Should Psychiatrists Assist in the Restraint of Children and Adolescents in Psychiatric Facilities?

Restraint and seclusion usually are prompted by a child’s interpersonal conflicts with peers or staff at the facility, by conflicts with family during treatment, or through a patient’s attempts at self-injury. In response to a patient’s behavioral crisis, a psychiatrist may be summoned to an impending restraint or seclusion. Restraint limits a person’s freedom of movement, and seclusion confines the person to a room. Both are felt by patients as coercive or intrusive interventions that routinely result in fear, anxiety, agitation, and physical resistance.

The psychiatrist may successfully avoid becoming involved in physical containment of a patient by using deescalation interventions (1,10). If these measures fail or cannot be implemented, then the issue of whether to physically intervene again arises. The considerations described below are central elements in making an informed choice.

The Joint Commission (JC) and the Centers for Medicare and Medicaid Services (CMS) require that a seclusion or restraint be ordered by a psychiatrist, but they provide no guidance about physical involvement. We must then consider how writing a seclusion and restraint order differs from being an active participant in the physical containment of a patient. Ordering restraint or seclusion is an accepted societal responsibility of a psychiatrist; physically restraining patients is not. In fact, when notified of a psychiatrist’s physically containing a patient, families, regulatory agencies, and the facility leadership team usually want an explanation of why it was necessary. Direct involvement from a psychiatrist is especially troubling, because restraint or seclusion incidents can arise as the result of negative staff morale or staff-to-staff conflict (10) and in hindsight are difficult to justify to the patient, the patient’s family, the facility, and regulatory agencies.

Psychiatrists’ responsibilities to patients include autonomy, beneficence (promote well-being of the patient), nonmalfeasance (do not harm the patient), and fiduciary responsibility (place the patient’s interests first) (1,11,12). Therapeutic interactions that include these principles generally assume that communication in these interactions is verbal. Boundary changes occur when a psychiatrist-patient interaction shifts from voluntary verbal exchanges to forced physical containment (13). Physical contact may engender allegations of sexual or physical abuse. Patients who are watching the physician carry out the restraint or seclusion or who learn of the incident may develop similar concerns about their own psychiatrist-patient relationship. However, if patients are in danger of hurting themselves or someone else and the psychiatrist is the only staff member present, then the psychiatrist must choose either to physically intervene or to call for other trained treatment team personnel. Doing nothing, even with justification of preserving autonomy in the psychiatrist-patient relationship, could be viewed as neglect or as dereliction of professional responsibility.

Accrediting bodies (CMS and JC) and other state and federal regulatory agencies would likely be informed of a psychiatrist’s participation in a restraint or seclusion through a complaint of improper treatment. The professional would have to explain how his or her behavior was not in violation of a patient’s rights. This defense would occur in the context of societal perceptions that have endured for more than a decade, that psychiatrists and psychiatric facilities have abused patients through their use of seclusion and restraint. From a regulatory point of view, the physical restraint of a patient by a psychiatrist suggests that there has been a failure of treatment and would call for an analysis to examine its root causes (17). For example, was there a failure of nursing, staffing, or deescalation efforts? Was there confusion about the professional roles of staff, a lack of adequate unit staff safety training, or a lack of administrative monitoring efforts to prevent seclusion and restraint?

A psychiatrist could be terminated from employment. His or her reputation could be challenged by investigations by state medical licensing boards or professional organizations and by Web-based public assessments of the psychiatrist’s practice abilities. A psychiatrist’s malpractice insurance also may be affected by a patient complaint.

A psychiatrist’s professional role requires a therapeutic alliance with the patient (12). Specific elements essential to this relationship are often delineated as professional duties in facility job descriptions. Examples would include expectations of professionalism through attire, communication, and maintenance of safe physical boundaries. These elements reflect societal and hence the patient’s expectations. Participating in physical restraint is not generally seen as part of a psychiatrist’s professional role, so involvement in this way may communicate confusing messages both to staff and to patients. For example, a patient who has been restrained may conclude that treatment is defined as “might makes right” and that verbal therapeutic work is neither authentic nor valuable. Many patients with histories of abuse come to therapy with this mind-set already and thus could view their psychiatrist as another abuser.

Staff may conclude that a psychiatrist who participates in physical containment of a patient wants to support the use of restraints or seclusion as a validated treatment for aggression and violence. An unintended consequence may be that personnel then create crisis situations involving emotionally labile, aggressive, or impulsive patients and call the psychiatrist to help manage them. The psychiatrist would then become the actual “Doctor Strong,” which in some facilities is the code call for a crisis team to carry out a restraint.

As with any physical intervention, both the clinician and the patient risk being injured. Either or both could develop long-term disability, financial hardship, and increased individual and family stress. The emotional fallout from the injury could disrupt the therapeutic alliance and prevent further treatment.

The psychiatrist should document the circumstances of the behavioral crisis in clear, factual, and concise sentences that can be understood by patients and families. Documentation should include the reason the restraint or seclusion was necessary and describe the psychiatrist’s role during the restraint or seclusion. Documentation of these incidents can clarify the clinical circumstances that surround a seclusion and restraint incident and help dispel concerns that information is being omitted or incorrectly stated for self-protection. This information would be essential if litigation ensued.

We have discussed the issues surrounding psychiatrist involvement in physical containment of patients. This information may also be applicable to other clinicians who function as primary therapists with patients in an inpatient or residential facility. By primary therapist we mean social workers, psychologists, and other counselors who have a direct responsibility to provide individual therapy and to manage a patient’s treatment in the facility. We exclude nurses, recreational staff, residential care staff, and others whose role is to supervise or provide group therapy or activities, because they do not have these individual primary therapist responsibilities. We have focused mainly on the seclusion and restraint of children and adolescents. However, many of these issues also apply to adult psychiatric patients and crisis management expectations of their treating psychiatrists.

In summary, the choice of what involvement a psychiatrist or clinical professional should have in a restraint or seclusion must be determined by the practitioner in conjunction with the facility in which he or she works. Knowing the issues raised in this Open Forum, planning ahead, and working with the staff should help the psychiatrist or primary therapist to make an informed decision.

The authors report no competing interests.