APA Resource Document Outlines Principles on Use of Seclusion, Restraint

Decision-support algorithms help guide the use of S/R. Agitation is defined as a hyperaroused state (ranging in severity from anxious and cooperative to violent and combative) in which the individual exhibits excessive, repeated, and purposeless motor or verbal behaviors. These may include pacing, fidgeting, clenching fists or teeth, prolonged staring, picking at clothing or skin, responding to internal stimuli such as hallucinations, and threatening or carrying out violent acts. It is important, and in some jurisdictions mandated, to develop protocols and decision-support algorithms for staff to safely manage agitated patients in acute care facilities such as emergency departments and inpatient psychiatric hospitals. (See box above for nine key principles to guide the development of protocols.)

Understanding the clinician’s role in S/R can lead to more appropriate use of these interventions. Psychiatrists need to know their roles and responsibilities in S/R. APA has produced an interactive presentation on this topic at the SMI Adviser website.

Understanding the risks can reduce harm when using S/R. It is important to understand the differential risks of physical restraints compared with seclusion. While some studies have not found a significant variation in adverse effects between the two procedures, others have described notably heightened risks with physical restraint, such as deep vein thrombosis and aspiration pneumonia. Compared with non-physically restrained patients, more total days of physical restraint have been associated with an increased risk for pulmonary embolism.

Advocating for availability of environmental interventions, including seclusion rooms, can minimize the need for restraint. Because restraints are associated with the highest level of morbidity and mortality, every effort should be made to avoid their use. Plans for new psychiatric facilities or renovations should include calming, sensory, and seclusion rooms to minimize the need for restraint. The choice of seclusion vs. restraint should be based on any federal or state requirements and the clinical presentation and/or patient preference.

The patient’s experience of S/R is important. Most psychiatrists have not likely experienced their own S/R in a psychiatric facility or other clinical setting. One way to develop empathy is to consider how they may have felt in other situations in their lives when their freedom, physical or otherwise, was limited or suppressed.

A culturally competent, trauma-informed, and patient-centered approach is necessary when making decisions about whether to use S/R. The prevalence of a history of trauma among psychiatric inpatients ranges from 50% to 80%. As such, mental health professionals should recognize the impact and signs of trauma when considering S/R, keeping in mind that these interventions can legally be used only as a last resort. In this context, trauma-informed care has emerged as an approach to allow patients to engage in their health care, develop a trusting relationship with their physician, and improve health outcomes.

Patient preferences and psychiatric advance directives are critical when considering the use of S/R. Patients who have experienced seclusion and/or restraint likely have strong opinions about their use. Most patients would choose seclusion over restraint, but there may be exceptions, depending on previous experience, including psychological traumas. In this context, psychiatric advance directives (PAD) have emerged as a tool to allow people with mental health conditions to state their preferences in advance for treatments in case a mental health crisis impacts their ability to make decisions at the time.