Behavioral precipitants of restraint in the modern milieu

Abstract

Physical restraint of the psychiatric patient is a persisting reality in the acute management of uncontrolled, disruptive, or violent behavior. Depite advances in pharmacologic and milieu management, the “quiet room”, locked seclusion, or mechanical restraint often remain the last resort in control of the acutely disturbed patient. In this era of nonrestraint, little is taught or written of the practice of restraint. The literature contains few systematic studies of its persistence in modern milieu wards. The practice of restraint is viewed in resident education as an embarrassing anachronism, yet persists in some form in most clinical settings. This incongruity between teaching and practice led us to systematically survey our own use of physical restraint in an acute inpatient milieu. The diagnosis of patients restrained and the behavioral precipitants of restraint are the focus of this report. The modern therapeutic milieu stands in philosophic opposition to physical restraint by virtue of widespread acceptance of dynamic management of violent patients and confidence in the efficacy of pharmacologic treatment. The clinical belief that dynamic understanding in experienced hands can render a potential combatant “quickly cooperative” 1 is widely held. Following Connolly's famous admonition that “restraint and neglect are synonymous,” 2 the milieu staff shares responsibility for the patient's disruptive behavior. Violence and impulsive behavior are not so much the product of autistic process as they are defensive responses to “ambiguous, confusing, belligerent or threatening treatment.” 1 A violent outcome and resort to physical restraint implies staff failure and a punitive response to fear of the threatening patient. In his study of factors sustaining the practice of locked seclusion at the Boston Psychopathic Hospital, Greenblatt identified the “evils” of “overroutinization of use, lack of knowledge concerning the patient's feelings, poor communication about these feelings among the staff and lack of adequate motivation for serving the basic psychologic needs of the patient.” 3 Attention to these dynamic considerations in a therapeutic milieu augmented by the use of potent pharmacologic agents has greatly reduced but not eliminated the use of physical restraint. The question of who is restrained on the modern milieu ward and why must be asked in this dynamic context.