Restraining patients to stop their assaults toward others or themselves has a history dating back at least 3 centuries. Restraint can take 1 of 3 forms: (1) physical restraint is the involuntary restriction of a patient's freedom of movement by one or more staff members, (2) mechanical restraint is the involuntary restriction of a patient's freedom of movement with straps or portable restraint boards; and (3) chemical restraint is the involuntary restriction of a patient's freedom of movement with a medication.
History of Restraint in Psychiatric Patients
A legal precedent for the use of restraint was established with the vagrancy laws in English towns in the 1740s.1 The laws granted public authorities the right to restrain unruly people (often inebriated disturbers of the town's peace) based on the quid pro quo principle. Permission to restrain these people was granted under the assumption that it would be of benefit to them and that the restraint would lead to an improvement or cessation in their unruly behavior. Although the benefit of this intervention was certainly not accepted by the person (who often ended up being placed in stocks in the middle of the town square), it still provided legal justification for the action.
For the next 200 years, reducing the use of restraint became a cause of reformers, mostly psychiatrists who were superintendents of mental health facilities. The most famous was Philippe Pinel, who in 1794, during the “Reign of Terror” of the French Revolution, delivered an address to the Revolutionary Council advocating that mental patients be accorded the same rights as promised in the Revolution's Declaration of the Rights of Man (written in 1789);2,3 namely liberty, freedom, and to be treated as brothers and sisters. This required their release from physical restraint unless there was evidence of imminent physical danger, and therefore freedom from being chained almost perpetually to walls.
In 1856, John Conolly, the superintendent of the Middlesex Lunatic Asylum at Hanwell, published Total Abolition of Personal Restraint in The Treatment of the Insane,4 describing his practice there. What both Pinel and Conolly noted was the tendency for the attendants at these facilities to abuse and assault patients, particularly in response to verbal threats and gestures of defiance. Reports of these abuses and prolonged mechanical restraints led the British Parliament to establish a “Lunacy Commission” in the 1840s,5 whose mission was to pressure mental health asylums, through their superintendents, to diminish or abolish the use of restraint on patients in their care.1
In American, there was a more positive view of the use of restraint, as it was deemed beneficial for the peculiar nature of “American violence” according to Eugene Grissom, and because it was beneficial for the patient.5 Special boxes were built in which to place agitated patients. Well-known psychiatrists such as John Gray, who was the editor of the American Journal of Insanity, agreed with this justification.2,5 This prompted an editorial in the Lancet in the 1870s by John Charles Bucknill,6 an English psychiatrist who had visited asylums in America, in which he stated that the reliance on restraint was an infernal barrier to the care of mentally ill patients. The difference of opinion between American and English psychiatrists on the issue of restraint seemed to be that the American physicians saw restraint as a procedure ordered by a physician in his or her role as the caretaker of the patient. The English psychiatrists, however, saw themselves as part of a team that included mental health staff, who required governance in the application of restraint.
These debates continued to the end of the 20th century. The consumer movement in mental health in the 1960s brought concerns about the use of restraint to public attention, in part through movies such as “One Flew Over the Cuckoo's Nest.” At the same time, the rights of patients with mental health problems against incarceration and coercive treatment were affirmed in several cases regarding the 14th amendment to the US Constitution. These cases included O'Connor v Donaldson7 (affirming the right to treatment), Youngberg v Romeo8 (supporting the need for treatment to be directed by a licensed physician), and Wyatt v Stickney9 (supporting the right of patients to receive individualized treatment).1,2
Some therapists used the “restraint is beneficial” belief as a basis for treating children with reactive attachment disorder, reasoning that these children lacked bonding experience and that enforced holding during temper tantrums was of therapeutic benefit. This appeared to be a misreading of Harry Harlow's research on monkeys that emphasized not only attachment, but also forcing the young to experience independence.10 Unfortunately, one of these children suffocated during a “rebirthing” effort based on this therapy.2
The Hartford Courant reported in 1998 that during the previous 10 years, 140 patients in the United States had died as a result of physical and mechanical restraint.11 Many of these were children who had died of asphyxiation, either due their chest being compressed by the person(s) restraining them or to the child's restraint position.11 This set off a decade of regulatory and administrative efforts to curtail the use of physical restraint and to provide education about avoiding its use, to monitor all restraints at all times, and to collect data about restraint rates and incidents for further reduction efforts.
Curtailing the Use of Restraint
Both the Joint Commission and the Center for Medicare and Medicaid Services (CMS), which accredit most hospitals and psychiatric residential facilities, established guidelines12 for use of restraint. This is a lengthy document, but the relevant CMS Standard summarizes it as:
482.13(e) Standard: Restraint or Scelusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have a right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or Seclsuion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time.12
The first step in this endeavor was the incorporation into hospital administrative oversight all seclusion and restraint incidents, policies, staff training, data collection, and reduction efforts. This information was then provided to these accrediting agencies at the time of credentialing, and also in the event of a morbidity or mortality event associated with seclusion or restraint.
Typically, incidents were originally targeted to be at the rate of no more than 0.45 hours of restraint per 1,000 hours of inpatient care.13 These rates applied to inpatient psychiatric care only, not to restraints in the emergency department. Because training occurred mostly on site, examination of the floor plan of the ward or emergency department became part of efforts to reduce the use of restraint. It was proposed that “quiet” or “comfort” rooms, where patients could sit in a relatively quiet and inviting area, would be helpful in de-escalating anxious and angry patients, both on psychiatric units and in emergency departments.
Training generally required two areas of restraint-reduction efforts: (1) attempt on the part of the staff to obtain patient and family input at the time of admission and during the hospitalization, and (2) staff training in deescalation.13 This could include ways to communicate and listen to each patient about their treatment preferences, and ways that could promote deescalation of anxiety- or anger-provoking situations. Two major programs providing these strategies are collaborative problem solving,14 and the trauma informed care curriculum of the National Association of State Mental Health Program Directors.15
Supplementing these efforts were specific programs aimed at de-escalating a patient already in crisis, with use of physical or mechanical restraint as the last resort. Such programs included Cornell University's therapeutic crisis intervention16 and the Crisis Prevention Institute's nonviolent therapeutic crisis intervention.17
Both the Joint Commission and CMS limit the use of patient restraint (physical, mechanical, and chemical) to situations in which the patient is an immediate danger to himself/herself or others. This means that patients cannot be restrained as punishment, reprisal, for rowdy behavior, or because of refusal to follow rules or to take medications. Any restraint can only be ordered by a licensed medical practitioner (LMP), which, depending on the state, could include physicians, nurse practitioners, physician assistants, and sometimes psychologists. The restraint has to be terminated as soon as the patient shows evidence of having regained self-control. Restraints cannot be ordered pro re nata (ie, as needed).18
Combining restraint with seclusion is not permitted. Also, if a patient is being given an intramuscular medication for a chemical restraint and is being physically restrained at the same time, then they must be noted as two different restraints, so orders, monitoring, and data collection are required for each.
According to the Joint Commission and CMS regulations, all restraints require continuous visual monitoring. All patients must be examined by a trained professional in the use of seclusion and restraint and alternatives within 1 hour of the restraint order. Any restraint lasting longer than 1 hour has to have a follow-up order from an LMP. If the restraint lasts longer than 1 hour for a patient younger than age 10 years, 2 hours for a patient age 10 to 18 years, or 4 hours for patients older than age 18 years, then it has to be accompanied by a face-to-face encounter with the ordering physician or the designee. In all cases where the restraint is terminated prior to the end of the ordered time, there has to be a face-to-face visit with the ordering physician or the designee within 24 hours. All of this information has to be entered into the patient's medical record, and can then be used as data for restraint-reduction efforts.13
All restrained patients have to be monitored for vital signs, respiratory status, and dehydration. Because asphyxiation is a common cause of restraint deaths, the use of pulse oximetry to monitor oxygenation during restraints has been suggested and supported by clinical experience.19 Generally, the participation of the treating physician or therapist in the physical restraint of patients is not recommended, as it can void the trust of the patient and disrupt the therapeutic alliance.20
All instances of restraints should be concluded with a debriefing of the patient by a staff member, preferably one involved in the restraint, as well as a separate staff assessment of the restraint. The goal of this activity is to prevent future restraints by making changes to the treatment plan, staff/patient interactions, and, where appropriate, with family input. This activity is important because in many cases the immediate precipitant to a restraint is an issue within the family of the patient, rather than a disagreement with another patient or staff. Information about the total number of restraints and their length of application in a fixed time period (eg, monthly) can be used to examine the restraint process in an individual unit, whether it is the inpatient or emergency department.
Information about the repeated restraint of a patient can be used to involve the family, staff, psychiatrist, and patient in revising the treatment plan to prevent recurrence of use. Indeed, when patients are restrained several times during the course of a day, an immediate review of the circumstances and suggested alternatives are a regulatory requirement.21
We have come a long way in understanding of our responsibilities in the management of troubled patients, from the quid pro quo of the village stocks, to shared working through of stress, misunderstandings, and knee-jerk reactions with patients. However, improvement is always possible, and perhaps technologies such as virtual reality will provide new understandings of restraint situations as it has for other mental illnesses such as anxiety and posttraumatic stress disorder. Meanwhile, our constant efforts to use alternatives and to minimize physical restraint is an abiding commitment for those who work in this field.
- Masters K. Seclusion and restraint. In: Psychiatry Board Review Course. Glendale, CA: Audio Digest Foundation; 2014.
- Masters K. Modernizing seclusion and restraint. In: Nunno M, Day DM, Bullard LB, eds. For Our Own Safety: Examining the Safety of High-Risk Interventions in Children and Young People. Arlington, VA: Child Welfare League of America; 2008:45–68.
- Weiner DB. Philippe Pinel's “Memoir on Madness” of December 11, 1794: a fundamental text of modern psychiatry. Am J Psychiatry. 1992;149(6):725–732. doi:10.1176/ajp.149.6.725 [CrossRef]
- Gardiner Hill R. Total Abolition of Personal Restraint in The Treatment of the Insane. April 13, 1839. Reprinted: New York, NY: Arno Press; 1976.
- Tomes N. The Great restraint controversy: a comparative perspective on Anglo-American psychiatry in the 19th century. In: Porter R, Bynum WF, Shepherd WF, eds. The Anatomy of Madness: Essays on the History of Psychiatry. London, England: Routledge; 1988:190–225.
- Bucknill JC. Notes of asylums for the insane in America. Lancet. 1876:418.
- O'Connor v Donaldson, 422 US 563 (1975).
- Youngberg v Romeo, 457 US 307 (1982.)
- Wyatt v Stickney, 325 F Supp 781 (MD Ala 1971).
- Blum D. Love at Goon Park. Harry Harlow and the Science of Affection. Cambridge, MA: Perseus Books; 2002.
- Weiss EM. Deadly restraint: a Hartford Courant investigative report. Hartford Courant. October11, 1998:1A. http://articles.courant.com/1998-10-11/news/9810090779_1_mental-health-deaths-restraint-policy. Accessed November 28, 2016.
- Centers for Medicare and Medicaid Services. Pub 100-07 State operations, provider certification. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf. Accessed December 12, 2016.
- Masters K. Ask the expert. seclusion and restraint. Focus (Am Psychiatr Publ). 2015;13(1):47–49.
- Greene RW, Ablon JS, Hassuk B, Regan KM, Martin A. Innovations: child and adolescent psychiatry: use of collaborative problem solving to reduce seclusion and restraint in child and adolescent inpatient units. Psychiatr Serv. 2006;57:610–612. doi:10.1176/ps.2006.57.5.610 [CrossRef]
- Huckshorn KA. Trauma Informed Care (TIC) Planning Guidelines for Use in Developing an Organizational Action Plan. Alexandria, VA: National Technical Assistance Center NASMHPD; 2010.
- Cornell University. TCI system overview. http://rccp.cornell.edu/tci/tci-1_system.html. Accessed November 29, 2016.
- Crisis Prevention Institute. Nonviolent crisis intervention training. https://www.crisisprevention.com/Specialties/Nonviolent-Crisis-Intervention. Accessed November 29, 2016.
- Joint Commission Standards on Restraint and Seclusion. Nonviolent Crisis Intervention Training Program. http://www.crisisprevention.com/CPI/media/Media/Resources/alignments/Joint-Commission-Restraint-Seclusion-Alignment-2011.pdf. Accessed December 12, 2016.
- Masters K. Pulse oximetry during physical and mechanical restraint. J Emerg Med. 2007;33:298–291. doi:10.1016/j.jemermed.2007.02.064 [CrossRef]
- Masters KJ, Nunno M, Mooney AJ. Should psychiatrists assist in the restraint of children and adolescents in psychiatric facilities?Psychiatr Serv. 2013;64:173–176. doi:10.1176/appi.ps.001652012 [CrossRef]
- Masters KJ, Bellonci C, Bernet W, et al. American Academy of Child and Adolescent Psychiatry. Practice parameter for the prevention and management of aggressive behavior in psychiatric institutions, with special reference to seclusion and restraint. J Am Acad Child Adolesc Psychiatry. 2002;41(2 Suppl):4S–25S. doi:10.1097/00004583-200202001-00002 [CrossRef]