National Association of State Mental Health Program Directors
The
members of the National Association of State Mental Health Program Directors
(NASMHPD) believe that seclusion and restraint, including "chemical
restraints," are safety interventions of last resort and are not treatment
interventions. Seclusion and restraint should never be used for the purposes of
discipline, coercion, or staff convenience, or as a replacement for adequate
levels of staff or active treatment.
The
use of seclusion and restraint creates significant risks for people with
psychiatric disabilities. These risks include serious injury or death,
retraumatization of people who have a history of trauma, and loss of dignity
and other psychological harm. In light of these potential serious consequences,
seclusion and restraint should be used only when there exists an imminent risk
of danger to the individual or others and no other safe and effective
intervention is possible.
It
is NASMHPD's goal to prevent, reduce, and ultimately eliminate the use of
seclusion and restraint and to ensure that, when such interventions are
necessary, they are administered in as safe and humane a manner as possible by
appropriately trained personnel. This goal can best be achieved by: (1) early
identification and assessment of individuals who may be at risk of receiving
these interventions; (2) high quality, active treatment programs (including,
for example, peer-delivered services) operated by trained and competent staff
who effectively employ individualized alternative strategies to prevent and
defuse escalating situations; (3) policies and procedures that clearly state
that seclusion and restraint will be used only as emergency safety measures;
and (4) effective quality assurance programs to ensure this goal is met and to
provide a methodology for continuous quality improvement. These approaches help
to maintain an environment and culture of caring that will minimize the need
for the use of seclusion and restraint.
In
the event that the use of seclusion or restraint becomes necessary, the
following standards should apply to each episode:
As
part of the intake and ongoing assessment process, staff should assess whether
or not an individual has a history of being sexually, physically or emotionally
abused or has experienced other trauma, including trauma related to seclusion
and restraint or other prior psychiatric treatment. Staff should discuss with
each individual strategies to reduce agitation which might lead to the use of
seclusion and restraint. Discussion could include what kind of treatment or
intervention would be most helpful and least traumatic for the individual.
·
Only
licensed practitioners who are specially trained and qualified to assess and
monitor the individual's safety and the significant medical and behavioral
risks inherent in the use of seclusion and restraint should order these
interventions.
·
The
least restrictive seclusion and restraint method that is safe and effective
should be administered.
·
Individuals
placed in seclusion or restraints should be communicated with verbally and
monitored at frequent, appropriate intervals consistent with principles of
quality care.
·
All
seclusion and restraint orders should be limited to a specific period of time.
However, these interventions usually should be ended as soon as it becomes safe
to do so, even if the time-limited order has not expired.
· Individuals who have been secluded or restrained and staff who have participated in these interventions usually should participate in debriefings following each episode in order to review the experience and to plan for earlier, alternative interventions.
States
should have a mechanism to report deaths and serious injuries related to
seclusion and restraint, to ensure that these incidents are investigated, and
to track patterns of seclusion and restraint use. NASMHPD also encourages
facilities to conduct the following internal reviews: (1) quality assurance
reviews to identify trends in seclusion and restraint use within the facility,
improve the quality of care and patient outcomes, and help reduce the use of
seclusion and restraint; (2) clinical reviews of individual cases where there
is a high rate of use of these interventions; and (3) extensive root cause
analyses in the event of a death or serious injury related to seclusion and
restraint. To encourage frank and complete assessments and to ensure the
individual's confidentiality, these internal reviews should be protected from
disclosure.
NASMHPD
is committed to achieving its goals of safely preventing, reducing, and
ultimately eliminating the use of seclusion and restraint by: (1) encouraging
the development of policies and facility guidelines on the use of seclusion and
restraint; (2) continuing to involve consumers, families, treatment
professionals, facility staff, and advocacy groups in collaborative efforts;
(3) supporting technical assistance, staff training, and
consumer/peer-delivered training and involvement to effectively improve and/or
implement policies and guidelines; (4) promoting and facilitating research
regarding seclusion and restraint; and (5) identifying and disseminating
information on "best practices" and model programs. In addition,
NASMHPD supports further review and clarification of developmental
considerations (for example, youthful and aging populations) which may impact
clinical and policy issues related to these interventions.
Approved by the NASMHPD membership on July 13, 1999.
See
next page please.
Note:
This position statement was approved by the NASMHPD membership. There was a series of meetings and resulting
series of Technical Reports involving a work group. The NASMHPD Medical
Director’s Council Technical Report Meetings on Seclusion and Restraint
included a broad range of participants. Different meeting dates included
slightly different participant lists. The February 18-19,1999 meeting included:
NASMHPD MEMBERS
Meredith
Alden, M.D., PhD.
Director,
Division of Mental Health
DHS,
Utah
Charles
G. Curie
Deputy
Secretary for Mental Health
Dept.
of Public Welfare
Office
of MH and SA, Pennsylvania
Medical Directors Council
Rupert
Goetz, M.D.
Medical
Director
MH
and DD Service Division, Oregon
Thomas
Hester, M.D.
Medical Director and Director, Facility Ops.
Division
of MH, MR, SAS, Georgia
Joseph
Parks, M.D.
Deputy
Director for Psychiatry
Dept.
of MH, Missouri
Alan
Radke M.D., M.P.H.
Medical
Director
DHS,
Minnesota
ADULT SERVICES DIVISION
Debra
Kupfer, M.H.S.
Mental
Health Planner
Division
of MH Services, Colorado
CHILDREN, YOUTH AND FAMILIES DIVISION
Gary
Blau, Ph.D.
Bureau
Chief of Quality Management
Dept
of Children and Families, Connecticut
FORENSIC DIVISION
John
Main
CEO,
Forensic Psychiatric Hospital
Division
of MH, New Jersey
LEGAL DIVISION
Marybeth
McCaffrey, J.D.
Special
Assistant Attorney General
Dept.
of Developmental and Mental Health Services
Vermont
OLDER PERSONS DIVISION
Kathy
Grissom
Director
Mary
Starke Harper Geriatric Psych. Ctr.
DMH,
Alabama
NAC/SMHA (National Assoc. of Consumer/Survivor Mental Health
Administrators)
Cathy
Bustin Baker
Director
of Consumer Affairs
DMHMRSAS,
Maine
Karen
Kangus
Director
of Community Education
DMH,
Connecticut
ORYX WORKGROUP
Barbara
Carey
Chief,
Quality and Risk Management
Mental
Hygiene Admin., Maryland
FACILITATOR
John
Gates, Ph.D.
Director,
Mental Health Program
Carter
Center, Emory University
WRITER
Andrea
Blanch, Ph.D.