7 Myths about Physical Restraints in Psychiatric Facilities

We’ve probably all seen movies such as “One Flew Over the Cuckoo’s Nest” (starring Jack Nicholson), where an individual with a mental illness is placed in a straitjacket in a psychiatric hospital due to being aggressive or out of control. These images are often disturbing and hard to forget. Further, they perpetuate the myth that this is how people with mental illness are managed in psychiatric facilities when they become violent or unpredictable.

Having worked in a psychiatric hospital for well over two decades, I’d like to separate the myths from the truth about how aggressive behavior is currently managed in today’s inpatient mental health facilities. This is important to understand so we can fight the ever-persistent stigma surrounding this issue.

Here are 7 myths about the use of physical restraints in psychiatric facilities and the corresponding facts about the appropriate standards of professional practice today. Since I initially published this article, I’ve gotten some comments from individuals who have been in psychiatric facilities and who have had negative personal experiences related to physical restraints and overprescribing of psychiatric medications.

Their comments have suggested that my description below about the use of restraints is overly positive and may be misleading. I agree that my views are based only on my professional experience and my understanding of the optimal standards of practice regarding physical restraints.

It’s certainly true and disheartening that people do still continue to experience negative and distressing experiences in psychiatric facilities. My hope though, is that by describing more optimal standards of care related to physical restraints, we can help stimulate discussion and encourage additional facilities to adopt more humane and compassionate approaches to treatment.

Myth #1: Straitjackets are still frequently used to control psychiatric patients.

The Facts: Straitjacket use was discontinued long ago in psychiatric facilities in the US. Physical restraints that are currently used typically include soft nylon and Velcro wrist and ankle bracelets which attach to a bed with a mattress. The patient will lay on their back on the bed while in the restraints, and their head is often elevated with a cushion. In some cases, a soft cushioned band may also be placed across their chest.

Myth #2: Use of physical restraints is highly unsafe and unregulated.

The Facts: In the mid to late 1990’s, several deaths of psychiatric patients in restraints were documented, largely due to accidental asphyxiation from inappropriate procedures. Extensive reforms were instituted by The Joint Commission, which accredits US hospitals, and by other state and Federal agencies. The entire process of using psychiatric restraints is now highly regulated and carefully monitored, with multiple safeguards in place to ensure the physical health and safety of both patients and staff.

Myth #3: Physical restraints are routinely used to control and to punish psychiatric patients.

The Facts: The use of psychiatric restraints is considered a “last resort” approach after all other measures to calm and support the person (verbal encouragement, medications, therapeutic activities, etc.) have failed. Physical restraints are only used to ensure the safety of the person in restraints and that of other patients and staff in the facility.

Myth #4: Psychiatric staff do nothing to avoid using physical restraints.

The Facts: Using psychiatric restraints is considered a “treatment failure.” Staff are required to analyze each use of restraints and debrief the event with other staff and with the patient who was restrained to determine what steps can be taken to avoid the future use of restraints. The prevailing philosophy and goal is to achieve a “restraint-free” environment, in which restraints are rarely, if ever used. Many psychiatric units have already achieved this goal of being completely free from the use of physical restraints.

Myth #5: Patients who are physically restrained may languish for hours or days with little staff supervision.

The Facts: Use of physical restraints is extremely time-limited and is required to be discontinued as quickly as possible, as soon as the person has regained control of their behavior. While in restraints, patients are continuously monitored by staff for safety, and they are offered food, drink, and bathroom access on a regular basis. Every effort is made to help the patient be as comfortable as possible, with respect for their privacy and dignity.

Myth #6: In addition to physical restraints, patients may also be “chemically restrained” by being forcibly loaded up on strong sedative medications.

The Facts: Using medications in this fashion is explicitly prohibited. Patients may be provided medications against their will during a psychiatric emergency involving the risk of harm to self or others, but only on an as-needed basis to help them calm down. They should never be given large doses of sedatives on a regular basis just to control or subdue them.

Myth #7: Staff in psychiatric facilities have little training in the management of aggressive behaviors.

The Facts: Psychiatric facility staff are highly trained in crisis management and prevention approaches, with the overriding goal of preventing the use of physical restraints, while ensuring the safety of everyone in the facility. Many facilities use proven, standardized staff training programs such as CPI (Crisis Prevention and Intervention), which require staff to demonstrate skill in these safe and effective techniques. Regularly scheduled mandatory refresher classes are held to make sure staff maintain these skills over time.

From this review, it’s apparent that physical restraints are still employed in rare circumstances when a person’s psychiatric issues prevent them from being able to control their behavior, thereby putting themselves and others at potential risk for harm.

However, the prevailing philosophy is to use physical restraints only in last resort situations when all less restrictive measures have failed, and to do everything possible to avoid the use of restraints in the first place.

Perhaps one day soon we can achieve the very desirable goal of being “restraint-free” and close the chapter once and for all on the long and troubled history of using physical restraints for those struggling with mental illness.

Here’s a question: What other issues have you encountered regarding the use of physical restraints among psychiatric patients? Please leave a comment. Also, please subscribe to my blog and feel free to follow me on Twitter, “like” my Facebook page, or connect on LinkedIn. Thanks!

  • Joseph McCartney

    Well David, After read your myth busting and coming from the other side of the fence it frustrates me know end to read some of the miss leading statements you make regarding these matters. Stop trying to candy coat a very broken system.

  • Joseph, I certainly never mean to mislead anyone. My comments come from 24 years working in a large public psychiatric hospital, but I can’t speak for practices in other facilities. I realize the mental health system has a lot of room for improvement and I’m hopeful we can make things better with our continued advocacy. Thanks so much for your comment.

  • Joseph McCartney

    Hi David, Sorry if I came across personally towards you and again I humbly apologize. but the system is so broken I had a very resent situation were a 45yr old gentleman was having serious suicidal thought’s and behaviors and I convinced him to go to the doctor (I had talk to the sister before hand to take him which which she agreed to and as you know is a first step for support ) to get a referral to the local hospital to be assessed by Mental Health. When I rang him the day after the assessment the poor fellow was crying telling me in his exact word that a women done the assessment and said to him there and then that she could not make any decision and that she would go and talk to the powers that be, after about 10-15 mins she came back a said that she had discussed the situation and there is nothing they would do, for F*** sake David is that not handing this poor gentleman a LOADED GUN. I would love to hear your comments on how we may be about to address the multitude of problems with the system. Thank’s David

  • Hi Joseph, I wasn’t offended at all by your previous comment. I’m so sorry to hear about the situation you described. I know all too well about the difficulties in helping people get appropriate care whey they are most vulnerable. You might be interested in my earlier blog post on “8 Reasons Why People Don’t Get Treatment for Mental Illness.” It outlines several of the barriers in the current system and some possible solutions we can keep promoting. Thanks again.

  • Joseph McCartney

    Thank you David, We might only be a mustered seed in this endeavor but what a big beautiful tree we can become. Will look at the blog you suggested. Thank’s again

  • Jack David Walters II

    David every run across a person who wanted to into restraints volunteerly?

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