Seclusion and Restraints

To the Editor: Several psychiatric hospitals are making significant strides in reducing the use of seclusion and restraints. Pennsylvania's state psychiatric hospitals have set a goal of eliminating seclusion and restraints as treatment interventions. The result has been a marked reduction in their use.

In 1998 the Hartford (Conn.) Courant published a series of articles revealing that 142 deaths occurred during the use of restraints over the previous decade. Close to 30 percent of the deaths were of children under the age of 17. "Treatment" interventions with these outcomes are alarming. They compel us to reexamine our approaches in support of recovery and psychiatric rehabilitation.

It is widely recognized that some conditions may warrant the use of interventions to reduce the likelihood of harm to an individual or others within a care environment. Patients- consumers-psychiatric survivors have emphasized that the use of seclusion and restraints produces more harm than benefit. We have been asked to limit their use to circumstances in which there is an unequivocal likelihood of harm and other, less invasive methods have not been effective.

A cornerstone of the approach in Pennsylvania is that use of seclusion or restraints represents a failure of ongoing psychiatric treatment. Stringent guidelines have been developed for their use that include the following:

• Each use of seclusion or restraints must be ordered by a physician.

• In an emergency, a nurse may order the use of seclusion or restraints; however, the patient must be examined by a physician within 30 minutes of the initial order.

• The length of time per order is limited to one hour.

• An assessment by a physician is required to extend an order beyond the hourly limit.

• The patient and other members of the treatment team participate in a debriefing to review the circumstances that precipitated the incident and discuss ways to avoid similar circumstances.

The National Alliance for the Mentally Ill and the National Mental Health Association have advocated the use of treatment approaches that support recovery and enhance the quality of the lives of persons with mental illness. The increasing availability of state-of-the-art medications and the principles and technology associated with psychiatric rehabilitation make the goal of eliminating seclusion and restraints a reality for the new millennium.

Dr. Altenor is superintendent of Norristown (Penn.) State Hospital.