Manual Restraints in Psychiatric Settings: Empirical Realities – C. J. Ryan


Manual Restraints in Psychiatric Settings: Empirical Realities: A rare insight from patients’ and nurses’ perspectives

By Carl J. Ryan

Paperback: 460 pages
Publisher: VDM Verlag Dr. Muller Aktiengesellschaft & Co. KG (5 Jan 2010)
Language English
ISBN-10: 3639219198
ISBN-13: 978-3639219197

Dealing with weapons

The ability to verbally de-escalate conflict situations might simply appear natural to most people. However, when the conflict involves weapons, the risk of harm to limb or life is increased. Acquiring specific awareness, skills and competencies will make the difference between personal safety and potential harm.

Pain compliance in restraint applications

Pain stimulus can be a deliberate or indiscriminate action executed by restraint practitioners with the objective of forcing the person being restrained to comply with instructions. Pain compliance is grounded in the prison version of control and restraint. This procedure has also filtered into the police and some psychiatric settings. The patient is restrained with his wrist held in the flexed position generically called “the wrist lock”. The pain is applied by exerting uncontrolled manual force on the flexed wrist, of the person being restrained. The wrist lock technique is the ultimate technique in the prison’s arsenal of restraint procedures and is adapted from the martial arts forms of Aikido and Ju-Jitsu.

The practical approach towards utilising the painful wrist lock technique is not fully explored in classroom training programme, which usually leads to indiscriminate applications. However, in practice, the resistive patient being restrained should be first allowed several opportunities to comply with given instructions. On failing to comply, a decision will be taken by the restraint team leader to apply the pain stimulus in order to exert compliance. For example immediately after the patient refuses to comply on the last occasion, one of the practitioners holding the person’s flexed wrist will be instructed to “apply pressure” on that wrist. The patient is supposed to associate the pain with not complying and might eventually choose to comply rather than experience further pain. There might be several attempts before it was realised that the pain stimulus was regarded as either effective or indeed ineffective.

The pain applications hardly follow the conventional protocol of administration in difficult real life restraint situations because in order for the wrist to be flexed it has to be in a relaxed position. However, in the immediate restraint situation, the patient’s wrist is often rigid and tense perhaps due to anxiety or fear or anger. During the restraint struggle to achieve the flexed wrist, there can be indiscriminate painful applications by either or both of the persons holding the person’s wrists, often resulting in the patient complaining of being hurt unnecessarily.

The essence of restraint is to subdue the individual safely and painlessly as possible when absolutely necessary using a compassionate humane approach.

Definitions of restraint

There is confusion surrounding the definition of restraint. The Oxford Dictionary 1993 defines restraint as “the deprivation or restriction of liberty or freedom of action or movement”. Duff et al 1996 reported there is no precise legal definition of restraint. In broad terms, it means restricting someone’s liberty or preventing them from doing something they want to do.

Others suggested that physical restraint refers to actions or procedures, which are designed to limit or suppress movement or mobility (Harris 1996) or defined as “an episode where staff had as part of clinical management, been required to lay hands on the patient without his or her consent” (Smith and Humphreys 1997).

The purpose of restraint is also viewed as “taking control of a dangerous situation and to limit the patient’s freedom for no longer than is necessary to end or significantly reduce the threat to himself or those around” (Mental Health Act Code of Practice (HMSO 1993). Harris J 1996 interjected that “physical restraint procedures were used for managing challenging behaviour presented by mentally retarded adults and children”, while Willis and LaVigna 1985 stated that it was “an emergency management procedure often used as a last resort”; Mcdonnell et al 1993 argued that “the aim primarily was to manage the violent individual and not to treat them”.

According to Bonner et al 2002, “control and restraint involves the use of techniques which endeavour to contain violent or potentially violent situations in a safe manner”. Harris and Rice 1986 referred to restraint as “the self-initiated application of manual physical control to a patient”. The Royal College of Psychiatrist (RCP 1998) indicated that “physical restraint should be a last resort, only being used in an emergency where there appears to be a real possibility of significant harm if withheld”. Lefensky et al 1978 and Harvey and Schepers 1977, simply mentioned that “arm locks were used to restrain people”. Interestingly most of the restraint definitions mentioned in this study sample tended to associate restraint with the management of violent situations, when violence is not the sole antecedent trigger for restraint applications.

History of restraint development in the UK

Restraints are unique procedures undertaken for restricting a person’s movement for various reasons. In the context of psychiatric practice restraint is as old as psychiatry. Prior to the eighteenth century people who were considerer mentally disordered and difficult to manage were restricted by shackling.  The straight jacket or camisole was also used as a type of restraint.

There is little substantial written documentation regarding the historic development of restraint practice in the UK. However patchy information indicated that restraint was developed in the prisons in the 1980s and subsequently filtered unaltered into the police and psychiatric establishments.  The origin of conventional manual restraint techniques might have started at St Thomas Hospital in Canada, which developed a restraint programme in 1974 (Wilson and Croker 1976). The St Thomas restraint training programme reportedly included self-defence skills, the use of pressure points and certain restraint techniques, which were influenced by a Korean style of martial arts. It is also possible that the UK prison restraint system was based on adaptations from the Canadian model. The prison restraint system is termed “control and restraint” (C&R. C&R is the terminology that legal and medical professionals are mostly familiar with.

The pathway to the prison restraint accreditation and curriculum development is hardly detailed. However, it appears that initially the Home office approved the use of restraint techniques in the prisons and perhaps that influence spilt over to the special hospitals, which provided what they termed “Home office approved training”. Nurses who were trained by those special hospitals in the 1990s assumed that they were Home office trained, when in fact, that was not necessarily so.

There are various interpretations to UK training system which comprises of two modules, which are self defence type skills referred to as “Breakaway techniques”. Breakaways are disengagement techniques used in one to one confrontations against physical attacks such as grabbing or choking or holding of the victim’s body parts. “Restraints techniques” are implemented by a team of three or four individuals. On observation, the UK restraint techniques are influenced by Judo, Ju-Jitsu and Aikido. Similar to the St Thomas restraint concept, the prison techniques also include the use of pressure point techniques and martial arts type holding techniques. The ultimate technique in the prison and certainly in the police and certain hospitals is the “Wristlock”. This technique is achieved by applying uncontrolled pressure on the flexed wrist of the person being restrained. Presently, C&R is referred to by a range of different terminologies each perhaps striving for political correctness rather than evidence-based development.