Steven S. Sharfstein, MD

Tina, a 35-year-old legal secretary, is admitted to the hospital hearing voices that demand she gouge out her own eyes as punishment for having lived a sinful life. She was seen in the local emergency room prior to admission, both for involuntary certification and treatment for corneal damage from having attempted to harm herself. She states to the admitting psychiatrist, "If thine eye offend thee, pluck it out!"

John, a 17-year-old gang member, is admitted to the hospital because he has threatened to murder his parents and siblings. He is sitting in a group therapy session when he stands up in the middle of the group, clenches his fists, and starts pacing the floor, screaming "I will kill you and I will kill anybody who gets in my path. I'm getting out of this hospital immediately. You can't stop me. Nobody can stop me. I need to go and do what I have to do!"

The care and treatment of the mentally ill who may become violent is both a public health and public safety issue. Untreated and undertreated mental illness predisposes some individuals-especially those with the diagnosis of paranoid schizophrenia-toward a high risk for suicide or homicide. Deinstitutionalization of the mentally ill over the last 30 years has created a public health crisis across the country as evidenced by the recent shootings in Utah as well as similar incidents in New York and Baltimore. Access to hospitalization of acutely ill and dangerous people is essential today.

At the same time, the use of seclusion and restraint in psychiatric hospitals has come under great criticism as highlighted in the "60 Minutes II" program aired April 21, 1999. Tragic and preventable deaths have led federal legislative representatives and well-intentioned advocates to call for restricting the use of seclusion and restraints in inpatient settings. Recent hearings in Congress are focusing on new legislation that would limit the use of these procedures and establish national standards with additional reporting requirements.

In this era of managed care, psychiatric patients are admitted to hospitals almost exclusively in crisis on criteria of dangerousness to themselves or others. The potential for violence is inherent in an inpatient unit. At times, it is necessary to restrain or isolate individuals to prevent them from harming themselves or others. Staff in psychiatric hospitals must feel safe in order to perform basic psychotherapeutic tasks that often prevent or avoid such violence. The safety of other patients in the inpatient unit is also a major concern. Consideration of legal and regulatory apparatus that would be implemented to monitor the misuse of seclusion and restraints in psychiatric inpatient settings must be tempered by acknowledging the need for added resources that ensure adequate staffing and training in the appropriate use of these procedures to prevent violence. The ability to stabilize patients with dangerous behavior requires the flexible use of these approaches, with the safety of patients always first and foremost.

If it becomes more difficult to provide a safe institutional environment for these patients, more psychiatric hospitals will close. What will happen to the patients then? They will be subjected to the ultimate in seclusion and restraint in the nontherapeutic environments of prisons and jails. The incarceration of the mentally ill is a public shame. Today, there are tens of thousands of individuals in jail who belong in hospitals. We could increase that jailed population with misguided, single-minded regulations on the restriction of appropriate and safe use of seclusion and restraint in hospitals.

Author | Steven S. Sharfstein, MD

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