Preventing the Use of Seclusion and Restraint:

A National Initiative to Transform Mental Health Systems of Care

Kevin Ann Huckshorn, RN, MSN, CAP, ICADC

Director, NationalTechnicalAssistanceCenter

National Association of State Mental Health Program Directors

References

American Association of Community Psychiatry (AACP). (2003). AACP guidelines for recovery oriented services. Retrieved on June 2, 2004, from the Internet at and restraintOSMenu.html

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders(4th ed.). Washington, DC: Author.

Anthony, W.A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s.Psychosocial Rehabilitation Journal, 16(4), 11-23.

Bluebird, G. (in press). Defining the roles of consumers: Changing culture and practice in mental health settings.

Bullard, L., Fulmore, D., & Johnson, K. (2003). Reducing the use of seclusion andrestraint: Promising practices and successful strategies. Children’s Welfare League of America. Washington, DC: CWLA Press.

Campbell, J., & Leaver, J. (2003). Emerging new practices in organized peer support.Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center for State Mental Health Planning (NTAC).

Center for Mental Health Services (CMHS) & Human Resource Association of the Northeast (HRANE). (1995, July). Dare to vision, shaping the national agenda for abuse and mental health services. Proceedings of a conference in Arlington, VA.

Center for Medicare and Medicaid Services (CMS). (2002, October). Testimony from the public hearing on the one hour rule.Baltimore, MD: Author.

Children’s Health Act (CHA) of 2000, H.R. 4365. Part H - Requirement relating to the rights of residents of certain facilities; Part I - Requirement relating to the rights of residents of certain non-medical, community-based facilities for children and youth. Engrossed Senate Amendment.

Colton, D. (2004). Checklist for assessing your organization’s readiness for reducing seclusion and restraint. Unpublished paper. Staunton, VA: CommonwealthCenter for Children and Adolescents. Available at

Conley, J. (2004, May). The NTAC training curriculum for the reduction of seclusion and restraint. Evaluation Fast Facts from the Evaluation Center at HSRI,3(1), 1-4.

CornellUniversity Symposium. (2005). Examining the safety of high-risk interventions with children and young people. Ithaca, NY: College of Human Ecology, FamilyLifeDevelopmentCenter.

Curtis, L.C., & Diamond, R. (1997). Power and coercion in mental health services. In B. Blackwell (Ed.), Treatment compliance and the therapeutic alliance (pp. 97-122).Toronto, Canada: Harwood Academic Publishers.

Cusack, K.J., Frueh, B.C., & Brady, K.T. (2004). Trauma history screening in a community mental health center. Psychiatric Services, 55(2), 157-162.

Cusack, K.J., Frueh, B.C., Hiers, T.G., Keane, T.M., & Mueser, K.T. (2003). The impact of trauma and posttraumatic stress disorder upon American society. Report to the President’s Commission on Mental Health. Unpublished subcommittee report. Washington, DC.

Davis, S. (2002). Autonomy versus coercion: Reconciling competing perspectives in community mental health. Community Mental Health Journal, 38(3), 239-249.

Deegan, P.E. (1993). Recovering our sense of value after being labeled. Journal of Psychosocial Nursing and Mental Health Services,31(4), 7-11.

Donat, D. (August, 2003). An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Services, 54(8), 1119-1123.

Fallot, R., & Harris, M. (2002). Trauma informed services: A self-assessment and planning protocol. Unpublished papers.Washington, DC: Community Connections.

Federal Task Force on Homelessness and Severe Mental Illness. (1992). Outcasts on main street. Washington, DC: Interagency Council on the Homeless.

Fellitti, V.J., Anda, R.F., & Nordenberg, D. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. American Journal of Prevention Medicine, 14(4), 245-258.

Finke, L.M. (2001). The use of seclusion is not evidence-based practice. Journal of Child and Adolescent Psychiatry, 14(3), 186-188.

Fisher, W.A. (2003). Elements of successful restraint and seclusion reduction programs and their application in a large, urban, state psychiatric hospital. Journal of Psychiatric Practice, 9(1), 7-15.

Frueh, B.C., Dalton, M.E., Johnson, M.R., et al. (2000). Trauma within the psychiatric setting: Conceptual framework, research directions, and policy implications. Administration and Policy in Mental Health, 2812, 147-154.

Frueh, B.C., Cousins, V.C., Hiers, T.G., Cavanaugh, S.D., Cusack, K.J. & Santos, A.B. (2002). The need for trauma assessment and related clinical services in a state public mental health system. Community Mental Health Journal, 38, 351-356.

Goodman, L.A., Rosenberg, S.D., Mueser, K.T., & Drake, R.W. (1997). Physical and sexual assault history in women with serious mental illness: Prevalence, correlates, treatment, and future research directions. Schizophrenia Bulletin, 23, 685-696.

Goodman, L.A., Salyers, M.P., Mueser, K.T., Rosenberg, S.D., Swartz, M., Essock, S.M., et al. (2001). Recent victimization in women and men with severe mental illness: Prevalence and correlates. Journal of Traumatic Stress, 14, 615-632.

Graham, A. (December, 2002). The use of physical interventions in managing violence in a mental health setting. Mental Health Practice, 6(4), 10-15.

Green, B.L., Goodman, L.A., Krupnik, J.L., Corcoran, C.B., Petty, R.M., Stockton, P., et al. (2000). Outcomes of single versus multiple trauma exposure in a screening sample. Journal of Traumatic Stress, 13, 271-286.

Hardenstine, B. (2001). Leading the way toward a seclusion and restraint-free environment: Pennsylvania’s success story. Harrisburg, PA: Pennsylvania Department of Public Welfare, Office of Mental Health and Substance Abuse Services.

Hawryluk, M. (2002, December 23/30). CMS reconsidering the one-hour rule for restraint use: Doctors, hospitals seek to overturn the requirement of a face-to-face physician evaluation within this restrictive time frame. Amednews.com, The newspaper for America’s physicians.

HCFA Interim Final Rule. (1999). Medicare and Medicaid programs;Hospitalconditions of participation: Patient’s Rights. 42 CFR Part 482. Baltimore, MD: U.S. Department of Health and Human Services.

HCFA Interim Final Rule. (2001). Medicaid Program. Use of restraint and seclusion in psychiatric residential treatment facilities providing psychiatric services to individuals under age 21. 42 CFR Parts 441 and 483. BaltimoreMD: U.S. Department of Health and Human Services.

Herman, J.L. (1992). Trauma and recovery. New York: BasicBooks.

Holzworth, R., & Willis, C. (1999). Nurses’ judgments regarding seclusion and restraint of psychiatric patients: A social judgment analysis. Research in Nursing and Health, 2, 189-201.

Honberg, R., & Miller, J. (2003, May). Seclusion and restraint: Task force report of the NAMI Policy Research Institute. Arlington, VA: NAMI.

Huckshorn, K.A. (2005). Examining the Safety of High-Risk Interventions with Children and Young People: An International Symposium. Ithaca, NY: College of Human Ecology,FamilyLifeDevelopmentCenter.

Huckshorn, K. A. (in press). Reducing and eventually eliminating seclusion and restraint: A prevention based policy proposal and analysis.

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st Century. Washington, DC: Author.

International Association of Psychosocial Rehabilitation Services (IAPSRS). (2003). Language guidelines. Unpublished document submitted to the Board on May 3, 2003, by the Language Policy Task Force.

Jennings, A.F. (2004). The damaging consequences of violence and trauma: Facts, discussion points, and recommendations for the behavioral health system. Alexandria, VA. National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center for State Mental Health Planning (NTAC).

Jones, K., & Alexander, M.J. (2004). Impact of untreated trauma on public treatment costs. A presentation at the National Association of State Mental Health Program Directors Research Institute Conference in Arlington, VA.Orangeburg, NY: Center for the Study of Issues in Public Mental Health, Nathan Kline Institute for Psychiatric Research.

Jonikas, J., Cook, J., Rosen, C., Laris, A., & Kim, J. (2004, July). A program to reduce use of physical restraint in psychiatric inpatient facilities. Psychiatric Services, 55(7), 818-820.

Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the national comorbidity study. Archives of General Psychiatry, 52, 1048-1060.

Kilpatrick, et al., cited in Layne, C.M., Pynoos, R.S., & Cardenas, J. (2001). Wounded adolescence. School-based group psychotherapy for adolescents who sustained or witnessed violent injury. In M.Shafii & S. L. Shafii (Eds.), School Violence: Assessment, Management, Prevention (pp. 163-186). Washington, DC: American Psychiatric Press, Inc.

Lalemand, K. (2004). Non-Abusive Psychological and Physical Intervention for a Safer Workplace. Training Program Information. Auburn, ME: NAPPI, Inc.

LeBel, J., Stromberg, N., Duckworth, K., Kerzner, J., Goldstein, R., Weeks, M., et al. (2004). Child and adolescent inpatient restraint reduction: A state initiative to promote strength-based care. Journal of the AmericanAcademy of Child & Adolescent Psychiatry, 43(1).

Lieberman, J., Dodd, C., & DeLauro, R. (1999). Testimony to the Senate Committee on Finance. United States Senate proceedings.Washington, DC.

Linhorst, D.M., Eckert, A., & Hamilton, G. (2005). Promoting participation in organizational decision making by clients with severe mental illness. Social Work, 50, 21-30.

Masters, K.J., Bellonci, C., & the Work Group on Quality Issues. (2001). Practice parameters for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions with special reference to seclusion and restraint. Unpublished document. Available to AACAP members at Washington, DC: AACAP.

Mildred, L. (2002). Seclusion and restraints: A failure, not a treatment.Sacramento, CA: California Senate Office of Research.

Mohr, W.K., & Anderson, J.A. (2001). Faulty assumptions associated with the use of restraints with children. Journal of Child and Adolescent Psychiatric Nursing, 14(3), 141- 151.

Moses, D.J., Reed, B.G., Mazelis, R., & D’Ambrosio, B. (2003). Creating trauma services for women with co-occurring disorders: Experiences from the SAMHSA Women with Alcohol, Drug Abuse and Mental Health Disorders Who Have Histories of Violence Study. Delmar, NY: Policy Research Associates.

Mueser, K.T., Goodman, L.B., Trumbetta, S.L., Rosenberg, S.D., Osher, F.C., Vidaver, R., et al. (1998). Trauma and posttraumatice stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 66, 493-499.

NASMHPD Medical Directors Council. (1999). Reducing the use of seclusion and restraint. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center for State Mental Health Planning (NTAC).

National Association of State Mental Health Program Directors (NASMHPD). (2005). Position statement on services and supports to trauma survivors. Retrieved on May 12, 2005, from

National Association of Consumer/Survivor Mental Health Administrators (2003). Roadmap to a restraint free environment. Draft manual. Washington, DC: Author.

National Association of Protection and Advocacy Systems (NAPAS). (2004). Restraint and seclusion: Overview of federal laws and policies. Prepared by Gary Gross, Senior Public Policy Counsel. Retrieved from the Internet on January 15, 2004, from

National Executive Training Institute (NETI). (2005). Training curriculum for reduction of seclusion and restraint. Draft curriculum manual. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center for State Mental Health Planning (NTAC).

National Executive Training Institute (NETI). (2003). Training curriculum for reduction of seclusion and restraint. Draft curriculum manual. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center for State Mental Health Planning (NTAC).

Norris, F.H., Byrne, C.M., Diaz, E., & Kaniasty, K. (2002, September). The range, magnitude, and duration of effects of natural and human-caused disasters: A review of the empirical literature. A NationalCenter for PTSD Fact Sheet. See

Onken, S., Dumont, J., Ridgeway, P., Dornan, D., & Ralph, R. (2002). Mental health recovery: What helps and what hinders? A national research project for the development of recovery facilitating system performance indicators. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center for State Mental Health Planning (NTAC).

Petti, T.A., Mohr, W.K., Somers, J.W., & Sims, L. (2001). Perceptions of seclusion and restraint by patients and staff in an intermediate-term care facility. Journal of Child and Adolescent Psychiatric Nursing, 14(3), 115-127.

Powell, T., Yeaton, W., Hill, E., & Silk, K. (2001). Predictors of psychosocial outcomes for patients with mood disorders: The effects of self-help group participation. Psychiatric Rehabilitation Journal, 25, 3-11.

The President’s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. DHHS Pub. No. SMA-03-3832. Rockville, MD.

Ralph, R. (2000). Review of recovery literature: A synthesis of a sample of recovery literature 2000. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center for State Mental Health Planning (NTAC).

Ray, N.K., Myers, K.J., & Rappaport, M.E. (1996). Patient perspectives on restraint and seclusion experiences: A survey of former patients of New YorkState psychiatric facilities. Psychiatric Rehabilitation Journal, 20(1), 11-18.

Rosenberg, S.D., Mueser, K.T., Friedman, M.J., Gorman, P.G., Drake, R.E., Vidaver, R.M., et al. (2001). Developing effective treatments for posttraumatic disorders among people with severe mental illness. Psychiatric Services, 52, 1453-1461

Rosenberg, S., Mueser, K., Jankowski, M.K., & Hamblen, J. (2002).Trauma exposure and PTSD in people with severe mental illness.PTSD Research Quarterly, 13(3), 1-4.

Salzer, M. (2002). Mental Health Association of Southeastern Pennsylvania Best Practices Team. Best Practice guidelines for consumer-delivered services. Behavioral Health Recovery Management Project, Initiative of Fayette Companies, Peoria, IL, and Chestnut Health Systems, Bloomington, IL.

Saxe, G., Vanderbilt, D., & Zuckerman, B. (2003, Spring). Traumatic stress in injured and ill children. PTSD Research Quarterly. The NationalCenter for Post-traumatic Stress Disorder. ISSN 1050-1835.

Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal, 27, 392-401.

Solomon, S.D., & Davidson, J.R.T. (1997) Trauma: Prevalence, impairment, service use and cost. Journal of Clinical Psychiatry, 58(Suppl. 9), 5-11.

Steele, E. (1999). Seclusion and restraint practice standards: A review and analysis. National Mental Health Association, ConsumerSupportTechnicalAssistanceCenter. Alexandria, VA: NMHA.

Stefan, S. (2002, Summer/Fall). Legal and regulatory aspects of seclusion and restraint in mental health settings. networks, p. 3. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center for State Mental Health Planning (NTAC).

Stilwell, E.M. (1991). Are nurses educated on the use of restraints? Journal of Gerontological Nursing, 17(2), 23-26.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2003). A national call to action: Eliminating the use of seclusion and restraint. Summary report from the call to action event on May 5, 2003, in Washington, DC. Washington, DC: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2004). SAMHSA priorities: Programs and principles matrix. Retrieved from the Internet on January 5, 2004, at

Success Stories and Ideas for Reducing Restraint/Seclusion. (2003). A compendium of strategies created by the American Psychiatric Association (APA), the American Psychiatric Nurses Association (APNA), the National Association of Psychiatric Health Systems (NAPHS), and the American Hospital Association (AHA) Section for Psychiatric and Substance Abuse Services. Retrieved from the Internet on January 10, 2004, at

Switzer, G.E., Dew, M.A., Thompson, K., Goycoolea, J.M., Derricott, T., & Mullins, S.D. (1999). Posttraumatic stress disorder and service utilization among urban mental health center clients. Journal of Traumatic Stress, 12, 25-39.

U.S. General Accounting Office. (1999, September). Mental health: Improper restraint or seclusion use places people at risk. GAO/HES-99-176. Washington, DC: Author.

U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

U. S. Department of Health and Human Services. (1999). The Surgeon General’s call to action to prevent suicide. Washington, DC: Author.

Visalli, H., McNasser, G., Johnstone, L., & Lassaro, C. (1997). Reducing high-risk interventions for managing aggression in psychiatric settings. Journal of Nursing Care Quality, 11(3), 54-61.

Weiss, E.M., Altimari, D., Blint, D.F., & Megan, K. (1998, October). Deadly restraints: A nationwide pattern of death. The Harford Courant.

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