Creating a Culture of Care

The STARS Grant

In September 2007, Texas was awarded a federal grant from the Substance Abuse and Mental Health Services Administration for the reduction or elimination of restraint and seclusion in four state mental hospitals in Austin, Big Spring, San Antonio, and Vernon/Wichita Falls. The project was titled State of Texas Alternatives to Restraint and Seclusion (STARS). It used as its template for change a document titled “Six Core Strategies for Reducing Restraint and Seclusion” by Kevin Huckshorn.

Through the STARS grant, Texas was able to realize significant improvements in the culture of care at the state mental hospitals, most notably reflected in reductions in both the numbers of incidents of restraint or seclusion, the numbers of patients involved, and the length of time spent in restraint or seclusion per incident.

The grant advisory committee included representatives of public and private mental health facilities and state agencies with responsibility for people with mental illness, intellectual and developmental disabilities, juvenile and adult criminal offenders, children and adolescents, and adults in state-run residential care. In the process of meeting, it became evident that many of the tools used to change the culture of care and reduce restraint and seclusion in state mental hospitals could be applied in other care settings as well. The findings of the STARS project are applicable to all human service settings, and the toolkit, below, was developed broadly for this purpose.

Single Most Important Project Finding: Trauma-Informed Care

The single most important finding of the project was that restraint and seclusion are emblematic of an approach to care that is based on control and coercion. In such a culture of care, attempts to reduce the use of restraint and seclusion will ultimately fail.

Statistics suggest that most people receiving mental health services have been significantly traumatized, with “trauma” defined as the experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence, and/or the witnessing of violence, terrorism, or disasters (NASMHPD, 2006). The American Psychiatric Association defines trauma as a situation in which an individual’s response involves intense fear, horror, and helplessness, an extreme stress that overwhelms the person’s capacity to cope (DSM IV-TR, 2000).

Further, Dr. Joan Gillece, the director of SAMHSA’s National Center for Trauma-Informed Care, cites the following statistics and many more that substantiate the fact that victims of trauma are found across all systems of care:

  • 90% of public mental health clients have been exposed to trauma.
  • 97% of homeless women with serious mental illness have experienced severe physical and sexual abuse, with 87% experiencing the abuse in both childhood and adulthood.
  • 70-90% of incarcerated girls in the child mental health and youth detention population have experienced sexual, physical, and emotional abuse.
  • Up to two-thirds of men and women in substance abuse treatment report childhood abuse and neglect.

The pervasive underlying influence of trauma on the lives of the people being served and, to some extent, on the lives of the individuals providing care, requires recognition and informed management to reset the value base of care giving. The therapeutic value of services is diminished or negated when delivered in an environment that does not take into account the effect that trauma has on individuals receiving services. The National Center for Trauma Informed Care has a wealth of material that supports the objectives of this toolkit (

The Toolkit

In order to benefit the most people possible, this toolkit has been intentionally designed to be of use in any setting in which restraint or seclusion is used. One of the state’s partners in its efforts to reduce and eliminate restraint and seclusion has been the Hogg Foundation for Mental Health at the University of Texas, Austin. The Hogg Foundation provided valuable support to mental health providers in 2006 by bringing federal experts into San Antonio for a two and a half-day conference on reducing and eliminating restraint in a wide range of settings (including mental health). The Hogg Foundation is now providing similar support for state centers that serve people with intellectual and developmental disabilities and for state-licensed residential treatment centers serving adolescents and youth.

This toolkit is provided in the same spirit—that is, in acknowledgement that the underlying principles of trauma-informed care that are so useful in reducing and eliminating restraint and seclusion are not specific to mental health settings. These principles should have the broadest application possible, especially in view of the fact that individuals seen in one type of care setting are often seen in other types of care settings throughout their lifetimes.

Last updated June 26, 2014