Improving outcomes requires more, not less, from psychology.

Abstract

Over the past 15 years, many public and private providers of inpatient psychiatric services have reduced the availability and sophistication of psychological and behavioral interventions while the concentration of people with comorbid psychiatric and behavior disturbances has increased. This has resulted in a move away from providing direct treatment of behavior dysfunction and an increase in the use of high dosages of psychoactive medications, leading in many cases to unnecessary chemical restraints, mechanical restraints, and seclusion (see Hunter, 1995; Hunter, 1999; Hunter, 2000). ********** An overdependence on neurobiological and biochemical theories of mental disorders, a society oriented to quick-fix medical and chemical solutions to complex problems (Hunter, 2000), and beliefs advanced by the massive promotion of by the pharmaceutical industry (Valenstein, 1998; Glenmullen, 2000) have contributed to restricted case formulation strategies that have been described as little more than drugs and TV therapy (Hunter, 1999; Hunter, 2000). These limited case formulation strategies have resulted in poor outcomes and increases in restrictive and coercive interventions. Deaths and other adverse reactions from, often unnecessary, restraints and seclusion have led to action by Congress and several public and private organizations (e.g., HCFA, DOJ, JCAHO, SAMSHA). During 1999 and 2000 there was much legislative activity on Capitol Hill attempting to regulate the use of restraints and seclusion. Numerous bills and legislative proposals, at one time or another, contained language that would have eliminated many psychological and behavioral interventions (e.g., Time-Out, hand-over-hand guidance, graduated guidance, redirection) and excluded psychologists from providing the necessary leadership for case formulation decisions, writing orders, or training and directing staff in implementing appropriate psychological and behavioral interventions. The American Psychological Association's Practice Directorate took an active role in advocating for appropriate inclusion of psychologists and attempted to protect psychological interventions when they were unintentionally (or intentionally) impacted by various definitions of terms. For example, the wording in several definitions of seclusion would have impacted the procedure Time-Out in a way that in order to use Time-Out, the behavior would have had to rise to the level of imminent dangerousness. In September 2000 the restraint and seclusion language of various bills and amendments were rolled into the Children's Health Act of 2000 (HR 4365), which passed the Senate on September 22nd and the House on September 27, 2000. President Clinton signed the bill into law on October 17th. This law, although not entirely written as APA or its consultants would have preferred, contained language allowing for physicians or other licensed practitioners (psychologists) to write seclusion or restraint orders, required staff of facilities using restraints or seclusion to train staff in alternatives to the use of these restrictive procedures, exempted Time-Out from the definition of seclusion, attempted to limit the use of chemical restraints, and exempted physical escort from the restraint stipulations. Prior to the legislative activity in 1999 and 2000 resulting from the reports of deaths from restraints and seclusion, HCFA was revising its children's residential facility regulations. After HR 4365 passed, HCFA completed its revisions on its RTF