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"When They Restrain You They Ignore You"-What We Should Learn From the People We Restrain in Emergency Departments.

Increasing numbers of people in the United States seek mental health care in emergency departments (EDs). From 2009 to 2015, mental health ED visits increased for pediatric and adult patients by 56.5% and 40.8%, respectively, and the ED length of stay among persons awaiting psychiatric hospitalization increased by 31.7%.1 More visits and longer waits result in persons with mental health crises crowding facilities better suited to treating vehicular than psychological trauma. Most ED staff training for the care of patients with mental illness focuses on emergent treatment, and few EDs are designed as therapeutic environments for people with mental illness. Emergency departments are often the opposite of calming; they are fast-paced, high-acuity clinical settings where staff must exert rapid control in chaotic circumstances to save lives. In contrast, mental health facilities are typically purpose-built as therapeutic environments for individuals experiencing mental health crises. At their best, these facilities are home-like settings designed to promote recovery by providing private spaces and access to natural light and outdoor settings and encouraging engagement with family and staff while eliminating the possibility of harm to self or others. The staff of these facilities are trained and experienced in person-centered, evidence-based care, including how to respond therapeutically to a patient in crisis and how to understand the experiences of persons with mental illness. When a person experiencing a mental health crisis seeks care in a setting not designed for mental health, the ensuing encounters can be stressful and even traumatizing. In the study by Wong et al,2 the authors described the experiences of 25 patients who experienced agitation, almost all because of mental health crises, and were subsequently restrained in urban EDs. The authors concluded that these patients desired a therapeutic encounter but instead experienced “coercion and physical restraint during their visits that created lasting negative consequences.”2 Patients often reported feeling assaulted or ignored by staff. One patient said, “The experience in the emergency room, it’s traumatic as hell,” and another said, “[W]hen they restrain you they ignore you.”2 For the present study, Wong et al2 carried out qualitative interviews and surveys with a group of patients who had been recently restrained in the ED and were selected to match the demographic characteristics of restrained patients in an earlier prospective observational study of agitated patients in the ED at an urban tertiary referral center.3 Although nearly 60% of the patients they contacted did not or would not participate in the present study, there is little reason to believe nonparticipants had more salutary experiences of being restrained. Remarkably, more than half of these patients reported mixed or even positive feelings about the use of restraints when needed to prevent harm, which is striking, given that most reported that being restrained was harmful to them in the moment and had lasting deleterious effects on their well-being.2 When participants offered analogies to the ED experiences in which they were restrained, they compared them to incarceration or childhood abuse, not a therapeutic encounter; many described lingering problems with hypervigilance and flashbacks,2 symptoms of incipient posttraumatic stress disorder that can be induced by physical restraints.4 Some patients said they had learned that being restrained is an inevitable outcome of receiving treatment in the ED. The study did not report how many participants had been restrained previously, but the perception that a negative outcome is inevitable is reminiscent of the learned helplessness + Related article