By James Rioux
The reduction of patient seclusion and restraint is a national safety goal in psychiatric facilities, both private and public, including at Bridgewater State Hospital (BSH). Over the past year and one half, BSH embarked on a program of reducing seclusion and restraint in compliance with legal mandates through policy changes in a collaboration between security and clinical staff and external stakeholders to effect this goal by: training in trauma and de-escalation techniques; increasing our crisis coverage; developing individualized de-escalation plans for each patient; and the re-purposing of areas to create therapeutic options on each unit called Quiet Rooms equipped with de-escalation items. One particular BSH program has made tremendous progress in meeting this national safety goal. The S.T.E.P. (Specialized Treatment and Education Program) has recently published promising results in increasing patient participation in unit and off unit groups, improving patient medication compliance, and ultimately decreasing episodes of patient seclusion and restraint.
S.T.E.P. was originally developed in September 2014 as a Joint Commission initiative to address an identified treatment gap for patients transferring from the maximum and minimum units. It was discovered through this process that the majority of patients transitioning from maximum to minimum units were unable to effectively manage the routine of living in a dorm setting, attending multiple unit treatment groups, and completing all activities of daily living independently. S.T.E.P. was created to assist these patients with their transition to less secure units and to less secure settings e.g. Department of Mental Health hospitals, traditional penal settings, and traditional minimum units.
Through a highly individualized and graduated four step incentive program many of the patients who have historically been managed in the maximum units of the hospital are now adjusting to the expectations of the unit team. As S.T.E.P. patients graduate from one step to the next their incentives increase. Newly enrolled Step 1 patients who are beginning to learn about the expectations of living in a minimum unit may earn additional outdoor time for demonstrating behavioral control while patients who have graduated to Step 2 will have an opportunity to attend off unit groups, spend more time in the Commons building where leisure and recreational activities are offered, and will spend less time restricted to their unit. As patients progress through the steps, their expectations increase. For instance, Step 3 patients will be expected to transition from a single room to a dorm setting, which is typically the most challenging obstacle to overcome and a decision that requires much clinical discussion. Finally, Step 4 has the highest expectations for patients and resembles a traditional minimum unit experience. A unique component of Step 4 is the expectation that the patients will become mentors to the newly enrolled S.T.E.P. patients.
According to Dr. James Schrage, Psychologist and Unit Director, the success of the S.T.E.P. program is attributed to the specialty groups offered by a multidisciplinary team of activity therapists, clinicians, and psychologists. As the patient progresses through the steps more treatment intensive groups are added. Life Skills, Mindfulness, Competency Restoration, and Cognitive Behavioral Therapy (CBT) are just a few of the groups offered to patients that help them to progress through the program. Out of the fourteen patients who have participated in the program to date, seven have been successful in transferring to a less secure setting and only one patient has been returned to a higher security setting. Of the six patients who remain in the program, all have been compliant with their prescribed medication and are engaged in treatment. Lastly, there has been a 79% reduction in the use of seclusion and restraint in patients enrolled in the program.
The BSH community congratulates Dr. Schrage and his colleagues, for helping patients obtain the skills they need to effectively transition to minimum settings, and for bringing BSH one ‘S.T.E.P.’ closer to meeting our national safety goal. Dr. Schrage is a Beyond Excellence Award recipient for 2015.