PPC

Restricted Restraint

PPCRight, here’s a restraint related situation for you! —

It doesn’t matter which of the following three scenarios we’re contemplating or whether you’re thinking of your own – it could be a police officer dealing with a drunk person who is offending and needs to be arrested; a mental health nurse attempting to safeguard a patient or administer medication that is required; it could be security in a pub or A&E attempting to remove a disruptive customer. Of course, there are plenty of other possibilities.

Just imagine you are the person who will have to engage in the restraint of another person and they are exhibiting what the police would described as passively resistant behaviours. In other words, they’re not attempting to hurt you or anyone else, not armed with weapons and not lashing out to hit people. The person is just refusing to move or leave; or consent to medication. This little thought-experiment starts after considerable efforts have been made in the circumstances to persuade, influence, encourage etc., and you have now reached the view that restraint is necessary and unavoidable.

What you do has to amount to reasonable and proportionate force, the least restrictive method of achieving the objective and as you approach the practical issues involved, you must have regard to the various rules or conditions laid down by your employer as to how restraint should occur.

Here are the rules -

  • You can’t deliberately hurt the person in order to gain their compliance – no wrist locks, application of pressure points or other painful holds being used to prevent further agitation.
  • You can’t use any kind of mechanical restraint – no devices or handcuffs, no leg restraints and certainly no tasers.
  • You cannot use any incapacitate sprays – so no CS “gas” and no pepper spray of any kind.
  • You cannot hold the person in a prone position, face down on the floor – not at all, not ever.

Now! – your scenario is this: you must restrain a 6’1″, stocky, heavy man who is 31yrs old and move him to somewhere that he doesn’t want to be. So you’re moving him against his will – either under arrest to the cells, to a seclusion room or from a pub to the street depending on which of the scenarios you’re envisaging. On you go! – make sure you keep the rules in mind.

Given the rules, you’re probably thinking of pushing them there or getting them into a form of bodily hold and hoping to walk them to where you want them to be, whilst in hold. Can we think of any other way?

CONDITIONS OF RESTRAINT

All trained systems of restraint impose conditions and qualifications upon those who are trained in its approach. There are various noteworthy differences between the training that police officers and mental health nurses receive, for example. You would expect this – police officers deal with a far broader variety of circumstances and are still expected to face situations from which mental health nurses are encouraged to back away so their training must reflect this. But my point is not about the differences between the sorts of things that different professional groups face; it is about how the police and a mental health nurses would potentially deal differently with an identical situation.

Let’s imagine that for various reasons that are quite legitimate and proportionate, staff in an inpatient mental health ward have decided to seclude a patient. The patient is in their own room, having caused damage to it and is refusing to move to the seclusion room. When mental health nurses attempt to restrain and move him, he resists. The various kinds of hold that would be available would not be holds that allow for pain compliance and no mechanical interventions allowed. So if the patient was held, bodily by staff and then started to push and resist, the success of the intervention would depend upon whether those staff could keep the hold in position and then move the person, without resort to the deliberate application of pain or to equipment used in restraint by others.

What happens if this is unsuccessful? – were the police to be called, they would then consider their full array of tactics and techniques to move people. They include all of the things banned, above!! One might ask what cultural change we invoke and what ethical advantage we secure by invoking rules that are predicated on very worth virtues of dignity and well-being, only surrender the importance of them should it become too difficult. Except we’re not just setting aside those principles, we’re also criminalising the escalation process.

Of course this is only the case if the police were to be called and then actually do attend – there is uncertainty as to whether they could, whether they should or whether they would, depending on which police officer or police force you speak to. In the debate about the extent to which the police have a role in inpatient mental health units, my previous post, Weapons, Barricades and Hostages sums up what I think and we know that some forces have reinforced the limits they see for themselves. So there’s uncertainty about issues connected to safety – not a great place to be.

NEW GUIDANCE ON NHS RESTRAINT

RiverHouseWhy am I bothered about this? Well, the Government published new guidance last month on restraint – Positive and Proactive Care. I’ll be amongst the first to endorse and celebrate much of what is said in the prefaces to these documents about the need to see change in operating cultures within mental health services. I have often found myself called to a mental health ward to use force on behalf of nurses who have assessed that force is necessary and that the nature of the threat renders it appropriate for the police to be the agents of coercion. In the majority of situations, things get resolved without resort to the use of force and when I’ve observed this phenomenon previously, the usually reply is something about police uniforms engendering something that mental health nurses cannot manage. I accept that point but I honestly do not think this fully explains why officers sometimes decline to use physical force on patients – it sometimes simply isn’t necessary.

So I have a few questions: if the NHS are now, in effect, banned from using restraint techniques in the above circumstances, have they been taught how to implement other tactical options that either do not involve restraint at all or which involve acceptable tactics? It’s all very well removing options from the list, but what replaces them? Surely the culture change spoken about is not just about listing all the things that staff must not or cannot do – surely, it is part of a positive approach that enables them to do so.

The status of this guidance is listed on page thirteen and it is “relevant for the police.” Notwithstanding that, relevance doesn’t explain the extent to which the police – called to such incidents without notice on the majority of occasions – are expected to set aside their established training and guidelines. What happens if officers who’ve tried are then investigated after an untoward event? You can almost anticipate the reaction of some! And if the effect of restricting tactical options is that the NHS more frequently assess a threat as being something beyond their ability to cope and they call the police to use the very tactics that they, themselves are banned from using, does it not actually make the situation worse? All we will have done is ensure that when restrictive interventions are perceived to be necessary, we call upon other people to act who are not subject to the same rules, restrictions and regulations and who are perfectly at liberty to do all of those things and more, according to their own training guidelines.

I see this document as a cultural signal of intent rather than a tactical template: but it is precisely for this reason that I worry. Not for the first time, we’re talking in vague terms about precise situations in which decisions have to be made. So it’s all very well further stripping away the ability and thereby the willingness of mental health staff to lead recovery oriented interventions, but unless they are equipped (and staffed) to have other options, it will suffer – like other initiatives – from the law of unintended consequences. I am already getting emails from health staff telling me that this guidance from the Minister of State will mean that the police are called more frequently to be the agent of coercion in our mental health system. This is precisely what our Home Secretary is hoping to avoid!

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BadgeThe Mental Health Cop blog
– won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs
– was highlighted by the Independent Commission on Policing & Mental Health
– was highlighted in the UK Parliamentary debate on Policing & Mental Health

 

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6 thoughts on “Restricted Restraint”

  1. I have worked in an inpatient unit, psychiatric emergency room, and also a restraint free day program for mentally ill adolescents. It was enlightening to hear from the law enforcement perspective. It should never be about coercion, the decision to restrain should be about safety. I had a client in a teachers words “hold her classroom hostage” by sitting the doorway refusing to do work. The client was safe and so was everyone else. Rules are rules but safety is safety, let’s work together to use all the verbal tools but as soon as someone is unsafe then restraint needs to happen. I am a fan of the steps taken in Therapeutic Crisis Intervention (tci) or something like it to exhaust verbal intervention.

    1. That’s interesting to read, really very much so. The police approach would not be predicated purely on safety – we frequently arrest people in circumstances where they are essentially safe and so are the victims of the crimes that have been alleged, but the offender, despite their safety is not willing to engage in the investigative process.

      I don’t deny and have written elsewhere, that staff in all agencies need to do and know far more about de-escalation and models of giving effect to it. If I’m frank, that wasn’t the point of the post and I stated that somewhere near the top. The post was about what MH staff and then the police may do or think at the point where they have legitimately tried and failed to do everything non-physical that they can.

      But imagine in your scenario – let’s say that incident began at 1:00pm: how long do you try talking it out before you start thinking about the need of the other kids to use the toilet, drink something or go home? … immediate safety may not be compromised but surely other kinds of safety problems start to emerge the longer things go on?

      1. Got it…I guess my point is that mental health, teachers, police, MD’s etc..differ in their definition of “exhausting all options”. There was a lot push back when police would respond to assaults. There WAS an attitude from police and prosecutors like “you work HERE (inpatient facility), didn’t you sign up for this?” Our leadership, local police, and legal stakeholders got together to ask your question in the original post. They debriefed some of the incidents and things seemed to improve greatly with the partnership between inpatient psych and law enforcement. This is what helped us get “unstuck” from this issue. Point well taken about the question in your reply. Something has to give and discourse like this is really helpful.

  2. Having worked as a management of violence and aggression trainer for some 16 years within a very large trust with every sub specialty of mental healthcare from community day centers to medium secure care i find this document many things but one is insulting. For many many years the main ethos of our training has been that flexion of the wrists and prone restraint are the absolute last resort and only if there is a clear risk of imminent danger. The tone of this document is one that, from the first paragraph tries to link physical intervention training with the barbaric acts of torture seen at Winterbourne View. Don’t get me wrong there are lots of things within the document i applaud the call for better care interventions,a greater emphasis on De-escalation and Crisis Communication is something we have been trying to implement for some time but to identify triggers and recognise signs escalating behaviors staff need to be on the wards interacting with service users this means that an increase in staffing or a reduction in computer work is needed. Behavioral Support Care Planning,Trauma Informed Care and the Safewards model will go along way in reducing the need for Restraint and Seclusion but only if there are the staff available to implement them. But to outlaw the teaching of high end interventions not only puts service users and staff at risk but as you mention will mean that officers are called upon more regularly to deal with service users that low level physical interventions will not be sufficient to manage risk. I feel this will be more detrimental to the therapeutic relationship then mental health staff using Justifiable, Appropriate, Reasonable and Proportionate physical interventions due to the perceived criminalization of disturbed behavior of an individual suffering from an already traumatic serious mental illness. I also worry that it will cause friction between mental health staff and police staff both of whom are working at times under tremendous stress with limited resources

    1. totally agree Andrew- what is also extremely alarming is the total lack of an evidence base for many of the recommendations- as you mention there is substantial research to support both the Safe Wards and Trauma Informed care models but instead Positive and Safe almost exclusively focuses on PBS which has little/ no evidence of efficacy in MH services.
      everyone would want to eliminate all restraint but that remains an aspiration rather than an achievable outcome- for the foreseable future. MH nurses have a duty of care and are required to prevent self harm, prevent physical aggression and administer medication- at times without consent for those covered under the Act.

      ignoring the research that showed that the hyper flexed position is actually worse for respiration than prone is difficult to understand- all restraint carries risks to both staff and patients- by ignoring that fact and entirely focussing on the risks of prone seems dangerous and ill informed. The suggestion by the DH that the prone position is so dangerous that the individual must be released or immediately moved to a safer position combined with a statement that pain compliance can be used in an immediately life threatening situation may have an unintended outcome. Previously staff would have assessed the physical condition of the individual held prone whilst communicating / negotiating / seeking concordance but now- DH guidance seems to suggest That staff should be thinking about inflicting pain immediately- horrific!!

      The whole consultation process and policy development has been hijacked for political purposes- patients and staff deserve better than this.

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