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!