Seclusion & restraint: a historical perspective

(1) The use of restraints in the care of psychiatric patients has been a topic of ethical controversy since the beginning of psychiatric medicine. (2) Enlightenment physicians regarded psychiatric illness as the loss of reason, and many advocated the use of restraints to help violent patients regain the use of reason. (3) John Conolly, a British alienist (a term used for psychiatrists) of the mid 1800s, claimed it was possible to treat psychiatric patients without the use of mechanical restraints, but he made liberal use of seclusion and physical restraint by attendants to manage violent behavior. (4) American alienists expressed misgivings about the use of mechanical and chemical restraint but most were reluctant to relinquish any usable intervention.     

From 'human being' to 'social subject': "unfreezing" ergonomics and the implications for understanding and intervening health-disease process

Ergonomics has been successful in increasing productivity and comfort in the work arena. It has also contributed to reducing occupational accidents. Despite this, ergonomics is frequently limited to understanding the health-disease process related to human-technology interactions, as this process is more complex than what can be understood from an ergonomic evaluation. Recognising this limit, this work ontologically and epistemologically contrasts the notions of 'human being' and 'social subject', and concludes that the study object of ergonomics, or human-technology interaction, greatly depends on social aspects that nowadays are not tackled explicitly: route (history), project, structure, agency, motivations and power. It also analyses how participatory ergonomics tacitly includes many of these aspects, including some implications that the change of notion, from 'human being' to 'social subject', brings to the understanding of the health-disease process and the reduction of associated risks during human activities.     

Seclusion. The nursing challenge.

The research to date shows that there is not much data to guide nursing decisions about the use of seclusion. The justification for its use is not always as clear as one might hope. Although many patients are secluded for violence against themselves or others, there are others who have not been violent who are secluded. There may be justification for secluding violent patients, but, as indicated earlier, it may reinforce the behavior it is designed to stop. There probably is no justification for secluding patients who make loud noises, refuse to take medication, or refuse to participate in activities. In addition, it is disconcerting that a large percentage of patients are secluded for "escalating agitation," that is, they have not acted violently against themselves or others. What is problematic is that staff are undoubtedly predicting violent behaviors in these patients--predictions that might be erroneous. Thus, there is ample room for injustice to occur. The potential for injustice is even greater if certain patients are singled out for seclusion or if patients are secluded longer than they or the staff think that they need to be, as is indicated in some of the studies to date. Moreover, if unit variables are associated with seclusion activity, this too, may be indicative of decision making at certain times of the day or by certain staff members that may not be in the best interest of the patient. What seems fairly clear is that secluding a patient is a distressing event for staff and is viewed extremely negatively by some patients and as a reward by others.(ABSTRACT TRUNCATED AT 250 WORDS)     

Seclusion & restraint. Understanding recent changes

1. Seclusion and restraint must be a last resort, emergency response to a crisis situation that appears to present imminent risk of harm to the patient, staff, or others. 2. JCAHO-accredited hospitals billing for Medicare or Medicaid must meet HCFA requirements to maintain compliance. 3. Policy writers and administrators must carefully scrutinize all applicable regulatory standards to ensure all requirements are met.     

Stability of psychological symptoms: drug use consequences and intervening processes

We integrate aspects of coping response, impaired ability, and motivational explanations for the causes and consequences of drug abuse, all which were cast previously as competing or alternative paradigms. We projected a model of 1) continual daily drug use as a consequence of early adolescent psychological symptoms and 2) continual daily drug use as an influential variable in maintaining or exacerbating these symptoms over the young adult life-course. Gender, race, and education also were modeled explicitly according to their presumed theoretical importance. Finally, we modeled contemporaneous factors such as physical health and employment status as the common consequences of the shared independent variables in order to reduce bias in the estimated structural relationships. We found that continual daily drug use is significantly dependent on early psychopathology and increases psychological symptoms significantly. Daily proximate drug use has direct negative effects on education. Education, in turn, improves both mental and physical symptoms significantly. During young adulthood, psychological symptoms are related significantly to contemporaneous unemployment and physical health limitations; thus modeling these symptoms as common consequences reduces potentially biased estimates of the effect of shared independent variables.     

Patient Abuse and Trauma: A Policy Analysis of the Regulation of Seclusion and Restraint in Mental Health Care

Historically, justifications for the seclusion and physical restraint of hospital patients have stereotyped individuals with mental illness as “dangerous” to themselves and others (Huckshorn, 2004a). It can be argued, however, that it is the policies that regulate the use of seclusion and physical and chemical restraints that are dangerous. This article analyzes the Patients’ Rights section of the Hospital Conditions of Participation (CoPs), Part 482 of CFR 42, including sub-sections: e. Standard: Restraint or seclusion; f. Standard: Restraint or seclusion: Staff training requirements; and g. Standard: Death reporting requirements. The set of CoPs regarding Patients’ Rights are analyzed from a value-critical, process-oriented perspective. This article proposes the following six-point framework as uniquely suited to evaluating 42 CFR 428.13: 1) introduction to the background and historical significance of the problem; 2) evaluation of the clarity and measurability of the goals and objectives of the policy; 3) overview of the intended impact of the policy; 4) examination of the value criteria; 5) examination of existing power struggles for those impacted by the policy; and 6) examination of the actual impact of the policy. Results of the policy analysis suggest that the policy does not go far enough to reach its stated goals and objectives in full. In the conclusions, suggestions for further protection of patients’ rights are provided. Examples of alternatives to restraint and seclusion are discussed. Finally, the grave importance of reshaping the culture of mental health care, in terms of life-and-death consequences, is considered.     

Council of Europe regulations relevant to intervening in psychic capacities

The paper highlights the need to clarify the definition of psychic capacities and the difficulty in distinguishing between improved capacity and improved functioning. Before considering whether it is legally permissible to undertake an intervention on psychic capacities, and if so under what conditions, it is necessary to consider whether such an intervention is ethically appropriate. If the intervention is ethically appropriate, whether it is legally permissible according to the instruments of the Council of Europe will depend on the persons status (for example, whether the person is an adult or a child, or able or not able to give consent), the type of intervention proposed, and in certain cases the type of material used in the intervention. The paper discusses the regulations that are relevant to these different situations.

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Zusammenfassung  Dieser Beitrag unterstreicht die Notwendigkeit, die Definition des Begriffs psychische Fähigkeiten zu klären, und die Schwierigkeit, zwischen verbesserten Fähigkeiten und verbesserter Funktion zu unterscheiden. Bevor wir erörtern, ob ein Eingriff in psychische Fähigkeiten rechtlich zulässig ist und, wenn ja, unter welchen Bedingungen, müssen wir überlegen, ob eine solche Intervention ethisch angemessen ist. Wenn das der Fall ist, hängt die rechtliche Zulässigkeit, entsprechend den Instrumenten des Europäischen Rates, vom Status der betroffenen Person ab (zum Beispiel, ob es sich um einen Erwachsen oder ein Kind handelt), von der Art des Eingriffs, der zur Debatte steht, und in bestimmten Fällen dem Material, das bei diesem Eingriff benutzt wird. Der Beitrag behandelt die Vorschriften, die in diesen unterschiedlichen Situationen zum Tragen kommen.

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Résumé  Cet article met en lumière le besoin de clarifier la définition des « capacités psychiques » et la difficulté à faire la différence entre capacité améliorée et fonctionnement amélioré. Avant de décider sil est légalement licite dintervenir sur les capacités psychiques, et si oui, dans quelles conditions, il est nécessaire de se demander si une telle intervention est justifiée du point de vue éthique. La question de savoir si une intervention est appropriée du point de vue éthique et si elle est légalement licite en vertu des instruments du Conseil de lEurope, dépend du statut de la personne (si la personne est un adulte ou un enfant, si elle est capable ou non de donner son consentement, etc.), du type dintervention envisagé, et dans certains cas du type de matériel utilisé pour lintervention. Larticle examine les réglementations qui sappliquent à ces différentes situations.

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All opinions expressed in this paper are solely those of the author.

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Public attitudes towards human life extension by intervening in ageing

A number of biogerontologists have expressed an interest in intervening in the ageing process in order to extend the human life span. This study explored the attitudes of members of the Australian public towards the potential development and use of life-extension technologies and their attitudes towards the ethical, social and personal implications of life extension. Participants were presented with a vignette outlining the prospect of a “life-extension pharmaceutical” that could increase maximum life span by slowing the ageing process. While 65% supported such research, only 35% said that they would use a life-extension technology if one became available. Men were more supportive of research and more disposed to use life-extension technologies than women. Concerns about the potential ethical, social and personal implications predicted levels of overall support for, and intention to use, life-extension technologies. Our survey suggests that public attitudes towards life extension are neither overwhelmingly “pro” or “con” and in fact more nuanced than either proponents or opponents of life extension have often assumed.     

Cleveland 20 years on: what have we learned about intervening in child sexual abuse?

This is the first of two linked papers. It examines the main changes in approach to child sexual abuse that have occurred since the events in Cleveland 20 years ago. Comparison between estimated prevalence rates and registrations for sexual abuse suggests that we are aware of only the tip of the iceberg. It is argued that in many cases uncertainty may have to be accepted, and that protection may be better achieved through a protective parent than through the child protection system. Clinical examples of cases presenting to a specialist child and adolescent mental health service are given. It is argued that, although society is now more willing to recognise the existence of child sexual abuse and professionals are better at dealing with families, outcomes for this group of children are not much improved. Copyright © 2008 John Wiley & Sons, Ltd.     

Evaluability assessment: Reflections on the process

As a formal process, evaluability assessment is 10 years old. In the Cooperative Extension Service (CES), the process is 5 years old. Since 1984, evaluability assessments have been implemented in five states with six different major programs in an effort to define the process in a practical methodological sense and to encourage its adoption in CES. Implementation proceeded iteratively and after each study, procedures were analyzed, clarified, and, wherever possible, simplified to make the process more usable and more “operator robust.” The purpose of this article is to reflect on the process as it evolved in applications in CES. Underlying philosophy and methodological considerations are discussed. To put these in perspective, background information is provided on the evaluability assessment process and on the studies conducted in CES.     

Corporate campaigns: The perversion of the regulatory process

Conclusion Regulatory agencies thus play a major role in union comprehensive corporate campaigns. The willingness of these agencies to adopt the union-assistance role is sometime motivated by bias, often by ignorance of the union’s true purpose, and sometimes by the legislation involved. Even when the last is the case, there is little excuse for some regulatory action in the union behalf. For example, the NLRB’s lopsided actions in the Caterpillar case challenge both common sense and common considerations of fair play. The EPA’s role in rushing to the aid of unions when state agencies, after laborious examinations of the issues, found no violations or impediments, calls loudly for congressional action. And OSHA’s rush to inspect facilities where a labor dispute exits, but where no serious safety or health faults were previously found or complained about, needs to be rethought and revamped. Most of all, the action of the current Congress, particularly the House of Representatives, in reexamining, rethinking, and hopefully successfully rewriting regulatory legislation so that it comes closer to meeting its purpose rather than continuing to degenerate into labor dispute tactics to harass industry and to befuddle the public, promises to be a proper move for the public good.     

Understanding the meanings of children: a reflexive process

This paper identifies a number of children's voices within qualitative academic writing. It suggests that researchers can discover a variety of children's voices by employing reflexive techniques to ensure that their interpretations are not influenced by their personal prejudice, or the ethics, tools, roles and theories of their professional paradigm. It concludes that those who work with children may be able to reinforce the theme of the UN Convention on Rights of the Child by employing this reflexive approach to enable them to attribute equal status to the views of all the children whom they encounter.     

Decoding deception: A look at the process

This study examined the effects of sex and response format on the process of decoding deceptive messages. A videotape was made containing 32 items (16 honest and 16 dishonest) in which encoders described a person they liked and a person they disliked both honestly and deceptively. Two response formats were used: (1) the rating of items on a six-point liking scale and a six-point deception scale and (2) a forced choice format whereby subjects had to choose between the four types of items. Decoders were given five sets of scores: (a) accuracy scores, (b) awareness of deception scores, (c) confidence scores, (d) cues scores, which were the number of items on which they mentioned using a particular type of cue (verbal, nonverbal, or both combined), and (e) a measure of response time for each item. In the accuracy analyses, there were so significant main effects for sex for either format. However, when decoding males, females (relative to males) tended to read the overt rather than the covert, affect. Females, however, were more aware of the possibility of deception but did not differentiate between honest and dishonest items. Males were more confident and took less time than females to make a decision. Females mentioned the use of cues more than males did. There were no significant correlations between accuracy and the process variables although for males, but not females, there were significant correlations among the process variables for both honest items and dishonest items.An earlier version of this paper was presented at the International Applied Psychology Congress (IAAP), Jerusalem, Israel, July, 1986.