The forensic hospital for the state of Alabama, the Taylor Hardin Secure Medical Facility in Tuscaloosa, has one of the lowest rates of seclusion and restraint use in the United States.

So reported the hospital’s acting clinical director, Verona Lawson, M.D., at the annual meeting of the American Academy of Psychiatry and the Law (AAPL). The meeting was held in Vancouver in October. Lawson spoke during a session called "Raising the Bar on Seclusions and Restraints."

Compared with other psychiatric hospitals throughout the United States, Taylor Hardin has consistently reduced the use of seclusion and restraint year after year, Lawson pointed out. The last time the staff of the 107-bed facility secluded a patient, Lawson said, was in fall 1999, and the last time it restrained a patient in a restraint chair was last February.

So how does the Taylor Hardin staff manage to use seclusion and restraint so infrequently? After all, many of the hospital patients are facing trial for crimes ranging from selling narcotics to murder, many are deeply troubled psychologically, and some have been placed there after having been acquitted on an insanity plea. One of the hospital’s recent patients, for instance, had used a knife to cut up his girlfriend. The answer is that the Taylor Hardin staff employs a number of methods so that they can avoid having to resort to seclusion and restraint. Lawson described some of them at the AAPL session, as did James Hooper, M.D., the hospital’s medical director.

First, the physical environment of the hospital is structured and safe. For example, the entire hospital is maintained in maximum security, and all clinical areas are monitored by camera. Hospital chairs weigh 250 pounds so that patients cannot throw them around.

A second reason why the hospital manages to use so little seclusion and restraint is that it has an ample, well-placed staff. For instance, the hospital has a low staff-to-patient ratio—one worker to five patients in acute care (admissions), one worker to seven patients when the patients are a little more stable than during admission, and one worker to eight patients in the least restrictive part of the hospital. Staff members are also allocated specifically to especially dangerous patients. One patient with paranoid schizophrenia screamed and cursed at people and hit one of the staff. As a result, a staff member stayed constantly with him during the remaining four or five months he was in the hospital—not close enough to the patient to risk injury, but close enough to make sure that he didn’t hurt anybody else.

"It takes a lot of manpower; it takes a lot of resources," Hooper said. "But it works."

Still a third explanation for why the Taylor Hardin staff has to resort to seclusion and restraint so seldom is that the staff is well trained. For instance, staff members are taught how to handle potentially dangerous patients when they act up. In fact, Hooper explained, one of the major reasons they need to resort to seclusion and restraint so little is that staff members know how to put patients in seclusion and restraint, they are confident of their ability to do it, and as a result, they can work without fear of harm from the patients. The staff is also especially vigilant at the change of shifts, since this is a period when patients often act up.

A fourth reason for the rare use of seclusion and restraint is that patients are kept busy and offered various types of psychological help. For instance, they participate in psychoeducational groups in which they learn how to identify the causes of their anger and how to handle it. Individual psychotherapy is also offered as the need arises and depending on staff availability. "We recognize that we have patients who are experiencing posttraumatic stress, that we have persons who are grieving, that we have young patients who have killed their parents," Lawson said.

Finally, a major reason why seclusion and restraint are so rarely employed at Taylor Hardin is because prevention is strongly emphasized. In fact, Lawson is convinced that the focus on prevention is the prime key to the hospital’s success. Or as she put it in an interview, "Being very vigilant, watching for changes, intervening. . . ."

For instance, staff members recognize behaviors that precede violence, such as a patient’s becoming loud and demanding or taking off his clothes, and they quickly act. First they try to calm him down. If that doesn’t work, they suggest that he go to his room to cool off and regain some control over himself.

"For some patients that works," Lawson said. But when it doesn’t, staff members may have to give the patient medication to subdue him. If he wants to stay in his room after being medicated, he can, but a staff member remains with him until the medicine takes effect. Only if the above tactics do not work do staff members seclude a patient, and only if seclusion does not work do they restrain him in a restraint chair.

If staff members have to seclude or restrain a patient, they will get together afterward for a debriefing session. Such a session helps staff members realize where they might have possibly taken different actions that would have precluded having to resort to seclusion and restraint. The debriefing session also allows staff members a chance to come to grips with negative emotions that they may have felt upon secluding or restraining the patient. All staff members know what it feels like to be restrained: They were strapped into a restraint chair themselves as part of their training.

Indeed, when Taylor Hardin staff members undergo orientation, the philosophy is impressed upon them that seclusion and restraint are a last resort.

Or as Hooper explained it, "If you put someone in seclusion, you have failed—you have not done what you’re attempting to do, because your job is to treat those people without having to resort to seclusion and restraint."