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dissertation entitled

SECLUSION ROOM USAGE AT AN ACUTE CARE
PSYCHIATRIC UNIT OF A STATE REGIONAL MENTAL HEALTH CENTER

presented by

HARRY WESLEY WRIGHT

has been accepted towards fulfillment
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Ph.D. Counseling

 

 

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SECLUSION ROOM USAGE AT AN ACUTE CARE PSYCHIATRIC UNIT
OF A STATE REGIONAL MENTAL HEALTH CENTER

By

Harry Wesley Wright

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling, Educational Psychology.
and Special Education

1988

ABSTRACT

SECLUSION ROOM USAGE AT AN ACUTE CARE PSYCHIATRIC UNIT
OF A STATE REGIONAL MENTAL HEALTH CENTER

By
Harry Wesley Wright

This study had the purpose of examining factors which
influenced the incidence of seclusion room usage in a state
regional psychiatric facility. Three areas of interest were
examined: (a) patient characteristics which were associated
with the decision to seclude; (b) the influence staff
training had on seclusion room usage; and (c) the impact
various treatment modalities had on the use of seclusion as
a means of behavior control.

The subjects were 110 hospitalized inpatients at an
acute—care. admitting unit of a State of Michigan regional
psychiatric facility. There were two groups: the treatment
group. which consisted of all patients secluded for the
first time over a ten month. ten day period. December 1,
1986 through October 10. 1987: and a "control" group. which
consisted of a random sample of non-secluded patients, who
were admitted during the same time period as the secluded

population.

Harry Wesley Wright

Four forms of treatment were available: (a) milieu
alone: (b) milieu and work-activity: (c) milieu and
medications: and (d) milieu. work-activity. and medication.
Whether or not a patient received a particular treatment was
dependent on the person's psychiatric condition. legal
status, or desire to be involved hithe treatment program.
Also. the regular staff of the admitting unit received 40
hours of training. May 4 - 8, 1987. The characteristics of
all secluded subjects were examined prior to and after the
staff training. In addition comparisons were made between
secluded and non-secluded patients. A series of t-tests and
Chi-square tests ruled out the statistical significance of
the training program as a factor in the incidence of
seclusion. Results indicated there was a: relationship
between seclusion incidence. diagnosis, and medication
treatment.

The findings suggested that psychiatric hospitals can
reduce the incidence of seclusion by being more aware of
when patients are bi-polar or schizophrenic: and that active
treatment especially medication beyond themilieu can assist
patients to be more in control of their actions. and thus

avoid more restrictive forms of behavior control.

HARRY WESLEY WRIGHT
1988

To my father. Harry Wesley Wright. who would have enjoyed
calling me "DrJh but did not live tochiso: to my mother.
Helen P. Wright. whose nurturing planted the seeds of my
work in psychology: and to Marlinlt Roll. PhJL. who made
it possible for me to begin the study. but who unfortunately
passed away before he could see the fruits of his labor in
the results —- to all of you this dissertation is dedicated.
in that you provided significant parts of the foundation

upon which this experience was built.

"If someone comes to you and asks your help. you shall not
turn him away with pious words. saying: 'Have faith. God
will help you.‘ You shall act as if there is no God. as
though there was only one person in the world who could help
this man -- yourselfJ'

-- Martin Buber

 

ACKNOWLEDGMENTS

James.H. Duke said: "If you find a turtle on top of a
fence post. you know it had some helpJ' Idhen a dissertation
is completed. the student had a great deal of help. and I
certainly did. There is no way I could mention everybody.
but I want to acknowledge as best I can those who played a
significant part in facilitating [my reaching this point in
life. Their support. understanding. and encouragement
contributed to the completion of this dissertation. I
undertook this study because I wanted to contribute to more
effective treatment of persons who. for the most part. are
economically disenfranchised. I have spent twenty-six years
of my life working with persons who have struggled with life
because of one reason -- they were poor. economically. But
they were rich in so many other ways. and because of their
generosity. I have learned most of what I know -- so to
clients from Delray. Jackson. Lansing. State Prison of
Southern Michigan. and the Caro Regional Mental Health
Center. I thank you because you taught me so much.

Several mentors have played a significant part in my
growth and development as a person and a psychologist. The

Rev. Mr. George H. Yount was my pastor as a youth. and he

vi

pushed me in the right direction. Richard T. Gore. Ph.D..
at the College of Wooster. stimulated my intellectual
curiosity in ways which still effect me. George Smith. when
I was at McCormich Theological Seminary. taught me to
communicate Inore effectively. Clark Moustakas. PtuD..
touched my deep inner self when I studied at Merrill-Palmer
Institute. and his impact is still felt as I struggle to be
authentic to myself. When I attended Eastern Michigan
University. James Weeks. Ph.Du provided me friendship and
new insights into psychological assessment. At Michigan
State University. William Farquahr. Ph.Dn introduced me to
some of the great psychological philosophers. and I am
better as a psychologist because of him. Floyd Echols.
ACSW. when he was at the Caro Regional Center. provided me
freedom to be the most effective professional I could be.
and showed patience when I made mistakes. allowing me to
learn from them.

A dissertation cannot be completed \uithout an
accomodating and supportive committee. Throughout the whole
of my research and learning experience at Michigan State
University. Gloria Smith. Ph.D.. has been my adviso-r.
teacher. and chairperson. She continually gave me
encouragement and insight. and it would not have been
possible for me to find my way through the academic maze of
the University without her. Robert Griffore. Ph.Du offered
me support. friendship. knowledge. and dealt with nut

vii

phil050phical questiona which facilitated getting through
the process. I gained my first significant awareness of
research methodology from Norman Bell. Ph.D.. and I
appreciated the human way he approached the subject. I hope
that humanity 'is reflected 'Hi this research. Richard
Thomas. PhJL. was particularly helpful early in my academic
experience at M.S.U. He introduced me to the concept of the
"underclass". and how devastating that state in life can be.
I was introduced to the concept of "Systematic Counseling"
by Thonms Gunnings. PhJL This approach played a
significant part in the development of my dissertation
topic.

At the Caro Regional Center. the heart of the
dissertation was to be found. Many people there made it
possible for me to accomplish what hadix>be done. Donald
Carr. Ph.Du. was generous with time. advice and counsel. He
was also an adjunct member of my committee. Ray Bates.
ACSW. was helpful in many ways. especially in giving me
encouragement and flexibility Mischeduling so Icmuld do
both my work as well as the research. Pam Reuter. RN. gave
me valuable insight into the seclusion room process at
Woodside Cottage. Barry Binkley. M.Du 'listened a great
deal as I was sorting out my approach to the dissertation.
Stan Flory. PhJLq gave me several nights of his time while
generating the data through chart review. He also listened
a great deal while I went through periods of doubt. Others

viii

who helped were Florence Hale. Garnett Olilla. Denise
Sandback. Merry Mikkelson. Jan Oliver and Marilyn Hobart.
Earl Branding. DJL. Acting Director of the Caro Regional
Center. allowed me to continue the research process after
Dr. Roll's death. and I am thankful for that.

Several others played a significant part in finishing
this project: Janet Vredevoogd helped me through the
mystery of the computer and the data it generated: Pip Jones
gave me much needed help in getting the study processed and
printed; Robert Orlando. FWLD.. and Kathy Smits M.A" helped
me review data and raised solid questions. Dayton McLellan
facilitated my ability to communicate ideas more clearly by
being my editor. Gordon Wright. my brother. did an
invaluable service by helping me keep a fitting perspective
about the whole research process.

Finally. my wife. Marjorie McLellan. has lived through
it all withlne. She was patient. encouraging. and helpful
in all the ups and downs. In addition. she gavelup aigreat
deal of time on our sailboat in order for the dissertation
to be finished. I look forward to being on the water with
her more often.

I am grateful to all.

ix

LIST OF

LIST OF

Chapter
I.

II.

III.

TABLE OF CONTENTS

FIGURES
TABLES . . . .

INTRODUCTION .

Purpose of the Study . . .
Statement of the Problem . .
Research Questions and Hypotheses.
Definition of Terms.

Summary and Overview .

REVIEW OF THE LITERATURE .

An Historical Review . . .
Recent Historical Perspectives .
Social Forces and Seclusion. . .
Legal Issues Related to Seclusion.
State and Facility Policy. . . .

Research and Theoretical Questions .

Treatment Issues and Seclusion .
Summary and Conclusion .

METHODOLOGY.

Introduction . . . . . . . . . . .
The Setting. . . . . . . . . . . .
Subjects . . . . . . . . .
The Research Variables . . . . .
Milieu . . . -
Work Activity Program. .
Medication Therapy . . .
Patient Characteristics. .
The Training Program . .
The Seclusion Procedure. .
Data Collection Procedure. . .
The Research Design. . . . . .
Data Analysis. . . . . . . . . .
Summary. . . . . . . . . . . . .

Page
xiii

xiv

IV. RESULTS. . . . . . . . . . . . . . . . .

Hypotheses Investigating Differences

Between Characteristics of Secluded

and Non- Secluded Patients. . . . . .
Hypotheses Investigating Differences

Between Various Psychiatric Treatment

Modalities and Their Effect on

Seclusion Room Usage . . . .
Hypotheses Investigating The Influence

of Staff Training on Seclusion Room Usage
Summary. . . . . . . . . . . . . . . . . . .

V. SUMMARY. CONCLUSIONS. AND IMPLICATIONS . .

Introduction . . . . . . . . . . .
Summary of the Study . . . . . . . .
Review of the Problem. . . . . . . . .
Review of the Procedures . . . .
Delimitations. . . . . . . . . . . . .
Major Findings . . .
Conclusions and Discussion . .
Implications for Future Research
and Practice . . .
Implications for Future Research . .
Implications for Practice.

APPENDICES

A. MICHIGAN MENTAL HEALTH CODE. . . . . . . . . .
DMH ADMINISTRATIVE RULES .
CRC SECLUSION POLICY . . . . . . . . . .
JCAH SPECIAL TREATMENT PROCEDURES. . . . . . .
CRC SECLUSION STUDY. . . . . . . . . . . . . .
CRC TREATMENT GOALS. . . . . . . . . . . . . .
PSYCHIATRIC GUIDELINES OF CARE . . . . . . . .

I G) "‘1 I71 U n on
I I I I I I

. JCAH THERAPEUTIC ENVIRONMENT . . . . . . . .
I. CRC/DMH REPORT FORMS . . . . . . . . . . . . .
J. TRAINING SCHEDULE. . . . . . . . . . . . . .

xi

Page
118

119

127

129
139

142
142
142
142
143
144
145
147
157

157
159

161A
163
135
189
193
1'97
210
220
226
230

K. STAFF TRAINING EXAMINATION . . . . . . . . . . 232
L. ADMITTING UNIT DIAGRAM . . . . . . . . . . . . 242
M. PERMISSION TO QUOTE LETTERS. . . . . . . . . . 243

N. RESEARCH APPROVAL CORRESPONDENCE . . . . . . . 248

O. DIAGNOSES OF PATIENT SAMPLE . . . . . . . . . 252
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . 254
CITED REFERENCES. . . . . . . . . . . . . . . . . 254
GENERAL REFERENCES. . . . . . . . . . . . . . . . 258

xii

Figure

LIST OF FIGURES

Patients secluded for the First Time
From 12-1-86 to 10—10-87 . . . . . .

Incidents of Seclusion Involving First
Time Secluded Patients From
12-1-86 to 10-10-87 . . . . .

Patients Secluded 12-1-86 to 10-10-87 .

Incidents of Seclusion 12-1-86 to 10-10-87.

Total Admissions Per Month at Admitting
Unit (C-S) from 12-1-86 to 10-10-87 .

Monthly Z of Patients Admitted to Acute
Care Unit Who Were Secluded
12-1-86 110 10-10-87 a o o I o o 0

Average Daily Census for Psychiatric
Admitting Unit (C-S) From
12-1-86 120 10-10-87 a o o o 0

Z of Total Patients Secluded at C-5 in

Relation to Average Daily Census at C—5
From 12-1-86 to 10-10-87. . . . . . .

xiii

Page

122

122

123
123

136

136

137

138

Table

10.

LIST OF TABLES
Page

An Historical Overview of the Treatment
of the Mentally Ill . . . . . . . . . . . . 48

Seclusion or Restraint Precipitants
Identified in Ten Studies . . . . . . . . . 79

Restraint of Seclusion Incidence Reported
in 13 Studies of Adult Psychiatric
Inpatient Units . . . . . . . . . . . . . . 81

Sample Characteristics of Secluded and
Non-Secluded Patients . . . . . . . . . . . 119

Results of t-Tests Investigating
Differences Between First—Time Secluded
Patients and a Random Sample of
Non-Secluded Patients . . . . . . . . . . . 124

Results of Significant t—Tests
Investigating Differences Between Secluded
and Non-Secluded Patients . . . . . . . . . 125

Results of Chi-Square Tests Investigating
Differences Between First-Time Secluded
Patients and a Random Sample Group of
Non-Secluded Patients . . . . . . . . . . . 125

Results of Significant Chi-Square Tests
Investigating Characteristic Differences
Between Secluded and Non-Secluded
Patients . . . . . . . . . . . . . . . . . 126

Results of Chi-Square Tests Investigating
Differences Between Treatment Modalities
and Other Related Variables . . . . . . . . 128

Results of t-Tests Investigating
Differences in Incidents. Lenth. Days
After. Average Time for Patients
Secluded Before Staff Training and
After Staff Training . . . . . . . . . . . 130

xiv

l4—

11.

12.

13.

14.

15.

Results of t- Tests Investigating Secluded
Patient Characteristics Before Staff
Training and After Staff Training

Results of Chi-Square Tests Investigating
Secluded Patient Characteristics Before

Staff Training and After Staff Training.

Results of Significant Chi—Square Tests
Investigating Differences for Patients
Before Staff Training and After Staff
Training . . . . . . . . . . . .

Results of Chi-Square Tests Investigating
Differences Among Nurses Who Secluded
Patients Before and After Staff
Training . . . . . . . .

Criteria and Conditions Related to
First-Time Secluded Patients

XV

130

132

133

134

138

CHAPTER I
INTRODUCTION

More than three million years ago. human life appeared
on the earth in some form. A definition of humanity in the
course of history has been difficult to ascertain: but there
does seem to be some consensus that "humanity" is a function
of both a cabability to communicate and an ability to think.
Within this long period of human existence. written records
have extended back only a few thousand years. But brief

"primitive history" through art and oral

glimpses of
tradition have given an albeit fuzzy picture of earlier
times.

In the course of attempting to be aware of history.
historians have often focused on questions related to the
mysteries of the human mind and spirit. The relationship of
both to behavior has been extensively examined. A part of
this process has focused (H1 abnormal behavior. or
psychopathology. Other words have been used: deviancy.
madness. lunacy. mental illness. and mental disorders.
Mental disorders. and understanding the causative factors.

were often a religious or philosophical concern. as much as

they were a medical one. More often than not. the two

points of view were linked together. For example. Coleman.
Butcher. and Carson (1980) indicated the following:
The earliest treatment of mental disorders of which we
have any knowledge was practices by stone age cave
dwellers some half million years ago. For certain
forms of mental disorders. probably those in which the
individual complained of severe headaches and developed
convulsive attacks. the early shaman. or medicine man.
treated the disorder by means of an operation now
called "trephining". The operation. .. consisted of

chipping away one area of the skull in the form of a

circle until the skull was cut through. The opening .

. . presmnabky permitted the evil spirit that

supposedly was causing all the trouble to escape. (p.

25)

An argument could be made that the above procedure was an
early form of psychiatric treatment.

Since those early beginnings. religion and psychiatry
have made quantum leaps in the way troubled and mentally
disturbed peOple are treated. The progress can be observed
as history has evolved. But even though various cultures
have advanced in the ways mentally ill people have been
treated. many old practices still persist. One. seclusion.
has been a part of behavior management methodology since
various societies have attempted to deal with those who were

mentally different.

That seclusion. as part of the treatment spectrum.
still is being used in the Twentieth Century is both curious
and interesting. It becomes more so in light of the fact
that psychiatric treatment as currently practiced is varied
in its modalities. and has become more oriented to a
scientific frame of reference. New methods of diagnosis. in
the form of the PET-Scan. can predict with some certainty
whether or not an individual has been afflicted with a bi-
polar condition or schizophrenia. Treatment has progressed
to where iflue effectiveness of a rnedication can be
ascertained through sophisticated hematology studies.

Aside from the advances in treatment and diagnostic
technology. psychiatry. in the Twentieth Century. has many
methodologies. These practices have attempted to build on
empirical advances. But. for the most part. treatment is
still considered closer toeu1art than a science. Irithis
context many forms of treatment have existed. and continue
to do so. They have included the following therapies:
medication: individual and group: various activity formats.
such as recreation. music. and occupational: and milieu. For
persons hospitalized. the milieu becomes the most intensive
kind of treatment and the most inexact. In the context of
milieu treatment. especially in acute care and admitting
facilities. seclusion has been experienced by many
psychiatric patients.

Seclusion. as a behavior management technique. has been

common in most private and public psychiatric facilities: it
has been a means of managing aberrant behavior since the
beginnings of psychiatric history. As seclusion has
continued totueused. it has created much controversy and
discussion. including the generation of significant court
cases. Because of the recent focus on seclusion. most
states have addressed the issue through mental health codes.
administrative policies. and change in facility practices.

The State of Michigan Department of Mental Health has
been part cyf the national policy development process.
Statements regarding the practice of seclusion and restraint
have been put in place in state code (Appendix A) and
Departmental Administrative Policy and Rules (Appendix B).
An essential part of policy has been the requirement that
each inpatient DMH facility' and progran1 formulate
appropriate policy guidelines regarding seclusion and
restraint practices. It was also required that each
treatment facility report on a quarterly basis summary
statistics on incidents of seclusion and restraint. It was
in the context of this reporting procedure that this study
was conceived.

The Caro Regional Mental Health Center is located in
Caro. Michigan. approximately 90 miles north of Detroit and
30 miles east of Saginaw. The facility. for the past five
years. has had a psychiatric population of 110 and one

seclusion room that was available when patients lost control

of their behavior. As required by departmental policy.
quarterly reports were submitted by the facility director.
But the reports only related information about incidents of
seclusion and restraint. Because it was thought more was
needed. the Utilization Review Committee of the Caro
facility decided to audit the seclusion process. There was
a desire to examine additional factors related to incidents
of seclusion, including the following: average duration of
episode. sex. race. legal status. diagnosis and average age
of secluded patients. Thus far nine reports have been
submitted. beginning with January‘h 1986 and ending with
June 30. 1988. (Appendix E)

The audit reports were summary data. based on persons
who were secluded. There was no comparison made to the
population of patients who were not secluded. The data was
not tested in any way for levels of significance in relation
to stated hypotheses. There was no evaluation of the data
in relation to treatment strategies. With these
limitations. and others not stated. the committee gained
from the data some insight into areas of concern which could
be investigated in greater depth at a later time. The
following represents a summary of some of the information:
(1) Persons secluded were primarily schizophrenic. with bi—
polar. manic. second: (2) most persons secluded were
involuntarily committed; (3) aggression to staff or peers

was the primary stated reason for individuals being secluded

except for one reporting period;(4) persons from counties
with an urban center were more likely to be secluded than
those from rural counties: (5) in some reporting periods.
black patients were secluded more than their proportion of
admissions: (6) males were generally secluded more than
females: (7) the average age was about 35.

Much of the data did indicate concerns. and brought out
questions that were of interest. It was because of that
interest and the following reasons that this study was
undertaken: (1) seclusion is still a significant form of
behavior control in psychiatric hospitals and has a
potential for abuse: (2) economically disenfranchised
persons have constituted the population of state hospitals
and become at risk for seclusion: and (3) little empirical
work has been accomplished in this area of psychiatric

behavior control.

Euxeess at the Study

 

The purpose of this study was to empirically examine
seclusion room usage at an acute care psychiatric unit of a
state regional mental health center. The variables of
interest were patient characteristics: modalities of
treatment experienced by patients: and staff training. The
relationship of these variables to the incidence of
seclusion was tested. Previous studies have provided an
unclear picture as to whether or not there was a

relationship between decisions to seclude and patient

characteristics (Borstein. 1985: Convertine. 1980: Flaherty.
1980: Gerlock. 1983: Roper. 1985: Schwab. 1979: Soloff.
1979. 1985. 1987). The literature was inconsistent in
providing a clear-cut picture of the impact active treatment
had on usage of seclusion as a behavior control intervention
(Anders. 1977: Bornstein. 1985: Gerlock. 1983: Roper. 1985:
Soloff. 1985: Wadeson. 1980). There was little research
regarding the influence of staff training (DiFabio. 1978:
Romanoff. 1987: Tardiff. 1985). Few of the studies were
based on empirically based designs.

In this study first-time secluded patients provided the
basis of the research. as well as a random sample of non-
secluded patients. Past research has not yielded results
which have been consistent. Clarification on this
significant issue can help staff understand how to minimize
seclusion room usage. and find more therapeutic means to
assist patients in regaining control of their lives. In
addition. ff bias is involved in decisions in) seclude.
training can address this problem and remove bias as a
factor in secluding a patient. Finally. it is important to
discover if active treatment helps reduce the incidence of
seclusion. If it does. then responsible staff can devise
more effective programs to enhance the patient's mental

state.

Statement 2f the Problem

 

 

The problem investigated was approached in three ways.
One issue examined was whether or not decisions to seclude
were based by patient characteristics such as age. sex.
race. socio-economic status. diagnosis. or legal status re:
admission. Based on preliminary studies conducted at the
Regional Center. it was anticipated that some relatidnship
would emerge between incidence of seclusion and certain
kinds of pataient characteristics. especially diagnosis.
race. age. and physical stature.

The second area investigated by this study was the
effect various kinds of treatment would have on the
incidence of seclusion. The treatment variables considered
were milieu. ivork activity. and medication. Based (n1
clinical experience. it was expected that the work activity
program and medication would have a significant impact on
reducing incidence of seclusion.

A third aspect evaluated was whether or not a staff
training program for the regular staff of the admitting unit
would reduce the incidence of seclusion and the average
length of time in seclusion. The one week staff training
program had as its purpose teaching staff about the basic
philosophy of the facility. which was to minimize external
control and to maximize patient internal control. The
researcher anticipated there would be a statistically

significant reduction of the incidence of seclusion that

could be attributed to the staff training program.

Other areas of interest. but not statistically tested.
were reasons for seclusion; temporal issues such as work
shift and day of the week secluded; and percentage of
seclusion incidents in relation to census and admissions.

The subject groups compared were as follows:

A. First-time secluded patients during a period

covering December. 1986 through October 10. 1987.

B. A random sample drawn from all non-secluded patients

admitted during the same time-frame as A.

In addition. a comparison was made within the secluded group
between those secluded prior to the training program and
those secluded after the training program. Staff
characteristics were also examinecL The training program

time period was May 4 - 8. 1987.

Research Questions and Hypotheses

 

As indicated earlier. the primary objective of this
study was to investigate factors related to the incidence of
seclusion. with special attention paid to characteristics of
patients who were secluded. the effects of various treatment
modalities. and the impact of staff training. Comparisons
were made between secluded and non-secluded patients in
order to ascertain the significance of patient
characteristics as *well as the effects of various
treatments. Using a pre-training post-training comparison.

incidence of seclusion and patient characteristics in

10

relation to seclusion incidents were examined. An
appropriate alpha level. .05. was determined for
consideration of statistical significance 'Hi all analyses.
In order to test these questions. several research
hypotheses were formulated. The hypotheses. stated in the
null format. were as follows:

flypgthgsig 1: There are no differences in patient
characteristics when comparing secluded and non-
secluded patients. The following patient

characterstics were considered:

Sex;

Ethnic group:

Age:

Height;

Weight;

Stature:

Education;

Marital status:
Military experience;
County of residence:
Geographic area:
Living situation:
Job status:
Occupation;

Income:

Year last employed:
Legal status:
Previous treatment:
Year began:

Times in C.R.C.:

. Times in other hospitals:
22. Diagnosis.

_.|——|_|_.|
wN—JOKDGJNO‘m-wa—I
I . I I I I I I I I

Nada—3.44
OQmNO‘M-h

N
_|

flypgthgsis 2: There are no differences in treatment
variables when comparing secluded and non-secluded
patients. The following variables were considered:

1. Milieu alone:

2. Milieu and Medication:

3. Milieu and Work Activity Program:

4. Milieu. Work Activity. and Medication.

11

flypgthgsis 3: Comparing the pre-training secluded
group with the post-training secluded group. there are
no differences in the relative influence of variables
that lead to seclusion. The following variables were

considered:

Sex:

Ethnic Group:

Age:

Height:

Weight:

Stature:

Education;

Marital status:
Military experience
County of residence:
Living area;

Living situation;
.Job status;
Occupation:

Income;

Year last employed:

mmbwwaoomwmmwa—I
I I I I I I I

A

17. Legal status:

18. Previous treatment:

19. Year began;

20. Times in C.R.CJ

21. Times in other hospitals;
22. Diagnosis:

23. Secluded/not secluded:

24. Date secluded:

25. Day of week secluded:
26. Days after admission secluded;
27. Shift secluded:

28. Duration of seclusion:
29. Incidents of seclusion;
30. Reason given;

31. Treatment received;

32. Staff sex;

33. Staff race:

34. Staff seniority:

35. Staff classification;
36. Staff trained:

37. Mentally ill census:
38. Admitting unit census.

Definition 2: Terms

 

The terms described in this section are defined as they

are used in the text of study. Many of the basic

12

definitions had their origin in the Psyghigtgig Glgssagy
(1984). with permission to quote granted (see Appendix )

Aggtg §a_e: Psychiatric care given when a patient's
illness is in its most intense and exacerbated state.
Usually. the acute state is early in a psychiatric episode.

Agit_tigfl: Motor activity that is excessive. and is
usually nonpurposeful and associated with internal tension.
Examples are: inability to sit still. pacing. excessive
energy. and fidgeting.

ABA: American Psychiatric Association: The primary
professional organization'anpsychiatrists'hithe United

States.

Biological Psychiatry: Treating mental illness with an

 

emphasis on treatment approaches that use drugs to reduce
symptoms. Causes of mental illness are thought to have a
physical. chemical or neurologic basis.

Bipolar Disorder: A major affective disorder in which
there are either episodes of mania or depression. or both.
Bipolar disorders may be subdivided into manic. depressed.
or mixed types. depending upon presenting symptoms.

Chemical Restraint: The administration of medication.
regularly. or as needed. for the purpose of preventing or
stopping disruptive. destructive. aggressive. self-
injurious. or other behaviors considered dangerous to the
individual or others (Orlando. 1982).

Chronic Mental Illness: A psychiatric condition which

13

persists over a long period of time. and disables the
person. Generally. this is associated with schizophrenia.
and usually progresses to an irreversible psychosis.

Commitment: A legal process which facilitates admission
to a psychiatric hospital. Usually. it applies to a court
procedure. but can also be voluntary.

£JL£;= Initials for the Caro Regional Center. or Caro
Regional Mental Health Center. located in Caro. Michigan. or
more precisely Wajamega. Michigan.

Deinstitutionalization: Change in the focus of care in

 

mental health from traditional in-patient institutional
settings to community—based out-patient services.

23133193: A false belief that a person holds onto
despite clear evidence to the contrary. and it is a belief
not accepted by persons in the individual's culture. An
example would be a person who thinks she is the bride of
Christ.

0 Eggssigfl: When describing a mood. this refers to
feelings of sadness. despair. or discouragement. It can be
reactive. as in response to a significant loss: or it can be
a part of a bi-polar condition. which is based on a bio-
chemical imbalance. Sometimes this kind of condition can
result in extreme agitation.

D.M.HJ Initials used to refer to the Department of

Mental Health. State of Michigan.

Dual Diagnosis: Refers to persons who are diagnosed with

 

14

both a psychiatric problem such as a Bi—polar illness and a
drug problem. e.g. cocaine abuse.

Qyflamig Ih_gapy: Therapy which emphasizes examining
motivation. meaning. and biologic insticts as a part of a
process of understanding human behavior. The treatment
focus is on the patient talking and working through the
problem areas.

E91: Commonly called "shock" treatment. but correctly
called Electroconvulsive TheraDY: a small electric currrent
is used to induce convulsive seizures. which have a positive
effect in treating depression. The treatment was first
introduced in 1938.

Empathy: The awareness that one person has about the
meaning of feelings. emotions and behavior of another
person. Some think of it as the ability to "walk in
another's shoes".

Etiglggy: The process of understanding the causes of a
disease.

Existential: Refers to the way a person experiences the

world and takes responsibility for what is happening.

Exorcisnu A religious practice or ritual used in

ir -Time Admission: In the context of this study.

refers to a first admission during the time frame of the

studyu i.e. December 1. 1986 through October 10. 1987. The

15

patient could have been previously hospitalized in the
admitting unit earlier.cn~later during the time-frame of
the study.
figggggphig Aggg: Refers to the kind of area where a
person had lived prior to admission to the hospital.
Examples are city. small town. rural area. inner city. or
suburban.
Guidelines pf 9353: Policy statement regarding various
forms of treatment to be made available at the psychiatric

unit of the Caro Regional Center.

Hallucination: A sensory experience that occurs in the

 

absence of actual external stimulus. In psychiatric
populations the most common are auditory and visual.

Incidence: The number of cases of a disease or behavior

 

which took place in a specific time period.
Igsight: Having an understanding about the nature and

extent of an illness: in this situation mental illness.

Involuntary 999111139333: Being admitted to a psychiatric

 

facility against the will of the patient: usually. a probate
court effects the order as the result of a petition.

JCAH: Joint Commission on Accreditation of Hospitals:
an agency that surveys and accredits hospitals as fulfilling
their particular standards.

Labile: Rapidly shifting emotions: unstable.
Legal Status: Refers to the means of admission into

the hospital. e.g. voluntary or court—ordered examination.

16

Living Situation: Indicates the level of independence a
person had prior to a psychiatric admission; e.g. dependent
meant having resided in an adult foster care home: Semi—
independent indicated having lived with a family member:
independent described having relied on one's self.

AAA: Least restrictive alternative: a legal as well as
a clinical concept: used in the context of behavior
management. where ir1 choices cfi’ treatment" the least
restrictive measure is chosen in order to manage out-of—
control behavior.

Mggtgl Illgggg: An illness with psychologic or
behavioral manifestations. which is characterized by
symptoms that result in impairment in functioning. In a
legal sense. it is considered a disorder of mood or thought.
where the person's judement is impaired. the individual is a
danger to others. self or property. or cannot take care of
basic needs.

Miligg: See definition Chapter III.

Mgggl Igggtmggt: This was a philosohy of treating
mental patients that emerged in very last part of the 18th
century and first half of 19th century. The emphasis was.on
removing restraints and treating people in a humane and
kindly way.

ALMA: National Institute of Mental Health: a federal
government agency which funds research programs.

922222212221 1222221: A therapy approach which

17

utilizes purposeful activities as a means of altering the
course of an illness. The program is viewed as a means to
assist the patient to regain self-control and self-esteem.

BET Sggg: A form of x-ray using computer technology to
diagnose schizophrenia and bi-polar illness.

Poly-Pharmacy: Using more than one medication to treat
a mental disorder. Generally. this process is discouraged.

Egggipitggtg: In this study. reasons given for
patients being secluded. The focus is on behavior and the
intensity of agitation and agression.

Psychosis: A thought disorder which effects a persons

 

ability to think. remember. communicate. and interpret
reality.

Egyghotropic Mggiggtigg: Medication which is used
primarily to treat mental illness. Examples are Haldol.
Mellaril. and Elavil.

QMAE: Qualified mental health professional; a person
who monitors and coordinates a treatment program.

Aggidegt Cgre Aiggg: Commonly called direct care
staff. or attendants: persons who work directly with a group
of patients in a residential building of a psychiatric
hospital. At CRC. RCA staff also work with patients in
activities away from the residential area.

Restraint: The use of any device or mechanical method
to restrict the mobility of an individual. or the movement.

use of. or access to. any portion of an individual's body

18

for the purpose of preventing or stopping disruptive.
destructive. aggressive. self-injurious. or other behaviors
considered dangerous to the individual or others (Orlando.

1982).

Retrospective: In this instance. evaluating data based

 

on events that have already taken place. and not manipulated
by the researcher.

Schizophrenia: A large group of disorders that usually

 

are psychotic. manifested by characteristic disturbances of
thought. affect. perception and behavior. and usually
lasting six months or more. It is believed that the
etiology of the disease is organic in nature.

Sgglgng: Confinement of an individual alone in a
locked or lockable space for protection of the individual.
others. or property. and/or contingent on exhibition of
specific behaviors (Orlando. 1982).

Sigg Effiggtg: In the context of medication usage.
effects on the body that are not normal and sometimes
dangerous. Two common effects are tardive dyskinesia and

dystonia.

Staff-O-Genic: Staff actions which result in patient

 

behavior which is not appropriate.

Stgtggg: A characteristic of patients. combining the
variables height and weight. The measure is pounds per inch
of height.

Igggtmggt lggm: A group of staff who are primarily

19

responsible for the treatment of patients. The team
consists of the following: Psychiatrist. social worker.
psychologist. occupational therapist. nurse. and direct care
staff.

Umggmglggg: A sociology term which refers to a group
of people who have become disenfranchised economoically. and
find it difficult to break the cycle because of systemic
forces.

Umigg 9:19: A restraint device created in the 19th

century. which was used ix) control overly aggressive

mentally ill people.

Summary and Overview

 

In chapter I. the reader was introduced to seclusion as
a behavior control method. and asaiproblem in psychiatric
treatment. The history of this methodology was shown to be
long. controversial. and troublesome. Even with the paradox
of seclusion. it is still used extensively in public and
private hospitals. As a result of legal cases. particularly
XQEEQEELQ y; Agmgg (1982). states such as Michigan have
developed codes. policy and rules regarding seclusion and
restraint.

Because of the attention paid to seclusion room usage
in recent years. researchers have examined practices related
to the behavior control method. For the most part. the

results of the research have been inconsistant. Also most

of the research has not been emperically based. The intent

20

of this research was to address some of the points of
unclearitw and add new dimensions to the current
literature. Of particular interest is. whether (us not
structured treatment programs will facilitate a reduction in
the incidence of seclusion: and whether or not a staff
training program 1vill impact (”1 seclusion room usage
patterns. Finally. it was examined as to whether or not
patient characteristics contributed in any biasing way to
the decision process regarding seclusion.

Chapter II reviewes pertinent historical. theoretical.
legal and research literature. The methodology of the study
is described in Chapter III. The results of the data
analysis are contained in the fourth chapter. Chapter V
presents a summary of the study. major findings.
conclusions. discussion. and implications for future study

and practice.

CHAPTER II

REVIEW OF RELATED LITERATURE

n Historical Review

 

Psychiatric historians have taken the view that the
study of human behavior is as old as recorded history: "The
history'of psychiatry/is. at the same time. the history of
civilization. As man increased his knowledge of the world
around him. he also increased his knowledge of the world

within.’ (Kaplan and Sadock. 1981. p.1)

The views about abnormal behavior became more clear as
ancient societies moved from oral tradition to writing ideas
and points of view. There were "references to mental
disorders Hithe early writingscfiithe Chinese. Egyptians.
Hebrews. and Greeks [which] show that they generally
attributed such disorders to demons that had taken
possession of the individualJ' (Coleman et a1". 1980. p.25)

In many of ancient cultures. spirits were viewed as
either "good ones" or "evil ones". It depended upon what
kind of behavior was being exhibited. as to whether the
inhabiting spirit was called positive or negative. This

belief was part of a broader perspective which had as a

foundation that good and bad spirits "were widely used to

21

22

explain lightning. thunder. earthquakes. storms. fires.
sickness. and many other events that otherwise were
incomprehensible". (Coleman et al" 1980. pp. 25-26)

Most. if not all. of the deviant behaviors were viewed
as stubborn ailments. and it became a significant pursuit to
discover the causes of the madness. In the context of evil
spirits inhabiting the person. Gross (1978) reported the
following: "The Assipu priest-physicians of ancient
Mesopotamia preached that mental illness was generated by
devils within the body. They could only be exorcised by
religious magic. including incantations which bear
remarkable resemblance to modern psychotherapy. (p. 100)

In another part of the region. "The Hebrews spoke of
the one God. Yahweh. as a cause of mental illnessJ' (Gross.
1978. p. 100) Yahweh was viewed as the creator and arbiter
of health and disease. \Nlth mental illness as one
manifestation of His wrath. Gross (1978) summarized from I
Samuel 27-31 in the Old Testament. a threat that Yahweh
seemingly enforced against King Saul. which resulted in Saul
going into a deep depression. and then suicide. This was
thought to be a fulfillment of a statement attributed to
Moses in Deuteronomy 28:28:'WWm Lord will smite you with
madness. . . . and confusion of mind". (p.100) The
interpretation of this particular incident was seen in the
following way: "Apparently this was thought to involve

primarily the withdrawal of God's protection. and the

23

abandonment of the individual to the forces of evil".
(Coleman et al.. 1980. p. 25) So central to Hebrew theology
was the belief about the religious basis of mental problems
that treatment for these problems was reserved strictly for
the priests. This frame of reference was maintained even
when lay physicians began to deal with various illness.
(Gross. 1978. p.100)

Early Greek culture believed supernatural powers were
the primary reason for mental disorders. Basically. the
belief was that possessed people were being punished for
offending the gods. one being the goddess "Mania".(Kaplin
et a1” 1981. p. 1) The deviant behavior'fincwhich "Mania"
was blamed could be close to what is currently called bi-
polar illness. manic phase.

Early Greek culture provided no specific treatment or
care facilities for the mentally ilL. But" as wisdom and
knowledge grew. Gross (1978) noted that "Aesculapian healing
temples were constructed on beautiful sites. adorned with
gardens and offering luxurious baths". (p. 100) Gross
further stated that in settings such as these. instructions
were given concerning diet. cleanliness. and dreaming.

Most likely. the healing temples were a form of the
seclusion process. McCoy and Garritson (1983) observed the
rooms were designed so patients could sleep and dream away
their illness. (p. 9) In a similar vein. Wells (1972)

discovered an observation written by a Roman. Soranus. in

24

the second century A.DJ
Have the patient lie in a moderately light and warm
room. The room should be perfectly quiet. unadorned by
paintings. .. . Do not permit many people. especially
strangers. to enter the room. And instruct them to
correct the patientds aberrations while giving them a
sympathetic hearing. (pp. 410-413)
However. it would be a mistake to presume that all the
treatment was as humane as in the Aesculapian temples.
Coleman et al.. (1980) said that often those who were too
ill to be helped were turned away: or those who were
recalcitrant were starved. flogged or chained. So basically
the early Greek period was one of transition. Exorcism and
harsh means were used in the context of accepted beliefs in
demonology. but the Greek time period was a beginning of
more enlightened treatment of mental disturbances. (p. 26)
As a part of this period of transition. and the
evolution of ideas concerning mental illness. several Greek.
Roman. and Arabic scholars eXpressed the belief that mental
disorders were a part of natural functioning and phenomena.
Plato and Hippocrates effectively put forth this position in
the fourth century. B.C. (Sarason. 1976. p. 9) The problem
was that as enlightened as these persons were.
"superstitious practices continued to determine the popular
attitude toward the mentally ill who were neglected. banned.

or persecuted". (Kaplan and Sadock. 1981. p. 21)

25

Instead of the progressive approaches (H: Hippocrates.
and others. many preferred less desirable means of
"treatment" such as bleeding. purging. and mechanical
restraints. Most likely the dark ages in the history of
abnormal psychology began around 200 AJL. at the time of
the death of Galan. a Roman devoted to the tradition of
Hippocrates. At this time popular superstition prevailed.
and most of the medical people of Rome returned to believing
in some form of demonology. (Coleman et al.. 1980. p. 29)

The Dark Ages in European history were brought about by
the fall of the Roman Empire toward the end of the fifth
century. The growth of superstition continued. and as noted
above. flnpacted<n1the treatment ofindividualsinflicted
with various forms of mental illness. As theology.
superstition and demonology became intertwined. "human
beings.. .became the battle grounds of demons and spirits
who waged eternal war for the possession of their souls".
(Coleman et al.. 1981. p. 30)

During the Dark Ages Christianity became predominant.
but treatment accorded the mentally ill was not reflective
of the Christian gospel of "Agape" or love. Benign
attitudes were suppressed. with belief in mysticism and
witchcraft becoming wide-spread. Religion became
contaminated with magic and alchemy. and "the authoritarian
church arbitrarily labeled specific behaviors unwanted or

undesirable and claimed it could exorcise the demons that

26

possessed people". (Sarason. 1976. p. 9)

In contrast. during medieval times. it was primarily
in Arabic countries where the more scientific aspects of
Greek thought on mental illness survived. In 792 A.D. a
mental hospital was established in Baghdad. and others were
established in Aleppo and Damascus. In the context of the
treatment received by the mentally ill. there was a
significant discrepancy between the apparent humane
treatment given in these areas and the more primitive and
cruel treatment given in Christian countries. (Coleman et
al.. 1980. p. 29)

In addition to the Arabians. there were others in this
time frame who attempted to present an enlightened and
scientific view. But more often than not they were labeled
heretics or trouble makers. As these individuals attempted
to suggest the thought that strange behavior might result
from a psychological or physical malady. it was summarily
rejected. As McMahon (1976) stated:

Medicine during the Middle Ages and the early
Renaissance was hopelessly inadequate when coping with
bizarre behavior. Most diagnoses of mental disturbance
by layman and "physician" alike seemed to amount to
labeling the patient either a "madman" or a "fool". (p.
22)

Even though by contemporary standards. the attitudes

and treatment for the mentally ill were primitive. generally

27

people were treated in a benign way. In some cultures.
those who were seen as deviant were viewed as being special
and possessing unique religious powers. But over-all.
persons were allowed to roam free and were left to their own
devices. unless they became a problem. Then the various
treatments of the time were put in place. Coleman et al.
(1980) made this observation:

During the early part of the medieval period. the

mentally disturbed were for the most part treated with

considerable kindliness. Much store was set by prayer.
holy water. sanctified ointments. the breath or spittle
of the priests. the touching of relics. visits to holy

places. and mild forms of exorcism. (p. 29)

But as theological beliefs and ideas concerning mental
illness became Inore developed and confounded. so too
treatment became more harsh. There seems to be a
correlation between the rise of the institutional church
and the rather ingenious ways that were devised to deal with
those people who were viewed as different. If persons were
seen as devient or dissident. they were dealt with in harsh
and cruel ways. and justified by church leaders as a means
to maintain the peace and the purity of the church.

It was in this context that the embryonic development
of seclusion and restraint methodology began to emerge. The
following was the belief which justified the harsh treatment

of those considered mentally ill:

28

It was generally believed that cruelty ix) peOple
afflicted with "madness" was punishment of the devil
residing *within them“ and when "scourging" proved
ineffective. the authorities felt justified in driving
out the demons by more unpleasant methods. Flogging.
starving. chains. immersion in hot water. and other
torturous methods were devised in order to make the
body such an unpleasant place of residence that no
self-respecting devil would remain in it.(Coleman et

al.. 1980. p. 33)

Thus. as the middle ages wore on. exorcism of persons
supposedly possessed by unknown and harmful intruders became
a regular occurence. It was in this context that beliefs
regarding witchcraft began to appear. As this train of
thought began to grow in the early 15th century. the new
system of printing. which facilitated communication. spread
the belief. Pope Innocent VIII. through a papal bull. in
1484 encouraged persecuting those accused. (Kaplin and
Sadock. 1981. p.3) There were some who were detractors.
but they were basically a minority. By the close of the 15th
century. persons mentally ill were considered heretics and
witches. (Coleman et al.. 1980. p. 34)

In addition to the harsh treatment given. including the
placment of mentally ill persons in prisons or in the
cellars of monasteries. by the 15th century some unique

means were employed to exclude the "mad". Miller (1976)

29

wrote about "ships of fools" and described the process this
way where mentally ill people were placed on:

ships with instructions to the captain to discharge

them at the next port.. . . The typical response..

.was to return these troublesome people to their native

city. and thus for a period the mad wandered back and

forth across EuropeJ'(p.4)

In the 16th century. monasteries and prisons slowly
relinquished caring for persons \Nlth mental disorders. As
this happened. special institutions for mentally ill persons
began to be established in significant numbers. Miller
(1976) reported about an historian who had written abouton
the mentally ill in the Renaissance and called the time.
"The Great Period of ConfinemenUh The newer approach
involved not only the mentally ill. but many other kinds of
"troublesome" persons. At first the purpose was containment
and maintaining social order: but restraint and seclusion
became more predominant. (p. 45)

Coleman et al.. (1980) wrote about the beginning of the
confinement period. and the establishment of one of the
first hospitals. or asylums. created. It was the monastery
of St. Mary of Bethlehem in London. which was created in
1547 under an edict of Henry VIII. Its name. as time
passed. became shortened to "Bedlam". and the institution
became known for deplorable practices and cruel treatment of

mental patients.(p. 29) IWcMahon (1976) indicated that in

30

places such as Bedlam. mentally ill persons were caged like
wild animals. If an individual was thought to be dangerous.
chaining him/her to the wall was the primary means of
control. (p. 23)

Many during the period were not comfortable with what
was happening: therefore rationalizations emerged which went
beyond the theological and medical justifications. McMahon
wrote about this time. including material from Foucault:

One of the reasons given for treating patients in this

fashion was that they were considered specially endowed

by nature with special "abilities" such as those found
in animals in which the "lunatic was protected from
whatever might be fragile. precious. or sickly in man".

For example. itziuas thought they could inherently

survive the cold. and thus had no need to be covered or

warm. Furthermore. this animality of the patient could

only be mastered by severe dicipline or torture. (p.

24)

Coleman 1H; al. (1980) presented an outline of the
growth of asylums for the mentally ill. which were
established in various countries during the next three
centuries: Mexico (1566). France (1641). Moscow (1764).
Vienna (1784). Philadelphia (1756). and Williamsburg (1773).
It was noted that the hospital in Williamsburg was the first
facility constructed in thelJnited States which had as its

exclusive purpose treatment of persons with mental

31

disorders. The authors also stated the basic problem with
these early asylums was they were essentially modifications
of prisons. Persons confined in them were treated more like
animals and criminals than sick persons. (p. 39)

The treatment given was justified by the animal like
rationalization indicated above. Yet. in this period. "the
arrangements that presented the insane as wild and dangerous
beasts was an appeal to the public to accept the moral
yardstick of the absolute state of its (””1 measure of
reason".(Doerneru 1981. p.17) Doerner then described how
most mentally ill persons were treated:

Special forms emerged. whereby the unreason of the

insane was related to social rationality. .. . The

insane occupied a special position -- and particularly
the most dangerous among them namely the frenzied. the

angry. the threatening. i.e. the maniacs. These were .

. . exhibited as caged "monsters" to a paying populace.

. . . These exhibitons in Paris. London and various

German cities vied for audiences with animal acts.. .

They were displays ofaiwild and untamable nature. of

"bestiality". of absolute and destructive freedonu of

social danger which could be demonstrated far more

dramatically behind the bars of reason. (p. 16)

The point of view the "exhibitions" showed was that
mentally ill people reflected humanity in a fallen state.

It was vividly shown to the people. and was to be a deterent

32

to the populace so they might more readily be motivated to
avoid Satan and thus be in a state of grace.

Snelling (1943). focusing on seclusion and restraint.
gave an overview of how the chronically mentally ill were
treated in a hospital in Paris.

The patients were ordinarily shackled mathe walls of

their dark. unlighted cells by iron collars which held

them flat against the wall and permitted little
movement. Ofttimes there were also iron hoops around
the waists.of the patients and both handsiand feet were
chained. Although these chains usually permitted
enough movement that the patients could feed themselves
out of bowls. they often kept them from being able to
lie down at night.. .. The cells were furnished only
with straw and were never swept or cleaned: the
patient was permitted to remain in the midst of all the

accumulated ordure. (PP. 54-55)

Coleman et al. (1980) observed that conditions for
mentally ill people in the United States were not much
better. They gave the following description of treatment in
colonial times:

The mentally ill were hanged. .. tortured and other-

wise persecuted as agents of Satan. Regarded as sub-

human beings. they were chained in specially devised
kennels and cages like wild beasts. and thrown into

prisons.. . like criminals. .. . They were left to

33

wander about stark naked. driven from place to place

like mad dogs. (pp. 40-41) subjected to whippings as ??

vagrants and rogues. (pp. 40-40)

Coleman et al. further noted:

Even as late as 1830. new patients had their heads

shaved. were dressed H1straitjackets. .. and placed

in a dark cell. If these measures did not quiet unruly

or excited patients. more severe measures such as.. .

cold baths were used. (p. 41)

Even with the controling and punishing methods
described in the preceeding paragraphs. the late eighteenth
and early nineteenth centuries was a period of transition in
the care of the mentally disturbed. It was realized that
not all mental patients had to be confined. secluded or
restrained. The person who who most symbolized this period
of change was Phillipe Pinel. a French physician who was
appointed to be the director of the La Bicatre Hospital in
France. The movement was known as "moral treatment". and
had a significant influence on how mentally ill people were
cared for in Europe and in the United States. (Almond. 1974
(p. xxxiv)

Pinel believed mental patients should not be chained or
confined in dungeons. but instead be treated with
consideration and kindness. He argued for reform during the
French Revolution. and as a part of an experiment the chains

were removed. after many had been shackled for over 30

34

years. Living areas were made more habitable. and patients
were allowed to walk around the hospital grounds and
generally have freedom of movement. The response was often
miraculous. with many patients who had been confined for
years going home with symptoms in remission. (Coleman et
al.. 1980. p. 42)

During this period there were others who contributed to
reform. Ir1 Italy Vincenzo Chiarugi (1759-1820) prohibited
cruel methods of restraint or physical force. with the
exception of occassional use of a straitjacket. William
Tuke (1732- 1822) in England began a hospital for mentally
ill Quakers. and developed a treatment philosophy based on
principles related to moral treatment. The only means of
restraint were strait-waistcoats. and confinement rooms for
temporary occupancy. (Kaplin and Sadock. 1981. pp. 4-5)

Ir1 the United States. 'the transition from ‘the
superstitious to more humane treatment was facilitated by
the moral therapy movement that was going on in Europe.
Benjamin Rush (1754-1813) and Dorothea Dix (1802-1887). wew
particularly influencial with both reformers being effected
by the work of Pinel and Tuke. Tuke had an impact in
Pennsylvania because Quakers from England settled in the
state. and imported with them Tuke's treatment philosophy of
dealing with the mentally ill. (McMahon. 1976. p. 24)

McMahon saw Benjamin Rush as an advocate for reform and

one who encouraged more humane treatment of those who

35

experienced mental problems. He placed great emphasis on
organic reasons as being a significant contributing cause of
mental disturbance. (p. 24) Jimenez (1987) writes about
Rush in the following terms: He "made the first and most
elaborate attempt to link somatic and ethical dimensions of
insanity in this country". (p. 72) He believed the brain
was essential to understanding the process and cause of
mental illness. Thus. he was "distinguished by being one of
the first American authors to describe madness as a
diseaseW.(p. 73)

But Jimenez observed that related to the cmganic
perspective was the moral dimension. Rush agreed with
Pinel's category of moral insanity. a concept which Rush
introduced to the United States in 1786. Thus. as Rush
speculated about mental illness. and saw it partly as a
moral and spiritual phenomenon. he thought:

Madness could affect both the will and the reason.

since the will was thought to be the seat of moral

faculty. The notion that the will was affected by
madness was central to the belief that failure of

willpower could lead to the condition. (p. 73)

The belief Rush had about the will being the seat of
the moral faculty contributed to a paradox “ibis point of
view. He believed in "moral insanity". and that the will
also had a great deal to do with controlling behavior. Rush

further thought that passions were a part of what made

36

madness what it was; therefore. control had to be imposed
when there seemingly was no control. For instance. he
invented the "tranquilizing chair" as a means to bring
mentally disordered persons back to sound reasoning. This
was a torturous device in which the patient was immobilized
by use of straps. The feet were tied to the bottom of the
chair: the hands to the arm rests: and the torso to the back
of the chair. About the head was placed a block-like
apparatus. which apparently squeezed in on the temple areas.
(Coleman et a1” 1980.IHL 44-45)

The punishing nature of some of Rush's treatment had a
direct relationship with his belief about the reason for
mental illness. From Rush's standpoint "madness" was often
brought about by lack of control and excesses of the mind or
body. Based on this frame of reference. aside from the
restraining chairs. he used other means that were typical of
the period such as purging. blistering. dunking in water.
blood-letting. and use (Hi straitjackets. Solitary
confinement was also used. All were thought to be useful.
especially for the unruly and those inflicted with the
wildness of mania. (Jimenez. 1987. pp. 108-109)

But Benjamin Rush was a symbol of the transition
period. and he established the first hospital that had as
its purpose treating persons with psychiatric problems.
Based on Tuck's philosophy. in 1817. the Friends' Asylum was

created in Philadelphia. and this was the first American

37

Hospital that had moral treatment as its basic treatment
philosopy. Almont (1974) reported that over the next 30
years 18 hospitals were built for this kind of treatment.
At first. they were privately backed. and then joint state-
private institutions were created. The first of these was
in Worcester. Massachusetts. (p. xxxv)

In 1833. the Worcester State Lunatic Hospital opened
and was created for the "furiously mad". It had the premise
that the hospital would have a system of humane treatment
that would not include whips. confinement. starvation. or
suffocation in water. But half of the 164 admitted were
viewed as hopeless and out of control. and they were
confined. Thus. from the beginning. the original purpose of
"moral" treatment iuas violated. In addition. the
confinement at Worcester served the purpose of removing the
people a great distance from the "sane population" of the
state. (Jimenez. 1978. pp. 114-115)

In the middle 1800Hh the 19th century optimism about
moral therapy provided a rich background for Dorothea Dix to
begin her work. Coleman et al.(1980) stated that between
1841 and 1881 she carried on an intense campaign:

that aroused the people and the legislatures to an

awareness of the inhuman treatment accorded the

mentally ill. Through her efforts many millions of
dollars were raised to build suitable hospitals and

some twenty states responded directly tolun*appeals.

38

(p. 45)

Overall. she is credited with the establishment of thirty-
two hospitals. two of which were in Canada. In addition.
she directed the reform of the asylum system in Scotland and
several others countries. (Coleman et al.. 1980. p. 50)

hi spite of the impact (fl: Rush and Dorothea Dix.
attitudes toward the mentally ill were still based on
superstition. fear. and repugnance. But with Dix's work
there was a significant beginning to a public system to
treat mental patients. "at the same time the original small
asylums had been transformed into large custodial
institutions to house chronically ill patients. Once again.
the therapeutic function provided by the Inilieux was
reverting to confinement." (Gunderson. Will. and Mosher.
1983. p. 2)

According to Jimenez (1987) the direction toward
confinement had begun in Massachusetts with a 1796 law which
authorized the detention of those called "furiously mad".
With this legal justification. the trend toward confining
the harmless insane became accepted policy. This movement
carried into the nineteenth century. and into the twentieth
as well. This meant that the custodial mental hospital
became the primary solution for treating mental illness all
over the country. By 1875 there were more than sixty state-
supported mental institutions in the United States. (pp.
137-138) Coleman et al. (1980) noted that the rural

39

institutions Dix advocated as places for moral treatment
became in the last half of the nineteenth century:

the big house on the hill" with its high turrets and

fortresslike appearance (and) became a familiar lan-

dmark in America. .. . To the general public .. .

the asylum was an eerie place. and its occupants a

strange and frightening lot. (p. 46)

The hospitals were supposed totnecenters of holistic
treatment. and places where persons could experience
meaningful care. Instead they became large facilities.
housing thousands of emotionally disturbed persons. The
reformers 1vho advocated Inoral treatment inadvertently
created chaos. With the large influx of patients from all
directions. the staff and the facilities became overtaxed to
the breaking point. Because of the large numbers. control
rather than treatment became the central issue. (McMahon.
1976. p. 26)

Almond (1974) presented a picture of the period by
citing Henry Burdett. an English physician who in 1891
described care in American mental hospitals through a four-
volume study called 222212.12 222 2211222 2: 222 E2212-
Burdett said "it would appear lunatics in America were still
regarded as a class to be confined first. and perhaps cured
afterwards". American institutions were depicted as being
overcrowded. deteriorating. extensively using physical

restraint and Inanipulation. and very seldom having a

40

therapeutic orientation. (p. xxxix)

Because of the increasing numbers of people. many being
unmanageable. various devices were created for purposes of
control. For example. as late as 1882. many institutions
used the "Utica crib". It had the shape of a single bed.
with slats eighteen inches in height on the sides. The top
and bottom were also covered with slats. The person would
be forced into the crib. and kept there many hours. until
he/she calmed down.

Clifford Beers. in 1908. published A Mimg_lmgt Egmmg

133311. In this autobiographical account he described his
own mental illness and treatment in three institutions.
Chains and other torture devices were not used. but the
straitjacket was. He told of the painful immobilization of
the arms. and how this affected him and other overwrought
mental patients by increasing inner excitement. (Coleman et
al.. 1980. pp. 45-46)

In addition to devices such as the crib and strait
jacket. the seclusion room became a reality in the many
hospitals built in the late nineteenth and early twentieth
century period. Inspection of buildings built during this
time shows numerous rooms being set aside for seclusions
purposes. This was true in the large public hospitals and
in the smaller private facilities as well. As the hospitals

became more overcrowded. and control issues became more

predominant. staff persons. for the most part. were

41

untrained or unaware of issues related to moral treatment.
When difficult management issues arose. and because of staff
attitudes toward the mentally ill. the seclusion room became
the primary answer to solving the problems of out-of-control
patients.

Another significant change began to take place as
treatment philosophies changed in the decades around the
turn of the twentieth century. As written above. one of the
contributions of Rush was his thought that the causes of
mental illness could be found in the organic realm. As this
focus began to take hold. physical means of treatment became
more predominant.

All through history. there have been attempts to alter
the behavior of the mentally disordered by means of physical
manipulations. Earlier. mention was made of treatment
directed at the body through the process of a trephined
skull. Barbiturates have been used for centuries as a means
of calming hyperactive persons. McMahon (1976) noted that
various forms of "shock treatment" also have been used since
the eighteenth century. Examples of some rather primitive
and gruesome procedures included dropping persons into snake
pits oraavat of cold water. and injecting the person with
various diseases such as small pox. The idea behind all of
this was to stimulate the organism to the point where the
individual would be shocked into reality and sensibility.

(p. 251)

42

This kind of treatment was often used as a form of
punishment and control as well as being used in attempt to
heal and cure. Coleman et al. (1980) observed:

The fundamental purpose seems to have been not so much

to frighten the person out of his or her madness. but

rather either hipunish the demon Hiresidence in the
patient's body or to alter the patient's physical or
biological state which was presumed to be the under-
lying cause of disorder. The latter rationale still
forms the basis of biological treatments of the present
day. though methods have become more sophisticated and

more guided by scientific advances. (p. 617)

In the early 1900's. the intrapsychic or dynamic approach
came into being. especially with the Freudian influence. In
some respects. this persepctive has its heritage in the
moral treatment movement. and made use of some of its
methodology. especially "talk" therapy. But in the United
States. as the Twentieth Century progressed. Kaplan and
Sadock (1981) observed the period could be "characterized by
a rather strong dichotomy between the biological orientation
and the dynamic orientation". (p. 10)

The biological. or physical. methods did become an
important part of treatment methods in the 1930's and the
1940's. especially shock treatments and psychosurgery.

Coleman et al. (1980) wrote that shock treatments. or

43

convulsive therapies. in contemporary times. came into usage
when insulin shock therapy was introduced in 1932. This
method of treatment was seen as dangerous. unreliable and
disappointing. In its place came electro-convulsive therapy
(ECT). which was introduced in 1938. At first. this means
of treatment was used for a variety of psychiatric
conditions including schizophrenia. hysteria. obsessive—
compulsives. personality disorders. various other forms of
neurosis. and depression. Without understanding why. it was
discovered that ECT had positive effect on depression. and
is currently used in most private hospitals as a form of
treatment for endogenous type depression.

Coleman et al. also wrote about a surgical procedure
which was introduced hithe 1930HL "prefrontal lobotomy".
"In the two decades between 1935 and 1955 (when the new
anti-psychotic drugs became widely available) tens of
thousands of mental patients throughout the country and
abroad were subjected to prefrontal lobotomy and related
neurosurgical procedures." (p. 620) This form of treatment
was an attempt to help people who were suffering chronic
psychoses. But a tragic feature was that psycho-surgery
became a means of controling unruly and out-of—control
patients. The problem with the surgical procedures. in
addition to the misuses. was significant side effects.
including death.

The point in bringing in the development of these

44

various treatment modalities Hithe context ofaastudy on
seclusion is that these approaches were used as ways to
control patients who would be out of control or who would
not conform. Ken Kesey (1962) in 9mg £13m Over the Cuckoo's
Nggm particularly brought out this perspective in a
fictionalized account of his own experience in psychiatric
treatment. His primary character was a rebelious person.
who would not be controlled within the context of the milieu
of the hospital. As a result. he first was secluded and
restrained. When 1H3 continued to rebel. ECT was
administered. Finally. when he disrupted the facility
routine one time too many. a prefrontal lobotomy was
performed.

Kesey's position has been criticized as not reflecting
the reality of much of psychiatric treatment. but these
procedures were used as a means of control and restraint in
recent past history. An example will illustrate how these
treatments were used to control patients who would not. or
could not control themselves or fit the expectations of the
treatment facility. In the middle 1950's. at a private 100
bed middle-west psychiatric hospital. ECT was used as a
means of treatment as well as control. This facility also
made extensive use of seclusion and restraint. especially
with straitjackets. ECT was used for a variety of
diagnostic categories as well as when patients became unruly

and unmanageable.

45

The procedure was to first seclude an agitated
individual in one of the fifteen seclusion rooms located in
the basement c”: the acute-care building. In addition.
various barbiturates were used in conjunction with the
seclusion room. If the person did not calm down. then
he/she would often receive ECT. The patients all reported
fearfulness about receiving ECT. and often the promise of
the procedure acted as a deterrent to out-of-control
behavior. A common comment by some direct care staff was.
"If you don't shape up. you'll be zapped". In July 1954.
the psychotropic medication. Thorazine. was introduced to
the facility for experimental use. Almost immediately.
seclusion room usage was cut in half. and as this facility
moved into the emerging era of pharmacology. so did a new
form of restraint. i.e. chemical restraint and control.

In the same hospital. another way to control patients
was the use of enemas at least twice a week. This practice
at the facility was never explained medically. Because
constipation was not a significant problem of the patients.
the practice was reflective of the early purgings that were
used hundreds of years ago.

As mentioned earlier. the 1950's brought in a new era
when medication compounds were discovered which could
significantly impact on treatment outcomes. Coleman et a1.
(1980) reflected on how drugs were used prior to the

introduction of psychotropic medications in the 1950's:

46

Early efforts in this direction were limited largely to

a search of chemical compounds that would have

soothing. calming. or sleep-inducing effects. Such

drugs. .. would make it easier to manage distraught.
excited. and sometimes violent patients. Little
thought was given to the possibility that the status
and course of the disorder itself might actually be
brought under control by appropriate medication: the
focus was on rendering the patient's overt behavior
more manageable and thereby making restraint devices

such as straitjackets unnecessary. (p. 621)

As psychoactive medication became a more central part
of treatment. especially in custodial facilities. seclusion
and restraint practices did go through a process of change.
i.e.. treatment facilities used seclusion rooms with less
frequency.

As the 1960's progressed into the 1970's. with the new
therapeutic developments. psychiatric patient population
figures began to become smaller. Jimenez (1987) observed
that until the middle of the Twentieth Century:

The custodial mental hospital was the dominant solution

all over the country. .. . By 1875 there were over

sixty public mental hospitals in the United States. In

1976. thirteen years after the federal government

inaugurated a policy of deinstitutionalization and a

reduction in the number of state mental hospitals

47

through the Community Mental Health Centers Act. there

were three hundred public mental health hospitals in

the country.(p. 138)
For a period well into the 1980H5the reduction in patient
population continued. But in recent years. the patient
numbers in public hospitals has begun to creep up to 1963
levels. As admisions increased. and as there have been
significant cut-backs in the availability of financial
resources for mental health care. problems related to
seclusion and restraint usage again became significant.

The historical survey is summarized in Table 1. It
shows that seclusion and restraint has been consistantly

used from the earliest times to the present.

Table 1:

Mentally

48

An Historical Overview

Ill

of the Treatment of the

 

TIME PERIOD

SOURCE OF ILLNESS

TREATMENT METHOD

 

To 500 BC

500 BC to
100 BC

100 BC to
400 AD

Dark ages
to
1500's

1600's

1700's

1800's

1900 to
present

Demons.
whether
"bad"

spirits
"good" or

Greek popular:
Super-natural

powers:

Greek

scholarly:

natural

powers

Enlightened view:

physical
popular

reasons:
view:

devils and demons

Spirits
demons.
and devil

Demons.

"special abilities"

Primitive physical

etiology
Spiritua

physical

At first
ologica

inhabiting.
evil spirits

S

animalism

l and
Psych-
1 causes.

and later bio-

logical and stress

induced.

Exorcism. religious
incantations

Some religious through
healing temples. For
others. flogging and
chaining.

For enlightened. retreats
and quiet: Popular view -
purging. bleeding. and
mechanical restraints.
Benign - people roaming
free.

Exorcism. burning at
stake torture. chaining.
imprisonment. isolation

Confinement in prison.
small homes. work houses.
and wandering: also
seclusion and restraint.

Cages. chains.
bloodletting.
hospitals.

purges.
jail. first

Moral treatment. some inc-
luding physical modalities:
large facilities in [L54
seclusion and restraint
towards end of century.

Large hospitals. talk
therapy. pharmacology.
ECT and various forms of
restraint and seclusion

 

49

Recent Historical Perspectives

As the historical review showed. various forms of
seclusions and restraint have been used to deal with
mentally disturbed persons. Contemporarily. patients have
continued to be placed in seclusions rooms: restraints are
still used. including straitjackets: and lately. chemical
restraint by means of medicinal compounds has become more
comnunn As behavior control interventions. seclusion and
restraint have a long history. But many over the years have
raised questions about the validity of seclusion and
restraint. either from a treatment philosophy point of view.
a legal perspective. or a recipient rights frame of
reference. Soloff (1987) made this observation:

In an era of psychodynamic: sophistication and

pharmacologic advances. discussing physical control of

the mentally ill may seem distinctly anachronistic. To

some. the discussion may suggest regression to the

methods of a less enlightened era. Memories may be

evoked of the nonrestraint movement of the last

century. which challenged the legitimacy of physical

controls as a form of treatment for the mentally ill.

(p. 119)

There have been some attempts to establish treatment
programs where there will be no use of physical restraints.
Gove and Lubach (1969) report on one program known as the

"Northwest Washington Hospital -- Community Pilot program".

50

The program came into being in the 1960's. when non-
traditional approaches were encouraged and funded by the
federal government through the National Institute of Mental
Health.

Greenblatt. York. and Brown (1955) wrote about some
significant attempts to eliminate the use of seclusion and
restraint practices at the Boston Psychopathic Hospital
during the 1940's and early 1950's. The primary goal was to
use the social environnunfi; of the hospital for therapeutic
purposes. Greenblatt et al. believed that various forms of
restraint and isolation of patients were an "evil" which at
first may have served some purpose.tnn;had since outlived
its usefulness. It was stated:

The "evils" we have discussed consist. therefore.
essentially in overroutinization. emphasis upon
procedure rather than the person. lack of knowledge
concerning patients' feelings among the staff. and lack
of adequate inotivation for serving the basic
psychological. as contrasted with physiological. needs
of patients.(pp.83-84)

In spite of the philosophical questions. seclusion and
restraint remain as treatment and control methods. A vast
majority of psychiatric hospitals continue to have areas
which are called a variety of names -- quiet room. isolation
room. seclusion room. segregation room. or multipurpose

room. All have the stated purpose of protecting the

51

patient. peer patients. and/or staff from violent or out-of-
control behavior. which would lead to injury or to the
destruction of property.

Because practices concerning seclusion and restraint
remain a troublesome concern to the mental health community.
the topic has generated increased discussion in recent
years. This is best illustrated by the interest the
American Psychiatric Association has taken on the issues of
physical controls in treatment. A task force was appointed
in 1981. and the results of the work of that group were

published in a report Task Force Report 22: Seclusion and

 

 

I30

EEELEIEE (1985): and in book form (1984) under the title
of 122 E2222122212 2222 2: 22.21.2122 2-2 522222122 It is
because of the uses and potential abuses of seclusion and
restraint that the issue of physical control has continued
to plague the mental health field.

The APA Task Force Report (1985) placed the subject in
this perspective:
Today the scope of this problem. its social and profes-
sional implications are poorly understood outside of
psychiatric circles and underestimated by many within
the mental health field. . . . We live in violent
times. .. which extends;to the working reality of the
psychiatric treatment setting. . . . Social forces
outside the profession direct our efforts toward the

care of violent patients Niever growing numbers.(p. 3)

52

In its report. the Task Force mentioned social policy
decisions which have impacted on mental health practices.
Coleman et al. (1980) told of one significant policy
development which took place in 1963. when funding from the
federal government was made available through the Community
Mental Health Centers Act. 'This program came about as the
result of a message sent to Congress by President John F.
Kennedy and his request that there be "a bold new approach"
to mental disorders. Since the enactment. of the
legislation. over 700 community-based centers have been
formed. The basic goal of the program was to deinstitu-
tionalize persons from large custodial psychiatric
hospitals. and return as many as possible to the community.

On the positive side. there was a significant reduction
in patient populations of the large state custodial
hospitals. Many of the people were able to succeed in
staying out of hospitals because of the out-patient programs
of the community mental health agencies. and the newly
discovered medications which helped persons keep psychiatric
symptoms under control. On the negative side. Tardiff
(1985) spoke about deinstitutionalization creating a flood
of chronically disturbed patients who were:

often poorly prepared for independent existence.

inadequately supported by community resources.

increasing the visibility and frequency of .. .

violent behaviors in the community.. . . These

53

patients turn in increasing numbers to emergency rooms

of the community mental health centers or general

hospitals. and a variety of acute psychiatric inpatient

settings for. .. treatment.(p. 3)

Legislative funding priorities in recent years have
affected the ability of community agencies to respond in
significant and meaningful ways In the 1960K“ when the
community mental health legislation was enacted. there was a
committment to funding the programs. even in the times when
defense spending was increasing because of the Vietnam war.
President Johnson maintained during this time a "guns and
butter" policy. as far as budget priorities were concerned.
Thus. many social programs received their fair share. But
as economic and political times changed. undid the fiscal
priorities. Mental health programs became more and more the
responsibility of states and counties. meaning that many
programs were not renewed. Slowly. pressures began to build
whereby hospital in-patient levels started moving upwards.
with many of those returning for hospitalization being more

prone to out—of-control or violent behavior.

Social Forces and Seclusion
Even though social policy has impacted on the seclusion
and restraint question. other social forces also have played
a central part in confounding the problem. The increase of
poverty and economic disenfranchisement has been a part of

this. Auletta (1982) wrote of a society that has been

54

developing a significant underclass who have struggled to
survive. and thus live with a great deal of distress.

One result of the negative stress can be extreme anger.
and also atypical psychotic breaks. Since these persons
have not been able to afford private hospitalization. they
end up at emergency centers. community-based psychiatric
treatment facilities. or* many. eventually. at state-
supported acute care units. Most are involuntary. and will
not take medication at admission or prior to a.cmurt
decision. Thus. when violence happens. seclusion and
restraint is one behavior control option significantly
employed. Ryan (1971) states the problem is that most of
these people are blamed for their illness. when the reality
is that they are psychologically breaking down under the
pressure of being poor.

In terms of the underclass and poor being
psychiatrically hospitalized. the "blaming the victim"
syndrome created an additional dilemma. Most staff who
attendediu>the mentally iTlin treatment facilities came
from a middle class background. or at least had that
cultural influence as a part of their makeup. In many
psychiatric facilities that provided services for poor
people. many of the staff had a great deal of difficulty
being empathic to the stresses of the underclass and disen-
franchized. Because of 'the lack (H: understanding.

communication problems often resulted. This showed most

55

often when aggression on the part of a patient became a
problem. and the lack of communication often ended up with
patients being secluded rather than less restrictive means
used to solve the problem.

Another social issue which has impinged on psychiatric
units is alcohol and substance abuse. An emerging
diagnostic puzzle has been that of the dual diagnosis. and
attempting to ascertain whether a psychiatric problem is
purely a case of mental illness: or whether the psychotic-
like behavior is being caused by drugs or alcohol. Soloff
(1987) considers the problem ‘UD have epidemic proportions.
In the 1960's and the 1970's the drugs of choice were LSD.
amphetamines. PCP. along with marijuana and heroin. These
drugs have often resulted in organic damage to the brain.
causing a greater number of violence-prone individuals. The
consequence has been that many persons experienced
psychosis. aggression to others. suicide. or self—
mutilation. In later years. "crack cocaine" has taken over
in the urban centers and in many rural areas: the full
implications of this epidemic have not become known. But
psychiatric units have increasingly admitted persons with
new disorders of chemically associated violence. Alcohol
abuse has had a similar outcome. The end result has been
the creation of new behavior management problems in

psychiatric facilities. both public and private.

56

Legal Issues Related 33 Seclusions

 

Another dimension of social policy that became more
prominant has been legal challenges. Treatment issues.
especially psychiatric ones. have come to the forefront in
the courtroom during the last twenty years. Most likely.
this trend comes in the context of a greater awareness of
and conunitment to civil libertarian issues. As a part of
this awareness. our society has become more litigation
oriented: and seclusion and restraint issues have not
escaped the emerging process.

Garritson (1983) gave information about legal
applications that have focused on a treatment premise called
the "least restrictive alternative". This premise was first

applied in the landmark case of 23k

y; 22mgmgm (1967). The
case focused on involuntary commitment to a psychiatric
hospital. and whether a patient had the right to be
considered for a treatment setting that iuas less
restrictive. The plaintiff won her case. and other cases
followed which extended into the treatment received in
hospitals. One case. 23mm13.y2.§lgim (1979) resulted in a
court ruling "that antidepressant and antimanic medications
were less restrictive than antipsychotic medications". (p.
16) Two of the most significant cases have been 19me rg

v. Romeo (1982) and Agger§.y2'ggim (1979).

Tardiff (1985) considered Youngberg as the primary case

which has focused on seclusion and restraint. Romeo. a

57

profoundly retarded person. was an involuntary patient at
Pennhurst State School and Hospital in Pennsylvania. and
while hospitalized was injured on many occasions. The
injuries sustained were sometimes due to his own violence.
and on other occasions due to the reactions of other
residents. In the context of the violence. Romeo was often
physically restrained. Pennhurst and its officials were
sued because Romeo claimed he had a right to freedom of
movement as well as safety and training. Dix (1987) stated
the court ruled in favor of Romeo when it held "that a safe
environment must be provided and that any decision to
restrain (seclude) a patient must be made in accordance with
a professional judgment and not in a cavalier manner". (p.
202)

Youngberg established. according to Coval (1983) three
new constitutional torts: (a) the right to be free from
undue bodily restraints: (b) the right to personal
protection and security: and (c) the right to adequate
treatment. In terms of restraining an individual. it was
found that the "shackling" must be the least restrictive
means of dealing with a patient. and there must be
compelling reasons for whatever restraining action is taken.
Coval noted that an implication of the case was that
restraints cannot be used for the convenience of the staff.
Regarding the compelling reasons for restraint. Justice

Powell. in delivering the opinion of the Supreme Court.

58

stated the decision regarding reasonable restraint must be
based on the judgment exercised by a qualified professional.

"when the decision by the

and that liability is present
professional is. a substantial departure f1wm1 accepted
professional judgment". (PP. 15-16)

The Supreme Court decision in the Romeo case was not
clear in its clinical implications. according to some
observers. Tardiff et al. (1985) stated:

Perhaps the most important point about lggmgmgmg y;

Agm_g is not precise rule of law announced by the case

but rather its general and clear-cut attitude about the

propriety of deferring to professional judgments and
the clinical considerations.. .. Romeo teaches that
legal arm ethical concerns wjll give substantial
flexibility to clinicians. .. . (and) .. . suggests
that emergency seclusion or restraint may well be

warranted to prevent behavior that would be seriously .

. . disruptive to the therapeutic community. (pp. 14-

16)

Tardiff's belief was that Romeo did give a great deal
of leeway. but not in non-emergency situations. Also. using
seclusion and restraint for punishment purposes was not
fitting: and for treatment purposes. questions were
unanswered.

Wexler (1982) agreed that clinicians and staff possess

a great deal of legal leeway in administering seclusion and

59

restraint in emergency situations. But. even with this kind
of flexibility. there is a "Catch-22" kind of situation
whereby staff had to be cognizant of protecting patients
from themselves and others, but yet be aware of the least
restrictive alternative applicable. Wexler considered the
case in the context of treatment questions. particularly an
approved behavior therapy program. If such a program sought
to use methods such as locked time-out and contingent
restraint only with regard to patients engaging in. or about
to engage in. behavior that was destructive. disruptive. or
seriously dangerous. then Romeo could be interpreted in such
a way that could be comparable to an emergency situation.

Cook (1983) summarized the impact of Romeo. and stated
that mentally disabled persons cannot be deprived of due
process and certain "liberty interests". such as:

1. Reasonable care and safety:

2. Freedom from bodily restraint:

3. Adequate food. shelter. clothing and medical care:

4. Those liberty interests to which convicted criminals

are entitled: and

5. Adequate training and habilitation to ensure the

enjoyment of liberty interests that are recognized as

constitutionally required.
Cook comments further in regards to freedom from bodily
restraint:

Residents of institutions have the right to freedom

60

from the inappropriate use of . . . physical

restraints. The right also encompasses confinement in

a "seclusion" room or "time-out" room and may preclude

unnecessary strictures on the movement of residents.

(pp.346-357)

Gutheil (1980) discussed the Boston State Hospital
case. nggmg y; 921m (1979). This litigation came about
because of a dispute by a group of mental patients who
wanted to enjoin certain seclusion and medication practices
at the hospital. and who desired to recover damages from
those responsible for the practices. One of the patients
was a large man who had problems with outbursts of
aggressive behavior. He was secluded for thirty days.
though in the latter days of the seclusion he received
progressively longer time—out periods. He was also
medicated while in seclusion. The court ruled the first
four or five days of seclusion were fitting. but the
remaining days were viewed as questionable. It also ruled
that a patient who was competent had the right to refuse
medication. As medication has become more prevalent in
psychiatric treatment this is a significant issue. Rogers
y; 921m also had significant impact on issues related to
seclusion and restraint versus treatment.

Gutheil (1980) expressed that the case created
significant problems in the treatment of mentally disabled

people. especially concerning seclusion and medication

61

practices in relation to historical treatment
responsibilities. If the use of seclusion. restraint and
medication must be curtailed and /or limited. the issues
that remain center on the rights of innocent third parties.
the orderly administration of institutions. and the welfare
of psychotic patients themselves. The conclusion was that
the Boston State Hospital case showed with clarity how far
apart the law and the pragmatic world of clinical issues can
be. and that some resolution is required. In addition. the
Rogers decision. Gutheil believes. created more questions
than it answered.

Coval (983) summarized another case related to the
issue of seclusion and restrainh which was gliigg y;
22mpggli (1982). Clites was a mentally retarded person who
at age 21 was admitted to a State of Iowa residential
facility for the developmentally disabled. In 1970 his
treatment program included the prescribed use of psycho-
active medication used Via poly-pharmacological way. He
was also secluded. restrained. and shackled to his bed in a
spread-eagle fashion. Because of the use of the medication.
tardive dyskinesia developed in a way that was permanent and
disabling. The court ruled against the State of Iowa in the
following areas: on excessive use of psychoactive drugs and
polypharmacy: failure to follow precautionary fitting
measures: and neglecting to abide by industry standards of

care practices. In the issue related to seclusion and

62

restraint. the court ruled staff did not have knowledge of
the institutional policy on physical restraints. and that
physical restraint was used for the convenience of the
staff. and not for reasonable medical treatment.

The "least restrictive alternative" is a central
concept in seclusion and restraint issues. Gutheil et al.
(1983) believed the concept of the least restrictive
alternative (LRA) has been misunderstood and probably
misapplied in relation to interventions commonly used in
psychiatric hospital wards. ids seclusion. restraint. and
forced medication. In a clinical and ethical analysis of
problems in the applications of LRA. the authors presented
evidence which demonstrateml the arbitrariness of the
classification of restrictiveness. Based upon the
examination of the issues. Gutheil et al. concluded that LRA
was an inappropriate model fortiealing realistically with
clinical issues raised by the involuntary treatment of the
institutionalized mentally ill.

Garritson (1983) looked more favorably on the least
restrictive alternative. She viewed the treatment concept
as progressive and enlightened. but believed that LRA was
susceptible to subjective interpretation. As a means to
create more objective criteria for the LRA frame of
reference in treatment. sixciimensions of restrictiveness
were discussed: structure. techniques. attitudes.

regulations. enforcement and patient characteristics.

63

Structure was related to the forms of restrictiveness:
regulations were described as the policy of an institution:
enforcement was defined as consequences that apply to staff.
if policy was not followed: attitudes were seen as staff
perception of patients and degrees of staff
authoritarianism: and patient characteristics were discussed
as the level of functioning of the patient. It was stated
that further research was required to determine the degree
of restrictiveness routinely experienced by patients with
different kinds of symptoms.

Some authors rejected outright the use of restraint and
seclusion and other intrusive means of treatment. Murray
(1979) presented this point of view 'hi the context of
unresolved ethical issues that relate to hospitalization on
an involuntary basis at a state hospital. He assumed a
strong civil libertarian point of view. viewing the use of
seclusion and restraint as a form of patient punishment. He
stated these tactics of control were both immoral and

illegal.

State and Facility Policy
Because of the philosophical. social policy. legal and
environmental pressures. state mental health agencies have
attempted to address the issue of seclusion and restraint
through a variety of policy statements. The American
Psychiatric Association. through its task force on seclusion

and restraint. surveyed mental health directors in the 50

64

states of thelLS. Tardiff (1985) reported that the survey
generated 36 responses from state directors. with 23
reporting state-wide written regulations and 20 reporting
policy established by each state facility.

The substance of the survey. according to Tardiff. was
that most states were in agreement on the basic indicators
of need for restraint and seclusion. with the reasons
focusing on preventing harm to the patient or to others. A
few included general disturbance and destruction of property
as reasons for isolating the patient from the rest of the
milieu of the ward. Also. a number of states did report
problems iri implementing the seclusion guidelines and
policy. There was a great deal of variability in areas such
as who makes the decision about secluding: how long a person
may stay H1 seclusion and restraint: and required
documentation.

The Michigan Department. of Mental Health has
established statewide and local policy requirements. and
these are based on the Michigan Mental Health Code (1986)
(Appendix A) and Department of Mental Health Administrative
Rules (1987). (Appendix B) The seclusion section of the
Administrative Manual stated the follow purpose:

To establish policies and standards for the use of

seclusion when seclusion would be of clinical or thera-

peutic benefit for the patient/resident. or to prevent

a patient/resident from physically harming himself or

65

others. or in order to prevent patient/ resident from

causing substantial property damage. (p. 1)

The application covered all programs operated by DMH or
under contract with the state agency. Justification was
covered. along with time requirements. record-keeping. who
may authorize seclusion. and requirements for evaluation
while a person was secluded.

As part of DMH requirements. each facility was to have
in place resident policies regarding seclusion. as well as a
freedom cfi' movement policy. Each state-supported DMH
institution must report on a quarterly basis to the central
office. The total number of facilities involved was
seventeen and covered the developmentally disabled. mentally
ill. forensic. adolescent and children's units.

The Caro Regional Center served both the develop-
mentally disabled and the mentally ill. with the one
seclusion room located Hithe Psychiatric Unit admissions
building. The Caro policy (1986) (Appensix C) was
institution wide. and was oriented to the treatment program
at the Caro Regional Center. The policy statement reflected
statewide policy and directives. with the addition of the
term "temporary" in the Caro language. The facility policy
regarding seclusion and restraints was discussed by Roll
(1985):

We have only one seclusion room in the facility.

located in the admissions/acute care unit. The room is

66

seldom used except for new admissions when we have not
obtained a treatment order. . . . Seclusion is NOT
used for any purpose other than to protect patients and
staff when the patient is not able to control his
behavior. . . . Mechanical restraints are only used in
the medical treatment area when necessary for medical
treatment. e.g. I.Vfls. . . . Medications are
monitored closely. and every effort made to avoid

excessive medication and polypharmacy. (p. l)

The belief behind the treatment program as outlined by
Roll was that 'H; was not necessary to control patients
unless they were endangering themselves or others. The
primary ain1 of the program inas to help individuals to
control themselves. When a person's behavior was not
fitting. the goalcflia treatment program was to assist the
person in gaining control of his/her behavior. Punitive
responses to pathological behavior were not tolerated:
rather assistance was given to effect more appropriate
behavior.

The use of restraint was covered in resident policy
(1983) at the Caro Regional Center. and was similar to State
seclusion policy. A significant difference was that
restraint was used solely in the developmentally disabled
hospital ward. On the other hand. medication restraint was
sometimes used1va1the mentally thipopulation. In this

kind of situation. if staff observed a patient escalating

67

toward aggressive and/or out-of—control behavior. a request
or recommendation was made for as as-needed. or PRN. shot.
usually Ativan or Haldol.

Within the organization of the Caro Regional Center the
Behavior Management Committee was concerned about uses of
seclusion and restraint within the institution. One of the
functions of the Committee was to make certain that policies
regarding seclusion and restraint were fiallowed. and
alternatives to secluding patients were considered. The
Behavior Management Committee also had the task of reviewing
particular seclusion incidents that lasted more than two
hours. or when an individual patient was secluded more than

three times in an admission.

Research and Theoretical Questions

 

Staff Training

 

The issue of staff involvement and awareness of
institutional policy was a critical issue in relation to
seclusion practices. Soloff (1987) stated that "The
psychiatric literature is strangely silent regarding the
actual techniques of properly applying seclusion and
restraint". He then said:

Psychiatric residents are rarely prepared for managing

violent or disruptive patients. and nurses. attendants.

and security staff fare little better in their

training. The theory and practice of seclusion and

68

restraint must be effectively taught to front-line

mental health personnel. (p. 132)

Tardiff (1985) observed that the APA task force review
showed uniform techniques regarding seclusion and
restraining maneuvers were lacking on a nationwide basis.
The report did point out that the Department of Mental
Health in Maryland had a program for certification of mental
health personnel in seclusion and restraint techniques. The
State of Michigan also had developed a training program for
direct care staff in order to sharpen staff skills in least
restrictive alternative interventions. when patients become
disruptive.

Romanoff (1987). in reporting about management and
control at Western Psychiatric Institute in Pittsburg.
emphasized the seclusion and restraint policies. Out of two
weeks of training in clinical orientation: "a total of 18
training hours [are] devoted to the clinical management and
prevention of patient violence. . . . These skills are
periodically updated. and staff receive annual certification
in crisis control." (p. 242) Others have discussed the
need for staff training. including Gertz (1980): Hacket
(1981): and Lehmann (1982). This review did not discover
empirically-based studies which evaluated the outcomes of
staff training programs. and whether or not usage of
seclusion was reduced because of the training.

Various approaches to training included demonstration.

69

lecture. use of audio-visual materials. small group
discussion. and direct observation. DiFabio (1978)
described a program that taught the use of restraint through
role-playing and discussion. The program focused on
techniques of management. feelings generated by having to
restrain a patient. and policies of the institution. She
said the value of the program was that it generated empathy
toward the patient. fostered understanding of policy. and
helped staff have a feeling of shared experience and mutual
respect. DiFabio believed the program could be applied to

different kinds of psychiatric settings.

General Issues

 

Various types of research literature regarding general
questions concerning seclusion were readily available. The
following is a sample of a larger population of articles and
reviews. McCoy (1983) observed that seclusion as a method
of psychiatric treatment remained controversial from a
variety of perspectives. including treatment philosophy.
ethical. and legal. In order to provide a rationale. two
theoretical explanations were presented: (1) a technique to
reduce sensory stimuli for patients who were overly
sensitive to the environment: and (2) to protect group
integrity. It was recognized that personal liberty
questions were involved when considering whether or not to

seclude a patient.

7O

Roper (1985) reported on an audit on the use of
mechanical restraints and seclusion in psychiatric care.
Issues considered were patient diagnosis. nmdication usage
in relation to seclusion and restraint. and time of day that
incidents of seclusion and restraint took place. In
addition. purposes and outcomes for seclusion and restraint
were considered. One finding was that usage of seclusion/
restraint was highest during the day. Based on the study a
standard care plan was devised to deal with the problem.

A view of the role of physical restraint was considered
by Rose and DiGiacomo (1978). wherein the practice was
considered to be a specific therapeutic technique with
definable indications. dosages. contraindications and side
effects. The approach was similar to how medication usage
would be indicated or contraindicated. It was stated that
few guidelines have appeared in recent psychiatric
literature. thus the need for the approach. One dimension
considered in the article. going beyond commonly stated
reasons for secluding patients or restraining them. was the
request for restraint by the patient. Criteria for
evaluating the duration and effectiveness of the treatment
were proposed by the authors.

One perspective considered that has not often been
covered in the literature. cn' in guidelines regarding
seclusion and restraint. was that of secluding a patient in

order to defend the social mileau. Soloff (1979) completed

71

a study of ten patients who were not psychotic but required
restraint. The patients involved in the study were persons
who were diagnosed as possessing an immature personality
pattern. or a borderline personality syndrome. Often the
precipitating factor was an episode of hupulsive behavior
which was disruptive to the social environment but not
dangerous to it. Examples given of such behavior were self-

abuse and suicidal behavior.

Reasons Given to Seclude

 

Generally. though. seclusion and restraint were
prescribed because of violence to others. and because of the
perceived need for behavior control. In nmny institutions
disruptive behavior that was viewed as not dangerous to
others was a secondary factor involved in decisions to
seclude. As an overview to this section. the sample of
articles chosen reflects a rather pragmatic approach to
violence and control of the behavior. In most respects. the
focus was on how and what to do. In this review. unique
aspects of the literature reviewed will be highlighted.

Etiological considerations must be carefully weighed by
emergency psychiatric specialists. so observed Jacobs
(1983). He stated that in the context of admitting.
emergency. or acute care units. the staff must recognize the
interplay of biologic. psychologic. or social factors when a
patient was 'H1 an exacerbated psychological situation. He

also believed that interview and intervention procedures

72

must be willing to diverge from traditional psychiatric
examination procedures. He expressed there was no certain
way to prevent violence. but believed that a
multidisciplinary approach would help minimize violent
patient episodes. and thus the need for seclusion.

A point of view not often stated was given by Anders
(1977). He suggested that when a patient became violent
other patients be directed to leave the area and the
potentially violent patient be encouraged to verbalize
rather than act out. The significance of this point of view
was that a patient often feeds off of the reactions of peer
patients. The violent patient was often attempting to
enhance his/her own self-esteem by acting out in the
presence of an audience. Anders presented strategies for
calming the potentially violent patient. including the
identification of the anxiety. iuays of giving reassurance.
and provision of alternative non-violent actions.

Lion (1972) wrote in "Restraining the Violent Patient".
that physical curbs (N1 aggression were meaningful to
patients who were afraid of going out of control. Verbal
intervention should come before physical restraint was
employed. As a part of the process. Lion asserted that the
potentially violent patient must be told she/he will be
prevented from acting on her/his impulse. If physical
restraint has to be used. it was not viewed as a final step.

Staff contact was essential. and allowing the patient to

73

vent was required.

A specialized team approach when managing violent
behaviors was encouraged by Lenefsky. de Palma. and Locicero
(1978). A sequence of orderly. planned actions should be
carried out by a team of 2-4 staff members. One-on-one
restraint was discouraged and viewed as undesirable. because
the staff could become dependent on one person in an
emergency situation. A key person on the team must be
identified. and this person should serve as facilitator of
the specific action. After an intervention. it was
recommended that a post-episode discussion be held in order
to relate to potential anxiety aroused by the restraint
action. to discuss other possible options. or to evaluate
the whole behavior management procedure.

In England. a consultative documewn; "The Violent
Patient" (1971) was issued for the benefit of psychiatric
nurses in response to appeals from within the nursing
profession for guidance on handling patients 1Hu> were
violent. The article issued typical guidelines for dealing
with aggressive patients. But the opening statement was
different from most points of view: "The essential process
in the care of the potentially violent patient. as of all
patients. is to establish and nurture a good relationship
with him. to gain his trust and confidencefl' (p. 15)

Psychological management should never be overlooked as

a means of dealing with violent patients. so stated Lion

74

(1981) in another article. He examined the combined
approaches (If psychopharmacologic: and psychotheraeutic
approaches. Lion focused on minimizing the individual's
sense of helplessness and of being out of control. since
both could intensify rage and belligerance. One means to
accomplish this was by engaging in a one-on-one involvement
and avoiding. if at all possible. the need for a number of
people involved in holding the patient down. This stands in
contrast to the Lenefsky et al. point of view expressed
above.

Lion also indicated that on an institutional level.
assaults were generally underreported. He believed patterns
of staff and patient encounters need to be studied more
extensively. One perspective he suggested was one which has
not been supported by many. i.e. sometimes it was more
effective to restrain a patient mechanically within the
context of the milieu. rather than separating that person by
means of seclusion.

Wells (1972) recorded. over a period of a year.
observations on the use of seclusion rooms at a university
hospital psychiatric in-patient unit. He concluded. first
of all. that the use of seclusion can be an effective tool
to control destructive behavior. especiallyr for some
schizophrenic. hypomanic. organically impaired and depressed
patients. Even though the numbers were relatively low in

comparison to total admissions (4%). he thought the

75

possibility existed that \Nlth a properly designed setting.
and better trained staff. fewer persons could be treated
without having to resort to seclusion.

Issues related to handling physically assaultive
patients in state psychiatric hospitals were considered by
ScLafani (1986). He observed that in the 1980's persons
"entering 'Uua patient population 'Hi state psychiatric
hospitals tend to be younger. sicker. and more assaultive".
(p. 8) Because violence was becoming more prevalent in
hospitals. and with that an increase of assaults on staff as
well as on other patients. a general protocol for crisis
management and intervention was thought to be needed. He
outlined a five-step crisis management protocol as a means
of diffusing violence and by showing concern and interest.
The steps were as follows: (1) Therapeutic Environment and
Programming: (2) Verbal Intervention: (3) Team Approach: (4)

Pharmacologic Intervention: (5) Mechanical Restraint.

Patient Characteristics

 

Characteristics of patients and situations leading to
seclusion made up a significant percentage of the content of
various investigations on the subject. The studies reviewed
focused on four primary categories: characteristics or
demographics of patients secluded or restrained:
precipitators of seclusion or restraint: temporal factors

related to seclusion. including incidence. length of time in

76

seclusion. as well as the month. day of week. and time of
day the patients were secluded: and treatment
considerations. including the use of medication and
structured programming.

Many investigators included in their studies demo-
graphic characteristics as factors that could be related to
seclusion and restraint practices. Soloff (1987) believed
that the implicit question underlying the inclusion of these
factors was whether or not "systematic bias in the use of
seclusion that is not related to the therapeutic principles
of the method suggest it is being used asaasanction". (p.
129)

Soloff. Gutheil and Wexler (1985) in a literature
review concluded:

Schizophrenic and manic patients appear at highest risk

for seclusion in acute treatment settings.. .. Young

patients are secluded more than older patients. Race
and sex bear no significant relationship to incidence
of seclusion. andiwhere trends appear involving these
variables. the question of systematic bias should be
entertained. Chronicity of illness and involuntary
commitment are correlated in several studies with

increased incidence of seclusion. (p. 655)

Other literature supported the Soloff et al.
perspective that schizophrenic and manic patients appeared

at highest risk for seclusion in acute care units: Gerlock

77

(1983). Tardiff (1984). Schwab (1979). Roper (1985). and
Borstein (1985). This was also true for young patients. who
were secluded more often than older persons: Tardiff
(1984). Borstein (1985) and Tardiff (1985). But some
studies disagreed on the sex issue. suggesting that males
were more at risk for being secluded than females: Tardiff
(1984). (1985) and Borstein (1985). Convertine (1980) did
not discover a correlation between psychiatric diagnosis and
seclusion usage.

Race as a variable involved in seclusion practices was
considered by most researchers not to be a significant
factor: and this generally supports the frame of reference
of Soloff et al. (1985). But several presented evidence
that race correlated with decisions to seclude: Flaherty
(1980). Roper (1985). Gift et al. (1985). (1986). Soloff and
Turner (1981). Flaherty and Meagher (1980). in particular.
affirmed this position. Their study ruled out the
possibility of more severe pathology in Black patients by
assessing mental illness intensity wiifli the Brief
Psychiatric Rating Scale. Flaherty and Meagher concluded
there was racial bias involved in seclusion decisions. and
it was attributed to subtle stereotyping and the staff's
greater familiarity with white patients.

Legal status as a factor in seclusion decisions by
staff was significant for some: Bornstein (1985) and Oldham

(1983). Okin (1985). (1986). on the other hand. disagreed.

78

Okin (1985) concluded that legal status was not correlated
with seclusion usage. but that diagnosis. violent-related
behavior. prior admissions and demographics were predictors
of an at-risk person for seclusion and restraint.

Other characteristics which emerged in various research
projects suggested some other correlates with seclusion:
marital status (single or divorced) Bornstein (1985). Oldham
(1983). previous history of hospitalization: Oldham (1983).
Soloff and ‘Turner' (1981): and background of ‘violence:
Bornstein (1985) and Binder (1979L

Precipitants gf Seclusion

 

 

Soloff et al. (1985) presented a table of precipitants
of seclusion or restraint. and drew the summary data from
ten studies which were listed in the references. The

results are outlined in Table 2.

79

 

 

 

Table 2: Seclusion or Restraint Precipitants Indentified in
Ten Studies*
Study Precipitant Unit of
Measure 2
Ramchandani Shouting. loud. agitated Patients 54.3
(1981) violent threat or attack secluded 41.3
Phillips Multiple reasons including Incidents
(1983) violence to self. screaming 39.0
Agitation. poor impulse
control 31.0
Act of violence toward others 30.0
Convertino Disruptive or agitated Incidents
(1980) behavior 38.0
Violent behavior 31.0
Oldham Escalating agitation Incidents 38.0
(1983) Threats to others 25.0
Assaultiveness 21.0
Sololl Attack on staff with contact Incidents 34.6
(1981) Agitation escalating not able
to control behavior 24.3
Mallson Disruptive Behavior to Mileau Incidents 34.4
(1978) Assaultive to others 24.3
Schwab Overstimulation Cited 28.0
(1979) Agitation reasons 17.0
Poor impulse control 15.0
Threatening assault to others 6.0
Actual assault 4.0
Plutchik Agitated and uncontrolled Incidents
(1978) behavior 21.0
Violent behavior 15.3
Binder Agitation Incidents 13.0
(1979) Uncooperativeness 12.0
Anger 10.0
Violent behaviors 12.0
* From "Seclusion and Restraint in 1985" by P.H. Soloff.
T.G. Gutheil. and D.B. Wexler. 1985. Aggpimgl 2mg
Community Psychiatry. 22. pp. 652-657. Copyright 1982 by

 

 

Hospital and Community Psychiatry.
by permission.

Appendix N.

Adapted and reprinted

80

This table defined behavior. events. or precipitators
which preceded a patient being secluded. The report stated:
0f the ten studies that explicitly measured precip-
itating events. nine cited 'a nonviolent behavior
pattern as leading to the greater use of seclusion.

This behavior was variously described as "behavior

disruptive to the therapeutic environment". "agitated.

uncontrolled behavior". and "escalating agitation". In
the nine studies actual physical attack ranked below

nonviolent behavior as a precipitating factor. (p.

656)

Seclusion was also used for administrative sanction. verbal
abuse. refusal to participate in activities. or medication
non-compliance. (p. 656)

In contrast to Soloff et al.. Tardiff (1985) found that
assaultiveness was a: significant characteristic leading to
seclusion. Bornstein (1985) discovered that primary
precipitators for seclusion were verbal and physical
assaults against staff. Soloff and Turner (1981) concluded
that seclusion was used primarily to contain physical
violence. They thought one reason for this was that the
patients secluded tended to be economically disenfranchised.
with the violence being engendered by anger and frustration.

Temporal factors related to seclusion room usage were

considered by Soloff et al.(1985). Eleven retrospective

(14-24) and twc> prospective studies (25. 26) were

81

summarized based on the incidence of seclusion or
restraint. All involved a variety of adult psychiatric
inpatient settings. Table 3 presents the overview of the 13

studies.

Table 3: Restraint or Seclusion Incidence Reported in 13
Studies of Adult Psychiatric Inpatient Units

 

 

Study Population Setting Incidence 2—
Wadeson Acute. Public NIMH Research
(1976) Status Unknown Unit 66.0
Phillips Acute. Public State Hospital
(1983) Voluntary/Involuntary Research Unit 51.0
Binder Acute. Public Crisis Interven-
(1978) Voluntary/Involuntary tion Unit. Locked
Psychiatric Unit 44.0
Schwab Acute. Public/Private University General
(1979) Status Unknown Hospital 36.6
Plutchik Acute. Public Municipal Psych-
(1978) Voluntary/Involuntary iatric Facility 26.0
Convertino Acute. Public Patient Locked Unit.
(1980) Status Unknown Community Mental
Health Center 24.0
Oldham Acute. Private University Psych-
(1983) Voluntary/Involuntary iatric Hospital 18.0
Soloff Acute. Public University Psych-
(1981) Voluntary/Involuntary iatric Hospital 10.5
Mattson Acute. Private General Hospital
(1978) Voluntary Psychiatric Unit 7.2
Ramchandani Acute. Public General Hospital
(1981) Voluntary/Involuntary Psychiatric Unit 4.7
Wells Acute. Public-Private Locked Psychiatric
(1972) Status Unknown Unit. University
Hospital 4.0

Table continues

82

 

 

Study Population Setting Incidence Z—
Soloff Acute. Active Duty Military Hospital

(1978) Voluntary/Involuntary 3.6
Tardiff Chronic. Public State Hospital

(1981) Voluntary/Involuntary 1.9

 

* From "Seclusion and Restraint in 1985":by P.H. Soloff.
T.G. Gutheil. and D.B. Wexler. 1985. 29531221 3mg
Community Psychiatry. 22. pp. 652-657. Copyright 1982 by
Hospital and Community Psychiatry. Adapted and reprinted
by permission. Appendix N.

 

The following was stated by Soloff et al. concerning
the results shown on Table 3.
The incidence of seclusion and restraint varies
directly with two parameters: the composition of the
patient population and the treatment philosophy of the
unit. Specific variables relevant to the incidence of
seclusion include hospital setting .. . (public and
private). type of care (acute or chronic). and patient
status (voluntary or involuntary). (p. 654)
Then they considered the role of medication and seclusion:
The philosophy of the unit toward the use of
medication and medication-free observation for
diagnosis or research relates directltho the incidence
of seclusion. . . . The highest. incidence of
seclusion. 66 X was found on an NIMH research unit for
schizophrenia ‘where a treatment philosophy of
medication-free maintenance was part of the research

strategy. (p. 654)

83

In summary. the acute care public facilities had a higher
percentage of incidents of seclusion than did the private.
Also for private and public facilities there was a positive
correlation between incidence of seclusion and the number of
committed patients. The private hospitals tended to have a
lower incidence of seclusion in as much as they exercised

more control over \NhO entered the hospital. (pp. 654-655)

Temporal Factors 1m Seclusion

 

 

Soloff et al.. along with considering incidents of
seclusion. also presented data related to the duration of
seclusion and correlates. They stated concerning average
length of time in seclusion:

In some studies. it correlates with age. sex. and

psychosis at the time of seclusion: in others. it

appears more directly related to philosophy of care. .

. . In the prospec tive study the mean duration of

seclusion episodes was 10.8. with a median of 2.8 hours

and a range of 10 minutes to 120 hours. Patients under

age 35 spent more total time in seclusion than did

older patients. Patients who were psychotic spent more

time in seclusion than nonpsychotic controls. Men had

longer individual seclusion episodes than women. (p.

656)

During the course of the review. Soloff et al. discovered
what they considered in) be significant disparities in

seclusion times and a lack of correlation "between duration.

84

precipitating behavior. and diagnosis". (p. 656) They
observed:

Unpleasant questions [are raised] about arbitrary

determination of duration of seclusion and its

potential use as a punitive sanction. .. . Factors
outside the individual patient's immediate needs may

play a role in determining duration. (p. 656)

Other temporal factors studied were the time of day.
day of the week. and related time issues. Gerlock (1983)
considered a variety of time issues. including daily and
seasonal variation. weather. biorhythms and horoscopes.
Peak seclusion was during the late night and early morning:
more seclusion occurred during the winter and spring. with
April and January being the highest months. There was no
correlation between incidence of seclusion and the weekend.
when there were fewer structured activities.

Schwab and Lahmeyer (1979) showed in their study on a
general hospital psychiatric unit. that the highest
incidence of seclusion was between 10 pm and 2 am. with
forty-five percent of the patients being secluded in this
time period. Oldham (1983)found that Unepeak occurrence
of seclusion usage was during the day when time was not
structured. or when key staff were unavailable. Roper
(1985) conducted two chart audits. covering 43 incidents of
seclusion and restraint. He discovered the highest

percentage of isolation or physical control was during the

85

day shift. with a total of forty-three percent of incidents

being initiated by the day staff.

Treatment Issues and Seclusion

Incidence of seclusion in relation to general treatment
considerations has been considered by some investigators.
Of particular interest was the relationship between
incidence and duration of seclusion and medication usage.
Roper (1985) discovered that individuals who were medicated
in conjunction wdth being placed hi seclusion stayed
secluded longer than those who were not. Bornstein (1985)
found that persons secluded were on an inadequate medication
regimen. Schwab (1979) showed that patients who required
seclusion received pharmacotherapy more frequently. Gerlock
(1983) had the same finding as Schwab: his control group
most commonly received antidepressants. or no medication.

Oldham (1983) and Gerlock (1983) both considered in
relation to the incidence of seclusion the issue of time
structuring and availability of activities. Oldham thought
that not having structured activities effected seclusion
incidence in terms of increased usage. Gerlock did not find

a similar correlation.

Summary and Conclusion
In the literature review. four areas of concern were
covered: (1) characteristics of secluded patients: (2)

precipitants of seclusion: (3) temporal factors in

86

seclusion: and (4) treatment issues. In each category. the

following areas had conflicting answers:

A.

Characteristics of patients secluded and the possible

presence of a systematic bias:

L Though young males were primary candidates in most
studies. some studies indicated sex was not
significant:

2. Most studies indicated race was not a factor. but
several disagreed:

3. Legal status was not seen as a factor in some
studies. especially involuntary commitment: but others
did not concur:

4.Diagnosis. especially schizophrenia and manic. was
seen as significant. but some investigators did not
agree:

5. Lhnited study has been completed (H1 other
demographic factors. e.g. marital status. socio—
economic status. education. place of residence.

Precipitators leading to seclusion:

1. There was not consistent agreement among
investigators about the significance of nonviolent and
violent events precipitating decisions to seclude:

2. Few studies considered the correlation between
demographic characteristics. treatment issues. and
precipitators of seclusion.

Temporal factors involved in seclusion:

L Temporal factors. including incidence and
duration of seclusiom. were not often correlated with
demographic characteristics of patients who were
secluded:

2. Relationships between incidence and duration of
seclusion and various treatment modalities. including
medication and structured activities. were not often
considered:

3. The relationship between time of day and day of the
week to incidence and duration of seclusion was not

87

considered by many investigators.
0. Treatment issues in relationship to seclusion usage:

1. The results were mixed in relation to medication
involvement and the incidence of seclusion:

2. The effects of activities were not often considered
in studies dealing with seclusion:

3. Staff training and its impact on seclusion has not
been systematically studied.

Based on the historical overview and the review of the
literature. it was apparent that seclusion as a means of
behavior control in psychiatric treatment remains an enigma
and controversial. Seclusion usage has remained a
significant means of behavior control in psychiatric
facilities. But legal interventions have changed how
hospitals make use of the seclusion alternative. Now. as a
result of litigation. the concept of least restrictive
alternative has entered into the nomenclature. and has
impacted on seclusion policy. As a result. many states and
treatment centers developed policy statements regarding the
use of seclusion and restraint. Also. the literature has
reflected the change by focusing on seclusion as one of the
last resorts in behavior control. Research in this area has
for the most part been descriptive in nature. with some
exceptions. More often than not the research has been
retrospective.

In this research project. an attempt was made to build
on what has been accomplished. and to consider unanswered

questions related to seclusion room usage. It was first of

88

all retrospective. Characteristics of patients who had been
secluded were examined and secluded patients were compared
to a random sample of non—secluded patients. These two
groups consitituted the treatment groups. with the non—
secluded group acting as a control group. Psychiatric
treatment variables for these two groups were evaluated.
with the focus being on the milieu. medication. and a
structured work activity program. A new dimension was
evaluated: the effect staff training had on incidents of
seclusion. For the statistical tests. the dependent
variable was incidents of seclusion for the first time
secluded patients.

Finally. in order to be complete. summary data for all
incidents of seclusions during the time frame of the study
was reviewed. No statistical tests were effected on this
data. but it was evaluated. In addition. data gathered
related to the circumstances of decisions to seclude was
also reported. The setting and methods of the study are

more fully outlined in Chapter III.

CHAPTER III

METHODOLOGY

Introduction

 

This chapter presents the methods used in the study to
accomplish the research goals. The following descriptions
are included: the setting. subjects. variables of interest.
sources of data. and research design. Also. the statistical
procedures used in analyzing the research data are

described.

The Setting

 

The research project on seclusion room usage was
designed and implemented at the Caro Regional Mental Health
Center. The Caro Regional Center. or CRC. is located in the
central. eastern part of the lower peninsula of Michigan. in
an area called the "Thumb". The closest residential
community is Caro. Michigan. which has a population of
4.500. and is the county seat of rural Tuscola County.
Saginaw. Michigan is approximately 30 miles west. and
Detroit. Michigan is 90 miles to the south.

The Caro Regional Center is an agency'of the Michigan

Department of Mental Health with responsibility for

89

90

providing services to both developmentally disabled and
mentally ill persons. The developmentally disabled
population is 270: and the mentally ill population is 127.
including a 17 bed specialized independent living program.
The annual C.RJL budget is $32,000,000. and 700 people are
employed at this facility.

The hospital provides psychiatric services for a
catchment area designated by the Michigan Department of
Mental Health. At the time of study the following counties
were served by the hospital: Huron. Saginaw. Sanilac.
Tuscola. Bay. Arenac. Lapeer. Midland. Gladwin. and St.
Clair. 'The largest percentage of patients. 41%. come from
Saginaw County. Although the Michigan Mental Health Code
requires direct admission of certain patients. every effort
is made to have admissions screened by the staff of the
appropriate Community Mental Health Board and community
alternatives utilized when available. In all cases. CMH
staff are notified of admissions. since placement and after-
care are considered a CMH responsibility. Only adult
persons receive services. The Caro Regional Center is
accredited by JCAH (Caro Regional Mental Health Center
Profile. 1988. p. 5).

The psyciatric program unit functions under the inter—
disciplinary treatment team concept. All professional staff
are assigned to one of three treatment teams. and each team

serves a designated group of patients. One of the

91

professional members serves as a team leader. and has the
responsibility of facilitating the weekly treatment team
meeting for which she/he is responsible. All patients
assigned to the treatment team have a professional who is
the Qualified Mental Health Professional (QMHP). The QMHP
is responsible for the development and implementation of the
individual treatment pl an that is created for the patient.
The treatment plan designates the responsibilities of direct
care staff on each shift. Responsible direct care staff are
invited to participate in team (neetings and share
observatiorm. about. patients for \uhom they liave
responsibility. Tim patient participatesw and 'family
members and CMH staff also are often involved in treatment
planning Ineetings (Caro Regional Mental Health Center
Profile. 1988. p. 7).

The psychiatric unit is part of the total program of
the Caro Regional Center. There are five psychiatric
residential buildings. including the acute care/admitting
building. Woodside Cottage (C-5). Other facilities are
shared with the developmentally disabled program. These
include the gym. Work Activity Center. the Center Mall. the
medical unit. and administrative offices. Other support
services are also shared. including transportation.
maintenance. the store. and medical records.

The focus of the research was the acute care/admitting

unit. This residential unit has 21 beds and serves both

92

males and females. All patients who are admitted to CRC
pass through Woodside Cottage. The building is a 24 hour
intensive care unit. and contains the only seclusion room on
the grounds of the facility. The building is shaped like
the letter T (Appendix L). There is a male and a female
wing: a main hall. with a nursing station and three bed-
rooms: and the dining area and kitchen. All residential
rooms are on one floor. The front of the building consists
of offices and a visitor area. The residential area is
locked at all times. There is a recreation area in the
basement. but it was not in use at the time of the study.
All activities took place in the lounges. or in the day room
(which was the dining area at meal times). There are two
television sets available. one 'Hi each of the lounges.
There is also a piano in the female lounge.

The supervision at Woodside is intensive because of the
needs of patients who are admitted. Most are admitted in
state of crisis. and require close attention. It is the
intent of the program that most patients will remain at
Woodside for a short time. As soon as the patient is
thought stable enough to participate in an out-of-cottage
program. she/he is transferred to another residential
building (Caro Regional Mental Health Center Profile. 1988.
p. 41).

During the course of the study the average monthly

admissions were 49: and the average monthly census for the

93

total pyschiatric program was 96. Readmissions constituted
55% of the admissions. and involuntary patients made up 76%.
The average number of days in the hospital for a patient who
was discharged was 48. In recent years. the nature of the
population of psychiatric program has changed to more

seriously ill and chronic patients.

Subjects

 

The subjects of the study were patients in the
psychiatric program unit from December 1. 1986 to October
10. 1987. There were two groups: secluded patients and
non-secluded patients. The secluded group was first time
secluded patients who were in the admission unit during the
course of the research. If persons were discharged.
readmitted. and secluded again. they were not counted more
than once in terms of the population pool. Incidents of
seclusion and time in seclusion for readmissions were
counted. After adjustments 52 persons were in this group.

The non-secluded group was chosen from admitted persons
on the basis of a monthly stratified random sample. The
count for each month was determined by the initial number of
people secluded during the same month. For example. if
eight patients were secluded in December. 1986. then eight
petients were selected at random without replacement from
the 49 people admitted that month. This proceedure was
replicated for each of the remaining nine months. The

random sampling process was as follows: For each month. the

94

names of all admitted non-secluded patients were written on
slips of paper. and placed in a container. The slips were
appropriately mixed up. and a draw made. After each draw.
the slips were again mixed up. This procedure continued
until the fitting number had been drawn. The non-secluded
group numbered 58.

The final group of "subjects" was the staff at the
admitting unit. The primary statistical analysis was
completed in relation to the patient population. But
implicit in the research was the staff. and the role they
played in the seclusion process. Patients. with few
exceptions. do not place themselves in seclusion. Staff do.
in response to some action or behavior on the part of a
patient. This research examined. in a cursory way. the
impact of staff on the decision making process to seclude.
The involved staff were regular and relief staff at the
admitting unit. All the regular staff participated in the
May 3-8. 1987 training program. which will be discussed
later.

It is important to indicate that the researcher did not
manipulate the subjects involved in this research. The
study. as noted earlier. was a retrospective one. The
subjects were part of the existential reality of the
program. in that they were a part of the natural scene which

was being observed.

95

The Research Variables

The psychiatric program treatment variables considered
by this study were the following: milieu therapy: milieu
and medication therapy: mileu and the work activity program:
and milieu. medication. and work activity. All three forms
of treatment were. for the most part. available to all
patients at the admitting unit. Whether or not a person
received a particular form of treatment was dependent on the
individual's condition. behavior. legal situation. or
willingness to be involved in the treatment process. The
reality was that all persons did not receive the same kind
of treatment. The one form that was consistently available
to all patients was milieu therapy.

Milieu Treatment.

 

Milieu Treatment was defined by the' American
Psychiatric Association (1980) an. "Socio-environmental
therapy in which the attitudes and behavior of the staff of
a treatment service and the activities prescribed for the
patient are determined by the patient's emotional and inter-
personal needs. This therapy is an essential part of all
inpatient treatment" (p. 91). Gunderson (1986) outlined
five programatic activities which contribute to the
therapeutic atmosphere: (1) containment. (2) structure. (3)
support. (4) involvementa and (5) validation. Ir1 the
context of these activities. the acute care/admitting unit

milieu treatment will be examined.

96

Most of the admitted patients at C-5 either were
confused. depressed. suicidal. or agressive. For those
persons viewed as being a danger to self or others. contain-
ment was the first task of the psychiatric milieu in C-5.
The unit building was locked at all times as noted earlier.
There were no bars or security screeens. The first task of
the program was defined as providing safety for the
patients.

The second dimension. structure. had the purpose of
promoting an atmosphere where a person could begin to regain
self-control. Willmuth (1987) stated "structure promotes
change by providing a predictable organization of time.
place. and person for patients" (p. 6). The structure
provided by C-5 began the moment a client entered the ward.
For most patients. prior to being admitted. their lives were
unstructured and disorganized. When newly admitted people
told of their pre-admission life style. the common theme was
they had nothing to do and little to which to look forward.
One patient stated: "when I leave here and go back into the
neighborhood. itHslike falling off a cliffJ' He meant he
was faced with the problem of finding some kind of structure
once he left the structured life in the hospital.

The first tasks in the admitting unit were assessments.
which required contact with the professionals involved. The
Guidelines of Care (1986) (Appendix G) required the

following admitting assessments: psychiatric examination.

97

physical examination. activitiy assessment. nursing
assessment. and social assessment. While at C-5. the person
may also be evaluated by a psychologist. nutritionist. or an
occupational therapist. Finally. the patient was to be
interviewed by the assigned qualified mental health
professional.

All residential buildings including the admitting
building had scheduling and activity requirements. and these
are found h1"Guidelines of Care".(a) meals.(b) assisting
in setting and clearing tables. (c) off-grounds activities.
(d) maintaining living area. including making beds. (e)
maintaining personal hygiene. and (f) building recreational
activities. Recreational activities in the context of
admitting unit included watching television. table games.
reading. and some omtside activities. These may have
included walks. playing basketball. or using the yard
swings. During the week. on a daily basis. a crafts group
was held. usually for an hour.

Involvement was a natural component of structure. It
was viewed as an essential aspect of facilitating a patient
being able to regain control of his/her life. For the
confused. involvement in the milieu was seen as a means of
assisting the person to regain order and clarity. For the
depressed. being involved was a way energy levels could be
raised and thoughts that caused depression refocused. The

aggressive patient was encouraged to take part in activities

98

as a means of re-directing negative and potentially
destructive energy. Whatever the activity. the treatment
had as its focus helping the person regain control of life
by involving the individual in treatment in a pro-active
way.

Most patients. when they were admitted to the
psychiatric unit. experienced low self-esteem and/or a high
sense of alienation. These attitudes generally governed the
lives of people diagnosed as psychotic or depressed. An
important aspect of the milieu that attempted to relate to
these beliefs was the support offered by all staff. from
psychiatrist to housekeeper. When people were demoralized
and felt separated frmmi life around them. the support
offered by all levels of staff became essential. During the
day and afternoon shifts there were the following full-time
staff available: one registered nurse. one licenced
practical nurse. three resident care aides. and at least one
domestic services aide. Iiipatient needs required it. one
or more attendants were made available on an as needed
basis. Though each discipline had its unique function. the
underlying responsibility was to interact with the patients.
and to work with them in gaining back a sense of self-
esteem. self-control. and purpose. The staff who were with
the patients eight hours a day more often than not became
the "therapists" in that they were there in those

spontaneous moments when people chose to open up about what

99

was troubling them.

When staff support resulted in the patient experiencing
empathy. validation became the final part of the milieu
formula. Validation is that part of the treatment puzzle
which enhanced the patient's ability to think positively
about self. It was also the most difficult to measure and
assess. Gunderson believed that validation had an essential
part to play in helping paranoid and borderline patients
attain a greater ability for closeness and self—identity.

In order to comprehend the meaning of the milieu aspect
of treatment in the admitting unit. Roll (1985) outlined the
underlying philosophy:

lde do not feel it is necessary to control the

individual. unless he is in fact endangering himself or

others. but rather-it is our aim to help him be able to
control himself. Iria sense.the treatment milieu is
an experimental social setting for the patient. where
the expression of his psychopathology does not result
in punitive responses from the staff. but assistance in

selecting more appropriate behaviors" (p. 2).

The direct care staff had the responsibility of
carrying out the admitting unit milieu treatment approach.
Roll addressed the issue of their involvement in this
fashion:

The direct care staff is considered the crucial element

in this treatment approach. It is they who must

lOO

understand the treatment objectives. and consistently
reinforce the appropriate behaviors. The professional
staff have responsibility for assessing the needs of
patients. for working together with the direct care

staff to develope an appropriate treatment program."

(1)- 2)

Work Activity Program.

Another treatment variable was the work activity program.
This program was governed by the administrative rules of the
Department of Mental Health (see Appendix B). Patients from
the admitting unit participated in the work program. but not
in all cases. The "Guidelines (rf Care" (1986) stated:
"Under normal conditions patients admitted to the
Psychiatric Treatment Program will remain at Woodside (C-5)
Admissions Unit for 48 hours before they will be assessed
for participation in the Work Activities Center Program."
There were some exceptions when patients started the work
program within 24 hours. During the study period 20% were
referred to the Work Activity Center.

The program began at 9 aJm” and C-5 patients returned
at 1 p.m. At the work center the first task was an
assessment to determine a suitable work assignment. Choices
of work included wood sanding. wood finishing. bicycle
repair. sewing. weaving. ceramics pouring. ceramics
cleaning. ceramic painting. grounds crew and the print shop.

Roll (1987) stated that the primary purpose of the

101

program was "to assist the patients in developing a 'Pattern
of Success'in responding to social expectations.. .. The
emphasis is on task completion. following directions.
working cooperatively with others. and other psychosocial as
opposed to vocational skills and behaviors common in the

work setting' (p. 3% When tasks were completed. the
patients received pay for their work. The pay was a
secondary part of the work program. in that Roll considered
the process to be a form of therapy. The focus was to help

' that was as normal

patients get into a "pattern of the day'
as possible. including getting up. getting ready for work.

doing the work. and using leisure time appropriately.

Medication Therapy.

As indicated earlier. psychophamacology as currently
practiced had its beginning with the introduction of
Thorazine in 1954. Prior to this time the options regarding
drug therapy were minimal. and there was a significant
reliance on psychological and milieu forms of treatment.
But in the last two decades. biological psychiatry has
emerged as being the primary modality of treament. Willmuth
(1987) stated: "Biological psychiatry stresses relief of
individual pathology with the milieu serving primarily to
shelter the patient and ensure his compliance with drug
treatment3'(p. 6%

At the time of the study. the facility had four full-

102

time psychiatrists and two part-time resident psychiatrists
who worked weekends. There were three treatment teams. each
having an assigned full-time psychiatrist. Every patient
admitted to the acute care unit was evaluated by the
assigned doctor within 24 hours. At that time it was
determined how fitting the patient was for medication. If a
patient was voluntary. or had signed a treatment agreement.
then medication was ordered if needed. The administrative
rules of the Department of Mental Health (1987) stated that
medication was not to be ordered prior to a court hearing
"unless the individual consents or unless administration of
chemotherapy is necessary to prevent physical injury" (p.
18).

The medications used in psychiatry. and at the
admitting unit. were classified in five major catagories:
(a) antianxiety drugs. (b) antidepressants. (c) antimanic
drugs. (d) antipsychotic drugs. and (e) antiseizure drugs.
The unwritten policy of the psychiatric unit was that the
least amount of medication was prescribed in order to help
the patient regain control of her/his thought process or
behavior. While a patient was on medication. the person was
reviewed at least weekly by the treating psychiatrist in
order to ascertain progress on the medication regimen. If
behavior had changed toward the person being more in
control. the medicine was usually titrated downward. The

titration process was continued until minimal dosages were

103

reached and swnptoms could be controlled at those
prescription levels. Nursing and direct care staff also
observed the patient for significant changes and
communicated these observation to the treating psychiatrist.
A final observation about medication: most patients do
not like being on psychotropic medication. Many of the
persons that were admitted to the acute care unit had been
on medication because of previous psychiatric episodes.
Even though they had information which indicated a necessity
to stay on medication in order to maintain stability. most
when they felt better ceased taking the prescription. The
medications were powerful. and had the potential of
significant and uncomfortable side effects. Many patients
described the feeling as "being in a chemical strait-
jacket". Berger (1977) stated the dilemma this way:
Each time any of these powerful medications is
prescribed. we have Maconsider the drawbacks as well
as the advantages of each medicine for each individual
patient. . . . It is important to be aware that all of
these new medicines may have disturbing side effects. .
. . Some .. . are drowsiness. dry mouth. low blood

pressure. fibrillations. tremors. and weight gain" (p.

61).

Patient Characteristics.

 

Also examined in this study were patient

characteristics of people secluded and not secluded. The

104

characteristics considered were suggested by the literature
review. and preliminary studies conducted by the psychiatric
unit utilization committee (see Appendix EL Most of the
data was collected at admission and placed on a face sheet
(Appendix I). Also. the information was generated by the
various professional disciplines. \Nlth appropriate reports
being placed in the assessment section of the clinical
record of the patient. Patient characteristics were
included so it could be determined if any of these variables
were systemically related to the seclusion process. Of
particular interest was determining if any bias contributed
to the seclusion process decision making.

As a part of the review of the clinical record.
criteria and conditions related to the seclusion process
were also considered. This involved looking at some basic
staff *variables sucfii as sex. race. seniority. and
classification. The staff component was also joined with
training program variable. in order to ascertain any effect
the training program had on staff. Other issues considered

were reasons for seclusion. time factors. and census data.

The Training Program

On May 4-8 the psychiatric program unit held its first
comprehensive staff training program. It was aimed at
focusing on the treatment offered by hospital as a whole.

.and the admitting/acute care unit in particular. All

105

available full-time regular nursing and RCA staff of
Woodside Cottage (C-S) were involved. with 21 staff from all
three shifts taking part in the program. Also. two new
nurses took part in the program. While regular staff were
in training. relief staff provided treatment services in C-
5. Because schedules were staggered. the open window of the
study was May 1-10. 1987. This allowed for staffing
adjustments so that persons were able to participate in a
Monday through Friday training schedule.

This particular training approach was unique as
compared to previous training efforts. Shithe past. staff
had been trained in relation to a variety of issues which
were applicable to the Regional Center program as a whole.
The previous training was not oriented to the unique needs
of the psychiatric program and the admitting/acute care
unit. The need for the training program was based on
several factors: (1) over half of the C-5 staff were
relatively low in seniority. and had little experience
working with psychiatric patients: (2) many of the staff had
been experiencing symptoms of job-related burn-out: (3)
psychiatric admissions were increasing and placedaagreat
deal of pressure on the admitting building staff: (4) as a
result of a series of short training sessions. staff
expressed the need for more intensive training.

Because of these factors. the Facility Director

approved the one week program. A representative team of

106

staff was appointed to develop the content of the training
program. The persons involved were: the director of
psychology. a nurse supervisor. and a senior direct care
staff person. This group not only created the program
outline. but also put together the content of the training
sessions. This included scripting and taping a series of
vignettes which portrayed what was called staff-o-genic
behaviors.

The staff training program had the following goals:

1) to teach staff the underlying philosophy of the

psychiatric unit:

2) To enhance the ability of staff to communicate more

effectively with persons who were hospitalized.

3) To enable workers to understand better the concept

of mental illness and the various diagnoses which were

treated at the psychiatric unit:

4) To consider the most effective and least restric-

tive means to assist patients to be more in control.

5) To help the care providers understand the specific

functions of the admitting unit.
The training program schedule which was developed to fulfill
these purposes. is Appendix J.

At the end of program. all persons were given a
multiple choice examination (Appendix KL After the exam
was scored. each employee who participated in the training

experience was interviewed by representatives of the

107

planning group. The post workshop interviews had the
purpose of further evaluating what was learned by staff.
The employees were graded on a pass/fail basis: 18 staff
persons passed. (NH? was conditionally passed. and two
failed. The two who did not succeed were by mutual consent

of management and labor transferred to other program units.

The Seclusion Procedure

The use of seclusion as a behavior management method at
C-5 is governed at three levels: Michigan Mental Health
Code. (1986) (Appendix Ah DMH Administrative Rules. (1987)
(Appendix B): and CRC Resident Policy. (1986) (Appendix C).
When JCAH accreditation is an issue. the policy and practice
is evaluated tu/ guidelines found iri Special Treatment
Procedures. an n_gliga _gg Sta ng_mg§_Mgfl al. 1221 (Appendix
D).

A patient may be secluded. according to DMH policy. for
one of three reasons:

(a) when justified and specified in the plan of service

as being of clinical benefit to the patient/resident.

or

b) for the purpose of preventing a patient/resident

from physically harming himself or others as

substantiated in the clinical and/or Inedical

records. or

c) to prevent a patient/resident froni causing

substantial property damage.

108

CRC policy requires that "a dangerous resident may be
ordered in seclusion by a supervisor. Telephone
authorization from a physician must be obtained within one—
half (1/2) hour after imposition of an emergency seclusionfl'
(p. 2)

A separate chronological record is kept to show
specific instances of seclusion usage. TImrrecord is kept
on a specified form (Appendix I). which includes the
following information: the patient's name. case number.
date of birth. county of residence. reason for seclusion.
date of incident. time seclusion began and ended and
behavior at the end of seclusion. The staff is expected to
observe the patient every fifteen minutes. and a
professional staff person had to evaluate the patient at
least every two hours. Completed reports are turned over to
the medical records department. which tabulates the total
number of incidents and duratjon of the incidents.

It was stated above that seclusion is ordered by a
supervisor. which at C-5 means the nurse supervisor. Each
shift at Woodside has a supervisor nurse who is in charge of
RCA. or direct-care staff. During the course of the study
there was a change in practice. in terms of who requested
seclusion. In the earlier months. some RCA staff'who were
involved initially in the incident leading to seclusion
requested the management procedure. After the training

program. all requests for seclusion were made by nursing

109

(RJL) staff. This did not mean that the R.M. involved
actually initiated seclusion: rather. it meant that he/she
authorized it.

Theoretically. the following was supposed to happen: if
direct care staff were involved in a difficult management
process. and they thought it required seclusion. the request
to seclude was made to the nurse (often while on the way to
the room). hi those fen! moments. the supervisor was
supposed to determine if the action was the least
restrictive alternative. If that was judged to be the case.
then approval for seclusion was given. and authorization
received from the on-call physican.

Thus far. seclusion has been discussed in the context
of policy and procedure. In order to ascertain the process
as completely as possible it is important to be aware of
what is happening to the patient during admission.

When a patient enters the milieu of a psychiatric
hospital. crisis is a central reality for the individual
involved. The crisis is felt because of two primary
reasons: first. the shock of going into a controlled
environment which is generally viewed as oppressive and
foreign. Everything is different. including the bed slept
upon. food eaten. the over-all ambiance of the building. and
the strangeness of the people. both peers and staff. This
dynamic is an expression of the milieu. described above.

The second reason is that the patient is generally

llO

experiencing a level of impairment which is both frightening
and bewildering. especially when compared with the premorbid
state. This kind of experience distorts how external
reality is being perceived by the person in crisis. This is
an expression of major mental disorders which contributes to
most people being admitted to any psychiatric hospital.
particularly the Caro psychiatric program. Liberman. Eckman
and Phipps (1987) have outlined conditions which contribute
to the vulnerability and predisposition of an individual
being impaired. and thus hospitalized. Writing in the
context of schizophrenia. it was stated:

The appearance of. . . characteristic schiZOphrenic

symptoms and impairments may be caused by changes .. .

such as the following:

1. The underlying biological .. .vulnerability .. .

physiologically stressed. esg" by abuse of alcohol or

street drugs:

2. Stressful life events or daily levels of tension

intervene . . . e.gn overstimulating. critical. or

overinvolved family relationships:

3. The individual's . . . support network . ...

diminishes. e.g. family tnmnber dies. therapist

terminates. or patient leaves home:

4. Social problem-solving skills .. . atrophy as a

result of disuse. reinforcement of sick role. or loss

of motivation. .. .

111

Either too much environmental change. stressors. or
ambiant tension or too little coping skills and social
support can lead to a break down and exacerbation. (p.

l)

The intensity of thought and feeling that the exacer-
bation generates creates a situation which. as noted above.
increases the probability that seclusion as an intervention
will take place around the admission event. This study has
shown that 25% of incidents of seclusion occurred on the day
of admissicm. and an additional 20% happened one day after
admission. Therefore. 45% of the incidents of seclusion
took place within 36-48 hours of admission. Also. 80% of
secluded persons were involuntarily' committed ‘to the
hospital. and were transported to the admitting unit either
by police officers or in an emergency vehicle. In almost
all instances. when people were transported in this fashion.
they came to C-5 in some kind of mechanical restraint.
either handcuffs or leather cuffs. Thus. when the
involuntary state was added to the equation. seclusion

became even a greater reality.

Data Collection Procedures
The primary data source for the research was the
clinical record. or chart. Each patient admitted to the
psychiatric unit has a chart which was opened for that
person. The record consists of: the treatment program.

daily progress notes. assessments. medical and psychiatric

112

orders. medical records and test results. legal documents
including a patient information form. and communications.
Most of the data used in this study was generated by the
progress notes. assessments. and face sheets. The seclusion
forms completed by staff. when there was an incident of
seclusion. were placed in the patient's progress notes.
Copies of these forms were made by the responsible nurse.
and forwarded to medical records. The copies of the
seclusion forms evaluated by the researcher were those from
medical records.

Once the time frame of the study was determined. all of
the appropriate clinical records \uere obtained and
evaluated. A copy of each secluded patient's face sheet was
made and the additional data added to the face sheet. The
above procedure was also followed with the non-secluded
sample. Altogether. 120 clinical records were reviewed and
evaluated. The data was entered and verified at the
Michigan State University Computer Laboratory.

Using program records. such as the clinical record of
the psychiatric program. created some problems for the
reseacher. First of all. there was a problem of incomplete-
ness. There was not easy access to data about patient
characteristics. This was particularly true with job and
occupational information. as well as information about
previous psychiatric treatment. Either the information was

not available.(n~it was placed in rather obscure parts of

113

the record. Another problem was that catagories of
information desired by the researcher. were not readily
available. and on occasion had to be inferred. An example
was the variable "patient demographic living area". This
was determined by the researcher's knowledge of the catch-
ment area. but it did create some margin for error.

A different problem that emerged in data collection was
the communication procedure regarding the seclusion usage
reporting form. It was discovered that some incidents of
seclusion were inadvertently not reported beyond the
clinical record. This meant that some copies of the
individual seclusion report forms did not reach the medical
records department. or the building supervisor. Quarterly
reports to the state DMH office are based on the records
from medical records. Also. this meant that the building
supervisor did not have the records available in order to
ascertain whether (u: not appropriate procedures were
followed by staff. This exclusion of seclusion incidents
did present the potential for a 5% to 10% error in under-
reporting incidents of seclusion.

Weiss (1972) summed up the problem with using program
records and agency files:

If the participants do not supply certain items of

information or if the staff fails to enter data.

(often) nobody checks on the missing items and follows

up. .. . (An evaluator) cannot rely on data on file

114

for a complete count. Agencies sometimes change record
keeping procedures. If this happens during the period
under study. it can vitiate all attempts at before-
after comparisions. .. . Agency records are often
based on the reporting of practitioners. and when they
know that they are being "judged" by the data in the
records. they may intentionally or unintentionally bias

their accounts. (pp. 54—55)

The researcher experienced all three problem areas when
collecting the data. Information was incomplete. as noted
above. Reporting procedures did change in the seclusion
report process. where after the training program R.NJs
became fully responsible flar initiating 'the seclusion
process. Finally. the researcher believes some of the
seclusion reports were biased when staff reported the

reasons for seclusion.

The Research Desigm

 

From the description of the setting and subject
selection it can be ascertained the research was conducted
in a naturalist setting. using available subjects. Subjects
were not manipulated by the researcher. but by the available
treatments and dynamics in the environment of the admitting
unit. The study was retrospective in nature. in that the
researcher was looking back on events which had already
taken place. There wa51u>random assignment to treatment

groups: there was random selection of the non-secluded

115

group. Secluded patients were all first-time secluded
persons the designated time period of the study.

The design. based<n1the above description.is.quasi-
experimental. Because this was a field study. random
assignment to treatments was not possible. Further. the
study is an interrupted time-series design. Cook and
Campbell (1979) described the concept:

A time series is involved when we have multiple

observations over time. The observations can be on the

same units. as when particular individuals are
repeatedly observed: or they can be on different but
similar units. .. . The purpose of the analysis is
to infer whether the treatment had any hnpact. If it

did. then we would expect the observations after the

treatment to be different from those before it. That

is. the series would show signs of an 'interruption' at

an eXpected point in time. (p. 207).

In this study the "interruption" was the staff training
program. The subjects were different. but over theicourse
of study similar.

The resulting design was a one-group pre-test-post-test
time series design. or the one-group interrupted time series
design. This design has inherent internal validity
problems. and inferring causation is questionable. But Borg
and Gall (1971) have stated that the "additional

measurements enable the researcher to rule out maturation

116

and testing effects as sources of influence on shifts from
pretest to posttestfl'(p. 395)

In this study. the dependent variable was incidents of
seclusion involving first-time secluded patients. and it was
this variable that was tested statistically. Other measures
were examined. including all incidents of seclusion and
over-all time in seclusion for first-time secluded people:
the total incidents of seclusion during the time of the
study: and percentages which reflected incidents of
seclusion in relation to monthly admissions and in relation

to the average monthly census of the admitting unit.

Data Analysis

 

The primary objective of this research was to
investigate what factors in the psychiatric unit contributed
to the incidence of seclusion. Patient characteristics were
examined: psychiatric treatment effects were studied: and
the impact of staff training was researched.

All of the hypotheses were initially tested and analyzed
by the t-test for interval data and the chi-square for
catagorical data. Crossbreaks were used to study and test
relationships between two variables while controlling for
the effects of a third‘variable. This process allowed the
researcher "to observe and control for differences in degree
of relationships at different levels of a control variable
(thus) unmasking 'spurious' relationships." (Isacc &

Michael. 1981. p. 163) A probability level of p<.05 was

117

required for consideration of statistical significance in

all of the analyses.

Summary

The methodology used in the study was discussed in this
chapter. The Caro Regional Mental Health Center in Caro.
Michigan was the setting. and the research was designed and
implemented there. Seclusion room usage at the psychiatric
acute care/admitting unit was the focus of the research.
The subjects were 52 first-time secluded patients and 58
randomly selected non-secluded patients. They were patients
who were admitted to the acute care unit during a period
covering December. 1986 to October. 1987. 90% had received
pervious psychiatric treatment: 45% were never married: 90%
were involuntary. The average income of both groups of
people was $5.500(M~less. 55% were males: 70% were white
and 22.5% were black. Staff who participated in a training
program held May 4-8. 1987 also were studied. The primary
treatment variables inere discussed. including patient
characteristics. psychiatric treatment modalities. the
training program. and the seclusion process. The research
design was reviewed. and the statistical procedures used in

analyzing the data were described.

CHAPTER IV

RESULTS

The major purposes of this study were (a) to investi—
gate whether staff decisions to seclude patients at the Caro
Regional Center psychiatric admitting unit were biased by
patient characteristics such as age. sex. race. socio-
economic status. diagnosis or admission legal status: (b) to
examine whether various psychiatric treatment modalities had
an effect on the incidence of seclusion: and (c) to deter-
mine if a staff training program for regular staff at the
admitting building made any difference in the incidence of
secluding patients. The findings presented in this chapter
are based on the analysis of data gathered from clinical
records of first-time secluded patients and non-secluded
patients over a 10-month period. Also. some staff data will
be reviewed and discussed. as well as data related to all
incidents of seclusion during the 10 month period.

This chapter is a presentation of the results of the
statistical analyses that addressed the research hypotheses
and related questions posed in Chapter I. The chapter is
divided into the following sections: Hypotheses

Investigating Differences Between Characteristics of

118

119

Secluded and Non-secluded Patients: Hypotheses Investigating
Differences Between Various Psychiatric Treatment
Modalities in Relation to Seclusion Room Usage: and
Hypotheses Investigating the Impact of Staff Training on
Seclusion Room Usage. An alpha level of p <.05 was required
for consideration of statistical signifcance in all
analyses.

Hypotheses Investigating Differences Between
Characteristics gf Secluded and Non-secluded Patients

 

fig 1: There are no significant differences in patient

characterists when comparing secluded and non-secluded
patients.

fig 1: There are significant differences in patient
characteristics when comparing secluded and non-
secluded patients.

Table 4: Sample Characteristics of Secluded and Non-
secluded patients.

 

 

 

 

Variables Secluded Non-secluded P
N=52 N=58 (a=.05)

232 N.S.

Male 30 30

Female 22 28
3222_ N.S.

White 35 45

Black 11 11

Other 6 2
Ag; (mean) 36.7 37.0 N.S.
Agigmm (mean) 5 ft. Bin. 5 ft. 6 in. S
[gigmm (mean) 166 lbs. 160 lbs. N.S.
éiéiflifi (lbs/inch) 2.45 lbs. 2.45 lbs. N.S.
Education (mean) 11.8 yrs. 11.2 yrs. N.S.
marital Status S

Never married 29 22

Not currently

married 20 22

Married 3 14

120

Table 4. continued

 

 

 

 

 

 

 

 

 

 

 

 

 

Variables Secluded Non-Secluded P
N=52 N=58 (a=.05)
Previous Treatment S
No 2 10
Yes 50 48
Year Treatment
figggm (mean) Aug. 1977 Feb. 1978 N.S.
Previous Hospitali-
EEEIQPE St
222_ (mean) 2.4 2.5 N.S.
Diagnosis S
Schrophrenic 26 14
Manic 19 9
Depression 5 12
Non-psychotic 2 14
Organic 4
Not known 5
Treatment Received S
Milieu 24 14
Medication only 16 32
Work & Meds 12 12
211.1222! M-
Non-veteran 45 49
Veteran 7 8
Living Area N.S.
Inner City 8 12
City 25 18
Suburban 5 3
Rural-small town 14 25
Living Status N.S.
Independent 19 27
Semi-independent 21 20
Dependent 12 11
Job Status N.S.
Employed 3 4
Homemaker 4 9
Unemployed 17 15
Disabled 26 26
Retired 2 3
Incomg (mean) $3738 $5323 N.S.
Last Year
2mplgygg (mean) August. '83 Feb. '84 N.S.
Legal Status N.S.
Voluntary 10 19

Involuntary 42 39

 

121

The data related to testing the null hypothesis are
presented in Tables 4 through 8. and Figures 1 and 2. The
results indicated there was significant difference in five
of the 20 variables tested statistically. An examination of
Tables 6 and 8 indicates the significant differences in
characteristics of secluded and non-secluded patients were
as follows: height. marital status. previous psychiatric

treatment. diagnosis. and treatment received.

122

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124

 

 

 

 

 

 

 

 

Table 5: Results of m-test Investigating Differences Between
First-Time Secluded Patients and a Random Sample
Group of Non-Secluded Patients

Variable Group Numbers Mean 22 E gj p

Agg Group 1 52 36.7 12.7 -O.15 108 .817
Group 2 58 37.0 12.3

Agigmm Group 1 52 67.96* 3.9 2.17 108 .032
Group 2 58 66.40* 3.7

flglgmm Group 1 52 166.35 30.7 1.11 108 .268
Group 2 58 159.98 29.3

§£gmgmg Group 1 52 2.45** 0.46 0.53 108 .595
Group 2 58 2.41** 0.41

Education Group 1 51 11.80 2.33 1.42 106 .158
Group 2 57 11.16 2.4

lmggmg Group 1 47 $3738 $2914 -l.93 91 .056
Group 2 46 $5323 $4785

Last Year Group 1 33 83.67 4.08 -0.66 68 .514

ngAgg Group 2 37 84.30 3.96

Year Treat- Group 1 37 77.59 6.9 -0.30 84 .763

ment Began Group 2 47 78.14 9.2

Ngmmgm Group 1 52 2.4 2.6 -0.21 108 .833

Hospitalized Group 2 58 2.5 3.1

C-5 Census Group 1 52 16.2 2.15 -O.87 108 .386
Group 2 58 16.5 1.98

M_I_ _gm§_g_§ Groupl 52 100.2 6.19 -0.49 108 .624
Group 2’ 58 100.7 5.97

 

Group 1 = Secluded patients
Group 2 = Non-Secluded patients
* Measure isin inches
** Measure is pounds per inch

125

Table 6: Results of Significant m-Tests Investigating
Characteristic Differences Between Secluded and
Non-Secluded Patients

 

Variable Group Number Mean* 2 E df p

 

Patiemm Secluded 52 67.96 3.9 2.175108 .03

Agigmm Non-Secluded 58 66.40 3.7

 

* measured in inches

Table 7: Results of Chi-Square Tests Investigating Differences
Between First-Time Secluded Patients and a Random
Sample Group of Non-Secluded Patients

 

 

 

 

 

 

 

 

 

Variable Chi-Square g: p
§gm 0.394 1 .5303
2222 2.931 2 .2309
marital Status 7.869 2 .0195
Milligmy 0.008 1 .9308
Experience

Living Area 5.230 3 .1557
Living Status 1.135 2 .5669
Job Status 2.166 4 .7052
Occupation 3.353 3 .3402
nggl §£2££§ 2.584 1 .1079
Emgyigmg 5.062 1 .0245
Treatment

Diagnosis 28.881 5 .0001

 

Treatment 7.660 2 .0217

 

126

Table 8: Results of Significant Chi-Square Tests
Investigating Characteristic Differences
Between Secluded and Non-Secluded Patients

 

 

 

 

 

Variable Chi-Square g: 2

Previous Treatment 5.06 1 .0245
Diagnosis 26.88 5 .0001
Marital Status 7.87 2 .0195
Treatment 7.66 2 .0217

 

 

One variable. previous treatment. \uas an anomaly.
Before a Yates correction. it was significant (p=.0245L
After a Yates correction. it was not (22.0519). Examination
of chi-square cells indicated those who had not been
previously hospitalized tended notixibe secluded. 10 out
of 12 who had not been previously treated were part of the
non-secluded sample.

A comparison of income levels between secluded and non-
secluded patients was close to statistical significance. An
examination of Tables 4 and 5 show secluded persons had an
average income of $3,438.20: non-secluded patients
$5,322.83. The difference between the two groups was
$1,584.53. The m-test was not statistically significant
(p=.058): but in practical terms. significant. especially
with the income levels being compared.

The results indicated there were significant

differences in some patient characteristics when comparing

127

secluded and non-secluded patients. Therefore. the null
hypothesis was rejected.
Hypotheses Investigating Differences Between Various

Psychiatric Treatment modalities and Their Effect gm
Seclusion Room Usage

 

 

Ho 2: There are not significant differences in
psychiatric treatment variables when comparing secluded and
non-secluded patients.

fig 2: There are significant differences in psychiatric
treatment variables when comparing secluded and non-secluded
patients.

The data related to the testing of Hypothesis 2 are
presented in Table 9. The results indicated there were
significant differences in treatments in relation to whether
or not a person was secluded. The most significant form of
treatment was Milieu. This was determined by doing a chi-
square of treatment by secluded, controlling for milieu.
Tables 4 and 6 indicate a test result with 23.0007. An
examination of the descriptive data shows 462 of individuals
secluded received milieu treatment alone: 552 of non-
secluded patients were on medication treatment alone. Other
significant chi-square results were legal status status by
treatment. and diagnosis by treatment.

Diagnosis and treatment have a close relationship
because schizophrenia and bi-polar disorders most often
require medication treatment. Also. most schizophrenic and
manic patients came to the hospital involuntarily. This

generally meant that initially only mileau treatment was

received by these patients. thus creating a higher

128

vulnerability to being secluded during the first days of
treatment. Based on all of these results. the null
hypothesis was rejected.

Table9: Resultsof Chi-squaretests investigating

differences between treatment modalities and
otherrelated variables.

 

Variables Chi-Square df p

 

Treatment 7.660 2 .0217
my secluded/
non-secluded

 

 

 

Legal Status 8.395 2 .0150
my treatment
secluded/non-secluded

 

 

 

Diagnosis Controlling 16.904 3 .0007
for treatment (miligg)
secluded7non-secluded

 

 

 

 

Diagnosis Controlling 5.635 3 .1308
For Treatment [mgggi
secluded7non-secluded

 

 

 

 

 

 

 

 

 

 

Diagnosis Controlling 1.477 3 .6876
For treatment (mQLA 3mg

22221

secluded/non-secluded

Diagnosis my Treatment 20.816 10 .0224
Qigmggig my Treatment 1.896 2 .3873

 

schizophrenia7manic

 

129

Hypotheses Investigating the Impact gf Staff Training gm
Seclusion Room Usage

 

 

Ag 2: Comparing the pre-training secluded group with the
post-training secluded group. there are not differences in
the relative influence of variables associated with
seclusion.
gig 2: Comparing the pre-training secluded group with the
post-training secluded group, there are differences in the
relative influence of variables associated with seclusion.
The data related to the testing of Hypothesis 3 are
presented in Figures 1-4 and Tables 10-14. This hypothesis
considers whether a staff training program makes a
difference 'Hi factors related ‘UJ seclusion roonl usage.
Figures 1 and 2 examine graphically the descriptive data
from the perspective of first-time secluded patients.
Figure 2 excluded incidence data of one patient secluded 21
times over a two month period. Figures 3 and 4 present
graphically data that represents all patients secluded, and
all incidents of seclusion during the study time period.
Tables 10-14 present the results of the statistical
tests of significance. The results depicted in Table 10
indicate there was no difference in various conditions
related to seclusion. The criteria tested were: the
average number of days after admission a patient was
secluded: the average length of time secluded, the average
time per incident secluded. and the per patient average
number of incidents secluded. This data did not include one

patient who was secluded 21 times over the December. '86 -

January, '87 period of the study. Similar data including

130

this patient is shown in Table 11. Whether or not that
particular patient was included in the data tested made
little difference. The null hypothesis. based on these
tests. was not rejected.
Table 10: Results of m-Tests Investigating Differences

in Incidents. Length. Days After. and Average

Time For Patients Secluded Before Staff Training
and After Staff Training.**

 

Ir!-
a.
*1.

1'0

Variable Group Number Mean 22

 

 

 

 

 

Days After Group 1 28 38.4 123.9 1.34 49 .187
Admission Group 2 23 3.7 8.2

LgngA Group 1 28 153.8* 167.8 1.17 49 .279
§gglgggg Group 2 23 112.3* 75.7

Incidents Group 1 28 1.61 1.10 1.41 49 .164
§gglgggg Group 2 23 1.26 0.45

Aygmggg Group 1 28 91.89* 84.98 0.17 49 .864
11mg Group 2 23 88.28* 59.10

Group 1 Pre-Training Secluded Patients

Group 2 Post-Training Secluded Patients

*Variable is counted in minutes

**Excludes one patient secluded 20 times in December. 1986.
and three times in January. 1987.

Table 11: Results of m-Tests Investigating Differences for
Patients Secluded Before Staff Training and
After Staff Training

 

 

Variable Group Numbers Mean 22 E g: p

Agg Group 1 29 37.07 11.9 0.26 50 .794
Group 2 23 36.13 13.9

Heighm Group 1 29 67.7* 3.8 0.63 50 .531
Group 2 23 68.3* 4.1

fle'ghm Group 1 29 169.05 33.6 0.71 50 .483
Group 2 23 162.96 29.9

131

 

 

 

 

 

 

 

 

 

 

 

 

Table 11: Continued

Variable Group Numbers Mean 22 m g: p

2mgmgmg Group 1 29 2.50** 0.52 0.95 50 .347
Group 2 23 2.38** 0.36

Education Group 1 29 11.6 2.7 -0.78 49 .438
Group 2 22 12.1 1.6

lncomg Group 1 27 $3589 2826.3 -0.40 45 .688
Group 2 20 $3940 3091.1

Last Year Group 1 18 83.6 3.1 -0.08 31 .933

EQEAEQ Group 2 15 83.7 5.1

Year Treat- Group 1 20 77.8 6.6 -0.15 35 .885

ment Began Group 2 17 77.4 7.5

11mg; Group 1 29 2.2 2.44 -0.67 50 .508

Hospitalized Group 2 23 2.7 2.74

C-5 Census Group 1 29 16.5 1.99 1.23 50 .225
Group 2 23 15.8 2.32

‘Ml 23m§g§ Group 1 29 98.7 7.4 -1.97 50 .055
Group 2 23 102.0 3.6

Days After Group 1 29 164.2 30.5 1.61 50 .114
Group 2 23 8.2 1.7

£22932 Group 1 29 386.7 71.8 1.30 50 .201

§gglgggg Group 2 23 75.7 15.8

Incidents Group 1 29 2.4 3.1 1.36 50 .179

Sgglgggg Group 2 23 1.3 0.5

Staff Group 1 29 8157*** 7592 -0.55 50 .587

Seniority Group 2 23 9775*** 13481 .

2N Seniority Group 1 29 4977*** 924 0.09 50 .929
Group 2 23 3589*** 748

 

Group 1 a Secluded patients prior to staff training
Group 2 a Secluded patients after staff training
'* Measureis hiinches

** Measure is pounds per inch
Measure is in hours - 2080 hours equals one year

***

132

TabLe 12 shows the results of chi-square tests of
significance. related to both patient and staff
characteristics. The results indicated there were
differences between the pre-training and the post-training
groups of secluded patients. The differences were reflected
in these patient catagories: patient race and treatment
patients received while in the admitting unit. In terms of
staff data.tfim following were statistically significant:
work shift patient secluded: over-all staff 1.0” R.N.I.D.:
and R.N. sex. All the chi-square results are in Table 13.
Table 12: Results of Significant Chi-Square Tests

Investigating Differences for PatientsSecluded
Before Staff Training and After Staff Training.

 

 

 

 

 

 

Variable Chi-Square gm 2
Egg; 6.469 2 .0394
Treatment 6.139 2 .0464
Work Shift Secluded 11.275 2 .0036
Staff 1.0. 25.496 15 .0437
R.N. I.D. 19.433 8 .0127

 

R.N. s95 7.354 1 .0067

 

133

Table 13: Chi-Square Tests Investigating Differences for
Patients Secluded Before Staff Training and After
Staff Training

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable Chi-Square g: p

232 0.170 1 .6796
2_g_ 6.469 2 .0394
marital Status 0.153 2 .9262
.Military Experience 0.006 1 .9373
Living Area 3.804 3 .2834
Living Status 2.440 2 .2952
Job Status 1.099 4 .8944
Occupation 6.073 3 .1081
Legal Status 2.114 2 .3476
Previous Treatment 0.028 1 .8670
Diagnosis 0.958 3 .8115
Treatment 6.139 2 .0464
ng 3: W222 3.208 6 .7823
york Shift 11.275 2 .0036
Reason Secluded 1.663 4 .7974
Staff 1.0. 25.496 15 .0437
Staff Sex 2.525 1 .1120
Staff Race 0.809 1 .3685
Staff Classification 1.689 2 .4297
R.N. I.D. 19.433 8 .0127
22112 222 7.364 1 .0067

134

Further data related to testing Hypothesis 3 are
presented in Table 14. This analysis was required because
there was a change in policy regarding who was responsible
for initiating seclusion at C-5. After the training program
took place May 4-8. 1987. ILN. nurses were required to
assume responsibility 1%”: initiating all incidents of
seclusion. Through a process of controlling for variables
related to the sex and identity of the R.N. staff involved,
it was determined that the effect of the training program
was essentially on one male registered nurse. who was
primarily the supervisory nurse for first shift. Based on
this process. and because of previously discussed data. the
null hypothesis was rejected. but conditionally. This
conditional result will be further explained in the
discussion.

Table 14: Results of Chi-Square Tests Investigating

DifferencesAmong Nurses Who SecludedPatients.
Before and After Staff Training.

 

Variable Chi-Square df

I'D

 

Trainlmg my Shift 8.499 2 .0143

controlling for

R. N. _S_ex (malg)

Trainingb Shift 2.844 2 .2412
control ingr

2L22Qwflfl

york Shift 2y 9.183 2 .0101
B22; 5 2

 

 

 

135

Other Descriptive Data Related 39 Seclusion Usage

 

 

Figures 5-8 and Table 15 present other data of interest
related to seclusion room usage. The graph in Figure 5
shows data that indicates average admissions per month, both
before and after staff training. Figure 6 shows the percent
of all patients secluded in relation to monthly admissions.
both prior to and after the training program. This material
was included in order to take into account all patients
secluded and their respective incidents of seclusion in
relation to admissions. Admissions prior to and after the
training program were relatively constant, with a difference
of plus three for the post training period. There was a
decrease of 1.5% in the incidence of seclusion in the post-
training program, as compared with the pre-training period.

The average daily census by month is depicted in Figure
7. The pre- and post-training program comparisons showed
there was a .32 increase in census. Figure 8 shows the
percent of all patients secluded during the same period
covered by the previously discussed data. There was a.2%
decrease of patients secluded during the post-training
period. in comparison with the pre-training period.

Table 15 presents descriptive data about various
criteria and conditions related to first-time secluded
patients. Reasons for seclusion was of interest because
those stated indicators were the justifications for a staff

person effecting the seclusion process. 54% were related to

136

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138

threat of injury to staff: 26% to verbal agression. 71% of
first-time secluded patients were secluded once during the
reported admission. 75% of incidents of seclusion took
place during the first and second shifts. with first
accounting for 40% and second 35%. This data was tested for
statistical significance. and found not significant. The
same holds true for the time-of-week data. (See Table 13.)

Table 15: Criteria and Conditions Related to First Time
Seclusion.

 

Variables N=52

 

Reason for Seclusion

 

 

 

 

 

 

 

Threat of injury to self 1 (2%)
Threat of injury to peers 6 (12%)
Threat of injury to staff 28 (54%)
Property Destruction 3 (6%)
Verbal Aggression 14 (26%)
1122 22‘. 2222
Weekday 33 (63%)
Weekend 19 (37%)
1122 22 222 (work-shift)
First (6:30 a.m.-2:30 p.m.) 21 (40%)
Second (2:30 p.m.-11:00 p.m.) 18 (35%)
Third (11:00 p.m.-6:30 a.m.) 13 (25%)
Days After Admission (Mean)*** 8.7
Incidents (Mean)*** 1.5
Timg 1m Seclusion (minutes) (Mean)*** 135
Incidents gj Seclusion
Once 37 (71%)
2-3 12 (23%)
More than 3 times 3 (6%)
Admitting Unit A122 Census* 16.2
Total 21 ggnsus** 100.7

 

*Bed Capacity = 20
**Bed Capacity = 110
***Excluded one patient secluded 21 times

139

222222.!

The findings in this chapter were based on the analysis
of data drawn from 110 clinical records of patients who were
at the admitting unit of the psychiatric program at the Caro
Regional Mental Health Center. Caro. Michigan. These data
were used in analyzing the three major hypotheses and
related questions of the study.

Based on m-tests and chi-square tests conducted on
Hypothesis 1 investigating differences between secluded and
non-secluded patients, the researcher concluded there were
differences in the following areas:

1. Diagnosis, whereby secluded patients had a higher
probability (rf being schizophrenic arm bi-polar: non—
secluded patients tended to be non-psychotic. depressed,
personality disorders and organic.

2. Marital status. whereby secluded patients had a
higher probability of never having been married. and non-
secluded patients tended to be married or divorced/
separated.

3.Height. whereby secluded patients. on the average,
were two inches taller than non-secluded patients: there
were no significant differences between secluded and non-
secluded patients in weight or stature.

4. Treatment received. whereby treatment received by

secluded and non-secluded patients was different

140

(differences will be discussed under hypothesis 2).

5. Previous treatment, whereby secluded patients had a
higher probability of being previously treated than did non-
secluded patients.

Based on chi-square tests conducted on Hypothesis 2
investigating differences between secluded and non-secluded
patients. the researcher concluded there were differences in
the following areas:

1. Secluded patients had a higher probability of
receiving milieu treatment alone than did non-secluded
patients:

2. Non-secluded patients had a higher probability of
being treated on a regular medication regimen than did
secluded patients:

3. Being involved in the work activity program had
little to do with whether a patient was secluded or not
secluded.

Based on m-tests and chi-square tests conducted on
Hypothesis 3 the researcher concluded there were differences
in secluded patient characteristics when comparing pre-
training and pos-training. Also some staff differences
emerged. The differences were reflected Hithe following
catagories:

1. Patient race. whereby Hispanics had a higher
probability of not being secluded after the training: a

higher percentage of Black patients were secluded after the

141

training program:

&.Treatment, whereby pre-training secluded patients
had a higher probability of receiving milieu and/or work
activity and medication: post-training secluded patients
tended to receive medication alone:

3. Staff characteristics. whereby staff I.D.. R.N.
1.0” and RJL sex were influenced by the training program.
Also, the work shift to which an employee was assigned made
some difference.

Review of additional data. but not tested
statistically, showed that in relation to patient admissions
per month. approximately 16.5% were secluded: compared to
daily census data. approximately 1.7% of patients were
secluded. Most secluded patients. 71%. were secluded once.
45% were secluded during the first 24 hours of admission.
75% were secluded during the lst or 2nd work shift. 54% of
the incidents of seclusion were because of threats to staff:

26% because of verbal aggression or general agitation.

CHAPTER V

SUMMARY. CONCLUSIONS. AND IMPLICATIONS

Introduction
The final chapter includes a review of the problem that
was researched, the procedures used in conducting the
study. delimitations of the project. the major findings. and
a statement of conclusions. Finally. recommendations and
implications for future research and practice are presented

and discussed.

Summary 91 the Study

 

Review of the Problem

 

The problem in this study was threefold. First, the
researcher investigated the effect patient characteristics
had on the seclusion process. Previous studies have not
been consistent in determining whether or not patient
characteristics such as race, sex, age. diagnosis. or size
had an impact on biasing staff decisions to seclude.
Secluded and non-secluded patients were compared in order to
ascertain if any differences existed.

Secondly. the research focused on treatment

considerations in relation to the seclusion process. The

142

143

admitting unit of the psychiatric program offered a variety
of treatment modalities. and the basic question was how
different aspects of active psychiatric treatment impacted
on the level of seclusion usage. Treatments of interest
were milieu. medication. and work activity. All patients in
the admitting unit experienced the milieu. but not
necessarily the other forms of treatment.

A third problem area was the influence of a staff
training program on the incidence of seclusion. All regular
staff of C-5 participated Via one-week training program,
and an evaluation was made to determine if this program
changed how staff reacted to patients who were apparently
not in control.

Over-all, as much as was possible. the researcher
wanted to identify the key factors which contributed to the
event of seclusion in instances when this form of behavior

control was required.

Review of the Procedures

 

 

The researcher employed an interrupted time-series
design. in a naturalist setting. This design is quasi-
experimental, and was retrospective in nature. The
researcher did not manipulate the variables studied. The
design had problems with internal and external validity: but
in spite of these issues. causation cannot be dismissed: but
it cannot be strongly inferred either.

The subjects were 110 hospitalized in patients who were

144

housed at the acute—care admitting unit of the psychiatric
program at the Caro Regional Mental Health Center. The
secluded group was all first-time secluded patients from
December 1, 1986 to October 10. 1987. The non-secluded
group was a stratified random sample. by month. over the
same time period as the secluded group. The staff involved
in the study were regular and relief staff assigned to the
admitting unit during the course of the study. All regular
staff participated in a training program held in May. 1987.
The psychiatric treatments considered were those commonly
available to the patients who resided in the admitting unit.
All of the data were gained from the clinical records of the
patients involved in the study. Also, policy. procedures

and law were reviewed.

Delimitations

 

When the researcher first considered the problem of
seclusion room usage as a research project. it was assumed
this was a subject that had been well considered. The
review of the literature was completed, and it was
discovered that in comparison with other areas of concern in
psychiatric treatment. the subject apparently has had
limited interest. In addition to that. empirical research
has essentially been even more limited. It seemed
appropriate then that the issue of seclusion be explored
empirically in order to begin to understand some of the

dynamics that have entered into the procedure. which in 20th

145

Century psychiatric treatment seems like an anachronism.
Particularly essential in the delimiting process was the
addition of the staff-training component. which gave the
research task more power in terms of testing the hypotheses
that eventually emerged.

There was the desire to move more aggressively into
staff issues as far as seclusion room usage was concerned.
But it could not at this time be accomplished. This
limitation should not be viewed as an expression of "blaming
the victim". which in this case is the patient secluded.
The patient is currently the focus because his/her treatment

is paramount.

Major Findings

This section provides a summary of the findings derived
from the statistical analysis of data concerning factors
related to seclusion room usage at the Caro Regional Center
Psychiatric Admitting Unit. The data were generated by a
retrospective review of 110 patient records. who were
residents of the admitting unit from December 10. 1986 to
October 10, 1987. The data were analyzed using m-tests. and
chi-squares. with p < .05 being required to obtain
statistical significance. Three major hypotheses were
tested.

Null Hypothesis 1 regarding patient characteristics and

seclusion usage was rejected because the m-tests and chi-

146

square tests yielded satistically significant results at the
p < .05 level. Examination of the data indicated that five
of the twenty patient characteristics studied had some kind
of association with the seclusion experience. For the
purposes of this hypothesis. patient height. marital status.
previous psychiatric treatment, and diagnosis stood out. It
was determined that previous treatment and marital status.
in the context of the sample studied. were closely related
to diagnosis.

Null hypothesis 2. which focused on the role of
psychiatric treatment in relation to seclusion. was rejected
because chi-square tests yielded statistically significant
results at the p < .05 level. The data was examined. and it
was revealed that milieu treatment alone was associated with
being secluded: medication treatment alone was associated
with not being secluded: work activity had no impact on
either the process of seclusion or not being secluded.

Null hypothesis 3 focused (N1 the effect of staff
training on the incidence of seclusion. Chi-square tests
and m-tests yielded statistically significant results at the
E <.05 level. and therefore the hypothesis was rejected.
But examination of the data placed reservations on this
conclusion. First of all. there were no statistically
significant changes in incidences of seclusion. number of
times individual patients were secluded. length of

seclusion. or average length of seclusion. These factors

147

were tested two ways: one with a patient who was secluded
twenty-one times over a two month period: the second without
this patient. Secondly. an examination of staff data which
was statistically significant revealed that one male staff
nurse was the primary reason for the data showing
statistical significance.

Other information of interest that emerged from the
research was that 54% of the patients were secluded because
of an actual or perceived threat of injury to staff. Most
patients. 71%, required one incidence of seclusion to
control behavior necessary to maintain safety for the
patient and others. Statistical testing showed there was no
significance when comparing incidence of seclusion and the
census of C-5. The average time spent in seclusion was two
hours, fifteen minutes. though this figure was affected by
some few patients who spent an excessive amount of time in
the seclusion room. There were no statistically significant
differences when comparing work shifts secluded: and also

when comparing weekdays with weekends.

Conclusions and Discussion

 

This research discovered that seclusion was primarily a
product of two factors: the patient's diagnosis, along with
commensurate behaviors and psychological dynamics that are
correlates of the psychiatric condition the patient had been
experiencing: the other factor was the treatment the patient

received while in residence at the admitting unit.

148

As a result of this study, the researcher is confronted
with the question "What was missed and not accounted for".
This question becomes even more imperative when a rather
interesting happening is considered. The study had what
could be called "an open window", which was that period of
time before. during, and after the training program when
regular staff were not in the admitting building. This
period covered ten days. During that ten-day period, and
three days after, no patients were secluded. So, for a
thirteen-day period no patients were secluded. The dynamics
of that fact. it seems to the researcher. are at least
somewhat related to the question raised about what was
missed.

When the study was begun. the investigator had some
anticipations about what might come from the research: and
the basis of those expectations came from the literature
review as well as from clinical impressions.

First of all. in relation to patient characteristics.
it was expected there would be many differences between
secluded and non-secluded patients. For example. it was
thought a bias would be apparent in decisions to seclude,
which would tend toward young, male. black. urban, disabled.
poor. involuntarily in the hospital. and psychotic. Also,
it was thought secluded people would tend to be larger.
There were actual differences between the secluded and non-

secluded population. but with the exception of

149

characteristics related to diagnosis, the differences were
not statistically significant.

For example, secluded patients were two inches taller
and six pounds heavier, on the average, that non-secluded
patients.*

There was an actual difference of $1600 hithe income
levels. and in the reality of most of the patients. that
dollar amount could be most significant. 0n the racial
issue, what the study did reveal was that the percentage of
Black patients in the hospital went far beyond their
population proportions in the catchment area. This raises a
question about race and mental illness. Also. what the
general data revealed was that people who end up at the Caro
Regional Center fall way below the established poverty
guidelines. This raises an issue about the relationship of
poverty to mental illness.

As far as significant variables were concerned. the
results were not unexpected -- schizophrenic and bi-polar
patients had a greater vulnerability to being secluded than
persons with other diagnoses. But not all of those patients
ended up in seclusion. So what differentiates non-secluded
and secluded psychotic persons? Is there a predictive

relationship here? Or do other factors enter into finding

 

* On this characteristic, it is natural to assume bigger
people would end up secluded. In reality. they were. If a
larger sample had been obtained, this variable could have
been significant. It is the belief of the researcher that
the size factor needs to be examined more extensively.

150

the answer to the original question that was asked, i.e.
"what was missed"?

When dealing with the question about diagnosis as a
predictor. the nature of the illness has to be considered.
Schizophrenia is not one mental illness -- rather it is a
family of illnesses. The behaviors related to the condition
can vary. depending on what form the patient is
experiencing. DSM-III (1980). the major diagnostic
reference for American psychiatry. lists five different
types of schizophrenia. each with a numerical rating to
indicate the severity of the disorder. And even though each
carries the general name of the disorder (schizophrenia).
each catagory of the disease has its own unique fingerprint.
Catatonic is the opposite of paranoid, to consider one
contrast in this family of disorders.

The same holds true for bi-polar disorders. Most
patients who are diagnosed as bi-polar. and have been
secluded. fit criteria that describe a manic condition. But
there are the differences between a hypo-manic and a hyper-
manic. There are "pleasant" manics and "nasty" manics.
Some have paranoid type delusions: others are grandiose.
Also. a person can be diagnosed as having a bi-polar
disorder. mixed. Sometimes a person can be diagnosed as
being bi-polar. depressed -- but experiencing an agitated
depression.

To further confuse the issue, the problem of diagnostic

151

certainty is confounded when a person is determined to be
schizo-affective. All of this is stated to indicate that
even though diagnosis can be an apparent predictor in terms
of the seclusion experience. diagnostic uncertainties create
the potential for significant confounding.

Treatment issues were the second area of concern
considered by the researcher. It was predicted that an
active treatment involvement would make a (HfTerence.
Medication turned out to be the most powerful variable in
terms of reducing seclusion room usage. The converse of
this was that if patients were treated in the milieu alone.
that increased the probability of the incidence of
seclusion.

That medication made a significant difference is no
surprise, though past research has been inconsistent in
reporting that medication was an importnat variable in
reducing seclusion. Because of the properties of medication
in terms of controlling symptoms, it would be expected that
medicine would play a part in calming people down enough
that seclusion would not be a needed alternative.

This raises another issue. i.e. chemical restraint.
Often. 'Hi most psychiatric facilities. including Caro. prn
(pro mg na a. as required or necessary) medication is
administered in conjunction with secluding a patient. This
practice has significant treatment. legal, and philOSOphical

implications. Justification usually centers on the safety

152

of the patient and the environment: but the Youngberg and
Olin cases raised troublesome issues, and this practice
would fit in the framework of those issues.

As examined in this research. the work activity program
had little impact on seclusion room usage. This result was
unexpected. Some of the literature reviewed earlier
suggested that structured activities within an acute-care
residential psychiatric unit made a positive difference in
the incidence of seclusion. It seemed logical to assume
that an out-of-building program would have a similar impact.
In this instance it did not. Was that because the concept
had no validity in relation to behavior control? Or was it
because of the way the program was put into effect in the
admitting unit? Though there is no hard evidence to support
this impression. it is the belief of the researcher that it
was a systemic issue. and not a conceptual one.

One reason to consider a systemic hypothesis is that
work activity, by policy, is not generally considered until
48 hours after admission. Over 70% of incidents of
seclusion occurred within 36 hours of admission: and 37% of
seclusion incidents occurred over the weekend. when the work
activity program was not available. Another issue was
related to intentioning. The belief has been that if a
person is stable enough to participate in an out-of-building
activity, then he/she should be seriously considered for a

less restrictive residential setting in the psychiatric

153

program. But there was inconsistency in having people
attend the work program in a timely way. Irirecent months
that has changed. but at the time of the study some patients
did not go to the program as soon as they might have been
able.

From a treatment perspective. it would seem fitting to
consider the possibility of implementing some kind of work
activity program at the acute-care unit. More structured
programming will mean less out-of—control behavior on the
part of patients, which would reduce the need for seclusion
as a means of behavior control. If patients can be involved
in something outside of themselves. a result can be a
facilitation of patients regaining self-control.

The final reason considered in this research was staff
training. and whether the program would make a difference in
the incidence of seclusion. Even though the null hypothesis
was rejected. it was done so with reservation. Differences
did exist in certain staff and patient characteristics, but
in variables such as incidence, average time, and length of
time in seclusion there was no statistical significance.
There was a perceptible dr0p in the number of patients who
were secluded. and in incidence of seclusion during the five
week period following the beginning of the training program.
As a part of this (as noted earlier) in the ten-day period
when regular staff were not in the building. and three days

following. there were no incidents of seclusion. Admissions

154

and census at C-5 were nominal during this period. though it
was not known for research purposes what diagnoses admitted
patients carried.

Concerning the effect of the training program. as
stated earlier. one staff person was impacted both
clinically and statistically. and can be viewed as an
"outlier". There was a significant reduction in the
incidents of seclusion when he was the supervisory nurse, no
matter what shift he was working. During an interveiw, he
stated he noticed not only a difference in himself but also
in the staff for whom he was responsible. He observed a
difference in how patients who were agitated or aggressive
were dealt with. Because of the training program, he
believed he was more sensitive to what was happening with
patients who were in a state of crisis.

The training program had the purpose of teaching staff
about the philosophy of the facility. and also to be more
effective in assisting patients to regain self-control. The
program iuas not specifically designed to teach people
alternatives to seclusion usage: it had a broader purpose
than that. But it seems logical to presume that within the
larger purpose, some impact might have been felt in terms of
reducing seclusion room usage. 1

One area that is often not emphasized in staff training
is the importance of the relationship between staff and

patient. The content of most programs will have sections on

155

communication, or methods that will enhance empathy: or
there may be portions of the program that focus on
understanding the dynamics of mental illness. But few
programs touch on establishing an authentic person-to-person
relationship between staff and patient.

If the primary purpose of care is to facilitate an
experience whereby a patient can regain self-control and
self-esteem. then an authentic relationship experience must
exist between the care providers and the care receivers.
This has been talked about for years in the context of
therapy: but little has been stated concerning this in
regard to staff. who provide 24-hour care. The central
barrier that exists between patients and staff is the
resentment that is generated when patients feel they are
being over controlled, and when they believe that staff are
using their power to enhance their own ego. These are
issues and perceptions that are illusive and difficult to
quantify, but central to meaningful treatment.

Finally. it could prove helpful to have a clearly
stated outline of procedure and criteria which would easily
be accessible to staff. Redmond (1980) presented an example
of such an outline. which was developed by the Psychiatry
Department of the University of Texas. Something similar
that reflects Caro Regional Center philosophy could be

helpful. The protocol stated:

156

Seclusion 3222 92122212

 

Justification for Seclusion

 

1. Discharge diagnosis of psychosis (schizophrenia, manic
depression. major affective disorders)

2. Patient (pt) was dangerous (combative. suicidal)

3. Other methods of control were tried first (anti-psychotic
medication. one-on-one interaction between staff and pt)

4. Physician's order prior to use of seclusion room was
written within 24 hours

5. Progress note on reasons pt was secluded

Patient Outcome

 

6. Pt in seclusion room on less than three consecutive days

7. No physical injury

8. No attempted suicide

9. No special incidents (e.g. injury to others. fires.
possession of potentially lethal objects)

10. Progress note describing course in seclusion (to be
monitored every 15 minutes)

11. Pt in seclusion room less than two hours (exception
granted for patients who fall asleep). (p. 23)

It is the belief of the researcher that most of the
variability unaccounted for can be found in all dimensions
of the hypotheses tested in this study: what the patient
brings: what the program brings in terms of the treatment
environment and program: and what the staff brings in terms

of values, attitudes. and experience. Therefore, the

157

following is offered as a means to move to more effective

treatment and greater knowledge.

Implication for Future Research and Practice

There is a great need for further investigations on
seclusion process, as well as the effects of the practice on
patients who are secluded. There is a need to consider
further issues related to patient characteristics and bias.
Treatment programs and their impact on seclusion usage
should be examined further. Staff training in psychiatric
care in general. and how it relates in particular to the
incidence of seclusion, needs to be studied more. This
research is just one small step. especially in an emperical
sense. More needs to be accomplished. making use of more
sophisticated and powerful models so there can be movement

beyond clinical impressions.

implications for Future Research

 

Results of this research suggested specific areas as
being particularly relevant for future study.
Recommendations first come from the study. and then move
into related questions that need examination.

1. Investigation is needed to determine why Black patients
are being hospitalized in numbers that are greater than
their representation in the general population.

2. Research is required to understand further the effects

of distress related to poverty and how this impacts on the

158

occurance of mental illness.

3. Research is needed to examine more extensively reasons
why patients are secluded.

4. Replication of this study using larger samples and a
longer time frame.

5. Research is needed to explore the impact of staff
training programs (M1 changing attitudes hi regard to
providing the least restrictive alternative of behavior
management to culturally different people.

6. Structured programing is important in treatment. More
knowledge is needed on how this kind of programing reduced
distress, agitation and confusion.

7. Chemical restraint is a relatively common practice. Its
prevelence needs to be examined both from a legal and
treatment standpoint.

8. There were many days when patients were not secluded.
What was the difference between days patients were secluded
and not secluded?

9. Replication of this study at the following kind of
institutions: private acute-care unit: community based
acute-care unit: similar state-related institution:
university acute-care unit, long-term state hospital.

10. Research efforts should focus on examining the
experiences of patients who have been secluded. and how
those experiences affected them.

11. Research would be fitting on how staff view their

159

involvement in secluding a patient, especially perceived
threats to their safety.

12. Staff burn-out is a serious problem. and it has an
effect on how difficult and agitated patients are treated.
Research needs to be done on the causes and impact of staff
burn-out.

13. There is a need to compare the philosophies and
practices of several institutions in order to ascertain
differences in procedures and their effectiveness.

14. Some raise the question about the need for seclusion at
all. Research programs need to be developed to explore this

option.

implications for Practice

 

1. Create a new protocol for seclusion reporting which does
not require copying and will minimize redundancy in
reporting.

2. Develop with staff a step-wise procedure which outlines
clearly management options. from the least restrictive to
most restrictive.

3. Hold periodic staff training programs (NI behavior
management issues. using role-playing methods and other
experiential modalities of training.

4. Periodically. use a particular incident of seclusion as
a focus for a retrospective look at behavior management
approaches. This method of learning is most effective

immediately after the incident.

160

5. Create a staff training module which focuses on non-
control relationships between staff and patient. Of
particular importance is the inclusion of guidelines for
being "non-parentf' in those situations which require some
kind of intervention by staff.

6. In comprehensive staff training programs. include
information about seclusion policy. vulnerable patients,
prevention options and least restrictive alternatives.

7. In the admitting unit make available more structured
treatment options. including timely involvement in work
activity. planned outside activities, various group
therapies. various activity therapies including exercise.
recreation. music and crafts.

8. Involve the behavior management committee as a check and
balance when seclusion goes beyond two hours: when a patient
is secluded more than three times: and when seclusion and
prn medication are used together.

9. Seclusion at the Caro Regional Center. with exception of
the admitting unit, has been abandoned as a behavior manage-
ment option. The usage of seclusion is minimal. in
comparison with other institutions. private and public.
Create a task force representative of administration,
direct-care staff. professionals and former patients to
develop optional behavior management techniques that would
be used in difficult management situations.

It is the belief of the researcher that seclusion as a

161

behavior management methodology is outmoded and unnecessary.
The procedure is (a carryover from another time in
psychiatric history. Patients who are not in control. need
assistance in regaining controL. It is the responsibility
of treatment personnel to be more creative in developing new
ways to assist agitated patients become more calm and less
distressed. All too often. practitioners (including the
writer) have used seclusion as an easy way out of difficult
situations. Possibly, if the option was not available. then
other ways would be found. Hopefully, this research will

facilitate finding new ways.

APPENDIX A
MICHIGAN MENTAL HEALTH CODE

0rd

an
Aut
Drc

161A

MICHIGAN'S MENTAL HEALTH CODE
MICHIGAN DEPARTMENT OF MENTAL HEALTH

330.1742 Seclusion

Sec. 742. (1) A resident shall not be kept in seclusion
except in the circumstances and under the conditions set
forth in this section.

(2) A resident may'be placed in seclusion £2mpgmgmily
only pursuant to subsection (5) and only if it is essential
in order to prevent the resident from pmygigglly Agmmimg
Aiméglf or 9211252 or in order to prevent the resident from
causing 22222222121 22222222 222222- A resident may be
placed in seclusion upon an authorization or written order
only pursuant to subsection (3) or (4) and only if it is
essential to prevent the resident from physically harming
himself or others, or to prevent the resident from causing
substantial property damage. or if seclusion would be of

clinical or therapeutic benefit for the resident.

(3) A resident may be placed in seclusion pursuant to
an order of a qualified professional person made after
personal examination of the resident. Ordered seclusion
shall continue only for that period of time specified in the
order.

(4) A resident may be placed in seclusion pursuant to
an authorization by a qualified professional person.
Authorized seclusion shall continue only until a qualified
professional person can personally examine the resident.-

(5) Seclusion may be temporarily employed in an
emergency without an authorization or an order. Immediately
after placing the resident in temporary seclusion, a
qualifed professional person shall be contacted. If, after
being contacted. the qualified professional person does not
authorize or order the seclusion. the resident shall be
removed from seclusion.

162

(6) The governing body of the facility pursuant to
standards of the department of mental health shall establish
in writing the qualifications necessary to be considered a
qualified professional person for purposes of this section.
the maximum length of time ordered, authorized. and
temporary seclusion may last, the frequency at which a
secluded resident shall be examined. the persons qualified
to make the required examinations. and other regulations
which the governing body deems appropriate.

(7) A secluded resident shall continue to receive
food. shall remain clothed unless his actions make it
impractical or inadvisable. shall be kept 'Hi sanitary
conditions. and shall be provided a bed or similar piece of
furniture unless his actions make it impractical or
inadvisable.

(8) A secluded resident shall be released from
seclusion whenever the circumstance which justified its use
ceases to exist.

(9) Each instance of seclusion, full justification for
its use. and the results of each periodic examination shall
be placed in the record of the resident.

APPENDIX B
DMH ADMINISTRATIVE RULES

163

ADMINISTRATIVE RULES
DEPARTMENT OF MENTAL HEALTH
STATE OF MICHIGAN

Part 4. Administrative Action for Mentally Ill
Persons Requiring Treatment

Subpart 3. Admission Conditions

R 330.4025 Equality of Care

Rule 4025. A hospital shall not discriminate or give
differential care 'U) any individual admitted to that
hospital based on the type of admission or income status of
the individual. Patients shall receive the highest possible
quality of care and treatment without regard to race.
nationality, religious or political belief. sex, age. or
handicap.

R 330.4028 Physical Inspection

Rule 4028. A patient shall be inspected by a physician
or registered nurse upon admission and notation shall be
made in the clinical record of bruises. scars. marks, and
possible fractures or other injuries.

R 330.4031 Voluntary admission

Rule 4031. (1) An application for voluntary admission
shall not be considered as lacking voluntariness because an
individual has agreed to that action as a result of a
probate court proceeding.

(2) The hospital director or his designee shall
evaluate an individual's clinical suitability for informal
or formal voluntary admission and shall include the
following criteria in making the determination.

(a) The individual has a condition that the hospital
director determines can benefit from the inpatient treatment
that is provided by the hospital.

(b) Appropriate alternatives to hospitalization have
been considered by the hospital. and with the consent of the
individual. the community mental health program in the
individual's county of residence.

(c) Adequate alternative treatment is not available or
suitable at the time of admission as determined by the
hospital. and with the consent of the individual. the

164

community mental health program in the individual's county
of residence.

R 330.4035. Formal voluntary admission.

Rule 4035. (1) When an individual requests formal
voluntary' admission and the hospital director or his
designee determines the individual to be clinically suitable
for that form of admission, the hospital shall admit the
individual and shall include the application as part of the
case record.

(2) An individual under 18 years of age shall be
admitted as a formal voluntary patient if deemed clinically
suitable by the hospital director. upon the application of a
parent. guardian. or in their absence. a person in loco
parentis.

R 330.4045 Involuntary Admissions.

Rule 4045. (1) For the purpose of establishing the
point at which hospitalization begins. 1 of the following
conditions shall be met:

(a) An individual arrives at or is at a hospital and an
application for hospitalization is completed and given to a
hospital staff member with a completed certificate.

(b) An individual arrives at<ncis at a hospital under
a court order for immediate hospitalization. other than an
order'to undergo an examination. aftereipetition has been
filed with the court.

(c) An individual is at a hospital after giving written
notice of an intention to terminate formal voluntary
hospitalization and the director of the hospital or his or
her designee has filed with the court an application for
admission by certification and the required certificates.

(2) For the purpose of establishing when an individual
may complete a reasonable number of telephone calls and when
a preliminary hearing shall be convened if the person is not
released. the time (H1 individual is received for
hospitalization by certification, or court-ordered immediate
hospitalization. is any time the individual arrives at the
hospital. A formal voluntary patient who is being admitted
as an involuntary patient by application of a hospital
director is considered received for hospitalization at the
time application and certificates are filed with a probate
court.

(3) When an individual is presented to a hospital, the
hospital shall do all of the following:
(a) Require that the application for hospitalization.

165

if any. meet the requirements of section 424 of the act.

(b) Require that the certificate accompanying the
application. if any. meet the requirements of section 400(K)
of the act.

(c) Determine if the individual presented is clinically
suitable for informal or formal voluntary hospitalization.
If this determination is affirmative, immediately offer the
individual the opportunity to apply for hospitalization as
an informal or formal voluntary patient, and as many times
thereafter as deemed appropriate by the hospital director
until an order of hospitalization, alternative treatment, or
discharge is received. If the individual is hospitalized as
a voluntary patient. the hospital director shall inform the
court and recommend whether dismissal of pending proceedings
would or would not be in the best interest of the individual
or the public.

(d) Allow the individual to complete not less than 2
phone calls. If the individual does not have sufficient
funds on his or her person. calls shall be made at hospital
expense with the condition that they be limited to persons
who are willing to receive the calls. The hospital director
or his or her designee may determine the appropriateness of
a call or calls that are at hospital expense and may limit
their length to a reasonable duration. but a call shall not
be limited to less than 5 minutes.

(e) Provide to the individual, not more than 12 hours
after hospitalization. a copy of the application for
admission asserting that the individual is a person
requiring treatment. a written statement that the individual
will be examined by a psychiatrist within 24 hours of the
hospitalization. and a wrjtten statement, in simple terms.
explaining the right of the individual to request a
preliminary hearing. to be present at the preliminary
hearing, and to be represented by legal counsel, if the
individual is certified as a person requiring treatment: a
written statement. in simple terms, explaining the right of
the individual to a full court hearing. to be present at the
hearing. to be represented by legal counsel, to a jury
trial, and to an independent evaluation: and a copy of each
certificate executed in connection with the individual's
hospitalization if available. Each certificate shall be
delivered to the individual within 24 hours of either a
certificate's completion or receipt of a certificate by the
hospital from a source outside the hospital.

(f) If the individual is unable to read or understand
the written materials. every effort shall be made to explain
them to him or her in a language he or she understands, and
a note of the explanation and by who made shall be entered
in the case record.

(9) The admission officer. as soon as administratively

166

possible after receiving an individual by certification who
has been certified as a person requiring treatment. shall do
all of the following:

(1) Notify the probate court by phone.

(ii) Obtain. when available. the tentative date of the
preliminary or full court hearing and the name and address
of counsel appointed by the court.

(iii) Notify the patient of this information.

R 330.4047 Admission by certification.

Rule 4047. (1) A state hospital, as designated in R
330.4005. shall receive and detain for examination by a
psychiatrist any individual presented to the hospital who is
accompanied by a certificate and an executed application. A
psychiatrist. either from the hospital staff or from outside
the hospital. shall examine an individual not more than 24
hours after admission. The hospital director shall provide
a room and other equipment necessary to provide a complete
examination.

(2) A psychologist or physician who has examined a
patient shall be permitted. by the hospital director.
adequate time to be deposed or to testify. if so required at
a probate court hearing regarding that patient.

R 330.4049 Examination upon application by peace officer or
court order.

Rule 4049. (1) A state hospital, as desigated in R
330.4005, shall receive and detain an individual for
examination if that individual is presented to the hospital
by a peace officer who has executed an application for
admission. The hospital shall also receive and detain for
examination any individual ordered by iflua court to be
examined. A psychologist or physician. either from the
hospital staff or from outside the hospital, shall examine
the individual within 24 hours. A psychiatrist, either from
the hospital staff or from outside the hospital. shall
examine the individual. if necessary. within 24 hours of the
completion of the first certificate. The hospital director
shall provide a room and other equipment necessary to
provide a complete examination.

(2) A psychologist or physician who has examined an
individual presented shall be permitted by the hospital
director adequate time to be deposed or to testify. if so
required, at a probate court hearing.

R 330.4051 Admission by petition.

Rule 4051. An individual shall be admitted to a
hospital on a petition pending a hearing only upon order of
immediate hospitalization by a probate court. The hospital

167

director shall have the individual examined within 24 hours
of hospitalization. If the required examination has not
been accomplished within 24 hours. the hospital director
shall release the individual and document in the records the
reasons the examination was not completed. The hospital
shall notify the probate court.

Part 7. Rights of Recipients of Mental Health Services
Subpart 3. Additional Rights of Residents of Facilities

R 330.7139 Resident's right to access

Rule 7139. (1) A resident shall not be prevented from
acquiring, at his expense. or from reading. written or
printed material or from viewing or listening to television.
radio, recordings, or movies available at a facility for
reasons of. or similar to, censorship.

(2) Restrictions or limitations may be imposed if
documented in written plans of service.

(3) Each instance of restriction or limitation and
justification for its application shall be documented and
placed in the record of the resident.

(4) Restrictions or limitations shall be removed when
not essential to achieve objectives which justified their
application.

R 330-7151 Safe. sanitary. and humane living environment.

Rule 7151. (1) A resident has the right to basic human
dignity and privacy provided in a manner consistent with the
care and treatment setting and is entitled to a humane
living environment. Provision for the safety. sanitation
and comfort of residents shall comply ‘with standards
established by the department and with the following
requirements:

(a) A resident shall be appropriately dressed and
permitted to have and wear his own clothing. which shall be
inconspicuously marked with the resident's name. Exceptions
shall be documented and justified. A resident who does not
have suitable clothing of his own shall be provided an
adequate allowance of appropriate and seasonal clothing.

(b) Clothing, both in amount and type. shall make it
possible for residents to go out-of-doors in inclement
weather and to go on trips and visits.

(c) Nonambulatory residents shall be1iressed daily in
their own clothing. including shoes. unless contraindicated
in the written plan of services.

168

(d) A resident with a physical handicap shall be
provided with appropriate clothing. in accordance with
individual needs.

(e) A resident shall be provided suitable opportunities
for social interaction with members of the opposite sex.
with appropriate supervision. except where a written plan of
service includes an essential restriction or limitation on
these opportunities and the justification for the
restriction or limitation.

(f) A resident shall be provided facilities and
equipment for regular physical exercise. A resident shall
be provided. in the absence of contrary medication
considerations. an opportunity to be outdoors at regular and
frequent intervals. with supervision as necessary.

(9) Residents in a multiresident room shall be
allocated a minimum of square feet of usable floor space per
resident and a clearance between beds according to standards
of the department. Single rooms shall have a minimum of
square feet of floor space according to standards of the
department. A resident shall be provided, unless
contraindicated in a written plan of service all of the
following:

(i) A bed of proper size and height with adequate
changes of linen. and other appropriate furniture.

(ii) The right to suitable decorate his room, or
portion of a multiresident room.

(iii) Screens or curtains to provide for privacy within
a multiresident room for adult residents.

(h) Water closets and bathing and toileting appliances
equipped with appropriate devices shall be provided for use
by the physically handicapped.

(i) There shall be 1 toilet for each 8 residents. with
separate stalls to ensure privacy, kept clean and free or
odor. Toilet paper shall be available in each water closet.

(j) Water closets. bathtubs. and showers shall provide
for individual privacy.

(k) There shall be 1 lavatory for each 6 residents with
soap and towels or drying mechanisms available. On lavatory
shall be accessible to. and usable by. residents in wheel-
chairs.

(1) Theme shall be 1 tub or shower for each 10
residents. A tub or shower area shall be divided by
curtains. doors. or partitions to provide for privacy.

(m) A resident shall be provided 40 square feet of day
activity room space. Day activity rooms shall have outside
windows and shall be adequately furnished. and shall
approximate normal patternscflihome living. Recreational
and leisure time supplies and equipment shall be provided.
Corridors and chapels with fixed pews shall not be counted
as day room space.

169

(11) Dining room areas shall have a minimum of 15 square
feet per resident as provided for in the department
standards. Dining rooms shall be separate from kitchens and
shall be furnished with comfortable chairs and tables with
washable surfaces.

(0) Special equipment.shall be provided for geriatric
and nonambulatory residents to assure safety and comfort.
including appropriate devices on toilets and wheelchairs.
Provision shall be made for nonambulatory residents to
communicate their needs to staff.

(p) A facility shall have a system of linen supply
which insures.that linen is available at all times for the
proper care and comfort of residents. that there is adequate
space and equipment for handling clean and soiled linen. and
that there are frequent changes of bedding and other linen,
not less than once every week. Soiled bedding shall be
changed immediately. Soiled linen shall be removed from the
living unit daily. Clean linen and clothing shall be stored
in clean, dry, dust-free areas.

(2) A facility shall be in compliance with the
sanitation. health. and environmental safety codes of state
and local authorities having primary jurisdiction over the
facility.

(3) A facility shall have a system (H: maintenance
service which insures that the facility is being kept in a
continuous state of repair and operation in accordance with
the needs of the health. comfort. safety. and well-being of
the residents.

(4) A facility shall maintain a sanitary environment in
keeping with pertinent public health standards and utilizing
practices. including.

(5) The holding. transferring. and disposal of waste
and garbage shall be done in a manner that will not create a
nuisance. nor permit the transmission of disease. nor create
a breeding place for insects or rodents.

(6) Handwashing facilities shall be available in. or
adjacent to. bathrooms. water closets. and kitchens.

(7) There shall be adequate insect screens on windows
and doors when those windows and doors are opened for
ventilation.

(8) There shall be adequate janitorial equipment and
storage space in each unit of the facility.

170

(9) A facility shall have a pharmacy, or contract for
pharmaceutical services with E: pharmacy. licensed and
subject to. and conducted in accordance with. existing
statutes, rules. and procedures.

(10) A resident shall receive prompt and adequate
medical treatment for physical ailments and for the
prevention of illness or disability which meet standards of
the medical community.

R 330.7158 Medication
Rule 7158. (1) Medicatiom shall be administered only
at the order of a physician.

(2) Medication use shall conform to medication use
guide-lines adopted by the department, which guidelines
shall, at a minimum. conform to federal standards and
nationally recognized peer review organization standards.
The medication use guideline adopted by the department on
psychotropic medication shall allow a provider to select
between standards on dosage levels recommended by 1 or more
nationally recognized organizations or those of the
manufacturer of the medication.

(3) Medication shall not be used as punishment. for the
convenience of the staff. or as a substitute for other
appropriate treatment.

(4) Telephone orders for medication shall be accepted
only in emergency situations. In psychiatric hospitals.
centers for developmental disabilities, and Inental
retardation service facilities, emergency telephone orders
shall be received, recorded. and signed by a registered
nurse. and countersigned by a physician within 24 hours.
The receiving. recording. signing, and countersigning of
emergency telephone orders in other facilities shall be by
such personnel and within such time periods as is specified
by licensing or certification requirements or standards
applicable to the type of facility.

(5) Orders for medication shall be effective only for
the specific number of days indicated by the prescribing
physician.

(6) Orders for schedule 2 controlled substances shall
expire after 3 days unless otherwise provided for in the
guidelines established pursuant to subrule (2) of this rule.
and stop order procedures for other medications shall be
adopted. printed, and made available by the facility for
review and approval by the authorized regulatory agencies.

171

(7) The administration of a psychotropic medication
shall be reviewed at least once every 30 days to determine
the appropriateness of continued use.

(8) Medication shall be administered by or under the
supervision of residential facility personnel who are
qualified and trained pursuant to Act No. 368 of the Public
Acts of 1978. as amended. being #333.1101 et seq. of the
Michigan Compiled Laws.

(9) The administration of medication shall be recorded
in the resident's medical record.

(10) Medication cards<n'other approved systems shall
be used in the preparation and administration of medication
in psyhiatric hospitals and centers for developmental
disabilities.

(11) Nursing units in psychiatric hospitals and living
units of centers for developmental disabilities shall be
equipped with adequate medication areas which provide
appropriate and sufficient space for dosage preparation and
setup. Administration shall be in accordance with Act No.
368 of the Public Acts of 1978. as amended, being #333.1101
et seq. of the Michigan Compiled Laws, and rules promulgated
by the Michigan board of pharmacy.

(12) Medication errors and adverse drug reactions shall
be immediately reported to a physician and the facility
director and shall be recorded in the resident's clinical
record.

(13) Only medication that is authorized in writing by a
physician shall be given to residents upon leave or
discharge.

(14) Medication that is given to residents upon leave
or discharge shall be in compliance with state rules and
federal regulations pertaining to labeling.and packaging.

R 330.7171 Resident health, hygiene, and personal grooming.

Rule 7171. Provision for resident health. hygiene. and
personal grooming shall include assisting and training
residents to exercise maximum capability in personal
grooming practices. including bathing. toothbrushing.
shampooing. hair grooming. shaving. and care of nails. In
addition. a resident shall be provided with all of the
following:

(a) Toilet articles.

172

(b) A toothbrush and dentifrice.

(c) An opportunity for shower or tub bath at least once
every 2 days. unless medically contraindicated.

(d) The services of a barber and a beautician on a
regular basis.

(e) If a male. the opportunity to shave daily.

R 330.7185 Mental health services in a facility.

Rule 7185. A resident has a right to those mental
health services suited to his condition which the governing
body of a facility is required or has elected to provide.
Provision of services may be limited as provided by these
rules. Mental health services suited to (1 resident's
condition and in accordance with the written plan of service
shall include:

(a) Diagnosis and treatment to disturbances.
intellectual deficienceies. biological defects. illnesses,
and injuries.

(b) Protection against communicable disease and
personal injury.

(c) Minimum restriction on movement.

(d) Habilitation or rehabilitation which maximizes abi-
lity'to cope with as normal an environment as possible and
which develops and realizes potential abilities.

(e) Treatment in the shortest practicable time.

R 330.7191 Orientation and in-service training.

Rule 7191. (l) A staff training program shall be
provided and include orientation for new employees. as well
as basic skill training. A summary of the content and
provision of training shall be made available at the request
of the director of the department.

(2) Staff shall be provided regularly scheduled in-
service training to update and inmrove skills and
competency. including training in pertinent aspects of civil
admission and discharge procedures. A summary of the
content and provision of training shall be made available at
the request of the director of the department.

(3) A facility shall maintain records of resident-staff
ratios, supervisory structure. and orientation and training
programs.

R 330.7195 Change of type of treatment.

Rule 7195. (1) A resident shall remain in a facility's
progressive treatment and care program until sufficiently
rehabilitated for release to the community. until a
discharge is required by law, or until the resident has. in

173

the judgment of the facility director. received the maximum
benefit from the program. Justification for a change from 1
type of treatment and care to another within the program
shall be in writing and made part of a resident's plan of
service and case record. Types of treatment and care shall
be designated by a facility director based on professional
standards. resident to staff ratios. and frequency of
professional consultation.

(2) A resident shall be informed when it is determined
that he is ready for another type of treatment and care,
release, discharge. or has received maximum benefit from the
program.

R 330.7199 Plan of Service

Rule 7199. (1) A plan of service shall be developed by
an interdisciplinary team of mental health professionals for
each resident and shall be included in the record of the
resident.

(2) Mental health professionals involved in the care of
a resident shall work together to develop an integrated plan
of service.

(3) One mental health professional whO'Hsa member of
the treatment or habilitation team shall be responsible for
the development. coordination. and implementation of an
individual plan of service. record progress and changes.
initiate changes or reviews, when necessary, and incorporate
in the plan restrictions or limitations of rights placed on
the resident. The first plan of service shall be aproved,
signed. and recorded in the medical record by the mental
health professional responsible for the plan within 5
working days after admission or after completion of the
comprehensive examination. whichever occurs first.

(4) An individualized plan of service shall contain.
when applicable. all of the following:

(a) A statement of the nature of specific problems or
disabilities and specific needs.

(b) Evaluation of strengths as well as weaknesses.

(c) Evaluation of the degree of physical disability and
the plan for remedial or restorative measures.

(d) Evaluation of the degree of mental disability and
the service plan for appropriate measures to be taken to
relieve treatable conditions and distress and to compensate
for nonreversible impairment.

(e) Evaluation of capacity for social interaction and a
plan for appropriate measures to increase adaptive capacity.

174

(f) Evaluation of environmental and physical limits
required to safeguard health and safety.

(9) Determination of the least restrictive treatment or
habilitation setting necessary to achieve the purposes of
admission.

(h) A statement of, and rationale for. intermediate and
long-range goals. specifiying the manner ir11uhich the
facility can improve the resident's condition with a
projected timetable for attainment.

(i) Proposed staff involvement with the resident in
order to attain goals. including a minimum number of
individual contacts and consultations planned between the
resident and professional staff and the expected minimum
number of hours of the consultations in each 30-day period.

(j) The frequency and extent of physical examination.

(k) Criteria to be met for release or discharge. and
the prognosis for placement.

(1) Notation of therapeutic tasks, labor. personal
house-keeping. recreation. or other scheduled activities to
be performed, including those as a condition of residence in
a small group living arrangement and a rationale for these
in relation to goals.

(m) An estimated date for release or discharge, with a
proposed date for development of a plan of service needed
after release or discharge. including participation of
community mental health services.

(n) Drug regimens by type. dosage, and frequency.
changes in medication or dosages. and notation of effects
and behavior changes.

(0) Dates for reviews at intervals of at least every 90
days, and by whom the review shall be done. including
provision for a written assessment of progress toward goals
and reasons for progress or lack of progress.

(p) Documentation of a restriction or limitation of
rights and any restraint or seclusion.

(q) Record of surgery: electro-convulsive therapy:
other procedures intended to produce convulsions or coma:
experimental procedures: family planning services. including
sterilization and abortion: and guardianships. legal. and
other protective services.

(5) A plan of service of a resident through the age of
25 shall consider the chronological. maturational. and
developmental level of the resident and provide for develop-
mental. educational. and training needs and for contact with
family members.

(6) A written plan of service and subsequent reviews
shall be easily identifiable as distinct and separate
written entries into a case record or separate forms which

175

become part of the record.

(7) Progress notes in a resident's record which
indicate that a plan of service is being implemented and
which document that a program plan is being carried out
shall include both of the following:

(a) Notes recorded In! mental health professionals
involved in the treatment or habilitation of the resident.

(b) Notes recorded at intervals appropriate to the
type of treatment. but not less often than once a week.

(8) A treatment or habilitation team shall include all of
the following persons:

(a) One or more physicians.

(b) Two or more of the following:

(i) Registered nurses.

(ii) Certified social workers.

(iii) Psychologists.

(iv) Vocation. occupational, or recreational therapists.

(v) Mental health counselors.

(vi) Other members of the facility staff. including
non-professional staff who work directly with the resident.

(9) Residents shall be informed. either verbally or in
writing. or their clinical status and progress.

(10) A plan of service shall specify either the
intervals for informing a resident in a manner appropriate
to the resident's clinical condition or that this is a
responsibility of the person in charge of the plan.

(11) A resident shall be given the required information
not less than once a month, and more frequently if a short-
term resident, unless waived by the facility director. The
waiver and statement of the reasons for a waiver shall be
placed in the record of the recipient.

(12) The record of the resident shall include the date
and time the resident was informed. a brief summary for the
information given. and a note of the resident's response.

(13) A facility shall allow a resident to request a
report. and a requested report shall be given to the
resident or a person chosen by the resident within 10 days.
A requested report to the resident shall satisfy the current
obligation of the facility to inform the resident. A report
may be given to a relative. guardian. or other person when
not requested by a resident only in a manner consistent with
the disclosure of confidential information as specified in
secions 748 and 750 or the act and R 330.7051.

176

(14) A clinical status and progress report shall
include. unless in the judgment of the person in charge of
hnplementing a plan of service disclosure would be
detrimental to the resident. all of the following:

(a) Current diagnosis and evaluation of physical and
mental condition.

(b) Assessment (1f progress, including whether an
involuntary resident continues to meet the criteria for
admission, whether treatment goals are being met, and. if
the goals are not being met, the reasons for failing to meet
the goals.

(c) The length of time residence is expected to
continue.

(d) Information about medication. including the type.
dosage and effects.

(e) Scheduled court proceedings which concern admission
or discharge.

(f) Restrictions (H‘ limitations currently imposed. an
explanation of reasons. the duration of restrictions or
limitations. and when they shall be reviewed.

(9) Interhn results or effects. 1vhen appropriate.
relating to experimental procedures in which the resident is
participating.

(h) Other information requested by a resident or deemed
advisable by the resident's physician or person in charge of
implementing the plan of service.

(15) Information which remains unchanged since a
previous report need not be repeated unless a resident
inquires or it appears likely the resident does not recall
prior disclosure and would benefit by the repetition.

(16) When information is withheld. the reason it is
considered detrimental to a recipient shall be placed in the
record of the recipient. A resident who inquires about
information being withheld. or about whether information is
being withheld. shall be told if a11etermination has been
made. Procedures of the facility shall allow a resident to
obtain a review of this determination by the director.

(17) A plan of service shall not contain privileged
information of communications.

(18) Copies of a current plan of service, or portions
thereof, may be given to the following entitles:

(a) Individuals not on the staff of the provider who
are involved in release planning for the resident. if the
resident. or a person empowered on the resident's behalf.
consents or if required by statute.

177

(b) A probate court in connection with a hearing in
civil admission or discharge.

(c) A probate court in connection with admission or
transfer of a prisoner.

(d) A criminal court in connection with a determination
of incompetency to stand trial if pursuant to court order or
subpoena or if the resident. or a person empowered on the
resident's behalf. consents.

R 330.7205 Chemotherapy and physical treatment.

Rule 7205. (1) Use of psychotropic chemotherapy shall
be subject to restrictions. as follows:

(a) Unless the individual consents or unless
administration of chemotherapy is necessary to prevent
physical injury. as described below, to the individual or to
others. psychotropic chemotherapy shall not be administered
to:

(i) A resident who has been admitted by medical
certification or by petition until after a fjnal
adjudication.

(ii) A defendant undergoing examination at the center
for forensic psychiatry or other certified facility to
determine competency to stand trial.

(iii) A person acquitted of a criminal charge by reason
of insanity while undergoing examination and evaluation at
the center for forensic psychiatry.

(b) Consent shall meet the requirements of an informed
consent.

(c) Chemotherapy may be administered to prevent
physical injury after signed documentation of the physician
is placed in the record of the resident and when acts of a
resident or other objective criteria clearly demonstrate to
a physician that a resident is presently dangerous to self
or others.

(d) Initial administration of psychotropic chemotherapy
may not be extended beyond 48 hours, unless there is
consent. The initial period of treatment shall be as short
as possible. shall be terminated as soon as there is little
likelihood that the resident will quickly return to an
actively dangerous state. and shall be the smallest possible
dosage needed. .

(e) Additional chemotherapy may be administered if a
resident again is presently dangerous.to self or to others
following termination of a period of medication prior to
final adjudication or during a period of examination or
evaluation ordered by a criminal court.

(f) A governing body shall adopt policies and
procedures regarding psychotropic chemotherapy which:

(i) Define.psychotropic chemotherapy.

(ii) Establish objective criteria for determining

178

present dangerousness.

(iii) Provide for the medical staff to develop agree-
ment on the minimal duration between commencing treatment
and safe termination for different disorders.

(iv) Establish when and how documentation is placed in
records of residents.

(2) Prior to final adjudication or during a period of
examination or evaluation orderd by a criminal court. the
medical staff of a facility may provide essential emergency
physical treatment services requested or consented to by the
resident or the individual empowered to give a consent.
When the life of a resident is threatened and concent cannot
be obtained. emergency essential physical treatment may be
performed after the medical necessity has been documented
and entered into the record of the resident.

R 330.7229 Resident labor.

Rule 7229. (l) A facility providing work and work
training for residents or utilizing a resident's labor shall
adopt procedures which complement both the therapeutic needs
or residents and the basic human dignity to which a resident
is entitled and is consistent with regulations and policies
of the United States department of labor. other federal
departments, and rules of the department.

(2) The labor of a resident, whether deemed therapeutic
or not inconsistent with the resident's plan of service.
shall require approval by the person in charge of the plan
of service. Approval shall not be withheld unless reasons
explaining how the labor is inconsistent with the plan of
service are stated in the case record. Disapproval of labor
by the person in charge of the plan may be reversed by the
director of the facility. In approving labor. the person in
charge of the plan may set limits. Resident labor shall not
consume more than 6 hours of a resident's day. unless
approved by the director of the facility. Labor shall not
interfere with other ongoing treatment or habilitation
programs suitable for the resident.

(3) A resident's right to compensation shall be
protected by the facility when performing labor which
results in an economic benefit to another person or agency
other than the facility.

(4) Labor by a resident of a personal housekeeping
nature or as a condition of residence in a small group
living arrangement shall be in accordance with standards of
the department.

179

R 330.7231 Freedom of movement

Rule 7231. (1) A facility's governing body shall
ensure that freedom of movement of residents shall not be
restricted more than is necessary.

(2) A resident shall have a right to the least
restrictive conditions necessary to achieve the purposes of
treatment and habilitation with due safeguards for safety of
persons and property. To this end. a facility shall make
every attempt to provide maximum freedom within the facility
grounds. outside the facility grounds. and to move
restraints from:

(a) More to less structured living.

(b) Larger to smaller facilities.

(c) Larger to smaller units.

(d) Segregation IWTWI the community to integrated

community living.

(3) A facility shall ensure that residents are not
transferred to settings which increase restraints on
personal liberty unless the resident has committed or is
expected to commit an act or acts which if committed by a
person criminally responsible for his conduct. would
constitute homicide or, felonious assault or is so dangerous
a mentally disabled or retarded person that his presence in
a facility is dangerous to the safety of other residents.
employees, the community. or himself. Procedures for this
determination shall In: consistent with the applicable
statutes. rules. policies, and procedures relating to
transfers and appeals of transfer or shall provide
substantially similar procedures which permit a resident to
challenge such a move.

(4) A resident shall have the right to freedom of
movement on the grounds. and in the buildings and areas.
within the facility suitable for and designated for
recreational or vocational activities or for social
interaction when the freedom of movement does not impair the
effective functioning of the vacility. Freedom of movement
may be restricted on the basis of reasonable and lawful
criteria. Policies and procedures may require a short
period of restricted freedom or no freedom after initial
admission.

(5) Any limitations on freedom of movement shall be
clinically justified on a time-limited basis and entered
into the resident's record. A limitation shall not exceed
the justification for the limitation either in scope or
duration.

180

(6) A resident shall be given the right to appeal
restrictions on access which are substantial in scope or
duration and the restrictions shall be reviewed with the
plan of service. Polciies and procedures shall specify the
scope and duration of restrictions which entitle a resident
to an appeal. A restriction includes a refusal to grant a
resident's request for a transfer to a setting on the same
facility or other facility which provides greater access.

(7) A facility shall provide for a rational and fair
manner in which a resident may request leaves and appeal
denial of requests.

(8) Whenever there is a justified movement of a
resident to a more restrictive setting. a justified denial
of access. or an authorized security precaution, an asses-
sment shall be made of whether it results in a substantial
limitation on a resident's treatment or habilitation
opportunities. The facility director shall take all
feasible and prudent steps to minimize limitations on treat-
ment or habilitation.

(9) A governing body shall establish the maximum
duration of a movement to a more restrictive setting. denial
of access or a security precaution which limits treatment or
habilitation opportunities and a redetermination on new
evidence.

R 330.7243 Restraint and seclusion.

Rule 7243.(1) As used in this rule:

(a) "Authorized professional" meansaiphysicial when
referring to physical restraints. and means a qualified
professional person when referring to seclusion.

(b) "Drug-induced physical restraint" means the use of
medication which is administered to a recipient for the sole
purpose of preventing physical injury or substantial
property damange when acts of the recipient or some other
objective criteria clearly demonstrate that the recipient
poses an immediate danger to himself or herself or others or
is in danger of causing substantial property damange.

(c) "Medical restraint" means the use of physical
restraint or drug-induced physical restraint to render a
resident quiescent for medical reasons. Medical restraints
shall be used only as specified in a written plan of
service.

(d) "Physical restraint" means the use of mechanical
or material appliances to restrict the activity of a
resident.

181

(e) "Qualified professional person" means a mental
health professional who is specifically authorized by a
facility director pursuant to section 742(6) of the act.

(f) "Quiet room" means a room with a closed. unlocked
door which limits both the movement of a resident and his or
her contacts with others when placed in the room for
temporary periods.

(9) "Seclusion" means the temporary placement of a
resident in a room alone. monitored by staff. and with the
door locked.

(2) For purposes of preventing a resident from
physically harming himself or herself or others or for the
purpose of preventing a resident from causing substantial
property damange, the following Ineasures, other than
physical management, listed in order of increasing restric-
tiveness. shall be utilized. when appropriate. using the
least restrictive measure possible:

(a) Quiet room.

(b) Seclusion.

(c) Short-term physical restraint.

(d) Drug-induced physical restraint.

(e) Other physical restraint.

(3) The order of preference set forth in subrule (2)
of this rule is subject to limitations on the use of psycho-
tropic chemotherapy before the final adjudication of a
petition on the application for involuntary admission and
during a period of examination or evaluation which is
ordered by a criminal court.

(4) The governing body of a facility shall establish
policies and procedures which define the use of physical
restraint and seclusion and which designate the members of
the staff who may impose temporary physical restraint or
seclusion from an authorized professional.

(5) A record of each physical restraint and seclusion
shall be available at all times for inspection by an
authorized representative of the department.

(6) Emergency uses of physical restraint or seclusion
that will place a resident in physical restraint or
seclusion before a written order is obtained require that
both of the following requirements are complied with:

(a) That written or telephones authorization from an
authorized professional is obtained within 1 hour after the
imposition of a temporary physical restraint or seclusion.

(b) That authorization is entered ir1 the medical
record.

182

(7) If physical restraint or seclusion is considered
necessary. both of the following requirements shall be
complied with:

(a) A written order shall be obtained from an
authorized professional who has examined the resident within
8 hours of the temporary or authorized physical restraint or
within 2 hours of seclusion. An authorized physical
restraint or seclusion may follow a temporary physical
restraint or seclusion.

(b) The type of physical restraint or conditions of
seclusion. the duration of the restraint or seclusion. and
clothing to be moved, if any, shall be specified in the
order and shall be documented in the resident's medical
record.

(8) llseparate, permanent chronological record shall
be kept for the purpose of listing specific instances of the
use of physical restraint or seclusion and shall include all
of the following:

(a) The name, age. and sex of the resident.

(b) The type of physical restraint or conditions of
seclusion.

(c) Full justification for each application of
physical restraint or seclusion. including why the measure
is essential and why a less restrictive measure would not
suffice.

(d) The name of the authorizing and ordering physician
or qualified professional person.

(e) The nanue of the person instituting temporary
restraint or seclusion.

(f) The date and time placed in temporary, authorized.
and ordered physical restraint or seclusion.

(g) The date and time removed from temporary.
authorized. and ordered physical restraint or seclusion.

(h) A notion of the steps taken during the period of
physial restraint or seclusion. with regard to all of the
following:

(i) Examination.

(ii) Opportunities for free movement.

(iii) Food.

(iv) Sanitary conditions.

(v) Clothing or other cover.

(vi) An opportunity to sit or lie down.

(vii) Toilet access.

(viii) Bathing.

183

(ix) Telephone calls made on behalf of a resident in
seclusion or restraint.

(9) All orders for physical and drug-induced physical
restraint shall automatically terminate 12 hours after they
are given. and all orders for seclusion shall automatically
terminate 24 hours after they are given.

(10) A new written order and documentation shall be
obtained from a physican for physical restraint and from a
qualified professional person for seclusion if further use
of physical restraint is considered necessary after 12 hours
or if seclusion is considered necessary after 24 hours.

(11) A resident in restraint or seclusion shall be
evaluated and inspected by an authorized professional twice
daily.

(12) A resident in restraint or seclusion shall be
inspected at least once every 15 minutes by designated ward
personnel.

(13) Documentation of staff monitoring and observation
shall be entered into the medical record of the patient or
resident.

(14) Inspection and documentation procedures for
medical restraint shall be provided for in any order by a
physician authorizing medical restraint.

(15) A resident in physical restraint or seclusion
shall be provided hourly access to a toilet.

(16) A resident in physical restraint or seclusion
shall be bathed as often as needed. but at least once every
24 hours.

(17) Physical restraint devices shall not be steel or
other metal, unless required by conditions of a criminal
arrest or conviction status.

(18) A resident in physical restraint shall be given
the opportunity to sit or lie down and to move freely for
not less than 15 minutes nor more than 30 minutes during
each 2-hour period. unless medically contraindicated.
Removal from restraint for more than 30 minutes shall result
in termination of the order of restraint.

184

(19) A governing body shall establish the policies and
procedures which specify criteria for all of the following,
which procedures shall be followed unless contraindicated in
the records:

(a) Using authorized or ordered seclusion for the
clinical benefit of a resident.

(b) Removing the clothing of a secluded resident if
clothing would be hazardous to life.

(c) Providing cover for a restrained resident.

(d) Providing food, sanitary conditions, and
furnishings.

APPENDIX C
CRC SECLUSION POLICY

185

CARI) REGIONAL II‘NIAI. IIiAIIIII (FN‘II‘R
CARD. HICIIIGAN

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UH‘IINI'IY PLACEH‘NI' IN‘FIIJE.

7. QIAR'IFIIIN S'I'A'IIII‘IENI'S 01’ ALI. SI-ZIZIJISIONS SHALL IIIi REVIEWED ANII SIINIEII [W 11".
FACILIIY UIRIECIIIR.

11011111119115

1. 59¢.) 11.11911, manna the Imnmrnry plnmnmnt. (11‘ n rcmlclnnt. alone In 11 room
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nut having ll doorknob InnIdo. etc.

11. Anthnrzlzegl,5129111911111; I‘Incomnl. (11‘ n HmIIIonI. In mlnnlnn m1 mmII‘ImI
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canal. he ohtnlned I‘m the phynlcdnn.

IIEQ NMWAL AHMED

 

186

CAR” REGIONAL II‘NIN. II'AIIIII (liN'IFR
CARD, MICHIGAN

RESI lltN‘I‘ POLICY

 

“

wwgsmum: .
wussum:..i.1-1.~o§_mmnesU......Jd..Im.smuau:_;..m.zs..___JrMa-ts__:-2..-.

b. Emrgencyfigllmlong Emergency aeclnnlon Innt lore than 112 hour) my be
laderented at uhlch the: a phynlclen‘a verbal order aunt he ohtalned.

W
I - Emmwjimxmlgn.

D

a. A dangerous realdent my he ordered ln aenlmalon hy a nunervlsor.
Telephone autlnrlzntlon from a Mlyslclan event he nbtnlned ulthln one-half
III?) hour after lmnmltlnn of an enerneney noeluulon. ‘Ihla authorlzatlnn
la entered Into the cllnlcal record.

mama

I. A separate. perm-ment ehnnmlcmleal record nhaII he kept fur the Immense ol'
llstlnc aneclflc Instances of use of seclusion and shall Include:

a. ‘Ihe 1mm, age. and sex of the resldent.

h. ’lhe condltlons nl‘ aecluslnn.

c. Full Justlrlcatlon for aeclunlon. lncludlnn why the manure In essentlal
and why a less restrlctlve manure would not suffice.

d. 'Ihe navpe of the qualll'led [unreaalonal per-nun.

e. ‘lhe name or the person lnstltutlnq emruency aecluslon.

I” . ’Ihe date and tlre waged, In emergency or antlmrlzed aeclualon.

a. 'lhe date and tlne pegged. r roe emergency or nuthorlud aecluelnn.

2. The need for the procedure ahall he explalned to the realdent when he ls
helm placed ln aeclnslon or luedlately followlng neclualon.

3. A realdent ln'neclmlon ahall he nhserved not lose than every IS nlnutea hy
deslcated cottage nu‘aunnel. lbcumntntlon of staff mnltorlum and
ohnervatlone shall he entered lnto the cllnlcal record of the resldent and
shall deacrlhe the I‘ollnvlna:

a. I‘bala. In keeplng vlth phyaleal needs. shall he aerved to the realdent nt
omrnprlate tlnm. Speelal ureaautlmm nhnuld he taken ulth regard to the
one or almmre. dlahen. or metal utenalls. 'Ihe eununt and type of loud
and I’Iulds eIaII be documented.

IEQNIUILJI IMAL III'ITIQVELL

 

 

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187

(ZARO Ill‘llllNAl. HENI'AI. IIEAIIIII (I'IN'IIER
CARI). HIUIIGAN

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h. A resldent ln secluslon shall he provlded wlth I'lnlds (water. Julce. etc.I
at least every two hours.

c. A resident ln secluslon shall he provlded hourly access to tollet. or more
often as approprlahe.

d. A resldent ln secluslon shall he hathed as often as needed to ensure
personal hyulene needs. hut at least every 2" hours.

e. Telephone calls made on hehall’ or the resldent shall he docupmted.

I‘. A resldent In secluslon shall he ulven the opportnnlty to slt or Ila down at
least for I5 Minutes dnrlnu each twnuhour per lod. unless contralndlenlml.

a. Slnce secluslon Is to he used as a tenurary measure for resldents unable to
control their own hehnvlor. I‘m‘nlshlnes wlIl Imranlly not he provldod. A
resldent Is to he reamed from secluslon to a sure approprlate settlna when
behavioral control has heen attalned.

All orders for secluslon shall sutomtlcally terslnate 2'I hours after they are
elven. lI' contlmned smlmlon ls necessary. a physlclan slat write and slan a
new order after exanlnlna the resldent.

l
A qualll‘led professlonnl person shall personally evaluate and Inspect the
reclplent once durlng any perlnd oI‘ secluslon that lasts beyond two hours and
every two hour penlod thereafter.

A resldent In secluslon heyond two Ismrs shall he esaslned hy a physlclan wlthln
I2 hours or lsposltlon. and a wrltten. slnned note or the I‘lndlnus slmll he
placed In the cllnlcal record hy the physlclan. Resldonts placed ln seclunlon
for 2" hours oust he exaslned by a physlclan twlce withln the ZlI-hour perlod.

After removal from secluslon. the resldent‘s hehnvloral reactloos shall he
observed and docmnted In the cllnlcal record In accordance wlth the lndlvldual
[mourns plan.

Reports of Seclnslon are to he condeted and sent to the Entltlesents.
Statlstlcs and Umwllty I’lacesent oI'I‘lce.

Alimvnn

 

 

 

 

 

188

GAR" REGIONAL I‘I‘NI‘AI. HEAL“! (l‘N’l‘Ell
CARD. HHJIIIMN

RESHI'IN'I' l‘lIJlN

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REFEREKIE: Department or “motel Health A-lnlnlstratlva Rules. mam-72m.
' l-‘ehruary l. l‘mll

liepartsent or fientnl lbnlth Adslnlstratlve ”natal. ()mpter M.
Sectloa 220. Subject (XXII. S-ll-‘In

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APPENDIX D
JCAH SPECIAL TREATMENT PROCEDURES

189

 

19. Special Treatment
Procedures (SC)

SCJ

SCJJ

50.1.2

SCJJ

Designated special treatment prrrccdurcs rcrprirc clinical justification!

Such treatment procedures include. hut are not necessarily limited to. the
iulirnving: ‘

SCJ. Li The use oi rcstraint;’
SC.l.i.2 The use oi scciusiorr;°

SC. [1.3 The use oi cicctrocurrvnisivc therapy and other iorrns oi convul-
sive therapy?

SC. l. 1.4 The pcriurruanre oi psychosurgcry or other surgical proccdurcs
ior the intervention in or alteration ui a mental. emotional. or behavioral
disordcrf

SCJ. 1.5 The use oi hchavior nrodiiicatiua procedures that use painiul
stimuli?

SC.l.i.6 The use oi unusual medications and invcstigatioual and experi-
mental drugs?

SC. i.i.7 The prcscrihing and administering oi drugs ior maintenance
use that have almsc potmrtial (usually considered to he Schedule ll drugs)

and drugs that are known to involve a suhstantial risk or to he associated
with undcsirahlc side cliccts;‘ and

SC.l.i.0'iicscarch projects that involve inconvenience or risk to the
patient.’

The. rationale ior using special treatment procedures is clearly stated in the
patient rccord.’

When appropriate. there is evidence in the patient record that propourd
special treatment procedures have lrcca reviewed hciorc implementation
hy the head oi the proicssiunai staii and/or his or her designcc.‘

 

"i'lrc asterislml hears are key lat-tors in the accreditation decision process. For an estimation
oi the we oi the hey iacturs. ace "Usiug the Manual." page vii.

Circle One

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NA

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Consolidated Standards Manual. PAW 0'3

' 190

Special Treatment Procedures

80.1.4

80.1.5

80.1.8

80.2

80.2.1

80.2.2

80.2.3

80.2.4

80.2.5
80.2.8

The plan ior using special treatment procedures is consistent with the
patient's rights and the iacility's policies governing the use oi such proce-
dures.‘

The clinical indications ior the use oi special treatment procedures are
documented in the patient reeorrl.‘

The clinical indications lor the use oi special treatment procedures out-
weigh the known eontraindieations.‘

The iacility has written policies and procerlrrrcs that govern the use oi
restraint or seclusion.’

The use oi restraint or seclusion requires clinical justii‘rcatirat.‘

80.2.1.1 Restraint or seclusion is used only to prevent a patient innn iniuo
ing hinrscli or others or to prevent serious disruption oi the therapeutic
environment.’

80.2.1.2 Restraint or seclusion is not trscrl as punishment or ior the conve-
nierrce oi staii.‘

80.2.1.3 The rationale ior the use oi restraint or seclusion addresses the
inadequacy oi less restrictive intervention technirprcs.‘

To ascertain that the procedure is instiiierl. a physician conrlrrcts a clinical
assessment oi the patient lrciore writing an order authoriring the use oi
restraint or sedusion.’

80.2.2.1 The assessment and the order are. documented in the patient
record when the procedure is implenrented.’

liar-h written order ior restraint or seclusion is time liruitcd and rlocs not
esceed 24 hours.’

In an emcrncncy. restraint or seclusion nrny ire utilised lry trained. clinically
privileged staii.’

80.2.1.1 The clinical assessment oi the patient arrrl the order ior the use.
oi emergency restraint or seclusion are documented in the patient record
when the procedure is implemented.’ ‘

80.2.4.2 The emergency implementation oi restraint or seclusion does
rrrrt eseced one hour. at which time a physician stall member's oral order is
required ii restraint or seclusion is to he continued.’

80.2.4.2.1 The physician's order is entered in the prrtient record as soon
a pudltle. but not more than 24 horas alter implementation oi the order.‘

i'iiN orders are not used to authorise the use oi restraint or aechrsirnr.‘

All uses oi restraint or seclusion are rep-uteri daily to the head oi the pro-
ieasional staii and/or his or her designee!

"l‘he aatcrisleri-i-t-ems are hey iactors in the accreditation decision rum. l'ssr an explanation
oi the use oi the hey iactors. ace “Using the usual.“ page vii.

Circle One

2

.‘l

a

4

5

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

 

M Consolidated Standards Manual. "87

80.2.7

80.2.3

80.2.9

80.2.10

80.3

80.3.1

80.3.2

191

Special Trenton-tit l‘rrn-cdnrcs

The head oi the proiessiooal staii and/or his or her designee reviews daily
all uses oi restraint or seclusion and investigates unusual or possihly unwar-
rantcrl patterns oi utiiiuttioo.’

Staii who implement written orders ior restraint or seclusion have, docu-
mented training in the proper use oi the procedure ior which the order was
written.’

Restraint or seclusion is not to he used in a manner that causes undue
physical discrnniort. harm. or pain to the patient.’

Appropriate attention is paid every 15 minutes to a patient in restraint or
seclusion. especially in regard to regular meals. hathing. artrl use oi the
ltrilcl.'

80210.1 There is dra-unrentation in the patient rccorrl that such atten-
tion was given to the patient.‘

The iacility has written policies aorl procedures that govern the use oi elec-
troeonvrdsive therapy and other iornrs oi convulsive therapy.’

The written inior utr-d consent oi the patient ior the use oi electror-mrcul-
sive therapy or other iornrs oi convulsive therapy is ohtained and made part
oi the. patient record.’

80.3.1.1 The patient may withdraw consent at any tinre.’

80.3.1.2 When required. the written iniormed consent oi the iamilv and/or
legal guardian ior the use oi electroconvulsivc therapy or other iorms oi
convulsive therapy is ohtained and nrade part oi the patient record.’

$0.3 1.2.1 The inruily and/or guardian may withdraw consent at any
tirrtc.’

80.3 1.3 in cases dealing with children or adolescents. the rcsporrsihic
patcrrtlsl. relative, or legal guardian and. when appropriate. the patient
give written. dated, and signed iuiorrucd consent ior the use oi electrocuti-
vulsive therapy or other iorrrrs oi convulsive therapy.‘

80.3.1.3.1 The. iantily and/or guardian and. when appropriate. the child
or adolescent patient may withdraw consent at any time.’

lilcctrraéonvrrlsive therapy or other iorms oi convulsive therapy are not
adrrrinistercrl to children or adolescents unless. prior to the initiation oi
treatment. two rprnliircd psychiatrists who have training or espericrrcc. in
the treatment oi children and adolescents and who are not alhliated with
the treating program have csarniued the patient. have consulted with the
responsihlc psychiatrist. and have written and signer! reports in the patient
record that concur with the rlecision to administer such therapy.’

80.3.2.1 The records oi patients under the age oi 1.1 «attain documenta-
tirrrr that such esanrinations and erarsultations were carried out hy qnaliiied
child psychiatrists.’

"l‘he aaerislcd items are hey iacrors in the accreditation decision process. for an esplaaatinn
oi the an: oi the hey lactors. ace “lining the Manual." page vii.

(Their-One
12.145NA
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12.1 5NA
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12.1 SNA
12.1 SNA
12.1 SNA
l2.1 SNA
12.1 SNA

 

Consolidator! Standards Ainnrrai. I937 87

192

Special 'lreatrrrent i‘roccrlrrrcs

80.7

80.7.1

80.8

80.3.1

80.8.2

The iacility has written policies and procedures that gratern the prescrihing
arrrl administering o1 drugs ior maintenance use that have ahusc potential
(usually considered to he Schedule 11 rlrugsl and drugs that are known to
ianrlve a sulrstantial risk or he m-eiated with undeairalrle aisle eilccts.’

Drugs that have alnrse potential are preseriherl arrrl administered ior main-
tenance use only when the lollowing criteria are met:

50.7.1.1 A physician memher oi the proiessional stall has reviewed the
patient record and has recorded the reasons ior prescrihing the rlragtst in
the patient record;‘

30.7.1.2 Tire prescrilred drug is listed in the iacility‘s iornnrlaryz‘ and

80.7.1.3 Prior to the administration oi the drug. the patient arrrl. when
required hy law. the patient's parenttst or guardian are iniorrnerl orally and
in writing anrl. ii possilrle. in the patient's native language. oi the lrcneiits
and harards oi the drug.‘

The iacility has written policies and procedures that protect the rights oi
patients ittvolsttl in research projects that involve inconvenience or rislr to
the patients.‘

The policies and procerlrrrcs require a statement oi the rationale ior a
patient’s participation in any research project that involves inconvenience
or rislt to the patient.’

The written iniorrnr-d consent oi the patient who will participate in the
research project is ohtained and made part oi the patient record.°
30.8.2.1 '1 he patient may withdraw consent at any time.‘

80.8.2.7. When required. the written iniorrncd consent oi the iarnily and/or
legal guardian is ohtairrerl anrl made part oi the patient record.‘

50.“ 2.2.1 The lamiiy and/or guardian may withdraw consent at any
time.’

50.8.2.3 in cases dealing with children or adolescents. the responsilvle
parcnttst. relative. or legal guardian and. when appropriate. the patient
give written. dated. anrl signed iaiormed consent.‘

80.8.2.3] The lamiiy and/or guardian and. when appropriate. the child
or adolescent patient may withdraw consent at any time.’

Overall carapliance: special treatarcat procedures

"l’he asterished items are hey iactnrs in the accreditation decision process. For an eaplanatinn
oi the lac rd the hey iaetora. lee “Using the Hanual.‘ page vii.

Circle One

2.145NA

 

m Consolidated Standards Manual. 7117

APPENDIX E
CRC SECLUSION STUDY

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APPENDIX F
CRC TREATMENT GOALS

197

OURIDIILS

The staff of Caro Regional Hental Health Center are omitted to
providing appropriate training and treatment and constant and humne
care to all our residents and patients. we endeavor to meet or exceed
all applicable standards or the various state agencies Involved in our
operation and to achieve and maintain relevant certification and accred-
itation. The facility is accredited by the Joint Oomission on Accredi-
tation of Ibspitals. and the program for the developmentally disabled Is
certified as an intermediate Care Facility for the mntally Retarded.

He endeavor to create and naintain a physical environment which
is as normal as possible and which is conducive to the development of
appropriate behavior and social coping skills.

He endeavor to create and. maintain a social and psychological
environment which reinforces appropriate behavior and provides for the
acquisition, retention or resuuption or social skills required for
coping with the demands or living in a less restrictive environment.

in the belief that the mentally ill and the developmntally
disabled are entitled to live in as normal a setting as their condition
permits. we work closely and cooperatively with the Commity Ibntal
Health System to ensure that only those people whose needs cannot be met
in the community are admitted to--or rennin at--the facility. and we
support efforts to iuprove and expand community services which are
currently inadequate.

Us recognize the iuportance of the family as a support system for
our residents and patients and endeavor to include than in our efforts
as much as possible. A

1 98
BUILDING PATTERNS OF SUCCESS

A Residential Treatment Philosophy

Whether admitted because of a developmental disability or mental
illness, the people we serve have had difficulty in coping with the
demands of daily living, and social coping skills are inadequate. Most
have developed behaviors and attitudes resulting from failures--failure
to meet expectations of parents, community, peers, or themelves. They
have met defeat so regularly that it has become a pattern of behavior.
Since success is not anticipated, they have difficulty being motivated
to achieve.

The difference between success and failure is often a difference
of expectations. Children and adults alike learn from success--learn to
have confidence, learn to try new things, learn to like themelves and
others, learn to grow physically, mentally and emotionally. It is our
goal to help people build a pattern of success in their daily lives and
experiences. we aim to create an environment which is appropriate to
their needs and abilities. We try to make the environment as normal as
their disabilities permit, but within that concept to provide structure
and support necessary for them to achieve success at their developmen—
tal and functional level.

Our evaluations are directed to identify strengths and abilities
and to determine readiness for experiences which will improve social,
mental, emotional and physical functional abilities. By providing a
variety of experiences in a variety of settings, we create opportunities
for the individual to succeed, and to begin to develop a PA'ITERN OF
SIXJJESS. We avoid, as much as possible, a renedial approach which
emphasizes the areas of weakness. Instead, we euploy a habilitative
approach which provides opportunities to function in areas where there
are demonstrated skills, and to emphasize those strengths that will aid
in the acquisition of new skills. Ours, we hope. is a humanistic, posi-
tive approach to the whole person.

199
A PATTERN FOR LIVING

It is our intent that Caro be more than a Ibspital, as we strive
to create a residential treatment facility which will provide therapeu—
tic experiences in all aspects of life. The living units are as nmch
like homes as the design of the buildings and the needs and characteris-
tics of the residents will permit. Meals are prepared and served in the
living units, privacy in sleeping areas is provided, personal laundry is
done in the buildings, alternative living and activity areas are availa-
ble.

Every activity of daily living is considered a possible learning
opportunity. Residents and patients are expected to be as responsible
as their condition permits for their personal care, for their own living
areas, for assisting in normal household chores, and for meal prepara-
tion, service, and clean—up.

Direct care staff are provided to assist residents and patients in
developing independent living skills and learning to be responsible for
themselves, rather than to foster dependence through provision of care
and control. The staff on the morning shift assist residents/patients
in meeting their responsibilities for getting up, getting dressed,
making their bed, having breakfast, and getting to "work" on time,
whether ”work" be school, an activity center, or other assignment.
Staff accompany residents/patients to the various locations, where they
direct activities, so that it is not possible to ”stay home" for the
day. [by care is provided in the I-bspital unit for anyone too ill to
attend activities. Ihe emphasis for the day shift is on those social
behaviors and attitudes normally associated with going to work and
keeping a job, rather than on the acquisition of specific vocational

skills.

200

The afternoon shift has primary responsibility for the acquisition
of residential living skills and the appropriate use of leisure time.
Freedom of movement and freedom of choice regarding use of leisure time
is provided as consistent with clinical condition and treatment needs.
Staff are expected to motivate participation, and share planning and

implementation of activities with the residents and patients.

201

PSYCHI ATRI C SERVICES

Any review of the history of Ibntal Health services illustrates the
fact that there are both similarities and differences in the needs of
the mentally ill and the developmentally disabled. At certain times and
in certain places all persons with "mental problems" who could not
function adequately within the social framework were housed and "treat-
ed" together. The inadequacy of this approach led to the effort to
recognize the distinctions between those who were mentally ill and those
who were mentally retarded or suffering from other developmental disa-
bilities, and the creation of separate service delivery systems depend-
ing on the "primary diagnosis.” The use of the term ”primary diagnosis"
itself recognizes that there are individuals with symptoms of both
classifications, and, perhaps, indicates that behaviors and treatment
needs do not always differentiate one group from another. IIhile diag-
nostic procedures available today are adequate to differentiate mental
illness from mental retardation in most cases, the criteria utilized
often relate to the etiological basis or time of onset of the symptoms
rather than clear differences in behaviors or treatment needs. Further-
more, it is increasingly evident that the incidence of mental illness in
those of limited intellectualcapacity is, perhaps, greater than in
those without such limitations.

Currently, the medical aspects of mental illness receive prominent,
if not exclusive, consideration in most psychiatric facilities, with
great reliance on medication as the preferred treatment approach. The
rapid increase in the number of psychiatric units located in general
hospitals is an indication of the validity of this observation. A short
average length of stay is viewed as an indication of effective and
appropriate treatment, while the constantly increasing rate of
readmission gets significantly less attention. The (bro program is
designed to affect both the length of stay and the recidivism rate, and
both are considered in evaluating effectiveness of treatment. The

medical aspects of mental illness receive prominent, but not exclusive,

202

consideration in the treatment of all psychiatric patients. Since the
symptom of mental illness are behavioral, and admission to the service
is invariably a result of demonstrated inability to cope with the
demands of living in the social environment of the family and/or commu-
nity, an interdisciplinary approach to assessment, diagnosis and treat-
ment is utilized.

203

PSYCHIATRIC TREATMENT PROGRAM

The Psychiatric Treatment Program provides adult inpatient psychi—
atric treatment services to residents of a ten county catchment area.
Close associations are maintained with the conmunity mental health
service boards serving the catchment area, and those boards are involved
in all admissions and discharges. Patient treatment is highly individu-
alized and individual treatment plans are developed and implemented by
three interdisciplinary teams assigned to the program. Each patient is
evaluated by a psychiatrist at least one time per week. In addition,
all other resources and support services at Caro Regional Mental Health
Center are available as appropriate to meet the needs of the individual
patient.

The overall goal of the program is to provide effective inpatient
psychiatric treatment to residents in the catchment area, helping the
patients to develOp, maintain or restore their social functioning to the
best of their ability to enable them to live as normal and productive a
life as is possible.

There are three program areas located in four residential build—
ings containing a total of 109 certified beds, assigned to the Psychiat-
ric Treatment Program. Each area is staffed on a 2M-hour basis and is
supervised by a registered nurse. Each patient is assigned a level of
supervision, which is reviewed at least weekly:

Level I - patient's freedom of movement is limited only by

facility policy;

Level II - program staff must know the patient's whereabouts at
all times;
Level III - patient must be within view cf staff during waking

hours and regularly checked during sleeping hours.
Smoking is permitted in each residential building in designated

areas only.

204

PSYCHIATRIC ADMISSIONS

Admissions to the Psychiatric Service are controlled by the Michi-
gan Mental Health Code, Act 258 of 197“, Chapter 14, Civil Admission and
Discharge Procedures: Mental Illness. mro Regional I‘Iental Health
Center is the designated State hospital for ten counties served by eight
Community Mental Health Services Boards, i.e., Bay-Arenac. Lapeer.
Midland-Gladwin. Huron, Saginaw, Sanilac. Tuscola, and St. Clair.

The facility is licensed and accredited by JCAH as an Adult Psychi-
atric Hospital. Persons under age 18 will not be admitted but referred
to the appropriate designated Children's Psychiatric I-bspital. Patients
requiring forensic evaluations are not admitted, since the Department of
Mental Health maintains the Center for Forensic Psychiatry to perform
this function. Patients who require electroconvulsive therapy will not
be admitted since this procedure is not available at Caro.

Persons whose- mental faculties have simply been weakened as an
aging process will not be admitted for long-term care. An aged person
may be admitted for a short period of time for treatment of a behavioral
problem but must be returned to a community-based program as soon as
possible.

By law, substance abuse detoxification and treatment is a responsi-
bility of the Department of Public Health, and these services are not
available at Caro. Persons who have a substance abuse problem will only
be admitted if they are determined to be mentally ill and require
treatment for the mental illness.

Since the Mental Health Code places primary responsibility for
services for the mentally ill with the Conmunity Ibntal l-balth system,
we encourage all referring agencies to contact the appropriate Oonmunity
Mental Ibalth Board for screening services. If patients are presented
for admission without the knowledge of the CHI staff and admission is
legally required, then the staff of CR)“: will notify the appropriate
CIT-i staff at the earliest opportunity.

205

IDODSIDE
(Cottage 5)

This 21 bed residential building, housing both nale and female
patients, serves as the admissions unit for the program. The only
seclusion room in the program is located here. Intensive 21)-hour
supervision is maintained for all patients due to their clinical, needs
and the building is locked at all times. Patients may be on any level
of supervision. Sleeping and lounge areas are separate by sex, but
dining and activity areas are coeducational. As soon as the patient is
deemed stable enough to participate in an out-of-cottage program, he/she
is transferred to another residential building. This is the only
building in the program in which meals are not prepared in the cottage.

Most patients remain at Woodside for a very short time.

THE INTERDIQéIPLINARY TEAM

It is the policy of Caro Regional Mental i-balth Center to utilize
an interdisciplinary approach to diagnosis, evaluation, and individual
program planning in which professional and other personnel participate
with parents or guardians and, when possible, residents/patients as a
team. Participants share information and reconmendations, so that a
unified and integrated habilitation program plan is devised. We urge
family participation in all aspects of planning and implementation of
program.

A system of staff activity, program development, and documentation
has been developed to insure an appropriate and adequate individualized
habilitation plan for each person. This system is based on an
interdisciplinary team evaluation of the resident/patient and the
setting in which he/she functions, and the treatment habilitation plan
is kept current by periodic review. It is the policy of this facility
that the status of each resident be reviewed by the team on admission,
at thirty, sixty, and ninety day intervals following admission, and at
least annually thereafter. Periodic review of the patients in the
psychiatric unit is dictated by legal requirements related to the
admission status, and our policy is to meet or exceed review require-
ments of the law and relevant accrediting or certifying bodies.

There is one interdisciplinary team for each Unit in the program
for the developmentally disabled, and three team for the psychiatric
unit. All clinical personnel function as members of a Team, and in the
development of the Individual Treatment Plan, the following are invit-
ed/assigned to participate:

1. Resident/Patient Advocate (This may be the person himelf,

and/or the interested parent, relative or guardian.)

2. Staff of the Conmunity Rental Health Board from the county of

residence.

3. Staff of the Tuscola Intermediate School District as appro-

priate.

II. Assigned Resident Care Personnel .

Each team meets every Tuesday for purposes of review and evalua-

tion of appropriateness and adequacy of individual treatment/training

207

programs. .At these meetings, the entire treatment program (including
medical, social, habilitative and/or training aspects) of the individu-
al is subjected to the collective scrutiny of the group. This review
process follows an established procedure and includes a standardized
system of documentation of staff activity which becomes a part of the
individual's permanent record.

Prior to the staff meeting, all relevant disciplines complete an
independent evaluation of the resident. and their conclusions are
presented at the meeting. Comparison of current and previous reports
provides a base of information which is utilized to:

1. Assess progress toward treatment goals

2. Determine new and continuing goals and objectives

3. Formulate a treatment plan based on assessed needs

n. Determine suitability for alternative placement

Concurrently, the team is expected to evaluate and assess the
various aspect of past program planning and implementation, and to
analyze whether the successes and failures encountered with the particu—
lar individual are unique or indicative of a need for systems altera-
tions.

For each person, a member of the team is designated as the Quali-
fied Mental Health/Retardation Professional responsible for the partic-
ular resident's program. The "Q" formalizes the team action in a
written plan of service, monitors the appropriateness and effectiveness
of the plan by reviewing it and its documentation at least every thirty
days, and ascertaining that all appropriate staff are aware of the plan
and their responsibilities for its implementation. While the ”Q" is
expected to modify objectives to ensure current appropriateness, if it
is determined that major revisions involving modifications of Goals are
indicated, these recommendations are presented to the team for consid-

eration at the next weekly meeting.

208
A PATTERN FOR IDRKING

In the normal rhythm of life, most people leave their homeIduring
the day for some form of meaningful occupational activity. This re-
quires some organization and planning, and to facilitate the acceptance
of a normal rhythm to a day, all residents and patients who are clini-
cally able leave the residential unit for one of several locations at
9:00 AM and participate in a therapeutically directed activity designed
to replicate a work environmnt in term of behavioral expectations

rather than vocational performance expectations.

209
THE WORK ACTIVITY CENTER

Psychiatric patients and residents from Gardenview and Apple Gate
are assigned to the Work Activity Center, where primarily arts and
crafts activities are utilized to encourage acquisition of social and
behavioral skills normally associated with work, e.g. task completion,
following directions, cooperating with others, distinguishing work time
from break time. The program is implemented by residential unit staff
assigned to the day shift, assisted by occupational and recreational
therapists, with professional staff from the psychiatric treatment team
monitoring effectiveness in term of the individual's treatment needs.

Activities available include woodworking, textiles, ceramics,
printing and grounds-keeping. Individuals may be assigned to other work
experiences on an individual basis. Compensation is provided, based on

performance .

APPENDIX G
PSYCHIATRIC GUIDELINES OF CARE

210

(:iII‘I) III:|:I (liliiI liceIII.tII II¢:III I.II II¢EII|.¢:t'
P3 YIJII I A'I'II I C 'I'IIIi A'I'MIE "1' PROGRAM

III) I "III. I NIiii III‘ IIAIII'L

October I 907

lNUEx:.
INDIVIDUAL RRocRAMS pg. I
DOCUMENTATION pg . 2
DAILY ASSIGNMENT pg. 3
NEDICATIONS AND TREATMENTS pg. 3
NUTRITION pg. n
PATIENT ACTIVITIES pg. 5
PERSONAL CARE pg. 6
1:me nc pg . 6
PERSONAL ITEMS pg. 7
noNEY pg. a
FREEde or anVEnENT pp. A
LEAVES or ABSENcE ILoA-S) pg. )0
BUILDING lNSPECTIONS pp. )0

LNQLMIQDAL.PRQQRAH§;.

1.

All patients admitted to the Psychiatric Treatment Program
will have a current Individual Treatment Plan II'I'P):

A.

II.

0

Patients newly admitted to the facility will have a
preliminary ITP Implemented at the time of admission and
an initial lTP, normally developed hy the psychiatrist,
implemented within 72 hours of admission.

All patients whose inpatient hospitalization exceeds )0
days will be scheduled for a complete Interdisciplinary
staffing review to develop a Master ITP.

All patients admitted to the Psychiatric Treatment
Program will receive the following assessments to assist
the treatment team In developing an appropriate treatment
plan: psychiatric, physical, nursing, social,

‘nutritlonall, activities, audiologicaII and, when

appropriate, psychological. II initial screening as part
of admission PE.) '

Upon admission, each patient will he assigned a Qualified
Mental Health Professional (QMHP) who will be responsible for

 

 

 

U'.

211

writing the treatmeni. plan developed by the team and for
coordinating the patient's care while In the Psychiatric
Treatment Program.

Each patient's treatment plan will he reviewed by their
assigned treatment team approximately 30 days after admission
and by the assigned QMHP every 30 days thereafter. If a
change in treatment goals is indicated, the complete
Interdisciplinary team must formulate those changes; the QHHP
may update objectives to meet treatment goals.

iTP'a will he completely updated every six months.

A direct care staff person must participate in the .
formulation of each ITP. information regarding the patient
will be sought from each shift prior to such a staffing.

Patients admitted to the hospital ward for care are to have
their iTP's reviewed and, if necessary, amended by
Psychiatric Treatment Program staff to insure that the
current needs of the patient are met while in the hospital
setting. Ideally, this will he accomplished prior to the
patient's admission to the hospital. -

DQQQIIIE MIM'LQNL

'I.

All patients admitted to the Psychiatric Treatment Program
for care will have pertinent information regarding their
behavioral and emotional responses to the therapy offered,
documented with date and time by direct care staff.

At Uoodside (Cottage 5) each Resident (tare Aide/iJcensed
Practical Nurse will he responsible for daily documentation
on patients in their assigned group.

Summary documentation, regarding the patient's response to
treatment plan goals/objectives and containing
recommendations for revisions III the I'fP, will he done weekly,
hy the Psychiatrist, Nurse, Social worker I'or the first two
months and at least once a month thereafter.

weekly summary documentation reflecting iTP goals/objectives
will be provided weekly hy assigned Resident Care
Aide/Licensed Practical Nurse.

Each entry Into the clinical record is to be legible and
include the time, date, signature and title of the reporter.

Incident Reports and, if indicated, Administrative Report
Forms (ARP'sl are to he completed whenever a patient Is
observed to have an injury, Is aggressed by another, eIIihits
self-injurious behavior, is secluded or restrained in any

way, etc., as per facility and Department of Mental Health
policies. .

 

 

212

“I. Self-sticking labels may he used for progress reports by
adjunct therapies, for progress reports originating in the
Pork Activities program, for reporting behavioral Incidents
-Inot requiring an Incident Report) away from the living unit,
for reporting ”incidental Contacts" with family
members/guardians, etc., and for reporting discussions held
in stai'i'ings hy the interdisciplinary treatment teams.

I). Only the Program Secretaries are allowed to purge a clinical
record.

9. a verbal report of each patient's .coadition, behavior, etc.,
will be given to the staff of the oncoming shift by the staff
of the OI'IV-going aiIII't. ‘

i0. "Communication books” are in each living unit and are for
administrative purposes (e.g., work orders needed or
completed, supplies information, census, staffing, etc.) and
to refer personnel to specific clinical records only.
QLULI.§fll.liilL§fl_§f§. $£L.I.'§...9!LLQIL£SL_9DLY-.IJIIgiLJIIJILJZI lilISLIIJ-
[1991;LIL Ml staffing moves, including relief staff, etc.,
are to be recorded in the Communication Book.

DAILUESJQHHENIJ-

Nursing supervision will assure that every patient has an
assigned direct care staff responsible and accountable for the
patient's daily care as outlined in this Guidelines of (tare.

fliiillllli'i'lflii LANILJBIIA'IHIEM'I'SJ-

2.

Only Registered Nurses and Certified Licensed Practical
Nurses will pass medications.

Medication cabinets will he kept locked and the nurses will
keep the keys on their person at all times.

when medications are returned to the residential building by
Pharmacy, medication checks, involving comparing
prescriptions, medication sheets, and the actual medication
will be done by the I‘Ildnight Nurse on duty. if the
medication must be started at 5 p.m., the preceding will be
done by the nurse on duty when the medications arrive. The
Hidnight Nurse is responsible for assuring a once monthly
medicine room inspection, completing the required form.

Treatments may he administered by the resident care staff
under the supervision of the nurse on duty.

Temperature, pulse, respiration, and blood pressure will he
done on an Individual basis as determined by the patient's
medical condition or as ordered.

 

(i.

213

liny physical condition being treated requires daily

documentation reflective of condition/treatment (e.g.,

description of wound, condition of dressings, etc.)

iiifl'lti If i DN 3.

All patients' diets will reflect information from .the
nutritional assessment.

i‘lenltimes in the psychiatric residential buildings are as
follows:

Muscular. All...ethcr...izsLilliaca

Ureakfast Hon-Fri: 7:00—0:00 A" 7:00-b:00 AH
weekends: 7:30-9:00 as 7:30n9:00 AH

Lunch i‘lon -Fri : l i :.l() - i 2 :00 PH mu: Schedule
Weekends: ll :Eiil- l2 : ()0 PM i2? : (lilrl :00 PH

Supper 5:00—5:30 PM 5:00-6:00 PM
ICoffee is available at 6:00 Mi in all buildings.

ilietary consults will be ordered by the physician, who must
review, initial and date all dietary recommendations before
implementation. The QMHP is to receive a copy of the
consultation.

Special dietary restrictions will he followed as approved by
the interdisciplinary Team or as ordered-by the physician.

Meals are served family-style and staff are expected to
participate and to serve as role models for appropriate
mealtime behavior.

liben patients are having lab work done, which requires

fasting, their breakfast will be delayed and held until after
the lab work is completed. ‘

Staff will encourage patients to eat with different people at
mealtimes and emphasize the development or refinement of the
patients' social skills.

Patients will he expected to assist in setting and clearing
the tables in all residential buildings. Patients at
Pinegrove may assist in meal preparation when specified by
their individual 'i‘reutment Plan. Patients at Sagan-bush and
Spring (lak are expected to assist in the preparation of
their meals. Appiegate patients will prepare their own
meals, with staff supervision.

9.

214

Silverware and other related ”sharps” will he counted hy
Domestic Service Aides after each meal and documented on the
appropriate form.

l’Ji'i‘l ENUQUY iIl iii:

I.

All patients admitted to the Psychiatric Treatment Program
will he expected to participate in unit activities . unless
determined otherwise hy the patient's l'fl’.

Under normal conditions. patients admitted to the Psychiatric
Treatment Program will remain at iioodnide iii-5) Admissions
Unit for "8 hours hefore they will he assessed for
participation in the Uork Activities Center program.

All patients residing at i’inegrove. Sugarhush. Spring Oak and
Applegate, as well as selected patients at Woodside, are
expected to actively participate in the Hork Activities
(.‘enter (VAC) program on a l‘londny--i-'ridoy hasis. Specified
therapeutic activities may take place at VAC, the "AC Annex,
or in other designated areas of the facility. if indicated in
the patient's l'l'i’.

Patients at i’inegrove, Sugarhush. Spring Oak and Applegate
will he encouraged to walk to the work Activities Center

(WAC) program, unless specified otherwise in the ”1’ or due
to inclement weather.

Any restrictions on physical activity will he included in the
l 11’ .

All patients with adaptive equipment will he assisted by
staff in its use if necessary. The staff also will monitor
the condition of the equipment.

All patient activities are to be selected with the criteria
of appropriateness of activity. benefit to the patient and
"normalization“ being considered. liuildinuuspecil‘ic

goals/ohJectives regarding socialization activities for all

patients residing in the huildiug must he posted in the
hui iding .

Ofi'o-ground activities must he approved hy Activities
'l‘herapist. RN ill. Program Coordinator or designee.

Requests for such activities land for any monies involved)
must he on the Off-(hounds 'l'rip Form and should he submitted
for approval one week hefore the activity. Activities out of
the immediate Caro area (25 miles round trip) require
additional approval hy the Facility Director.

All patients will he expected to he responsihle for mailing
their own heds and keeping their personal living area neat,
unless specified otherwise in their ”1’. Domestic Service
Aides will be notified of any exceptions hy the hullding

 

i0.

215

supervisor. iluilding~specific training goals/objectives for
all patients residing in the building (e.g., development of
personal domestic tasks skills which would he needed on
discharge, such as laundry, general cleaning of personal or
Community areas) must be posted in the building.

Patients also will he expected to help keep the community
living areas neat and clean.

Patients will he assessed hy the interdisciplinary Treatment
Team for participation in available group therapies and the
Alcoholics Anonymous Program.

i’iiRSONALMILEJ.

i.

2.

U!

All patients will be responsible for their own personal
hygiene.

All patients will he provided with their own toothpaste,
toothbrush, deodorant, comb and/or hairhrush, soap. and
access to razor and after—shave lotion (if indicated).

Personal toilet Items are to be marked with the patient's
name and are to accompany the patient should he/she he
transferred. hospitalized, etc. Community razors or other
shared personal items are prohibited.

For patients who lack the ability to maintain their own
personal hygiene, the direct care staff will assist them to
bathe at least three times weekly and to change clothes
daily. Fingernails are to be checked after bathing and
clipped as needed. ‘l‘oenails are to he checked at least
weekly. and the nurse notified if they are in need ol'

trimming. Preper oral hygiene is to he performed at least
two times per day.

ilreast examinations are to be completed as per facility
policy.

£21.91“le

‘0

All patients are to he dressed to provide safety. comfort.
warmth, hody coverage and. where indicated, to enhance skill
development. Clothing is to reflect accepted. contemporary
style and be appropriate for the activity. season. etc.
Nightwear will not he permitted in the dining room or the
living room areas after bathing time in the A" or before
bathing time in the PH.

All patients will be responsible for keeping their own
clothing clean unless determined otherwise in their ITP. it
is the responsibility of the direct care staff to assist
patients who need help in laundering. mending their clothing.
or maintaining a reasonably neat clothing storage area.

 

10.

ii.

216

Direct care staff will account for patient's clothing and
other personal property in accordance with «.1ch Resident
Policy 02.256 “Personal Property." '

Clothing is available at Woodside on a temporary basis for
patients who are admitted without a change of clothing.

Clothing is also available for permanent use, on a limited
basis. for patients who have on clothing or the resources to
obtain any. whenever possible. supervisors will arrange for
these patients to obtain clothes l'rom the facility supply
prior to their leaving Uoodslde.

All patients' clothing is to be appropriately identified.

Clothing is to be labeled/marked only in the facility Sewing
Room.

Patients will he informed that the facility is not
responsible for clothing or other belongings left in the
patient's possession. unless the patient has been determined
to be incapable of caring for his/her personal property.

Patients will not be permitted to sell, exchange. trade,

barter or gamble any article of their clothing to another
patient.

Patients transferred back to Uoodnide from other residential
buildings should bring only three changes of clothing.

ilhen patients are transferred from one residential living
unit to another. their belongings shall be inventoried in
their presence, if possible. The personal inventory record

will be updated as needed. Any missing items are to be
reported to the RN lll via an Aill‘.

ilben patient's belongings are inventoried, particularly at
the time of discharge. staff are to insure that the patient

has 9nl.y...thqac._clethlnurtiszLessdiich are.-markc.d_v.l.th_.the.
sweat? Lucius-ta

ifEliSilliALJIfifliz.

All personal items that present a danger to the patient or
others will be locked up. items defined as “excluded" in
cunnc liesident Policy 02.56 l'all into this category. Other
items (e.g.. pens, pencils. cosmetics. perfumes. after-shave.
keys. etc.) will be evaluated on an individual basis.

Knives. scissors. aerosols. nail files are to be locked up
and used under staff supervision only.

Personal radios, cassette players, televisions. etc., will
not be permitted in the residential living areas as they
interfere with the therapeutic process. if given to the'

 

217

patient for use out of the residential building, the item
must be noted on the inventory sheet. llhen in the building
they are to be kept in a safe deposit area.

All valuables will be sent home with relatives. locked in a
safe deposit area or placed in the facility safe. For
patients who decide to keep any valuables in their
possession. staff are to inform them that the facility is not
responsible for the safety of their valuables. Staff are to
document a complete description of the valuables. kept by the
patient, in the clinical record and that the patient was
apprised of his responsibility.

HQNEI :.

The facility is not responsible for money kept by the patient
in his/her possession.

Patients are encouraged to keep no more than five dollars
($5.00) in their possession.

Limitations or restrictions on the patient's use of money
must be documented in the i'i'P and be implemented in
accordance with facility policy.

Patient monies not in the possession of the patient will be
deposited in the individual patient's account at the

CBSMEP'S ol‘l'lce- Ne-eatianmenice..le.L.bc..lsskcd.in..tlut
rcaMctMMMmtmti t-u -

Patients are encouraged to withdraw no more than ten dollars
(“0.00) at any one time for incidental personal use.
withdrawals may be made at the Social Skills Center or the
Cashier's Office during regularly scheduled hours.

At the time of discharge of each patient. both the Resident
Affairs Office and the Accounting Department are to be
notified of the patient'sJixlclgm-ge, mull-em; to insure that

any monies/personal belongings located after discharge can be
forwarded to the patient.

EJiiEiiQQflJE—i‘iflfiifliifl'ili. X

2.

All patients admitted to the Psychiatric Treatment Program
will be given a copy oi“ the Premium of Movement policy.

Patients in the Psyrbiatric Treatment Program will be
assigned a supervision level by the RN lli assigned to the
residential building (or the nu li who is relieving for the
RN iill, which will specify any additional restrictions
placed on their movement. These levels will be determined

though consideration of. but not necessarily limited to, the
following:

 

218

a. perceived danger to une'a sell“;
b. perceived dnnger to others;

c. potential property destruction;
d. potential e I opeinent;

e. ndhernnce to I'l'i';

r. assessment of mental status; etc.

These levels will he reviewed at least weekly hy the RN Ill
and modified as necessary. Determination ol‘ the levels is
not considered n Treatment Teen decislon, hut input from Team
nenbera is encouraged.

The levels of supervision are as follows:

LEYEL...LL The patient only need adhere to the general
restrictions for all petients/residents ol‘ (:nro
Regional Hental Health Center.

LEVELJJJ. Patients must keep stafl‘ informed of their
whereabouts at all times. They may go outside
the building if accompanied by staff or alone
with permission. Patients at this level may
complete personal hygiene without supervision.
They will be checked every 30 minutes while
sleeping.

LEVfiLJJLL Patients on this level must be within the
staff's eyesight during waking hours. Patients
may go outside the huildlnga only if accompanied
by stuff. Patients at this level, at times, may
be restricted to their building due to their
special needs. Stai‘l‘ may need to accompany
patients during personal hygiene care. as
directed by the RN ill/RN li/INJAS Vii. and will
check on natientn at least l5 minutes while
sleeping. Patients on Suicide Alert or Self-
Abuse Precautions will be assigned to this
level.‘

“:ijin (lniy patients on SUICIDE PRECAUTIONS to he
determined in accordance with liflll Policy ill-
003-0003-H dated 7/22/66 will be assigned to
this Level oi‘ Supervision. in accordance with
cunnc Policy 0?..Ii'l.:i. ‘

Uoodside (admissions unit) is a locked residential building.
l’lnegrove. Sugar-bush, Spring (lalc and Amulegete are
programmatically designed to be open buildings. However.
this status is subject to eimnge honed on needs and
characteristics of inpatients present.

.\

 

219

tiihwiLAIlfiliNGMQlij 11L}.

1. The initial Hill for all patients admitted to the Psychiatric
Treatment Program must be approved by the treating
psychiatrist.

2. Subsequent Mill's will be arranged and authorized in
accordance with general facility policy.

 

Dill LDlIiLLLNfiREiL'i'lQNiLL

Residential building supervisors (i.e.. RN ll's, Wills Vil'sl. both
All and PM shift, are to inspect the residential living units a
minimum of two times per week to insure proper cleanliness.
compliance with accepted health standards and that appropriate
supplies and equipment are available and in good repair.

 

APPENDIX H
JCAH THERAPEUTIC ENVIRONMENT

 

220

 

32. Therapeutic
Environment (TI-I )

THJ

Tli.2

'l’li.2.l

Til.3

Tli.4

Tli.4.l

Tii.4.2
“1.4.3

Tli.4.4

Tii.5

Tii.5.l

The iztcility establishes an environment that enhances the genitive sell-image
oi patients and preserves tbcir lntuntu dignity.’

Tire grounds oi the iacility have adequate spncc ior the incility to carry otrt
its started gonls.‘

When patient needs or incility goals involve outdoor activities. trrctrs appro-
printc to the ages rrnd ciinicrrl uccds oi the prrticnts trrc provided.‘

The facility is accessible to handicapped individuals or the irrcility lnts writ-
ten policies turd procedures that describe how handicapped individuals can
gain access to the incilit y ior necessary scrviccs.‘

Waiting or reception areas are corniortrrblc. rtnd their design. location. and
inrnishings accommodate the characteristics oi patients rrnd visitors. the
anticipated \vniting time. the need ior privacy iiiitl/tif support irotn stail.
and the goals oi the incility.‘

Appropriate stnii are rtvnilnblc irt writing or reception areas to address the
needs oi patients turd visitors.‘

Rest roorns rue nvniinblc ior patients and visitors.’
A telephone is available ior privntc crrrrvcrsrrtions.’

Art ndcrptatc number oi drinking units are accessible at appropriate itcigltts.‘

“1.4.4.1 ii drinking units employ cups. only single-use. disposable cups
are uscd.‘

Facilities that do not have emergency medical care resources have iirst-ttid
irits rrvrrilrrblc itr appropriate places.‘

All supervisor y staii arc iaruilirtr with the locations, contents. turd use oi the
iirst-uid irits.’

 

'i'he asteriskcd items are key iactors in the accreditation decision pmcess. For art «rd-nation
oi lite use oi the icy iuctors. see “Using the Manual.” page vii.

Circle One

l2)

lZJ

l23

-
N
U

4

5

NA

NA

NA

NA

NA

NA
NA
NA

NA

NA

NA

NA

 

Conroinlateri Slamianl: Marital. [”7

I77

221

'l‘lrernpetrtir' iitwirrrrrmettt

"4.8
1H.6.l

"1.8.2
Tll.0.3
Tli.6.4

Til.6.5

Tli.6.6

1H]

THJJ

"1.7.2
"1.8
Til.9

Tll.?.l

1". l0

THJOJ
TH.”

TH. Ii.l

THJLZ

1H.ll.3

l‘rograrns providing partial-hospital or 2-l-lrortr care services provide an
environnrent appropriate to the needs oi patients.‘

1 he design. structure. iurnislting. anrl lighting oi the patient environment
promote clear perceptions oi people and irrnctions.’

When appropriate. lighting is controlled by patients.’

Where [a.rssible. the environment provides views oi the ontrloors.‘

Areas that are used primarily by patients have windows or skylights.‘
Appropriate types oi mirrors that rlistort as little as possible are placed at
reas- onable heights in appropriate places to airl in grooming and to enhance

patients‘ sell-awareness}

('iocirs attd calendars are provided itt at least major use areas to promote
awareness oi tirrrc anrl season.‘

Ventilation contributes to the lrabitability oi the cnviroument.’

Direct outside air ventilation is provided to each patient's room by air-
conditioning or operable Windrnvs.‘

Ventilation is suiiicicnt to remove uurlesirable orlors.‘
All areas arrrl suriaces shall be iree oi undesirable odors.‘
Door locks anrl other structural restraints are used minimally.‘

'l he use oi door locks or closed sections is approved by the proiessioual
stnii attrl the governing body.‘

'l he iacility has written policies arrrl procedures to laciiitate. staii-patient
interaction. particularly when structural barriers in the therapeutic envi-
ronrrrent separate staii irrrnr patients.’

Staii respect a patient's right to privacy by knocking on the door oi the
patient's room bciorc errtcring.‘

Areas with the iollorving characteristics are available to meet the needs oi
patients:

Areas that accommodate a irrll range oi social activities. irom two‘person
conversations to group activities?

Attractively itrrnished areas in which a patient can be alone. when appro-
priate;° and

Attractively iurnisbed areas ior private eonversatirrns with other patients.
ianriiy members. or iriends.’

‘The Instr-risked items are trey iaetors ia the accreditation decision preteen For as esplanatioa
oi the rise oi the key iactors. see “Using the Natural." page vii.

Circieilne
2.145NA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
2.1 SNA
23 SNA

 

I78 Consolidated Standards Manual. 2987

 

 

222

'l‘beraprartir- lirrvirrmrnent

 

 

(.‘lrcle One

Tll.l2 Appropriate iurnislrings and equipment are available.’ I 2 .1 4 5 NA
Til.l2.l Furnishings are clean and in good repair.’ l 2 .1 4 5 NA

Tll.12.2 Furnishings are appropriate to the ages aurl physical conditions oi the
patients.’ l 2 .1 4 5 NA

Tll.l2.3 All iurnishings. equipment. anrl appliances are maintained in good operan-
ing order.’ I 2 .1 4 5 NA
Tli.12.4 llrolren itrrnishings and equipment are repaired promptly.’ l 2 .1 4 5 NA
THJJ Dining areas are contiortable.attractive.anrl eonrlncive to pleasant living.’ l 2 .1 vi 5 NA

Tli.13.l Dining arrangements are bascrl on a logical plan that meets the neerls oi the
patients and the requirements oi the iacility.’ l 2 .1 'l 5 NA

Til.13.2 Dining tables seat small groups oi patients. unless other arrnugerucnts are
justilicd on the basis oi patient necrls.’ l 2 .1 4 .1 NA

TH.l3.3 When staii members do not eat with the patients. the dining rooms are

aderprately supervised arrrl staiierl to provide assistance to patients when

needed and to assure that each patient receives an adequate amount and
variety oi iood.’ l 2 .1 4 5 NA
TH.“ Sleeping areas have rloors ior privacy.’ I 2 .1 4 5 NA

TH.l4.l In rooms containing more titan iour patients. privacy is provided by parti-
tioning or the placement oi itrrrtiture.’ l 2 .1 4 5 NA

Til. “.2 The nrrnrber oi patients in a room is appropriate to the goals oi the incility
and to the ages. developmental levels. anrl clirricrrl ncerts oi the patients.’ t 2 11 4 5 NA

TH. 14.3 lireept when clinically irrstilied in writing on the basis oi program require-
ments. no more titan eight patients sleep in tr rorrrn.’ I 2 .1 4 5 NA

Tii.i4.4 Sleeping areas are assigned on the basis oi the patient's ncerl ior group
support. privacy. or indeperrdcnce.’ I 2 .1 4 5 NA

1”. t4.4.l l‘atients who need estra sleep. whose sleep is easily disturbed.

or who need greater privacy because oi age. emotional disturbance. or

arlinstment problenrs are assigned to berlrorrrns in which no more than two
persons sleep.’ i 2 .1 4 5 NA
Tll.15 Areas are provided ior personal hygiene.’ l 2 .1 4 5 NA
Tll.lS.l The areas ior personal hygiene provide privacy.’ l 2 .1 4 5 NA
truss bathrooms and toilets have partitions arrrl dorrrs.’ t 2 .r r 5 NA

"the asterisired items are hey lacrors in the accreditation decision process. For an esplaaatloa
oi the ave rd the hey lactors. see "Using the Manual.“ page vii.

 

Consolidated Standards Manual. I987 I79

223

'l herapeutic l’nvirommcut

"1.15.3

"1.16

"1.16.1

111.16.?

Tll.lB.3

Tll."

"1.17.1

114.18

"1.18.1

111.19

TH.19.1

"1.19.2

"1.19.3

"1.20

"1.20.1

'l'oilets have scats.’

iiood standards oi personal hvgierre and grooming are taught and main-
tained. particularly in regard to bathing. brushing teeth. caring ior hair anrl
nails. anrl using the toilet.’

i‘atients have the personal help needed to periorm these activities anrl.
when irrdicatcrl. to assume responsibility ior scli-eare.’

incontinent patients are cleaned and/or bathed immediately upon voiding
or soiling. with rlrrc regard ior privacy.’

The services oi a barber and/or beautician are available to patients either
in the iacility or in the connnrurity.’

Articles ior grooming nnrl personal hygiene that are appropriate to the
patient's age. developmental level. and clinical status are readily available
in a space reserved near the patient's sleeping area.’

li clinically indicated. a patient's personal articles may be lrept trttrlcr loci:
and key by staii.’

Arrrple closet arrrl drawer space are provided ior storing personal property
anrl property provided ior patients' use.’

lsrclrablc storage space is providcrl.’

Patients are allowed to lreep anrl display personal belongings and to add
personal touches to the decoration oi their rooms.’

The iaeility has written rules to govern the appropriateness oi such decora-
tive display.’

li access to potentially dangerous grooming airls or other personal articles
is contraindicated ior clinical reasons. a member oi the proiessirural staii
captains to the patient the conditions under which the articles may Ire nserl.’

111. 19.2.1 The clinical rationale ior these crntrlitiorrs is rlocunreuterl irt the
patient record.’

ii the hanging oi pictrrres on walls and similar activities are privileges to be
earned ior treatment ptrrprrsr' re member oi the prolessionnl stall captains
to the patient the conditions under which the privileges may be granted.’

"1.19.3.1 The treatrneut anrl granting oi [nivilcges arc rlocumentcrl in
the patient record.’

Patients are encouraged to take rcsprnrsibility ior mairrtniniug their own
living rprruters arrrl ior day-to day lnnrsehccping activities oi the program.
as appropriate to their clinical status.’

Such responsibilities are clearly deiinerl in writing. artrl staii anistance and
equipment are provided as neerlerl.’

"l‘he asterlshcd items are hey lactors la the accreditation decision pores. lint an esplanation
oi the use oi the hey iaenumna “Using the Manual.“ page vii.

Circle 1 inc

2.145NA

 

Mil Consolidated Standards Manual. M17

 

11110.2

111.20.:1

111.21

111.2 1.1

111.211

11121.3

111.2 1.4

11121.5

111.22

111.23

111.24

11124.1

111.25

111.26

111.27

111.211

111.28

224

Therapeutic liro-ironnrent

Descriptions oi srrch responsibilities are included itr the patient's orienta-
tiott prograrn.‘

llocunrentation that these responsibilities have been incorporated in the
patient's treatment plan is prmidcd.’

Patients are allowed to wear their own clothing.‘

11 clothing is provided by the program. it is appropriate and is not
dehumanizing.‘

Training and help in the selection and proper care oi clothing are available
as appmpriate.‘

Clothing is suited to the clitnnte.‘

('lotlriug is becoming. in good repair. oi proper sire. and sirrrilar to the
clothing worn by patients' peers in the connuuttity.‘

An adequate arnouut oi clothing is available to permit laundering. clean-
ing. and repair.‘

A larrrrdry room is accessible so patients may wasir their clothing.‘

The use and location oi tnrisc-prrnltrciug equipnrent and appliances. such
as television sets. radios. and record players. do not intetiete wittr ottrcr
therapeutic activities.‘

A place and equipment are provided ior table games and italividuat hobbies.‘

'i‘oys. equipment. atnl games are stored on shelves that are accessible ttr
patients as appropriate.‘

llook s. magarines. and arts and eraits nraterials are available in accordance
with patients' recreational. cultural. amt educatiturat backgrounds and
needs.‘

'l’ire incitity iorrnulates its own policy regarding the availability and care oi
pets and other aninrats. consistent with the goals oi the ineitity and the
requirements oi good health atnl sanitatirrn.‘

Depending on the sire oi the program. iacllities are available ior serving
snaclrs and preparing meals ior special occasions and ior recreational
activities.‘

The iacilities permit patient participatiott.‘
Unless contraindicated ior therapeutic reasons. the iaeility accommodates

patients' need to be outdoors through the use oi nearby parts atnl play-
grounds. adjacent countryside. and lacility gruutnls.‘

:1 he nsterislred items are key incans la the accreditation decision graces; For an erphnatlan
oi the use oi the hey lacuna. ace “Using the Manual." page vii.

Circle 1 ltre

1.115NA

2.115NA

2.1451111

IJJSNA

2.1451111

2.11SNA

2.1451411

IJJSNA

ZJ1SNA

 

Cnmaiairrreri Standards Manrari. I217 MI

 

 

225

'l lu'm'n'mir Furhmnm-M

( 'iu'lc 0m-

TI-LZBJ chwufimm! lac-5min mul rqni'mwm me m'nilalflc. mmsislcm «in. patients'

ncqu andmell‘cupcmkgmugcmn.’ I 2 J 4 5 NA
"L212 Iln‘oralicmulnmi'um'm knuaimaimwlin muting-MIN} I 2 .\ 4 5 NA
(Du-val! rmnp'iam'r: Ila-"prank "airman-M I 2 J 4 5 NA

 

° l k::l:i;‘nl 608m au- h-v lac-Inn in II“- nrrvnlicnoi-m «II-rki-m pun-r“. I'ut In uplamuiun
«I ah:- mr nl Ilur Icy bums. sec "Using the Manual." page vii.

 

(.‘nmmrnu mu! Rc-rcunnu'mluu'um
I‘mv'ulc specific clux'umcmminm Um each 2. J. 4. m S "fling.

——————-o--.-.. —- ..- .—..-.

 

——-——..—

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M) Cmunh'clnlml Stan-hula Manual. I?"

 

APPENDIX I
CRC/DMH REPORT FORMS

 

 

 

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w 19.21132!"
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mismamr ‘ ‘“
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BESllMINl' MI) QUIET noon USAGE SEUMSION
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lhrlln ll. Iloll. Ph.D.. lllroctor --
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‘ Total Eplnmlnn
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lhrlln n, Roll. ru.n.. lllrector “
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ll) . lll Total Hours
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APPENDIX J
TRAINING SCHEDULE

230

Caro Regiona1 Menta1 Hea1th Center
PSYCHIATRIC UNIT INSERVICE
MAY 4—8. 1987

Mendez; flex 5; 12.].
8:00 a.m. Introduction to Training Program
Dr. Mar1in R011. PhJL. Faci1ity Director
Mr. Maurice Forrest. Personne1 Director
Mr. Rick Jenkins. ATA III. Union President
9:00 a.m. "What is Menta1 111ness?"
Mr.Avni CirpiLL R.N.

10:15 anm Break
10:30 a m. Menta1 I11ness, Continued
12:15pnm. Lunch '
12:45 p.m. Major Disorders Treated at CRMHC
Dr.Diane List.Efl.Du Director of
Psycho1ogy. M.I.
2 15 prn Break

2:30 p.m: Disorders. continued

TuesdayL May é; lgfil

 

8:00 a.m. Communication
Dr. Diane List. Ed.D.
Mr.Avni CirpiLL R.N.
Mr. Joseph Warack, RCA 1118
10: 00 a.m. Break
:15 a.m. Communication. continued
12:00 noon Lunch
12:30 p.m. Documentation
Mr. Raymond Bates. ACSW. Psychiatric
Program Coordinator
Mr. Kim Hopper. RCA VB
m. Break
2:15 p.m. Introduction to Psychotropic Medication
Dr. Irene Reive. MD. Director of Psychiatry
3:30 p.m. Leve1s of AccountabiIity and CRMHC Phi1050phy
Dr. Mar1in R011. Faci1ity Director

231

NednesdayL May QL 1981

 

8:00 a.m.

10:00 a.m.
10:15 a.m.
12:00 noon

1:30 p:m.

23K)
.5"
UT
'0

3

Staff-o-Genic Behaviors: Effects of
Treatment Interventions
Dr. Diane List. Ed.0.
Mr.Avni Cirpikh R.N.
Mr. Joseph Warack. RCA 1118
Break
Staff-o-Genic. continued
Lunch
Staff-o-Genic. continued
Physica1 Management Techniques
Mr. Robert Wa1ker. RCA 1118
Ms. Judy McCrumb. RCA 1118
Break
Admission Procedures
Mr. Raymond Bates. ACSW. Psychiatric
Program Coordinator

Thursdayy May 1; 1281

 

8:00 a.m.
8:30 a.m.

10:30 a.m.
10:45 a.m.

12:00 noon
12:30 p.m.

3: p.m
3: p.m.

E1opement Precautions
Mr. Joseph Warack. RCA 1118
Medication Side Effects
Dr. Irene Reive. MD. Director of Psychiatry
Break
Sec1usion Room Procedures
Mr.Avni Cirpikh R.N.
Lunch
Suicide Risks
Dr. Diane List. Ed.0” Director of
Psych0109yo M.I.
Break
Avoiding Job Re1ated Burn-Out

FridayL May BL 1281

 

8: 00 a.m.
9: 00 a.m.
10:00 a.m.
11:00 a.m.

Side Effects of Medication
Dr. Barry BinkTey. MD. Staff Psychiatrist
The Acute Care Admitting Unit
Ms. Pam Reuter. R.N.
C10$ing Comments
Dr. Mar1in R011. Faci1ity Director
Staff Test

APPENDIX K
STAFF TRAINING EXAMINATION

 

NAME:

(0

6.

 

 

A patient states that he is God and can control the
whole world. He is staying up at night pacing and
speaking continually in a pressured manner. This person
has the characteristics of an individual who has a:

A. Schizophrenic Disorder

N. Bipolar Affective Disorder

C. Borderline Personality Disorder
i). Organic iirain Syndrome

The coapnnents oi the coaannicatlon process include

A. Body language’ot the speaker
B. Tune of voice

C. Eye contact with the audience
I). All of. the shove

in working with a aanipulative patient staii need to use
all of the following interventions exgeg :

A. Explain to patient limits of aeceptahle behavior

ll. lie consistent

C. iinve one staff as the primary nttendeut, if possible

i). iiive patient several chances to improve their
hehnvior hefore intervention occurs

iiho can move a patient. [roan one level to another:

A. Direct care staff
ii. Social worker

C. Registered nurse
i). iiiilii'

Hheu a patient is aggressive on.the unit appropriate
interventions would include all of tile [allowing um:

Tell the patients not involved to leave the area

B. "a what is necessary to show to the patient you are
IJl CiNilrlil

C. Avoid a situation where you or the patient have to
..VIJI.

D. Request assistance from othe staff

All of the following are components of a suicide
assessment excentz

A. Plan

B. Availahility of aenns

C. Nnaher of household aeuhers
ii. Gender and ethnicity

 

i0.

233

Which of the following is not. generally exhlhited by an
individual who is diagnosed as having a Borderline
Personality Disorder.

A. Patient expresses feelings of emptiness

.li. Tend to he manipulative

C. Expresses hallucinatory thoughts
I). Are fearful of being alone

lir. iiih has heen up and down all shlit. Several patients
on the unit have complained that lir. EU: has heen
hotheriug them. "hat is the proper order of
interventions:

l. Physirai management

2. Seclusion

3. Move to quiet/less stimulus area
A. Verbal redirection

A. l. 2, 3. h
B. 7., ’3, 'i, i
i2. ’0. 3. l. 2
"0 II: '0 19 2

Which of the following terms is not used to describe 0
types of delusion:

A. llemeut in

B. (irandlose
l3. Paranoid

ii. Persecutory

When dealing with a patient verhallzing suicidal threats
the most important consideration is:

A. A suicidal identlon is a suicidal thought

it. Threats of suicide should he considered seriously and
appropriate laterveni ions defined.

(2. The patient should he placed on a level. TV as soon as
”an” i h l i!

ii. iiulridal threats should generally he considered to he
niient ion seeking lwhnvior

When raring for an organically mentally ill person, your
primary concern should he for their safety.

A. True
B. False

12.

[3.

M.

[6.

17.

18.

l‘).

234

"Staffogenic" helmviors are defined as those behaviors

exhibited by patients that. are a direct result of
maladaptive behaviors and attitudes by staff.

A. True
B. False

Understanding yourself. your thoughts. perceptions.
values and behaviors is an essential part of being a
good care-giver.

' A. True

B. False

Agitated behavior is generally unpredictable and has an
underlying cause.

A. True
B. False

flue does not need to use simple directions when caring

for a schizophrenic patient hecanse schizophrenia is not
a thought. disorder.

0

A. True
B. Poise

When a patient is experiencing anxiety, it is most
likely that he/sbe is actually feeling fearful.

A. True
Ii. l"a lse

Chronic patients cannot. funct ion outside of a hospital
setting.

A. 'l'rue
ii. Pulse

A patient on an Adult Pormai Voluntary elopes. He are
obligated to contact the police as soon as possible.

A. True
B. False

You can rhaage a person's delusion by telling that
person what. they think is happening really isn't.

A. True
B. False

235

20. Hrist cutting is a highly lethal scans of suicide. An
individual attempting suicide using this method should
be placed on 1:! for at least 2’. hours.

A. True
B. Pa i so

2|. Side effects of anti-depressants include:
i. Drowsiness

. Ataxia

. Constipation

. iiypatension

. Weight gain

'.,s:~'...i\:

A. i and 'i
B. 2 and ’0
it. All of the above
ii. None of the above

22. individuals diagnosed as Bipolar Affective iiisoder are
generally characterized as having a disorder of:

A . 'i'hong h i.
B. Nomi
it. Organicity
. ii. Personal ity

23. 'i'he. daily documentation in the progress notes is often
utilized in all of the following situations except:

A. TI provide a basis for describing behavior that may
be used to develop or confirm a diagnosis

it. To provide orders to other staff members about; the
appropriate treatment of a particular patient

ii. To identify possible positive or negative side
effects of medications

i). To indicate the extent. to which the objectives in the
treatment plan are being implemented

24. - Based on the philosophy of treatment at Caro Regional
Center the .‘i it's are all of the following excgpt:

A. Belai'orre appropriate behavior
ii. Redirect to appropriate ari iviiy
ii. Refer pal lent. to their l).ii.ii.i'
ii. iiemove the stimulus

26.

27.

2B.

236

All of the following statements about stress are true
except:

A. Stress is always had for an individual

B. Relationships are often a basis for stress

.. Stress too prolonged and severe can eventually
cause physical symptoms

D. Stress can be caused by any significant life change -
either positive or negative

When interartiag with a patient who is suffering from an
acute psychotic episode, staff need to:

A. Focus the patient on to reality as much as possible

B. Always be in control the patient's behavior in order
to avoid confrontation situations

C. iixpert the patient. to be able to answer question and
carry out tasks rat ioaaiiy amt logically

ll. iinke sure that. the seclusion room is empty and ready
in case it. needs to be used

r—V'"*r‘*v fl

ilrs. .ioues received it) mg of iinldol last. evening. This

morning she is complaining of feeling jittery and just

can't sit still. The most iikley problem is

l. She is just a hypochondriar

2. She is reacting to last- night's dose of_ haldol with
akethesla

.1. She is nervous and tense because the iinldol effect.
has worn off

A. All of the above
ii. i and 'i
C. 2 and ’i
ii. lioiie of the above

The philosophy at Caro Regional Center may best be
descibed as:

A. Our responsibility is to realize that patients are
incapable of deciding things for themselves and do
for them what. they cannot. do for themselves
it. Recognizing that. our role is to control patient.
behaviors to the best. of our ability ‘
C. understanding that our expectations for patients
( i.e. expecting them to act normal ) will greatly
influence their behaviors
B. Setting down the limits and rules on the unit and do
what is necessary to have the patients comply

29.

3".

3i.

32.

33.

36.

35.

237

Patients may be admitted to Caro Regional Center
involuntarily on the following types of orders except:

A. Court order examination

b. Police petition

(2. Medical certification

0. informal adult formal voluntary

When a patelnt is becoming agitated the most appropriate
intervention may be:

A. Explain to them that they should calm down

B. Attempt to redirect then to a more appropriate
activity

C. Ask them ”Why are you getting upset?"

D. Reassure them that everything will be fine soon

line of the side-effects of ant i-psychot.lc/neuroleptic
medications is tardive dyskinesia.

A. True
b. False

i-chh stressful situation in a person life should be
treated individually because past expriences of how the
person has dealt with stress has little. if any. effect
on this new siessfnl situation.

A. True
b. False

'i'be phi losophy at: Caro Regional Center is based on the
theory that the primary responsihl l ity of staff is to
control patient behaviors

A. True
fl. False

The Michigan Mental Health Code defines a person as
being mentally iii if they are suffering from a
substantial disorder of thought or mood.

A. True
it. False

Mental hodtb workers are always objective in their
interpretation and diagnosis of mental illness
regardless of their own personal and cultural
backgrouds.

A. True
b. False

36.

37.

38.

fill.

238

it is best to leave a patient who is withdrawn alone
because these individuals are non-problematic and will
eventually seek out staff when they are ready.

A. True
". False

Mental illnesses are easily defined, easily identified
disorders.

A . True
b. False

line of the recmamended physical intervention techniques
for a physically aggressive patient is the Russian Grab.

A. True
B. False

The need to draw the line and maintain the rules is the
key to rmiulng a good unit.

A. True
ii . Fa i so.

Telling the pat lent that. they shouldn't think about
suicide is an appropriate intervention.

A . True
H. False

‘l.

’12.

239

You have been assigned to Mr. Hun. a newly admitted
patient to C-5. Me is diagnosed as Schizophrenic and has
the following symptoms: delusions of paranoia, little
insight into his probiea. refuses any medications.
refuses to do any of his care. and has a past history of
aggressive behavior. briefly describe some of the

possible interventions that you implement in caring for
this patient.

Mental illness is very subjective in nature. Explain how
two mental health professionals assessing the same
patient can come up with two different: conclusions.

240

A1. List five alternatives to physical management.

66. Define each of the disorders listed below.

A. Sch lzopbrenia

ll. lllpolar ( Manic/Depressive ) ilisorder

(I. liordoriine Personality Disorder

I). Organic lienlai Disorder

ll"). in class we have discussed the courept of control
,severnl times. is it appropriate to control a patleats
behaviors? Explain your answer.

 

llAlli‘I:
l. A
2. A
3. V A
4. A
5. A
6. A
7. A
ii. A
‘1. A
ii). A
'i‘Rill".
ii. A
l2. A
i3. A
i’o. A
i5. A
iii. A
i'l. A
iii. A
i". A
20. A

FA LS i".

ll

ll

ll

ll

ll

-*.-—.--o-_c----

il

l)

i)

ii

i)

241

 

ANSWER

8 ii ii i'Z'l'

2i.

28.
2‘).

3i.) .

Si.
.12.
.13.
Ii".
35

36.
37.
fill.
39.

M).

>>>

333::

ii

ll

Tiliili

A

30.10006

0

O

l)
i)

i)

FA LS i".
ll
ll
ll
ii

ll

APPENDIX L
ADMITTING UNIT DIAGRAM

'I“ i. al.-ere!"

if

242

MIN
. mu‘ .0 ’

' o
l 1
~ l
C... .-_-=‘ '—'..'

O . . -
ii 3 t '2' sun“ no runr‘rrsn
-' a .‘

-%

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I " , '.

. 3' '.

a i -- i

t. . _ :'

!.

“mu! ' .'
-.- q -_00 :.:-.

 

 

 

 

 

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-' . . 9:32-52:1qmnzpi lax-5m». 4.’ '2‘

 

        

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L41

'. O_.o--I

‘ii‘u mm.-mn~uvm. Atrium-tn

fiqfl d'oyoeu‘x". 7/( [did J jg?!” [ff/344

 

 

APPENDIX M
PERMISSION TO QUOTE LETTERS

2113

sure our tau-om perm or «emu. mars/:‘szt‘xz
("'“h M D. Votive. qh. W'

_ "\" h a", a“! .
8‘ case REGIONAL/3' " g 'i- 001 3 .988
: MENTAL Heston CENTER . , "

,. ‘5

‘ Caro. MW uwmrsffx I ' '
JMAES .i. mucaam is") 6734191 ‘-.'.

PERMISI NGR mm
septelber 26. 1988 r ' ' M

'.‘ "7"}: .
l. l 00‘}. . ' 3’.

  

 
 
 

 

 

 

Ronald E. Mailma- ‘ 4
Director. Publication Pole [0 - I «Q
and Nerkellnq F... m

 

Editor-ln-Chief ’
Merican Psychiatric Press
"00 K. Street. li.li.
Hashington. D.C. 20005

TO HIGH IT MY CMCERN:

i am in the process of cowleting a Dissertation for a Ph.D. in Counseling
Psychology at Michigan State University. The title of my study is Seclusion
Room Usage at a State Regional Mental Health Center. As a part of my Tirst
Chapter, {have aSection hhicWTines various psychiatric terns.
Forfinately. I had as a resource Psychiatric Glossary (1984) with appropriate
are t g ven.

i would like permission to use parts of or all of the following definitions:

Agitation Etiology
Bipolar Disorder hallucination
Deinstitutional ization incidence
Delusion Mental Disorder
Depression Moral Treatment
Dynamic Psychiatry Occupational Therapy MW".
Swath!
Thank you for any consideration you can give Ia.
STRCQVEI’a
Wa’ “0.14);de-
. llarry ii. llright

Cl inical Psychologist

244

man on anti-nun two-Munro cw mun: mum 'ii i y r
. I
than... n. Wain-vs. a... luv-clam .l ”lib

iiEiKT cnno neolount
- mi;

MENTAL HEALTH CENT Ell

 

"Sag..."
Clan, Mudflaps" {I'll Ill‘all
JAMES J twancnano (Sill am .mn
(boomer

Septeaber i3. was

John A. Talbot. M.D.. Editor
hospital and Continuity Psychiatry
Man K Street. ll.ii.

liashiagtoa. B.C. 20005

Dear Dr. Talbot:

i am a Clinical Psychologist at the Caro Regional Mental Health Center. Psychiatric
tinit. and a ”Lil. candidate in Coimsei ing Psychology at Michigan State University.
My dissertation tapic is “Seclusion room usage at an acute care psychiatric unit of
a state regional amtal health center“. Variables of interest are patient charac-
teristics. various treatment modalities. and staff training. The focus is ‘on how
the above effect incidence of seclusion. especially on first tile secluded patients.

i am writing to request permission to mate use of part of an article published by
liQEBii‘iJild gunman" Psychiatry. June. l9il5. The particular piece of interest

was written-By Solof ."ifinthell. and Healer. and was entitled “Seclusion and Restraint
in l905: A Review and Update". The parts I want to use are tables I and ii. and i
wish to adapt the: to any study. and include the adaptation as a part of any literature
review. i found the article to be very helpful. and i would appreciate having per-
mission to value use of the sateriai; of course. with fitting credit given.

lhaul: you for any consideration you can give me.

Sincerely.

Nww7b3AU

liarry ll. llrlght
Clinical Psychologist

cc: Gloria Smith. f'h.ll.

Michigan State University 9/16/00
.. . 'a.‘ 0: . I
Mel-FM" ' ' . Permission granted provided. warn-lesion
.9." ‘ -° ' is also obtained from the author. The
$3.15. .“ '-'; 1' ddress for Dr. Soloff «given in the
i': ‘3‘ 2 .. - r tale is sti 1 current.
2 ' '3. "0‘ ‘. :- _-' ...-fl'
i: ':‘- " a L %M {7%,
's ' "-..,"3 -
. V . .0 '0', .. ‘ ([Z’ (5‘ 3 .
' ".1” . ”.13 ‘reddye 'layton
,‘. i ‘ ~ ' Diamaginq lidito

245

O O C ‘-
lhuveashyoiFMflsbumgh k' .
.u ;.
WESTERN PSYCHIATPIIC lNSTlTUTE AND CtiNiC \. -‘~...’I' .
' n '
4

0..
.Q’. a‘a ’

I a'
..‘

September 15, 1988." ’"

Harry M. Hright

Clinical Psychologist

Caro Regional Mental
Health Center

Lock Box A

Caro, Mi 48723

Dear Mr. Wright:

You must obtain permission from the publisher to
reproduce published data. (They hold the copyright.)
You certainly may use our format to meet your own needs
and cite us as a reference.

Sincerely,

i; @W/i/f

Paul H. Soloff. M.D.
Associate Professor
of Psychiatry

PHS/mc

246

TRAINING PROGRAM SPECIALISTS

no MICHELLE DRIVE . uoweu. momma m3
(517) 546-8354

August 25. 1988

Harry W. Wri ht

Caro Regiona Mental iiealth Ccntcr
Lock Box A

Caro, Mi 48723

Dear Harry,

i understand that you are preparin a doctoral dissertation and wish to have
rmission to quote from a document wrote. Permission is hereby granted to quote
mm a memorandum dated September 6. 1982. addressed to C. Richard Tscgayc-
S ates, Ph. 0., Bureau of Clinical and Medical Services. Department of Mental
i caith, Lansing. Mi 48926. RE: Survey of Seclusion and Restraint, including the
attached 3 page document titled ”Survey of Restraint and Seclusion Use". This
permission is extended to any and all use you wish to make of this material.

i am delighted that you are finding this material useful. Please let me know if you
require further assistance.

Cordially;

Robert Orlando. Ph. D.

247

KO: 4&1 w‘ ”ya

\J/Ju, flier,» ,cigu l/a helm/7 ”vii. 1‘54‘1“2f
712$m¢ad£a7gl 2%,) 17¢“) V; “.11.. 5114,, /¢-//HA.¢7 .

,6; /~ .0 walnut/a.) and, adv... ”(414-4421; «ham-t-

{7, IO}./. filly/zit.) fl. $32011: 794/ 714W (fiéujflc‘l/(ézr
O 5/al/py [95470717 fif'vu/ fie, J’ycte‘flcj.< 4L,
)jvm u. /)ce//flti‘ ”V" In" Cm’m'tflzj‘)
”9 .fZ’H. ((4.14 ‘4’, /)_c/rx.’/ 10’ adj-elb 771$ 5711;) '
flatten (.107: Jew. as, .010! .
3) 777..“ ’, /7i/~/'£c2</Mz an ' §(24.2'<7u.3 (at)-
/ (7 ,
70m. 4 ('l\/ /5‘ w“; 4 "U U 72(4”:2M’“’“£
6’) Q /'fff [an amt/L VIII/(2 dz/I-p:[€J fil/fléaéz.o.m;

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)flI/‘Lfl‘tc ea) -

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Wed/Ida 4&1) all/al..?ri—ILJ {li‘ any It; {(3, fa b 5.11% 4' ’

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APPENDIX N
RESEARCH APPROVAL CORRESPONDENCE

‘_'__Z "

,HI'

248

Sislt 0" mm VFW!" 0' KNIM DEAN"
' ,. a. Thames ofiwaem. 41.. Director
TQM)“ cnno REGIONAL
“(fig-[)3 MENTAL HEALTH CENTER
'-;.‘.;.;i Cum. Minn" 4017!! 0153
«was J. suncmmo (bill 613319: "a, 9 . '95”
Governor

 

Office for Research and Graduate Studies
Ross 230

Administration Building

Hichiqen State University

East Lansing. Hi "602“

RR: UCRIHS review of research proposal by Harry Uriaht

Hr. "right has proposed a review of patient records for data
collection regarding seclusion roon usage in this fncility. This
would not involve identification of any individual patient.
either directly or indirectly. Since Hr. Wright holds n stuff
psychologist position at this facility. he has legal access to
these records as a setter of course in peri'orsinrz his duties.
The study would in no way affect the course of treatsent of any
of the patients.

Vc strongly support Hr. "right in this effort. since we feel
the information to be obtained sight well have a positive effect
on our continuinn efforts to reduce/eilsinate the use of secluo
sion in our treatsent progress.

Sincerely,

i/jE/U-‘C; 7/7’22 6'. K .

florlin n. Roll. Ph.D.
Facility Director

 

 

249

CM“), HICiliGNI

RESIDLNI POLICY

-.é!!!!~.'§£.'.s-|.--.K';§L".'€E!,'--.__.._

O - --.-o—s~o-- -- A -- .-- ------c-.—..--..—-- ’_ o---——.-----o- —---_ n-k-C— -..-.—

--. -—o--.- c c -— .---~—

 

‘ue- -..-..c

 

I
_‘Jttlt.-_|.§§'!L!22-l--.J.-1;§) "9L|.‘.i!.!!‘!.t!"iits ---.sz PM“ I-»

 

tiheoever the facility Initiates a research program the proposed plan
shall he sniaaltted to the facility llirector ior consideratitm. lhe
plan shall include a detailed outline oi the proqras which includes
the ia-neiits to he expo-czted, potent iai risks and disronliurt, and
possible alternative services which might provo- equally advanta-
geous. ‘lhe plan shall include a listing oi all residents proposed ior
participation in the prugrda as well as the staii conducting the
investigation.

Provisions ior consent amst he outlined to Insure conildent iality.
privacy and interned consent.

following the Facility ilirmztor's review, the plan shall he reviewed
hy the Resident Care (Lunittee ior «tuition. '

Final reports oi projects are to he solaaitteoi to the Facility illreetor
and itesident Care iii-naittee.

REFERUICE: Nhittislralive Roles. "Jill. little 3]“.l0l5
JlNi Consolidated Standards. l‘liil tdition. liege-arch, pg. 47.

250

STATE OF MiCiIGAN
4"?“-
rlqu

( ‘4! °
L.‘-
'fi."
M3 J stmwio. Mil!

DEPARTMENT OF MENTAL HEALT

[EMS CASS HIM
tausm. WM Mill
"MS 0 WATKI‘S. ll.

0am

 

March 22. l988

Mr. Harry Wright. Psychologist
Psychiatric Unit

Caro Regional Psychiatric hospital
Caro. Hi 68723

Dear Hr. Bright:

Contrary to the information i gave you when we spoke by telephone
on March 9. l988. your dissertation proposal. as descrlhod. will
not require review bv the Department of Mental Health Technical
Advisory Research Connittee. Because your study does not involve
direct contact with recipients of departmental services. approval
to implement your studv is at the discretion of the record holder
who. in this case. is Dr. Roll. the facility director. You are
responsible. however. for adhering to the confidentiality
safeguards as specified in section llO.l748 of Niehiean's Mental
Health Code. Section llo.l750 concerning privileged
communications nay also be relevant.

if you have questions or require additional information. i say he
reached at (Sill llS-Ol29. i wish you well in the completion of
your doctoral studies.

Sincerely”

enicc L. Rhodes-Reed. Director
Research Unit

  

GLRRIkw

cc: Dr. Harlin Roll

251

MICHIGAN STATE UNIVERSITY

 

llNlVIlVIT (IDIINII'II’I "N IFQLAIILII INWIS'ING EAST MN‘ING 0 IKIIKiAN 0 “H I.“
IIIIN‘N SUMO-1:“ "if IIIIS)

“I AIWINBTIAIKW I‘IUIING

HI?) “ill“

May 16, 1988

llarry W. Wright
6794 3rd Street
Cass City, MI 48726

Dear Mr. Wright:
Subject: ”FACTORS WI IlClI INFLUENCE Tl IE INCIDENCE AND DURATION
OF SECLUSION ROOM USAGE IN A STATE REGIONAL
PSYCHIATRIC FACILITY M”

The above project is exempt from full UCRIIIS review. I have reviewed this project and approval
is granted for conduct of this project.

You are reminded that UCRII lS approval is valid for one calendar year. If you plan to continue
this project beyond one year, please make provisions for obtaining appropriate UCRIIIS approval
prior to May 16, 1989.

Any changes in procedures involving human subjects must be reviewed by the UCRII IS prior to
initiation of the change. UCRII IS must also be notified promptly of any problems Spuexpcctcd
side effects, complaints, etc.) involving human subjects during the course of the wor .

Thank you for bringing this project to our attention. If we can he of any future help. please do not
hesitate to let us know.

Sincerely -

in“ {'1
. ,m/
.. ) .

John K'. lludzik, mm.
Chair, UCRII is

J K" /sar
cc: 0. Smith

APPENDIX 0
DIAGNOSES 0F PATIENT SAMPLE

252

DIAGNOSES 0F PATIENT SAMPLE SECLUDED/NON-SECLUDED

 

 

Number Diagnosis - DSMIII
Schizophrenic Disorders
1 295.00 - Schizophrenic. Simple (ICD-9)
23 295.30 - Schizophrenic. Paranoid
20 295.60 - Schizophrenic. Residual
1 295.90 - Schizophrenic. Undifferentiated
Psychotic Disorders not Elsewhere Classified
5 295.70 - Schizoaffective Disorder
1 298.90 - Atypical Psychosis

Affective Disorders

 

 

 

 

 

 

3 296.20 - Major Depression. Single Episode
2 296.30 - Major Depression. Recurrent
20 296.40 - Bipolar Disorder. Manic
8 296.50 - Bipolar Disorder, Depressed
2 296.60 - Bipolar Disorder. Mixed
3 296.70 - Atypical Bipolar Disorder
1 296.80 - Atypical Depression
Paranoid Disorders
1 297.10 - Paranoia
1 297.90 - Atypical Paranoid Disorder
2 298.30 - Acute Paranoid Disorder
Anxiety Disorders
1 300.30 - Obsessive Compulsive Disorder
Other Affective Disorders
2 300.40 - Dysthymic Disorder
Personality Disorders
1 30l.00 - Paranoid
1 301.83 - Borderline
Substance Use Disorders
1 303.00 - Intoxication — Organic Disorder
1 303.90 - Alcohol Dependence. Unspecified

1 304.90 - Unspecified Substance Dependence

NN—‘N

253

Adjustment Disorder

 

309.00 - With Depressed Mood

309.24 - With Anxious Mood

309.28 - With Mixed Emotional Features

309.40 - With Mixed Disturbance of Emotions and
Conduct

Other Diagnoses

310.10 - Organic Personality Syndrome

294.80 - Atypical or Mixed Organic Brain
Syndrome

311.00 - Depressive Disorder. not Elsewhere
Classified (ICD-9)

V7l.09 - No Diagnosis on Axis I

 

BIBLIOGRAPHY

254

BIBLIOGRAPHY

Cited References

 

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Lansing. Michigan.

Administrative
Mental Hea

 

_£_£_
lt h.

Almond. R. (1974). The Healing Cgmmggity. New York:
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American Psychiatric Association. (1980) Diagnostic
and Statistical Manual 9f Mental Disorders
13rd ed.7. Washington DC: Author.

 

 

American Psychiatric Association. (1984) Psychiatric
filg§§g:y. Washington. DC: Author.

American Psychiatric Association. (1985). Seclusion
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Report No. 227 Washington DC: Author.

 

 

 

Anders. R. (1977) When a Patient Becomes Violent.
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Auletta. K. (1982). The Underclass. New York: Random
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Berger. M.M. (1977). Working With PeOple Called
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Borg. W.R. & Gall. M.D. (1971). Educational Research.
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Caro Regional Mental Health Center. (1988). Caro.
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Caro Regional Mental Health Center. (1988). Resident
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Colempan.£l.Cu Butcher..J.N..and Carson.R. C. Abnormal

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255

Cook. T.D.. and Campbell. D.T. (1979). Quasi:
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Cook. T. (1983) The substantive due process rights of
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Coval. T.E. (1983) Clites J. Campeeli (1982). Behavior
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Coval. T.E. (1983). Romeo V. Youngberg Personal Liability
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The LawL 1983 (pp. 49-60). University of
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DiFabio. S.. & Ackerhalt. E.J. (1978). Teaching the use
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Dix. G.E. (1987). Legal and ethical considerations in the
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Doerner. K. (1981). ‘Mggggg and the Bourgeoisie. Oxford:
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Flaherty. J.A. (1980). Measuring racial bias in inpatient
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Garritson. S.H. (1983). Degrees of restrictiveness in
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Gove. W.. & Lubach. J.E. (1969). An intensive treatment
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Greenblatt. M.. York. R.H.. & Brown. L.E. (1955). F5211
Custodial Lg Therapeutic Patient Care lg Mental
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Gross. M.L. (1978). The Psychological Society. New York:
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Gunderson. J.G.. Will. 0.Au. and Mosherx L.R. (Eds.).
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256

Gunderson. J. (1986). Defining the Therapeutic Processes
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Gutheil. T. G. (1980). Restraint versus treatment:
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Gutheil. T.G.. Appelbaum. P.S.. and Wexler. D.B. (1983).
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Isacc. S. and Michael. W.B. (1981). Handbook lg figsearch
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Jacobs. 0. (1983). Evaluation and management of the

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Jimenez. M.A. (1987). Changing Faces gj Madness.
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Joint Commission on Accreditation of Hospitals. (1986).
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Kaplan. H.I. and Sadock. B.J. (1981). Modern Synopsis of
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Kesey. K. (1962). One Flew Over The Cuckoo's Nest.
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Liberman. RJL. Eckman. T.. and Phipps. C.C. (1987).
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Miller. K.S. (1976). Managing Madness. New York: The
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Murray. J.T. (1979). Ethical issues in a state psychiatric
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Redmond. FLC. (1980). Study on the Use of the Seclusion
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Roll. M.H. (1985. May). [Testimony Presented to House
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Roll. M.H. (1987). Approach 59 Behavior Management.
Unpublished Manuscript.

 

Roper. J.M.. Coutts. A.. Sather. J.. and Taylor. R. (1985).
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Rosen. H.. and Di Giacomo. J.N. (1978). The role of
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Ryan. W. (1976). Blaming the Victim. New York: Vintage
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Sarason. I.G. (1976). Abnormal Ps cholo : Igg Problem 2:
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258

Soloff. P.H. (1979). Physical restraint and the non-
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Soloff. P.H.. Gutheil. T.G.. and Wexler. D.B. (1985).
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Soloff. P.H. (1987). Physical controls: The use of
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Sense of Place

   

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