Psychiatric Restraint and Seclusion: Resisting Legislative Solution

The use of restraint and seclusion in the American psychiatric setting has a rich history—rich in medical, ethical, legal, and social controversy. For centuries, mental health care providers used movement restrictions and solitary confinement to manage psychiatric patients. Superintendents of eighteenth and early nineteenth century insane asylums and other institutions of confinement believed that strait-waistcoats, “tranquilizer chairs,” “maniac beds,” chains, shackles, and “quiet rooms” deescalated agitation and promoted self-control. Reforms beginning in the nineteenth century helped make some psychiatric institutions more humane, in part because staff members were trained to find ways to calm potentially violent patients without imposing holds or isolation. With the advent of Freud’s psychoanalysis, advances in microbiology in the late nineteenth and early twentieth centuries, as well as the explosion of psychotropic drugs in the latter half of the twentieth century, many traditional uses of restraint and seclusion became unnecessary. Federal and state legislatures and administrative agencies responded to these philosophical, scientific, and medical developments by restricting restraint and seclusion to emergency situations and forbidding their imposition as a means of coercion, discipline, or convenience. Although restraint and seclusion are used less frequently in the twenty-first century, they persist as methods of behavior management. A number of recent injuries and deaths associated with these interventions have refueled the dialogue regarding their appropriate use, bringing centuries old questions to the fore. Some stakeholders, who believe that the use of restraint and seclusion are evidence of patient warehousing, institutional abuse and neglect, and human rights violations, support legislation that would further reduce restraint and seclusion use or eliminate it altogether. Other stakeholders, who believe that restraint and seclusion can be used to prevent violent or assaultive patients from harming themselves and others, are questioning the scientific basis, cost, and feasibility of restraint-and-seclusion-free initiatives. In recent legislative sessions, federal and state lawmakers have attempted to respond to these seemingly irreconcilable concerns. Many commentators believe that heightened awareness of inappropriate restraint and seclusion practices and more intense education and regulation will resolve these concerns. I argue instead that the psychiatric restraint and seclusion controversy resists legislative solution because it is a function of more fundamental problems relating to mental health care access and finance. The controversy persists because of these practical problems, and because the use of restraint and seclusion implicate seemingly competing goals of patient safety and individual autonomy and, more broadly, the philosophical doctrines of legalism and medicalism