Comments

May 15, 2008

Ms. Summer King
SAMHSA Reports Clearance Officer
Substance Abuse and Mental Health Services Administration
One Choke Cherry Road, Room 7-1044
Rockville, MD 20857
Dear Ms. King,
Thank you for the opportunity to comment on the proposed Data Collection and Analysis for the Alternatives
to Restraint and Seclusion Grant Program (the SIG). We applaud SAMHSA’s leadership in this area and
look forward to the data and practical information the program will generate for the field.
To be most useful, the data should be comparable with other data collected by SAMHSA as well as across
public and private treatment systems. For example, the pending National Mental Health Services Survey
includes different facility types, ownership categories and licensing information than does the proposed SIG
collection, and also requests accreditation information. Definitions of terms (such as restraint, seclusion,
time-out, coercion) are important not only for consistency across the 21 facilities participating in the SIG, but
also for public and private non-participating facilities which later wish to understand and use the resulting
best practice information. A key point of comparability would be whether all or any of the participating
public facilities comply with federal Medicaid regulations governing the use of restraint and seclusion, as
private hospitals and Psychiatric Residential Treatment Facilities are required to do. More detailed
comments on the three SIG data collection instruments are below.
FACILITY/PROGRAM CHARACTERISTICS INVENTORY (FPCI)
Section I.
Question 1. What does “free standing” mean? Does “Residential Program” include residential treatment
centers (RTCs)? RTCs for children and adolescents are often “free standing,” if that means not physically or
administratively connected with a hospital. If any are participating in the SIG, how would they respond?
Section IV.
The inventory form asks for data per “unit within the facility.” The choices for Age Group include “Adult,”
“Child/Adolescent” and “Both Adult and Child/Adolescent.” Would both adults and children/adolescents
ever be in the same unit?
The choices for Mission are not clearly distinct. Does “Residential Unit” include RTCs for children/
adolescents? How would an RTC identify the mission of a unit with a length of stay of 30 days or less, i.e.,
is it “acute” or “residential”?
Regarding the choices for Policy, are there definitions of seclusion and restraint? Regarding choice 3 (both
seclusion and restraint are allowed) is it assumed that only seclusion or restraint would be used at one time?
If there is a possibility that they would be used simultaneously, that should be an additional and distinct
answer choice.
1025 Connecticut Avenue, NW, Suite 1012 • Washington, DC 20036-3536 • (202) 857-9735 phone • (202) 362-5145 fax • [email protected] • www.nacbh.org

INVENTORY OF SECLUSION AND RESTRAINT INTERVENTIONS
Worksheet 1
1: State Policy
Description. Is there a definition of “coercive measures”? Do the SIGs require that states develop “systems of
care that are trauma-informed”? Is there a definition of “trauma-informed systems of care”?
L.1.2. Is there a description of what is meant by “a policy providing for a program of trauma-informed care”?
Does “program” refer to a facility, a statewide program encompassing multiple facilities and/or services, only
the facilities participating in the SIG project, everything funded by the state mental health authority, etc.?
L.1.5. If the consumer is a child or adolescent, what would “full participation” be? Is there an expectation that
their parents/guardians would “participate”?
L.1.6. Is the risk of imminent harm to self not a legitimate use of restraint or seclusion?
L.2.2. Is there a description of “principles of recovery” related to children and/or adolescents?
2: Facility Policy
L.2.3. What is the referenced “system of care”? Systems of care for children are larger than one facility,
provider entity, type of service, funding stream, etc., such as the CMHS-funded systems of care.
4: Leadership for Recovery-Oriented and Trauma-Informed Care
L.4.A.1. Is it expected that children and/or adolescents would participate in all of these activities? If the
responding facility serves both children/adolescents and adults, but only engages adults in these activities, how
would it respond and how would its response be understood? For children/adolescents, is there an expectation
that parents/guardians would participate in all of these activities? How would that be indicated?
L.4.A.2. What does “informed consent” mean for children and adolescents? Is it expected only from
parents/guardians for all clients younger than the age of legal consent or legal competency in that state?
L.4.A.3. Is there an expectation that children and/or adolescents would have choices of daily living and
treatment activities? If so, to the same extent as adults? How would a facility serving people of all ages answer
this question if it only allowed adults to make such choices?
L.4.A.4. Same questions as for L.4.A.3. One characteristic of residential treatment programs for
children/adolescents is structure, which is not arbitrary but is directly responsive to the client’s clinical need to
be in that level of care, as well as their educational and social development needs.
Worksheet 2
1: Immediate Post-Event Debriefing
Description: Is there a definition of “event”? Regarding the last sentence of the first paragraph, shouldn’t
clients who are in seclusion be monitored?
D.1.3. What is “indirect” input?
D.1.6. “Consumers or staff” should be “consumers and staff.”

There are no review elements related to the participation of the consumer. There are no review elements related
to the participation of or notification to the parents/guardians of child/adolescent consumers.
2: Formal Debriefing Interview
D.2.2. Is there a definition of “credentialed facilitator”?
D.2.10. What does “ASAP release” mean, e.g., what determines “possible”?
D.2.11. This is completely unclear.
There are no review elements related to the participation of the consumer. There are no review elements related
to the participation of or notification to the parents/guardians of child/adolescent consumers.
Worksheet 3
1: Data Collected
U.1.10. Is there a definition of “avoidances/near misses”?
Worksheet 4
2: Training Program
W.2.7. How would “consumer” be defined for treatment programs serving children/adolescents? Instead of or
in addition to “consumers,” is there an expectation that parents/guardians would be involved?
W.2.8. What is meant by “peer support” (whose peers)?
Worksheet 5
2: Emergency Intervention
Description: It is not clear whether seclusion is an emergency intervention.
Worksheet 6
1: Consumer Roles
How is “consumer” defined for treatment programs serving children/adolescents? Clarify which roles are
expected for consumers currently receiving services from the responding treatment facility, and which are
expected for former clients or consumers who are receiving/have received services elsewhere.
2: Family Roles
There is no distinction among “family members.” Clarify which roles are expected for families of
children/adolescents currently receiving services from the responding treatment facility, and which are expected
for family members of former clients or children/adolescents who are receiving/have received services
elsewhere.
3. Advocate Roles
Who are “advocates”? How are they (or are they) distinct from consumers or family members?

SECLUSION AND RESTRAINT EVENT DATA MATRIX
Page 1, Service Recipient – Referral Source. Should juvenile, drug and mental health courts be included? What
is the difference between an outpatient provider and a community-based program?
Page 3, Seclusion: How is “time-out” defined? Also, it is confusing to see it listed as both an example of what
should not be reported (in the third paragraph) and on the list of “other exclusions.”
Pages 4-5, Restraint: There is a list of “exclusions.” Excluded from what? Are these devices and methods
excluded from the definition of restraint? After the list of exclusions is the instruction: “Documentation of the
reason for the use of the restraint must clearly indicate whether these exclusions apply.” If the device or method
is “excluded,” what “restraint” is being documented?
Thank you again for the opportunity to review and comment on SAMHSA’s planned data collection for this
extremely important grant program. We would be pleased to offer the resources of this Association as you
move forward with the development and evaluation of best practices in reducing the use of restraint and
seclusion.
Cordially,

Joy Midman
Executive Director

NACBH represents multi-service treatment agencies providing a wide array of
behavioral health and related services. Services provided by NACBH members include
assessment, crisis intervention, residential treatment, therapeutic group homes, in-home
treatment, therapeutic foster care, independent living, alternative educational services,
respite, day treatment, outpatient counseling and myriad community outreach programs.
Providers serve clients from the mental health, social service, juvenile justice and
educational systems.