Seclusion and Restraint

NAMI’s Position (summarized from the NAMI Policy Platform)

The use of involuntary mechanical or human restraints or involuntary seclusion is only justified as an emergency safety measure in response to imminent danger to a patient or others. These extreme measures can be justified only so long as, and to the extent that, an individual cannot commit to the safety of him or her-self and others.

Restraint and seclusion have no therapeutic value and should be used only for emergency safety by order of a physician with competency in psychiatry or a licensed independent mental health professional (LIP). A physician trained in psychiatry or a LIP should see the patient within one hour after restraints are initiated.. Restraints should be continued only for periods of up to one hour at a time, and a face-to-face examination of the patient by the physician or LIP must occur prior to each time a restraint order is renewed..

Alternatives to the use of restraint and seclusion should be used. De-escalation techniques and debriefings should be used after each restraint and seclusion incident.

A Clear Pattern of Abuse Exposed

In October 1998, The Hartford Courant published a five-part investigative series that revealed an alarming number of deaths resulting from the inappropriate use of physical restraints in psychiatric treatment facilities across the United States. A 50-state survey conducted by the newspaper documented at least 142 deaths in the past decade connected to the use of physical restraints or to the practice of seclusion. The report also suggested that the actual number of deaths is many times higher because many incidents go unreported. According to a separate statistical estimate commissioned by The Courant and conducted by the Harvard Center for Risk Analysis, between 50 and 150 restraint- or seclusion-related deaths occur every year across the country.

As a result of The Hartford Courant series and NAMI’s communications with its members, NAMI members have shared their horror stories of abuse and death. These are compiled in NAMI’s report, Cries of Anguish. More than 60 personal stories of incidents from 24 states and the District of Columbia were reported as of August 2000.

Understanding the Issue

Restraints are human or mechanical actions that restrict freedom of movement or normal access to one’s body. Since the development of more effective psychotropic medications, emergency situations have become increasingly rare. In fact, some hospitals have moved to restraint-free policies.

In current practice, physical restraints are sometimes imposed on a patient involuntarily for control of the environment (curtailing individual behavior to avoid the necessity for adequate staffing or clinical interventions); coercion (forcing the patient to comply with the staff’s wishes); or punishment ( staff punishing or penalizing patients). NAMI rejects these as legitimate reasons to impose restraints.

Federal Protections Enacted in 2000

In October 2000, President Clinton signed the Children’s Health Act of 2000, P.L. 106-310. This significant new law established national standards that restrict the use of restraint and seclusion in all psychiatric facilities that receive federal funds and in "non-medical community-based facilities for children and youth."

NAMI will be following the implementation of key provisions under the general requirements, which include:

Restraints and involuntary seclusion (R/S) may only be imposed to ensure the physical safety of a patient. They cannot be used as punishment or for staff convenience.

R/S may be imposed only under the written order of a physician or other licensed practitioner permitted to issue such orders under state law. Orders must specify the duration of and circumstances for the R/S.

Although no timeframe is specified for conducting face-to-face evaluations of patients who have been or will be restrained or placed in seclusion, the legislation declares that the lack of a specified timeframe should not be interpreted as offsetting or impeding any federal or state regulations that provide greater protections for patients. This declaration then affirms hospital rules promulgated last year by the Health Care Financing Administration (HCFA) including the "one hour rule" that requires face to-face evaluations by licensed professional practitioners within one hour of initiating R/S.

Facilities must report every death that occurs within 24 hours after a patient has been removed from R/S or where it is reasonable to assume that a death is the result of R/S. Reports must be made to agencies determined appropriate by the Department of Health & Human Services (HHS), which most likely will include state protection and advocacy agencies.

Within 12 months, HHS also must issue regulations specifying adequate numbers of staff for facilities and appropriate training for the use of R/S and its alternatives.

For children's non-medical community programs:

R/S may be used with children in community programs only in emergencies and to ensure immediate physical safety for the child or others. Mechanical restraints are prohibited. Seclusion is allowed only when a staff member continuously monitors a child face-to-face. Time-outs, however, are not considered seclusion, and physical escorts are not considered physical restraints.

Only individuals trained and certified by a state-recognized body may impose R/S. Until a state certification process is in place, R/S can be used only when a supervisory or senior staff person with skills and competencies specifically listed in the legislation conducts a face-to-face assessment of the child within an hour after R/S is imposed. The use of R/S must then be monitored by the supervisory or senior staff person.

Required skills and competencies include an understanding of the needs and behaviors of the populations served, relationship-building, avoiding power struggles, de-escalation methods, alternatives to R/S, time limits, monitoring signs of physical distress, position asphyxia, obtaining medical assistance, and familiarity with relevant legal issues.

Within six months, states (which license such facilities) must develop licensing and monitoring rules and HHS will begin to develop national staffing standards and guidelines.

These R/S standards apply only to psychiatric treatment facilities that receive federal funding. They do not affect use of restraint and seclusion in schools, wilderness camps, jails, or prisons. P.L. 106-310 also does not impede any federal or state laws or regulations that provide greater protections than written in the Children’s Health Act of 2000. Thus, rules issued by the Health Care Financing Administration in 1999 that included a requirement for face-to-face evaluations by mental health professionals within one hour of initiating restraint are affirmed.

NAMI’s Advocacy Goals and Strategies

NAMI strongly supports full implementation of the restraint and seclusion provisions included in P.L 310-106;

NAMI will monitor the progress of the Department of Health and Human Services in issuing national guidelines and regulations specifying adequate number of staff in facilities and appropriate training in the use of R/S and their alternatives;

NAMI will also advocate for a national standard in schools, wilderness camps, jails, and prisons

What Should You Do If You Experience Restraint And Seclusion Abuse?

If you or your family member has experienced abuse of R/S in a treatment facility, you should take the following action.

Contact your state’s Protection and Advocacy program. For the phone number of your state’s program, call the National Association of Protection and Advocacy Systems (NAPAS) at 202-408-9514. If a P & A does not assist you, let NAMI know by contacting Kim Encarnation at 703-312-7895 or by email at kim@nami.org.

File a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) hotline at 1-800-994-6610 and/or complaint@jcaho.org

File a complaint with your state’s health and hospital-licensing agency.

File a complaint with your U.S. Health Care Financing Administration (HCFA) regional office. There are 10 regional offices in the United States. To find yours, call the HCFA Medicare Hotline,1-800-638-6833. You can also call the HCFA Office of Medicare Customer Assistance, 410-786-7413.

Share your story in writing and submit it to be included in NAMI’s Cries of Anguish report. Contact Kim Encarnation at 703-312-7895 or kim@nami.org

Consider sharing your story with your local media.

Consider retaining an attorney if you believe your legal rights have been violated.