Hogg Foundation for Mental Health

Seclusion and Restraint Reduction Spotlight: Settlement Home for Children Embraces New Strategies

December 1, 2007

Teenage laughter fills the air as young girls swing gently on the porch, immersed in the vivid sun rays of a lazy autumn afternoon. Basking in an atmosphere of security and calm so rarely found in their lives, these children of abuse are reaping the benefits of groundbreaking seclusion and restraint reduction strategies implemented by the Settlement Home for Children staff.

Located in North Austin, the Settlement Home provides 24-hour care for girls between the ages of 7 and 17 who have serious mental health needs and histories of physical or sexual abuse. The Settlement Home provides a three-prong continuum of care for girls in their treatment to address the girls' varying levels of severity and unique needs, ranging from a residential treatment center to a therapeutic group home and finally into a foster family home.

In September 2006, the Hogg Foundation for Mental Health hosted a Seclusion and Restraint Reduction Training Institute aimed at teaching organizations the dangers of and alternatives to seclusion and restraint practices. The Settlement Home was one of twenty-nine Texas agencies that participated in the free, two-and-a-half day training.

Armed with the seclusion and restraint reduction plan they developed during the training institute, the Settlement Home staff have instituted a host of new strategies for working with their clients at risk of harming themselves and others. In the year since the training, they have seen dramatic reductions in their use of seclusion and restraints – reductions that make a real difference in the lives of the girls they serve.

The Settlement Home staff attribute their successes to lessons learned in the 2006 training institute.

"The training gave us a step-by-step restructuring guide and completely changed our thought process on working with kids," said Linda Kokemor, the Settlement Home Executive Director.

The training attempted to shatter the myth held by mental health providers that seclusion and restraint are acceptable practices by highlighting the deaths, injuries, and lasting traumatic effects they cause.

When you use "restraints, you see kids dissociate, become violent; you hear them say things to someone not present who abused them," said Kokemor. "You know you're traumatizing them in some way."

With this new awareness, the Settlement Home staff have embraced a new way of thinking about the residents' disruptive behaviors. They include the girls more in treatment decisions and facility policy making. They train staff to intervene early and de-escalate situations that would have previously led to restraints. They work with the girls, too, on increasing their skills for handling intense emotions.

From an all-time high last year of 158 restraints in one month, September 2007 set a record low for the Settlement Home restraints, with a total of only five restraints facility wide.

"We're no longer crisis oriented, intervening physically," said a Settlement Home licensed counselor Darcie Deshazo. "We are calmer now."

The Settlement Home staff have instituted a range of effective new practices.

The agency implemented trauma assessments in which girls identify their triggers for becoming distressed. This helps staff identify warning signs that a resident is becoming upset, so they can react before an incident happens. Girls are taught coping mechanisms that relieve agitation and are provided stress-reducing tools such as squeeze balls, bicycling, or reading something from the Settlement Home's 1600-book library.

"We had one very troubled girl who would just cry and cry," said Michael Downing, the Settlement Home Director of Residential Services. "Then she discovered the library. Now, she gets absolutely lost in the books."

The staff also reevaluated their facility's rules after the September 2006 training. "We talked about each rule, why it exists and if it was necessary to enforce," said Deshazo.

Prior to the training, the girls' radios were routinely confiscated as a punishment for acting out. After the training, however, the staff reconsidered this rule. They realized music is a coping mechanism for many girls, and now upset residents are allowed to keep radios.

The Hogg Foundation's 2006 training institute taught the Settlement Home staff that integrating the residents at every level of a facility to empower them and expedite recovery is a key element of preventing unsafe incidents.

The Settlement Home's adherence to this recommendation is best seen in the formation of its Leadership Council, a group of girls from the residential treatment center who meet with Downing weekly to generate new ideas for programs, activities and solutions to problems.

One council member said, "I like being on the council. We get to make new ideas for the whole campus, so they can all feel safe."

Girls are nominated by staff on the basis of safe behavior to attend council. There is no limit to the number of girls who can be chosen each week.

The therapeutic group homes, another aspect of the Settlement Home program that provides a halfway house-based living structure for girls ready to leave residential treatment centers, have a similar group for residents called the Residence Council.

One Residence Council creation is a token system that reinforces positive behavior. "We thought it would be good if we got rewarded for being safe, that it would help us learn," said one girl on the council.

Girls save tokens to purchase items from the token store, which has hair and beauty products, books, games and other goodies that the council members pick out from catalogues. "The hot item everybody really wants to save up for this month is an inflatable palm tree to decorate their room with," said Downing with a smile and a shrug.

The council also decided that safety levels posted daily on girls' doors and used to determine eligibility for participating in activities would be best represented by Dr. Seuss characters. "The highest level is Lorax," explained one council member, "because he is friendly all the time." The lowest level, given to those who exhibit dangerous behavior, is Yurtle the Turtle.

The Settlement Home "timeout rooms" were another project of the council. These small rooms, which provide a safe space for girls in distress, are decorated in a therapeutic style to provide an escape for the girls.

The council decided how the rooms would be decorated, what would go in each one and what to call their meditation spaces. They chose the name "timeout room," deciding the rooms were a place to take a "timeout" from the stress of life.

"'Timeout rooms' are a place to go before you do something that would cause you to get restrained," said a resident when asked why she chose to utilize the rooms.

Other girls said they liked to retreat to "timeout rooms" when they needed a moment of quiet away from the chatter of their noisy adolescent female companions.

In an October staff meeting on restraint reduction, the group discussed plans for implementing a new mentor program that will allow residents to counsel peers.

"Since implementing all these changes, girls have become more interested in doing fun things and being recognized for achievements," said Deshazo. "They seek attention in a positive way now."

"At other facilities I have been to, they don't observe all your behaviors, only the aggressive ones," said one resident. "There are no tokens for safety. I feel like I'm not getting anything out of it. The Settlement Home notices all your behaviors, which makes me feel like they're here to actually help me."

Despite progress, challenges remain that prevent the complete eradication of seclusion and restraint use. Staff continue to struggle with how to intervene with residents who try to run away, hurt themselves or hurt others. Abused children often act out by hurting themselves, and self-injury is common. It is difficult for the staff not to restrain a girl who is hurting herself or running out into a busy street.

Downing recently asked the Leadership Council for their help in solving these problems.

One girl suggested sharing coping mechanisms they have discovered with each other. "Last time I wanted to cut myself, I wrote on myself with a marker instead," she said. "It made me feel better and washed right off. Other girls could try that."

As they continue to find new ways to reduce their seclusion and restraint use, the Settlement Home is a model of how the ideas presented in the Hogg Foundation's training can be embraced and implemented.

"These steps taken by the Settlement Home can be modeled regardless of facility size and resource limitations," said Aaryce Hayes, mental health policy specialist with Advocacy Inc., and co-facilitator of the Texas Seclusion and Restraint Reduction Leadership Group. The one essential ingredient in successfully reducing restraint, according to Hayes, is a philosophical and cultural shift in leadership.

"Your initial group is the key," said Kokemor, claiming that the staff members she took to the 2006 training were strong leaders who quickly embraced new ideas and were passionate about teaching other employees the information they had learned.

Kokemor advised other agencies to position themselves for success by starting training with employees who demonstrate a solid foundation for reform in their attitudes, commitment to the facility and ability to think creatively.

With an outstanding record of successes to date, the Settlement Home has set the goal of being entirely restraint free by March 2008.

"Once we get there, the goal will be to maintain," said Kokemor. "Also, now that we have started on the process of developing clinically, we will continue to look for new and challenging ways to evolve."