August 13, 2004

Problems with 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 and 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 subject to the whims of an angry and possibly vengeful staff.

This is often the scenario for patients. I should know, having been a victim of forced restraints too many times.

I say �victim� and yet I am not particularly opposed to their use, if a patient agrees to them and there is the understanding that they will be removed as soon as the patient has calmed down. I am adamantly opposed to the way they are applied so often instead: in anger or frustration or motivated not by concerns for the safety of the patient or others but because there are not enough hospital personnel assigned to a shift to attend to an agitated patient. In hospital units today, restraints are used when there is a lack of manpower, something which is more and more common, and are rarely meant to provide brief calming reassurance to the patient and others that she cannot harm anyone.

No one likes to be wrestled to the floor or pinned to a bed like a pithed frog, especially not when you�re a frightened, delusional schizophrenic. Worse, despite official claims to the contrary, you can be ignored by staff for hours after a crisis has passed. I was once restrained for three days because, I believe, 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 couldn�t actually happen.

Had I been felt secure enough to request restraints before I got out of control, had hospitals policies encouraged their use as a short-term way to deal with serious agitation rather than as retribution, or worse, because they were too short-staffed to deal with the problem one-to-one, they might have been helpful. But familiarity with the process made it too scary, too dangerous and degrading in just about every hospital I�ve been in. Indeed, if restraints had been recommended before being implemented by force, I�d have screamed, �NO! I don�t need them!� That culture has to change. And it can. But not by downsizing staff or settling for less than fully trained nurses and aides due to cost-cutting efforts.

What also must change is the reflexive restraining of any patient, in hospital or nursing home, whom the nursing staff consider too much trouble or too time-consuming to deal with. Too often the simple lack of personnel assigned to a shift forces nursing homes and psychiatric units to resort to restraints when they are not necessary.

Although use of restraints has declined nationwide, a Hartford Courant investigation in 1999 found that 100s of people were dying while restrained in psychiatric hospitals all over the country, a despicable fact that has led Pennsylvania to ban all use of restraints in state hospitals. Federal figures from 2001 show that 12 percent of Connecticut�s nursing home residents have been physically restrained compared to 8 percent nationwide. This statistic speaks volumes: no one should ever be restrained for any length of time or in such a way that their lives are endangered. Too often, because hospital staff are grossly underpaid and overworked, restraints are used for convenience, not because a crisis genuinely calls for them. If a single person dies while restrained, it is prima facie evidence of abuse, either directly, by grotesquely unethical treatment of the patient, or indirectly, due to short staffing, which allows a situation to arise where death could result.

Yet, taken out of the context of punishment or convenience, sometimes forcible restraints can provide relief, when properly implemented for as brief a time as possible. To do so requires skill and compassion as well as a fully trained staff. The common practice of dealing with demented residents in nursing homes by tying them into wheelchairs and parking them along the walls for many hours, unattended and barely noticed, does not qualify. But just because restraints can be and are too often abused doesn�t mean they don�t have an appropriate use. A friend suggested they can work like socking a punching bag. Restraints, and struggling against them, have occasionally been more effective in calming me when I am in a frenzy, and doing so more quickly and effectively, than massive doses of tranquilizers with their intolerable side effects.

When voices shriek in my ear that the doctor wants to kill me, that I must run or escape, and I am restrained to prevent this, I can fight against them without injury to myself or others and simultaneously expend enough energy to tire of fighting. Sheer fatigue by itself can work to relieve my terror and reduce the emotional valence of my symptoms. But the situation must be constantly monitored by someone trained to assess when a crisis has passed and compassionate enough to call for their removal at the earliest moment. Otherwise restraints are less therapeutic than a cruel way to baby-sit a patient no one has the time for.

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 will ask for something that helps them, especially if it does not involve humiliation or punishment. Requests for restraints in her hospital were honored; they 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 of the moment.

Today, this is not possible in most psychiatric units, because restraints have been relegated to the province of punishment, their therapeutic use completely discounted on the one hand, as the rate of use for the convenience and benefit of overworked staff has increased on the other. This is unfortunate, because the hospital culture that indicates restraints are used only when patients are �bad� could just as easily promote them for patients� benefit, for those patients "good" enough to know when they would be helpful. In any case, they must be applied in a non-threatening way, with the understanding that they will be individually assessed, and as brief as possible.

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 themselves. That doesn�t mean they don�t want to. If patients, and nursing staff, can be taught that restraints are not punishment but a genuinely helpful form of therapy, and if some patients come to prefer restraints to a �chemical straitjacket,� why not make them available by request before they are required?

Posted by pamwagg at August 13, 2004 09:34 AM | TrackBack


I am relieved to hear that I am not alone in feeling the safety and security that restraints can provide. I suffer from bipolar I and post traumatic stress disorder. When I have been siezed by virulent mixed states or pure manic energy that reaches a crescendo, I feel desperate and out of control. I long for a place of safety until the wave passes. Chemical restraint can take too long in such a state, and can be too debilitating due to the side effects. When placed firmly in restraints, I immediately felt relief, and a lessening of fear. Sometimes I have been afraid that I would be released too soon from my restraints. Given the choice between chemical or physical restraint, I would request to be placed in physical four point restraint, applied with understanding and care. The proper timing and application of restraint has saved my life.

Posted by: Chantal at January 7, 2008 05:20 AM

what are restrainds like do the have belt that goes across your chest to and lock it with key to hold you so you can not get out

Posted by: crystal at November 25, 2006 02:31 AM

i agree cem restraints dont get to the root of the prob if you feel unsafe and out of control and ask to be restrained you should be then the therpy to find out why you feel like losing control should start while restraind and u feel safe is that so much to ask

Posted by: crazy? at September 22, 2006 11:15 PM

Pamela, I happened across your article almost by accident while browsing the Internet on various mental health topics. I hope it's okay that I'm posting to a schizophrenia website, when my own diagnosis is on the post-traumatic stress disorder spectrum. Your article touched a chord for me.

I understand and respect that a lot of people who are forcibly restrained find the experience frightening and traumatic. But the mental health profession's efforts to reduce the use of restraints seem too absolutist, often referring to physical restraints as a "last resort" and "representing a treatment failure" (with chemical restraints considered a preferable alternative, despite their often stupefying side-effects). I once read an abstract of a medical journal article that, by actually asking patients, found that a percentage of patients consider physical restraints to be a less restrictive intervention than chemical restraints.

I've been in situations in the hospital in which I somehow managed to not lose control, but the intensity of the psychic energy I had to expend to do so, in the face of extreme internal distress, was painful and felt traumatic in and of itself. Restraints, if applied with compassion, would have helped me to feel physically and emotionally safer. It seems like inpatient staff won't allow restraints until the patient has actually lost control, and then it automatically becomes an adversarial relationship. It strikes me as more than odd that patients who are admitted to a psych unit because they're having difficulty staying in control are immediately told on admission that they are expected to stay in control.

Thank you for your article. It helps me to feel less alone with my "politically incorrect" desires for physical help with safety when I'm feeling overwhelmed.

- Phil

Posted by: Phil at August 21, 2004 02:29 PM

I think it comes down to money, it seems that most hospitals don't have enough money to have more staff to help when people are losing control so patients are restrained. When I went to the county hospital last year I remember how few staff there where and the higher-ups had way to many responsibilities to handle. People are against spending money, but I think if they saw what was going on in the inside it would probably change their minds.

Posted by: endthis at August 18, 2004 07:01 AM

This is an excellent rewrite of your former reflections on the use and misuse of restraints, Pam. It is obviously well researched, planned, and executed. It covers virtually all of the bad and good characteristics of the entire subject. This article will hopefully have an impact which may well affect the policies that many hospitals have used for far too long. Fine journalistic material! Congrats, Paula

Posted by: Paula Kirkpatrick at August 14, 2004 04:07 PM

i never got put in restraints, but was often put in cold wet packs. i hope that is no longer done. it felt more like rape than therapy.

Posted by: .::a::. at August 13, 2004 09:53 AM

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