Is There an Alternative to Seclusion or Mechanical Restraint?

Sir: The treatment of agitated patients has been reviewed in the literature.¹ We would like to comment on the use of restraints and seclusion for such patients. We agree that mechanical restraints or seclusion should be the last measure used in the majority of cases, but think that application of such methods is sometimes necessary. A decline in the use of seclusion or mechanical restraint due to administrative regulation might be dangerous and the reason for increased violence on psychiatric wards.² Furthermore, some patients have been known to request placement in seclusion³ or to be mechanically restrained. Although significant literature exists, there is a lack of knowledge about patients' attitudes toward these methods independent of personal experiences.

Method. Attitudes of currently hospitalized patients with schizophrenia toward use of mechanical restraints (seclusion is a rare practice in Croatia) were examined. We constructed a questionnaire consisting of questions mostly related to patients' emotional reactions toward use of mechanical restraints and to the phenomenon of aggression on psychiatric wards. The participants gave consent to participate in the study after the purpose was explained. Data were collected in August 2006. Although 120 patients agreed to participate in the assessment, 13 patients (11%) refused further participation during assessment and 36 (30%) failed to provide analyzable data because of poor psychiatric states. Analyzable data were collected from 71 patients (59%) (male = 54, female = 17; mean [SD] age = 41.47 [12.62] years, range, 19–70 years; mean [SD] duration of disorder = 12.70 [9.03] years; 11 patients had been treated on “acute wards,” 23 on “chronic wards,” and 37 at the Department of Forensic Psychiatry).

Results. Of the final sample, 61 patients (86%) had the opinion that mechanical restraint was sometimes necessary, and 42 (59%) had the attitude that mechanical restraint of another aggressive patient reduced their feeling of insecurity. Thirty-two patients (45%) had been mechanically restrained 1 or more times. Of those who had been mechanically restrained, 17 (53%) had the attitude that, in their case, restraint was, at least once, necessary; 11 (34%) requested restraints 1 or more times; and 12 (38%) had experienced feelings of being safer during restraint.

We agree that, in terms of clinical guidelines, mechanical restraints or seclusion should be used for the least amount of time possible. Yet, use of restraints influences the “atmosphere on a ward.” In accordance with our results, decreasing feelings of insecurity or danger, which are present in a significant number of patients on the psychiatric ward, is part of that “atmosphere.”

Furthermore, we think that, in some cases, fortunately rare, feelings of insecurity among patients in the ward might become the reason for prolonged use of seclusion or mechanical restraint. For example, hostile attack of a patient by another patient might lead to increased feelings of insecurity among other patients on the ward. Feelings of insecurity among the other patients might be so intense that, independent of the psychiatric state of the patient who made the attack, seclusion or restraints should be used for longer periods of time. In similar cases, these methods might paradoxically protect the restrained patient from his or her environment. We do believe that such situations are more frequent on forensic wards, but are possible on all kinds of wards.