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Dealing With Aggression Through Restraining — When is it a Necessity?

Submitted by on February 11, 2018 – 12:23 AM

restraintWhen we hear the word ‘anger’, people often construe it as a bad or immoral action — but anger is a normal human emotion. Yes, it becomes immoral or abnormal when it leads to aggression (such behaviors in which a person shows disrespect, unhappiness, and becomes annoyed with himself/herself or others). According to Cherry (2016), anger occurs in reaction to a perceived threat; humans experience aggression as a physical and verbal way of harming others in their society.


The prevalence of psychological problems may vary from culture to culture (Jafri, Shah & Riaz, 2014). For example, a study was conducted to explore the level of aggression among the Punjabi population in Pakistan. In this study, a questionnaire was used to measure the aggression level based on important factors like age, gender and marital status; according to this study, male and un-married defendants were found to be more aggressive than the rest of the Punjabi population (Khalily, 2011). In Pakistan, the prevalence of violent situations on a regular basis is increasing the incidence of mental illnesses such as depression, anxiety disorder and aggression.


During my psychiatry clinical rotation, I came across a 49-year-old patient with anger issues who seemed to be depressed. He paced around the entrances and experienced self-pressure when talking.  After some time, I saw him in his bed while he was restrained.


When I went to his room to take his patient file, he started crying and begged me to release his hands. “I want to go home,” he said. “I can’t live here anymore.” As students, we were unable to take any decisions at that time, but we asked to staff to address the appeal of the patient. However, they only answered that he was still aggressive and requires restraints.


After my encounter with this scenario, I came to believe that restraining is only one of the optional ways to deal with aggressive behavior. As healthcare providers, we relieve the patient from miserable conditions, but we sometimes fail to manage such patients, and so restraints become a necessity. Are there other techniques which may help a person in making their mental health better, as well as upholding their human dignity with it? The answer to this requires exploration of the root cause of aggression.


The causes behind this abnormal behavior are many, including biological and genetic. Many psychological problems run in families. Frustration towards unfulfilled goals can transform into provoked aggression. Aggression can be learned from the environment either by imitation of elders or by reinforcement. Failure in delaying gratification in childhood may also be causative (Stuart, 2014).


In some cases, healthcare negligence in the form of inexperienced staff, understaffing, and poor milieu management in the hospital setting can also initiate aggression. In its entirety, this affects a person’s mental, physical, emotional, psychological and social well-being. People with such inappropriate behavior are neglected in society because, in the perspective of others, they inadvertently defy social norms. And their community, instead of understanding that this is a disease process, start ostracizing them, which worsens the problem.


In medical terminology, restraint is a forceful limitation to control a person with disoriented, irritated and aggressive behavior. Nowadays, it is practiced as physical or chemical means to deal with aggressive patients and patients with other psychological disorders in mental hospitals.


A patient who has been restrained experiences a feeling of having their freedom taken from them. Their actions in this situation may also go against the healthcare system. But in some specific situations, restraints become necessary to safeguard the safety of the patients and others in their surroundings. As a professional healthcare provider, a nurse may also be ethically responsible for basic human rights to confirm appropriate use of restraints. Improper use of restraints, however, may do more harm than good.


Restraining evokes many different behaviors, either positive or negative. It may lead to distrust between the client and nurse. Negative feelings of helplessness and low self-esteem may be provoked. On the other hand, restraining may also produce therapeutic effects; for example, when a patient in aggression is unable to control himself, but later reflects on his thoughts and actions due to being restrained.


The use of restraints is acceptable in some cases where a person poses a high risk of harm to oneself or to others, and it is also applicable when a client gets violent for the purpose of self-protection of the healthcare provider (Royal Nursing College, 2008). In this situation, according to nursing ethics, beneficence take precedence over the autonomy of the patient. It is important to take a positive action for the patient’s well-being.


However, there are strategies other than restraining known as de-escalating strategies, adopted behaviors used consciously to remove all escalating actions (rise) that may potentially harm someone. It is done with non-verbal and with verbal communication techniques. Mind diversion and developing the ability to organize one’s own thinking may remove patients from or allows patients to escape stress or depression. Mindfulness is nowadays more widely practiced in the clinical setting for improvement of psychological illnesses (Richmond & Berlin, 2012).


One of the main methods to manage aggression is catharsis (releasing anger in constructive ways, e.g. by running, drawing, punching, or yelling), deep breathing exercises and the Take Time Out method, in which a person consciously takes out time to calm himself/herself down rather than showing aggression. Cognitive behavioral therapy (CBT) is an effective technique for depressed clients who deal with negative narratives. If a person experiences negative thoughts that have an outward effect on his/her entire behavior, CBT helps them to change their way of thinking from negative to positive, which eventually reflects in behavior.


The Safewards model generates an idea to provide safe psychiatric wards for patient and staff as aggression and restraining places the client and staff at risk of harm. This model explains six originating factors; staff team, hospital setting, client characteristics, community, outside hospital, and the regulatory framework. These domains can give rise to flashpoints for conflict which may increase aggression and then containment (restraint). Staff should attempt to reduce the factors which create clashes or dispute. Removing the connection between aggression and other factors that may involve restraining or seclusion helps to ensure that restraints will create no further conflict.


As a healthcare provider, I recommend that aggressive behavior needs treatment in very sensitive and specific clinical settings, wherein all health-team members work in collaboration to enhance the patient’s individual quality-of-life. These patients should always be encouraged to engage in group activities, which will limit isolation and depression.


In conclusion, restraining is a form of preventing from self-harm and harm to others. Dealing with aggressive patients is a big challenge to healthcare professionals, such that it is important to examine its causes first and subsequently treat its effects on mental, physical, emotional and social health. This will help in promoting of health of the client as well as the satisfaction of their family. Restraints should never be used as a punishment or for staff ease. They are only to be used as a last resort for the safety of patients and visitors.




Warburton, W. A, and Anderson, C.A. (2015). Aggression. In L. berkowiz (Eds.), (pg.294-259).
Springer, G. (2015). When and How to Used Restraint.  January 2015. Vol.10.

Novroz, I. (2017). Relying Restraints in Psychiatric settings: Distasteful yet Necessary? 12 February 2017.

Gastmans, C., and Milisen, K. (2006). Use of Physical Restraint in Nursing Homes: Clinical-ethical consideration. March 2006; Vol.32(pg. 148-150).

Iqbal, S., Naqvi, H., and Siddiqui. (2004). Psychiatric In-patient Violence: Use of chemical and physical restraint At a University Hospital in Karachi Pakistan. January 2006; vol.3(1).

Donnellan, M.D., Khal.H., And Robins, R.W. (2005). Low Self-esteem is Related to Aggression and Antisocial Behavior. April,1,2005.

Bowers, L. (2014). Safewards: A New Model of Conflict and Containment on Psychiatric wards. Journal of Psychiatric and Mental Health Nursing. 19 March 2015. (pg.499-508).



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