In Reply: The assertion that seclusion and restraint can ultimately be eliminated, as evinced by Pennsylvania's remarkable achievement, stands squarely on its own merits. Pennsylvania has done what no other state has done—eliminate restraint and seclusion altogether at two state hospitals, and eliminate seclusion at seven of its nine state hospitals. Dr. Liberman's letter, which implicitly derides this extraordinary effort by describing its goal as "fatuous" and by likening its principles to an "ideological straitjacket," is remarkable for its lack of knowledge about other facilities that have eliminated seclusion and restraint, insensitivity to consumers who have suffered in a true straitjacket, and denigration of the dedicated partnership of Pennsylvania professionals, consumers, and advocates who have worked diligently toward this attainable goal.
Dr. Liberman's fundamental argument is flawed. He cites a lack of awareness of "clinical realities," which are offered without supporting data. The increased use of PRN medication is one of the "realities" offered as an example, and yet Pennsylvania effectively eliminated PRN medication one year ago throughout their state hospital system. The letter also leaves the reader wondering why 20-year-old practice recommendations are invoked when federal regulations, standards of accrediting bodies, Congressional mandates, and regulations in several states have superseded many of these guidelines (1).
Unfortunately, the arguments made do not recognize the successful efforts to eliminate seclusion and restraint at facilities throughout the country, such as Salem Hospital in Oregon, which successfully eliminated these practices by implementing a model of care based on trauma-informed care principles; Taylor Hardin Secure Medical Facility in Alabama, the state's only forensic hospital, which virtually eliminated these interventions after working for more than six years to change its treatment culture; and the Boston Medical Center intensive treatment program, which serves adolescents in a secure setting and which eliminated mechanical restraint, seclusion, and medication restraint by implementing the trauma systems therapy model developed by Glenn Saxe (2). Work at these facilities and others (3) has led to national reductions in the use of seclusion and restraint (4) and underscores how changes in practice can alter the use of these interventions.
Psychiatry has played a great leadership role in efforts to achieve the goal of eliminating seclusion and restraint—efforts that preceded those of Philippe Pinel and that continue today. The steadfast work of Elizabeth Childs, M.D., commissioner of the Massachusetts Department of Mental Health, will lead to the promulgation of some of the most progressive seclusion and restraint regulations in the Unites States on April 3, 2006 (5). These new regulations articulate the goal of elimination and are designed to prevent the use of these interventions and implement alternatives, which will mitigate harm to consumers and staff. It is a sad commentary that not all members of the psychiatric community can accept a vision of care without seclusion and restraint and adopt advancing standards of practice to mutually further this important work.
Dr. LeBel is affiliated with the child and adolescent division of the Massachusetts Department of Mental Health in Boston. Ms. Huckshorn is affiliated with the National Technical Assistance Center for State Mental Health Planning and the National Coordinating Center to Reduce and Eliminate the Use of Seclusion and Restraint of the National Association of State Mental Health Program Directors in Alexandria, Virginia.
Zusman J: Restraint and Seclusion: Understanding the JCAHO Standards and Federal Regulations. Marblehead, Mass, Opus Communications, 2001
National Executive Training Institute: Training Curriculum for Reduction of Seclusion and Restraint. Alexandria, Va, National Association of State Mental Health Program Directors, National Technical Assistance Center for State Mental Health Planning, July 2005
LeBel J, Goldstein R: the economic cost of using restraint and the value added by restraint reduction or elimination. Psychiatric Services 56:1109-1114, 2005
Glover R: Reducing the use of seclusion and restraint: a NASMHPD priority. Psychiatric Services 56:1141-1142, 2005
Commonwealth of Massachusetts, Department of Mental Health Regulations 104 CMR 27.00: Licensing and Operational Standards for Mental Health Facilities. Available at http://mass.gov/eeohhs2/docs/dmh/rsri/104cmr27.doc. Accessed Feb 27, 2006