Seclusion and Restraint in Psychiatric Hospitals
Updated: Jul 11, 2019
Seclusion, restraint and forced treatment did not end with the outlawing of lobotomy and psychic driving. Psychiatric patients are consistently treated more like inmates and less like patients in need of care and recovery. Here, we talk about when and why patients are restrained or secluded, and why no one knows.
In the psychiatric unit of the University hospital, a patient cries. She’s having an episode, nurses whisper, as they soundlessly pass her a sedative.
In a three-bed patient room, security guards ransack drawers, clothing, backpacks. A patient lingers in the doorway as so many fingers rifle through her belongings.
A patient asks for information about her new medication and its side effects. The doctors refuse, for her own good. I am chastised for talking to fellow patients about their rights. The psychiatrist tells me it's because the patients are much sicker than me. They can't handle it.
I return to my room to find the cactus my friends brought me as a get-well gift gone. My nurse – infamous for harsh treatment of patients – tells me I am at risk of other patients using its small pot as a bludgeoning device. She gives me a plastic cup, and I try and fail to scrape the soil into the harmless vessel. It is my second day in the hospital, and a small comfort has been stripped away. I cry. The nurse tells me I am being inappropriate and hands me an Ativan.
A suicidal patient wears only a gown and is strapped down with a five-point harness: his hips, wrists, and ankles bound. He is secluded from other patients in a room without windows, books, music, healing. The room is furnished with a foam mattress atop a ledge protruding from the wall. When he goes to the bathroom, he is monitored by video cameras.
Approximately one in four Canadian psychiatric patients are secluded in the course of their treatment, and one in five are restrained. These rates are similar for patients under 21. Young patients with psychotic, bipolar, substance use, or personality disorders are at greatest risk of seclusion and restraint. The World Health Organization reports severe damages to a patient’s psychological well-being due to being held in seclusion and restraint, including loss of control, humiliation and degradation, damage to the therapeutic relationship helplessness, and feelings of rejection by healthcare staff.
Behaviours That Lead to Seclusion and Restraint
Any expression of emotion in a psychiatric hospital is viewed as symptomatic of disorder, explain Slemon, Jenkins and Bungay (2017), and emotional distress is often met with chemical or mechanical restraint:
“Within the mental institution, inmates are continuously observed and monitored, and are afforded a narrow margin of acceptable behaviour and expression that is not interpreted as symptomatic of mental illness. Individuals who demonstrate behaviour which is deemed disruptive or indicative of disorder face such punitive measures as removal of off-ground or personal clothing privileges, seclusion in isolation rooms and physical restraint.” (p.2)
Yes. In a psychiatric hospital – a place devoid of comfort, colour, or joy – patients are punished for expressing emotion or behaviour outside the range of “acceptable”. In this case, “acceptable” can be read as sitting quietly, taking medication without fuss, and complying with any regulation set forth by nurses and psychiatrists. It means not asking questions, questioning treatment, or self-advocating. Both the World Health Organization and the United Nations agree the practice of seclusion and restraint are counterproductive to recovery and meet criteria for torture, the culture of safety in psychiatric hospitals relieves the ambivalence healthcare providers feel toward the practice. However, seclusion and restraint are not only used in acute episodes of violence. Healthcare providers report using seclusion and restraint to control, punish, to manage perceived shortage of staff and resources, and to cope with insufficient deescalation and crisis resolution skills.
The Goal of Psychiatric Treatment: Risk Management or Recovery?
It is unnerving to contemplate the lack of recovery-oriented treatment in an inpatient psychiatric setting. According to WHO (2017), recovery-oriented services “provide hope, support empowerment and respect people’s choice allowing them to drive their own care and recovery journey and to live the life they want” (p. 14). While recovery and healing are the typical priorities of hospital settings, inpatient psychiatric wards are more closely related to prisons. In their paper “Safety in Psychiatric Inpatient Care: The Impact of Risk Management Culture on Mental Health Nursing Practice”, Slemon et al. point to perceived risk as the reason for this imprisonment orientation. Risk in psychiatric settings is conceptualized as risk to self, risk to others, and risk to the public – more similar to risk in a prison than risk in other hospital wards. While the Vancouver Coastal Health mission statement reads “We will be leaders in promoting wellness and ensuring care by focusing on quality and innovation”, safety is seen as the first priority in psychiatric care. In this way, practices that harm patients and prohibit wellness are excused under the premise of safety.
Behind Closed Doors
The stigma of inpatient psychiatric wards has not yet been touched by the current anti-stigma movement. This stigma allows psychiatric hospitals to operate beneath a shroud of secrecy. Patients and physicians are the only people who know what happens behind the locked doors of a psychiatric ward. As I begin to tell my research colleagues what happened to me in the hospital, I pull at the edges of the shroud. I lift a corner of the mystery and let the light in. Faces fall and eyebrows rise as they struggle to believe what is happening, now, fifty-one years after the lobotomy was outlawed. A pervasive belief that the psychiatric profession has moved past the era of MK Ultra’s psychic driving and depatterning – since the president of the American Psychological Association and the Canadian Psychological Association administered intensive electroshock therapy and psychoactive drugs to patients without their consent.
Slemon et al. write: “Although most unethical practices from the era of institutionalization have been identified as inhumane and discontinued, many of today’s practices still resemble those from the past, including confinement from the outside world, seclusion and restraint, observation and surveillance, denial of leave and removal of personal belongings including clothes.” (p.3)
Rather than engaging patients in meaningful treatment programs, the hospital turns basic human needs – fresh air, companionship, entertainment – into privileges. Patients are framed as incompetent at best and dangerous at worst, and denied meaningful involvement in their care. They are too fragile to understand, they’re too sick. It seems unethical, but it’s for their own good.
In popular discourse, risk management strategies like seclusion and restraint are framed as last-resort solutions. These practices are employed only when absolutely necessary to keep patients and others safe. However, Bowers et al. found the common reasons for seclusion, “as needed” medication, and coerced intramuscular medication were non-violent behaviour: refusing to take medication, failure to follow rules, and leaving the unit without a pass. Often, nurses escalate patients’ irritable or agitated behaviour: one study found nurses’ increased aggression toward patients correlated with increased use of seclusion.
I am in the emergency psychiatric unit and a man sits handcuffed, guarded by a police officer. He asks for a drink of water and the officer refuses. The nurses huddle, anxious and gawking. They are preparing for his inevitable violence; when he snaps from thirst and chaffed wrists. They are waiting for a reason to administer the risperidone, to remove every freedom and place him in a room with a food-delivery slot and surveillance cameras in the bathroom.
I stand and ask the nurses to stop staring. It’s protocol, they reply, it’s safety.