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.

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“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.

  • My physical health hospital uses observation room with glass I could not hear through due to hearing impairment .They have a mentally ill or behaviorally disturbed person in there to de escalate with use of medications that you use. They do that to regain control in the ER. My responses were frustration and anger. I felt demoralized. Kathleen

  • This kind of seems to be an example of “higher ups” making changes to the policies/rules, when they aren’t the ones working on the floor! You know, changing things around to make the hospital look better, or to make even the worst, disrespectful patients happy.

  • Restraint are always a last resort, and come with a massive amount of state mandated monitoring and documentation, for patients’ safety. Nobody wants to have to restrain you, both for the sake of your well-being, and quite frankly, because it a hellacious amount of extra red tape to deal with, to get you out of the department you’re in, to get you placed wherever you need to go next, and just to keep up with the charting and monitoring once you’re restrained.

    Restraints have to be removed and readjusted frequently if a person is restrained. Violent restraints for people attempting self harm or to harm other people can be applied when absolutely necessary, but the patient has to be evaluated frequently and reevaluated for necessity every hour, so nobody is going to be left alone much.
    As to the person thinking mindfulness and meditation should happen first, well, the people who are capable of reasoning and self calming at the moment aren’t the people requiring restraints. It’s the people who are endangering their own safety, or that of other people, who aren’t able to be deescalated or calmed in other ways.

    Also, do note that out of the 25 people interviewed, 16 had positive or mixed feelings, rather than just negative. So in actual reality, of the small subset of people who were out of control enough to require restraints, a significant majority still actually weren’t entirely negative about their experience.

    • Stop it boo, you’re embarrassing yourself. The regulators and the hospital administrators are the same people. You don’t have to document a damned thing you don’t want to document and often times what’s really going on doesn’t make it into the logs.

  • I was restrained in ICU because I kept taking all my tubing out. My hands had to be restrained, so sitting in a chair, my hands still had to be restrained.

  • I was a nurse in the ED. An agitated psych pt threw me over a gurney and broke my neck and shoulder. My career is over and the pain is a daily struggle. The problem is, with drug abuse and psych diagnosis , more and more of us are being severely injured or even killed. We are mindful of the trauma to both staff and pt, but ER is notoriously under staffed and unsupported by management. There are never enough psych beds so we have to maintain safety while the pt is in crisis, while having a full assignment of traumas and severe illnesses and drug seekers etc. My career is over, when the injury happened, I wasn’t expected to live.

    • I’m appalled that this happened to you! It’s UNACCEPTABLE! Everyone else on this thread that thinks hospitals are so “barbaric” for using restraints, take a look at this woman’s story!! We’re supposed to put up with this?? This is all okay? And if you think her story is a rare occurrence, try again!

  • First all your studies does not keep staff or pt safe. The only times cuffs are used is when they are in police custody and the are the ones who applied them and are present in the room with the patient. I have worked the Er for the last 27 years and have seen nures obtain fractured ribs and a subarachnoid bleed from out of control patients. So how does your study stop patients from spitting, biting and foul language from out of control patients? I am not in favor of restraints. When is the medical field ever going to learn that when a patient does like something they will give a negative response. Same goes for patient stratification. If a patient or family does not going to get what they want the nurse is blamed and reported. So studies should be done on patient satification reports. So many excellent nurses have lost their job and devastated by these reports. The nurse is never questioned first and just assumed they are in the wrong.

    • I worked in a Nursing Home for over 20 years, and everything Wanda Williams said happens in the ER, happens in the Nursing Home. Punching, Spitting, hitting, ect.

  • Try being on the other side, kicked at, hit, spit on! You can’t reason with someone so out of control. Believe me, no one runs to restraints. It is a last resort when patient and staff, (and other patients) safety is at risk.

    • Nah, they’re not interested in that!! Bunch of ivory tower psych researchers. They’re the last people to ask for advice on how to deal with violent and psychotic patients but are quick to pass judgement on anyone else’s actions. They’ve probably never even treated one of these patients but they’ve seen them when they’ve been referred when they’re stable/calm/outpatient.

  • What this article doesn’t talk about, are the legitimate reasons as to why patients are restrained. It’s not like any of them are left alone once restrained either. The primary nurse documents (EVERY 15 MINUTES) on these restraints, the positioning, they make sure circulation isn’t being cut off anywhere, etc. It’s for everybody’s safety and it’s always a last resort. Healthcare staff, especially paramedics and ER staff are constantly verbally and physically assaulted. Many of these patients will start to spit at you once they’re in restraints. I can assure that this isn’t done because nobody wants to try hard enough to help them or calm them down. Usually, there’s no other options. It’s just a shame that patient satisfaction has far exceeded the need to keep hospital staff safe. Nobody comes to work asking to be assaulted.

    • Amen!
      The whole time I was reading this I was looking for the stats on ED staff assualts and violence towards those of us who work with these patients.
      Not mentioned at any point.
      My staff and Is safety is ultimately paramount when patients utilize drugs/alcohol, threaten to rape/murder us, assault us with verbal and physical means, put nurses and doctors in the hospital, and so forth.
      Their feelings about it are very secondary. This is the only way we can safely help them. Not sorry.

  • I think I wouldn’t be negatively affected by this type of restraint because I practice mindfulness meditation. I can be aware of what I am sensing if/when held this way and it would even challenge my mindfulness practice (which would be a good thing). So, in these types of situations, perhaps the best thing for a patient might be to first let him/her listen to some calming music and then lead or guide that patient through meditation – perhaps ‘body-scan’ meditation, as taught by MBSR.

    • Are you serious? This is an emergency room not a meditation studio. By the time they are going to restarints I find it hard to believe that they would be willing to do meditation with you. They are not even willing to agree not to harm themselves or others which is usually the only agreement that the emergency room asks for before going into restarints. The nurse is not asking them to agree that the hospital is the best or the plan is the best just that they will not harm themself or someone else in the department and stay in the room if it is believed they are a harm to self or others until they can be evaluated by a trained clinician. That is not alot to ask but if you think that if they are not willing to do that but your meditation would work go to your local ER and ask the doctor on the next patient they want to restrain if you can go in first and try meditation with them. You might be right and if you are you will make a millions of dillars but I wont stand next to you in the room.

    • Yeah that’s why you’d never need to be restrained. You’re not in the group who would need restraints. The researchers are missing the point: introspection is limited when you’re delirious. If someone is high or psychotic, asking them to be aware of their own mental status is like asking a drunk if he/she is fit to drive.

    • Ever tried to calm down a meth addict with meditation?..didn’t think so. As a Wardsman in a busy ED..I am trained in safe restraint of patients as a last resort probably saved the patients and colleges lives as well

    • KDN, great idea! While we’re at it, let’s bring in puppies, scented candles and a yoga instructor, maybe throw in a heated oil massage too. 🤦‍♀️

    • Assuming that mindfulness practices cannot be undertaken for these types of people is one’s opinion only – it is not based on actual studies (perhaps someone needs to conduct such studies). Ultimately these are human beings who experience emotions – they are not monsters who would attack no matter what. If these patients can be restrained, they can also be fitted with ear phones that would give them auditory cues (perhaps audio recordings) regarding how they can cope with the situation, etc. This would prevent them from ruminating anger related thoughts that make these types of situations so much worse.

  • I’m sorry that these patients have this negativity. As a paramedic working in tandem with law enforcement; what choice are WE given when showing up on scene for a person’s first recoded episode? You know, the condition that they have lied about to concerned friends and family and their Doctor!!! We encounter an individual who is naked and waving a loaded gun screaming nonsensical things!! What other choice do we have besides some form of restraint?

    • AMEN!! I said above, this article doesn’t go into detail as to WHY patients are restrained. It’s not done for the hell of it!

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