To the Editor: The findings of the study by Martin and colleagues (1) in the December 2008 issue—that use of restrictive interventions can be reduced through a collaborative problem-solving model—are both interesting and exciting. Steps taken to decrease the use of such interventions are to be welcomed and should be reinforced on an international scale. It is unlikely, however, that such interventions will be completely eradicated from psychiatric services. Therefore, debate and discussion on ways to reduce the risks of such interventions are important.
One reason for reducing the use of restrictive interventions is that the evidence base for their safety and effectiveness is distinctly lacking (1). In addition, individuals who apply the interventions and those to whom they are applied may experience many adverse psychological consequences (2). Patients may view the interventions as unwarranted and as punishment for their actions (2). They may also report that such interventions cause pain, which all care providers should seek to avoid. Staff may experience anger and anxiety, and in some cases staff may reawaken memories of their own untoward experiences (2).
More recently, researchers have explored the physical consequences that such interventions may have for both parties. Clearly, the most serious physical consequence is death, and Martin and colleagues describe such cases in the United States. Another obvious consequence is injury to both staff and patients. Research on this important topic is limited, but one U.K. study of a medium-secure unit published in 2003 found that nearly one in five incidents of physical restraint resulted in injury to staff or patients (3). Two more recent studies found that the prevalence of such injuries was considerably lower (4,5), even though the patients in these studies, older adults and persons with acquired brain injury, respectively, typically have a far more complex physical presentation than seen on a general adult medium-secure ward.
These studies found that employing a physical therapist who screened all patients for physical ailments that would increase the likelihood of injury or pain was central to reducing patients' injuries. If any ailments or restrictions on activity were identified, the physical therapist worked with the hospital's physical restraint tutor on adopting pain-free techniques. Restrictive measures must be used with caution when they involve children and adolescents because in most cases their musculoskeletal systems are immature, which elevates the risk of injury. Individuals who apply such interventions in populations at risk of pain and injury might consider involving a physical therapist to reduce risk.
In summary, all staff should seek to reduce the use of restrictive interventions for the good of both patients and staff. Employing a physical therapist to screen patients is one way to reduce the risk of pain and injury. My U.S. colleagues might consider taking this approach.
Mr. Stubbs is clinical specialist and lead physiotherapist at St. Andrews Healthcare, Northampton, United Kingdom.
Martin A, Krieg H, Eposito F, et al: Reduction of restraint and seclusion through collaborative problem solving: a five-year prospective inpatient study. Psychiatric Services 59:1406–1412, 2008
Stubbs B, Leadbetter D, Patterson B, et al: Physical intervention: a review of the literature on its use, staff and patient views and the impact of training. Journal of Psychiatric and Mental Health Nursing 16:99–105, 2009
Leggett J, Silvester J: Care staff attributions for violent incidents involving male and female patients: a field study. British Journal of Clinical Psychology 42:393–406, 2003
Stubbs B, Yorston G, Knight C: Physical intervention to manage aggression in older adults: how often is it employed? International Psychogeriatrics 20:855–857, 2008
Stubbs B, Alderman N: Physical interventions in the management of aggression arising from brain injury: frequency of use and injuries associated with implementation. Brain Injury 22:691–696, 2008