WAGblog

Restraints

When last I wrote in these pages about restraints, it was about their voluntary use by psychiatric patients. Ever since then, I have been uncomfortable, knowing I took that position more or less dishonestly, toeing the “party line” of hospitals in Connecticut where such restraints are used all too often. I want to officially disavow that position here.

America has had a long love affair with restraints and seclusion as a method of treatment of its mentally ill. Benjamin Rush himself, the so-called “father of American psychiatry,” invented the restraint or “tranquilizing” chair, that is still in use today. With a succession of devices, from the cage-like locked box of a bed -- the Utica crib – and the well-known straitjacket, to the continuous flow tubs in which Van Gogh writes of hearing men screaming, to wet packs and any number of leather and metal shackles and wrist/ankle/full body restraints, you would never believe that we had enthusiastically embraced what was called “moral treatment,” which evolved gradually into the psychological treatments of today.

In 2005 I was hospitalized at a Fairfield country hospital and witnessed a nurse call for restraints because a young woman, who had been restricted to her room for swearing, kept on sticking her toes over the threshold. This girl was no danger to herself or others and the restraints were purely punitive. More recently, at a Hartford hospital, restraints were forcibly applied to several young women – one a night it seemed – because they were loud and obstreperous, making mild suicidal gestures or scratching themselves, but nothing that a little one-to-one attention could not have handled. In fact, one might wonder how restraints handled it better, since brutality cannot have been the cure to anyone’s problems, whatever they were. There were plenty of nurses on during those evenings, but it seemed they did paperwork only, and handed out meds, had no time for patient contact otherwise.

In fact, as I was told, hospitals these days, are crisis centers only and do not aim to cure, only to patch up and ship out the walking wounded. The use of restraints in this case was not intended to cure suicidality or even “cutting” but only to prevent further “acting out” before discharge could be effected. Acting out seemed to be the diagnosis used for all behaviors that were not the norm at this particular hospital and little concern (though a great deal of scorn) was expended on them, except for the use of restraints.

I myself have been the victim of punitive restraints for trying, in my psychosis, to escape a locked unit, and in the 80s was kept in them, spread-eagled, with my hands and feet tied to the bed’s four corners, for days at a time. (I did not know that this was NOT standard, that most restraints kept the patient’s arms by the sides.) What good is it to assure someone they cannot be kept in restraints longer than 3 hours without a doctor’s renewing the orders, when that doctor can do so by phone, without even seeing the patient? During that time, I was not fed and when I needed to use the toilet I was freed to go to the bathroom, which I did calmly, then was told I had to get back into my restraints, willingly and voluntarily! I balked. I was calm now. Why should they continue to restrain me? But they forced me, saying they would put me back in if I did not. I felt like I was cutting my own switch. How dare they demand such a humiliating procedure? I will never forget how degraded I felt by the act of lying down on the four posted bed and putting my own wrists and ankles in four point restraints.

Restraints are used in most cases because they are available and staff is not. If it were extremely difficult, or the barriers very high to using them at all, you can be assured that other methods of dealing with troubled young adults and agitated psychotic individuals would be found, and fast. I know that if someone had persisted in talking to me, even after I had acted on self-mutilating orders from the voices, or when I was paranoid and raging and afraid, restraints would have been unnecessary. But hospitals need trained staff and enough of them for interventions like that and often they do not have them, though I must say they find them quickly enough when the restrained person needs a sitter, as the law requires. In my experience, aides and techs do a lot of the work in hospitals these days, and their training, such as it is, tends to be solely on the job, though for all that many are terrific. Nurses in the Hartford hospital I was admitted to had virtually no patient contact other than administering meds and they seemed to resent it when they did.

So restraints were used instead of talking humanely and calmly to these admittedly difficult to deal with young adults, who nonetheless needed care and humanity in their treatment. If, instead of ordering them back to their rooms for a time-out, someone had offered to talk with them about their very real problems, not pretending that they didn’t exist for the sake of convenience, it might have done them the world of good that they needed before going back into the horrendous and abusive situations they came from. A day or two later they would leave in any event – tell me how putting them in restraints was either necessary or helpful? Did it change their living situation? Did it help them learn to cope better? Did it change their habit of cutting themselves when stressed out? Most likely it did nothing but what it was intended to do, punish them, quiet them down, and make sure they were kept docile enough for rapid discharge. Out of sight being out of mind, that problem could be considered solved by the hospital at any rate. Furthermore, readmittance two weeks later in another crisis did not matter; insurance readily paid for that. Just not an extended stay!

This restraint policy is the hospital’s fault, the staff’s fault and the insurance company’s fault. All are to blame, as well as congress, which will not write strong enough rules to govern the use of restraints such that they are applied rarely and under strictly guided procedures, or quickly lowers the bar once it is raised. But I reserve my disgust for the insurance corporations that pretend to understand mental illness and actually claim to know when a person is better before that person or that person’s doctor knows. It is the same for all conditions, I realize, so my disgust runs deep, but to play with people’s minds for the sake of money...? My revulsion knows no bounds. They are the ones forcing hospitals to ignore the crises that make their psych units crisis intervention centers, to force meds on everyone and ship them out in 3-5 days. They are the ones encouraging restraints to quiet and make someone ready for discharge.

Nevertheless, when staff acquiesces to easy restraint, we lose, and they lose too, part of their humanity and part of the idealism that made them seek out their particular jobs. Restraints should be reserved for those in “imminent danger of serious harm to self or others” not as punishment for a desultory suicidal gesture, or psychotic agitation. If we lower the bar, it should be a matter of the lindy not the high jump when restraints are used.

Posted by pamwagg at September 5, 2007 06:52 AM | TrackBack