The use of restraint and seclusion remains a controversial issue, and emergency care providers must remain absolutely current on it. We can come under criticism both for using too much coercion and for not using enough. Restraint and seclusion exist at an intersection of science, government policy, and public perception. These seemingly straightforward forms of medical coercion are still, in actuality, far from straightforward.
Those who would have us eliminate the use of restraint and seclusion from our practice altogether need to consider what conditions are actually like in today's typical psychiatric emergency service (PES) or emergency department (ED). These settings routinely see very extreme states of agitation, rage, psychosis, sociopathy, delirium, and despair. Restraints make some persons feel therapeutically contained and safe during a time of psychic overload and fragmentation. Others with comorbid unstable medical conditions, such as a cervical spine fracture, are protected physically by remaining strapped in on a gurney. Still others clearly exceed the limits of dangerousness set out by state statutes, with often predictable increases in volatility when they learn of being hospitalized against their will.
There are budgetary constraints on staffing and square footage in the PES and ED, and there is the problem of surge volumes. De-escalation techniques take time, space, and energy, yet these may be in insufficient supply, especially when a service "ramps up." Emergency care practitioners must be held accountable to a high standard of humane conduct, yet it also falls to us doing the actual work to distinguish the real innovations of noncoercion from ivory tower pronouncements.
What is true for a long-term-care setting is not necessarily true for the PES or ED. When a person with schizophrenia who cannot afford his or her medication uses crack cocaine to quiet the "voices" instead, and when within seconds of admission he lunges at a security guard because he thinks the guard is Lucifer, restraint and seclusion do not represent a failure of treatment. They are the beginning of treatment.
One might argue that the outpatient system failed to provide the person in this example with his medication or failed to offer him chemical dependency treatment or failed to train the police in how not to antagonize a psychiatric patient on the way to the hospital. But it would be quite unfair to say that the staff of the PES or ED, who are the safety net of a shaky health care system and whose primary concern must always be everyone's safety, had failed.
Noncoercion and Nonviolence
That said, those working in the trenches and intuitively using restraint and seclusion as it is needed have to remind themselves periodically and listen to feedback from patients about the enduring negative psychological impact it can have on patients.1 Although real-life circumstances sometimes leave us no other choice, we must know all the dangers of restraint and seclusion, the long-term benefits of noncoercion, and the latest strategies to avoid coercion.2 Experienced practitioners must challenge themselves and push the envelope on the use of de-escalation techniques.3,4
Our therapeutic agenda for persons whose condition is acute is to promote the acquisition of nonviolent coping skills for everyday life (where nonviolent means not hurting oneself or others). Our patients often experience coercive physical management as a form of violence. Therefore, we must practice what we preach. When we push ourselves beyond the comfort zone and avoid using restraint and seclusion in a crisis situation, we are modeling what we want our patients to learn. This is never truer than when emotions are running high and patients' interpersonal behavior is trying our patience.
Self-control, virtuoso verbal skills, and voluntary administration of appropriate medication are not always enough. A particularly difficult situation occurs when there is a history of childhood abuse and a diagnosis of a borderline personality disorder. As Gabbard points out, "In a paradoxical way, patients [with borderline conditions] find it predictable, familiar, and even soothing to re-create a sadomasochistic internal object relationship from childhood with the therapist."5 This re-creation often starts in the emergency care setting with an onslaught of "intense anger, aggression, and hate" directed at the staff. Ideally, while the unhealthy part of the patient invites the use of restraints--usually with an openly defiant suicide attempt--an insightful staff member tries to refrain from it. But even trying to engage the healthy part of the person and objectively pointing out this "script" may not succeed in interrupting this archaic cycle of violence.
Absolute Last Resort
People tend to think in absolutes on the subject of medical authority. From a safe distance, it is easy to fault emergency caregivers for being too coercive or too lenient. Practitioners must be able to tolerate these contradictions and practice in the real world. To my mind, the only absolute on the subject of restraint and seclusion is that it should be used only as an absolute last resort. Those who would use it reflexively, as well as those who would totally restrict its use, would do well to exercise some restraint themselves.
Jon S. Berlin, MD
Assistant Clinical Professor of Psychiatry and Behavioral Medicine
Medical College of Wisconsin
Medical Program Director--Crisis Service
Milwaukee County Behavioral Health Division
President, American Association for Emergency Psychiatry
REFERENCES1. Lidz CW, Mulvey EP, Hoge SK, et al. Factual sources of psychiatric patients' perceptions of coercion in the hospital admission process. Am J Psychiatr. 1998;155:1254-1260.2. Fishkind A. Calming agitation with words, not drugs: 10 commandments for safety. Curr Psychiatr. 2002;1(4). Available at: www.currentpsychiatry.com. Accessed July 29, 2005.3. Battaglia J. Pharmacological management of acute agitation. Drugs. 2005;65:1207-1222.4. Berlin JS. Approaching the agitated patient in the emergency setting. Psychiatr Issues Emerg Care Settings. 2004;3(1):7-11.5. Gabbard GO. Psychodynamic Psychiatry in Clinical Practice. 3rd ed. Washington, DC: American Psychiatric Press, Inc; 2000:439-440.