To the Editor: We are writing in reply to Dr. Liberman's well-articulated letter to the editor (1) about seclusion and restraint in the April 2006 issue. We agree with Dr. Liberman's observation that the elimination of seclusion and restraint is "laudable in idealism but lacking in clinical reality." The aim should be reduction to minimal use, because elimination carries many unacceptable risks, including patient and staff injury; overuse of scheduled, PRN, and stat medication for sedation (in essence, chemical restraint); and premature discharge and blacklists to keep potential users of these "last-ditch-effort safety measures" from accruing inpatient days or ever being admitted.
However, we take issue with Dr. Liberman's point that implementing psychosocial rehabilitation by using rationales of "recovery" and "empowerment" cannot contribute to a reduction in the use of seclusion and restraint. Dr. Liberman cites data from California and does so to the best of our knowledge accurately. But the outcome in California may not be a failure of the rehabilitation-recovery model. It may well be a failure in implementation of the model.
In our experience, state hospitals have effectively adapted the principles of recovery and empowerment, especially through the use of "treatment malls." Outcomes have included fewer patient and staff injuries, fewer missed days of work from staff injuries, and less use of seclusion and restraint accompanied by less use of PRN and stat medication and lower rates of polypharmacy. One such state hospital earned a Significant Achievement Award in 2000 from the American Psychiatric Association for developing a centralized psychosocial rehabilitation program focused on recovery while decreasing staff injuries and the use of restraint and seclusion (2). Another state hospital received a Best Practice in the Treatment of Schizophrenia Award in 2002 from the American Psychiatric Nurses Association for developing a safety infrastructure to support off-ward recovery-focused rehabilitation programs (3).
We are aware that more research is needed in this area, but let's not throw out a model because one state seems to be struggling with its implementation. Every opportunity is a rehabilitation opportunity.
Dr. McLoughlin is a mental health clinical and systems consultant and federal court-appointed special monitor in Honolulu. Dr. Geller is professor of psychiatry and director of public-sector psychiatry, University of Massachusetts Medical School, Worcester.
Liberman RP: Elimination of seclusion and restraint: a reasonable goal? Psychiatric Services 57:576, 2006
Significant Achievement Awards: A rehabilitation program for inpatients in a large institution—the psychosocial rehabilitation program at Eastern State Hospital, Williamsburg, Virginia. Psychiatric Services 51:1439-1443, 2000
Wilbur S, Tait J, Stevens G: An appreciation of excellence: the APNA 2002 awards and recognition program. Journal of the American Psychiatric Nurses Association 9:35-38, 2003