Recovery in Acute Care
by Maggie Bennington-Davis, M.D., MMM.
Recovery to Practice Highlights April 26, 2012
There is an old medical school adage that says “first, do no harm.” In acute hospital settings, people describe all-too-frequent experiences of fear and panic, loss of control, loss of self-determination, seclusion, restraint, and unwanted medications. Inpatient units can seem downright dangerous, not only to those hospitalized, but to staff as well. Before healing can occur, people must feel safe.
During my tenure as the medical director of psychiatry at Oregon’s Salem Hospital, I was part of the miraculous transition to a trauma-informed environment. Seclusion and restraint were eliminated, and there was a substantial decline in the administration of involuntary medications (as well as a 30 percent decline in the use of routine medication). People became more involved in psychoeducational groups and therapeutic exchanges with staff. Injuries sustained by staff and those hospitalized dropped dramatically, lengths of stay decreased, and financial performance improved. It was a wonderful example of parallel process-recovery for those coming into the hospital and for the hospital itself.
Recently, I had a phone call from a psychiatrist who specialized in organizational consultation. He asked me, “After you quit doing restraint, what did you do when someone was really upset and out of control?”
I had to pause before I answered, because there wasn’t a simple way to respond. Staff in the program were never told not to use seclusion, restraint, medication, or other means of control. Restraint went away because it was no longer necessary, not because it was “banned.” If a situation required restraint or seclusion to prevent serious harm, appropriate measures would be taken. But the environment had drastically changed, and those situations didn’t occur very often.
We included the people we served as we began our transformation and philosophical shift. We immersed ourselves in understanding the neurobiology of trauma, fear, fight-or-flight response, and the realization that traumatized people perceived our clumsy attempts at “safety” as predatory and controlling. We were astonished to learn virtually everyone who came (or was brought) to us had suffered through difficult childhood experiences. It humbled us to think about our past reactions to these folks and the pejorative language we had used to explain what suddenly seemed like perfectly rational behavior (manipulative, aggressive, help-seeking, belligerent, difficult, etc.). Suddenly, power struggles made a lot of sense, disengagement seemed self-preserving, and the minor events that precipitated catastrophic reactions didn’t seem so minor after all. When we changed the lens to one that was trauma informed and started asking “What happened to you?” instead of “What is wrong with you?”, everything else changed too.
In essence, when we changed ourselves and the hospital to be really, truly “safe,” the people we were serving also felt safe. Independent of diagnosis, symptoms, age, sex, or history, we were by far the most significant variable.
Then the fun really began. We started using our environment to regulate certain physiological responses of people at the hospital. We used drumming techniques to normalize heart rates, music to soothe, colors to evoke calm, and artwork to inspire (instead of posted rules forbidding balloons and knives). We asked ourselves and those we were serving, “What helps us feel safe?” The answers were friendly greetings, calm voices, beauty in our surroundings, constant information, sharing meals, and talking openly about upsetting events. We changed our language, our assumptions about recovery, and our expectations, and made a point of including families and friends. We educated ourselves about customer service. Putting people’s fears to rest as soon as possible became our business.
We also realized that staff interactions completely set the tone for everyone else, so we became mindful about communicating and working with one another.
Dr. Sandra Bloom, creator of the Sanctuary Model, taught us how to hold daily community meetings to discuss safety with those we were serving as well as staff (doctors, administrators, janitors, cooks, security, etc.). The twice-daily meetings became the anchors of our serenity. If something happened that shook our sanctuary, we spent the next community meeting determining how to return to safety. We knew when something frightening happened to one person in the community, everyone was affected.
Every now and then, we still experienced an upsetting event. I will never forget the woman who repeatedly banged her head against the hospital wall. She had been restrained many times before, always to keep her from harming herself. We mulled over how we could help her in our new environment. In a community meeting, another hospitalized woman told the newcomer, “Honey, when you bang your head like that, it hurts my head.” The group suggested we move the bed to the center of the room, away from the walls that facilitated her head banging. Finally, the banging stopped and the woman began to heal.
There was the man who paced the unit’s perimeter, talking frenetically to himself and occasionally banging his fist on the wall. During a community meeting, folks who had been in the hospital for a few days kindly told him they were frightened of him. He looked shocked and apologized, saying he would never hurt anyone. His pacing stopped, his fear and anger seemed to subside, and he began to pursue the opportunities we offered to support his healing process.
We learned to have a different threshold for upsetting behavior. Staff were constantly encouraged by managers to do what was necessary to keep things safe, but the word “safe” became much more inclusively defined. Our staff created an environment where everyone really did feel safe, and the outbursts, anger, and violence mostly melted away.
All of these changes created completely different roles for staff-jobs that focused less on maintaining order and policing the unit, and much more on healing and partnering with people to initiate and support their recovery journeys. The transformation exemplified recovery more than any treatment plan I have ever witnessed. It was truly a highlight of my career.
Dr. Bennington-Davis is the Chief Medical and Operating Officer at Cascadia BHC in Portland, Oregon.