Psychiatric Crisis Intervention: How to Avoid Restraints and Violence


*Note that when I write of a psychiatric crisis, I mean a patient who is not actively on street drugs. I cannot speak to any situation where someone has been taking unknown quantities of unknown chemicals. In such a situation I have absolutely no experience.

That said, I would like to tell you a few simple things about dealing with an unarmed, undrugged person who seems agitated and paranoid. It is true that I speak of myself, but I believe that the only difference between me and a two hundred fifty pound man, is only size and the fear factor. I think that there is no reason on earth why he would not respond to the following interactions just as well as I know I would.

First all of, remember that the person you are dealing with is indeed agitated, and is if paranoid  by definition terrified. Keep that uppermost in your mind, because everything you do will be evaluated by her in terms of what threat it poses. If you frighten her or threaten her, she will become much more  unpredictable, and the probability of violence increases enormously.

Never approach such a person with a show of force.Not even if she is being “loud” and disruptive. You gain nothing by such brute force methods, and you lose a great deal…Ganging up on a patient who is paranoid only puts her in the “fight” mode. After all, she is already frightened and you have cut off her only perceived avenue of “flight.”  Why  escalate a crisis situation, making it worse, upping the potential for a violent response. If the situation has already devolved into accusations, yelling and swearing — all three signs of increasing anger and desperation — that is a signal that whatever you are doing is making the paranoia worse; at such a time the best thing to do is NOT to worsen the situation by pushing back, responding with equal anger, and making demands and ultimatums. No, instead back off and WAIT. The person most likely has not had access to a weapon or anything to hurt herself or others, so patience is a virtue and can be put to good use here.

Usually a patient who is paranoid will not do anything of her own accord but try to escape the situation. But if you force the issue, if you prevent her from escaping to a comforting place or from her own feelings of fear by permitting her what she needs to calm herself, or worse, attempt to do something to her that she could perceive as an attack – for instance, if you try to force medication, or grab her or simply threaten her with a group of staff or guards approaching en masse, you may very well provoke her to respond as anyone would when attacked, i.e. with self defensive maneuvers.

Why be surprised, when several people try to rush her and grab her to hold her down for IM medication, or simply gang up on her in some misguided attempt “to calm her down,” if she then responds with apparent aggression? After all, it is several of you against the one of her and it is surely understandable that she feels threatened. Her life feels in danger and in such a situation all bets are off as to what she thinks she must do to preserve her safety.

If you really want the situation to end well, refrain from threatening or attacking her, no matter how impatient you may feel. Instead, choose one calm, unthreatened and unthreatening person, preferably of the same sex or somehow compatible with the paranoid patient’s personality, and have that person approach to a safe distance (safe for the paranoid patient, not just “safe” for the staff person or for lack of a better term, “negotiator.” The negotiator is safe so long as he or she does not threaten or attack the patient, who is much more frightened than the negotiator.

Approach to a safe distance and possibly sit down, calmly and in a relaxed position, so that she understands that you are not scared of her but also not angry or threatening. If necessary, you might indicate that the patient is speaking too loudly for you to hear her, or too rapidly, but that you are there to listen and talk, when she can lower her voice or slow down. Do not speak loudly or angrily yourself. Talk about anything at first. Don’t talk about the patient or what is going on and do not argue or demand. order or talk  about your expectations of or for her. Try to talk about calming external things. Does she like nature, art, sports, reading? Is she cold? Hungry? Can she take some deep breaths? Maybe she would like to sit down now, too? Finally, when she can, would she like to tell you what is going on? There is plenty of time, no hurry. It is important to find out what the problem is…

It may be you fear that she will attempt to self-harm or hurt someone impulsively. If the latter, keep everyone a safe distance away. And emphasize the possibility of violence so that they will stay  away until the all-clear.  Then talk to the person in a soft voice and gently remind her that you know she doesn’t want to hurt anyone, not even herself, that she is already in enough pain…What does she need, right at this very moment, to help her feel better? Then negotiate a way to get it for her, or something that will do as a substitute or an approximation.

It isn’t that hard to negotiate a calm solution to this sort of crisis, without violence or retribution, when you don’t threaten the person and are truly on her side. But you must never lie to her or to swoop down upon her immediately afterwards to put her in restraints. The point is to bring the crisis to a peaceful resolution. It is not a contest you must somehow win, and then punish her because you were scared and got angry. Exacting retribution  is unconscionable and if that is your impulse you need to have a talk with your supervisor. Negotiators and other employees who do such things need to be reassigned to other areas or other jobs. They do not belong in crisis intervention settings.

Now I am certain that you can think of other scenarios where four point restraints are absolutely essential. If so, I would like to have you describe one. We can discuss this because I am becoming more and more convinced that Seclusion and Restraints CAUSE more mental illness and suffering than they relieve. How would you feel if you found out that by putting a patient in four point restraints even once, you may have caused enough  trauma to induce more self-injurious behavior, plus PTSD? I believe this happens. I also believe that it is terribly dangerous for the sense of self and the self–esteem and the relationship between the patient and ANY  health care provider of any sort at all.  I see nothing good to come from restraints. NOTHING. I do not even see them as providing safety, not in the long run and scarcely in the short run since those who are restrained tend to become more violent not less. Why will people not learn that the “catch more flies with honey than vinegar” works with people in every instance?

But talk to me. Let me know what you think. A confession:  I once wrote an Op-Ed  for the biggest  state paper around her that suggested that restraints could be an okay form of treatment if patients were taught to ask for them voluntarily! (I cring just thinking how I toed my sister’s “party line” about the helpfulness of restraints. She learned that sort of thinking from being the attending psychiatrist at Y__ Psychiatric Institute where they taught patients to ask for wet packs or to have their wrists chained to their belts all day long… The difference between us is that she still believes in that sort of  brutality.)

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