Rethinking Restraint and Seclusion

The Six Core Strategies, created by the National Association of State Mental Health Program Directors (NASMHPD) in alliance with the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2010, is a conceptual framework aimed at creating organizational change that impacts R&S reduction. The framework emphasizes communication between staff, patients, and key stakeholders, guiding staff on patient interaction and trust building and highlighting the importance of leadership support within this framework (Azeem et al., 2011; Bausman et al., 2023; Perers et al., 2021).

The framework, which focuses on minimizing conflict and promoting resolution, includes six core strategies (Azeem et al., 2017; Bausman et al., 2023; Lee-Aube et al., 2023; SAMSHA, 2010):

1. Leadership towards organizational change. This strategy aims to hold individuals accountable, create a clear action plan, and play an active role in the change process (Lee-Aube et al., 2023). Effectiveness as this step requires commitment from leadership teams to create a shared goal of reducing restraint and seclusion, an assessment of current barriers to change, and a focus on improving current practices and staff training (Azeem et al., 2017).

2. The use of data to inform practice. Accurate data allows program facilitators to assess the scope of the issues and intervention effectiveness. As discussed, a lack of consistent data reporting is an ongoing issue in the current R&S practices, highlighting the importance of more transparent data reporting (Azeem et al., 2017). This step also allows for the collection of consistent quantitative comparison data to drive the reduction of R&S practices (Lee-Aube et al., 2023).

3. Workforce development. This step assures adequate staff training, coaching, and monitoring. An example of workforce development may involve staff becoming educated in trauma-informed care, recovery facilitation, or person-centered care (Azeem et al., 2017; Lee-Aube et al., 2023).

4. The use of prevention tools. This step assesses the risk of violence, medical and psychological risk factors, and aids in developing de-escalation and safety plans. Preventative measures may involve awareness of an individual trauma history, the creation of a safety plan, and the use of de-escalation strategies prior to restrictive interventions (Azeem et al., 2017). This strategy recognizes the importance of the physical environment in client self-regulation and the need for spaces that reflect a calm and safe environment (Bausman et al., 2023).

5. Supporting consumer and advocate roles in inpatient. Involving the youth, family, and advocates in meaningful roles is essential to enhancing the client experience. This step encourages involvement from patients, families, and an individual’s external team, such as their case worker (Lee-Aube et al., 2023).

6. Debriefing tools. Event debriefing allows for reflecting on policy, procedures, and program practices, and is arguably one of the most essential steps within the Six Core Strategies. Debriefing, which is required to be completed 48 to 72 hours from the restraint or seclusion event, provides the patient with emotional support and aids in rebuilding trust between the individual and their care team (Azeem et al., 2017; Perers et al., 2021). Debriefing also serves to ensure the safety of all involved in the event and that the incident is accurately documented (Lee-Aube et al., 2023).

The Six Core Strategies have been proven effective in several countries and have been shown to reduce staff turnover, increase job satisfaction, and improve patient-staff relations; however, research on the individual elements of this framework is encouraged (Asikainen et al., 2023). Implementation of the Six Core Strategies requires careful insight into program assessment and a high quality of completion, with several studies highlighting leadership and debriefing as essential organizational steps (Asikainen et al., 2023; Bausman et al., 2023; Lee-Aube et al., 2023).