Rethinking Restraint and Seclusion

Reducing restraint and seclusion (R&S) in youth residential treatment centers isn’t about one single solution—it requires coordinated change across policy, staff training, and clinical practice. While R&S is often used to manage immediate safety risks, it carries a significant risk of physical and psychological harm. Below are three evidence-supported solutions towards safer, more preventative care.

1. Increase Policy Clarity and Enforcement

Strategy one to reduce R&S use in residential treatment settings involves increasing the clarity of the language used in R&S current policy and increasing enforcement efforts of these policies. In the United States, policies governing restraint and seclusion in adolescent residential treatment centers remain disjointed, inconsistent across states, and often weakly enforced due to limited federal laws and regulations addressing the practice (Behavior Management and Prohibition on Restraint and Seclusion, 2024; GOA, 2009; Kern et al., 2024; Ober, 2020). As a result, definitions of restraint, documentation standards, and enforcement vary widely –and gaps in oversight allow unsafe or unnecessary practices to persist.

Research recommends several steps:

• Set clearer definitions and criteria around when R&S can be used
• Require standardized documentation and external reviews of incidents
• Mandate regular de-escalation and crisis intervention trainings
• Align policy with trauma-informed care standards, such as the Six Core Strategies

While improving policy is only one small piece of the puzzle, stronger policy with help establish the foundation for safe and more accountable practices.

2. Improve Staff Training in Crisis Management

Strategy two of R&S reduction is to address gaps in staff training, which are evident in areas such as crisis management and de-escalation, often contributing to the overuse of the practice (Abdikardir, 2025; Steinkopf et al., 2022). Staff working in residential settings play a central role in shaping the daily living experiences of youth in their care, often serving both as caregivers and a support system (Pinherio et al., 2022). Many frontline workers enter residential care without adequate preparation for managing high-stress and complex behaviors. Without effective training and support, even intentioned staff may resort to reactive or restrictive responses.

Effective staff training emphasizes:

• De-escalation and conflict prevention
• Understanding trauma and behavior within the context of trauma-informed care
• Staff-client professional relationships built on trust

            The Six Core Strategies framework highlights comprehensive staff training as essential to R&S reduction (SAHMSA, 2010; Slatto et al., 2021). Facilities that implement and teach the Six Core Strategies have reported reductions in restrictive interventions, improved staff and youth relationships, and improved team cohesion (Slatto et al., 2021). It is encouraged that all youth residential care staff complete crisis and conflict management training, training on evidence-based and preventative interventions, and training on providing individualized trauma-informed care. Collectively, these findings underscore the critical role of staff training, not only in providing crisis management and de-escalation but also supporting staff well-being, reducing the use of R&S, and fostering a safer environment for youth and staff.

3. Art Therapy as a Preventive Tool

            Strategy three of R&S reduction utilizes art therapy as a preventive tool, due to evidence showing the practice can increase emotional awareness, and an increase in therapeutic engagement – both contributing factors to the reduction of R&S (Ivanivna & Leonidivna, 2024; Mantilla, 2021). Clinical interventions play a crucial role in the prevention of crisis escalation, particularly in youth residential treatment settings, where youth often suffer from significant mental health difficulties and trauma histories (Roy et al., 2019).

Among the available therapeutic interventions, art therapy offers a multifaceted approach to emotional expression, emotional regulation, and trauma processing (Gallagher, 2022). Art therapy is a therapeutic intervention that uses artistic means to treat mental illnesses and improve mental health. Art therapy can use various means, such as (Shukla et al., 2022).:

• Theater therapy
• Body psychotherapy
• Music therapy
• Drawing
•  Painting therapy

Unlike therapies rooted in verbal communication (e.g., talk therapy), this intervention allows young people to explore and process overwhelming experiences by identifying feelings non-verbally (Ivanivna & Leonidivna, 2024; Versitano et al., 2022).

Art therapy, while it has been minimally studied regarding R&S reduction, has proven to be useful in crisis de-escalation and prevention, especially in individuals with PTSD, autism spectrum disorder, depression, anxiety, and other mental illnesses (Annous et al., 2022; Zhang et al., 2024). Evidence shows that art therapies can expand emotional awareness and help individuals learn to accept their emotions by at tending to, acknowledging, and accepting them (Ivanivna & Leonidivna, 2024; Mantilla, 2021).

The Six Core Strategies demand preventative tools and workforce development, both of which are fulfilled by art therapy (Azeem et al., 2019; SAMHSA, 2010). Youth who consistently participate in art therapy develop emotional vocabulary, increased emotional regulation, and have increased therapeutic engagement (Gallagher, 2020; Sesar et al., 2022). Art therapy shows promise of reducing rates of restrictive practices for children in inpatient mental health settings and can be effectively utilized before a restraint is required (Naya, 2022; Versitano et al., 2022). However, despite these promising findings for youth with traumatic histories, such as many of those in residential settings, more research is required for adolescent populations in restraint and seclusion research (Versitano et al., 2022).