Sanctuary in a State Hospital - Lyndra J. Bills, M.D.

  Bills and Bloom, From Chaos to Sanctuary

  Bills and Bloom, Trying Out Sanctuary the Hard Way

State Hospital: The Situation

• 2 psychiatrists for 250 patients
• 24 women on the unit, all involuntarily committed.
• 25% hospitalized for six months to four years
• 25% for more than ten years
• Average age was thirty-eight.
• 50% of the patients had a high school degree or equivalency and two had Master’s.
• 75% schizophrenia, 10% mood disorders, 10% personality disorders and 5% with dissociative disorders
• No therapeutic program
• On the average there were >100 reported violent episodes per month, which included violence to self, others, and accidents.
• But this did not take into account the hundreds of other violent incidents and threats that did not get reported,
• Only the most severe incidents were worth the trouble of filling out the inevitable and time-consuming paperwork.

 State Hospital: Results

• Rediagnosed 60% of those carrying a schizophrenic diagnosis and of these, 50% met criteria for post-traumatic stress disorder or a dissociative disorder.
• Violence greatly reduced
• A striking salute to the effectiveness of the trauma-based approach was the month of October, 1994 in which no seclusion and restraint was used.
• This was a first in the history of the institution

 Five Years Later

• Five years after LJB left, one of the original patients had died, but only one remained in the hospital.
• All the rest have been discharged and in that five year period had not been readmitted.
• The dissociative identity disorder patient who had consumed so many months of two-to-one supervision was released from the hospital thirty months after her admission and at least two years after discharge had not self-harmed, been suicidal, or been rehospitalized.

Sanctuary in a General Hospital Psychiatric Unit, Salem Hospital, Salem, Oregon - Maggie Bennington-Davis, M.D.,Former  Medical Director; Timothy Murphy, M.S., Former Administrative Director

Description of the Salem Hospital implementation process

Powerpoint about the Salem Hospital experience

Creating Sanctuary: Toward the Evolution of Sane Societies

 Salem Hospital, Salem, Oregon

•  Acute Care Inpatient,

•  24 Bed, Locked Unit

•  General Adult & Geriatric Population

•  60% Involuntary / 40% Voluntary Admissions

•  866 Admissions Per Year

•  8 Day Average Length of Stay

•  Diverse Staffing Mix

Vision

• Promote Best Practices in a Compassionate Environment

• Provide Non-Coercive, Collaborative Treatment,     Neutralizing Power and Control

• Provide a Healing Environment that Promotes Patient Involvement

• Elimination of Seclusion & Restraint

 Beginning the Journey of Change

• Administrative Leadership

• Physician Participation and Leadership

• Received Input from Patients & Families

• Nationally Known Mentor Leaders: Drs. Bloom, Frese, Minkoff, Amador & McGorry

• Staff Education

 Multiple Contributions

• Bloom, M.D.:    Sanctuary

• McGorry, M.D.: Early Psychosis

• Minkoff, M.D.:  Co-occurring disorders

• Frese, Ph.D.:    Experience as a patient

• Amidor, M.D.:   Partnering with patients

 The Road To Success

• Promotion of a Non-Violent Community

• Leveling of Hierarchy (eg, Community Meeting, Visitor   Access, Dining with Pts)

• Change in Physical Environment

• Promotion of Community and Safe Environment (eg, Social Cues to Maintain Safe Behavior)

• Frequent Community Meetings

• User Friendly Admission Process

• Staff Awareness of Trauma Associated with Seclusion and     Restraint

• Promotion of Respect and Dignity

 Sanctuary

• Before people can engage therapeutically, they must feel safe

• People behave in response to their environment

• People live up to others’ expectations

• People will respond to a safe and nonviolent community

 Community Expectations

• This is a place for people in life crisis, a place of treatment and hope.  Violence in any form, whether directed at yourself or others, physically or verbally, hurts the community and adds to life crisis. 

• Everyone shares in the responsibility of community safety.  It is expected that you will respect the rights of our community and keep yourself and others safe.

• If there is injury to anyone or damage to property, such violence will be reported to authorities.

 Salem Hospital Nonviolence Statement

• Salem Hospital is a place to heal.  To be a healing place, there are certain expectations of everyone in this community.

• One of those expectations is that we all will work to keep this a nonviolent environment.

• Violence includes:

  • acts of hitting

  • verbal abuse

  • bad language

  • threats of violence

  • hurting yourself

  • making anyone a victim of these behaviors in any way

• With this expectation, then we all can make this a safe place that has a sense of security and trust.

 Salem Hospital Psychiatry Community Statement - (Created by our Patient Partners)

• This is a community.

• We are all here to participate.

• Successful treatment involves listening, empathy and finding areas where we can  work together.

• This partnership will help us to set and achieve measurable goals. 

• The patient is the most important member of the treatment team.

• This community shares some beliefs about people that include:

• We want to learn new ways to improve.

• It is important to know that some of us have experienced trauma and continue to suffer its effects.

• To recover, we must be honest with ourselves and others.

• We are all doing the best we can.  At the same time, we hope to get better.

• We may not have caused all of our own problems, but we are responsible for the solutions.

• We are here to learn new ways to cope.

• By being here in treatment, we are already taking responsibility for our success.

• As a community, we all need support and validation.

• If we all follow these basic beliefs, respect one another, and treat others as we wish to be treated, then we may begin to heal.

 What We Learned Along the Way

• Pace the Changes Wisely

• Constant Staff, Patient and Family Involvement

• Intensive Support for Staff

• Continuous Staff Education

 Results

• 97% Decrease in Seclusion, 100% decrease in restraint

• Decreased Staff Injuries (Fewer Employee Health Visits, Fewer Worker’s Comp Claims)

• Increase in Patient Satisfaction

• 39.8% Increase in Annual Admissions

• 1/3 Decrease in Use of Emergent Medications

• Overall Slight Decrease in Antipsychotics

• Overall Slight Increase in Benzodiazepines

• Improved Staff Morale

• Increased Family Involvement

• Low staff turnover, 98% of all nursing staff positions filled

Sanctuary in Residential Childcare Settings:

Trauma-Focused Intervention Targeting Risk for Violence

The research is funded by the NIMH though the R21 funding mechanism (developmental research), under a RFA for research on interventions for youth violence. Primary Investigator - Jeanne Rivard, Ph.D.

Research Site - Hawthorne-Cedar Knolls, Linden Hill School, Goldsmith Center, Jewish Board of Family and Children's Services, Center for Trauma Program Innovation,New York, New York 

Project Summary

• The research examined the implementation and proximal effects of an intervention designed to reduce trauma-related symptoms of youth that place them at risk for violent behavior, poor adjustment, and serious mental health difficulties. 

•  The Sanctuary Model, developed by Sandra Bloom, M.D. (1997), is composed of two primary components:

  • Creation and maintenance of a non-violent, democratic, therapeutic community

  • Psychoeducation exercises and modules

The Children

Previous studies of population (Guterman & Cameron, 1999; Guterman, Cameron, & Hahm, 2000) 

• 66.9% of youth had a known history of child maltreatment (31.9% neglect, 37.3% physical abuse, and 20.5% sexual abuse)

• 19.5% reported to have witnessed domestic violence

• 30% entered the residential programs from a psychiatric facility

• 30% came from other residential, group, or foster home care

• 20.5% came from their own homes or another setting in the community

• 62% were diagnosed with attention deficit and disruptive behaviors;

• 11.2% had psychotic disorders

• 14.3% had adjustment disorders, mood disorders or other disorders

 Design

• Random assignment of twelve residential units

• (n = 150 youth; n = 96 staff) to: 

• Sanctuary Model versus Standard Residential Services. 

 Demographics and Background

• N = 111: Sanctuary Model (SM)= 48; Standard Residential Services (SRS) = 63

• Mean age 15.4 years; in SM 15.0 vs SRS 15.7

• SRS 73% male; SM 62.5% male

• SRS 44.3% black; SM 60.4% black

• SRS 39.4% Hispanic; SM 27.1% Hispanic

• Average of six less-restrictive community-based placements, average of three previous psychiatric hospitalizations

•  Sanctuary Model children had significantly higher mean number of foster care placements 3.9 vs. 2.6

• 34.2% substantiated physical abuse

• 12.6% substantiated sexual abuse

• 45% substantiated neglect

• Across types, 70% of youths had experienced at least one incident of abuse or neglect.

• Exposure to Violence

• 84% witnessing someone being hit, slapped, punched, or beaten up

• 73% directly experiencing being hit, slapped, punched, or beaten up

• 42% seen someone attacked with a weapon

• 23% have been attacked with a weapon

• 11% shot at

• 69% hearing gunfire close by

• 10% rape, molestation, sexual assault

Sanctuary Research
Child Measures (baseline & 6 months, N=87)

• Decreased verbal aggression (significant trend) Imagine that you’re in line for a drink of water.  Someone your age comes along and pushes you out of line.  What would you do?; You see your friend fighting with another person your age. What would you do?

• Increased internal locus of control (significant trend): Are you often blamed for things that just aren’t your fault?; Do you believe that whether or not people like you depends on how you act?

• Decreased incendiary communication and increased tension management (significant difference):  (…..Get angry and yell at people?..…Blame others for what’ s going wrong?.)

 Sanctuary Research (baseline & 6 months) COPES Community Oriented Program Environment Scales

Significant differences in:

• Support: how much clients help and support each other; how supportive staff is toward clients

• Spontaneity: how much the program encourages the open expression of feelings by clients and staff

• Autonomy: How self-sufficient and independent clients are in making their own decisions

• Personal Problem Orientation: the extent to which clients seek to understand their feelings and personal problems

• Safety: The extent to which staff feel they:

  • can challenge their peers and supervisors

  • can express opinions in staff meetings

  • will not be blamed for problems

  • have clear guidelines for dealing with clients who are aggressive.

 Factors That Promote Implementation

• Staff training – the more the better, hands on, didactic and experiential, interactive, diverse, multidisciplinary

• Use of the word “safety”

• Community meetings

• Building in structured times for discussing implementation and team-building

• Proceduralizing use of the psychoeducation tools

• General openness of staff and children to change

• Keeping staff happy and motivated

• Small successes that build enthusiasm and constant reinforcement

• Helping the children to get a broader and deeper understanding of the SELF recovery framework

• Group cohesion among children and staff

• Providing community-level incentives for positive community behaviors

• The presence of therapists and administrators on the residential unit

• Less confusion for children about who the authority figures are

• Sanctuary facilitators perceived as helping in:

• making change happen fast,

• in “breaking the norm”,

• in teaching staff how to incorporate trauma treatment strategies,

• in facilitating implementation through problem-solving

• Leadership

• Leadership

• Leadership

Barriers to Implementation

• Not enough on-going training

• Lack of clear vision of what “ideal” Sanctuary program for children would look like

• Insufficient time to do the constant communication and team-building needed

• Different ways that crises are handled in school and in the residential programs

• Inconsistent training because of new hires, on call, or over-extended staff

• Other Barriers to Implementation

• Perceived lack of, or changing, administrative support and allocation of resources

• Regulatory agencies who may have regulations that are in opposition or a problem for Sanctuary methods, i.e. working through child accusations of staff.

• When the entire organization is not yet committed to Sanctuary methods

Sanctuary in Residential Childcare Settings

W. McSparren: Models of Change and the Impact on Organizational Culture in Nonprofit Agencies: Comparison and Validation of The Sanctuary Model ®

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