Seclusion and Restraint Practice Standards: A Review and Analysis
Table of Contents
Although numerous injuries and deaths have been associated with restraint and seclusion, these dangerous and controversial interventions remain loosely and erratically regulated in the United States. Policies and procedures do exist at various levels, but there are no uniform and universal national standards for the use of seclusion and restraint in psychiatric facilities. This monograph describes the history that underlies current practice. It reviews existing guidelines, model standards, and standards that address the needs of various special populations. Its goal is to provide a useful resource for those who seek to ensure that seclusion and restraint are never a source of physical or psychological harm or trauma.
Many consumers disapprove of any application of seclusion or restraint. Clinicians have not reached consensus either, differing about whether those techniques ever should be used as therapeutic interventions or to secure the safety of patients and staff. To some extent, courts, legislatures, and administrative bodies have stepped in to address these concerns, but not in a coordinated way.
Seclusion and restraint are rarely used in some Western European countries. A historical review explores the divergent paths taken by European and American psychiatry. It also reviews a variety of approaches taken in the United States, based on standards that differ by philosophy and expectations, by system, by location of care and "category" of consumer, and by level of oversight.
A literature review was conducted and documents from various sources were reviewed, compared, and analyzed. Existing guidelines were reviewed along six major parameters: definitions, appropriate use, length of time, procedures, accountability, and training. General models that try to provide standard policies and procedures for seclusion and restraint were analyzed. Standards specific to certain sub-populations were reviewed separately.
The review of Existing Guidelines showed that:
- Definitions vary widely; sometimes, the terms are not defined.
- There is little agreement on appropriate use, although there is general agreement that there should be no inappropriate use.
- The length of time permitted for use varies from guideline to guideline.
- Procedures also vary extensively. Some existing regulations and guidelines are extremely prescriptive; others leave wide latitude for professional judgment.
- Accountability and external monitoring are of interest to all constituency groups. Requirements vary.
- There is general agreement that staff should be trained in the techniques they will be required to implement. However, some guidelines only speak to a general need for training, whereas others identify specific educational requirements.
The review of Model Standards also looked at the six parameters noted above, but the individual focus of each model was also addressed. For example, one model includes recommendations for the administrators of juvenile correctional programs; another shows how a hospital’s nursing department developed a standard and a standard care plan related to seclusion and restraint.
A review of models for Special Populations showed that::
- A history of physical or sexual abuse is common among women, and should be considered in setting standards that would avoid retraumatization.
- Children have an elevated risk for being harmed during seclusion or restraint procedures. Despite this, their specific needs are often omitted from relevant regulations and there is wide divergence of opinion about whether and how these techniques should be used with youth
- Elderly people are governed by rules that differ according to place of residence.
- People with Developmental Disabilities are protected by federal law. They cannot be physically restrained as punishment, and the use of chemical restraints is regulated. As is true for elderly people, they are generally subject to the rules of the institutions in which they reside.
- People who are Deaf may be isolated by difficulties in communicating with mental health staff. Behaviors that stem from frustration may lead to the imposition of seclusion or restraint, further isolating the patient by limiting his ability to use hands and body in the service of communication.
This review of guidelines and standards for the use of seclusion and restraint highlights the diverse approaches to their use in this country. There is little consensus even on basic issues and definitions. The only general agreement identified was a belief that seclusion and restraint, whatever they may be, should never be used inappropriately, however that may be defined.
Seclusion and Restraint Practice Standards: A Review and Analysis
By Elizabeth Steel, M.S.W.
Restraint and seclusion are among the most dangerous and controversial of all mental health procedures. Yet despite the high level of risk associated with their use, they are also among the most erratically regulated of all clinical interventions.
Clinicians have not reached consensus around professional guidelines for using these interventions. In the absence of such consensus, federal courts have stepped in to set some basic requirements (NYS 1994a). The paramount legal case, Wyatt v. Stickney (1972), affirms that patients have the right to be free from restraint and isolation. The court ruled that those interventions may be used only when the patient might otherwise cause harm to himself or others and there is no less restrictive way to prevent such harm.
Legislatures have also addressed seclusion and restraint issues, although not in a coordinated fashion. For example, federal regulations govern the use of seclusion and restraints in nursing homes that receive funds under Medicare or Medicaid (42CFR483.483.13[a]). These regulations ban all use of seclusion and all nonmedical use of restraints in covered nursing homes. Other federal regulations guide the use of seclusion and restraints in intermediate care facilities for people with mental retardation (42CFR483.420,440,450). There are no uniform national standards or guidelines governing the use of seclusion and restraint in psychiatric facilities. Several bills recently introduced in the House and Senate by Senators Lieberman and Dodd and Representatives DeGette and Stark would help to correct this situation.
To date, the Health Care Financing Administration (HCFA), which promulgated and enforces the regulations for nursing homes and intermediate care facilities, has taken a less prescriptive approach to the regulation of seclusion and restraint in public and private psychiatric hospitals and psychiatric units in general hospitals. Language addressing the rights of patients with mental illness in relation to restraint and seclusion practices was included as part of the preamble to a proposed rule was published for comment in the Federal Register (December 19, 1997).
In a letter to Senator Lieberman (Min DeParle 1999), the HCFA Administrator indicated her support for the Senator’s recently introduced legislation that would increase Federal oversight to prevent inappropriate seclusion and restraint practices in mental health settings. Administrator Min DeParle noted that the "Patients Rights" section of the Proposed Rule cited above (Federal Register [December 19, 1997]) would be carved out of the whole and a final standard addressing seclusion and restraint, among other patient rights, will be published by late summer of this year. At this writing, publication of the final rule is imminent, and it is expected that the regulations will require hospitals to achieve the intended outcome of never imposing restraint and seclusion inappropriately.
The HCFA guidelines as currently proposed will only apply to hospital based services. No federal policies address the use of seclusion and restraint in group homes or residential treatment centers, although these are major care locations for mental health consumers. The HCFA Administrator’s letter (Min DeParle 1999) supports Senator Lieberman’s effort to expand federal oversight authority to residential treatment centers for children and congregate care services.
Some state laws designate rules for secluding or restraining patients in certain mental health facilities (e.g., Arizona, Massachusetts). A number of individual inpatient programs have also developed and adopted internal guidelines (e.g., NIH 1997a-d, US Naval Hospital 1998, Manhattan Psychiatric Center 1992/93). Facilities with accreditation from the Joint Commission on the Accreditation of Healthcare (JACHO) also are guided by that organization’s (quite general) standards regarding seclusion and restraint. It is safe to say that in most communities, non-hospital facilities such as group homes and residential treatment centers for children are not required to adhere to policies and procedures for the use of seclusion or restraints.
It is evident that patients in certain settings have a reasonable assurance of minimal exposure to seclusion or restraints, whereas patients in other settings do not have that assurance. In some settings, patients can anticipate being secluded or restrained only when specific clinical criteria have been met, and then only by trained staff. They can expect each episode to be strictly monitored and carefully documented. Patients in other settings may suffer relatively unpredictable and non-standardized episodes of seclusion or restraint.
Both restraints and seclusion pose inherent physical and psychological threats. They can and do result in injuries and deaths. The melange of rules and regulations leaves some people more vulnerable than others to the inappropriate imposition or misuse of seclusion and restraint. A set of articles in The Hartford Courant (October 1998) is the latest in a long series of reports by investigative journalists (Strumpf and Tomes 1993) to draw attention to the dangers of seclusion and restraint. The Courant series linked episodes of restraint and seclusion in psychiatric facilities, facilities for people with mental retardation, and group homes to the deaths of 142 mental health consumers. Various government agencies and advocacy groups are taking advantage of the opportunity presented by heightened public awareness to engage in an in-depth examination of issues related to seclusion and restraint.
The Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Administration (SAMHSA) has a leadership role in improving mental health services in the United States. In order to move towards developing uniform guidelines for seclusion and restraint that would apply to all settings in which psychiatric services are delivered, CMHS is taking steps to gather a comprehensive body of knowledge about existing policies and procedures. This report constitutes an initial part of that process. The report includes a literature review and an analysis of current standards, guidelines, models, position statements, and policies related to seclusion and restraints.
Between-Nation Disparities: Seclusion and restraint are used far less often in many Western European countries than they are in the United States (Strumpf & Tomes 1993; Ljunggren et al 1997). The use of these interventions is simply not acceptable in some places. Conversely, some degree of use is considered almost inevitable in many settings in this country (Fisher 1994).
Seclusion and restraints are issues for debate in the United States, where these controversial interventions are still used fairly regularly. In many parts of Europe, where seclusion and restraint are rarely utilized, they are no longer widely debated. People do not have to debate what they do not expect to encounter. It is interesting to look at the evolution of these differing positions.
In 1794, Philippe Pinel removed the shackles from his patients at Bicetre Hospital in Paris (Strumpf and Tomes 1993). That dramatic move was an important statement in favor of humane treatment for people with mental illness. However, Fisher (1994) points out that Pinel did not advocate the total abolition of restraints, but favored balancing safety with patients’ rights.
The concept of "moral treatment" was propounded by members of the Society of Friends. Samuel Tuke published an account of this approach as it was implemented at the Quaker Retreat at York. Restraints were very sparingly used at York Retreat and at the Philadelphia Friends’ Asylum in the 1820s (Strumpf and Tomes 1993). Like Pinel, these early proponents of moral treatment did not totally reject the use of restraints. Later, though, British physicians at the Lincoln and Hanwell Asylums began to equate restraints with neglect, "…a substitute for the thousand attentions required by troublesome patients (Strumpf and Tomes 1993, quoting Victorian alienist Andrew Scull)."
By the middle of the 1840s, the use of restraints, seclusion, and sedation in British psychiatric institutions had been minimized. This was especially the case in public hospitals, where there was little need for concern about liability suits if a patient should injure himself or another individual. A culture of non-restraint had caught on and continues to this day, although there is still an occasional use of restrictive interventions.
The United States took a different path in the 1840s and thereafter. Although the general tenets of moral treatment were accepted, physicians argued that seclusion and restraints had value as therapeutic interventions. Concerns about liability and public relations led to a high value being placed on safety, even over freedom. American psychiatrists also claimed that American patients were more aggressive and less responsive to authority than were British patients. Strumpf and Tomes (1993) characterize the American resistance to nonrestraint as stemming from "a conception of the American patient as inherently boisterous, freedom-loving, and aggressive in defense of personal liberty."
American psychiatry continues to argue in favor of the judicious use of seclusion and restraints. Fisher (1994), reviewing the professional literature and statements by consumer/survivors, listed arguments on both sides. The arguments in favor included findings that seclusion and restraints have been described as safe, effective, and useful for preventing injury, reducing sensory overload, preserving ward calm, conserving nursing resources, and building therapeutic relationships. The interventions are seen as ways to demonstrate caring and prevent maladaptive behaviors. Burton (1975) cites cases to illustrate his view that seclusion and restraints have value for some acutely disturbed psychiatric patients who are imminently dangerous to themselves or others, or who request such external controls. He also contends that nonrestraint policies can lead to the diversion of violent patients from private to public hospitals (and presumably, to prisons).
Conversely, certain American professionals have described seclusion and restraint as unnecessary, punitive, and degrading. Fisher (1994) reported that seclusion has been called "a tyrannical relic" and mechanical restraints have been viewed as museum pieces that are used only because of "staff ignorance, fear, anger, and administrative convenience. Nurses Freida Outlaw and Barbara Lowery (1992) pointed out that isolation and restraints are sometimes counterproductive, as when they are experienced as reinforcers by the restrained patient.
This brief review highlights the divergent paths taken by some European countries and the United States in regard to the use of seclusion and restraint.
Within-Nation Disparities: Within the United States, different standards for using restraints and/or seclusion may be related to the type of treatment system, the geographic location, the patient’s demographic or diagnostic characteristics, the philosophy and expectations of the staff and administrators, and even the local traditions. In the absence of uniform guidelines, there has been little movement toward lowering rates of use. In hospitals across the country, for example, Crenshaw et al (1997) found relatively stable use rates over time, despite changes in the political environment and changes in hospitals’ sizes and missions.
Evans and Strumpf (1989) noted a high use of restraints with elderly, nonpsychiatric patients in nursing homes during the twentieth century, although nursing literature had cautioned against this as early as 1885. Public concern led to the passage of the Nursing Home Reform Act (OBRA 1987), and Castle and Fogel reported an overall prevalence rate of physical restraint that declined from 25% in 1977 to 15% by 1990. Clinical practice in psychiatry responds to legal decisions (such as Wyatt v. Stickney) and to federal, state, and local laws and regulations as they emerge. However, the APA Task Force (Tardiff 1985) emphasized that its preference is for professional judgment to remain paramount in making decisions about using restraints and seclusion. The Supreme Court upheld this point of view in the case of Youngberg v. Romeo (1982), declaring that a decision to seclude or restrain a patient that is based on professional judgment is "presumptively valid." Jones (1999) noted that Youngberg states that people with mental retardation who are involuntarily committed are entitled to "minimally adequate or reasonable training to ensure safety and freedom from undue restraint." However, the exact parameters of these rights are unclear and great deference is given to the judgment of the treating professionals.
American diversity extends to a diversity of beliefs and practices regarding the use of seclusion and restraint in the treatment of people with mental illness. Some provider and professional organizations believe that certain clinical situations justify or require the application of seclusion or restraints in order to ensure the safety of people or property (National Association of Psychiatric Health Systems 1999; American Academy of Child and Adolescent Psychiatry 1998; American College of Emergency Physicians 1996; Tardiff 1985). Furthermore, there is some belief that, properly applied, these interventions have a place in certain treatment plans and behavior modification programs (Tardiff 1985). On the other hand, many people who have experienced seclusion or restraint report that the experience was degrading and counter-therapeutic (e.g., Campbell, CMHS meeting, Feb. 10, 1999; Chamberlin 1985). Indeed, some mental health consumers today totally reject the use of seclusion and restraints. However, the majority of constituency groups, including many representing consumers and families, appear to agree that the use of seclusion and restraints may be justified under extreme emergency conditions for limited periods of time.
It is interesting to take a closer look at some of the ways in which expectations and standards differ within the United States. Note that there is a great deal of overlap among these factors.
--Different standards by philosophy and expectations. Attitudes about behavior management and the therapeutic value of restraints and seclusion will have an effect on practice.
The introduction to APA Task Force Report 22: Seclusion and Restraint (Tardiff 1985) identifies these as "violent times" in American life. Indeed they are, to the point where one of every 1,000 young African American males is murdered every year (Isaacs 1992, p 5), and in 1985 the United States Surgeon General declared family violence to be a national epidemic (American Psychological Association 1996, p 9). The Tardiff (1985) document goes on to say that this violence is "a fact of…life which extends to the working reality of the psychiatric treatment setting," and claims that social policy decisions such as deinstitutionalization have "increased the visibility of violent patients and the demands that the mental health profession deal with them." As already noted, the psychiatrists’ group concludes that seclusion and restraints must be available for use in the face of threatening and dangerous situations.
Strumpf and Tomes (1993) point out that American views of restraint practice at the end of the nineteenth century could be summarized as "Moderate use (is) therapeutically and morally sound; it (is) required by the peculiar violence of American insanity; and it prevent(s) tragic accidents and injuries." Clearly, this view continues to hold. The therapeutic value of seclusion and restraint, however, seems to be less of a concern than the management of violent or potentially violent behaviors.
The philosophical opponents of seclusion and restraints are also articulate in their advocacy efforts. Strumpf and Tomes (1993), for example, cite various nursing textbooks and manuals that speak of restraint as an aggravating factor in delirium, suggest that forcible restraint exhausts the patient, and propose that nurses should find other ways than restraint to deal with troublesome behaviors. Even more to the point, there has been little research that demonstrates the efficacy of restraints and seclusion.
--Different standards by system. Formal standards and administrative expectations certainly affect practice, and these vary by system and type of facility. People with mental illness who reside in nursing homes receive treatment under one set of federal standards (42CFR483.13[a]). Other standards (or no standards) apply to consumers with similar characteristics who are treated in other systems, such as acute care hospitals, psychiatric hospitals, prisons, or group homes.
The tradition and culture of a system are also relevant. People who are treated in facilities that have a tradition of secluding and restraining and where there is no incentive to change (e.g., a court order, an administrative decision, or publicity about a death) are at risk for experiencing seclusion or restraint. People who are treated in facilities that historically have prided themselves on minimal use of these interventions are at lower risk for being restrained or secluded.
People who are treated in "restraint free" facilities will not be restrained. Facilities in which management expects that restraint and seclusion will not be used are likely to use those techniques very sparingly indeed. People with similar diagnoses and characteristics who are treated in facilities that seek to control behavior or expect to modify behavior through seclusion and restraint have the potential to be subjected to these interventions.
--Different standards by location and assigned "category." People in one state or region will be treated based on one set of laws, regulations, and/or standards, whereas people who have similar characteristics but reside in another locality may be treated based on another set of guidelines entirely.
Within states and regions, people may be seen as belonging to a category based on a single characteristic or condition (e.g., elderly, retarded, mentally ill, or delinquent) and treated according to their assigned category. Laws and regulations that pertain to specific categories influence the nature of the treatment. For example, a person with mental retardation who resides in an intermediate care facility is covered by the HCFA standards set out in 42CFR483.420, 440, and 450. A person with the same diagnosis who resides in a psychiatric group home is not covered by those standards.
Further complicating matters, state laws may apply to certain types of persons, regardless of the type of facility in which they reside. For example, if a person with mental retardation happens to reside in New York State, state laws leaves him subject to being restrained, but he cannot be secluded.
--Different standards by level of oversight. People who are treated in facilities that are subject to significant oversight by accreditors, monitors, government surveyors, or other authorities are likely to have episodes of seclusion and restraint managed and monitored according to specific policies and procedures. In the absence of oversight, whether because the overseers lack jurisdiction or have limited resources, there is a higher risk that intrusive and dangerous interventions will be used inappropriately.
One recent trend in oversight involves using consumers and families as monitors and consultants. For example, the Alliance for the Mentally Ill in Delaware (AMID) has an agreement with the state mental health authority and the Delaware Psychiatric Center that outlines a formal structure for onsite monitoring of the use of seclusion and restraints. AMID monitors make unscheduled visits to the Center and file reports that can lead to the Center’s taking corrective action when indicated. Another example involves the inclusion of consumers on committees of the JCAHO (Johnson, CMHS meeting, February 10, 1999) and human rights committees of individual facilities such as the Northern Virginia Mental Health Institute (Beall, CMHS meeting, February10, 1999). Consumers in these instances have been positioned to have input into policy and program level deliberations about seclusion and restraints.
The National Mental Health Association (Faenza 1999) has urged that federal legislation require the installation of monitoring groups composed of consumers, family members, and volunteers in every American psychiatric facility. These groups, by serving in an ombudsman role, could help to avoid untoward events and tragedies.
A literature review was conducted and standards, guidelines, and similar materials from various sources were reviewed, compared, and analyzed. Although some of the guidelines fall into more than one category, the documents can be grouped loosely as follows:
- Laws, regulations, court decisions, and other government policy documents;
- Voluntary guidelines and standards;
- Policy statements and position papers from consumer, family, and advocacy organizations;
- Local program guidelines and standards;
- Model guidelines;
- Guidelines for special populations.
Existing guidelines: This is a large and varied body of information. Existing guidelines were reviewed along six major parameters: definitions; appropriate use; length of time; procedures; accountability, and training. Results are reported in tables and text.
Model Standards: Many of the existing standards contain sections that might be considered excellent model language for addressing particular issues. However, this section focuses on certain more general models that directly try to standardize policies and procedures related to seclusion and restraint.
Special Populations: Restraint and seclusion have particular implications for some subgroups of the general population. A separate section reviews standards that address these sub-populations. Note that information of this type is quite limited. For example, no standards were found that specifically consider a patient’s racial or ethnic identification.
Many existing standards and guidelines were reviewed and compared in relation to six major parameters: definitions of seclusion and restraint, appropriate use, length of time, procedures, accountability, and training. Table 1 presents an overall outline of these comparisons. Tables 2 and 3 give examples of how these factors apply in different situations. Table 2 addresses two sets of federal regulations (those for nursing homes and those for intermediate care facilities). Placed next to these are elements of the proposed federal rule for hospitals that would guide (voluntary) but not regulate (mandatory) their use of seclusion and restraint. Table 3 again looks at the proposed federal rule for hospitals, this time juxtaposed with elements of the voluntary guidelines of the Joint Commission for the Accreditation of Healthcare Organizations and the American Psychiatric Association.
Definitions of seclusion and restraint. At first glance, the definition of each term appears to be straightforward and self-evident, with seclusion meaning isolation and restraint meaning prevention of movement through mechanical, physical, or chemical means. However, more detailed definitions of various lengths and varying content have been put forth. Perhaps that is why so many states do not define those terms at all. A survey by the National Association of State Mental Health Program Directors (Tardiff 1985, p. 9 ff.) drew responses from 36 states. Nineteen had no definition of seclusion and 23 had no definition of restraints.
Federal and State documents that did include definitions varied widely in specificity. For example, the Massachusetts Statute on Restraint and Seclusion did not appear to provide a definition of seclusion. On the other hand, a vetoed California Bill SB 895 (1994) defined seclusion as the involuntary confinement of a person alone in a room, which the person is physically prevented from leaving for any period of time. It defined physical restraint as any method or physical device used for restricting movement, such as hard or soft ties, cloth vests, and posey chairs. It excluded restraints used for diagnostic or medical procedures (a common exclusion in many of the documents reviewed).
As would be expected, definitions in regulations tended to be quite specific. For example, Arizona’s mental health regulations identified restraint as any form of physical, mechanical, pharmacological restraint, or even seclusion itself as defined in the regulations, as well as any other means which unreasonably limit a client’s freedom of movement. Furthermore, physical restraint was defined as the use of bodily force to restrict the person’s freedom of movement, but it does not include the firm but gentle holding of a person for less than five minutes with no more force than necessary to protect the person or others from harm. Mechanical restraints were defined as the use of any article, device, or garment that restricts a client’s freedom of movement or the movement or normal function of a portion of the client’s body, but does not include an orthopedic, surgical or other necessary medical device. Pharmacological restraints were defined as the use of medication for the purpose of controlling behavior in response to a likelihood of serious harm or for unreasonably restricting a client’s freedom of movement.
Appropriate use: Seclusion and restraint are interventions that constitute a serious infringement on individual liberties. They offer the potential for severe negative outcomes. Negative psychological sequelae have been noted, including cognitive decline (Burton 1992), exacerbated agitation (Castle and Mor 1998), and stress reactions (Williams and Finch 1997). Patient reports include feelings of anger, confusion, and helplessness in the face of their own or another person’s seclusion (Outlaw 1992), and these may be long lasting effects, as observed by Wadeson and Carpenter (1976).
Physical outcomes may include serious injuries and even death (Hartford Courant 1998). On the other hand, failure to restrain has not been linked with increased morbidity and mortality, and may even predict the opposite. For example, Strumpf and Tomes (1993) reported that when rates of restraint were reduced in British public asylums in the 1840s, the overall level of violence in the facilities declined. Capezuti and her colleagues (1998a) found no increase in falls or fall-related injuries among patients released from restraints in nursing homes. Steven Miles (personal communication 1999) noted that even when an increase in the number of falls is recorded, there is a decrease in serious fall-related injuries.
Restraint reduction (but not its total elimination) has been a goal of nursing homes and intermediate care facilities for people with mental retardation since the passage of the Omnibus Reconciliation Act of 1987 (PL 100-203). Burton and her colleagues (1992) report that prior to the passage of OBRA 87, nursing homes had increased their use of restraining devices. This was justified by a perceived need to prevent falls, to keep the resident from interfering with treatment, and to control aggressive behavior and wandering. At the same time, psychiatric facilities had reduced their use of physical restraints following the introduction of psychotropic medications in the 1960s.
Since 1987, research in nursing homes has shown that staff education along with nursing consultation centered on issues relevant to specific residents can decrease the use of restraints without increasing staffing levels, psychoactive drug use, or serious fall-related injuries (Evans et. al. 1997; Seigler et. al. 1997). Evans and Strumpf (1989) identified physiological care, psychological care, activities, environment, and staff as potential areas for alternative interventions. Castle and Mor (1998) outlined some of those potential alternatives and indicated that restraint reduction can be done in a cost-effective manner. For nursing homes at least, the goal of reducing the use of restraints appears to be achievable and worthwhile.
The justification for continuing to use restraint and seclusion in psychiatric institutions varies widely. Many laws and regulations permit the use of seclusion and restraint when there is no other way to protect the patient or others from imminent harm. Some limit the use of these interventions quite strictly. Professional organizations tend to rely heavily on clinical judgment in their guidelines or recommendations about seclusion and restraint (e.g., Tardiff 1988). Consumer, family, and advocacy organizations vary in their preferred approaches to using these interventions, from outright opposition to limited acceptance. The National Alliance for the Mentally Ill (NAMI 1998), for example, takes the position that involuntary seclusion or restraint is "only justified as an emergency safety measure…[and] only so long as…the individual cannot commit to the safety of themselves and others." NAMI and other advocacy groups recommend that seclusion and restraint be addressed through advance directives.
JCAHO accreditation standards (1996) require only that restraint or seclusion be used with adequate justification, documentation, and regard for patient safety. However, at the level of the JCAHO-accredited facility, where implementation issues and liability issues come together, one would expect that policies and procedures would address seclusion and restraint quite specifically.
Length of time: Although this factor is technically a subset of procedures, it was examined separately as a marker for specificity. Guidelines and rules vary widely in regard to how long a person may be secluded or restrained, from zero to 72 hours or more (with periodic reassessments). States responding to the NASMHPD survey indicated an outside limit of 24 hours. Most laws and regulations require that orders for these interventions be time limited and based on clinical assessments. Some set different limits for emergencies, and some give a maximum number of hours that these interventions may be applied during each 24-hour period.
Professional organizations also vary in regard to the length of time permitted for using these interventions, relying generally on periodic clinical evaluations for decision-making. Consumer, family, and advocacy organizations are less likely to express an opinion about length of time than to deal with overall positions and policies. Local program procedures are apt to address length of time between required observations as well as length of time between renewal of orders. They are also likely to mandate periodic release periods for exercise and other purposes.
Procedures: Some existing regulations and guidelines are extremely prescriptive, while others leave wide latitude for professional judgment. According to Tardiff (1988), the APA Task Force held that each institution should have written guidelines and manuals, approved by the administration and its lawyers, as well as by the state authorities. Staff should be educated and techniques should be rehearsed. Guidelines should be revised in accordance with staff feedback.
The nature and extent of procedural guidance depends partially on the special concerns of the generating bodies. As one moves closer to the point of implementation, more detailed guidance is presented (e.g., New Hampshire Hospital 1998, NIH 1997a-d, Roper et. al. 1985). Program-level guidance usually deals with requirements related to orders, periodic observation and assessment, nursing responsibilities, and documentation. Staff members are advised by their professional organizations to be familiar with rules governing specific facilities as well as state and local regulations.
Accountability: Government policies generally indicate specific legal and regulatory accountability standards and/or processes. For example, the Massachusetts regulations for community programs (104 CMR 3.12 ) require that the director of any program using physical restraint must submit a monthly report for review by the relevant Department and the Human Rights Committee. At the federal level, the Food and Drug Administration (1992) characterizes restraints as medical devices that can only be used by prescription. The Safe Medical Devices Act of 1990 requires that deaths or serious injuries related to the use of any medical device be reported to the specified authorities, which vary according to individual situation.
Professional organizations tend to rely on the standards and ethics of their professions to ensure compliance with (acceptable) policies. Facilities may grant privileges based on expertise and training, and a credentialling process might be considered (e.g., Tardiff, 1985).
External monitoring is of interest to all constituency groups. JCAHO (1996) accreditation is perhaps the most widely known. The goal of the JCAHO standards in regard to seclusion and restraint is to "ensure that patients are cared for in the least restricted manner possible (Kobs 1998)." The fact that JCAHO accreditation is a voluntary process with little external oversight raises some concerns among advocates. This is especially important since the accreditation is generally accepted by HCFA as an acceptable proof of compliance with federal regulations.
Another source of external monitoring is the Protection and Advocacy System. State-designated Protection and Advocacy organizations have the legal authority to investigate abusive practices and deaths related to seclusion and restraint. However, under current law, restraint-related deaths and injuries need not be reported to outside independent agencies for investigation and corrective action (National Association of Protection and Advocacy Systems [NAPAS] March 15, 1999). In addition, advocates indicate that resources are insufficient to meet the need for such oversight (Decker, CMHS Meeting, 1999).
Training: There is little disagreement that staff who are going to implement seclusion and restraint should be trained in appropriate techniques. However, not every statement and guideline addresses training (e.g. JCAHO 1996). Of those that do, some guidelines require written training policies but others only speak to the general need for training. Documentation of training is often required, but the specific content of the training often is not delineated. The National Mental Health Association (NMHA 1998) encourages training and demonstration of competence in techniques of intervention, including alternatives to seclusion and restraint. The New York State Office of Mental Health (1994) recommends very concrete and specific educational requirements, such as annual training that includes sections taught by people who have experienced restraint and seclusion. Training would include the experience by all staff of these interventions. Some individual programs, such as the US Naval Hospital in Naples (1998), also specify extensive staff training requirements.
Many of the seclusion and restraint guidelines that are now in use contain language that could be included as part of an overall model of excellence. This section, however, focuses on documents that reflect ideals of practice, rather than existing practice. The authors of these documents are individuals or groups with concerns about the current, non-standardized approach to seclusion and restraint. The documents express various points of view, and this analysis does not try to assign relative value to any author(s)’ perspective.
Six documents containing practice models were selected for review.
For general populations:
- Daar, Melissa and Teresa Nelson (1992). Reforming Seclusion and Restraint Practices: An Advocacy Manual, May 1992; Protection and Advocacy, Inc.: Sacramento, CA. (The P&A Manual)
- New York State Office of Mental Health (1994b). Final Recommendations on the Use of Restraint and Seclusion, Division of Quality Assurance, June 1994. (The New York Model)
- Proposed Rule: Medicare and Medicaid Programs; Hospital Conditions of Participation; Provider Agreements and Supplier Approval. Federal Register, Volume 62, Number 244, Pages 66725-22763.December 19, 1997. (The Proposed Rule)
- Roper, Janice M., Coutts, Adam, Sather, Janet, and Roselia Taylor (1985). Restraint and Seclusion: A Standard and Standard Care Plan. Journal of Psychosocial Nursing 23(6) 18-23. (Roper and colleagues)
- Fassler, David, and Nancy Cotton (1992). A National Survey on the Use of Seclusion in the Psychiatric Treatment of Children. Hospital and Community Psychiatry; April 1992, Vol. 43(4); 370-374. (Fassler and Cotton)
- Mitchell, Jeff, and Christopher Varley (1990). Isolation and Restraint in Juvenile Correctional Facilities. Journal of the American Academy of Child and Adolescent Psychiatry 29(2), 251-255. (Mitchell and Varley)
A general overview of the goals, targeted populations or facilities, and developmental processes of these models sets the stage for comparing them along the same six parameters (definitions, appropriate usage, length of time, procedures, accountability, and training) that were used to compare existing standards and guidelines. Table 4 compares the four model standards for general populations along those six parameters. Table 5 does the same for the two models that specifically address children.
Goals and Targeted Populations/Facilities: Although all the models propose to improve current practices, each has specific goals and each targets particular populations or facilities. Therefore, the guidelines proposed in any one document are not exact parallels of those set forth in any other document. This is also true of target audiences. Outside advocates who seek to change a system must convince influential insiders of their right to make recommendations as well as the value of their suggestions. Groups that already have official sanction may be able to put less effort into advocacy and more into developing concrete policy and program recommendations for an already receptive audience.
The P&A Manual posits that advocacy strategies can be used to improve seclusion and restraint practices. This "Campaign for Reforming Seclusion and Restraint Practices" focuses on practices in mental health facilities in California. Its goals are to reform current practices; increase the legitimacy of the P&A advocate as a patients’ rights enforcer; raise awareness of patients’ rights and clinical standards; and improve relationships with providers. The P&A Manual is targeted toward an audience of advocates.
The New York Model begins with the premise that the goal of the seclusion and restraint policy of the State Office of Mental Health must be to reduce the use of those interventions. The focus is on practices in psychiatric facilities. The target audience for this report is the body of decision-makers who determine mental health policy at the state level.
Roper and her colleagues also address mental health facility practices. Although they do not necessarily endorse the use of seclusion and restraints, they acknowledge the use of these interventions and have a goal of ensuring their safe and appropriate use. Nurses are the target audience.
HCFA’s Proposed Rule would apply to hospitals that participate in programs under Medicare and Medicaid. If the rule became final, HCFA’s expectation is that seclusion and restraint never would be employed inappropriately. Standard procedures are delineated, but these, if included at all, might be part of a preamble rather than part of the rule itself. The use of standard procedures would be voluntary. The target audience for the Federal Register notice of the proposed rule was the public (including all constituency groups), which was invited to submit comments.
Fassler and Cotton focus on children in psychiatric hospitals and residential treatment centers. Few states have separate seclusion and restraint policies for children and adults. The authors’ goal is to establish uniform guidelines for the use of these interventions with children. Their target audiences are clinicians and mental health administrators.
Mitchell and Varley raise specific concerns about children in correctional facilities. Although they would prefer that restraints and seclusion not be used at all, their primary goal is to reduce the abusive use of seclusion and restraints in juvenile justice settings. Their target audiences are mental health clinicians and juvenile corrections administrators.
This spectrum of primary goals illustrates the complexity of attempting to reach consensus on a single set of standards for use across systems and populations.
Development Processes: The method by which a model is developed has implications for the likelihood of its dissemination and the potential for its being enforced. Models that are developed with official sanction are likely to be considered seriously in policy deliberations, although there is no guarantee that they will be adopted. If implemented, however, they have good potential for enforceability.
Models developed by and for advocates provide a framework for action. That action, if conducted, has the chance to influence the development of policy. Models developed by clinical staffs may be implemented in specific facilities but not generalized to other settings. Models conceptualized by individuals and published in the professional literature will have influence to the extent that they are discovered and promoted by advocates, policymakers, or clinical administrators.
The P&A Manual was prepared under a contract with Protection & Advocacy, Inc. and draws on the authors’ knowledge of the field and review of the literature. The New York Model is based on the deliberations of an official task force, supplemented by recommendations of a recipient workgroup that responded to the task force report. Both documents were prepared within a framework that is grounded in patients’ rights and addresses a range of philosophical, legal, and clinical issues. They draw from a variety of sources, but take a frank position in favor of reducing or eliminating the use of seclusion and restraint.
The HCFA Proposed Rule reflects input from various sources of expertise, including CMHS. It is still in development but the portion of the final rule that relates to patient’s rights should be released by late summer (Min DeParle 1999).
Roper and colleagues show how a hospital’s nursing department developed a standard and a standard care plan for seclusion and restraint. Two record audits were conducted, one looking at staff compliance with hospital policies and procedures, the other examining clinical issues relevant to the use of seclusion and restraint. The audit findings led the department to conclude that there was a need for more structured practice guidance. A standard care plan was prepared, pilot tested, and evaluated. The result is a care plan developed by staff and with high staff "buy-in." The format of the plan makes it easier to ensure that patients receive appropriate treatment and that the procedures are fully documented. This development process could be adapted for use by multidisciplinary teams.
Fassler and Cotton draw on their backgrounds in research and child psychiatry and psychology to conceptualize an approach to seclusion and restraint. Their model is put forward to encourage dialogue and debate. Mitchell and Varley, both psychiatrists, have particular expertise in juvenile justice and have served as expert witnesses in court proceedings. Their paper includes specific recommendations for the administrators of juvenile correctional programs and their mental health consultants.
Restraint and seclusion have particular implications for certain subgroups of the general population. However, information about the nature and extent of their use with specific groups is limited. One law (California SB 895) would have required facilities using these interventions to collect and report data on patient age, sex, race, and primary diagnosis. However, that law was vetoed.
Partly because of this paucity of data, issues of cultural competence are rarely addressed in guidelines for using restraint and seclusion. Still, some special populations have been singled out for attention in deliberations about relevant policies and procedures. The groups for which such information was found are women, children, the elderly, people who have hearing deficits, and people with developmental disabilities.
Histories of physical and sexual abuse are common among women, as well as children and many men, treated in mental health settings. A Massachusetts Department of Mental Health Task Force on the Restraint and Seclusion of Persons who have been Physically or Sexually Abused (1996) addressed this concern. The Task Force noted that, "As a consequence of inadequate assessment and inappropriate treatment…there is growing evidence that in most mental health settings, such [people] are likely to be retraumatized [partially by the use of seclusion and restraint], leaving them in a continuing cycle of trauma and response." Survivors of abuse indicated that restraint and seclusion often bear marked similarities to prior real-life experiences. Therefore, seclusion and restraint often had the opposite effect from their intended result of de-escalating agitation.
The Task Force recommended over all that the meaning of the term "cultural competence" be extended to include gender-specific needs related to clinical treatment. It made specific recommendations that would apply to public as well as purchased services. Each facility would be required to have a process to obtain information about the history of abuse, de-escalation strategies that have worked for the individual consumer, and forms of restraint or seclusion that are most helpful and least traumatic for that person. A trauma assessment would be conducted at intake to collect information about the consumer’s history of sexual or physical abuse. Restraint reduction data would be collected to help consumers identify interventions that might retraumatize, as well as strategies that had been or might be effective in avoiding or reducing the use of seclusion or restraint.
Furthermore, the Task Force recommended that a person with a history of sexual abuse should not be restrained with any mechanical device requiring the patient’s legs to be spread. A staff person attending the patient during restraint would be required to be female (or of the opposite gender of the abuse perpetrators) unless the patient requested otherwise.
The use of seclusion and restraint with children and adolescents raises special concerns. Children accounted for nearly 26 percent of the deaths related to these interventions that were uncovered by the Hartford Courant, although children make up less than 15 percent of the population of facilities treating people with mental illness or mental retardation. Despite this and other indications of elevated risk, however, only 6 states (of the 36 responding to the NASMHPD survey) have regulations that specifically address the use of seclusion for children (Fassler & Cotton, 1992).
Some organizations and authors have taken a stand on using these techniques with children based at least partly on a developmental perspective. Fassler and Cotton (1992) reported that some authors emphasize the limited impulse control, immature defenses, and immature interpersonal skills of children. The American Psychiatric Association’s Task Force on Seclusion and Restraint (Tardiff 1985, p 37) noted that "the intrinsic need for external controls that characterizes all of childhood…is additive to the effects of mental illness which lead to deficiencies in both judgment and self-control…Self-injurious, violent, destructive or chaotic behavior must be interrupted if overt or as soon as it is clearly threatened. If it cannot be stopped by any other means available at that time, then it becomes an indication for seclusion or restraint."
In this vein, the American Academy of Child and Adolescent Psychiatry has asked the American Medical Association to work with state and local medical societies and with specialty organizations to coordinate the development of updated national guidelines for using seclusion and restraint safely and appropriately with children and adolescents (AACAP Resolution 509, 1998). The NMHA reported that AACAP has drafted a policy statement on seclusion and restraints and will develop practice guidelines for its members (NMHA, 1998). According to a NAMI analysis of the draft AACAP guidelines (Ross, 1998) properly used seclusion and restraint will be considered to be safe, clinically appropriate, and important components of a comprehensive treatment plan. AACAP will propose that these interventions be available for use when a patient poses an immediate threat of harm to self or others or an imminent threat of disrupting the milieu or destroying property.
NAMI noted some concern about the permissive nature of the AACAP guidelines as drafted, but neither it nor NMHA took a position completely opposed to the use of seclusion and restraint with children and adolescents. On the other hand, the Federation of Families for Children’s Mental Health (FFCMH) rejects the use of seclusion or restraint with this population. The FFCMH is strongly opposed to the use of mechanical restraints and seclusion with any child, but especially children and youth who have mental, emotional or behavioral disorders. Physical restraints and involuntary seclusion are considered to be techniques that relieve stress for the adults in charge and increase stress for the youth (Trina Osher, personal communication, 1999).
Only a few written procedures specifically addressed children and adolescents, but some did speak to the length of time for which a child or adolescent may be secluded or restrained. These were generally shorter than those permitted for adults, or two hours as opposed to four. One set of detailed procedures was identified, in that the NIH Clinical Center Nursing Department has developed specific guidance for managing children under age 12 in papoose restraint (NIH 1997b).
The restraint and seclusion of children and adolescents in juvenile correctional facilities deserves separate mention. The overlap between mental health and juvenile justice populations has been documented. A 1996 Emory University study found that sixty-one percent of youth entering the Georgia juvenile justice system have psychiatric disorders (Department of Justice 1996). Mitchell and Varley (1990) reported that a study of child and adolescent services in the State of Washington found 76% of incarcerated adolescents to be as severely emotionally disturbed as adolescents in a public psychiatric inpatient facility.
The similarities in client characteristics "do not necessarily correspond to similarities in institutional practice (Mitchell and Varley 1990)." Both types of facilities use seclusion and various forms of restraint as behavior modification techniques. Correctional institutions, however, may use both techniques as punishment rather than as elements of a controlled therapeutic behavior modification program. Mitchell and Varley noted that it is not unusual to hear of children being isolated for weeks at a time, and there are numerous reports of youth being restrained in unnatural positions that cause pain and physical damage.
Elderly persons with psychiatric disorders are governed by different rules in relation to seclusion and restraint depending on their place of residence. Language in the Omnibus Budget Reconciliation Act of 1997 directed nursing homes to reduce their use of physical restraints and asserted that nursing home residents had the right to be free of restraints imposed for discipline or staff convenience. Based on this law, elderly people who reside in nursing homes or other long-term care facilities that are subject to HCFA regulations are almost completely shielded from involuntary seclusion (42CFR483.13). They may not be subjected to any physical or chemical restraints that are not required to treat their medical symptoms. The regulations apply to every resident, whether or not he bears a psychiatric diagnosis, and whether the diagnosis reflects late-onset cognitive impairment or long-standing psychotic illness.
Restraint reduction efforts in nursing homes are ongoing and have been studied (e.g., Capezuti et. al 1998a & b; Siegler et. al. 1997; Evans et. al. 1997). It is beyond the scope of this paper to review those studies in depth, but it is clear that restraint reduction efforts have had some success. As restraint use has declined, there have been fewer serious patient injuries and the decrease in use of mechanical restraints has not been offset by an increase in pharmacological restraints (Siegler et. al. 1997; Miles, personal communication, 1999). Restraint-free facilities have been found to have a high ratio of registered nurses to residents as well as other characteristics that imply a trained and motivated staff (Castle and Fogel, 1998).
The elderly population includes people with psychiatric disorders related to aging, as well as people who have struggled with mental illness over the course of much of their lives. Elderly people with mental illness who live anywhere other than in nursing homes covered by the HCFA regulations are subject to the guidelines followed in their particular places of residence. Few if any community facilities are governed by formal rules and regulations. Facilities such as psychiatric units within general hospitals may be accredited by JCAHO. Those standards and similar guidelines do not make specific reference to patient age except for children and adolescents.
The American Psychiatric Association identifies the elderly as a population having special clinical features that warrant attention when seclusion and restraint are being considered as therapeutic interventions (APA Task Force, 1985, p 39). APA notes that rates of restraint and seclusion are lower for this group than for the general psychiatric population, suggesting that staff prefer to cope with objectionable behaviors in the elderly through other means. Although assaultive behaviors can occur at any age, old people may be perceived as less dangerous than young people, resulting in a lower level of staff anxiety when faced with disruptive behaviors or behavioral emergencies in elderly patients. The APA appears to caution against under-use of seclusion and restraint, noting that these interventions may be indicated when they meet the patient’s needs better than alternative treatments. However, it notes that potential adverse effects should be considered and the interventions should be instituted only with close supervision of the patient and in the presence of measures to safeguard rights and dignity.
Federal law protects the rights of people with developmental disabilities (42 USC Sec. 6009, Title 42, Chapter 75). The law establishes that they have a right to appropriate treatment, services, and habilitation in the least restrictive setting. Public funds may not be provided to any institution or residential program that uses physical restraint as a punishment or as a substitute for a habilitation program. Chemical restraints may not be used excessively or in quantities that interfere with services, treatment, or habilitation.
HCFA regulates the use of seclusion and restraint in intermediate care facilities for people with mental retardation (42CFR483.420, 440, and 450). The Conditions of Participation for these facilities require that clients be kept free from unnecessary drugs and physical restraints and provided with active treatment to reduce dependency on drugs and restraints. Each client must have an individual program plan that includes his specific developmental and behavioral management needs. All interventions that are used to manage inappropriate client behavior must be specified by the facility and designated on an implementation hierarchy, from most positive or least intrusive to least positive or most intrusive. Less intrusive techniques must be tried first, systematically, and demonstrated to be ineffective before more intrusive techniques can be used. Any techniques can be used only as part of the client’s individual program plan. Behavioral interventions that involve risks to client protection and rights are subject to review by a committee or committees composed of facility staff members, parents, legal guardians, consumers ("as appropriate"), people qualified in contemporary practices to change inappropriate behavior, and people with no ownership or controlling interest in the treatment facility.
As in the case of the elderly consumer, the person with developmental disabilities may receive treatment in various settings. Although retaining their legal rights, those individuals who do not reside in a facility covered by the HCFA regulations generally would be subject to the rules and guidelines of the places where they live or receive treatment.
The American Psychiatric Association Task Force (Tardiff 1985, p 41) noted that people with developmental disabilities often behave aggressively, and proper treatment requires that they may be restrained or secluded as part of a behavioral treatment program. The specific characteristics of this type of patient may increase the likelihood of aggressive behavior while at the same time they may decrease the effectiveness of interventions. Particular care is needed to safeguard the patient’s right to be free from unnecessary or excessive medication. The task force report calls for the effectiveness of all forms of seclusion and restraint to be evaluated in terms of their effects on target behaviors. However, the difficulty of conducting such evaluation studies is acknowledged.
The rates of major psychosis are approximately the same in the Deaf and hearing populations. However, deafness can be isolating. Few mental health facilities offer even basic telecommunications equipment that is accessible to Deaf consumers. Limited sign language interpretation services are available, and poor communication between the Deaf client and the hearing clinician often leads to misdiagnosis and over-diagnosis.
In the absence of mental health staff who are fluent in sign language or of skilled sign language interpreters who are trained to work in the mental health setting, the Deaf consumer may have no reasonable way to communicate his needs. Behaviors stemming from this frustration may lead to the imposition of seclusion or restraint. These interventions further isolate the patient by limiting or removing his ability to use his hands and body in the service of communication.
Moreover, an adequate array of community-based supports for people who are Deaf and also have a mental illness is not available in many states. Deaf consumers who lack access to community care tend to be over-represented in long-stay, institutional settings. Thus, Deaf people with a diagnosis of mental illness may be considered to be at increased risk of being secluded or restrained because of their proximity to such interventions, even if for no other reason.
The Illinois State Code includes language relevant to the restraint of people who are Deaf and have mental illness. Section 3-204 (General Provisions) states that "Whenever a statement or explanation is required to be given to a patient under this Chapter and the patient does not read or understand English, such statement or explanation shall be provided to him in a language which he understands. Such statement or explanation shall be communicated in sign language for any hearing impaired person for whom sign language is a primary mode of communication. When a statement or explanation is provided in a language other than English, or through the use of sign language, that fact and the name of the persons by whom it was provided shall be noted in the patient’s record."
Section 4-206 expands this (sign language) notification requirement by indicating that the same process will be followed if the client is under 18 and notice is given to his parent, guardian, or person acting in loco parentis. If the client is 18 years of age or older, notice shall be given to the consumer, his guardian, if any, and any 2 other persons whom the consumer may designate. If the consumer is 18 or older but lacks sufficient capacity to understand and consent to the designation of persons to receive notice, notice shall also be sent to his nearest adult relative.
The Illinois Provisions regarding Restraint state in section (h): "Whenever restraint is imposed upon any recipient whose primary mode of communication is sign language, the recipient shall be permitted to have his hands free from restraint for brief periods each hour, except when such freedom may result in physical harm to the recipient or others."
Finally, Article III, Administrative and Temporary Admission of the Developmentally Disabled addresses diagnostic evaluations. Section 4-300 (b) states that "The evaluation shall include current psychological, physical, neurological, social, educational and developmental evaluations. It shall be conducted under the supervision of qualified professionals including at least one clinical psychologist and one physician. Any tests that require language familiarity shall be conducted in the person’s primary language."
This review of guidelines and standards for the use of seclusion and restraint highlights the diverse approaches to their use in this country. There is very little consensus even on basic issues, such as whether or not these interventions have therapeutic value. Even the meaning of the terms seclusion and restraints varies from place to place, guideline to guideline. The only general agreement that was identified is the belief that seclusion and restraint, whatever they may be, should never be used inappropriately, however that may be defined.
In commenting on the post-OBRA literature review by (Castle and Mor, 1998), Zinn (1998) points out a lack of research coordination among disciplines. "Unfortunately, the various disciplines investigating restraint use focus on different variables without recognizing complementarities and sharing findings." Obviously, this adds to the difficulty of developing uniform policies, whether one is talking about nursing home residents or people in psychiatric facilities.
Although there is little consensus around seclusion and restraint, the very existence of so many guidance documents and models shows that it is possible to develop standards that are applicable to these interventions. Some degree of collaboration by all stakeholders may make it possible to begin to develop consensus on standards by seeking broad principles to which all can agree. That would be a good first step toward designing uniform policies and practices. Even if complete consensus cannot be reached, however, focussing on seclusion and restraint as important policy issues cannot help but raise awareness of their dangers and the need to manage their use with extreme care.
Advocates for all points of view are certain to continue to press for policies that meet their needs. Their task will be easier to the extent that their efforts can be supported by research-based arguments. This monograph, by presenting a range of current standards and models, intends to provide references for developing those position statements. More than that, however, it hopes to provoke further study and discussion that will enhance adherence to the rare but vital point on which everyone agrees: seclusion and restraint should never be used unless they can be used appropriately
- American Academy of Child and Adolescent Psychiatry (AACAP 1998). Resolution to the American Medical Association House of Delegates on the Seclusion and Restraint of Children and Adolescents, Resolution 509, June 1998.
- American College of Emergency Physicians (ACEP 1996). Use of Patient Restraint, January 1996, ACEP Policy Statement.
- American Psychological Association (1996). Violence and the Family: Report of the American Psychological Association Presidential Task Force on Violence and the Family. Washington, D.C.
- Arizona Mental Health Regulations: Chapter 15, Article R9-15-101: Definitions.
- Arizona Mental Health Regulations: Chapter 15, Article R9-15-206: Restraint and Seclusion.
- Beall, Mary Ann: CMHS Meeting on Restraint and Seclusion Issues, Rockville, MD February 10, 1999.
- Burton, Lynda C., German, Pearl S., Rovner, Barry W., and Larry J. Brant (1992) Physical Restraint Use and Cognitive Decline among Nursing Home Residents. Journal of the American Geriatric Society 40(8), pp. 811-816.
- Burton, Lynda C., German, Pearl S., Rovner, Barry W., Brant, Larry J., and Rebecca D. Clark (1992). Mental Illness and the Use of Restraints in Nursing Homes. The Gerontologist 32(2) pp. 164-170.
- Bursten, Ben (1975). Open Forum: Using Mechanical Restraints on Acutely Disturbed Psychiatric Patients. Hospital and Community Psychiatry 26(11) pp. 757-759.
- California Law SB 895 (Vetoed). Introduced by Senator McCorquodale, March 4, 1993.
- Campbell, Jean: CMHS Meeting on Restraint and Seclusion Issues, Rockville, MD February 10, 1999.
- Capezuti, Elizabeth, Strumpf, Neville E., Evans, Lois K., Grisso, Jeane Ann, and Greg Maislin (1998a) The Relationship Between Physical Restraint Removal and Falls and Injuries Among Nursing Home Residents. Journal of Gerontology 53A(1), PP M47-M52.
- Capezuti, Elizabeth, Talerico, Karen A., Strumpf, Neville, and Lois Evans (1998). Individualized Assessment and Intervention in Bilateral Siderail Use. Geriatric Nursing 19(6), pp. 322-30.
- Carpenter, Mary D., Hannon, Virginia R., McCleery, Gerald, and Joseph A. Wanderling (1988). Variations in Seclusion and Restraint Practices by Hospital Location. Hospital and Community Psychiatry, (39)4, pp. 418-423.
- Castle, Nicholas G., and Barry Fogel (1998). Characteristics of nursing homes that are restraint free. The Gerontologist 38(2), pp. 181-188.
- Castle, Nicholas G., and Vincent Mor (1998). Physical Restraints in Nursing Homes: A Review of the Literature since the Nursing Home Reform Act of 1987. Medical Care Research and Review 55(2), PP 139-170.
- Chamberlin J (1985). An ex-patient’s response to Soliday. Journal of Nervous and Mental Diseases 173, pp. 288-289.
- Civil Rights of Institutionalized Persons Act, 42 U.S.C. 1997.
- Code of Federal Regulations, Requirements for Long Term Care Facilities. (42CFR483.13[a]). Resident behavior and facility practices. Restraints.
- Code of Federal Regulations, Requirements for Long Term Care Facilities. Subpart I—Conditions of Participation for Intermediate Care Facilities for the Mentally Retarded.
- (42CFR483.420). Condition of participation: Client protections.
- (42CFR483.440). Condition of Participation: Active treatment services.
- (42CFR483.450). Condition of Participation: Client behavior and facility practices.
- Crenshaw, Wesley B., Cain, Kimberly A., and Paul S. Francis. (1997) An Updated National Survey on Seclusion and Restraint. Psychiatric Services 48(3), pp. 395-397.
- Daar, Melissa and Teresa Nelson (1992). Reforming Seclusion and Restraint Practices: An Advocacy Manual, May 1992; Protection and Advocacy, Inc.: Sacramento, CA.
- Decker, Curt: CMHS Meeting on Restraint and Seclusion Issues, Rockville, MD February 10, 1999.
- Evans, Lois K. and Neville E. Strumpf (1989) Tying Down the Elderly: A review of the Literature on Physical Restraint. Journal of the American Geriatrics Society 37(1), pp.67-74.
- Evans, Lois K., Strumpf, Neville El, Allen-Taylor, S. Lynne, Capezuti, Elizabeth, Maislin, Greg, and Barbara Jacobsen (1997). A Clinical Trial to Reduce Restraints in Nursing Homes. Journal of the American Geriatrics Society 45, pp. 675-681.
- Faenza, Michael M. (March 23, 1999). Letter to Senator Joseph I. Lieberman from the National Mental Health Association.
- Fassler, David, and Nancy Cotton (1992). A National Survey on the Use of Seclusion in the Psychiatric Treatment of Children. Hospital and Community Psychiatry; April 1992, Vol 43(4); 370-374.
- Fisher, William A. (1994). Restraint and Seclusion: A Review of the Literature. American Journal of Psychiatry November 1994, 151(11). Pp. 1584-1591.
- Food and Drug Administration (1992). Safe Use of Physical Restraint Devices, July 1992; FDA Backgrounder: Rockville, Maryland.
- Illinois State Mental Health and Developmental Disabilities Code, Illinois Department of Health and Mental Disabilities. November 1990 (revised 1991). Articles II and III. Clauses related to the evaluation and treatment (seclusion and restraint) of people with mental illness or developmental disability whose primary language is sign language.
- Isaacs, Mareasa R. (1992). Violence: The Impact of Community Violence on African American Children and Families. Arlington, VA. National Center for Education in Maternal and Child Health.
- Hartford Courant (October, 1998). A series of articles on deaths related to seclusion or restraint in mental health facilities, mental retardation facilities, and group homes.
- Johnson, J. Rock: CMHS Meeting on Restraint and Seclusion Issues, Rockville, MD February 10, 1999.
- Joint Commission on Accreditation for Healthcare Organizations (1996). 1996 Accreditation Manual for Hospitals: Volume 1 - Standards; 1996, JCAHO: Oakbrook Terrace, IL.
- Jones, Nancy Lee (February 9, 1999). Memorandum to Senators Dodd and Lieberman from the Congressional Research Service re Federal Law on the Use of Restraints and Seclusion in Mental Health Care Facilities.
- Kobs, Ann (1998): Restraints Revisited: Questions and Answers from the JCAHO. Nursing Management, January, 1998.
- Ljunggren, Gunnar, Phillips, Charles, and Antonio Sgdari (1997). Continuing and Rehabilitative Care for Elderly People: A Comparison of Countries and Settings. Age and Aging 26(6) 543.
- Manhattan Psychiatric Center (7/24/92 and 11/12/93). Policy and Procedure Manual: Seclusion and Restraint. Transmittal Letters 92 MPC 10 and 93 MPC 08. (See Appendix 3: New York State Office of Mental Health [1994b]. Final Recommendations on the Use of Restraint and Seclusion, Division of Quality Assurance, June 1994.)
- Massachusetts Department of Mental Health (1996). Report and Recommendations of the Task Force on the Restraint and Seclusion of Persons who have been Physically or Sexually Abused, January 25, 1996.
- Massachusetts Mental Health Regulations for Community Programs. 104 CMR 3.12 (3) Definitions.
- Massachusetts Mental Health Regulations for Community Programs, 104 CMR 15.00 The Use of Restraint and Seclusion.
- Massachusetts Statute on Restraint and Seclusion.
- Miles, Steven, University of Minnesota, personal communication, 1999.
- Min DeParle, Nancy-Ann (March 24, 1999). Letter for Senator Joseph I. Lieberman in support of his proposed "Freedom From Restraint Act of 1999."
- Mitchell, Jeff, and Christopher Varley (1990). Isolation and Restraint in Juvenile Correctional Facilities. Journal of the American Academy of Child and Adolescent Psychiatry 29(2), 251-255.
- National Alliance for the Mentally Ill (1998a). NAMI Board Says Involuntary Restraints Only For Emergency Safety Measures; November 28, 1998; NAMI: Arlington, VA.
- National Association of Protection and Advocacy Systems (NAPAS). March 24, 1999. Statement of Curtis L. Decker, Executive Director, in support of legislation introduced by Senators Lieberman and Dodd and Representatives DeGette and Stark.
- National Association of Psychiatric Health Systems (NAPHS) and American Hospital Association (AHA), February 25, 1999. Guiding Principles on Restraint and Seclusion for Behavioral Health Services.
- National Institutes of Health Clinical Center Nursing Department Standards of Practice: Management of the Patient in Restraints. Revised 9/97 (NIH 1997a)
- National Institutes of Health Clinical Center Nursing Department Standards of Practice: Management of the Patient in Papoose Restraint (for children under the age of 12). Revised 9/97 (NIH 1997b).
- National Institutes of Health Clinical Center Nursing Department Standards of Practice: Care of the Patient in Locked Seclusion. Revised 9/97 (NIH 1997c).
- National Institutes of Health Clinical Center Nursing Department Standards of Practice: Procedure: Physical Intervention with an Aggressive Patient. Revised 9/97 (NIH 1997d).
- National Mental Health Association (1998). Position Statement on the Use of Restraints and Seclusion for Persons with Mental or Emotional Disorders, December 5, 1998; NMHA Program Policy p. 41; NMHA: Alexandria, VA.
- New Hampshire Hospital Policy and Procedure: Seclusion/Restraint. Effective 9/15/98.
- New York State Commission on Quality of Care (1994a) Governance of Restraint & Seclusion Practices by NYS Law, Regulation, and Policy. Draft released October 1994.
- New York State Office of Mental Health (1994b). Final Recommendations on the Use of Restraint and Seclusion, Division of Quality Assurance, June 1994.
- Omnibus Budget Reconciliation Act (OBRA) of 1987. PL 100-203. Subtitle C. The Nursing Home Reform Act.42 USC 1395i-3(a)-(h) (Medicare); 1396r (a)-(h)(Medicaid).
- Osher, Trina. Federation of Families for Children’s Mental Health. Personal communication, 1999.
- Outlaw, Freida H. and Barbara J. Lowery (1992). Seclusion: The Nursing Challenge. Journal of Psychosocial Nursing 30(4) pp. 13-17.
- Proposed Rule: Medicare and Medicaid Programs; Hospital Conditions of Participation; Provider Agreements and Supplier Approval. Federal Register, Volume 62, Number 244, Pages 66725-22763.December 19, 1997.
- Roper, Janice M., Coutts, Adam, Sather, Janet, and Roselia Taylor (1985). Restraint and Seclusion: A Standard and Standard Care Plan. Journal of Psychosocial Nursing 23(6) 18-23.
- Ross, E. Clarke: National Alliance for the Mentally Ill. "Restraints Policies—Some Particulars." Unpublished document. December 3, 1998.
- Siegler, Eugenia L., Capezuti, Elizabeth, Maislin, Greg, Baumgarten, Mona, Evans, Lois, and Neville Strumpf (1997). Effects of a Restraint Reduction Intervention and OBRA ’87 Regulations on Psychoactive Drug Use in Nursing Homes. Journal of the American Geriatrics Society 45(7) pp. 791-796.
- Strumpf, Neville E. and Nancy Tomes (1993). Restraining the Troublesome Patient: A Historical Perspective on a Contemporary Debate. Nursing History Review Vol. 1, pp. 3-24.
- Tardiff, Kenneth (1985). Seclusion and Restraint, The Psychiatric Uses, Report of the American Psychiatric Association Task Force on the Psychiatric Uses of Seclusion and Restraint, 1984.
- Tardiff, Kenneth (1988). Management of the Violent Patient in an Emergency Situation, Psychiatric Clinics of North America; Dec. 1988, Vol. 11(4): 539-549.
- UCLA Medical School. Activities for Physical Restraint. http://neurosun.medsch.ucla.edu/BM…t/new.htdocs/NICHTML/intrv_26.html.
- United States Code: 42 USC Section 6009, Title 42, Chapter 75. Programs for Individuals with Developmental Disabilities.
- United States Naval Hospital, Naples, Italy. Use of Restraints and Seclusion. USNHNAPINST 6320.9D, 13 Jan 98. http://220.127.116.11/directives/files/6320_9D.HTM
- Wadeson, Harriet and William Carpenter (1976). Impact of the Seclusion Room Experience, Journal of Mental and Nervous Disease, Vol 163(5).
- Williams, Carter C. and Caleb E. Finch (1997). Physical Restraint: Not Fit for Woman, Man, or Beast. Journal of the American Geriatrics Society 45, pp. 773-775.
- Wyatt v. Stickney (1972). 344 F. Supp. 373 (M.D. Ala. 1973).
- Youngberg v. Romeo (1982). 457 U.S. 307.
- Zinn, Jacqueline S. (1998). Commentary on Castle, Nicholas G., and Vincent Mor (1998). Physical Restraints in Nursing Homes: A Review of the Literature since the Nursing Home Reform Act of 1987. Medical Care Research and Review 55(2), PP 171-175.