Olivia Matthes Theriault
Those struggling with mental illness are placed in inpatient psychiatric care when they are at-risk to themselves or others (Torio, Encinosa, Berdahl, McCormick, & Simpson, 2015). Psychiatric inpatient units are not designed to provide longterm care; the objective is patient recovery, which occurs when treatment sufficiently alleviates a patient’s acute symptoms for safe return to their community (Torio et al., 2015). In psychiatric inpatient units, psychiatrists utilize a variety of techniques to improve patient symptoms and aid recovery, including medication, safety planning, and talk therapy (Torio et al., 2015). However, when a patient is at risk of harming themselves or others, and previous deescalation attempts are unsuccessful, staff and psychiatrists frequently rely on restraint and seclusion practices (Azeem, Reddy, Wudarsky, Carbabetta, Gregory & Sarofin, 2015; Azeem, Aujla, Rammerth, Binsfeld, & Jones, 2017; Braun, Adams, O’Grady, Miller, & Bystrynski, 2020; De Hert, Dirix, Demunter, & Correll, 2011). Restraints come in either physical or chemical forms and are used to limit a bodily movement (Azeem et al., 2015, 2017). Physical forms of restraints include weighted vests, straight jackets or belts that forcibly keep the patient confined to a bed or chair, while chemical restraints include drugs, such antihistamines and antipsychotics, used to sedate patients (Day, 2002). Additionally, seclusion is the act of locking a patient in their room away from the rest of the group (Azeem et al., 2015, 2017). This practice is used when patients are being disruptive to group care or potentially aggressive (Azeem et al., 2015, 2017).
In recent years, there has been significant controversy over the use of these tactics, as research has indicated that the use of restraints and seclusion is physically and psychologically harmful for patients and for those who witness these methods (Butler et al., 2011; Hammer et al., 2011). Yet, some psychiatric caregivers argue that the use of restraint and seclusion tactics are necessary for controlling aggressive patients and teaching patients how to verbalize their emotions and exhibit self-control (Day, 2002; De Hert et al., 2011). Thus, this literature review sought to explore the following question: How effective are restraint and seclusion tactics in aiding patient recovery?
Restraints
Restraining patients is seen as a necessary tool for controlling those who might be at risk of harming themselves, others, or property (Day, 2002). Theoretically, restraints are only used when other deescalation tactics to return a patient to an unagitated state, such asconsulting a patient’s safety plan, voluntarily moving a patient to a quieter room, or avoiding known patient stressors in the first place, have failed (Azeem et al., 2015, 2017). More than half of all patients are restrained within five weeks of treatment, and 20% are restrained within their first week of treatment (Braun et al., 2020). The practice came under scrutiny when patients and staff cited the experience as traumatizing, and moral concerns about the use of restraint and seclusion arose (Butler et al., 2011; Hammer et al., 2011). In fact, the repeated use of restraints to prevent harm actually results in increased staff and patient injuries due to patients resisting restraint (Azeem et al., 2015, 2017; Day, 2002; De Hert et al., 2011; Greenwald et al., 2011; Lebel et al., 2010; Nelstrop et al., 2006).
However, in practice, restraints are frequently viewed as the only available method for controlling a patient who is perceived as aggressive (Moghadam, Khoshknab, & Pazargadi, 2014). Staff often cite aggressive patient behavior and potential for self-harm as antecedents for restraining patients (Braun et al., 2020). While staff administer restraints in the hope of reducing harm to patients, there have been several high profile cases of restraint usage resulting in patient asphyxiation, ultimately leading to their death (Lebel, Huckshorn, & Caldwell 2010). Reports on deaths in psychiatric facilities due to restraints sparked public concern and reformed training requirements for staff administering restraints (Altimari & Weiss, 1998; Lebel et al., 2010). Similarly, research has indicated that reducing the frequency of their use in psychiatric hospitals has led to fewer staff and patient injuries as well as lower rates of staff turnover (Azeem et al., 2015, 2017; Day, 2002; De Hert et al., 2011; Greenwald et al., 2011; Lebel et al., 2010; Nelstrop et al., 2006). The physical harm coupled with patient distrust fails the ultimate goal of hospitalization in aiding patient recovery (De Hert et al., 2011; Lebel et al., 2010).
Nevertheless, restraints remain the predominant method for tending to a patient who is perceived by staff to be aggressive (Day, 2002; De Hert et al., 2011; Lebel et al., 2010; Moghadam et al., 2014; Nelstrop et al., 2006; Prinsen & van Delden, 2009). Studies of restraint usage in psychiatric hospitals have not linked the number of restraints per patient to less aggressive patient behavior, yet this practice continues to be used (Day 2002; De Hert et al. 2011; Nelstrop et al., 2006; Prinsen & van Delden, 2009). Furthermore, restraint use is not related to improved therapeutic outcomes, such as functional impairment—a measure of the impact of a patient’s illness on their day-today functioning (Brown et al. 2013; Greenwald et al., 2011). The therapeutic efficacy (i.e., or the impact on successful treatment of a patient as measured by behavior and self-reports) of restraints is not known, as the practices are not evidencebased, but rather based on theory and everyday practice (Day, 2002; De Hert et al., 2011; Lebel et al., 2010; Moghadam et al., 2014; Nelstrop et al., 2006; Prinsen & van Delden, 2009). When restraint usage declines, a patient’s length of stay and levels of functional impairment also reduces, indicating that the use of restraint and seclusion does not positively contribute to improving patient recovery (Brown et al., 2013; Greenwald et al., 2011). Yet restraint use remains widely practiced, in part due to its historical use in standard practice (Day, 2002).
Restraints also undermine a patient’s progress, as patients cite their time in restraints as traumatizing, resulting in feelings of powerlessness and fear (Butler et al., 2011; Hammer et al., 2011; Fryer et al., 2004). In particular, patients with trauma histories of sexual and physical abuse are reminded of their experiences of abuse when forced into restraint, or even when watching another patient forced into restraints (Butler et al., 2011, Hammer et al., 2011). Patients with trauma backgrounds are more likely to be put in restraints than patients without those histories, as aggression is often a behavioral symptom of trauma histories (Braun et al., 2020; Hammer 2011; Fryer et al., 2004). This method can cause retraumatization for the patients which can subsequently disrupt the therapeutic process and hinder progress towards their recovery (Butler et al., 2011; De Hert et al., 2011; Fryer et al., 2004; Hammer et al., 2011). The effect of restraints usage in patients with trauma histories often extends patient length of stay and removes patients from their support network, indicating that patients are not receiving the highest level of care available to them (Butler et al., 2011; Hammer et al., 2011; Muskett, 2013). Ultimately, restraint use is traumatizing for all patients, posing a particular threat to patients with trauma histories (Butler et al., 2011; Fryer et al., 2004; Hammer et al., 2011). Despite the theoretical basis behind the practice and its widespread use, this tactic has well documented harms of their use and impedes a patient’s ability to recover (Braun, 2020).
Seclusion
Similarly, the use of seclusion remains popular in psychiatric hospitals, without substantial supportive evidence on the behavioral benefits needed for patient recovery. Seclusion is designed to limit a patient’s ability to cause harm and to teach patients how to control their behaviors by placing patients in a different room away from the group (Day, 2002; De Hert et al., 2011). The theoretical basis of seclusion is rooted in behavioral psychology, with the idea that patients’ inappropriate behavior will stop after being removed from the group they wish to be a part of (Day, 2002). However, what constitutes inappropriate behavior is largely at the discretion of staff members and lack concrete guidelines—which might lead to seclusion being overused or used unjustifiably (Day, 2002: De Hert et al., 2011).
The application of seclusion varies, and is largely dependent on hospital resources and practices (Day, 2002). Some hospitals have a designated seclusion room, which typically has limited to no furniture, but may have a bed equipped with physical restraints (Day, 2002). The absence of furniture creates a space that lacks comfort and aims to reduce inappropriate patient behavior with the idea that patients will not want to be uncomfortable again (Day, 2002). The key difference between a seclusion room and a standard patient room is that patients do not stay overnight, and it is established as a place of punishment in response to a behavior staff want to decrease (Butler et al., 2011; Day, 2002; Fryer et al., 2004; Hammer et al., 2011). Hospitals that do not have designated seclusion rooms will involuntarily confine the patient away from the group by locking the patient in their room alone, whereas other deescalation techniques ask patients to leave the group to calm down and return when ready (Azeem 2015; 2017; Day 2002; De Hert et al., 2011). Seclusion, however, removes the patient’s agency and choice by controlling their ability to return to the group (Azeem et al., 2015, 2017; Day 2002; De Hert et al., 2011). Similar to restraint use, the loss of control stemming from seclusion is cited as a traumatizing experience while hospitalized (Butler et al., 2011; Fryer et al., 2004; Hammer et al., 2011). However, seclusion continues to be used as a deescalation technique because, unlike restraints, it does not result in physical harm (Azeem et al., 2015, 2017; Lebel et al., 2010).
Although patients have reported fewer negative experiences in seclusion than restraints, seclusion continues to be a potentially traumatizing experience for patients (Bergk, Einsiedler, Flammer & Steinert, 2011). Seclusion allows staff to remove a potentially aggressive patient from areas where they could cause harm (Bergk et al., 2011; Huf, Coutinho & Adams, 2012). On average, 9.5% of adult patients and 47% of youth patients in psychiatric facilities are secluded during their stay (Crenshaw & Francis 1995; De Hert et., al, 2011.) However, seclusion is not found to reduce the use of subsequent seclusions for patients as their treatment progressed, which, theoretically, is the purpose of the tactic (Hickerson & Garrison, 1991). In particular, seclusion does not reduce the inciting behaviors that deem patients at risk to themselves or others, thus ineffectively aiding patients’ recovery (Hickerson & Garrison, 1991). Patients often report seclusion as traumatizing and express feelings of disempowerment, anger, and fear, hindering their treatment progress (Butler et al., 2011; Hammer et al., 2011; Fryer et al., 2004; Meehan, Vermeer, & Windsor, 2000). Debriefing conversations with patients after experiencing seclusion further reveal the traumatic effect of seclusions, with reports that nearly half of patients who experience seclusion have “probable PTSD” stemming from the event (El-Badri & Mellsop, 2008; Meehan et al., 2000; Whitecross, Seeary & Lee, 2013). Overall, much like restraints, the use of seclusion is based in theory and not evidence (Day, 2002).
Exploring Alternatives
The use of restraint and seclusion in psychiatric inpatient hospitals offers no clear therapeutic gain, while causing harm to patients who experience either tactic (Azeem et al., 2015, 2017; Braun et al., 2020; Day 2002; De Hert et al., 2011; Meehan et al., 2000). Restraints put patients as well as hospital staff in harm’s way (Azeem et al., 2015; 2017). Reducing the use of restraints has resulted in fewer staff and patient injuries and lower rates of staff turnover (Azeem et al., 2015, 2017). The main argument for continuing to use these methods is fear that patients will harm themselves, other patients and staff, or hospital property, despite research that indicates that staff and patient injuries decrease when restraint and seclusion use is decreased (Azeem et al., 2015, 2017; Brown et al., 2013). Although restraint and seclusion may temporarily limit a patient’s ability to cause harm, the psychological repercussions of restraint and seclusion for patients are serious (Azeem et al., 2015, 2017; Brown et al., 2013; Butler et al., 2011; Hammer et al., 2011; Fryer et al., 2004; Meehan et al., 2000; Whitecross et al., 2013).
Acknowledging that it is necessary to prepare for instances when a patient may become aggressive, several alternative measures are recommended. One suggestion is the use of Trauma Informed Care (TIC), a collection of best practices for service providers that emphasizes the importance of understanding a patient’s trauma history and cultivating safe and trusting environments for patients (Berliner & Kolko, 2016; Butler, Critelli & Rinfrette, 2011; Fallot & Harris 2009).
To further explore TIC in inpatient psychiatric hospitals and how it can be used as a potential alternative to restraint and seclusion use in these settings, an interview was conducted with Kate Vooreheis, a Project Coordinator at the Bellevue Hospital Child and Adolescent Acute Inpatient Psychiatric Unit. Bellevue is the oldest public hospital in America and a pioneer in medical research, and their child and adolescent psychiatric unit was the first in the country and is committed to providing high quality mental health care to children in New York City. Ms. Vooreheis has been at Bellevue for three years, managing research projects regarding the role of trauma backgrounds in child and adolescent psychiatric inpatient admissions, on a unit committed to TIC principles.
OMT: What is your professional background? How long have you been working with TIC?
KV: I began working at Bellevue after graduating from NYU, [for] about three years. I was excited to work at Bellevue because they were examining the role of trauma in psychiatric admissions, which is often overlooked. I have spent the past three years collecting data about the role of trauma in child and adolescent psychiatric inpatient admissions and working alongside a team that is very committed to understanding the trauma backgrounds of the patients at Bellevue.
OMT: How would you define TIC?
KV: I am a big proponent of TIC. TIC to me means not discounting a patient’s history [and] always keeping the whole patient in mind when developing a treatment plan. It is important to keep trauma histories in mind because it does significantly affect a patient’s presentation and recovery. TIC was not something I had heard of before coming to Bellevue. TIC allows clinicians to treat patients effectively, and I think a lot of other hospitals and treatment centers could be using this care model to more effectively treat their patients.
OMT: How long has Bellevue been practicing TIC?
KV: I cannot give an exact date, but Bellevue began doing more work and generating awareness around TIC in 2009 with the development of the Bellevue Innovation Lab.
OMT: Is Bellevue currently doing any studies to demonstrate the strengths of TIC?
KV: No current studies, however, we do collect data examining the role of trauma in treatment, presentation and length of stay among other factors.
OMT: What makes Bellevue’s Psychiatric Unit unique? How does Bellevue define trauma and does it differ from other settings?
KV: I think the idea of early intervention makes these units unique. We understand the role of trauma in presentation and are able to address patients’ trauma backgrounds at a young age.
OMT: Does Bellevue use a specific model of TIC?
KV: Bellevue does not use a specific model of TIC. The former chief of service was very committed to TIC and understanding patients’ trauma histories, so there is an expectation of the department to enact general TIC principles. We also screen patients upon admission and discharge for trauma histories to ensure that clinicians know a patients full background and take that into account when developing a treatment plan.
OMT: How do you think Bellevue’s use of TIC and their use of restraint and seclusion complement or oppose each other?
KV: The majority of clinicians at Bellevue are practicing a TIC module, so it is my impression that they really aren’t using restraints or seclusions, or those “extreme measures” unless they absolutely have to. There’s an argument that restraint and seclusion can be more traumatizing and further traumatize a kid, and even that a hospitalization itself is a trauma. I think it is necessary in some cases, but the staff does not want to be restraining a child. Restraints are only used if the child is at risk to themselves or others. When treatment is effective and clinicians are really getting to the root cause, then “extreme measures” like [seclusion and restraint] are not really necessary.
OMT: Do you see different emphasis from clinicians and nursing staff when it comes to TIC?
KV: I think clinicians place a higher priority on TIC than nursing staff. The staff at Bellevue works together in an efficient way that I have not really seen elsewhere. But I know nursing staff and techs are on the ground with patients all the time and so I wonder if TIC practices and responses are not always implemented in the hectic hospital environment. But I do feel that Bellevue’s department creates a strong community feel and staff works together to do what is best for the patient.
OMT: Is TIC enough of an alternative to the use of restraint and seclusion? Or will psychiatric care always have to use these tactics?
KV: I think restraint and seclusion will always be there as an option. However, I think that as more clinicians are educated about TIC and the role that trauma plays in psychiatric care, restraint and seclusion use will decrease. Restraint and seclusion will always be there for patients who do not have trauma histories. It may be something that patients have to experience before significant progress is made in their treatment. We see a lot of very traumatized kids and if aggressive behavior is accompanying that, it might take some time for that kid to have a “breakthrough” or to “let you in,” but as treatment progresses it should be used less and less.
OMT: Do you think TIC should be encouraged as a replacement for the use of restraints and seclusion? If so how can we disseminate information about TIC and promote this practice over restraint and seclusion?
KV: I think restraint and seclusion should be the last resort. I think with time, as the role of trauma in treatment is better understood and we are able to address the root of the behavior, one would likely see fewer aggressive outbursts that warrant the use of restraint and seclusion.
OMT: What are your personal thoughts on restraint and seclusion?
KV: As I mentioned before, I think that restraint and seclusion should be a last resort. I think especially in children and adolescents there is a risk of further traumatizing the child. [Thus] restraint and seclusion should be avoided unless absolutely necessary in keeping patients and staff safe.
OMT: What are some limitations to TIC?
KV: I think the lack of knowledge of the general psychiatric community. TIC is still pretty up and coming. I am not sure I see a drawback to TIC, but there is a lack of education and understanding of the role of trauma in psychiatric presentations. I do not think it’s standardized in clinician training and education.
OMT: What are the strengths of TIC and why do they outweigh the limitations?
KV: I think safety is the biggest strength of TIC. Keeping staff and patients safe should be a priority in inpatient settings.
OMT: How can we ensure that not only clinicians are aware of TIC but also the staff?
KV: I think trainings on the role of trauma in psychiatric diagnoses and how trauma may present itself in patients would be beneficial for staff. These trainings are lacking in many settings and are not standardized.
OMT: Where do you see TIC going in the future? How can we make it a standardized practice in clinical settings?
KV: I think raising awareness of TIC and the role of trauma in psychiatric presentation is important. Ensuring that staff and psychiatric presentation is important. Ensuring that staff and clinicians understand the role of trauma and how it may present is important for children getting the best care. Programs such as Think Trauma are great examples of education for staff and clinicians and I think more programs like it are needed.
Analysis and Conclusion
Given the high risk of retraumatizing patients while in restraints or seclusion, it is important to account for patient’s histories when considering how to regulate patients who may be perceived as aggressive. Interviewee Kate Vooreheis and others hope there will be a shift away from the overreliance of restraint and seclusion and promote TIC instead. Trauma Informed Care (TIC) is a newer model of care that has been suggested as a method for limiting, or replacing, the use of restraints and seclusion (Azeem et al., 2015; 2017; Brown et al., 2013; Greenwald, Siradas, Schmitt, Reslan, Fierle & Sande 2012). TIC is a collection of best practices for service providers that emphasizes the importance of understanding a patient’s trauma history and cultivating safe and trusting environments between service providers and patients (Berliner & Kolko, 2016; Butler, Critelli & Rinfrette, 2011; Fallot & Harris 2009). Implementing TIC models in inpatient psychiatric hospitals has resulted in decreases in the use of restraint and seclusion tactics, staff and patient injuries, staff turnover and patient length of stay (Azeem et al., 2015; 2017; Brown et al., 2013; Greenwald et al., 2012). While there will always be a multitude of approaches available for clinicians and staff to use when treating patients, it is important to carefully examine which ones best aid patient recovery and minimize additional trauma during a patient’s stay.
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