Restraint and seclusion in psychiatric treatment settings: regulation, case law, and risk management

Changing federal regulations, civil rights and malpractice cases, and new treatment methods have influenced the use of restraint and seclusion (R&S) in inpatient psychiatric treatment settings, such that restraint and seclusion today are among the most highly regulated practices in psychiatry. Despite increased pressure from regulatory bodies and litigation, the use of R&S remains controversial and risky. These procedures can compromise safety if performed incorrectly or monitored inadequately, but intervention by restraint or seclusion may be necessary to maintain safety on the treatment unit, especially during emergencies. Case law and medical research have demonstrated the importance of a patient-focused, treatment-oriented approach toward risk management. Analysis of specific clinical scenarios can help to develop risk mitigation strategies that are therapeutically conceptualized rather than driven by regulation. Insights drawn from clinical cases that have resulted in litigation can offer an opportunity to develop an approach oriented to patient care from a clinical or risk management perspective. In this article, we seek to provide a foundation for evaluation of current protocols, an analysis of adverse R&S events, and strategies to minimize risk.