The need to develop alternative methods than seclusion and restraint

Abstract

The use of seclusion and restraint (S/R) in studies of psychiatric inpatients varied between 0 and 66% of admissions. Frequent use was associated with e.g. psychopathy of the patient, but particularly with the ward culture of the unit.

The comparison of the costs and benefits of S/R is problematic since there are no randomised controlled studies of their safety or effectiveness. S/R may save lives and prevent injuries in acute violent or suicidal incidences. However, S/R are used also in less serious situations. A national study reported considerable economic costs caused by S/R related psychological and physical injuries of staff and patients, and huge loss of working hours. Patients experienced S/R as frightening, dehumanizing, humiliating, claustrophobic, and punishing. A physical intervention may be stressful also for staff and other patients. The consequences of stress are particularly harmful for inpatients since genetic vulnerabilities and histories of stress or maltreatment are common among them. Frequent use of S/R instead of de-escalation may harm relations between staff and patients, the effect of medicines, and the recovery. In USA, S/R have been highly prioritized since 1998 when 142 S/R-related deaths, published in a journal, lead to congressional hearings. Asphyxia is a common cause of S/R related death. The deaths or injuries associated with S/R are not systematically registered in Europe.

It is difficult but not impossible to change practices and attitudes. Several countries, settings and nursing organizations (e.g. APNA) have projects committed to the reduction of S/R. Alternative, safer methods are needed.