Adult/Older Adult > Alternatives to Seclusion and Restraint
Bullet Alternatives to Coercive Techniques (ACT) Initiative
Bullet State Hospitals
Bullet Where We Have Been
Bullet Publications
Bullet Annotated Bibliography on Alternatives to Seclusion and Restraint
Bullet Additional Resources


Alternates to Coercive Techniques (ACT) Initiative
Pennsylvania is joining the nation-wide movement to enhance trauma-informed care and services within residential facilities. Best practices, high quality programming, and well-trained staff are critical in providing care that reduces the need for the use of restraint, while ensuring the safety of all residents and staff. Resources listed at the bottom of this page are intended to assist residential facilities in achieving the ultimate goal of eliminating the need for the use of coercive techniques in residential facilities.


State Hospitals
In the 1990s, new policies regarding the use of seclusion and restraint were implemented in Pennsylvania’s state hospitals. These policies were implemented after leadership’s attitudinal shift from restrictive to recovery focused treatment. It was emphasized that consumers are to be treated with dignity and respect and the use of restraint and seclusion are not in line with this belief. In February of 1993, 5,292 hours of seclusion and 10,724 hours of mechanical restraint were used in Pennsylvania’s state hospitals. As of January 2008 the monthly average for seclusion use is 2 hours and the monthly average for mechanical restraint is approximately 9 hours. Pennsylvania’s changes were successful because of a cultural transformation in which leadership supported the change, the staff to patient ratio was increased, performance improvement measures were implemented, staff training was increased, and an attitude change occurred that fostered an environment of care which was safer and less traumatizing for consumers and staff. For more information about the Pennsylvania State Hospital initiative on reducing and eliminating seclusion please contact Brandi Kennedy at 610-740-3416 or 1600 Hanover Ave, Allentown, PA, 18109-2498.

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Where We have Been

Seclusion Hours Used 1990 - 2008

Mechanical Restraint Use 1990 - 2008

Physical Restrain Use 1990 - 2008


Pennsylvania State Hospital System's Seclusion and Restraint Reduction Program, Gregory W. Smith, MS, et. al.

SAMHSA's Commitment to Eliminating the Use of Seclusion and Restraint, Charles Curie, MSW, ACSW

Reducing the Use of Seclusion and Restraint: A NASMHPD Prioirty, Robert W. Glover, PhD

Seclusion and Restraint Risk Management Guide

Reducing Use of Seclusion and Restraint

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Annotated Bibliography on Alternatives to Seclusion and Restraint
prepared by Gordon R. Hodas, M.D., Statewide Child Psychiatric Consultant to OMHSAS

The documents identified within this annotated bibliography have been grouped according to the six core strategies identified by the National Association of State Mental Health Program Directors (NASMHPD). These core strategies involve: 1) leadership toward organizational change, 2) use of data, 3) workforce development, which is further subdivided, 4) use of seclusion/restraint reduction tools, 5) consumer roles/advocacy, and 6) debriefing activities. Additional resources are available from the Substance Abuse and Mental Services Administration web site under Seclusion and Restraint Activities, and from NASMHPD.

Leadership Toward Organizational Change

  • Curie, C. (2005). SAMHSA's commitment to eliminating the use of seclusion and restraint. Psychiatric Services, 56 (9), 1139-1140. Mr. Curie, former administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), initiated restraint and seclusion reduction in the State Hospital System while in Pennsylvania. Here, he highlights the need for a vision of recovery and culture change, and identifies SAMHSA's efforts to promote these.
  • Glover, R. (2005). Reducing the use of seclusion and restraint: A NASMHPD priority. Psychiatric Services, 56(9), 1141-1142. Dr. Glover, executive director of the National Association of State Mental Health Program Directors (NASMHPD), indicates that restraint reduction has been NASMHPD's priority for the past decade. He supports a trauma informed, recovery based system of care.
  • Gunn, S. (2000). Organizational systems to minimize restraint and maximize dignity, effective treatment and safety. Presentation to Walker Trieschman Conference, May 11, 2000. This paper is applicable to any system serving children and adolescents in care. It offers an overview of 10 organizational systems needed to provide a safe environment that respects the dignity of the individual and minimizes the use of restraint. These systems are: leadership, treatment program, assessment and care planning, Human Resource issues, accountability and client rights, restraint processes, review of selected training programs, sentinel events and root cause analysis, and risk management.
  • Smith, G., Davis, R., Bixler, E., Lin, H., Altenor, A, Altenor, R., Hardenstine, B., Kopchick, G. (2005). Pennsylvania State Hospital System's seclusion and restraint reduction program. Psychiatric Services, 56(9), 1115-1122. The authors provide an excellent overview of the restraint and seclusion reduction initiative in Pennsylvania 's State Hospital System, which became a national model and continues to influence efforts in other states.

Use of Data

  • Hughes, W (2002). Replacing control with empowerment is a proven solution. Networks. Alexandria , VA. National Technical Assistance Center for State Mental Health Planning, Special Edition, Summer/Fall 2002, 17. The author, chief executive officer of the Columbia Behavioral Health System, a division of the South Carolina Department of Mental Health, relates how a reduction process involving education with both staff and consumer involvement dramatically reduced use of restraint and seclusion with consumers in acute state psychiatric facilities. Sensitivity training helped staff appreciate the needs of consumers.
  • LeBel, J., and Goldstein, R. (2005). The economic cost of using restraint and the value added by restraint reduction or elimination. Psychiatric Services, 56(9), 1109-1114. The Massachusetts restraint initiative in adolescent inpatient facilities was not only effective – a 91% restraint reduction, based on 2003 data as compared to 2000 data – but also highly cost effective. The aggregate cost of restraint was reduced by 92%, a substantial savings for facilities. In addition, there was a 98% decrease in staff workdays missed due to restraint-related injury, and an 80% decrease in staff turnover.
  • Rivard, J., Bloom, S., McCorkle, D., Abramowitz, R. (2005). Preliminary results of a study examining the implementation and effects of a trauma recovery framework for youths in residential treatment. Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations, 26(1), 1-12. Outcomes related to treatment environment and youth coping were monitored in this study comparing implementation of the Sanctuary Model in residential treatment units with other units that did not implement the Model. Among the findings was an increase in: safety for staff and clients, help and support within the community, open expression of feelings, and self-sufficiency and independence in decision-making.

Workforce Development


  • National Center for Injury Prevention and Control (2005) Child maltreatment: Fact Sheet. This document offers data on trauma and maltreatment that can help staff understand the likely life experiences of many children and youth in their care. Child maltreatment is discussed in terms of occurrence, consequences, and risk and protective factors.
  • Hennessey, M., et al (2004). Trauma among girls in the juvenile justice system. Washington, DC: Juvenile Justice Working Group of the National Child Traumatic Stress Network, Data from many sources indicate that females in the juvenile justice system are highly likely to have experienced trauma, especially direct victimization. These individuals are at high risk of substance use, involvement in violent activity, further victimization, and development of mental health problems. Ensuring safety in care is essential. In addition, gender-specific programming is needed.


  • Perry, B (2000). Traumatized children: How childhood trauma influences brain development. Journal of the California Alliance for the Mentally Ill. 11(1): 48-51. Starting with a clinical vignette, Perry describes changes in brain structure and neurobiology that occur in children subjected to trauma, and how this may influence the child's functioning. The Child Trauma Academy website has many related articles.


  • Hodas, G. (2005). Empowering direct care workers who work with children and youth in institutional care. Harrisburg, PA: Office of Mental Health and Substance Abuse Services. In recognition of the key role of direct care workers in reducing the use of restraint, the paper proposes a systematic approach to the hiring, orientation, training and supervision, performance evaluation, and mentoring of direct care staff, so that they can provide appropriate interventions consistent with trauma informed care.


  • Bloom, S. (2005). The Sanctuary Model of organizational change for children's residential treatment. Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations, 26(1), 65-81. This paper offers a good overview of the Sanctuary Model, highlighting the role of leadership and the need for culture change in order to create a therapeutic community. Specific elements of the Model, to be implemented by staff, are described.
  • Mahoney, K., Ford, J., Ko, S., Siegfried, C. (2004). Trauma-focused interventions for youth in the juvenile justice center. Washington, DC : Juvenile Justice Working Group of the National Child Traumatic Stress Network, Many children and youth in juvenile justice facilities have experienced trauma and maltreatment, and it is essential that their trauma-related needs be recognized and addressed. The authors discuss the importance of pretreatment assessment, trauma-focused interventions, treatment of co-occurring disorders, and family based interventions with this population.
  • The Sanctuary Model

Use of Seclusion/Restraint Reduction Tools

  • Hodas, G. (2005). Parameters to consider in response to frequent restraint use. Harrisburg, PA: Pennsylvania Office of Mental Health and Substance Abuse Services. This document offers a systematic approach to analyzing possible contributing factors, when there is frequent use of restraint in a facility. The information obtained can then be used to develop an action plan.
  • Masters, K. (2005) How to create and evaluate a seclusion and restraint prevention plan. AACAP News, 36 (3), 110-111. This brief column identifies 10 elements that should be addressed in a safety plan. Many current protocols incorporate some but not necessarily all of these elements. (Used by permission of the American Academy of Child and Adolescent Psychiatry.)

Consumer Roles/Advocacy

  • Alliance to Prevent Restraint, Aversive Intervention, and Seclusion (APRAIS) (2005). In the name of treatment: A parent's guide to protecting your child from the use of restraint, aversive interventions, and seclusion. Baltimore: TASH. This publication, developed by the Alliance to Prevent Restraint, Aversive Interventions, and Seclusion (APRAIS), provides education and guidance to families regarding the dangers of restraint, seclusion, and aversive interventions in education and care. In addition to discussion of Positive Behavior Support, the following are addressed: dangers and risks to children, rights, evaluating the program, warning signs, and taking action.
  • Robins. C., Sauvageot, J., Cusack, K., Suffoletta-Maierle, S., Frueh, B. (2005).Consumers' perceptions of negative experiences and “Sanctuary Harm” in psychiatric settings. Psychiatric Services, 56 (9), 1134-1138. Even though this article describes negative experiences of adult psychiatric patients in Inpatient treatment, the emerging themes are much more broadly applicable. Individuals in care can be traumatized by restraint or perceived threats of physical violence. Rules often appear arbitrary to them. They not infrequently experience disrespect and humiliation from staff, and need to be listened to and understood as unique individuals.

Debriefing Activities

Additional Resources

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