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
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:
- staff using a type of restraint they weren't trained in
- staff leaving patients strapped down for more than one hour without review
- staff telling patients "you brought this on yourself" or "that attitude [is] just going to keep those on longer".
- 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."
- less restrictive means not tried before multiple cases of restraint use
- 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.
Oberg, B. (2011, April 11). When Convenience Trumps Treatment: The Abuse of Psychiatric Restraints, HealthyPlace. Retrieved on 2022, June 26 from https://www.healthyplace.com/blogs/borderline/2011/04/when-convenience-trumps-treatment-the-abuse-of-psychiatric-restraints
Author: Becky Oberg
I am at a residential treatment facility right now. I am one suicide attempt to get put back on the waiting list for larue and i am beyond scared because i have been to awful places and i cant imagine what a state hospital is like.
I was a ward of the state and put into restraints weekly. I was left on the table. I was left in seclusion. So I dont know what year you was there. Thorzine shot scars all over my body.I was on B1. Would like to know where you was at?
I have been put into restraints many times over the years after being given a shot of Haldol.
Most people I have told cannot imagine that happening to me as I'm normally gentle and peaceful.
The times I was put into restraints, I was out of control, but I think if they had just put me into a room by myself with a comfortable chair and music or television, I would probably have calmed down sooner.
Most of the time, I was left in restraints much longer than necessary, and it was physically painful as I was in an awkward position and the leather cut into my skin.
You worked at a hospital that was worse than Larue Carter? Seriously?
I was on their adolescent unit for a year being "treated" for depression. Teenagers as young as 13 were regularly put in seclusion for weeks on end for trivial offenses - often just because they were accused of breaking a rule by some other teenager who was trying to curry favor with the staff.
As Angel writes above, the facility was filthy and infested with vermin. Communication with family was monitored - the worst punishments of all were handed out to kids who asked their parents to take them home, and parents were routinely told not to believe their kids' complaints. More than once I saw kids taken to the emergency room because physical medical problems had been ignored until they became desperate - the assumption was that if you told staff about physical symptoms, you were just lying and being "manipulative" (their favorite word).
The experts may say that seclusion and restraint have "no therapeutic value", but at Larue Carter's it was the cornerstone of their program.
If I locked my kids in a bare brick room with a urine-soaked piece of styrofoam to sleep on, and left them their for weeks on end with only a few minutes a day for monitored bathroom breaks, I'd be sent to jail. But apparently it's fine if you work for a hospital and tell parents you're doing it for their kids' own good.
I'm sorry your experience was so bad. At Richmond I saw people taken to the ER because physical medical problems became actual emergencies--like your experience, we were "making it up to get meds". I was even denied my inhaler one time in the midst of a severe asthma attack. I don't remember seeing rats at Larue Carter--ants, yes--and I remember parts of the hospital being dirty. The food wasn't always adequately cooked, either.
I knew someone who died at Larue Carter--suicide. Now how in the hell she could have hanged herself and died by the time staff found her I'll never know.
You're right, if you or I treated our kids the way some psych professionals treat us, we'd be in jail. Reform is desperately needed.
going to larue carter hospital was the worst 4 and a half months of my life. the units were dirty. and the staff definitely were not well trained. i was assaulted by another patient and i was the one moved to a different unit. unit 3e was dirty. the elderly patients were not well cared for. i was smacked by staci cambron, another patient on unit 4a, three times. staff did not care about my well being. instead, they comforted staci and treated her as the victim. when i got to 3e, they took my level and stuck me on one-one treatment for six weeks. i felt like and was treated worse than an animal. when it was time for me to be discharged, i had nowhere to go. the staff did not care to help me. i almost ended up on the street. larue carter is a terrible place to be and i would not wish it on my very worst enemy. the doctor on unit 3e though he was God md kept removing my levels and what few phone rights i had. besides jail and prison, this is the worst place on the planet. i will never go back. i sltill have nightmares about the place.