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April 25, 1999
Principles for the Elimination of Restraint:
An ICSPP Report
Prepared by Peter R. Breggin, M.D., Director for
The Joint Commission on Accreditation of Health Care Organizations
This report is offered in response to the Joint
Commission's request of February 18, 1999 for ICSPP's recommendations on
"restraint use and therapeutic holding." This report focuses on two
aspects of your inquiry: "Criteria for the use of restraints in
individuals with mental illness" and "Effective alternatives to the use
of restraints." ICSPP offers ten specific recommendations:
(1) Restraint should be defined as broadly as
possible in order to facilitate the goal of reducing coercion as much as
possible in health care organizations.
(2) Restraint can be defined as the use of force or
the threat of force for the purpose of controlling the actions of a
person. Restraint includes a broad range of activities such as the use
of "take downs," "therapeutic holding," and other bodily interventions;
isolation rooms; strait jackets and four point restraints; and
neuroleptic drugs and other central nervous system depressants. The
definition of restraint can also be broadened to include any restriction
on the individual's freedom to reject a specific treatment or to leave
the facility or setting. In this regard, involuntary treatment of any
kind should be viewed as a form of restraint.
(3) Restraint should be limited to acute
emergencies involving threats to the physical safety of people, and only
when other non-coercive methods are clearly ineffective.
(4) The use of restraint should be viewed as a
therapeutic failure. Conversely, it should never be viewed as
"therapeutic." The attempt to impose "treatment" by force is always
counterproductive--creating humiliation, resentment, and resistance to
further treatment that might be more effective. Even if a hypothetical
use of "therapeutic holding" could be proposed for specific situations,
the overall therapeutic disadvantages of restraint are sufficient to
rule it out as a treatment alternative. For these reasons, the concept
of "therapeutic holding" is self-contradictory and unacceptable in a
health care setting.
(5) Most violence perpetrated by patients and
inmates in psychiatric settings is the direct result of actions
initiated by health care staff, including the use or threat of force,
ridicule and humiliation, lack of respect for basic human needs and
rights, and especially the failure to make a meaningful relationship
with the individual. Before resorting to restraint, the staff should
immediately examine the aggravating role of its own omissions or
commissions, and especially focus on factors disrupting the relationship
with the individual.
(6) Most violence in any setting is motivated by
feelings of humiliation. To avoid the use of restraint, to create a
therapeutic environment, and to maintain a high standard of ethics, all
health care settings should aim at eliminating humiliation and
encouraging respect. This requires empathic attention to the feeling and
needs of clients or patients.
(7) Patience is an antidote to the use of
restraint. In most cases, avoiding direct conflict or confrontation with
an individual who is upset or angry will reduce the likelihood of an
adverse outcome.
(8) Relationship is the single most important
therapeutic modality for ameliorating threats of violence, emotional
crises, and the need for restraint. Too much emphasis is placed on
becoming skillful in the use of restraint. Much more emphasis should be
placed on becoming skillful in the development of caring, respectful,
empathic relationships during time of stress and conflict. Almost all
"emergency" situations in which restraint is used can be better resolved
by a non-coercive, caring intervention from a person willing and able to
spend time with the upset or angry individual with the aim of peaceful
conflict resolution.
(9) All psychiatric and health facilities should
conduct regular training programs on the handling of emotional crises or
psychosocial emergencies through empathic, caring relationship and
conflict resolution without the use of restraint.
(10) As a part of informed consent for potential
patients, all health care organizations should be required to make
public their rates of seclusion and restraint, and to compare them to
regional or national averages.
While the Joint Commission cannot itself change
state law, it is important to recognize the harmful effects of
involuntary treatment. As long as the law endorses involuntary
treatment, the use of restraint will persist and will interfere with the
delivery of genuinely helpful treatment. Involuntary treatment motivates
doctors to use coercion rather than to build therapeutic, empathic
relationships. It also frightens people away from mental health
services. Therapeutic issues should be separated from public safety and
police issues. Mental health services should never be coercive; they
should be liberated from the burden of involuntary treatment.
Bibliography
Peter R. Breggin, Brain-Disabling Treatments in
Psychiatry. New York: Springer Publishing Company, 1997.
Peter R. Breggin,"Psychotherapy in Emotional Crises
without Resort to Psychiatric Medication." The Humanistic Psychologist
25:2-14, 1998. Attached to this report.
Notes
The misuse of psychiatric medications as restraints
is discussed in Breggin (1997).
Some of the basic principles for handling
emergencies without resort to restraint, including medication, are
discussed in Breggin (1998) which is attached to this report.
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Peter R. Breggin, MD
101 East State Street, PMB 112
Ithaca, New York 14850
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Phone 607 272 5328
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