S P E C I A L A R T I C L E Restraint and Seclusion in Psychiatric Treatment Settings: Regulation, Case Law, and Risk Management Patricia R. Recupero, JD, MD, Marilyn Price, MD, Keelin A. Garvey, MD, Brian Daly, MD, and Sarah L. Xavier, DO Changing federal regulations, civil rights and malpractice cases, and new treatment methods have influenced the use of restraint and seclusion (R&S) in inpatient psychiatric treatment settings, such that restraint and seclusion today are among the most highly regulated practices in psychiatry. Despite increased pressure from regulatory bodies and litigation, the use of R&S remains controversial and risky. These procedures can compromise safety if performed incorrectly or monitored inadequately, but intervention by restraint or seclusion may be necessary to maintain safety on the treatment unit, especially during emergencies. Case law and medical research have demonstrated the importance of a patient-focused, treatment-oriented approach toward risk management. Analysis of specific clinical scenarios can help to develop risk mitigation strategies that are therapeutically conceptualized rather than driven by regulation. Insights drawn from clinical cases that have resulted in litigation can offer an opportunity to develop an approach oriented to patient care from a clinical or risk management perspective. In this article, we seek to provide a foundation for evaluation of current protocols, an analysis of adverse R&S events, and strategies to minimize risk. J Am Acad Psychiatry Law 39:465–76, 2011 The use of restraint and seclusion (R&S) in noncor- rectional psychiatric treatment settings is one of the most controversial and highly regulated practices in mental health treatment. The primary goal of R&S in inpatient psychiatry is to maintain the safety of everyone in the treatment environment. Because risks to patients can be severe, some scholars advocate the complete elimination of R&S. However, failing to use R&S in emergency situations can also result in adverse outcomes to the individual himself or to oth- ers in the milieu. Inpatient psychiatrists face intense scrutiny and pressure from regulatory agencies to re- duce the use of R&S. In developing effective risk management strategies, it can be helpful to examine the case law from a therapeutic perspective rather than to develop policies in response to regulation. This discussion presents an overview of some of the major regulatory activity aimed at reducing R&S- related adverse events, success stories from the med- ical literature, and relevant case law to help clinicians and administrators manage risk through patient- centered, treatment-oriented strategies and analysis of case-specific clinical scenarios. Regulatory Bodies and Professional Organizations In the 1990s, the Hartford Courant’s expose ´ of R&S-related deaths prompted an increase in regula- tory activity and scrutiny of R&S. 1 Reports and pol- icies calling for the reduction and regulation of R&S have been released by other agencies, including the Joint Commission (hereinafter TJC, formerly Dr. Recupero is Clinical Professor of Psychiatry, Warren Alpert Med- ical School of Brown University, and President/CEO of Butler Hos- pital, Providence, RI. Dr. Price is Clinical Instructor, Department of Psychiatry, Harvard Medical School, and Assistant Psychiatrist, Law and Psychiatry Service, Massachusetts General Hospital, Boston, MA. Dr. Garvey is psychiatrist, Massachusetts Department of Corrections, Bridgewater, MA. Dr. Daly is a Fellow in Forensic Psychiatry at the University of Michigan Medical School, Ann Arbor, MI. Dr. Xavier is a faculty member at the Warren Alpert Medical School of Brown University, Providence, RI. Address correspondence to: Patricia R. Recupero, JD, MD, Butler Hospital, 345 Blackstone Boulevard, Prov- idence, RI 02906. E-mail: patricia_recupero@brown.edu. Disclosures of financial or other potential conflicts of interest: None. 465 Volume 39, Number 4, 2011