” It offers data from Rockland Children’s Psychiatric Center which serves 250 to 300 inpatients per year that show decrease in verbal and physical aggression and enhancement in selfcontrol skills and cooperation. It also shows a decrease in security incidents from a median 150.5 to 76.5 and decrease in runaway incidents from a mean of 32.3 to 3.3 with program implementation. The emphasis on renewal of skills through retraining is doubtless essential to all successful anger management programs.

However, there are limitations. Neither program discusses strategies for carrying out seclusion or restraint. Presumably that is part of a separate training program. Neither program discusses the need to modernize seclusion rooms. I would like to see them become like video arcades or virtual reality anger management sites. The need to modernize restraint equipment is also not discussed. With modern technology perhaps we could replace straps with gravity restraint and permit more freedom of movement for the patient? Since neither seclusion nor restraint equipment have been significantly modernized in 300 years, when Pinel first attempted to humanize them, it is no wonder that they are a source for morbidity or mortality.

Nonetheless, the NET and PEM Programs are outstanding in the results they achieve and are worth reviewing if one is learning about, planning, or modifying one’s own institutional aggression management program.

For more information about NET, visit www.nasmhpd.org. For more information about PEM, visit nrtcmarketing@girlsandboystown.org.

References
Barnett SR, dos Rios S, Riddle MA (2002) The Maryland Youth Practice Improvement Committee for Mental Health J. Am. Acad. Child and Adolesc. Psychiatry 41 897-905.

Harper G (2003) Restraining and Secluding, AACAP News 34, 3 142-145.

LeBel J, Stomberg RN, Duckworth K, Kerzner MS , Goldstein R, Weeks M, Harper G, LaFlair L, Sudders M (2004) Child and Adolescent Inpatient Restraint Reduction: A State Initiative to Promote Strength- Based Care. J. Am. Acad. Child and Adolesc. Psychiatry 43(1); 37-45.