By Kevin R. Betts
The Joint Commission, an independent health care oversight group, recently expressed alarm over violence in U.S. hospitals. Russell L. Colling, a consultant who advised the Joint Commission said, “The reality is, there is violence every day in the emergency department.” On inpatient units in psychiatric hospitals, violent behavior among patients is often met with forced isolation. A primary goal of isolating these patients is to ensure their safety, as well as that of other patients and staff. However, isolation is also thought by many to act as a deterrent for potential future acts of violence. Having been directly involved in this process as a mental health technician, I often pondered the effectiveness of isolation as a way to combat violent behavior among patients.
Perhaps counterintuitively, research on social ostracism suggests that isolation may promote later aggressive acts (Williams, 2007). In order to understand why this may be the case, imagine yourself in the position of a patient involuntarily committed to an inpatient unit at a local psychiatric hospital. Disagreeing with your involuntary admission, you verbally express your anger to the staff. Told that you may not leave, you become even angrier, perhaps trying to access locked doors. You feel an utter lack of control over your situation. Making matters worse, the staff expresses concern that you may become violent as a result of your distress and “for your safety,” escorts you to a locked room so that “you may reflect on your acting out behavior.” You are in isolation. Your anger further increases and you find yourself behaving in ways you could not previously imagine, yelling “let me out” and banging on the only door in a windowless room. You think to yourself, “They will regret this once they let me out of here.” What you (and many other patients placed in similar situations) are experiencing is an impaired sense of belonging, self-esteem, control, and meaningful existence―direct consequences associated with social ostracism (Williams, 2007). In the eyes of an isolated patient, these needs may wrongly be perceived as restorable through aggressive means.
If isolation can promote violent behavior, what should be done to combat violence among distressed psychiatric inpatients? Solutions that prevent violent behavior in the first place may be most successful. Listening to patient complaints in a timely manner is essential. Empathizing with these complaints, helping patients manage their distress, and ensuring patients that their distress is temporary should also be effective.