Rethinking Restraint and Seclusion

Restraint and seclusion (R&S) are among the most debated practices over the last decade. These interventions are typically used only when other de-escalation strategies, such as crisis communication or the use of coping skills, have been exhausted and there is an immediate need for emergency safety intervention.

What are Residential Treatment Centers (RTCs), and Who Do They Serve?

Residential treatment centers (RTCs) are highly structured and supervised environments designed to support youth with complex behavioral or mental health needs (Geoffrion et al., 2021; Javandi et al., 2023; Roy et al., 2021; Smith et al., 2017). These programs combine daily therapeutic and psychoeducational interventions to help young people manage challenges that may be too severe for less intensive settings, such as foster care or group homes.

RTCs typically serve youth ages 6-21. Youth in RTCs often suffer from acute mental health challenges, functional impairment, trauma, and comorbid diagnoses, such as mood disorders. These challenges are often paired with co-occurring behaviors, such as behavioral or emotional dysregulation and impulsivity, which may lead to unsafe behaviors (Geoffrion et al., 2021; Roy et al., 2021).

What are restraint and seclusion?

• Restraint refers to the involuntary restriction of an individual’s movement through the use of manual, mechanical, or chemical holds.
• Seclusion involves the involuntary confinement of a client in a room, where the client is physically prevented from leaving.

While both of these interventions are used to keep clients and staff safe, they are not without risks. Youth and staff subjected to R&S may experience re-traumatization, physical injury, and in extreme cases, death (Duxbury et al., 2019; Slatto et al., 2021; Smithard & Randhawa, 2022; Spennato et al., 2022).

Who is at greatest risk?

Youth experiencing the following are at a significantly higher risk of experiencing restraint or seclusion:

• Emotional and psychological distress, especially those exhibiting self-harming behaviors or suicidal tendencies
• Exposure to trauma or other negative life events
• Restricted educational opportunities
• Familial crises (e.g., parental separation or divorce, death of loved ones)

These behaviors are often linked to puberty, particularly in females, due to increases in emotional disorders during this stage of development. Youth with these experiences may have more difficulty regulating emotions, increasing the likelihood of behaviors that trigger R&S interventions.

Demographic factors linked to higher risk include:

• Younger children (11-13)
• African American youth

Why is R&S a concern?

Theoretical support for strategies reducing R&S has risen from concerns regarding high rates and consequences of the practices in RTCs. These concerns raise ethical and legal considerations, particularly regarding the risk of harm, violation of youth rights, and disproportionate impact on minority populations (Daniels et al., 2023; Griffiths et al., 2022; Roy et al., 2021; Slatto et al., 2021; Vidal et al., 2020).

Exploring Alternatives

Current literature identifies a gap in the widespread implementation of preventative and non-restrictive safety interventions in youth RTCs (Roy et al., 2021; Slatto et al., 2021; Vidal et al., 2020). Evidence-based alternatives, such as art therapy (Versitano et al., 2024; Zhang et al., 2024), comprehensive staff training (Duxbury et al., 2019), and organizational policy change (Azeem et al., 2011; Bausman et al., 2023; Perers et al., 2021), are being increasingly examined as potential methods for the reduction of R&S interventions. Investigating the effectiveness of these approaches is critical to understanding how RTCs can shift towards the utilization of more preventative strategies for youth with complex behaviors (Duxbury et al., 2019; Geoffrion et al., 2021).