Last Resort, Done Right
A Pocket Guide to Restraint Chairs and Isolation for Jail Officers
Hayden P. Smith, PhD
It is past midnight in a small jail, and intake is stacked. A new arrival is naked, confused, smearing feces on the wall, screaming, pacing in tight circles, pounding the door, and threatening to hurt himself. Staffing is thin, and the unit feels on edge. In that moment, a restraint chair and an isolation cell can look like instant control. These tools are not neutral, though. Used outside the guardrails of policy and recognized standards, they create security, liability, and dignity risks; used correctly—only as true last‑resort measures with tight observation and quick step‑down—they can stabilize a dangerous situation and restore order (American Psychiatric Association [APA], 2022; Metzner et al., 2007).
This guide gives officers something usable: clear minimums that keep people safe and the record clean, plus best‑practice steps that build calmer units and a stronger custody culture. “Minimums” here are the non‑negotiable floor that tracks commonly adopted standards from the American Correctional Association’s Performance‑Based Standards and Expected Practices for Adult Local Detention Facilities, Fifth Edition (updated 2023) and the National Commission on Correctional Health Care’s Standards for Health Services in Jails (2026), together with applicable state requirements (for example, Ohio Admin. Code 5120:1‑8‑09). “Best practices” go beyond that floor, drawing on national clinical guidance and operational evidence to reduce injuries, shorten events, and lower liability (ACA, 2023; NCCHC, 2026; Ohio Administrative Code 5120:1‑8‑09).
In mental health crises occurring in jail, you often see a cluster of concerns: self‑injury or threats, aggression and violence, sustained screaming, repetitive pacing or other erratic aggression, loss of self‑control, and often intoxication and/or withdrawal. Debating motives or “faking” wastes time. Safer practice is to describe the behavior you observe, control imminent danger with the least restrictive response that will work, and move the person toward safer housing and clinical support as conditions allow. Current standards of practice identify seclusion or restraint as emergency measures only—when de‑escalation fails—and emphasize continuous monitoring and prompt discontinuation. When these factors fail, statewide jail reviews may find weak justifications for placing a person in a restraint chair, missed checks, excessive force, and delayed release (APA, 2022; Iowa Citizens’ Aide/Ombudsman, 2009; Iowa Office of Ombudsman, 2024).
To empower officers facing an often-challenging jail environment, the following approaches to restraint chairs and isolation are recommended.
The S.T.A.R.T. protocol—short, shared, and practical.
S.T.A.R.T. turns “talk first, restrain last” into a repeatable routine any shift can execute. It aligns with APA’s emergency‑only, least‑restrictive, and time‑limited principles and with implementation strategies shown to reduce restraint through leadership, workforce development, and data‑driven practice (APA, 2022; National Association of State Mental Health Program Directors, 2006). The aim is simple: organize the team, try de‑escalation first, verify last‑resort criteria, run the event on a clock, and step down early.
S — Set the scene. Assign roles (lead communicator, hands, camera, door, runner), put on PPE, clear hazards, start cameras, and write down the exact start time. Take a 30‑second huddle (if non-emergency)—what the team will do if specific behaviors continue, and when the team will stop—so everyone acts in sync. These steps strengthen safety and make documentation defensible; oversight reviews consistently highlight the value of organizing before contact and time‑stamping key actions (Iowa Citizens’ Aide/Ombudsman, 2009; Iowa Office of Ombudsman, 2024).
T — Talk and test de‑escalation. Use calm, direct, simple instructions; employ Crisis Intervention Training (CIT) protocols; reduce the audience; offer basic choices (water, blanket, quieter space) when safe. Use a team approach with security and health staff. If risk falls to an acceptable level, stop and step down. This is the core “de‑escalation first, restraint last” principle (APA, 2022; Metzner et al., 2007).
A — Authorize and apply. Confirm an imminent risk of serious self‑harm or violence and that less‑restrictive steps failed or are unsafe. Obtain supervisor approval, notify health services (on‑site, on‑call, or telehealth), and state a clear reason (for example, “stopping head‑banging after de‑escalation failed”). This satisfies emergency‑only, last‑resort criteria and aligns with widely used operational and health standards, including state rules for jail health operations (Metzner et al., 2007; Ohio Administrative Code 5120:1‑8‑09).
R — Record and recheck. Start clock‑driven observation immediately. Maintain continuous monitoring and conduct in‑person checks at least every fifteen minutes. Use a tick‑sheet with officer initials so every check covers airway and breathing; distal circulation and limb comfort; strap fit and skin integrity; pain or distress, hydration, and bathroom needs. Escalate to health if risk flags are present (for example, intoxication or withdrawal, heavy sedation, obesity, conducted‑energy device exposure, breathing concerns, health complaints). Reviews show missed checks and thin notes are common pitfalls; timers and checklists prevent both (APA, 2022; Iowa Citizens’ Aide/Ombudsman, 2009; Iowa Office of Ombudsman, 2024).
T — Transition and debrief. Release as soon as it is safe—there is no minimum time in a chair. If moving to isolation, treat it as an active safety intervention: set the observation level, continue checks without a gap, and write clear release criteria. Afterward, hold a short huddle to capture lessons and tighten practice. This mirrors APA’s emphasis on prompt discontinuation and active follow‑through (APA, 2022).
Checklist — Restraint Chair and Isolation Quick Card (Tick Sheet)
When to consider using a restraint chair or isolation (all items should be yes). Use these tools only when there is an immediate risk of serious self‑harm or violence, and safer, less‑restrictive options have failed or are not safe to attempt. Obtain supervisor approval, notify health services, and write a clear, plain‑language reason. This “emergency‑only/last‑resort” threshold reflects APA guidance and helps you stay aligned with commonly used minimums and state rules (APA, 2022; Ohio Administrative Code 5120:1‑8‑09).
☐ There is a present and serious risk of self‑harm or violence that cannot be controlled safely by less‑restrictive means. ☐ Attempts at de‑escalation or environmental changes have been tried or reasonably ruled out, and this is documented in plain language. ☐ Supervisor authorization has been obtained with the approving supervisor’s name and approval time written in the log. ☐ Health services have been notified and are available to advise, whether on‑site, on‑call, or via secure telehealth. ☐ A plain‑language reason explains why restraint or isolation is necessary at this moment.
Before contact (security set‑up). Assign roles, don PPE, clear hazards, start cameras, time‑stamp the start, and identify the health lead (on‑site, on‑call, or video). A short “what we’ll do/when we’ll stop” huddle keeps the team in sync and reduces hesitation under pressure (Iowa Citizens’ Aide/Ombudsman, 2009; Iowa Office of Ombudsman, 2024).
☐ Roles assigned for lead communicator, hands, camera, door, and runner; personal protective equipment is on. ☐ Hazards cleared; cameras recording; start time written clearly in the log. ☐ Health lead identified and reachable in person, by phone, or by video. ☐ Brief huddle completed, stating the plan, decision points for stopping, and immediate goals.
Choose the tool—restraint chair or isolation. Use the chair only when the person is actively striking, head‑banging, or self‑harming and cannot be safely contained otherwise. Use an isolation cell when violent behavior has ceased, but close observation in a ligature‑resistant space is still necessary. Treat chair‑to‑isolation as a step‑down, not a pause: set observation level, define release criteria, and continue checks (APA, 2022).
☐ Chair selected only for active self‑harm/violence that cannot be controlled by less‑restrictive means. ☐ Isolation selected when calmer behavior still requires close observation in a ligature‑resistant cell. ☐ If transitioning chair→isolation, observation level, and release criteria are set; checks continue without interruption. ☐ At hand‑off, next‑check time and observation level are stated to the receiving officer.
Placement (do it right). Avoid pressure on the chest, neck, or abdomen, and do not keep the person prone. Protect the airway and dignity (offer clothing or a blanket promptly). Record a quick baseline: behavior, breathing, and appearance, obvious injuries, intoxication/withdrawal flags, and the clear start time. These steps reduce medical risk and improve the defensibility of the record (Castillo, Coyne, Chan, et al., 2015).
☐ No prone pressure is applied; airway is protected; dignity is maintained with prompt clothing/blanket. ☐ Baseline is recorded (behavior, breathing/appearance, injuries, intoxication/withdrawal, start time).
While in the restraint chair (continuous monitoring and checks at least every fifteen minutes). Keep eyes on continuously and conduct in‑person checks on a fifteen‑minute clock. At each check: confirm easy breathing; assess hands and feet for color, warmth, and movement; verify strap fit and skin condition; ask about pain; offer water and bathroom when safe; call health for risk flags (for example, intoxication/withdrawal, heavy sedation, obesity, conducted‑energy device exposure, breathing concerns). Release as soon as it is safe; there is no minimum time (APA, 2022; Metzner et al., 2007).
☐ Continuous observation; in‑person checks at least every fifteen minutes using a timer or tick‑sheet. ☐ Each check covers breathing, distal perfusion, strap fit/skin, pain/distress. ☐ Water and bathroom offered when safe; offers and responses noted. ☐ Health contacted for risk flags; vital signs/direction obtained as needed. ☐ Released promptly once the initiating risk resolves; no minimum time.
While in isolation (active observation). Set observation level explicitly: constant observation or in‑person checks at least every fifteen minutes. Write clear release criteria (for example, calm, oriented, agrees to a basic safety plan). At each check, document mental status, respiratory status, hydration, and other needs, and any clinical guidance. Quiet does not automatically mean safe—maintain clinical contact after chair removal (APA, 2022; Metzner et al., 2007).
☐ Observation level is set, and release criteria are written in the log. ☐ Each check documents mental/respiratory status and hydration/needs; clinical guidance is recorded. ☐ Clinical contact remains frequent; quiet behavior alone is not taken as proof of safety.
Release and transition (close the loop). Write the exact stop time, perform a quick skin and limb check, and record injuries or “none observed.” Hand off to safe housing with observation level and next‑check time stated plainly; when appropriate, explain next steps to the person and briefly inform staff of release and continued observation. Early release once criteria are met is both safer and more defensible (Iowa Citizens’ Aide/Ombudsman, 2009).
☐ Stop time written; quick skin/limb check; injuries documented or “none observed.” ☐ Hand‑off includes observation level and next‑check time; person informed in plain language. ☐ Unit staff informed in simple terms to continue observation.
If you must extend—raise the bar. Extensions require a written reason, higher‑level approval, and closer clinical involvement. Reconsider alternatives (step‑down observation, clinical evaluation space, transfer for specialized care) rather than simply adding time (Metzner et al., 2007).
☐ Written reason and higher‑level approval obtained. ☐ Alternatives reconsidered with health: step‑down, evaluation space, or transfer.
Red‑flag safety signs—call health now. Call health immediately for labored or noisy breathing, bluish lips or fingertips, sudden unexplained quiet after extreme agitation, chest pain, vomiting or suspected aspiration, loss of consciousness, seizure activity, or severe muscle pain with dark urine—possible life‑threatening complications (Castillo et al., 2015; APA, 2022). Report all health complaints or comments to health staff.
☐ Any red flag above prompts immediate clinical response.
After‑action—same‑shift huddle and records. Hold a short huddle with custody, the supervisor, and health: Was it necessary? Which alternatives were tried and in what order? Were checks complete? Was release prompt once the criteria were met? The log should show start and stop times; each in‑person check or constant‑watch note; offers of water and bathroom; any vital signs; reasons for any extension; and that video was flagged for retention. Track simple monthly metrics (uses, average duration, missed checks) to refresh training and supervision (Iowa Office of Ombudsman, 2024).
☐ Brief huddle completed (necessity, alternatives, checks, release). ☐ Log complete (times, checks, offers, vitals, extension rationale, video retention). ☐ Monthly metrics tracked and used for training.
Closing note
When used rarely and correctly—by trained, attentive staff under clear policy and clinical oversight—restraint chairs and isolation can interrupt lethal momentum, prevent injuries, and save lives. The same disciplined habits you practice here—S.T.A.R.T. roles and de‑escalation, continuous observation, fifteen‑minute checks, early release, and same‑shift review—also curb inappropriate or prolonged use that drives medical risk and lawsuits. Investing in training, documentation discipline, and strong health‑care partnerships turns these devices from potential liabilities into tightly controlled safety tools that protect people, reinforce a professional culture, and stand up under scrutiny (APA, 2022; ACA, 2023; NCCHC, 2026; Metzner et al., 2007; Iowa Office of Ombudsman, 2024; Castillo et al., 2015).
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Hayden P. Smith, Ph.D., is a Professor in the Department of Criminology & Criminal Justice at the University of South Carolina. His work centers on use of force, restraint chairs, PREA, mental illness in corrections, suicide and self‑injurious behavior, officer wellness and resilience, standards of care, and program evaluation. Dr. Smith regularly consults with correctional agencies on evidence-based practices, training, and policy development, and serves as an expert witness in legal cases involving correctional systems. For more information, he can be contacted at SmithHP@mailbox.sc.edu
References
American Correctional Association. (2023). Performance‑Based Standards and Expected Practices for Adult Local Detention Facilities (5th ed., 2023 update). American Correctional Association.
American Psychiatric Association. (2022). Seclusion or restraint (Resource document). American Psychiatric Association.
Castillo, E. M., Coyne, C. J., Chan, T. C., et al. (2015). Review of the medical and legal literature on restraint chairs. Annals of Emergency Medicine. https://escholarship.org/uc/item/501663s9
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Iowa Citizens’ Aide/Ombudsman. (2009). Investigation of restraint device use in Iowa’s county jails. Des Moines, IA.
Iowa Office of Ombudsman. (2024). Sitting in place: A re‑examination of restraint device use and regulations for Iowa’s county jails. Des Moines, IA.
Isenberger, S., et al. (n.d.). Emergency department use of a restraint chair is associated with shorter restraint periods and less medication use than four‑point restraints. Western Journal of Emergency Medicine.
Metzner, J. L., Tardiff, K., Lion, J., Reid, W. H., Recupero, P. R., Schetky, D. H., & others. (2007). Resource document on the use of restraint and seclusion in correctional mental health care. Journal of the American Academy of Psychiatry and the Law, 35(4), 417–425.
National Association of State Mental Health Program Directors. (2006). Six Core Strategies for Reducing Seclusion and Restraint Use. Alexandria, VA.
National Commission on Correctional Health Care. (2026). Standards for Health Services in Jails. National Commission on Correctional Health Care.
Ohio Administrative Code. (n.d.). Rule 5120:1‑8‑09: Medical/mental health (full‑service jails). State of Ohio.