All persons with a mental illness… shall be treated with humanity and respect for the inherent dignity of the human person. – UN Resolution 46/119
Restraints (here to also incorporate seclusion) are CRUEL.
I’m not talking about restraints like handcuffs used to apprehend a criminal or seatbelt restraints to keep you safe in a car accident. Here, I mean to discuss the restraints many hospitals, nursing homes and other institutions still use on the mentally ill, disabled, and elderly.
Restraints are archaic, do not work, are not safe for patients or staff, and psychologically damage patients – stripping them of all dignity and the right to be involved in their own treatment while retraumatizing and punishing many. Restraints are supposed to be used in emergencies to protect the person restrained or those around them. However, even if used “correctly” and with good intention, the use of restraints is still cruel and a violation of human rights.
Physical (or “protective”) restraints are defined by the Food and Drug Administration as:
device[s], including but not limited to a wristlet, anklet, vest, mitt, straight jacket, body/limb holder, or other type of strap that is intended for medical purposes and that limits the patient’s movements to the extent necessary for treatment, examination, or protection of the patient or others.” 
They can include leg and arm restraints, hand mitts, lap cushions and lap trays that cannot be removed, waist/belt restraints, pelvic restraints, and vest/chest/jacket restraints among others.
The use of restraints is archaic – harkening back to times when people did not have any idea how to treat the mentally ill. Used in asylums and on mentally ill treated like criminals, restraints were thought of as treatment to subdue those thought to be out of control. In other countries, these out-dated notions remain, restraining those thought to be “criminals, crazy and dangerously aggressive people.” In some places shackles and stocks are still used.
In 1797, Philippe Pinel, “physician of the infirmeries” at Bicêtre Hospital in France (then an asylum) and Governor Jean-Baptiste Pussin, freed the mentally ill (then regarded as insane) from strait jackets (though unfortunately still keeping them in iron shackles). Even they were concerned with a more compassionate approach to treating those with mental illness, knowing that restraint was inhumane. How can it be that after centuries of knowing that restraints are not humane, we continue to use them?
Today, restraints are used for the elderly and disabled under the justification that they will prevent injuries to persons who are at risk of accidental falls. Restraints are used for mentally ill and the disabled to “protect” and pacify patients. In this context, physical restraints would theoretically be used to allow a doctor to treat an individual uncooperative with treatment measures deemed necessary. In truth, they are used more as a means to control patients when staff are ill-equipped (because of lack of mental health training, staff shortages, or other reasons) to work with patients in severe distress.
Commonly accepted practice hold that restraints should not be used as the first line of intervention. According to the Department of Justice (DOJ), “standards dictate that restraints be employed only in the face of imminent risk of harm, when less restrictive interventions have proven unsuccessful and never as a punishment.” Yet patients are often restrained for trivial reasons such as an elderly person refusing to move to another dining table.  Many nurses don’t know how to recognize when to properly use restraints such as for a potentially violent situation. They even don’t know that there are alternatives to restraints or that restraints can kill.
Laws exist to protect individuals from restraints. The Nursing Home Reform Act specifically states the following requirements for those in institutions:
(A) Specified rights: A skilled nursing facility must protect and promote the rights of each resident, including each of the following rights: …
(ii) Free from restraints The right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms. Restraints may only be imposed—
(I) to ensure the physical safety of the resident or other residents, and
(II) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances specified by the Secretary until such an order could reasonably be obtained). 
Nursing homes accepting Medicare or Medicaid payments must care for residents “in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident.” Yet, in applying restraints, residents’ feel socially isolated, fearful, demoralized, humiliated, angry, uncomfortable, and confused – feelings that remain months or years after restraint removal.
Courts have found that institutionalized persons have a legal right to “freedom from bodily restraint” The American Medical Association likewise states that “All individuals have a fundamental right to be free from unreasonable bodily restraint.” The AMA emphasizes the need for informed consent and restraints should not be punitive or used for convenience or used because of inadequate staffing. Still restraints are used, and they are used liberally and inappropriately to certain cruelty.
[R]estraints – with their inherent physical force, chemical or physical bodily immobilization and isolation – do not alleviate human suffering. They do not change behavior. And they do not help people with serious mental illness better manage the thoughts and emotions that can trigger behaviors that can injure them or others. [R]estraints are safety measures of last resort. They can serve to retraumatize people who already have had far too much trauma in their lives. – Charles Curie, Administrator of Substance Abuse and Mental Health Services Administration 
Restraints do not keep people safe. In fact, each year approximately 150 deaths occur nationally due to restraints. Beyond deaths, restraints can cause pressure sores, higher rates of infections, higher rates of falls, contractures, incontinence, bone demineralization, and increase aggression in both patients and staff among other effects. Restraints do not protect the elderly from falls or fall-related injuries. Staff are also hurt by restraints with studies showing that for every 100 mental health aides, 26 injuries were reported. Not to forget that restraining patients has a psychological impact on nurses. Thus, Restraints do not ensure physical safety, and there is no reason to ever use them for as it is a violation of legal rights.
Abuse has widely been documented about the use of restraints. In 1998, the Hartford Courant published a series of investigations on the use of restraints, confirming 142 deaths during or shortly after restraint or seclusion in mental health or mental retardation facilities (noting that many deaths may not have been reported). They found that the aides who execute most restraints were the least trained and lowest paid in their field. They also found that because of poor oversight and legal recourse, few were punished for their misuse of restraints.
Following this report, the National Alliance on Mental Illness (NAMI) started tracking reports of restraints and seclusion abuse, producing a report of 58 such incidents in only 2 years including the following disturbing incidents:
- A Man asking for something to help him sleep and was placed in seclusion with no bathroom, left to defecate in his clothing
- A Man admitted to psych ward involuntarily through ER after calling 911 for help was given antipsychotic drugs despite lack of consent and denied sleep medication even thought it was prescribed. He became agitated and hit an exit sign at which point staff told him that if he would go into seclusion room he would not be restrained. He cooperated but was still put into restraints in seclusion for 12-14 hours; during which time his charts showed he was calm and cooperative
- A 12 year old boy died at a wilderness camp when placed face down in a physical restraint.
- A 9 year old girl was left in a “time-out” room for three hours where she screamed, when the girl did not quiet down she was then placed in a therapeutic hold, and then given four shots of a sedative. The parents had no idea.
- A 44 year old professional woman sought voluntary treatment for bipolar disorder and was placed in 4 point restraints
- A man was kept in seclusion and sometimes in restraints for 10 days, because staff said that he “needed to sleep” instead of pacing at night and that he was not acting “appropriately.”
- A 28 year old woman voluntarily committed for treatment of conditions related to child abuse including rape was put in restraints with padlocks.
- A woman was given medications for 3 days until she was found “semi-comatose on the floor.” They placed her in restraints and stopped all meds and she woke up 3 days later unable to talk. She continued in the hospital for 3 weeks without counseling or rehabilitation.
- A 9 year old boy died after two hospital workers pinned him to the floor during a violent struggle.
- A 16 year old girl died while in restraints from a heart condition.
Most of those reported were in hospitals, residential facilities, or mental health institutions. These likewise happen to the elderly as evidenced by several court cases.
In Saunders v. Beverly Enterprises, a 56-year-old terminal cancer patient, a known smoker, was admitted to the defendant’s nursing home with orders for bed rest and restraint as needed. He was restrained 24 hours a day. He later obtained a lighter and tried to “burn himself free from the restraints, setting himself on fire.” Two weeks later, the hospitalized man died from second and third degree burns to his torso and neck.
An 84-year-old resident who had been restrained in her bed with a vest-type restraint was found hanging from the side of her bed strangled.
Then there is the 2008 report by the DOJ on the conditions in Texas’s State Schools for the Developmentally Disabled finding a failure to provide freedom from unnecessary or inappropriate restraints. From January through September 2008, a total of 10,143 restraints were applied to 751 Facility residents. The year before on resident’s shin bone was broken while forced into restraint after the resident did not answer what he wanted to eat and became agitated when staff touched him. That same year a teenage resident of one Facility died while being held in six-point restraints.
These examples are a few of the many sad tales of restraint abuse. Yet still these restraints are used frequently upon our most vulnerable – mentally ill, elderly, and disabled – those most in need of compassion and help. In 2008, a 26 year-old woman was placed in restraints for asking to discuss with her doctor the need to take a certain medication. The doctor never discussed the matter with the patient and she was put in 4-point restraints with an NG tube forced down her esophagus. She was left in this state for hours while nurses laughed at her in the hallway.
Regrettably, those who are restrained are seldom listened to. Their experiences are ignored even when these restraints are used “appropriately” (restraints are never appropriate but as deemed acceptable under today’s standards). Few studies have addressed how it feels for a person to be restrained. I recently came across an article by Tania Strout – Perspectives on the experience of being physically restrained: An integrative review of the qualitative literature. She found that restraints had a negative psychological impact, retraumatized those restrained, and were perceived as unethical. Common themes in the restrainees’ perceptions arose, including:
- Violation of personal integrity
- Imbalance of power with the restrained feeling powerless
- Restraints used as a means of punishment and control
- Retraumitization inducing flashbacks, nightmares, and anxiety related to prior abuse experiences
- Increased distress even after the restraints were removed
- Increased anxiety, fear, and anger, helplessness
- Lack of concern and empathy
She additionally found that there were perceptions of
- Lack of communication prior to restraint
- Being for refusing treatment, following staff directions, or loss of control
- That many were just trying to defend themselves
How sad it is to hear these accounts by those restrained – particularly when alternatives exist.
If worried about falls, institutions can work to identify each individual’s risk factors for falling and target their interventions accordingly such as addressing medication side effects, observing residents, facilitating safe mobility and transfer, rehabilitative programs, etc. Institutions can implement exercise programs to improve strength and balance.
For others with mental illness or disability, institutions should focus on communication between staff and patients. This alone could abate many circumstances which may escalate because of misunderstanding and leave a person feeling defensive and scared. As with those in nursing homes, mentally ill or disabled should have more individualized treatment assessing and recognizing triggers that may make someone more agitated, being aware of early warning signs and symptoms, implementing crisis plans and post crisis plans. Proper education for staff including doctors, nurses, and assistants in all areas of care from emergency rooms to residential treatment centers should focus on helping providers understand mental disorders and disabilities. Of course increased staffing would also help to ensure more individual attention on each person and eliminate the use of restraints as a means of control.
The Substance Abuse and Mental Health Administration states that eliminating the use of restraints requires:
- An adequate number of qualified staff to meet patient treatment needs
- Staff training, especially in verbal crisis management, including de-escalation techniques
- Active treatment
- Active risk assessment and risk-based treatment planning
- An environment of care that promotes patient comfort, dignity, privacy, and personal choice
- An emphasis on recovery for the mentally ill 
Most cannot imagine the horror of being restrained – the degradation, humiliation and pain of restraints. These methods are as cruel as use of frontal lobotomies or electro-shock therapy. They are torture for the patient and ultimately result in incredible physical and mental harm, harm which they are ironically meant to prevent. Still they are used under ridiculous justifications. Perhaps people do not understand the seriousness and think the call to end restraint use as an overreaction to a few bad examples. As the author of One Flew Over the Cuckoo’s Nest (most remembered for its portrayal of a mental hospital/ward and damning the use of frontal lobotomies) stated regarding his book and play, “And to those who think it is fictionally exaggerated I only say try it first and see.” 
It is no exaggeration to state that restraints are cruel punishment for the most vulnerable. If you think otherwise try it first and see.
- Mental Health: Improper Restraint or Seclusion Use Places People at Risk (GAO, 1999a)
- Mental Health: Extent of Risk from Improper Restraint or Seclusion is Unknown (GAO, 1999b)
One final note – Apologies for the dismal citations!
 United Nations General Assembly Resolution 46/119: The protection of persons with mental illness and the improvement of mental health care. http://www.un.org/documents/ga/res/46/a46r119.htm, accessed 5/29/11.
 21 CFR Section 880.6760
 Minas, H. and Diatri, H., Pasung: Physical restraint and confinement of the mentally ill in the community. International Journal of Mental Health Systems (2008); 2: 8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442049/ accessed 5/29/11.
 Redl, F. & Wineman, D. (1952). Controls from Within: Techniques for the Treatment of The Aggressive Child. New York: The Free Press.; http://www.samhsa.gov/Seclusion/SR_Report_May08.pdf
 Report by the US Department of Justice regarding statewide CRIPA investigation of the Texas State Schools and Centers. December 1, 2008. http://www.justice.gov/crt/about/spl/documents/TexasStateSchools_findlet_12-1-08.pdf, accessed 5/29/11.
 US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Summary Report, A National Call to Action: Eliminating the Use of Seclusion and Restraint, May 5, 2003. http://www.samhsa.gov/Seclusion/SR_Report_May08.pdf, accessed on 5/29/11.
 Supra, note 6.
 42 USC 13951-3(c)(1)(A)(ii).
 Id. & 1396r(b)(1)(A) (Supp. IV 1998) [Medicaid]; 42 C.F.R. 483.15 (1999) (featuring slightly different language — “A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life.”)
 Kathy A. Gorski, Myths & Facts … About Physical Restraints and the Elderly, 25 Nursing 25 (1995).
 Savidge v. Fincannon, 836 F.2d 898, 906 (5th Cir. 1988) (finding that Youngberg v. Romeo, 457 U.S. 307 (1982) recognized that an institutionalized person “has a liberty interest in ‘personal security’ as well as a right to ‘freedom from bodily restraint.’”)
 American Medical Association Code of Medical Ethics, Opinion 8.17: Use of Restraints. Adopted June 1989. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion817.page, accessed on 5/29/11
 Conversation with Charles Curie, SAMHSA Administrator (2002). See also Curie, C. “SAMHSA’s Commitment to Eliminating the Use of Seclusion and Restraint.” Psychiatric Services 59(9):1139-1141 (2005). http://www.mentalhealthamerica.net/go/position-statements/24, accessed on 5/29/11.
 Braun, J. and Capezuti, E., Article: The Legal and medical aspects of physical restraints and bed siderails and their relationship to falls and fall-related injuries in nursing homes. 4 DePaul J. Health Care L. 1 (Fall, 2000). (noting that no clinical study demonstrates that any intervention, including restraints, unequivocally prevents falls or fall-related injuries, that “one-half of all falls occur among restrained [residents]” and “serious injury rates are higher in facilities that use restraints”).
 Supra, note 6.
 Perspectives on the experience of being physically restrained: An integrative review of the qualitative literature. 19 International Journal of Mental Health Nursing 416-427 (2010).; Braun, J. and Capezuti, E., Article: The Legal and medical aspects of physical restraints and bed siderails and their relationship to falls and fall-related injuries in nursing homes. 4 DePaul J. Health Care L. 1 (Fall 2000).
 Perspectives on the experience of being physically restrained: An integrative review of the qualitative literature. 19 International Journal of Mental Health Nursing 416-427 (2010).
 Supra, note 6.
 Supra, note 18.
 Weiss, E. et. Al. Hundreds of the nation’s most vulnerable have been killed by the system intended to care for them. Series: Deadly Restraint, A five-part series. Hartford Courant A. 1, October 11, 1998.
 Saunders v. Beverly Enters., No. 89C-10930 (Marion Cty. Ct. Or. filed Mar. 18, 1991).
 Green, W. & Pollack, E., Nursing Home is Liable in Restraint Case, Wall St. J., Mar. 26, 1990, at B5.
 Supra, note 5.
 Supra, note 18.
 Supra, note 6.
 Kesey, K. letter to New York Times, January 7, 1964. http://www.lettersofnote.com/2011/05/it-can-never-be-as-bad-in-fiction-as-it.html, accessed on 5/29/11.