No Recovery By Force

No Recovery by Force, Seclusion and Restraint, David W. Covington, Recovery, Behavioral Health Version 3.0There were only two of us left in the group room and the ten chairs that had been in a circle were now scattered. To my left 15-year old Kenneth* towered over me holding his chair above his head, with huge tears streaming down, his lips quivering, the angriest I had ever seen him. To my right, I could see my co-worker Mark, standing outside in the hall, peering through the small round portal in the door. He was holding his hand to his ear like a phone and his eyes were questioning. We didn’t need to talk for me to know he wanted to call 9-1-1. I slightly shook my head no and turned back to Kenneth.

We frequently speak of clinical “judgment.” Just a few minutes earlier, Mark and I were leading a productive discussion with a group of adolescent males, and one of them related an ankle injury over the weekend that led to a visit to the “hospital.” Despite the different context, just the reference to the word set off memories in Kenneth of an involuntary hospitalization from two years prior. As he had done many times previously, he became very upset, began revisiting his inpatient experience and expressing anger at the psychiatrist who signed the order, an individual no longer with the clinic.

I, too, reflected on that day and remembered my concern for Kenneth’s safety. The risk appeared imminent and I had approached the psychiatrist with the order for detainment for assessment. When law enforcement arrived, and despite my encouragement to do otherwise, they shackled his hands behind his back and placed him in the back of the patrol car. He was a tall African American teenager and the challenges of that day had him scared and confused even prior to the arrival of the police. The officers weren’t taking any chances.

As Kenneth was once again perseverating about an event two years earlier, I reflected on the strength of our two year relationship, the gains we had made together and my genuine good intentions on that day… So, I determined it was time for Kenneth to make a breakthrough. I had not even finished the sentence but looking into his eyes I realized I had misjudged the depth of pain. “Kenneth, it wasn’t Dr. Eastman* that sent you to the hospital… I did.”

I never got to the part about my concern and rationale before the other boys were fleeing the group room, and there we stood together with Kenneth holding his chair above his head and Mark gesturing whether we should re-engage law enforcement once again. What neither Mark nor I grasped at that time was that being demeaned like a prisoner for transportation was not Kenneth’s worst memory.

I didn’t get it at that time, but Charlie Curie did. He who would go on to lead the Substance Abuse and Mental Health Service Administration (SAMHSA) for the federal government, but a couple years after my interaction in the group room, Charlie’s responsibilities included a state psychiatric hospital in Pennsylvania that began looking at care differently.

Previously, it was just expected that individuals in inpatient care would become agitated, angry and/or threatening, and the response would be a take-down code announced over the loud speakers. Male staff would come running from all parts of the facility and everyone nearby would take part in what could more closely resemble football field tackling. When it went wrong, it was more like fighting. When it went right, it frequently led to the individual being secluded in a padded room or carried by their limbs to a hard table where their wrists and ankles were restrained so that they could be forcibly injected with medication and left until the treatment took effect.

At that time, the behavioral health field saw seclusion and restraint as a key tool in the treatment arsenal. Charlie Curie’s team won the 2000 Harvard University Innovations in American Government award because they changed the expectation, and recast the use of seclusion and restraint as an organizational treatment failure. They began to tackle a culture where there had previously been psychiatric inpatient staff with metaphorical stickers on their helmets representing the number of successful “sacks.”

By 2004-2005, SAMHSA’s National Center for Trauma Informed Care (NCTIC) was beginning to educate the broader field on the very high rate of individuals with physical and sexual abuse histories in the public mental health system. Survivors and peers were sharing with us their trauma histories; encouraging us to address trauma in care; and highlighting the re-victimization experienced in residential or in-patient settings through practices like seclusion and restraint.

It was during this same time that I began having long discussions with national peer leaders like Eduardo Vega and Tom Kelly about the impact of involuntary detainment. I remember vividly a conversation in which Eduardo talked about the unintended consequences, even when treatment is caring, effective and safe. After discharge, individuals often return to learn they have lost a job, been displaced from housing or lost key friendships, as their committal was signaled by their abrupt disappearance for days paired with the presence of law enforcement or emergency personnel.

However, I have also talked with many peers about the shocking impact when care feels more like a prison, and when inpatient staff threaten individuals with physical altercations to control their feelings and behaviors. Some peers disclosed that they would not share a concern for a friend with professionals, even if it was considered imminently dangerous, because they loathed subjecting someone they care about to such painful and traumatic disrespect and abuse (even if the alternative is their potential suicide). We simply have not walked in the shoes of those who have been there.

In 2009, when my new job was to oversee clinical and program outcomes for the behavioral health system in Phoenix, Arizona, I spent a lot of time shadowing the system. I spent a third shift in a patrol car with an officer responding to individuals in crisis and transporting them to key facilities (we were dressed in jeans and did not disclose our leadership roles). It gave me an up-close and genuine look at the way individuals in crisis were treated and how services worked.

It was my intention to go a step further and be the “undercover boss” in the court-ordered treatment inpatient evaluation process, posing as a consumer. I felt I could muster the courage to do it; however, the risk of seven to ten days inpatient, the potential for the kinds of trauma, forced medication, physical altercations, etc. that are still commonplace in many facilities across the country was more than I could take on given my family responsibilities (sole provider with two small children). I never went through with it, but I had intimate conversations with those who did. In recent months, the federal government has investigated the Arizona State Hospital related to allegations of excessive injuries for both peers and staff.

Several years ago, Recovery Innovations in Phoenix caught my eye as my team was reviewing a variety of metrics for our crisis stabilization and acute care hospital services, and we noticed something very different. While other facilities were reporting seclusion and/or restraint several times per day, there were entire months in which Recovery Innovations might report one, two or three incidents. Sometimes zero.

I previously assumed Recovery Innovation’s success had to do with engagement and collaboration, creating a culture of respect and openness, and naming things very differently. Individuals are “guests,” not “patients” or “consumers,” and the facility looks and feels much more like a retreat, with names on the doors instead of numbers (e.g., “Revive,” “Refresh,” “Rejoice,” etc.). The crisis stabilization program is referred to as the “living room” and the crisis respite is called “restart.” I also learned from their CEO Gene Johnson about an approach to “risk-sharing” with the individual as opposed to the more typical top-down method.

Earlier this spring, I spent most of a day shadowing in a facility west of Phoenix and noted what may be the silver bullet. Law enforcement arrives with an individual like Kenneth in the back seat of a patrol car at a secure area for intake, and a nurse and psychiatrist provide an initial intake and triage (just like other similar programs across the country). However, the first person in this room to greet the individual is a certified peer specialist who provides a brief overview of what to expect and offers support. This collaboration and engagement with peer supports staff on the medical team continues throughout the care, and it generates a very different type of culture and set of outcomes.

Back to that group from so many years ago. Forty-five minutes later we reconvened the group of teenage boys and I was very proud that Kenneth and I had mutually made some breakthroughs together. I solicited from the group feedback hoping that someone would praise him for talking through these painful experiences. “What did Kenneth do well?” I asked. One of the teens answered simply, “He put down the chair.”

Over a decade ago, Charlie Curie changed the view of seclusion and restraint from an accepted intervention to a treatment failure. Today, Gene Johnson and Recovery Innovations are taking the philosophy of “no-force first” to an entirely new level. There is a line of sight to safer, more effective and better care, and it may also be simpler than we think. It is time for us to take action, and peers with lived experience (better yet, lived “expertise”) stand ready to support. And, if we won’t, perhaps Kenneth would encourage us all to take a few days to go through the treatment ourselves. Then we might all better understand.

*Note: The names in the story were changed. Also, I have not made distinctions as to the differences between physical holds, chemical and physical restraints as they all share a common element of violating the autonomy of individuals in care, many of whom have previously experienced trauma (including physical and sexual abuse) and may have those memories reignited by these practices.

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