Legal and Clinical Perspectives on Eliminating the Deadly and Psychologically Damaging Practice of Restraint and Seclusion

Susan Aranoff, J.D. of the Connecticut Legal Rights Project
Maggie Bennington-Davis, M.D., Medical Director, Salem Hospital
Laura Cain
, J.D., of Maryland Disability Law Center
Rupert Goetz, M.D., Medical Director, Clackamas Co.

Thanks in large part to the Hartford Courant's 1998 series highlighting the deaths of numerous individuals during, or as a result of, restraint or seclusion, there has been an increased awareness of the dangers of these coercive practices. This has, in turn, led to policy changes and increased regulation on the use of restraint and seclusion in various mental health settings. The National Association of State Public Mental Health Directors (NASMHPD) issued a policy statement declaring that restraint and seclusion represented treatment failures and set a goal to reduce, and ultimately eliminate, its use. The Joint Commission on Accreditation of Healthcare Organizations set forth new standards for the use of restraint and seclusion, including limiting the use of such practices to situations in which there is an imminent risk of physical harm. The Center for Medicaid and Medicare Services (CMS) released final regulations on "Conditions of Participation" for facilities receiving Medicaid or Medicare funding that similarly restricted the use of restraint and seclusion to emergency situations where the individual poses an imminent risk of physical harm. Finally, CMS subsequently issued regulations with greater resident protections governing Residential Treatment Centers for children and adolescents.

While a few states, as well as individual facilities, have undertaken vigorous and successful efforts to drastically reduce the use of restraint and seclusion, there has not yet been widespread reform across the nation. This is likely due, in large part, to the ingrained belief of many mental health professionals and staff that restraint and seclusion are necessary tools to control "violent" patients and ensure safety. In addition, stringent oversight of facilities by state, federal and accreditation agencies is notoriously poor.

The workshop panel, comprised of two attorneys and two psychiatrists, will discuss restraint and seclusion reform from both the legal and clinical perspectives. Participants will learn what the current legal requirements and standards on the use of restraint and seclusion are, as well as hear examples of various advocacy tools that have been employed to enforce compliance by facilities. Participants will also hear the clinicians' experiences in both advocating to eliminate the use of these coercive practices, and the dramatically successful results that have been achieved with a true cultural shift on all levels - state, facility and unit.

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