Seclusion and Restraint Reduction through Graded Exposure

Aim

The aim of the Seclusion and Restraint Reduction Program (SRRP) is to safely reduce the use of seclusion and restraint through application of Cognitive Behavioural Therapy (CBT) (exposure) by an Individual Support Team (IST).

Outcomes

Compelling outcomes regarding the success of the IST’s implementation of this intervention have been illustrated when comparing the baseline phase (January – March 2024) to the intervention implemented by the IST phase (April 2024-March 2025). A significant reduction in seclusion for three patients, and steady reduction in seclusion for the fourth patient is a clearly demonstrated measure of success. Convincing results of the intervention’s success in reducing use of mechanical restraint has been demonstrated. From July onwards, only three months into the intervention, use of mechanical restraint ceased for two of the three patients who initially required this safety measure when trialling time out of seclusion due to risk of violence (fight response) to others.

Background

The seclusion of patients at Authorised Mental Health Services in Queensland is to be used as a last resort to contain a person’s risk of harm to self or others. Prior to use, less restrictive interventions should have been either unsuccessful, inaccessible, or unfeasible. When required, seclusion is authorised under The Mental Health Act 2016 and is to be used for the shortest duration and lowest frequency possible (Reilly, 2021). Within the High Security Inpatient Service (HSIS) of FSS four patients require ongoing long-term seclusion due the chronic and complex nature of their illness and associated risk of violence.

These individuals with treatment-refractory psychosis and a history of long-term seclusion display strong fight/flight responses when faced with novel or unfamiliar interpersonal and environmental situations. One such situation is when ward access is offered or required; these patients experience overwhelming anxiety symptoms at the point of exiting their rooms (a place of relative safety). Common anxiety symptoms such as increased heart rate, muscle tension and feelings of lack of control, are appraised in a paranoid manner, often resulting in violence to others (staff) and need for further seclusion, thus perpetuating the cycle of anxiety through avoidance; the individual patient has not had an opportunity to gradually confront their feared situation and test unhelpful beliefs. Published clinical practice guidelines report that Cognitive–Behavioural Therapy CBT for psychosis (CBTp) has emerged as an evidenced based treatment used in addition to pharmacotherapy to reduce the distress and disability associated with residual or persistent psychotic symptoms (Galletly, Castle, Dark, et al., 2016). Furthermore, Clinical Practice Guidelines for the treatment of anxiety disorders recommend the combination of CBT and pharmacotherapy (Andrews, Bell, Boyce, et al., 2018).

Additionally, the Australian Psychological Society (APS) have reviewed the literature and have published an evidence-based psychological interventions document recommending the use of CBT for the treatment of Psychosis and CBT (exposure) for the treatment of anxiety disorders (APS, 2018). Over the years many attempts have been and continue to be made to assist the four patients introduced above to progress safely out of seclusion. Treatment planning has historically prioritised pharmacotherapy and electroconvulsive therapy (ECT) with adjunct psychosocial therapies provided by the MDT. In practice, the workplace culture and treating team structure lends itself to largely prioritising the provision, review and reporting of pharmacotherapy to patients. With consideration of the published research and clinical practice guidelines clearly recommending the use of CBT in combination with pharmacotherapy to treat symptoms of both psychosis and anxiety, a knowledge practice gap was thus identified. The formal identification of this knowledge practice gap was timely due to the publication of Queensland Health’s Better Care Together plan (Queensland Health, 2022). This five-year plan focuses efforts on priorities including “reduce the use of restrictive practices"

Discussion

The IST functions to address previous challenges in reducing use of seclusion and restraint  in the High Security Inpatient Service through directly enabling capability, opportunity and motivation of the workforce to implement an evidence-based Cognitive Behavioural Therapy (CBT) (Graded Exposure) intervention.

• The IST:

1. has the knowledge of the  Graded Exposure intervention and the skills to implement it (capability)
2. is a dedicated resource to allow consistent opportunity for implementation of the evidence informed Graded Exposure intervention
3. allows for new habits and motivations to be formed by clinicians while engaging in reflective practice with the patients.

• The Graded Exposure intervention implemented by the IST is resulting in reduced use of seclusion and restraint. This is being achieved safely through the process of habituation and due  to increased relational security.
• Patients are experiencing an improved quality of life and are continuing to work towards their personal goals on their exposure hierarchies.

This translation of evidence-based knowledge into practice is indeed advancing  workforce development and provision of least restrictive mental healthcare for consumers who previously required protracted seclusion in a high secure mental health facility. Robust practice-based evidence has resulted; a dedicated team can effectively implement  a graded exposure intervention to safely reduce, and more recently cease, use of seclusion and restraint. Furthermore, data illustrating the reduction in RiskMan and/or staff assault directly refutes any concern that reduction in seclusion/restraint will increase  such incidents. The Graded Exposure intervention is resulting in reduced use of seclusion and restraint through the process of habituation to the open ward.

References

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