Restraint

There is, in my professional experience, a very distinct difference between restraining burglars or street robbers who have been arrested for offences and restraining patients who have been detained or re-detained under the Mental Health Act.  The concepts of resistance or aggression may be similar; the instinct of a police officer to contain the risks that arise from resistance or aggression may be similar, but I’m beyond doubt that arresting criminals and detaining patients are qualitatively very different.

It is the very fact that the two enterprises are NOT the same thing, that renders a similar approach to each to be far too crude.  It is also a false disctinction to differentiate based on the legal framework officers are applying: arrest for crime / detain MHA.  The approach should be governed by what we know about the person being restrained: arresting a criminal suspect for an offence where we know of serious mental health problems is something to which the caution in this post should apply.

This is a very difficult subject and I’ve waited ages before addressing it, although I’ve alluded to the use of force and medical emergencies from the restraint of patients in mental health crisis before.  We know there have been deaths in custody which have become political issues and which have brought about protest; and we know that there have been adverse outcomes from inquests and inquiries suggesting that policing, although complex and demanding, has not reached the necessary standard.  And there are ongoing investigations.

But it’s not too difficult to conceive a different approach, albeit one that sits just outside the unilateral control of the police – and it rests not only upon policing, but upon those with clinical skills and better training around health and mental health.  But we’re going to have to challenge some inherited thinking in policing and health to do it.

I’m about to make a massive generalisation for the purposes of drawing a distinction: your focus should be on the distinction, not the generalisation – it has been my operational experience that where the police are detaining resistant criminals after arresting them for offences, they’ll either resist until they know that they are properly caught and detained, and then they will desist into abusing you; OR, where offenders are drunk, may continue to physically resist, but are able to be quickly removed to a cell where they concentrate on banging the cell door to annoy everybody.

I realise that this is an extreme generalisation – but I pose it deliberately to contrast it with my experience of detaining and restraining resistant mental health patients:  patients are often so fearful of being restrained that they either start fighting in fear of their lives AND / OR they may have underlying health conditions or drug / alcohol complexities which mean a high-impact restraint renders it a difficult and dangerous situation – and sometimes, this protracts for a significant period of time, because the underlying fear of being detained or the background health risks do not suddenly go away.  Qualitatively, it is a very, very different kind of thing to arresting burglars and domestic violence offenders.

RESTRAINT AS A MEDICAL EMERGENCY

I’ve written loads on this blog that is intended to help police officers navigate difficult operational waters, but if they remember NOTHING else, I’d want them to remember this: >> the need for *ongoing*, especially-prolonged restraint of a psychiatric patient is a medical emergency – end of.

And this is NOT just my opinion: it has a basis in both medicine and law.

I’ve stressed, “ongoing”:  when some restraint or coercion interventions start, patients often do decide to then comply with what is happening and the intervention can be scaled back or stopped entirely.  It is when resistance begins and doesn’t stop that we need to start thinking clinically.

There are a few reasons for this.

  • If patients are under the influence of drugs or alcohol as well as suffering a mental disorder, restraint can compound what is occurring to the patient physiologically – this is where people start talking about things like Excited Delirium and Acutely Disturbed Behaviour, controversial though those concepts are for some;
  • There can be certain physiological side-effects to patients suddenly ceasing to take psychiatric medication like anti-psychotics – some patients are more affected than others and again, impact where it occurs can vary depending on (illegal) drugs / alcohol consumed; and restraint can exacerbate this;
  • Mental health patients, on average, have much poorer physical health than the population as a whole – as a rough rule of thumb, add 10 years to a patient’s actual age and then start to comprehend how restraint would impact;
  • Think of the intervention you are applying from the patient’s point of view: which may include, for example, paranoid delusions about who the police or what the police are trying to do – if you genuinely feared that restraint was something qualitatively different to what you were being told, however delusional that belief were, would you not resist in fear?

NOT JUST MY OPINION

During the Independent Inquiry into the Death of Rocky BENNETT, various expert medical witnesses and experts in restraint, talked of the ongoing need for restraint as a medical emergency.  It talked about doing so, only in a context where there were doctors and nurses trained in the use of defibrillators, appropriate medication and who are knowledge about of things like the NICE Guidelines on Acutely Disturbed Behaviour (2004).

We’ve seen during some critical incidents, that police officers were too slow to get people out of a prone position; too quick to use a police vehicle for the conveyance of that person, including over long-distances; unprepared to call paramedics for a range of reasons that may partly be attributed to (false?) presumptions that they wouldn’t attend anyway; and far too quick to fall victim of the inherited thinking that has prevailed for years that anyone who is violent should always be taken to the cells.  This is where we get it wrong:

Resistance, aggression and violence can be attributable to any number of things: head or brain injuries, some of which won’t necessarily be visible; diabetes; epilepsy, strokes.  Or it can be a natural reaction to paranoid delusions or auditory hallucinations – we need to know more before we start thinking “more force, police vehicles and cell blocks.”  The stakes are too high.

THE ROLE OF THE AMBULANCE SERVICE

We have seen criticism arising from police officers who are engaged in restraint of seriously resistant patients not calling paramedics to the scene.  Although paramedics are not licensed to carry the kinds of medications which the above-mentioned NICE Guidelines talk about, like benzodiazepines, they are in a position to administer some medications that may help and have other kit to monitor a patients condition.  They are also positioned to oversee clinical wellbeing and of course to react to any untoward developments that occur whilst in transit.  We’ve known patients suffer heart attacks and slip into diabetic comas in police vehicles after detention by the police under the MHA – previous conditions that no-one knew about where a paramedic with a bag of kit would have been quite handy to provide a swift-reaction.

It is these cases I think about when I hear that some ambulance trusts are pejoratively asking the police, “Why on earth do you need an ‘intensive-care-unit-on-wheels’ for someone who is ‘just’ mentally ill?!”  << This is a question I was actually asked several years ago by a senior paramedic.  And there are two answers to it –

  • Firstly – because I haven’t got a Scoobie-Doo whether the person I think is mentally ill is mentally ill or not because I’m a police officer; the first rule of good mental health assessment is to rule-out physical causation before concluding mental disorder and cops are not going to do basic obs like heart-rate, blood pressure, blood sugars, etc..
  • Secondly – because the Code of Practice and the Royal College standards say this is the way it gets done – they amount to agreed statutory and professional standards signed up to nationally by everyone who is important.  There is something here about patient dignity and reducing stigma in how we do what we do.

We should remember this – the Code of Practice to the Mental Health Act requires conveyance to be done by ambulance (as the only practical alternative to police transport which is criminalising) and where this is not possible, it is suggested good practice that a paramedic travels in the police vehicle with the patient.  Only recently, there was a scenario on my team where a first-responder paramedic indicated quick removal was needed and as the situation occured near to a major A&E, he got into the police car with police officers and the patient; whilst another officer drove his ambulance service car to the hospital for him so he wasn’t stranded afterwards.

It is also relevant to point out, that within the Safer Detention guidelines for the police, which pertain to detention in police custody, it talks about officers having awareness of conditions like Excited Delirium and the necessary responses = Accident & Emergency.

SAFE RESTRAINT

So, we can all name the cases where we have heard or even seen CCTV, of high-impact restraint by several police officers.  There is a sound basis for thinking clinically where this is believed to be attributable to a mental disorder, especially where drugs / alcohol are involved and call an ambulance.  In the West Midlands, where I can’t praise West Midlands Ambulance Service enough for their approach to this stuff, we have an agreed set of criteria, known as RED FLAGS, which then trigger consideration of removal to Accident & Emergency.  The need for ongoing restraint, amidst concerns about excited delirium, are RED FLAGS under this process which then allow the NHS in quick time to consider whether application of NICE Guidelines should apply, or whether another pathway into care is necessary.

As the risks of not getting this right are grave and have previously involved criminal investigation and indeed, prosecution of police officers and potentially in the future of health staff, it is important we don’t get caught in the over-functionalised thinking that has previously believed we can sort this out at the road-side or at a police station.  The stakes are too high, the underlying causation invisible and we are playing Russian roulette with people if we get outside our skill sets and gamble the odds.  In risk assessment, high-impact but low probability events – let’s be honest, most high-impact restraint does not lead to death, prosecution or untoward events – should be treated seriously and mitigated against in just the same way that fear of stroke or fears of heart-attack would be.

Any other approach is discrimination against some extremely vulnerable, however challenging, people at a very risky time.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


 

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9 thoughts on “Restraint

    1. Most grateful for this – accidentally renders the timing of the post very handy, although I hadn’t seen this report yesterday. Now hyperlink within the text and I’m grateful to you. 🙂

  1. I am surprised at your photograph of restraint especially having been on the training course to become a Police Officer myself. If someone is resisting arrest and in such a stated as “excited delirium” your photograph displays someone being held face down and this is completely wrong.

    My daughter is on a huge amount of drugs and has suffered heart abnormalities she has told me herself – palpitations and a “strain to her heart”. Someone can also calm down if approached appropriately and left to calm down and I believe that sometimes a former patient can do this better than yourselves or any nursing professional as they would have complete understanding. This is where peer support and the use of former patients to intervene would be a good thing and there are many former patients who would like to help others. I have seen this on the wards – patient comforting patient and calming a situation down whilst nurses sit in their office. It must be terrifying for any patient as I have heard to be faced with the prospect of arrest by loads of officers to be taking to the shocking wards and kept there for weeks on end especially since I have seen what goes on in such places.

    I can see that the police have to weigh up the situation but you are covering yourselves in terms of the outcome. NICE guidelines to which you refer are not protecting patients and that is evident at hospitals such as the Maudsley. You have only got to look at their research papers and what is allowed to go on there – it is a shame the police do not intervene in this cruel abuse to the patients or get involved in some kind of scheme within the hospital as they do with schools and go into the hospital, get to know the patients rather than just arrest them and then they can find out what abuse could be happening on the wards themselves. Many of the patients I am in touch with do not have much good to say for the police yet much responsibility is being given to the police that the professionals do not want to involve themselves with such as the Crisis team who will stay away when there is a crisis and expect the police to bring someone in to hospital.

    I know that someone acting up in this way can and will calm down if the right approach is given – they may calm down instantly if approached by someone they know who is a close friend or someone not a professional dressed in a uniform ready to arrest and throw them into a shocking place that you describe as “safe”. Forceful arrest can lead to death especially if someone is restrained as per your photograph. Your training course is excellent so I thought however you should not restrain someone in this way at all who has mental health problems. I believe that only if such an event happens in a crowded area with risk to the public should a forceful arrest be made and that is if the person is threatening another member of the public. That person will calm down eventually and I believe that patience is something that should be given bearing in mind the horrifying way that mental health patients are treated as a whole. Try involving other patients – former patients as peer support – this is what is needed.

    Also, It is not just a case of someone not taking their “drugs” prescribed by so called professionals but a patient can suffer delusions/psychosis on the drugs and my daughter has described the most terrifying experiences of her nightmares and feeling like she was “crawling out of her skin” – this is caused by the drugs they prescribe – a condition called Akathisia. The answer is to provide more and more drugs and ignore the patient when they complain of serious side effects. This is care? I think it is disgusting what is going on.

    If only that person was approached by willing volunteers of former patients firstly before the option of prolonged restraint.

    You are right in your paragraph there may be health problems that are not visible – this is only too true hence the reason why forced approach should not be used as a whole – I know that even being approached by many police officers can be frightening and intimidating for anyone suffering the terrible condition of Akathisia.

    1. Nothing in police training prevents people being held face down, but training does ram home that you don’t keep someone there for any more than the minimum possible time and you get them either stood up or sat up ASAP. Training is backed up with educating officers about positional asphyxia and excited delirium.

    1. Seems like this was another incident that police should never have been involved with in the first place.

  2. Shame the actual staff working in Mental Health dont see the distinction between the two very different types of restraint nor most Police officers called in to investigate allegations of assaut made by families of Mental Health workers using such force on patients being detained. I had to make the clear distinction after this happened to my mother whilst wrongly detained under the MHA for trying to commit suicide because she had had enough of her agonising physical condition which caused her incredible pain. After ‘volunteering’ to attend the unit and then being sectioned when she wanted to come home, as her protest she went for a walkabout in the grounds of the unit and sat behind a wall. When she heard everyone rushing around to find her she managed to get up and started walking towards 3 nurses waving her arms saying ‘Here I am’. Not entirley sure why then one of the nurses pushed her to the ground, bruising all her legs, and then decided to pull her up ‘wedgy’ style causing her great pain. She reported it to the Police, who arrived some 3-4 days later and never spoke to her. Instead making an agreement with the Manager on the ward that they should deal with it ‘internally’. I then had to make the distinction for the Inspector as to why it should be investigated, pointing out the differences between reasonable force used on an individual who is behaving violently and is a potential threat and that of my mother who was 70 at the time, 5ft 2 and so frail her bones looked like they might snap in two. Of course it was ‘investigated’ but dropped a few days later, as it was my mothers word against these 3 nurses.

    1. They weren’t removed – they were held before publication because they are your first ever comments on my blog, which is my standard set up. Now I’ve approved your first comments, subsequent ones will appear immediately. Feel free to say what you like.

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