Wednesday, June 19, 2013

Ban face down restraint in psychiatric hospitals

To his credit, Norman Lamb (who I have mentioned on my personal blog eg. see previous post), Minister of State at the Department of Health, says he is considering just banning face down restraint in psychiatric hospitals (see BBC news story). This is following a call from Mind demanding national standards on the use of physical restraint, accredited training and an end to face down restraint on the basis of data they have secured from NHS trusts under FOI requests (see news item).

It was a pity that the take up from the Blofeld report on the death of Rocky Bennett some years ago focused on institutional racism rather than also on restraint. As I said in my BMJ eletter, "Death of a patient under restraint should help us to refocus on the need for a therapeutic approach rather than just custodial practice in mental health services." Organisational interventions can dramatically reduce the use of seclusion and restraint, reflected in the wide variation found by Mind in their survey. Hence government intervention in the way considered by Lamb could have significant effects.

As I said in another eletter about this issue, we need to highlight "... the importance of the culture of mental health services in limiting the use of such restrictive procedures". The focus on defensive practice over recent years has not been helpful. Restraint may be better seen as an indication of treatment failure, rather than treatment as such.


Anonymous said...

But how else would the vicious human rights abusing brain rapists in mental health inject people's butt cheeks without slamming them face down to the floor?

Are you calling for a ban on forced drugging Dr. Double?

Anonymous said...

I think one has to be careful at indicating towards whether it is a failure of therapeutic treatment, as this in turn could falsely lead to a greater probability of blame culture laid at the hands of front-line or other involved care staff.

I think there needs to serious questions asked to whether there are limitations within psychiatry that are leading towards a greater propensity of soviet style approaches to care. Where both political correctness and social deviancy regarding mental disorder or illness are perhaps worryingly altered to fit auspices of care. Another words are there certain individuals in care that can be held to account for situations of restraint occurring?

From another interpretation are we increasingly living in the era of the pseudo patient whose likely issues are more likely to be behavioral than illness, which in turn leads to situations of restraint, where in fact there is no therapeutic relationship to break! As older patients die of off are we in fact replacing them with pseudo patients in order to keep psychiatrists in business and so store up a whole batch of Pandora box type issues for those carers who are trying to do a good job? I suspect this could be the case as issues such as restraint are increasingly questioned without understanding the increase in worker assaults within the National Health Services and Private Enterprises.

It is a concern to whether blanket skewed polarized approaches to mental disorder and illness are being utilized by psychiatrists to render persons in care incapable of actions associated with restraint and injury occurring.

I don't think anyone with sense would want to advocate the use of certain restraint techniques or unnecessary restraint. But one has to look at statistics to particular techniques as referred to or being investigated by Norman Lamb, and of course ignoring the bigger questions to anticedents and the nature of individuals in care involved in restraint.

Government research and statistics are renowned for being the least trust worthy of statistics to rely upon. For example if there are many trusts using the technique and only two are not, is it possible to turn round the question and ask how and where are these trusts not protecting their workers? In fact what about the patient profile and services on offer that may differ from the rest of the trusts? In fact lets be honest it probably goes deeper than that. And of course who is Norman relying on for his statistics?

There seems to be an unwritten laws of heresy in psychiatry and that in part is to whether psychiatrists can be too caring to the point of neglect to other spheres of debate and society regarding the actions of individuals and injury caused to others, other than the individuals and pressure groups complaining about this type of restraint being used.

Instinctual action to protect oneself, the patient and others may take president over innate training to use of variable restrain techniques. Most care workers are not professional experts in forms of restraint or specific management of physical violence or harm. And a lot of such training can only occur once a year. Whilst mechanics of the body may involve science the application of restraint in emergency situations is not. Even the best or worse written risk, needs assessments, management and care plans or bayesian probability can’t predict actual behaviours or actions of patients, due in part to the fact and existence of freewill. Services need to get out of the idea that staff can be blamed for the actions of patients in such circumstances where danger is a real potential result. It also seems absurd that staff can be blamed for being assaulted or protecting the patient or others when to not do so would be the greater neglect. In fact I would go so far and say it is sometimes the fault of the psychiatrist whose gate keeping by avoidance of confrontation that allows some malevolent service-users to gain entrance to the services and thus cause carers unfair issues in regard to restraint.

Anonymous said...


I think there is also a lot of potential injustice against carers who utilise restraint or management of physical aggression where they are certainly in fear of their or others lives. Are care organisations increasingly chastising carers, despite common law views on what self-defence and defence of others is?

Putting rules or bans on the nature of self-defence is both unwise and creating potential issues where carer’s lives are put at risk. If I were in a situation that was life and death, and decided to act instinctively and quickly which resulted in momentary face down restraint, I don’t think I could and should be seriously held to account. And any service that tried to do so should and must be held in the up most contempt, both legally, professionally and morally.

Common law doesn’t specify use of techniques and nor can it, for if it does we risk the tyranny of rulers in the guise of the polarised dictatorial state and psychiatrist action. Even where there exists well-meaning caring psychiatrists sometimes they still need a reality check to the fact they are not gods in situations, which involve incalculable probability rather than exacting executable science. And I’m afraid to say psychiatry is no science.

Anonymous said...

So what do you do with people who are violent to themselves or others, or even property? And if people do need to be restrained, do they sit down nicely or lie on their backs for you? Restraints are always messy affairs to a greater or lesser extent.

I do not believe it is possible to ban prone restraints, though of course one should move from that position as soon as possible. Anyone who says it is has not thought about it and has never been involved in restrains situations. It is certainly true that, in restraint, holds should use the minimum force necessary and the patient should be released from the hold as soon as is safe to do so.

I didn't come into nursing to restrain people or inject them against their will. I've only been nursing for 5 years and am 55 and 10 stone so it would hardly be a rational choice. I want to care and support patients and I believe that goes for all my colleagues in the adolescent unit where I work.

Of course we have to be aware of the possibility that a culture of abuse can grow in environments where many patients have difficulty speaking up for themselves, or have little access to people outside that will listen to them. This is a big danger as patients are being sent to hospitals further and further from their homes. But maybe Norman Lamb needs to spend a couple of weeks in an acute inpatient mental health ward.

Duncan said...

The issue surrounding the removal of face down restraint is what do we replace it with. After nearly 18yrs of teaching in this field. The problem is not the current position but the skill of the practitioners involved in the process. What you are discussing is a very small part of a care workers roll. If we where restraining on a frequent basis then we would run out of staff by the end of the week. I suspect that if restraint is being used frequently and individuals are being harmed. Then there is more pressing issues that need to be address in your service . Than restraint position.