The Use of Restraint – Why and Where are we going Wrong?

On reading the House of Parliament’s Joint Commission on Human Rights Report, The Use of Restraint in Secure Training Centres, published on 07 March 2008, I was reminded of the writings of David Wills. The report reflects the controversy that has existed about the use of physical restraint in England’s four privately-run secure training centres. The debate has been fired by the deaths in custody of 15-year-old Gareth Myatt and 14-year-old Adam Rickwood in April and August 2004 respectively.

Gareth, who weighed 6 and a half stones, died from suffocation after being physically restrained by three custody officers in his cell. The incident was prompted by his refusal to obey an instruction to clean a toaster. Adam Rickwood committed suicide soon after being subject to physical restraint, which involved the application of a technique known as the “nose distraction” technique. In December 2007 the Government suspended the use of “nose distraction” and another technique called the “double basket hold”.

David Wills

This describes what David Wills did as an act of restraint.

“One day ‘Yus’ went berserk. I forget what had annoyed him, but he threw a saucepanful of potatoes at someone, and when others attempted to restrain him he shook them off, picked up a heavy form six feet long and threw it at someone who had sought the safety of the other side of the dining table. He was just looking round for something else to throw when I gave him a hearty clip on the jaw, which I followed up with a shove in the midriff which put him in a corner of the room with me in front of him, and there I stayed until his ardour had cooled.” (p87)

David Wills was a Quaker, pacifist and the first English person to train as a psychiatric social worker. He was one of the pioneers of planned environmental therapy for troubled and troublesome young people! The book in which this extract appears, The Hawkspur Experiment, was first published in 1941. It is Wills’s personal account of the development of a therapeutic community, which was intended to provide a radical alternative to traditional custodial care for young offenders who would otherwise have been sent to Borstal or prison. The Hawkspur experiment started in 1936 and ended in 1941 on account of the outbreak of the World War II.

Wills explains his actions as follows.

“This was not punishment, and ‘Yus’, when he came round, was first to realise it. It was just the quickest way to end an intolerable situation. A smack on the jaw in the heat of battle was neither here nor there to ‘Yus’, and he was probably glad I stopped him from making a worse fool of himself. It did no harm, saved a lot of damage, and I would do the same thing again in like circumstances.”

To Wills, his action was a pragmatic response to the presenting situation. It was not a reflection of any restraint policy, for there was none, and he does not record having to repeat his actions. Wills indeed eschewed the range of punishments customarily administered in the penal establishments of the time. “Discipline derives largely from a fear of the persons upon whom it is imposed,” he wrote (p36).

He also gives this example taken from when he worked in a Borstal (the Secure Training Centre of the time).

“Three boys were sent to the cells for mischievously shouting something after an officer who had not the personality to command their respect. They had done no evil; they had not upset the routine for the maintenance of which discipline is necessary. But they had done something which, if passed unpunished, might affect the capacity of the staff to maintain that discipline. They suffered because discipline must be maintained”.

When reading in the Joint Commission’s report the account of how Gareth Myatt died not much appears to have changed in the treatment of young people in secure environments.

Hawkspur, which was David Will’s inspiration, ran as a therapeutic community based on ideas of shared responsibility. The rules and regulations were set and applied by the Camp Council to which every resident could contribute. To Wills there was a huge difference between punishments administered in the exercise of their authority and status by such as school teachers and Borstal governors and the penalties decided by the peers of wrong doers in a democratic assembly, which the Camp Council represented. He definitely favoured the latter.

Of course, by today’s standards, Wills’s restraint method – a spontaneous clip on the jaw – would be totally unacceptable. Indeed, if Wills’s actions had been judged by current standards, the course of therapeutic residential care of young people care could well have been significantly altered. Not only might he have been charged with the assault, but also he could be put on the POCA and POVA lists as being unsuitable to work with vulnerable children and adults!

Controversy continues

Seventy years on from the Hawkspur Experiment, it is clear that the subject of restraint still commands attention in all forms of residential care practice. Its use is controversial and difficult to get right. There is an aspiration – at present largely wishful thinking – that if only better alternatives could be found, restraint would never have to be used. Whenever used, it is invariably costly in terms of distress and stress for those involved in being restrained and those who do the restraining.

Commission for Social Care Inspection report published in 2004, which sought the views of young people in care who had experienced some form of restraint, describes the powerful impact of the experience of being physically restrained. The effects are not just on the person being restrained but on others who see her or him being restrained and the general ethos of the setting.

In some social situations the use of restraint is perfectly acceptable, reasonable and indeed is obligatory. For example, we all wear seat belts in our cars; otherwise we break the law. Wearing a seat belt is deemed to be in everyone’s interests and there is no right not to wear one. Parents are expected to restrain their young children in one way or another to prevent them from being hurt or to cause a nuisance to other people. Where restraints are imposed by law or by rules such as fastening one’s safety belt in an airplane it is assumed that there is a common good served by their use.

Different kinds of restraint are used in many care settings. Also the various influences on, and pressures to use, restraints are found in most care settings. Quite rightly, current policies are aimed at reducing and possibly eliminating the use of inappropriate forms of restraint by ensuring care services have clear strategies to address the situations in which restraint might be necessary.

Controlling the irrational

However, I cannot but help thinking that there is something missing in the current way of thinking which seems to assume that rational solutions can be found to regulate behaviour and situations that are largely driven by fundamentally irrational processes. These need to be far more fully understood in order to find at least partially effective remedies. Restraint must be understood as an institutionalised pattern of activity in which complex and often insidious organisational, psychological and social influences are invariably at work.

Rights, Risks and Restraints is the alliterative title of a recent report on the use of restraint in the care of older people (Commission for Social Care Inspection 2007). It reflects the common perspective on the legitimate use of restraint as encompassing both ethical (human rights) and psychological (risk) issues. The problem as I see it with this way of framing the issue is that ideas about how to prevent and make sparing use of restraint, which as the report states is rarely effective, tend to be individualistic, overlooking the systemic issues that should also be examined.

Every policy on restraint that I have come across in recent years emphasises the inclusion of risk assessment as a means of identifying when the use of restraint might or not be justified. The problem with risk assessment as an idea is that it assumes a rationality that does not exist in reality. As a method, it assumes an objectivity that is spurious in most situations but particularly so in situations in which physical interventions might be needed. In potential restraint situations there are strong emotionally charged subjective elements in any so-called risk assessments.

Assessments will be made according to the potential restrainers’ tolerance of risk, which will be based on their individual and collective sense of safety, security and anxiety levels. Front line staff’s tolerance of risk and their assessments will in turn be influenced by institutional risk tolerance levels, which will be set both formally by operational polices and informally by the staff culture. In settings where there is a real or perceived strong sense of threat, which is generated formally or culturally, risk tolerance levels will be relatively low. The predisposition to use physical interventions will be correspondingly high.

Why Restraint is Used

A common view is that physical interventions and other forms of restraint are needed because of individual pathology. The needs arise from the individual’s emotional disturbance, dementia, mental illness or whatever their ‘problem’ is which triggers the behaviour that has to be restrained. Restraint is a response to individuals who are vulnerable to losing self-control and who do so because of their lack of it. There are however many studies of institutional behaviour to suggest that the context in which the individual is placed plays an important part in creating the conditions in which behaviour needing to be restrained becomes more likely.

In Asylums (1961) the American sociologist Erving Goffman described in detail the complex process of socialisation that new residents of the psychiatric hospitals of the time went through as a feature of the ‘total institution’ which they were entering. In order to survive they had to learn a whole set of formal and informal rules and the penalties for disobeying them. Restraints used as threats and as active interventions were means by which staff coerced residents into conforming to the codes of conduct established for the efficient running of the organisation. The underlying message was to demonstrate to the resident who, in the last resort, was always the ‘boss’.

In July 2007 the Government issued the Secure Training Centre (Amendment Rules) on Physical Control in Care (PCC) – a euphemism for restraint. These authorised the use of restraint as a means of maintaining “good order and discipline”. They also maintain that restraint should only ever be used as a last resort, it should be applied no longer than necessary and it should inflict as little pain and discomfort as possible. However, all rules like this give out a contradictory set of messages. As Goffman states (p88) in his technical terms, “Those members of staff who are in continuous contact with inmates (residents) are being set a contradictory task, having to coerce inmates into obedience, while at the same time giving the impression that humane standards are being maintained and the rational goals of the institution realised”.
Organisational influences and pressures on the use of restraint

In child care practice there has been a long-standing interest in developing methods of restraining out-of-control children. The stated aim invariably is to make the child feel safe and secure as a result of the close physical contact experienced from being held. In the 1960s a set of films about a Canadian school called Warrendale showed a method of holding, which was adopted in several child care settings in this country. It involved the worker getting hold of the acting-out child in such a way that they could sit down with the child in front of them on their lap with both arms and legs tightly embracing the child. This prevented the child from struggling and the worker from getting hurt.

In care settings for younger (usually pre-teenage) children, staff use physical restraint as a means of achieving therapeutic goals. If children lose self control, they need to be held as parents hold a young child having a tantrum. Once calmed down, the child might then be able to talk about what has been troubling them. It is sometimes thought a healthy sign that children are able to act out their feelings to the point where they might need to be physically restrained as this then makes them more open and responsive to therapeutic intervention from counselling or psychotherapy. In American texts the discussion that followed the act of holding with a calmed down child was known as “on the spot counselling” (Whittaker and Trieschmann 1972).

Many of these ‘therapeutic’ restraint methods have in more recent times become discredited, in part because they have never been fully understood theoretically and have often been misapplied. There has often been a lack of training and professional supervision, which has contributed to their inappropriate application.

Staff who use holding methods inappropriately now lay themselves open to accusations and complaints of both physical and sexual abuse. In taking decisions to restrain, they have to take into account that the child might have been physically and / or sexually abused and attribute particular significance to the close physical contact that acts of restraint entail. Children can allege or infer physical and sexual abuse from any aggressive and physically inappropriate manner in which they have been restrained.

So-called therapeutic environments may engineer and explain the use of restraint in relation to their stated purpose and methods. Its use will be rationalised in therapeutic terms. At the other end of the care spectrum, secure units, as ‘total institutions’ in the Goffman sense, provide good examples of how physical interventions as forms of restraint can become built into an institutional culture. The incidence of physical interventions to restrain residents is paradoxically probably higher in secure units than in any other kind of residential establishment.

Secure Units

The House of Parliament Joint Committee report states that in 2006 restraint was used over 3,000 times in the four Secure Training Centres, which accommodate 250 – 300 young people. On average this works out at each person being restrained about ten times a year. The incidence is evidently similar according to the Youth Justice Board for local authority Secure Units. This suggests that much of the behaviour resulting in restraints being applied and in applying them is socially learned – a response to the institutional environment and regime – rather than being pathological in nature.

The irony is that Secure Units are constructed as restraining environments. A recent study of restraint in the care of older people (CSCI 2007) identified several different types of restraint, including the following.

Physical intervention: the use of force to hold a person down or moving them from one place to another against their will, or actions taken to stop them from doing what they want to do or to go where they want.

Forced Care: actions to coerce a person into acting against their will, for example having to be restrained in order to comply with the instruction or request.

Physical and Mechanical Restraints: the use of devices to tie or secure someone to a place such as a chair or a bed, sitting someone in a chair or bed from which they are unable to move or using bed or side rails similarly to prevent movement. ‘Pindown’, in which rule breakers were allowed to dress only in their night clothes, would be an example of this form of restraint.

Chemical Restraints: the use of drugs and prescriptions to modify a person’s behaviour. Medication that is prescribed to be taken ‘as and when required’ can be used as a form of restraint unless applied responsibly.

Environmental Restraint: the design of the environment to limit people’s ability to move as they might wish, such as locking doors or sections of a building, using electronic key pads with numbers to open doors, complicated locking mechanisms and door handles. Secure Units epitomise this form of restraint along with the next!

Electronic Surveillance: the fitting of electronic tags, exit alarms on doors and use of television cameras (closed circuit television (CCTV)) to monitor people’s movement.

In the context of care settings for adults, the improper use of these restraints directly infringes people’s human rights. However, it can be readily seen that most of these restraints are actually built into a Secure Unit. For example, there are physical devices together with laid down procedures for restraining residents’ freedom of action and movement in every aspect of the environment. Environmental (e.g. locked doors) and electronic restraints (e.g. CCTV) are used to monitor and control movements. Residents are restrained by the imposition of rules that effectively regulate every aspect of their daily lives. They are further restrained by the requirements of the systems of rewards, punishments and sanctions that are used to secure their conformity.

Secure Units provide the conditions in which behaviour requiring physical restraint are entirely predictable. ‘Acting out’ or ‘blowing up’ and then having to be restrained physically in many ways relieves the monotony of an extremely restrictive environment and daily life for the resident at the centre, other residents and for that matter staff too.

In all residential care settings, social learning makes an important contribution to the work culture and its practices. Activities, as they are repeated, can become self reinforcing. For example, a 1993 Social Services Inspection report on Aycliffe Secure Unit found that when it became policy to use physical restraint to enforce compliance to staff instructions the incidence predictably increased dramatically (SSI 1993). Refusal resulted in coercive action that would then escalate if the young person resisted and staff would be left with a major restraint incident to deal with. Once the policy was dispensed with, the number of recorded incidents of physical restraint predictably went down.

The Joint Commission Report also comments that many of the incidents resulting in the use of physical restraint in Secure Training Centres are trivial; as David Wills might say, “no evil having been done”.

Restraint Training

Restraint training, by which is meant instruction and practice in permissible or approved forms of restraint has in recent years become something of a growth industry.

One of the problems in the development of restraint techniques in children’s settings in recent years, particularly in Secure Units, is that they have relied too much on methods and techniques imported from the adult penal system. These techniques should not be applied to children unmodified, if they should be used at all.
Youth justice and child care policies have rightly been directed at limiting the use of restraint; but when used, they seek to carry it out according to laid down procedures. However, they seem to be addressing the symptoms rather than finding a cure. As a consequence the focus of debate has narrowed to one about the means of restraint rather than about the ends that it serves and the complex individual and social psychological processes that interplay in all acts of restraining.
Take this example from the Physical Control in Care Review Panel Recommendations to the Youth Justice Board, which were made in 2007 (prior to the suspension of double basket holds and nose distraction). The underlying thinking simply induces in me a sense of absurdity when related to what actually happens in a restraint incident.
“The seated double-embrace holds, including the de-escalation option (seated) and the relocation option (seated) should be permanently suspended, and should not be included in any new restraint system that may emerge from a wider review.

• The wrap-around arm hold should be a transitional hold and should not be maintained for more than one minute before moving to the standing double-embrace or other alternative hold.
• The double-embrace lift (plus escalation) should be subject to adequate supervision of the head support, and there should be adequate supervision and co-ordination in order to ensure that the spinal column is kept in a straight line, and that breathing is not impaired. This hold should be replaced in any new restraint system emerging from a wider review.
• A limit of three minutes should be imposed on Phase 3 restraints where the subject is in a lying position. Staff must then either cease the hold or change position. Staff should record the action they take to monitor this.
• Nose distractions should only be used to bring a violent situation to an end during the course of a Phase 3 hold. There should be a maximum of two nose distractions in the course of a PCC incident.”

Restraint training in these and similar techniques, which is now mandatory in many settings where restraint is a reality, can add to rather than ease the problem. However the training package is wrapped up, when this level of technical detail is required, staff learn how to restrain rather than why.

There is then a danger that care staff become dependent on their acquired techniques as their main strategy for controlling the young people. Unless the whole situation is well managed and regulated, staff can all too easily become ‘restraint happy’ with unfortunate unintended consequences to their actions.
Added to this is that in Secure Training Units Custody Officers, as they are called, receive on employment a total training of only 7 – 9 weeks. This hardly equips them to deal with the complex needs of both the young people to whose care they have been entrusted and the complex institutional environment in which they have to operate and to which they rapidly become acculturated.
In many care settings, a more positive trend is the development of policies and procedures to manage aggressive and violent behaviour as a Health and Safety measure. The purpose is to protect and keep safe staff and others from harm and injury. This seems a much more honest approach, if it is accepted that anxiety, fear and insecurity underpin the need for staff to engage in acts of restraint. Associated training focuses less on the use of restraint methods and more on the means of preventing the situations that could result in restraint being used from developing and escalating. This includes looking at the issues from a total organisational point of view and ensuring risk assessments and management strategies are comprehensive.
Where physical intervention of some kind is inevitable, the emphasis will be on reducing the risks of being injured and disengaging as quickly as possible, as opposed to grappling and holding. Actual bodily restraint should only be the very last resort when it is clear that less interventive means of reducing or controlling the behaviour in question have failed.

Conclusions

If the use of restraint is related as much if not more to the institutional regime as the characteristics of the people under restraint, then a study of its use and incidence in different organisational contexts should increase understanding of its causes and effects and possibly lead to more constructive ways of reducing even preventing its inappropriate uses.
The CSCI, in its Guidance to Inspectors (CSCI 2007a), discusses two levels of prevention. Secondary prevention refers to the means by which staff can learn how to defuse and de-escalate threatening situations and seek alternative ways of dealing with them that do not require recourse to physical restraint. Primary prevention requires a root and branch examination of the whole system in which restraints might be used. To learn the lessons of Adam Rickwood’s and Gareth Myatt’s deaths nothing will suffice short of a review of the total secure training system – and for that matter of any other provision where the use of restraint is endemic. Otherwise it is most likely that more young people will die as a result of the inappropriate use of force.

References

Commission for Social Care Inspection (2007) Rights, Risks and Restraints (Available from www.csci.org.uk)
Commission for Social Care Inspection (2007a) Guidance for Inspectors: How to Move Towards Restraint Free Care (Available from www.csci.org.uk)
Commission for Social Care Inspection (2004) Your Rights, Your Say (Available from www.rights4me.org)
Goffman E (1961) Asylums Harmondsworth, Pelican Books
Houses of Parliament Joint Commission on Human Rights Report (2008), The Use of Restraint in Secure Training Centres London; Stationery Office
Whittaker J and Trieschmann A. (1972), Children Away From Home, Chicago and New York, Aldine Atherton
Social Services Inspectorate (1993) A Place Apart, London, Department of Health
Wills D. (1941, 1967) The Hawkspur Experiment London, George Allen and Unwin