Research Needed for Those with IDD/MI Dual Diagnosis!!!!

We need more research in the following areas to advance the treatment of those with IDD/MI dual diagnosis.

1. The best methods of restraint and seclusion 

2. The best methods for de-escalating a crisis before, during, and after the crisis 

3. How to introduce body cameras to the psychiatric system 

4. What exactly is trauma-informed care, and examples of trauma-informed care

5. The effectiveness of barcode medication equipment to protect service recipients from medication errors

6. How ID cards or wristbands resolve major safety concerns, and how to encourage service recipients to wear their ID cards or wristbands 

7. How statewide bed registries and trackers reduce the amount of time a service recipient spends in crisis centers 

8. How many dual diagnosis inpatient beds are needed, and what do hospitals need to do to establish dual diagnostic capability 

9. How to circumvent the Medicaid IMD exclusion and why we need to do so

10. What medical clearance protocols are followed, and how can we ensure compliance 

11. Civil commitment, involuntary medication, forensic commitment, and guardianship standards around the world and country 

12. Ideal coercion-free healthcare for mentally ill service recipients, including the Trieste, Italy model

13. The benefits of having a separate State Hospital for those with dual diagnosis (I.e., a neuropsychiatric center) 

14. Forensic care of those with dual diagnosis and violent criminal charges, and what treatment models are effective for this subpopulation

15. Alternatives to group homes and supportive apartments (I.e., intentional community)

16. The PASRR (Pre-Admission Screening and Resident Review) process and nursing homes for those with dual diagnosis, and why we need specialized units in nursing homes for those with dual diagnosis 

17. The effectiveness of boot camp military-style programs for adults and youth with emotional behavioral disabilities and Autism 

18. How aversive behavioral interventions are abused, such as aversive shock for severe self-harm and aggression

19. How unfairly played group games impact recovery and treatment retention, if at all

20. Why does mechanical restraint go down when chemical restraint goes up 

SafeWards

SafeWards model

SafeWards is a nursing care model on psychiatric units, designed to reduce restraints, seclusions, and other containment strategies. 

SafeWards consists of 10 interventions described below:

1. Clear mutual expectations: guidelines for both service recipients and staff, which are not meant to feel like a child’s rules
2. Soft words: therapeutic limit setting designed with respect and negotiation in mind
3. Talk down: diffusion using words, not hands
4. Positive words: staff understand why difficult behavior occurs, and staff discuss positive things about each service recipient in shift reports to combat bad feelings about certain service recipients
5. Bad news mitigation: identifying service recipients who may have received bad news and allowing them to “vent” using active listening approaches
6. Know each other: staff and service recipients provide written information on themselves to use for conversation starters, kept in a binder in the unit for staff and service recipients to view.
7. Mutual help meeting: structured community meetings designed to help each other out with 5 sections, including thanks, news, suggestions, requests, and offers
8. Calm down methods: Before giving PRN medication, encourage the use of traditional coping strategies 
9. Reassurance: after an “incident”  (self-harm, aggression, restraint, seclusion, transfer to a more restrictive setting, etc.) in the unit, all service recipients are talked with to allow them to process the event 
10. Discharge messages: upon discharge, each service recipient writes a special card to be hung in a special place on the unit, about what they liked and disliked on the unit, the staff, and things that happened on the unit (without breaking confidentiality), to show to new service recipients to decrease hopelessness

The more we prioritize these interventions, the less conflict will be present, and as such, less upset, restraint, seclusion, and other containment strategies will be needed. 

Please take a moment and comment to let me know you were here and what you thought of my blog. 

My Official Views on the Use, Misuse, and Abuse of Restraints and Seclusion

Just posting this because there seems to be confusion about my views on restraints and seclusion. I am opposed to restraints and seclusion when it is not needed. However, when there is a clear and imminent danger to the service recipient or others, I highly support restraints and seclusion as a lifesaving measure, just like CPR for cardiac arrest. The commonality between CPR and restraints is that they are only used when necessary and all else fails, and are avoided when safe to do so 

While restraint and seclusion are not ideal, they cannot be eliminated. However, they can be reduced by changing the culture in our facilities. When done appropriately, safely, and correctly, they can be lifesaving interventions. 

For instance, if someone is banging their head and staff cannot stop them from doing so, they could go blind from detaching their retinas or suffer seizures or death from the neurological consequences of the behavior. 

We need more trauma-informed care and safe and therapeutic crisis intervention. 

Some service recipients find restraints and seclusion soothing. We need to teach these individuals other coping mechanisms that are more adaptive in the community that meet the same needs that restraints and seclusion are meeting. 

We need to track and trend antecedents to these adverse events on a weekly, monthly, quarterly, and annual basis. 

In my experience, nurses will restrain or seclude individuals they dislike more than those they like. Also, service recipients who “cause trouble” will be restrained or secluded for excessive periods.  Nurses and staff sometimes purposefully escalate a crisis, so they have an excuse to use restraints and/or seclusion. This is unacceptable, inappropriate, and should be considered abuse  

Nurses should not be allowed to combine seclusion and restraints by locking the door to a room where someone is restrained and having staff watch them via a surveillance camera. This is unsafe, inappropriate, and potentially frightening for the restrained individual. 

Until we wholeheartedly adopt the philosophies of psychiatric rehab, trauma-informed care, and person-centered treatment, we will continue to rely on restraints and seclusions. We need to try a different approach to crisis intervention, one that we are not used to. This is the only path to reducing and eliminating restraints and seclusion. 

Restraints do not teach anyone new skills, and they are little more than a punishment for bad behavior. 

Restraints and seclusion are traumatizing, both emotionally and physically. Service recipients can sustain serious physical injuries when restraints are used improperly, sometimes worse than the behavior that prompted restraints. 

Nurses need to take the time to listen to service recipients about their thoughts and feelings regarding the incident. Restraints are especially harmful when the service recipients do not know why restraints or seclusion were used, and what to do next time to avoid a similar situation. 

Centers for Medicare and Medicaid Services (CMS), The Joint Commission, CARF, and other accrediting bodies need to weigh in on the abuse and misuse of restraints and seclusion. 

We need crisis teams comprised of peer specialists, nurses, psychologists, psychiatrists, therapists, and therapeutic security officers to help de-escalate crises, hopefully without restraints or seclusion. More peer support specialists are needed at a higher or equivalent ratio to the direct care staff. 

In conclusion, restraints and seclusion should be a last resort intervention in a dangerous crisis. They should be thought of as a “treatment failure” rather than a “treatment intervention”; however, when needed, they should be available. It’s a tricky balance. 

Please take a moment to comment to let me know you were here and what you thought of my blog. 

Wheelchairs are Not Restraint Chairs on Wheels

Sometimes, traditional wheelchairs are used as restraint chairs on wheels to move uncooperative service recipients from place to place. This can be deadly. 

In my experience, I was physically held in a wheelchair to be moved from unit to unit when I refused the transfer. From the struggle that occurred during the incident, I ended up on the floor underneath the wheelchair in a position where my diaphragm could not easily expand and breathing was difficult. This can cause positional asphyxia and people can die this way. 

I also witnessed staff strap a child into a wheelchair with restraints and move them to the Quiet Room. As a result of the struggle that ensued, the child ended up in an upside-down position with the restraints wrapped around the child’s neck. This can cause strangulation. 

Rather than using makeshift restraints (I.e. Traditional wheelchairs), we need to purchase “real” restraint chairs with wheels and use safe and appropriate ways of moving uncooperative service recipients from place to place.