The question for META Services was how does an agency overcome these challenges and develop a crisis service that is consistent with a recovery orientation? META Services developed a training and organizational change manual that details these strategies (
26 ), and this manual was used to guide the transformation of the crisis centers. The specific strategies developed by META Services are very similar to the seclusion and restraint reduction strategies developed independently of META Services by the National Association of State Mental Health Program Directors during approximately the same period (
27,
28 ), and they also seem consistent with the Pennsylvania initiative to reduce seclusion and restraint in the state hospital system (
23 ). None of these seclusion and restraint initiatives has examined individual strategies to determine the unique effects of each. However, many of these strategies are similar in intent. The specific strategies developed by META Services that are consistent with other independently developed seclusion and restraint initiatives included strong leadership direction, policy and procedural change, staff training on specific issues, consumer debriefing, and regular feedback on progress.
Strategies
Strong leadership direction. The president and chief executive officer (CEO) of META Services, Gene Johnson, M.S.W., met with staff and very clearly and strongly informed them that META Services would no longer be using seclusion and restraint. This was a huge culture shift for META Services, especially because the use of seclusion and restraint had always been seen as a necessary part of its business and was routinely practiced. Staff threatened to quit. Some threatened to call the Occupational Safety and Health Administration, because they believed that the company was putting them at risk. Some claimed that the company didn't care about them anymore. The CEO held his ground. Because his genuine beliefs and concerns were evident, staff had the courage to try eliminating the use of seclusion and restraint, even though many still did not believe it would work (
12 ). At the time of META Services' seclusion and restraint initiative, data from like-minded initiatives were not available (
4,
20,
21 ).
Policy and procedural change. META Services had the usual array of policies and procedures, but as is often typical, they were not routinely used by staff to direct practice. Rather, staff were making decisions based on their personal and professional beliefs and values. Thus the challenge was to find a way to teach staff new values and beliefs about recovery. Then the decisions they made every day could be guided by these new recovery beliefs and values rather than by a procedural rulebook. Any new policies that were developed for any part of the agency were based on the principles that polices and procedures should be value based, not rule based; should be flexible enough to allow individualization; should be person centered rather than business centered; and should be understandable and within accreditation standards.
Staff training on specific issues. At the beginning of the initiative, a new training protocol was developed for staff to overcome the previously identified barriers of fear, hopelessness, prejudices, and negative attitudes. Training lasted for 12 hours, which consisted of a three-hour session each week for four weeks. The CEO participated in training by talking about how the organization itself was recovering. The training package included a three-hour session on the principles of recovery, and then the following three, three-hour sessions developed aspects of the "nuts and bolts" of how to actually put recovery into practice. The training protocol detailed specific ways of assisting people who were experiencing trauma, as well as those who were experiencing issues related to substance abuse. Another strong aspect of the protocol is a section on using the language of recovery in strength-based conversations. Finally, it included ways of building resilience through self-directed treatment planning. Staff were trained in practices that would empower each consumer, instead of having staff striving for compliance and control. Training also emphasized giving consumers as much responsibility as possible for their own lives and behavior as a key to eliminating seclusion and restraints.
The previous training that had been used to train staff in crisis management was continued, but we began to teach it with an emphasis on avoiding crises rather than simply managing them. The emphasis was on immediate engagement and building relationships, instead of control and compliance. Because training in the proper use of restraints is a licensing requirement, this was included in the training. However, it was described as something that should be used only as a very last resort, and use of it was considered a treatment failure.
To counter staff's prejudices related to the possibilities of recovery, stories of recovery were added to the training. People who had been served in the crisis program came back and talked about their continuing experience of recovery. However, adding peers to the team seemed to have the most significant impact on developing positive attitudes toward the possibility of recovery. When staff began to accept peers as coworkers and began to rely on them as a crucial part of the workforce, attitudes toward recovery changed significantly, and the tendency to use seclusion and restraint became more and more remote.
The most powerful message peers brought to people in distress was, "I know how you're feeling. I was once in here as a patient myself." This almost always got the consumer's immediate attention, and from there a conversation that was relevant to the consumer's perspective followed. Focusing on hope seemed to help people hang on to their strengths instead of falling further apart.
Debriefing. Included in the training was the viewpoint of the consumers who were using the crisis centers, particularly the perspectives of those who had experienced seclusion and restraint. Consumers were asked what staff could have done to avoid restraining them, what the consumers themselves could have done to avoid this, and what staff could do in the future to keep this from happening. For example, staff learned to listen closely to people and to give them what they were asking for whenever possible. This kept staff from getting into power struggles over relatively meaningless issues like cigarette breaks, phone calls, and space to pace. The information that staff learned from people who had previously been restrained was used to develop META Services' crisis intervention and deescalation training manual, which is currently available from Recovery Innovations (
26 ).