Sometimes, in especially intense moments in the emergency room, a staffer might have to take the drastic step of physically restraining a patient who is in mental health crisis.
ER staffers themselves have described it as an exceedingly difficult process, rife with the tension between providing good care and feeling physically threatened. And it raises questions that providers alone can’t answer: How does a patient feel during the experience, and how does that affect a person’s care and recovery?
To begin to answer those questions, researchers at Yale interviewed 25 patients who had been restrained in two urban ERs about their experiences. Their findings — published Friday in JAMA Network Open — shed light on the range of the patients’ perspectives.
“It was scary for me. I had no control over my body,” one participant said.
“The experience in the emergency room, it’s traumatic as hell,” another reported.
“When they restrain you, they ignore you,” a third patient said.
Health providers sometimes restrain patients using cuffs or sedative drugs when they’re experiencing acute agitation, a severe lapse in behavioral control that can become dangerous. The practice is seen as a way to keep both patients and health workers safe. But it has also been tied to physical health harms and psychological trauma in some patients — which means it’s largely used as a last resort.
“We are trying to avoid going down that road at any point,” said Nicole Visaggio, a nurse who specializes in mental health care at McLean Hospital and who has studied the use of restraints.
But in emergency rooms, where visits for mental health issues have risen dramatically in recent years, caring for an extremely agitated patient can prove exceedingly difficult. It’s a chaotic, intense environment that’s often ill-equipped to properly care for a person in crisis.
“Rapid control of an out-of-control situation is the default in ER settings. That’s definitely not ideal for someone in a psychiatric crisis,” said Dr. Matthew Wynia, a physician and bioethicist at the University of Colorado Anschutz Medical Campus. Wynia co-authored an editorial that accompanied the new study.
Nine of the 25 patients interviewed in the new paper reported negative feelings about the use of restraints, recalling that they felt as though they had lost their dignity and self-determination. Some said they felt alone or abandoned by staff. Ten of the patients said they had mixed feelings about their experiences. Another six said they had positive feelings — “the staff have got my best interest at heart,” one patient explained — or felt they were to blame for the experience.
Many of the patients included in the study did not go to the hospital willingly and reported feeling frightened and angry before their arrival — feelings that physical restraints could easily exacerbate, experts said.
“[Clinicians] may not recognize how incredibly damaging an experience of restraint can be,” said Wynia.
Experts said one of the study’s most disconcerting findings was the lasting effects of an experience with restraints, including making some symptoms of mental health conditions worse.
“After all the times I’ve been restrained in the emergency room, it makes my PTSD and anxiety worse. My provider increases my anxiety medication for a few days until I can adjust to being back outside and get it out of my mind,” a participant said.
Others described feeling like restraints were the inevitable end to a visit to the emergency room.
“I already experienced so many times when they go right to the straps, to me it’s a ritual. It’s just what it is. There’s nothing I can do about it,” one participant explained.
Patients in the study said their experiences in the ER often led them to lose trust in the health care system or avoid it altogether. Those who experienced complications from a restraint — such as a patient who reported being admitted to the ICU after being sedated in the ER — echoed that mistrust.
That’s of concern, given that patients who are restrained are likely to also be patients who might already have trouble accessing the health care they need. Many of the study participants had mental health conditions, a history of drug and alcohol use, or had experienced homelessness.
“These patients are unfortunately already vulnerable. This probably doesn’t happen in isolation,” said Dr. Ambrose Wong, an author of the new study and an emergency medicine physician. He said the study’s findings emphasize the need for systematic approaches that can keep both patients and health care workers safe in a crisis.
“It’s not [only] just that individual staff member or patient’s responsibility to make sure that experience goes well,” he said.
Some health centers have created dedicated teams that are responsible for de-escalating the situation when a patient in the ER becomes severely agitated, as well as to manage the use of restraints when needed. Experts also said it might be beneficial to create a dedicated space within an ER that’s designed to help staff de-escalate a crisis without the use of restraints.
Wynia said it could be beneficial to have someone sit with a patient who has been restrained to minimize feelings of isolation and abandonment. Visaggio added that research has shown using a chair-based restraint system — as opposed to cuffing a patient to a bed by their arms or legs — can reduce the risk of a negative experience.
“It’s much more humane to be in a seated position. You can make eye contact with staff as they talk to you, and you can see what is going on around you,” she said.