Facing Fear and Change

The intervention of seclusion is meant to be a measure of last resort, and there is increasing pressure within the mental health system to reduce or eliminate the use of seclusion and restraint for a number of persuasive reasons. This article describes the successful experience of integrating an unpredictably violent patient with autism who had been in seclusion on a forensic ward twenty-three hours per day on average, seven days per week, for seven years into the ward milieu and into the community with no further use of seclusion. Two of the authors are the main behavioral therapists who described the steps taken and the struggles faced in this process. Systemic barriers are reviewed, including concerns about staff and patient safety, the fear and resistance of front-line staff, and the culture shift needed to allow this patient the opportunity to make independent decisions and improve his quality of life.     

Seclusion and restraint in 1985: a review and update

The 1982 Supreme Court decision in Youngberg v. Romeo gave mental health professionals flexibility to exercise professional judgment in using seclusion to control violent patients, and also suggested that seclusion and restraint might be used when patients exhibit disruptive behavior that may lead to violence. The authors reviewed 13 studies of seclusion and restraint in adult inpatient psychiatric settings to define indications for use. They found that seclusion and restraint practices varied widely depending on the population served and the philosophical orientation of the hospital staff, and were more often used to contain behavior that might lead to violence rather than to control violent behavior itself. They conclude that there is overwhelming empirical support for using seclusion and restraint to limit the progression of disruptive behavior to actual violence, but that the decision to do so should be based on sound clinical judgment.     

Congresses

A questionnaire-based study examining the experiences and attitudes of staff to restraint and seclusion in a Norwegian university psychiatric hospital demonstrated that a majority of staff believed the interventions were used correctly. Staff at wards with high usage of restraint and seclusion, and male staff, were most critical to how often the interventions were used. Most staff favoured the use of physical restraint, although they believed it was the intervention patients were least favourable to. Highly educated staff were not more critical to the use of restraint and seclusion than other staff. Despite the fact that a majority of staff believed that using restraint and seclusion made patients calmer and did not cause aggression, anxiety or injuries, about 70% had been assaulted by patients in connection with the interventions. Many staff believed the use of restraint and seclusion violated patients’ integrity, could harm the provider–patient alliance and could frighten other patients. Violence, self-harm and threats were given as main reasons for the use of restraint. Increased staffing and more attention by level-of-care staff were cited as the most important strategies for reducing the use of restraint and seclusion. There is a need for informing all staff about the negative effects of restraint and seclusion and for training staff in less restrictive ways in dealing with aggressive and violent patients.     

Staff's attitudes to the use of restraint and seclusion in a Norwegian university psychiatric hospital

A questionnaire-based study examining the experiences and attitudes of staff to restraint and seclusion in a Norwegian university psychiatric hospital demonstrated that a majority of staff believed the interventions were used correctly. Staff at wards with high usage of restraint and seclusion, and male staff, were most critical to how often the interventions were used. Most staff favoured the use of physical restraint, although they believed it was the intervention patients were least favourable to. Highly educated staff were not more critical to the use of restraint and seclusion than other staff. Despite the fact that a majority of staff believed that using restraint and seclusion made patients calmer and did not cause aggression, anxiety or injuries, about 70% had been assaulted by patients in connection with the interventions. Many staff believed the use of restraint and seclusion violated patients' integrity, could harm the provider-patient alliance and could frighten other patients. Violence, self-harm and threats were given as main reasons for the use of restraint. Increased staffing and more attention by level-of-care staff were cited as the most important strategies for reducing the use of restraint and seclusion. There is a need for informing all staff about the negative effects of restraint and seclusion and for training staff in less restrictive ways in dealing with aggressive and violent patients.     

Seclusion and restraint in psychiatry: patients' experiences and practical suggestions on how to improve practices and use alternatives

PURPOSE: This study explored psychiatric inpatients' experiences of, and their suggestions for, improvement of seclusion/restraint, and alternatives to their use in Finland. METHODS: The data were collected by focused interviews (n= 30) and were analyzed with inductive content analysis. RESULTS: Patients' perspectives received insufficient attention during seclusion/restraint processes. Improvements (e.g., humane treatment) and alternatives (e.g., empathetic patient–staff interaction) to seclusion/restraint, as suggested by the patients, focused on essential parts of nursing practice but have not been largely adopted. PRACTICE IMPLICATIONS: Patients' basic needs have to be met, and patient–staff interaction has to also continue during seclusion/restraint. Providing patients with meaningful activities, planning beforehand, documenting the patients' wishes, and making patient–staff agreements reduce the need for restrictions and offer alternatives for seclusion/restraint. Service users must be involved in all practical development.     

Seclusion and restraint and prediction of violence

The authors studied the use of seclusion and restraint on an inpatient unit in a state psychiatric hospital. Of 69 randomly selected inpatients, 51% experienced seclusion or restraint at least once. More psychotic than nonpsychotic patients required seclusion or restraint. However, neither psychosis/nonpsychosis nor voluntary/involuntary admission status predicted the likelihood of violent threats or actions. Patients experiencing seclusion and restraint showed a nonsignificant trend toward longer mean length of stay in the hospital. The frequency of patient behavior leading to seclusion or restraint appeared to be directly related to the stimulation caused by the presence of many staff members and other patients.     

Restraint and seclusion in psychiatric inpatient wards

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.     

Impact of therapeutic management on use of seclusion and restraint with disruptive adolescent inpatients

Use of seclusion and restraint on three inpatient adolescent psychiatric units was examined during two five-month periods before and after implementation of a "therapeutic management" protocol. Under the protocol, staff classified disruptive behaviors into four stages and provided verbal and behavioral interventions to control behavior at each stage. Patients who required seclusion and restraint had significant latitude to determine the timing of their release from the interventions and met with staff one hour and 24 hours after their release to explore alternatives to aggression. The number of episodes of seclusion and restraint fell by 64 percent after the protocol was adopted, and the number of patients who required those interventions dropped by 39 percent. The mean duration of episodes of seclusion and restraint was reduced by 59 percent. Therapeutic management provides a corrective experience by addressing the developmental needs, deficient cognitive skills, and poor internalized controls of disruptive adolescents.     

Effects of a Recovery-Oriented Cognitive Therapy Training Program on Inpatient Staff Attitudes and Incidents of Seclusion and Restraint

We investigated the feasibility of implementing a recovery-oriented cognitive therapy (CT-R) milieu training program in an urban acute psychiatric inpatient unit. Over a 1-month period, 29 staff members learned short-term CT-R strategies and techniques in an 8-h workshop. Trainees’ perceptions of CT-R, beliefs about the therapeutic milieu, and attitudes about working with individuals with psychosis were evaluated both before the workshop and 6 months after the workshop had been completed. Incidents of seclusion and restraint on the unit were also tallied prior to and after the training. Results indicate that staff perceptions of CT-R and their beliefs about the therapeutic environment significantly improved, whereas staff attitudes towards individuals with psychosis remained the same. Incidents of seclusion and restraint also decreased after the training. These findings provide evidence that CT-R training is feasible and can improve the therapeutic milieu of an acute psychiatric inpatient unit.     

The review of seclusion and restraint in psychiatric practice]

In order to create the least restrictive setting in psychiatric practice, we investigated the effects of an assessment by a committee on seclusion and restraint. Using consistent procedures, the committees, which were established in 9 hospitals, reviewed seclusion and restraint maintained for periods of over 2 weeks during a 4-month period. Frequency and duration of seclusion and restraint, staff perceptions of and attitudes to the review system, and patient satisfaction were evaluated before and after the study period. As a result of this review process, the frequency of seclusion decreased slightly in 7 hospitals and 1 of the remaining 2 hospitals showed an increased frequency of seclusion days that were partially interrupted. Frequency of restraint decreased slightly in 5 hospitals, and of the remaining 3, 1 interrupted all periods of restraint, while the other 2 institutions showed an increase in interruption of restraint periods. As there were no common patients in 2 specialist psychiatric emergency hospitals between before and after the study periods, statistical analyses were performed. Only minor variables such as duration of partially interrupted periods of restraint, and duration of periods of restraint that were partially released showed a statistically significant increase. Although patient satisfaction showed a significant increase, staff attitudes to and perceptions of the review system became appreciably more negative. These findings suggest that although the review system had the potential to slightly reduce the use of seclusion and restraint, and to increase patient satisfaction, staff burnout was risked because staff effort was perceived to be disproportionately high in relation to the effect achieved. Furthermore, the possibility remains that the slight decrease of seclusion and restraint demonstrated did not necessarily reflect the appropriate use of these strategies, and were not necessarily lasting effects. However, as differences in opinion existed between the review system committee and treating clinicians regarding continuation of long term seclusion and restraint, the review system could have a role in monitoring the long term use of seclusion and restraint. Further investigation is needed into the long term effectiveness of procedures reviewing the use of seclusion and restraint in the psychiatric setting, taking into account both positive and negative outcomes.     

Re-Designing State Mental Health Policy to Prevent the Use of Seclusion and Restraint

The members of the National Association of State Mental Health Program Directors (NASMHPD) believe that seclusion and restraint, including “chemical restraints," are safety interventions of last resort and are not treatment interventions. Seclusion and restraint should never be used for the purposes of discipline, coercion, or staff convenience, or as a replacement for adequate levels of staff or active treatment. The use of seclusion and restraint creates significant risks for people with psychiatric disabilities. These risks include serious injury or death, retraumatization of people who have a history of trauma, and loss of dignity and other psychological harm. In light of these potential serious consequences, seclusion and restraint should be used only when there exists an imminent risk of danger to the individual or others and no other safe and effective intervention is possible. (Endorsed by the State Mental Health Directors, July 13, 1999). (NASMHPD 1999, NASMHPD Position Statement on Seclusion and Restraint. Alexandria, VA: National Technical Assistance Center for State Mental Health Planning.)The views expressed in this article are those of the author only, and do not necessarily represent the views of the author's employer.     

Seclusion use with children and adolescents: an Australian experience

OBJECTIVE: To summarize the current state of knowledge on the use of seclusion and restraint with children and adolescents and to report the findings of an exploratory study to identify factors that place a child or adolescent at increased risk of seclusion during their admission. METHOD: Literature searches were undertaken on MEDLINE, CINAHL and PsycINFO databases. Articles were identified that focused specifically on seclusion and restraint use with children and adolescents or contained material significant to this population. The study reports findings from a retrospective review of patient charts, seclusion registers and staffing from an Australian acute inpatient facility. RESULTS: The data available in regard to seclusion use in this population is limited and flawed. Further research is needed on the use and outcomes of seclusion and restraint and on alternative measures in the containment of dangerousness. Both the literature and this study find that patients with certain factors are at increased risk of being secluded during an inpatient stay. These factors include being male, diagnoses of disruptive behaviour disorder and a previous history of physical abuse. Staffing factors did not show a relationship to the use of seclusion. CONCLUSIONS: There are patient factors that predict increased risk of seclusion; these factors and their interrelationships require further elucidation. Further research is also needed on the outcomes, both positive and negative, of seclusion use and of alternatives to seclusion.     

Crisis and emergency on the psychiatric ward

The hospital psychiatric emergency is usually conceptualized as a single patient requiring immediate attention.^1–3 Ewalt defines an emergency as occurring “when an individual is faced with a situation beyond his particular adaptive capacity at a particular time.” Miller defines it as a “sudden or rapid disorganization in his capacity to control his behavior or to carry out his personal, vocational or social activities.” Although this restricted view is valuable in providing a guide to the immediate management of the emergency, it fails to take into account the relationship between the patient's social environment and his behavior. Usually there are intense group issues associated with the emergency that have been latently present prior to it and are of central importance to its development and resolution.⁴ An awareness of the group issues provides the opportunity for prevention and more successful therapeutic work, as opposed to emergency-centered management. In this paper we present a conceptual model that facilitates the recognition and evaluation of ward emergencies. The evolution of emergencies and their prevention and management are discussed.The term crisis will refer to persistent group behavior that threatens or prevents the psychiatric ward from accomplishing its work as a therapeutic agent. Thus a crisis may be chronic, may be not consciously perceived, and may not need emergency action. It may, however, evolve into an emergency. The term emergency will refer to ward behavior that is grossly disruptive and requires immediate management. It occurs when a crisis comes to focus in an individual or a small subgroup of individuals and usually consists of an imminent threat to physical safety via self-destructive or assaultive behavior. By so defining a psychiatric emergency—which is usually viewed as the end result of intrapsychic events—we wish to call attention to aspects of group structure and functioning that may precipitate the emergency.Concepts described in this paper follow from the ideas of group function espoused by Wilfred Bion.⁵ Bion observed that any work group has covert tasks as well as the overt, agreed-upon work tasks. For this article, the clinical staff and patients of a psychiatric unit comprise the work group, and the restoration to health of the patients is the work task.     

Seclusion: A Last Resort Measure

The practice of secluding patients after violent incidents has long been a treatment used by mental health nurses. While seclusion keeps the patient from further self-inflicted pain and restores normalcy to the unit, the practice often sets up an unending cycle of negative behavior. Other methods of dealing with the violent patient are explored in this article, including early intervention by nurses, ignoring the outburst, separating the disruptive person for a shorter time, and speaking gently with the client. The conclusion reached is that nurses must keep in mind the goal: to help the patient reintegrate into the group as safely and quickly as possible.     

Eliminating seclusion and restraint in recovery-oriented crisis services

The use of seclusion and physical restraint is viewed as a practice incompatible with the vision of recovery, and its therapeutic benefit remains unsubstantiated. This Open Forum describes an initiative that began in 1999 at two crisis centers that was designed to completely eliminate the practice of seclusion and restraint. Seclusion and restraint elimination strategies included strong leadership direction, policy and procedural change, staff training, consumer debriefing, and regular feedback on progress. Existing records indicated that over a 58-month follow-up period (January 2000 to October 2004), the larger crisis center took ten months until a month registered zero seclusions and 31 months until a month recorded zero restraints. The smaller crisis center achieved these same goals in two months and 15 months, respectively. The success of this initiative suggests that policy makers and organizational leaders familiarize themselves with these and other similar seclusion and restraint reduction strategies that now exist.     

Social skills training for chronic psychiatric patients: Rationale,research findings,and future directions

In 1969 Gordon Paul stated that “the ‘hard core’ refractory group of chronic mental patients is clearly one of the most difficult problems facing the mental health field today.”¹ Although some progress has been achieved in this area since then,^2–7 this same hard-core group of patients (most of whom bear schizophrenic diagnoses) remains a persistent challenge to mental health practitioners. A variety of pharmacologic, socioenvironmental, and behavioral approaches (primarily the token economy) have been applied to this group of chronic psychiatric patients. We will very briefly examine the major contributions and limitations of each approach.     

Planning for crisis on a psychiatric research ward: A task analysis

The organizational structure of a psychiatric research ward facilitates its major tasks of data collection and clinical care. However, this structure also reflects the value conflicts inherent in pursuing both tasks.^1–4 Previous work has suggested that a ward's values and their conflicts may be highlighted during a crisis.⁵ The research ward described in this article was planning for a crisis, a threatened “job action” by the nursing staff. This anticipated job action involved possibilities ranging from a nursing staff “sick out” to strike action.This article discusses the interaction of clinical care and research values in this planning process. On this psychiatric ward, where biological research is conducted with severely impaired patients, data collection cannot occur without good clinical care. However, the specific type of care offered is determined by many factors including task priority, available personnel, assumptions about the efficacy of various forms of treatment, degree of patient impairment, phase of hospitalization, research protocol involvement by the patient, and responsiveness of the patient to medication and psychotherapy.The major task of the ward is research, in which all patients voluntarily participate. Following completion of their research protocols, patients usually are ready for individualized rehabilitative treatment. A high staff to patient ratio permits staff to engage patients in group, milieu and family treatments. In the transition from research to rehabilitative treatment the patient's role evolves from a passive research subject to an active therapeutic collaborator.In planning for the anticipated job action, the patient role was limited to a passive one. The ward values and boundary decisions which led to the definition of a passive rather than active patient role are discussed in this article as a reflection of the ways in which the conflicts between research and clinical care may be resolved on a psychiatric research ward.     

Restraint and seclusion in psychiatry: review and prospects

In this article, the authors reviewed the literature published since 1965 concerning restraint and seclusion. They synthesized the contents of the articles reviewed using the categories of indications and contraindications; rates of seclusion and restraint as well as demographic, clinical, and environmental factors that affect these rates; effects on patients and staff; implementation; and training. The literature on restraint and seclusion supports the following: 1) Seclusion and restraint are basically efficacious in preventing injury and reducing agitation; 2) It is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint; 3) Demographic and clinical factors have limited influence on rates of restraint and seclusion; 4) Training in prediction and prevention of violence, in self-defense, and in implementation of restraint and/or seclusion is valuable in reducing rates and untoward effects; 5) Studies comparing well-defined training programs have potential usefulness.     

Enhancing patient safety in psychiatric settings

OBJECTIVE: There is growing national consensus that use of institutional measures of control, such as seclusion, restraint, enforced medications, and hand-cuffed transport, within psychiatric hospitals is all too common and is potentially counter-therapeutic. Unfortunately, little is known about how to reduce such measures of last resort. This article reviews the available literature and describes a proposed research agenda involving a behavioral effort, the Engagement Model, for reducing seclusion and restraint procedures and enhancing patient safety in psychiatric settings. METHODS: Using Medline and PsychInfo, we reviewed studies that specifically evaluated efforts to reduce seclusion and restraint on psychiatric units. Key search terms included seclusion, restraint, reduc*, psychiatric patient safety, psychiatric safety, psychiatric sanctuary, and quality of care psychiatry. RESULTS: Only very limited data are available on reducing measures of last resort and improving the safety of psychiatric settings, and virtually no controlled data are available concerning the effectiveness of specific behavioral efforts on subsequent reduction of seclusion and restraint events. In light of the paucity of data, we describe efforts to incorporate and evaluate such a model in a large academic psychiatric hospital using a multiple baseline times-series design and review principles for and obstacles to implementing this model. CONCLUSIONS: It is hoped this discussion will stimulate research on this understudied topic and provide a framework for improving patient safety in psychiatric settings.