Senate Bill 569 (2024) directed the Department of Behavioral Health and Developmental Services (DBHDS) to convene a workgroup to propose additional regulations allowing for (i) evidence-based and recovery-oriented seclusion and restraint practices and (ii) alternative behavior management practices that may limit or replace the use of seclusion and restraint in hospitals, residential programs, and licensed facilities. This report provides the General Assembly with DBHDS and workgroup recommendations and consultant research findings.

Virginia has an opportunity to lead the nation in reducing seclusion and restraint use in behavioral health and developmental disability services. Research demonstrates that comprehensive, coordinated efforts can successfully limit seclusion and restraint to true emergency situations. The Commonwealth can implement these proven strategies through the recommendations outlined in this report. This work occurs within a uniquely challenging operational environment shaped by Virginia’s robust human-rights protections and statutory requirements such as “Bed of Last Resort," both of which influence how frequently restrictive interventions must be reported and where individuals with the highest acuity are served.

Importantly, Virginia’s long-standing human rights regulations and broad reporting requirements set a higher standard for transparency than many states, shaping how data in this report should be interpreted.

The Evidence Base for Transformation

Centers for Medicare and Medicaid Services (CMS) data released April 2025, which reflects calendar year 2023, demonstrates that Virginia's inpatient psychiatric hospitals (public and private) rank 5th highest in utilization among all 50 states, D.C., and Puerto Rico for physical restraint use at 0.90 per 1,000 hours – three times the national average of 0.30 per 1,000 hours. Virginia ranks 14th highest for seclusion use at 0.45 per 1,000 hours – 1.3 times the national average of 0.36 per 1,000 hours. It is important to note that Virginia’s human-rights and regulatory framework is widely understood to require broader reporting of restrictive interventions than many other states, which can make utilization rates appear higher even when practice patterns are similar.

While these disparities demand action regardless of measurement considerations, direct state comparisons may be misleading because state regulatory frameworks create conflicts that influence provider interpretation and reporting practices even within federally regulated settings. Analysis reveals significant definitional variations across states that can affect reported rates. Virginia's definitional framework captures a broader scope of restrictive interventions as reportable incidents, while other states use various exclusions that may reduce their reported rates. Another factor to consider is that states may divert patients to criminal justice systems rather than treating them in psychiatric facilities. These practices and definitional differences make direct state comparisons potentially misleading, as "better performing" states may simply be avoiding reporting restraint use rather than avoiding restraint use itself or using a narrower scope of restrictive interventions as reportable incidents.

The legal framework of “Bed of Last Resort"(*1) is also unique to Virginia and should be considered when making cross state comparisons of use of seclusion and restraint in state operated facilities. Under Bed of Last Resort, state hospitals are required to admit individuals under a temporary detention order (TDO) for whom no private bed could be located during the emergency custody order (ECO) period. Within five years of passage in FY 2014, Civil TDO admissions to state hospitals had risen by almost 400 percent. This increased demand for services has created hospital census pressures that have had significant impacts on the state hospital system’s ability to maintain a safe therapeutic environment and adequate staffing levels.

When viewed together, Virginia’s broader definitions, stronger human-rights safeguards, and statutory admissions mandate create structural conditions that elevate reported rates even as they strengthen individual protections and transparency. Acknowledging these differences, the evidence base remains a tool to understand the overarching landscape in which public and private facilities in Virginia implement restrictive interventions.

NOTE: For community-based settings, incident data for individuals receiving behavioral health, mental health, intellectual disability, and developmental disability (BH/MH/IDD) services is nationally systematically unavailable to the public for benchmarking, unlike hospital settings which have federal reporting requirements.

The Solution Framework

Through intensive stakeholder engagement, the Senate Bill 569 Workgroup achieved consensus on recommending implementation of(*2) the Six Core Strategies for Reducing Seclusion and Restraint Use (6CS), a nationally recognized, evidence-based framework developed by the National Association of State Mental Health Program Directors (NASMHPD). Through the 6CS framework, Virginia can establish clear 'No Force First' messaging that positions the use of seclusion and restraint, except in true emergencies, as system failure requiring prevention strategies. The framework accomplishes this transformation through six core strategies:

1. Leadership Toward Organizational Change
2. Use of Data to Inform Practice
3. Workforce Development
4. Use of Restraint/Seclusion Prevention Tools
5. Involving People Who Are Receiving Services
6. Debriefing Techniques

Implementation Roadmap and Resource Requirements

Immediate actions requiring minimal financial resources can create a system-wide foundation for transformation and include establishing a unified philosophy of care system-wide, reaching consensus on key definitions and embedding 6CS principles, leveraging existing infrastructure to create communities of practice and peer learning opportunities. Additionally, there is a need to increase the community provider reporting rate, currently at 70 percent, for seclusion and restraint incidents that represents a fundamental system reliability problem requiring implementation of enforcement mechanisms.

Longer-term actions with significant fiscal impact include workforce development, data system improvements, and training standardization.

Virginia's approach should strive to prioritize resourced implementation providing training and technical assistance, infrastructure support, and phased implementation with adequate provider support and engagement of diverse stakeholders to ensure successful adoption across settings.

The Bottom Line

Virginia has the evidence, stakeholder consensus, and agency commitment necessary for transformational change. Other leading states have proven that reducing and eliminating seclusion and restraint enhances rather than compromises safety while reducing costs and improving therapeutic outcomes. Embedding evidence-based, trauma-informed practices in permanent regulatory frameworks, would position the Commonwealth as a national leader in behavioral health transformation. With clearer definitions, strengthened data systems, and reforms that reflect Virginia’s unique statutory and human-rights context, the Commonwealth can make meaningful progress toward reducing reliance on restrictive interventions across all settings.

This report provides an overview of Virginia's seclusion and restraint performance compared to national benchmarks, presents the Senate Bill 569 Workgroup's consensus recommendations organized within the Six Core Strategies framework, and outlines implementation priorities for transforming Virginia's behavioral health and developmental disabilities system to prioritize prevention over restrictive interventions.
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(*1) 2014 Virginia Acts of Assembly Chapter 691
(*2) Several workgroup members noted the importance of DBHDS gathering additional input on how 6CS will be implemented.