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SAMHSA Matrix: Seclusion and Restraint
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SAMHSA Seclusion and Restraint

Seclusion and Restraint: Statement of the Problem and SAMHSA's Response

SAMHSA National Action Plan on Seclusion and Restraint
Revised and Adopted May 2003

Statement of the Problem

The use of seclusion and restraint on persons with mental health and/or addictive disorders has resulted in deaths and serious physical injury and psychological trauma.  In 1998, the Harvard Center for Risk Analysis estimated deaths due to such practices at 150 per annum across the nation.  Children have been noted at especially high risk for death and serious injury.  Individuals with addictive or co-occurring mental health and addictive disorders also appear to be at risk due, in part, to the possibility of increased agitation.  Older adults in nursing homes and other settings also face a reported high risk.

The General Accounting Office and the HHS Office of Inspector General both have noted the paucity of known data related to the use of these practices.  Research has revealed that the use of seclusion and restraint varies dramatically from facility to facility with a wide range of facility and staff knowledge on how to prevent and avoid such use.  While a growing number of stakeholders have developed guidelines on seclusion and restraint, the quality of such have yet to be determined and their widespread application has yet to be documented.  There has been widespread agreement that training and technical assistance is a priority need.  In 2000, the Children's Health Act was signed into law which established specific requirements - including training - in healthcare (Part H) and non-medical children's residential facilities (Part I).  It also required the promulgation of regulations for these settings. 

It is also known that sentinel events (e.g., deaths and injuries) from restraint and seclusion occur in a number of settings which currently have no national guidelines, such as schools and juvenile justice facilities.  In contrast to the mental health field, the addictions field has only begun to examine issues of restraint and seclusion and further analysis and awareness of such concerns appears needed.  Finally, the capacity of Protection and Advocacy agencies to respond to allegations of rights violations - including those associated with seclusion and restraint is limited.

Response

SAMHSA has set forth a vision to reduce and ultimately eliminate the use of seclusion and restraint practices for all age groups in behavioral health care settings both institutional and community-based.  The agency recognizes that these are to be used solely as safety interventions designed to protect consumer and staff safety.  The focus is on identifying and encouraging the application of alternatives to prevent such use.

Long-term outcomes include a reduction in seclusion and restraint-related deaths and injuries and in the frequency of use of such interventions while working toward the elimination of these practices.  Initial outcomes include an increase in the knowledge, skills, and abilities of consumers, providers, facilities, States, advocates, and others to prevent, reduce, and monitor the use of seclusion and restraint including an increase in the number of States and facilities that implement best practice prevention and reduction guidelines.

In reaching this vision and outcomes, SAMHSA - via its organizational goals of Accountability, Capacity and Effectiveness - has identified five (5) domains to focus on:

  • Data Collection: There is a clear need to improve our knowledge on the utilization of restraints and seclusion and sentinel events associated with such.  SAMHSA, in conjunction with States, has identified a broad definition of how to measure such usage in mental health settings.  Further, each State Protection and Advocacy program provides annual data on the number of reports of restraint and seclusion alleged rights violations and the number of investigations completed.  SAMHSA proposes to work with other groups to identify additional data measures that can track restraint and seclusion issues.

  • Evidence-Based Practices and Guidelines: SAMHSA proposes to identify, develop, and disseminate evidence-based practices and guidelines to prevent and reduce the use of restraint and seclusion.  This will include population-specific guidelines (e.g., older adults, people of color, women, children and persons who are Deaf).  Efforts will be made to encourage the adoption of these practices in clinical training programs – including those for Emergency Room personnel – via professional guilds.

  • Training and Technical Assistance: Through a $2 million, three year study, SAMHSA is identifying evidence-based staff training approaches for mental health residential facilities that serve children.  In conjunction with States, SAMHSA is providing regional training to States to develop strategic plans within State mental hospitals to reduce such practices.  SAMHSA is also developing a consumer-based staff training manual.  SAMHSA proposes to expand the adoption of self-care and recovery-based approaches to prevent the use of seclusion and restraint.  In FY '04, SAMHSA proposes to initiate a targeted capacity expansion program that would fund 9 States to implement evidence-based training programs. Funding would also be used to support an evaluation center to assess the impact of grants and provide technical assistance to States.

  • Leadership and Partnership Development: In addressing restraint and seclusion, it is known that leadership is a key variable.  SAMHSA is demonstrating leadership by convening a National Summit of stakeholders to address these issues.  Further, SAMHSA is working in conjunction with the Centers for Medicare and Medicaid Services (CMS) and other Federal agencies to reduce seclusion and restraint use.  SAMHSA also proposes to partner with other public and private entities to further address these issues in the substance abuse, juvenile justice, and education fields.

  •  Rights Protection: SAMHSA funds and administers the $32 million Protection and Advocacy for Individuals with Mental Illness program which supports State programs in responding to allegations of patients rights violations including those associated with restraint and seclusion.  Technical assistance is also provided to these programs to improve their operations.  SAMHSA also proposes to promote the increased use of advance directives as well as increased consumer rights education.

SAMHSA recognizes that an effective national action plan to reduce and ultimately eliminate seclusion and restraint will take the combined efforts of a range of public and private stakeholders.

 


Last Update: 9/24/2008