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Unlock the doors

July 1, 2009
by Lori Ashcraft, PhD, William A. Anthony, PhD, and Patty Blum, PhD
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Residential programs can truly transform by taking this step

Many of you have heard us express our opinion, either in person or in this column, about seclusion and restraint (For example, see http://behavioral.net/ashcraft1208). We don't like them. They significantly impede recovery by robbing people of self-worth. Seclusion and restraint send a message to people that they are dangerous and out of control. They reinforce the staff role of managing and controlling instead of inspiring and supporting. Seclusion and restraint are an easy target because they are so obviously not a part of the recovery process. The actions involved often are violent, both for staff and for the person who is trying to recover.

In this issue's column we are not carrying on much about seclusion and restraint. We are moving on to a close relative-locked residential care, a less obvious and more insidious practice. This column may make some of you mad, but we need to shine the light on the thousands of people who spend long stretches of their lives behind locked doors.

Can you imagine how hard it must be to relate to your strengths when everything around you reflects your weaknesses? A locked setting silently tells people they are either dangerous to others or to themselves, or both. This is not a confidence builder. It often is internalized as “self-talk” and quietly erodes the strengths needed to recover.

If we were locking up only a very few people on whom we had tried everything else many times, and this was the only way to keep them and others safe, we could go along with that for a few minutes. But, dear friends, this is not the case. We are locking up way too many people for way too long. Are we doing this for our own convenience and at the expense of their recovery?

Why the doors stay locked

At least the practices of seclusion and restraint, while revolting, are relatively quick. Being locked up in a residential facility can be part of one's life for years. Why would we ever lock anyone up, especially when we now know that it interferes with recovery? Well, here is a list of the usual “reasons” we are given:

“It's cost-effective. We can hire fewer staff if we lock the doors.” This is a really dumb concept. Locked doors and fewer staff translate into longer stays for most people, which in the long haul costs all of us, especially the person locked up, a lot more. Later in this column our friend Patty Blum, PhD, vice-president of Crestwood Behavioral Health in California, expands on this topic.

“There is no other way to manage some people.” This response reveals a real lack of trust in staff, who are capable of coming up with a lot of creative and motivating ways to inspire people to react appropriately. It also reveals a real lack of trust in the person's ability to respond, when inspired, to use new ways of dealing with frustration and pain. Come on, people. We are capable of doing much better!

“The conservator, doctor, or parents want the person locked up.” Let's stop hiding behind what others less familiar with recovery request of us. If an authority figure requests a lock, recommend against it as soon as you can. Request permission to move the person to an unlocked setting soon after admission.

“We want to keep the person safe.” Locking someone up may keep them physically safe for the moment, but it will eat away at their self-efficacy. So while we keep his body alive, we are killing his spirit. Is this what we should consider “safe”? We think not! A person can be kept safe in many ways without eroding their spirit.

Imagine how things would change if all the civil units in state hospitals were unlocked or if each resident had his/her own key. Think of it-states actually setting a good example! Have you been in a state hospital lately? We visited one a few weeks ago and wondered why in the world people were locked in there behind uniformed guards, high razor-wired fences, and sophisticated locking systems. Most people in state hospitals these days are pretty calm and don't seem to be hatching any devious escape plans. Unlocking, or giving everyone a key, would significantly change the culture and the people locked in, including the staff, who would need to draw on their best skills to make things work out.

Patty's insight

What if we unlocked all the locked residential programs? Some are more restrictive than state hospitals ever were, yet we call them “community treatment.” We asked Patty this question and, if you know Patty, her response won't surprise you. She is a passionate believer in recovery and for the past 29 years has worked hard to bring recovery opportunities and environments to Crestwood's programs. Here's what she has to say:

“There has been so much opportunity for system transformation throughout the mental health system, yet residential services have experienced little to no evolution. In fact, most people don't seek residential services. The choice is not even theirs to make. They are ‘placed.’

“‘Placing’ people in residential programs often means they are removed from their local community, far from their families, their friends, their faith communities, and their support systems. The people who are integral to their recovery are unable to visit and support the recovery process. For many the only visitor is their conservator or case manager, who is usually the person responsible for placing them involuntarily in the setting. Soon they are forgotten by the community that they once lived in and should be thriving in.”

We asked Patty to describe the typical environment of these unchanging locked facilities. What is it like behind those locked doors? She unblinkingly tells the truth: