xxAACP Newsletter, Volume 13, Number 3, Summer 1999
PRESIDENT'S COLUMN
The Conundrum of Restraint and Seclusion
The AACP has jumped into the discussion of restraints and seclusion because the issues involved represent the heart of what we are about; advancing the most humane and effective care for our patients. Our involvement in this discussion has placed us in a remarkable dialogue with our allies in NAMI, the APA and other professional groups. We have been sought out by legislators drafting regulations on these practices. (See article on Page 4) By entering this national discussion as the issues arose following a series of deaths and journalistic exposé, we have found ourselves in the midst of high emotion and great passion. There are multiple opportunities for creating unintended consequences with hasty public policy changes. It has been my hope that our discussions with colleagues and allies could lead to clarification of many related issues. Our involvement is in the spirit of positive and earnest dialogue which we believe will shed light and clarify values leading to improvements in policy.
It is easy to support the spirit of the NAMI policy on restraint and seclusion. Their policy speaks to the grindingly difficult situations in in-patient settings where a patient's behavior and staff anxieties demand some action due to acute safety issues. They ask us to consider the impact of restraint on an already confused individual. As advocates they most properly demand accountability, adequate resources, training and a high level of skill in conducting the interventions. They want us to debrief the patient, mindful of the traumatic nature of forced restraint. These seem to be reasonable demands. The deaths, particularly of children in residential facilities, seem to have occurred in situations where the skill level was very low and where accountability was very unclear. We agree that the unfortunate situations where acute restraint or seclusion is necessary represent failures in our approach to the patient leading to the practical necessity for safety measures. Restraint or seclusion should not be rationalized as treatment interventions.
NAMI has asked that physicians tightly supervise any episode of restraint or seclusion. They properly view an incidence of acute restraint as a medical emergency demanding a physician's presence. This concept has created some discomfort in many of us. On the one hand we are delighted to have our allies in NAMI recognize the importance of our roles in bearing responsibility in acute crises. On the other hand, as community psychiatrists we don't want to overvalue our roles with respect to our team members. We are very respectful of nurse practitioners, psychologists and others on our teams who know the clinical issues and have the sufficient professional values to monitor acute crises in partnership with psychiatrists. We worry that these constants fail to acknowledge the reality of who possesses the expertise in the painful area of psychiatric restraint and seclusion.
Three special populations warrant consideration in this discussion, younger children, adolescents and the sick and elderly. The elderly who are confused, as well as the many acutely ill patients our colleagues see in consultation and liaison activities, often require soft restraint as part of their subacute or chronic management. Policies on restraint and seclusion must account for the humane practice of a soft restraint assuring that a confused frail elderly person won't fall out of bed or that a delirious patient won't grab at IV's or nasogastric tubes.
When considering children, the group most cited as victims of poor restraint practices, we must be very careful to not take leave of the realities of developmental factors. Who would have problems with picking up a three year old child in a therapeutic day care program who was tantrumming while in acute emotional pain? Such children most often need to be held lovingly and talked to soothingly. The problem is that in so many programs for these tragic children staff fail to make such skilled therapeutic interventions. Quiet rooms, time outs, or even holdings, can be very appropriate therapeutic interventions for older children. Do we want to preclude such treatment interventions or even the opportunity to properly research them? Many parent advocates would strongly support such programs when performed expertly.
Adolescents represent an even more difficult conundrum regarding restraint and seclusion. States have radically different laws on the involuntary treatment of adolescents and the means one may properly use to constrain a youth who is out of control. If one is going to follow the practices promoted in the CMHS sponsored system of care reform movement one needs to account for what to do with a dangerously out of control teenager being served as an outpatient in an intensive wraparound program. One needs to promote one policy for the entire system of care that serves mentally ill youngsters; i.e. juvenile justice, social service, special education as well as in-patient and out-patient mental health. The AACP has tried to promote such consistent care in our Child and Adolescent version of the Level of Care Utilization System (CALOCUS).
Clearly changes in policy, both legislatively and in the administration of our community based programs, must reflect the complexity of the issues involved. They must be based on our core values of humane care for those who are suffering. We must also recognize that the focus on policy changes regarding restraints and seclusion may be dodging the real issues. We may be ignoring the consequences of trends away from more individualized treatment, from a value on treatment relationships and the value of stable, coherent programs where the clientele are known and crisis plans are clear and based on long experience. We may be ignoring the impact of a rapid turnover of staff who have been overwhelmed with caseloads that are too high, or of hospitals that are asked to contain a crisis rather then provide true treatment. The calamities that lead to a need for restraints and seclusion brings us to consider the failings in our systems of care. We must keep in mind that tighter regulations alone will do nothing to solve the larger system dilemmas.
Charles Huffine, MD
President, AACP
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