Human services restraint: its past and future.

03Original abstract

Restraints and seclusion are used on people in institutions, children in schools, nursing home residents, general hospital patients, and other locations, but most often with people who have disabilities. Questions regarding legality, morality, and efficacy abound. These questions, compounded by the serious possible adverse consequences of restraints and seclusion, have commanded wide-ranging attention from legislatures, government agencies, human service professionals, direct care staff, advocates, clients and families, and the public. This article addresses the use of physical restraints and seclusion. It does not address the use of drugs as a behavior restraint, although much of the discussion applies in that context as well.Is the use of human services restraint therapeutic? Can restraint use be reduced or replaced with alternatives? Is it time to relinquish these practices, at least when incorporated in a treatment or habilitation plan?In this article I begin with a look at the early institutional use of restraints and seclusion and, as a reminder of what may ultimately be at stake, I note some worst-case results in the United States. I then consider efficacy and risks of “human services restraint.” I review efforts to reform and reduce the use of restraint and address legal liability questions that impact on agency policy and professional behavior. I conclude with some thoughts on the current state of knowledge, policies, and practices regarding human services restraint and on the future of these techniques.Dr. John Conolly accepted the judgment of Dr. Robert Hill, who had experimented with nonrestraint at the Lincoln asylum. Dr. Hill had stated, “In a properly constructed building with [enough attendants], restraint is never necessary, never justifiable, and always injurious” (Ozarin, 2001, p. 27). That was 170 years ago.Dr. Conolly was appointed superintendent of the Middlesex County asylum at Hanwell in England in June 1839. Over 40 of the 800 patients were restrained at the time. Within 3 months, by September 21, all forms of mechanical restraint were gone (Hunter & Macalpine, 1963). Dozens of other facilities followed suit. As a modern commentator explained (Saks 1986),Dr. Conolly epitomized the no-restraint policy within the “moral treatment” movement influenced by the Quakers in England and post–French Revolution reformers in France in the late 1700s and into the 1800s. England's 1854 Lunacy Acts prompted the reduction of restraint use as well. The names of Tuke, Pinel, and Kirkbride are a familiar part of this history (Ozarin, 2000; Tomes, 1984).In the United States, psychiatric hospital superintendents in the mid- to late 1800s were divided on the use of restraints but generally opposed the no-restraint, English position. Physical restraint was viewed as a form of therapeutic treatment and was an accepted practice for dealing with violent patients. American psychiatrists extolled the value of restraint and seclusion, with one noting that these practices are required by a specific American violence. Eugene Grissom of the North Carolina state asylum argued “that the moderate use of mechanical restraint was therapeutic and morally sound, that it was required by the peculiar violence of American Insanity; and it that prevented tragic accidents and injuries” (Tomes, 1988, p. 190). John Gray, the editor of the American Journal of Insanity wrote, “We look upon restraint and seclusion, directed and controlled by a conscientious and intelligent medical man, as among the valuable alleviating and remedial agents in the care and cure of the insane” (as cited in Tomes, 1988, p. 206).In 1875, Dr. (Lord) John Buckmill, a former superintendent of an asylum in England, visited American public and private asylums. He disagreed with the American viewpoint. At the superintendents' annual meeting that year, he invited any superintendent to visit England for a month, and he bet £100 that such a visitor could not find any form of restraint in British asylums. He had no takers. He later wrote, “[The American superintendents] will look back to their defense with the same wonderment … that has been said in defense of domestic slavery” (Ozarin, 2001, p. 27).Although the vast majority of cases of restraint and seclusion do not result in physical harm or death, and for the most part shackles have given way to personal physical restraint, it is sobering to keep in mind at least some of the instances in which death during restraint has occurred recently. Contemplating these deaths assists in reflecting on how alternative practices might have affected the situation, if at all.It is sometimes said that the use of restraints represents a treatment failure. Here are seven stories of such failure; they represent tragic results in the use of restraints.Restraint is the use of force to limit another person's movement. This may occur by physical contact among individuals, mechanically by devices to limit movement, or chemically by the use of drugs. Seclusion is the involuntary placement of a person in a room, exit from which is not a permitted choice.Human service restraint, a term taken from Tumeinski (2005), is used here. The term encompasses both restraints and seclusion. It refers to restraint of a client under the mandate of a program or agency, public or private, by staff who are taught specific restraint techniques. We distinguish human service restraint from actions among parents, friends, and others in freely given relationships.Human services restraint is used in response to, or to control, injury to others, self-injury, property damage, resistance to behavior control, inappropriate behavior, rule-breaking, and the like. It may or may not be used solely in emergency situations. It may or may not be used for treatment, as part of a planned behavioral intervention, or as an aversive consequence for a target behavior.Restraints do not include orthopedically prescribed devices, protective helmets, holding someone to conduct routine physical examinations or tests, protections against one falling out of bed, or assistance to permit someone to participate in activities without risk of physical harm [42 C.F.R. 482.13 (e)(1)(i)(C)].In hospitals, restraint appears to be allowed in nonemergency situations; in intermediate care facilities–mental retardation (ICF/MR) programs, physical restraint and time-out are specifically permitted in nonemergency situations and, when prescribed, must be included in a client's individual program plan for active treatment. The United States provides some regulatory definitions. These differ depending on the type of program and people served. Two examples are provided here.For Medicare and Medicaid participating hospitals, including psychiatric facilities, the regulations are new. Restraint is “Any manual method, physical mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely” [42 C.F.R. 482.13 (e) 2006]. Restraint is allowed in nonemergency situations. Seclusion is “The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. Seclusion may only be used for the management of violent or self- destructive behavior.”The older ICF/MR regulations forbade “unnecessary” restraints and required that clients must be “provided active treatment to reduce dependency on drugs and physical restraints” [42 C.F.R. 483.420(a)(6)]. The ICF/MR regulations permit the use of a time-out room as part of “an approved systematic time-out program” incorporated into the client's individual program plan. [42 C.F.R. 483.450(c)]. Physical restraints are permitted only:The use of these human services restraint techniques is not simply a response to client behavior. There is an interplay among staff, setting, the characteristics of the individual, and the individual's behavior, which is perhaps best conceptualized, in the words of one researcher, within an “ecobehavioral” perspective (Day, 2000). Day noted, for example, that age and nature of disability may affect restraint use; there is a greater use of restraints for children with “lower intelligence or neurological impairments.” (Day, 2000, p. i). As discussed below, policy, training, and staff behavior greatly affect the extent of restraint use.Fisher, in a review of the existing literature published in 1994, reached the conclusion that “[l]ocal non-clinical factors, such as cultural bias, staff role perceptions and the attitudes of hospital administrators, have a greater influence on the use of these practices than any clinical factors” (Fisher, 1994, p. 1590).There is a vast amount of literature on these practices, much of it simply descriptive, policy oriented, and useful in training staff in techniques. There is a also what might be called a “negative literature” and a “positive literature.” Critiques of restraint use have been made on multiple grounds:The negative literature includes a small number of self-described “voices of protest” who defend restraint and seclusion and seek to “slow down the locomotive of opinions and pressure tactics that may lead mental health treatment in the wrong direction:The discussion here focuses on what the author believes are two fundamental questions that are most likely to influence governmental, agency, and judicial decisions on restraint: (a) efficacy and (b) risk of harm. There is relatively little scientific investigation of the techniques' efficacy, and no proof of their efficacy. There is, however, much evidence of their risks.Rapid intervention limited to protecting someone from immediate harm is sometimes necessary in an emergency. In such cases, the intervention is limited to the least duration and to the least risky method and must be accomplished by specially trained personnel. “Emergency restraint” is not planned and is not for the purpose of treatment or reduction of harmful behavior.Planned human services restraint for treatment, to support positive behavior, or to reduce negative behavior has not been shown to be effective. For example, a review of 109 articles spanning 35 years between 1965 and 2000 on restraints and seclusion on children and adolescents found that the techniques have only “questionable efficacy” (Day, 2000, p. 28). Research on human services restraint is characterized as sketchy and inconclusive. Both governmental and professional reviews have found no therapeutic value in the practices. For example, the state of Wisconsin concluded,The National Alliance on Mental Illness (NAMI) stated:In a training manual, A Roadmap to Seclusion and Restraint Free Mental Health Services for Persons of All Ages, the U.S. Department of Health & Human Services' Substance Abuse and Mental Health Services Administration (SAMHSA; 2006) set a goalDespite the absence of evidence of efficacy, there are volumes on proper procedures and criteria, minivolumes on documentation, and innumerable dollars spent annually on programs for staff training in techniques that have not been found to be effective.It is difficult to evaluate the relative risks in the use of human services restraint. The absence of data on restraint use (including data on routine use as well as the frequency of untoward events) makes it extremely difficult to comment on the relative risks involved in restraint, the comparative risks involved across a wide range of individual procedures, and the relative risks involved in alternative interventions, including seclusion, mechanical restraint, or medication (Busch & Shore, 2000; Patterson, 2003).Clients and staff may be injured during the imposition of restraint. The ultimate risk is death. In the professional literature, there has been discussion of the risk of death associated with the use of physical restraints since at least the 1980s. More recent research has focused on deaths and other adverse consequences in restraint (Fisher, 1994; Milliken, 1998; Mohr, 2003; Patterson, 2003). Although much of the research concerns psychiatric restraint use, the physiological effects of restraint are no different for individuals with intellectual and developmental disabilities. These risks exist with both mechanical restraint and with so-called personal restraint, where a staff person's body is used to impose the restraint.Upset clients, when restrained, are held down or held tight, often with bodily organs and chest compressed; the heart begins to beat faster or out of rhythm, as the body attempts to obtain more oxygen to support itself (DiDino & Zaccardi, 2007). Restraints involving neck holds or obstruction of the nose or mouth have a high risk of fatality, as do mechanical restraints or prone tying, including “hobble tying.” “Hobble tying is the term used to describe the prone positioning of a patient, following which their wrists are secured behind their back, their ankles are tied, and their wrists and ankles are subsequently secured together by pulling the shoulders back and bending the legs towards them” (Horsburgh, 2004, p. 8). In a series of 214 cases of hobble tying in agitated delirium, death occurred in nearly 12% of the cases (Stratton, 2001). Seated restraint is also risky; preexisting physical conditions, such as obesity, heart disease, general physical ill health, or exhaustion, are additional risks (Horsburgh, 2004).It is fair to say that there is no way to predict who may die due to the use of physical restraint or who may be seriously injured. Almost 10 years ago, an editorial in the Canadian Medical Association Journal noted the asserted benefits of human services restraint and then reminded us, “However, restraint is not itself harmless; some of who are restrained may We do not what this is, or how others will death and to be p. to be likely to be to restraints and to die restrained & & & The use of restraints in is of and is the of specific research restraint use in is often not to or regulatory & is a of evidence that the use of human services restraint be reduced and, as some programs have for this result is the use of positive behavioral which back, in at to the by Pinel, Tuke, and the treatment movement, and American institutional reformers such as policies, and of restraint of and specially staff training have all to reduction taught staff on an behavioral and a treatment that focused on the The reduced the number of of restraint and seclusion, these the at published in regarding reduction program the use of seclusion and mechanical restraint from to 2000 and the of staff from patient from to 2000 in state hospital to 2000, the of seclusion from to The duration of seclusion from to The of restraint from to The duration of restraint from to were in of staff from to 2000 National Association of Mental Health has training on human services restraint reduction and has that were reduced by as much as the of individuals in was reduced by as much as and the of in a were reduced by as much as These data are on to of the with data alternative often (a) and policy (b) and to clinical such as of the behavior or to restraints or seclusion, or the use of alternative for reduction include such as the following of & 2000; Milliken, 1998; are other to human services restraint. These may be by the that is These include the discussed in the use of restraints or seclusion as planned or treatment, only emergency This is a with who use of restraints have or are restraint on restraints is in Health restraint examples are as public or private, facilities, a to be from … any restraints or involuntary for of or The and of of 2000 [42 includes that public be for programs that to of the use of physical restraint and seclusion for such an individual necessary to the immediate of the individual or others, and of the use of such restraint and seclusion as a or as a for a habilitation a state mental health medical spent the in he their use in state and have also been affected by institutional staff restraints to U.S. Department of Health and Human Substance Abuse and Mental Health Services Administration to the use of seclusion and restraint in behavioral on Mental Health that seclusion and restraint be used as of not as treatment Mental Health p. The force on the that aversive behavior be without as part of a behavior intervention p. A is by The Alliance to and Seclusion was by a number of professional and decisions may have a I to the in the discussion on the use of human services restraint focuses on legal of care are to on which legal liability is will staff, or an agency be for for restraint at or for to use is there liability for a restraint gone does it treatment to use, or not to use, liability may affect agency and professional behavior, it is to consider the current state of the in this the of how the cases have been and the have generally been of restraint use and have not to the use of restraint. It does not however, that the least in their published have taken into the professional research on efficacy and risks or the by professional and governmental is a to be from bodily restraint, with the by the by the years in a in the and restraint practices of restraint have been by the under the and other legal and such as the and is a patient is to and in the of a for restraint, the are as a found 2007). A fair of the state of the is found in that practices are that are in that are not to a purpose or that are but are in of their current the legal cited likely restraint use when treatment or to or someone for or behavior and the is taken in at least and actions have not been by the some of these specific on the restraint techniques by decisions on and other At the same it is that the decisions in these cases found in the use of have not been provided a of the history and nature of restraint, the of evidence of efficacy, the high or the of professional The will likely from current state as that At that I the decisions to another will the of the decisions restraint and will begin to that restraints are therapeutic with by a or as an treatment for in a treatment or as an will likely be by The efficacy evidence is The specific ICF/MR regulations that permit time-out and restraint as part of an individual active treatment plan will be as in individual cases and then more use of restraint is to and and professional in recent years have of any use of restraint and noted, on Mental Health and restraint will be used only as of not as treatment Mental Health p. The National on and Research provides research on positive behavioral as a way to reduce the use of restraint and seclusion. has stated, a as do the practices of seclusion, restraint, and treatment” In seclusion and restraint as a area and a National to of seclusion and restraint mental health Department of Health and Human attention has focused on the both in the and in response to government The U.S. a 10 years ago, Restraint or Seclusion At The National for Mental Health a on the treatment professionals, and other have the and the who have are the American of and American of American American Association of and of Health National National Mental Health and the on are to this There is an by Restraint and and one by multiple to the use of seclusion and restraints Restraint to all restraint the of attention on restraint and seclusion from and personal with the imposition of these involuntary on with and the risks by these techniques. Human services restraint not the individuals to restraint but also staff, agency families, and the public. wide-ranging effects have a that is often both in practice and in the published is valuable to consider the use of human services restraint within planned treatment is with the of treatment programs, and personal and that it is to impose restraint on people who are and who have a have gone and that all use of human services restraint be simply on the for restraints is treatment, then that restraints are therapeutic or that the risks be does the future The use of human services restraint is into We that emergency restraint be in instances policy and training, positive and other We that restraint as part of a treatment program does not and is extremely There is a professional and governmental against the use of all restraint will be and that restraint will not be permitted in an habilitation or treatment plan or as an aversive consequence for a target behavior. I this will occur for there is a for restraint or seclusion in an emergency to immediate harm to a the techniques may be to such as in recent regulations to in these cases, only restraint be permitted to the death risk of prone and that restraint for a limited duration and under are back to discussion in the to years is is that have research on efficacy and and have perhaps a more of the due to who might be at risk of of a nonrestraint policy in human services will occur in an I the by together with administrators, professionals, advocates, and the and in a years of service to people with will do no than Dr. do

Intellectual and developmental disabilities, 2008 · doi:10.1352/0047-6765(2008)46[154:HSRIPA]2.0.CO;2