As Mind publishes survey data and calls for a ban on face-down restraint, The Stuff of Social Care looks at the issue from the point of view of those doing the restraining
It’s been a long time since I last took part in physical restraint, but for many years I did work in environments where the need to prevent harm was part and parcel of a nurse’s working day.
For the most part we relied on the first resort. Talking, listening, reasoning, observing. Using a rapport that may have been built up over a period of time, and developing skills that were fundamental to working with highly distressed, agitated people. For most of my nursing career I was lucky enough to work in well-staffed forensic units where staff and patients knew each other well, and where the very thought of an agency or locum nurse was unimaginable.
But at times the last resort was unavoidable. Most of the trained, professional staff I worked with would much rather not use physical restraint. Like me, they would loathe the idea of holding down another human being to inject them with powerful drugs. But when all else has failed, or extreme harm was imminent, or where leaving a severely psychotic man or woman unmedicated would almost certainly leave them more terrified, confused and at risk than they already were, then I for one would not lose any sleep restraining that individual.
By the time I had qualified as a nurse, physical restraint had gone from the often chaotic bundle of arms legs and torsos of my student days toward a set of techniques called Control and Restraint (C&R), a Home Office approved means of managing physical aggression. I along with my colleagues attended regular training in C&R. We turned up at sports halls in trackies and trainers spending hours and days learning and practising the management of physical aggression.
A major (and rather unpopular) part of the training involved role-playing ‘the patient’ and being subjected to the procedures oneself. C&R was based on a 3-person team immobilising the patient. It used a certain amount of discomfort and even short bursts of pain to contain violent people, a fact which we as the role player would be only too well aware. Some of the techniques we learnt involved immobilising the patient face-down on a floor or bed. The reasons for this were that a) the person on their back can fight back much more effectively than if they are face down, and b) saliva and teeth make very potent weapons when they belong to a person who really, really doesn’t like being held down on a floor by several nurses. A key part of the 3-person team was the ‘head’ man or woman, whose job was to ensure minimum discomfort for the person on the floor and protect their airway.
But apart from the actual physical techniques, a fundamental of the training was that physical restraint was absolutely a last resort once every other strategy had failed, or where danger was imminent.
There are those who believe that physical restraint of the mentally ill is little more than state-sponsored thuggery, or who wonder whether restraint is necessary at all. Well, physical restraint is a necessary part of mental health care at times. That’s an undeniable fact, but it’s easy to see why and how restraint gets such a bad press, and why bodies such as Mind need to spend time, money and effort surveying it’s use.
We need go little further than Winterbourne View to acknowledge the presence of thugs masquerading as care professionals. From the very first emergence of the lunatic asylum, the opportunity to get paid for wielding power, authority and physical dominance over others has always proved attractive to a certain type of psychopath.
But there are much deeper and wide-ranging reasons why physical restraint may be over-used or abused. Mental health care certainly needs a sensible, contextualised and much broader discussion about physical restraint per se, and the reasons behind it’s use and misuse. The ‘face down’ issue is perhaps something of a narrow lens, and when 22% of staff report not having had face-to-face training in the last 12 months, we need to ask why that is.
I have a few observations. Questions about restraint are far from being a solely modern phenomenon, but for those whose 7.5 hour shift seems incomplete without a dose of adrenalin-pumping action and a ‘good decking’, current conditions have never been better.
Beds are disappearing. Only the very sickest of the sick have access to hospital treatment. The most distressed and disturbed are funnelled into smaller and smaller pockets of in-patient chaos, often provided by companies with shareholders and profit margins to maintain and gladly filling the gaps left by the running down of NHS in-patient psychiatry.
I would hope that such critical care would be delivered by the sort of skilled, well trained staff I described earlier. This all too often isn’t the case. Many of our most severely ill patients are being cared for by agency and locum staff with bare minimum training, a lack of experience and often poor communication skills. Many will barely know the names of the people in their temporary care.
This is where the ‘jump on, grab a limb and for f*** sake make sure they’re still breathing’ model of managing potential and actual aggression is practised today much as it was in the dungeons of Bedlam.
Right at this moment, someone, somewhere is in a psychiatric unit posing potential or actual danger to themselves or others. People with mental disorders can and do become violent, and staff are needed to contain the violence and minimise that risk. Hopefully they are with staff who can reassure, listen and diffuse aggression with empathy and skill. They are trained to use restraint safely and appropriately, and to be able to make decisions as to when and how it is used.
Mind’s survey results suggest this is all too often not the case.