Developing a perspective on restraint and the least intrusive intervention

Abstract

This article explores contemporary practice in the use of restraint in the light of recent European Council Guidance endorsing the principles of least restrictive environment/least intrusive intervention. Violence is a source of concern in many European mental health services but approaches to its immediate management continue to display remarkable diversity reflecting the adoption of differing perspectives on what constitutes 'least intrusiveness'. This article examines the basis for practice in terms of the range of procedures available, reviews the literature on restraint safety and presents a model based on the concept of reasonableness which can be used to evaluate whether a given intervention meets the European guidance. Current practice across Europe is largely a function of tradition and local values rather then evidence based. Collaborative large-scale studies are required to determine the relative risks of the range of interventions in use such that practice is informed by evidence rather than opinion.

The Eileen Skellern Lecture 2014: physical restraint: in defence of the indefensible?

“…(), for example, have stated that it is widely accepted that effective inpatient care can include the use of coercive measures, such as seclusion and restraint. Recommended as a last resort in many instances, it is seen as part of an interventional menu for practitioners subject to the right circumstances (National Institute of Clinical Excellence , Paterson ). However, its efficacy has been under scrutiny for some time (Kynoch et al .…”

Physical intervention: a review of the literature on its use, staff and patient views, and the impact of training

“…When questioned staff reported that it was always used as a last resort, whereas patients perceived it was not. Paterson & Duxbury (2006) argued that services which claimed restraint was a necessity and used only as a last resort sometimes did so without adequate exploration of the root causes of violence and aggression, which might obviate the need for PI. Without such efforts being made the continuing use of restraint could be seen as a form of systematised abuse of both service users and staff, and as such, unlawful and potentially actionable as it would constitute a breach of a patient's entitlement to be treated in the least intrusive manner in the least restrictive environment (Keywood 2005, Paterson & Duxbury 2006).…”

“…The delivery of PI skills training as a stand‐alone intervention (a not uncommon practice until very recently in some organisations) divorced from training in promoting human rights, the primary prevention of violence, conflict resolution, post‐incident support or even exploration of the key safety issues in the practice of PI, is a particular source of concern. This is because European Council Guidance requires all staff trained in PI to have undertaken training in these areas before training in restraint (Paterson & Duxbury 2006).…”

The role of physiological arousal in the management of challenging behaviours in individuals with autistic spectrum disorders

“…Fourth, restraint methods such as prone holds may be associated with fatalities (Allen, 2008). Some experts have called for a ban on all prone restraint holds in care (McDonnell, 2010); other academics refute the claims that these postures are strongly associated with sudden deaths (Paterson, 2006). Incorrect application of methods is associated with some childhood deaths in care in the United States (Nunno, Holden, & Tollar, 2006).…”