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Disease and treatment

How patients perceive mechanical restraint in forensic psychiatry

Denmark has committed to limiting the mechanical restraint of patients in forensic psychiatry. Fulfilling this ambition also requires understanding how these patients perceive the use of mechanical restraint in forensic psychiatry. Researchers have now asked patients about this.

In 2002, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment visited Denmark and was not impressed by how forensic psychiatry uses mechanical restraint. Fortunately, Denmark agreed with this recommendation and set a goal of reducing the use of mechanical restraint by 50%. Based on this, research council funding and other government funding have been provided for research on initiatives that could help to reduce the use of mechanical restraint.

One such initiative is a qualitative research project aiming to determine how patients in forensic psychiatry perceive the use of mechanical restraint. The results of the research project were recently published in the International Journal of Mental Health Nursing.

The research shows that these patients have great difficulty understanding why mechanical restraint is necessary to get them to calm down. However, the patients accepted mechanical restraint better if they had behaved aggressively or violently in connection with a psychotic or delusional episode.

“Reducing the use of coercion in forensic psychiatry, including mechanical restraint, requires understanding the patients’ perceptions. This research is thus connected with many research projects aiming to develop interventions that will enable us to fulfil our ambition of reducing the use of mechanical restraint,” explains the first author, Ellen Tingleff, Lecturer and PhD student, Department of Psychiatry, Region of Southern Denmark and University College Lillebælt.

Interviews with 20 patients

Ellen Tingleff interviewed 20 patients who had been treated in forensic psychiatry (4 women and 16 men) about how they experienced being mechanically restrained.

Staff members at forensic psychiatric hospitals are allowed to restrain patients mechanically if they assess that the patients pose a danger to themselves or others. Patients are mostly restrained in their own room by being mechanically restrained to the bed with a belt. This should be implemented for the shortest possible time. Staff members may also restrain the arms and legs of a patient if they consider it necessary. A permanent staff member should always be present when the mechanical restraint is implemented.

The patients Ellen Tingleff interviewed had been mechanically restrained between 1 hour and 7 weeks.

“I interviewed patients in depth about how they experienced and perceived the events that led to the mechanical restraint, the situations that developed during mechanical restraint and what they experienced afterwards,” explains Ellen Tingleff.

Two types of patient experiences

Ellen Tingleff found that patients’ experiences of mechanical restraint very much depended on the events immediately before they were restrained and thus comprised two types.

• Some patients perceived that they had been unfairly treated in the events leading to mechanical restraint. Ellen Tingleff calls these overt protest reactions.

• Other patients demonstrated illness-related behaviour: for example, a psychotic or delusional episode led to mechanical restraint.

The first type of patients often felt that they had been unfairly treated before they were mechanically restrained.

This situation typically arose when patients were frustrated over, for example, curfew rules, which resulted in an anger episode.

“Patients often perceive that staff members degrade and reject them. When patients get angry, they do not feel that staff members try to understand their perspective or try to calm them down. When situations like this are not resolved, the end result is that staff members mechanically restrain the patients. This is how the patients’ perceive this,” says Ellen Tingleff.

Patients protest silently

After the patients had been mechanically restrained, they invariably continued to protest about the treatment they had received. They did this through various forms of protest behaviour, such as resisting restraint, shouting at the staff or making verbal threats.

In these situations, many of the patients perceive that staff members do not try to calm them down. They also feel that the supervisory doctors speak condescendingly during consultations.

However, at some point the patients gave up and reverted instead to protesting silently, following the rules set by the staff but still being angry inside. The reason for this silent protest behaviour was that the patients realized that that they could not escape from the situation until they changed their behaviour.

“When they were released from restraint, they continued to protest silently. They had not changed their perception of the staff, but they knew that if they became aggressive again, this would result in more mechanical restraint,” explains Ellen Tingleff.

Patients did not feel that they had been offered a follow-up meeting

Following mechanical restraint, patients must be offered a meeting in which they can discuss the situation with the staff. The idea is that they should understand why they have been mechanically restrained and what they can do to avoid this in the future.

The problem, however, is that the patients say that these meetings did not take place.

“If patients do not perceive that a meeting has taken place, then they clearly will continue to protest silently. This is totally undesirable, but unfortunately this is also the dominant pattern among the patients I interviewed,” says Ellen Tingleff.

Patients accept mechanical restraint better if they have had a psychotic episode

The second typical reaction of these patients to mechanical restraint arises in connection with such episodes as psychosis. Ellen Tingleff calls this reaction an illness-related pattern.

Here the patients’ understanding of the need for mechanical restraint differs completely.

After a psychotic episode, patients often regret their behaviour and do not exhibit the same protest patterns as in the silent protest type of reaction.

They also feel that the staff members behave in a caring way towards them and typically also remember having a good meeting afterwards.

“In these situations, the patients do not protest in silence, and their perception of the process differs completely,” says Ellen Tingleff.

Ellen Tingleff explains that her research results should not stand alone but should be integrated with many research projects aiming to examine how to reduce the frequency and duration of mechanical restraint.

In this context, understanding patients’ perceptions and their experiences in greater detail are important for researchers to develop tools that can reduce the use of mechanical restraint by 50%.

"Forensic psychiatric patients' perceptions of situations associated with mechanical restraint: A qualitative interview study" is published in International Journal of Mental Health Nursing. In 2015, the Novo Nordisk Foundation awarded a grant to Ellen Tingleff, a principal investigator of the project "Reduction of mechanical restraint in forensic psychiatry - Patient and relatives' perceptions and perspectives on mechanical restraint in forensic psychiatry."

Ellen Tingleff
Associate Professor, PhD student
In Denmark, the objective is to reduce coercion in psychiatric settings by 50 % in 2020. However, the number of prolonged episodes of mechanical restraint (MR) is currently increasing, especially among forensic psychiatric patients. Research suggests that involvement of patients and relatives contributes to reduction in coercion, including MR. However, research into forensic psychiatric patients and relatives' perceptions of situations before, during and after MR episodes and their perspectives on what can help reduce use and duration of MR is very sparse. We aim to generate knowledge about what characterizes the meaning forensic psychiatric patients and relatives' ascribe to perceptions of situations before, during and after MR episodes and to develop knowledge about what can reduce use and duration of MR.