When Convenience Trumps Treatment: The Abuse of Psychiatric Restraints

Judging by the comments in my inbox, my piece "When Policy Is Harmful: Should Psychiatric Patients Be Handcuffed When Transported?" struck a nerve with a lot of people. The use of restraints--whether metal ones used by police or the cloth or leather ones used in an inpatient setting--is one of the dirty secrets of mental health. Due to the destructive nature of some symptoms of borderline personality disorder (BPD), it is something of an open secret for us.

The laws no one knows

On December 17,1991, the United Nations passed Resolution 46/119, which covers the rights of people with mental illness. Principle 11, Paragraph 11, mandates restrictions on the use of restraints and seclusion.

"Physical restraint or involuntary seclusion of a patient shall not be
employed except in accordance with the officially approved procedures of the mental health facility and only when it is the only means available to prevent immediate or imminent harm to the patient or others," reads the paragraph. "It shall not be prolonged beyond the period which is strictly necessary for this purpose. All instances of physical restraint or involuntary seclusion, the reasons for them and their nature and extent shall be recorded in the patient's medical record. A patient who is restrained or secluded shall be kept under humane conditions and be
under the care and close and regular supervision of qualified members of the staff. A personal representative, if any and if relevant, shall be given
prompt notice of any physical restraint or involuntary seclusion of the
patient. "

Similar federal and state laws exist, requiring that restraint and seclusion are used a) only to ensure physical safety of the individual or others and are b) subject to a written order from a professional permitted by the facility and state law.

The problem is state law is not always followed--sometimes because staff don't know the relevant laws.

Staff convenience and lack of training

"Restraint and seclusion have no therapeutic value," reads the Public Policy Platform of the National Alliance on Mental Illness [8.8.2]. "They should never be used to 'educate patients about socially acceptable behavior;' for purposes of punishment, discipline, retaliation, coercion, and convenience; or to prevent the disruption of the therapeutic milieu."

A statement like that doesn't arise in a vacuum. In 2005, I e-mailed my friend Dr. Cynthia Wall about some restraint abuses I'd seen, including:

1. staff using a type of restraint they weren't trained in
2. staff leaving patients strapped down for more than one hour without review
3. staff telling patients "you brought this on yourself" or "that attitude [is] just going to keep those on longer".
4. a nurse telling a patient who insisted a restraint was unjustified "That belief that it's other people's fault is just going to keep those [finger control] mitts on longer."
5. less restrictive means not tried before multiple cases of restraint use
6. restraints were used on a previously sleeping patient

I've heard it said "Restraints and seclusion aren't treatments, they're treatment failures." In these cases of "treatment failure", treatment wasn't even tried--restraints and seclusion were simply used for convenience.

I filed a complaint with the Indiana State Department of Health, who cited the hospital after sending me a five-page report detailing the violations they found. Perhaps the most concerning one "[staff member in psychiatric intensive care unit] had no training in Crisis Intervention, restraint and seclusion techniques, only take-down and how to fill out the old restraint check list."

When staff aren't trained properly, easily avoidable mistakes are made.

What proper training looks like

I spent nine months on the BPD unit at LaRue D. Carter Memorial Hospital, a state hospital in Indianapolis. As you can imagine, I saw multiple people lose control. However, because the staff was well-trained, restraints were used relatively rarely.

Staff would first try to talk to a patient who was having symptoms. Many times the patient would calm down after an initial hostility--I'd say maybe eighty percent of disruptions never went past this level. As-needed medication was the second line of defense, depending on how talking went and how the person felt. A third option was a temporary nursing measure such as unit restriction, typically used when a patient felt suicidal.

Restraints were used only when a patient turned violent toward another person. While never easy to watch, proper training and using that training ensured that it rarely happened. It's ironic that although the least restrictive means can be inconvenient for staff, it's the best course of action for the patient and can lead to less trauma for both.