SAMHSA
Summary Report - A
National Call to Action:
Eliminating the Use of Seclusion and Restraint
http://alt.samhsa.gov/seclusion/SRMay5report6.htm
Consumer and Staff Experiences
Consumer advocates Tom Lane, Gayle Bluebird, and Joyce Jorgensen read aloud stories of actual patients who experienced seclusion and restraint and of staff who witnessed or participated in such incidents.
Common Assumptions and Realities
Mental health provider Mary Ann Nihart presented several common assumptions about seclusion and restraint and also presented data challenging each assumption:
ASSUMPTION |
REALITY |
|---|---|
| Restraints keep patients safe. | Each year, 50-150 deaths occur nationally due to seclusion and restraints. |
| Restraints keep staff safe. | For every 100 mental health aides, 26 injuries were reported in a three-State survey in 1996. |
| Restraints are used only when absolutely necessary and for safety reasons. | Patients are restrained for such trivial "offenses" as refusing to move to another dining table. |
| Unit staff know how to recognize a potentially violent situation. | In a study of nurses' decisions based on clinical cues of patient agitation, self-harm, inclinations to assault others, and destruction of property, nurses agreed only 8 percent of the time, when data were analyzed for agreement due to chance alone. |
| Staff know how to de-escalate potentially violent situations. | Almost half the mental health technicians interviewed in one study either believed that no good alternatives to restraints exist or could not identify good alternatives. A survey of nurses found that only 7.4 percent were aware that death was a risk factor of restraint use. |
| Seclusion and restraint interventions are based on clinical knowledge. | Little evidence exists for beneficial claims regarding restraint and seclusion. |
| Restraints are not used as, or meant to be, punishment. | People who have been secluded or restrained typically experience a sense of punishment. |
| Seclusion and restraint are used without bias and only in response to objective behavior. |
Research demonstrates the existence of cultural and social
biases in the use of seclusion and restraint.
|
| Seclusion and restraint are "therapeutic interventions." | Patients characterize the experience as dehumanizing and humiliating and report no beneficial results. |
Challenges to Cultural Change
Facility administrator W. Russell Hughes, Ph.D., M.B.A., discussed the cultural changes needed to reduce and eliminate the use of seclusion and restraint. The culture must change from one in which seclusion and restraint are viewed as positive and therapeutic to one in which they are regarded as violent acts that result in traumatization to patients, observers, and others. The impact of abuse and trauma on the lives of consumers and staff must be acknowledged and addressed therapeutically.
Staff are trained predominantly in the medical model of treatment, which is based on identifying illnesses and using treatments from the research literature. This model is highly effective in treating illnesses but not in promoting health. Staff also have experience working in huge hospitals, in which the only way to operate was through policies and procedures. Many staff are trauma survivors with a strong need to control their environments. The consequences of this culture include a focus on disability, rather than recovery, and the view of pain as an acceptable byproduct of treatment.
Staff are likely to treat their patients in the same way as they are treated by management. When staff are treated in a dictatorial, controlling manner, they treat their clients through extreme control and use of rules. But if staff are treated in a warm and caring way, they treat those they serve with compassion and care.
Legal Issues
Advocate Susan Stefan, J.D., reported that the standard of care for people with serious mental illness in this country is changing. Deaths due to restraints are no longer acceptable, and criminal charges can be brought against the staff involved. When someone with a known medical condition dies while being restrained, a State grand jury investigation may be initiated. The standard is shifting from viewing deaths and injuries as due to improperly used restraints to the problem being the restraints themselves. People are increasingly realizing that restraints are excruciatingly painful, labor intensive, injury prone, and less effective than alternatives.
Ms. Stefan also pointed out that:
- Although eliminating restraints from all State and private hospitals is an important start, the use of restraints must also be eliminated from departments of juvenile justice, foster care, and other settings in which troublesome young people are placed;
- To eliminate restraints, the culture of force must be addressed. Otherwise, facilities will replace seclusion and restraint with equally objectionable techniques, such as pepper spray; and
- Deaths and injuries from seclusion and restraint are not inexplicable aberrations in an otherwise outstanding system of care but indications that the system is not working.
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