Seclusion and Restraint: The Voice of the Patient

Aguilera-Serano and colleagues ¹ in this issue of the journal provide a perspective on the treatment of the mentally ill in which the autonomy and preferences of the patient have replaced seclusion and restraint as first-line strategies to deal with disorganizing behavior and violence in inpatient settings. Furthermore, as the authors document, the subjective experiences of the patients when given voice and influence have resulted in marked reduction in the need for seclusion and restraint, as well as involuntary medication.

Two multimodal approaches mentioned, the Six Core Strategies and Safewards, put patients’ experience and needs as the central feature of their management strategies.

The ultimate goal in mental health treatment should be the replacement of coercive strategies with collaborative ones. The article by Aguilera-Serano and colleagues ¹ provides a patient-oriented and patient-driven perspective to achieve it. Other approaches have been used, for example, eliminating seclusion as an option, by closing these rooms. This administrative fiat approach has disadvantages. It removes one coercive option, without providing patients and staff the opportunity to consider how to prevent a compensatory increase in restraint and involuntary medication. These options are potentially more dangerous in terms of morbidity and mortality: suffocation in restraint, aspiration, and bronchospasm in involuntary medication. In addition, the opportunity to reconfigure the seclusion room as a comfort or snoezelen room that patients could chose as a refuge or respite could be lost.

Alternately, the voices and desires of patients regarding alternatives to coercive interventions provide opportunities in secondary preventions—preventing their use in an at-risk hospitalized population—and tertiary prevention, using debriefing to prevent their repeated use based on information and suggestions from patients. The power of both options is increased if families of the patients can be involved in the discussion of how the facility works with patients to avoid coercion. Families can help explain a patient’s issues to the hospital staff and help a patient understand the hospital regulations and approaches to maintaining a safe environment. Once this information is communicated to relevant staff, the possibility of patient-staff collaboration to diminish conflict is greatly increased.

The transformation of involuntary medication into patient-supported pharmacologic treatment is bedeviled in part by its definition. In some, perhaps most, facilities, involuntary means an intramuscular injection that the patient does not wish. On the other hand, an oral medication dose that the patient does not want but takes can be seen instead as a PRN (pro re nata = as the occasion may arise) even though its use is coerced. In the United States, a major regulatory agency defines involuntary medication as a ‘chemical restraint’ that renders a patient unable to participate in activities because of sedation. Since chemical restraint is seen as an undesirable term by both patients and health care providers, it can become difficult to obtain an accurate picture of use, as PRN medication dose could be a more acceptable substituted description. Replacing involuntary medication with a collaborative alternative requires a standardized definition that then applies the same secondary and tertiary discussions with patients and families advocated for seclusion and restraint.

One of the greatest motivators to eliminating coercive interventions is their potential for causing injury and death. Patients and families need to be informed about the potential dangers of restraint, seclusion, and involuntary medication and what mitigation measures have been instituted. Staff training in how to carry out a seclusion or restraint without causing injury is not part of the Six Core Strategies or the Safewards program models. While there are proprietary programs that offer training like the Crisis Prevention Institute’s nonviolent crisis intervention and Cornell University’s therapeutic crisis intervention, there is no requirement for facilities to have such a program. In addition, staff who carry out these procedures are, at least in the United States, the lowest paid members of the treatment team and subject to rapid turnover. ² In some facilities, this can reach up to 20% to 30% a year, so that trained staff frequently leave, putting the patients who may be restrained or secluded in the hands of novices. Whenever seclusion, restraint, and involuntary medication are employed, frequent staff training and ongoing monitoring of each incident until the patient has returned to his or her prerestraint or seclusion or preinvoluntary medication state are essential, as addressed in standards by accrediting agencies such as the Joint Commission. Since death can occur from asphyxiation and aspiration, the use of pulse oximetry during and after the procedures has been suggested to detect a drop in oxygen saturation during and after the coercive procedures. ³

Finally, although the article restricted its scope to adults, there are 2 compelling reasons to expand the inquiry to include the views of elderly patients on geriatric mental health units and children: (1) because the opinions of both are likely to be discounted by inexperienced staff as being invalid either because of assumed lack of decisional capacity on the part of the elderly or manipulation on the part of children and (2) because both are more at risk than the adult population to medical morbidity and mortality due to illness and frailty on the part of the geriatric population and the smaller size of children. For example, physical holding, which is commonly used as an alternative to mechanical restraint in children, has resulted in deaths due to compression of the respiratory airway of the child by the restraining staff or aspiration due to anxiety, while the complaint ‘I cannot breathe’ is liable to be discounted by a restraining staff member who may be provoked by a struggling patient.

Aguilera-Serano and colleagues ¹ have provided us with patient-centreed insights that should inform our efforts to rid patients of coercive interventions as they engage in recovery work during their psychiatric hospitalizations. We should act on them.