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Use of Physical Restraints and Seclusion in Psychiatric Facilities

In psychiatric facilities throughout the world, physical restraints are used as an emergency procedure to control patients that pose an imminent danger to themselves or others. Physical restraints include devices used to restrict a patient’s physical movement, including limb holders, safety vests, and belts among many others .  

When first used, the seclusion room resembled the stereotypical padded cell, but it now hides under the guise of “quiet rooms” where a patient is kept alone in a room with only a bed, not too far off the locked isolation of the past.

Some of these patients come in to the hospital in an involuntary admission, where they have been deemed a sufficient danger to themselves or others to be admitted against their will, or they may have been consensually admitted, knowing the sever nature of their behavior, or experiencing a severe escalation in behavior during the hospitalization.

There is global awareness concerning the need to better train and equip nurses to deal with difficult situations. Nations such as China that identify that they do not have sufficient staff within their mental institutions appear to be willing to increase the number of nurses on staff so they less frequently have to turn to restraints.

Some of the tools used to restrain patients in the pre-reform era.

History of Restraint and Seclusion Policies

In the early 1800’s physical restraints were commonplace in asylums with some of the most extreme usages coming from America. Straitjackets, coercion chairs, and protection beds were used to force “self-control” on patients^[3]. In Europe, particularly in Britain, protests replaced some of these harsher methods with the supposedly gentler padded seclusion room, cold packs and wet sheets to rapidly lower body temperature, all with the goal of regulating emotions and behavior^[3]. Patient advocates disliked the personal contact with patients required for the physical restraints and the neglect of the isolation room.     

Policies by Nation and/or Region

United Nations/World Health Organization

When these two organizations set about making regulations lots was left up to the individual nations. They did, however, assert that seclusion and restraints should be used as a last resort, and not as an alternative to structure or resources.

During one meeting of the UN they passed the Resolution on the Protection of Persons with Mental Illness. Directly concerning physical restraints was Principle 11: “Physical restraint or involuntary seclusion of a patient shall not be employed except in accordance with the officially approved procedures of the mental health facility and only when it is the only means available to prevent immediate or imminent harm to the patient or others. It shall not be prolonged beyond the period which is strictly necessary for this purpose. All instances of physical restraint or involuntary seclusion, the reasons for them and their 8 nature and extent shall be recorded in the patient's medical record. A patient who is restrained or secluded shall be kept under humane conditions and be under the care and close and regular supervision of qualified members of the staff. A personal representative, if any and if relevant, shall be given prompt notice of any physical restraint or involuntary seclusion of the patient.”

These same regulations include Principle 9: “Every patient shall have the right to be treated in the least restrictive environment and with the least restrictive or intrusive treatment appropriate to the patient's health needs and the need to protect the physical safety of others,” and Principle 10, concerning medication: “Medication shall meet the best health needs of the patient, shall be given to a patient only for therapeutic or diagnostic purposes and shall never be administered as a punishment or for the convenience of others.”

Other components of the resolution spoke more generally to the rights that psychiatric patients maintained, such as privacy, religion, expression, and representation in front of the law. The WHO also found it necessary to lay out in Principle 16 criteria for involuntary admission so that a person who is not a danger to themselves or others cannot be detained against their will. As the bodies responsible for setting the global standard for humane treatment of patients the United Nations and the World Health Organization sets clear requirements that still leave space open for individual interpretation by each member country.

A potential example of a more modern restraint that could be used in an inpatient setting.

United States

The American Psychiatric Nurses Association, which represents those who have the most interaction with those on an inpatient unit support the reduction and elimination of the use of restraints and seclusion through collaboration with patients, families, and doctors (American Psychiatric Nurses Association). However, in order to reduce the use of restraints there must be proactive behavior on inpatient units. This involves but is not limited to: a high presence of staff on the unit observing patients for change, assessing and intervening early, and changing the environment when necessary to promote calmness, cooperation, and structure.

Many non-profit organizations in the US are involved in advocacy for those with psychiatric illnesses. One of these groups – Mental Health America – calls itself “the nation's leading community-based nonprofit dedicated to addressing the needs of those living with mental illness and to promoting the overall mental health of all Americans”. Their goal is to help individuals find care and to ensure that that care is of the highest quality possible. When it comes to restraints, they firmly stand for the “abolition of the use of seclusion and restraints and prohibition of the use of sedatives and other medications as chemical restraints.” They make some qualifications for prisoners, both those in transit and at the extreme those kept in solitary confinement but continue to assert that restraints must be avoided at all costs.

The US Department of Health and Human Services is aware of this problem and issued a brief in 2010 acknowledging the deaths occurring nationwide and providing a number of solutions to reduce future deaths. Some suggestions were increased staff training, more treatment options with an emphasis on evidence-based methods, a focus on patient dignity, and regular communication between patients and staff. Individual states also independently monitor the private and state facilities under their jurisdiction for careless deaths that could be avoided, specifically those related to the use of seclusion and restraints.

European Union

When it comes to human rights and mental health, the EU sees its goal as standard setter, who ensures each nation has its own investigative group, not necessarily the enforcement body going to individual institutions checking for violations. In its most recent review the EU found that all nations except Azerbaijan, Turkey, Lithuania, and Latvia had organizations to do this work. There are huge inconsistencies between the power of these bodies to initiate change within their nation.

Almost all countries participate in involuntary admission and/or the use of restraints and/or the use of seclusion. There is no way to have confirmed statistics on this because every country has a different definition, a different standard for recording, and a different method of recording. Some don’t store any of the data nationally, so it cannot be accessed outside of each hospital.

The EU urges member nations to increase data collection and accessibility concerning restraints and seclusion and add policies for dealing with other forms of patient violence so less is left up to chance. Having more data to review would allow EU governing bodies to identify poor practices and work with nations to implement solutions.

China

In China the biggest problem is that a large number of the mentally ill go untreated. There are 173 million diagnosed with disorders and only 1.83 are registered as receiving treatment in mental health settings, leaving over 158 million completely untreated (some receive community based care, unregistered care, etc.) And even as the number of patients treated remains low, the use of restraints increased from 42.6% in 1994 to 51.3% in 2014. Much of this is explained by an extremely nurse to citizen ratio: only 3.77 nurses per 100,000 Chinese compared to 5.1 nurses per 100,000 citizens globally. Fewer nurses makes it more difficult to handle patients in crisis, hence the increased use of restraints. A report funded by the Chinese Nurses Association recommends the noting of usage in medical records, notification of next of kin, and explanation to patient and family for use of restraints, and care upon release from restraints.

Australia

Australia has a very precise, centralized system of keeping track of restraint and seclusion data. In 2016-2017 seclusion was used at a rate of 7.4 events per 1,000 bed days. This was a 6.7% decrease in usage from 2012-2013, the first-year data was recorded. Regions of Australia varied in usage of seclusion but not significantly enough to be noted here.

Things get a bit muddier when it comes to use of restraints. Definitions of restraints and implementation policies vary greatly between regions, so there are many inconsistencies. Nationally, there were 8.3 physical restraints per 1000 bed days, with Victoria having by far the highest number of total restraints, potentially since they only admit more acute patients.

on other regions will be added as possible and their addition is welcomed.

Ethics and Controversy

Protection for patients and for nurses is the reason most often cited in favor of the use of restraints. When left unrestrained, patients have at times lashed out violently, injuring themselves as well as nurses and other patients. However, a restrained patient can be vulnerable to injuring themselves, with 50-100 deaths reported annually. And even in the situations where restraints makes both the patient and those around them safer, it deprives the restrained of their basic right to autonomy, which cannot be ignored (Kaski-Valkama).

Many if not most of these decisions are made under the assumption that the mentally ill cannot act in their own best interest and if allowed will make harmful decisions. It is assumed that it is really in their best interest, but that the genuine interest can be corrupt and used to violate rights.

In every nation there are campaigns to stop the use of restraints, saying that they are inhumane and put patients at risk instead of creating the safer climate they claim to. Here in the United States, the Citizens Commission on Human Rights has investigated over 150 deaths attributed to restraints, at least 13 of which were children, and found that few if any of these deaths were prosecuted. This group calls on citizens to reach out to law enforcement and law makers, as current laws exempt psychiatric caregivers from assault and battery laws. CCHR advocates for the human rights of all those with mental illness.

Another US advocacy organization, National Alliance for the Mentally Ill (NAMI), published a response to a newspaper report in 1998 that found here may be as many as 50 to 150 deaths related to the use of restraints each year. Their top priority was establishing third party investigative bodies to look into all deaths in psychiatric facilities, with the ability to suggest and implement necessary changes. They also demanded more state funding for staff training, so that those who work with psychiatric patients are properly trained on the use of restraints, as misuse is the most common cause of death.