LEARNING OBJECTIVES

After reading this article you will be able to:

• • differentiate between the various types of coercive practice used in European psychiatric settings, including mechanical restraint, physical restraint, pharmacological restraint and seclusion, with an understanding of when these measures are required in in-patient settings

• • recognise the variation in European law and policy on the use of coercive measures in psychiatric in-patient settings, with an appreciation of the high variability in the reported rates of use of these measures across Europe (and within specific countries)

• • evaluate the various physical and psychological consequences of restraint or seclusion for both patients and staff, with an appreciation of the current trends in literature that suggest alternatives to these restrictive interventions.

There is growing interest in understanding the use of coercive measures in psychiatry, particularly interventions such as seclusion and restraint (physical, mechanical and pharmacological), as there are associated human rights and safety issues attached to these concepts. The aim of this article is to explore use of these interventions European in-patient mental health settings. Where possible, the most up-to-date evidence on the use of coercive measures in European psychiatric settings is provided, so current practice can be analysed. Older research and seminal papers in the area are included to provide background and further perspective.

The use of seclusion and restraint in psychiatric in-patient settings

The use of coercive measures such as restraint and seclusion is common in psychiatric hospitals, with considerable variation in regulations and clinical practice between European countries (Steinert Reference Steinert, Hirsch and Goebel2009). Restraint is not just confined to psychiatry. It is also used in other medical specialties (such as emergency medicine, geriatrics and orthopaedics) and in non-medical settings (e.g. by law enforcement). For various reasons, the use of restraint in psychiatry is more controversial than its use in other fields (Negroni Reference Negroni2017).

It is widely acknowledged that those with acute and severe mental illness (such as acute psychosis or mania) are at highest risk of being secluded and restrained. There are many adverse effects associated with restraint, from the patient's death to harmful physical and psychological effects on both patients and staff (Sailas Reference Sailas and Fenton2000; Sashidharan Reference Sashidharan, Mezzina and Puras2019). The potential for misuse or overuse of physical interventions in corrupted cultures of care has emerged as a social policy problem in recent years. Seclusion and restraint continue to be employed widely in mental healthcare, despite concerns about their consequences and the dearth of controlled evaluations of their value (Stubbs Reference Stubbs, Leadbetter and Paterson2009).

When is restraint or seclusion necessary?

The primary goal of actions such as restraint and seclusion in in-patient psychiatry is to maintain the safety of everyone in the treatment environment. Although there are many advocates for eliminating such actions completely and numerous strategies implemented to reduce their use, failure to use restraint or seclusion appropriately in emergencies can also result in adverse outcomes for the patient or others in the environment (Sashidharan Reference Sashidharan, Mezzina and Puras2019). It is widely accepted that problems such as self-harm, aggression and violent behaviour are frequently observed on psychiatric wards (Lozzino Reference Lozzino, Ferrari and Large2015).

The most common reasons for needing to consider the use of restrictive physical interventions are physical assault, dangerous or threatening behaviours, extreme overactivity that is likely to lead to physical exhaustion, attempts to abscond and self-harm or risk of injury by accident (Department of Health 2015: para. 26.40). Coercive measures may be necessary if de-escalating techniques are not sufficient to handle such situations. A skilled, hands-on method of physical restraint involving trained healthcare professionals is used to prevent individuals from harming themselves, endangering others or seriously compromising the therapeutic environment by safely immobilising the individual concerned (National Institute for Health and Care Excellence 2015).

The current code of practice for the UK Mental Health Act 1983 states that physical restraint should be used as a last resort where there appears to be a real possibility of harm if it is withheld, that it should be applied with the minimum degree necessary and be reasonable and proportionate (Department of Health 2015). Practically, this means that the least restrictive intervention possible should be used with the minimum amount of force necessary to achieve the objective; any intervention beyond this is legally and ethically unjustifiable (Sethi Reference Sethi, Parkes and Baskind2018). There is broad international consensus on the use of least restrictive and least dangerous measures under such circumstances (Høyer Reference Høyer2012).

It must be remembered that physical restraint and seclusion are coercive and potentially traumatic procedures to be used in specific circumstances as a last resort, when other methods have failed. With this in mind, interventions such as restraint should always be used as a safety intervention, rather than a therapeutic measure (Allen Reference Allen and Currier2004). From an international perspective, the American Medical Association Code of Medical Ethics, specifically states that the restraint of patients is sometimes warranted, but should never be for punitive reasons, for convenience or to offset staff shortages (American Medical Association 2016).

If restraint is considered, it is important that aspects such as the type and duration of restraint be taken into account to prevent its unnecessary use. Documentation also plays a key role. The need for restraint should be regularly reviewed and documented in the patient's medical record, with any period of seclusion ending as soon as clinically possible (Zaami Reference Zaami, Rinaldi and Bersani2020). The recommendations of the UN General Assembly state that physical restraint should only be employed in accordance with the procedures of the given mental health facility and only to prevent immediate harm to the patient or others, with patient dignity being of utmost importance (United Nations General Assembly 1991).

Prevention and Management of Violence and Aggression (PMVA; formerly Restrictive Physical Intervention) is a national guidance relating to the de-escalation, management and prevention of violence and aggression, including restrictive physical interventions for people with learning disabilities and autistic spectrum disorder in health, education and social care settings. The policy provides guidance and summarises the actions that staff are required to take in order to maintain a safe working area and their own and others' safety, and what to do if they find themselves in a potentially violent situation. This policy applies across all NHS Trust care groups and services (National Health Service Sussex Partnership 2020).

Types of restrictive intervention used in in-patient psychiatry

When a patient poses a severe threat that cannot be controlled by means of verbal intervention/de-escalation or the voluntary acceptance of clinically indicated medications, the use of emergency interventions such as pharmacological, physical and mechanical restraint or seclusion (Box 1) may be necessary.

Physical or ‘manual’ restraint has been defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to a person's body that restricts their freedom of movement or normal access to their body, which commonly involves staff restricting and holding a patient by hand (Negroni Reference Negroni2017). The generally accepted definition of mechanical restraint refers to the use of devices (such as belts or handcuffs) or bodily garments for the purpose of preventing or limiting a patient's free movement of their body (Mental Health Commission of Ireland 2009).

The definition of seclusion that is generally used in psychiatry settings and in the law is the placing or leaving of a person alone in any room, at any time of the day or night, with the exit door locked or fastened or held in such a way as to prevent the person from leaving (Mental Health Commission of Ireland 2009).

Pharmacological restraint usually means the administration of medication against the patient's will, through coercion or through pressure or insistence by staff (Raboch Reference Raboch, Kališová and Nawka2010). The use of pharmacological restraint in psychiatric in-patient units is widespread globally and can involve the concurrent use of physical restraint. Generally, typical or atypical antipsychotics and benzodiazepines are used for this purpose, even though the scientific evidence regarding their efficacy for the treatment of acute aggression is limited (Rocca Reference Rocca, Villari and Bogetto2006). Agents such as intramuscular midazolam have been found to be effective in providing sedation in acute agitation, but because of increased oxygen saturation problems, its use is restricted to the emergency departments of general hospitals (Bak Reference Bak, Weltens and Bervoets2019).

Seclusion is used worldwide, but concerns remain regarding its appropriateness and the lack of alternatives, with patient perspectives highlighting subsequent difficulties in the patient–professional relationship in some instances (Allikmets Reference Allikmets, Marshall and Murad2020). The consequences of these practices will be explored in further detail later in this article.

The usual sequence of events is that when techniques such as de-escalation, enhanced observations, disengagement and oral medication do not resolve the situation, tertiary strategies (restrictive physical interventions) can be used in accordance with civil and criminal law, with all staff being accountable for any force they use (National Health Service Sussex Partnership 2020). If physical restraint is not sufficient, it may be combined with rapid tranquillisation (with benzodiazepines or antipsychotics) or with seclusion measures and then mechanical restraint (although mechanical restraint is not widely used in the UK and is not authorised in NHS PMVA guidelines: (National Health Service Sussex Partnership 2020).

Mechanical restraint in European psychiatric in-patient settings

A major difference between physical restraint and mechanical restraint lies in its duration: physical restraint is intrinsically limited to a few minutes, whereas mechanical restraint may last for several hours (Negroni Reference Negroni2017). Mechanical restraint in psychiatry is not completely independent of physical or ‘manual’ restraint, in that physical restraint is normally employed in order to implement mechanical restraint (Negroni Reference Negroni2017). The use of mechanical restraint is widespread across Europe and internationally, but it is not permitted for general use in countries such as the UK. There is no clear international consensus on specific indications for its use (Bak Reference Bak, Brandt-Christensen and Sestoft2012a).

In a large study on the use of mechanical restraint in acute psychiatric wards in Italy over 7 years, it was found that it was primarily used as a safety procedure to manage the aggressive behaviour of male patients. Risk factors associated with increased use of mechanical restraint included neurocognitive disorders, organic comorbidities, being detained under mental health legislation and a long duration of admission (Di Lorenzo Reference Di Lorenzo, Miani and Formicola2014).

Laws and European policy on restraint

In some countries, the law permits the use of mechanical restraint in psychiatric in-patient units, whereas in other countries, such as the UK, only seclusion and physical restraint are legal (except in exceptional circumstances in special hospital environments) (Bak Reference Bak, Brandt-Christensen and Sestoft2012a). Reliance on seclusion, restraint and psychotropic medication for behaviour management has been the primary focus of human rights litigation by the US Department of Justice against state psychiatric hospitals in the past (Donat Reference Donat2005).

In Europe, regulations on the use of restraint vary considerably from country to country (Mayoral Reference Mayoral and Torres2005). Variability in clinical practice, coupled with differences in international, European, state, and local laws and regulations, makes it difficult to develop guidelines for clinical practice which would standardise and regulate the use of these measures (Fernández-Costa Reference Fernández-Costa, Gómez-Salgado and Fagundo-Rivera2020). This absence of European-wide regulation on coercive measures has been highlighted in a multicentre study carried out in 12 European countries (Kalisova Reference Kalisova, Raboch and Nawka2014).

According to German law, it is mandatory that patients undergoing compulsory admission and/or restraint have their case legally reviewed and have a personal hearing with an independent judge. Mental health professionals are not allowed to proceed with these coercive measures without the judge's approval (Thome Reference Thome, Coogan and Simon2020).

Even though mechanical restraint is used within the law in many European countries, thorough ethical consideration of the patient's right to self-determination and human rights should be undertaken in determining the extent to which this intervention should be used. The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment has stated that applying instruments of physical restraint to psychiatric patients for days cannot have any medical justification and amounts to ill treatment (Bak Reference Bak, Brandt-Christensen and Sestoft2012a).

Article 3 of the European Convention on Human Rights is the only absolute Convention right and it states that ‘No one shall be subjected to torture or to inhuman or degrading treatment or punishment’. This must be considered in the clinical setting in complaints arising from conditions of detention, seclusion, control and restraint (Curtice Reference Curtice2010). Judgments from the European Court of Human Rights have noted that the use of handcuffs or other instruments of restraint does not normally give rise to an infringement of Article 3 if the measure has been imposed in connection with lawful detention and does not entail the use of force or public exposure exceeding what is reasonably considered necessary (Curtice Reference Curtice2010).

In Ireland, the Mental Health Act 2001 states that seclusion or bodily restraint by mechanical means can be used for the purposes of treatment or to prevent the patient from injuring themselves or others. However, it must be carried out in accordance with certain rules, such as ensuring the patient's dignity and safety, and only when all alternative options have been tried and proven unsuccessful (Mental Health Commission of Ireland 2009).

Frequency of use of coercive measures in European countries

Globally, both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest major differences in the percentage of patients subject to coercive interventions and significant differences in their frequency and duration between countries, with highest rates in Poland, Greece and Italy (Steinert Reference Steinert, Hirsch and Goebel2009; Kalisova Reference Kalisova, Raboch and Nawka2014). The difficulties experienced by researchers comparing countries are due to lack of available data, variability in reference sampling within countries and non-uniform terminology (Mayoral Reference Mayoral and Torres2005). For example, terms include ‘physical psychological restraint’, where a patient is threatened with mechanical restraint, unless he or she agrees to undergo drug therapy.

There are means of restriction used in psychiatric in-patient units that differ from physical restraint, pharmacological restraint or seclusion, but nonetheless affect the patient's personal freedom; these must be classified as restraint, although they are less invasive than physical or pharmacological restraint (Negroni Reference Negroni2017). These include ‘environmental restraint’, i.e. restricting a person's free access to all parts of their environment (for example, the locked doors of a psychiatric ward), and ‘psychological restraint’, such as the withholding of privileges and participation in activities. Owing to this heterogeneity, there is no uniform and internationally accepted terminology that includes all such restrictive interventions.

Individual studies and broader reviews that have attempted to determine the overall rates and average duration of restraint vary enormously in their findings (Beghi Reference Beghi, Peroni and Gabola2013). A review of 45 empirical studies of manual restraint (defined as physically holding the patient to prevent or restrict movement) in adult psychiatric in-patient units (mostly from the UK) found that on average up to five occurrences per month might be expected on an average 20-bed ward. Restraint was found to last 10 min on average and tended to involve younger male patients, who were detained under mental health legislation (Stewart Reference Stewart, Bowers and Simpson2009).

In a 2010 study of coercive practices during involuntary hospital admissions in ten European countries, forced medication was seen to be the most common coercive intervention (56%), followed by restraint (36%) and seclusion (8%), with the rate of mechanical restraint exceeding the average figure in centres in Germany and Greece (Raboch Reference Raboch, Kališová and Nawka2010). A recent study of coercive measures in forensic psychiatric hospitals in Germany noted that one-quarter of patients are affected by such measures, with seclusion (21.2%) being used much more often than mechanical restraint (3.2%). This contrasts with general psychiatric hospitals in Germany, where restraint is more common than seclusion (Reinwald Reference Reinwald, Horten and Dressin2022).

Even within specific countries (such as the UK), there can be significant variation in the rates of restraint that are reported, with confounding issues such as heterogeneity of service profiles, organisational reporting bias and confusion about definitions (Sethi Reference Sethi, Parkes and Baskind2018). In Denmark, there is up to a ten-fold difference in the rates of restraint reported by various psychiatric hospitals in the country (Bak Reference Bak and Aggernaes2012b).

In Iceland, there is one psychiatric hospital serving the country's 300 000 inhabitants, and reports by local experts suggest that seclusion and mechanical restraint were abolished some 30 years ago and have not been used since (Snorrason Reference Snorrason2007). Traditionally, Iceland has used less coercion within its mental health system compared with other northern European countries, with low rates of involuntary admission (Matthiasson Reference Matthiasson2017).

An 11-year comparison of physical restraint and seclusion data across Ireland (from 2008 to 2019) showed a year-on-year increase in the number of physical restraint episodes (with a slight decrease in 2019), with steady general increase in the number of residents experiencing physical restraint. There was a general decrease in the number of seclusion episodes recorded over this time (Mental Health Commission of Ireland 2020).

In Italy, following a national recommendation for the prevention of all mechanical restraint measures in 2010, there was a significant reduction in such practices, for example a 62% reduction in the Emilia-Romagna region over the following 5 years, from 2011 to 2016 (Regione Piemonte 2007).

Restraint measures have been shown to be more prevalent in psychiatric hospital care in certain countries, such as India, than they are in Europe. One study highlighted that restraint was used on 66.5% of a sample of 200 patients in India (20% were subjected to physical restraint, 58% to chemical restraint, 18% to seclusion and 32% to involuntary medication) (Gowda Reference Gowda, Lepping and Noorthoorn2018).

Consequences of restrictive interventions

There is a paucity of evidence for the benefits of coercive practices in terms of their efficiency, efficacy, frequency and effectiveness (Chieze Reference Chieze, Hurst and Kaiser2019). As mentioned above, the risks of seclusion and restraint range from adverse physical and psychological effects on patients and staff to the death of the patient. There are estimates of the incidence of post-traumatic stress disorder after such occurrences ranging from 25 to 47% (Sailas Reference Sailas and Fenton2000; Chieze Reference Chieze, Hurst and Kaiser2019).

Seclusion and restraint may cause re-experiencing of childhood trauma (or of previous traumatic experiences of these coercive practices). This is particularly relevant to psychiatric in-patients, given the high levels of physical and sexual abuse reported in this population. The subjective perception of such coercive events has a high interindividual variability, and can be positive (with feelings of safety or help), but they are most commonly associated with negative emotions, particularly feelings of punishment and distress (Chieze Reference Chieze, Hurst and Kaiser2019).

A systematic review that included a qualitative analysis of patients’ perspectives on being physically restrained identified themes including negative psychological impact, re-traumatisation, perceptions of unethical practices and broken spirit (Strout Reference Strout2010). Compared with other coercive measures (notably, forced medication), seclusion seems to be better accepted, whereas restraint seems to be less well tolerated, possibly because of the perception of seclusion as being ‘non-invasive’ (Chieze Reference Chieze, Hurst and Kaiser2019). Another systematic review found that patients tended to consider seclusion to be less intrusive and more acceptable than mechanical restraint, while mechanical restraint was associated with being preferable for patients with regard to the duration of coercion (Gleerup Reference Gleerup, Østergaard and Hjuler2019).

It is generally acknowledged that over the past two decades there has been a reduction in the prevalence of restraint episodes globally due to evolving regulations and education or training, but there is still concern about the morbidity and mortality related to the practice (Rakhmatullina Reference Rakhmatullina, Taub and Jacob2013). The most frequently reported events of physical harm secondary to coercive measures found in the literature are patient death, alongside cardiac arrest, pulmonary embolism, venous thromboembolism and physical injuries. However, it is acknowledged that this is an under-researched area (Kersting Reference Kersting, Hirsch and Steinert2019).

The perspectives of nursing staff, the risk of injury to staff from physical aggression, the effect on ward culture and staff burnout are important considerations in assessing the consequences of coercive measures and in considering implementation of strategies to reduce their use (Cochrane Reference Cochrane and O'Kane2018).

Measures to reduce the use of restrictive interventions

Gaining insight into theories on causes of violence and aggression and understanding factors that may pre-empt or exacerbate violent episodes can be helpful in beginning to reduce use of coercive measures (Ewington Reference Ewington, Völlm and Nedopil2016). A Finnish study exploring the experiences and suggestions of psychiatric in-patients reported that providing patients with meaningful activities, making patient–staff agreements, empathetic patient–staff interaction and adequate planning reduced the need for restrictions and offered alternatives to seclusion and restraint (Kontio Reference Kontio, Joffe and Putkonen2012).