Seclusion and restraints have no therapeutic value, cause human suffering, and frequently result in severe emotional and physical harm, and even death. Therefore, as a matter of fundamental policy, Mental Health America (MHA) urges abolition of the use of seclusion and mechanical restraints and prohibition of the use of sedatives and other medications as chemical restraints and elimination of the use of physical restraints except for very brief periods and only when necessary to prevent imminent physical harm.
The most isolated people in our society are those confined in the dungeons, the “holes,” of administrative and punitive segregation in jails and prisons, on death row, and in “supermax” prisons. Many of these people are in seclusion for their own protection, rather than for disciplinary reasons.1 Seclusion exacerbates the suffering of people with mental health conditions, who make up approximately half of the prison population.2 And solitary confinement is a cruel and traumatizing threat to the mental health of anyone so deprived of human interaction. As Justice Kennedy remarked in 2015 in his concurrence in Davis v. Ayala,3
The human toll wrought by extended terms of isolation long has been understood, and questioned, by writers and commentators…. One hundred and twenty-five years ago, this Court recognized that, even for prisoners sentenced to death, solitary confinement bears “a further terror and peculiar mark of infamy.” In re Medley, 134 U. S. 160, 170 (1890); see also Id., at 168 (“A considerable number of the prisoners fell, after even a short [solitary] confinement, into a semi-fatuous condition. . . and others became violently insane; others, still, committed suicide; while those who stood the ordeal better were not generally reformed, and in most cases did not recover sufficient mental activity to be of any subsequent service to the community”).
The In re. Medley court held that additional punishment of one month of solitary confinement was simply too egregious to ignore; declared Mr. Medley a free man; and ordered his release from prison. Mr. Justice Rehnquist continued:
[R]esearch still confirms what this Court suggested over a century ago: Years on end of near-total isolation exacts a terrible price. See, e.g., Grassian, “Psychiatric Effects of Solitary Confinement,” 22 Wash. U. J. L. & Policy 325 (2006), https://openscholarship.wustl.edu/cgi/viewcontent.cgi?article=1362&context=law_journal_law_policy (common side-effects of solitary confinement include anxiety, panic, withdrawal, hallucinations, self-mutilation, and suicidal thoughts and behaviors). In a case that presented the issue, the judiciary may be required, within its proper jurisdiction and authority, to determine whether workable alternative systems for long-term confinement exist, and, if so, whether a correctional system should be required to adopt them.4
Thus, the constitutional validity of long-term segregation remains a matter of serious doubt, which MHA shares.
MHA also cautions against any unnecessary use of restraints. Handcuffs and leg irons are still used indiscriminately for prisoner transfers throughout the criminal justice system and for civil committees as well as persons accused of crimes. MHA is already on record opposing use of such restraints in juvenile justice interactions whenever possible.5 MHA has authored legislation advocating an imminent danger standard for use of seclusion and restraints in child residential care 6. And caution is appropriate for adult prisoners as well, especially those with mental health conditions. Previous trauma is a strong contra-indication to any use of restraints and should be clearly noted to avoid further harm whenever possible. But this position statement is focused on use of restraints and seclusion in behavioral health treatment facilities.
Behavioral Health Treatment
People are still being traumatized and dying from the use of seclusion and restraints. Lack of adequate staffing cannot justify the use of seclusion and restraints, and staffing may need to be increased to further this goal. It is noteworthy, however, that Pennsylvania has greatly and sustainably reduced the use of seclusion and restraints without increasing staffing or other resources, and that reduction in the use of seclusion and restraints has increased staff safety and has not increased violence. 7
In the tradition of Clifford Beers, Mental Health America challenges the mental health professions to live up to the vision expressed by SAMHSA, NASMHPD (the National Association of State Mental Health Program Directors), and the Commonwealth of Pennsylvania, all of which have adopted the goal of ultimately eliminating the use of seclusion and restraints in behavioral health facilities.. This goal was adopted by SAMHSA in its 2005 “Roadmap to Seclusion and Restraint Free Mental Health Services” 8 and by NASMHPD in a comprehensive 1999 position statement.9 State and federal agencies should take a greater role in assuring the safety and protection of children, young people, and adults in psychiatric settings. Use and abuse of restraints and seclusion are symptoms of poor quality of care, poor oversight, and misdirected public policy.
The recent work of Haugom, Ruud & Hynnekleiv (2019), demolishes the “Big Nurse” insistence that seclusion or restraints can be justified as “treatment:”
In this study, the principle of beneficence may conflict with autonomy when staff wants to use seclusion as treatment when the patient does not desire it. Beneficence includes a moral obligation to act for the benefit of the patient. However, patient preferences should be acknowledged, and staff should weigh all available options and carry out seclusion only when the benefits exceed the disadvantages. One should then know that seclusion as treatment is effective enough to outweigh the disadvantages of acting against the patient’s desire. Unfortunately, there are, to our knowledge, no studies that definitively support the therapeutic effect of seclusion. Hence, it is difficult to find sufficient ethical arguments for the implementation of seclusion against the patient’s will.10
Despite deep abhorrence of the long history of abuse of seclusion and restraint and the fact that these practices cause trauma even when used by well-meaning practitioners, MHA’s policy must also take into account exceptional circumstances in which physical restraints, in the least restrictive manner possible, may be required to avert imminent serious physical harm. Even in Pennsylvania, which has worked hard to eliminate coercion, physical restraints continue to be used about 700 times a year. Seclusion and mechanical restraints have been eliminated, but voluntary disengagement has been preserved. MHA stresses that truly voluntary disengagement, as with time-out and comfort room procedures, and occasional physical restraints for the safety of staff and people in treatment, are essential tools, along with committed staff, in reducing conflict and restoring calm. The unlocked door and the avoidance of physical restraints except when absolutely required makes all the difference.
It is an indictment of American society that secure mental health facilities are not available in many rural areas and there may be no appropriate facility in a given area that will accept individuals without the latitude to use restraints. Nonetheless, where it is unavoidable, use of physical restraints under careful medical supervision as detailed in this policy is preferable to confinement in a jail or other correctional facility. In all such circumstances, MHA insists that any use of restraints be in the least restrictive manner and accompanied by ample safeguards to protect the person being restrained.
Mental Health America evolved from the National Committee for Mental Hygiene, which was founded in 1909 by Clifford W. Beers, a person with a mental illness who had experienced restraint and seclusion and was horrified by the abuse that he witnessed and experienced in the back wards of the asylums and mental hospitals of his time. He founded the organization that now is called Mental Health America to put an end to such needless suffering. MHA has as its symbol a 350-pound bell cast from melted-down shackles and chains formerly used to restrain people with mental illnesses in psychiatric facilities.
In his autobiography, A Mind that Found Itself, Beers remarked of the coercive aspects of the mental hospitals of his day: “Is it not, then, an atrocious anomaly that the treatment often meted out to insane persons is the very treatment that would deprive some sane persons of their reason?”11
Charles G. Curie, administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) from November 2001 to August 2006, made reducing and ultimately eliminating the use of seclusion and restraints in psychiatric facilities one of his top priorities. In 2002 he stated:
Seclusion and restraint – with their inherent physical force, chemical or physical bodily immobilization and isolation – do not alleviate human suffering. They do not change behavior. And they do not help people with serious mental illness better manage the thoughts and emotions that can trigger behaviors that can injure them or others. Seclusion and restraint are safety measures of last resort. They can serve to re-traumatize people who already have had far too much trauma in their lives. It is my hope that we can create a single, unified policy – a set of primary principles that will govern how the Federal Government approaches the issue of seclusion and restraint for people with mental and addictive disorders.”12
Under Charles Curie’s leadership, continued under his successors, SAMHSA’s vision has been to reduce and ultimately eliminate seclusion and restraints from behavioral health treatment and rehabilitation facilities.
Likewise, NASMHPD (the National Association of State Mental Health Program Directors) has called seclusion and restraints “safety interventions of last resort” and “not treatment interventions,” and NASMHPD has put a priority on “prevent[ing], reduc[ing], and ultimately eliminat[ing] the use of seclusion and restraint and . . . ensur[ing] that, when such interventions are necessary, they are administered in as safe and humane a manner as possible by appropriately trained personnel.”13 This position was reiterated by then NASMHPD executive director Bob Glover in 2005 when he wrote, “I believe that state facilities and other service providers must continue to make it a priority to reduce and ultimately eliminate these coercive practices in order to improve the quality of people’s lives.”14 NASMHPD led the way by passing the 1999 policy cited above (revised in 2007)15, advocated change, and the states responded. Data gathered by the NASMHPD Research Institute from more than 200 psychiatric facilities between January 2000 and December 2004 showed a 16% reduction in the use of restraint (400 fewer patients per month) and a 45% reduction in the use of seclusion (1,000 fewer patients per month) over that period.16
NASMHPD officials are persuaded that all states would like to achieve major reductions in the use of seclusion and restraints but concede that no funding has been available to help, and evaluation and transparency have languished since 2009, so progress since then is unknown. As the states work toward eliminating the use of seclusion and restraints in behavioral health facilities, MHA advocates for much more transparency so that states and caregivers are both supported and accountable. Trauma-informed care and strict safeguards are also needed, to minimize trauma and harm.
Unfortunately, despite this progress, there are still insufficient national standards governing how and when to use or avoid seclusion and restraints. Few states make available aggregate data on the use of seclusion and restraints or even require the reporting and investigation of a death in a private or state psychiatric facility, and the federal government does not collect data on how many people are injured. The Harvard Center for Risk Analysis at the Harvard School of Public Health has estimated that the annual number of deaths range from 50 to 150 per year, which translates to three deaths every week.17
In 2011, reinforcing its 2005 Roadmap, SAMHSA issued an important “white paper” stating the “business case” for limiting use of seclusion and restraints.18 The abstract of the white paper demonstrates the overwhelming character of the business case for reform:
Restraint and seclusion are violent, expensive, largely preventable, adverse events. The rationale for their use is inconsistently understood. They contribute to a cycle of workplace violence that can reportedly claim as much as 23 to 50 percent of staff time (LeBel & Goldstein, 2005; Flood, Bowers, & Parkin, 2008), account for 50 percent of staff injuries (Short et al., 2008), increase the risk of injury to consumers and staff by 60 percent (Florida Taxwatch, 2008), and increase the length of stay, potentially setting recovery back at least 6 months (Florida Taxwatch, 2008) with each occurrence. Restraint and seclusion increases the daily cost of care (Cromwell et al., 2005) and contributes to significant workforce turnover reportedly ranging from 18 to 62 percent (Paxton, 2009), costing hundreds of thousands of dollars to several million (LeBel & Goldstein, 2005; Besemer, Siler, & Vargas, 2008). These procedures also raise the risk profile to an organization and incur liability expenses that can adversely impact the viability of the service. Many hospitals and residential programs, serving different ages and populations, have successfully reduced their use and redirected existing resources to support additional staff training, implement prevention-oriented alternatives, and enhance the environment of care. Significant savings result from reduced staff turnover, hiring and replacement costs, sick time, and liability-related costs.
Conclusion: Successfully reducing or preventing seclusion and restraint requires leadership commitment, resource allocation, and new tools for staff. Substantial savings can result from effectively changing the organizational culture to reduce and prevent the use of restraint and seclusion.
Unfortunately, outside of SAMHSA’s efforts, the federal government has failed to stand behind and enforce earlier-established regulatory standards governing seclusion and restraint. The Health Care Finance Administration (HCFA), now the Center for Medicare and Medicaid Services (CMS), promulgated revised regulations for hospitals in 1999 and residential treatment facilities for young people under 21 in 2001 to make the use of seclusion and restraint safer for both young people and adults. The regulations require a face-to-face evaluation by a physician or licensed independent practitioner of any individual in seclusion or restraint within one hour of the event to check on the need for these interventions and on the individual’s safety. The “one-hour rule” evoked considerable controversy and strong objections from some quarters. CMS responded in 2007 by issuing a Final Rule19 which allowed for other staff members, including nurses, to conduct patient evaluations and issue seclusion and restraint orders, a change which has been decried as insufficiently protective of patient safety.20
Pennsylvania’s Success Story
Since 1997, the Pennsylvania State Hospital System has been recognized as a worldwide leader at reducing the use of seclusion and restraints in its large state hospital system.
As Deputy Secretary of the Pennsylvania Office of Mental Health and Substance Abuse Services, Charles Curie oversaw a statewide program to reduce and ultimately eliminate the use of seclusion and mechanical restraints in the state hospital system. By 2000, Pennsylvania had reduced the incidence of seclusion and restraints in its nine State hospitals by 74 percent, and reduced the number of hours that people in treatment spent in seclusion and restraints by 96 percent. In the 2018-2019 fiscal year, There was no use of seclusion or mechanical restraints, but physical restraints were still used for short periods 700 times in the State’s civil hospitals and forensic centers. Seclusion has not been used in the State hospital system since July 2013. Moreover, Pennsylvania’s hospitals have demonstrated that over-time, from 2001-2010, patient-to-patient and patient-to-staff assaults have declined while the use of containment procedures significantly decreased.21 Pennsylvania worked to change the culture of its state hospitals to a recovery-based system of care.22
The key components of Pennsylvania’s seclusion and restraints reduction policy are:
- Seclusion and restraints are treated as exceptional and extreme practices and as an intervention of last resort.
- Staff must work with the person in treatment to end seclusion and restraints as quickly as possible.
- Orders are limited to 30 minutes and require a physician to physically assess the person in treatment within 30 minutes. Physical restraint is limited to 3 minutes and any type of floor control, prone or supine, is prohibited. Physical restraint use can be extended an additional 3 minutes, but after that the individual must be transitioned to mechanical restraint. In 2018-2019, this has never occurred. Flexible PRN (as needed) orders for psychiatric medications are prohibited. Each use of medication for a psychiatric indication must be approved by a physician. Each hospital unit must create a “Do-Not-Restrain Patients identified with Special Precautions to Restraint” list of people served on the unit who may not be restrained or secluded due to a pre-existing medical or psychiatric condition.
- People being restrained may not be left alone. In-person observation is required.
- Chemical restraints are prohibited. The treatment plan must include specific interventions to avoid seclusion and restraint.
- Other prohibited practices include:
- Using compliance, trigger points, pressure points,
- Hyper-extension of any part of the body,
- Pressure or weight on the chest, lungs, sternum, diaphragm, back or upper abdomen,
- Any technique that obstructs or restricts the circulation of blood and/or airway,
- Straddling or sitting on any part of the body,
- Any type of choking, hand chokes, arm chokes,
- Any technique that involves pushing into the person’s mouth, nose, eyes or nay part of the face, or covering the face or body,
- Any technique that involves substantial risk of injury,
- Any manual restraint that maintains a person on the floor in any position (prone, supine, side-lying),
- Any technique that keeps the person off balance, e.g. shoving, tripping and pushing on the back of knees.
- People in treatment and staff are debriefed after every incident, and treatment plans are reviewed and updated as needed. Any use of seclusion or restraints is documented in the person’s file along with the rationale as to why alternative measures failed or were not attempted.
- With the permission of the person undergoing treatment, family members are notified of each containment event.
- Staff is trained in verbal de-escalation, using the Mandt techniques,23 and refresher training is required annually. PA has recently expanded the curriculum to include advanced trainings to better deal with specific situations and for additional techniques in dealing with highly aggressive individuals to include Verbal Judo, Trauma Informed Care, and Mental Health First Aide.
- Clinical alerts are used to identify people who are high-users of containment procedures and people who engage in frequent assaults.
- Monthly reports on hospital and system use of these procedures, along with 40 other measures, are issued through the State webpage.
- Psychiatric Emergency Response Teams (PERT) promote a non-violent approach to supporting people in behavioral or psychiatric distress.24
Pennsylvania has continued to work on reducing any type of restraint including physical holds. Contributing factors in this reduction include – training staff in Verbal Judo, the use of unlocked and remodeled “comfort rooms,” daily monitoring of patient behavior and use of STAT meds with a rapid clinical intervention led by administration with the treatment teams via a complex case meeting to support the staff and the patient to get through the crisis, developing specific nursing interventions for aggressive behavior as appropriate on each patient’s plan of care, updating restraint documentation with reminders to include and offer less restrictive intervention, and developing a team/plan prior to admission to manage aggressive behavior prior to the person’s admission.
This initiative has produced a cultural change conducive to expedited recovery, hospital discharge, and community reintegration. Seclusion and restraints are no longer considered an acceptable first response to aggressive or self-injurious behavior. The demonstrated stability of Pennsylvania’s results and the transparency of this initiative are especially commendable. This is not a temporary PR effort, aided by the “Hawthorne effect,”25 looking good while the evaluators are looking. It is an ongoing transformation in the true sense of that overused term: a change of attitude under which restraints and seclusion are routinely avoided as other techniques are shown to work in practice and ward staff are supported in doing the right thing. If staff safety and morale are not protected, this kind of transformation is impossible.
To the Pennsylvania policy, MHA would add the following recommendations:
- Trauma-informed care requires a real commitment to prevent the incidents/flash-points that cause treatment staff to consider coercion.
- Voluntary time-out, comfort rooms, and any other voluntary separation of a person in treatment must be truly voluntary and should be easily available.
- Subject to confidentiality protection under HIPAA, any authorized representative of people in treatment, as well as the management of the facility, should be informed of each restraint or seclusion event immediately.
- Subject to HIPAA, families or authorized representatives, people in treatment, and involved staff should engage in a de-briefing session after each event to discuss the circumstances leading up to the event, why alternatives to seclusion and restraints failed, and other interventions that might be more effective in future situations. In order to reduce trauma related to the event, de-briefing sessions with staff should be separate from de-briefing sessions with the person in treatment and the family.
- A person’s age, developmental needs, gender identity, ethnicity, and history of sexual or physical abuse should be taken into account when implementing seclusion and restraint procedures.
- As suggested in PA, staff training on the safe support of people in crisis should be required (not just offered) at least every six months with emphasis on non-violent approaches in care and service. More frequent updates and alerts via in-house electronic media, email, etc. on related safe-practices should also be used to promote a safety-first approach to care.
- Many mental health facilities ration treatment based on behavior. This can make it difficult to get an early intervention to prevent use of seclusion and restraints. Excessive fidelity to level systems should be avoided so that people in treatment have access to treatment when they need it to prevent an incident or flash-point.
- The physical environment can be a powerful tool. It must be addressed in an ongoing manner to prevent deterioration. See description of South Carolina study, immediately below.
Physical Environment-- The South Carolina Study
Although the quality of staff interaction is the ultimate technique to reduce coercion in mental health treatment, research shows that changes in the physical environment may be an important ingredient in bringing about culture change. A study of success factors among the reforms implemented at a South Carolina hospital included important physical changes as well as staff interaction changes:
- For rules and language, all unit staff attended a standardized training seminar on the effect of rules and language on patients’ perceptions. The rules and language intervention included the establishment of a team for each unit that was tasked with reviewing or eliminating unit rules that were too restrictive. All unit staff attended follow-up half-day seminar during which the rule changes were articulated and the effect of coercive language on patients’ experiences was discussed. All signs on the units were reviewed and revised as necessary to ensure that they reflected the new, less restrictive rules and used non-coercive language. The therapeutic environment intervention involved making inexpensive physical changes, including repainting walls with warm colors, placement of decorative throw rugs and plants, and rearrangement of furniture to facilitate increased patient-patient and patient-staff interaction, as well as holding staff-patient group meetings regularly on the unit. Two separate therapeutic environment interventions were allotted to each unit. The second intervention included replacing worn-out furniture and continuing with environmental changes initiated during the first intervention.
The study concluded:
- After the analysis controlled for the effects of acuity and the observation-only phase effect, one intervention was uniquely associated with significant reductions in the rate of seclusion and restraint independent of when and where it was implemented in the schedule. The implementation of change to the physical characteristics of the therapeutic environment was associated with a significant reduction in use of seclusion and restraint (F=7.94, df=1 and 119, p=.006).26 None of the other interventions of the engagement model were uniquely and significantly associated with a reduction in use of seclusion and restraint.
Examination of 10 years (January 1, 2003, through December 31, 2012) of seclusion and restraint use at the same institution elaborated:
- The findings suggest that reduction in seclusion and restraint use is sustainable, and judicious use of seclusion and restraint can become the new normative practice—even in the face of potentially disruptive administrative and environmental changes.27
It is unknown to what extent physical facility upgrades contributed to Pennsylvania’s success, which was system-wide, making isolation of success factors more difficult. Nonetheless, it seems clear that physical changes to the treatment environment are an important building block in implementing a successful transition to less coercive treatment. Both the staff and the people in treatment can benefit enormously from improvements in the physical environment. But a well-designed treatment setting can be easily marred by coercive, authoritarian signage and red tape on the floors. It takes a culture change to make a physical change truly transformative.
SAMHSA and NASMPHD
In 2002, SAMHSA identified the reduction and eventual elimination of seclusion and restraint in mental health and substance abuse treatment as a key priority, which is what led to the issuance of the 2005 Roadmap. Accordingly, SAMHSA developed the Alternatives to Restraint and Seclusion (ARS) State Incentive Grants (SIG) Program, which was administered by NASMHPD. In 2004, SAMHSA awarded a maximum total of $237,000 per year to states for up to 3 years. Grantees for the first round of the ARS SIG program included state mental health authorities in the following states: Hawaii, Illinois, Kentucky, Louisiana, Maryland, Massachusetts, Missouri, and Washington. Technical assistance was provided to the States through a contract with the National Association of State Mental Health Program Directors (NASMHPD). In 2007, Connecticut, Indiana, New Jersey, New York, Oklahoma, Texas, Vermont and Virginia received grants. Funding ended in 2009.The majority of the facilities (n=28, 65.1 percent) reached stable implementation of the prescribed SAMHSA Six Core Strategies at the end of the project period. Unfortunately, there has been no follow-up to determine long-term effects of the grant program.
SAMHSA/NASMHPD’s 2010 report on the Alternatives to Restraint and Seclusion grants found:
- Seclusion Rates
- Of the 28 facilities that reached stable implementation, 20 (71.4 percent) were able to reduce seclusion hours per 1,000 treatment hours by an average of 19 percent (p=.001). These facilities were also able to reduce the percentage of consumers secluded by an average of 17 percent (p=.002). Of the 20 facilities, 16 facilities (80.0 percent) significantly reduced seclusion hours per 1,000 treatment hours (p<.10); while 12 facilities (60.0 percent) significantly reduced the percentage of consumers secluded (p<.10).
- Facilities that reached stable implementation showed a greater decrease in seclusion hours per 1,000 treatment hours between pre- and post-implementation than facilities in the other implementation groups (r=.88; p=.02). However, facilities that were still attempting to implement the Six Core Strategies at the end of the project (but had not reached stability) showed the greatest decrease in the percentage of consumers secluded (r=.40; p=.03) in comparison to the facilities in the other implementation groups.
- Restraint Rates
- More than half of the 28 facilities that reached stable implementation (n=15, 53.6 percent) were able to reduce restraint hours per 1,000 treatment hours by an average of 55 percent (p=.083), while 16 of the 28 facilities (57.1 percent) in this group were also able to reduce the percentage of consumers restrained by an average of 30 percent (p=.027). Thirteen facilities (86.7 percent) significantly reduced restraint hours per 1,000 treatment hours (p<.10), while 9 facilities (56.2 percent) significantly reduced the percentage of consumers restrained (p<.10).28
Though these results should be added to the results of earlier efforts to reduce coercion previously reported by NASMHPD, which improves the picture substantially, facilities in Pennsylvania and Massachusetts experienced much greater reductions in the use of seclusion and restraints even without the additional advocacy, expertise, and money leant by SAMHSA and NASMHPD through federal policy development and the ARS grants. Nonetheless, improvement was shown by each state that accepted a grant and worked to reduce coercion in its stewardship of people in treatment. The Hawthorne effect probably produced some of the immediate improvement in a bad situation, and NASMHPD officials doubt that the effects were sustained after the grant program ended and the states stopped reporting their rates of use of seclusion and restraint. There are (therefore) insufficient data to demonstrate this. MHA’s commitment is to keep attention focused in order to prevent a return to the coercive practices that we all now know are unnecessary as well as futile and harmful.
The Safewards Model
Finland, Australia, and the United Kingdom have undertaken recent systematic programs to reduce the use of coercion in mental health treatment.29 The experience in the United Kingdom has focused on the “Safewards Model.” This model is well-articulated and depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. These domains give risk to “flashpoints,” which have the capacity to trigger conflict and/or containment.
Under the Safewards Model, it is critical to develop a staff team approach to respond to these flashpoints. To be effective, the response must include: (a) critical roles of leadership and staff in successful R/S reduction projects; (b) ability of leaders and staff to change their beliefs and behaviors; (c) ability of leaders and staff to build a shared vision that was critical to the reduction of R/S use in in-patient settings; (d) identification and resolution of key challenges staff and leaders experienced in reduction efforts; (e) use of a solid performance improvement lens to direct changes in practices; and (f) iterative study and reporting of important lessons learned.30 Staff interventions can reduce the conflict-originating factors, prevent flashpoints from arising, cut the link between flashpoint and conflict, avoid use of seclusion and restraints, and ensure that containment use does not lead to further conflict. The Safewards Model eloquently describes the transformation that is needed.
The staff modifiers of the Safewards Model include the following:
- Minimizing staff anxiety and frustration, or rather maximizing the degree to which staff can regulate their normal emotional responses to disruptive behavior that threatens the internal structure of the ward. Staff anxiety accentuates anxiety and self-control ability and hinders staff's ability to respond in the most effective and socially skilled way. Staff frustration and anger have the capacity to amplify anger, or alternatively trigger catastrophic loss of self-esteem, either of which can trigger further or more extreme conflict behaviors.
- Making moral commitments, particularly to honesty (even when it was difficult or costly), bravery (being willing to confront and risk violence when necessary), equality (demonstrating, through a variety of ways, a lack of superiority), nonjudgmentalism (eschewing large-scale moral valuation of the person in treatment), universal humanity (expression of an inclusive picture of the human race and a valuing of people despite their diversity) and individual value (an appreciation of the value of the individual person).
- Increasing psychological understanding, meaning being able to deploy a range of alternative explanations for the difficult behavior, derived from psychological models, studies or psychotherapeutic approaches, instead of judging people to be morally bad and worthy of punishment. These psychological understandings, thus, generate different ways for staff to respond to such behaviors, as well as aid with emotional self-regulation.
- Increasing teamwork and consistency refers to the way in which the staff support each other practically and psychologically so as to aid emotional regulation, specifically in allowing ventilation of emotions ‘off stage’ [in a suitably private setting] and in sharing the burden of face-to-face contact with challenging patients. In addition, the team produces consistency in asserting and applying the internal structure to patients, consistency over time, between nurses, and between patients. This aids in legitimizing the internal structure in the eyes of patients, supporting self-control, and dampening any sense of injustice and therefore anger.
- Promoting technical mastery refers to the range, depth and quantity of social and interpersonal skills and responses available to the staff in order to deal with patient challenges to the internal structure, including bringing comfort to the distressed and the de-escalation of those becoming agitated, as well as skilled exercise of power and control.
- Sustaining positive appreciation indicates the degree to which the staff like and enjoy being with people in recovery, affording them respect, compassion and companionship.”31
Staff commitment to non-coercive ways of containing disruption is the key to success. Strengths-based programs can increase the resilience of people in treatment and give them new skills to handle flash-points on their own. Resilience is the ability of an individual to adapt to stress and return to competence and equanimity, and it comes in many forms. Patience is indispensable. As stated by one staff supervisor interviewed for this analysis: “Over the years I have sung, danced, reassured and complimented patients in every imaginable way, let patients call people on the phone, tried pills, food, drink, exercise, all manner of art therapy, jokes, appealed to their intelligence, ignored when they have called me every nasty word in the book and abused my staff with racial and sexual slurs. People on my acute unit can yell and scream, roll on the floor, practically anything as long as they are not harming themselves or someone else.”
Christopher Feltner has developed a promising model of de-escalation that can be used for all but the most violent physical encounters.32 Feltner drew on his background to come up with something that used the gentle parts of an array of martial arts techniques. At first, it was mostly blocking techniques using soft objects. The aim was to emphasize comfort rather than control, reinforcing relationships rather than tearing them apart.
Calling it Ukeru, from a Japanese word meaning “to receive,” and based on his understanding of body mechanics and his martial arts experience, Feltner has now developed a full set of techniques.33 The results have been promising and support Feltner’s idea that it is possible to do this job without restraining and secluding patients and without anyone getting hurt. Moving to facilities in Virginia, Ohio, Alabama and Australia, Ukeru is an instructive practical technique to reduce coercion in mental health treatment facilities.
Call to Action
- The states should require all psychiatric facilities (public and private) to implement, monitor and enforce strategies and staff training to prevent and ultimately eliminate the use of seclusion and mechanical restraints.
- Improvement of physical facilities is the most powerful single change in fostering a non-coercive environment.
- The states should improve enforcement of the basic human rights of residents in psychiatric facilities by immediately investigating any harm resulting from a facility’s use of seclusion and restraints.
- The states should maintain and publicize records of deaths and other complications which occur during the use of seclusion or restraints.
- Seclusion and restraints should never be used as punishment or discipline or for the convenience of staff.
- Medication should never be used as a “chemical restraint” to reduce the ability of a consumer to move for purposes of discipline or staff convenience. MHA calls on professional associations and the federal government to develop and maintain practice guidelines for emergency medical interventions to avoid the use of chemical restraints.
- All staff should be trained and demonstrate competence in non-physical intervention and de-escalation techniques to prevent the use of seclusion and restraints and in the safest and least restrictive ways to use seclusion and restraints. These trainings should take place when staff are first hired and continually at regular intervals. Only staff persons who have received this training should be involved in seclusion or restraint of consumers. HHS, SAMHSA and the Center for Mental Health Services should develop a curriculum for states to certify trainers to do this work.
- Psychiatric facilities should encourage people in treatment to develop advance directives that specify the conditions in which they authorize that seclusion and restraints be used and detail alternative techniques that the person in treatment requests to help reduce his or her agitation and problematic behavior prior to the imposition of seclusion or restraints.34 Engaging consumers in this activity should take place immediately upon admission or at the next clinically appropriate time because a disproportionately large number of seclusion and restraint events take place in the first few days after a person is admitted to a psychiatric facility.
- Facilities should be sufficiently constructed, maintained and staffed to prevent the need for restraints and seclusion.
- Weakened federal regulatory standards on seclusion and restraints, including the Final Rule's less stringent interpretation of the “one-hour rule,” should be returned to their previous strength in order to safeguard the rights of residents and ensure their well-being. Note that PA has successfully implemented a 30-minute policy, and, for physical restraints, a three-minute policy.
- As advocated by NASMHPD in its 2007 position statement, the four techniques recommended by the National Technical Assistance Center (NTAC) should be implemented to reduce the need for use of seclusion and restraints.
- To reduce and ultimately eliminate the use of seclusion and restraints, the federal government and the states should drastically improve the mechanisms currently available to monitor these activities and the harm caused by them to mental health consumers. As one step to improve monitoring of the use and abuse of seclusion and restraints, MHA calls on the states to publish on their websites data on the use of seclusion and restraints including the number of hours spent in restraint for each public facility and any private facility contracting with the state as well as data on any injuries or deaths associated with the use of seclusion and restraint and diversion to correctional facilities. To the extent feasible, states should measure hours of seclusion and restraint use, using the forms and information technology used by SAMHSA and NASMHPD in the Alternatives to Restraint and Seclusion grants.
- External monitoring groups comprised of consumer advocates, family members, and concerned citizens should be established in each state.35 External monitors can educate the public and key policy-makers about the needs and problems of people win treatment. Subject to strict confidentiality protection consistent with HIPAA, these monitors should be allowed to visit facilities any time and should file written reports to which the facilities must respond in a timely manner.
- Psychiatric facilities should be required to have offices of consumer or patient affairs staffed by people with lived experience of mental health challenges and their advocates, tasked to intervene in any treatment issue. These offices should have meaningful participation in governance and policy-making activities, particularly regarding the use of seclusion and restraints.
- Public education and outreach is needed to better inform people in treatment, family members, and advocates about best practices for preventing the use of seclusion and restraints to ensure that they are aware of what can and should be done.
- Additional outreach is also needed to educate people in treatment, family members, and advocates about where to turn to address abuses by facilities.
- Judges should be educated about current thinking on the use of seclusion and restraints and how such actions can and should be prevented.
- MHA reiterates the concerns about solitary confinement in correctional facilities and in juvenile justice interactions and related action steps, reflected in Position Statements 51 and 56.
The Mental Health America Board of Directors adopted this policy on. It will be reviewed as required by the Mental Health America Public Policy Committee.
Expiration Date: December 31, 2025
1 On August 16, 2015, the New York Times brought to light the bureaucratic snafu that ensnared Ke'jorium McKnight, a teenager who languished in solitary confinement before even standing trial. Just 16 years old, he was isolated not for behavioral reasons or as punishment but because he was being tried as an adult. Under Mississippi law, that required that he be held in an adult jail. And federal law requires that if he is held in an adult jail, he must be kept separate from other inmates, for his own protection. In 2012, the American Academy of Child and Adolescent Psychiatry called for an end to all solitary confinement of children and youth. https://www.aacap.org/aacap/policy_statements/2012/solitary_confinement_of_juvenile_offenders.aspx (last visited September 27, 2015).
3 Davis v. Ayala, __ U.S. ____, 135 S.Ct. 2187, 2208 (2015).
4 See MHA Position Statement 25, Community Inclusion after Olmstead
5 See MHA Policy Position 51, /positions/juvenile-justice
7 Putkonen, A., Kuivalainen, S., Louheranta, O., Repo-Tiihonen, E., Ryynänen, O.P., Kautiainen, H. & Tiihonen, J., "Cluster-Randomized Controlled Trial of Reducing Seclusion and Restraint in Secured Care of Men with Schizophrenia," Psychiatr Serv. 64(9):850-5 (2013). doi: 10.1176/appi.ps.201200393, http://www.ncbi.nlm.nih.gov/pubmed/23771480
8 Roadmap to Seclusion and Restraint Free Mental Health Services. DHHS Pub. No. (SMA) 05-4055. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (2005), pdf file available at https://www.clwk.ca/
9 http://www.theannainstitute.org/NASMHPD.pdf See also National Executive Training Institute: Training Curriculum for Reduction of Seclusion and Restraint. Alexandria, VA, National Association of State Mental Health Program Directors, National Technical Assistance Center for State Mental Health Planning (July 2005).
10 Haugom, E.W., Tuud, T. & Hynnekleiv, "Ethical Challenges in Psychiatric Inpatient Wards: A Qualitative Study of the Experiences of Norwegian Mental Health Professionals," BMC Health Services Research 19:879 (2019),
12 Conversation with Charles Curie, SAMHSA Administrator (2002). See also Curie, C. "SAMHSA's Commitment to Eliminating the Use of Seclusion and Restraint," Psychiatric Services 59(9):1139-1141 (2005),
14 Glover, R., "Reducing the Use of Seclusion and Restraint: A NASMHPD Priority," Psychiatric Services 56(9): 1141-1142 (2005), https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.56.9.1141?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed
17 Weiss, E.M., "Deadly Restraint: A Hartford Courant Investigative Report," Hartford Courant, Oct. 11, 1998. http://www.charlydmiller.com/LIB05/1998hartfordcourant11.html; see also Weiss, E.M., "From ‘Enforcer' to Counselor," Hartford Courant, Oct. 15, 1998. Part of a five-part series published by the Courant which brought national prominence to the issue of seclusion and restraint.
18 Substance Abuse and Mental Health Services Administration. The Business Case for Preventing and Reducing Restraint and Seclusion Use. HHS Publication No. (SMA) 11-4632. Rockville, MD: Substance Abuse and Mental Health Services Administration (2011), https://edsource.org/wp-content/iframe/seclusion-restraint/Businesscaseagainstrestraint.pdf See also LeBel, J., and Goldstein, R.. "The Economic Cost of Using Restraint and the Value Added by Restraint Reduction or Elimination." Psychiatric Services, 56(9):1109-1114 (2005).
19 71 Fed. Reg. 71377, https://federalregister.gov/a/06-9559, and 42 C.F.R. § 482.13 (2014). http://www.gpo.gov/fdsys/pkg/CFR-2014-title42-vol5/pdf/CFR-2014-title42-vol5-sec482-13.pdf
'Regulatory Scotoma'?" Psychiatric Services 59:194-196 (2008).
"Pennsylvania State Hospital System's Seclusion and Restraint Reduction Program." Psychiatric Services, 56(9), 1115-1122 (2005). https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.56.9.1115?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed Updated data and information about the Pennsylvania initiative's ongoing success are available online at https://www.dhs.pa.gov/docs/For-Providers/Pages/State-Hospital-Risk-Management-Summary.aspx
22 Pennsylvania found that making this kind of data publicly available was one of the key factors to decreasing the use of seclusion and restraint in its state hospitals. Pennsylvania Department of Public Welfare, Office of Mental Health and Substance Abuse Services (OMHSAS), "Leading the Way toward a Seclusion and Restraint Free Environment: Pennsylvania's Success Story," Harrisburg, PA, 2001 (no URL available); see also Smith, G., Davis, R., Bixler, E., Lin, H., Altenor, A, Altenor, R., Hardenstine, B., Kopchick, G., "Pennsylvania State Hospital System's Seclusion and Restraint Reduction Program," Psychiatr. Serv. 56(9):1115-22 (2005), http://www.ncbi.nlm.nih.gov/pubmed/?term=Pennsylvania+State+Hospital+System%27s+Seclusion+and+Restraint+Reduction+Program . New York State also reduced restraint use and the number of related deaths by requiring the reporting of usage rates and investigating all deaths, and through an initiative encouraging the use of comfort rooms as a preventive tool.
24 Smith, G., Ashbridge, D., Davis, R. & Steinmetz, W., "Correlation Between Reduction of Seclusion and Restraint and Assaults by Patients in Pennsylvania's State Hospitals," Psychiatric Services Journal, (2015), available at: http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201400185?journalCode=ps ; Smith, G., Ashbridge, D., Davis, A., et al., "Relationship Between Seclusion and Restraint Reduction and Assaults in Pennsylvania's Forensic Services Centers: 2001–2010," Psychiatric Services Journal, Aug 3:appips201400378. [Epub ahead of print] (December 2015), available at: http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201400378 or http://www.ncbi.nlm.nih.gov/pubmed/26234329 ; and Pennsylvania State Hospital System Monthly Risk Management Summary Reports. https://www.dhs.pa.gov/docs/For-Providers/Pages/State-Hospital-Risk-Management-Summary.aspx
26 Borckardt, J.J., Madan, A., Grubaugh, A.L., et al, "Systematic Investigation of Initiatives to Reduce Seclusion and Restraint in a State Psychiatric Hospital," Psychiatric Services 62(5):477-483 (2011), http://www.ncbi.nlm.nih.gov/pubmed/21532072 http://ps.psychiatryonline.org/doi/abs/10.1176/ps.62.5.pss6205_0477
27 Madan, A., Borckardt, J.J., Grubaugh, A.L., Danielson, C.K., McLeod-Bryant, S., Cooney, H., Herbert, J., Hardesty, S.J., & Frueh, B.C., "A 10-year Perspective on Efforts to Reduce Seclusion and Restraint Use in a State Psychiatric Hospital," Psychiatr Serv. 65(10):1273-6 (2014). http://www.ncbi.nlm.nih.gov/pubmed/25022602
28 Substance Abuse and Mental Health Services Administration (SAMHSA), Office of the Administrator. (2010). Promoting Alternatives to the Use of Seclusion and Restraint—Issue brief #2: Major Findings from SAMHSA's Alternatives to Restraint and Seclusion (ARS) State Incentive Grants (SIG) Program. Rockville, MD: U.S. Department of Health and Human Services, http://www.samhsa.gov/sites/default/files/topics/trauma_and_violence/seclusion-restraints-2.pdf
29 LeBel, J.L., Duxbury, J.A., Putkonen, A., Sprague, T., Rae, C. & Sharpe, J., "Multinational Experiences in Reducing and Preventing the Use of Restraint and Seclusion," Journal of Psychosocial Nursing and Mental Health Services 52(11): 22-29 (2014), http://www.researchgate.net/publication/266947426_Multinational_Experiences_in_Reducing_and_Preventing_the_Use_of_Restraint_and_Seclusion
30 Huckshorn K.A., Reducing Seclusion and A Phenomenological Study of State Psychiatric Hospital Leader and Staff Experiences. J Psychosoc Nurs Ment Health Serv. 52(11):40-7 (2014). doi: 10.3928/02793695-20141006-01. Epub 2014 Oct 15.
31 Bowers, L. (2014), Safewards: a new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing, 21: 499–508. doi: 10.1111/jpm.12129. Full text available at http://onlinelibrary.wiley.com/doi/10.1111/jpm.12129/full. Trial at Bowers L,, James K,, Quirk A,, Simpson A., Stewart D. & Hodsoll, J., "Reducing Conflict and Containment Rates on Acute Psychiatric Wards: The Safewards Cluster Randomized Controlled Trial," Int. J. Nurs. Stud. 52(9):1412-22. doi: 10.1016/j.ijnurstu.2015.05.001 (2015).
34 See MHA Position Statement 23, Advance Psychiatric Directives