Myths and Assumptions about Seclusion and Confinement
in Disability Services
Jeffrey Chan, PhD
Chief Practitioner Disability and Director of Forensic Disability
Queensland Advocacy Inc. Seclusion and Solitary Confinement
27 July 2011, Banco Court, Brisbane
Myth and Assumption –
Restraint and seclusion keep people we serve safe
• 142 deaths found from 1988 to 1998, reported by the Hartford
Courant
• 50 to 150 deaths occur nationally each year due to seclusion
and restraints estimated by the Harvard Center for Risk
Analysis
(NAMI, 2003)
• At least 14 people died and at least one has become
permanently comatose while being subjected to S/R from July
1999 to March 2002 in one state alone
(Mildred, 2002)
What do people with disabilities feel when they were
subject to restrictive practices?
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They do not feel safe
They recount their trauma and negative experience
They feel violated and go through cycle of psychological distress
They feel practices are unethical
They feel helpless, hopeless and “spirit broken”
They view their behaviours are in response to an offending or
maladaptive environment
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Ramcharan et al. (2009)
Strout (2010)
Myth and Assumption –
Restraint and seclusion keep staff safe
• For every 100 mental health aides, 26 injuries were reported
in a three-state survey done in 1996
• The injury rate was higher than what was found among
workers in:
– Lumber
– Construction
– Mining industries (Weiss et al., 1998)
Myth and Assumption –
Restraint and seclusion are used when absolutely necessary,
not punitive and for safety reasons
• Andrew McClain was 11 years old and weighed 96
pounds when two aides at Elmcrest Psychiatric Hospital
sat on his back and crushed him to death.
• Andrew’s offense?
• Refusing to move to another breakfast table.
Myth and Assumption –
Restraint and seclusion are used when absolutely necessary,
not punitive and for safety reasons
• Edith Campos, 15, suffocated while being held face-down after
resisting an aide at the Desert Hills Center for Youth and
Families.
• Edith’s offense?
• Refusing to hand over an “unauthorized” personal item. The
item was a family photograph.
(Lieberman, Dodd, & De Lauro, 1999)
Myth and Assumption –
Restraint and seclusion are used when absolutely necessary,
not punitive and for safety reasons
• Ray, Myers, and Rappaport (1996) reviewed 1,040 surveys
received from individuals following their New York State
hospitalization
• Of the 560 who had been restrained or secluded:
– 73% stated that at the time they were not dangerous to
themselves or others
– ¾ of these individuals were told their behavior was
inappropriate (not dangerous)
Myth and Assumption –
Restraint and seclusion are used when absolutely necessary,
not punitive and for safety reasons
•
Analysis of six studies reported 58 – 75% conceptualized
seclusion as punishment by staff
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Many persons-served believed:
 Seclusion was used because they refused to take medication
or participate in treatment program
 Frequently, they did not know the reason for seclusion
Assumption:
Staff know how to identify potentially difficult situations
• Holzworth & Willis (1999) conducted research on nurses’
decisions based on clinical cues of patient agitation, selfharm, inclinations to assault others, and destruction of
property
• Nurses agreed only 22% of the time
• When data was analyzed for agreement due to chance
alone, agreement was reduced to 8%
• Nurses with the least clinical experience (less than 3 years)
made the most restrictive recommendations
(Holzworth & Willis, 1999)
Assumption:
Staff know how to de-escalate potentially difficult or
violent situations
•
In a study conducted by Petti et al. (2001) of content from 81
debriefings following the use of seclusion or restraint, staff
responses to what could have prevented the use of S/R included:
 36% blamed the patient
 Example: “He could have listened and
followed instructions”
 15% took responsibility
 Example:
“I wish I could have identified his
early escalation”
Assumption:
Staff know how to de-escalate potentially difficult or
violent situations
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Other responses included:
 15% provided no response
 12% were at a loss
 Example:
“I don’t see anything else…all
alternatives used.”
 11% blamed the system
 Example:
“Need to make a plan for shift
change”
 9% blamed the level of medication (Petti et al, 2001)
The dollars of restraint and seclusion:
Organisational cost
• Flood, Bowers & Parkin (2008) – study on conflict
and containment using an interview schedule with
key staff and event data from 136 wards and costs
from 15 wards.
– Cost of a single episode of physical restraint = $240.24 and
seclusion = $330.88
– 50% of all UK nursing resources were expended to manage
conflict and implement containment procedures
The dollars of restraint and seclusion:
Organisational cost
• US restraint use of an adolescent inpatient service
claimed (Lebel, 2011) –
– > 23% of staff time
– > $1.4M in staff related costs
– 40% of operating budget
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Medication – 26 - 11.07 hrs staff time - $287 per event
Physical – 25 – 11.57 hrs staff time - $302 per event
Mechanical – 25 – 11.90 hrs staff time - $309 per event
Combination – 29 – 13.40 hrs staff time - $355 per event
Grafton Inc., Virginia – Four year data reveal
• 41.2% reduction in client-related staff injuries
• 10% reduction in staff turn-over and estimates annual
savings of $500K
• 94% reduction in employee lost time and lost time expenses
• 50% reduction in workers’ compensation claims
• 21% reduction in liability premiums
• Cumulative savings in excess of $1.2M
• $483K cumulative workers compensation costs savings
• Increased staff satisfaction and staff perception of greater
safety
Other evidence
• John Hopkins Hospital – 75% reduction in restraints and
seclusion with no increase in staff or consumer injuries
• Florida State Hospital – 54% restraint reduction and
realised nearly $2.9M in cost savings from reduced workers
compensation, staff and consumer related injuries, and
length of stay costs
• Forster et al (1999) – staff training decreases use of
seclusion and restraint in an acute psychiatric hospital
resulted in 13.8% reduction in annual restraint rates, 54.6%
decrease in average duration of restraint per admission and
18.8% in reduction in staff injuries
Mindfulness – Singh et al
• Adult offenders with intellectual disability – Singh et al
(2008): Reduction in lost work hours to $2244 from $53K 12
months prior. (Note: further unpublished studies note
significant reduction in overall organisational cost
benefits), reduction in physical.
• Other studies by Singh et al showed reduction in restraints
and seclusion, increase in staff well-being, increase in staff
satisfaction and happiness, and safety. Improvement in
client well-being.
• See also studies on parents of children with autism.
Lebel & Golstein (2005) – restraint reduction strategy
• Benefits for the person –
– Decreased injuries, length of stay and readmissions
– Significantly increased functioning at discharge
• Benefits for staff and facilities –
– Decreased injuries, sick time, replacement staff
– Decreased staff turnover, hiring costs, workers compensation
(medical claims and compensation)
– Increase in cost savings and redeployed staff
Characteristics of success in safe elimination strategies
• Leadership with clear goals in policy direction and
implementation driven by compassion and human rights
• Systematic collection and analysis of the evidence (e.g.
episodes of incidents and restrictive interventions, OHS data,
support plans data, processes etc)
• Translating evidence into organisational practice and learning
– preventative environmental and support strategies,
communication strategy etc
• Quality support plans and monitoring of implementation
• Practice leadership in supporting and training staff
• Implementation of a range of protective supports (e.g.
debriefing, staff training and support, staff wellbeing/mindfulness etc)
Myths
Facts (Lebel, 2011)
• Need more $$
Flexible use of resources
• More staff or new staff
Core staff, OPEN to change
• Micromanage
Pragmatic teaching, mentoring
• State of the art environment
Flexible and creative use of space
• Control and limitation
Collaborate and negotiate
• No data or strict use of data
Data drives practice and meaningful
Andy Pond, LICSW
President & CEO of Justice Resource Institute
“Restraint and seclusion are costly in all kinds of ways –
they are just plain costly. Whatever new costs we had
were minimal.
Most of the training we put in place to reduce restraint
and seclusion were really good clinical practice
and what we should be doing anyway.”
Questions and discussion