Letter

In Reply: We think Dr. Becker makes an extremely important point. Although our report did not specifically address use of seclusion and restraint, the most common reason for their use is the management of assaultive behavior ( 1 ). Therefore, if an intervention succeeds in reducing the number of aggressive incidents committed by patients in a psychiatric facility, use of seclusion and restraint will also decrease as a natural consequence.

Numerous organizations have expressed concern about the deleterious psychological effects and physical risks associated with seclusion and restraint ( 2 ). The Centers for Medicare and Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations have emphasized the need to limit their use to emergency situations. In response, psychiatric facilities across the nation have made concerted efforts to reduce seclusion and restraint use, and many have succeeded. However, the actual success of these efforts should be examined closely. As Dr. Becker points out, some facilities have reported that a decrease in seclusion and restraint use has been accompanied by a corresponding increase in the number of assaults and injuries to staff. In our opinion, a successful seclusion and restraint reduction program achieves a significant decrease in the number of aggressive incidents along with a decrease in use of seclusion and restraint.

Psychiatric hospital administrators must achieve a delicate balance when implementing policies that are intended to reduce use of seclusion and restraint. They must protect psychiatric patients from unnecessary or prolonged confinement in seclusion and restraints. At the same time, they must be careful that a policy is not so restrictive that clinicians are unable to justify use of seclusion and restraint when necessary to prevent injuries to staff and other patients. Staff injuries from patient assaults can exact a heavy toll in terms of physical disability, psychological damage, lost work days, and poor staff morale. Further, psychiatric patients are entitled to "safe conditions of confinement," and mental health professionals in many states have a statutory duty to protect third parties—for example, as set forth in Tarasoff ( 3 ).

We believe that the most effective approach to this problem is to target the root causes of aggressive behavior rather than rely on administrative policies that seek to restrict or even ban use of seclusion and restraint ( 4 ). Although our current understanding of the causes and optimal treatment of aggressive behavior remains limited, and this lack of knowledge likely plays a role in the misuse and overuse of seclusion and restraint, staff education can have positive effects. For example, after an urban psychiatric hospital implemented a staff training program on the management of assaultive behavior and mandated weekly team meetings to discuss strategies for treating aggressive patients, a decrease in both staff injuries and the rate and duration of restraint use was observed ( 5 ). The results of our study suggest that inpatient aggression is a multifaceted problem that requires heterogeneous treatment interventions; any "one size fits all" approach will not be effective in the long term.