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.

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“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.

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  • No guilty conscience here, scooter, just a conscience. You don’t want to be assaulted, try not acting like an animal. And whether *they* get away with *their* behavior has nothing to do with whether *you* get away with *yours*, although your attempt at reversal is pretty slick, and, I have to say, pretty standard. Zero points out of ten.

    • No, the staff doesn’t act like “animals”. I can’t get over how wrong you are. Why are you so pressed about out of control patients being restrained? If you don’t fit the description of the sort of patient that it happens to, stop worrying over it. You were obviously “treated unfairly” once in an ER, now you have a vendetta against them all.

    • Um, there’s actually a ton of accountability for the professions within the ER. MD, RN, ER Tech, etc.. Don’t act like employees don’t get written up or reprimanded for behavior towards patients. Having said that, when we need to physically restrain someone, it’s obviously for good reason. You sound like you have no idea how it works, especially if you were a patient at one time, and not a staff member.

      A rescue arrives with police presence. The patient isn’t under arrest, they just came for the ride to make sure this person ended up where they needed to be. He’s a large, tall man, well over 200 pounds, in full blown psychosis. Sometimes, they’re just heavily intoxicated and very belligerent. The patient had leather restraints on while in the rescue, that tells us a lot about this particular person before he comes into our care. We strategically move him from the EMS gurney onto one of our hospital stretchers. One limb at a time is released because we know how he is. Once the police and paramedics leave, we still have him leathers for everyone’s safety, including his own. This man, several times before, had punched nurses and techs in the face. Most of my coworkers, nurses and techs are females. The attending physician in that part of the ER might also be a woman on any given shift. We have security guards and they help tremendously when we need to restrain a patient.

      I guess my whole point is… when your faced with an angry, psychotic man (who already has previous assaults in his history) that’s twice your size or more, what are other options you suggest? Because even chemical restraints don’t cut it all the time.

      Oh, and it’s usually cops that get away with all the stuff you speak of. How many of them are held accountable for shooting people they shouldn’t have?

    • I love that you think that because I was a patient, I can’t possibly know how you do things. Like its some 33rd level Mason thing, some magical unknowable information. Stop bruh. You humiliate yourself.

      YOU are spouting the party line about what happens, and like most of your ilk you do it well. I guess you kind of have to.

      *I* on the other hand am talking about the way it *actually* works at ground level in the real world.

      So you’re welcome to BS as much as you like; you can’t change the plain and simple truths of the issue.

  • Love the providers here. As someone below said, I would never go to the ER, even if I knew I were dying. I’d rather die at home with dignity, and besides, the ER will assume I am an addict and treat me that way. I have never done an opiate drug in my entire life, not now, not ever.

    C’mon though let’s get real. You people are disordered; you’re passive dependent. You get a big bang out of having power over people who can’t fight back and for whom there are no consequences for anything you do to them. Why can’t you just own it? You like it. You get off on it.

    • Nah, it’s not a power trip. We’re just all set with being assaulted by patients. You have some sort of a guilty conscience over there? Very bold of you to assume that “there are no consequences for anything we do to them”. If you knew anything at all, it’s often these types of patients that get away with their behavior. We can’t even ban these people from a hospital where they’ve assaulted and threatened staff several times.

  • If the patient is threatening harm to themselves or others, then YES the staff has the right to physically restrain the patient. Often the psych patient is off their med therapy and has no idea of time, person place or reality. The restraints are for their own good, and for the safety of the medical staff. But then again this all could be avoided if the patient would take their meds as prescribed, which many of them don’t. It was far better when the psych hospitals where open and not closed, society was so much safer.

  • I was put in leather restraints during labor 35+ yrs ago! Can you believe it? I was not out of control, a danger to myself or others. I never got a good answer to questioning why! How barbaric

  • Couldn’t sleep for days and went to hospital for help. I screamed and got tethered to a bed in the hallway. I’ll always remember asking a nurse to please wheel me out if there would be a fire while I slept–they’d given me a shot of Haldol, which I was grateful for. That my rational mind was working has always been a consolation for me. Does anyone understand how terrifying a first manic episode is and that calming someone down is more beneficial than doing things that put them in a state of terror? Imagine if we treated screaming women in labor by tieing them down! Tieing me down was for the convenience of the staff and not for my health; the other patients came over the next day to make sure I was OK. They understood the terror. We got each other through the experience despite the care we received.

  • I’m sorry, when you have an out of control patient who presents a danger to themselves and others, restraint is often the only answer. Granted, it would be nice if every ED had staff whose sole job was to babysit misbehaving patients but, that’s just not feasible.

    I see people claiming how barbaric the practice is but, I don’t see anyone offering viable alternatives so…

    • Haha, I got a good alternative! People, control yourselves. And if you have lost control of yourself, restraining you not only protects others, it protects you from yourself too!

    • I hugged a seemingly violent fellow patient who was backing up to get a running start to bash his head into a wall. They calmed him down and he walked away. His family later thanked me because the staff decided not to put him in a strait jacket. I learnt the hard way, though, that hospital policy is to use chemo-restraint when a patient “interferes.” I hope that models of care that are curative get explored at some point.

  • 25 people is not a study! I see in the comments a bunch of providers dismissing the feelings of patients. I can say there are just as many awful providers as patients. Im a disabled adult and refuse to go to an ER for anything. Id rather die at home with dignity. Even minus restaraints…there is zero respect for patients and everyone is now seen and treated like an addict. This study is as obsurd as the comments. Ive been demoralized by even without restraints. Maybe try to interview those of us who would rather suffer…be it physical or emotional pain rather than subject ourselves to being dismissed and degraded.

    • Do you even realize what kind of patients are physically restrained?? Let’s see a 220 lb. man in full blown psychosis start swinging at you, all while verbally threatening to come back and “shoot the place up”… what are your suggestions?!

    • Are you a psych patient who isn’t medication compliant and prone to outbreaks of violent aggressive behavior? No? Then chances are, this study doesn’t apply to your situation.

      If you feel marginalized by medical personnel, speak up, ask to see a patient advocate or make sure that you always have someone with you who will advocate for you. Bear in mind that doctors and nurses aren’t there to wait on you hand and foot, the ED is not a restaurant and the medical professionals taking care of you aren’t waiters. I’ve seen far too many patients treat them like trash only to complain about them being mean later.

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