Insanity and Non-Restraint

[For centuries tradition has firmly held that the ’evil spirits’ of the insane must be exorcised by various methods of restraint. Our ancestors prevented the insane from injuring society, and thought their duty done. In modern times, the methods employed have grown milder with the advance of humanitarianism, but the principles involved have undergone little radical change, and legislation concerning the treatment of the insane has, until recently, concerned itself more with the safety of the persons of the wardens and of the property of the state than with the cure of the patients themselves. The restraints by means of which institutions seek to render insane people comparatively harmless are three in number: 1. Mechanical appliances. 2. Solitary confinement. 3. The chemical restraint of drugs. Singly or in combination, these methods are still very generally employed. In institutional work throughout the United States a determined effort is now on foot to solve the terrible problem of insanity without weapons other than those of kindness, wisdom, and unlimited patience. Already in Scotland, the employment of restraint of any kind in the care of the insane is prohibited by law, while in England restraint is strongly discountenanced. In America, New York and Kentucky have adopted advanced legislation on the subject, Massachusetts is following more conservatively in their wake, while much interesting experimentation is going on in other parts of the country.

PUBLIC sentiment requires that the insane in hospitals shall, so far as possible, be restored to normal health; and that patients, of both acute and chronic classes, shall be provided with substantial comforts, shall be protected from abuse and unnecessary hardships, and shall enjoy a reasonable degree of freedom. It is well known that the insane were subjected to shocking treatment in earlier times; and no doubt insane patients, in hospitals set apart for their proper care and treatment, still suffer much at times from the hands of those employed to nurse and watch over them. Such abuse cannot be wholly suppressed until the old system of coercion, with its severe discipline and its mechanical appliances ready to substantiate threats, is eradicated from hospitals for the insane, and practical compassion, with gentle arts and persuasive measures, is adopted by the entire management, nurses, and medical officials, as the ruling principle in managing the patients.

Strict rules, admonishing nurses and attendants to avoid abuse of patients, abolishing instruments for mechanical restraint, and increasing the wages of the employees, are commendable steps in the right direction; yet such measures fall short of protecting troublesome, unreasonable patients under the absolute control of thoughtless, dictatorial attendants, and dependent for comfort upon what abridged rights and restricted freedom they can obtain from employees. Where the ward-management of turbulent patients is left largely to the discretion of attendants who have had no practical experience in controlling the insane without threats and mechanical restraint, these attendants naturally assume that patients must be held in such a state of subjugation that they will promptly obey any command. Their ignorant and undisciplined inclination incites them to bully the patients, and to compel them to obey unnecessary orders, simply by way of testing their docility. Too often some of the rougher class of attendants will deliberately attack a new patient in order to show him who is master. One motive for such cruelties is the desire to impress the patient early with a fear of consequences should he report to medical officials instances of abuse which he, or other patients, may have suffered. When patients who have been badly treated by employees suppress the facts and refuse to answer questions, intimidation is the most probable explanation. The pitiless attendant who is cautious enough to fear detection, and possibly discharge, can usually irritate and provoke the patient into resistance or attack; and when the patient has actually struck the first blow, his fate is sealed. Under the plea of self-defense the attendant can safely pommel his innocent victim.

Public opinion is occasionally fanned into indignation by published reports of hospital abuses. At such times an investigation of the reported death or serious injury of some insane patient may be ordered by the governor or legislature, and as an outcome, some employee may be censured and discharged; but more frequently the final report will minimize the outrage because the situation, as represented by interested hospital parties, was one of great peril to the employee. In the findings, the sad results of such ‘hospital accidents ’ are always regretted, but are deemed unavoidable so far as the investigators are able to judge. Such official investigations are almost always superficial, and the verdict serves little purpose beyond softening the process of closing the incident.

Happily such hospital conditions are now exceptional, but without doubt a minor phase of ward-despotism does exist, not infrequently, in some wards of most hospitals for the insane. Too often attendants order patients about in rough terms, even with profanity, manifest a degree of impatience most exasperating to nervous invalids, and threaten them with removal to back wards, seclusion rooms, or with straitjackets, unless they respond instantly when addressed by the ward ‘dictator.' The great majority of patients submit to such treatment — some meekly, some sullenly; but occasionally some irritable or semi-demented person will continuously ignore the commands of the churlish overseer. Louder and more terrible menaces follow, until the baffled petty autocrat, intent upon maintaining his idea of discipline, strikes or seizes the ‘rebellious subject,’who may then unexpectedly show fight, and, in consequence, some one will be injured, usually the poor patient.

And yet, the attendants who inflict such discomfort and misery have some defense for their conduct. The hasty arbitrary measures enforced by the average state hospital ward-attendant may represent his best judgment and be the measure of the meagre or erroneous instruction he has received, as well as of the faulty character he is developing through inadequate instruction and incompetent guidance. To insure the proper treatment of the insane in large hospitals, the individual members of the nursing staff should be trained to understand the propriety and the importance of controlling patients by gent le persuasive measures. Their sympathies for the patient should be awakened and cultivated. They should be inducted into the practice of leading patients by suggestion, deliberation, conscious mental power and the advantages of position. They should take professional pride in winning mental victories over the turbulent insane, and should deplore the subjugation of confused and terrified insane men and women by brute force and straitjackets.

The humane management of the insane in conformity with the most modern ideas has come to be designated as the ‘non-restraint’ system. The term docs not characterize the whole scheme but suggests it, because strait-jackets, wristlets, and bed-harnesses are the obvious and tangible insignia of the repressive methods too commonly enforced. Moreover, the pacific arts involved in the proper treatment of the insane cannot be successfully inculcated and enforced unless mechanical restraint be altogether discarded. Nonrestraint in its literal, narrow sense may be made the rule of an institution without bettering the treatment of the patients. Processes more painful and more dangerous than wearing the camisole, can be employed by tyrannical attendants to frighten and intimidate defenseless inmates.

Doubtless a patient will occasionally betray critical symptoms which seem to necessitate mechanical restraint; and the use of such restraint may result in no in jury, mental or physical, to that particular patient. Could the treatment of such a case be entirely dissociated from all other cases in the minds of the physicians and nurses, the use of straps and jackets might be regarded as unobjectionable. But in institutions for the custody of the insane, the general welfare of the whole body of inmates depends very much upon the morale of the nursing staff; and the demoralizing effects upon its members of making exceptions to the ‘non-restraint’ rule are so pernicious and wide-reaching, that yielding to the use of mechanical restraint with occasional patients would sacrifice the best interests of a multitude of other cases having equal claims on the management for protection from unnecessary restraint and ignominy. The superintendent who fancies that he is controlling the use of mechanical restraint in the hospital where he directs affairs, when he reserves to himself the power to decide whether or not mechanical restraint shall be used in any given case, does not see himself as others see him. Even the nurses understand the situation better than he does. They clearly realize that it is they who inspire the judgment of their superior.

Sometimes, for instance, the superintendent receives a telephone report from nurses that some patient is desperately suicidal or dangerously maniacal, with a request that permission for restraint be granted. He dares not decide against their evident wishes under such circumstances, for the urgency of the appeal seems to show that the nurses are physically incapable of further effort. Unless he has previously established the ‘non-restraint’ treatment as the undeviating working practice in his hospital, the executive chief is mentally and morally helpless.

Amid all these precautions, however, it must be remembered that if humane methods are to prevail in hospitals for the insane, nurses must be allowed to take some risks with bad patients, and this they cannot be expected to do without the approval of the superintendent. They must act for him in such work, and he must be ever ready to support and defend all subordinates who conscientiously and intelligently endeavor to manage the insane without restraint or other harsh measures.

The outlines of a desperate case and some of the methods employed to change the patient’s mental habit will suggest the dangers involved, and the necessity for deviating from hospital routine in caring for such cases.

A seventeen-year old girl from the West Indies drifted into a state institution. She had occasional epileptic attacks with some hysterical indications, and suicidal impulses persistently recurred. While the convulsions were infrequent, for days at a time she would appear morose, nervous, and irritable. During such spells she sometimes made vicious attacks on nurses, and unless closely watched would endeavor to strangle herself by twisting articles of clothing, twine, or strips of cloth about her neck. She often packed rags, paper, and small articles in her mouth, nose, and throat; and so stealthy were her movements that nurses in the room with her sometimes became aware of her suicidal attempt only when her face became dusky as the result of obstructed respiration.

This case gave the doctors and nurses an endless amount of trouble and anxiety. They feared the girl would kill herself unless her hands were restrained by mechanical appliances. But she was so unusually supple that she could squirm out of any ordinary restraining apparatus. Finally, a special bed-harness was devised, from which she could not escape. After several months of such confinement she was removed, by official orders, to another institution, where the ‘nonrestraint’ system of treating patients had been adopted.

The nurse who conducted the transfer said the change was made because at the first institution they ‘could do nothing with the patient.’ When asked if mechanical restraint had been employed, she replied, ‘Yes, she has been allowed out of it only two hours each day.’ In the second institution this patient remained three or more years, and was at no time subjected to mechanical or chemical restraint. Such a record was possible only as the result of concerted work by the superintendent, the assistant physician, and the nurses. Naturally, the most difficult part fell to the lot of the nurses. They were given to understand that the case was certain to test ‘non-restraint’nursing, and their best efforts were enlisted. The nurse in charge became devotedly interested, and in her personal attentions to the case she became vigilance personified. She possessed unusual tact, was fertile in devising expedients, and fathomed human motives with facility. She quickly discerned that vanity was the patient’s distinctive characteristic, and with this clue she proceeded to reclaim this uneducated but cunning epileptic. The girl was praised and flattered upon all possible occasions, and constant efforts were made to give her pleasure and to encourage her self-esteem. All conspired to pay her special attention. She was provided with pretty dresses, decorated with ribbons, and scented with perfume. When nurses went out fora day they usually brought her some present, such as candy, fruit, cheap rings, beads, etc. They secured special articles of food for her, and invited her to share their extra lunches and little feasts, and all made a pet of her. The ward physicians aided in these plans by giving her special prominence and complimenting her good appearance. They would accept from her reports concerning other patients which had been suggested by the nurses.

To encourage her self-esteem, nurses often requested her to watch some troublesome patient, and found they could depend upon her good conduct and fidelity when her usefulness was thus magnified. They gave her the use of a drawer with a private lock in the linen-room, and permitted her to wear the key on a tape around her neck. They often requested her to keep their small personal belongings, and never was such confidence misplaced, although she would pilfer from nurses in other wards without hesitation.

She was frequently taken out of doors for special walks, to the storeroom for ward-supplies or personal knick-knacks and to the greenhouse for flowers. As her general conduct improved she was taken to the general dining-room for meals and to the weekly dance. On such occasions she was decked out with especial care, and often wore by permission a nurse’s watch or other jewelry. To arouse her from her morbid broodings, the nurse sometimes gave her the ward key and requested her to visit other wards to convey a message or receive a report. This was done at times when the nurse had so little confidence in the patient that a previous arrangement was made with the other nurse to put night-locks on outside doors and to watch the patient carefully. Gradually under such influences her despondent periods became less frequent and less prolonged, and in time sheactually enjoyed limited parole outside the hospital wards.

After several years spent under such friendly and stimulating associations she was again officially transferred to another institution.

Room for acute cases was urgently needed in the hospital, and because of her epileptic infirmity she was this time taken to an asylum for chronic cases. But the asylum management continued the methods employed in the second institution. She was constantly under kind, judicious watch. She was provided with toys, amusing games, attractive pictures, bright-colored ornaments, etc. As a rule she responded to such pleasant surroundings in a satisfactory manner, but on several occasions while in the last institution she almost succeeded in committing suicide. Eventually, however, her improvement was so pronounced that the state authorities deemed it prudent and justifiable to deport her to her native island, where her brother lived and was to take charge of her.

The special attention given this case was costly to the state and burdensome upon officials and nurses, and yet the money was well expended and the personal efforts were well directed. Of the many nurses who freely gave to this afflicted child the service of mind and heart which riches cannot command, none ever regretted her contribution or failed to reap her reward. The moral effect of such a triumph over serious mental conditions was well worth the state’s financial investment, if only for the good it accomplished in the two institutions which faithfully endeavored to discharge their moral obligations to a thankless alien.

Occasionally a medical superintendent who believes in the use of mechanical restraint, at least for exceptionally hard cases, will cite an affray with an insane patient, stating conditions which actually confronted the attendants, and will request a solution of the situation from some advocate of non-restraint. Such superintendents misapprehend the theory. Probably nothing short of some form of restraint or seclusion would meet instantly all the requirements of the case as delineated. The correct and the better method had been too long neglected. Rational treatment, should have been applied to the case weeks, months, possibly years, before such a violent culmination of threats and neglect. The cure for such troubles consists in educating nurses and attendants to become true nurses, with a thoroughly humane conception of their duties.

The superintendent who seriously desires to avoid the use of mechanical restraint will have not only to forbid it, but to keep a careful watch over the nurses, particularly in those wards where there are new and troublesome cases. Especially should he investigate personally every instance of violence between nurses and patients, and keep a record of his findings.

The superintendent should in all possible ways adopt plans which will facilitate the successful working of the policy of non-restraint. The overcrowding of wards, especially those appropriated to the care of noisy and fractious patients, should be avoided. He may not be able to regulate admissions to the institution, but overcrowding interferes so seriously with skillful nursing that he should register his protest when conditions prevent the best work.

The proper classification of all patients likely to cause trouble is a great aid to ‘non-restraint’ methods. Not that all patients inclined to be disorderly should be herded in back wards; irritable patients react upon each other and should be frequently changed from ward to ward, that they may form new companionships and avoid tiresome associations. In making such changes, personal antipathies between patients, or patients and certain nurses, should receive consideration. But nurses should not be permitted to force such changes where it is evident that they are chiefly concerned to rid themselves of the care of troublesome patients. Convalescence, with some patients, may be retarded if they are not transferred from a noisy to a quiet ward before the excitement has wholly subsided. Such transfer from back to front ward, and then from front to back, repeated several times, is often the correct way to stimulate them to exercise self-control.

Seclusion may be necessary at times, but it should be remembered that prolonged seclusion is bad practice. The shorter the period of seclusion, as a rule, the better the effect upon the disturbed patient. Noisy, destructive patients are seldom improved by solitary confinement. Exercise out of doors to the point of physical fatigue, with a competent guard of nurses, is a much better form of isolation from other patients, and a practical way of treating such cases. Ample facilities for prolonged warm baths must be provided. When the temperature of the water is maintained a degree or two below blood heat there is little risk of heart failure. Persistent destruction of clothing is fostered, not cured, by the use of illfitting canvas dresses. Better provide material having bright colors and striking figures — something that will appeal to what vestige of pride may exist — that will attract the eye, and, possibly, alter the purpose of the patient.

Daily out-of-door exercise for all able-bodied patients should be insisted upon whenever the weather is suitable; and all patients who are physically able to work should be urged to engage in some form of labor, at least a part of each day. Let t hose who object to physical exertion accompany those willing to labor, even if at first they simply stand around and watch the busy workers. The i nfluence of a good example is suggestive, frequently inducing idlers to participate in useful employment. Patients who work faithfully and diligently should receive some reward. Occasionally, a small sum of money regularly paid as a gratuity will secure their good-will and stimulate their exertions. Special diet, extra clothing, tobacco, occasional excursions, may be profitably granted as inducements to the continued rendering of efficient service. Compelling patients to work should be strictly forbidden, as serious conflicts have resulted frequently through attempts on the part of attendants or nurses to force patients to serve them at ward-duty or in the performance of some disagreeable task. Inducing patients to work, or to conduct themselves properly, through gifts, rewards, or favors, is a prominent feature in the ‘non-restraint’ system. Head-nurses over all wards where there are restive and contrary patients should be liberally supplied at all times with extra food, fruit, candy, or pictures, for use in distracting the attention of excited patients, and in establishing friendly relations with patients who are suspicious.

Nervous, restive patients should be assigned to large roomy wards whenever possible, so that they may roam about freely, and greet new acquaintances, and vent their explosive energy while aimlessly tramping about the long wards. Cramped accommodations and restricted movements are as irritating t o the insane as to any of the healthiest of us, and should be avoided except when exhaustion is likely to supervene upon too prolonged physical exertion. Noisy, talkative persons should be taken into the fields and woods to correct their unpleasant habits, not consigned to out-of-the-way dark rooms. The more close the restrictions, as a cell or strait-jacket, the more intense the irritation, fear, and suffering; consequently the more persistent the noise and the louder the shouting. As a result of natural laws, it is to be expected that painful mental tension incident to extreme limitations of space or motion will gradually relax, to be succeeded bya sense of relief and quiet, as the restrictions are mitigated and gradually transformed into a state of freedom.

There are good reasons why it is advisable to open hospitals for the insane to the public often and fully. When public inspection or visiting days occur frequently, the nurses are stimulated to keep their wards in a presentable condition, as they know that the general appearance of the halls and rooms, as well as the dress of the patients, will fall under critical observation. This constant anticipation keeps both nurses and patients more active and more cheerful than would the dead level of hospital routine. The patients’ hopes are awakened and their spirits are elevated by coming into such close contact with people of the outside world. When public visiting days occur twice weekly, as in some institutions, and a large number of strangers pass through the wards each open day, the patients become so accustomed to the spectacle that they regard the visitors with comparatively little curiosity, maintaining a good degree of dignity, and seldom exhibiting undue excitement.

Properly conducted hospitals for the insane no longer afford such grotesque and shocking spectacles as, according to Pepys and Hogarth, were on exhibition in old ‘Bedlam.’ No doubt many persons at the present day are prompted by curiosity to visit hospitals for the insane, but the tables are practically turned in hospitals where frequent wardvisiting is the rule: there the parading visitors provide the exhibition. Their evident timidity and unconscious stupidity often interest the patients, who quietly note and enjoy the passing show and subsequently criticize or analyze it with jest and merriment.

Hospital life is necessarily monotonous, and liberal diversion is the rational antidote with which to counteract its bad effects. Amusements varying in character should be provided at short and regular intervals for the entertainment and mental relaxation of the patients. Anything which agreeably enlists and engrosses the attention fulfills the requirements. Music and dancing can always be depended upon to produce satisfactory results.

A general dining-room can be utilized to add variety to the patients’ daily life, to change the drift of morbid thoughts and inclinations, and to introduce normal conditions as fully as possible into hospital methods. Both men and women patients should be accommodated in the same dining-room, their tables being separated by a wide passageway through the centre of the hall. No eatables should be placed upon the tables until all have been seated; food can then be distributed from rubber-tired cars in the centre aisle, or served from sideboards against the walls, by selected patients acting as waiters, one waiter to each table. The meals should be so planned that the food can be served in a number of courses, the more table etiquette the better, allowing fully one hour for dinner, and forty-five minutes for breakfast and supper. In such dining-rooms haste is objectionable, and from five hundred to fifteen hundred patients can be managed and properly fed with ease and quietness. The time that patients thus spend at table and in going from and returning to their wards will amount to at least three hours a day. An orchestra should furnish music at all meals.

Only those who have had experience with such an arrangement of meals can appreciate the power this method of serving has in promoting the self-respect of the individual patients and in tranquilizing ward conditions throughout the whole hospital. The aim and purpose of such dining-room practice should be to cultivate good table manners, to occupy the patients’ time agreeably, to increase the selfrespect and self-control of the patients by adopt ing the dining-room customs of large crowds of normal people. Incidentally, the plan allows ample time for the serving of quiet meals to attendants and nurses, usually in one section of the same room. It also removes from the living wards objectionable odors and annoying housekeeping duties, and, last to be considered, it is decidedly economical as regards waste, service, and cost for food.

The music is an important, probably an essential, feature. Many patients listen with pleasure, and all are affected. Without music there would be more noise, more loud talking, and some patients would find it difficult to repress an inclination to lecture the officials or others present, and to make statements leading to rejoinders and disputes. With attractively arranged tables surrounded by plants and flowers, and with patients neatly dressed, entertained by good music, little more is required to make the general diningroom the acknowledged social centre of the establishment, from which will emanate good influences to tone and characterize the whole institution.

In the brief compass of this article I can do no more than suggest the methods which in more than one intelligently managed institution have completely displaced the crude system of restraint. Already it is possible to foresee the time when every form of restraining device, and even the desire to employ one, will vanish in the wake of all the other relics of medical mediævalism now happily consigned to oblivion.