By Rebecca Fish
In 2005 I published some research with my colleague, Eloise Culshaw, about physical intervention (commonly referred to as restraint) on locked wards for people with learning disabilities, looking at experiences of staff and service users. We found that sometimes, restraint is not used as a last resort:
Service-user: All I have to say is that sometimes it’s necessary and sometimes it isn’t. It’s stupid things for someone to be restrained about. I mean if you were going to attack someone well that’s alright, but just restraining you for the hell of it…. (Fish & Culshaw, 2005)
Restraint is used by staff to restrict someone’s freedom of movement when there is the threat of injury to others or damage to property. The Mental Health Act code of practice (Department of Health, 2007, 2015) advises that before the use of restrictive interventions, staff should be communicating with service-users:
- Where possible, the patient should be asked to stop the behaviour.
- An explanation should be given of the consequences of refusing the request from staff to stop the behaviour.
- The explanation should be provided calmly and every attempt should be made to avoid the explanation being perceived by the patient as a threat.
In this way, UK policy makes it clear that restraint should be reactive rather than proactive, and used as a last resort. Despite this guidance, Department of Health reports show that in some services, rates of physical restraint are too high and the types of physical restraint used are unnecessarily harmful.
Why is restraint used in practice?
My 2012 research with women on locked wards found that many things hadn’t changed since 2005, and people were being restrained for reasons other than the containment of aggression:
Julie: A while ago I was banging my head on the floor, they just grabbed hold of me and put me to the floor.
Julie’s comment suggests that there was no request to stop the behaviour and no explanation of the consequences before she was restrained. What’s more, another service-user Annie told me it was impossible to predict whether you will be restrained for doing something, as it depended which staff are working:
Annie: You can never know who’s going to restrain you, because sometimes some people will restrain you and some people won’t for certain things.
This shows that whether a person is restrained relies on individual staff’s interpretation of the situation. To some extent, I would say this is reasonable, as staff need to protect people from harm. However, when services rely heavily on temporary and bank staff – who do not know people well enough – it can result in overuse of restraint and a controlling or punitive environment. As I have said before, working successfully with people takes extensive engagement with them, and involvement of their families. This sort of engagement cannot happen when budgets are cut to the bone and staffing is minimal and transient.
The staff in my research told me that they found restraining people unpleasant and upsetting, like Dawn, who told me ‘we will do generally anything to not restrain because nobody wants to be holding someone like that – it’s the most uncomfortable thing in the world.’ Yet restraint continues to be the method of choice as a day-to-day behaviour management technique.
Restraint as retraumatisation
The most concerning thing from the 2005 research, was that being restrained made some of the women relive bad experiences and abuse from their pasts. This also featured in my 2012 research, for example:
Ellie: I get worse when I’m lied on the floor because people with glasses – I mean men – I can’t look at them
Ellie: Because, I’ll tell you. When I was in a care home in (place) a guy which was staff did something what weren’t nice
The potential for retraumatisation is particularly significant when male staff are restraining women.
What can be done about this?
Annie said that when her guidelines changed and she was no longer restrained by men, this significantly reduced the escalation of aggression and therefore the amount of incidents:
Annie: They’ve got it down to where I could only be restrained by females and that helped because I started getting restrained less, and when I did get restrained I wasn’t fighting as much, and I wasn’t having injections as much, I wasn’t going in seclusion as much.
Annie told me that being restrained by men made her remember her extremely distressing past experiences of sexual violence. The knowledge that she would only be restrained by women resulted in fewer incidents of anger escalation to the point where restraint was used. This shows the importance of knowing the person and their responses as well as taking into account the context where incidents arise.
Silencing of anger
Some of the women gave suggestions about how things could be better. Brenda said that staff should allow people to discuss what is making them angry before it gets to a situation where restraint is needed:
Brenda: Talking. Talking to us more – seeing why we’re angry, letting us try to explain who we’re angry with. Yeah, let us try to explain.
Services should acknowledge that anger and distress is a legitimate response to being detained in a unit for long periods with no release date. Most of the women I spoke to said that restraint made them more angry. If expression of anger is allowed – and worked through – escalation to aggression can perhaps be avoided. Bonnie said that she calmed down when staff talked to her during the restraint, as lack of engagement made her more angry:
Bonnie: Yes, not giving me no contact makes me worse. If they’re holding me but not talking to me, I’m trying to talk to them and they don’t talk to you back, that really does my head in and I go worse.
A member of staff confirmed this; she told me about a person she had worked with, and showed how good relationships on the wards can reduce or even eliminate the need for restraint:
Iona: My attitude towards her was very upbeat and very OK. I was never negative towards her, if she couldn’t do something I didn’t say it in a negative way. . . And the relationship was very different because I’d never had aggression [from her].
This comment shows that when relationships are good, restraint can be avoided. This is key to my argument.
But it should not just be down to individuals to create good relationships, services should foster and support them, provide time for their maintenance, ensure good relationships are part of the working culture. We need to change systems of hierarchy so that we are working together with people towards common goals.
Institutions do not reflect society at large, and this is most evident where physical force is sanctioned by institutional culture and policy. Physical restraint is the embodiment of power imbalance between staff and service-users and can result in further anger and distress. I am not arguing that tools such as physical restraint shouldn’t be available for when situations get out of hand. However I am suggesting that more could be done to promote the healing relationship before it gets to this point.
By Rebecca Fish
Link to article by Rebecca Fish and Chris Hatton called Gendered experiences of physical restraint on locked wards: click here
Accessible summary: click here
DEPARTMENT OF HEALTH 2002. Guidance for Restrictive Physical Interventions: How to provide safe services for people with learning disabilities and autistic spectrum disorder. In: DEPARTMENT OF HEALTH (ed.). London.
DEPARTMENT OF HEALTH 2007. Mental Health Act: Code of Practice. London: HMSO.
DEPARTMENT OF HEALTH 2014. Positive and Proactive Care: Reducing the need for restrictive interventions. In: DEPARTMENT OF HEALTH (ed.). London.