Semel Institute of Neuroscience and Human Behavior, 760 Westwood Plaza, Los Angeles, CA 90024, USA.
J Am Acad Psychiatry Law. 2011;39(4):480-95.
Regulatory and administrative imperatives, when paired with staff training in humanistic, verbally mediated interventions can reduce the frequency of seclusion and restraint but can be associated with increases in the frequency and severity of staff injury, with concomitant tension and apprehension in the treatment setting. Even when educational programs for staff are made available for patient-centered, therapeutic, and persuasion-based modes of de-escalation, aggression, destructiveness and self-injury may continue to occur or even increase. Administrative contingencies can lead to less reporting of such incidents by staff with consequential, adverse effects on their morale and the unit milieu. Given the neurocognitive deficits, learning disabilities and lengthy histories of inadvertent reinforcement of provocative and aggressive behavior among persons with developmental and serious psychiatric disorders, basic principles of learning are needed to teach alternatives for belligerent behavior. Examples of behavior therapies that have been documented as effective in reducing aggression and self-injury include differential reinforcement of other behavior, social skills training, teaching interaction, social learning modalities, and time out from reinforcement. These evidence-based behavioral interventions must be superimposed on optimal, diagnostically driven, and monitored pharmacotherapy. When evidence-based, person-centered, and recovery-oriented biobehavioral interventions are made available to inpatient units, favorable clinical outcomes with reductions in the use of seclusion and restraint are likely.
监管和行政要求，当与人文关怀、口头干预的员工培训相结合时，可以减少隔离和约束的频率，但可能会导致员工受伤的频率和严重程度增加，同时在治疗环境中会产生紧张和担忧。即使为员工提供了以患者为中心、治疗和劝导为基础的缓和模式的教育计划，攻击、破坏和自残行为仍可能继续发生甚至增加。行政应急措施可能导致员工对这些事件的报告减少，从而对他们的士气和单位环境产生不利影响。鉴于具有发育和严重精神疾病的人存在神经认知缺陷、学习障碍和长期无意强化挑衅和攻击行为的历史，需要学习基本原则来教授对抗性行为的替代方法。已经记录为有效的减少攻击和自残行为的行为疗法的例子包括其他行为的差异强化、社交技能训练、教授互动、社会学习模式，以及从强化中暂停。这些基于证据的行为干预措施必须叠加在最佳的、基于诊断的、并受监测的药物治疗上。当为住院病房提供基于证据、以患者为中心和以康复为导向的生物行为干预措施时，可能会带来有利的临床结果，减少隔离和约束的使用。
