There is such a thing as psychiatric control. A patient signed into the hospital should be aware that the practice of locked wards, drugging, forced intramuscular (IM) injections, confinement, restraints, and isolation are used in the treatment of persons with mental health issues. The staff determines when a patient is "a danger to oneself or others" and intervenes with control measures to eliminate that danger.

In searching the Internet, the few web sites I found about restraint and seclusion in the psychiatric hospital system were either critical of these practices or provided information on how best to perform them. Several sites described instances where the patient died as a result of these practices. These incidents are tragic and point to the necessity of care in treatment. This article reviews the seclusion and restraint (physical, chemical, and not so well known, verbal) procedures that are used on psychiatric patients.

Psychiatric patients are admitted with behavioral health problems and mental health diagnoses. Their conduct can be very upsetting or intimidating. There are instances of passive aggression and all-out aggression, verbal and physical. Some patients often act in an offensive manner. They may try to agitate staff or other patients to get staff’s attention. Patient reactions to staff and each other often include withdrawal, attention seeking, acting out (often a response to frustration and conflict), resisting treatment, passivity (misconstrued as "model" patient behavior), aggressiveness, defensiveness, and hostility. The patients’ attempts to manipulate each other and staff are "desperate attempts to secure more privileges, win attention or otherwise attempt to wrest a shred of control over their bodies and minds from the twin robbers of illness and its treaters" (Berger and Vuckovic, p. 93).

In the staff’s defense, their jobs are difficult. They must manage a ward of 15 or more patients, all presenting various diagnoses. They are sharing a locked ward for eight hours a day with patients who may exhibit paranoid and/or irrational thinking, racing thoughts, loose associations, etc. Staff must be prepared to handle out-of-control behavior, verbal or physical. The management of violence and aggression are central to the proper running of the psychiatric ward.

VERBAL RESTRAINTS

The word "restraint" has several meanings. In the case of verbal restraint, I am referring to restrictions and cautions. These spoken disciplinary methods are common. Most ward staff employ this hands-off approach. Ward nurses, mental health assistants and aides, and (to a lesser degree) occupational and recreational therapists will be firm and exacting in their commands or admonitions. Most common are directive phrases to alter or curtail unwanted patient behavior: "Don’t sit there," "Leave the patient alone," "We don’t talk about that here," or "Go to the day room." Attempting to modify a patient’s behavior through verbal means usually requires the staff to speak loudly and firmly and to convey consequences if the behavior is not stopped. When staff attempts to direct a patient’s conduct, words are the frontline tools they use.

Sometimes, staff respond to patients’ questions and requests at their convenience and/or with irritability. It feels depersonalizing when one is ignored or dismissed, especially in the name of care and treatment. One hopes that people working in the psychiatric hospital system are helpful, humane, and respectful. This is not always the case. Sometimes, displays of kindness and common courtesy are few and far between. Staff’s prolonged exposure to others’ painful and unstable mental states may require them to detach emotionally, making them less susceptible to job stress and burnout. Staff may become hardened to depressed, upset or disturbed patients. "Professional detachment. . . reduces a patient’s emotional turmoil to business-as-usual" (Berger and Vuckovic, M.D., p. 98).

Optimally, the use of humane verbal force is a central tactic to maintaining ward discipline. Since patients require treatment in a safe and secure setting, free from abuse or threat, intentionally disruptive behavior (verbal or physical) may require restraint or seclusion. The psychiatric staff has procedures in place to guarantee patient compliance, even if that patient refuses treatment or resists, verbally or physically.

CHEMICAL RESTRAINTS

In dangerous situations on the ward, staff must approach and intervene. Chemical restraint is the common response to these circumstances. Upon admission, the psychiatrist writes the scripts, including a PRN order (medication on an as-needed basis) if the patient requires antipsychotic drugs over and above the daily regimen. Usually, it is the ward nurse who determines if an upset, agitated, or dangerous patient requires administration of such a drug. The staff will prepare for the drug administration, and as necessary, restraint and/or seclusion. In the case of a resistant patient, additional staff are called to the ward to facilitate the drug being given.

The term "chemical restraints" suggests that psychotropic drugs can operate as a containing agent in the individual to whom it is administered. This, often forced, drugging usually is an intravenous injection of Haldol (or another antipsychotic drug) into the buttocks. These injections are meant to work fast to calm, sedate or "knock out" the patient.

If the staff maintains that the patient is a danger to himself or others, the patient will be given a shot, whether or not s/he thinks it is necessary or appropriate treatment. In the case of an emergency, the staff is not required to tell the patient what drug is being injected or why. This is ward policy. In a system that would sensitively regard the rights of patients, there is room here for education, discussion and compromise.

PHYSICAL RESTRAINT AND SECLUSION

Expression of aggression and/or violence on the wards is not permitted. When agitated patients act out in anger and frustration, restraint and seclusion are considered a necessary procedure. There is a potential for misuse of these practices depending on the administration’s definition of "agitated patient." According to Gerard Clancy, MD, it is defined (often from medical providers) as a patient who is "upset, anxious, loud, uncooperative, threatening, aggressive, assaultive, and/or violent" (see virtualhospital.com). In a survey of ex-patients, restraint and seclusion were allegedly used as punishment for not taking medication or disobeying staff (NYS Commission on Quality of Care, 1994). It has also been documented that "staff places a patient in restraint (and/or seclusion) without first trying to calm them down or resolve their problem" (www.familypracticenotebook.com).

Staff are taught techniques to physically control a (violent) person. Restraints involve a variety of physical holds and mechanical devices to control a patient’s movements. In the case of four-point leather restraints, "arms and legs are strapped down for the protection of the patient or people nearby." (Berger and Vuckovic, M.D., p. 12) The American Psychiatric Association recommends at least five people for restraint, one for each limb plus someone to watch. . . in any physical restraint (Megan & Blint, 1998). The federal rules require that a physician or licensed practitioner authorize a restraint and have a face-to-face visit with the patient within the first hour (Hamilton & Weiss, 2000).

Seclusion is not a form of treatment. It is considered safe containment. It is usually unpleasant and difficult for the patient to understand and experience as anything other but punishment. In some cases, a patient is told to stay in his room. The consequences for not obeying this order may include time in "the quiet room." Contrary to popular belief, this is not a padded room. About 10' x 10', the unadorned room (that I was in) has a 2" thick gym mat covering the linoleum floor. During isolation, a staff member "sits watch" at the open door of the seclusion room.

Ex-patients report inpatient care and treatment might improve if staff first used less restrictive interventions to calm patients or solve their problems. However, inpatient psychiatric staff typically do not counsel patients. Their job duties consist of keeping the ward running smoothly: getting the patients up in the morning (and to their rooms at night), overseeing meals, distributing medication, routing patients to groups, handling the day-to-day activities of the ward, and ensuring the safety of everyone on the ward. Any physical or behavioral interference by patients to these ends may necessitate their restraint and seclusion.

An individual can be traumatized in the process of restraint. Uninvolved patients inadvertently viewing the procedure can be distressed. For emotionally vulnerable persons, the feelings generated in the wake of staff’s physical force may bring up past trauma issues. S/he is physically put to the ground, asked to expose underwear, given a quick, sharp needle stab in the buttocks, strapped to a gurney in a small room on a locked ward. The patient must succumb to complete immobilization. The patient’s experience and perception of pain (and humiliation of being forced to submit to chemical and physical restraint) may be exacerbated when in certain psychiatric states. Restrained patients might scream, swear or cry. Other patients on the ward may become upset, a state called vicarious traumatization. It is by no means a therapeutic situation for anyone.

Respondents who had been restrained or secluded were twice as likely to have negative feelings about their inpatient care and treatment (NYS Commission on Quality of Care, 1994). The use of restraint and seclusion is absolutely necessary only when other, less restrictive measures have been attempted. It is necessary for patients at risk of hurting/harming themselves or others. Seclusion is an emergency procedure used when there is an immediate risk of significant personal harm (to the patient him/herself or to others).

The staff has general agreement about certain types of behavior that they believe warrant seclusion. These written policies could be made available to patients, their family members, and/or their advocates, so episodes of restraint and seclusion can be avoided or reduced.

It has been shown that the negative influence of restraint and seclusion was far less if staff first tried less-restrictive interventions to calm patients or solve their problems (NYS Commission on Quality of Care, 1994). It is so important to offer patients alternatives and to outline consequences of continuing agitated, aggressive, or violent behavior.

Staff can discuss how better to avert, handle, and humanize, as far as possible, restraint and seclusion practices. Consumer representation on their boards and committees may assist in these endeavors.

Staff should always first make a conscientious effort to de-escalate a situation by verbal means. It has been recommended that staff develop communication skills that allow them to rarely touch patients, since doing so may precipitate an angry outburst from a frightened or frustrated patient. Staff can learn a variety of active listening techniques, and effective verbal techniques. Staff should receive ongoing education on how to talk with and assist upset or agitated patients. Gerard Clancy, MD, in The Emergency Psychiatry Service Handbook, offers suggestions: "Try to be nonjudgmental. You are in a position of authority. Patients who are depressed or psychotic already have low self-esteem. Don’t make it worse. Be calm and supportive" (see virtualhospital.com). Control your own emotional response. Appear centered and calm. Respond selectively, only answer informational questions, not abusive ones. Lowering one’s tone, volume, pitch and tempo of voice is important. Do not talk over a patient when s/he is yelling. Speak in the quiet seconds."

Staff can learn how to change the manner in which they respond to disturbed or psychotic behavior. First and foremost, limit the danger. Allow the patient time to talk. Staff is not required to counsel, but they have many opportunities to listen, acknowledge anger and show honest concern. Clear up misunderstandings and respond to valid complaints. Ask what would be helpful for the patient to regain control. Set limits respectfully but firmly and explain the consequences.

Many patients are admitted with the diagnosis of clinical depression. Take the time to educate patients about their diagnosis and symptoms. Tell them it is a biochemical disease and psychotropic drugs can help. Reassure the patient that with treatment (medication and, later, counseling), people with mental illness can and do recover.

How is the hospital administration keeping up with these issues? Do they have consumers on their boards, do they take recommendations from patient advocates, do they provide workshops, seminars or trainings to keep their staff informed and up-to-date on methods of "compassionate" restraint and seclusion as the last necessary means? What is the administration’s role in staff development for managing agitated patients?

Protection for psychiatric patients in hospitals is needed against being restrained for punishment or for the convenience of staff. According to the Health Care Financing Administration, the patient has the right "to be free from restraints of any form that are imposed for coercion, discipline, convenience or retaliation by staff - including drugs that are used as restraints" (hcfa.gov/quality/4b7.htm#define).

More complete information on hospital rules, specifically the circumstances under which you may be restrained or secluded, should be posted in all facilities.

Become involved in your treatment. Ahead of time, plan an Advance Directive (in Erie County, call the Mental Health PEER Connection at 716-836-0822). Work with a Peer Advocate (again, call the Mental Health PEER Connection at 836-0822). Call the Erie County Medical Center Peer Advocate directly at 898-6225 or the Buffalo Psychiatric Center Peer Advocate at (716) 885-2261. In Monroe County, contact the Mental Health Association to find a Peer Advocate or Consumer Guide Trainer at (716) 325-3145. At the Rochester Psychiatric Center, Patient Advocates can be reached at (716) 473 -3230 ext.1735.

You have the right to ask what you need to do (or not do) to prevent future IM (intramuscular) shots, restraint and seclusion. You have the right to ask what medication was administered during a chemical restraint. You have the right to ask the doctor or nurse what the circumstances for the restraint and seclusion were. You may not get an answer, but you have the right to ask. Copies of medical records that you petition from the hospital will not provide this information. Only certain psychiatric emergency room forms and laboratory results from your inpatient stay are included.

If you are an (ex-)patient, you may be too frightened to complain, see no positive outcome, or fear reprisal from staff. You may believe that if you do speak out on abuse against yourself or other patients, staff will be more likely to verbally mistreat you or more liberally administer chemical or physical restraint. Many consumers of mental health services have been through (and some are still going through) "the system." We understand your fears. We gently invite you to share your perspective on this or related topics. If you wish, your anonymity is insured. Please mail us your article without name or return address. Take care of yourself and those you love.

If you feel you received incompetent, negligent, or fraudulent care from a nurse, social worker, psychologist, occupational therapist or other health care professionals, you may file a report with the:

New York State Education Department

Office of Professional Discipline

One Park Avenue

New York, New York 10016

(800) 442-8106

If you have a concern, problem or complaint related to any aspect of care and/or treatment during your hospital stay or if you would like more information on accessing your medical records, contact the New York State Department of Health in your area for assistance:

or call PAIMI (Protection and Advocacy for Individuals with Disabilities), c/o Neighborhood Legal Services at 716-847-0650

or call the New York State Commission on the Quality of Care toll-free at 1-800-624-4143

or file a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Call their toll-free hotline at 1-800-994-6610.

Berger, Lisa and Vuckovic, M.D., Alexander, Under Observation: Life Inside a Psychiatric Hospital, Tickner & Fields, New York, 1994.

Hamilton, Elizabeth & Weiss, Eric M., "Restraints Still Killing Patients," projects/restraint.