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Management of violence by psychiatric patients

Uses and abuses of means of restraint in the UK-a literature review

Dr John CrichtonThe Orchard Clinic

Edinburgh

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“Restraining the anger and violence of mad men is always necessary for preventing their hurting themselves or others; but this restraint is also to be considered as a remedy. Angry passions are always rendered more violent by the indulgence of the impetuous motions they produce; and which their passions would otherwise occasion. Restraint therefore is useful and ought to be complete.” Cullen 1780

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“Restraint forms the very principle on which the sound treatment of lunatics is founded. The judicious and appropriate adaptation of the various modifications of this powerful means with the peculiarities of each case of insanity comprises a large portion of the curative regiment of the scientific and rational practitioner; in his hands, it is a remedial agent of the finest importance”. Dr Samuel Hadwin of Lincoln Asylum 1841

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“They are fit for pauper lunatics; if the gentleman was put in irons he would not like it”. Dr Monro 1816

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“Lunatics quickly perceive, or if not, they are informed on their first occasion, that their treatment depends in great measure, on their conduct. Coercion thus flowing as a necessary consequence, and being executed in a manner which marks the reluctance of the attendant, it seldom exacerbates the violent patient, or produces that feverish and sometimes furious irritability, in which the maniacal character is completely developed: and which all power of self-control is developed”.William Tuke 1813

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“More actual cruelty hidden under the show of humanity in a system of non-coercion than is openly displayed in muffs, straight-waistcoats, lead locks and coercion chairs.” John Conolly 1840

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“Seclusion is found to have a very powerful effect in tranquillising, and subduing those who are under temporary excitement or paroxysms of violent insanity. As a temporary remedy, for very short periods, in case of paroxysms and of high excitement, we believe seclusion to be a valuable remedy”. Commissioners of Lunacy 1844

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Bedfordshire Asylum

Inventory for the woman’s gallery 1834.

6 new straight-waistcoats12 old straight-waistcoats11 pairs of police handcuffsForcible feeding bottles

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On opium “……. it [is] the right hand of the physician in the treatment of insanity …… a true balm to the wounded spirit, a sedative in mania and a restorative in melancholia”. Manual of Psychological Medicine, Bucknill and Tuke 1858

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Chemical restraints in 19th century British psychiatry:

1860s bromideLate 1860s chloral hydrate1870s hyoscine1880s paraldehyde

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“The Commissioners …. Seldom omit to notice the presence or absence of excitement among the patients in the asylums they visit, and, as it is generally regarded as evidence of skillful treatment to have the wards quiet, any and every means could be adopted to make them so. If this desired result was obtained by means of a straight waistcoat and a gag, or by hitting the patient on the head, public opinion, if not the law, would soon put an end to the practice. But it is more humane to compel the restless and noisy patient to be quiet, by simply crushing them under the stupefying action of drugs?Pritchard Davies 1881

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“I felt restrained from doing what seemed likely to be useful to my patients because of this so-called principle of non-restraint; but during the past two years I have gained confidence from experience and I have tried the experiment with results that have justified my actions, …… I would say that I acknowledge no principle of “non restraint”, but only the higher one of humanity and humane treatment which, if it means anything, means the use of every method likely to restore health ….. However the slavery of restraint is over, its service as a hand maid to the physician will continue to have its place and be better understood”. Dr George Savage 1888

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“… by a gradual yielding to a growing consensus of opinion, and by statutory rules, [mechanical restraint] has been regulated within very narrow margins”.“So negligible is the amount of mechanical restraint, or of any form of physical coercion used in the mental hospitals of this country, that, although quarterly and other returns of such use continue to be requisitioned by us, its absence, same in isolated and exceptional cases, is so taken for granted that we frequently omit all reference to it in our entries. …. During 1927, out of 139,876 patients under treatment ….. only 76 were subject to mechanical restraint and for a total of only 26,449 hours”Board of Control 1927

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Studies into the response of staff to inpatient violence

Series of studies mostly based on case vignettesThree broad responses:– Measures to restore safety– Treatment of underlying pathology– Moral censure

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Factors positively associated with seclusion and chemical restraint:

-Male patient- acting violently- past history of violence- staff feeling personally threatened- untrained staff-(for chemical restraint) diagnosis

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Factors associated with moral censure

- diagnosis - a past history of violence- Staff feeling personally threatened- Patients felt to be personally blameworthy

Highest censure:- female patients with personality disorder and history of violence.

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Factors associated with mechanical restraint (Canadian sample):

- Subjects feeling personally threatened

- Subjects feeling that others are under threat

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Significant differences in Canadian versus British response to patient violence.

more popular in Canadian sample:- Chemical restraint- Seclusion- Police involvement

less popular:- Using relaxation techniques- Talking through the patient’s problems

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Factors associated with chemical restraint in learning disability community sample.

- personal threat

- appearance

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Factors associated with morally censure

- degree of learning disability - appearance- personal threatened- staff assessing patient as being personally more blameworthy.

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Conclusion

All forms of restraint are liable to be abusedStaff require to work in a safe environmentViolence prevention is better than violence responseRole of psychosis, learnt behaviour and patient choice need to be understood

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Final thought

“All the substitutes for [mechanical] restraint, like restraint itself [are] liable to be abused, but none can be made such an instrument of cruelty by abuse”

John Connolly 1840