July 24th, 2010

Use of restraint, seclusion is controversial, Part 1

The first of a two-part column.

When the justice and mental health systems believe that someone is a risk to himself/herself or a threat to others, the courts may intervene and involuntarily commit that person. To the public, an involuntary commitment might be the end of the inquiry regarding the treatment and care of those in mental health treatment.

This month’s column focuses on the use of seclusion and restraint for patients being treated within the mental health system. These issues are important, especially settings where the program is understaffed.

First, it’s important to discuss the variety of people who are served in treatment settings. There are patients who weigh little and haven’t shown a violent action and others who weigh 200 to 300 pounds or more who demonstrate violent behavior and every variation in between.

Gender and size differences may lead to assumptions that may not be true.

The real issue regarding restraint and seclusion is the belief that not using these methods will result in an unsafe environment for the patient or others in that setting. However, the process of removing the patient to a situation of restraint or seclusion may be occasioned by injury to others. The patient and the staff may not be in agreement as to the patient’s needs. These thoughts lead to the following suggestions.

When a patient is violent, it is probably important to first remove the most vulnerable people from the location as quickly as possible. It’s also important for everyone in the setting to be well trained regarding what to do. Secretaries, janitors, security staff, mental health workers and other personnel must know what is expected from each person if an incident occurs.

Who will call security or the police? Who will remove or calm the other patients? Who will address the upset or violent patient? Training for these issues and more should be done in advance and regularly.

It’s best to assume that if a mental health worker is involved in an incident with a patient when that patient shows violence, that the particular mental health worker should not be the person to continue the confrontation or attempt to control the patient if the situation escalates.

Clinicians, providers and patient advocates generally agree that when patients lose control and put themselves or others in harm’s way, staff may legitimately restrain or seclude them on an emergency basis. (www.samhsa.gov GAO/HEHS 99-176 “Use of Restraints and Seclusion,” 1999)

There’s less agreement about the use of restraint and seclusion in other situations. Some clinicians think these methods are an appropriate early intervention strategy to reduce over stimulation, teach self-control and protect the treatment setting.

For people with mental retardation, however, seclusion is generally not considered appropriate, but some clinicians consider restraint to be a legitimate part of a behavioral treatment plan, for example, as a way to reduce self-injuring behavior. However, many patient advocates, state mental health program officials and representatives of the psychiatric nursing profession disagree. They consider it an emergency response to a treatment failure to be used only as a last resort.

In an article by Laura Stokowski, RN, MS, entitled “Alternatives to Restraint and Seclusion in Mental Health Settings: Questions and Answers from Psychiatric Nurse Experts,” she defines the terms, restraint and seclusion from the Center for Medicare and Medicaid Services (CMS).

In summary, restraint is a method that halts or reduces the patient’s ability to move freely or a drug or medication used as a restriction to manage the patient’s behavior or restrict freedom of movement. It is not a standard treatment or dosage for the patient’s condition.

It does not include orthopedic devices or surgical dressings or bandages, protective helmets or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examination or tests, to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm.

Seclusion is defined as involuntary confinement of the patient alone in a room or an area where the patient is physically prevented from leaving. A situation where a patient is restricted to a room or area alone and staff physically intervenes to prevent the patient from leaving is also considered seclusion.

The definition notes that seclusion can only be used for management of violent behavior that jeopardizes the immediate physical safely of the patient, a staff member or others and shouldn’t be used as punishment, coercion, or threat. The method is used when a patient is temporarily unable to control impulses or surges of emotion leading to behavior that might harm someone else but is not safe for people who might harm themselves (for example, patients who bang their heads).

A locked seclusion room should also be avoided especially for patients with medical conditions.

According to the article, mechanical restraint may be preferred when the person would benefit from continued verbal interventions by staff that may safely remain near them to assist with calming strategies, allowing restraints to be removed at the earliest possible time. It should be avoided, however, for patients with a history of sexual abuse and trauma and used very cautiously in all instances owing to the risk of positional asphyxia or sudden cardiac collapse.

Since use of seclusion or restraint can disrupt the therapeutic alliance, honoring patients’ advance directives or preferences is important.

All use of restraint or seclusion should be monitored and reviewed and observation and watch logs must be maintained.

Edward M. Stern, J.D., has a private law practice in Newtonville, Mass. Stern serves as assistant dean for pre-law advising at Boston University and is a visiting lecturer for the University of Massachusetts/Boston Department of Sociology.

By Edward Stern J.D.

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