Chemical Restraints and Seclusion “Everyday” Practices in Ontario Psychiatric Hospitals

Rob Wipond
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Almost one in four patients in psychiatric hospitals in Ontario, Canada between 2006 and 2010 were subjected to “control interventions” such as chairs that prevent rising, wrist restraints, seclusion rooms, or “acute control medications,” reported a study published in Healthcare Management Forum.

University of Waterloo researchers looked at records for 115,384 admissions from 72 hospitals throughout the province of Ontario. They found that 24% or 27,171 patients experienced at least one form of control intervention. The most frequently used method was acute control medication with 19% or 21,422 events, followed by mechanical or physical restraints in 7% of cases or 7,476 events, and seclusion in 6% or 6,544 cases. Chairs that prevent people from getting up were used 1,068 times. The researchers also found that the rates of use of control intervention methods overall, and in the particular forms, varied greatly from one region of the province to another.

“The latest findings show that the use of restraints and medications as control interventions is still an everyday practice in inpatient mental health units,” said study co-author John Hirdes in a press release.

Lead author Tina Mah commented that, “Control interventions are not ideal because they counter a patient-centered approach to care and can damage therapeutic relationships while further stigmatizing patients.”

In the limitations section of their study, they suggested that their findings likely underestimated the actual prevalence rates of use of control interventions, because the way the data was recorded really provided only three-day snapshots at any time. Elsewhere, they also indicated that they had not included uses of “PRN” or “as needed” medications that were identified as part of patients’ treatment plans. However, physicians sometimes prescribe PRN drugs for nurses to give to patients for control interventions.

They wrote in their conclusions: “The time is now for healthcare leaders to be aware of the quantitative evidence pointing to the unacceptably high rates of CI (control intervention) use in Ontario hospitals, to clearly articulate this burning platform, and to call to action those who can make an impactful change to improve the safety of care for adult in-patient MH (mental health) services. One way forward to improvement is to publicly report CI use not as a punitive act but an act of transparency in accountability for patient safety to create motivation through attention. Rates of CI use are not uniform across Ontario, therefore understanding regional differences will be an important consideration when identifying potential CI reduction strategies.”

Mah, Tina M., John P. Hirdes, George Heckman, and Paul Stolee. “Use of Control Interventions in Adult in-Patient Mental Health Services.” Healthcare Management Forum 28, no. 4 (July 1, 2015): 139–45. doi:10.1177/0840470415581230. (Abstract)
Restraint, confinement still an everyday practice in mental health settings (University of Waterloo press release on ScienceDaily, July 6, 2015)

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Rob Wipond
Rob Wipond is a Victoria, British Columbia-based freelance journalist who has been writing on mental health issues for fifteen years. His research has particularly focused on the interfaces between psychiatry, the justice system, and civil rights. His articles have been nominated for three Canadian National Magazine Awards, six Western Magazine Awards, and four Jack Webster Awards for journalism. He can be contacted through his website.

19 COMMENTS

  1. Tina Mah (lead author) apparently does not know of the true purposes of psychiatry.
    To control the angry proletariat, to prevent crime before it can happen with “medicine”.

    The feeling and expression of anger is a mental illness.

    People are supposed to be good robots and follow orders at all times.

    “In our fervor to medicalize morals, we have transformed every sin but
    one into sickness. Anger, gluttony, lust, pride, sloth are all the symptoms of mental diseases.
    Only lacking compassion (kindness) is still a sin.” wrote Thomas Szasz.

    How do you be kind to the angry?

  2. Psychiatry also exists to cover up child abuse for the religions and easily recognized iatrogenesis for the incompetent and unethical doctors. And anyone who believes in “God” who has concerns or symptoms of child abuse or a “bad fix” on a broken bone must be violently restrained, tranquilized, poisoned, and “snowed” by the likes of doctors like V. R. Kuchipudi and Humaira Saiyed. Seemingly, according to my medical records, and V. R. Kuchipudi’s subsequent arrest warrant, so doctors / hospitals can defraud patients’ medical insurance companies out of lots of money for unneeded, but according to the ELCA Advocate Good Samaritan hospital in Downers Grove, IL, “appropriate medical care.”

    http://www.justice.gov/usao/iln/pr/chicago/2013/pr0416_01a.pdf

    Advocate Good Samaritan hospital believes that having six giant men violently terrify a petite and non-violent woman of rape, by strapping her to a bed, then immediately “snowing” her with Benztropine, Haloperidol, Lorazepam, Geodon, Tylenol, Mi-Acid II, and Milk of Magnesia. Then the next day with Benztropine, Depakote, Haloperidol, Lorazepam, Seroquel, Geodon, and Milk of Magnesia. Then eight more days of willy nilly massive poisonings, to cover up prior easily recognized iatrogenesis and child abuse for an ELCA pastor, is “appropriate medical care.”

    I’m quite certain giving even the private “non-profit,” “Christian” hospitals and their psychiatrists the legal right to force medicate people for any unethical or profit driven reason they please is too much power to give to the medical community. Both those doctors are still licensed and practicing medicine in the state of IL, despite Kuchipudi’s arrest.

    • Mental health usually = violent control of people who don’t matter, the “expendables.” Even if you start out with enough status, money, prestige, what have you to “matter,” the experts’ use of stigma and diagnosis will invalidate you…and you will be an expendable.

      I’m a Born Again Christian. I’m also increasingly frightened by the number of M.Divinity holders in mental health, fee based pastoral counselors, and the “mental health awareness” that so many churches are engaging in. Locally, a NAMI group meets in a Methodist church just up the road from me.

      The only group I can think of that still speaks out against mental health–because there was a time, not so long ago, when many Christians recognized that mental health treatment and Christ are often, perhaps usually, maybe always, incompatible–are the Pentecostals. Call them “holy rollers” if you want to…they read and teach the whole Bible. My real “counselor” at this point in my life is an elderly Pentecostal woman. Raised Pentecostal, all that. She’s more insightful and wise than anyone I’ve ever met. And, without having ever read Foucault, Szasz, Goffman, etc…she’s decidedly “anti-psychiatry.” I told her my story, of forced shock and violence and docs “making an example” out of me because I was/am a “trouble maker,” and she told me: they torture people. She briefly worked, on weekends, in a pscyh ward. She quit because of the screams of the shock patients and the torture she saw. Most people wouldn’t have quit. Real Christians have a conscience.

  3. Without a doubt, constraints, whether chemical or physical are used primarily to control people and to make life easier for the systems that mandate this control. People who show aggressive behaviour are usually terrified themselves, and the last thing they need is to be further terrorized. When people are frightened they do need a calm and caring environment, and sometimes might need the presence of a containing environment. Let me share a couple of stories to highlight these points.
    When I was a psychiatric resident at the Douglas hospital in Montreal, the Douglas did not have a restraint team for the emergency room. They had Vince. Vince was around 6″4″, probably weighed 280 pounds, with hands like baseball mitts. He was also as gentle as a lamb. When a person came in agitated, Vince would just talk to them quietly, say “settle down buddy” and perhaps put one of his big hands on the person’s shoulder. The person would almost always calm down immediately, and you could almost see the anxiety just flow out of them. I don’t remember restraints ever being necessary.
    At another Montreal hospital there used to be a patient that frightened people in the emergency. She would come in about once a month, and often would throw things around the ER, ending up being put in restraints or arrested. I was called one evening to find her in the psych room of the ER in restraints. I sat with her, talking quietly. After about ten minutes I asked her if she would like me to remove the restraints. She said yes. We then talked for about another 15 minutes, and she then said she felt better and left. She came in the next evening that I was on call. She said she felt violent inside and was frightened that she couldn’t control the feeling. I asked her if she would like to be put in restraints, and she said yes. Again we talked for while, with her pushing against the restraints at times, and then the restraints were taken off and we talked some more. She stopped coming to the ER except when I was on call. Eventually she would come in to talk and did not want or need the restraints. After that year she stopped coming, and I heard that she was doing well.
    The important aspect here is that any type of “treatment” should only be used for the benefit of the patient. We need to recognize when someone is frightened and to do what we can to reduce their fear. Sometimes outside limits or containment may be helpful, but we need to be very careful with using any type of outside control because these modalities can be so easily misused and abused.

  4. May I translate it for you:
    psychiatric hospitals = prisons that practice torture
    control interventions = torture
    patients = inmates, torturees
    acute control medications = chemical lobotomizers, torture drugs

    I think it’s a good thing to call spade a spade once in a while.

    • Psychiatrists and hospital workers can not understand a room you are not allowed to leave is a prison, not a hospital.

      The sane response to this insult (unlawful imprisonment) IS anger, but the average person does not know the power of psychiatry.

  5. I would say the rates are higher in other provinces, but we should call this as it is violence against other humans. Somehow the mental ‘health’ care system justifies violence and the people who work in the field are taught violence in the first day they start in the ‘system’. These people need to recognize their violence and stand up and ‘say no more’.
    How can one heal when one is traumatized by the very people that are paid by our health system to ‘help’ those in need?
    Could we start a campaign “say no to violence in mental health care”?

  6. “One way forward to improvement is to publicly report CI use not as a punitive act but an act of transparency in accountability for patient safety to create motivation through attention.”

    What!? Is that confused thinking or is that confused thinking?

    Control Intervention (CI) versus what? Not non-intervention? Doesn’t intervention by definition imply control? Whether an improved situation is attained or not depends on whose interests are being represented. I suggest that those interests represented don’t tend to be the victims of such intervention. They tend to be the interests of the state. Want to do away with the control aspect? Get rid of non-consensual treatment.

  7. “Control interventions are not ideal because they counter a patient-centered approach to care and can damage therapeutic relationships while further stigmatizing patients.”

    “Not ideal?” Seriously?

    How about “control interventions are inherently and uniformly harmful to patients and must be avoided by all means possible. They often occur as a result of inappropriate or abusive behavior on the part of facility staff, and frequently provide an easy excuse for failure and incompetence by professional personnel.

    “They can only be considered appropriate when violent or criminal actions are involved, and are never a method of therapy, but are an absolutely last resort means of protecting someone from physical harm when the full range of other de-escalation efforts have been honestly attempted without achieving safety. They should never be considered a part of any therapeutic intervention plan.”

    —- Steve

  8. The problem with nay kind of restraint or control is that it becomes a very slippery slope. Anyone who works in an emergency room will tell you that there are situations, such as a person coming in high on alcohol or drugs, aggressive and with a weapon, where there is a clear danger to staff and other patients that has to be contained. I don’t think that anyone would argue that an establishment doesn’t need some way of preventing people from getting hurt. I know of a number of nurses who have been assaulted and have felt very traumatized. So I think that there can be a dialogue on what are the best ways to deal with potentially dangerous situations. It has to be recognized that any procedure to deal with violence will likely end up being abused as staff become accustomed the discomfort that should always be there in any violent situation.

    • Hospitals are not places for drunk or aggressive people to begin with – I’ve heard there’s such thing as justice system, which includes police and jails. Besides 99.9% of “aggressive” behaviour by the “patients” is provoked by the stuff anyway starting with forcing someone in distress into these places against their will.

    • I think there are two huge issues that need to be addressed but are never talked about. The first is that clinical people confuse restraint to protect people with therapy. There is nothing therapeutic about restraint, chemical or otherwise. It serves the needs of the people doing the restraining. Admittedly, sometimes those safety needs transcend the needs of the client, and that has to be recognized. But often the restraining is couched as some sort of assistance to the client to “help get him/herself under control.” This is especially true of chemical restraints, and doubly true with kids.

      The other issue, which B mentions above, is that restraint is very frequently “necessary” because of abusive or thoughtless or incompetent behavior by staff people who end up provoking the client by putting them in a no-win situation. It’s so easy to always blame the client for such situations. Any time I read a report that says “Client assaulted staff” I want to read what exactly happens. More often than not, what happened is “Staff assaulted client” by putting hands on him/her or trying to take something away or force them to take medication or some such power struggle, and the client was defending him/herself, at least in his/her mind. Remembering that huge proportions of the “mentally ill” population have had multiple and serious traumatic events, often perpetrated by other staff in this or another facility, their sense of threat is naturally heightened and staff absolutely need to take responsibility for not threatening them. If staff can’t do that, they should not work at such a facility. Sadly, the staff almost always get a pass, no matter how poorly they behaved, and the client always gets the short end of the needle.

      A restraint ought to be a rare event and be handled as a critical incident by the facility, with a full debriefing (including with the person so restrained, whose version of events must be fully respected) and proper discipline of staff as appropriate, including firing and/or criminal charges if they apply. It should never become so routine that 25% or more of the clients are experiencing it.

      If staff people were held accountable for practicing good deescalation techniques and for avoiding power struggles, we could eliminate 99% of such situations without any physical intervention. Unfortunately, the people with the most power are the most likely to be held blameless, and the result is that restraint is common and unjustly and inappropriately applied daily at most facilities I have gotten to know.

      —- Steve

  9. When I was a psychiatric resident, I decided to do a research project on “difficult patients” at a chronic psychiatric hospital. I spent many days sitting in the lounge of a ward observing patients and staff and marking down every interaction. It became clear after a while that certain patient were quite sensitive to the atmosphere on the ward, and that tension in the atmosphere was usually created by the staff. So when certain staff members were in bad moods, certain patients would tend to become agitated. Of course, this led to the patient being excessively medicated or restrained, not the staff. It is always easy to blame patients fro their behaviour rather than looking for the causes of tension