Our Results With CPI: Restraint Reduction and Client Empowerment

June 9, 2016
Two people engaged in conversation in a office

Whenever I ask new Telecare employees arriving at a CPI training for the first time what they anticipate the day is going to be about, the most common answers are a version of “learning physical holds,” “how to stay safe when a client attacks you,” and “how to defend yourself.”

When I ask them again at the end of the day what they are taking away, the answers are very different: “A whole new way of communicating with clients, and each other!” and “How to work effectively as a team so that everyone can feel safe—especially the clients.”

For me, as a CPI trainer, that is the power of CPI—that it can transform perspective through the Training Process.

For 50 years, Telecare’s mission to “provide excellent services and systems of care for people with serious mental illness and complex needs” has been achieved through a wide variety of delivery systems.

Throughout all of these, a unifying culture is grounded in Telecare’s uniquely developed Recovery-Centered Clinical System (a “Power-With” approach rather than a “Power-Over” one). This dovetails well with CPI’s philosophy of using the least intrusive approach available.

At our location in Lakewood, WA, we provide acute psychiatric stabilization services at an in-patient 16-bed evaluation and treatment (E&T) center. Our average length of stay is two to three weeks and well over 90% of our clients come to us initially on an involuntary hold. This typically means that a crisis has occurred in the community and they have come to the attention of first responders and/or a designated mental health professional who has ordered an initial 72-hour hold.

Put more clearly, at the beginning of their stay, almost all our clients do not want to be here.

Understanding what our clients are going through

At the beginning of their stay, our clients are angry, feel disempowered, are in a locked (and nonsmoking) facility, and initially may be disconnected from family, friends, and community supports, who do not know where they are.

As if that wasn’t enough, many are experiencing hearing voices and/or visual hallucinations; they may be having thoughts of harming themselves or others; their thoughts may be largely fueled by fear—seeing the world and people around them as likely to hurt or harm them, leading to terror, panic, and impulsive, self-protective behaviors.

Confusion. Fear. Anger. Desperation. Hopelessness. Self-loathing. Shame. Disbelief.

A sense of having failed.

These make for a potentially explosive mix.

There is a long list of internal (thoughts, feelings, memories, flashbacks, etc.) and external (other people, hospital environment, treatment demands, etc.) factors that can propel someone who is already in a highly anxious state into a set of angry, frightened, and rageful behaviors very quickly.

As a result, we don’t have a designated “Safety Team.”

Instead, all of our staff are trained in every aspect of CPI’s Nonviolent Crisis Intervention® program, including the personal safety techniques and disengagement skills, because any of us may be called to use those skills at any moment.

Or perhaps I should say every moment.

Because every communication is an opportunity to build a safe relationship with another person, and the CPI perspective supports that.

Every #communication is an opportunity to build a safe relationship.

Strengthening our communication skills

Participants in our monthly trainings are often surprised by how much time is spent on communication skills. Almost two-thirds of the material is about engagement, assessment, and verbal intervention. Understanding the dynamics of an evolving crisis means that we can get ahead of it more often than not.

So when I ask participants in a training, “When do we start using our CPI training with clients?” the answer I’m looking for is, “As soon as someone arrives through the front door.”

And we are good at it.

Really good.

I see it happen every day. Our staff work diligently to build rapport with a person from the moment they arrive.

Whether they arrive strapped to an ambulance gurney or in handcuffs accompanied by Department of Corrections staff (a number of our clients are routed from jail to our hospital setting after it’s determined that we’re a better fit for their needs), we greet them as a peer—a fellow human being who happens to be experiencing a life crisis.

From the moment a client arrives, our CPI training helps us more effectively assess how the person is feeling and thinking—and it enables us to respond appropriately so that we neither become the match that ignites the fire, nor underestimate the potential impact of smoldering embers.

Using seclusion and restraint only as a very last resort

Given the acuity of behaviors that we encounter at times, we also have some of the highest levels of legal response available to us to ensure the safety of clients and staff.

These are seclusion (a monitored period of time in a locked, windowed room, where a bed is available for rest) and restraint (the use of specially designed safety straps to restrict someone’s movements while they lie on the bed, to prevent repeated aggression towards others or themselves).

These are truly the last resort, where clients have temporarily lost control of rational thought and safe behavior to such a degree that their freedom of movement is restricted to maintain safety.

Since Telecare opened this E&T in 2012, we have collected data on the use of these most restrictive options. Having a fully-trained CPI staff has significantly contributed to a 68% reduction in the use of seclusion. In that same period, the use of restraints has dropped by over 80%! And we have had periods of up to 12 months at a time when there has been no use of restraints at all.
Having fully trained CPI staff reduces restraint by 68%

Practice makes protocol

Knowing how to assess someone’s emotional state and respond in an appropriate, supportive way; feeling competent and confident enough to support someone “blowing off steam” safely without escalating them into a confrontation; looking to “catch people doing something right” as soon as they begin to calm and to rebuild therapeutic rapport; learning how to set and manage limits effectively to divert someone toward more self-supportive choices—these are skills that we practice not just every day, but multiple times a day.

In the last 12 months, there is one number we have seen increase multifold—the number of clients who initially arrive under an involuntary hold but who then transfer their legal status to voluntary during their stay.

This means that they agree to stay in the hospital voluntarily while they work on feeling better and thinking more clearly.

It returns as much responsibility to the client as possible and puts them in the driver’s seat of their own recovery.

At times during the last year, out of our 16 clients, we have had 10 or more on voluntary status.

There is no doubt in my mind that our ability to work as compassionately, professionally, and safely as possible (and especially during periods of behavioral dysregulation) helps us build trust more quickly with any client concerned, and with others also positively affected by what they see and hear.

It helps someone shift from looking only at “getting out” to getting and staying well.

Our CPI skills run through the tapestry of the complex work that we do in our community, and this translates into greatly enhanced Care, Welfare, Safety, and Security℠ for our entire workplace community, both staff and clients.

Toby Estler, M.A., LMFT is a licensed marriage and family therapist in both Washington state and California. He has been working at Telecare’s adult in-patient evaluation and treatment center in Lakewood, WA for three years as a Social Service Specialist and in 2014 joined the team of CPI Facilitators, offering monthly trainings to new and current staff. Since starting in the field in 2000, Toby has worked in a variety of mental health delivery systems, including Wraparound, acute in-patient adolescent, community mental health centers, and educational settings. Toby also maintains a private practice seeing clients in person and online. When not working, he’s most likely to be found running trails through the forests, hills, and mountains of Washington.