January 2003. Several years ago I served on the Behavioral Health Professional and Technical Advisory Committee of the Joint Commission on Accreditation of Behavioral Healthcare Organizations (JCAHO). At that time, new standards were being drafted by JCAHO on the use of restraint and seclusion in hospitals. In the initial draft, the standard proposed was that all hospitals strive to be “restraint and seclusion free.” While a laudable goal, this standard seemed too difficult to achieve to be realistic, and certain modifications were made in the language, to emphasize appropriate minimization of the use of restraint and seclusion, rather than total discontinuation of these interventions. The discussion was intense and quite interesting, and included consideration of the question of whether these interventions should be considered components of treatment or conceptualized as safety interventions. In such discussions, there is a risk that the perspective may shift from a medical model to a debate about social control versus individual rights. After all, one could mount the same arguments in many fields of medicine, but we don’t hear them. Is holding a patient and using a mouth guard when the patient is having a grand mal seizure part of treatment or is it a safety intervention? Is isolation of a severely immunocompromised patient or a patient with a highly contagious infectious disease part of treatment or is it a safety intervention? And how important, really, is the distinction? Many of the most severely disabled patients in psychiatric hospitals have comorbid conditions which can include extreme substance abuse, criminal history, history of physical or sexual abuse, history of head injury, and the like. I would argue that in some cases, the unpredictability of such patients’ behavior, and their inability to control it, means that restraint or seclusion may be periodically necessary, to help a patient return to a state of control and relative calm and be able to safely return to the company of others. And overall, I would call this part of good treatment, which in my book is the most important right a patient, any patient, should have.
In any case, I have become convinced that systems, even underfunded hospitals with marginal staffing levels, can change. Perhaps more skeptical than I should have been, I worried that a worthy ideology might lead to an environment unsafe for patients and staff. What became clear, time and time again, however, was that systemwide, concentrated efforts to devise alternative strategies, in lieu of restraint and seclusion, could be remarkably successful. Does that mean that the initial JCAHO standard might not have been so unrealistic, that all hospitals could become restraint and seclusion free? In my opinion, not yet, at least for some forensic and high acuity units. But it may be closer to an achievable goal for many hospital settings than I thought.
In this issue of the journal, Allen et al. present a summary of expert consensus guidelines for psychiatric emergencies. In a companion piece, Allen et al. present a survey of patients’ reports about their experience of restraint and seclusion. Although not necessarily representative of all such experiences, these reports are valuable and informative. Also in this issue, Currier discusses the appropriate and inappropriate use of involuntary medication, and Reid reviews the state of our knowledge about assessing patients to determine their category of risk, if any, for dangerous behavior. Finally, Fisher presents a compelling example of how a large urban state hospital succeeded in radically reducing the use of restraint and seclusion, and doing so safely.