Mechanical restraint: Legal, ethical and clinical issues

Abstract

The use of mechanical restraint as a means to manage the violent and/or selfinjurious behaviour of psychiatric patients remains controversial, due primarily to this practice restricting freedom, and often being implemented against the patients will (Georgieva et al. BMC Psychiatry 12:54, 2012). The thought of mechanical restraint conjures up cruel and often barbaric interventions, confined to historical ideas about how to treat and manage the mentally ill. With modern advances in psychiatry, particularly in relation to an increased understanding of mental illness, and more effective psychotropic medication, there was hope that interventions of this nature were no longer required. Policies on the use of mechanical restraint vary significantly from country to country and depend greatly, although not consistently, on the prevailing culture and legal framework (Steinert and Lepping. European Psychiatry 24:135-141, 2009). Within the United Kingdom (UK), mechanical restraint is relatively uncommon, compared to other countries (Stewart et al. Mechanical restraint of adult psychiatric inpatients: A literature review. Report from the Conflict and Containment Reduction Research Programme. City University, London, 2009), and it attracts the highest levels of disapproval of all the containment methods by UK student psychiatric nurses (Bowers et al. Nurse Education Today 24:435-442, 2004; Whittington et al. Psychiatric Services 60:792-798, 2009). However, there remains a small group of patients, whose severe mental disorder, combined with "grave and immediate" violence and life-threatening self-injury, has deemed it necessary to consider restrictive interventions of this nature. Within the UK, these patients will most likely reside in "Special Hospitals", which offer high secure hospital accommodation for mentally disordered offenders. Thus, the clinical teams who attempt to treat patients who present with these challenges face an ethical conflict between patients’ autonomy and physical and mental integrity on the one hand and the requirement to prevent harm on the other (Bergk et al. Psychiatric Services 62:1310-1317, 2011). Within this chapter, we consider the legal, ethical and practical considerations to exploring the implementation of mechanical restraint in a secure psychiatric setting.