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Original Essays

Freedom of Motion

by Elyn Saks
  1. The Center Cannot Hold: My Journey through Madness
    $11.95 Used Hardcover add to wishlist
    "[An] engrossing memoir....This is heavy reading, but Saks's account will certainly stand out in its field." Publishers Weekly (Starred Review)

    "[T]he most lucid and hopeful memoir of living with schizophrenia I have ever read." Oliver Sacks, M.D., author of Awakenings

I suffer from paranoid schizophrenia, a diagnosis it took me years to accept. I was hospitalized three times for lengthy periods, tied hand and foot to the cold metal of a hospital bed with a net strapped tight across my chest in the psychiatric equivalent of solitary confinement. I was given "very poor" and "grave" prognoses. In other words, I was expected to live in a board-and-care facility and work at a menial job when my symptoms allowed.

I am relieved to report that my life has turned out differently. I am a chaired professor of law and psychiatry, an advanced candidate at a psychoanalytic training institute, and author of three books and over thirty scholarly articles. I graduated valedictorian of Vanderbilt University, was named a Marshall scholar and studied at Oxford, and received my degree with honors from Yale Law School. I was named an endowed chair on a prestigious law faculty, the University of Southern California Gould School of Law, at an unusually early point in my career. And I was named an Adjunct Professor of Psychiatry at the University of California, San Diego, School of Medicine. I am fortunate to have many friends and a bright, loving, and funny husband.

How did this happen? I'm speaking publicly about my illness and my continuing recovery for the first time in The Center Cannot Hold: My Journey Through Madness. Many things have helped me in my ascent from the depths of madness: psychoanalysis, medications, good friends, a gratifying professional life. Other things have clearly hurt. In this space, I'd like to address one aspect of this latter category: the use of mechanical restraints in psychiatric hospitals.

I had my first of many episodes of being put and held in mechanical restraints when admitted to the ER in New Haven, Connecticut. The doctor entered the room. He was everything I'd imagined in our telephone conversation: short, bureaucratic (right down to the ballpoint pen he kept clicking), authoritarian, and short on patience. The man who makes the trains run on time. I slipped my hand into my pocket and wrapped my fingers around a nail, my concealed weapon. His eyes followed my hand.

"Give that to me," he said.

"No," I said.

He immediately called for security. Another attendant came in, this one not so nice. And once he'd pried the nail from my fingers, I knew I was done for. Within seconds, the doctor and his whole team of goons swooped down, grabbed me, lifted me out of the chair and slammed me down on a nearby bed with such force that I saw stars. Then they bound both my legs and arms to the metal bed, with thick leather straps.

A sound came out of my mouth that I'd never heard before. Half-groan, half-scream, barely human, and pure terror. Then the sound came again, forced from somewhere deep inside my belly and scraping my throat raw. "Noooooo," I shouted. "Stop this, don't do this to me!" I glanced up to see a face watching the entire scene through the window in the steel door. Why was she watching me? Who was she? I was an exhibit, a specimen, a bug impaled on a pin and helpless to escape. "Please," I begged. "Please, this is like something from the Middle Ages. Please, no!"

For years after the several-week period that followed, in which I was restrained sometimes for very long periods (as many as twenty hours) and sometimes for shorter periods (an hour or so), I had nightmares. Often in my dreams I would get a measure of revenge: I would seclude and mechanically restrain the entire staff of the hospital, leaving them there for long stretches. (I would also open the hospital doors so people could leave. Interestingly, in my fantasy, a significant percentage of patients chose not to leave.) The dreams were a way for me to try to process and come to terms with the experience.

It is impossible to overstate how horrible it is to be in restraints, especially long term. There is considerable pain: try not moving your arms or legs even a bit for a long period of time. It hurts like hell. Then there is the indignity and degradation. There's also a terrible sense of helplessness that is compounded by not knowing when you will be released. Last but not least, patients are often restrained by being tied spread-eagle to a bed. I believe that people who have been sexually abused will be retraumatized by being held in this position. (Even someone who has not been sexually abused — as I have not been — may feel in a compromised sexual position.)

The prime benefit cited for mechanical restraints is that they prevent patients from harming themselves, even killing themselves at times. Yet, a series run in the Hartford Courant uncovered many restraint deaths in psychiatric hospitals. Many of these were covered up. Based on what we do know, a Harvard statistician estimated that there are 50 to 150 restraints deaths a year. It's hard to estimate how many deaths restraints prevent that wouldn't be preventable in other ways (e.g. "staff specialing" the patient). But the number of deaths per week is at the least noteworthy. Moreover, restraints aren't a foolproof way to prevent patient harm. A person determined to hurt or kill himself will be able to do it, in restraints or out. Indeed, a better way to protect the patient is to have someone present at all times to respond to any attempts the patient makes to injure him/herself.

My own recommendations for a law surrounding restraints would allow them to be used only when absolutely necessary: when a doctor needs to talk to a patient, say, or a patient is being transported in an emergency and won't comply with instructions to stay still. The time of restraint should not extend beyond the need. Second, I would procedurally burden even such acceptable uses of restraints: e.g., the doctor needs to meet with the patient after one or two hours. Third, I would change the legal incentives: doctors should be found liable for harm from not restraining patients only if their failure to do so was grossly negligent. Finally, I would outlaw four- and six-point restraints tying patients to beds spread-eagle. Cuff their hands to their belt, restrain them to a chair — but no four and six point restraints to beds.

My chart at one of my hospitals said that I should be "restrained liberally." I was, and it was horrible. Thankfully, I have not been restrained since 1983. I hope I never am again. And I hope my story will lead the general public to wonder if we should ever use restraints at all, let alone with the ease with which we do today. Freedom of motion is something we very much take for granted until it is taken away.

÷ ÷ ÷

Elyn R. Saks is a professor at the University of Southern California Gould School of Law and an adjunct professor of psychiatry at the University of California, San Diego, School of Medicine. She is a research clinical associate at the New Center for Psychoanalysis. Saks lives in Los Angeles with her husband, Will. spacer

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