Restraints and Self-Injury

A few weeks ago, I received a request from a psychiatry resident working at a state prison about the use of restraints with patients who engage in severe self-injury.  He was looking for guidance on the use of physical restraints with this population in prison.  He noted that his role of ordering and monitoring patients in restraints caused him to feel more like a provider for the facility, rather than for the patient.  I shared with him with the best resources I know – Resource Document on the Use of Restraint and Seclusion in Correctional Mental Health Care (http://jaapl.org/content/35/4/417) as well as Dr. Applebaum’s commentary on the same (http://jaapl.org/content/jaapl/35/4/431.full.pdf). As I sat down to write this, I intended to discuss the rules and regulations surrounding restraint (e.g., Center for Medicare and Medicaid Services (CMS) 42 CFR § 482.13) but I stopped myself.

The inquiry was not about regulations and requirements for the use of restraints.  The question was about patient care. 

And not just the care of any patient, but a patient who engages in lethal and dangerous destruction of his or her own body.  The truth is restraint will serve its purpose of physically stopping the patient from hurting him/herself right now. But that’s all it will do.  Restraint is not treatment.  Restraint is not where the behavior ends and is certainly not responding to where the behavior began.  When faced with a patient in the throws of severe self-injury, everyone involved is impacted:  the patient, obviously, but also nursing staff, correctional staff, mental health staff, physicians and other inmates.  It is horrific and terrifying. It is trauma.  And I don’t just mean that the event is traumatic. It is. I mean that the behavior is coming from trauma.

The ultimate question is what has happened and/or what is currently happening to this patient such that self-injury is the best possible option? Think about that question – put on your empathy cloak and open your heart.  What would it take for you to get to a point where intentionally maiming yourself is your best solution?  For me, my life would have to be excruciatingly awful and I would have to believe that I am completely out of other options.  Interestingly, the decision to restrain a patient likely comes from a response to a situation that is excruciatingly awful when staff believe they are completely out of other options.

Here’s how I see it – the patient and the staff believe there are no other options. There are indeed other options – for the patient and for the staff.

The other options, however, take expertise, hard work, time and dedication.  The other options are wrought with challenges and bound to result in relapse along the way.  These other options require that we work together as a team, with the patient as a central member of that team.  The process involves four basic steps:  1) functional analysis of the behavior; 2) thoughtful treatment planning to support behavior change; 3) implementation of the treatment plan; and 4) analysis of the impact.  All four steps are necessary, and they must occur in that order.  Clinicians cannot provide treatment to a patient who engages in severe self-injury until they and the patient understand the function of the behavior and collaboratively come up with a plan to support changing it.  This requires slowing down, listening to the patient, listening to staff who work with the patient, tracking the behaviors, recording the responses to the behaviors and developing the best hypothesis and treatment plan.  This work is not for everyone.  This work requires training and expertise in behavior change, often a clinical psychologist and/or behavior specialist. 

Seeing severe self-injury through a trauma lens, as a patient’s best solution to a problem and a behavior that can be changed leads to the conclusion that restraint is not the way to address it.  CMS tells us that “Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm.”  When facilities decide to use restraints, the process discussed earlier has often not been tried.  One response I hear is, “our facility doesn’t have the resources.”  And yet, when a patient engages in severe self-injury the facility has no choice but to provide the time, the staff, and the money for emergency response, medical interventions on-site, transport to the outside hospital, medical interventions at the hospital, provide security for the patient in the hospital, transport back, implement restraint or watch status, monitor the patient, assess the patient, provide wound care, provide psychiatric care, write injury reports, draft incident reports, and attend all the associated quality assurance and debriefing meetings.  That’s a lot of resources.

What I have shared here is my opinion, based on my training, research and experience.  I could have missed something or just be plain wrong.  If you think I’ve got it wrong, please let me know why in the Comments.

Do you have any thoughts on restraint or self-injury reduction?  Please feel free to share.

6 thoughts on “Restraints and Self-Injury

  1. thank you for sharing that information. It’s very helpful. But what do we do with an inmate who repeatedly harms himself because he wants to cause the state to spend as much money as possible on him. He started by trying to bleed himself out. He did that three or four times. Then he progressed to trying to pull his esophagus out with a wire. He was unsuccessful and it was surgically repaired. During his recovery in the hospital, he went into the restroom, pulled the coil out of the toilet paper roll and try the pull his esophagus out one more time. he was eventually discharged back to prison and within one month, open the mediastinal wound and stuck foreign objects in the wound there by getting an infection requiring more surgery. Most recently, he opened an abdominal surgical wound and tried to eviscerate himself. back to another hospital for surgery because the previous hospital refused to see him anymore. He returned to the prison in four-point restraints, after approximately one week, he convinced mental health that he was no longer harm to himself and he was discharged back to his locked housing cell. Within 3 days and after they gave him sharp colored pencils, he opened the wound, stuck the pencils in and try to eviscerate himself one more time.he was in our infirmary and promise mental health that he would not do it again. he was discharged back of his locked housing unit. On side note, mental health. It would be a good idea to give him some sharp colored pencils to occupy his time with drawing. Within three days he had opened his wound, stuck the pencils in and perforated bowel. This inmate has been hospitalized for self-mutilation at least 10 times in the past 12 months. Nothing is going to change this behavior. He does this because he likes the attention and because he has vowed to cost the state as much money as possible. Any suggestions on how to change his behavior are greatly appreciated.

    • I appreciate your frustration and the intense challenges trying to help this patient but it sounds like something much greater than “he likes the attention.” My opinion continues to be what I posted in the article. The behavior needs to be understood in order to support changing it.

  2. Having had the same type of experience in a county jail it brought back some pretty uncomfortable feelings.

    The fellow we were dealing with was diagnosed with borderline personality and like the case mentioned in the comments was dedicated to either devastating the county budget or convincing someone to release him back to community – not going to happen.

    Most offenders have made a mistake for any number of reasons and can often ‘come to terms’ with their situation. Not bad people just bad choices.

    Though, in the last 28 years of providing correctional health care, it seems that there are some truly evil individuals who will do whatever gets them what they want, Additionally, when they are in a situation that does not allow their behavior they will ‘act out and push the envelope’ despite every effort to address the issues.

  3. Crisis intervention ( the use of restraints ) is not, nor should it be the end all of handling a self harm event.
    When I worked with in a children / adolescent population I replaced the word behavior with communication. Bad communication instead of bad behavior. I brought that approach with me when I worked in the corrections system.
    Seeing patients as people who are not willing or able to express their needs is a first step, in my opinion, towards finding the core of the issue.
    As human beings, we experience situations in a personal way, which leads to our own unique personal emotional response and interpretation of what we experienced. This emotional response is the driving force behind our mental and physical reactions. This applies in both good and bad experiences.
    When there is a problem, especially in a confined environment which has it’s own threatening experiences and negative factors from which a person can not escape, it opens an overwhelming flood gate of problems.
    What we do is directed by what we choose. What we choose is directed by what we think. What we think is directed by what we feel. What we feel is a direct result of what we experience . In order to change behavior we have to go to the core of the emotion that is driving the entire mechanism.
    I completely understand the use of restraint and isolation as a crisis intervention only, not a a continuous response to a situation that is deeper than the surface behavior.
    Both crisis intervention and follow up intervention is a minimum necessity.

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