Rethinking Restraint and Seclusion

            Restraint and seclusion (R&S) remain some of the most ethically charged and legally complicated practices in youth residential treatment care (RTCs) (Matte-Landry & Cllin-Vezina, 2020; Nielson et al., 2020). While these interventions may often be necessary to prevent immediate harm, they carry significant risks – especially for vulnerable youth. This reality puts staff and organizations in a difficult position of balancing safety, legal requirements, and ethical responsibility.

Why R&S Raises Ethical Concerns

The ethical tension surrounding R&S is tied directly to the harm they can cause. Even when used with the intention of keeping a youth safe, R&S can lead to physical injury, retraumatization, and in extreme cases, death. Because of these risks, federal and state regulations require that R&S only be used as a last resort intervention.

Care staff hold a legal and ethical duty to protect the youth they serve. However, protection also means making careful and moment-by-moment assessments of risk (Finch, 2025):

• Has every de-escalation strategy been tried?
• Is the youth’s behavior posing an immediate risk of harm to self or others?
• Could restraint or seclusion cause more harm than it may prevent?

These decisions must be weighed against agency policy, training, and the broader legal structures governing R&S use.

The Challenges to R&S Policies

Despite decades of scrutiny, R&S policy across the U.S. remains fragmented. While many states have laws or guidelines addressing restraint and seclusion, they vary widely in (GOA, 2024; Graves, 2024; Kern et al., 2024; Ober, 2024).:

• Definitions of restraint or seclusion
• Conditions under which R&S can be used
• Documentation and reporting requirements
• Enforcement and accountability

The lack of uniformity in R&S regulations means that two youth in different states may experience vastly different levels of protection and oversight. Some states have implemented strong rules and comprehensive training requirements, while others rely on vague language or have no enforcement provisions at all, leaving programs to interpret the law on their own.

The Role of Federal Regulation

In the United States, federal laws and regulations regarding behavior management and sanctions on seclusion and restraint in residential settings (45 CFR § 410.1304) have been implemented. These regulations limit the circumstances under which restraint and seclusion may be used and require care provider facilities to have evidence-based, trauma-informed, and linguistically responsive behavior management strategies in place (Behavior Management and Prohibition on Restraint and Seclusion, 2024). These regulations state that R&S may only be used in emergency safety situations, and prohibit the use of:

• Prone physical restraints
• Chemical restraint
•  Peer restraint

Despite these legal safeguards, significant inconsistencies remain in the interpretation, implementation, training, and oversight surrounding these practices, emphasizing the need for improved regulatory enforcement and interventions that reduce the need for R&S practices (GOA, 2009; Kern et al., 2024; Ober, 2020).

The urgency of stronger protections became even clearer in the U.S. Government Accountability Office’s 2009 review, which revealed hundreds of cases of alleged abuse and death related to the use of R&S on school children over the preceding two decades. One reported example included a 7-year-old who passed away after being held in a face-down position for several hours, while another reported a 13-year-old who hanged himself in seclusion after prolonged isolation (U.S. GOA, 2009). While these are extreme cases of the misuse of R&S, it is necessary to prevent and address the maltreatment that can occur from a lack of training or regulations surrounding these high-risk practices (GOA, 2024).

Ethical Decision-Making

Even with polcieis in place, decisions about restraint are complex. Staff must weight several factors, often in high-intensity situations. One frontline care worker described their thought process before initiating restraint:

“. . . you start to think about, ‘if I take on this situation, am I gonna be safe? Is this young person gonna be safe? Is the area safe? Do I need to remove people from the area? You know, what am I actually hoping to achieve by, by intervening? How is it gonna make the young person feel?’ So you do really think those things . . . I really do think that that goes through people’s heads. They might not recognize and understand that’s what they’re doing, but I think it happens (Staff member). (p.559).”

This complexity is not unique to residential settings, with research across psychiatric and hospital environments reporting that staff often experience (Acevedo-Nuevo et al., 2021; Slatto et al., 2021):

• Fear of causing harm
• Fear of being blamed if harm occurs
• A lack of clarity about what constitutes as imminent danger
• Gaps in training or inconsistent polices

These findings signify a need for more training in risk assessment, clearer definitions of imminent risk, and improved organizational practices to ensure that restraint is being implemented only as a last resort and with proper technique (CPI, 2025; McDonnell et al., 2023).