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

There 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 (1–3). 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. Drawing on recommendations of the National Association of State Mental Health Program Directors and others (3,4) and with encouragement from accrediting bodies such as the Joint Commission, several systems of care have made efforts to reduce the use of seclusion and restraint. These efforts generally yield significant reductions in use of seclusion and restraint after the intervention (5). Although these data are promising, studies are largely descriptive, lack an experimental design, are unable to compare the effectiveness of the interventions used, and report limited follow-up data (6–10).

We previously described a plan that we undertook to reduce seclusion and restraint use (11,12). The plan involved implementing a multicomponent intervention that used a multiple-baseline, time-series design. The first component of the intervention consisted of an observation-only period, given the established relationship of administrative commitment and reduction in seclusion and restraint use. Subsequent, active components of the intervention included training related to trauma-informed care (for example, trauma’s effects on patients’ physiology and psychology), changes to rules and language (for example, making policies less restrictive), training related to patient involvement in treatment planning (for example, highlighting the clinical benefits of shared decision making), and changes to the therapeutic environment (for example, repainting walls with warm colors, using decorative rugs and plants, and replacing and restructuring furniture in common areas). The final component was part of a larger institutional effort and included a scripted introduction geared toward improving patient-staff communication. Of note, each hospital unit was assigned two separate periods in which to make changes to the therapeutic environment. The medical director led all trainings over dedicated, half-day seminars.

Each unit implemented all components of the intervention over time and each in a different and randomly selected order, allowing researchers to examine the unique effects of each component while controlling for competing explanations of time, order, and location. Major findings showed an 82.3% reduction in the rate of seclusion and restraint over a 3.5-year period. After we controlled for illness severity and nonspecific effects, changes to the physical environment were uniquely associated with a significant reduction in the rate of seclusion and restraint, whereas changes related to trauma-informed care training, unit rules and language, and involvement of patients in treatment planning did not uniquely contribute to outcomes. Ongoing improvements to the physical environment may have served as a reminder to staff of the institutional commitment to eliminating seclusion and restraint use (13).

During the subsequent 4.5 years, limited administrative efforts were directed toward seclusion and restraint reduction, and a number of factors could have increased or decreased use. Training in trauma-informed practices was included as part of new staff orientation (trimmed in content and duration), but the medical director had limited involvement. No additional efforts were directed toward sustaining changes to unit rules or further involving patients in treatment planning. There were significant changes in administrative structure, with the departure of advocates of the original intervention, including the hospital’s administrator and medical director. Environmental changes were also made—for example, all 64 restrooms in the hospital were systematically remodeled from October 2009 to September 2012—that had the potential to negatively affect intervention gains. Regulatory changes also could have affected seclusion and restraint use.

This naturalistic, follow-up study examined archival data on rates of seclusion and restraint by using a longer preintervention baseline phase and examined the longer-term sustainability of intervention gains in the absence of a specific research agenda. Thus our analysis examined seclusion and restraint rates at a single institution over ten years (January 1, 2003, through December 31, 2012). These data are significant in that we could find no published data on the longer-term impact (sustainability) of interventions to reduce seclusion and restraint in psychiatric settings.