Seclusion and Restraint
People with trauma histories are routinely and unnecessarily retraumatized in the mental health system through the use of seclusion and restraint and other coercive interventions.
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Facts and Discussion Points:
1--Consumers with trauma histories are often re-traumatized in psychiatric inpatient units and other settings when subjected to restraint and seclusion.1,10
2--When asked, individuals virtually always report experiencing seclusion and restraint as traumatic. Children, adolescents, and adults report experiencing vulnerability, neglect, and a sense of punishment while in seclusion.2
3--Restraint and seclusion have been responsible for consumer deaths and other adverse effects, and also place staff at higher risk for injury. 4, 3
4--Effective practices exist to reduce and/or eliminate restraint and seclusion.3
5--Best practice models based on collaboration, consumer empowerment, and a clinical approach that emphasizes the development of skills, teaching and learning processes, conflict resolution, and pro-active strategies exist, but they are inconsistently utilized.5
6--The use of restraint and seclusion among children and adolescents is particularly high in some states. Child-oriented best practice models demonstrating little or no use of restraint and seclusion include: Girls and Boys Town Psychoeducational Treatment Model (PEM), Teaching Family, and Ross Greene’s Collaborative Problem Solving Approach.5
7--For persons with histories of trauma, seclusion and restraint can cause disturbing behavior to increase (rather than de-escalate), thereby re-traumatizing the client and increasing risk to staff and other consumers.6
8--Seclusion and restraint can trigger responses to previous experiences with coercive control, physical abuse, isolation, bondage, etc. These responses might include flashbacks (hallucinations), dissociation, aggression, self-injurious behaviors, depression, etc.6
9--Coercive interventions involving forcible medication (whether physical, legal, or both) are often experienced as retraumatizing. Forced psychotropics are a form of chemical restraint.7
10--Conventionally accepted psychiatric practices and institutional environments may retraumatize consumers with histories of trauma by replicating the dynamics and even the specific abuses of the original childhood trauma, thus exacerbating the pain and sequelae of the traumatic childhood experience.8
11--Without knowledge of medications known to be helpful in treating symptoms of trauma, the use of psychopharmaceutical interventions can cause both physical and psychological damage. Forced medication violates personal boundaries, alters the mind, body and emotions, and may replicate the original traumatic abuse.8
12--Restraint and seclusion, which are currently accepted methods for the management of psychiatric consumers in this country, meet the DSM-IV definition of human-induced traumatic stressors. Both exert violent and absolute control while engendering utter helplessness and fear. 9
13--Trauma survivors may be especially vulnerable to additional traumatic and/or iatrogenic (physician-caused) experiences that occur within the psychiatric setting.11 For example, routine use of seclusion, restraints, or handcuffs may serve to recapitulate previous traumatic experiences, and thereby exacerbate symptoms of PTSD.12
Recommendations:
1---SAMSHA should establish clinical guidelines that reflect the most promising evidence-based practice models to reduce and ultimately eliminate the use of seclusion and restraint.
2---Consider incorporating a public health prevention model that includes the following: primary prevention (organizational leadership accountability, empowering strength-based culture, well-trained staff), secondary intervention (knowing triggers and using trauma-informed strategies, creative/innovative early interventions to de-escalate conflict) and tertiary intervention (if intervention is necessary), which will allow for the least traumatic treatment experience, early release, and active de-briefing of staff and consumers in order to minimize risk of harm. Feedback from each stage needs to inform the next stage and support ongoing prevention.3
4---Immediate post-event debriefing followed by a timely root cause analysis should be standard practice in all treatment settings.
5---Assessment of all service recipients for trauma histories should be routine.
6---Create (with client, upon admission) an individualized “de-escalation” plan.
7---Train staff on specific alternative, trauma-informed responses to aggressive or behaviorally inappropriate actions.
8---Wherever referencing “seclusion and restraint,” include the phrase “and the violence associated with the use of these measures” as a reinforcing step to be assimilated into the literature.
9---Involve survivors of forced mental health treatment in all aspects of policy and intervention development and practice.
Seclusion and Restraint References
1. Carmen, E., Crane B., Dunnicliff, M., Holochuck, S., Prescott L., Rieker, P., Stefan, S., Stromberg, N. (January 1996). Report and recommendations: Massachusetts DMH Task Force on the restraint and seclusion of persons who have been physically or sexually abused. Boston, MA: Massachusetts Department of Mental Health.
2. Petti, T. A., Mohr, W. K., Somers, I. W., Sims, L. (July-September 2001). Perceptions of seclusion and restraint by patients and staff in an intermediate-term care facility. Journal of Child and Adolescent Psychiatric Nursing, Vol. 14, No 3.
3. NASMHPD Medical Directors Council, (2000); and National Executive Training Institute (NETI). (2003, July). Training curriculum for the reduction of seclusion and restraint. Alexandria, VA: National Technical Assistance Center (NTAC), National Association of State Mental Health Program Directors (NASMHPD).
4. Petti, T. A. (January/February 2002). Seclusion and restraint: A paradigm shift for the millennium. American Academy of Child and Adolescent Psychiatry (AACAP): AACAP News, Vol. 33, No. 1.
5. N. Stromburg (personal communication, April 2002).
6. E. Giller (personal communication, April 2002).
7. R. Mazelis (personal communication, April 2002).
8. Jennings A. (1998). On being invisible in the mental health system. In B. L. Levin, A. K. Blanch, A. Jennings (Eds.), Women’s Mental Health Services: A Public Health Perspective. Sage Publications.
9. Cohen-Cole L. (Summer/Fall 2002). Restraint and seclusion: Iatrogenic trauma comes out of the closet. In networks. Alexandria, VA: National Technical Assistance Center for State Mental Health Planning, National Association of State Mental Health Program Directors.
10. Bloom, S. L. (Summer/Fall 2002). Creating sanctuary. In networks. Alexandria, VA: National Technical Assistance Center for State Mental Health Planning, National Association of State Mental Health Program Directors.
11. Cohen, L. J. (1994). Psychiatric hospitalization as an experience of trauma. Archives of Psychiatric Nursing, 8, 78-81.
12. Frueh, B. C., Dalton, M. E., Johnson, M. R., Hiers, T. G., Gold, P. B., Magruder K. M., Santos, A. B. (November 2000). Trauma within the psychiatric setting: conceptual framework, research directions, and policy implications. Administration and Policy in Mental Health, Vol.28, No. 2.