Special Section on Seclusion and Restraint: Encouraging Alternatives to Seclusion, Restraint, and Reliance on PRN Drugs in a Public Psychiatric Hospital

Abstract

Reliance on seclusion, restraint, and psychotropic PRN (as needed) medication for behavior management has been tied to a variety of untoward outcomes that detract from the quality of care in public psychiatric hospitals. A large body of evidence has accumulated to demonstrate that behavioral approaches to care can provide useful alternatives to reliance on seclusion, restraint, and psychotropic PRN medications. This article draws from the research to outline how behavioral approaches to psychiatric care can assist in realizing alternatives to these restrictive interventions. Strategies to assess the behavioral competence of direct care staff, improve it, and establish ward programmatic structures that facilitate competent behavioral applications are discussed as well as methods to enable expert consultation and demonstrate clinical and administrative support. These steps have had a positive impact in reducing reliance on seclusion, restraint and psychotropic PRN medication in the inpatient psychiatric setting. Given the wealth of supportive data to confirm the value of behavioral applications, there is no excuse for failing to aggressively pursue these options.

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

“…It is widely accepted that effective mental health care sometimes includes the deployment of coercive measures such as seclusion and restraint by staff to contain dangerous or severely disruptive behaviour by a service user. Extensive efforts have been made in Europe and America over the past decade to assess rates of coercive measures systematically [1][2][3] and to reduce them [4]. D'Orio et al [5], for example, report a 39% reduction in coercion following introduction of a package which included enhanced access to expertise during emergency situations.…”

Recovery-Oriented Training and Staff Attitudes over Time in Two State Hospitals

“…Although there has been considerable research specifically on reducing the use of restrictive interventions, such as seclusion, restraint, and benzodiazepines (19), trainings more broadly related to recovery in state hospitals have not been well-studied. There have been a few demonstration projects (20)(21)(22)) that have generated interest in this area.…”

Efforts to Reduce Seclusion and Restraint Use in a State Psychiatric Hospital: A Ten-Year Perspective

“…Conclusions: The findings suggest that reduction in seclusion and restraint use is sustainable, and judicious use of seclusion and restraint can become the new normative practice-even in the face of potentially disruptive administrative and environmental changes. T here is a growing consensus that the use of institutional measures of control in psychiatric units and hospitals, such as seclusion and restraint, are common and potentially countertherapeutic-especially for vulnerable patients with prior exposure to traumatic events (1)(2)(3). Various health care organizations and patient advocacy groups have called for care that is more "trauma informed" and less dependent on institutional measures of control.…”