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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 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