Kim J. Masters, M.D.

At the request of AACAP News Editor Stuart Copans, M.D., this issue’s column will review the current state of de-escalation programs. It has turned into a mammoth effort and should occupy this column for a long time. Let’s start with an overview.

Before the restraint related deaths reported by the Hartford Courant on October 11, 1998, de-escalation programs focused on talking angry patients into calming down, and if that failed, employing procedures for seclusion and restraint. These programs were almost all Level Two type interventions, which involved defusing crises several minutes to several seconds before they became assaults. While some programs developed their own approaches, there were national training programs as well, most notably those of the Crisis Prevention Institute, for psychiatric inpatient facilities and Therapeutic Crisis Intervention for residential and group care settings. These programs, and many others which we shall review in the future, train many mental health and child care staff today.

The Courant articles prompted a 60 Minutes II program on deficiencies in the now defunct Charter Hospital System and legislative hearings.

In response, the Health Care Financing Administration (HCFA), which was renamed the Centers for Medicare and Medicaid Services, and the Joint Commission on Accreditation of Healthcare (JCAHO) put forth regulations to ensure: 1) a patient’s right to be free of restraint and seclusion except in situations where it was required for patient safety (previously these procedures had also been used as part of therapy); 2) having independent professional monitoring when these interventions were employed; 3) limits on the time that they could be used without reassessment; and 4) requirements that accredited institutions establish a performance improvement process to monitor and decrease the use of these procedures.

It became obvious that line staff, those dealing directly with patients, had insufficient training and support to carry out these new regulations. They had simply been attempting to diffuse crises before they blew up. Studies and program initiatives began at many facilities and agencies to reduce the use of seclusion and restraint. They all now emphasize Level One interventions dealing with aggression prevention and management before crises.

Thus, de-escalation has come to be broadly defined as any strategy, Level One or Level Two, that decreases the need for seclusion and restraint. An example of the former would be changing the culture of a facility from authoritarian (“do it my way because I said so”) to collaborative (“let’s work together to individualize anger control opportunities”). An example of the latter would be offering an angry patient individualized strategies, such as a walk outside instead of seclusion and restraint.

Groups, individuals, agencies, and organizations throughout this country have produced de-escalation recommendations, and guidelines. Some of the ones that I have reviewed include: 1) the Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY); 2) the Maryland Youth Practice Improvement Committee for Mental Health; 3) the National Technical Assistance Center for State Mental Health Planning; 4) the Massachusetts Initiative to Promote Strength Based Care; 5) the Petti et al PRN Medication study; 6) the Child Welfare League of America‚s Best Practices Project; 7) the American Psychiatric Association’s Learning From Each Other; 8) the National Association of Psychiatric Health Systems and the American Psychiatric Nurses Association; 9) the New York State Office of Management and Budget (the Psychoeducational Treatment Model from Boys Town, the Therapeutic Crisis Intervention Program from Cornell University, and the National Crisis Prevention Institute Program); and 10) AACAP’s Practice Parameter on the Prevention of Aggressive Behavior. If you know of other efforts, please email me at, so I can include them in my review.

Each one of these efforts, like flowers in a garden, make their own unique contributions and their recommendations must be viewed in that light. For example, current TRAAY studies require a six week length of stay in a child/adolescent program. These findings may have limited application to a crisis-based inpatient unit where most stays are less than one week. Some of the CWLA findings may best serve residential facilities that do not emphasize a medical model.

In assembling an aggression management program, one may have to select pieces from different groups for each of the intervention levels. For example, Level One intervention efforts such as staff and anger management training, require different skills than talking a child out of a crisis or processing the incident after a blow out. These procedures require different skills than applying physically restraints or holding a child or monitoring a seclusion or administering intramuscular medication to an aggressive youth. Furthermore, to some people, hands on strategies are anathema to the process of reducing seclusion and restraint, and should be abolished, not taught. One must be sensitive to those ideologies which accompany the scientific attempts to treat our patients in the most humane way. John C. Nemiah, M.D., Emeritus Editor of the American Journal of Psychiatry and Emeritus Professor of Psychiatry at Harvard Medical School, suggested to me once that the field of aggression management generally divided itself into those who preferred psychological means and those preferred Mrazek from page 105 physical means to resolve crises. Unfortunately, until now, both have been necessary in mental health.

In future columns, I will discuss features of individual de-escalation programs and ultimately develop a synthesis, or a table, identifying the various applications of individual programs to aggression management.

Remember, if you have an interest in writing about your experience with seclusion and restraint in this column, email Michelle Morse, AACAP News Production Editor, at Have a seclusion and restraint free month!!

Dr. Masters is Medical Director of Focus by the Sea, a private psychiatric hospital on St. Simons Island, GA. He is also co-author of AACAP’s Practice Parameter on the Prevention of Aggressive Behavior.