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Position Statement 24: Seclusion and Restraints
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 restraints and prohibition of the use of sedatives and other medications as chemical restraints.
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”).
…[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. & Pol’y 325 (2006) (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.
Thus, the constitutional implications of long-term segregation remain to be determined.
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. MHA is already on record opposing use of such restraints in juvenile justice interactions whenever possible.4 MHA has authored legislation advocating an imminent danger standard for use of seclusion and restraints in child residential care.5 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.6
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”7 and by NASMHPD in a comprehensive 1999 position statement.8 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.
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 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, restraints continue to be used about 10 times a year. Seclusion has been eliminated, but voluntary disengagement had been preserved. MHA stresses that truly voluntary disengagement, as with time-out and comfort room procedures, are essential tools, along with committed staff, in reducing conflict and restoring calm. The unlocked door 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 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?”9
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.”10
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.” This position was reiterated by 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.”11 NASMHPD led the way by passing the 1999 policy cited above, 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.12
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.13
In 2011, reinforcing its 2005 Roadmap, SAMHSA issued an important “white paper” stating the “business case” for limiting use of seclusion and restraints.14 The abstract of the white paper demonstrates the overwhelming character of the business case for reform:
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 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 2014-2015 fiscal year, restraints were used only 10 times in the State’s civil hospitals and forensic centers. Seclusion has not been used in the State hospital system since July 2013. Five State hospitals have eliminated the use of seclusion and restraints entirely. 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.17 Pennsylvania worked to change the culture of its state hospitals to a recovery-based system of care.18
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 10 minutes and any type of floor control, prone or supine, is prohibited. Physical restraint use can be extended an additional 10 minutes, but after that the individual must be transitioned to mechanical restraint. 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” list of people served on the unit who may not be restrained or secluded due to a pre-existing medical or psychiatric condition.
- People in treatment 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.
- 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 de-escalation, using the Mandt techniques,19 and refresher training is offered at six month intervals. PA has recently expanded the curriculum to include the advanced trainings to better deal with specific situations and for additional techniques in dealing with highly aggressive individuals.
- 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.20
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,”21 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.
- Seclusion and restraints should only be used for the amount of time needed to restore safety and security to the person in treatment and others.
- In order to minimize the length of time in restraints, an authorizing physician should be required to write specific criteria for determining when restraints should be discontinued, and as soon as those criteria are met, the person should be released.
- 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 in PA, staff training on the safe support of people in crisis should be required 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.
SAMHSA and NASMPHD
The Safewards Model
Finland, Australia, and the United Kingdom have undertaken recent systematic programs to reduce the use of coercion in mental health treatment.25 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.26 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 the disruptive behavior of patients that threatens the internal structure of the ward. Staff anxiety accentuates patient 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 patient 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 patients and risk violence when necessary), equality (demonstrating, through a variety of ways, a lack of superiority), non-judgmentalism (eschewing large-scale moral valuation of the patient), 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 of patients, derived from psychological models, studies or psychotherapeutic approaches, instead of judging patients 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 patients, affording them respect, compassion and companionship."27
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.”
Call to Action
- The states should require all psychiatric facilities (public and private) to implement plans and staff training to prevent and ultimately eliminate the use of seclusion and 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 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 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.28 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 restraint, 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.
- 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 per hours of treatment, 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.29 External monitors can educate the public and key policy-makers about the needs and problems of consumers. 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 recipient affairs staffed by consumers and advocates that 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 consumers, 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 consumers, 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 December 5, 2015. It will remain in effect for a period of five (5) years and is reviewed as required by the Mental Health America Public Policy Committee.
Expiration: December 31, 2020
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).
4. See MHA Policy Position 51, http://www.mentalhealthamerica.net/positions/juvenile-justice
6. 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
7. 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 SAMHSA Store, http://store.samhsa.gov/shin/content/SMA06-4055/SMA06-4055-A.pdf
8. 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), http://www.hogg.utexas.edu/uploads/documents/risk_factors-ref.pdf and http://www.health.vic.gov.au/chiefpsychiatrist/creatingsafety/ntac/module8.pdf
10. 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), http://www.parecovery.org/documents/SAMHSA_SR_Commitment.pdf .
11. Glover, R., “Reducing the Use of Seclusion and Restraint: A NASMHPD Priority,” Psychiatric Services 56(9): 1141-1142 (2005), http://www.parecovery.org/documents/SR_NASMHPD.pdf
13. 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.
14. 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), http://store.samhsa.gov/shin/content/SMA11-4632/SMA11-4632.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), http://www.mass.gov/eohhs/docs/dmh/rsri/economic-cost-restraint.pdf
15. 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
16. LeBel, J., “Regulatory Change: A Pathway to Eliminating Seclusion and Restraint or 'Regulatory Scotoma'?” Psychiatric Services 59:194-196 (2008). http://www.mass.gov/eohhs/docs/dmh/rsri/reg-scotoma.pdf
17. 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.” Psychiatric Services, 56(9), 1115-1122 (2005). http://www.parecovery.org/documents/PA_SR_Reduction_Program.pdf. Updated data and information about the Pennsylvania initiative's ongoing success are available online through PA’s OMHSAS at http://www.dpw.state.pa.us/cs/groups/webcontent/documents/bulletin_admin/d_005645.pdf and http://www.parecovery.org/services_seclusion.shtml
22. 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
23. 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
24. 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
25. 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
26. Huckshorn K.A., Reducing Seclusion and Restraint Use in Inpatient Settings: 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.
27. 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).
28. See MHA Position Statement 23, Advance Psychiatric Directives, http://www.mentalhealthamerica.net/positions/psychiatric-advance-directives
29. According to NAMI, “Some State hospital systems and some facilities such as Delaware, Massachusetts, New Hampshire, New Jersey, and Pennsylvania, have reduced the use of seclusion and restraints by using third party citizen, consumer and family monitoring groups.” See www.NAMI.org and MHA’s Checking Up on Juvenile Justice Facilities: A Best Practices Guide, a guide for developing these external monitoring programs. No URL available. See also World, Heather, “Mental Health Care's New Model Shuns Restraint and Seclusion -The Nursing Spectrum.” (2007), online at: http://mentalhopenews.blogspot.com/2007/08/mental-health-cares-new-model-shuns.html.