In early February, when #CrisisTalk spoke with Matthew Holtsclaw on the Renew seclusion and restraint (S&R) initiative he launched a year ago, we had no idea what was around the corner for the United States and the overall healthcare system. At a time when physically distancing from each other is critical to flatten the COVID-19 curve, the need to reduce S&R has never been greater. The full interview follows:
In the mid-1800s, John Conolly, an English psychiatrist (called alienists at the time), introduced the no-restraint system while simultaneously an avid supporter of seclusion. Leslie Topp wrote in Social History of Medicine that at the time, some psychiatrists supported restraint but not seclusion, while Conolly and others supported seclusion but not restraint, though the former’s definition seemed to focus on mechanical and chemical control. It became such a point of contention that John Adams, a magistrate in Middlesex, England, wrote to The Lancet to clear up what restraint meant. He stated that it’s “confinement in a separate apartment” as well as “instrumental restraints,” such as handcuffs, straitjackets, and sleeves. Seclusion, he said, along with quiet were “great auxiliaries to the cure.” The debate on seclusion and restraint (S&R) continues today, with staff working in the highest intensity levels of psychiatric care often doubtful that reducing seclusion and restraint is even possible.
Matthew Holtsclaw is the nurse manager at RI International’s Crisis Recovery Center (CRC) and the company’s Chief Crisisologist, a new role that brings open-source learning, scientific analysis, and documentation to the crisis sphere. He says that many of his staff felt similarly pessimistic when he introduced the Renew initiative on February 15th, 2019. RI International founded the Living Room model of peer-empowered crisis facility in 2002 and pioneered early work on reductions in forced care, which they called “no force first” at the time, but the general acuity of guests was very different.
In 2014, the CRC adopted the practice of no wrong door, accepting 100% of referrals and police drop-offs (the latter of which come directly to the center without “medical clearance” at a hospital emergency room). No wrong door is a critical part of the crisis continuum, helping to divert people in crisis from the emergency department and jail, but it also significantly raised the challenge. In fact, 82% of the clientele in the center’s observation unit arrive in the back of a police car, and 60% are there involuntarily. “We have an acute population who has lost much of their autonomy.” Their loss of independence, says Holtsclaw, combined with staff who were trying to maintain order, was resulting in power struggles. “That is when we’d see a rise in seclusion and restraint numbers that we weren’t comfortable with, which is what happened over 2017 and 2018.” It was this upward tick that was the impetus for Holtsclaw to launch Renew. Though, at the time, he could not have anticipated the cultural shift that was to follow and the corresponding results. In the first year, the center decreased S&R by 40%, and some staff shifts saw an even more substantial decrease of 60%. This is particularly noteworthy, says Holtsclaw, because the center simultaneously experienced a record high of clients in 2019—a 10% increase from the previous year. By November, the number of S&R events plummeted, dropping to zero for three consecutive weeks. This was an ah-ha moment for everyone involved in the initiative: Renew wasn’t just working, it was thriving.
‘Renew’ was the name of the center’s S&R room. Holtsclaw notes that every room in the CRC has a name because “people aren’t numbers” and “naming the rooms helps to chip away at stigma.” It was fitting, says Holtsclaw, to incorporate the name into the renewed look at the behavioral intervention. The first step was to review the literature and best practices. Next, Holtsclaw met with RI International’s Director of Quality and Compliance, Angela Pon, and their Chief Medical Officer, “Dr. Chuck” Browning. “We sat down and changed the language in our policy to consider seclusion and restraint a treatment failure.” Nationwide, seclusion and restraint is often thought to be a part of last resort psychiatric care. It’s a different viewpoint to consider it a treatment failure any time it’s done. “It’s a small verbiage shift but a large one in mindset.”
When Holtsclaw first introduced the initiative to staff, he was met with resistance. The most common question asked was: “How are we going to maintain safety without restraining someone dangerous?” Over time, staff began to realize that it was during S&R when injuries were most likely to happen, whether to clients or staff. “Spending time on de-escalation and other non-physical interventions resulted in fewer injuries and was safer for everyone.” It’s not only physical injury that can result from S&R, but also psychological trauma to both staff and guests. Holtsclaw notes that one nurse became so distressed when doing an S&R that she ended up quitting. Even so, staff members started off defensively, worried that the initiative was punitive. “We had to make clear—not just with words but also actions—that this is about fostering a culture change, not punishing people.” The CRC has cameras in all of the units, which allows Holtsclaw and staff to review each S&R. He says that during a crisis, people’s memories of what happened may be different than what occurred, or maybe there were additional elements at play that they weren’t aware of at the moment. Perhaps they would have responded differently had they been. “Let’s say the person moved his body in a way that the guest could see as aggressive, and so the guest, in turn, became more agitated. How does it feel when you see three men putting on gloves and coming toward you? Even though there’s no intent to restrain at that point, the message it says to the guest is, ‘We are going to restrain you.’ Seeing the escalation on video has been hugely impactful. It allows staff to review the event in a different light and think of strategies they can employ next time.”
At the CRC, the staff is accessible at all times, which means that the nurses’ station is a busy place. Staff members may be working on charts with protected information, and guests come up wanting to engage or ask questions. “It’s sometimes a tough balance to strike.” Holtsclaw said before the initiative, there was a lot of push and pull with staff asking or demanding that guests step away from the station and guests refusing. “It would escalate, and the staff would enter the guest’s personal space. The person would get louder, raise his arm, or push the staff member away, and then seclusion and restraint would ensue. That’s all about control.” Under project Renew, staff focus on trying to determine the needs of the guest. Perhaps the person wants to know when a visitor is coming or wants to hang out. “The objective is to address their needs and give options instead of trying to control the situation.” Previously, staff on the unit faced similar challenges when guests would hang out by the locked doors or topple recliners. When guests stood by the doors, staff were concerned the person might try to run away or could get hurt by a door. Instead of trying to control the person, now the staff member will encourage them to move, offer an alternative, or just radio other staff, asking them to use caution when entering that door. “Giving choices promotes autonomy, and we have the ability, as staff, to keep people safe, even if they continue to spend time by the doors.” On the unit, there are large recliners. They aren’t easy to pick up, but people can tip them over. If a guest gets frustrated and knocks one over, it may seem inherently dangerous. “If a person flips over a recliner with an angry look on his face, it looks like he’s ready to throw down. In the past, that’s when we would do seclusion and restraint. Nowadays, if someone does it, we say, ‘Woah, you just flipped a recliner, man, what’s going on? What can I help you with?’” Holtsclaw notes the recliner is already toppled over, and nobody’s getting hurt. “We’ve gone from trying to control the situation to a more person-centered approach of figuring out what the person needs.”
Treatment failure isn’t just about an S&R event but also weaknesses in the care plan leading up to it. “We are looking at the crisis and the other 48 hours they were with us.” An interesting finding, says Holtsclaw, is that examining S&R has led to improved treatment plans. For example, the data showed an unusual number of S&Rs were happening at 9 a.m., double the rate of any other time of the day. He said that he would have anticipated spikes during shift changes but not first thing in the morning and wondered what could be happening. It turns out that nothing was happening, and that was the problem. Guests were waking up and not knowing what was in store for them, wondering, ‘Am I going home or somewhere else? When am I going to meet with the doctor?’ “What’s next is on everyone’s mind when they wake up on a 23-hour unit.” The answer was to get ahead of people’s anxiety and set expectations, having discharge planners, also called recovery liaisons, let guests know the routine for the day. “It’s like the movie ‘Groundhog Day:’ we do the same routine every morning. In the absence of information, people fill in the blanks. If we don’t tell guests that they are going to see the doctor at 10 a.m., they may assume that they are never going to see the doctor. Or they might not know that they are going to be transferred to the inpatient unit.” Letting people know the day’s schedule has significantly decreased seclusion and restraint.
Early into the initiative, Holtsclaw started a peer review committee that would meet once a month. He says he invited all staff to the first meeting and was met with crickets. “I sat there alone, twiddling my thumbs. No one showed up.” People still had reservations, and “no one wants to go to a meeting to be told what they did wrong.” Holtsclaw changed his tactic, inviting specific staff members he felt would provide useful insight such as charge nurses and staff passionate about the initiative. Over time, once people realized it was a safe space, attendance grew. Today, says Holtsclaw, the committee meetings are packed. “I bring food, so that probably helps.” Holtsclaw reviews all S&R events and selects ones he thinks are beneficial for the committee to examine. He says discussions are about improvement, not humiliation. Meeting participants sign a non-disclosure agreement to help foster an open, safe space to talk about case studies. “If we talk about an S&R a staff member did, we aren’t going to gossip about him after the meeting.” Holtsclaw notes that while it often involves a power struggle, resorting to S&R typically comes down to whether the staff member felt unsafe. “They are telling me by their actions that they didn’t feel safe and so had to go hands-on, and here we are looking at the video, pointing out that they were safe. That’s emotional, and why they need to come to that conclusion on their own.
To avoid seclusion and restraint events, Holtsclaw says Renew trainings focus on trauma-informed care and de-escalation strategies for different populations. “If you talk to somebody who is psychotic the same way you do to someone who is depressed, it is not going to be efficacious. So, you have to change your tactic based on the presenting problem.” He says two of the most challenging populations to work with when it comes to S&R reduction are people with intellectual disabilities or amphetamine use. Staff will offer someone experiencing amphetamine intoxication a dark room and food to help take the edge off. A person with an intellectual disability may also not do well with a lot of stimuli, which is often part and parcel of the crisis unit experience. To develop a calmer space, the CRC went through a remodel, creating an open area that has capacity for several guests who need more individualized care. It includes a chalkboard wall, a television, an area for dining, and a bathroom with a shower, allowing staff to provide care, in part or entirely, in the space. It has been a game-changer, says Holtsclaw. In fact, the difference can be seen in the S&R numbers of a frequent client who has an intellectual disability. “During one of her stays with us, she experienced 19 seclusion and restraint events. A month later, she returned, and there were no events during the same duration. It’s because we debriefed and found ways we could do better. The safe room is what we used with her during her second stay. We were able to give her restraint-free personalized care in an open environment without agitating stimuli.”
Holtsclaw says there is no silver bullet when it comes to reducing S&R. “The secret is caring and believing it can change. You can teach trauma-informed care and all the different tools, but most of all, you need staff who are invested in continuous quality improvement. It has to be part of the culture.” He says that today CRC shifts regularly compete with one another to see which one can have the fewest events. Successes, like the one previously mentioned, help to illustrate that it’s possible. “It gives staff tangible examples of how we are making a difference and that these changes are better for everyone.”