Administration and Policy in Mental Health and Mental Health Services Research, Vol. 33, No.

4, July 2006 (Ó 2005)

DOI: 10.1007/s10488-005-0011-5

Re-Designing State Mental Health Policy to Prevent

the Use of Seclusion and Restraint*

Kevin Ann Huckshorn1,2

The members of the National Association of State Mental Health Program Directors
(NASMHPD) believe that seclusion and restraint, including ‘‘chemical restraints," are safety
interventions of last resort and are not treatment interventions. Seclusion and restraint
should never be used for the purposes of discipline, coercion, or staff convenience, or as a
replacement for adequate levels of staff or active treatment. The use of seclusion and
restraint creates significant risks for people with psychiatric disabilities. These risks include
serious injury or death, retraumatization of people who have a history of trauma, and loss of
dignity and other psychological harm. In light of these potential serious consequences,
seclusion and restraint should be used only when there exists an imminent risk of danger to
the individual or others and no other safe and effective intervention is possible. (Endorsed
by the State Mental Health Directors, July 13, 1999). (NASMHPD 1999, NASMHPD
Position Statement on Seclusion and Restraint. Alexandria, VA: National Technical
Assistance Center for State Mental Health Planning.)
KEY WORDS: seclusion and restraint; state mental health policy; restraint reduction; ethics and
seclusion; restraint use.

INTRODUCTION USGAO, 1999). In spite of the documented risk

Seclusion and restraint (S/R) are among the
most controversial procedures used in the mental
health field (Steele, 1999). Currently, seclusion and
restraint are widely considered to be high risk,
problem-prone interventions that can be dangerous
to both consumers and staff in inpatient mental
health treatment environments (JCAHO, 2004a;
*
The views expressed in this article are those of the author only,
and do not necessarily represent the views of the author’s
employer.
1
National Technical Assistance Center, National Association of
State Mental Health Program Directors (NAMSHPD), Alexan-
dria, USA.
2
Correspondence should be directed to Kevin Ann Huckshorn,
R.N., M.S.N., C.A.P., I.C.A.D.C., National Technical Assistance
Center, National Association of State Mental Health Program
Directors (NAMSHPD), 66 Canal Center Plaza, Suite 302,
Alexandria, VA 22314, USA; e-mail: Kevin.huckshorn@nas-
mhpd.org.
associated with their use, S/R remain the most
erratically regulated, and under-reported of all the
intrusive interventions used in the healthcare field
today (Steele, 1999).
The use of S/R is a political and economic issue
that affects consumers, staff, provider organizations,
regulatory agencies, and local, state and federal
legislators. While the costs associated with S/R re-
lated injuries and deaths for consumers and staff
have not been widely explored, a recent Massachu-
setts study has calculated cost estimates to be over
$300 per event and three million annually (LeBel &
Goldstein, 2004). In addition, psychological and
physical injuries to staff are estimated yearly to re-
sult in millions of lost work hours (NASMHPD,
2002). As such, the use of seclusion and restraint has
become an issue of high priority to state mental
health authorities across the country (NASMHPD,
1999).

482
0894-587X/06/0700-0482/0 Ó 2005 Springer Science+Business Media, Inc.

Seclusion is defined as ‘‘the involuntary con-
finement of a person in a room where they are
physically prevented from leaving, for any period of
time’’ (JCAHO, 2004a, p. 444). Restraint is a
‘‘manual method or mechanical device, material, or
equipment attached or adjacent to the patient’s body
that he or she cannot easily remove and that restricts
the patient’s freedom or normal access to one’s
body’’ (HCFA, 1999). This article excludes chemical
restraint.
In 1998 the Hartford Courant highlighted the
use and abuse of S/R in a series of articles entitled,
‘‘Deadly Restraint: A Nationwide Pattern of Death’’
(Weiss et al., 1998). The series catalogued the deaths
of 142 individuals in the previous ten years who had
died while in S/R (Ibid). This published exposé of
unreported deaths, serious injuries, and iatrogenic
trauma to previously traumatized disabled individ-
uals of all ages resulted in public outrage and gov-
ernmental intervention. Furthermore, the Courant
indicated that S/R related deaths were widely be-
lieved under-reported since neither states nor the
federal government consistently monitor either the
use of S/R or the negative outcomes associated with
these interventions (Ibid).
The response following the Courant series re-
sulted in Congressional hearings and calls for revi-
sions in monitoring and accountability from health
care regulatory organizations such as the Health
Care Financing Administration (HCFA) and the
Joint Commission on Accreditation of Health Care
Organizations (Weiss et al., 1998).
The initial legislative activities and hearings
resulted in the congressionally commissioned 1999
U.S. General Accountability Office (USGAO)
report, Improper Seclusion and Restraint Use Places
People at Risk. The GAO concluded that S/R can
injure patients and staff; incomplete reporting leaves
the full extent of patient risk unknown; reporting
procedures are either incomplete or ignored;
reporting is not comprehensive; federal require-
ments do not address the use of S/R for all providers;
S/R use varies among programs, states and facilities;
and accreditation programs lack specifics in
addressing S/R (USGAO, 1999). The report also
noted that certain ‘‘states have lowered S/R use
through regulation, reporting, training and staffing’’
and cited examples from Pennsylvania, Massachu-
setts, New York, and Delaware (USGAO, 1999,
p. 17). Finally, the GAO report clearly listed policy
recommendations directed to the U.S. Department
of Health and Human Services and the Joint
483
Commission including consistent reporting require-
ments, standardized policies for all Medicare and
Medicaid reimbursed facilities and stronger safe-
guards for patient and staff safety (USGAO).
In 1999 HCFA, [now the Centers for Medicare
and Medicaid Services (CMS)], issued new condi-
tions of participation for all hospitals that participate
in Medicaid and Medicare reimbursement for ser-
vices provided in adult inpatient psychiatric units in
hospitals (HCFA, 1999). In 2000, Congress passed
the Children’s Health Act (CHA) that established
national standards restricting the use of S/R in all
public and private health care facilities that receive
any federal financial assistance including hospitals,
nursing facilities, psychiatric facilities, and interme-
diate care facilities (NAPAS, 2004). To implement
the CHA, two sets of regulations were required. One
set, the 2001 HCFA Interim Final Rules on ‘‘Use of
S/R in Psychiatric Residential Treatment Facilities
Providing Inpatient Psychiatric Services to Individ-
uals under Age 21,’’ is completed. The second set of
regulations, being promulgated by SAMHSA, will
affect other types of group homes and residential
facilities.
The most controversial change in the regulations
was the CMS condition of participation entitled ‘‘the
1-hour rule,’’ which was issued in 2000 (NAMI, 2003).
This interim regulation requires a physician to be
available 24-hours-a-day, 7-days-a-week, to perform
a face-to-face assessment within 1 hour of any adult
or child placed into S/R, including physical holds of
any duration. The rule meant that hospitals without
24-hour physician coverage had to arrange for doc-
tors to visit the hospital for these events.
The 1-hour rule created an administrative and
financial burden for many facilities that were ill
prepared to implement this new requirement. Many
psychiatrists immediately became aware of how re-
moved they were from S/R incidents and how they
would now be expected to judge events, after the fact.
Nursing associations reacted to placing physicians in
a primary role since this change reversed the histor-
ical practice wherein psychiatric nurses had been
primarily responsible for initiating the use of S/R,
albeit with a retroactive physician order (CMS,
2002). The American Hospital Association (AHA)
also voiced concern stating that it was an unnecessary
use of physician resources and that nurses could
competently provide the necessary assessment (Ibid).
In 2002, the AHA surveyed its membership regard-
ing the cost and benefit of the 1-hour rule and
reported that clinicians stated they could not recall a
484
case when the physician conducting the face-to-face
evaluation within the required hour had ever dis-
agreed with the initial on-site evaluation conducted
by the registered nurse (Hawryluk, 2002). In spite of
opposition by the American Medical Association
(AMA), the AHA, the American Nurses Association
(ANA), the American Psychiatric Nurses Associa-
tion (APNA), and managed care organizations, the
rule went into effect in 2001 and remains in force to
date (Ibid).
In response to requests to amend the 1-hour
rule, CMS held a public town hall meeting in 2002 to
hear from major mental health stakeholders (CMS,
2002). The associations that testified were evenly
divided. The AMA and the AHA felt the rule
‘‘unreasonably limited the ability of physicians to
order the use of reasonable and necessary patient
restraints ...’’ and that ‘‘the rule has diverted limited
resources from direct patient care’’ (Hawryluk, 2002,
p. 1). Many of the mental health providers urged
CMS to approve the policy of having the registered
nurse on duty perform the evaluation. On the other
hand, advocates of the rule made impassioned pleas
that CMS leave the rule in place. Those who wished
to preserve the rule indicated that given the poten-
tial lethality of restraints, transferring oversight to
the nurse symbolically diminishes the dangerousness
of these interventions and the worth of individuals
with a psychiatric illness (Hawryluk, 2002). The
point was also made that few nurses receive any
training about the use of S/R and may not possess
the knowledge required to order the use of these
high-risk interventions (Ibid). Other organizations
such as NAMI (National Alliance for the Mentally
Ill) and NASMHPD echoed these sentiments and
stated that until more was known, the 1-hour rule
should stand (Huckshorn, 2002).
The outcome of these legislative hearings,
resultant governmental attention by CMS, and the
CHA resulted in new regulations to strictly regulate
S/R use and standardize these regulations across
states, behavioral health providers and agencies. The
new regulations clarified definitions of use, orders for
use, time limitations, reporting of deaths, monitor-
ing, certification of staff, and differentiated between
S/R use for behavioral health reasons and those re-
lated to medical and surgical care (NAPAS, 2004).
These regulations have provided excellent direction
on how to more safely use S/R and they also certainly
attempted to move the field toward reduction.
However, the knowledge base has been significantly
expanded since, and this new knowledge needs to be
incorporated into current law, rules, and regulations
on both a federal and state level (HCFA, 1999;
OOMHMR, 2002; NAPAS, 2004).
The current administrator of the federal Sub-
stance Abuse and Mental Health Services Admin-
istration (SAMHSA), Charles Curie, was the past
deputy secretary for mental health and substance
abuse in Pennsylvania, one of a handful of states that
addressed the issue of S/R prior to the Hartford
Courant exposé. Pennsylvania has been extraordi-
narily successful in directing significant reduction
and (in some cases) actual elimination of use of S/R
in its state mental health institutions (Hardenstine,
2001). Mr Curie took up his position at SAMHSA
with the reduction and eventual elimination of S/R
as both a passion and a vision (Ibid). As a result, S/R
reduction and eventual elimination has become one
of the core priority initiatives in the SAMHSA
‘‘Matrix,’’ a visual depiction of the priority programs
and crosscutting principles that direct the agency
(SAMHSA, 2004). IN 2002, SAMHSA also released
a National Plan Action Plan to reduce and eventu-
ally eliminate the use of S/R with two initial goals: to
increase the ability of States, consumers, providers
and advocates to prevent, monitor and reduce use
and to increase the number of States that adopt best
practices to prevent and reduce use. In response
several health care associations have become
involved in researching best practices to reduce and/
or eliminate the use of S/R (CWLA, 2002; NAS-
MHPD, 2002; Success Stories, 2003). These activities
are responsible for much of what is now known and
available for use in current reduction efforts
(CWLA, 2002; Hardenstine, 2001; NASMHPD,
2002).
Available and replicable core interventions
that have proved successful in reducing S/R need
to be codified into federal rules and regulations.
These interventions seek to engender a cultural
change in mental health treatment environments by
using a public health prevention approach that
significantly differs in direction from the current
regulations. As part of its National Plan, SAMHSA
has recently announced a grant program to pilot
these promising practices in a way that supports
standardization of best practices and the gathering
of empirical and comparable data across states
(SAMHSA, 2004).

LITERATURE REVIEW
Although consumers have widely condemned
the use of S/R (NAC/SMHA, 2003), few research
studies have been conducted on these interventions
(Mohr & Anderson, 2001). However, related
research has been conducted in other fields of study
that bear on S/R reduction efforts.
The first area of investigation includes studies
on the effects of trauma and violence on human
subjects. Although trauma exposure was previously
thought to be relatively rare except in combat or
disaster experiences, current research indicates that
trauma exposure is common, even in the middle
class. Fifty-six percent of a national adult sample
reported experiencing at least one traumatic event
(Kessler, Sonnega, Bromet, Hughes, & Nelson,
1995). When studies examined recipients of mental
health services, the proportions were considerably
higher. In 1998, Mueser et al. (1998) found that 90%
of public mental health clients have been exposed to
multiple incidents of severe trauma with up to 53%
reporting childhood sexual or physical abuse and 43–
81% reporting they were victims of trauma. A more
recent study indicated that fully 91% of clients in a
community mental health center had histories of
trauma (Cusack, Frueh, & Brady, 2004).
Consumer self-reports of being in S/R charac-
terize it as ‘‘dehumanizing and humiliating’’ and in
one study, 54% reported ‘‘nothing beneficial’’ from
the experience (Binder & McCoy, 1983). In another
qualitative study, S/R were reported to have ‘‘sub-
stantial deleterious physical and, more often, psy-
chological effects on both patients and staff’’ (Sailas
& Fenton, 2002). In a 1996 study of more than 1040
individuals, with over half having been subjected to
either seclusion, restraint, or both; 94% of these
people reported at least one complaint about the
appropriateness of use and the negative sequalae
they experienced (Ray, Myers, & Rappaport, 1996).
Mental health staff also report traumatization from
being involved in violent takedowns in the process
of secluding or restraining people (NAC/SMHA,
2003; NASMHPD, 2002).
Recognition of the high prevalence of trauma
experiences in individuals with mental illness and
substance abuse histories has led to emerging mod-
els of treatment known as trauma-informed care
(Fallot & Harris, 2002). The models have common
characteristics and are based on acknowledging the
high rates of Posttraumatic Stress Disorder (PTSD)
and other psychiatric disorders related to trauma
485
exposure in people with serious mental illness (Fel-
liti, Anda, & Nordenberg, 1998). Trauma-informed
care is based on belief that treatment environments
are often both overtly and covertly traumatizing,
coercive, and violent, (Fallot & Harris, 2002; NAS-
MHPD, 2002). In addition trauma-informed care
environments recognize that the majority of mental
health staff are uninformed about trauma and its
sequelae and therefore neither recognize nor treat it
(Ibid). Most importantly, trauma-informed care
systems recognize that the executive leadership in
treatment settings need to focus on the prevention of
violence and aggression as key priorities. These
trauma informed activities include routine trauma
assessment, individualized treatment planning, staff
training, consumer involvement in all aspects of
care, desired and effective treatment programming,
and a total focus on prevention of escalation and
violence at all times (NASMHPD, 2002).
Another extremely important issue for the
mental health field is the concept of recovery (On-
ken, Dumont, Ridgeway, Dornan, & Ralph, 2002;
The President’s New Freedom Commission on
Mental Health, 2003; Ralph, 2000). Recovery has
been a subject of study for consumer groups and
researchers since the 1980s and interest has grown
exponentially. In 2003, the ‘‘promise of recovery’’
was named as the overall goal in the transformation
of the mental health system of care explicated in the
Commission Report. The report defined recovery as
‘‘... the process in which people are able to live,
work, learn, and participate fully in their communi-
ties. For some individuals, recovery is the ability to
live a fulfilling and productive life despite a dis-
ability. For others, recovery implies the reduction or
complete remission of symptoms’’ (The President’s
New Freedom Commission on Mental Health,
2003).
Research has shown that having hope plays an
integral role in an individual’s recovery. This state-
ment is significant with regard to the use of S/R.
Qualitative studies reporting on the recipient’s
experiences in S/R overwhelmingly report deleteri-
ous effects (NASMHPD, 2003; Onken, Dumont,
Ridgeway, Dornan, & Ralph, 2002). These experi-
ences are characterized as dehumanizing, humiliat-
ing, claustrophobic, frightening, and punishing
(Ibid). Individuals describe S/R as creating hope-
lessness and powerlessness, resulting in anger,
resentment, and a breakdown in the therapeutic
relationship with treatment staff (Ibid). These
reports clearly raise concerns that using S/R in
486
clinical treatment for persons with serious mental
illness is potentially traumatizing and should be
avoided. The Office of Mental Health in Pennsyl-
vania adopted this belief in its statewide efforts to
eliminate the use of these restrictive interventions
(Hardenstine, 2001). Feather O. Houstan, then sec-
retary of Pennsylvania’s Department of Public
Welfare, summarized this philosophy most clearly:
‘‘Ultimately, the reduction of S/R is about the safety,
dignity, and well-being of our consumers. It’s about
reductions in serious staff injuries. Most importantly,
it’s about improved treatment that expedites recov-
ery, restores hope, and allows the hospital consumer
to return to his home, family, and a productive life in
the community’’ (Hardenstine, 2001, p. 2).
A PREVENTION MODEL FOR REDUCING
S/R USE
Following the Courant series and subsequent
federal revision of associated rules and regulations,
much interest has been generated about the states’
use of S/R. In 2001, staff at the National Association
of State Mental Health Program Directors’ (NAS-
MHPD) began to compile all available information
on S/R reduction interventions. In 2002, NAS-
MHPD created a curriculum to use as a basis for
training states in S/R reduction techniques. State
focused trainings, funded by the Center for Mental
Health Services, were held throughout 2003–2004.
Over 650 staff, including state mental health agency
senior leadership and executive administrators of
state-operated facilities from 26 states, participated
and began piloting S/R reduction efforts in their
respective states. Although funding did not support
an empirically based research study, the interven-
tions identified in the training were reported as
promising in informal follow-up surveys and were
also partially evidenced through preliminary data
(Huckshorn, 2004; Schacht, 2004). Eight of the ini-
tial states trained in 2003 provided pre- and post-S/R
use data and the initial results showed that S/R
hours were reduced by as much as 79%, the pro-
portion of consumers in S/R was reduced by as much
as 62%, and the incidents of S/R events in a month
were reduced by as much as 68% (Conley, 2004).
The NASMHPD S/R reduction curriculum in-
cludes sixteen training modules that together provide
a theoretical framework that forms the basis for
teaching the six core interventionsÓ to reduce S/R
use. The training modules include the public health
prevention approach; leadership roles and responsi-
bilities; key characteristics of trauma-informed care
systems; the use of data to inform practice; devel-
oping a culture of recovery for staff; consumer roles
in inpatient settings; assessment and reduction tools;
and debriefing guidelines. These interventions have
been discussed and supported in publications of the
NASMPHD Medical Directors Council, the Ameri-
can Psychiatric Association, APNA, the National
Association of Psychiatric Healthcare Systems, the
American Association of Hospitals, the Children’s
Welfare League of America, and individual state
mental health agency reports (Bullard, Fulmore &
Johnson, 2003; Colton, 2004; NASMHPD Medical
Directors Council, 1999; OOMHMR, 2002; Success
Stories, 2003).
A PREVENTION-BASED S/R REDUCTION
POLICY FOR STATE IMPLEMENTATION
Current knowledge should inform a policy
modification in current CMS rules and regulations
and re-focus national accreditation agency (e.g.,
JCAHO) standards. Such a policy modification
would mandate that hospitals create a performance
improvement plan that is focuses on prevention and
is designed to reduce (and eventually eliminate) S/R
in state mental health inpatient facilities using pro-
ven methods. Such an individualized, facility-specific
seclusion and restraint reduction plan could be re-
quired of all applicable facilities within 60 days fol-
lowing adoption of such a policy into CMS rules and
would apply to the same organizations as the current
rules. The S/R reduction plan would include, but not
be limited to, the following subcomponents.
First, and considered most critical, there must
be a clear delineation of the roles and responsibilities
of the facility leadership to develop, implement, and
monitor the S/R reduction plan. Included would be
the assignment of S/R reduction responsibilities to
individual staff members (champions) at every hor-
izontal and vertical level of accountability in the
organization; the development of a facility policy
statement that describes the use of S/R as a safety
measure to be used only in situations of grave and
imminent danger, and the concept of prevention as
the primary approach. If an executive board governs
a facility, the board must approve and monitor the
implementation of the plan through the chief exec-
utive of the facility.
The plan would include a description of how
data depicting S/R use will be compiled and used on

every unit to document for every incident of S/R.
The data plan would start with the facility’s histori-
cal and current S/R baseline rates and articulate
future performance improvement goals. Data would
be reported daily by unit and shift to be both
graphed and posted in all clinical staff areas using
de-identified methods to protect individual’s identi-
ties. These data would be formatted to allow
comparisons to national S/R rates (NRI, 2004). It is
recommended that a confidential mechanism be
used to identify staff members and consumers who
are involved in repeated episodes in order to mon-
itor the former’s training needs and the latter’s
treatment issues. The chief executive of the facility
would be expected to quantify his/her daily review
of these data.
The plan would also include a workforce devel-
opment component that addresses training in
S/R prevention and in the principles of the public
health prevention model, trauma-informed care, the
concepts and components of a recovery-oriented
system of care, and continuous quality improvement
processes. Staff performance expectations would
also be clearly articulated in this plan component
through formalized human resource processes that
cover the hiring of new staff; documented in job
descriptions; the performance of specific competen-
cies; conduction of performance evaluations; orien-
tation of new employees, and annual reviews.
External trainers (outside contractors utilized by the
facility) would need to demonstrate compliance with
these requirements to justify their use, while any
acceptable S/R application and use training pro-
grams would supply data demonstrating that the
interventions being taught actually result in reducing
S/R use.
The plan would include the development and
implementation of core assessment and prevention
tools. At a minimum, these tools would include the
use of a de-escalation preference survey, a risk for
violence assessment, an individual’s history of S/R, a
medical risk for restraint tool, and a trauma history
assessment upon admission to the facility. The use of
these tools would be documented in policy and
procedures and assessment results would be placed
in the medical record. The relevant results of these
assessment tools would then be integrated into the
comprehensive individualized treatment plan and
reviewed and revised either as necessary or when the
clinical situation changes.
487
The plan would include the mandatory
involvement of consumers/family members or former
consumers in its development, implementation, and
ongoing monitoring. Roles for consumers and family
members would be formalized and integrated
into the human resource and staff development
organizational plan for the facility. Training and
mentoring activities would be provided to all con-
sumers and family members hired as staff in the
facility and utilized in volunteer programs. Clinical
and administrative supervisors would also receive
training in supervising consumers as staff and vol-
unteers and all staff would receive clear communi-
cation on consumer roles and responsibilities.
Finally, the plan would include two event-
debriefing procedures that together would assure for
a rigorous incident analysis following every event.
Immediate post-event debriefing activities would
assure safety for all involved persons, foster adequate
documentation, and facilitate the environment’s
return to the pre-crisis milieu. The second debriefing
activity involves all who participated in the S/R event
in a formal post-event analysis. The purpose of the
analysis would be to identify the variables that led to
the use of S/R and feed this information back into
clinical and administrative activities. Effective event
debriefing will result in changes in clinical
approaches, treatment planning and, at times, revi-
sions to operational policies that appear to exacer-
bate S/R use. Key staff involved in debriefing
activities include the entire treatment team, espe-
cially the attending physician and the individual who
was secluded or restrained. It is important to note
that the individual who was the victim of the S/R
event be included in the formal debriefing procedure,
if this is possible and if the person voluntarily agrees
to participate. If the person cannot, or will not, par-
ticipate, all efforts must be made to interview and
gather information from that person, prior to the
formal debriefing, as to what happened from his/her
perspective and how the event could have been
handled differently. This information would be pre-
sented on behalf of the individual by a staff person or
an advocate acting as spokesperson. A person not
involved in the original event would facilitate formal
debriefing meetings and the meeting would include a
member of the executive staff. Debriefing meetings
and procedures would be facilitated in a non-punitive
manner with findings actively addressed and any
follow-up thoroughly documented.
488
THE SOCIAL AND POLITICAL CONTEXT
OF THE NEW S/R POLICY MODIFICATION
An important social and political variable that
bodes well for moving the new S/R policy modifica-
tion through the policymaking process is that it would
require only modest additions and clarifications to
existing CMS policies and rules. This incremental
policy formulation process ‘‘build[s] on existing
policies by modification in small steps to allow time
for the economic and social systems to adjust with-
out... being unduly threatened (Longest, 2002,
p. 269). With the exception of the 1-hour rule, the
process thus far in S/R policymaking has followed
this incremental process with the first round of leg-
islative changes serving to clarify and define previous
policy. It is interesting to note that the one-hour rule
was the only component of the S/R policy process
that resulted in active opposition, which could sug-
gest support for this new revision.
The fundamental goal that the new policy mod-
ification would address is in helping to create safer
mental health inpatient treatment environments that
are less traumatizing, coercive, and violent by pre-
venting the use of S/R. Therefore, one outcome of
revision to current policy would be to move beyond
regulations that focus on using S/R in a safer manner,
to a prevention approach that identifies measurable
strategies that reduce use and move toward elimina-
tion.
Analysis of any proposed policy that affects the
states and their providers should include a compar-
ison of at least two alternative courses of action that
are possible in lieu of implementing the new pro-
posed prevention policy (Longest, 2002). One com-
monly used policy alternative is to do nothing.
The consequences of the doing nothing alter-
native leave the mental health field focused on using
S/R in a safer manner (as many are doing now). The
safer use focus will not, in an of itself, lead to a real
culture change such as is called for in the New
Freedom Commission Report or the Institute of
Medicine Report: Crossing the Quality Chasm
(2001). The do nothing approach leaves the current
regulations intact and will not, proactively, encour-
age states or providers in moving toward new and
creative alternative approaches since the current
rules focus mostly on safety and accountability.
Granted, this alternative could possibly reduce use
due to the new restrictions and documentation
requirements in current law and regulations, but this
would be a serendipitous outcome since the current
law and rules do not provide clear direction on how
to reduce use. In addition, external monitoring of
safer use will be staff intensive and may be difficult
for an external regulatory agency to perform in any
standardized manner. Monitoring activities would
perhaps default to reviewing reported deaths and
serious injuries and would not address the serious
psychological (but more invisible) harm that could
occur. The do nothing approach also fails to address
the two standards of care in the field by failing to
recognize organizations that are using the preven-
tion approach and continuing to compare them to
organizations that are only focused on improving
restraint techniques. This approach will not
encourage an understanding or utilization of the
promising practices that have emerged about suc-
cessful reduction efforts or effective S/R prevention.
The other alternative is to adopt one of the op-
tions to the 1-hour rule identified by CMS (2002) that
included adding a requirement for an outside com-
mittee to scrutinize the use of S/R and/or allowing an
appropriately trained registered nurse or other
licensed independent practitioner to perform the
1-hour evaluation instead of a physician (HCFA,
2001).
Outcomes from the second alternative will
basically be identical as the do nothing approach.
The mental health organizations using S/R would be
relieved of the financial burden of the 1-hour rule
for physician coverage. There would be some eco-
nomic impact resulting from the need to organize an
external committee and the policy, procedures, and
legalities inherent in that activity plus the need to
train other staff to perform the 1-hour evaluation.
This alternative also relieves the physician of
accountability for the choice of S/R in an emergency
event where he or she is not present and assigns that
responsibility on lesser-trained staff that do not have
the comparable power, authority, or stature of the
physician in the organizational hierarchy.
A third alternative would be the states’ volun-
tary adoption of the new policy without formaliza-
tion in federal policy. Volunteer states would
standardize the use of the proposed best practice S/R
reduction strategies that could be implemented at
little or no cost and can be monitored internally. This
alternative can be implemented immediately but
would most likely result in delayed action in some
states.
In the policy scenarios presented above, it
seems clear that the preferred alternative would be
federally formalized implementation of the new

prevention based policy modification to reduce, and
eventually eliminate, the use of S/R. The new policy
modification provides specific direction on how to
reduce and eventually eliminate the use of trauma-
tizing and violent interventions in mental health
treatment environments. The new policy modifica-
tion avoids an untoward economic impact on states
and their providers of care and is congruent with
current rules and regulations and therefore does not
require new rules but only minimal revision. There is
a good possibility that the adoption of this new
policy would render the contested 1-hour rule ob-
solete and therefore eliminate that rule and its fiscal
impact. Most important, a new policy standard, de-
fined by a prevention approach places the reduction
action plan into a performance improvement
framework and encourages the participation of all
facility staff and persons served to be creative in a
developing a non-punitive, problem solving envi-
ronment that not only will reduce use but will begin
the journey to creating recovery oriented systems of
care called for by best practice knowledge, service
recipients and their families, and the New Freedom
Commission Report.
POTENTIAL ETHICAL ISSUES
The new prevention focused policy modification
raises three potential ethical issues. The first con-
siders the issue of restricting S/R use in the face of
real, perceived, or potential danger to staff that rely
on these interventions to maintain safety. The sec-
ond ethical dilemma is related to the need to keep
an individual and others safe from harm when per-
sonal self-control has been lost due to mental illness,
intoxication, post-traumatic stress disorder dysregu-
lation, or anger management issues. The third ethi-
cal question is whether or not to use seclusion or
restraint at all, given what is now known about the
neurobiological and psychological effects of trauma
and the very real (but difficult to predict) risk of
serious injury or death to consumers or staff.
Regarding the first ethical issue, it is true that
most inpatient mental health staff have grown
accustomed to having S/R available in the face of
what is considered imminently dangerous behavior.
However, it is equally true that the majority of S/R
interventions are used prematurely and because staff
lack the knowledge, skills, or abilities to proactively
choose other, less restrictive interventions
(NASMHPD, 2002). Research on nurses’ decisions
489
to use seclusion or restraint found that a group of
nurses agreed only 22% of the time on which inter-
vention to use (Holzworth & Willis, 1999). When the
same nurses were separated, agreement declined to
8% (Ibid). In addition, when the Lalemond Behav-
ioral Scale was used, a majority of staff believed that
restraint was being used prematurely (Huckshorn,
2004). The majority of nursing staff, including
mental health technicians, have received very little
training on the prevention of S/R (NASMHPD,
2002). In addition, mental health workers are more
likely to be injured when restraints are used than
when they are not (NAMI, 2003; NASMHPD,
2002). On a related note, the current state of the art
about S/R reduction realizes and accepts that, on
rare occasions, individuals can act in ways that are
clearly and imminently dangerous. This is why the
proposed policy does not call for the immediate
elimination of use of these techniques but on plan-
ned and thoughtful reduction over time. While the
goal is elimination, the field has much to learn and
implement before the goal of elimination is realized.
The second ethical issue is the need for external
controls in situations where individuals have lost
control and are putatively dangerous. It is a fact that
such events do happen, especially in acute care set-
tings and when individuals who are under the
influence of alcohol or other drugs are admitted. In
such situations, S/R may need to be used. However,
a majority of S/R events, exclusive of intoxication,
can be prevented through the implementation of the
prevention model interventions (NASMHPD, 2002;
Success Stories, 2003). A facility’s policy statement
needs to clearly differentiate the new approach from
the historical and prevailing belief that S/R are
therapeutic interventions that provide appropriate
and useful external controls to individuals who have
lost control. This latter philosophy has been abused
to the extent that some facilities have routinely al-
lowed individuals to be voluntarily placed in re-
straint under the misguided belief that this
intervention was helpful in learning self-control and
building ego strength. There is no research whatso-
ever that supports these themes and, as such, these
practices should not continue (NASMHPD, 2003).
The third ethical question considers the deci-
sion to allow the use of S/R at all. Glenn Saxe, M.D.,
chair of Boston University’s Department of Child
and Adolescent Psychiatry and a principle investi-
gator for the National Child Traumatic Stress Net-
work, believes that the use of S/R centers on the
moral question of ‘‘how we want to practice
490
clinically’’ (Saxe, 2003). He asks, ‘‘ldots what does it
mean when you have a sexually abused kid who is
having some impulsivity and dyscontrol problems
and suddenly finds herself jumped on by 7 or 8 staff
members, tied up in restraints and left...?’’ Dr Saxe
notes that once he realized how he was conducting
his clinical practice he could no longer reconcile the
use of restraint with the value of the imperative, to
do no harm (Ibid).
Gordon Hodas, M.D., the medical director for
Pennsylvania’s public child and adolescent office,
also believes that the use of S/R is an ethical issue
and moral choice professionals must make with re-
gard to their practice. He believes that use of S/R is
clear indication of therapeutic failure and that such
events signal the need to re-double efforts to avoid
use in the future (Hodas & Lieberman, 2004).
The literature on S/R is consistent in its reports
of the negative experiences consumers, adults, and
children have had in S/R (NAC/SMHA, 2003;
NASMHPD, 2002). Across the board, consumers
report feelings of hopelessness, fear, terror, disas-
sociation, lost trust, ambivalence toward caregivers,
and re-enactments of the events (Ibid). If indeed we,
in the state mental health arena are attempting at
the least to do no harm, and we are aware of the
prevalence of trauma histories in the lives of the
children and adults that we serve, and we know of
low cost, effective, and replicable interventions that
can prevent and reduce the use of S/R... how can we
morally and ethically continue to use these inter-
ventions? This is the question that every mental
health policy maker, administrator, and clinician
must answer for him or herself. For those who do
accept the challenging task of reducing and even
eliminating the use of S/R, the prevention based
policy modification described here provides a tem-
plate to begin this clinically necessary and morally
obligatory task.
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