Many of you have heard us express our opinion, either in person or in this column, about seclusion and restraint (For example, see http://behavioral.net/ashcraft1208 ). We don't like them. They significantly impede recovery by robbing people of self-worth. Seclusion and restraint send a message to people that they are dangerous and out of control. They reinforce the staff role of managing and controlling instead of inspiring and supporting. Seclusion and restraint are an easy target because they are so obviously not a part of the recovery process. The actions involved often are violent, both for staff and for the person who is trying to recover. In this issue's column we are not carrying on much about seclusion and restraint. We are moving on to a close relative-locked residential care, a less obvious and more insidious practice. This column may make some of you mad, but we need to shine the light on the thousands of people who spend long stretches of their lives behind locked doors. Can you imagine how hard it must be to relate to your strengths when everything around you reflects your weaknesses? A locked setting silently tells people they are either dangerous to others or to themselves, or both. This is not a confidence builder. It often is internalized as “self-talk” and quietly erodes the strengths needed to recover. If we were locking up only a very few people on whom we had tried everything else many times, and this was the only way to keep them and others safe, we could go along with that for a few minutes. But, dear friends, this is not the case. We are locking up way too many people for way too long. Are we doing this for our own convenience and at the expense of their recovery? Why the doors stay locked At least the practices of seclusion and restraint, while revolting, are relatively quick. Being locked up in a residential facility can be part of one's life for years. Why would we ever lock anyone up, especially when we now know that it interferes with recovery? Well, here is a list of the usual “reasons” we are given: “It's cost-effective. We can hire fewer staff if we lock the doors.” This is a really dumb concept. Locked doors and fewer staff translate into longer stays for most people, which in the long haul costs all of us, especially the person locked up, a lot more. Later in this column our friend Patty Blum, PhD, vice-president of Crestwood Behavioral Health in California, expands on this topic. “There is no other way to manage some people.” This response reveals a real lack of trust in staff, who are capable of coming up with a lot of creative and motivating ways to inspire people to react appropriately. It also reveals a real lack of trust in the person's ability to respond, when inspired, to use new ways of dealing with frustration and pain. Come on, people. We are capable of doing much better! “The conservator, doctor, or parents want the person locked up.” Let's stop hiding behind what others less familiar with recovery request of us. If an authority figure requests a lock, recommend against it as soon as you can. Request permission to move the person to an unlocked setting soon after admission. “We want to keep the person safe.” Locking someone up may keep them physically safe for the moment, but it will eat away at their self-efficacy. So while we keep his body alive, we are killing his spirit. Is this what we should consider “safe”? We think not! A person can be kept safe in many ways without eroding their spirit. Imagine how things would change if all the civil units in state hospitals were unlocked or if each resident had his/her own key. Think of it-states actually setting a good example! Have you been in a state hospital lately? We visited one a few weeks ago and wondered why in the world people were locked in there behind uniformed guards, high razor-wired fences, and sophisticated locking systems. Most people in state hospitals these days are pretty calm and don't seem to be hatching any devious escape plans. Unlocking, or giving everyone a key, would significantly change the culture and the people locked in, including the staff, who would need to draw on their best skills to make things work out. Patty's insight What if we unlocked all the locked residential programs? Some are more restrictive than state hospitals ever were, yet we call them “community treatment.” We asked Patty this question and, if you know Patty, her response won't surprise you. She is a passionate believer in recovery and for the past 29 years has worked hard to bring recovery opportunities and environments to Crestwood's programs. Here's what she has to say: “There has been so much opportunity for system transformation throughout the mental health system, yet residential services have experienced little to no evolution. In fact, most people don't seek residential services. The choice is not even theirs to make. They are ‘placed.’ “‘Placing’ people in residential programs often means they are removed from their local community, far from their families, their friends, their faith communities, and their support systems. The people who are integral to their recovery are unable to visit and support the recovery process. For many the only visitor is their conservator or case manager, who is usually the person responsible for placing them involuntarily in the setting. Soon they are forgotten by the community that they once lived in and should be thriving in.” We asked Patty to describe the typical environment of these unchanging locked facilities. What is it like behind those locked doors? She unblinkingly tells the truth: “The settings tend to be conventional with treatment that looks about the same as it did 20 years ago. The service models have evolved slightly and you may recognize recovery language, but the setting is still institutional, with nursing stations, restraints, seclusion rooms, reward and privilege systems, and health records full of medical model jargon.” Since Patty is so committed to bringing change to this situation, we asked her to describe what she's doing to change all of this. She's enthusiastic about what she has been able to do so far and about her future plans. “There is an alternative. The alternative is the community housing and support services model. This model is cost-effective, uses evidence-based treatment, and is driven and led by the people it is intended to serve. This model provides opportunities for funding sources, providers, conservators, and residents to work together in a completely new way that can lead to recovery and true community living. “The first step in developing the community housing and support services model is to shift the power differential. The model is based on the resident being the lead in the development and the mental health staff providing consultation and support. The resident's leadership must be respected. This shift in power enables the resident to create the service plan, identifying the resources needed to make the plan work. “At Crestwood's Pleasant Hill, Vallejo and Sacramento facilities this system has started to emerge. In Pleasant Hill the residents wrote the program. It helps that many of the clinical, paraprofessional, clerical, and culinary staff have lived experience or family experience [of mental illness].” We asked about the setting itself. How does it change when the program changes from a locked residential treatment model to a community housing and support model? Patty filled us in: “The new services are still in the same facilities that have served people for decades, but the living space has been transformed into homelike living space, with comfortable rooms, apartments, meditation rooms, small kitchens, family rooms, workout rooms, creative arts space and, of course, television space for the Wii and Xbox. The folks who helped design this setting have lived in IMDs, homeless shelters, and board and cares so they have a lot of good ideas about how to make improvements. They understand the importance of a microwave at 11:30 at night to warm up a snack, the value of adequate locked storage for each person's belongings, the benefits of soothing colors, mostly earth tones, carpet, and a clean, well-maintained home. “These open facilities were once locked with bars on the windows and were licensed by state departments of public or mental health. They are now licensed by community care licensing as adult residential facilities. They now have a strong focus on employment opportunities through Dreamcatchers Employment Network (DEN), a small not-for-profit that specializes in supported employment and supported education for folks with significant mental health issues.” Now that we had an idea of what has been added, we asked Patty what had been eliminated. “There are no seclusion rooms, no restraints, no point systems, no involuntary medications, and no coercive treatment. The reduction of power struggles and elimination of any physical intervention have produced a dramatic reduction in staff and consumer injuries, with virtually no workers' comp experience since these changes have been in effect. “The staffing pattern has changed. There are less licensed staff and more trained peer and family partners involved. The program's remaining nursing position is focused on promoting wellness instead of being in charge of everything. The programs have fewer social workers and more trained peer mentors. The program recruits and hires people with lived experience for all aspects of service delivery, expecting that people with lived experience can mentor and support persons in recovery through empathy, inspiration, shared experiences, and storytelling.” We asked Patty to elaborate on her staff, knowing that any program is only as good as the staff who carry it out. She recognizes this, too. “Staff motivation and enthusiasm are an absolute necessity in the recovery process so there is an ongoing effort to not just train but to inspire and create a learning community where staff and residents are encouraged and empowered to grow. The learning environment acknowledges that all lived experience is a gift to be shared. It reduces burnout, inspires hope, and helps keep staff from reverting to traditional controlling, coercive forms of treatment.” We asked Patty to share a success story that illustrates her point. “There are many success stories, but one which is most poignant: a young man who at 27 years old had been bounced from one facility to another for repeated suicide attempts and was finally placed at a state hospital. He spent the next 7 years there and left when he was 34 years old, with very few life skills and virtually no hope for a life worth living. He was placed at a locked mental health rehabilitation center (MHRC), where he learned about and started his first WRAP [Wellness Recovery Action Plan], had an in-house vocational job, learned communication skills, basic life skills, and developed a sense of hope for his future. He spent a year at the first MHRC and then was transitioned to another MHRC closer to his home. This MHRC was transitioned into this new model. He enrolled in DEN and through this was able to start a small part-time job with a paycheck and then was supported as he started to pursue his career goals. He had always been interested in gardening and landscaping, so he was encouraged to explore the horticulture class at Solano Community College. He chose to attend this class while still working part-time. At 38 years old he graduated last spring from Solano Community College, completing the horticulture program. He was again supported to pursue full-time work opportunities and after a few months with peer vocational support, he landed a job at Home Depot in the landscaping department, which will eventually provide benefits and a full-time paycheck. He now has his own car, an apartment with a roommate, and a girlfriend.” When we think about making changes in the way we do our business, we often take the road most traveled and make little, inconspicuous shifts so no one will notice if they turn out to be a mistake. But if we're serious about transforming community living opportunities, we need to have the courage to make big changes, like unlocking the doors. This one decision will produce the single most magnificent change that would reverberate throughout our entire system. It would change all of us forever. If you really want to make a difference, then think about unlocking a few doors! Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc., in Phoenix. She is also a member of Behavioral Healthcare's Editorial Board. Her new book is Offering Wellness: A New Generation of Behavioral Health Services from Recovery Innovations Press. William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University. Patty Blum, PhD, is vice-president of Crestwood Behavioral Health in California. For more information, e-mail loria@recoveryinnovations.org . Behavioral Healthcare 2009 July-August;29(7):11-15
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