Psychiatric Restraint

An intervention with risks and benefits, no matter how grim

Yesterday's New York Times featured a remarkable article about psychiatric restraint, as presented at the American Psychiatric Association. If you read this newsletter, you owe it to yourself to read that article. It describes a presentation at the APA annual meeting by a former patient who experienced a traumatic psychiatric restraint.

I have been a critic of inpatient psychiatric care as it's currently practiced—in that it doesn’t reduce death by suicide. When I worked in inpatient settings, much of my time was spent thinking about how to reduce the use of restraint. I am a child and adolescent psychiatrist, so the trauma associated with psychiatric restraint was evident. I’ve written about that topic before, also.

I was proud to work on teams that understood how pernicious restraint and seclusion could be from very early in my training, including medical school. When I was in medical school, I was introduced to collaborative problem-solving, an approach developed by Dr. Ross Greene at MGH that was deployed initially at Cambridge Health Alliance. The doctor who was the chief of that unit became a mentor of mine, Bruce Hassuk, M.D.

Reducing restraint and seclusion is crucial. Dr. Hassuk’s success at Cambridge Health Alliance, which was achieved by deploying a de-escalation technique like CPS and eliminating restraint on a unit, was remarkable. I read the research voraciously before I ever met the physician in charge.

However, when I met him and talked about what happened after this triumph, I learned that this remarkable outcome came at a cost. In the real world, you need to screen out those who might end up in restraints in order to run a restraint-free unit. What happens, practically, when you eliminate restraint as an option? You can’t admit anyone who might need it. There are other units where “higher acuity” humans can find themselves.

I later worked with Bruce in the state hospital setting here in New York, at Rockland Children’s Psychiatric Center, dealing with the most severe psychiatric illnesses in children. In this setting, eliminating restraint felt like a pipe dream. This was where other units sent kids to make their restraint numbers look better. We didn't have endless choices about who walked in our doors—state hospitals are the last stop. We had to ensure we were ready for anything, which meant being ready to reduce the dangers of restraint, even while it was still a tool that could be used in extreme situations. Each one made us sick to our stomachs, and extensive work went into making restraint rare and, when it did occur, as “less traumatic” as possible. In that setting, for example, there were no mechanical restraints—no leathers, no straps. If a patient was going to be restrained, it would be done with the hands of human staffers. This has both pluses and minuses, but one of the pluses is that human hands tire, and nobody holds down a child a second longer than necessary. The physical effort was a built-in check on the duration of the experience.

The New York Times article describes a horrific experience which, other than the pepper spray, sounds typical of experiences I saw:

The last thing he heard was a warning from one of the guards, who said he would be legally accountable if he hit them. The room filled with pepper spray, and the men were on top of him. He remembers being face down, under bodies, and hearing someone ask, “Are you going to be a good boy?” They cuffed him to the bed and gave him the shots. He remembers being alone in the dark, the pepper spray stinging his eyes, his genitals.

However, the warning in the beginning? That's real. I've had patients who had charges pressed after injuring nursing staff in a restraint gone south. That can lead to thousands in legal fees and months to years in proceedings and can become its own source of grinding trauma.

It's easy to imagine restraint just doesn't ever need to happen. Except, sometimes, it does. In my first 30 minutes of residency training, the following happened—after a restraint didn’t happen in time.

The story is as close to the truth as I can tell and does not violate patients' privacy. I trained as an adult psychiatrist on Long Island at The Zucker Hillside Hospital. This site, too, did remarkable work reducing restraint and seclusion. One of the ways we did that was to require a higher standard of supervision from physicians than the state required. The legal requirement was that a physician examine a patient in restraints every four hours. At Hillside, the standard became once an hour. This creates more work for the doctor on-call, which while I was a resident there, was me. More work for the doctor on call is a good thing. Anything that leads to more work is something we work even harder to ensure doesn't happen. We will also act faster to get patients out of restraints if it's more of a pain in the neck if we don't. Psychiatrists—we are like everyone else in this regard!

Within 30 minutes of my first day on-call shift, a restraint didn't happen fast enough. A patient savagely attacked a nurse. When I made it onto the unit after the code was called, the individual had already been violent and safely restrained. It was traumatic for everyone that day. On the floor, grasping at her bloody ear, in which an earring had been ripped out, lay one of our nursing staff. Minute 32 of my first call? I ensured she was safe, and the ambulance was on the way to take her to the emergency room. Next, I turned my attention to our patient—the senior resident was already at the bedside.

Some of our patients can be very violent when unwell. The patient that day required an examination. When I asked him if there was anything he needed—after obtaining consent to listen to his heart and lungs with my stethoscope, he turned his head and screamed (with paraphrasing for privacy):

“I need more cocaine!”

He was in restraints for six hours, and I evaluated him every hour. I did everything I could, prescribing medication gradually to reduce the risk of overprescribing. This increased the risk that he'd be in restraints longer at the same time. I wanted this man to suffer less. But I couldn't have, at the same time, more of my staff get assaulted. That risk looked likely at hour one, hour two, hour three, hour four, and hour five…but at hour five and 45 minutes? I came early for the last check because the staff called me and told me he had calmed down. I ended the restraint. My nursing colleague was out of work for six months, recovering from her injuries.

Taking One For The Kids

I've been physically assaulted twice in the inpatient psychiatric setting, once by an adult and once by a child. I’ve also been assaulted in my outpatient office—with doors slammed in an attempt to break my hand, and more. In the state hospital, an adolescent assaulted me. She didn't hurt me very badly, and the staff restrained her briefly—and she apologized. I thanked her for taking it easy on me. That same young person had sent 5 staff members to the emergency room with 5 separately broken bones in her more than a year as an inpatient in the state hospital.

The Director of the Office of Mental Health of the State of New York came to meet speak with us about her case. Honestly, she was one of my favorite patients. She was smart and funny and did well before leaving the unit. But at times, she was unwell. This can leave one filled with rage and trauma, and she was strong. She survived a nightmare of a life before the hospital. Trying to keep her safe and trying to keep us safe too? It was an unsafe thing to do, and everyone who worked with her to help her and every other child like this risked their bodies and lives to make it more likely she would leave better than she arrived.

I was serious about reducing restraint. In my final year of fellowship and a subsequent year working as an attending in the state hospital, I did a thing most physicians don't do— I took the same training as direct care staff on how to perform a restraint. I learned their de-escalation procedure, too. I had other ideas about how it could be done, but until I was on the front line, taking the same risks, I didn't have credibility. I completed the entire five-day training required of all staff who might participate in restraint. Later, when the young person attacked me, I sensed it would happen. I had seen her be violent before. I understood the risk. It was important to model for the rest of my team that some of my new ideas—borrowed from Mentalization-Based Treatment—could help in even the most extreme situations. I also understood that if the staff didn't trust me, nothing I said would be relevant. Thus, they needed to trust that I would take the same risks they did. So, I did.

Humans, in the throes of illness, can be unpredictable, dangerous, and still vulnerable. Restraint is one of our regrettable tools; every time it happens, it's a failure of the systems and tools that came before. It's a nightmare that leaves patients traumatized, staff traumatized, and all of us in a worse place than before. At the same time, absent the ability to enforce physical safety, we are left with violence unchecked and agitation unquelled.

These are terrible choices. We're making the least bad choice at any given moment, and we always need to acknowledge that we can do better.

Doing Better

One version of “Better” is having more robust tools at our disposal for de-escalation. Imagine someone screaming, “Just calm down” at you on your worst day. That would also be an attempt at calming you down—some techniques work better than others. It’s worth nothing. The individuals who need to be absolute masters of these skills are not the doctors—they are the frontline nursing and direct care staff. They are with patients all the time—there is often only one doctor on call for an entire hospital, so the individuals who need to be able to deploy the techniques are both the least trained and the most personally at risk. I saw the possibility of Mentalization-Based Treatment (MBT) in acute care and emergency settings—I even have a chapter in my book on the topic (amazon affiliate link). (Feel free to use the search function on this newsletter for many articles on the topic and subscribe to my other MBT-themed substack.)

Here is what MBT looks like in practice, in narrative form (again, fictionalized for privacy):

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I had a patient named Jeremiah, who was 14 years old. He was in the hospital but hadn’t said anything to any of the doctors. He hadn’t said anything to me. He’d only talk to one person in the entire building, a recreation staff member, and would take the kids out for basketball. This particular person Jeremiah talks to is pretty good with kids. But it’s limiting for me, as a doctor, to assess anybody based on what they’re telling someone who isn’t you when you’re never around. However, in this situation, that’s what I had to work with.

Jeremiah swallowed sharp objects. Repeatedly. Jeremiah had single-handedly trained an entire generation of local gastroenterology fellows. Every other day, a sharp object would go down Jeremiah's throat, and God knows where these came from. This would require a trip to the operating room, he would go under sedation, and they would try to retrieve the sharp object before it would puncture his intestines or stomach again. 

At the time I was going to see Jeremiah, I had recorded a podcast. Since I knew he likely wouldn’t talk to me, instead, I had a conversation with myself in front of him. I played the podcast I had recorded, which was an interview with a colleague talking about her experience of depression. I listened to it, and then I had a conversation with the character, out loud. 

“Lara didn’t tell anybody. She was suicidal for years. She was struggling. When she finally told me about it, she hadn’t told anyone before because she had been afraid of what doctors would think. Now we’re both doctors, so maybe that’s why she finally told me, I don’t know. I wonder if this is the situation you’re in, Jeremiah? I wonder if you’re worried about telling me what’s going on that’s getting to you. I worry about you swallowing that stuff. I don’t know why it’s happening. It’s really hard for me to not-know.”  

Jeremiah gave me a little smile, then spoke to me for the first time: “Thanks. I’ll see you tomorrow.“

I didn’t see him tomorrow. He was in the hospital for swallowing a sharp object that day. Two days later, I did see him again. I was called to the unit while he was screaming. His limbs were flailing, and he was clawing at the walls. A staff member was trying to hold his hands from clawing anything—anything— off the walls. 

“Jeremiah, I don’t get it, what’s wrong?!” I said as I walked up to the situation.

“They’re trying to stop me.”

“They have to stop you, I guess?” [clarification]

“Swallowing things makes me feel better!!”

“Wait, so we’re trying to stop the only thing that makes you feel better?” [clarification, not-knowing stance]

“Yes!!!!”

“Wow, that’s messed up. No wonder you hate this hospital. Here we are, forced to stop you from doing the only thing that helps you feel better?” [validation]

“Yes!!!! Yes!!!!”

“This is an awful problem to have. We can’t let you swallow things. But we’re getting in the way of something that makes you feel better. No wonder you hate it here.” I said. He calmed down a little bit. And then a little bit more. [validation]

The next day we had a full conversation, over a meal; a meal that included no sharp objects. He didn’t swallow sharp anything for the next week. He didn’t swallow anything the next month. He was discharged a month and a half later. It has been over a year since he was in the hospital.

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He wasn’t expecting me just to acknowledge where he was at—that is what “validation,” in the MBT model, directs us to do. Sometimes, validation of what’s happening right now is the most surprising thing you can say. It can get people out of their heads in a way you can’t— when trying to use force to stop them from doing something crazy. The reason people do outrageous things is because they don’t feel understood. When they feel understood, they stop. When you try to understand something that seems nonsensical to you, you create a shared connection that is desperately needed. MBT directs us to attempt to imagine their mind, however imperfectly, and then check if we got it right. This simple formula helps others understand we put in the effort to understand them. It’s not about mind reading—it’s about checking to see if we imagined correctly. Not getting it right—routinely—is part of this magic.

Having conversations out loud lets people understand what’s in your mind without having to wonder or worry. This strategy takes the pressure off. In kids like Jeremiah, it’s too dark in their own minds to imagine someone else might care. Mentalizing is about turning on the lights so people can see who is home in your head, too.

This technique has a growing evidence base in complex settings and with difficult cases. This includes residential settings for kids who aren’t safe at home.¹. Single-session training models for police officers have been published.². There are even adaptations for pathological narcissism³ and antisocial personality disorder.⁴ This is in populations of violent male offenders⁵—not softball cases.

We often think of “therapy” as something provided by somber therapists in rooms with two chairs or perhaps by cloistered texting. But most of what is therapeutic? It’s not therapy. It can be feeling understood, using tools from therapy, in any situation in which you find one’s self, at a moment’s notice, and using the ability—with some practice—to deploy radically genuine curiosity about the internal world of another. We have myriad pharmacologic treatments—many of them not very good—for the management of acute agitation in adults. We have none approved for use in children—and limited evidence any drugs work at all in this population.⁶

Given the trauma inherent in the use of restraint in psychiatric settings, it behooves us to learn all we can about ways to limit both the use of psychiatric hospitalization and to equip front-line heroes with the best tools to help patients in their charge regain their equipoise. We all deserve dignity, which sometimes means someone has to be curious and validating about how undignified a moment can be.

1. Domon-Archambault V, Terradas MM, Drieu D, De Fleurian A, Achim J, Poulain S, Jerrar-Oulidi J. Mentalization-Based Training Program for Child Care Workers in Residential Settings. J Child Adolesc Trauma. 2019 Jun 21;13(2):239-248. doi: 10.1007/s40653-019-00269-x. PMID: 32549935; PMCID: PMC7290019.

2. Drozek, R. P., Bateman, A. W., Henry, J. T., Connery, H. S., Smith, G. W., & Tester, R. D. (2021). Single-session mentalization-based treatment group for law enforcement officers. International Journal of Group Psychotherapy, 71(3), 441-470.

3. Unruh, B. T. Mentalization-based Treatment for Pathological Narcissism. Journal of Abnormal Psychology, 127, 496-502.

4. Bateman, A., O’Connell, J., Lorenzini, N., Gardner, T., & Fonagy, P. (2016). A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder. BMC psychiatry, 16, 1-11.

5. Fonagy, P., Yakeley, J., Gardner, T., Simes, E., McMurran, M., Moran, P., ... & Bateman, A. (2020). Mentalization for Offending Adult Males (MOAM): study protocol for a randomized controlled trial to evaluate mentalization-based treatment for antisocial personality disorder in male offenders on community probation. Trials, 21, 1-17.

6. Hoffmann JA, Pergjika A, Konicek CE, Reynolds SL. Pharmacologic Management of Acute Agitation in Youth in the Emergency Department. Pediatr Emerg Care. 2021 Aug 1;37(8):417-422. doi: 10.1097/PEC.0000000000002510. PMID: 34397677; PMCID: PMC8383287.