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ON THE USE OF RESTRAINTS
By Pamela Spiro Wagner
Imagine this scene: A patient on a psychiatric unit is screaming, bellowing threats, swearing at invisible persecutors, throwing things. Finally a hurled shoe hits a staff member. He becomes understandably upset, understandably enraged. The “goon squad,” several burly men in scrubs or security officers’ uniforms, is summoned to subdue the offender. They toss her onto a bed and strap her down with locked leather cuffs, pinioning wrists and ankles, only to leave her there, immobilized and completely subject to the whims of a staff angry and eager to punish.
This is very often the scenario, or one like it. But it is not the best or, more important, not the most helpful way to use restraints. I should know, having been a victim of them too many times.
I say “victim” and yet I am not particularly opposed to their use, only to the all too common fact that they are used to appease the fury of staff members, not to help a distressed patient or ensure his or her safety. In hospital units today, restraining someone is rarely meant to provide a source of calming reassurance, even less to emphasize the security of knowing that you cannot harm anyone.
No one likes to be wrestled to the floor or pinned down to a bed like a pithed frog, especially not when you’re a frightened, delusional schizophrenic. Worse, you may be ignored for hours by staff impervious to and unaffected by the fact that the crisis has long since passed. Revenge and punishment once justified keeping me restrained for three whole days because the nursing staff wanted to have what it considered a troublemaker off its hands. I was never a troublemaker, just a terrified young woman who didn’t know that what she experienced wasn’t actually happening.
Had I been able to request restraints, on time, before I got out of control, had hospital policy encouraged it as a short-term way to deal with serious agitation, I suspect they could have been helpful. But I couldn’t. Familiarity with the process made it too scary, too dangerous and degrading. If restraints had been recommended before being implemented by force, I’d have screamed, “NO! I don’t need them!”
So I admit that changes might not work for me, not yet. Perhaps because of a hospital culture that makes going into restraints ultimately fraught with indignity and humiliation, much of the experience would have to alter radically before I could accept it.
Yet even forcible restraints provide relief. A friend suggested it may work like socking it to a punching bag. Restraints, and struggling against them, have sometimes been more effective in calming me when in a frenzy than the massive doses of tranquilizers, with their intolerable side effects, to which I used to be subjected as a more “humane” alternative.
If restrained when voices shrieked in my ear that the doctor wanted to kill me, that I must run, escape, do something, I fought a physical obstacle, expending energy, without fear of causing injury. This relieved the pent-up terror while reducing the emotional valence of my symptoms.
My sister is a psychiatrist who for years ran an in-patient unit at a psychiatric hospital. She oversaw the voluntary use of restraints, restraints requested by patients aware that they were getting beyond the point of reasoning, beyond a threshold of self-control, when the safety of all was in jeopardy. She knows that patients ask for something that helps them, especially if it does not involve humiliation or punishment. Requests for restraints were honored; it meant patients knew when they were escalating and were asking for help. Also it meant they preferred not to be drugged into oblivion for what was a problem only of the moment.
Psychiatric units justify many measures during a crisis, but why wait for a crisis? Patients, aware that they are getting out of control, may be unable to stop it. That doesn’t mean they don’t want to, don’t want both to be protected and to protect others from harm. If some patients prefer restraints to a “chemical straitjacket,” why not make them available by request before they are required?
Dear Pam,
I did not comment on your last blog on restraints, because it was essentially the same piece you had written about previously, and upon which I had already commented.
This"improved" article, written with a much more tempered tone and a thoughtful, rational look at the dynamics that occur when both the staff and the patient are confronted with a 'crisis" situation(although a hospital policy which preserves the dignity of both parties is the ideal). You were able to remove yourself enough to write in true(and as impartial as could possibly be expected, given your negative experiences)jounalistic style that is worthy of your talent as a writer. I am genuinely impressed by this rewrite, Pam. Congratulations on a fine piece of writing. Always truthful, Paula.