This week, as part of Jane Fradgley’s held exhibition at the MRC SGDP Centre at the Institute of Psychiatry, a public symposium focused on the difficult topic of restraint in mental health care. This was inspired, in part, by a focus group held last year at the Bethlem Gallery, in which service users, artists and doctors discussed the different ways in which restraint might be understood and experienced. Indeed, as one participant in the earlier discussion reflected, the very visible historical garments offered a useful focus to reach into less tangible modern encounters: rapid tranquilisation or physical holding, for example. A sedated person is less obviously restrained to those around them than someone in a canvas dress, although the person constrained might well not see this distinction.
Speakers ranged across the spectrum, looking at clinical practices, historical debates and personal experiences to reflect on the topic, questioning the very use of restraint, as well as the way it is managed. Particularly striking was the suggestion of one psychiatrist that, prior to being invited to speak, restraint had not been something he had really reflected on, although aware that it occurred in the unit in which he practiced. The way in which restraint was reported and understood was noted to be a shaky area: often being seen as a response to an event, rather than an episode that, in itself, requires to be understood, in particular allowing patients an opportunity to respond and explain their feelings. Acknowledging that restraint – even where it seems to be the only course of action – may nonetheless have important consequences for vulnerable people was agreed to be an important step forward. Guidelines, in particular, were shown to be inadequate: something highlighted in the recent Mind campaign on physical restraint in crisis care.
Today, The Lancet published an online editorial reflecting on some of the issues raised by the panel, who had a variety of different perspectives and experiences of mental health care. Some felt that restraint was entirely avoidable, and the ‘No Force First’ movement in North America was raised as a possible model for removing restraint from mental health care. Others insisted that restraint was inevitable in a system in which confinement occurs, and that other aspects of psychiatry might be more unpleasant for patients than physical restraint. All agreed, however, that it was an important discussion to have, and that the views and suggestions of patients on their experiences of constraint and how it might be avoided as well as best regulated – the impetus for the exhibition and symposium in the first place – was vital.