Restraining children is NOT caring

July 11th, 2014  |  Published in Mental health

restrain15It seems unlikely that a nine-year-old child could be more physically threatening than a full-grown adult. And yet, children in psychiatric care are more likely to be forcibly restrained (click here).

A child would be easier to overpower than an adult, and the obvious possibility is that they are subjected to brute force because they can be.

Restraint and seclusion have been recognised as human rights issues and the United Nations Special Rapporteur on Torture has called for a total ban (click here).

This is not to dismiss the safety issue – for the child, other patients, or staff. There is, however, no evidence that restraint improves safety and the reverse may actually be true. The coercive nature of the practice can escalate aggression and increase danger (click here).

The Mental Health Commission receives more complaints about restraint and seclusion than anything else, says Professor Allan Fels, who describes these practices as signs of a failing system.

Restraint and seclusion raise questions about the concept of treatment, the blurring of restraint and punishment, alternatives possibilities, and accountability.

A mother’s view

The idea of being forcibly restrained is abhorrent, and the thought of witnessing a child in this predicament is even worse.

Kerrin Hall’s son was in psychiatric care when he was nine years old, and has been diagnosed with anxiety, depression, and oppositional defiant disorder. Such labels erase the violence in his childhood, the effects of extended involvement in the Family Court, and the failure by family and mental health services to address the underlying issues or provide adequate access. The child, in effect, is turned into the problem rather than the circumstances of his life being problematised.

Kerrin Hall has shared ideas with me in personal correspondence, and says: “In my experience, people who support the use of restraint usually haven’t seen the trauma it causes for already traumatised children. I believe it needs to stop in children under twelve, and in adult services it should be an absolute last resort. There has to be a better way.”

Kerrin Hall is not alone

Another (adult) patient says: “Here I was, scared and not understanding what was happening to me because I had demons in my mind saying things. I was seeking help and I went to the hospital and they locked me in a room with myself and my demons – that ‘s the last place I wanted to be, alone, surrounded by these voices.”

Kellie Comans reflects on her experience: “I didn’t need to be shut down and physically restrained. I needed to be heard. I needed to tell my story and have someone bear witness to that.”

Disconnect between subjectivity and outward behavior

Kerrin Hall sums up: “Professionals look at mentally unwell individuals and don’t see what’s driving the behaviour; they’re too busy or don’t think it’s important or don’t bother to delve deeper. There’s always something, though; people don’t just act out for no reason.”

The subjective experience of patients may not, however, rate highly as a professional priority (click here).

Restraint and seclusion are NOT treatment

restrain18

Locking a distressed person in a padded cell could be the worst possible treatment, writes Peake. In fact, restraint and seclusion should not be referred to as treatment at all. They are counter-therapeutic, damage trust, cause physical and psychological harm to patients, and trauma for both patients and staff (click here, here, and here, for example).

“Restraint controls the behavior,” says Kerrin Hall, “and the behavior may well be a problem, but it’s the surface problem. I observed other children in the ward with my son. They were mostly there because of behavioral dysregulation caused by trauma. These kids are never going to get better if they just get more abuse.

“Staff refused my son’s PRN medication when I asked for it, and allowed him to become deeply disturbed and have aggressive outbursts. Then he was forcibly restrained, physically hurt and deeply traumatised.

“It broke my heart. After they let him out, he said:

‘I promise I’ll be a good boy, Mummy. Take me home. I don’t want them to do this to me anymore. I hate it here. They’ve hurt me and I just want to go home.

Nobody loves me. Nobody gives a shit about me. You promised me they’d help me and all they’ve done is f**k my head even restrain16more. I want to go home and I want to die.’”

Beau Turner is similarly clear that restraint and seclusion were damaging for her (then) seven-year-old son, Saxon, who was restrained for a couple of hours a day while in hospital, on one occasion being held face down by five staff.

“As soon as they let him out he’d run and have another meltdown, I guess because he was in there.”

Restraint and seclusion thus triggered the behavior they were meant to stop.

Restraint blurs with punishment

Picking up the connection her son made between restraint and punishment, Kerrin Hall says: “I don’t think the majority of the population (or staff who treat mentally ill people) are able to see that it’s not a matter of ‘being good’. It’s about a mentally unwell individual not being able to regulate themselves.”

Beau Turner also comments on the blurring of restraint and punishment: “When we first went in to the unit there was a little boy. He had a black eye and a scratch, I think, on his chest. And Saxon said ‘Oh, look at him, Mum. What happened to him?’ A nurse replied, ‘That’s what happens when you’re a naughty boy.’”

This idea of restraint as punishment for ‘bad behavior’ does not need to be explicit, says Professor Newton. Children make the connection for themselves and that makes the situation worse.

Restraint and seclusion effectively reproduce the abuse that causes problems in the first place.

Alternative approaches

If, then, restraint and seclusion are counter-therapeutic, and don’t improve safety, what alternatives are there?

Some possibilities include (click here):

  • Prevention practices including advance planning based on comprehensive assessment, knowledge of patient histories particularly of traumarestrain17 and abuse, understanding and management of triggers such as anger, fear, and frustration, careful observation, and provision of alternative activities and distractions.
  • Practices for deescalation, including staying calm, engaging the person, avoiding argument and power struggles, problem solving, stress management, and giving the person space.
  • Safety practices, including clearing the area of people and objects as far as possible, staying out of personal reach, keeping the person in sight, maintaining access to the door, and calling for help if needed.

These possibilities require adequate staffing, training, resources, experience, and a nonauthoritarian culture. But they can work, and the variation in use of restraint between facilities provides one form of evidence.

Beau Turner’s son, for example, went from hospital to a residential care unit where, she says, they use a more therapeutic approach. “It’s soft. It’s gentle. He still has meltdowns but nothing like [before].” After two months, he hadn’t been restrained or secluded once.

Accountability

Kerrin Hall argues for Closed Circuit Television (CCT) in communal areas of treatment facilities so that practices can be reviewed and improved. She has found case notes to be inadequate records, based as they are only on what staff observe and document, and there is no mandatory requirement for use of restraint to be documented.

“The night my son was restrained the staff tried to tell me he was only held down for two minutes and they didn’t hurt him. This is not what happened at all!”

Accountability is an important consideration, and CCT might contribute, although its invasive downside makes it worth looking for other options – including patient advocates, whose employment would need to be independent of service providers so that attention to the interests of patients did not compete with loyalty to an employer.

Kerrin Hall says she will continue to advocate for her son, and for other children in the system.

“Someone needs to give these kids a voice,” she says.

I agree and wish her success in achieving change.

restrain11

Your comments are warmly invited…Joan Beckwith

Get free monthly emails about new blog posts

3 comments on “Restraining children is NOT caring”

  1. Embedding the (brief) Facebook post here, which linked to this website post, mainly because of the associated discussion, which has been substantial and has included comments from family members, mental health practitioners, and more general commentators…Joan Beckwith.

  2. Kieran says:

    I think this article is great; it opens the floor for future discussion and direction for the way people are treated in hospital settings and services for people with mental illness. I think it is not only crucial, but critical that professionals are able to see that how they treat and care for unwell children (and adults) may in fact be overall more detrimental to their overall wellbeing. This article poses a number of challenges for professionals, patients and carers. Ultimately, I think paramount to any treatment must always remain “no further harm”. Whilst we are always concerned about the “immediate” safety of the person and those around them, it is a common misconception that if we restrain or seclude an individual, they will “get over it and no harm is caused”. What about the safety of the individual concerned being secluded or restrained, both short and long term? Often, both more short and long term harm comes about in seclusion, I have seen this first hand. I have been with my child in a seclusion room for dysregulated behavior and he has smashed his fist into a concrete wall, and repeatedly banged his head on the cold, hard, concrete floor. Later, when I have managed to deescalate him, and bring him down, the confusion and pain sets in and he has not known why his fist and head hurt the way they do. People with trauma, often disconnect, and I for one believe there needs to be more effort on the part of the treating healthcare professionals (not just nurses) to aim at finding out what that trauma may look like for the patient and look at addressing that, rather than the behaviors. Unless we get to the root causes of the problem and work towards assisting the person with the issue, the behaviors will always remain present. People can recover from trauma if they receive the right help from the right people. Professionals just need to care enough to help. After all, it’s not just about the money, it’s about helping those they are trained to help.

    • Most importantly, Kieran, I am so sorry about your son’s experience and yours also in being witness to it.
      You make important points. Firstly about the guiding principle of “doing no harm”. As far as I can tell it is well recognised that restraint and seclusion do more harm than good – for everyone involved – and do not provide greater safety for either staff or patients.
      I also think your comment about your son disconnecting while in seclusion is an important indicator of the harm. It demonstrates the practice can actually reproduce the circumstances of the trauma, during which disconnection provides a means of survival.
      The distinction you make between behaviors and underlying issues is also important, but complex, reflecting as it does one of the very longstanding debates within psychology, psychiatry, mental health, and therapy. Different models reflect different emphases.
      My own opinion is that, rather than approaching people with our preferred models, we should work at figuring out which model(s) are a good fit for which people at which times. The behaviors can be a problem, as you would recognise, but need to be managed in ways that, as you note, do not do more harm. The issues are also the key to unraveling the harm already done and finding ways into a better future.
      I hope and trust your son will navigate his way to a better future…Joan Beckwith.

Leave your comment

Show the 'Share' buttons
Hide Buttons