Comfort Rooms

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A Preventative Tool Used to Reduce the Use of Restraint and
Seclusion in Facilities that Serve Individuals With Mental Illness

Ideas & Instructions for Implementation

February 2009

Please Note:
While this guide was prepared with child and adolescent treatment sites in mind, this information can be applied to adult and geriatric units as well. Many of these sites have successfully utilized comfort rooms.

Table of Contents

• Introduction An Overview
• Section I What is a Comfort Room
• Section II Brain-Storming Items for Your Comfort Room
• Section III Developing a Comfort Room
• Section IV Evaluation
• Section V Additional Resources

Acknowledgments

We extend our appreciation and gratitude to the Directors, Staff and Consumers at the sites below who provided valuable assistance in the development of this guidebook.

South Beach Psychiatric Center, Staten Island, NY
Hutchings Psychiatric Center, Syracuse, NY
St. Lawrence Psychiatric Center, Ogdensburg, NY
Greater Binghamton Health Center, Binghamton, NY
Woman’s Christian Association of Jamestown at WCA Hospital

We also acknowledge with appreciation the contributions of Paula T. Hennessy, Susan Callaghan, Walter Boppert and Elizabeth Chura in editing and producing this guide.

Introduction and Overview

Background:

The Positive Alternatives to Restraint and Seclusion (PARS) grant was awarded to the New York State Office of Mental Health in August of 2007. The grant provides three years of funding, from the Substance Abuse and Mental Health Services Administration (SAMHSA) through the Office of Mental Health, for the development of strategies to reduce the use of restraint and seclusion in three diverse mental health facilities serving children and adolescents in New York State.

The PARS project will promote efforts to create a therapeutic, trauma-informed culture of healing and recovery that meets the goals of significantly reducing the use of restraint and seclusion; providing mental health services that support recovery and incorporate trauma-informed care; and determining strategies that assist organizations in establishing comprehensive, positive, system-wide alternatives to restraint and seclusion. Part of the strategy towards implementing these changes is providing funding for the development of comfort rooms and calming environments.

This information on calming and comfort rooms was compiled through an extensive literature review, visits to calming and comfort rooms across New York State, attendance at conferences, and interviews with experts in the field. The resulting information has been compiled in this binder for use by the grant recipient sites, as well as other interested facilities, to guide an informed process for the development of calming and comfort rooms.

The purpose of this binder:

This binder provides information to service providers that are interested in developing comfort rooms and calming spaces. It has been compiled to assist in the planning and implementation process.

As you will quickly come to realize, the development of a comfort room (i.e., deciding where to put the room, what to put in it, and developing policies and procedures around its use, etc.) requires an agency wide commitment and an agency specific plan. The location and content of your room and how it will be used should be determined based on the individuals you serve and the resources you have. Learning more about comfort rooms and reflecting on your own population and environment will help you to develop a successful plan.

The information included in this binder should help to get you started; references have been included to help initiate your research if you find it necessary to gather more information. The information has been presented in a three-ring binder so that you can add articles, ideas, sketches, and notes. This binder is meant to stimulate creative thinking. Please do not hesitate to share your ideas with others.

Contents:

Section I provides an overview of what comfort rooms are and how they are used. Part II includes written interviews that were conducted with facilities that have comfort, multi-sensory, and Snoezelen® rooms. Interviewees provided information about the processes their sites used in developing the room. They offered suggestions to take into consideration when beginning the process of developing a calming space. Informative, quick, and easy to read articles have been included in Part III to provide further explanation and background information on comfort, multi-sensory, and Snoezelen® rooms.

Section II can be used to help stimulate creative thinking about what items you might want to consider including in your comfort room. Images, lists and suggestions for the use of specific items have been included. Items have been categorized by the sense (touch, sight, sound, scent) they stimulate. As you browse through these items, begin to think about what you would like to include in your comfort room.

In Section III the process of developing your comfort room is discussed. The first document provides a list of questions to consider as you begin to develop your room. The second is a document developed by Tina Champagne, which can be found in the Sensory Modulation and Environment handbook, and can be used to consider what type of environmental changes you will make in your facility in order to create a more calming and comforting atmosphere. The second part of Section III provides examples of policies that have been developed by facilities in New York State that use comfort, multi-sensory, and Snoezelen® rooms.

Section IV discusses evaluation plans. Participating facilities in the PARS grant initiative will receive funding for the planning, development and evaluation of a comfort room at each of the three sites. This will provide an opportunity to contribute to the field of knowledge about the use of comfort rooms by collecting information at each site. Through the use of evaluation we can document the process of developing policy and shaping opinions about use of the room. This information can then be used by other facilities to develop comfort rooms in the future. Additionally, plans are being made to collect data to show the correlation between use of the comfort room and episodes of restraint and seclusion. It is anticipated that an increase in the use of the comfort room will correlate with a decrease in the use of restraint and seclusion.

Section V includes several additional resources and a copy of the Power Point presentation that can be used to introduce comfort rooms to facilities beginning the implementation process. The Power Point slides are followed by information gathered from articles read. It can be used as a quick reference handout. Additional references have also been included.

We hope this guide will be helpful to facilities by sparking enthusiasm for creating comfort rooms. There is no "right or wrong" way to design a comfort room. The process will be agency specific The only underlying rule for creating a comfort room is that it should be designed in a way that is safe and effective for the individuals using it.

Best of Luck!

Please feel free to contact Paula Hennessy, PARS Project Coordinator, with feedback, suggestions, or any questions you might have.
Phone: (518) 474-0884

This manual was compiled and produced by:
Megan MacDaniel
2008 Fellow on Women in Public Policy, through the Center for Women in Government and Civil Society
January-June 2008

New York State Office of Mental Health, Office of Quality Management
Jayne Van Bramer, Director

Section I What is a Comfort Room?

A comfort room is a designated space that is designed in a way that is calming to the senses and where the user can experience visual, auditory, olfactory, and tactile stimuli. A comfort room is furnished with items that are physically comfortable and pleasing to the senses in order to provide a sanctuary from stress.

A comfort room is used as a tool to teach individuals calming techniques in order to decrease agitation and aggressive behavior. The goal in using the comfort room is to develop practical skills that can be used in inpatient settings and after being discharged from care.

A Comfort Room Is:

• A tool that is used to prevent the use of restraint and seclusion
• To be used at will and not forced upon individuals
• To be used when necessary to avoid episodes of restraint and seclusion- not as a reward for good behavior or a privilege that is taken away as a punishment (unless the individual is unable to use the room safely)
• To be used before the onset of aggressive/uncontrolled behavior

A Comfort Room is Not:

• An alternative to restraint and seclusion
• A seclusion room
• A time-out space
• A punishment or reward
• To be used after an individual has already lost control of his/her behavior

Where is the Best Location for a Comfort Room?

Comfort rooms are often developed in available spaces, such as a room that had previously been used for seclusion or in an unoccupied bedroom.

It is important that the room is located in an area of the facility that is easily accessible to those who will be using it. Often times the comfort room is located near the nurses’ station to afford increased supervision. Some comfort rooms are adjacent to the nurses’ station and connected with a window to allow for supervision.

Sometimes, facilities do not have extra space for a comfort room. They might then develop "comfort kits" and/or "comfort carts" that incorporate similar calming items, but are mobile. These comfort alternatives can also be utilized in addition to your comfort room.

How are items chosen for the comfort room?

Individuals who will be using the comfort space and the staff assisting them should participate in planning the room and selecting the items that will be placed in the room. This encourages ownership and ensures that the room meets the needs of the facility’s population. Rooms developed without the participation of staff and consumers often go unused.

Calming techniques and strategies from patients’ individual calming plans should also be taken into consideration when developing the comfort room.

The type of supervision required for those using the comfort room depends on what type of equipment is in the room. For example, a room filled with specialized equipment may often only be used under the supervision of trained facilitators. Selection of advanced, specialized equipment necessitates that adequate training and staff resources be devoted to comfort room use.

Encouraging direct care staff and residents to use the comfort room:

Approval and support from upper management is important for securing funding and adequate resources for implementation of comfort rooms. It is also important that direct care staff, supervisors and users receive training on the benefits of the comfort room. If direct care staff and residents do not believe in the benefits of using the comfort room, it will not be used. The following information about the use of comfort rooms should be discussed with direct care staff and users:

Benefits of using comfort rooms:

• Provides staff with an additional tool to proactively reduce the use of restraint and seclusion
• Studies show a strong correlation between the reduction of restraint and seclusion and the use of comfort rooms. For example, individuals who have access to comfort rooms have shown decreased "rebellious, aggressive, and depressive behavior".
• Creates an empowering environment in which to practice self-directed behavior
• Helps youth to increase self-awareness and develop resiliency skills
  • Develop skills to recognize/adapt/cope with triggers
  • Self-nurture
  • Self-care
• Decreases staff burn out/injury
• A less violent and coercive environment
• Gives staff the role of teacher rather than enforcer
  • Improves staff and user relationships
  • Staff relate to individuals - not behaviors
  • Individual users see that staff really care
• Provides a space that is sensory supportive rather than sensory depriving
• Individuals are able to develop skills they can use outside of a treatment setting
• Individuals are given an opportunity to learn how to explore new activities in a new environment

Suggestions for gaining the support of direct care staff and comfort room users:

Incorporate use of the comfort room and equipment into individual calming plans.

Create a schedule that allows for the room to be accessed 24/7 (whenever it is needed).

Carry out as many activities as possible in the comfort room (i.e. new patient orientation, one-on-one sessions with psychiatrist and social worker, self-awareness activities, etc.).

Include users and staff as part of the steering committee when developing the room.

Make information available that highlights positive outcomes associated with use of comfort rooms.

Incorporate knowledge and practices into staff orientation and ongoing training.

Develop policies that support the use of comfort rooms.

Reinforce why, when, how comfort rooms are used.

Interviews with facilities in New York State that use comfort rooms:

The following section includes interviews with individuals who successfully championed the development of a comfort room in their facility. The interviews were conducted at five facilities across New York State. These facilities serve children and adolescents and have a comfort room, multi-sensory room, or Snoezelen® room on site. The interviews share experiences and insights that will assist others in creating their own comfort spaces. Their stories highlight the positive outcomes they have seen. Illustrations and a brief description of each room are included, along with an overview of other initiatives the facilities have adopted to reduce the use of restraint and seclusion.

Interviewees have generously agreed to share their contact information. Please do not hesitate to take advantage of this valuable resource. They are willing to answer questions via phone or email and might even be willing to host visitors for a tour of their comfort room. This is an invaluable opportunity for gathering first hand information.

The excitement and enthusiasm that is produced during discussions about the use of the comfort room is contagious. Staff members, as well as the youth that use the rooms, recognize positive changes in behavior and have data to support their belief that use of comfort rooms helps to reduce restraint and seclusion in facilities that serve youth with mental illness.

Contact Information:

South Beach Psychiatric Center
Staten Island, NY
Bill Langford, Treatment Team Leader (Adolescent Unit)
Phone Number: (718) 667-2585

Hutching Psychiatric Center
Syracuse, NY
Annette Sierak, Occupational Therapist

St. Lawrence Psychiatric Center
Ogdensburg, NY
Joette Holgado, Director of Quality Management
Phone Number: (315) 541-2202
Carol Brew, Child and Youth Chief of Services
Phone Number: (315) 541-2590
Ashleigh King, Occupational Therapy Assistant
Phone Number: (315) 541-2533

Greater Binghamton Health Center
Binghamton, NY
Karen Witbeck, Treatment Team Leader
Phone Number: (607) 773-4044
Barbara Vartanian, Supervisor of Rehabilitation Services
Phone: (607) 773-4262

Interviews not included but feel free to contact:

Woman's Christian Association of Jamestown at WCA Hospital
Trish Mclennan, Counselor III
Phone Number: (716) 664-8687
Mary ann Wilcox, RN, MSN , Nurse Manager
Phone Number: (716) 664-8658

South Beach Psychiatric Center
Staten Island, NY

Comfort Room Visit with Bill Langford and Diane Disavow
March 19, 2008

The comfort room at South Beach was created to look like a bedroom that could be found at home or in a typical college dorm. This facility purposely did not use state issued furniture in order to create a space that felt separate from the youths’ typical living space in the facility. This room has been in use for two years and has suffered no significant damage.

South Beach Psychiatric Center (SBPC) was one of the first facilities in New York State to implement a comfort room. It has been operational since the Spring of 2006. Although the facility has included other creative initiatives to reduce the use of restraint and seclusion, South Beach claims that their successful reduction program has been most influenced by the use of their comfort room.

Over the course of six months, SBPC saw a 66% reduction in the use of restraint and seclusion. Restraint and seclusion rates had been unusually high the previous quarter due to the aggressive activity of a high risk child. This child had been in acute care where she required multiple 4-point restraints daily. When she came to the facility she often lost the ability to control her behavior, necessitating locked seclusion multiple times a day. Over the course of several months and through the use of the comfort room, she was able to learn the skills necessary to recognize when she was beginning to feel agitated and aggressive. Developing increased self-awareness provided her with the skills to calm and control her behavior on her own while the facility provided her with the tools to do so. Before leaving care, she was able to go from being restrained and secluded several times a day to going four months without a single episode of restraint or seclusion. After seven months of treatment, she was discharged from South Beach and had developed the skills necessary to allow her to become a less frequent consumer of care.

The following interview with Bill Langford, Treatment Team Leader, and Diane Disavow, Chief of Child and Youth Services, highlights the importance of gaining the support of upper management, direct care staff, and the youth served. They emphasize the importance of allowing for a slow implementation process, and explain the importance of being willing to learn from what isn’t working and to then make the appropriate changes.

Population: Children and youth Ages 12-18 with a wide range of disorders

Size of the facility: 10 bed unit with an average length of stay is 116 days

Client to staff ratio: 2:1

How long have you had the comfort room? 2 years

How much did you budget for the comfort room? $3,000 - $3,500. They were very "cost­conscious" when choosing items for the room including:

• Use of items they already had -rug, recess lighting.
• Use available staff talents- i.e. staff member did mural.
• Use of cost effective venders for bed, desk, drapes

What kind of planning did you do? The idea of implementing a comfort room was presented at a facility meeting, encouraged by the leadership and OMH Central Office. Bill Langford was the champion for the comfort room and was able to elicit support from direct care staff and youth by sharing information and getting them involved. With the support of upper management, supervisors, direct care staff and residents, they were able to transform one of their two seclusion rooms into a comfort room. Most importantly, they allowed implementation to be an incremental process to gain staff support and to ensure that staff "owned the project".

Based on what you went through, do you have any suggestions for facilities trying to implement comfort rooms?

Suggestion #1: Allow for a slow implementation process

• "How do you eat a 1,000 lb elephant?……One spoonful at a time"
• 5-6 months of planning before it was up and running
• Always assess and re-assess to ensure that staff is ready to take the next step forward
• Work hard to get staff on board
• Teach them how to use the room and involve them in the design process
• Help staff and ways to use the room for other activities
• Staff begin to see that the room is effective
• Show them how using the room will make their jobs safer and easier, as well as save time and money

Suggestion #2: Emphasize need for upper management support

• You need leadership with a vision

Suggestion #3: Be open to learn from what isn’t working and be willing to make changes

Suggestion #4: Emphasize that it is a room for the youth, not for the staff to use whenever they want.

• Staff can use the room to interact therapeutically with youth.

Suggestion #5: Don’t get hung up on "What if’s"

• "What if’s" -Fear that you are reinforcing negative behavior with a reward
• Don’t look at the room as a reward- youth that have the most behavior issues are most in need of the room
• Don’t be afraid of trial and error, learn from what is not working and make the appropriate changes.

Suggestion #6: Operate under the assumption that, "The more you give to kids the more you get back from them."

Description of the comfort room:

• Yoga mats
• Stereo
• Computer desk
• Bed
• Rocking Chair
• Recliner
• Bean bag
• Mural on two walls
• Low lighting
• Curtains to block sunlight as well as industrial looking wall
• Books
• Curtains are hung with Velcro
• Music (mixed CD’s rather than "babbling brook"–Kids didn’t like that)
• Bubble wrap
• Hand lotion
• Books

Youth have also created comfort boxes to keep in their rooms. These are shoe boxes that are decorated as a group activity and then filled with items to promote self-soothing behavior. Youth choose what they want to keep in their comfort box. Items might include a family photograph, a stress ball, or CD. These boxes can be taken home with them when they are discharged from care or visiting their family for the weekend.

The room is used as a place for youth to emotionally regulate, which in turn reduces episodes of restraint and seclusion. For youth, the room has become associated with calm (brain patterns are changed and child’s auto-response is to become calm when using the room).

Items the youth use most? Computer, music

How did you decide what to put in the room? Bill presented magazines and ideas, but ultimately youth and staff picked items out. They purposely put non-state furniture into the room– to make it feel like an escape or a setting you would see in a home or college dorm .

Conditions of use:

Can a child use the room when ever they choose? Yes, however when they are in group or at school they are expected to stay, but they are welcome to use the room if need be during those times.

How many residents can be in the room at a time? 1 (several if staff provide supervision)

Does the room stay unlocked? No, the room is locked and is opened by staff member when youth requests use of the room.

Can youth use room unsupervised? Yes, most of the time

• Staff use their judgment based on the behavior that the youth is displaying
• If a child is emotionally escalated a staff member is in with them
• If a child is left in the room alone, they are checked in on every 15 or 30 minutes based on their "observation status"

The comfort room is also used for:

• DBT and PEM skills training
• Yoga groups
• Relaxation groups
• Crochet groups (make blankets and sell as fund raisers for activities)
• Girl’s group

Suggestion: "Find ways to use the room as much as possible".

What kind of results have you seen based on use of the comfort room? Over six months SBPC saw a 66% decrease in R/S (had been high the previous quarter due to a high risk individual)

Individual Success Story:
Girl, who had previously been in and out of care, came into the facility needing to be R/S multiple times a day. An individualized treatment plan was developed including use of the comfort room, and three months later she gained control of her behavior. Eventually she went four months without R/S and was discharged from care.

• Difficult to measure how many incidents of R/S it has prevented but believe that the effects have been significant
• Improvement in staff/client relationship– moved to a teaching, nurturing role rather than enforcer
• Less punitive environment
• Staff and youth are now working together
• Increased support for DBT
• Nurture staff/youth relationships
• Supportive/different place for one-on-one sessions
• Comfort room gives staff another tool to use to prevent R/S
• Therapeutic for both patients and staff
• Youth enthusiasm
• Youth say when they go home they are going to set up their own comfort room
• Parents try to incorporate aspects of the comfort room into their home

Besides the comfort room, what additional efforts has the facility made to reduce the use of restraint and seclusion? South Beach Psychiatric Center uses a combination of DBT and PEM .

• Renamed DBT "Doing Better Today" and restructured the manual to be more appealing to youth
• SBPC has bulletin boards that highlight concepts of DBT and PEM hung in the hallways that are "kid friendly", bright and colorful.
• There is a "Comfort Board" that is decorated with pictures and representations of skills they can use for Distress Tolerance and Self Soothing.
• With youth’s permission, the Individual Crisis Plan is hung on the "Comfort Board" as a reminder of what staff can do to help during a crisis.

The facility looks at trends in episodes of restraint and seclusion, noting when rates are lowest and highest and evaluating why those trends exist. In response, programs have been implemented.

For example, rates appear lowest on days when youth go to the PEM "rewards store", so an additional rewards day was added on a day of the week when R/S rates were highest.

Rates are highest on the weekends so SBPC created additional programming:

• "Wii-kend"; youth who cannot leave the facility to visit their family are provided with fun programming options, such as playing the Wii.
• Parent advocates run structured activities with parents and youth.

St. Lawrence Psychiatric Center
Ogdensburg, NY

Comfort Room Visit with Joette Holgado, Director of Quality Management Peggy Roddy, Adult Services OT & Champion of the Adult Comfort Room Carol Brew, Child and Youth Chief of Services Ashleigh King, Champion of the C/Y Comfort Room
March 5, 2008

Population: Acute care for child and adolescents, average length of stay: 21 days

Size of facility: There are three separate halls: one for children (with an average of 8 living on the hall at a time), one for female adolescents (average of 10 at a time), and one for male adolescents (average 10)

Client to staff ratio: On average the client to staff ratio is 2.5:1 for day and evening shifts

How long have you had the comfort room? About a year

How much did you budget for the comfort room? On average, each room cost about $1,000 with a total of three rooms (one on each hall).

What kind of planning did you do?

With the support of Joette Holgado and Carol Brew, Ashleigh King, Occupational Therapy Assistant, was the champion for implementation of the comfort room. She worked with Peg Roddy in researching the process of developing a comfort room, got the youth who would be using the room involved (by having them vote on themes, pick items, and help paint the walls), and made pillows and other items for the rooms. She persevered and made sure that the comfort room was implemented.

Based on what you experienced, do you have any suggestions for facilities trying to implement comfort rooms?

Suggestion #1: To make sure that your comfort room does not go unused

• Pick a room that can be conveniently accessed
• Involve the individuals who will be using the rooms as much as possible in the implementation process to encourage ownership of the room. They will be more likely to use it and less likely to damage equipment.
• Do a risk assessment on the room to ensure safe windows, doors, outlets. Assess risk of any objects placed in the comfort room.
• Encourage commitment among staff. Make sure they are excited about the room and check in to make sure they are using it.

Suggestion #2: Decorating

• Peggy Roddy reflects that she would avoid painting murals on the walls because they are time consuming to complete and difficult to finish as volunteer participation may be inconsistent. Try pre-printed wall murals.

Description of the comfort room:

Young children’s room:

• Under water theme
• Sponge painted blue walls
• Nemo painted on the wall
• Industrial chairs and couch
• Bean bag chair
• TV
• Book Shelf with games and toys
• 2 pillows
• Squishy ball

Adolescent girls’ room:

• 60’s theme
• Purple walls with a hippie
• Flower painted on the wall
• Piano
• Industrial chairs, bean bag, pillows
• Tupperware drawer with items in it (art supplies and squishy balls)
• Table with puzzle

Adolescent boys’ room:

• Adirondack theme
• Walls painted medium green with large forest/waterfall mural
• Table with chairs
• Large beanbag bed with pillows
• Small bean bag
• Squishy balls
• Posters have been put up on boys hall encouraging use of room
• There are speakers in each comfort room that receive general hospital announcements. It is hoped that they will be removed because they tend to be disturb the calming atmosphere of the comfort room.
• Boys room is used most frequently.

Items used most?

• Children: picture books
• Adolescent Girls: art supplies
• Adolescent Boys: floor puzzles

Do you use any assessment tools? St. Lawrence Psychiatric Center keeps a "Comfort Room Log Sheet" to track which individuals use the room and for how long. This information is used to compare frequency of use of the comfort room to the number of episodes of restraint and seclusion. Data collected has shown a correlation between increased use of the comfort room and decreased use of restraint.

A feedback form is kept in the comfort room for youth to fill out after use. It lists what they liked and didn’t like about the room and what changes could be made to make the room more effective.

(See Section IV, "Evaluation", for a copy of St. Lawrence Psychiatric Center’s assessment tools)

Conditions of use:

• Each room is located directly next to the nurses station with a window that looks into the room
• Rooms are left unlocked and open at all times and can be used by youth at will
• Youth are to be checked in on every 15 minutes when using the room

(See Section III for a copy of St. Lawrence’s policy for use of the comfort room)

What kind of results have you seen? As a result of the use of the comfort room, St. Lawrence Psychiatric Center has seen a decreased use of restraint and seclusion, as backed by the data they have been collecting.

Youth are able to the use self-soothing skills when discharged home. Youth develop a "comfort kit" to use while in the comfort room and take with them when they leave care. They also use the comfort room as part of the DBT program.

(See Section II for more information on developing comfort kits.)

Besides the comfort room, what additional efforts has the facility made to reduce the use of restraint and seclusion?

• Development and use of Individual Crisis Plans
• Journaling, deep breathing exercises
• Increasing standards/expectations when hiring new employees. Make them aware of R/S reduction initiative, if not on board, not hired
• PMCS training as well as the use of a combination of PEM and DBT techniques
• R/S data posted on facility website for staff to review
• Multiple R/S episodes reviewed by facility upper management team
• Post event acute analysis and debriefing process with staff and youth after an episode of restraint or seclusion
• Youth are given restitution homework after an altercation and asked to consider "What could you have done differently to avoid the incident?"

Hutchings Psychiatric Center
Syracuse, NY

Comfort Room Visit with Annette Sierak
March 4, 2008

"The Peaceful Place"

Population: Acute care children and adolescents, ages 5-12- average length of stay is several months

Size of facility: 11 bed unit How many youth? Hutchings serves on average 11 youth

Client to staff ratio? Varies, some require 1:1, but in general there is a 3:1 ratio

How long have you had the comfort room? The comfort room became operational in the summer of 2007.

How much did you budget for the comfort room? $8,000 Items for the room were selected under the guidance of the facility’s occupational therapist, Annette Sierak. "The Peaceful Place" is a multi-sensory room, rather than a comfort room. Items were chosen that could be used by youth with little guidance. They provide youth with an opportunity to practice self-directed behavior.

What kind of planning did you do? The idea of implementing a comfort/multi-sensory room was initially proposed before the current OT was on staff, and funds were denied. The motivation to give the proposal a second try was sparked after staff (including the COO and CYS-TTL ) attended a conference. At the conference a speaker presented on the benefits of implementing a comfort room in teaching individuals self-soothing techniques. All were responsive and motivated, so Hutchings’ Occupational Therapist, Annette Sierak, took this as an opportunity to re-propose the plan. She pulled information together and, using data from the first time the idea was proposed, she compiled a new equipment list and attached supporting articles. This was re-presented and approval for the purchase was granted by the CEO/Executive Committee. As an occupational therapist, Annette Sierak used her knowledge of multi-sensory integration to choose what items to put in the room in order to create an environment that would provide youth with an opportunity to practice self-directed behavior and practice self-soothing skills.

Based on what you went through, do you have any suggestions for facilities in the beginning stages of implementing a comfort room?

Suggestion #1: Annette suggests contacting an occupational therapist to help decide what items to choose.

Description of the comfort room:

• Bubble tube, located in corner with mirrors behind it, connected to a pad that allows youth to change the color of the bubble
• Small shelf by window with hand held puzzles and ball on it
• "Cloud Chair" - Beanbag Snoezelen® chair with speakers, vibrates with music
• CD player with relaxation and rhythmic music
• Weighted blanket: small 5 lb blanket and larger 10 lb blanket
• "Kid garage" - mat cave (about the size and shape of large cardboard box with giant stuffed animal inside)
• "Roundabout", platform sits on the floor and can be spun around by therapist and or the child
• Tactile path tiles that lay on the floor with different textures
• Aroma therapy diffuser
• Night: Lavender based products
• Day: Peppermint
• Evening: Woody scent added to lavender base
• Locked closet with items in it that can only be used under supervision
• Scent box
• Different textured balls
• Card games (old maid)
• Oral stimulation- chewy tubes
• Beads and String

The Peaceful Place is located in a room next to the cafeteria, not on the halls where youth sleep. Individuals use the comfort room by appointment with the occupational therapist and trained staff members. In addition to the multi-sensory room, there is a small, square-carpeted room on one of the resident halls, known as the "quiet room". Each has a small and large weighted blanket and a ball blanket in it for comfort.

Items the youth use most? Bubble tube, CD player, cloud chair, ball blanket, weighted blanket, kid garage, aromatherapy (rub on arms before bed), chewy tubes, color morph molecule ball, slinky pop tubes, Simon Says game, and Roundabout.

Do you use any assessment tools? Some of the children are evaluated by the occupational therapist using a "Sensory Profile" developed by Dr. Winnie Dunn (published by the Psychological Corporation, 1999). This information is then used when interacting with youth in The Peaceful Place. It is not required. A brief safety assessment is necessary to avoid the potential for property destruction, to preserve the room over time. Typically, a child who has been unable to remain calm or been unable to use the room to calm before a "crisis", or has PEM related "frownies", is required to earn back "smilies" before entering the room. One child is allowed in the room at a time.

Annette Sierak is also in the process of developing an evaluation plan as part of a Performance Improvement Project on CYS. The PI Project aims to have all CYS staff trained in the use of the room, and to adopt a way to measure the impact of room use on the staff. Information on perceived levels of agitation, near misses, and number of restraints, will also be collected and used to establish room routines.

Conditions of use:

Initially the Peaceful Place stayed locked and was only used under the supervision of the facility’s occupational therapist. Youth were and are scheduled to meet with the therapist for 15-20 minute intervals, one at a time, one after another. When an individual seems to be nearing a state of distress they are given precedence. The occupational therapist trains all direct care staff on how to use the room. The occupational therapist first demonstrates to the staff how to use the equipment and then they must each perform an accurate "teach back".

Written Policy: The policy that guides use of the Peaceful Place was developed by Annette Sierak.

What kind of results have you seen? Initially the room was only used under the supervision of the OT , but as staff began to see positive results associated with use of the multi-sensory room, floor and clinical staff asked that certain youth be taken into the room more often. Now, most of the regular day staff have been trained and have access to the room. They are using the room at their liberty while the OT still uses the room two evenings per week.

Individual Success Story:

A seven year-old child with Conduct Disorder, PDD , and an average IQ uses the multi-sensory room as part of his regularly scheduled behavioral management program. He is directed towards objects in the room that facilitate fine-motor skill development, an area of delay that is addressed by his OT in treatments as well. Due to the calming effects of the room, he is able to learn these skills without getting frustrated and, as a result, his episodes of restraint have also decreased due in part to the use of the room.

Besides the comfort room, what additional efforts has the facility made to reduce the use of restraint and seclusion? Hutchings implemented a "restraint reduction strategic plan" last year. In response to the frequency of restraints on the children’s unit, the focus of this strategic plan is to reduce restraint. This implementation group had its first meeting in Spring , 2008. There has been ongoing training throughout the campus on client centered care. On the children’s unit there are weekly unit community meetings where the child and adolescent population provides feedback about programming. The adult units have set up a "world cafe" forum that is now being used to inform and direct programming changes.

Greater Binghamton Health Center
Binghamton, NY

Snoezelen® Room visit with Karen Witbeck, Treatment Team Leader, CSE Chair, February 29th, 2008
with Barbara Vartanian, Supervisor of Rehabilitation Services, May 27, 2008

Population: Children and adolescents, ages: 5-17; Primarily mood disorders (90% +/-), sensory integration D/O, conduct D/O, aggression, anxiety, mood, bi-polar, high risk, self-injurious behavior, PDD ; average length of stay is 30 days (+/-)

Client to staff ratio: In the Snoezelen® Room, 1:1

How long have you had the Snoezelen® room? The Snoezelen® room in the Child and Adolescent Unit has been in use since December 2006. The Child and Adolescent unit is a new service provided by Greater Binghamton Health Center that opened in August of 2006. The Snoezelen® Room was built into the new facility. Initial training was provided to staff in September of 2006 by Linda Messbauer, who is one of the leading experts in creating multi-sensory environments, with over 30 years of experience (http://www.lmessbauer.com/index.php ), on how to use the equipment and the room. However, technical difficulties with the installation of equipment delayed the use of the Snoezelen® room until December of 2006. Staff training with Linda was repeated again in the spring of 2007 and has been carried out several times since.

How much did you budget for the Snoezelen® room? Due the specialized Snoezelen® brand equipment that has been selected for use in this room the budget was high. Barbara Vartanian feels that some of the equipment used could have been purchased at a lower cost (such as the "squishy balls", disco ball, bean bag chairs, etc.), while some items needed to be bought through the Snoezelen® vendor (ball pit, bubble tube, etc.).

What kind of planning did you do? Greater Binghamton Health Center began by researching recreational therapy equipment. Eventually, one staff member suggested they look into using Snoezelen® brand equipment for anxiety reduction and relaxation, and it seemed a perfect fit.

Barbara Vartanian became the champion for the Snoezelen® Room, eliciting support from Karen Witbeck, treatment team leader, and Margaret Dugan, Executive Director. After gaining their support, Barbara was able to contact Linda Messbauer. Linda helped with the selection of items for the room and explained which items work best for specific populations. Barbara found Linda’s guidance to be particularly helpful.

The first year was one of trial and error, ultimately resulting in great success. Over the course of the year, staff members learned how to use the specialized equipment in a way that would be most effective for the youth in care, and developed an evaluation plan for collecting data on use of the room.

The room is currently used 4 to 5 times a day resulting in significant improvement in the behavior of the children. Use of the room helps youth with self-regulation, increased awareness of the environment and how it affects their behavior, and promotes decreased anxiety and anger.

Based on what you went through, do you have any suggestions for facilities trying to implement comfort/Snoezelen® rooms?

Suggestion #1: Barbara would suggest contacting a consultant with expertise in multi-sensory environments and would highly recommend eliciting the services of:

Linda Messbauer
http://www.lmessbauer.com/index.php
(718) 776-3015).

Suggestion #2: Participate in continued education; attend conferences, contact and interact with experts in the field, research, get involved with organizations that promote multi-sensory environments

Such experts and organizations include (as suggested by Barbara Vartanian):

Linda Messbauer
http://www.lmessbauer.com/index.php
(718) 776-3015

American Association of Multi-Sensory Environments
http://www.aamse.us/

The Hidden Angel Foundation
http://www.cdhaf.org/

Suggestions #3: Evaluate! Share what you have learned. Collecting data on the use of the room is a way to determine the effectiveness of the room and to gain insight on what is working and what improvements could be made.

Feel free to contact Barbara Vartanian as a resource:
Phone: (607) 773-4262)

Description of the Snoezelen® Room:

• Padded ball pit in the corner of the room that vibrates with music (multi­colored balls)
• Half the floor and half way up the walls are covered with white mats for safety.
• The walls and mats are white so that images of the youth’s choosing can be projected on them.
• Projector with multiple slides
• Slides are labeled numerically from most soothing to most stimulating
• Slides (10+ under water, animals, patterns, etc.) are projected on to the wall. Some slides have relaxation CD’s that go along with them
• Disco ball, projected images reflect off disco ball and rotate around the room
• Sound system - music is instrumental, tribal drum beats, music with a bass
• 10+ bean bags for youth to tunnel, stack, climb on, and jump in
• Vibrating pillow to hug
• Weighted medicine ball
• Basket of textured balls
• Bubble tube with fish and control pad to change colors of bubbles
• Large Snoezelen® bean bag that vibrates with music
• Two weighted blankets

Items the youth use most? The padded ball pit (sit in the ball pit while the pit vibrates with the music that is being played through the sound system)

The large bean bag (sit on the bed sized bean bag chair with the weighted blanket on their lap, next to the bubble tube or viewing images projected onto the wall, as the chair vibrates with the bass of the music)

The bubble tube (provides visual stimulation, as well as an opportunity to practice self-directed behavior since youth can control the color of light that is projected though the tube)

Music (youth can select which CD to listen to, from calming instrumentals to alternating tribal drum beats)

Do you use any assessment tools? Greater Binghamton Health Center uses two different assessment tools to evaluate use of the room. One of the tools, a "Multi-Sensory Data Collection Sheet", is used to collect quantitative data on when the room is used and what items the individual used while in the room. The other assessment tool is used to determine if use of the Snoezelen® Room is effective in changing mood.

(See Section IV, "Evaluation", for a copy of Greater Binghamton Health Center’s assessment tools)

Conditions of use:

The Snoezelen® Room is used by youth under supervision. They have scheduled sessions to use the room, but can also use it by request.

• Youth are always supervised in the room for up to 30 minutes at a time
• When the room is not in use it remains locked
• When youth enter the room they are asked to remove their shoes and empty their pockets as a safety precaution
• Protocols are in place which guide the structure of each session and the pace at which change is introduced by the practitioner.
• Protocols are in place to assure cleanliness of equipment.
• Only trained staff is allowed to use the room and operate the equipment.

What kind of results have you seen? Do you have data to back it up? Greater Binghamton Health Center recognizes the importance of collecting data in order to prove the effectiveness of the use of their Snoezelen® room. The Center has developed and adapted evaluation tools and has found a statistically significant difference in anger levels before and after use of the Snoezelen® room. They have also been able to illustrate a strong correlation between use of the room and a decrease in the number of episodes of restraint. (See Section IV, "Evaluation")

To the left is a bar graph comparing the frequency of Snoezelen® Room use and episodes of restraint over a fifteen month period. As use of the Snoezelen® room increased there was a sharp decrease in use of restraints. In March of 2008, GBHC went restraint free.

References

Articles of Interest:

Articles on comfort rooms by Gayle Bluebird:
https://www.cwla.org/programs/groupcare/rgcqspring2005.pdf and http://download.ncadi.samhsa.gov/ken/pdf/SMA06-4055/Manual_Module5.pdf

Articles on Multi-Sensory Rooms by Tina Champagne:
Sensory Modulation & Environment: Essential Elements of Occupation, Handbook & Reference, 3rd Edition. This book can purchased from: http://www.ot-innovations.com/index.php?option=com_ezstore&Itemid=28&func=viewcategory&catid=1

The article on Snoezelen® Rooms, "History of Snoezelen®" http://www.peicod.pe.ca/sno-history.htm

For further information search the following websites: Coping, Calming, Comfort Room (CCC): For Adults in Mental Health Settings (Sensory Room) by Sensory Connection Program, from: www.sensoryconnectionprogram.com

Coping, Calming and Comfort Room Development: Ideas for Creating and Furnishing a Sensory Room by Sensory Connection Program, from: www.sensoryconnectionprogram.com

Building Bridges to Function in the Community by Sensory Connection Program, from: www.sensoryconnectionprogram.com

Pictures, Stories, and Studies on Coping, Calming, and Comfort Rooms from a Variety of Mental Health Settings Sharing Ideas on Sensory Rooms by Sensory Connection Program, from: www.sensoryconnectionprogram.com

History of the Snoezelen® Room from: http://www.peicod.pe.ca/sno-history.htm

The effects of the use of the sensory room in psychiatry by Tina Champagne, M.Ed. , OTR/L from: http://www.ot-innovations.com/images/stories/PDF_Files/qi_study_sensory_room.pdf  (PDF)

For general information on Multi-Sensory Rooms: http://www.ot-innovations.com/content/view/49/46/ http://www.sensoryconnectionprogram.com/index.php

Section II Brain-Storming Items for Your Comfort Room

Section II is meant to stimulate thinking as you begin to consider what items to put in your room. The first part contains images of items that have been used in comfort rooms in the past. The images are accompanied by commentary on how certain items can be used. The images are followed by a list of items. Both the images and lists are broken down by the senses (touch, sight, sound, scent, taste) that each object is meant to stimulate or calm.

Is it the items you choose that determine your policy or the policy that determines the type of items you choose? Materials for the room and policy development go hand-in-hand, one influencing and building upon the other. It is important to keep in mind that the decisions you make (about what type of room you will create, what items you plan to put in the room, and the development of policy around room usage) should all be made with the best interest of the user in mind. The decisions should be specific to the population you care for. Also, when choosing specialized equipment it is best to consult with an occupational therapist or expert in the field.

As a suggestion, look though Section II to get some ideas about possible items. Be sure to get users involved with this process. The lists in this binder are by no means complete. Add to the lists or create new lists. Include materials that stimulate the senses in a way that is calming and encourages self-directed behavior. Choose items that are safe to use.

In order to make the right choices, try brainstorming with staff, users and parents about what the comfort room will look like, items to be included and activities that will take place in the room. Make a sketch of the room. Cut out images from magazines that you want to see as part of the room.

Photographs provided by Flaghouse at http://www.flaghouse.com/bring_AL.asp

Visual Stimulation

Use black lights, different colored lighting, and various tinted sunglasses to provide visual stimulation that can impact mood and behavior.

The Bubble Tube is a Snoezelen® brand product that is very common in multi-sensory rooms. The color control pad provides youth with an opportunity to control their environment as they select the color of bubbles.

To maintain a safe environment, items with long cords can be placed behind Plexi glass on a shelf. Consult your maintenance staff.

If you are thinking about including a fish tank you must be sure to find someone who will volunteer to maintain it.

Sleeping masks can be used to block out all visual stimulation, if that is what the individual prefers.

Soft, alternative lighting is suggested to replace harsh florescent lights that are typical of institutionalized settings. Florescent lights can be covered. A dimmer switch provides a variety of lighting effects.

Ideas for the Walls

Wall decals and safety mirrors are a quick and easy way to provide visual stimulation.

Life size posters or murals can be added, Youth should be involved with selecting themes and images.

Installation of a white board gives staff and youth a space to record items borrowed from the room, to take notes during group activities, and provide a large space for drawing. As an alternative, chalkboard paint can be applied to the walls and used for the same purpose.

Cover overhead florescent lights with calming clouds or other pictures.

Please be advised that flashing lights and projected images may result in confusion and disorientation for some individuals with acute mental illness. Adjust use of these items accordingly.

Sound

It is important to consider what types of music to allow in your comfort room. While selection can provide an opportunity to practice self-directed behavior, the choices should be calming and not promote aggression.

Seating products are available (i.e. Snoezelen® Cloud Chair or Ball Pit; see "seating" page) with the technology to incorporate a sound system. Once connected, the seat vibrates in sync with the music that is playing. Adding a weighted blanket or lap pad creates a soothing experience.

Drums and other musical instruments are used for self expression. The facilitator plays a rhythm, which youth must carefully listen to and play it back. A drumming group is a good way for youth to practice their listening skills together.

Suggestion: See if you have a staff member who has the ability to teach musical instruments. Think creatively about your resources and use them!

Sound machines provide options for nature sounds as well as white noise, which can be used to drown out other sounds.

The rhythmic sound and feel of passing a slinky back and forth between your hands can be soothing.

Scent

Various essential oils can be used in an oil diffuser. Scents elicit different reactions. For example:

• Lavender can reduce anxiety, depression, and stress.
• Chamomile can reduce anger, anxiety, fear, and irritability.
• Lemon increases happiness and peace, as well as memory and concentration.

Warning: Aromas and scents can act as triggers for traumatic memories. If an individual is having an adverse reaction to an olfactory item, be sure to remove it immediately. Consult with an individual certified in aroma therapy.

Scented lotion can be used for a soothing hand or foot self-massage. Bring volunteer students in from local massage schools to run a session on self-soothing techniques or therapeutic touch.

Put a dab of scented oil on an individual’s wrist before bedtime to promote relaxation and sleep.

A scented room can create a multi-sensory, therapeutic environment.

"Follow Your Nose" is an aroma-therapeutic game that can be found where Snoezelen® brand items are sold.

Touch

Fiber optic lighting is not only aesthetically pleasing, but provides individuals with a new form of tactile stimulation.

The Multi-Sensory Path consists of blocks that are different textures and can be walked on and touched.

Stress balls can be used to squeeze and squish away frustrations. Having a variety of shapes, sizes, and textures provides individuals with an opportunity for choice and self-directed behavior.

One way to encourage respectful treatment of the items in the room is to encourage "ownership" by involving youth in selection of those items, suggesting themes for the room and, developing policy around use of the room.

Fine Motor Skills

Beading, sewing and knitting are activities that can be done as a group in the comfort room.

Completing puzzles is an activity that requires concentration and use of fine motor skills.

In a study done at McFarland Mental Health Center in Illinois, individuals reported decreased levels of stress after using the comfort room which contained inexpensive items, such as markers, paper, beads, pillows, music, and stress balls.

Utilizing fine motor skills requires individuals to stay focused on the task at hand, which may result in de-escalating aggressive behavior and helping the individual to move beyond the trigger event. Providing individuals with a creative outlet can also lead to increased confidence and personal growth as they find new ways to express themselves.

Journaling is one way for individuals to express themselves.

Textures

Include as many different textures as possible to add to the opportunities for tactile stimulation.

You can use different textures and fabrics when choosing:

• Blankets
• Pillows
• Wall art
• Textured wall paper
• Rugs
• Couches

Youth can make a "tactile book" by cutting out and pasting different textured papers and fabrics into a book that is then kept in the comfort room.

Textured materials can include various colors and patterns to be visually pleasing as well as stimulating to touch.

Weighted Modalities

A weighted exercise ball can be used as a therapeutic tool. The rhythm of tossing the weighted ball back and forth between the individual and therapist can have a soothing effect.

Weighted stuffed animals work in a similar way to a weighted lap pad, but are soft and cuddly like a pet. Weighted stuffed animals can be purchased or made by staff and youth.

Weighted blankets and lap pads have proven to be an effective tool for people with mood disorders, autism, trauma histories, substance abuse histories, and those who engage in self-injurious behaviors. Individuals have reported positive effects when using weighted items to produce a grounding effect.

If possible, consider offering weighted items in different materials; such as, fleece, cotton, velour, etc.

A weighted neck wrap can also include aroma-therapy features and options for heat or cold.

Blankets designed to allow modification and placement of weights are particularly effective in meeting individual needs.

Seating

Bean bag chairs are a youth friendly option. If you have space for several, they can be used for tunneling or building.

If your budget allows for it, you might want to consider including a vibrating massage chair in your comfort room.

The Snoezelen® brand bean bag, ball pit, and "Cloud Chair" can be hooked up to a stereo system and vibrate with the music.

A less expensive seating option is a rocking chair.

It is important to make sure that youth have access to comfortable seating during group sessions that are held in the comfort room. Yoga mats or small rugs are a space and money saving option.

Seating that allows for swinging and rocking can create a very calming effect.

Other Items to Consider

Fountains not only add to the aesthetic of the room but also provide soothing auditory stimulation.

A microwave and mini refrigerator provides access to a quick snack, as well as the ability to heat and cool items, such as eye masks and aromatherapy neck wraps.

In addition to brightening your space, plants create an opportunity for youth to take the responsibility of caring for them.

Puzzle books (such as word searches, mazes, & sudoku) and puzzles are good items to stimulate the brain.

Books shelves are an ideal space for the storage of books, miscellaneous items, and individualized comfort kits. Any items that must be used under supervision can be kept in a locked cabinet to ensure safety.

Having a supply of current news, books and magazines is an ideal resource to keep youth updated on current events. Included in a collection of self-help books should be literature written by recovered individuals.

Suggested Items for your Comfort Room

Keep in mind that the listed items are only suggestions. Take note of which items would be appropriate for your facility and be sure to add to the list, and don’t forget to… Be Creative!!

On a tight budget?
Think: What kind of resources does your facility have? Do staff members or volunteers have special skills to make or help acquire items? Where are some places you could look for safe, inexpensive or donated items?

Touch:

• Stress balls
• Multi-sensory walking path
• Slinky
• Tupperware container with raw rice
• Vibration
• Exercise band
• Tunnels
• Weighted Modalities
• Weighted blanket
• Weighted stuffed animals
• "Heavy Duty Dog"
• Medicine ball
• Ankle and wrist weights
• Massage tools
• Vibrating foot massage board
• Hand and foot rollers
• Back massage
• Vibrating pillow
• Textures
• Fabrics (blankets, pillows)
• Rugs
• Wall paper
• Textured art
• Developing fine motor skills
• Sewing projects
• Knitting
• Beading supplies
• Finger painting
• Colored pencils
• Sketch books
• Jigsaw puzzles
• Light Bright
• Etch-a-Sketch
• Straws, cotton balls, play dough, feathers, felt, foil, sponges

Sight:

• Lighting
• Bubble lamps
• Color control pad
• Lava lamps
• Glitter lamps
• Black light
• Multi-colored lights
• Multi-colored sun glasses
• Dimmer switch
• Sleeping eye mask
• Non-florescent lighting
• Covers for florescent lighting panels
• Floor lamps
• Fiber optics spray lamp
• Aquarium display
• Plants
• Mobiles
• Sponge painted walls
• Poster of nature scenes
• Oversized poster scenes
• The use of soft colors
• White walls for projections
• Disco ball
• Multi color lighting
• Rotating image projector
• Murals painted by youth or staff
• Glow stars
• Wall decals
• Chalk board paint
• Photography
• Youth’s art

Sound:

• Relaxation and nature sounds
• Rhythmic music
• Youth’s choice
• Books on tape
• Head phones
• Portable CD player/iPod
• Sound system
• Sound machine
• Nature sounds
• White noise
• Fountains
• Instruments
• Guitar
• Tribal drums
• Rain stick

Scent:

• Scent box
• Aromatherapy supplies
• Oil
• Diffuser
• Dried herbs
• Lotion, hand cream, soap, oil
• Scented markers
• Scented room and linen spray
• Specific Scents
• Lemon balm to reduce agitated behaviors
• Lavender to calm
• Chamomile to calm
• Eucalyptus

Comfort:

• Soft blankets
• Stuffed animals
• Extra large stuffed animal for hugging
• Inspirational reading materials
• Neck pillow

Seating:

• Bean bag chairs
• Rocking chair
• Gliding rocker
• Recliner
• Yoga mats
• Comfortable couch or chair
• Soft carpeting
• Vibrating Chair
• Massage Chair

Intellectual stimulation:

• Journals
• Activity books (word search, sudoku, cross word puzzle)
• Reading material
• Current magazines
• Animal magazines

Self-help books

Books written by recovered individuals

Art supplies

Paper, colored pencils, sketch books, coloring books

Additional Items:

• Large locked cabinet for items to be used under supervision
• Skin and nail care kits
• Craft basket
• Stress ball basket
• Dry Erase board to sign materials out or make notes for group meetings
• Bubble solution for deep breathing exercises
• Personal Reminiscence Book
• Activities basket
• Microwave
• Comfort Kit/Box
• Mini fridge
• Comfort cart
• Water cooler
• Grooming kits

Comfort Room Policy and Procedure

1. Purpose:

   The Comfort Room is a supportive therapeutic environment which assists patients in their self-calming efforts by affording them an environment conducive to relaxation. When people are in distress, a crisis could occur that results in a restraint or seclusion. At St. Lawrence we are committed to reducing these interventions and believe the Comfort Room is one tool that can assist in this effort. Comfort Rooms are located in close proximity to staff work stations. They are designed and furnished to provide an area of low stimulus and an absence of peer interpersonal interactions for the purpose of tension reduction. The entire room from the color of the wall to its furnishings has been designed to facilitate the process of self calming and soothing. The purpose of this policy directive is to set forth conditions and procedures for use of the Comfort Room at the St. Lawrence Psychiatric Center.

2. Relevant Statutes and Standards:
   • Mental Hygiene Law, Section 33.04
   • New York Code, Rules and Regulations (NYCRR), Title 14, Section 27.7
   • Office of Mental Health (OMH) Official Policy Manual, Section PC-701 (11/7/95)
   • Accreditation Manuals for Hospitals (JCAHO)
   • SLPC Strategic Planning Framework
3. Policy Overview

   The SLPC mission, vision, and values statements reflect the guiding principles used to develop the Comfort Room: respect, safety, recovery, hope, teamwork. The Comfort Room is a supportive therapeutic environment in which patients can use self help techniques to manage their behavior and emotional state in a safe environment. Staff are trained in facilitating patient use of the Comfort Room via this policy. Patients are made aware of the Comfort Room on admission and via the ongoing Recipient Council/Recipient Town Hall process. Using the principle of continuous quality improvement, a survey of patient responses regarding what they found helpful/unhelpful about the Comfort Room is collected and analyzed so that further modification/enhancements may be made.

4. Definition:

   At the St. Lawrence Psychiatric Center the Comfort Room is defined as an enclosed room where the door is not locked when a patient is present, and which is located in close proximity to the staff work station. It is designed and furnished to provide an area of low stimulus and an absence of peer interpersonal interactions for the purpose of tension reduction. The Comfort Room will contain furniture which is free from sharp corners and cannot be easily picked up or thrown; it shall be free of dangerous objects, long cords, hooks, and non-breakaway window coverings and any other item that might be used for suicide or inflicting self-harm. Items conducive to a reduction in tension such as bean bag chairs, cots, music, pillows, dimmer for light regulation, mural, books and magazines are to furnish the Comfort Room. All objects will meet infection control requirements.

5. Procedure

   The Comfort Room is always to be used on a voluntary basis. The Comfort Room is never to be used as a containment intervention. The patient must continue to demonstrate self control to use the Comfort Room, and must be using the Comfort Room to assist with tension reduction as an objective towards the goal of maintaining self control. The Comfort Room may be used along with other available therapeutic modalities clinically determined to be appropriate in assisting an individual patient with tension reduction/de­escalation. To the extent possible, according to the clinical status of a patient, other calming areas or activities on the ward may be used to assist a patient in gaining time alone or tension reduction. This becomes most pertinent when more than one patient is requesting use of the Comfort Room.

6. Indications for Using the Comfort Room

   The Comfort Room is a supportive intervention which can be used for any of the following conditions:

   1. Upon patient request, and when it is clear the patient desires time alone (personal time/space), away from noise or other environmental distractions.
   2. Upon patient request, and it is clear to ward staff that any agitation which is exhibited by the patient is safely within control of the patient, him or herself.
   3. Upon suggestion from staff as a means of assisting a patient to increase or maintain self control, and the patient is agreeable and capable of maintaining self control. This would be considered an early stage de-escalation intervention.
   4. For C/Y: only one individual at a time may use the Comfort Room.
      For Adult Services: Since the Comfort Room is also used as a TV/Quiet Room in some areas, more than one individual at a time may occupy the Room. In some cases, when TV may be too loud or distracting and, depending on another individual’s need for calming, use of the Room by the patient seeking relaxation/calming will take precedence over use of the room by someone watching TV. The RN’s clinical judgment will be used in these cases.
7. Implementation of Comfort Room Use
   1. When a patient requests to use the Comfort Room it should be available immediately and as long as the patient is able to maintain his/her self control.
   2. Ward Staff can suggest to a patient that they use the Comfort Room. Should the patient choose not to use this therapeutic tool, staff can offer other therapeutic interventions to assist in tension reduction. Should the patient choose not to use other tension reduction interventions, and in the opinion of the staff the patient presents a risk of escalation of agitation to the point of loss of self control, the nurse will request evaluation of the patient by the ward psychiatrist or MD on call.
   3. The patient will inform staff of their use of the Comfort Room.
8. Monitoring
   1. While a patient is in the Comfort Room, an assigned staff member will monitor the patient at least every 15 minutes in the C/Y Services Comfort Room and every 30 minutes in the Adult Services Comfort Room by direct visual observation, or more often if clinically indicated.
9. Terminating Use of the Comfort Room
   1. The patient may choose to leave the Comfort Room at any time.
   2. Ward movement (i.e., mealtimes, fire drill) will dictate leaving the Comfort Room. If another individual (in C/Y) is waiting to use the Comfort Room, then a limit of 30 minutes is expected.
   3. If no one is waiting to use the Room, there is no time limit for its use for a specific intervention. However, if it becomes clear that a patient is isolating him or herself through excessive use of the Comfort Room, the Treatment Team will address this as a clinical issue.
10. Documentation of Comfort Room Use
    1. Comfort Room use will be documented on a log sheet kept at the Nurses Station.
    2. As with any noteworthy clinical observation, any significant issue or observation which occurs while the patient is in the Comfort Room shall be documented in the Progress Note Section of the medical record by ward staff.
    3. Patient will be asked to voluntarily complete a feedback form on what was helpful or unhelpful about their time in the Comfort Room.

Comfort Room Voluntary Feedback Form

Your answers to the following questions will help the staff to consider ways of making the Comfort Room more useful. Please answer the following questions:

1. The Comfort Room (Select One):
   Helped me Did not help me
2. What I liked about the Comfort Room was
   
3. What I did not like about the Comfort Room was
   
4. The Comfort Room would be more helpful to me if
   
5. Comments/Suggestions:
   

Name(Optional):

Ward:

Date:

Thank you for completing this form.

If staff assistance was provided to help the patient complete this form:

Staff Name:

Title:

Signature: __________________________________________ Date:

Comfort Room Log Sheet Ward:

Name of User	Time In	Time Out	Staff Initial

Section III Developing the Comfort Room and Policy Around Its Use

In Section III, the process of developing your comfort room is discussed. The first document provides a list of questions to consider as you begin to develop your room. The second is a document developed by Tina Champagne, expert in the field of sensory modulation, which can be found in the Sensory Modulation and Environment handbook. This document should help you to consider what type of environmental changes you will make in your facility in order to create a more calming and comforting atmosphere.

St. Lawrence Psychiatric Center has developed policy and procedure for use of their comfort rooms. In addition, they have created informational flyers and promotional posters to inform staff and youth about the purpose of the comfort room and to promote its use.

Hutchings Psychiatric Center has developed guidelines for use of the multi-sensory room by outlining how each item in the room should be used. A competency checklist is used when direct care staff members are trained to use the room and equipment by the occupational therapist. Staff are required to perform a "teach back" to ensure that they understand what they have been taught.

South Beach Psychiatric Center has shared their room use protocol.

Cayuga Medical Center, Adult Behavioral Services is a hospital that has created a comfort room for the use of the adults they serve and has provided another example of policy and procedure that govern the use of the comfort room.

Sample Policy for the use of a Sensory Modulation Room: The final example that has been included in this part is a sample policy developed by Tina Champagne. In her policy, she highlights the various aspects of policy development that should be touched upon: defining purpose, giving an overview of the policy, discussing who it will apply to, and outlining the procedure for use of the room.

Questions to Ask When Developing a Comfort Room and Room Use Policy:

These are critical questions to explore in order to provide guidance through the development process.

Developing a mission and vision:

1. What is the main purpose of the room?
   1. What do you hope to accomplish through use of the room?
      1. Restraint and seclusion reduction?
      2. Improved staff/patient relationships?
      3. Less punitive environment?
      4. Teaching self regulating behaviors?

Defining the population served:

2. Who will be allowed to use the room?
   1. Should staff be allowed to visit the room when they have free time?
   2. Children and parents?
   3. When will the room be available?
      1. 24/7?
      2. During group sessions? Meal time? School hours?

Safety:

3. Who will supervise the environment?
   1. How will personal safety be maintained?
   2. Who will inspect items before they are placed in the room?
   3. Are you selecting items that are washable and fire proof?
   4. Who will supervise users of the room?
   5. Will users of the room be allowed in alone?
   6. How often will staff check in?
   7. How will equipment be cleaned and stored?
   8. Will you include items that can only be used under supervision?

Space:

4. What space is actually available and how can it be adapted to fit therapeutic goals?
   1. Do you have permanent space available in your facility for a comfort room?
   2. Do you have the resources to develop a comfort room?
      1. Monetary
      2. Staff leadership and involvement
      3. Enthusiastic residents
   3. Are there any other factors that can be changed in your facility to create a more calming environment in or outside of the comfort room?

Section IV Evaluation

Your opportunity to contribute to the field

Participating sites in the PARS grant initiative will be given assistance in planning and developing comfort space at each of the three sites. In addition, evaluation forms will be completed following the implementation and through out use of the comfort room. This will document the room’s effectiveness in reducing restraint and seclusion. This information can then be used by other facilities to develop comfort rooms in the future. Data collection will demonstrate the correlation between use of a comfort room and episodes of restraint and seclusion. It is our anticipation that an increase in the use of the comfort room will result in a decrease in the use of restraint and seclusion. Greater Binghamton Health Center has already initiated an evaluation plan and has collected data that reflects positive results.

To the left is a bar graph that was compiled using data collected on use of the Snoezelen® Room at GBHC and episodes of restraint. As use of the Snoezelen® Room has increased, beginning in October ’07, there has been a sharp decrease in the episodes of restraint.

In March of 2008, GBHC was restraint free.

This data was collected by simply recording the name of the youth who used the room, and the date and time the user signed-in and out of the room. Greater Binghamton Health Center has developed a single sided evaluation sheet to record pre and post-session anger and mood levels, as well as to document which items were used by the youth while in the Snoezelen® room. The evaluation form at Greater Binghamton Health Center is filled out by the supervising staff members.

St. Lawrence Psychiatric Center also tracks when the room is used most frequently and by whom. Youth fill out a feedback form, which provides them with an opportunity to express what they liked most and what could be added to the room to improve effectiveness.

This section also includes a sample "Comfort Room Guest Book". This can be filled out by youth who use the room. When developing an evaluation plan for your facility be sure that the data collection method is user friendly and not a deterrent to the use of the comfort room.

Evaluation Survey
Date:

The following is a brief survey to gauge your knowledge and perception about comfort rooms. Please answer questions to the best of your knowledge, using the back of this form if you run out room in the space provided. If you do not know the answer to a question, simply respond "N/A". Please check all that apply:

Position:
Administrator
Clinician
Direct care staff
Other, Specify
Full-time
Part-time

Shift:
Day
Evening
Night
Other

How would you describe the concept of a comfort room to someone who has never heard of it before (i.e. explain the purpose of the room, what it would look like, how it is used)?

What kind of changes do you anticipate seeing as a result of use of a comfort room?

1. Do you believe that use of a comfort room in your facility will help to decrease the use of restraint and seclusion in your facility?
   5 Very much    4    3 Somewhat    2    1 Not at all    N/A

2. Do you believe that use of a comfort room in your facility will help to improve staff/consumer relationships?
   5 Very much    4    3 Somewhat    2    1 Not at all    N/A

3. Do you believe that use of a comfort room in your facility will help to improve staff moral?
   5 Very much    4    3 Somewhat    2    1 Not at all    N/A

4. Do you believe that use of a comfort room will help to decrease stress levels for individuals who are recipients of care in your facility?
   5 Very much    4    3 Somewhat    2    1 Not at all    N/A

5. Do you believe that use of a comfort room will help to decrease stress levels for individuals who are employed by your facility?
   5 Very much    4    3 Somewhat    2    1 Not at all    N/A

6. Do you believe that use of a comfort room will be an effective tool for helping to teach individuals the skills necessary to control aggressive behavior?
   5 Very much    4    3 Somewhat    2    1 Not at all    N/A

Thank you! Please add additional comments on the back of this form!

Comfort Room Guest Book

Welcome to the Comfort Room!

The purpose of this "Guest Book" is to give you a way to tell us about your experience in the room. We encourage all users of the comfort room to make suggestions on what can make the room as useful as possible. Staff members are also asked to fill out a survey based on their observations.

Instructions for filling out the guest book:

Please include comments about what items you found most useful in helping to destress, as well as items you would like to see in the room that have not yet been included.

Complete the scale on the right hand side of the page to rate your mood before you use the room and then again after you use the com­fort room. Circling number 1 indicates distress, while 10 indicates joy and happiness.

Don’t forget to include your name, date, and times you checked in and out of the room.

Enjoy!

Comfort Room Guest Book

Name:
Date:  

Check in time:

How are you feeling before the comfort room?

1	2	3	4	5	6	7	8	9	10

Check out time:

How are you feeling after the comfort room?

1	2	3	4	5	6	7	8	9	10

Items you used while in the comfort room:

• Weighted Blanket
• Lotion
• Journal
• Aromatherapy
• Music
• Knitting
• Stress Balls
• Art Supplies
• Lava Lamp
• Bubble Tube
• Puzzle
• Books/Magazines
• Image Projector
• Medicine Ball
• Stuffed Animal

Other:

Comments/Suggestions:

Staff perspective:

1. Please check to see that the individual’s name, time, and date have been included on the reverse side of this form.
2. Please answer the questions below.
3. Upon completion, remove this page from the "Comfort Room Guest Book" and file with the other comfort room evaluation forms. Thank you.

From your perspective, please rate individual’s level of escalation before the use of the comfort room?

1	2	3	4	5	6	7	8	9	10

From your perspective, please rate individual’s level escalation after their use of the comfort room?

1	2	3	4	5	6	7	8	9	10

Please include comments on the individual’s use of the comfort room, as well as any suggestions to make use of the comfort room more effective:

What items did the individual use to most successfully gain control of his or her behavior?

Thank you for visiting.
Come back soon!

Section V Additional Resources

Power point, research notes, and references

Included in Section V is a copy of the Power Point presentation created and presented at each of the grant sites and for the PARS steering committee by Fellow Megan McDaniel. The power point slides are followed by notes developed from her research. References have also been included.

Quick Reference List

Creating Multi-Sensory Environments:

The following is a brief and general overview of an extensive literature review done on the purpose, effectiveness, implementation process, and policy development related to comfort rooms, multi-sensory rooms and Snoezelen® rooms.

Purpose of the Comfort/Multi-Sensory Room:

• Provide staff with an additional tool to de-escalate/redirect/guide youth
• Alternative opportunity to empower, encourage choice, increase awareness, develop skills, self-awareness, learning, social interactions for youth
• Self-awareness: recognizing and reducing distress, adapt to stressors
• Shift to client-centered practice
• Proactive step to reduce R/S
• Quite, safe and respectful space that is supportive rather than depriving of the senses not disorienting like seclusion rooms
• Not an alternative to seclusion and restraint, but a preventative measure
• Do not require specialized education to create comfort room
• All comfort rooms are created differently and should be client specific
• Person centered, trauma informed tool that reduces potential conflict
• Used to minimize or avert crisis
• Education on sensory defensiveness and to understand symptoms
• Nurturing and recovery-oriented therapeutic environment
• Crisis de-escalation and prevention
• "A designed change in care"
• Increase quality of life
• Increase quality of therapeutic relationship
• Increase choice of therapeutic interventions and attention to therapeutic tasks
• Relieve tension and pressure in attempts to improve behavior
• Individuals might engage in maladaptive behavior to obtain sensory stimulation, which is often lacking in health settings
• Sensory/comfort/Snoezelen® rooms provide an environment that stimulates the senses in a safe way
• Study in the 60’s showed that prolonged restriction of stimulation can lead to negative psychological outcomes for individuals (Zuckerman, 1964 as cited in 45)
• "Occupational therapy is most effective when it is embedded in real life" – create an environment that can be replicated at home
• People need sensory stimulation to function
• Sensory rooms work to fulfill this need
• Reduce Staff burn out: Snoezelen® environment works to encourage positive staff/patient relationships
• Increased self-awareness, resilience, self-esteem
• Increased ability to self-nurture, engage in therapeutic activities, self-care activities, engage in meaningful life roles, social activities, cope with triggers
• Model: Strength-based, person-centered, and relationship-centered
• Relieve anxiety, depression, psychosis
• Encourage exploration and different types of activities and environments to self-regulate
• Individuals with disabilities often have little opportunity to exert control on their environment; this combats learned helplessness
• Improve staff/patient relationship: remind staff that they are interacting with people – not just recipients of care

Multi Sensory:

• Places residents in a failure free environment in which they have control
• Relaxing environment that inhibits a sense of control that might foster a more equal relationship with care giver
• Provide remedy for sensory deprivation
• All senses can be systematically stimulated in controlled multi-sensory environment
• Eliminate intellectual demands, decrease social interactions or goal directed activities
• Snoezelen® is a composite of two Dutch words meaning to "sniff" (as in explore) and to "doze" (relax)
• Should be non-directive, lack specific education or therapeutic aims that are predetermined by those facilitating access to multi-sensory experience (this is not to say that it would not have therapeutic results)

Other uses for Comfort/Sensory Space:

• Education and training sessions (general intro to the room, mindfulness and self-soothing exercises, relaxation exercises, deep breathing, distress tolerance activities, sensory motor activities, stretching, deep pressure, imagery)
• Get everyone involved- Find as many people to use the room as possible so that is becomes an asset to the unit. Some hospitals in NYS have multi use comfort rooms.

Alternative activities to de-escalate:

• Add to the diversity of activities people can choose to use when in distress (take a walk, talk to a friend, listen to music, read, drink coffee/tea
• De-escalating activities: exercise, work on puzzle (well received at St. Lawrence), warm foot bath
• Art and creativity: writing, music, painting, dance
• Yoga classes
• Journal keeping
• Horticulture programs
• Caring for small pets and animal services
• Develop a sensory diet: activities that help ground, calm, center, and/or alert individuals
• Self-care approaches
• Peer-provided services
• Meditation
• Encouraging better communication
• Emphasize kindness, moral practice, humane treatment, teaching self-control
• Exercise
• Spirituality
• Physical comforts
• "How Does your Engine Run" Increase awareness of self-regulation to increase optimal functioning
• Stress reduction activities: Progressive Relaxation, Full Breathing Exercise, Guided Relaxation, Attend to the Breathing, Creative Visualization, Stretching
• Sensory Awareness groups
• Drumming
• Hot shower/bath
• Sand therapy
• Art therapy
• Sensory Gardens
• DBT

List of Objects in various Comfort Rooms:

• Sponge painted walls
• Posters of nature scenes
• Bubble lamp with mirrors behind it
• Comfortable seating (bean bag, rocking chair, glider rocker)
• Recliner (a chair that can be bolted to the floor may be necessary)
• Walls with soft colors
• Murals
• Images chosen by consumers
• Stuffed animals
• Soft blanket
• Inspirational reading material
• Large stuffed animal for hugging
• Headphones can be made available
• Music
• Rocking chair
• Aquarium
• Listening to books on tape
• Word searches/word games
• Scent box
• Hot candy ball, peppermint
• Exercise bands
• Mats for yoga
• Large locked cabinet for sensory treatment items
• Activities basket
• Basket of stress balls
• Aromatherapy supplies, diffuser
• Weighted modalities (weighted blanket, "heavy duty dog", neck pillow, medicine ball, ankle and wrist weights)
• Vibrating foot massager
• Decorations with universal appeal
• Comfortable couch, chair, bean bag
• Dimmer switch
• Comfortable carpeting
• Vibrating chair
• Sound machines
• Electried sound and motion
• Wall pictures
• White board
• White noise
• Fiber optic spray lamp (visual or touch)
• Lava lamp
• Plants
• Relaxation and nature sound CD
• Books on tape
• Mobiles
• Vibrating pillow, back or foot massage
• A selection of throws or small blankets
• Oral motor stimulation items
• Self-help books
• Photography
• Koosh, stress, squishy balls, slinky, hand and foot rollers
• Bean bag for tapping
• Art supplies
• Black lights, neon lights
• Comfort boxes
• Comfort carts
• Decorated boxes for personal comfort items
• Coloring books
• Journaling paper
• Display residents art work
• Lemon balm found to reduce agitated behaviors when applied to face and arms daily
• Sewing activities
• Sorting activities
• Bubbles to blow (breath support)
• Pet magazines, self-help magazines
• Dark walls
• Motion picture on the wall
• Swing
• Dome light
• Use lamps instead of fluorescent lights
• Create a "quiet corner" (Montessori)
• Bucket of fresh nature items during each season (things to sort through, smell, touch, etc.)
• Men’s grooming basket
• Women’s skin and nail care basket
• Bin of beading supplies for jewelry making
• Craft basket
• Reminiscence basket
• Be sure to use fire resistant materials
• Dry erase board to sign materials out, notes for group meetings, etc.
• Lotion for arm and hand massages
• Tupperware container with raw rice
• Disco Ball
• Vibration
• Tunnels, body socks, finger painting (tactile experiences)
• Various tactile objects: straws, cotton balls, play dough, feathers, felt, foil, sponges
• Snoezelen®: white walls. Researchers focusing on the psychology of color agree that white promotes a sense of coolness, offers sharp contrast with other objects, makes space recede, and enlarges the area. White is described as vast, endless, pure, spacious, relaxing and uplifting
• Radio
• Projector
• Mirror ball
• Fish tank
• Glow in the dark stars
• Remote control devises that gives control over equipment

To Calm:

• Soft voices, rhythmic music, muted colors, single stimuli, minimized background stimuli, soft lighting, orderly rooms, slow movements, rhythmic rocking, pressure touch, hugging, moving against resistance

To Arouse:

• Loud sudden noises, bright colors, excessive background stimulus, bright florescent lights, cluttered room, fast movements, sudden position changes, light or unexpected touching

Data collection methods in Comfort Rooms:

• Two-sided form (before and after), 10 point scale used to for self-rating level of calm to distress. Four face icon were used to display varying levels of calm to distress
• Form with check boxes – which items were used and offer comments (e.g. need more art supplies, it would be great if we had a ____)
• Time of use and duration, therapist’s comments and observations

Sensory Modulation-Related Assessment Tools (Tina Champagne):

• Infant and child sensory profile (Dunn)
• Adolescent/Adult sensory profile (Dunn and Brown)
• Sensory-Integration Inventory-Revised (Reisman and Hanschu)
• Developmental Test of Visual Perception (Hammill, Pearson, and Voress)
• Sensory Modulation Screening Tool (Champagne)
• Sensory Defensiveness Screening Tools
• Assorted Sensory checklists (OTA Watertown)
• Assorted Sensory Diet Checklists
• Assorted Cognitive Assessment Tools

Incorporate Individual Treatment plan:

• Individual’s history, concerns, strengths, functional limitations, treatment goals, client’s account of what is helpful when in crisis, sensory activities that help (hyper of hypo)

Developing the Room:

• Rooms can be furnished according need and budget
• Should be able to duplicate some elements of the environment at home
• Develop a safe space: determine if the space will be used as a "drop in" or "supervised" space
• Easy to clean furniture
• Electrical items should be inspected by facility
• Directions on how to use equipment so child can do it on his or her own (foster independence)
• Purchase objects made of washable material

Developing the Room: Questions to ask (Champagne):

• What will be the main purpose of the room? Who will use it?
• How will safety be maintained?
• What space is actually available and can it be adapted?
• Do you want a simple non-stimulating environment or a more complex one?
• Who will supervise the environment?
• How will equipment be cleaned and stored?

Guidelines for use of the room:

• time frames
• supervision
• assessments
• personal safety plans
• sign- in book
• acquiring feedback from staff and residents
• how will you run an introductory group: combination of information and activities

Research shows that:

• The majority of people using comfort rooms abide by rules (backed by Binghamton visits, Hutchings, St. Lawrence)
• Success requires staff training and buy in
• Need top level support
• Need for flexibility
• Should be located close to a nurse’s station so that individual can be monitored
• Consumer involvement promotes use of the room
• Choose colors, mural images, name the room
• Help paint walls, decorate, select furniture and art work
• Develop policies and procedures
• Name room
• Develop goals for use
• Comfort room development requires a collaborative process with consumers and staff and should evolve over time
• Aspects of the room should be replicable (patients able to take home treatment, "discharge packets")
• Journal of Intellectual Disability, The British Journal of Clinical Psychology, White Top Research Unit of the University of Dundee, Scotland – published findings on the benefits of multi-sensory rooms

Implementation, Staff and Community Involvement:

• Identify a champion organizer
• Ideas for group meeting when introducing the room and its function
• Use interviews and questionnaires with staff and consumers to collect the following information
• What people want the purpose of the room to be
• Ideas for ways to utilize the space
• Ideas for what to have in the room
• How people want the space to be decorated
• It can be beneficial to introduce the room through showing photographs first, or not having all the equipment on at once
• Room should be located in a space that will be convenient for use at any time

Use of Comfort Rooms is endorsed by:

• The New York State Office of Mental Health
• The Joint Commission
• National Association of State Mental Health Program Directors- National Technical Assistance Center

On data driven research findings about comfort rooms:

• Limited research and literature available regarding the use of comfort/sensory rooms in acute care inpatient mental health care settings
• There is not an abundance of literature on Snoezelen®, but the majority comes from England
• Most studies find positive effects on the mood and behavior of subjects
• Most of the research has been on populations with autism and dementia
• Reports of use of comfort/Snoezelen® rooms are documented but not extensively studied
• Europe and Australia use rooms for persons with autism, behavioral disorders and the developmentally disabled
• Research on Snoezelen® has primarily been focused on children and adults with profound learning disabilities, mental retardation, and adults with dementia -Martin et al., 1998
• Limitations for most studies (decrease validity and generalizability of studies):
• Sample sizes
• Lack of objective observers
• Lack of control groups– as volunteers or referred by treatment team
• There have been few reports of effective strategies to curtail or provide alternatives to R/S use with children and adolescents in mental health facilities
• Terms that are used in research are left undefined, for example, "challenging behaviors decreased by 97%" but "challenging behaviors" is left undefined
• Snoezelen®: Dutch workers have generally avoided formal evaluation of the rooms out of fear that it would force the room into being more objective and product-oriented
• Little diversity in participants
• Because of research techniques the health care industry has been skeptical of Snoezelen® rooms
• Too few studies to make broad conclusions

Website References

Web Based Search:

You might want to try entering some of the following Key Words for Research:

• Comfort rooms and mental health
• Multi-sensory rooms
• Tina Champagne
• Multi-sensory
• Sensory rooms
• Calming rooms
• Gayle Bluebird
• Snoezelen®
• Visual stimulation
• Sensory deprivation
• Comfort rooms

For general information on Multi-Sensory Rooms:

Good place to start:

http://www.ot-innovations.com/content/view/49/46/
http://www.sensoryconnectionprogram.com/index.php

Good articles to read:

http://www.ot-innovations.com/images/stories/PDF_Files/qi_study_sensory_room.pdf  (PDF)The Effects of the Use of the Sensory Room in Psychiatry by Tina Champagne, M.Ed. , OTR/L

Websites for general information about Comfort Items and Snoezelen® Brand Products:

http://www.ot-innovations.com/component/option,com_weblinks/catid,28/Itemid,23/ * This websites provides links to multiples resources

http://www.snoezeleninfo.com/products.asp

http://www.flaghouse.com/bring_AL.asp

http://www.somatron.com/

http://www.rompa.com/cgi-bin/Rompa.storefront

http://www.store.schoolspecialty.com

http://www.specialneedstoys.com/mse/viewcontent.asp?section=MSE

http://www.abilitations.com/sportime-shared/activityGuidesAB.jsp

http://www.changingimages.org

http://www.designerlightpanels.com

References:

Baillon, S., van Diepen, E., and Prettyman, R., (2002). Multi-sensory therapy in psychiatric care. Advances in Psychiatric Treatment. 8. 444-452.

Bluebird, G. (2002). Comfort and communication help minimize conflicts National Technical Assistance Center. Summer/Fall, Special Edition. 18-19.

Bluebird, G. (2005). Comfort rooms: reducing the need for seclusion and restraint. Residential Group Care Quarterly. 5(4). 5-6.

Bluebird, G., (2004). Redefining consumer roles: changing culture and practice in mental health settings. Journal of Psychological Nursing. 42(9). 46-53.

Bluebird, G. (2000). Using the arts to recover mental health. Mental Health Recovery Newsletter. 1(3).

Cantu, C. (2004). White space and sensory rooms. Advance for Occupational Therapy Practitioners. 20(19). 12.

Centers for Medicare and Medicaid Services (CMS), (April 11, 2008). "State Operations Manual: Advance Copy" Department of Health and Human Services, Centers for Medicare and Medicaid Services. Issued, April 11, 2008.

Champagne, T. (2008). Sensory rooms in mental health. Accessed on January 29, 2008 from: http://www.ot-innovations.com/content/view/49/46/

Champagne, T., and Sayer, E., (N/A). The effects of the use of the sensory room in psychiatry. Copyright by Tina Champagne.

Champagne, T., and Stromburg, N., (2004). Sensory approaches in inpatient psychiatric settings. Journal of Psychosocial Nursing. 42(9). 1-8.

Crisis Consultant Group, LLC (2005). Comparison: Pennsylvania regulation comparison to: CCG’s facing emergencies and reacting crisis intervention training. Crisis Consultant Group, LLC. Accessed February, 2008 from http://www.crisisconsultantgroup.com/

Curie, C. (2005). SAMHSA’s commitment to eliminating the use of seclusion and restraint. Psychiatric Services. 59(9). 1139-1141.

Donat, D., (2003). An analysis of successful effort to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Services. 54(8). 1119-1123.

Donat, D., (2005). Encouraging alternatives to seclusion, restraint, and reliance on PRN drugs in a public psychiatric hospital. Psychiatric Services. 56(9). 1105­1108.

Donovan, A., Siegel, L., Zera, G., Plant, R., and Martin, A., (2003) Seclusion and restraint reform: an initiative by a child and adolescent psychiatric hospital. Psychiatric Services.54(7). 958-959.

Donovan, A., Plant, R., Peller, A., Siegel, L., and Martin, A., (2003). Two-year trends in the use of seclusion and restraint among psychiatric hospitalized youth.

Glick, J., (2006). "Excited delirium" cited in deaths. ABC News Associated Press. Accessed on March 30, 2008 from: http://www.policeone.com/edp/articles/1179873-Excited-Delirium-cited-in-deaths/

Harmon, T. (2005). Restraint and seclusion: New York state practices receive national attention. CQC. Accessed February, 2008 from http://www.cqcapd.state.ny.us/advocacy/publications/pubvoice.htm

Hogg, J., Cavet, J., Lambe, L., and Smeddle, M., (2001). The use of Snoezelen® as multi-sensory stimulation with people with intellectual disabilities: a review of the research. Pergamon, Research in Developmental Disabilities. 22. (353­372).

Huckshorn, K. (n/a). 6 core strategies for reducing seclusion and restraint use©, draft example: policy and procedure on debriefing for seclusion and restraint reduction projects. National Association of State Mental Health Program Directors, National Technical Assistance Center. Accessed on April 24, 2008 from: http://www.nasmhpd.org/nasmhpd_collections/collection5/publications/ntac_pubs/Debriefing%20p%20and%20p%20with%20cover%207-05.pdf  (PDF)

Hudson, J., (2006). Sample S&R reduction priorities of P&As – 2006 TASC skills building conference. Written in association with the National Disabilities Rights Network.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO), (2004). System analysis: assess early and often avoid unnecessary use of restraint and seclusion. Joint Commission Perspectives on Patient Safety. 4(5). (5-6). Accessed on June 17, 2008 from: http://www.jcipatientsafety.org/fpdf/psp/PatientSafetyArticles/S3-PS-05-04.pdf  (PDF)

Jonikas, J., Cook, J., Rosen, C., Laris, A., and Kim, J., (2004). A program to reduce the use of physical restraint in psychiatric inpatient facilities. Psychiatric Services. 55(7). 818-820.

Kinkead, G., (2003). A room comes alive with color and sounds. The New York Times. December 23, 2003.

LeBel, J., (2006). Rediscovering pathways to compassionate care. American Academy of Child and Adolescent Psychiatry News. Accessed in February, 2008 from http://www.aacap.org/cs/root/member_information/practice_information/jan/feb_2006_aacap_news_seclusion_restraint_rediscovering_pathways_to_compassionate_care  (PDF)

LeBel, J., Stromburg, N., Duckworth, K., Kerzner, J., Goldstein, R., Weeks, M., Harper, G., LeFlair, L., and Sudders, M., (2004). Child and adolescent inpatient restraint reduction: a state initiative to promote strength-based care. Journal of the American Academy of Child and Adolescent Psychiatry. 43(1). 1-20.

Long, A., and Haig, L., (1992). How do clients benefit from Snoezelen®? An exploratory study. British Journal of Occupational Therapy. 55(3). 103-106.

Matson, J., Bamburg, J., and Smalls, Y., (2003). An analysis of Snoezelen® equipment reinforces persons with severe or profound mental retardation. Science Direct, Research in Developmental Disabilities. 25. (89-95).

Mawson, A. (1999). Stimulation-induced behavior inhibition: a new model for understanding physical violence. Integrative Physiological and Behavior Science. 33(3). 177-197.

McLoughlin, K. (2002). Following the yellow brick road: a story about a sensory awareness group. Social Work with Groups. 25(4). 21-35.

Minner, D., Hoffstetter, P., Casey, L., and Jones, D., (2004). Snoezelen® activity: the good shepherd nursing home experience. J Nurs Care Qual. 19(4). 343-348.

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