Severe Mental Illness and NVC

Intention

The intention of this page is to look at the use of NonViolent Communication (NVC) for treatment of Severe Mental Illness

NVC in an Intensive Treatment Unit

Table 1: Reduction in Seclusion and Restraint Hours

Since revision of Intensive Treatment Unit programming in March 2004 Riemer,D. and Corwith, C. (2007) report the introduction of NVC into the Intensive Treatment Unit (ITU) ,at Mendota Mental Health Institute in Madison, Wisconsin , a 21 bed medium security forensic unit. Riemer introduced a number of changes on the unit that added structure and calmness and utilizing a treatment team approach that facilitates partnership with the patient rather than control. They reduced the need for Seclusion and Restraints by using core strategies which included teaching patients how to meet their needs using therapeutic Nonviolent Communication (NVC) skills. Role playing, a NVC technique, was a major part of the staff education and training.

The use of these strategies, which included teaching NVC to patients and staff reduced the number of ITU seclusion and restraint hrs from 92 to 4 over a four year period. (see fig on right). It also reduced the number of seclusion and restraint incidents from 33 per yr to 2.0 per yr over the same four year period.

Management and Treatment Unit at Mendota Mental Health Institute

Table 2: Decrease in violence indicators after introduction of Sanctuary Concept and NVC
from Riemer, D. Creating Sanctuary: Reducing Violence in a Maximum Security Forensic Psychiatric Hospital Unit, On The Edge - Spring 2009

The Management and Treatment Unit (MTU) is a 14 bed unit that provides treatment to the most acutely civil and forensic male patients in need of maximum security at the Mendota Mental Health Institutein Madison Wisconsin. It provides treatment for patients with a history of aggression. In Aug 2007 the MTU team decided to revise its ways of treatment to reduce violence. The first step was to achieve a common agreement as to the meaning of the word “violence”. The meaning was extended to include passive and non verbal violence in addition to the usual verbal and physical violence . It was finally defined to mean “behavior that increased the acuity of the unit’s environment and threatens sanctuary”. NVC training was given initially to staff and eventually used in treatment groups.Several weeks of training in NVC skills were given to patients. De-escalation plans were developed and the concept of a Sanctuary introduced based on Sandra Bloom's Sanctuary Model. After these trainings were given the unit calmed down. After the patients and staff mutually developed their concept of sanctuary, it was implemented basically basically using the methodology of NVC. Riemer (2009) reports that the violence indicators dropped dramatically over a two year period as seen in the accompanying figure. The top bar shows that the number of injuries to staff from agression went down from 13 to 7.The next bar shows that the number of seclusion episodes were reduced from 40 to 20. The number of seclusion hours dropped from 320 to 174.Patients have Individual Emergency Response Plans (ERP) for use in emergency situations. The next bar on the graph (ERP) shows that their use dropped from 7.5 to 6.7. The use of Emergency Codes dropped from 14 to 5. The use of specially trained Emergency Intervention Teams (EIT) dropped from 62 to 32. It is important to note that the usage of Emergency Codes and EIT's declined despite the fact that patients were being managed with less reliance on restrictive measures. Patient grievances against staff also dropped by 54% from 133 to 61. Not only was there a reduction of forcible restraints for the patients, the staff also experienced an increase in safety. The number of lost staff days due to patient violence went down from 135 to 18 and light staff days went down from 41 to 17.

Comparison with CA State Hospitals & Prisons

Table 3: Seclusion plus Restraint and Staff Injury data ordered by increasing Seclusion plus Restraint incidents

is taken from a comparison study of the rates of violence in Psychiatric Institutions. Table 3 shows that the rate of violence in an institution using NVC. the Intensive Treatment Unit in 2007, is 11% of the average rate of violence for all CA State Hospitals and Prisons.

Ventura County,CA Behavioral Health Dept Intensive Psychiatric Unit

Liz Otterbein, R.N. is a certified NVC trainer who has been working in the Intensive Pyschiatric Unit (IPU) for about twelve years on weekends. The IPU is part of Ventura County,CA Behavioral Health Dept and is located at Hillmont,Ventura and has forty-five beds.
She uses the principles of NVC as an anger management technique. As the IPU is a crisis unit for acute care, a number of patients are admitted under a legal hold as they are deemed to be a danger to self or others. They are typically feeling very angry, not only at the situation that initially aroused their anger but also because they have been forcibly restrained by the police and bought into the unit under duress. She incorporates the principles of NVC in her discussions with the patients and, as a result, they calm down very rapidly. Tim's story illustrates such a discussion in which a very angry young man becomes peaceful and starts taking constructive action for himself in about thirty minutes without any use of violence, threats or medications because he is treated with respect, understanding and offered compassion and empathy. Liz labels describes the process she uses as anger management. It is primarily based on the principles and techniques of NVC.

Atascadero State Hospital

Kathi Aichner has written a report on the use of NVC at Atascadero State Hospital which showed that the patients were very enthusiastic about its use.

Books

Melanie Sears has published two books about the use of NVC in Mental Health settings. One is Choose your words, a book describing how NVC is used in a mental health system. The other is Humanizing Health Care with NVC, a book describing how the use of NVC can improve the delivery of mental health services.

References

Aichner,K. NVC at Atascadero State Hospital, personal communication, 2008
Bloom, Sandra Creating Sanctuary: Toward the Evolution of Sane Societies (1997) Routledge
Riemer,D. Corwith, C. Application of Core Strategies: Reducing Seclusion & Restraint Use, On The Edge, 13(3) (2007)
Riemer, D. Creating Sanctuary: Reducing Violence in a Maximum Security Forensic Psychiatric Hospital Unit, On The Edge - Spring 2009
Sears, M. Choose your words, CareInAction (2007)
Sears M.,Humanizing Health Care with NVC, iUniverse, Lincoln Ne, (2006)

Please add any other citations to the use of NVC in Mental Health Settings to this page. If you experience difficulty in adding to this page directly , please e-mail the submission to John Mudie directly.