A widely cited review from 1992 estimates the prevalence of use of restraints across institutional settings at 0% to 66% of admissions. Despite concerns about the potential harm of such restraints, ethical objections, and the lack of systematic evidence supporting the efficacy of seclusion and restraint, the practice continues. More rigorous trials are needed to examine the efficacy of prevention programs and innovative methods to reduce the use of restraint and seclusion.
Restraint and Seclusion in Psychiatric Inpatient Wards Posted 01/11/2006 Eila A. Sailas; Kristian Wahlbeck
Purpose of Review: Despite the controversy over the use of seclusion and restraint, these measures are commonly used to treat and manage disruptive and violent behaviour. This review summarizes recent research on the use of seclusion and restraint, and measures taken to reduce their use.
Recent Findings: Lately, prominent international recommendations have aimed to restrict the use of seclusion and restraint, and reminded that they should only be used in exceptional cases, where there are no other means of remedying the situation and under the supervision of a doctor. The use of seclusion and restraint has remained prevalent, but there are serveral innovative programmes that have succeeded in controlling and reducing their use. Staff attitudes about seclusion and restraint have changed little in the last few years.
Summary: There is a need for novel methods to treat violence and the threat of violence on psychiatric wards. Violence is a complex phenomenon that needs to be met with a multiprofessional approach. Customer involvement in this work is required. The assessment of the effectiveness of programmes aiming to minimizing seclusion and restraint has been hampered by the lack of parallel control groups and there is a need for cluster-randomized trials. When studying these interventions, the safety of staff and patients should be included as on outcome measure.
In psychiatric practice seclusion and restraint are interventions used to treat and manage disruptive and violent behaviour. For the purpose of this review seclusion and restraint are defined as follows: seclusion means the placement and retention of an inpatient in a bare room in order to contain a clinical situation that may result in a state of emergency. When the staff restrict and hold the patient manually, this is called physical restraint. Mechanical restraint refers to the use of belts, handcuffs and the like, which restrict the patient's movements or totally prevent the patient from moving. Other interventions loosely referred to as seclusion and restraint, such as time out (where patient stays in their own room or in the seclusion room, but door is unlocked) or chemical restraint (the use of medication to control agitated states) have been excluded from this review.
We review the literature on seclusion and restraint in adult psychiatric care. Although the review of the literature spans over many years, the main focus has been on papers published in 2004. The databases searched were MEDLINE, PsychInfo, Cinahl, PsiTri and Sociological Abstracts with the following search strategy: ((seclusion or restraint) and psych*). Articles for the review were obtained from peer-reviewed scientific journals.
Recommendations and Guidelines
Seclusion and restraint are controversial issues,[2,3] and their value has been much debated in the literature. They have been described as valid therapeutic interventions in themselves, methods of containment of a psychiatric emergency or a form of punishment.
During the last few years new legislation, recommendations, professional guidelines and some court cases to control the use of coercive measures in psychiatry have emerged.[5-9] The recurring message in all of these guidelines is the need to practise caution when applying seclusion and restraint. There is some evidence that these administrative measures can affect the use of seclusion and restraint. On the other hand, a lack of comprehensive and accurate knowledge of mental health legislation among nursing staff has been shown to exist.[11*]
The new recommendations emerging from the Council of Europe state that the benefits of using physical restraint and seclusion should be in proportion to the risks entailed. Their use is not prohibited, but they should be used only in exceptional cases, where there are no other means of remedying the situation and under the supervision of a doctor.[12**,13]
The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment of Punishment (CPT) considers seclusion and restraint matters of particular concern, given the potential for abuse and ill-treatment. The CPT points out that resort to mechanical restraint is justified only very rarely. The CPT has noticed a clear trend towards avoiding the seclusion of patients, and is pleased to note that it is being phased out in many countries. In some cases the CPT has defined seclusion as a form of ill-treatment, because of poorly ventilated seclusion premises, no means for the patient to contact the staff, unsuitable bedding, lack of window glazing or deplorable sanitary conditions. Restraint contains the greatest risk of abuse or ill-treatment. The CPT recommends regularly that a precise policy should be drawn up concerning the use of restraint or seclusion, and that events should be documented in detail.[15*] In addition, the CPT recommends that patients who have been subjects of seclusion or other means of restraint should also receive a debriefing after the end of these measures.
Who and How Often?
A widely cited review from 1992 reported that the use of seclusion varied to a great degree across institutions, from 0 to 66% of admissions. The rates of seclusion and restraint in the few studies published since fall within these margins.[18,19] In the European Union the use of obligatory psychiatric care varies widely from one country to another, but there is no detailed analysis of what obligatory psychiatric care contains in each country. Next to nothing is known about the use of seclusion and restraint in developing countries.
Violent behaviour or the threat of violence are commonly accepted indications for using seclusion and restraint,[22,23] but often coercion is used also to control agitation or disorientation.[19,24,25] The patients most likely to be secluded or restrained have been reported to be young, male and suffering from psychosis or personality disorder.[23,26] In Norway, restraint is more often targeted at young male, non-psychotic patients and seclusion at older male patients with an organic psychotic disorder.
A recent questionnaire study, which collected data from 51 psychiatric emergency services in the United States (91% response rate), stated that restraints were used on a mean of 7% of patients in rural areas, 6% in suburban areas, 12.3% in urban centres with populations greater than 1 million and 9.6% in university-based programmes. The mean duration of restraint was 3.3 h. The respondents were asked whether they agreed that restraints are usually necessary for violent patients (56% agreed) and also whether non-physician staff pressure psychiatrists into ordering restraints for patients who might otherwise be manageable (46% agreed). The overwhelming majority agreed that most patients recall and have adverse reactions to restraints (94 and 92% respectively).[28*]
A retrospective chart review of all inpatient admissions to an Australian adult acute psychiatric unit over 12 months revealed that 450 admissions resulted in 140 episodes of seclusion (31% seclusion rate). Patients secluded were more likely to be young, admitted involuntarily and have a diagnosis of schizophrenia. The most common indications for seclusion were risk to others (74%), risk to self (61%) and risk of absconding (55%). In 71% of seclusion episodes some other less-restrictive measure, like counselling, time out or medication, had been tried prior to seclusion.[29*] Violence is common in the care of adult persons with intellectual disabilities and more needs to be known about the usefulness of coercion in the treatment of learning disabilities.
There have been suspicions that the ethnicity of the patient might influence treatment decisions. In a UK study analysing all recorded violent incidents (1515 in total) on 14 general psychiatric wards over 3 years (1994, 1996 and 1998) it was found that black compared to white patients were more likely to be secluded - but not restrained - after a violent incident. After controlling for potential confounding factors the effect of the patient's ethnic background was no longer significant. The age of the patient, with black patients tending to be younger than white patients, was the strongest confounding variable. The most important parameter estimate for both seclusion and restraint was that a nurse had been the target of violence. These results indicate that ethnic differences in post-incident management did not reflect a form of racial bias.[33**] This finding is in accordance with an American study examining treatment patterns for patients with psychotic disorders. The finding was that differences between patients with different ethnic backgrounds during the early stages of treatment arise most prominently before, rather than during, the patients' first hospitalization.[34*] In a forensic setting the frequency of seclusions was correlated significantly with psychopathy, a reminder that coercion is connected to patient characteristics.
In psychiatric hospitals operating under the same policies and procedures, considerable variation in the rates of seclusion and restraint is found.[36,37*] The influence of the local cultural values was also evident in the use of so-called net beds (beds surrounded by wire) or cage beds (beds surrounded by steel bars) in the Czech Republic. These methods of patient containment have long been condemned by human-rights groups, but yet some of the staff who are used to these methods consider them more humane than other restraint techniques like straps, isolation or strong medication.[38*] This discussion illustrates the power of habit in clinical practice.
According to previous literature staff often regard seclusion as beneficial to the patient, or at least an acceptable patient-management strategy. Patients themselves tend to consider seclusion a form of punishment and report negative feelings.[39,40] In one study patients preferred medication over seclusion and restraint. These prior findings of discrepancy between patient and staff views were confirmed by an Australian study where 29 patients (66% of those approached) and 60 nurses (88% of those approached) were asked about their attitude towards seclusion practices. These two groups differed significantly in their opinions: nurses believed that the use of seclusion was highly necessary, not very punitive and that the procedure was effective in helping the patients to calm down and feel better. Patients believed that seclusion was used frequently for minor disturbances, and as a means for staff to exert power and control. Seclusion resulted in patients feeling punished and patients felt that it had little therapeutic value.[42*] Other studies from the Netherlands and Canada describe how patients experienced seclusion as negative,[43*] as a punitive measure and as a modality for social control that inflicts feelings of exclusion.[44*] The patients associated coercion most often with the use of seclusion, not with other compulsory treatment methods.[45*] In Finland, a survey showed that 16% of nurses perceived four-point restraints (where the patient's hands and feet are tied down to a bed) and 11% saw seclusion as ethically problematic.[46*]
When asking nine cohorts of student psychiatric nurses at different stages of their training to evaluate different means of containment, mechanical restraint and net beds attracted the most disapproval. No evidence of a professional socialization process towards accepting these methods during the training process was found. The authors conclude that the surrounding society and its cultural values set the context and determine psychiatric practice.[47*]
What to Do?
Seclusion and restraint can have substantial deleterious physical and more often psychological effects on both the patient and the staff. Restraint is an intrinsically unsafe procedure, and both mechanical and physical restraints have been reported to be associated with deaths of patients.[48-50] The excessive reliance on seclusion and restraints to minimize disruptive behaviour in custodial care settings makes it unlikely that mentally ill individuals will develop the daily living skills required to manage circumstances outside of the inpatient setting. Further, the implementation of these management strategies may precipitate aggression, model aggressive ways of interacting with others or reinforce aggression.
There is a dearth of controlled studies evaluating the value of seclusion and restraint in those with serious mental illness and very little rigorous evidence in favour of the widespread use of control and restraint techniques in the management of violence in inpatient psychiatry.
A variety of interventions have been demonstrated to be useful in reducing the use of seclusions and restraint in treatment settings. Mostly the studies have a time-series design comparing seclusion and restraint rates before and after the implementation of the programme. Because of the comprehensiveness of the programmes it is difficult to determine which components are the most effective in controlling the use of coercive practices. As an example of an innovative method for containing agitation and aggression the use of sensory approaches has been suggested, such as weighted blankets, 'multisensory' treatment rooms created by occupational therapists and furnished especially for relaxing, and using various pieces of equipment that appeal to different senses.[55*]
Recent reports on useful programmes to reduce episodes of seclusion and restraint include the early identification and management of problematic behaviours,[56*] and a complex intervention consisting of interviewing patients to determine their stress triggers and personal crisis-management strategies and training staff members in crisis escalation and non-violent intervention.[57*] One programme that proved to be successful included the identification of restraint-prone patients, patient education, staff education, development of a crisis-intervention team, daily review of all restraints and an incentive system for the staff.[58*]
An interesting strategy to decrease the use of mechanical restraints and seclusions in an inpatient adolescent unit included an attempt to have observing persons present during every possible crisis situation. Staff interviews revealed several misconceptions about when to use seclusion and restraint; for example, if a patient displays any self-injurious behaviour, they should be placed in restraints automatically. The observations corroborated the suggestion that some myths among the staff promoted too rapid a use of restraint or seclusion. Also, it was observed that a small number of specific staff members consistently self-delegated or were delegated by co-workers to make the intervention decisions during crises. Consequently, a small number of 'key decision-makers' influenced the outcome of crisis situations heavily, or served as crisis-team leaders.[59**]
Another successful programme to reduce the use of seclusion and restraint on a psychiatric emergency department included, among other things, the creation of psychiatric advocates who had the responsibility for the secluded or restrained patient and who were specially educated in crisis intervention.[60,61*] The introduction of patient-focused nursing did not affect the number of seclusions, but decreased the time spent in seclusion.[62*] It is worrying that a comprehensive programme that significantly decreased the rates of seclusion and restraint was accompanied by a significant increase of assaults on patients and staff.[63**]
The assessment of the effectiveness of these programmes to prevent seclusion and restraint is hampered by the lack of parallel control groups.
In spite of controversy and international recommendations seclusion and restraint continue to be a part of everyday psychiatric practice. The latest developments in the epidemiology and risk factors for seclusion and restraint need to be studied. Little has happened in the way patients and the members of the staff view these measures. Serious adverse effects are associated with the use of seclusion and restraint, hence the need to find alternative treatment strategies. Uncontrolled studies report success of programmes that reduce the use of coercion, but the overall evidence base for preventive programmes is weak. The value of seclusion and restraint in clinical practice is influenced by beliefs and habits, and thus coercive procedures can be difficult to change. It is useful to remember that certain reforms, which at the outset can create concern among staff, can be quite successful.
On the grounds of this review we suggest the following. (1) There is a clear call for cluster-randomized trials; that is, randomization of hospital wards or treatment units to either implement preventive interventions or carry on as usual, to assess the effectiveness of prevention programmes to reduce the use of seclusion and restraint. Study outcomes should be robust and easily measurable, and should include measurement of safety of patients and staff. (2) There is a need for novel and effective methods to treat violence and threatened violence on psychiatric wards. Violence is a complex phenomenon that needs to be treated with a multiprofessional approach. (3) There is a need for consumer involvment in the planning of inpatient aggression-management programmes in psychiatry.
CPT = Committee for the Prevention of Torture and Inhuman or Degrading Treatment of Punishment