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SAMHSA Helps Reduce Seclusion and Restraint at Facilities for Youth

By Rebecca A. Clay

mental health treatment advisor talking to young boy in crisis

(Photo by A. Martín Castillo)

At some mental health treatment facilities, children who misbehave risk being tackled, sat upon, and dragged to "seclusion rooms." That's not the case at the Lakeside Treatment and Learning Center, a nonprofit residential treatment facility for emotionally and behaviorally impaired children and adolescents in Kalamazoo, MI.

About a decade ago, the center's leaders realized that those types of restraint and seclusion techniques not only put their clients at risk of injury or even death but also were counterproductive. To avoid retraumatizing already troubled children, staff faced with problematic behavior these days first try strategies designed to calm clients and de-escalate conflicts. They only resort to seclusion or a restraint technique with great reluctance. Even more important, staff members work to prevent certain behaviors from occurring in the first place.

"Our agency is moving away from a culture based on coercive control of children to one based on committed relationships," explained Suzanne Friesner, M.S.W., the center's Assistant Director. "Although we recognize that sometimes safety concerns mandate the use of restraint or seclusion, our vision for the future is to move as much as possible to an environment free of restraint and seclusion."

SAMHSA's Center for Mental Health Services (CMHS) is helping to make that vision a reality. In 2001, CMHS awarded five 3-year demonstration grants to support the development of effective best-practice training models to reduce the inappropriate use of seclusion and restraint in non-medical, community-based, residential and day treatment facilities for children and youth. Lakeside and four other grantees across the country are developing methods to train staff who work with children and youth in facilities providing mental health services (see article 1 part 2). The Child Welfare League of America, in collaboration with the Federation of Families for Children's Mental Health, serves as the project's coordinating center. Together, the coordinating center and demonstration sites are developing best practices in training to reduce the use of restraint and seclusion.

"Restraint and seclusion represent treatment systems' failures," said CMHS Director A. Kathryn Power, M.Ed. "Through this initiative and others, consumers of mental health services will have improved opportunities for recovery."

Emphasis on Training

Over the last decade, investigations revealed that inappropriate use of restraint and seclusion can result in psychological trauma, physical injury, or even death (see "Breaking the Bonds," SAMHSA News, Volume XI, Number 2). Children are at especially high risk.

"Restraint and seclusion represent treatment systems' failures."

–A. Kathryn Power, M.Ed.
CMHS Director

Now, a patchwork of state laws and a series of Federal regulations and laws have been established to try to prevent such problems. The Children's Health Act of 2000 requires SAMHSA and the Centers for Medicare & Medicaid Services (CMS) to develop regulations governing use of restraint and seclusion in health care facilities receiving Federal dollars and in non-medical, community-based facilities for youth.

Mural of the Lakeside Treatment and Learning Center by one of the center's young clients.

As part of its Conditions of Participation, CMS already established standards that prohibit hospitals and residential psychiatric treatment facilities for people under age 21 from using restraint and seclusion except to ensure safety during emergencies. The regulations also require facilities to report deaths, debrief staff and consumers after incidents, and provide education and training to staff.

That last requirement is especially important, said Paolo del Vecchio, M.S.W., Associate Director for Consumer Affairs at CMHS. Because of the field's high turnover rates, staff may not receive adequate training. "Staff members need ongoing training on seclusion and restraint—most importantly, in how to prevent the use of such techniques in the first place," said Mr. del Vecchio. "Focusing on alternatives to the use of restraint and seclusion is the real key."

And that's just what the CMHS grants do. The program's goals are to develop a range of effective models for training professional and support staff in the appropriate use of restraint and seclusion and to analyze the training's impact on use, safety, and other outcomes.