Coercive Measures in the Management of Imminent Violence: Restraint, Seclusion and Enhanced Observation

Abstract

First paragraph: Even the most effective prediction techniques will not prevent all aggression in mental health care settings and when deescalation alone (see preceding chapter) is ineffective, staff will make the judgment to move toward more intrusive techniques, alongside continued deescalation, to coerce and ultimately control the patient. Such coercive and physical control is fraught with ethical, moral, and legal dilemmas and can be a potent cause of physical injury and psychological harm in both patients and staff. Once the decision to "up the stakes" has been taken, it is difficult to go back down the ladder of coercive interventions and there is a real risk that incompetent coercion can exacerbate the situation and be highly dangerous to the patient. In this chapter we will consider three things. Firstly, we will examine some of the difficult conceptual, ethical, and legal issues around the use of coercive measures in psychiatry. Secondly we will summarize some key, best practice, guidelines with regard to special observation, physical restraint, and seclusion with reference to the relevant sections of the UK National Institute for Clinical and Health Excellence (NICE) Clinical Practice Guidelines for the management of imminent violence. These guidelines are based on one of the most extensive and thorough appraisals of existing research on this issue. Thirdly, since this is a rapidly evolving area, we will examine recent research emerging in the past two to three years which was not included in the NICE review. Special attention will be paid in this section to two high priority questions: What is the service user perspective on the causes of conflict resulting in coercive measures and the actual experience of undergoing them? And, how can mental health services around the world act to reduce their reliance on seclusion and restraint and develop alternative, less coercive interventions?