A CHRONICLE OF SECLUSION AND RESTRAINT IN AN INTERMEDIATE-TERM CARE FACILITY

Adolescent Psychiatry, 2003 by Petti, Theodore A, Somers, John, Sims, Linda

It is encouraging that most of the patients' responses indicated that the solution to the situation should be with the teen himself or herself. The failure of the remaining 28 youth to give useful responses is a matter of concern, especially the 4 defiant responses ("Nothing; no one can help me when I'm angry"), the 10 coded denial or deflection ("I don't know" or "Leave me alone"), and the 4 non sequiturs ("I got a shot, I was held down"). Perhaps of even greater concern are the staff responses to the same question. Over half of the staff (9 members) blamed the patient, the system (9), or the medication level (7), whereas 10 staff members reported being at a loss as to what could have been done differently. Only 12 staff members accepted responsibility for finding an alternative solution, and an equal number had no recorded responses. Sadly, one staff member, with regard to the episode of a 12-year-old African American male, responded, "Nothing, really." A small percentage of such responses clearly indicated that much remained to be accomplished in this area.

When asked about what interventions were employed prior to the use of S&MR for the incident under discussion, discrepancies were noted between staff and patient perceptions. Because many patients responded with several answers for this question, more than 81 patient responses were coded. Confinement, broadly defined to include directing the patients to their room or quiet room by staff, was perceived to have been used by 37 youth as contrasted to 58 staff. Medication employed as a PRN was the intervention reported by 31 patients and 54 staff. Verbal interchange was reported by far more staff than patients. Therapeutic verbal interactions (e.g., one-to-one talks) were reported by 50 staff but only 18 youth; on the other hand, directives to behave from the staff were given as an answer by 21 staff and 9 youth. Other verbal interactions, such as verbal contracts and attempts to offer alternative activities, were reported by 21 staff. Coping skills are taught as a means to manage frustration or anger; five youth reported that deep breathing, counting to 10, and going off the unit to run were offered and attempted prior to the use of S&MR.

Given the horror stories surrounding the S&MR issues, including the number of deaths reported elsewhere with the use of seclusion or restraint in institutional settings (Ross, 1999), we queried youth and staff about the perceptions of safety during the seclusion or restraint process. Psychological adverse effects of S&MR have not been adequately researched. Feeling unsafe is a potential adverse effect of S& MR. Therefore, we wanted to determine if patients felt safe during the S&MR intervention. Even though 65% of patients reported that they had felt safe during the S&MR process, 25% said that they had not. Likewise, only 53% of staff reported feeling safe during the implementation of seclusion or restraint, with 36% reporting not feeling safe. No injury during the restrictive episode was reported by almost 75% of both patients and staff. Injury to staff or patient was reported by 12% of patients and 14% of staff. These findings have implications that require further exploration.