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A Mind That Found Itself: An Autobiography

Creator: Clifford Whittingham Beers (author)
Date: 1910
Publisher: Longmans, Green, and Co., New York
Source: Available at selected libraries

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This discloses the real solution of the controversy. Where restraint is permitted the general spirit of the management breathes coercion; antagonism, enforced submission. When Non-Restraint is the undeviating rule, tact, persuasion, and sympathy soften and mellow every act towards the inmates. The employment of mechanical restraint gives the attendants a wrong sense of their personal power over patients, such a physical advantage that they instinctively incline to self-assertion; to issue peremptory commands; to use ill-considered, irritating speech; to give curt answers; to make threats; in short, to attempt to intimidate all but the most quiet patients. "Do thus, or so, or you will be sent to the back wards, you will be secluded, or you will be put in a strait-jacket," is the natural style of speech adopted by attendants when threats and penalties are at their command. Having thus threatened a penalty, the average uninstructed attendant concludes that proper hospital discipline demands its infliction unless the excited, frightened patient meekly capitulates, a result one could hardly expect with a sane person, much less with a deranged, apprehensive lunatic. Even well meaning attendants naturally fall into such errors unless carefully drilled and faithfully watched. Fresh recruits are constantly entering the nursing service, and only by individual work with them can the highest ideals of a qualified nurse be instilled into their minds.


I cannot understand how the superintendent of an insane asylum can satisfactorily regulate the use of mechanical restraint if he permits its use. He may reserve to himself the decision as to whether or not it shall be used in each-case. But the chances are that he only learns of the final links in the long chain of circumstances which connect the special overt acts of the patient with some affair, trivial it may be, that originated the trouble, and which, by injudicious treatment from the attendants, ultimately assumed serious phases. Under such conditions the supervising medical officer, when he authorizes the use of restraining apparatus, simply endorses the judgment of the attendants.


Let it be understood that restraint can be used only in exceptional cases, and exceptional cases will be brought to his attention too frequently.


An eminent English authority has recorded his convictions that "there can be no real compromise between the frequent use of mechanical restraint and its entire abolition. One system or the other must predominate in every asylum." In managing the insane the first impulse of the attendant is to assume authority or superiority, and give commands or orders, often with a penalty for disobedience expressed or implied. When the Non-Restraint principle is adopted, attendants are under no temptation to utter such threats. Thus, they are dispossessed in advance of that which, in the great majority of cases, occasions troublesome friction between themselves and the patient. When driving patients is out of the question, attendants must induce or lead them. They must exercise the art of persuasion, of pleasing, of soothing. Thus fears will be allayed, confidence will be gained, and a relation of helpfulness and friendship be established. In such arts the capacity of the individual nurse varies; but all who approach patients in the right spirit, with the desire to befriend which qualifies attitude, tone of voice, choice of words, expression of the eye and use of the hands, can demonstrate the power of a kindly disposed, orderly mind over a disordered intellect. No doubt there are insane patients who would suffer no personal injury, mental or physical, by the application of restraining apparatus. Indeed, I am willing to concede that cases may arise where, could their management be absolutely dissociated in its influence from all others, mechanical restraint might be the most expedient treatment. But, in an institution for the insane, it should be only the last resort, since so much for the general good of the inmates depends upon the nursing morale of the hospital, and the demoralizing ill effects of exceptions to the Non-Restraint rule are so pernicious and wide reaching, that officials or nurses should use mechanical restraint only when satisfied beyond question that its use or neglect would determine the life or death of the patient.


Perhaps I speak with assurance, but I worked out this problem at Danvers, where mechanical restraint was abolished deliberately. As has been stated, its use was discontinued in the female wards four or five years before it was wholly given up in the male department. The annual report of the Danvers Insane Hospital for 1897 contains comments upon this subject. To quote: "I am aware that many persons regard Non-Restraint in lunatic hospitals as a fad of enthusiasts. I often hear this subject discussed in such terms, or dismissed with such indifference, that I infer comparatively few physicians even view this question from our standpoint, and therefore deem it proper to explain why mechanical restraint is abolished at Danvers. Mechanical restraint may be, and certainly is, used occasionally upon patients in general hospitals with no injurious consequences; but conditions in general hospitals and lunatic hospitals are so dissimilar, this fact proves little. I formerly permitted the use of restraining apparatus upon patients, endeavoring to limit its use to rare and exceptional cases. While working under this policy, I not only found it difficult to decide upon cases, and to convince the nurses that restraint was seldom necessary, but every exception in favor of mechanical restraint seemed to weaken the courage and resolution of the nurses, as well as to diminish my influence and control over them. Then, too, as long as nurses understood that straps and jackets could be employed as final measures, they not only relinquished mild efforts too quickly, but were inclined to assume a dictatorial, oppressive manner towards patients upon slight occasions; and this spirit of coercion as evinced by the nurse in his or her attitude towards the patient was, according to my observation, the starting-point of the trouble with refractory patients in the great majority of cases.

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