Right, 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 incapacitant 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
Why 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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