|
DMH proposes
regulations for negative behavior
(June
2005 Issue)
By Phyllis Hanlon
The Massachusetts Department of Mental Health (DMH) recently proposed
regulations restricting the use of negative interventions as consequences
for certain behaviors.
The suggested changes oblige facilities to limit sanctions including
loss of privileges or separation from a group or an activity. All
negative consequences are to be fully detailed in a patient's treatment
plan and should only be implemented following unsuccessful attempts
to employ positive behavioral supports. Corporal punishment, infliction
of pain, physical discomfort or food or sleep deprivation is prohibited.
Finally, the use of restraints or seclusion is not allowed. The
proposed regulations focus on positive and supportive behavioral
interventions that will promote a patient's self-esteem and sense
of accomplishment in accordance with that individual's needs, personal
history and ability.
According to DMH Chief of Staff Lester Blumberg, the proposed regulations
are an attempt to regulate and narrow the circumstances in which
negative consequences are imposed on psychiatric inpatients. "Without
regulation, we hear about inappropriate uses of negative consequences
only if complaints are made," he says. "By explicitly requiring
that behavioral support plans be consensual and positive and by
allowing limited negative consequences only after documented failure
of positive reinforcement, we are sending a clear message that consequences
such as restriction of privileges cannot be imposed arbitrarily
and without oversight."
Toby Fisher, MBA, MSW, executive director of the National Alliance
for the Mentally Ill of Massachusetts (NAMI), says, "Any time restraint
and seclusion is used, it is a treatment failure. All other interventions
should be tried first and only in the most desperate and life threatening
circumstance should restraints or seclusion be used." He adds that
NAMI commends all efforts to eliminate the use of coercive methods.
"With the advent of better treatment and recovery, there is great
hope for the future," he says.
Cambridge Hospital has led the way in implementing positive behavioral
interventions. According to Chris Pagano, Ph.D., staff psychologist
and Coordinator of Psychology Training, Child Assessment Unit, restraints
and seclusion are avoided whenever possible. Since Nov. 2001, the
hospital has not utilized any mechanical restraints. "Our whole
philosophy is built on the child's need for nurturance. We get to
know the children and develop relationships," he says. Using a collaborative
approach, staff members work with the children to identify and understand
triggers and build skills to regulate emotions and behavior, Pagano
explains.
In past years, the use of physical restraints could be attributed
to "received wisdom," Pagano says. "In some ways, it is a natural
response to be afraid and want to contain the potential for danger."
However, in such cases, staff missed the psychological impact on
the patient, he adds. Pagano has seen both positive and negative
interventions in his 20-year hospital experience and believes the
type of intervention underlies the importance of a patient's relationship
with caretakers.
Cambridge Hospital does not practice a "level system" of consequences,
except when safety issues are paramount, according to Pagano. Staff
attempts to engage children who become agitated rather than immediately
confine them to their rooms. "The staff will sit with or be near
the child," he says. "They let them know they're available to help
them figure out what is bothering them." He states that the facility
makes an "allowance for children to get physical affection" from
the staff. "We try to reach them at an emotional level," Pagano
says.
Pagano views the DMH efforts to implement statewide guidelines
on limiting loss of privilege as a positive step. In the absence
of such parameters, staff might miss the point of teaching the child
skills to develop self-control, he asserts. "Too much focus on taking
away privileges overlooks the psychoeducational aspect of the experience,"
says Pagano. He adds that privileges should be used as encouragement
and incentive rather than punishment.
The public is invited to comment on DMH's proposed regulations
(DMHRegs@dmh.state. ma.us, proposed regulations can be found at
the DMH home page). Blumberg says, "We are currently reviewing the
comments we have received and will be making decisions on whether
to revise the proposed regulations before promulgating them."
|
