November 25, 2018

Managing Psychiatric Inpatients Using Seclusion & Restraint: Lessons from 1976

Robin Tzivanis

Robin Tzivanis
Healthcare Consultant/Tzivanis Consulting

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I was just reading an Open Minds article about reducing the use of restraints using a trauma-informed approach ( - and I had to smile, remembering my first three years in the field. There was almost a zero-restraint/seclusion rate where I worked, and there are both good things to learn from that, and cautions to share.

I started my career in 1976 in a private, 20-bed, open psychiatric unit housed in the ‘old’ part of the hospital- which was separated from the main hospital by a tunnel that was approximately a quarter mile long. To say that it was not a secure unit would be the biggest understatement possible. We used the first two floors of an eight-floor building. The unit had an open balcony, and an open stairwell that went up all eight stories to the unused floors (which were supposed to be locked, but often were not). We had curtain rods and drapes; we served food with actual dishes and real silverware, and every night we served soda in bottles along with other snacks. We could lock the unit doors, but it was rarely done and didn’t provide much security since the doors had real glass in them. We had two seclusion rooms, but they were rarely used. I was the charge nurse on the evening shift and I had one LPN, named Tina, working under me.  Generally speaking, in my state and at that time, patients who could not learn to behave appropriately ended up committed to the state hospital- and likely for a long stay. It was an effective paradigm at the time, in that the vast majority of patients learned quickly to do what was needed to avoid that alternative. In fact, I only recall sending six patients on to the state hospital during the three years I worked on that very active unit.

I was fresh out of nursing school and knew very little still about human behavior and psychiatry, but I had good instincts, I paid close attention, and I had excellent clinical supervision to help mold my instincts into actions. The first thing I learned, was that people tended to live up- or down- to my expectations and that my role in every interaction was the first thing to assess and correct as needed. Patients were not ‘non-compliant’- I had just not found the right combination of motivation and support they needed or wanted. I also learned that all behavior is functional. People don’t behave in ways that don’t work. They are always getting something they want through their behavior- unless they are psychotic and absolutely not in control- which poses a different set of challenges. However, for most patients on the unit, part of my job was to help make the inappropriate behavior stop working for them in order to help make room for new behaviors.

I was taught to treat the patients like people who had something wrong with their brain chemistry and were having an acute and temporary exacerbation of chronic issues. There is nothing in that sentence that gives permission to act badly- nor is there anything that says they are not entitled to normal reactions to illness and other stressors. That meant that my expectations were set to expect that mental health patients needed to feel and act like anyone else as much as feasible considering their illnesses and that they had the same rights as I did to choose their destiny.

That was the foundation of my operational paradigm. To make that paradigm work, I learned to ‘partner’ with the patients. I learned what mattered to them and used that to help them find motivation for change. I negotiated behavior and rewards. I tapped into universal human needs and taught patients to exchange one reaction for another in order to ‘fit in’.  I held people accountable for the agreements we made. Most importantly, I listened, and minus some necessary ‘bluffing’, I leveled with them. Many a time, the lead psychiatrist would stop down to see me before they left for the day and ask me how I’d gotten some patient to do something because it was only happening on my shift. Sometimes, they’d help me reshape the interventions, but more times, I’d get a chuckle, and praise for my instincts and creativity.

I liked being creative and praised for it. It felt like who I was and what I believed in was just as important as what I knew about my field. I know that I have a creative mind, but most of those creative actions came about through desperation and necessity. On the evening shift, the patients are alone with the staff. There are no therapists, doctors, or groups to distract them. There are visitors- who far too often bring stress instead of comfort- and the staff, and that’s it. We spent more time with the patients than any other shift did, and as there were only two of us to deal with everything that came up- including new admissions and issues- we had to get good at creating a therapeutic milieu to establish and influence boundaries and help patients function within those boundaries.

I did have had rules for the unit, and they all were designed to create a milieu that would:

1.      Keep the patients and the staff safe. That was the number one priority. Just following Maslow’s hierarchy, safety comes long before self-actualization.

2.      Facilitate self-direction and planned detachment. I wasn’t going home with the patients. Learning anything from me wasn’t going to help if they couldn’t produce the behavior without me.

3.      Keep the patient moving forward on goals. The evening shift was often the ‘practice ground’ for something they were taught in therapy. They had the other patients and the evening shift staff- and sometimes family visits- to try a behavior or express an issue and see how it went. I encouraged even bad reactions to be seen as ‘safe practice’ and a chance to learn before ‘taking it on the road’.

We had our fair share of bad behavior. Some were simply inappropriate, and some became dangerous. In our open, unprotected ward, that tipping point could come suddenly. We had to be constantly on guard. I learned to operate on instinct. The ‘feel’ on the unit was just as important as the words being said. I encouraged patients to gather in the hall outside the nursing station, where I could hear them and where I would join them as often as possible. Tina and I were always floating around, in and out of rooms, watching TV for a bit in the common room with a group of patients, getting people to eat together in the small dining room for the company and support- and just being visible and keeping our antenna out. I became quite good at knowing, even without knowing anything, when someone was ramping up for an outburst of some kind, and often intervening before it could get that far.

The first rule on the unit was ‘safety’. All new patients were told the drill. If things got difficult or they got upset/scared for any reason- or if the staff ordered it- all patients were to go to their rooms and shut the door- no questions asked. The idea was to be sure that no one got hurt, and focus trouble towards me rather than other patients. Tina and I had a nice rhythm after working together for a while. When trouble started, she knew I’d step in and get the attention on me, while she got the patients out of the way and prepared to back me up. Calling for help from the main hospital was a good bluff that I used often, but not really a viable option. The medical teams in the main hospital didn’t understand behavioral health and wanted no part of our patients; they were a long run away; and, their reactions when they arrived would not consistently helpful as they were untrained in effective interventions with our patients.

Of course, it was impossible to see and prevent everything. Anytime that restraints or seclusion might have been needed, I had limited options and they were all versions of facilitating self-control and allowing chemical restraint to assist with self-control. In other words, in the environment I worked in, with the staffing I had, I couldn’t ‘force’ patients into seclusion or restraints. So, I had to entice them to control themselves. One option did include voluntary seclusion.

I had two seclusion rooms that were often in use for ‘regular’ admissions, but when they were vacant, I sold them as ‘sanctuaries’ where someone could go to stop all stimulation and relax or go to protect others from their emotions until they got control. I didn’t care if I had to change the sheets ten times a night. If anyone wanted time alone in a seclusion room, I supported that. That actually did work. I had patients ask me to go to the room or ask me to lock the door for a bit until they were sure they were calm. That had to be translated into walks, long baths, finding time to read- etc- for use at home, but many patients did find that option to take time for themselves by first using voluntary seclusion to ‘hide’ for a time and be alone.

So, we did our best with what we had using the milieu to influence the patients, therapeutic techniques to help people choose better behaviors and find older, bad behavior less functional, voluntary seclusion, and voluntary chemical restraint.  I have four examples of actual situations/conversations to the best of my memory:

·       (To a clearly hallucinating, schizophrenic male- 25-years-old, and 6’2” – shouting at the voices I knew told him that people were after him): “I understand that you’re scared and angry because of the voices you hear. You’re entitled to be. If you want to go into your room and yell for fifteen minutes, that’s okay- but you can’t yell in the hall because you’re scaring everyone else, and I can’t allow that. I also can’t let you yell all evening because I can’t let you suffer like that. It’s my job to protect people and help them. Let me give you some medication to calm you down, and you’ll feel good enough to watch the movie we’re showing at 8:00.”

Outcome- Amazingly enough, he let me give him the shot. He was a very large man and he could have broken me in half, and he knew it. I was no threat. Because I didn’t scare him, he let me help him. Quite honestly, I found it helpful, especially with large men, to be a ‘just a little nurse- and a woman’. I was not intimidating in stature or approach- not unless I had to be. I could put on a great steely-eyed dictator when that was needed, but most often, the soft approach worked better for me. Of course, after getting the injection, he wasn’t awake for that movie, so I did tell a little white lie on that. Still, I set parameters, and I gave him choices that were acceptable- including the choice to let me help- rather than hit him with restraints and force help on him. Now, I can’t take any credit for that. I simply didn’t have that choice. There was no take-down team. There were two skinny girls for staff. The only choice I had was to convince unruly patients to take charge of their own behavior.

The next evening, he knew he could trust me to be there for him. He willingly took his meds from me, though he often refused them on other shifts. Because he started to trust me, we loaded the majority of his meds into his evening regimen, and I tried to talk him into letting other nurses help him too.

·       (To a middle-aged woman with major depression standing in front of the balcony, and threatening to jump.) “I’m standing right here so first you have to get past me, which probably means you’d have to hurt me and I don’t think you want that.  Besides, it’s only one story down. Jumping over that balcony won’t kill you- it will just hurt you. You’ll be in pain, and you’ll make my evening miserable because I’ll have to haul you over to the ER and do paperwork half the night. Why don’t we just go back to your room and talk?”

Outcome: I used this bluff countless times. I of course, had no idea if they could kill themselves by jumping over, or not- but I think I was right that it would not be easy. I was 20-years-old and didn’t know what else to do but bluff- or use paradoxical interventions long before I even knew what they were. On a subsequent admission, this same woman did get over the railing and I grabbed her and pulled her back over-and I injured her back in the process because it was just me there and I couldn’t protect her from the railing and still keep my grip on her. Here’s a situation where having a large team to intervene would have helped. The patient out-weighed me significantly and the choice was to drop her or pull her back up and over the railing. It took adrenaline and every ounce of strength I had, but dropping her on purpose was clearly not a choice.

The sad part of this story is that a few years later after I was long gone, someone did go over that balcony and managed to die because he landed head-first. After that, the balcony and that eight-story stairwell were closed in.

·       (To a 20-year-old man, agitated, who pulled the heavy drapery rod off the wall and charged down the hall with it): “You don’t need that to break out you know. The door is open and I’m not stopping you. Drop the curtain rod and go. Come back later if you want to, but I won’t put up with any threats.

Outcome: He put the curtain rod down. I picked it up and secured it in the nurse’s station. I asked him what was wrong. His girlfriend didn’t come for visiting hours and didn’t answer his call from the pay phone in the lobby. He was intent on breaking out and finding her. I got out the AMA paperwork and told him his options. I told him that if he threatened me or the patients again, he might as well leave because I’d call the police and get him arrested. I further explained that if he wanted help, and agreed to behave responsibly, that I’d hate to see him go because he clearly had things to work out with his doctor and therapist. He stayed and I don’t recall any more issues with him.

·       (To the forty-five-year-old woman with Major Depression and Borderline Personality Disorder who broke a Coke bottle and threatened to cut her throat):

ME: “I heard the bottle break and I think you knew I would. You didn’t even close your door to muffle the sound. Then I had to walk back down the hall to get here and check the other rooms on the way since I wasn’t sure which room the noise came from. If you didn’t cut your throat before I got here, my suggestion is that maybe you don’t really want to. Maybe you just want me to know how much pain you are in. Maybe you just want to talk.”

HER: “I’ll do it right now and show you.”

ME: “I can’t stand here and watch that and you know it. I’ll have to tackle you and maybe you’ll hurt me instead of yourself. Either way, you won’t die. I’m fast and strong and as soon as I yell, Tina will be in here to help me. We will call for help and you will get treated in the emergency room if needed. Then after you are stable, you will get committed to the state hospital. Why not just set that bottle down and tell me what you wanted me to know? That’s why you broke the bottle, right? You wanted me to hear and come down.”

HER: “Will you talk to me?”

ME: “I will if you put that broken bottle down on the floor and let me take it away.  I don’t feel safe with you holding it.”

Outcome: I got the broken bottle and all the pieces cleared out and then we talked. As part of the conversation, I told her all she had to do was ask to talk to me and that the broken bottle was not necessary. She admitted that if I hadn’t heard the bottle break and come in, she had intended to come down the hall with the broken bottle until I saw it. I told her that I understood her desire to get my attention, but that if she ever broke another bottle, or did any similar thing to get it, I’d tell the psychiatrist to send her to the state hospital because she couldn’t be trusted on an open unit. I explained that she put my life, Tina’s life, the lives of other patients- and her own life- at risk when she did something like that- and though she didn’t hold her life in high regard, I did, and that I’d do whatever was necessary to keep her, and the rest of us, safe. Though she became a ‘regular’ admission a couple of times a year, she never did anything like that again, and we always found time to talk about her day and what she was doing to change her life. I even got her to play cards in the hall with me, so I could get another patient to finish the game, and substitute their attention for mine. After a few admits she sought me out when she needed me and she required no more interaction with me than any other patient.

These four examples show situations where my techniques worked to contain aggressive or inappropriate behavior- and there were many. I won’t tell you that I always got this right and nothing ever went wrong- because many things did- the most memorable of which was me out on the roof of the building, pulling a patient back from jumping over. She managed to pull the stops out of the window and went out. I discovered it and once I knew she was out there, I didn’t have much choice. I sent Tina to call the police and I went out after her. Had I never discovered her escape, she might have just come in on her own- but I certainly couldn’t count on that.

Another time, someone became very dangerous, and I couldn’t make a dent in his behavior. I had to protect the rest of the patients. I got him to follow me to the end of the hall, screaming threats at me the whole way, and then, I spun around him, got myself back on the unit, slammed the door shut- and locked him off the unit- and called the police to come to get him. He got arrested and spent some time in jail.

However, in general, I found ways to get people to stop themselves from acting inappropriately, and I think that’s preferable to ever laying on hands. Usually, even if I had to use chemical restraint after one shot was given if the patient had trouble again, they often were able to work it out without the aid of medication. Whether they’d had medication to help or not the previous time, I’d remind them how well they handled things the last time and encourage them to use alternative behavior again. I found that talking about what was happening- and distraction from it- worked equally well, and it was a matter of patient preference on which one was chosen. I also learned that a substitute was needed- so it was never going to work to just say ‘stop’. Instead, I gave choices- one of which was to tell me what they thought might help if I didn’t suggest anything that resonated with them.

Although there were some rough moments when the patient might have benefitted from more formal seclusion/restraints that I wasn’t capable of providing under the circumstances, I really am glad I never had easy access to that option early in my career. I admit that I get irritated with environments that worry about pencils, paperclips, and staples. There are a lot of worse things out in the real world that patients need to cope with. If the staff can’t manage behaviors related to a paper clip, then I can’t imagine how the patient can safely be discharged to the perilous real world. I also can’t imagine what anyone learns about behavior and self-control when they get restrained by a couple of large orderlies and put into seclusion or restraints against their will.

I do know that there are times when seclusion/restraints can and should be used safely to manage behavior and protect the patient- and the other unit patients. I’m not saying they should never be used. I’m simply glad, especially when I read articles on reducing their use, that my training was from the other side. Let me add, that despite the rough times on my open unit, the only time I ever got hurt at work was at a state hospital- during a take-down done with three other staff members. We got the patient on the floor safely and I was holding one leg. The orderly holding the other leg failed to hold it steady. The patient got it free and kicked me in the face- and broke my nose. I think that’s pretty ironic.

Conclusions: For me, it comes down to these thoughts.

·       I feel very lucky that I ‘grew up’ in the field in an environment that required me to use my brains to prevent or get out of trouble, rather than have access to an easy means to exert control over patients- but:

o   I feel very lucky that I didn’t get hurt being lucky about that environment; and

o   I feel very lucky that I had great mentoring- which probably helped keep the luck in the right balance.

·       I think all psychiatric units should err on the side of exposing patients to the ‘real world’- but should not so openly tempt fate the way my unit did back in the day.

·       I think all patients should be taught to make choices to contain their own behavior and not be subjected to external forces unless there’s no other option.

·       I think that having three big men hovering to do a takedown is intimidation, rather than a helpful occurrence.  When you have those resources, they should be well-trained to minimize intimidation, show up, sit down, and talk.

·       I think that every way to prevent hands-on interventions needs to be explored- but I think that when necessary, a good, fast, efficient takedown needs to be available. There were too many times that my bluff could have been called, and a disaster could have occurred because I had no backup position to the bluff.

·       I think that when you use that option, there needs to be a very complete review of why that option was used to be sure it was really the only viable and safe option. It’s far too easy to get scared or turn to the expeditious intervention. In the end, it’s still most important that patients learn to manage their own behavior.

Comments? You can contact me directly via my AdvisoryCloud profile.

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