xxAACP Newsletter, Volume 13, Number 3, Summer 1999
The AACP Confronts Seclusion and Restraint
In October, 1998, a series of articles in the Hartford Courant examined the use and abuse of seclusion and restraint in psychiatric facilities, and documented a large number of deaths associated with these practices. Since that series there has been an up swelling of concern about the dangers of seclusion and restraint. The National Alliance for the Mentally Ill (NAMI) has taken the lead in advocating for legislation to control and monitor the use of seclusion and restraint, and in calling for nationwide adoption of "best practices" in this area.
In March of 1999 NAMI's publication of a draft policy on seclusion and restraint led to an extensive discussion on the AACP E-mail list serve, which included a number of AACP members and Clarke Ross, NAMI's Deputy Executive Director for Public Policy. NAMI's proposal recommended use of restraint for emergency safety situations only, not for discipline or staff convenience; face-to-face evaluation by a physician every hour during use of restraints; mandatory reporting of deaths and serious injuries from restraints; and monitoring of facilities by consumer and family groups. There was overwhelming agreement that restraint should only be used for emergencies, but many questions and concerns were raised about various specifics of the NAMI policy. Mr. Ross responded that NAMI looked to professional organizations to take the lead in promulgating evidence-based best practices, but that had not happened, so NAMI filled the void by addressing an issue that is crucial to its members. We were challenged to participate as partners in identifying and advocating for best practices. The discussion was intense at times, but it was also clarifying and productive.
This E-mail interchange set the stage for an extended discussion at the Board meeting in May. First Clarke Ross joined us for a continued, face-to-face discussion of NAMI's position on the issue. Then we were joined by Ned McCulloch, a staff member in the office of Senator Joseph Lieberman. Senator Lieberman, with Senator Christopher Dodd, is the sponsor of the Freedom from Restraint Act, one of three bills on the subject currently being considered by Congress. This bill, which would cover all facilities funded by Medicare and Medicaid, prohibits the use of restraints "except to ensure the physical safety of the individual or other individuals in the care or custody of the provider", and requires a written order by a physician when restraints are imposed. It also requires reporting of deaths and serious injuries to an oversight authority, along with corrective actions to reduce future risk.
Mr. McCulloch presented the bill in detail, and in the subsequent discussion he urged the Board not to simply criticize specifics of the bill, but to offer alternative language that would address our concerns. Following his visit the Board voted write to Senator Lieberman to suggest specific changes. Our most substantive concern was the limitation of restraint to ensuring the safety of the individual or other patients. The Board felt that it was critical that the use of restraints also be allowed to protect staff and others as well as patients, and we requested that "safety of the individual or other individuals in the care or custody of the provider" be changed to "safety of the individual or others." With that change, and other minor changes in language, the Board felt that Senator Lieberman's bill represented a positive step forward on this complex and highly charged issue, and that AACP as an organization should support it.
As a result of these discussions, the AACP Board has created a task force to explore the larger issues surrounding seclusion and restraint as applied in different settings and with different populations, including children, the elderly, and culturally diverse groups. We expect to interact with other interested organizations and groups, and to bring the perspective of community psychiatrists to the discussion. The task force, which is part of the Clinical Committee, is open to all AACP members. Members who are interested in participating can contact the task force Chair, David Giles (dmgiles@commhospindy.org).
David Moltz, MD
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