Content uploaded by Hung-Mo Lin
Author content
All content in this area was uploaded by Hung-Mo Lin on Dec 01, 2015
Content may be subject to copyright.
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9
11111155
T
he use of seclusion and re-
straint in psychiatric hospitals
to control people with dis-
turbed or violent behaviors has been
occurring for centuries. The litera-
ture is replete with examples of how
clinicians have struggled with the eth-
ical issues involved with the use of
these interventions (1–4). The litera-
ture has also provided the rationale
for the continued use of physical con-
trols in modern psychiatric settings,
much like it did in the past for asy-
lums (4–6). More recent research has
questioned the need to use these
practices and pointed to studies
showing inconsistency in the applica-
tion of seclusion and restraint (6,7).
An international review of these pro-
cedures found the same inconsisten-
cies in the use of seclusion and re-
straint with psychiatric patients and
the same struggles with the ethics of
these practices (8). Seclusion and re-
straint has prevailed internationally as
the primary approach to managing vi-
olent behaviors, although the degree
of use depends on the country or ge-
ographical location (9–12).
Since 1990 the Pennsylvania state
hospital system has experienced con-
stant changes that have resulted in re-
markable outcomes in reducing the
use of seclusion and restraint. The
Pennsylvania state hospital system,
one of the oldest in the country,
serves adults within a civil and foren-
Pennsylvania State Hospital
System’s Seclusion and
Restraint Reduction Program
GGrreeggoorryy MM.. SSmmiitthh,, MM..SS..
RRoobbeerrtt HH.. DDaavviiss,, MM..DD..
EEddwwaarrdd OO.. BBiixxlleerr,, PPhh..DD..
HHuunngg--MMoo LLiinn,, PPhh..DD..
AAiiddaann AAlltteenno
orr,, PPhh..DD..
RRoobbeerrttaa JJ.. AAlltteennoorr,, MM..SS..NN..
BBoonnnniiee DD.. HHaarrddeennttssttiinnee,, BB..SS..
GGeeoorrggee AA.. KKooppcchhiicckk,, MM..SS..
Mr. Smith, Dr. Davis, Dr. Altenor, Ms. Altenor, Ms. Hardentstine, and Mr. Kopchick are
affiliated with the Office of Mental Health and Substance Abuse Services of the Com-
monwealth of Pennsylvania in Harrisburg. Dr. Bixler and Dr. Lin are with the Pennsyl-
vania State University School of Medicine in Hershey. Send correspondence to Mr. Smith
at Allentown State Hospital, 1600 Hanover Avenue, Allentown, Pennsylvania 18109-2498
(e-mail, grsmith@state.pa.us). This article is part of a special section on the use of seclu-
sion and restraint in psychiatric treatment settings.
Objectives: This study examined the use of seclusion and mechanical re-
straint from 1990 to 2000 and the rate of staff injuries from patient as-
saults from 1998 to 2000 in a state hospital system. Methods: Records of
patients older than 18 years who were civilly committed to one of the nine
state hospitals in Pennsylvania were included in the analyses. Two data-
bases were used in each of the nine hospitals: one identified date, time,
duration, and justification for each episode of seclusion or restraint and
the other identified when a patient was hospitalized and the demograph-
ic characteristics and the diagnosis of the patient. Rate and duration of
seclusion and restraint were calculated. Reports from compensation
claims were used to determine staff injuries from patient assaults. Results:
The rate and duration of seclusion and mechanical restraint decreased
dramatically during this period. From 1990 to 2000, the rate of seclusion
decreased from 4.2 to .3 episodes per 1,000 patient-days. The average
duration of seclusion decreased from 10.8 to 1.3 hours. The rate of re-
straint decreased from 3.5 to 1.2 episodes per 1,000 patient-days. The av-
erage duration of restraint decreased from 11.9 to 1.9 hours. Patients
from racial or ethnic minority groups had a higher rate and longer dura-
tion of seclusion than whites. Seclusion tended to be less likely, but
longer, during the night shift. Patients were restrained less often during
the night shift, but for a longer duration. The rate of restraint was high-
er during the week than during weekends and holidays. Younger patients
were more likely to be secluded and restrained, but older patients re-
mained secluded and restrained longer. No significant changes were seen
in rates of staff injuries from 1998 to 2000. Conclusions: Many factors
contributed to the success of this effort, including advocacy efforts, state
policy change, improved patient-staff ratios, response teams, and second-
generation antipsychotics. (Psychiatric Services 56:1115–1122, 2005)
SSppeecciiaall SSeeccttiioonn oonn SSeecclluussiioonn aanndd RReessttrraaiinntt
smi.qxd 8/22/2005 9:42 AM Page 1115
sic inpatient setting who have severe
and persistent mental illnesses. Dur-
ing most of its history the hospital sys-
tem provided direct admission servic-
es. However, during the study period,
the admission of civilly committed pa-
tients was limited to referrals from lo-
cal psychiatric acute care settings for
individuals who were unable to be
stabilized within a 30-day acute care
stay.
The purpose of this study was to
systematically report changes in pat-
terns of seclusion and mechanical re-
straint over an 11-year period (1990
to 2000) that took place within Penn-
sylvania’s nine state hospitals. Be-
cause so many changes were imple-
mented during this period it was not
possible to isolate and analyze the ef-
fects of a single variable. Changes
that influenced the reduction of
seclusion and restraint are discussed.
Methods
The data used for this study were tak-
en from two sources maintained by
each of the nine hospitals. The first
database identified date, time of day,
duration, and justification for each
event of seclusion or restraint. The
second database identified when a
patient was present in the hospital
and supplied basic demographic and
diagnostic information. All data were
merged and reformatted by using an
anonymous patient identifier for
analysis. Only adults 18 years and old-
er who were served on civil units of
the hospitals were included in this
study. In addition, only the use of
seclusion and mechanical restraint
was evaluated.
An individual annual rate was cal-
culated as the total number of events
divided by the total number of days
in the hospital that year multiplied
by 1,000 (referred to as rate per 1000
patient-days). If a patient was not re-
strained during that year’s stay in the
hospital, they were assigned a rate of
zero. For the year-specific average
rate, the individual rates were aver-
aged across all patients in the hospi-
tal that year. Duration was defined as
hours per event. An individual annu-
al duration was calculated if the pa-
tient had one or more events that
year. For the year-specific average
duration time, the individual means
were averaged across patients who
had at least one event during that
year.
The Jonckheere-Terpstra test (13)
was used to compare the ordinal dif-
ferences of the seclusion and restraint
rates over time or among different
classes. The generalized estimating
equations (GEE) method (14) was
employed to perform various hypoth-
esis tests, including testing whether
the overall duration or rate of one fac-
tor depends on the level of the other
factor. The GEE method is a useful
extension of the generalized linear
models for continuous and categori-
cal data that does not require the ex-
act knowledge of variance-covariance
structure of the repeated outcomes.
The GEE is favored over multivariate
analysis of variance (MANOVA) be-
cause our study consists of double re-
peated measurements from hospitals
and patients nested under hospitals
over the 11-year period. Estimation
of the covariance structure using
MANOVA proves to be problematic
sometimes.
For the purpose of analysis, the
sample was divided into four age
groups: 25 years and younger, 26 to
40 years, 41 to 65 years, and 66 years
and older. Race and ethnicity were
considered in terms of whites and all
racial and ethnic minority groups.
The events were categorized in terms
of hospital work shift (day shift, 7 a.m.
to 3 p.m.; evening shift, 3 p.m. to 11
p.m.; and night shift, 11 p.m. to 7
a.m.) and by weekday compared with
weekend or holiday. The Jonckheere
Terpstra test was used to evaluate
data derived from the annual census
data from the hospital system. All
other analyses were evaluated by us-
ing the GEE method (14).
Data on staff injuries from patient
assaults were available only for 1998
to 2000. We examined the number of
events in which employees lost time
from work as a result of injuries from
assaults and events in which first aid
only was needed as a result of an as-
sault. Each hospital’s compensation
claims were used for this analysis.
The counts were not duplicated with-
in these measures. To determine the
rate of change each year, these events
were calculated per 1,000 patient-
days of care.
Results
The annual census for the hospital
system during this 11-year period de-
creased 56 percent, from about 6,300
to about 2,800. During this time the
gender ratio remained constant (53
percent men and 47 percent women),
and representation of racial or ethnic
minority groups increased slightly
(p=.03). This change was consistent
with changes in the size of the popu-
lation of racial or ethnic minority
groups in Pennsylvania.
As shown in Table 1, the rate of
seclusion decreased from a high of
7.2 episodes per 1,000 patient-days in
1991 to .3 episodes per 1,000 patient-
days in 2000. The average rate of
seclusion was similar for men and
women, and this rate significantly de-
creased during the study period
(p<.01). The rate of seclusion was
greater for persons in racial or ethnic
minority groups than for whites (4.3
episodes per 1,000 patient-days com-
pared with 2.5 episodes per 1,000 pa-
tient-days, p<.01). Over the study pe-
riod, the rate of seclusion decreased
to a greater degree among persons
from racial or ethnic minority groups
(p<.05). The rate of seclusion was in-
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9
11111166
Since 1990
the Pennsylvania
state hospital system
has experienced constant
changes that have resulted
in remarkable outcomes
in reducing the use
of seclusion and
restraint.
smi.qxd 8/22/2005 9:42 AM Page 1116
versely associated with age—that is,
the youngest group had the highest
rate (6.0 episodes per 1,000 patient-
days for the youngest age group com-
pared with .3 episodes per 1,000 pa-
tient-days for the oldest age group,
p<.01). The rate of seclusion was low-
est during the night shift (1.4, 1.5, and
.4 episodes per 1,000 patient-days, for
the day, evening, and night shifts, re-
spectively, p<.01) and higher during
the week than during weekends and
holidays (2.5 episodes per 1,000 pa-
tient-days compared with .6 episodes
per 1,000 patient-days, p<.01).
The average duration of seclusion
decreased from a high of 11.6 hours
in 1991 to 1.3 hours in 2000 (Table 1).
The duration of seclusion was longer
for men than for women (8.7 hours
compared with 7.4 hours, p<.01) and
was shorter for whites than for per-
sons from a racial or ethnic minority
group (7.6 hours compared with 9.8
hours, p<.01). Older patients were se-
cluded longer than younger patients
(8.7 hours for the oldest age group
compared with 5.0 hours for youngest
age group, p<.01). The duration for
seclusion tended to be longer during
the night shift (8.0, 8.4, and 10.7
hours, for the day, evening and night
shifts, respectively, p<.01) and short-
er during the week than during week-
ends or holidays (8.0 hours compared
with 9.5 hours, p<.01).
The rate of mechanical restraint
decreased from a high of 6.4 episodes
per 1,000 patient-days in 1991 to 1.2
episodes per 1,000 patient-days in
2000 (Table 1). The rate of restraint
was about the same for women and
men and for whites and persons from
a racial or ethnic minority group. The
rate of mechanical restraint was in-
versely associated with age. The
youngest group had the highest rate
(8.2 episodes per 1,000 patient-days
compared with 1.2 episodes per 1,000
patient-days for the oldest age group,
p<.01). The rate of mechanical re-
straint tended to be lowest during the
night shift (1.8, 1.5, and .5 episodes
per 1,000 patient-days, for the day,
evening, and night shifts, respectively,
p<.01). The rate was higher during
the week than during weekends and
holidays (2.7 episodes per 1,000 pa-
tient-days compared with .7 episodes
per 1,000 patient-days, p<.01).
The average duration of mechani-
cal restraint decreased from a high of
12.1 hours in 1992 to 1.9 hours in
2000 (Table 1). The duration of me-
chanical restraint remained similar
for women and men and for whites
and persons from a racial or ethnic
minority group. Older patients tend-
ed to be in mechanical restraint
longer than younger patients (11.4
hours for the oldest age group com-
pared with 5.0 hours for youngest age
group, p<.01). Patients tended to be
in mechanical restraint for longer pe-
riods during the night shift (8.0, 8.0,
and 15.4 hours for the day, evening,
and night shifts, respectively, p<.01).
The duration was about the same dur-
ing the week and during weekends or
holidays (8.5 hours during the week
compared with 8.9 hours during
weekends or holidays).
Data on staff injuries from patient
assaults were available only from
1998 to 2000. Even though major re-
ductions in the use of seclusion and
restraint had already occurred, it is
valuable to consider this measure, be-
cause it is common for health care
workers to be concerned about staff
injury when the use of these proce-
dures is reduced. The rate of staff in-
juries did not change during this peri-
od. In 1998 the overall rate of staff in-
juries involving lost work time from a
patient assault was .1 episodes per
1,000 patient-days and in 2000 the
rate was .13 episodes per 1,000 pa-
tient-days. The overall rate of staff in-
juries from assault involving first aid
only was .21 episodes per 1,000 pa-
tient-days in 1998 and .23 episodes
per 1,000 patient-days in 2000.
Changes that influenced reduction
in seclusion and restraint
Leadership. The nonrestraint move-
ment within the Pennsylvania state
hospital system predates the period
covered by this study. Most of the dra-
matic reductions occurred from 1993
to 1997 and are credited to direct care
staff at local hospitals (aides, nurses,
doctors, and program staff) and com-
munity advocates (for example, par-
ents and representatives of the Na-
tional Alliance for the Mentally Ill and
Pennsylvania Protection and Advoca-
cy, Inc.). When these groups applied
their values through individual and
group leadership, they were success-
ful in changing the culture of restraint
that existed within the hospital system
in the early 1990s. Staff arguments at
the unit level for and against the use of
restraint, sometimes during the crisis
itself, were common. It was common
for advocates to complain to hospital
and state officials about the unneces-
sary use of restraint or seclusion. Staff
and advocates worked with the system
internally and externally to change the
culture of restraint in hospitals.
During the study period, five dif-
ferent individuals served as the
deputy secretary for the State Office
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9
11111177
TTaabbllee 11
Prevalence and duration of seclusion and mechanical restraint among adults who
were civilly committed to state hospitals in Pennsylvania
Seclusion Mechanical restraint
Duration Duration
(hours) (hours)
Rate per 1,000 Rate per 1,000
Year patient days Mean SD patient days Mean SD
1990 4.23 10.83 16.24 3.51 11.92 55.97
1991 7.20 11.64 16.00 6.41 9.76 30.37
1992 3.55 10.14 19.03 3.82 12.12 39.04
1993 3.61 9.91 21.44 4.70 8.98 18.33
1994 3.26 8.27 14.30 3.99 8.91 16.50
1995 2.52 5.79 9.93 3.61 5.09 5.59
1996 2.24 3.75 3.55 2.65 3.83 4.31
1997 1.73 2.68 2.05 2.01 3.19 5.14
1998 1.47 2.14 1.51 2.96 3.98 15.81
1999 .64 1.35 .82 1.57 1.97 2.76
2000 .28 1.31 .93 1.20 1.93 3.00
smi.qxd 8/22/2005 9:42 AM Page 1117
of Mental Health and Substance
Abuse Services (OMHSAS), and
three different individuals served as
chief psychiatrist for OMHSAS. All of
them played a role in reducing seclu-
sion and restraint. However, it was
Charles Curie, OMHSAS deputy sec-
retary from 1996 to 2001, who chal-
lenged the status quo by establishing
new standards that further limited
the use of these restrictive proce-
dures. In 1997 he announced that the
use of seclusion and restraint repre-
sented “treatment failure” and chal-
lenged the system to eliminate their
use and find more positive ways of
supporting a person in crisis. Accord-
ing to Curie, consumers and their
families, as well as the Pennsylvania
advocacy community, provided sup-
port for this important change. He
added that the use of restraint and
seclusion conflicted with the recovery
approach (15) that was being imple-
mented statewide (personal commu-
nication, Curie C, 2003).
The importance of this announce-
ment cannot be overstated. At the
time, the debate over the nonre-
straint approach was growing. Some
clinicians argued that it was a psychi-
atric decision if and when to use
seclusion or mechanical restraint.
They felt that seclusion and restraint
were important tools that were re-
quired to manage a crisis and that
without them the hospital environ-
ment would become more violent
and unsafe. Curie’s “treatment fail-
ure” announcement did not ban the
use of seclusion or restraint. Howev-
er, the announcement served as a
challenge to the system to find more
positive ways of supporting a person
in crisis. The announcement put to
rest arguments occurring at the hos-
pital level between clinicians and ad-
ministrators on the restraint issue and
established direction for further sys-
temwide changes.
Curie attributed the continued de-
crease in the use of seclusion and re-
straint to improved data collection
and greater transparency in the way
information is shared and used to
compare restraint rates between the
hospitals. He also credited statewide
performance improvement projects
that focused on ways to reduce the
use of these restrictive procedures.
This effort led to greater emphasis on
staff training in the areas of crisis
management and nonoffensive skill
development that reinforced verbal
deescalation techniques.
Finally, during the study period
there were several facility closures
across the state. These closures in-
creased the number of new staff who
entered the hospital system. These
closures affected every hospital and
typically involved staff from the state
mental retardation centers who chal-
lenged the long-standing treatment
concepts of the hospital system. This
group of workers, using behavioral
support principles, helped decrease
dependence on the use of restrictive
procedures. Their contributions to
this change, at all levels of the hospi-
tal system, were invaluable.
Advocacy efforts. Organized advo-
cacy efforts to reduce the use of
seclusion and restraint in the state
hospital system started long before
the study period. Often led by parents
and former patients who represented
local and state chapters of the Nation-
al Alliance for the Mentally Ill, the
Pennsylvania Mental Health Con-
sumers Association, Pennsylvania
Protection and Advocacy, Inc., and
others, these efforts were instrumen-
tal in challenging the system’s de-
pendence on these restrictive proce-
dures (personal communication
Banks J, Madigan P, 2003).
These groups were particularly ac-
tive in the southeast region of the
commonwealth, where they regularly
engaged the leadership of Allentown,
Haverford, Norristown, and Philadel-
phia state hospitals with complaints
involving the misuse and overuse of
seclusion and restraint (personal
communication, Rehrman M, 2003).
Additionally, by 1995 state govern-
ment had independent advocates as-
signed to each hospital. These facili-
ty-level advocates provided a needed
layer of protection for the patient on
a day-to-day basis (personal commu-
nication, Zuber B, 2003).
At the state level there were con-
stant questions by these groups about
the hospital system’s use of seclusion
and restraint. Demands were made
for regular reports on the use of these
procedures that led to improved data
collection. They also pushed for more
effective staff training that would
make the use of seclusion or restraint
an intervention of last resort.
Although these groups never joined
together to pressure the state govern-
ment to decrease the use of these
procedures, they were effective at ad-
dressing individual patient issues and
challenging the leadership of OMH-
SAS to monitor and reduce the use of
seclusion and restraint. Deputy Sec-
retary Curie’s announcement in 1997
that the use of seclusion and restraint
constituted treatment failure was a
credit to their individual efforts.
State policy change. State policy on
the use of restrictive procedures in
the state hospitals changed three
times during the study period. After
Curie’s “treatment failure” announce-
ment the policy was revised to further
limit the circumstances in which re-
strictive procedures could be used.
This change defined physical re-
straint, mechanical restraint, protec-
tive restraint, and seclusion as ex-
treme measures and limited their use
to emergency situations. It also de-
fined chemical restraint as the use of
medication for the specific purpose of
controlling aggressive behavior,
which restricts a person’s freedom of
movement by rendering him or her in
a semistupor or unable to attend to
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9
11111188
By 1995 the
state government had
independent advocates
assigned to each hospital,
who provided a needed
layer of protection
for patients on a
day-to-day
basis.
smi.qxd 8/22/2005 9:42 AM Page 1118
personal needs, and the policy pro-
hibited its use.
The policy also established guide-
lines for annual staff training sessions.
The policy change included proce-
dures for patient and staff debriefing
sessions after the use of restraint or
seclusion. It also required, with con-
sent, the notification of a person’s
family after the use of a restrictive
procedure. New physician protocols
were also part of this change, which
limited orders for restraint and seclu-
sion to no more than 60 minutes and
required that the person be seen
within 30 minutes of a phone order.
Each hospital’s performance im-
provement programs were required
to monitor the ongoing use of these
procedures (16). Finally, the policy
change limited to eight the number of
approved restraint devices that could
be used: one-, two-, three-, and four-
point soft Velcro restraint devices;
soft mitts; and two-, three-, and four-
point leather restraint devices.
Psychiatric emergency response
teams (PERTs). The concept of pre-
senting a large show of staff support
at the scene of a psychiatric crisis to
ensure safety has been around for
more than 200 years. In 1794
Philippe Pinel, a French psychiatrist,
was one of earliest to write about the
effectiveness of teamwork as a proce-
dure in managing a psychiatric emer-
gency (1,4).
PERTs bring together a large group
of workers at the scene of the crisis in
a short period. The goal of PERTs is
to manage a crisis by using conflict
resolution, mediation, therapeutic
communication, and violence-pre-
vention skills to diffuse and safely re-
solve a crisis.
This approach was first implement-
ed by Allentown State Hospital in
1993 during its peak year of seclusion
and restraint use. PERTs are credited
for eliminating the use of seclusion
and dramatically decreasing the use
of restraint in Allentown. This
method evolved out of a similar pro-
gram that was used at the Depart-
ment of Veterans Affairs Medical
Center in Coatesville, Pennsylvania,
but includes many enhancements.
PERTs involve a core group of
about 40 volunteer nursing and pro-
gram services staff who work during
the day and evening shifts. Teams of
seven, led by a captain, serve on-call
PERT duty about twice a week. If in-
sufficient volunteers are available,
nursing staff are assigned to the team
on a rotating basis.
When a crisis occurs the staff
member at the scene announces a
“code orange” and the location of the
emergency over the pager system.
When PERT members receive the
page, they stop what they are doing
and report to the area. As team mem-
bers arrive they are met by the PERT
captain, who determines which ap-
proach to take with the person in cri-
sis on the basis of personal observa-
tion and treatment team input. Un-
less the person presents an immedi-
ate danger to self or others, the initial
PERT response focuses on clearing
the area. Next, the PERT members,
under the direction of the captain, at-
tempt to engage the person in a ther-
apeutic conversation directed at
identifying the underlying reasons
for the crisis. The focus of this meet-
ing is to help the individual under-
stand what needs to occur for him or
her to regain control (17). Once the
crisis has been resolved, a debriefing
session is held with staff to critique
the response and review the out-
come. A separate debriefing session
is conducted with the patient when
he or she is calm. The Allentown
model also involves a PERT assist
process that is used in anticipation of
a possible crisis with people who
have a history of aggression.
Data on the effectiveness of PERT
in Allentown were available from
1998 to 2000. During this time PERT
has successfully managed 70 percent
of its crises without resorting to the
use of a restrictive procedure.
During the study period, all hospi-
tals were required to upgrade the
quality and quantity of their training
on crisis management and verbal
deescalation techniques, making it an
annual requirement for all clinical,
nursing, and program staff (16).
Unit size and patient-to-staff ratios.
The average number of people served
on a typical hospital unit during the
study period decreased from more
than 36 in 1990 to 32 or less in 2000.
In 1990 the typical hospital unit for
36 civilly committed individuals was
staffed with one licensed nurse and
three psychiatric aides during the day
and evening shifts. During 2000, the
average staffing for a 32-bed unit in-
creased to two licensed nurses and
four psychiatric aides during the day
and evening shifts.
The smaller units were made pos-
sible through the state-funded Com-
munity Hospital Integration Project
Program (CHIPP) that supports the
discharge of people with two or
more years of inpatient hospital care.
During the study period, more than
1,600 people were discharged
through this program. CHIPP is
credited with expanding the capacity
of local communities to support peo-
ple with severe mental illnesses
while decreasing dependence on
state hospital services (18).
Pennsylvania’s experience since
1990 reinforces the belief that having
fewer patients on a unit allows more
sensitive care and a safer, restraint-
free hospital.
Incident management system. Be-
fore 1998 the state hospital system
used a basic network database that
recorded the application of any re-
strictive procedures used for a patient
in the hospital system. The reporting
and tracking system required a cause
for each use of a restrictive procedure
(19). Most of the aggregate data used
in this study were taken from this sys-
tem. However, the complexities of
this database made it difficult for hos-
pitals to use. These difficulties meant
that staff at the unit level saw little of
the comparative information or the
history of individual patients that this
system contained.
In July 1998 a new application was
implemented statewide that increased
the number of performance indicators
on which the hospitals would report.
The application was designed to en-
able staff at the unit level to request
reports on any of the 35 performance
indicators. Enhanced at least twice
since its original design, the system
now enables measurement of physical
hands-on restraint to the second and
mechanical restraint use by type of de-
vice type. It also tracks the psychiatric
use of PRN (as needed) and STAT
(immediate) medications adminis-
tered as a result of a reportable inci-
dent. These data are summarized each
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9
11111199
smi.qxd 8/22/2005 9:42 AM Page 1119
month and shared with the hospital
system and external advocates. The re-
port provides comparative tables, by
type of care, on the use of restrictive
measures. This application also pro-
vides the state hospital system’s nation-
al benchmarking data (20).
Second-generation antipsychotics.
Another significant change that oc-
curred during this period was the in-
troduction of second-generation an-
tipsychotics. A central state formula-
ry for all hospitals was developed in
1993 in conjunction with the cre-
ation of a joint pharmacy, therapeu-
tics, and formulary committee. To
this day the committee maintains the
formulary and develops drug usage
policies and procedures (21). All sec-
ond-generation antipsychotics were
added to the formulary as soon as
they were released. Additionally,
there were no restrictions on their
use. As of December 31, 2000,
among people who had been given a
diagnosis of schizophrenia in the
state hospitals, 85 percent were giv-
en a prescription for second-genera-
tion antipsychotics.
The impact of second-generation
antipsychotics on the use of seclusion
and restraint in the state hospital sys-
tem cannot be isolated from the other
changes that occurred during this pe-
riod (22). Second-generation antipsy-
chotics have been shown to reduce ag-
gression and hostility as well as seclu-
sion and restraint (23–25). Studies
from Mayview State Hospital in Penn-
sylvania suggest that clozapine and
risperidone reduced the use of these
procedures (26,27). However, the au-
thors of these studies acknowledged
that among the weaknesses of their re-
search was the failure to control for
the many other changes that occurred
during this period.
Increase in the quantity and quali-
ty of treatment. Another significant
change in the hospital culture during
the study period was an increase in
the quantity and quality of active pa-
tient treatment. This change was im-
plemented in 1995 and involved
greater emphasis on functional pro-
gramming—such as vocational servic-
es, paid work, money management
skills, and training in the self-admin-
istration of medication—that would
be needed to prepare a person for
discharge. The increase in the quanti-
ty and quality of therapies was made
possible by the reduced unit size and
improved patient-to-staff ratios.
By 1997 there was a shift from the
practice of providing therapy for the
“cooperative few” to providing thera-
py for all patients by using small and
large group approaches to program-
ming. Program centers were estab-
lished to move therapy away from the
unit whenever possible. Much of this
change was driven by the need to pro-
vide patients with more functional
programs and activities that rein-
forced the skills that they would need
for their recovery (personal commu-
nication, Storm R, 2003).
The impact of this change on re-
ducing the hospital’s use of seclusion
and restraint has been difficult to
measure. However, anecdotal evi-
dence reinforces the belief that “the
more you do with your patients, the
less you have to do to them” (person-
al communication, O’Dea RM, 1995).
Discussion
The Pennsylvania movement toward
a nonrestraint approach to the care
and treatment of people with severe
mental illnesses predates the period
covered by this study. The dramatic
decreases in the use of these restric-
tive procedures by state hospital sys-
tems were the result of many
changes. It did not occur through
litigation or a sentinel event. Nor
did it happen at the same rate for
each hospital. The nine hospitals
used similar approaches, although
they applied them in different ways
and at different times. Rates of staff
injury from patient assaults from
1998 to 2000 suggest that the transi-
tion from a restraint culture did not
put staff at greater risk of assault.
Because this is one of the larger
studies on restrictive procedure use in
a large hospital system, our findings
were generally consistent with the
data published thus far. Differences in
the use of these restrictive measures
between the three shifts (day and
evening shifts compared with night
shift) may be attributed to reduced
levels of stimuli that would cause agi-
tation and trigger aggression. Anecdo-
tal evidence suggests that as patients
became engaged in more purposeful
activity during the day and evening
hours, sleep patterns improved and
there were fewer nocturnal behaviors.
The same can be said of the variances
between the use of these procedures
during the week compared with week-
ends and holidays.
Our study did not show any racial,
ethnic, or gender differences in the
use of mechanical restraint through-
out this study period. The rate of
seclusion during the early years of
this review was higher for racial or
ethnic groups than for whites. How-
ever, as the rate of seclusion declined,
the use of seclusion among racial and
ethnic groups reduced at a faster rate.
This difference and change may be
attributed to increased attention to
the data and more sensitivity by staff
toward the overall use of seclusion.
Personal leadership by direct care
staff who applied their nonrestraint
values helped to change the culture of
restraint within the system. The
Pennsylvania advocacy community
challenged the hospital system at the
highest levels of state government to
reduce the use of seclusion and re-
straint. Increased monitoring by staff
and advocates in the day-to-day use of
restrictive procedures, PERTs, policy
changes, increased quantity and qual-
ity of patient programming, reduced
unit size, and improved patient-to-
staff ratios coupled with effective
leadership at all levels of the hospital
accounted for this transformation.
OMHSAS Deputy Secretary Curie’s
1997 announcement that the use of
seclusion and restraint constituted
treatment failure was pivotal, because
this announcement, when coupled
with the resulting policy change, end-
ed all debate within the hospital sys-
tem about the nonrestraint approach.
Curie stated, with hindsight, that if he
had it to do all over again, he would
have started sooner, pressed harder for
this important change, and given
greater credit to the direct care staff
for the tremendous job that they did.
A challenge to Pennsylvania’s
seclusion and restraint reduction
program is the perceived difference
between the type of patients served
in a state hospital system and those
in other psychiatric acute care set-
tings. Differences such as a lack of
familiarity with patients who have
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9
11112200
smi.qxd 8/22/2005 9:42 AM Page 1120
shorter lengths of stays and the fre-
quency at which a patient is in crisis
somehow justifies, for some staff,
greater dependence on the use of a
restrictive procedure. Although this
issue deserves further review,
PERTs and similar response team
programs that are designed to man-
age psychiatric crises in a nonoffen-
sive manner have proven their effec-
tiveness, regardless of a patient’s
length of stay. We recognize the
need to work with other psychiatric
acute care settings to obtain data and
further study these differences.
Other issues that hospitals need to
consider and measure are the effects
that these changes will have on pa-
tient-to-patient and patient-to-staff
assaults. Khadavi and colleagues (28)
found an increase in “other-directed
patient violence” during a 12-month
study of three acute inpatient psychi-
atric units when seclusion and re-
straint were reduced. However, the
authors acknowledge that their find-
ings are at variance with previous re-
ports. Owen and colleagues (29)
found that the use of seclusion led to
a significant number of violent inci-
dents. Some warning sign preceded
three-quarters of the serious violent
incidents that they studied. They also
found that the relationship between
staffing level and violence was not
clear. More female staff, more staff
without psychiatric training or aggres-
sion management training, and more
staff absenteeism had a positive rela-
tionship with violence, whereas
younger staff and staff with high lev-
els of psychiatric experience had a
negative relationship with violence.
A study done in Norway found that
most staff believed that using restraint
or seclusion made patients calmer and
did not cause aggression or anxiety.
However, 70 percent of these same
workers reported having been assault-
ed by patients in places where these
interventions were used (30). Deesca-
lation strategies are an essential part
of minimizing the use of seclusion and
restraint while preventing and manag-
ing aggressive behavior (31). Although
one study suggested that fewer on-
duty staff resulted in decreased use of
seclusion (32), many studies have
shown that increased staff-to-patient
ratios with staff trained in recognizing
the early signs of aggression and man-
aging aggression result in reduced use
of seclusion and restraint and a more
therapeutic milieu (33–42).
It will also be important to measure
and monitor the effect that these
changes have on the use of STAT and
PRN medications during emergen-
cies. Additionally, seclusion and re-
straint may place a demand for more
one-to-one patient-staff assignments.
Conclusions
In 2000 the Ford Foundation, in con-
junction with Harvard University’s
John F. Kennedy School of Govern-
ment, recognized the Pennsylvania
state hospital system for its seclusion
and restraint reduction program with
the Innovations in American Govern-
ment Award. Many factors con-
tributed to the success of this effort,
including improved patient-staff ra-
tios and response teams. However,
the nonrestraint values of hospital
staff and community advocates with
the administrative recognition that
seclusion and restraint are not treat-
ment modalities but treatment fail-
ures were the major reasons for the
changes in attitude, culture, and envi-
ronment within Pennsylvania’s state
hospital system.
Since the end of this study period
the Pennsylvania state hospital sys-
tem, civil and forensic, has continued
to decrease its dependence on the use
of these restrictive procedure. Cur-
rently, five of the nine hospitals have
eliminated the use of seclusion.
Danville State Hospital has gone
more than two years without using
mechanical restraint or seclusion.
Since January 2005 the hospital sys-
tem, which averages more than
60,000 days of care each month, has
used seclusion only 19 times for a to-
tal of 18 hours. Mechanical restraint
has been used 143 times for a total of
160 hours. This past spring the hospi-
tal system established a goal eliminat-
ing the use of mechanical restraint
and seclusion by January 1, 2006. ♦
Acknowledgments
This research project was funded, in
part, by an award from the Ford Foun-
dation in conjunction with Harvard Uni-
versity’s John F. Kennedy School of Gov-
ernment and the Council for Excellence
in Government through an Innovations
in American Government Award. The
authors thank Mary Ellen Rehrman,
B.S., Charles Curie, M.S.W., Feather O.
Houstoun, M.B.A., Joan L. Erney, J.D.,
and Estelle B. Richman, M.S., for their
support of this transformational initia-
tive. Finally, the authors gratefully ac-
knowledge the work of Richard M.
O’Dea, M.S., R.N.
References
1. Weiner DB: Phillippe Pinel’s “Memoir of
Madness” of December 11, 1794: a funda-
mental text of modern psychiatry. Ameri-
can Journal of Psychiatry 149:725–732,
1992
2. Soloff PH, Gutheil TG, Wexler DB: Seclu-
sion and restraint in 1985: a review and up-
date. Hospital and Community Psychiatry
36:652–657, 1985
3. Gutheil T: Observations on the therapeutic
bases for seclusion of the psychiatric inpa-
tient. American Journal of Psychiatry
135:325–328, 1978
4. Tomes N: The Art of Asylum-Keeping:
Thomas Story Kirkbride and the Origins of
American Psychiatry. Philadelphia, Penn,
University of Pennsylvania Press, 1994
5. American Psychiatric Association Task
Force Report 22: Seclusion and Restraint:
The Psychiatric Uses. Washington, DC,
American Psychiatric Association, 1985
6. Fisher WA: Seclusion and restraint: a re-
view of the literature. American Journal of
Psychiatry, 151:1584–1591, 1994
7. Busch AB, Shore MF: Seclusion and re-
straint: a review of recent literature. Har-
vard Review of Psychiatry 8:261–269, 2000
8. Mason T: Seclusion: an international com-
parison. Medicine, Science, and the Law
34(10):54–60, 1994
9. Wynn R: Medicate, restrain, or seclude?
Strategies for dealing with violent and
threatening behavior in a Norwegian Uni-
versity Hospital. Scandinavian Journal of
Caring Sciences 16:287–292, 2002
10. Cannon ME, Sprivulis P, McCarthy J: Re-
straint practices in Australasian emergency
departments. Australian and New Zealand
Journal of Psychiatry 35:464–467, 2001
11. Needham I, Abderhalden C, Dassen T, et
al: Coercive procedures and facilities in
Swiss psychiatry. Swiss Medical Weekly
132:253–258, 2002
12. Dabrowski S, Frydman L, Zakowsha-
Dabrowski T: Physical restraints in Polish
psychiatric facilities. International Journal
of Law and Psychiatry 8:369–382, 1986
13. Stokes ME, Davis CS, and Koch GG: Cate-
gorical Data Analysis Using the SAS Sys-
tem, 2nd ed. SAS Institute, Cary, NC, 2000.
14. Heagerty P, Liang K-Y, Zeger S, et al:
Analysis of Longitudinal Data, 2nd ed. Ox-
ford University Press, New York, 2002
15. Anthony WA: A recovery-oriented service
system: setting some system level stan-
dards. Psychiatric Rehabilitation Journal
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9
11112211
smi.qxd 8/22/2005 9:42 AM Page 1121
24:159–168, 2000
16. Pennsylvania Mental Health and Substance
Abuse Bulletin on the Use of Restraints.
Seclusion and Exclusion in State Mental
Hospitals and Restoration Center, Jul 1,
2001. Harrisburg State Hospital, Harris-
burg, Penn, 2001
17. Allentown State Hospital Policy Memoran-
dum A-124, Psychiatric Emergency Re-
sponse Plan, Allentown State Hospital, Al-
lentown, Penn, 2002
18. Pennsylvania Community Hospital Integra-
tion Projects Program. Harrisburg State
Hospital, Harrisburg, Penn, 1999
19. Slawich S, Leitzel L, Martin R: Manual for
the Exclusion, Restraint, Protection, and
Seclusion Reporting and Tracking System,
Office of Mental Health, Allentown State
Hospital, Allentown, Penn, 1995
20. Pennsylvania Mental Health and Substance
Abuse Services Bulletin: Management of
Incidents: SI-815 Incident Reporting and
Risk Management Policy and Procedural
Changes, SMH-03. Allentown State Hospi-
tal, Allentown, Penn, Jun 1, 2003
21. Fiorello S: Developing and implementing a
statewide formulary system: one state’s ex-
perience. Formulary 30:808–811, 1995
22. Spivak B, Shabash E, Sheitman B, et al:
The effects of clozapine versus haloperidol
on measures of impulsive aggression and
suicidality in chronic schizophrenia pa-
tients: an open, nonrandomized, 6-month
study. Journal of Clinical Psychiatry
64:755–760, 2003
23. Citrome L, Volavaka J, Czobar P, et al: Ef-
fects of clozapine, olanzapine, risperidone,
and haloperidol on hostility among patients
with schizophrenia. Psychiatric Services
52:1510–1514, 1995
24. Chiles JA, Davidson P, McBride D: Effects
of clozapine on use of seclusion and re-
straint at a state hospital. Hospital and
Community Psychiatry 45:269–271, 1994
25. Mallya AR, Roos PD, Roebuck-Colgan K:
Restraint, seclusion, and clozapine. Journal
of Clinical Psychiatry 53:395–397, 1992
26. Chengappa KNR, Levine J, Ulrich R, et al:
Impact of risperidone on seclusion and re-
straint at a state psychiatric hospital. Cana-
dian Journal of Psychiatry 45:827–832,
2000
27. Chengappa KNR, Vasile J, Levine J, et al:
Clozapine: its impact on aggressive behav-
ior among patients in a state psychiatric
hospital. Schizophrenia Research 53:1–6,
2002
28. Khadivi A, Patel R, Atkinson A, et al: Asso-
ciation between seclusion and restraint and
patient-related violence. Psychiatric Ser-
vices: 55:1311–1312, 2004
29. Owen C, Tarantello C, Jones M, et al: Vio-
lence and aggression in psychiatric units.
Psychiatric Services 49:1452–1457, 1998
30. Wynn R: Staff’s attitudes to the use of re-
straint and seclusion in a Norwegian uni-
versity psychiatric hospital. Nordic Journal
of Psychiatry 57:453–459, 2003
31. Policy statement on the management of ag-
gressive behavior in psychiatric institutions
with special reference to seclusion and re-
straint. Washington, DC, American Acade-
my of Child and Adolescent Psychiatry
Council, Oct 24, 2000
32. Morrison EF: Violent psychiatric inpatients
in a public hospital. Scholarly Inquiry for
Nursing Practice: An International Journal
4:65–82, 1990
33. Position Paper on Seclusion and Restraint.
Alexandria, Va, National Association of
State Mental Health Program Directors,
Jul 1999
34. Schwartz T, Park T: Assaults by patients on
psychiatric residents: a survey and training
recommendations. Psychiatric Services
50:382–383, 1999
35. Kostecka M, Zardecka M: The use of phys-
ical restraints in Polish psychiatric hospitals
in 1989 and 1996. Psychiatric Services
50:1637–1638, 1999
36. Leiberman R: CHARPP Seclusion and Re-
train Update. Corvallis, Oreg, Child and
Adolescent Residential Psychiatric Pro-
grams, 2003
37. D’Orio B, Purselle D, Stevens S, et al: Re-
duction of episodes of seclusion and re-
straint in a psychiatric emergency service.
Psychiatric Services 55:581–583, 2004
38. Fisher WA: Elements of successful re-
straint and seclusion program and their ap-
plication in a large, urban, state psychiatric
hospital. Journal of Psychiatric Practice
9:7–15, 2003
39. Donovan A, Siegel L, Zera G, et al: Seclu-
sion and restraint reform: an initiative by a
child and adolescent psychiatric hospital.
Psychiatric Services 54:958–966, 2003
40. Donat D: An analysis of successful efforts
to reduce the use of seclusion and restraint
at a public psychiatric hospital. Psychiatric
Services 54:1119–1123, 2003
41. Jonikas J, Cook J, Rosen C, et al: A program
to reduce use of physical restraint in psy-
chiatric inpatient facilities. Psychiatric Ser-
vices 55: 818–820, 2004
42. SAMHSA action plan seclusion and re-
straint fiscal years 2004 and 2005. Washing-
ton, DC, Substance Abuse and Mental
Health Services Administration, Jun 2004
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9
11112222
CChhaannggee ooff EE--MMaaiill AAddddrreesssseess ffoorr AAuutthhoorrss aanndd RReevviieewweerrss
Authors of papers submitted to Psychiatric Services and peer reviewers for the
journal are reminded to visit Manuscript Central at http://appi.manuscriptcentral.
com and keep the contact information in their user account up to date. Because the
system relies on e-mail communication, it is especially important to keep e-mail ad-
dresses current. If you have questions about the information in your user account,
contact the editorial office at pscentral@psych.org.
smi.qxd 8/22/2005 9:42 AM Page 1122
