Restraint and Seclusion

Abstract

The use of restraint and seclusion (R/S) as a usual and traditional response to real or potential violence in inpatient mental health hospitals and residential facilities are interventions that have been used, and overused, for decades in behavioral health settings, both nationally and internationally. In recent years the use of R/S interventions have come under a lot of scrutiny as to: (1) the situations wherein they are used; (2) the specifics regarding individual patient behaviors that trigger this use for both adults and kids/youth; (3) the role of staff training and experience in using R/S; (4) the role of prevention in the usual conflicts that occur in inpatient and residential settings where individuals are often being held involuntarily; (5) the manner in which staff respond to these dangerous and traumatizing practices after they have been used, and (6) what are US healthcare provider organizations doing to adopt best practices to prevent conflict in their healthcare settings or rapidly intervene when conflict occurs.

What the behavioral health field should now know is that there is no evidence that the use of R/S is in any way therapeutic. We should all know that the use of these restrictive interventions is both dangerous and traumatizing to the staff ordered to perform these actions, as well as, to the client/subject of these interventions, and all who observe these, often violent, interventions. The last decade has seen much review, by both clinicians and researchers, about the use of R/S and the common finding is that these interventions should be avoided in any way possible. The use of R/S has been shown to not lead to any positive behavioral change, are ineffective to change individual’s behavior, lead to a complete loss of trust between provider and client, and have no therapeutic utility at all. In fact, current findings have demonstrated, over and over again, that inpatient and residential facilities should do everything possible to prevent the situations leading to the use of R/S. Not only due to the interruption in trust but because these interventions are routinely causing re-traumatization and or death.

The US behavioral health field is being called on to get up to speed on the use of violent and dangerous interventions, such as R/S. This will require training of healthcare professionals in both academic pursuits and also in post education, job orientation, and training. There is now at least one evidence-based practice that has been proven to be effective to greatly reduce the use of R/S in inpatient and residential organizations. Nursing staff need to pay attention to this issue as it is generally left to nursing staff to do the emergency order to use R/S and to oversee its use. In addition, physicians need to be mindful about what they are being asked to order in terms of R/S and also be trained in current best practices. Finally, there have not been any significant changes in the views on R/S in the last decade (since 2012). Most of the significant learnings occurred from 1998 through 2012 and are now being implemented in facilities who are committed to this work or who have been directed due to lawsuits or other internal issues.

This chapter is an update from the 4th edition. Previous edition authors were Kevin Ann Huckshorn, Janice LeBel