In Reply: We appreciate the thoughtful perspective offered by Dr. Liberman. At the heart of the issue is a central tension: How do we maintain safety and order on psychiatric units, where patients are by nature severely mentally ill and potentially subject to erratic and unpredictable behaviors, while at the same time maintaining the dignity, humanity, civil liberties, and therapeutic milieu of psychiatric settings? How do we achieve the appropriate balance between these two potentially conflicting aims? On the one hand, recent data suggest that the rates of interpersonal violence in psychiatric settings are high (1), while on the other we know that some of the institutional measures of safety and control that are frequently used are often perceived as frightening or humiliating by those on the receiving end of such practices (1,2).
The complete elimination of seclusion and restraint may eventually prove clinically unrealistic. Clearly, some individuals with violent tendencies can be found in psychiatric hospitals. However, certain forms of seclusion and restraint would seem to violate the dignity of patients just by being used. They also may be inhumane not only because of the manner in which they are applied but also for the capricious reasons that are frequently offered to justify their use (2). Perhaps it is time that we reconsider the fundamental principle of crisis prevention and intervention training, which is to eliminate the antecedent to a crisis.
For example, how does something like handcuffed transport to a psychiatric hospital, which had been experienced by 65 percent of the respondents in our sample (1), set the tone for the mental health care that is subsequently provided? What kind of message does handcuffed transport send to distressed and vulnerable patients as they begin an episode of psychiatric care? Although there may not be a clear consensus on what should be the end goal for changes in the use of seclusion and restraint—"ultimately eliminated" or "markedly reduced"—it seems we could all agree that there is vast room for improvement on this issue—an issue that is critical to the care of people with mental illness.
Frueh BC, Knapp RG, Cusack KJ, et al: Patients' reports of traumatic or harmful experiences within the psychiatric setting. Psychiatric Services 56:1123-1133, 2005
Robins CS, Sauvageot JA, Cusack KJ, et al: Consumers' perceptions of negative experiences and "sanctuary harm" in psychiatric settings. Psychiatric Services 56:1134-1138, 2005