Framing the Issue

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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

2
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 GoalRecovery 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?

10
Popular medias take on Institutional Cultures

• The 1960s saw the release of a movie (Cuckoos
  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?

• We professionals have been poorly prepared and
  expected to work from intuition lacking
  sophisticated theory, philosophy, or best
  practice missions
• We have been conditioned, in some settings, to an
  acceptance of ineffective, often non-existent,
  leadership or supervision
• We have been inculcated to insidious,
  discrimination as evidenced in practices and
  language
• We have rarely or never been introduced to an
  understanding of role of institutional triggers
  in violence

12
Inconvenient Truths?

• 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

13
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

15
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